Use of Sub-national Indicators to Improve Public Health in Europe (UNIPHE)

ANNEX 17: WP9 – CONFERENCE PROCEEDINGS (D4) UNIPHE Conference Towards Improved Local Public Health Bucharest 27–28 September 2010

National Institute of Public Health

The National Institute of Public Health was initially established by royal decree in 1927, by King Ferdinand I of Romania. The decree stipulated the establishment of an Institute of Hygiene and Public Health of the Ministry of Health, with a separate budget and activity in the area of “epidemiology and prophylaxy of infectious ailments, food hygiene, industrial hygiene, sanitary genius, social hygiene, eugenya, scholar hygiene, social assistance, social and work accidents insurance, statistics and demography, sanitary administration and legislation”. Over the years the Institute has gone through numerous changes, but its core activities have been maintained, modernized and continuously adapted to meet the needs of the population. The current Institute, the National Institute of Public Health, is an organization with legal personality subordinated to the Ministry of Health of Romania. It was reorganized and restructured during 2009 and 2010 by merging all the former national branches that dealt with public health – the Institute of Public Health Bucharest, Institute of Public Health “Prof Dr Iuliu Moldovan” Cluj-Napoca, Institute of Public Health of Iasi, Institute of Public Health “Prof Dr Leonida Georgescu” Timisoara, and Public Health Centre for Targu Mures and Sibiu – along with the National Centre for Health Statistics. Today the Institute the main methodological and technical institution for public health activities in Romania.

The main goals of the Institute are oriented towards: • Prevention, surveillance and control of communicable and non-communicable diseases • Monitoring health status • Promoting health and health education • Assessment of occupational health • Monitoring health in relation to the environment • Drafting regulations in the fi eld of public health • Managing public health • Development of specifi c public health services.

The work of the Institute is accomplished by four national centres and six regional public health centres, organized in its structure without legal personality. 2

The four national centres, which ensure technical and methodological coordination on specifi c issues for the Institute, are: • National Centre for Surveillance and Control of Communicable Diseases (CNSCBT) • National Centre for Environmental Monitoring of Risks in the Community (CNMRMC) • National Centre for Evaluation and Promotion of Health Status (CNEPSS) • National Centre for Public Health Statistics Monitoring (CNMSP).

The six regional public health centres, which ensure the coordination and execution of the work of the Institute, are: • Regional Centre of Public Health Bucharest (CRSPB) • Regional Centre of Public Health Cluj (CRSPC) • Regional Centre of Public Health Iasi (CRSPI) • Regional Centre of Public Health Timisoara (CRSPT) • Regional Centre of Public Health Targu Mures (CRSPM) • Regional Centre of Public Health Sibiu (CRSPS). UNIPHE Conference Towards Improved Local Public Health Bucharest 27–28 September 2010

Programme

Day 1 Monday 27 September 2010 Palace of the Parliament Madrid Conference Room 8:30–9:00 Registration and Coffee 9:00 –9:05 Opening Remarks Romania Ministry of Health Representative

9:05–10:30 Session 1: European Environment and Health Programme/Activities Chair: Ministry of Health Representative 9:05–9:20 Opening of Conference Alexandra Cucu, National Institute of Public Health, Romania Lorraine Stewart, Health Protection Agency, United Kingdom 9:20–9:50 Overview of the European Union Environment and Health Programme Raquel Duarte-Davidson, Health Protection Agency, United Kingdom 10:00–10:25 Environmental health developments within the World Health Organization European Region (WHO EURO) Andrey Egorov, World Health Organization, European Centre for Environment and Health, Bonn, Germany 10:30–11:00 Coffee

11:00–13:00 Session 2: Existing Environment and Health Information Initiatives in Europe – Part I Chair: George Morris, National Health Service Scotland, United Kingdom 11:00–11:40 Overview of the European Environment and Health Information System (ENHIS) project Dafi na Dalbokova, World Health Organization, European Centre for Environment and Health, Bonn, Germany 11:45–12:15 Overview of the Use of Sub-national Indicators to Improve Public Health in Europe (UNIPHE) project Lorraine Stewart, Health Protection Agency, United Kingdom 12:20–12:50 Overview of health indicators in the European Region (ISARE) project Wolfgang Hellmeier, NRW Institute of Health and Work, Germany Andre Ochoa, National Federation of Regional Health Observatories (FNORS), France 13:00–14:00 Lunch 2

14:00–15:30 Session 3: Existing Environmental and Health Information Initiatives in Europe – Part II Chair: Alexandra Cucu, National Institute of Public Health, Romania 14:00–14:35 Overview of the European Urban Health Indicators System (EURO-URHIS) project Arpana Verma, University of Manchester, United Kingdom Wolfgang Hellmeier, NRW Institute of Health and Work, Germany 14:45–15:25 Review of the Environment and Health Policies Report Dafi na Dalbokova, World Health Organization, European Centre for Environment and Health, Bonn, Germany 15:30–16:00 Coffee

16:00–17:00 Session 4: Tools and Approaches Used to Assess Environmental Health Chair: Andrey Egorov, World Health Organization, European Centre for Environment and Health, Bonn, Germany 16:00–16:25 Examination of the Environmental Burden of Disease Report Brigit Staatsen, National Institute for Public Health and the Environment (RIVM), Netherlands 16:30–16:55 Environmental health response for the ecological public health era George Morris, National Health Service Scotland, United Kingdom 17:00–18:00 Poster Session 19:30 Conference Dinner – Rin Grand Hotel

Day 2 Tuesday 28 September 2010 Palace of the Parliament Madrid Conference Room

9:00–10:15 Session 5: UNIPHE Results – Part I Chair: Wolfgang Hellmeier, NRW Institute of Health and Work, Germany

9:00–9:05 Review of Day 1 Lorraine Stewart, Health Protection Agency, United Kingdom 9:05–9:15 Progress to date within the UNIPHE project Lorraine Stewart, Health Protection Agency, United Kingdom 9:20–9:30 Process of ensuring that the deliverables meet the stakeholders’ perspective Raquel Duarte-Davidson, Health Protection Agency, United Kingdom 9:30–9:45 Methods used for the selection of the environment and health indicators Ingrida Zurlyte, Centre for Health Education and Disease Prevention, Lithuania 9:50–10:10 Methodology for data collection and analysis Anna Páldy, National Institute of Environmental Health, Hungary 10:15–10.45 Coffee 3

10:45–12:00 Session 6: UNIPHE Results – Part II Chair: Patrick Saunders, National Health Service, Sandwell Primary Care Trust, United Kingdom 10:45–10:55 Sub-national comparison of population-weighted annual mean particulate matter

(PM10) concentration in urban areas: emphasis on Hungary Anna Páldy, National Institute of Environmental Health, Hungary 10:55–11:05 Sub-national comparison of annual mortality rate due to respiratory diseases in children older than one month and under one year of age: emphasis on Slovenia Ana Hojs, National Institute of Public Health, Slovenia 11:05–11:15 Sub-national comparison of injury rates due to road traffi c accidents: emphasis on Germany Odile Mekel, NRW Institute of Health and Work, Germany 11:15–11:25 Sub-national comparison of incidence of melanoma in people aged under 55 years: emphasis on Lithuania Ingrida Zurlyte, Centre for Health Education and Disease Prevention, Lithuania 11: 25–11:35 Sub-national comparison of mortality due to respiratory diseases for all ages: emphasis on United Kingdom Adedoyin Awofi sayo, Health Protection Agency, United Kingdom 11:35–11:45 Sub-national comparison of infant mortality rate: emphasis on Spain Maria José Carroquino, Institute of Health, Spain 11:45–11:55 Sub-national comparison of life expectancy at birth: emphasis on Romania Adriana Galan, National Institute of Public Health, Romania

12:00–13:00 Session 7: Plenary Discussion – The Way Forward Moderators: Raquel Duarte-Davidson, Health Protection Agency, United Kingdom Adriana Galan, National Institute of Public Health, Romania Open Discussion 13:00 Final Remarks – Close of Conference Adriana Pistol, National Institute of Public Health, Romania UNIPHE Conference Towards Improved Local Public Health Bucharest 27–28 September 2010

Biographies

Ms Adedoyin Awofi sayo Health Protection Agency, United Kingdom Adedoyin Awofi sayo obtained a Bachelors degree in nursing and widwifery in 2006 and practiced for a short while. In 2007, she went into public health and worked with an AIDS organization in Nigeria where she was involved in the evaluation of public health interventions used in the control of HIV. She completed an MPH in 2008 at the University of Birmingham, and has since worked with the Health Protection Agency. She is currently a public health scientist at the Centre for Radiation, Chemical and Environmental Hazards of the HPA. She previously worked with the West Midlands Regional Epidemiology Unit and the Real-Time Syndromic Surveillance Team, where she carried out enhanced surveillance of several infectious diseases including meningococcal disease and measles. She also worked with the HPA West Midlands East unit, where she developed various databases, worked with several outbreak control teams and carried out enhanced surveillance on Mercian TB in the West Midlands East region.

Dr María José Carroquino Institute of Health, Spain María José Carroquino obtained a PhD from Cornell University, New York, and an MPH from San Diego State University, California, and has extensive experience in international environmental health projects. She has worked for the National Institute of Public Health (Instituto de Salud Carlos III) in Madrid since 2002, participating in EU-funded projects (ECOEHIS, ENHIS-1, ENHIS-2 and UNIPHE) and collaborating with the WHO on the development of environmental health information systems. This work has included the tasks of developing and processing indicators, conducting policy reviews, and analysis and developing indicators for the evaluation of policies. Current activities within the UNIPHE project include the research of inequality indicators as criteria for developing a methodology for regional comparisons. Previously, Dr Carroquino worked for the WHO, the European Commission (DG Environment), the US Environmental Protection Agency and Cornell University. She is a Fulbright Scholar and a Fellow of the American Association for the Advancement of Science (Postdoctoral Fellowships 1996–98). Dr Carroquino also works as consultant for the WHO. She has participated as an expert evaluator of research proposals for both the Executive Agency for Health and Consumers and Framework Programme 7 of the EU. 2

Dr Dafi na Dalbokova World Health Organization, European Centre for Environment and Health, Bonn, Germany Dafi na Dalbokova has been working at the WHO European Centre for Environment and Health (WHO-ECEH) since 1999, on the establishment of environmental public health indicators for policy-oriented monitoring in the WHO European Region. She has been the technical manager of a series of projects to implement a harmonized environment and health information system to support public policies in Europe. Before joining the WHO, Dr Dalbokova was a senior researcher at the National Centre of Hygiene, Medical Ecology and Nutrition, Sofi a, Bulgaria, and head of the Data Processing and Statistical Analysis of Surveys, Field and Experimental Studies Unit. She also led the ‘Development of National Health Environment Geographic Information System (HEGIS) for Bulgaria’ project within the framework of the WHO-ECEH programme. Dr Dalbokova has a computer science background, a PhD in information theory and extensive postgraduate qualifi cations in biostatistics and epidemiology. After her retirement from the WHO at the end of 2009, Dr Dalbokova has continued her activities as a consultant, focusing on initiatives related to the development of tools for monitoring public health and the environment in Europe.

Professor Raquel Duarte-Davidson Health Protection Agency, United Kingdom Raquel Duarte-Davidson heads the International Research and Development Group in the Centre for Radiation, Chemical and Environmental Hazards of the Health Protection Agency (HPA). She provides high level policy and scientifi c advice on environment and health issues and on risk assessment, manages an international programme of research and leads on the HPA contribution to the development and implementation of the Children’s Environment and Health Action Plan for the UK. Prior to joining the HPA she was a principal scientist at the Environment Agency, responsible for implementing that Agency’s chemical risk assessment policy.

