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  • 1. Adam, Martin
    et al.
    Schikowski, Tamara
    Carsin, Anne Elie
    Cai, Yutong
    Jacquemin, Benedicte
    Sanchez, Margaux
    Vierkötter, Andrea
    Marcon, Alessandro
    Keidel, Dirk
    Sugiri, Dorothee
    Al Kanani, Zaina
    Nadif, Rachel
    Siroux, Valérie
    Hardy, Rebecca
    Kuh, Diana
    Rochat, Thierry
    Bridevaux, Pierre-Olivier
    Eeftens, Marloes
    Tsai, Ming-Yi
    Villani, Simona
    Phuleria, Harish Chandra
    Birk, Matthias
    Cyrys, Josef
    Cirach, Marta
    de Nazelle, Audrey
    Nieuwenhuijsen, Mark J
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    de Hoogh, Kees
    Declerq, Christophe
    Bono, Roberto
    Piccioni, Pavilio
    Quass, Ulrich
    Heinrich, Joachim
    Jarvis, Deborah
    Pin, Isabelle
    Beelen, Rob
    Hoek, Gerard
    Brunekreef, Bert
    Schindler, Christian
    Sunyer, Jordi
    Krämer, Ursula
    Kauffmann, Francine
    Hansell, Anna L
    Künzli, Nino
    Probst-Hensch, Nicole
    Adult lung function and long-term air pollution exposure. ESCAPE: a multicentre cohort study and meta-analysis2015In: European Respiratory Journal, ISSN 0903-1936, E-ISSN 1399-3003, Vol. 41, no 5, p. 38-50Article in journal (Refereed)
    Abstract [en]

    The chronic impact of ambient air pollutants on lung function in adults is not fully understood. The objective of this study was to investigate the association of long-term exposure to ambient air pollution with lung function in adult participants from five cohorts in the European Study of Cohorts for Air Pollution Effects (ESCAPE). Residential exposure to nitrogen oxides (NO2, NOx) and particulate matter (PM) was modelled and traffic indicators were assessed in a standardised manner. The spirometric parameters forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC) from 7613 subjects were considered as outcomes. Cohort-specific results were combined using meta-analysis. We did not observe an association of air pollution with longitudinal change in lung function, but we observed that a 10 μg·m(-3) increase in NO2 exposure was associated with lower levels of FEV1 (-14.0 mL, 95%CI -25.8- -2.1) and FVC (-14.9 mL, 95% CI -28.7- -1.1). An increase of 10 μg·m(-3) in PM10, but not other PM metrics (PM2.5, coarse fraction of PM, PM absorbance), was associated with a lower level of FEV1 (-44.6 mL, 95% CI -85.4- -3.8) and FVC (-59.0 mL, 95% CI -112.3- -5.6). The associations were particularly strong in obese persons. This study adds to the evidence for an adverse association of ambient air pollution with lung function in adults at very low levels in Europe.

  • 2. Adrian, L.
    et al.
    Svanes, C.
    Johannessen, A.
    Lodge, C.
    Bertelsen, R.
    Dratva, J.
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Gislason, T.
    Benedikstdottir, B.
    Holm, M.
    Jogi, R.
    Modig, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Norback, D.
    Omenaas, E.
    Real, F.
    Schlunssen, V
    Sigsgaard, T.
    Skorge, T.
    Timm, S.
    Wieslander, G.
    Janson, C.
    Dharmage, S.
    Early life parental exposure to cats and dogs reduces the risk of allergic disease in their children: possible intergenerational effect2014In: Allergy. European Journal of Allergy and Clinical Immunology, ISSN 0105-4538, E-ISSN 1398-9995, Vol. 69, no Supplement: 99, p. 577-578Article in journal (Refereed)
  • 3. Analitis, A
    et al.
    Katsouyanni, K
    Biggeri, A
    Baccini, M
    Forsberg, B
    Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Occupational and Enviromental Medicine.
    Bisanti, L
    Kirchmayer, U
    Ballester, F
    Cadum, E
    Goodman, P G
    Hojs, A
    Sunyer, J
    Tiittanen, P
    Michelozzi, P
    Effects of cold weather on mortality: results from 15 European cities within the PHEWE project.2008In: American journal of epidemiology, ISSN 1476-6256, Vol. 168, no 12, p. 1397-408Article in journal (Refereed)
    Abstract [en]

    Weather-related health effects have attracted renewed interest because of the observed and predicted climate change. The authors studied the short-term effects of cold weather on mortality in 15 European cities. The effects of minimum apparent temperature on cause- and age-specific daily mortality were assessed for the cold season (October-March) by using data from 1990-2000. For city-specific analysis, the authors used Poisson regression and distributed lag models, controlling for potential confounders. Meta-regression models summarized the results and explored heterogeneity. A 1 degrees C decrease in temperature was associated with a 1.35% (95% confidence interval (CI): 1.16, 1.53) increase in the daily number of total natural deaths and a 1.72% (95% CI: 1.44, 2.01), 3.30% (95% CI: 2.61, 3.99), and 1.25% (95% CI: 0.77, 1.73) increase in cardiovascular, respiratory, and cerebrovascular deaths, respectively. The increase was greater for the older age groups. The cold effect was found to be greater in warmer (southern) cities and persisted up to 23 days, with no evidence of mortality displacement. Cold-related mortality is an important public health problem across Europe. It should not be underestimated by public health authorities because of the recent focus on heat-wave episodes.

  • 4.
    Andersson, Louise
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Oudin Åström, Daniel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Pettersson-Strömbäck, Anita
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Åström, Christofer
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Med värme ihågkommen2012Report (Other academic)
    Abstract [en]

    The purpose of this project has been to use an interview study and literature survey to show how the outdoor environment, public facilities and housing can be designed to reduce the risk for elderly and persons with disabilities to die prematurely during heat waves. The goal is to raise awareness and interest in the adaptation of the environment and buildings of the persons responsible for planning, housing stock, social service, health care and homes for elderly.

    Cities are generally warmer and less windy than the surrounding landscape. The urban "warmer climate" is mainly due to the greater heat storage that can be found in buildings, streets, sidewalks, etc., limited vegetation that can shade and release moisture and activities such as traffic and domestic heating, which generate heat. During heat waves the increase in mortality is larger in cities. To live alone, be confined to bed and stay on the top floor has been shown to be additional risk factors.

    Measures to reduce the city's urban heat island and effects on humans are sometimes divided into "soft measures" (information, warning systems for heat waves, interventions for vulnerable groups), "green actions" (make the city a greener environment) and “technical measures” (shaded structures, changes of the walls, refrigeration /air conditioning indoors, etc.), which all are complementary. In some countries, the care homes for elderly should have a common room that can be kept cool even during heat waves.

    The aim of the interview study was to describe how personnel in the elderly care experience these problems in Sweden. The data collection method was 20 semi structured interviews with elderly care

    Sid 3 (49)

    personnel in Botkyrka municipality during October 2011. Content analysis was performed on the transcribed interview data and categories and subcategories were created on repeated themes in the text. The conclusions suggest intensified education for and information to personnel in the elderly care sector and that already in the planning of new homes for elderly the personnel's knowledge and experience of the needs among the elderly should be taken into account. 

  • 5.
    Andersson, Martin
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Bjerg, Anders
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Pulmonary Medicine.
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Lundbäck, Bo
    Rönmark, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    The clinical expression of asthma in schoolchildren has changed between 1996 and 20062010In: Pediatric Allergy and Immunology, ISSN 0905-6157, E-ISSN 1399-3038, Vol. 21, no 5, p. 859-866Article in journal (Refereed)
    Abstract [en]

    Several studies have reported diverging trends in the prevalence of asthma and wheeze. The aim of this study was to investigate the clinical expression of childhood asthma in 1996 and 2006 by studying asthma morbidity, treatment, and environmental exposures in school children with physician-diagnosed asthma and wheeze, respectively. All children enrolled in first or second grade (7-8 yr-old) in three municipalities in northern Sweden were invited to a questionnaire study in 1996 and 2006, respectively. In 1996, 3430 (97%) participated; and in 2006, 2585 (96%) participated. The same parental completed questionnaire, including the ISAAC questions, was used in both surveys. Physician-diagnosed asthma was reported at 5.7% in 1996 and 7.4% in 2006. A significantly greater proportion of children with asthma were using inhaled corticosteroids (ICS) in 2006, 67% vs. 55% in 1996. This increase was parallel to a major decrease in severe asthma symptoms such as disturbed sleep because of wheeze (49% vs. 38%) and troublesome asthma (21% vs. 11%). The prevalence of current wheeze among the asthmatics decreased significantly; however, this was seen only among children not using ICS. Parental smoking decreased significantly as did the proportion living in damp buildings. In conclusion, although asthma remains a major public health issue in school age children, children with asthma had less respiratory symptoms and a better asthma control in 2006 compared to 1996. This parallels with an increase in treatment with ICS, more beneficial environmental conditions, and an increased diagnostic intensity resulting in a larger proportion of children with mild symptoms being diagnosed as having asthma.

