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School Air Quality Related to Dry Cough, Rhinitis and Nasal Patency in Children

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School Air Quality Related to Dry Cough, Rhinitis and Nasal Patency in Children Eur Respir J 2010; 35: 742–749 DOI: 10.1183/09031936.00016309 CopyrightßERS Journals Ltd 2010 School air quality related to dry cough, rhinitis and nasal patency in children M. Simoni*, I. Annesi-Maesano#, T. Sigsgaard", D. Norback+, G. Wieslander+, W. Nystad1, M. Cancianie, P. Sestini** and G. Viegi*,## ABSTRACT: Controls for indoor air quality (IAQ) in schools are not usually performed throughout AFFILIATIONS Europe. The aim of this study was to assess the effects of IAQ on respiratory health of *Pulmonary Environmental Epidemiology Unit, CNR Institute of schoolchildren living in Norway, Sweden, Denmark, France and Italy. Clinical Physiology, Pisa, In the cross-sectional European Union-funded HESE (Health Effects of School Environment) eUdine University-Hospital Study, particulate matter with a 50% cut-off aerodynamic diameter of 10 mm (PM10) and CO2 levels ‘‘Policlinico’’, Udine, in a day of normal activity (full classroom) were related to wheezing, dry cough at night and **Siena University, Institute of Respiratory Diseases, Siena, rhinitis in 654 children (10 yrs) and to acoustic rhinometry in 193 children. ##CNR Institute of Biomedicine and -3 Schoolchildren exposed to PM10 .50 mg?m and CO2 .1,000 ppm (standards for good IAQ) Molecular Immunology ‘‘A. Monroy’’, were 78% and 66%, respectively. All disorders were more prevalent in children from poorly Palermo, Italy. #UMR-S 707, Medical School ventilated classrooms. Schoolchildren exposed to CO2 levels .1,000 ppm showed a significantly St-Antoine, University Pierre et Marie higher risk for dry cough (OR 2.99, 95% CI 1.65–5.44) and rhinitis (OR 2.07, 95% CI 1.14–3.73). By Curie and INSERM, Paris, France. " two-level (child, classroom) hierarchical analyses, CO2 was significantly associated with dry IMA Institute of Environment and cough (OR 1.06, 95% CI 1.00–1.13 per 100 ppm increment) and rhinitis (OR 1.06, 95% CI 1.00– Occupational Medicine, A˚rhus -3 University, A˚rhus, Denmark. 1.11). Nasal patency was significantly lower in schoolchildren exposed to PM10 .50 mg?m than in +Uppsala University, Dept of Medical those exposed to lower levels. Sciences, Uppsala, Sweden. A poor IAQ is frequent in European classrooms; it is related to respiratory disturbances and 1Norwegian Institute of Public Health, affects nasal patency. Division of Epidemiology, Oslo, Norway. KEYWORDS: Carbon dioxide, indoor air pollution, particles, respiratory, rhinometry, school- CORRESPONDENCE children M. Simoni Istituto di Fisiologia Clinica CNR (CNR Institute of Clinical Physiology) ndoor environments contribute to human European Commission, through the Directorate Via Trieste, 41 56126 Pisa exposure to pollutants [1]. Levels of some General for Health and Consumer Affairs (DG Italy pollutants can be several folds higher indoors SANCO, Luxembourg, Luxembourg), funded our I E-mail: [email protected] than outdoors; even low concentrations of indoor study on Health Effects of School Environment pollutants may have adverse biological effects (HESE) held in different European countries; we Received: when exposures are prolonged. report the results here. Jan 30 2009 Accepted after revision: Several reports underline the role of indoor METHODS Nov 04 2009 pollution in affecting respiratory health in both The cross-sectional HESE study involved six First published online: children and adults [2–7]. Since children spend a operational units in five European countries Jan 14 2010 large part of their time at school, nationwide (Siena and Udine, Italy; Reims, France; Oslo, initiatives to evaluate such indoor air quality Norway; Uppsala, Sweden; and A˚ rhus, (IAQ) were developed in the USA [8]. Denmark). 21 schools (46 classrooms) with Respiratory/allergic disorders are common heterogeneous characteristics were selected, including a broad age range of buildings and a throughout Europe and represent a substantial variety of location characteristics (about half in burden of health service cost. Studies of school environmentally more advantaged areas and half environment and related health effects in chil- in less advantaged areas). The study, approved dren have been performed in Europe, especially by the ethics committees of each study centre, in northern countries, although mostly on small was carried out in 2004–2005, during the heating samples [9–13]. A European Union (EU)-funded season, and lasted a full week in each location. project developed by the European Federation of Asthma and Allergy Associations [14] found the The study protocol included: 1) one standardised European Respiratory Journal right of breathing clean air at school was not questionnaire on school characteristics and Print ISSN 0903-1936 widely respected throughout Europe. The IAQ policy completed by the teachers; 2) two Online ISSN 1399-3003 742 VOLUME 35 NUMBER 4 EUROPEAN RESPIRATORY JOURNAL M. SIMONI ET AL. OCCUPATIONAL AND ENVIRONMENTAL LUNG DISEASE standardised questionnaires derived from the International are the mean CO2 levels in the classroom and