Dr Andrey Egorov World Health Organization, European Centre for Environment and Health, Bonn, Germany Andrey Egorov graduated from Moscow Geological Prospecting Institute, Russia, in 1987. He had been involved in fi eld hydrogeological investigations and environmental assessments for industrial development projects in the former USSR, and the World Bank funded Environmental Management Project in Russia. In 2001, he received a Doctor of Science degree in Environmental Health from the Harvard School of Public Health in Boston, USA. His doctoral research focused on microbial contamination of drinking water and waterborne infections in Russia. After completing a post-doctoral research project at Harvard on exposures to halogenated byproducts of water disinfection, he taught statistical data analysis to public health students at Tufts University School of Medicine in Boston and conducted epidemiological studies of infectious diseases in the USA and Ecuador. From 2005 to 2010, he worked at the US Environmental Protection Agency, Offi ce of Research and Development, where he led an interdisciplinary research project to evaluate the public health benefi ts of advanced drinking water treatment in selected communities. His other duties at the EPA included microbial risk assessment, technical support for the development of new drinking water regulations, and coordination of an international US–Russian project to establish an environmental health data analysis centre in Russia and assess the potential impacts of climate change on waterborne infectious diseases. Dr Egorov joined the WHO European Centre for Environment and Health on 1 September 2010. 3

Dr Adriana Galan National Institute of Public Health, Romania Adriana Galan’s competence and experience lies in the fi eld of public health and health management. She obtained a Bachelors degree in Computer Science, with intensive postgraduate specialisation in public health and health management, both in Romania and abroad. She is currently the head of the Department of Health Status Evaluation and Priority on non-communicable diseases at the National Institute of Public Health, National Coordinator of the Stability Pact Programmes, and the WHO focal point for the surveillance and control of non-communicable diseases and reduction of alcohol-related effects. Her main areas of interest and expertise include design of public health strategies, human resources research and planning, training programme development, health policy development and analysis, design and implementation of health information systems, and health status evaluation (situation analysis, needs assessment and priority setting). She has collaborated with international institutions (WHO, World Bank, United Nations Population Fund, University of Bielefeld and European Health Management Association), international private consultancy companies (HLSP, SALUMONDI and EPOS Health Consultants), and with Romanian non-governmental organizations (CPSS and SASTIPEN). She is a member of the European Public Health Association, European Health Management Association, Task Force of the Forum of Public Health in South Eastern Europe, and the Romanian Public Health and Health Management Association since 1992 (member of the Board from 2000–04). She is also regional editor for the Croatian Medical Journal and member of the Advisory Board of the Macedonian Journal of Medical Sciences. She has published in Romanian and foreign journals, contributed to several books and handbooks, and was one of the main editors of the handbook for teachers, researchers and health professionals ‘Public Health Strategies: A Tool for Regional Development’, published by Hans Jacobs Publishing Company, Germany, in 2006.

Dr Wolfgang Hellmeier NRW Institute of Health and Work, Germany Wolfgang Hellmeier has been with the LIGA.NRW since 1988 and during this time has worked on several topics, always closely related to methods of epidemiology, health monitoring and health reporting for the state North-Rhine Westphalia and the local health authorities. He has taught epidemiological methods at the school of public health at the University of Bielefeld and participated in several projects on European level to adapt public health monitoring of new EU member states to the EU requirements. For ten years from 1995 onwards, he dealt mainly with environmental health, working on several topics including weather-related deaths, possible adverse health effects from cell phones and the implementation of a state database on drinking water quality. He was also involved in the European project ENHIS, led by the WHO. During recent years his responsibilities shifted from environmental health to public health in general. He worked on the design and implementation of ‘Information System on Health NRW’, towards a comprehensive surveillance system including analysis, reporting and dissemination of information on health. He has kept in touch with European developments by taking part in several EU projects in addition to UNIPHE, such as ECHIM, EUPHIX, Working Party Indicators, AMIEHS, I2SARE and URHIS I and URHIS II.

Dr Ana Hojs National Institute of Public Health, Slovenia Ana Hojs is a public health specialist at the Centre for Environmental Health in the National Institute of Public Health, Slovenia. She qualifi ed as a medical doctor in 1989. After internship and postgraduate study in public health medicine and specialization in public health (hygiene), she started to work in the fi eld of environmental health. She has been involved in preparing the National Children’s Environmental Health Action Plan. She works on environmental health threats and their impact on health. 4

Dr Odile Mekel NRW Institute of Health and Work, Germany Odile Mekel completed her MPH in 1983 at the University of Maastricht, an MSc in environmental management in 1989 from the University of Leiden, and a PhD from the University of Wuppertal. She has been the head of the unit of Innovation in Health at the NRW Institute of Health and Work (LIGA.NRW) since 2008. Previously, she worked as an environmental health risk assessor and at the University of Leiden 1989–90, University of Wuppertal 1990–95 and the University of Bielefeld 1995–2001. She joined the precursor organization to the LIGA.NRW, the Institute of Public Health NRW, Bielefeld, in 2001 and held the position of head of the unit of risk analysis, 2001–08. Dr Mekel is an established expert in health risk assessment and health impact assessment. She has been principal investigator on numerous projects in this area, funded by the EU and other sources. She acted as a temporary adviser to the WHO, in particular on risk assessment in health impact assessment and as an adviser to the EU Joint Research Centre (Ispra) on exposure assessment issues. She chairs the interdisciplinary German working group on probabilistic exposure and risk assessment (since 1997). Her current work focuses on innovation management in public health, exposure and risk assessment modelling.

Professor George Morris National Health Service Scotland, United Kingdom George Morris is a Consultant in Ecological Public Health with NHS Health Scotland, Scotland’s national health improvement agency. He joined the organisation in early 2009 following a fi ve-year period as a Scientifi c Policy Adviser to the Scottish Government and has previously worked in local government, academia and as a consultant in the fi eld of health protection. Whilst in government, Professor Morris led development of an innovative new policy on environment and health, Good Places, Better Health, and is retained as external adviser to the initiative. Good Places, Better Health, and indeed much of his work to date, is concerned with the development of a more sophisticated view of the role played by the environment in health and the development of new structures to assist policy makers and other decision makers in the fi eld. He holds a PhD in Bioscience and Biotechnology and Fellowships of the UK Faculty of Public Health and the Royal Environmental Health Institute of Scotland. He has presented and published widely on the challenge posed to policy makers by complexity in the fi eld of environment and human health.

Dr André Ochoa National Federation of Regional Health Observatories (FNORS), France André Ochoa was born in 1950. He holds a diploma in medicine, with specialization in public health. After working for more than ten years as a general practitioner, he has been the director of a French regional public health observatory since 1990. As such, he has been involved in or coordinated many studies in public health on several subjects, including the health of the young and of the elderly and delivery of health care. He is also responsible for the administrative and scientifi c duties of the health observatory. He is the treasurer and delegate of the National French Federation of Health Observatories and a member of many national organisations. He has been the project manager of ISARE projects since 1999, currently coordinating the I2SARE project, and has taken part in other European projects such as EURO-URHIS. 5

Dr Anna Páldy National Institute of Environmental Health, Hungary Anna Páldy is a medical epidemiologist with an MPH, PhD and 30 years of experience in different fi elds of environmental health. She is based at the National Institute of Environmental Health (formerly the National Institute of Public Health), heading the Division of Health on impact forecasting. Since 2002 she has been the deputy director of the Institute. Dr Páldy has been involved in several multicentre as well as Hungarian studies. Her research fi eld covers cytogenetics and environmental epidemiology focusing on the effect of pesticides, air and water pollutants. She was actively involved in the implementation of National Environmental Health Action Programme. She has been frequently invited to be a temporary adviser in climate and health-related issues by the WHO. In the last ten years she has studied the health impact of environmental pollution on mortality and morbidity, as well as the health impact of climate change. Dr Páldy has been actively involved in the WHO Environment and Health Process and has participated in several projects aimed at the elaboration of environmental health indicators (ENHIS-2, UNIPHE and CEHAPIS). She has contributed to the elaboration of the National Climate Adaptation Strategy and of the heat and health early warning system in the country, and participated in the work of the research group on Adaptation to Impacts of Climate Change of the Hungarian Academy of Science. Dr Páldy is a member of the National Environmental Council; she acted as president of the Central-Eastern European Chapter of the International Society of Environmental Epidemiology. She is currently the president of the Society of Hungarian Hygienists. She has led the unit of environmental epidemiology at the School of Public Health in Debrecen, Hungary. She has authored and co-authored more than 30 peer-reviewed papers and book chapters.

Bridgit Staatsen National Institute for Public Health and the Environment (RIVM), Netherlands Brigit Staatsen is currently project manager of the Knowledge and Information Centre on Environment and Health at RIVM, as well as project leader on Information of the Dutch Atlas Healthy Environment. She has a MSc in medical biology, with a major in epidemiology and toxicology. Through her work for the Dutch Health Council and at RIVM, she has developed expertise in translating knowledge on health information, tailor-made for different target groups. In addition, she has experience in the area of health impact assessment, healthy mobility, healthy environment, disease mapping, indicators and health information systems. She has contributed to the Dutch Public Health Forecast Report (VTV 2010) and contributed or coordinated the health sections in the yearly National State of Environment Reports or Outlooks (1997–2004, 2010) of the Netherlands Environment Assessment Agency. Internationally, she has contributed to several reports of the WHO and EEA on the state of environment and health in Europe. Recent products of the work of her team are a toolbox on healthy mobility (www.healthytransport.com), and an online guide for health impact assessment in spatial planning (www.gezondheidinmer.nl/isurvey/). She has been a coordinator of the Health Impact Assessment Schiphol (a multi-year research and risk assessment programme on the health impact of aircraft noise and airport-related pollution). She has been chair of the Technical Working Group on Indicators, advising on the further development of indicators and information systems for the EU Action Programme on Environment and Health (SCALE), chair of the Working Party on Environment and Health within the framework of the Health Monitoring Programme of DG SANCO (2004–2008), and leader of a working package on information system building in the framework of the WHO-ENHIS projects (2002–2008). 6

Dr Lorraine Stewart Health Protection Agency, United Kingdom Lorraine Stewart is a public health specialist in the Centre for Radiation, Chemical and Environmental Hazards of the Health Protection Agency (HPA). She has a PhD in environmental science and is currently completing her MPH at the University of Manchester. She also holds a Diploma in Environmental Monitoring, Modelling and Control and Public Health. She has been involved in national research projects in the fi eld of public health – the latest of which was an epidemiological study investigating the impact of indoor air quality on the health of asthmatic children. She joined the HPA in 2006 after working with local government, undertaking review and assessments of air quality in relation to public health. At the HPA she has been involved in a number of public health projects, notably the development of the Pilot Children’s Environmental Health Toolkit in the West Midlands area, which is designed to help with the delivery of the Children’s Environment and Health Action Plan for Europe. Her participation in the European ENHIS programme led to her successfully tendering for EC funding to undertake this UNIPHE project, which aims to develop a sustainable environmental health monitoring system consisting of a set of sub-national/regional indicators to improve public health in Europe. This work is being done in partnership with six other European countries.

Dr Arpana Verma University of Manchester, United Kingdom Arpana Verma is a Senior Lecturer and Honorary Consultant in Public Health in Greater Manchester for cancer, sexual health and other chronic diseases. She is the founder and head of the Manchester Urban Collaboration on Health (MUCH) at the University of Manchester; the principal investigator and coordinator of EURO-URHIS 2 (a European Commission Framework Programme 7 project investigating urban health indicators in European and non-European countries); and president of the urban health section of the European Public Health Association. Dr Verma qualifi ed as a medical doctor in 1995. Her research interests include urban health, hepatitis C, blood-borne viruses, vaccination and infection control. Given this, she is invloved in work on a wide variety of conditions ranging from cancer, sexual health to other chronic diseases. She also works within the National Health Service in Greater Manchester.