  • 6.
    Andersson, Martin
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine. The OLIN Studies, Luleå.
    Hedman, Linnea
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine. The OLIN Studies, Luleå.
    Bjerg, Anders
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Pulmonary Medicine. The OLIN Studies, Luleå ; Krefting Research Centre, Institute of Medicine, Göteborgs universitet.
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Lundbäck, Bo
    The OLIN Studies, Luleå ; Krefting Research Centre, Institute of Medicine, Göteborgs universitet.
    Rönmark, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine. The OLIN Studies, Luleå.
    Remission and Persistence of Asthma Followed From 7 to 19 Years of Age2013In: Pediatrics, ISSN 0031-4005, E-ISSN 1098-4275, Vol. 132, no 2, p. E435-E442Article in journal (Refereed)
    Abstract [en]

    BACKGROUND AND OBJECTIVE: To date, a limited number of population-based studies have prospectively evaluated the remission of childhood asthma. This work was intended to study the remission and persistence of childhood asthma and related factors. METHODS: In 1996, a questionnaire was distributed to the parents of all children aged 7 to 8 years in 3 municipalities in northern Sweden, and 3430 (97%) participated. After a validation study, 248 children were identified as having asthma; these children were reassessed annually until age 19 years when 205 (83%) remained. During the follow-up period lung function, bronchial challenge testing, and skin prick tests were performed. Remission was defined as no use of asthma medication and no wheeze during the past 12 months as reported at endpoint and in the 2 annual surveys preceding endpoint (ie, for >= 3 years). RESULTS: At age 19 years, 21% were in remission, 38% had periodic asthma, and 41% persistent asthma. Remission was more common among boys. Sensitization to furred animals and a more severe asthma (asthma score >= 2) at age 7 to 8 years were both inversely associated with remission, odds ratio 0.14 (95% confidence interval 0.04-0.55) and 0.19 (0.07-0.54), respectively. Among children with these 2 characteristics, 82% had persistent asthma during adolescence. Asthma heredity, damp housing, rural living, and smoking were not associated with remission. CONCLUSIONS: The probability of remission of childhood asthma from age 7- to 8-years to age 19 years was largely determined by sensitization status, particularly sensitization to animals, asthma severity, and female gender, factors all inversely related to remission.

  • 7.
    Andersson, Martin
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Hedman, Linnéa
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Bjerg, Anders
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Pulmonary Medicine.
    Lundbäck, B
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Rönmark, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Persistence and remission of asthma followed from 7 to 19 years of ageManuscript (preprint) (Other academic)
  • 8.
    Andersson, Martin
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine. The OLIN Studies, Norrbotten County Council, Luleå, Sweden.
    Hedman, Linnéa
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine. The OLIN Studies, Norrbotten County Council, Luleå, Sweden.
    Nordberg, Gunnar
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Eriksson, Kåre
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Rönmark, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine. The OLIN Studies, Norrbotten County Council, Luleå, Sweden.
    Swimming pool attendance is related to asthma among atopic school children: a population-based study2015In: Environmental health, ISSN 1476-069X, E-ISSN 1476-069X, Vol. 14, no 14, article id 37Article in journal (Refereed)
    Abstract [en]

    Background: By-products of water disinfectants have been suggested to cause asthma, especially in atopic children. However, studies on indoor swimming pool attendance and asthma in children have presented conflicting results. The present study examined the relationship between indoor swimming pool attendance and asthma among sensitized and non-sensitized children aged 11-12 years.

    Methods: An extended ISAAC questionnaire was sent to the families of all children attending fifth or sixth grade, aged 11-12 years, in two municipalities in Northern Sweden in 2010. A total of 1866 participated (96% of those invited) in the questionnaire study and 1652 (89%) also participated in skin prick testing for 10 standard airborne allergens. Asthma was defined as physician-diagnosed asthma in combination with wheeze or use of asthma medication in the last 12 months. Current swimming pool attendance was reported as >= 1/week or <1/week. Logistic regression models were used for data analysis.

    Results: The prevalence of current asthma was 8.9% (10.0% of boys; 7.9% of girls) and 14% had attended indoor pools >= 1/week. Children currently attending swimming pools >= 1/week had an increased risk of current asthma. Stratified analyses for allergic sensitization adjusted for sex, parental smoking, parental asthma, and damp housing, showed a statistically significant association for current asthma only among sensitized subjects (OR 95% CI 1.90 1.09-3.32). No association was found between current pool attendance and wheeze, sensitization, rhinitis or eczema.

    Conclusions: The present study supports the proposed link between indoor swimming pool attendance and asthma in sensitized children.

  • 9.
    Andersson, Martin
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Modig, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Hedman, Linnea
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Rönmark, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Heavy vehicle traffic is related to wheeze among schoolchildren: a population-based study in an area with low traffic flows2011In: Environmental health, ISSN 1476-069X, E-ISSN 1476-069X, Vol. 10, no 91Article in journal (Refereed)
    Abstract [en]

    Background: An association between traffic air pollution and respiratory symptoms among children has been reported. However, the effects of traffic air pollution on asthma and wheeze have been very sparsely studied in areas with low traffic intensity in cold climate with poor dispersion. We evaluated the impact of vehicle traffic on childhood asthma and wheeze by objective exposure assessment.

    Methods: As a part of the Obstructive Lung Disease in Northern Sweden (OLIN) studies, a questionnaire was sent to the families of all children attending first or second grade in Luleå (72,000 inhabitants) in Northern Sweden in 2006. The age of the children was 7-8 years and the participation rate was 98% (n = 1357). Skin prick tests were performed in 1224 (89%) children. The home addresses were given geographical coordinates and traffic counts were obtained from the local traffic authorities. A proximity model of average daily traffic and average daily heavy vehicle traffic within 200 meters from each participant's home address was used. The associations between traffic exposure and asthma and wheeze, respectively, were analysed in an adjusted multiple logistic regression model.

    Results: Exposure to high traffic flows was uncommon in the study area; only 15% of the children lived within 200 meters from a road with a traffic flow of ≥8000 vehicles per day. Living closer than 200 meters from a road with ≥500 heavy vehicles daily was associated with current wheeze, odds ratio 1.7 (confidence interval 1.0-2.7). A dose-response relation was indicated. An increased risk of asthma was also seen, however not significant, odds ratio 1.5 (confidence interval 0.8-2.9). Stratified analyses revealed that the effect of traffic exposure was restricted to the non-sensitized phenotype of asthma and wheeze. The agreement between self-reported traffic exposure and objective measurements of exposure was moderate.

    Conclusions: This study showed that already at low levels of exposure, vehicle traffic is related to an increased risk of wheeze among children. Thus, the global burden of traffic air pollution may be underestimated.

  • 10.
    Aström, Daniel Oudin
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Edvinsson, Sören
    Umeå University, Faculty of Social Sciences, Centre for Population Studies (CPS). Ageing & Living Condit Programme, Umeå University.
    Rocklöv, Joacim
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Acute Fatal Effects of Short-Lasting Extreme Temperatures in Stockholm, Sweden: Evidence Across a Century of Change.2013In: Epidemiology, ISSN 1044-3983, E-ISSN 1531-5487, Vol. 24, no 6, p. 820-829Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Climate change is projected to increase the frequency of extreme weather events. Short-term effects of extreme hot and cold weather and their effects on mortality have been thoroughly documented, as have epidemiologic and demographic changes throughout the 20th century. We investigated whether sensitivity to episodes of extreme heat and cold has changed in Stockholm, Sweden, from the beginning of the 20th century until the present.

    METHODS: We collected daily mortality and temperature data for the period 1901-2009 for present-day Stockholm County, Sweden. Heat extremes were defined as days for which the 2-day moving average of mean temperature was above the 98th percentile; cold extremes were defined as days for which the 26-day moving average was below the 2nd percentile. The relationship between extreme hot/cold temperatures and all-cause mortality, stratified by decade, sex, and age, was investigated through time series modeling, adjusting for time trends.

    RESULTS: Total daily mortality was higher during heat extremes in all decades, with a declining trend over time in the relative risk associated with heat extremes, leveling off during the last three decades. The relative risk of mortality was higher during cold extremes for the entire period, with a more dispersed pattern across decades. Unlike for heat extremes, there was no decline in the mortality with cold extremes over time.

    CONCLUSIONS: Although the relative risk of mortality during extreme temperature events appears to have fallen, such events still pose a threat to public health.

  • 11. Ayres, JG
    et al.
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Annesi-Maesano, I
    Dey, R
    Ebi, KL
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Helms, PJ
    Medina-Ramón, M
    Windt, M
    Forastiere, F
    Climate change and respiratory disease: European Respiratory Society position statement2009In: European Respiratory Journal, ISSN 0903-1936, E-ISSN 1399-3003, Vol. 34, no 2, p. 295-302Article in journal (Refereed)
    Abstract [en]

    Climate change will affect individuals with pre-existing respiratory disease, but the extent of the effect remains unclear. The present position statement was developed on behalf of the European Respiratory Society in order to identify areas of concern arising from climate change for individuals with respiratory disease, healthcare workers in the respiratory sector and policy makers. The statement was developed following a 2-day workshop held in Leuven (Belgium) in March 2008. Key areas of concern for the respiratory community arising from climate change are discussed and recommendations made to address gaps in knowledge. The most important recommendation was the development of more accurate predictive models for predicting the impact of climate change on respiratory health. Respiratory healthcare workers also have an advocatory role in persuading governments and the European Union to maintain awareness and appropriate actions with respect to climate change, and these areas are also discussed in the position statement.