outdoor, Study of Asthma and Allergies in Childhood (ISAAC) respectively [15]. questionnaire on characteristics of children (i.e. health condi- tions, lifestyle, home environment), one filled in by the pupils Clinical tests and the other by their parents; 3) school environmental Noninvasive clinical tests (skin-prick tests, spirometry, acous- assessments; and 4) noninvasive clinical tests on a subsample tic rhinometry, exhaled nitrogen oxide, collection of breath of pupils. condensate and nasal secretions, break-up time and tear film analysis) were performed on five randomised selected pupils Symptoms/diseases in each class. The standardised questionnaires were filled in by 547 pupils and 552 parents (response rate 84% for both). In Denmark, only For the current analyses, we focused on the results by acoustic parents’ questionnaires were available. Among children with rhinometry, because we considered upper respiratory tract both self- and parental report (n5445, 68% of total), symptoms/ disorders, and because the relationship between school diseases were considered as present when either children or environment and nasal patency (the degree of openness of parents reported any symptom/disease and absent when both the nose) of schoolchildren has never been investigated. children and parents did not report any symptom/disease. In Acoustic rhinometry precisely locates the nasal minimum order to retain the highest number of children and countries in cross-sectional area (MCA) of each nostril by analysis of sound the analyses, data on children with only self-report (n5107, reflection from the nasal cavity. Acoustic rhinometry was not 16.4%) or only parental report (n5102, 15.6%) were also performed in Norway. Except for Denmark, the same equip- included in the data set. Thus, health status was derived for ment (Rhin 2000; SR Electronics, Denmark; wideband noise, 654 children (47.2% young males, mean¡SD age 10¡0.8 yrs). continuously transmitted) was used. The continuous sound measurement makes it very easy to hear if the nose adapter The following recent symptoms/diseases were considered in does not tightly fit the nose. In Denmark, the measurements the analyses: 1) wheeze (‘‘have you had, or has your child had, were performed with a rhinometer using a single-spark signal wheezing or whistling in the chest in the past 12 months?’’); 2) (GJ Electronic, Skanderborg, Denmark). At start-up, both sets dry cough at night (‘‘in the past 12 months, have you had, or of equipment were calibrated using a tube with the same fixed has your child had, a dry cough at night, apart from a cough length and volume changes in order to obtain standardised associated with a cold or chest infection?’’); 3) rhinitis (‘‘in the measurements. Measurements were performed by experienced past 12 months, have you had, or has your child had, a medical staff while the child was sitting, after o5 min of rest; problem with sneezing, or a runny or blocked nose when you usually, because of queuing, the rest time was much longer. All did not have a cold or the flu?’’). schoolchildren waited in their classrooms for o1 h before the investigation. MCAs for each nostril were measured at a Environmental measurements distance of 0–22 mm (anterior MCA) and 23–54 mm (posterior During normal activities (full classroom), standard measure- MCA) from the nasal opening [16]. Mean values were ments (ventilation, temperature, relative humidity, lighting, calculated from three subsequent measurements on each side particles, nitrogen dioxide, carbon dioxide, ozone, formalde- of the nose, and presented data are the sum of the values hyde, dust and air allergens, moulds and bacteria) were recorded for the right side and the left side of the nose. The performed, both inside and outside each school, by personnel anterior MCA was measured in 193 children. The posterior from a single centre, where the instruments had been MCA was measured in 140 children (in Denmark, only the calibrated (Uppsala). Data were analysed at the IVL Swedish anterior MCA was measured). Environmental Research Institute in Gothenburg, Sweden and at the Department of Occupational and Environmental Statistical analyses Medicine, Orebro, Sweden. Statistical analyses were performed with SPSS version 13.0 Carbon dioxide (ppm) was measured by a Q-TracktTM IAQ (SPSS, Chicago, IL, USA) and STATA version 9.0 (STATA, -3 Monitor (TSI Incorporated, St Paul, MN, USA), a direct reading College Station, TX, USA). Levels of PM10 .50 mg?m (US instrument with an in-built data logger, by sampling 1-min Environmental Protection Agency (EPA) standard for long- average intervals at 0.9 m above the floor during 1 day term exposure) [17] and CO2 .1,000 ppm (American Society of (minimum 4 h). Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) standard) [18] were defined as elevated. A Respirable particulate matter with aerodynamic diameter -3 TM categorical variable of exposure was defined for both pollu- ,10 mm (PM10; mg?m ) was measured by a Dust-Trackt tants (elevated versus low). (Model 8520; TSI Incorporated) with a sensor-type 90u light- scattering laser photometer, measuring 1–10 mm particles for Levels of personal outdoor air supply ,8L?s-1?person-1 1–2 h.
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