Mrs Ingrida Zurlyte Centre for Health Education and Disease Prevention, Lithuania Ingrida Zurlyte obtained an MSc in biology and genetics in 1987 from the University of Vilnius, Lithuania. She is currently the Deputy Director at the Centre for Health Education and Disease Prevention under the Ministry of Health of Lithuania, a position she has held since April 2010. Her previous positions include: microbiologist at the research enterprise ‘Fermentas’ (1987–93); assistant, Centre for Ecological Medicine, Institute of Hygiene (1994–95); and specialist (1995–96), head of Environment and Health Division (1996–2003) and deputy director (2004 – March 2010) at the State Environmental Health Centre. The main fi elds of expertise of Mrs Zurlyte are environmental health management, environmental health monitoring and information and health impact assessment. She led or participated in a number of international and national projects and programmes on national environmental health action planning, housing and health, health impact assessment, environmental health indicators and monitoring. Mrs Zurlyte was invited to be a temporary adviser to the WHO Regional Offi ce for Europe for different environmental health issues; she acted as co-chair of the European Commission Working Party on Environmental Health Information and is one of the national counterparts for the European Environment and Health Process. Currently, she is responsible for the units dealing with non-communicable diseases, injury prevention and environmental health. UNIPHE Conference Towards Improved Local Public Health Bucharest 27–28 September 2010

Abstracts of Posters

First Author Title Page Awofi sayo Development of a methodology for consistent and common data collation 3 for newly developed indicators within Europe Chirilă Aspects of well water quality and rural population health in north-east 4 Romania Claici Cancer information west region’s population and variables fi les 5 Cordeanu The effects of irritant pollutants on children’s health 6 Cordeanu Toxic effects of heavy metal exposure on children 7 Cucu Health and environment in Romania – progress assessment from a 8 European perspective Cucu Social inequalities and environmental health: Romanian overview 9 Cucu Infant mortality in Romania, 1999–2008 10 Curea National synthesis "monitoring of health care waste management system" 11 2009 Deac Food-borne infections appeared in Transylvania county and their safety 12 considerations Domahidi Monitoring spa mineral waters in Mureş, Harghita and Covasna districts 13 Domahidi Heavy metal contamination of children playgrounds in Mureş district 14 Fulga Perception of risk generated by urban noise 15 Huidumac-Petrescu Students’ musculoskeletal disorders 16 Lupulescu Waste management and protection of population health 17 May Health survey among populations living in the vicinity of nuclear facilities 18 Mirestean Violence in students from Romania, multifactorial study design 19 Mirestean The evaluation of biochemical markers and risk factors in the depression of 20 child and adolescent Moga Registration and quality assurance in the microbiology laboratory involved 21 in drinking water monitoring programme, in eight counties of Transylvania Neamtu Evolution of air pollution with suspended particulate matter and health 22 indicators in Romanian regions 2

Nicolescu The assessment of attention performance in children exposed to neurotoxic 23 elements Özden RF electric fi elds measurements in an urban area and Turkish regulations 24 Páldy Elaboration of a pair of pollen indices for characterising the population 25 load to airborne pollens Todea The picture of occupational diseases in Romania in the past ten years 26 Tudor Evaluation of acute infantile methaemoglobinaemia cases generated from 27 well water in Romania in 2009 Vlad Pollution caused by household waste – a preventable aggression on the 28 environmental balance Zugravu Overweight and obese characteristics in a sample of Romanians from the 29 southern part of the country 3

Development of a methodology for consistent and common data collation for newly developed indicators within Europe Adedoyin Awofi sayo, Lorraine Stewart Health Protection Agency, United Kingdom

A number of indicator sets exist within the European Union which facilitate the national assessment of the health status of a population. However, it is recognised that sub-populations may experience different exposures and possess unique features but their status may be masked at a national level. Therefore the UNIPHE (use of sub-national indicators to improve public health in Europe) was developed with the aim of creating a harmonised environmental health information system of sub-national indicators. One of the work packages of the project is the development of method(s) to facilitate the consistent and common collation of data for newly developed indicators across the seven partner countries as well as other European countries. The identifi cation of new indicators included information gathering from existing national sources, existing indicator sets and views of relevant practitioners to ensure that the new indicators will monitor and identify relevant and specifi c population issues. Each indicator was assessed for environmental relevance and methodological sheets are being developed. The development of the indicators will be undertaken in collaboration with statistical offi ces and other relevant institutions in each partner country to determine the most appropriate method for data collation. It is anticipated that the developed methodology will be disseminated across Europe to ensure consistency and uniformity across all countries. This presentation will include a list of the set of new indicators and the methodology agreed among the consortium for the data collection. The methodological sheets developed for one indicator will also be presented. 4

Aspects of well water quality and rural population health in north-east Romania Ioan Chirilă1,2, Oana Iacob1, Luminita Minea1 1 National Institute of Public Health, Regional Centre of Public Health Iasi, Romania 2 PhD student at “Gr T Popa” University of Medicine and Pharmacy Iasi, Romania

The Global Burden of Disease project, coordinated by the World Health Organization (WHO), is an attempt to quantify and compare the level of illness at both world and regional levels. This can be done on a disease-by-disease basis or in relation to various risk factors such as exposure to poor water, sanitation, and hygiene. Disease burden, in relation to environmental risk factors, is generally determined by establishing the exposure of the population (on a regional basis) to the chosen risk factor and combining these data with exposure–response relationships for the selected health outcomes to estimate the number of people affected with each outcome. A descriptive epidemiologic study exploring a hypothetical relationship between contaminated well water exposure and disease burden (Suckling acute methemoglobinemy, in particular) was developed; well-water samplings were from public wells, drilled wells, captured springs (public drinking fountain, small distribution network) and centralized local networks (from groundwater sources, without a physical or chemical disinfection); the methemoglobinemy cases were reported by the county hospitals, based on the medical recorders and the data processing and interpretation was based on descriptive epidemiology criteria: chronological criteria, geographical criteria and the own characteristics of the cases. Between 2007-2009, 321 samples were analysed for 1038 microbiological indicators and 239 samples for 1792 physic-chemical indicators of drinking water from underground sources. Water quality from wells was affected due to non-compliance with hygiene rules on the location and construction of wells especially for newly built homes, and irrational and uncontrolled use of pesticides and agricultural fertilizers. On the decrease tendency of incidence background, Moldavien counties maintains an incidence range between 4,7-8,7 per thousand, with a higher frequency in boys in aged under 3 months, in artifi cially fed suckling and in suckling having slight clinical forms; over half of them are produced in suckling exposed to water nitrates quantities higher than 101 mg/dm3. By knowing the territorial distribution of the cases the risk areas of the county were revealed. It is important to inform the population about the conditions of construction, protection, maintenance and regular monitoring of local drinking water facilities and about the protection of vulnerable population. Resolving the question about health impacts of nitrate requires an epidemiological to get indications on the magnitude of exposure and health effects. Keywords: burden of disease, drinking water quality, methemoglobinemia, nitrates 5

Cancer information west region’s population and variables fi les Camelia Nicoleta Claici, Monica Potcovaru National Institute of Public Health, Regional Public Health Centre Timisoara, Romania

Age and gender are basic variables of health and disease. Data refl ecting the health status of population groups is shown separately for both men and women, and for different age groups. Although great advances continue to be made in research and treatment, cancer remains a key health concern for all. To incorporate the specifi c ENCR standards on classifi cation, coding, information security, confi dentiality and disclosure procedures in our area’s population-based cancer recording and reporting actions, in order to gain a successful pass through IARC checks and conversions. West-Region demographic indicator and cancer cases fi les preparation for data submission: verifi cation of inclusion criteria (period of time; all ages eligible for registration; all primary tumors, including non-malignant tumors of CNS, in situ tumors of breast, cervix, colon, rectum and melanoma of the skin), validation, removal of duplicate registrations, checking mandatory and optional variables, adhering to the recommended coding, zipping and protection; non- standard coding schemes used in any data fi les; reference to the source of population data. West Region of Romania’s population fi le by county/gender/age (tables no. 1 and 2) and cancer cases fi le’s quality and format – our model of record layout and coding (table no. 3). The monitoring of cancer occurrence is fundamental to planning and evaluating public health interventions. By sharing knowledge, capacity and expertise in cancer prevention and control, we can address the problem more effectively across the continent. 6

The effects of irritant pollutants on children’s health Aurelia Cordeanu1, Albescu Alina2, Elena Mihaela Cordeanu2, Alexandru Dieaconescu2 1 National Institute of Public Health, Bucharest, Romania 2 Student University of Medicine, Bucharest, Romania

Irritants are the most frequent air pollutants due to their multiple sources in the environment. Irritant air pollutants (sulphur dioxide, nitrogen oxide, ammoniac, chlorine, ozone) and air particles (nitrates, sulphate, ammonium) contribute to the appearance of acute respiratory infections in children (varying with the level of pollution), and the aggravation of chronic respiratory diseases. Previous studies carried on in our country showed the presence of a direct proportionality between air pollution with irritants and chronic pulmonary morbidity. The purpose of the study was to identify and evaluate the level of air pollution in Turnu Magurele and its effects on the growth process and health state of children. The study group was made of 316 children from Turnu Magurele exposed to high pollution levels caused by SC Turnu SA – a pyrites producer – and another 382 children (sample group) from Alexandria. The level of pollution was determined by the Agency for the Protection of the Environment, Alexandria. While there were no signifi cant changes in the values of the indicators for physical development, there was a high frequency of asthma cases in Turnu Magurele. The increase in the pollution level above the CMA was accompanied by an increased prevalence of respiratory diseases in children from the study group. To conclude with, the study revealed a parallelism between air pollution levels and respiratory diseases in children especially asthma. 7

Toxic effects of heavy metal exposure on children Aurelia Cordeanu1, Rodica Nicolescu1, Klaus Fabritius1, Cristian Petcu2, Eugenia Naghi3, Ion Popa1, 3 3 4 5 6 Agripina Rascu , Cristina Angelescu , Rolf Krebs , Gerhard Winneke , Margret Schlumpf 1 National Institute of Public Health, Bucharest, Romania 2 CMI Pantelimon Village, ILFOV, Romania 3 Department of Occupational Medicine, University Hospital Colentina, Bucharest, Romania 4 University of Applied Sciences, CH- 8820 Wädenswil, Switzerland 5 Heinrich Heine University, D-40225 Düsseldorf, Germany 6 GREEN Tox, University of Zürich, CH-8057 Zürich, Switzerland

All environmental changes give rise to major public health issues. Given the large quantities of toxic compounds ensued from industrial use, toxic minerals are widely spread and, unless detected in time, they become a signifi cant threat to people’s health. Toxic metals interfere with several enzymatic reactions and could disturb cellular activity. As a result, we are all exposed to high risks, but children are the most endangered category as their organism is more vulnerable to external aggression. • Evaluation of toxic metals in the environment (through soil markers, Part 1 of the study) • Assessing exposure of children to metals in the environment (concentrations in whole blood) • Evaluation of possible effects of toxic metals on children’s behaviour (Attention Test) The study included 52 randomly selected children ages 6 to 10 years from Pantelimon village (formerly contaminated area) and a group for comparison of 54 children aging from 6 to 10 from Bucharest, living in areas remote from any industrial source of pollution and high-traffi c roads. The selection criteria were age and patterns of pollution. The following data were collected: • parents written consent for the participation of the child • children’s identity (name, age, sex), living habits (smoking parents) and exposure to environmental pollutants • a complete physical examination, as well as a thorough anamnesis looking for all signs and symptoms suggestive of heavy metal intoxication such as headache, fatigue, hyperactivity, irritability, insomnia, behavioural disorders. Laboratory investigations were corroborated to the clinical data; blood samples from both groups obtained through venipuncture with vacuum tubes were sent for analysis to the Micro Trace Minerals GMBH Laboratory in Germany. The assessment of the clinical examination data identifi ed a series of inconstant and irregular clinical signs in both study and control groups. The most frequent symptoms were: recurrent abdominal pain, headache, fatigue, anorexia, irritability, hyperactivity, dizziness, learning disabilities, dyslexia and sleeping disorders. These symptoms are, however, more frequently encountered in the study group (55,76%) than in the comparison group (48, 41%). Blood samples revealed higher concentrations for aluminium, mercury, manganese and lead as compared to the CDC reference values (50μg/l for lead, 1 μg/l for mercury, 14 μg/l for manganese and 10 μg/l for aluminium). Children from the study group (living in a formerly contaminated area) had elevated blood lead levels (above 100 mcg/l according to the CDC reference range for children). Children from both study and comparison groups have augmented blood levels for aluminium, mercury and chromium. This poster will make recommendations with regards to screening programmes, nutrition and surveillance. 8