  • 12. Baccini, Michela
    et al.
    Biggeri, Annibale
    Accetta, Gabriele
    Kosatsky, Tom
    Katsouyanni, Klea
    Analitis, Antonis
    Anderson, H Ross
    Bisanti, Luigi
    D'Ippoliti, Daniela
    Danova, Jana
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Occupational and Enviromental Medicine.
    Medina, Sylvia
    Paldy, Anna
    Rabczenko, Daniel
    Schindler, Christian
    Michelozzi, Paola
    Heat effects on mortality in 15 European cities.2008In: Epidemiology (Cambridge, Mass.), ISSN 1531-5487, Vol. 19, no 5, p. 711-9Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Epidemiologic studies show that high temperatures are related to mortality, but little is known about the exposure-response function and the lagged effect of heat. We report the associations between daily maximum apparent temperature and daily deaths during the warm season in 15 European cities. METHODS: The city-specific analyses were based on generalized estimating equations and the city-specific results were combined in a Bayesian random effects meta-analysis. We specified distributed lag models in studying the delayed effect of exposure. Time-varying coefficient models were used to check the assumption of a constant heat effect over the warm season. RESULTS: The city-specific exposure-response functions have a V shape, with a change-point that varied among cities. The meta-analytic estimate of the threshold was 29.4 degrees C for Mediterranean cities and 23.3 degrees C for north-continental cities. The estimated overall change in all natural mortality associated with a 1 degrees C increase in maximum apparent temperature above the city-specific threshold was 3.12% (95% credibility interval = 0.60% to 5.72%) in the Mediterranean region and 1.84% (0.06% to 3.64%) in the north-continental region. Stronger associations were found between heat and mortality from respiratory diseases, and with mortality in the elderly. CONCLUSIONS: There is an important mortality effect of heat across Europe. The effect is evident from June through August; it is limited to the first week following temperature excess, with evidence of mortality displacement. There is some suggestion of a higher effect of early season exposures. Acclimatization and individual susceptibility need further investigation as possible explanations for the observed heterogeneity among cities.

  • 13. Bedada, Getahun Bero
    et al.
    Heinrich, Joachim
    Götschi, Thomas
    Downs, Sara H
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Occupational and Enviromental Medicine.
    Jarvis, Deborah
    Luczynska, Christina
    Soon, Argo
    Sunyer, Jordi
    Toren, Kjell
    Künzli, Nino
    Urban background particulate matter and allergic sensitization in adults of ECRHS II.2007In: Int J Hyg Environ Health, ISSN 1438-4639, Vol. 210, no 6, p. 691-700Article in journal (Refereed)
  • 14. Beelen, Rob
    et al.
    Raaschou-Nielsen, Ole
    Stafoggia, Massimo
    Andersen, Zorana Jovanovic
    Weinmayr, Gudrun
    Hoffmann, Barbara
    Wolf, Kathrin
    Samoli, Evangelia
    Fischer, Paul
    Nieuwenhuijsen, Mark
    Vineis, Paolo
    Xun, Wei W
    Katsouyanni, Klea
    Dimakopoulou, Konstantina
    Oudin, Anna
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Modig, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Havulinna, Aki S
    Lanki, Timo
    Turunen, Anu
    Oftedal, Bente
    Nystad, Wenche
    Nafstad, Per
    De Faire, Ulf
    Pedersen, Nancy L
    Ostenson, Claes-Göran
    Fratiglioni, Laura
    Penell, Johanna
    Korek, Michal
    Pershagen, Göran
    Eriksen, Kirsten Thorup
    Overvad, Kim
    Ellermann, Thomas
    Eeftens, Marloes
    Peeters, Petra H
    Meliefste, Kees
    Wang, Meng
    Bueno-de-Mesquita, Bas
    Sugiri, Dorothea
    Krämer, Ursula
    Heinrich, Joachim
    de Hoogh, Kees
    Key, Timothy
    Peters, Annette
    Hampel, Regina
    Concin, Hans
    Nagel, Gabriele
    Ineichen, Alex
    Schaffner, Emmanuel
    Probst-Hensch, Nicole
    Künzli, Nino
    Schindler, Christian
    Schikowski, Tamara
    Adam, Martin
    Phuleria, Harish
    Vilier, Alice
    Clavel-Chapelon, Françoise
    Declercq, Christophe
    Grioni, Sara
    Krogh, Vittorio
    Tsai, Ming-Yi
    Ricceri, Fulvio
    Sacerdote, Carlotta
    Galassi, Claudia
    Migliore, Enrica
    Ranzi, Andrea
    Cesaroni, Giulia
    Badaloni, Chiara
    Forastiere, Francesco
    Tamayo, Ibon
    Amiano, Pilar
    Dorronsoro, Miren
    Katsoulis, Michail
    Trichopoulou, Antonia
    Brunekreef, Bert
    Hoek, Gerard
    Effects of long-term exposure to air pollution on natural-cause mortality: an analysis of 22 European cohorts within the multicentre ESCAPE project2014In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 383, no 9919, p. 785-795Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Few studies on long-term exposure to air pollution and mortality have been reported from Europe. Within the multicentre European Study of Cohorts for Air Pollution Effects (ESCAPE), we aimed to investigate the association between natural-cause mortality and long-term exposure to several air pollutants.

    METHODS: We used data from 22 European cohort studies, which created a total study population of 367 251 participants. All cohorts were general population samples, although some were restricted to one sex only. With a strictly standardised protocol, we assessed residential exposure to air pollutants as annual average concentrations of particulate matter (PM) with diameters of less than 2·5 μm (PM2·5), less than 10 μm (PM10), and between 10 μm and 2·5 μm (PMcoarse), PM2.5 absorbance, and annual average concentrations of nitrogen oxides (NO2 and NOx), with land use regression models. We also investigated two traffic intensity variables-traffic intensity on the nearest road (vehicles per day) and total traffic load on all major roads within a 100 m buffer. We did cohort-specific statistical analyses using confounder models with increasing adjustment for confounder variables, and Cox proportional hazards models with a common protocol. We obtained pooled effect estimates through a random-effects meta-analysis.

    FINDINGS: The total study population consisted of 367 251 participants who contributed 5 118 039 person-years at risk (average follow-up 13·9 years), of whom 29 076 died from a natural cause during follow-up. A significantly increased hazard ratio (HR) for PM2·5 of 1·07 (95% CI 1·02-1·13) per 5 μg/m(3) was recorded. No heterogeneity was noted between individual cohort effect estimates (I(2) p value=0·95). HRs for PM2·5 remained significantly raised even when we included only participants exposed to pollutant concentrations lower than the European annual mean limit value of 25 μg/m(3) (HR 1·06, 95% CI 1·00-1·12) or below 20 μg/m(3) (1·07, 1·01-1·13).

    INTERPRETATION: Long-term exposure to fine particulate air pollution was associated with natural-cause mortality, even within concentration ranges well below the present European annual mean limit value.

    FUNDING: European Community's Seventh Framework Program (FP7/2007-2011).

  • 15. Beelen, Rob
    et al.
    Stafoggia, Massimo
    Raaschou-Nielsen, Ole
    Andersen, Zorana Jovanovic
    Xun, Wei W
    Katsouyanni, Klea
    Dimakopoulou, Konstantina
    Brunekreef, Bert
    Weinmayr, Gudrun
    Hoffmann, Barbara
    Wolf, Kathrin
    Samoli, Evangelia
    Houthuijs, Danny
    Nieuwenhuijsen, Mark
    Oudin, Anna
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Olsson, David
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Salomaa, Veikko
    Lanki, Timo
    Yli-Tuomi, Tarja
    Oftedal, Bente
    Aamodt, Geir
    Nafstad, Per
    De Faire, Ulf
    Pedersen, Nancy L
    Östenson, Claes-Göran
    Fratiglioni, Laura
    Penell, Johanna
    Korek, Michal
    Pyko, Andrei
    Eriksen, Kirsten Thorup
    Tjønneland, Anne
    Becker, Thomas
    Eeftens, Marloes
    Bots, Michiel
    Meliefste, Kees
    Wang, Meng
    Bueno-de-Mesquita, Bas
    Sugiri, Dorothea
    Krämer, Ursula
    Heinrich, Joachim
    de Hoogh, Kees
    Key, Timothy
    Peters, Annette
    Cyrys, Josef
    Concin, Hans
    Nagel, Gabriele
    Ineichen, Alex
    Schaffner, Emmanuel
    Probst-Hensch, Nicole
    Dratva, Julia
    Ducret-Stich, Regina
    Vilier, Alice
    Clavel-Chapelon, Françoise
    Stempfelet, Morgane
    Grioni, Sara
    Krogh, Vittorio
    Tsai, Ming-Yi
    Marcon, Alessandro
    Ricceri, Fulvio
    Sacerdote, Carlotta
    Galassi, Claudia
    Migliore, Enrica
    Ranzi, Andrea
    Cesaroni, Giulia
    Badaloni, Chiara
    Forastiere, Francesco
    Tamayo, Ibon
    Amiano, Pilar
    Dorronsoro, Miren
    Katsoulis, Michail
    Trichopoulou, Antonia
    Vineis, Paolo
    Hoek, Gerard
    Long-term exposure to air pollution and cardiovascular mortality: an analysis of 22 European cohorts2014In: Epidemiology, ISSN 1044-3983, E-ISSN 1531-5487, Vol. 25, no 3, p. 368-378Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Air pollution has been associated with cardiovascular mortality, but it remains unclear as to whether specific pollutants are related to specific cardiovascular causes of death. Within the multicenter European Study of Cohorts for Air Pollution Effects (ESCAPE), we investigated the associations of long-term exposure to several air pollutants with all cardiovascular disease (CVD) mortality, as well as with specific cardiovascular causes of death.