Health and environment in Romania – progress assessment from a European perspective Alexandra Cucu1, Claudia Dima2, Adriana Galan2 1 University of Medicine and Pharmacy “Carol Davila”, Bucharest, Romania 2 National Institute of Public Health, National Centre for Evaluation and Promotion of Health Status, Bucharest, Romania

A healthy, clean and harmonious environment, where physical, psychological, social and aesthetic factors are considered, is essential both for a good health of the population as well as for its well-being. These factors are infl uenced by a range of actions and choices of general public and authorities, which can ensure important health benefi ts. Assessment of the progress, both at national and at European level of the policies and their implementation, by providing an update of trends and developments is essential for future planning, policies monitoring and interventions. The objective of the study is to carry out a situation analysis of health and environment for Romania from the perspective of progress assessment in the WHO European Region. The study is a descriptive analysis using the data reported by the national authorities for the report “Health and Environment in Europe: Progress Assessment” of the World Health Organization and those delivered to European Environment Agency for the report “Quality of bathing water — 2009 bathing”. The assessment is organized in four sections which correspond to the WHO region priority goals: water quality, injuries, air quality and noise and chemical safety and approached the following areas: bathing water quality, road traffi c injuries, second hand-smoke and noise. There were addressed to types of assessments, one indicator-based that seek to provide information about health determinants, and the other one oriented to a policy profi le description taking into account six dimensions: (i) policy development; (ii) implementation and enforcement; (iii) policy accountability for health; (iv) health sector involvement; (v) equity considerations; (vi) provision of information to the public. The statistical data analysis revealed the following: • For Romania, the percentage of bathing waters complying with guide values had increased from 2,9% in 2007 to 8,2% in 2009, the percentage of bathing waters that comply with the mandatory values is 100 % and there were not anymore not compliant bathing water with mandatory values or banned. • Romania is situated geographically, in the eastern parts of the Region where the highest standardized death rates (three-year average) for road traffi c injuries, 0-24 years age, occur. • Romania is in the fi rst third of countries ranking, concerning the proportion of 13−15-year-old children exposed to SHS inside and outside the home, 2002–2007, the proportion being higher for those exposed inside the homes than outside. Regarding the percentage of people exposed to a night noise level of L > 55 dB from roads in European • night agglomerations with populations of ≥250 000, those exposed are fewer only than those in Slovakia, Hungary and Spain. The policy profi les are presented as images, for Romania comparing with the average of the WHO European Region, as radar plots using a scale of 0-100 in clockwise order of the six dimensions: (i) policy development; (ii) implementation and enforcement; (iii) policy accountability for health; (iv) health sector involvement; (v) equity considerations; (vi) provision of information to the public. A higher score refl ects a better performance for a given policy in Romania vs. average of the WHO European Region, mainly for: bathing water quality concerning health sector involvement, for road traffi c injuries concerning accountability and implementation and enforcement, for second hand smoke concerning all six dimensions and for noise all dimensions except provision information to public. 9

Social inequalities and environmental health: Romanian overview Alexandra Cucu1, Adriana Galan2, D Janţa1 1 University of Medicine and Pharmacy “Carol Davila”, Bucharest, Romania 2 National Institute of Public Health, National Centre for Health Promotion and Evaluation, Bucharest, Romania

Social inequalities and their consequences on health are among governmental and public health emerging priorities. It is well known that individual vulnerability, level of exposure, risk related knowledge’s as well as intervention on reducing those risks are aggregated in vulnerable groups enhancing disparities and affecting health related status. Identifying and quantifying vulnerable groups and the health impact of environmental and social seldom associated risks represents one of the premises of programmes and intervention at national level. In this context the aim of the study is to describe the characteristics of social and environmental determinants and their effect on Romanian population health. Descriptive transversal study based on national (CNOACSIISDM) data and international information for the 2000-2010 time period. The environmental indicators reveals an unfavourable situation for safe drinking water accessibility, sanitary endowments, habitable surface area, noise, and overcrowding, solid fuel used, green areas accessibility or professional exposure, uneven distributed by areas (inequalities) but also among social classes (inequities). The unfavourable environmental exposure is often associated with low education, income and social class. Systematic information on synergic effects of environmental and social risks associated are missing, even some national surveys tackled those issues, the problem off accessibility, coherence and comparability of data being limited, consequently a future integrated approach should be elaborated. Statitistical available information, especialy mortality and DALYs attributable to environmental risk factors situates Romania in one of the less favourable place in Europe. Inequalities that on the social existing and ongoing economic background should be surveyed and actions started for preventing and mitigating inequitable health effects. 10

Infant mortality in Romania, 1999–2008 Alexandra Cucu1, Claudia Dima2, Adriana Galan2 1 University of Medicine and Pharmacy “Carol Davila”, Bucharest, Romania 2 National Institute of Public Health, Bucharest, Romania

Infant mortality represents the demographic phenomena of the deaths 0-1 year age, within the live births population, a specifi c indicator to measure and describe the health status of children and one of the most sensitive indices of the living standard and health status of a population, the infants 0-1 year age being one of the most vulnerable groups of populations with a specifi c clinical pathology. The authorities from Romania, signatory country of the United Nations Millennium Declaration, within was established by target 6 to have reduced the under-fi ve child mortality by two thirds during 1990-2015, make sustainable efforts to reduce infant mortality. Their activities are organised within the framework of the national programme of women and child health, budgeted by the Ministry of Health, targeting among others: pre and postnatal diagnosis of genetic disorders, promotion of breast feeding, the increase of the access to health services for the prevention of the neonatal deaths, and the prophylaxis of some disorders such as: feriprive anaemia, dystrophy, malnutrition and rachitism. The study is a descriptive statistical analysis using the demographical data (data base of the Romanian Institute of Statistics and the data base of the World Health Organisation) and the current health statistics (for Romania – the fi ches of the deaths at 0-1 year age analysed by The National Center for Organization and Assurance of Informational and Informatics Health System Bucharest). The statistical data analysis revealed the following: • Infant mortality had in 2007 the rate 12 ‰ and in 2008 the rate 11‰, higher that the European average, neonatal mortality (6,9% in 2007 and 6,2% in 2008) being higher than postneonatal one (5,1% in 2007 and 4,8% in 2008). • On the fi rst place of infant deaths, by the main causes of deaths, in 2008 were some disorders originated in neonatal period (35,7%), followed by respiratory diseases (30%) and congenital disorders (21,6%), however all with lower level percentages comparing with 2007. The indices of infant mortality due to infectious and parasitic diseases, nervous system disorders and other causes maintain the same rates in 2008 as in 2007, while the infant mortality due to accidents was higher (0,5% in 2008 comparing with 0,4% in 2007). • On the Romanian territory there is an important decreasing trend of the inequalities among districts, for the distributions of the infant mortality rates fi gures. The infant mortality indicator registers a decreasing trend (from 18,6% in 1999 to 11% in 2008), but the number of deaths of children 0-1 year age continues to maintain at a high level, being among fi rst countries in the European Union and the value being almost 1,4 higher as the WHO European Region (2008) average. The decreasing trend of the phenomena confi rms the effect of the implemented actions. However its high level comparing with those of the European countries requires the necessity of an integrated intervention on the complex determinants of the phenomena and of the further researches about the infant mortality inequalities at the local level (district, communities). 11

National synthesis "monitoring of health care waste management system" 2009 Oana Curea, Ana-Maria Bratu National Institute of Public Health, National Centre for Environmental Monitoring of Risks in the Community, Bucharest, Romania

National Institute of Public Health Bucharest annually elaborates national synthesis concerning monitoring on healthcare waste management system. 1) Periodical evaluation of healthcare waste management system in hospitals 2) Qualitative and quantitative evaluation of healthcare waste 3) Identifying potential risks and hazards on human health and environment, generated by this particular waste 4) Healthcare waste minimization 5) Setting up the actions and policies which will conduct to the improvement of the healthcare waste management system. Data collection and reporting for the national synthesis and the data base on healthcare waste management were based on the methodology approved by the Ministry of Health’s Order no. 219/2002. The methodologies are quarterly applied in sanitary units with beds. The data are reported to the National Institute of Public Health Bucharest, by local Public Health Directorates. For the year 2009 were reported data by 41 local public health directorates and Bucharest. The reported data represent types and quantities of healthcare waste and management system developed at the level of sanitary units with beds. For 2009 were reported data 375 sanitary units with beds at the national level. Based on the analysed data have resulted certain improvements in healthcare waste management system stages. It was also observed defi ciencies which persist from previous years. The defi ciences are mainly represented by the lack of specifi c packages for sharps waste collection. This could be due to incorrect way of managing hazardous sharp wastes which may present risks of contamination to medical personnel and others.The internal transport of waste are mainly manually performed. There are also use special transportation means (trolleys, elevator, mobile containers). Here was not observed a dedicated circuit for pacients and visitors. As related to temporarily waste storage, there were build up special places into the majority of the assessed sanitary units. Final disposal practically means the last stage of the healthcare waste management, generated by the sanitary units. At the end of 2008, in Romania were closed all rudimentary burning facilities for hazardous healthcare waste generated by sanitary units.The sanitary units hospitals have outsourced sterilization/incineration services for hazardous healthcare waste. Another alternative is to treat medical waste in specifi c sterilization equipment, at the level of sanitary unit, waste is then landfi lled at the nonhazardous waste landfi ll from that region. In 2009, Ministry of Health has conducted a PHARE project in the fi eld of medical waste. Through the investment component of the project were purchased 28 sterilization equipment for hazardous medical waste, for hospitals. The technical assisstance component of the project was focused on activities concerning the improvement of healthcare waste management system, some of them were represented by training sessions for medical units staff, local public health directorates specialists and other. One of the main objective of this project was represented by the revising of Minister of Health Order no. 219/2002 on healthcare waste management of, modifi ed and completed by MHO no. 997/2004 si 1029/2004. The document represents specifi c technical reglementation for healthcare wastes management fi eld. 12

Food-borne infections appeared in Transylvania county and their safety considerations Liana Monica Deac National Institute of Public Health, Regional Centre of Public Health Cluj, Romania

Food-borne infections are health risks for people and that is the reason these had to be studied in all details when they appear somewhere, as the case was done by us with the outbreaks from Transylvania county in 2009. It is necessary to follow the CDC food safety guidelines to keep food contamination away and with to decrease the potential health risks of food-borne epidemic cases. Taken together, this study should lead to a better control for food in restaurants and with to contribute into reducing the number of such illnesses everywhere next. Because of the potential health risks of food-borne infections, it was fi nalized a descriptive epidemiological study for food poisonings occurred on last year in our Transylvania territory. The data interpretations are based on the results reported from the Regional Public Health Directions. The microbial strains were isolated on EMB medium and were identifi ed by using the biochemical screening tests for Gram-positive bacteria and Gram-negative bacilli. Our data represent an outlook of results reported from 99 cases of food poisoning occurred in 3 outbreaks in cities after food consumption from restaurants at family parties. Food usually became contaminated from poor sanitation or less preparation, as even after improperly packaged food stored at the wrong temperature. We show out remarks on the potential health risks associated with exposure to pathogenic microorganisms contamination, isolated from these food consumption. Salmonella enteritidis., Shigella sp., Staphylococcus aureus and Escherichia coli sp., were the bacterial strains at cases and in the food products. E. coli represented 57% from all of these. Gender or age were not signifi cant for developing food poisonings. The food-borne illnesses appeared as gastroenteritis, 69%, or colitis, 30%, with different symptoms present as: nausea, vomiting, diarrhoea, and abdominal cramping, which were up to the type of contaminant and the amount of eaten. In some cases the symptoms developed rapidly – within 30 minutes in 80% of cases, or slowly – worsening over days in 19 % of cases. The microbiological risk determined by the isolated bacteria is an important step in building an integrated food safety system for the prevention of food-borne infections in our Transylvania region. Up to the CDC indications, assessment of pathogen impact and its prevalence in food must represent a baseline for food-borne diseases surveillance everywhere today.

Keywords: food-borne, infection outbreaks, assessment 13

Monitoring spa mineral waters in Mure , Harghita and Covasna districts Ioan Domahidi1, Alexandra Cucu2, Attila Csiszér1, Coloman Buksa1, Klára Jeszenszky1, Orsolya Vitályos1, Ágnes Pálffy1, Anabela Iurian1, Tünde Marcoş1, Zorina Butiurcă1, Monica Oroian1 1 Regional Centre of Public Health Mureş, Romania 2 National Institute of Public Health, Romania

The spas are special functional categories in Romanian administrative structure. Thirty-fi ve cities and 103 rural settlements are considered to function as spas. The use of natural factors in therapy is authorized by the Ministry of Health, based on documents drawn by the National Institute for Rehabilitation, Physical Medicine and Balneo-climatology. Monitoring the contents of the mineral waters used in balneotherapy in Mures, Harghita and Covasna Districts; provide arguments for the necessity of sanitary surveillance of bathing balneary waters. The study was carried out in 2008-2009. During this interval 21 samples of mineral water were collected from 17 balneary units: 8 samples from Mures District, 7 from Harghita District, and 6 samples from Covasna District. The samples were collected from various sources: naturally salted ponds, outdoor and indoor pools, indoor taps, drinking mineral waters, and springs. The samples were spontaneously collected, regardless of the moments of sanitation or the stage of the use. The sampling conditions were in accordance with SR EN 25667-2, ISO 5667-2 /2002, SR ISO 5667-5 1998 SR EN ISO 1948/2007. The physical, chemical and microbiological parameters were analysed in the RCPH Mures laboratories, according to the current ISO standards. The radioactivity for the samples collected in Mures District was measured by the Public Health Directorate according to STAS 11598-83. The pH of the balneary waters from outdoor pools was slightly alkaline; the conductivity and hardness were in accordance with the degree of mineralization. The time variation of the values for nitrates, nitrites, and ammonium showed higher values in samples collected after the season than in samples collected during the season. The values for Pb and Cd exceeded the m.a.v. in some of the samples, pesticide concentrations were below the m.a.v; gross beta activity was below the m.a.v. The ratio of the low and medium temperature developing fl ora is lower than 3:1, and in some cases, is reversed; in some of the balneary waters E. coli and Streptococci were found. P. aeruginosa was found in all the samples, except in those collected from a spring; the p. aeruginosa burden of the outdoor pool waters was higher at the end of the season. These results highlight the necessity for monitoring of the balneary waters throughout the season, to allow for the necessary corrections. The water quality control is carried on by the laboratory of the National Institute for Rehabilitation, Physical Medicine and Balneo-climatology, and not by the State Sanitary Inspection. Drawing guidelines for sanitary quality surveillance and control for bathing balneary waters; establish particular protocols for changing water in therapy pools; the quality control should be performed by the local offi ce of the State Sanitary Inspection.

Keywords: balneary waters, pesticides, heavy metals 14

Heavy metal contamination of children’s playgrounds in Mure district Ioan Domahidi1, Alexandra Cucu2, Attila Csiszér1, Eszter Kelemen1, Edit Fekete1, Anabela Iurian1, Tünde Marcoş1 1 Regional Centre of Public Health Mureş, Romania 2 National Institute of Public Health, Bucharest, Romania

Children playing in the playgrounds may intake detrimental compounds from ground or sand through soiled hands. Therefore, the soil contents in the playgrounds should be carefully monitored for compliance with the maximum levels of chemicals allowed for sensitive soils by the OAP 756/1997. This study aims to evaluate children exposure to heavy metals while playing in the playgrounds, and to assess the level of contamination with heavy metals of the playgrounds in some towns in Mures District. Five towns were selected from the 11 towns of Mures district: Tg-Mures, Reghin, Sovata, Târnaveni, and Ludus. Local authorities were informed on our project, and were asked to provide information on the playgrounds in their town: number, names, locations, and date of construction. Local authorities provided tables with information on 176 playgrounds; from these, we randomly selected 20 playgrounds (11,36% of the total number): 3 playgrounds each from Reghin, Sovata, Târnaveni, Ludus, and 8 playgrounds from the city of Tg-Mures. From each of the selected playgrounds we collected samples of sand and samples of soil from the green area. The soil samples we fi nally analysed, with a minimum weight of 500 grams, consisted each of 20 partial samples collected from different points covering the whole collection area. The sampling was performed in accordance to the STAS 7184/1-84, ISO 10381-6, and SR ISO 11464. We determined Be, Cr, Mn, Co, Ni, Cu, Zn, As, Se, Cd, Ba, Pb, Al and Fe. The analyses were performed with a mass spectrometer. Sand samples: in some samples, the concentrations of Pb, Ba, and Se exceeded the intervention level; in others, Se exceeded the alarm level; in the remaining samples, the concentrations were within the normal limits for Se, As, Zn, Cu, Ni and Cr. Soil samples: in some of the samples, the alarm level was exceeded by the concentration of Pb; the levels of Ni, Pb, Cu, Zn, Cr, Mn, Se, Co, As and Be were within the allowed limits. Most of the samples showing high levels of metals came from towns with developed industries. Within a town, the samples with increased levels came from playgrounds located in the vicinity of a pollution source, and where the soil was made of building debris. When a new playground is built, the pollution sources in the area, and the chemical, microbiological, and parasitological composition of the soil should be given careful consideration. When the soil or the sand is changed, their origin should be taken into account, and the chemical, microbiological, and parasitological parameters should comply to the limits allowed by OAP 756/1997. No car parking should be allowed in the vicinity of children playgrounds. 15

Perception of risk generated by urban noise Mihaela Fulga1, Doina Lupulescu1,2, Monica Iancu1 1 National Institute of Public Health, Bucharest, Romania 2 University of Medicine and Pharmacy “Carol Davila”, Bucharest, Romania

The noise is often mentioned as the disturbing factor of the inhabited area and working places. The health effects of noise are a public health problem and a very important issue for the European population. Heavy traffi c in populated centers of large cities has caused that in some street networks the noise was approaching the intensity of the industrial noise. The increasing noise pollution of urban areas and of homes is very harmful for the exposed population. The study aims: • To evaluate of the comfort and the perception of the risk generated by the urban noise • To inform the representatives of local commission in charge with evaluation and management of environmental noise, and the public administration authorities, about the necessity of drawing of an acting plan containing the priority measures for the reduction of noise levels. The study carried out in nine cities, Bucharest, Brasov, Cluj, Craiova, Constanta, Galati, Iasi, Ploiesti and Timisoara having more than 250000 inhabitants, both in heavy traffi c areas and in residential areas (with low traffi c). In every city there have been identifi ed the main sources of noise pollution according to noise maps drawn by local administrative authorities. Using questionnaires there were estimated the discomfort and health risk caused by ambient noise. In the area with heavy traffi c evaluation of risk perception confi rms the existence of a percentage of 56% of people who accuse the discomfort caused by noise in the house during the day; during the night this percentage is 40%. In these areas the discomfort is severe for the persons who have dwellings’ windows facing the street. These results are confi rmed by the noise maps, developed by local governments on the basis of noise measurements. The age groups most affected are 51-65 years and over 65 years, as are a greater period of time in the house. The main sources of discomfort as are identifi ed were: heavy traffi c, the commercial activities, constructions and demolitions. In the residential areas, people complain about the noise created by cars, car alarms, illegal car and motor cycle races during the night and the noise generated by restaurants, bars and disco clubs. • In the majority of cities reorganization traffi c must focus on limitation of traffi c in the residential areas, which will be accompanied by action taken for the noise level reduction. • Local administrative authorities must fi nd technical and economic solutions to rehabilitation of buildings, focusing on the strengthening and thermal rehabilitation of buildings, action which will reduce the noise level inside the building. 16

Students’ musculoskeletal disorders Constanta Huidumac-Petrescu1, Aurelia Cordeanu2, Rodica Nicolescu2, Elena Nastase1 1 National Institute of Public Health, Regional Centre of Public Health Bucharest, Romania 2 National Institute of Public Health, Bucharest, Romania

The aim of the study is to assess the morbidity due to musculoskeletal disorders in students ageing 10-11 years. We had in view the correlation of morbidity due to musculoskeletal disorders with the physical growth, unhealthy postures and inappropriate furniture. This is a pilot study which has been carried out on a sample of 200 students from three schools in Bucharest. The assessment has been carried out through: clinical and anthropometrical examination of students and determination of musculoskeletal disorders percentage; inventory of the existing pieces of furniture including measurement of chairs, desks and comparison with standards; evaluation tests on the assimilated information for students, parents and school teachers. The data have been processed and analysed through EPI-INFO and SPSS programs. A presence of 45% of scoliosis attitude in the assessed sample represents an alert signal. Students (55%) complain about several ailments (back, shoulder, nape, arms) after sitting for a long time and in an unhealthy position at the desk. Students’ musculoskeletal disorders are similar to those of adults. The prevalence rates are comparable and the underlying risk factors are nearly alike. This insight could also help us develop better strategies to prevent risk factors from having an impact already at a young age. We need programmes educating students in ergonomic principles. Hopefully, such a programme would result in students refl exively adjusting their breaks, not necessarily with expensive equipment: let’s prepare them so as to be sure that they will use a healthy posture and sound working habits.

Keywords: musculoskeletal disorders, unhealthy postures, inappropriate furniture 17

Waste management and protection of population health Doina Lupulescu¹,², Mihaela Fulga¹, Monica Iancu¹ 1 National Institute of Public Health, Bucharest, Romania 2 University of Medicine and Pharmacy “Carol Davila”, Bucharest, Romania

In a stable and sustainable urban ecosystem, the natural or man-created environment must be preserved to ensure good life conditions for all groups or systems (plant, animal) that live in that place. An urban ecosystem has the following universal principles: • Provision of adequate reservoirs of water • Maintenance of the vegetation • Preservation of quality of the soil • Protection of natural areas to maintain wildlife • Maintenance of regional potentials for food production • Creating an urban environment to answer the needs of people, respecting the standards of town planning. Each year within the EU Member States there are produced about 1.3 billion tons of waste, out of which 33% are hazardous waste that damage the quality of the environment, mainly the quality of soil. EU Directive 2006/12EC focuses on effective management of waste resulting from human activities, having in view three major actions: • Prevention of waste production • Recycling and processing • Rigorous monitoring of waste production and reduction of incinerators emissions of nitric oxide, sulphur dioxide and hydrochloride. The objective of this study was the assessment of waste management systems in towns from districts from the area monitored by the Institute of Public Health Bucharest. In 2008 there were chosen six localities, Constanta, Drobeta Turnu Severin, Giurgiu, Santu Gheorghe and Slobozia, and these were included within a pilot study to test the methodology. • The average daily waste was 1.26 kg/person; this fi gure was the highest as compared to other European countries • Out of the total quantity of waste, the largest proportion is held by household waste (77%), followed by commercial waste (17%) • Waste disposal landfi lls complying with EU regulations in the fi eld of environmental protection were found only in 33% of localities • Approximately 25% of homes had no contract for waste collection services • The epidemic hepatitis morbidity in these investigated localities was between 3.84 cases/100000 inhabitants and 83.98 cases/100000 inhabitants. Morbidity by epidemic hepatitis presents the highest values in localities where there is the lowest percentage of homes connected to sewerage system and the smallest value of the quantity of waste reported per person. These results confi rm existing defi ciencies of urban waste management. 18

Health survey among populations living in the vicinity of nuclear facilities Cristina May1, Alexandra Cucu2 1 Regional Centre of Public Health Bucharest, Radiation Hygiene Laboratory, Romania 2 University of Medicine and Pharmacy “Carol Davila”, Bucharest, Romania