    METHODS: Data from 22 European cohort studies were used. Using a standardized protocol, study area-specific air pollution exposure at the residential address was characterized as annual average concentrations of the following: nitrogen oxides (NO2 and NOx); particles with diameters of less than 2.5 μm (PM2.5), less than 10 μm (PM10), and 10 μm to 2.5 μm (PMcoarse); PM2.5 absorbance estimated by land-use regression models; and traffic indicators. We applied cohort-specific Cox proportional hazards models using a standardized protocol. Random-effects meta-analysis was used to obtain pooled effect estimates.

    RESULTS: The total study population consisted of 367,383 participants, with 9994 deaths from CVD (including 4,992 from ischemic heart disease, 2264 from myocardial infarction, and 2484 from cerebrovascular disease). All hazard ratios were approximately 1.0, except for particle mass and cerebrovascular disease mortality; for PM2.5, the hazard ratio was 1.21 (95% confidence interval = 0.87-1.69) per 5 μg/m and for PM10, 1.22 (0.91-1.63) per 10 μg/m.

    CONCLUSION: In a joint analysis of data from 22 European cohorts, most hazard ratios for the association of air pollutants with mortality from overall CVD and with specific CVDs were approximately 1.0, with the exception of particulate mass and cerebrovascular disease mortality for which there was suggestive evidence for an association.

  • 16. Bjerg, Anders
    et al.
    Ekerljung, Linda
    Eriksson, Jonas
    Olafsdóttir, Inga Sif
    Middelveld, Roelinde
    Franklin, Karl A.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Larsson, Kjell
    Lötvall, Jan
    Torén, Kjell
    Dahlén, Sven-Erik
    Lundbäck, Bo
    Janson, Christer
    Higher risk of wheeze in female than male smokers: results from the Swedish GA(2)LEN study2013In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 8, no 1, article id e54137Article in journal (Refereed)
    Abstract [en]

    Background: Women who smoke have higher risk of lung function impairment, COPD and lung cancer than smoking men. An influence of sex hormones has been demonstrated, but the mechanisms are unclear and the associations often subject to confounding. This was a study of wheeze in relation to smoking and sex with adjustment for important confounders.

    Methods: In 2008 the Global Allergy and Asthma European Network (GA2LEN) questionnaire was mailed to 45.000 Swedes (age 16–75 years), and 26.851 (60%) participated. “Any wheeze”: any wheeze during the last 12 months. “Asthmatic wheeze”: wheeze with breathlessness apart from colds.

    Results: Any wheeze and asthmatic wheeze was reported by 17.3% and 7.1% of women, vs. 15.8% and 6.1% of men (both p<0.001). Although smoking prevalence was similar in both sexes, men had greater cumulative exposure, 16.2 pack-years vs. 12.8 in women (p<0.001). Most other exposures and characteristics associated with wheeze were significantly overrepresented in men. Adjusted for these potential confounders and pack-years, current smoking was a stronger risk factor for any wheeze in women aged <53 years, adjusted odds ratio (aOR) 1.85 (1.56–2.19) vs. 1.60 (1.30–1.96) in men. Cumulative smoke exposure and current smoking each interacted significantly with female sex, aOR 1.02 per pack-year (p<0.01) and aOR 1.28 (p = 0.04) respectively. Female compared to male current smokers also had greater risk of asthmatic wheeze, aOR 1.53 vs. 1.03, interaction aOR 1.52 (p = 0.02). These interactions were not seen in age ≥53 years.

    Discussion: In addition to the increased risk of COPD and lung cancer female, compared to male, smokers are at greater risk of significant wheezing symptoms in younger age. This became clearer after adjustment for important confounders including cumulative smoke exposure. Estrogen has previously been shown to increase the bioactivation of several compounds in tobacco smoke, which may enhance smoke-induced airway inflammation in fertile women.

  • 17.
    Bjerg, Anders
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Pulmonary Medicine.
    Ekerljung, Linda
    Middelveld, Roelinde
    Dahlén, Sven-Erik
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Franklin, Karl
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Pulmonary Medicine.
    Larsson, Kjell
    Lötvall, Jan
    Ólafsdóttir, Inga Sif
    Torén, Kjell
    Lundbäck, Bo
    Janson, Christer
    Increased prevalence of symptoms of rhinitis but not of asthma between 1990 and 2008 in Swedish adults: comparisons of the ECRHS and GA2LEN surveys2011In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 6, no 2, p. e16082-Article in journal (Refereed)
    Abstract [en]

    Background

    The increase in asthma prevalence until 1990 has been well described. Thereafter, time trends are poorly known, due to the low number of high quality studies. The preferred method for studying time trends in prevalence is repeated surveys of similar populations. This study aimed to compare the prevalence of asthma symptoms and their major determinants, rhinitis and smoking, in Swedish young adults in 1990 and 2008.

    Methods

    In 1990 the European Community Respiratory Health Survey (ECRHS) studied respiratory symptoms, asthma, rhinitis and smoking in a population-based sample (86% participation) in Sweden. In 2008 the same symptom questions were included in the Global Allergy and Asthma European Network (GA2LEN) survey (60% participation). Smoking questions were however differently worded. The regions (Gothenburg, Uppsala, Umeå) and age interval (20–44 years) surveyed both in 1990 (n = 8,982) and 2008 (n = 9,156) were analysed.

    Results

    The prevalence of any wheeze last 12 months decreased from 20% to 16% (p<0.001), and the prevalence of “asthma-related symptoms” was unchanged at 7%. However, either having asthma attacks or using asthma medications increased from 6% to 8% (p<0.001), and their major risk factor, rhinitis, increased from 22% to 31%. Past and present smoking decreased.

    Conclusion

    From 1990 to 2008 the prevalence of obstructive airway symptoms common in asthma did not increase in Swedish young adults. This supports the few available international findings suggesting the previous upward trend in asthma has recently reached a plateau. The fact that wheeze did not increase despite the significant increment in rhinitis, may at least in part be due to the decrease in smoking.

  • 18. Bjerg, Anders
    et al.
    Eriksson, Jonas
    Ólafsdóttir, Inga Sif
    Middelveld, Roelinde
    Franklin, Karl
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Larsson, Kjell
    Torén, Kjell
    Dahlén, Sven-Erik
    Janson, Christer
    The association between asthma and rhinitis is stable over time despite diverging trends in prevalence2015In: Respiratory Medicine, ISSN 0954-6111, E-ISSN 1532-3064, Vol. 109, no 3, p. 312-319Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Despite the well-known association between asthma and rhinitis, in Swedish adults the prevalence of rhinitis rose from 22% to 31% between 1990 and 2008 while asthma prevalence was unchanged. We tested whether the association of rhinitis with asthma was stable over time using the same population-based databases.

    METHODS: Two surveys of adults (20-44 years) living in three regions of Sweden, carried out in 1990 (n = 8982) and 2008 (n = 9156) were compared. Identical questions regarding respiratory symptoms, asthma and rhinitis were used. Asthmatic wheeze: Wheeze with breathlessness apart from colds. Current asthma: Asthma attacks and/or asthma medication use.

    RESULTS: Subjects with rhinitis had level time trends in asthmatic wheeze, current asthma and most nocturnal respiratory symptoms between 1990 and 2008, adjusted for age, sex, area and smoking. Any wheeze however decreased slightly. In never-smokers asthma symptoms were similarly associated with rhinitis in 1990 and 2008: any wheeze OR 4.0 vs. 4.4 (p = 0.339); asthmatic wheeze OR 6.0 vs. 5.9 (p = 0.937); and current asthma OR 9.6 vs. 7.7 (p = 0.213). In the whole population there were decreases in the asthma symptoms most closely associated to smoking, which decreased by half 1990-2008. Conversely current asthma, which was strongly associated with rhinitis and not with smoking, increased (p < 0.001).

    CONCLUSIONS: The association of rhinitis with asthma was stable between 1990 and 2008. The pattern in the time trends of asthma outcomes strongly suggests that decreased smoking counterbalanced the driving effect of increased rhinitis on asthma prevalence. The findings illustrate the public health benefits of decreased smoking.