The radiation hygiene network has established a methodology for health monitoring of population groups living in the vicinity of nuclear facilities. It provides a cross-sectional view of morbidity and mortality indicators at a given moment and their development over long periods of time. At the same time, environmental radioactivity is monitored through analyses of the fallout, surface water, drinking water, and food, collected from the same study areas. This ensures that any values exceeding the normal limits are immediately detected. The survey includes all the inhabitants residing in areas surrounding nuclear facilities in our country: the Bechet area, Cernavoda area, Feldioara area, and Mioveni area. Certain variables are followed each year: population structure, overall mortality, specifi c mortality from solid tumors and leukemia/lymphoma, and their incidence. Data analysis is based on rates and excess mortality/incidence. Cernavoda area Shows the lowest rates for overall mortality and mortality from solid tumors. Tumor incidence is less than half of the value for the entire country, but incident cancer cases among small children are to be noted. Three incident pleural mesothelioma cases were recorded. Feldioara area Mortality from leukemia/lymphoma has the highest values of all the studied areas. Tumor incidence is about one third of that for the entire country, but the mean age at diagnosis for women is lower than in the other studied areas. Bechet area Higher tumor incidence than the value for the entire country; 4 new cases of pleural mesothelioma during 2009. Incidence of leukemia/lymphoma is the highest among the studied areas, including 4 multiple myeloma cases. Mioveni area All indicators have values lower than the values for the entire country. It is worth mentioning 3 new case of thyroid cancer in young women. With the highest incidence for tumors and leukemia the Bechet area would justify further studies on cancer incidence. Although tumor incidence was found to be less than the value for the entire country, incident cases of solid cancer among children, as well as the highest number of mesothelioma cases of all the studied areas, recommend the Cernavoda area for additional study on the frequency of the malignancies and the risk factors in this region. 19

Violence in students from Romania, multifactorial study design Ileana Maria Mirestean, Sorina Irimie, Mariana Vlad National Institute of Public Health, Regional Centre of Public Health Cluj, Romania

The World Charter of Nature acknowledge the truth that the humanity and civilization are parts of nature, and the laws of nature recognize the right of nowadays people and of future generations for a healthy environment. In this frame, the state has the duty of adopting all the required measures for the protection of nature. The deterioration of nature goes along with human being deterioration. The magnitude of nowadays violence, the drug consumption, the social disease, express the degradation of relationships between people. By the recognition of relational, social-cultural and environmental causes of violence was created a multifactorial study design of violence, with enhanced chances for prediction and prevention. This study aimed to evaluate the violence among students from Romania using the multifactorial design in the view of initiation of effi cient preventive measures. There were differentiated four regions for study: Transylvania, Banat, Muntenia, Moldavia. 4920 students from high school level were examined, as it follows: Transylvania 1320, Banat 480, Muntenia 2160, Moldavia 960. The violence was assessed with the YRBSS questionnaire, elaborated by CDC, SUA for the assessment of health risk behaviors in youth. The study revealed that the violence of students was directly related the exposure to violence. 83% of the students exposed to violence in family turn to be violent as well. It was noted a gradient of violence in students according with the social-cultural criteria. In conclusion, in the region of Moldavia, the most disadvantaged social-economical and cultural region, it was noted the highest frequency of violence among students. The most frequent cases of violence were registered in peripheral neighborhoods with high risk for delinquency.

Keywords: violence, students, assessment 20

The evaluation of biochemical markers and risk factors in the depression of child and adolescent Ileana Maria Mirestean, Mariana Vlad, Nicoleta Muntean, Sorina Irimie, Cristina Viman National Institute of Public Health, Regional Centre of Public Health Cluj, Romania

Depression at young ages has been controversial for a long time. Only 18% of the depressed children and adolescents are currently diagnosed and the therapeutic approach depends on the understanding of the neurobiological support of the disease and the identifi cation of its specifi c risk factors. Evaluating some biochemical markers and identifying the risk factors in child and adolescent depression. 70 subjects aged 9 to 18 diagnosed with depression were pretherapeutically investigated. Serotonin and vanilmandelic acid (VMA) were evaluated by the chromatographic method with electro-chemical detection, using the Agilent 1100 system, ESA Coulochem III detector, and the Chromsystem specifi c kit. In order to identify the risk factors, dedicated questionnaires were elaborated and applied. The serotonin mean value in the patients whole sample was 241.8 μg/l, 11% of the subjects having values above the upper normal limit. The mean value of VMA was 4.4 mg/24 hours, 9% of the patients having levels above the normal limit. An increased prevalence of some risk factors was identifi ed in subjects with normal levels of serotonin, as compared to the frequencies recorded in patients with high levels of serotonin: psychiatric family history (60% vs. 45%), family history of severe chronic disease (90% vs. 40%), personal antecedents of thyroid disorders (40% vs. 14%), personal antecedents of anxiety syndromes (80% vs. 57%). The results outline the importance of determining the serotonin and VMA and the risk factors, in order to identify the subjects with an increased risk of depression and manage the child and adolescent depression by a complex therapeutic approach. Funding supported by Romanian government PC grant, contract no. 156/2006.

Keywords: depression, children, risk factors 21

Registration and quality assurance in the microbiology laboratory involved in drinking water monitoring programme, in eight counties of Transylvania Daniela Moga, Edith Vartic, Mariana Vlad National Institute of Public Health, Regional Centre of Public Health Cluj, Romania

After Romania admission as EU Member State in 2007, there is an obligation for our country to report every three years, on the quality of drinking water under the Drinking Water Directive 98/83/EC. Based on Law no. 458/2002 on the quality of drinking water, as amended and added by Law 311/2004, the Ministry of Health shall be responsible for the surveillance of drinking water (DW) quality and for the country report at the European level. The Romanian Ministry of Health requires that only registered laboratories should be accepted as raw data providers in order to achieve the monitoring programme for drinking water quality. A procedure for the registration of laboratories for DW Quality Monitoring as part of offi cial control was approved in 2005. The purpose of this procedure is that a registration system will make it possible to include the EU requirements on the quality of the results. This procedure is referring to the two types of laboratories which have implemented a quality assurance system according to ISO 17025: laboratories accredited by a recognised accreditation body and unaccredited laboratories. The registration should be based on an evaluation of the quality management in the laboratory. Quality assurance, a planned system of control measures, enables management and external benefi ciaries to ensure that the analytical data produced in the laboratory are valid. For the establishment of quality assurance in the microbiology laboratory, all activities that affect the analytical data must be documented and controlled at all levels. The account of registered laboratories taking part in the DW monitoring for microbiological quality (Escherichia coli, Enterococcus, coliform bacteria and heterotrophic bacteria), since 2006, in eight counties of Transylvania, are discussed. As the reported data from the county public health authorities, in the monitoring of microbiological DW quality are involved 28 laboratories. These laboratories, belonging to the county public health authorities or to the water producers, are providing data for audit, respectively control monitoring. Starting with 2006, were registered 4 laboratories (14,3%) which provided microbiological analytical data according with Romanian law; in the present there are registered at the Ministry of Health 12 laboratories (42,9%). Differences between laboratories regarding the number of microbiological parameters analysed are recorded.

Keywords: drinking water, microbiology laboratory, registration system 22

Evolution of air pollution with suspended particulate matter and health indicators in Romanian regions Andra Neamtu, Moldoveanu Anca, Catalin Staicu National Institute of Public Health, Bucharest, Romania

The increase of suspended particulate matter air pollution levels in atmospheric air can appear in cold seasons and in warm seasons. In warm days from combination of high level radiation and temperature, increase photochemical activity.

The sun UV radiation increase atmospheric ozone level results from NOX and volatile organic compounds (from traffi c and petrochemical industry) and aerosols secondary level. In conditions with high relative humidity, aerosols secondary levels increase, too. The combination of these factors causes decrease of visibility, that being a characteristic of summer warm days. In cold seasons the levels of suspended particulate matter are in general high, like SO2, especially when they proceeded from heating sources. The total suspended particulate composition varies in different times of episodes of increase pollution. Thus, it is directly infl uenced by pollution sources, time and even frequent which produce the pollution, humidity and weather factors. Air pollution with suspended particulate matter is considerate the most important in case of urban throng, but now is already known that in many areas of development country the differences between urban – rural are very small or even absent, indicating us that the exposure at this category of pollutant is everywhere. The analysis of air pollution evolution with suspended particulate and principal health indicators which can be infl uence by this, can shows us the trends at some time with social and economical transformation of society. The air pollution levels with total suspended particulate are still increase, in many regions The principal health indicators which are infl uenced by these are: mortality by respiratory diseases and respiratory diseases morbidity. Particulate matter size and them concentration can infl uence the effects on the human health and can fl uctuate by daily variations. These includes acute effects (increase of daily mortality, the hospital admissibility rate by respiratory diseases, the antibiotic user). The long term effects refer to mortality and morbidity by respiratory diseases. 23

The assessment of attention performance in children exposed to neurotoxic elements Rodica Nicolescu1, Aurelia Cordeanu1, Cristian Petcu2, Klaus Fabritius1, Eugenia Naghi3, Gerhard Winneke4, Rolf Krebs5, Margret Schlumpf6, Ursula Krämer4 1 National Institute of Public Health, Bucharest, Romania 2 CMI Pantelimon Village, ILFOV, Romania 3 Department of Occupational Medicine, University Hospital Colentina, Bucharest, Romania 4 Heinrich Heine University, D-40225 Düsseldorf, Germany 5 University of Applied Sciences, CH- 8820 Wädenswil, Switzerland 6 GREEN Tox, University of Zürich, CH-8057 Zürich, Switzerland

We investigated an industrial site near Bucharest, which is located 4 km south-east from Bucharest, about 2 km east from the nearest village (Pantelimon), and is thought to be the major source for heavy metal deposition in the surroundings. In a combined study the pollution of environment was related to public health in vicinity of this area. Metals have been studied intensively and many have been identifi ed as neurotoxicants. Consequently, we analysed trace metals in blood of male and female children, ages 6 to 10, in the area of Pantelimon and in the city of Bucharest To evaluate effects of trace metal body burden on health and mental health of children, we engaged in two activities: • Analysis of children`s body burden by determination of trace element profi les in children by IPC-MS. To perform the trace element analysis 52 children from Pantelimon and 54 children from traffi c deprived areas of the city of Bucharest were recruited. The election criteria for both groups of children were age (between 6 and 10), sex, living area and approval by parents or caretakers for study participation of the child. In order to asses the health status of the children clinical investigation accompanied blood donation. The blood samples were sent to Germany for analysis. • Analysis of neurotoxicity by introducing a test of Attention Performance for Children (the KiTAP test battery) to 95 children (Pantelimon, 47, and Bucharest, 48). Patterns of trace metal exposure has been compared to performance in the Test of Attention Performance for Children (KiTAP) providing differentiated measurement of diverse functions of attention. Before testing, the ADHS questionnaire for associations with the exposure data was completed by teachers and parents. In an interview the confounders/ covariates age, gender, health etc were determined. Regression analysis, as the statistical tool, was used to test the degree of association between the target and exposure variables after adjustment for confounding. Confounders/ covariates were selected from a large set of variables; important confounders/covariates are: study group (Bucharest/ Pantelimon), age, sex, computer experience, handedness, family size, eye problems; there are strong computer effects, age effects and area effects. Children from Bucharest, older children, girls (mostly) and those with computer games experience (often) were better. No consistent association was found between mercury levels and attention performance, and no association at all between aluminium levels and tests results. The regression coeffi cient (b) indicates that errors increase with increasing blood-lead values. The newest results with parental education added to the model show that the lead-effect for errors is statistically even more pronounced, and it makes sense that the strongest lead-effect is for distractibility (the lead symptom of ADHS). 24