  • 19. Boman, C
    et al.
    Forsberg, B
    Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Occupational and Enviromental Medicine.
    Sandström, Thomas
    Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Pulmonary Medicine.
    Shedding new light on wood smoke: a risk factor for respiratory health.2006In: Eur Respir J, ISSN 0903-1936, Vol. 27, no 3, p. 446-7Article in journal (Refereed)
  • 20.
    Boman, Christoffer
    et al.
    Umeå University, Faculty of Science and Technology, Department of Applied Physics and Electronics.
    Forsberg, B
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Sandström, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Pulmonary Medicine.
    Shedding new light on wood smoke: a risk factor for respiratory health.2006In: Eur Respir J, ISSN 0903-1936, Vol. 27, no 3, p. 446-7Article in journal (Refereed)
  • 21.
    Bosson, Jenny
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Pulmonary Medicine.
    Pourazar, Jamshid
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Pulmonary Medicine.
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Ädelroth, Ellinor
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Pulmonary Medicine.
    Sandström, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Pulmonary Medicine.
    Blomberg, Anders
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Pulmonary Medicine.
    Ozone enhances the airway inflammation initiated by diesel exhaust.2007In: Respiratory Medicine, ISSN 0954-6111, E-ISSN 1532-3064, Vol. 101, no 6, p. 1140-1146Article in journal (Refereed)
    Abstract [en]

    Exposure to air pollution is associated with adverse health effects, with particulate matter (PM) and ozone (O(3)) both indicated to be of considerable importance. Diesel engine exhaust (DE) and O(3) generate substantial inflammatory effects in the airways. However, as yet it has not been determined whether a subsequent O(3) exposure would add to the diesel-induced airway inflammatory effects. Healthy subjects underwent two separate exposure series: A 1-h DE exposure at a PM-concentration of 300 microg/m(3), followed after 5h by a 2-h exposure to filtered air and 0.2 ppm O(3), respectively. Induced sputum was collected 18 h after the second exposure. A significant increase in the percentage of neutrophils (PMN) and concentration of myeloperoxidase (MPO) was seen in sputum post DE+O(3) vs. DE+air (p<0.05 and <0.05, respectively). Significant associations were observed between the responses in MPO concentration and total PMN cells (p=0.001), and also between MPO and matrix metalloproteinase-9 (MMP-9) (p<0.001). The significant increase of PMN and MPO after the DE+O(3) exposures, compared to DE+air, denotes an O(3)-induced magnification of the DE-induced inflammation. Furthermore, the correlation between responses in MPO and number of PMNs and MMP-9 illustrate that the PMNs are activated, resulting in a more potent inflammatory response. The present study indicates that O(3) exposure adds significantly to the inflammatory response that is established by diesel exhaust. This interaction between exposure to particulate pollution and O(3) in sequence should be taken into consideration when health effects of air pollution are considered.

  • 22. Brunekreef, B
    et al.
    Annesi-Maesano, I
    Ayres, JG
    Forastiere, F
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Kuenzli, N
    Pekkanen, J
    Sigsgaard, T
    Ten principles for clean air2012In: European Respiratory Journal, ISSN 0903-1936, E-ISSN 1399-3003, Vol. 39, no 3, p. 525-528Article in journal (Refereed)
  • 23. Brunekreef, B
    et al.
    Forsberg, B
    Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Occupational and Enviromental Medicine.
    Epidemiological evidence of effects of coarse airborne particles on health.2005In: Eur Respir J, ISSN 0903-1936, Vol. 26, no 2, p. 309-18Article in journal (Refereed)
  • 24. Brunekreef, Bert
    et al.
    Künzli, Nino
    Pekkanen, Juha
    Annesi-Maesano, Isabella
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Sigsgaard, Torben
    Keuken, Menno
    Forastiere, Francesco
    Barry, Maeve
    Querol, Xavier
    Harrison, Roy M
    Clean air in Europe: beyond the horizon?2015In: European Respiratory Journal, ISSN 0903-1936, E-ISSN 1399-3003, Vol. 45, no 1, p. 7-10Article in journal (Other academic)
  • 25.
    Bråbäck, Lennart
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Forsberg, Bertil
    Department of Public Health and Research, Sundsvall Hospital, Sundsvall, Sweden.
    Does traffic exhaust contribute to the development of asthma and allergic sensitization in children: findings from recent cohort studies.2009In: Environmental health : a global access science source, ISSN 1476-069X, Vol. 8, no 17, p. 1-11Article in journal (Refereed)
    Abstract [en]

    The aim of this review was to assess the evidence from recent prospective studies that long-term traffic pollution could contribute to the development of asthma-like symptoms and allergic sensitization in children. We have reviewed cohort studies published since 2002 and found in PubMed in Oct 2008. In all, 13 papers based on data from 9 cohorts have evaluated the relationship between traffic exposure and respiratory health. All surveys reported associations with at least some of the studied respiratory symptoms. The outcome varied, however, according to the age of the child. Nevertheless, the consistency in the results indicates that traffic exhaust contributes to the development of respiratory symptoms in healthy children. Potential effects of traffic exhaust on the development of allergic sensitization were only assessed in the four European birth cohorts. Long-term exposure to outdoor air pollutants had no association with sensitization in ten-year-old schoolchildren in Norway. In contrast, German, Dutch and Swedish preschool children had an increased risk of sensitization related to traffic exhaust despite fairly similar levels of outdoor air pollution as in Norway. Traffic-related effects on sensitization could be restricted to individuals with a specific genetic polymorphism. Assessment of gene-environment interactions on sensitization has so far only been carried out in a subgroup of the Swedish birth cohort. Further genetic association studies are required and may identify individuals vulnerable to adverse effects from traffic-related pollutants. Future studies should also evaluate effects of traffic exhaust on the development and long term outcome of different phenotypes of asthma and wheezing symptoms.

  • 26. Cai, Yutong
    et al.
    Schikowski, Tamara
    Adam, Martin
    Buschka, Anna
    Carsin, Anne-Elie
    Jacquemin, Benedicte
    Marcon, Alessandro
    Sanchez, Margaux
    Vierkötter, Andrea
    Al-Kanaani, Zaina
    Beelen, Rob
    Birk, Matthias
    Brunekreef, Bert
    Cirach, Marta
    Clavel-Chapelon, Françoise
    Declercq, Christophe
    de Hoogh, Kees
    de Nazelle, Audrey
    Ducret-Stich, Regina E.
    Valeria Ferretti, Virginia
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Gerbase, Margaret W.
    Hardy, Rebecca
    Heinrich, Joachim
    Hoek, Gerard
    Jarvis, Debbie
    Keidel, Dirk
    Kuh, Diana
    Nieuwenhuijsen, Mark J.
    Ragettli, Martina S.
    Ranzi, Andrea
    Rochat, Thierry
    Schindler, Christian
    Sugiri, Dorothea
    Temam, Sofia
    Tsai, Ming-Yi
    Varraso, Raphaëlle
    Kauffmann, Francine
    Krämer, Ursula
    Sunyer, Jordi
    Künzli, Nino
    Probst-Hensch, Nicole
    Hansell, Anna L.
    Cross-sectional associations between air pollution and chronic bronchitis: an ESCAPE meta-analysis across five cohorts2014In: Thorax, ISSN 0040-6376, E-ISSN 1468-3296, Vol. 69, no 11, p. 1005-1014Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: This study aimed to assess associations of outdoor air pollution on prevalence of chronic bronchitis symptoms in adults in five cohort studies (Asthma-E3N, ECRHS, NSHD, SALIA, SAPALDIA) participating in the European Study of Cohorts for Air Pollution Effects (ESCAPE) project.

    METHODS: Annual average particulate matter (PM10, PM2.5, PMabsorbance, PMcoarse), NO2, nitrogen oxides (NOx) and road traffic measures modelled from ESCAPE measurement campaigns 2008-2011 were assigned to home address at most recent assessments (1998-2011). Symptoms examined were chronic bronchitis (cough and phlegm for ≥3 months of the year for ≥2 years), chronic cough (with/without phlegm) and chronic phlegm (with/without cough). Cohort-specific cross-sectional multivariable logistic regression analyses were conducted using common confounder sets (age, sex, smoking, interview season, education), followed by meta-analysis.

    RESULTS: 15 279 and 10 537 participants respectively were included in the main NO2 and PM analyses at assessments in 1998-2011. Overall, there were no statistically significant associations with any air pollutant or traffic exposure. Sensitivity analyses including in asthmatics only, females only or using back-extrapolated NO2 and PM10 for assessments in 1985-2002 (ECRHS, NSHD, SALIA, SAPALDIA) did not alter conclusions. In never-smokers, all associations were positive, but reached statistical significance only for chronic phlegm with PMcoarse OR 1.31 (1.05 to 1.64) per 5 µg/m(3) increase and PM10 with similar effect size. Sensitivity analyses of older cohorts showed increased risk of chronic cough with PM2.5abs (black carbon) exposures.

    CONCLUSIONS: Results do not show consistent associations between chronic bronchitis symptoms and current traffic-related air pollution in adult European populations.

  • 27.
    Carlsen, Hanne Krage
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Meister, Kadri
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Gíslason, Thorarinn
    Oudin, Anna
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Ozone is associated with cardiopulmonary and stroke emergency hospital visits in Reykjavik, Iceland 2003--20092013In: Environmental health, ISSN 1476-069X, E-ISSN 1476-069X, Vol. 12, no 1, p. 28-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Air pollution exposure is associated with hospital admissions and emergency room visits for cardiopulmonary disease and stroke. Iceland's capital area, Reykjavik, has generally low air pollution levels, but traffic and natural sources contribute to pollution levels. The objective of this study was to investigate temporal associations between emergency hospital visits and air pollutants ozone (O3), nitrogen dioxide (NO2), and particulate matter (PM10) in the Icelandic capital area.

    METHODS: We constructed a time series of the daily number of adults who visited the emergency room, or were acutely admitted for stroke or cardiorespiratory causes to Landspitali University Hospital 1 January 2003 -- 31 December 2009 from the hospital in-patient register. We used generalized additive models assuming Poisson distribution, to analyze the daily emergency hospital visits as a function of the pollutant levels, and adjusted for meteorological variables, day of week, and time trend with splines.

    RESULTS: Daily emergency hospital visits increased 3.9% (95% confidence interval (CI) 1.7-6.1%) per interquartile (IQR) change in average O3 the same and two previous days. For females, the increase was 7.8% (95% CI 3.6-12.1) for elderly (70+), the increase was 3.9% (95% CI 0.6-7.3%) per IQR increase of NO2. There were no associations with PM10.

    CONCLUSIONS: We found an increase in daily emergency hospital visits associated with O3, indicating that low-level exposure may trigger cardiopulmonary events or stroke.

  • 28.
    Carlsen, Hanne Krage
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Gislason, T
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Meister, Kadri
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Thorsteinsson, T
    Jóhannsson, T
    Finnbjornsdottir, R
    Oudin, Anna
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Emergency Hospital Visits in Association with Volcanic Ash, Dust Storms and Other Sources of Ambient Particles: A Time-Series Study in Reykjavik, Iceland2015In: International Journal of Environmental Research and Public Health, ISSN 1661-7827, E-ISSN 1660-4601, Vol. 12, no 4, p. 4047-4059Article in journal (Refereed)
    Abstract [en]

    Volcanic ash contributed significantly to particulate matter (PM) in Iceland following the eruptions in Eyjafjallajökull 2010 and Grímsvötn 2011. This study aimed to investigate the association between different PM sources and emergency hospital visits for cardiorespiratory causes from 2007 to 2012. Indicators of PM10 sources; “volcanic ash”, “dust storms”, or “other sources” (traffic, fireworks, and re-suspension) on days when PM10 exceeded the daily air quality guideline value of 50 µg/m3 were entered into generalized additive models, adjusted for weather, time trend and co-pollutants. The average number of daily emergency hospital visits was 10.5. PM10 exceeded the air quality guideline value 115 out of 2191 days; 20 days due to volcanic ash, 14 due to dust storms (two days had both dust storm and ash contribution) and 83 due to other sources. High PM10 levels from volcanic ash tended to be significantly associated with the emergency hospital visits; estimates ranged from 4.8% (95% Confidence Interval (CI): 0.6, 9.2%) per day of exposure in unadjusted models to 7.3% (95% CI: −0.4, 15.5%) in adjusted models. Dust storms were not consistently associated with daily emergency hospital visits and other sources tended to show a negative association. We found some evidence indicating that volcanic ash particles were more harmful than particles from other sources, but the results were inconclusive and should be interpreted with caution.

  • 29.
    Carlsen, Hanne Krage
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine. Centre of Public Health, University of Iceland.
    Gislason, Thorarinn
    Faculty of Medicine, University of Iceland.
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Meister, Kadri
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Thorsteinsson, Throstur
    Department of Environment and Natural resources, University of Iceland.
    Johansson, Thorsteinn
    Environmental Agency of Iceland.
    Finnbjornsdottir, Ragnhildur
    Centre of Public Health, University of Iceland.
    Oudin, Anna
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Effects of PM10 from volcanic ash, natural dust, and other sources on emergency hospital visits in Reykjavík, IcelandArticle in journal (Refereed)
  • 30. Castro-Giner, Francesc
    et al.
    Künzli, Nino
    Jacquemin, Bénédicte
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Occupational and Enviromental Medicine.
    de Cid, Rafael
    Sunyer, Jordi
    Jarvis, Deborah
    Briggs, David
    Vienneau, Danielle
    Norback, Dan
    González, Juan R
    Guerra, Stefano
    Janson, Christer
    Antó, Josep-Maria
    Wjst, Matthias
    Heinrich, Joachim
    Estivill, Xavier
    Kogevinas, Manolis
    Traffic-related air pollution, oxidative stress genes, and asthma (ECHRS).2009In: Environmental health perspectives, ISSN 1552-9924, Vol. 117, no 12, p. 1919-24Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Traffic-related air pollution is related with asthma, and this association may be modified by genetic factors. OBJECTIVES: We investigated the role of genetic polymorphisms potentially modifying the association between home outdoor levels of modeled nitrogen dioxide and asthma. METHODS: Adults from 13 cities of the second European Community Respiratory Health Survey (ECRHS II) were included (n = 2,920), for whom both DNA and outdoor NO(2) estimates were available. Home addresses were geocoded and linked to modeled outdoor NO(2) estimates, as a marker of local traffic-related pollution. We examined asthma prevalence and evaluated polymorphisms in genes involved in oxidative stress pathways [gluthatione S-transferases M1 (GSTM1), T1 (GSTT1), and P1 (GSTP1) and NAD(P)H:quinine oxidoreductase (NQO1)], inflammatory response [tumor necrosis factor alpha (TNFA)], immunologic response [Toll-like receptor 4 (TLR4)], and airway reactivity [adrenergic receptor beta2 (ADRB2)]. RESULTS: The association between modeled NO(2) and asthma prevalence was significant for carriers of the most common genotypes of NQO1 rs2917666 [odds ratio (OR) = 1.54; 95% confidence interval (CI), 1.10-2.24], TNFA rs2844484 (OR = 2.02; 95% CI, 1.30-3.27). For new-onset asthma, the effect of NO(2) was significant for the most common genotype of NQO1 rs2917666 (OR = 1.52; 95% CI, 1.09-2.16). A significant interaction was found between NQO1 rs2917666 and NO(2) for asthma prevalence (p = 0.02) and new-onset asthma (p = 0.04). CONCLUSIONS: Genetic polymorphisms in the NQO1 gene are related to asthma susceptibility among persons exposed to local traffic-related air pollution. This points to the importance of antioxidant pathways in the protection against the effects of air pollution on asthma.

  • 31. Cecchi, L
    et al.
    D'Amato, G
    Ayres, JG
    Galan, C
    Forastiere, F
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Gerritsen, J
    Nunes, C
    Behrendt, H
    Akdis, C
    Dahl, R
    Annesi-Maesano, I
    Projections of the effects of climate change on allergic asthma: the contribution of aerobiology2010In: Allergy. European Journal of Allergy and Clinical Immunology, ISSN 0105-4538, E-ISSN 1398-9995, Vol. 65, no 9, p. 1073-1081Article in journal (Refereed)
    Abstract [en]

    Climate change is unequivocal and represents a possible threat for patients affected by allergic conditions. It has already had an impact on living organisms, including plants and fungi with current scenarios projecting further effects by the end of the century. Over the last three decades, studies have shown changes in production, dispersion and allergen content of pollen and spores, which may be region- and species-specific. In addition, these changes may have been influenced by urban air pollutants interacting directly with pollen. Data suggest an increasing effect of aeroallergens on allergic patients over this period, which may also imply a greater likelihood of the development of an allergic respiratory disease in sensitized subjects and exacerbation of symptomatic patients. There are a number of limitations that make predictions uncertain, and further and specifically designed studies are needed to clarify current effects and future scenarios. We recommend: More stress on pollen/spore exposure in the diagnosis and treatment guidelines of respiratory and allergic diseases; collection of aerobiological data in a structured way at the European level; creation, promotion and support of multidisciplinary research teams in this area; lobbying the European Union and other funders to finance this research.

  • 32. de Hoogh, Kees
    et al.
    Korek, Michal
    Vienneau, Danielle
    Keuken, Menno
    Kukkonen, Jaakko
    Nieuwenhuijsen, Mark J
    Badaloni, Chiara
    Beelen, Rob
    Bolignano, Andrea
    Cesaroni, Giulia
    Pradas, Marta Cirach
    Cyrys, Josef
    Douros, John
    Eeftens, Marloes
    Forastiere, Francesco
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Fuks, Kateryna
    Gehring, Ulrike
    Gryparis, Alexandros
    Gulliver, John
    Hansell, Anna L
    Hoffmann, Barbara
    Johansson, Christer
    Jonkers, Sander
    Kangas, Leena
    Katsouyanni, Klea
    Künzli, Nino
    Lanki, Timo
    Memmesheimer, Michael
    Moussiopoulos, Nicolas
    Modig, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Pershagen, Göran
    Probst-Hensch, Nicole
    Schindler, Christian
    Schikowski, Tamara
    Sugiri, Dorothee
    Teixidó, Oriol
    Tsai, Ming-Yi
    Yli-Tuomi, Tarja
    Brunekreef, Bert
    Hoek, Gerard
    Bellander, Tom
    Comparing land use regression and dispersion modelling to assess residential exposure to ambient air pollution for epidemiological studies2014In: Environment International, ISSN 0160-4120, E-ISSN 1873-6750, Vol. 73, p. 382-392Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Land-use regression (LUR) and dispersion models (DM) are commonly used for estimating individual air pollution exposure in population studies. Few comparisons have however been made of the performance of these methods.