RF electric fi elds measurements in an urban area and Turkish regulations Semih Özden1, Arzu Fırlarer1, Nesrin Seyhan1,2 1 Gazi Non-Ionizing Radiation Protection Centre (GNRK), Gazi University Faculty of Medicine 06500 Besevler, Ankara, Turkey 2 Gazi University, Faculty of Medicine Biophysics Department, 06500 Besevler, Ankara, Turkey

During the last decade, the installation and operation of several wireless networks, such as GSM, UMTS, TETRA and Wi-Fi systems, have led to increasing public concern about the exposure to electromagnetic (EM) radiation emitted by such sources. The growth in the wireless networks is due to the increasing numbers of people using on mobile phone resulting in an increase in the numbers of base station antennas. Public concern results from the increase in the numbers of masts as well as the operation of the handset in close proximity to the human body. Although the radiofrequency (RF) levels produced by base stations at consumer locations are lower than those from use of the phone headset, the more continuous exposure from base stations has produced a greater public concern. There has been considerable scientifi c effort to understand the potential link between exposures to RF fi elds and the occurrence of cancer, multiple sclerosis (MS), and other diseases. The possible biological effects of RF/MW radiation have been a subject of ongoing investigations, since the more vulnerable groups such as pregnant, children and elder people are also exposed to RF at the same degree. Therefore, it is recommended that a precautionary approach to the use of mobile phone technologies should be adopted until much more detailed and scientifi cally robust information on health effects becomes available. Most of the national and international organizations have formulated guidelines establishing limits for occupational and residential EM fi eld exposure. ICNIRP also developed the exposure limits for EMF. The International EMF project of WHO has completed a standards database limiting exposure to EMF. Turkey has established its own EM standards since 2001 in coordination of Telecommunications Authority (TK) and Gazi Biophysics. TK published the Turkish EMF Standards for 10 kHz – 60 GHz frequency range in 12 July 2001 entitled “Regulation of EMF reference values, measuring methods and auditing of fi xed telecommunication instruments working at the frequency band 10 kHz - 60 GHz” which is based on the ICNIRP standards for total environment. In the regulation, ¼ of ICNIRP general public standards are taken as one instrument standard and total environment standard are taken as the same with ICNIRP standards of general public. According to this regulation electric fi eld limit value for one base station is 10.23 V/m and for total environment it is 41.25 V/m at 900MHz, and at 1800 MHz 14.47 V/m for one base station and 58.33 V/m for total environment. Gazi Biophysics recommends lower EM exposure limits for general public. In this study, RF exposure levels of 23 base stations in Ankara are summarized. The measurements were performed with Narda EMR-300. Eight of base stations in residential areas were exceeded 4 V/m where people are exposed to RF at least 8 hours/day. Measured maximum value was 15.31 V/m where the base station is located on the street lighting mass, the distance from the base station to the living place is 6.4 m. GNRK recommends that the institutions, countries’ national commissions etc. should collaborate in order to provide common and safe standards for base station installations and EMF exposure limitation and make the general public aware about the EMF exposure protection. As WHO defi nes health is the state of complete physical, mental and social well being and not merely the absence of disease or infi rmity. 25

Elaboration of a pair of pollen indices for characterising the population load to airborne pollens Anna Páldy, János Bobvos, Gergely Mányoki National Institute of Environmental Health, Budapest, Hungary

The ongoing spread of Ambrosia artemisiifolia in Europe is an increasing problem for human health and as an agricultural and non-agricultural weed. Changing climate and perhaps adaptation to local climate in Europe has further expanded ragweed’s potential distribution range from Central Europe towards the North and West. National Aerobiological Networks monitor the airborne pollen of ragweed, these data are a sound basis for creating indicators which can be used to monitor the changes of the ragweed pollen season in time and space and the population exposure. This poster presents a pair of pollen indices expressing the rate of exposed population to different categories of daily pollen concentration. These can be used to indicate the exposure not only to ragweed, but to other aeroallergen exposure. The indicator was elaborated using the pollen data of the Hungarian Aerobiogical Network (HAN), sampled and evaluated according to internationally standardized method. HAN has 18 monitoring sites (supplied with Burkard volumetric pollen traps, run under standard circumstances), 8 of which were selected as being representative for the characteristic macroclimate types of the country (enough sites per climate types), not overlapping with each other, representative in densely populated areas, with available long term series of data. The relevant population was defi ned as the population living within a 17.5 km boundary of the monitoring site. Two indices were defi ned and computed • Index A: Rate of time of population exposure to pollen concentration categories (TR: Time-Rate) Defi nition: Pollen season distribution according to pollen concentration categories at the selected monitoring sites of a given year. • Index B: Rate of population exposure to pollen concentration categories. (PR: Population-Rate) Defi nition: Rate of population exposed to different categories of daily pollen concentration at selected monitoring sites during the pollen season of a given year. The start and end of the pollen season (1% resp. 99% of cumulative daily pollen count) was defi ned, daily pollen counts/m3 were categorised into seven groups (0-9, 10-29, 30-99, 100-299, 300-499, >=500 pollen grains/m3 resp. missing value). Indices PR(catx) and TR(catx) indicate, the percentage of the total population exposed to a given pollen concentration category (x) in the percentage of the days of the total pollen season. Using the daily ragweed pollen data of the 8 monitoring sites in Hungary of the year 2009 it can be stated that 56% of the population was exposed to daily pollen exposure over 30 pollen grains/m3 (evoking allergic symptoms in every allergenic patient) during 52% of days of the season (37 days). 2% of the population was exposed to >500 grains/m3 (extremely high category) for 3.4% of days. In the future the index pairs can be used to examine time trends. The study was sponsored by the UNIPHE project (EC DG Sanco project No: 2008 13 04). 26

The picture of occupational diseases in Romania in the past ten years Adriana Todea, Aurelia Ferencz National Institute of Public Health, Bucharest, Romania

Workers health is strongly infl uenced by economy fl uctuations, by the increase in small and middle enterprises number, by the shift of the activity towards the private sector, where the profi t is on the fi rst place as well as, lately, the fl exibility of the workforce. “Traditional” activities are gradually replaced by new ones, along with the fast technological development bringing new occupational risks for workers, not always obvious in the fi rst place. Thus, in the past ten years, the traditional structure of occupational diseases changed gradually. In bygone days occupational poisoning, silicosis and occupational hearing loss were dominating the picture. Nowadays, their place was taken slowly by musculoskeletal disorders, occupational asthma etc. Another priority in Romania would be the problem of assessing and preventing occupational risks of medical staff, by ensuring occupational health services in all types of medical units. In the past ten years, according to statistical data, the offi cial number of workers in Romania has diminished. For the occupational physician, the situation got more complicated, having to determine the fi tness for work of an ever- changing workforce. Each workplace means another medical examination. The occupational physician also has to support unemployed workers in fi nding another occupation based on their state of health. The real number of people working in agriculture and their occupational health problems are very little known. It is a well-known fact that a large part of people laid off from work with occupational diseases or previous harmful exposures ended up in agriculture or other activities in the countryside, with no means of monitoring their state of health. The study of occupational disease in Romania in the past ten years reveals some general aspects, but also specifi c ones leading to the following conclusions: It is impossible to estimate the real number of occupational diseases in Romania. For instance, the fact that some counties do not report any occupational diseases (Giurgiu, Satu-Mare) is due to the lack of an occupational physician in the public health authority, which is supposed to offi cially report the disease and not due to some ideal working conditions. Occupational physician should accurately identify and assess occupational risks in workplaces. Thus, it is compulsory for all employees in Romania to have access to occupational health services, no matter their workplace, in order to properly cover these problems. Monitoring the dynamics of the occupational diseases’ picture by the occupational physician is meant to identify exposed target groups and the impact of new technologies upon the human organism. Changes identifi ed in the occupational diseases’ picture must be an alarm signal for workplace managers and occupational physicians monitoring workers’ state of health, in order to remedy those critical situations with negative impact upon workers’ health. It is important for the general public and especially for the exposed employees to acknowledge the importance of taking health seriously, especially participating in periodical medical examinations as means of identifying diseases in early stages, in order to avoid serious forms of disease, many times irreversible, unavoidably leading to a higher burden on the social protection system, which is already out of its depth. 27

Evaluation of acute infantile methaemoglobinaemia cases generated from well water in Romania in 2009 Anca Tudor, Catalin Staicu National Institute of Public Health, Bucharest, Romania

Under the Government Decision no. 367/2009, National Public Health Institute from Bucharest coordinated the elaboration of national syntheses: “Evaluation of acute infantile methaemoglobinaemia cases generated from well water”. This syntheses is done in collaboration with territorial County Public Health Directorates (CPHD). Among the various environmental factors affecting the health of infants, well water nitrates are a factor with high importance in Romania. In rural areas the well water is often contaminated with bacteria and highly polluted with nitrates. The toxicity of nitrate to humans is mainly attributable to its reduction to nitrite which is harmful because it is involved in the oxidation of haemoglobin to methaemoglobin and so, is unable to transport oxygen to the tissues. Because of their sensitivity to oxidizing agents, infants are particularly sensitive to nitrites. Methaemoglobinaemia (MtHb) clinical appears when the concentration of methaemoglobin is about 10% from normal haemoglobin. Physiological methaemoglobin is under 3% for infants under 3 months of age. Most clinical cases of MtHb therefore occur in infants under 3 months of age. Drinking water is the major source of nitrate for children and MtHb often occurs when infants have consumed water used for infant formula, with a high nitrate content. In Romania water standards for nitrate are < 50 mg/l and for nitrite, <0,50 mg/l. These are stipulated by Law 458/2002, regarding drinking water quality, Law 311/2004 that modifi ed the Law 458/2002 and Government Ordinance 974/2004. Law 458/2002 is the transposition of Directive 98/83/EC on the quality of water intended for human consumption. In Romania MtHb has been considered a public health problem of rural areas since 1955. National Institute of Public Health Bucharest (NIPHB) established in 1984 the fi rst reporting system for infantile methaemoglobinaemia, and since then the CPHD have reported the cases of infantile methaemoglobinaemia generated from well water. From a study of NIPHB carried out in 2003, results that in the rural areas there are about 1 million of wells, most of them of the depth of 10 – 20 m. Since 2001 NIPHB collected data about infantile MtHb from 2 type of questionnaire sheets that revealed informations regarding: infant’s sex, age, form of disease, association with diarrhea and respiratory diseases, source of water (public or private well), sanitary protection of the well, depth of the well, use of synthetic or natural fertilizers, chemical and microbiological water contamination. In 2009 were validated data for 89 cases. All recorded cases were hospitalized. According to age group, 48% were children aged 1– 3 months. 46% cases were related to mixt feeding (breast and formula milk); acute diarrhoea was associated with 43% of cases; most of cases were generated by the water from shallow wells with depth less than 10 m. The wells had sanitary protection in only 30% of cases. The water samples have excess values for nitrates in 58% of cases (101 – 500 mg/l). The vulnerable groups are: infants with age between 1 – 3 months and new-born. The predominant cases were related with mixt feeding. It must be promote breast-feeding and education of population regarding the importance of safe water. In order to improve the present situation and to protect the babies’ health, collective efforts should be undertaken to increase public awareness and to educate the population about the importance of the use of “safe water”. The target group for information regarding health related risks of the consumption of drinking water contaminated with nitrates should be pregnant women and those who have small children. The advocacy of breast feeding is also of crucial importance. 28

Pollution caused by household waste – a preventable aggression on the environmental balance Mariana Vlad National Institute of Public Health, Regional Centre of Public Health Cluj, Romania

The irrational exploitation of nature was accompanied by ignoring the risks of altering it. Technological progress, economical development, and demographic explosion already caused an important man-environment imbalance. These circumstances created what is referred to as “the environmental holocaust”. An environmental crisis arose as an “invisible bomb”, manifesting itself as violence against nature and humans as well. On the path of aggressing the nature for maximizing the profi ts, pollution is considered to be the core of the environmental crisis. Particularly, the huge accumulation of household and industrial waste exceeds nature’s biodegrading capacity. This study makes an assessment of the environmental pollution risk caused by household waste in Transylvania area, Romania. The obtained results put into evidence an average production of 0.7891 kg of household waste per inhabitant/day between 2006 and 2009, when the annual amount of household waste increased by 40%. The composition of the stored waste consisted of 49% recyclable materials (glass, metal, plastics etc.) and 51% organic material. The household waste in various urban districts is stored in open containers. Most of the waste storage areas do not observe the current sanitary regulations. In rural areas, only 34% of the communities have a proper sanitation system, household waste being frequently stored on river banks, road side, or directly on the fi eld. The environmental pollution produced by household waste represents a serious threat to the ecological integrity of the environment and can be prevented by a regional implementation of the principles of the World Carta and by enhancing the environmental education.