    OBJECTIVES: Within the European Study of Cohorts for Air Pollution Effects (ESCAPE) we explored the differences between LUR and DM estimates for NO2, PM10 and PM2.5.

    METHODS: The ESCAPE study developed LUR models for outdoor air pollution levels based on a harmonised monitoring campaign. In thirteen ESCAPE study areas we further applied dispersion models. We compared LUR and DM estimates at the residential addresses of participants in 13 cohorts for NO2; 7 for PM10 and 4 for PM2.5. Additionally, we compared the DM estimates with measured concentrations at the 20-40 ESCAPE monitoring sites in each area.

    RESULTS: The median Pearson R (range) correlation coefficients between LUR and DM estimates for the annual average concentrations of NO2, PM10 and PM2.5 were 0.75 (0.19-0.89), 0.39 (0.23-0.66) and 0.29 (0.22-0.81) for 112,971 (13 study areas), 69,591 (7) and 28,519 (4) addresses respectively. The median Pearson R correlation coefficients (range) between DM estimates and ESCAPE measurements were of 0.74 (0.09-0.86) for NO2; 0.58 (0.36-0.88) for PM10 and 0.58 (0.39-0.66) for PM2.5.

    CONCLUSIONS: LUR and dispersion model estimates correlated on average well for NO2 but only moderately for PM10 and PM2.5, with large variability across areas. DM predicted a moderate to large proportion of the measured variation for NO2 but less for PM10 and PM2.5.

  • 33. Dimakopoulou, Konstantina
    et al.
    Samoli, Evangelia
    Beelen, Rob
    Stafoggia, Massimo
    Jovanovic Andersen, Zorana
    Hoffmann, Barbara
    Fischer, Paul
    Nieuwenhuijsen, Mark
    Vineis, Paolo
    Xun, Wei
    Hoek, Gerard
    Raaschou-Nielsen, Ole
    Oudin, Anna
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Modig, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Jousilahti, Pekka
    Lanki, Timo
    Turunen, Anu
    Oftedal, Bente
    Nafstad, Per
    Schwarze, Per E
    Penell, Johanna
    Fratiglioni, Laura
    Andersson, Niklas
    Pedersen, Nancy
    Korek, Michal
    De Faire, Ulf
    Thorup Eriksen, Kirsten
    Tjønneland, Anne
    Becker, Thomas
    Wang, Meng
    Bueno-de-Mesquita, Bas
    Tsai, Ming-Yi
    Eeftens, Marloes
    Peeters, Petra H
    Meliefste, Kees
    Marcon, Alessandro
    Krämer, Ursula
    Kuhlbusch, Thomas Aj
    Vossoughi, Mohammad
    Key, Timothy
    de Hoogh, Kees
    Hampel, Regina
    Peters, Annette
    Heinrich, Joachim
    Weinmayr, Gudrun
    Concin, Hans
    Nagel, Gabriele
    Ineichen, Alex
    Jacquemin, Bénédicte
    Stempfelet, Morgane
    Vilier, Alice
    Ricceri, Fulvio
    Sacerdote, Carlotta
    Pedeli, Xanthi
    Katsoulis, Michalis
    Trichopoulou, Antonia
    Brunekreef, Bert
    Katsouyanni, Klea
    Air Pollution and Non-Malignant Respiratory Mortality in 16 Cohorts within the ESCAPE Project2014In: American Journal of Respiratory and Critical Care Medicine, ISSN 1073-449X, E-ISSN 1535-4970, Vol. 189, no 6, p. 684-696Article in journal (Refereed)
    Abstract [en]

    Rationale: Prospective cohort studies have shown that chronic exposure to particulate matter and traffic related air pollution is associated with reduced survival. However, the effects on non-malignant respiratory mortality are less studied and those reported are less consistent.

    Objectives: We have investigated the relationship of long-term exposure to air pollution and non-malignant respiratory mortality in 16 cohorts with individual level data within the multi center European Study of Cohorts for Air Pollution Effects (ESCAPE).

    Methods: Data from 16 ongoing cohort studies from Europe were used. The total number of subjects was 307,553. There were 1,559 respiratory deaths during follow-up.

    Measurements: Air pollution exposure was estimated by land use regression models at the baseline residential addresses of study participants and traffic-proximity variables were derived from geographical databases, following a standardized procedure within ESCAPE study. Cohort-specific hazard ratios obtained by Cox proportional hazard models from standardized individual cohort analyses were combined using meta-analyses. Main Results: We found no significant associations between air pollution exposure and non-malignant respiratory mortality. Most hazard ratios were slightly below unity, with the exception of the traffic-proximity indicators.

    Conclusions: In this study of 16 cohorts there was no association between air pollution exposure and non malignant respiratory mortality.

  • 34.
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Klimatförändring och hälsorelaterad miljöövervakning: - redovisning av utredningsuppdrag2009Report (Other academic)
  • 35.
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Slutrapport från pilotstudie Uppskattning av exponering för ozon2014Report (Other academic)
    Abstract [sv]

    Syftet med denna pilotstudie var att genomföra en undersökning angående ozonexponering under ”ozonsäsongen” (dvs maj-september) 2013 inne i skolor och utanför på skolgården samt i sovrummet hos skolbarn och i utomhus bostadens närhet. Pilotstudien ska ge vägledning angående kriterier och uppläggning vid mätning av ozon, samt leda till ett förslag till mätprogram för ozonexponering med fokus på ozonsäsongen och barns miljöer.

    För skolmätningen valdes 10 representativa skolor ut. Ozonprovtagare placerades öppet i två klassrum per skola, oftast på ca 2 m höjd, t ex ovanför en hylla. En provtagare placerades på en öppen plats på skolgården. Mätningarna pågick under samma veckolånga period inomhus och utomhus, alla skolmätningarna startades 13-14 maj. Vi en sköterska inbjöds skolbarn med astma att ingå i bostadsmätningarna”, och 25 tackade efter att ha fått skriftlig information ja till att medverka i studien. Skolornas och bostädernas avgasbelastning har indikerats med en modellberäkning av lokalt trafikgenererad halt av NOx/NO2. På skolgårdarna var veckomedelhalten i genomsnitt 67,4 μg/m3. Det var stora skillnader i utomhushalten av ozon mellan mitten på maj då mätningarna på de 10 skolgårdarna utfördes, och i slutet av september då bostadsområdena studerades. I klassrummen varierade ozonhalten från 12,3 till 48,1 μg/m3, med ett medelvärde på 23.3 μg/m3. I barnens sovrum fanns nästan inget ozon alls. Medelvärdet var 2,1 μg/m3 och spridningen från 0,4 till 5,8 μg/m3. Det observerades inget samband mellan ozonhalten inomhus och utomhus, vilket torde bero på liten ventilation och att ozon är så reaktivt. Utifrån denna pilotstudie kan kostateras att mätningarna för att spegla den mest intressanta exponeringen för ozon bör ske under sommaren, vilket om skolbarn ska inkluderas förmodligen innebär att det vore lättast att göra studien under slutet av vårterminen.

  • 36.
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Occupational and Enviromental Medicine.
    [Soot particles make the air hazardous--again]2007In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 104, no 48, p. 3652-5Article in journal (Refereed)
  • 37.
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Occupational and Enviromental Medicine.
    Stockholmsförsöket har folkhälsopotential2006In: Läkartidningen, no 103, p. 50-52Article in journal (Refereed)
  • 38.
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Traffic related PM and mortality: exposure-response functions and impact calculations for TESS2008Report (Other academic)
    Abstract [en]

    This is a report from the research project TESS – Traffic Emissions, Socio-economic valuation and Socio-economic measures, which is funded by EMFO. In 2002 an agreement about the EMFO program was reached between the partners from the Swedish Vehicle Research Council, PFF. EMFO is a sector-wide research competence to develop vehicles and vehicle components with emission levels that are sustainable in the long term. The aim of EMFO is to offer academia, industry and authorities access to necessary knowledge and pioneering solutions that are necessary if vehicle technology is to develop in the desired direction. One important task is to coordinate activities within the program with both national and international research in the field. EMFO comprises subsidiary programs and two of these were: “Socio-economic evaluation of the health and environmental impact of different emissions” and “Optimal range of socio-economic measures”. TESS undertakes research in these two areas but it is also related to the subsidiary program: “Health and Environmental Impact”. The application was approved in 2005 and the project runs during 2005-2008. The basis for the research in TESS is the valuation methods developed in the EU funded ExternE projects where the external cost of emissions is calculated by tracing the effects that the emissions have on human health and then valuing these effects. The aim is to calculate the external costs related to particles that local emissions (from traffic and other sources) generate on a local and regional scale using Stockholm as a case study. Based on this information an analysis will be made on what reductions measures are likely to be efficient from an economic point of view. The analysis undertaken in TESS requires collaboration between researchers from different research disciplines. There are four parties involved in this project; VTI, SLB analys (Environment and Health Administration, Stockholm), Umeå University and SMHI. This report is focused on the health impact assessment. The first aim is to overview and discuss the epidemiological basis for selection of an exposure-response function, ERF, (or several different) for traffic related particles and mortality. The second aim is to use the exposure calculations by SLB and SMHI presented in TESS to make impact calculations using the selected exposure-response assumptions for particles of three types; exhaust particles, road dust particles and secondary particles (especially nitrates).