Keywords: pollution, household, environment 29

Overweight and obese characteristics in a sample of Romanians from the southern part of the country Corina-Aurelia Zugravu1, Daniela Patrascu2, Anca Stoian2, Branduse Lacramioara1 1 National Institute of Public Health, Bucharest, Romania 2 University of Medicine and Pharmacy “Carol Davila”, Bucharest, Romania

Overweight and obesity are serious challenges for health systems worldwide and Romania makes no exception. The prevalence of serious weight problems is growing and their complications are taking their toll both over the personal well being, and over the expenses needed to treat them. Objectives: The target of this study was to make a demographical and attitudinal “portrait” of the average overweighed and obese Romanian from southern regions and Bucharest. We gathered data from a random sample of 1250 persons originating in Bucharest and in the southern counties of the country. Every individual had his weight and height measured (in order to calculate the body mass index) and had to complete a questionnaire with topics related to demographical, lifestyle and behavioural characteristics. The average BMI in the group was 24, 36 (95%CI: 24-24.72). Age was statistically signifi cant correlated with BMI (spearman rho= .512, p=.00), with an average BMI of 21.19(± 3.08), for the 18-24 years group, growing steadily to 28, 9 (±5, 3) at the 65-74 group. Women have a lower BMI than men (23,6 ±5,27 versus 25,74± 4) and higher values for BMI are found in groups describing themselves as being poor or having just enough for the bare necessities (27± 4, 8, respectively 25, 7 ±5.5), which is in concordance with data from similar studies carried out in other EU countries. Married individuals have greater chances of being obese, than singles, divorced or widowed. The self perception of the body weight is strongly correlated with the actual weight, but a signifi cant number of the obese perceive themselves as being just overweight, minimizing the severity of their nutritional status. Overweight and obese smoke more, are less interested in eating healthy food, are less satisfi ed with their perceived health and at least at a declarative mode, more preoccupied in having a normal weight. Bigger BMI is statistically associated with greater diffi culties in maintaining a constant weight. Obese and overweighed report higher weight variations during time, the differences with the underweighted and normally weighted being signifi cant. One third of the obese individuals declare having weight problems as children, this being the highest percent in all weight groups. In the same group, almost half of the persons have fi rst grade relatives with similar weight issues, but the study had not in target to identify the eventual cases with inherited weight problems. Weight problems are correlated with some demographical and behavioural traits. Not all are changeable, but some (like the attitude towards healthy eating or the smoking habit) deserve the effort to be modifi ed, as part of anti-obesity health programmes. 30 UNIPHE Conference Towards Improved Local Public Health Bucharest 27–28 September 2010

List of Delegates

Name Institution Mihaela Armanu Ministry of Health, Romania Adedoyin Awofi sayo Health Protection Agency, United Kingdom (UNIPHE) Sorin Baciu National Institute of Public Health, Romania Mihaela Balaceanu Public Health Directorate, Romania Mihaela Bartos Ministry of Health, Romania Ana-Maria Bratu National Institute of Public Health, Romania Eugenia Bratu University of Medicine and Pharmacy “Carol Davila”, Romania Cassandra Butu World Health Organization Country Offi ce, Romania Amalia Canton Ministry of Health, Romania Maria José Carroquino Instituto De Salud Carlos III, Madrid, Spain (UNIPHE) Olga Cavoura National School of Public Health, Athens, Greece Daniela Carlan Ministry of Health, Romania Ioan Chirila Regional Centre of Public Health, Romania Cristina Chirita National Institute of Public Health, Romania Livia Cioran National Institute of Public Health, Romania Camelia Claici Regional Centre of Public Health, Romania Aurelia Cordeanu National Institute of Public Health, Romania Alexandra Maria Cucu National Institute of Public Health, Romania (UNIPHE) Oana Curea National Institute of Public Health, Romania Dafi na Dalbokova World Health Organization, European Centre for Environment and Health, (ENHIS, UNIPHE) Bonn, Germany Claudia Dima National Institute of Public Health, Romania Ioan Domahidi Regional Centre of Public Health, Romania 2

Raquel Duarte-Davidson Health Protection Agency, United Kingdom (UNIPHE) Andrey Egorov World Health Organization, European Centre for Environment and Health, Bonn, Germany Julia-Edit Fekete Regional Centre of Public Health, Romania Aurelia Ferencz National Institute of Public Health, Romania Arzu Firlarer Gazi University, Ankara, Turkey Mihaela Fulga National Institute of Public Health, Romania Florentina Furtunescu University of Medicine and Pharmacy “Carol Davila”, Romania Adriana Galan National Institute of Public Health, Romania (UNIPHE) Wolfgang Hellmeier NRW Institute of Health and Work, Germany (I2ARE) Ana Hojs National Institute of Public Health, Slovenia (UNIPHE) Constanta Huidumac-Petrescu National Institute of Public Health, Romania Monica Iancu National Institute of Public Health, Romania Elena Lungu Regional Centre of Public Health, Romania Doina Lupulescu National Institute of Public Health, Romania Marco Martuzzi World Health Organization Rome offi ce, Italy Cristina May National Institute of Public Health, Romania Odile Mekel NRW Institute of Health and Work, Germany (UNIPHE) Ion-Petru Milos Regional Centre of Public Health, Romania Dana Galieta Minca University of Medicine and Pharmacy “Carol Davila”, Romania Ileana Mirestean Regional Centre of Public Health, Romania Anca Moldoveanu National Institute of Public Health, Romania Geza Molnar Ministry of Health, Romania George Morris NHS Health Scotland, United Kingdom (UNIPHE) Maja Muszyńska-Graca IOMEH, Sosnowiec, Poland Andra Neamtu National Institute of Public Health, Romania Rodica Nicolescu National Institute of Public Health, Romania Nicolae Nuta Public Health Directorate, Romania Andre Ochoa Observatoire Régional de la Santé d’Aquitaine and Fédération Nationale (I2ARE lead) des ORS, France Victor Olsavszky World Health Organization Country Offi ce, Romania Semih Ozden Gazi University, Ankara, Turkey 3

Anna Páldy National Institute of Environmental Health, Budapest, Hungary (UNIPHE) Valeriu Pantea National Centre for Public Health, Chisinau, Republic of Moldova Simona Parvu Ministry of Health, Romania Marta Petre Ministry of Health, Romania Adriana Pistol National Institute of Public Health, Romania Cezar Popa Canache National Institute of Public Health, Romania Florin Popovici National Institute of Public Health, Romania Maria Radulescu National Institute of Public Health, Romania Jüri Ruut Health Board, Tallin, Estonia Patrick Saunders Sandwell Primary Care Trust, United Kingdom Silvia Gabriela Scintee National School of Public Health and Management, Bucharest, Romania Ranjit Shraman Mahamakut Buddhist University, Thailand Momchil Sidjimov Laborex, Sophia, Bulgaria Rita Sketerskiene Ministry of Health, Lithuania Brigit Staatsen National Institute for Public Health and the Environment, Netherlands Lorraine Stewart Health Protection Agency, United Kingdom (UNIPHE lead) Linda Tacke NRW Institute of Health and Work, Germany (UNIPHE) Adriana Todea National Institute of Public Health, Romania Anca Tudor National Institute of Public Health, Romania Carmen Ungurean National Institute of Public Health, Romania Maria Varga Ministry of Health, Romania Adriana Vasile University of Medicine and Pharmacy “Carol Davila”, Romania Arpana Verma University of Manchester, United Kingdom (EURO-URHIS lead) Daniel Verman Ministry of Health Romania Mariana Vlad Regional Centre of Public Health, Romania Charlotte Wirl Gesundheit Österreich, Austria Corina Zugravu National Institute of Public Health, Romania Maria Zurini Public Health Directorate, Romania Ingrida Zurlytė Centre for Health Education and Disease Prevention, Lithuania (UNIPHE) Romania

Source: worldatlas.com

Location: Romania is located at the junction of Central and Southeastern Europe, north of the Balkan Peninsula, on the Lower Danube. It has a total surface area of approximately 240,000km2

Capital: Bucharest (Romanian: Bucureşti)

Main cities: Iasi, Constanta, Brasov, Sibiu, Timisoara, Cluj-Napoca

Population: 21,528,600, approximately 70% of which are aged 15 – 65 years

Ethnic composition: Romanians - 89.5%; Hungarians (including Szecklers) - 6.5%; Roma - 2.5%; other ethnic groups -1.5%. The other ethic minorities are Ukrainians, Germans, Lipovans, Turks, Tatars, Serbs, Slovaks, Bulgarians, Croats, Greeks, Russians, Jews, Czechs, Poles, Italians, and the Armenians

Language: The official language is Romanian which is spoken by 91% of the population. Other languages include Hungarian, German and Romani

Geographical landmarks: Romania has the 9th largest territory and the 7th largest population among the European Union member states.

History Overview: The modern state emerged in 1859 as a result of the union between Walachia and Moldova. In 1878 it gained independence from the Ottoman Empire and it has since been recognized as the Kingdom of Romania. At the end of the World War I in 1918, Transylvania became part of the Kingdom.

After the World War II, Romania became the Socialist Republic of Romania, the monarchy was forced to abdicate and the communist regime was established for the next 50 years.

Subsequent to the fall of Iron Curtain and the Romanian revolution in 1989, the country started a series of political and economic reforms. It joined the North Atlantic Treaty Organization (NATO) in March 2004 and the EU in January 2007. Romania is also a member of the Latin Union, the Francophone, the Organization for Security and Co-operation in Europe (OSCE) and the United Nations.

Main Attractions in Romania:

The medieval town of Transylvania Black Sea Coasts (Mangalia to Mamaia) The painted monasteries of Bucovinahe The Danube Delta (Delta Dunarii) which is a UNESCO Natural World Heritage Site Natural Spas such as Magnalia and Eforie Nord Castles and fortresses such as Bran Castle and Corvinesti Castle The wooden churches of Maramures; unique for their combination of Gothic style and traditional timber construction

In 2007, the city of Sibiu which is renowned for its Brukenthal National Museum was the nominated the European Capital of Culture together with Luxembourg.

Bucharest

Bucharest is the largest city in Romania, located in the southeast of the country along the banks of the Dâmboviţa River. It is the 6th largest city in the EU with 1.9 million people. Traditionally considered to have seven hills, the altitude varies from 55.8 metres to 91.5 m. Bucharest is the most prorperous city in Romania with wide tree-lined boulevards, magnificient buildings and a reputaion for high life which earned it the nickname “Little Paris” in the 1900s. It is one of the main industrial centres and transportation hubs of Eastern Europe. The city has a broad range of convention facilities, educational facilities, cultural venues, shopping arcades and recreational areas. Since its initial documentation back in 1429, it has gone through a variety of changes emerging as the state capital of Romania in 1862.

Main Attractions in Bucharest:

Herastrau Park - located in the north of the city Arcul de Triumf (The Triumphal Arch), built in 1935 and modeled after the Arc de Triomphe in Paris. Bucharest's botanical garden Cişmigiu Gardens The Romanian Athenaeum (concert hall) The National Museum of Art of Romania located in the former royal palace The Museum of Romanian History Museum of the Romanian Peasant (Muzeul Ţăranului Român)

The Palace of the Parliament: The palace is situated on Arsenal Hill, Bucharest. The Guinness Book of Records has described the Palace of Parliament as the world's largest, most expensive civilian administrative building and the heaviest building