  • 39.
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Urban air quality and indicators of respiratory problems1997Doctoral thesis, comprehensive summary (Other academic)
  • 40.
    Forsberg, Bertil
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Bråbäck, Lennart
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Keune, Hans
    Kobernus, Mike
    Krayer von Krauss, Martin
    Yang, Aileen
    Bartonova, Alena
    An expert assessment on climate change and health: with a European focus on lungs and allergies2012In: Environmental health, ISSN 1476-069X, E-ISSN 1476-069X, Vol. 11, no Supplement 1, p. S4-Article in journal (Refereed)
    Abstract [en]

    Background

    For almost 20 years, the Intergovernmental Panel on Climate Change has been assessing the potential health risks associated with climate change; with increasingly convincing evidence that climate change presents existing impacts on human health. In industrialized countries climate change may further affect public health and in particular respiratory health, through existing health stressors, including, anticipated increased number of deaths and acute morbidity due to heat waves; increased frequency of cardiopulmonary events due to higher concentrations of air pollutants; and altered spatial and temporal distribution of allergens and some infectious disease vectors. Additionally exposure to moulds and contaminants from water damaged buildings may increase.

    Methods

    We undertook an expert elicitation amongst European researchers engaged in environmental medicine or respiratory health. All experts were actively publishing researchers on lung disease and air pollution, climate and health or a closely related research. We conducted an online questionnaire on proposed causal diagrams and determined levels of confidence that climate change will have an impact on a series of stressors. In a workshop following the online questionnaire, half of the experts further discussed the results and reasons for differences in assessments of the state of knowledge on exposures and health effects.

    Results

    Out of 16 experts, 100% expressed high to very high confidence that climate change would increase the frequency of heat waves. At least half expressed high or very high confidence that climate change would increase levels of pollen (50%), particulate matter (PM2.5) (55%), and ozone (70%). While clarity is needed around the impacts of increased exposures to health impacts of some stressors, including ozone and particulate matter levels, it was noted that definitive knowledge is not a prerequisite for policy action. Information to the public, preventive measures, monitoring and warning systems were among the most commonly mentioned preventative actions.

    Conclusions

    This group of experts identifies clear health risks associated with climate change, and express opinions about these risks even while they do not necessarily regard themselves as covering all areas of expertise. Since some changes in exposure have already been observed, the consensus is that there is already a scientific basis for preventative action, and that the associated adaptation and mitigation policies should also be evidence based.

  • 41.
    Forsberg, Bertil
    et al.
    Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Occupational and Enviromental Medicine.
    Burman, Lars
    Johansson, Christer
    [Public health potential of the Stockholm trial. Estimated prevention of 23 premature deaths annually among the inner-city population]2006In: Lakartidningen, ISSN 0023-7205, Vol. 103, no 50-52, p. 4043-5Article in journal (Refereed)
  • 42.
    Forsberg, Bertil
    et al.
    Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Occupational and Enviromental Medicine.
    Hansson, Hans-Christen
    Johansson, Christer
    Areskoug, Hans
    Persson, Karin
    Järvholm, Bengt
    Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Occupational and Enviromental Medicine.
    Comparative health impact assessment of local and regional particulate air pollutants in Scandinavia.2005In: Ambio, ISSN 0044-7447, Vol. 34, no 1, p. 11-9Article in journal (Refereed)
  • 43.
    Forsberg, Bertil
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Meister, Kadri
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Segerstedt, Bo
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Luftföroreningshalter och akutbesök för astma samt några andra luftvägssjukdomar i Stockholm, Göteborg och Malmö 2001-2005: projektrapport till Naturvårdsverket2008Report (Other academic)
    Abstract [sv]

    Denna studie inom den hälsorelaterade miljöövervakningen har genomförts på uppdrag avNaturvårdsverket för att belysa eventuella korttidseffekter av luftföroreningar på akutbesökför astma och andra sjukdomar i andningsorganen, vilka ofta medför ökad känslighet förluftföroreningar. Halternas samband med sjukhusinläggningar för andningsorganenssjukdomar har tidigare studerats inom miljöövervakningen. För att underlätta jämförelser harmetodiken anpassats till dessa tidigare studier av sjukhusinläggningar, där betydelsen avhalterna de två senaste dygnen beräknas. Övervakning av denna typ av ”akuta samband” medhalter i miljön bedöms mindre känslig än enklare epidemiologisk bevakning av antalet fall förtrender och förändringar i diagnostik och vårdresurser, eftersom totala antalet fall i sig kanpåverkas av en rad olika typer av faktorer utan koppling till luftföroreningssituationen.

    Uppgifter om den skrivna befolkningens akutbesök under åren 2001 till och med 2005 förandningsorganens sjukdomar inklusive astma vid akutsjukhusen i StorStockholm (8 sjukhus),Göteborg och Mölndal respektive Malmö har inhämtats från Socialstyrelsens Patientregister.Uppgifterna från registret avser avidentifierade akutbesök med diagnoser dygn för dygn underperioden.

    Luftföroreningsdata i form av urbana bakgrundshalter har hämtats från Stockholm luft- ochbulleranalys (SLB) vid miljöförvaltningen i Stockholm, Göteborgs miljöförvaltningrespektive Malmö miljöförvaltning. Vi har studerat partikelhalten som PM10, avgashaltenindikerad med kväveoxider (NOx) samt ozon.

    Tidsserieanalyserna har utförts med Poisson-regression. I dessa analyser tas hänsyn tilltidstrender, årstidsmönster, influensaperioder, väderförhållanden, pollenhalt, veckodag,helgperioder mm. De studerade luftföroreningarna är ozon, kvävedioxid och partiklar. Allaluftföroreningsvariabler kan ses som indikatorer på olika typer av luftföroreningar, och har ikombinationer beaktats i de slutliga analyserna.

    Vi fann att resultaten inte skiljer sig signifikant mellan studieområdena beträffande effekternaav partikelhalten som PM10 och NOx, medan vi för ozon fann kraftigare effekter i Göteborg.När resultaten vägdes ihop för de tre studieområdena beräknas att antalet akutbesök förandningsorganen ökar med 1,4% (95% KI= 0,4-2,4%) per 10 μg/m3 PM10 och akutbesök förastma med 2,8% (95% KI= 1,8-3,7%). Motsvarande sammanvägda resultat för NOx visar enökning av totala antalet akutbesök för andningsorganen med 0,5% (95% KI= 0,1-1,0%) per 10μg/m3 och akutbesök för astma med 1,2% (95% KI= 0,4-2,1%).

    Eftersom föroreningssituationen som indikatorerna representerar kan förändras med tiden, böranalyserna upprepas med viss periodicitet.

  • 44.
    Forsberg, Bertil
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Environmental Medicine.
    Pekkanen, J
    Clench-Aas, J
    Mårtensson, MB
    Stjernberg, Nils
    Bartonova, A
    Timonen, KL
    Skerfving, S
    Childhood asthma in four regions in Scandinavia: risk factors and avoidance effects1997In: International Journal of Epidemiology, ISSN 0300-5771, E-ISSN 1464-3685, Vol. 26, no 3, p. 610-619Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The high and increasing prevalence of childhood asthma is a major public health issue. Various risk factors have been proposed in local studies with different designs.

    METHODS: We have made a questionnaire study of the prevalence of childhood asthma, potential risk factors and their relations in four regions in Scandinavia (Umeå and Malmö in Sweden, Kuopio in eastern Finland and Oslo, Norway). One urban and one less urbanized area were selected in each region, and a study group of 15962 children aged 6-12 years was recruited.

    RESULTS: The prevalence of symptoms suggestive of asthma varied considerably between different areas (dry cough 8-19%, asthma attacks 4-8%, physician-diagnosed asthma 4-9%), as did the potential risk factors. Urban residency was generally not a risk factor. However, dry cough was common in the most traffic polluted area. Exposure to some of the risk factors. such as smoking indoors and moisture stains or moulds at home during the first 2 years of life, resulted in an increased risk. However, current exposure was associated with odds ratios less than one.

    CONCLUSIONS: Our findings were probably due to a combination of early impact and later avoidance of these risk factors. The effects of some risk factors were found to differ significantly between regions. No overall pattern between air pollution and asthma was seen, but air pollution differed less than expected between the areas.

  • 45.
    Forsberg, Bertil
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Segerstedt, Bo
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Short-Term Effects of Air Pollution on Daily Emergency Visits for Asthma and Copd At Hospitals in Stockholm2004In: The Sixteenth Conference of the International Society for Environmental Epidemiology (ISEE): Abstracts, Cambridge, MA: Blackwell Scientific Publications , 2004, Vol. 15, no 4, p. 58-Conference paper (Refereed)
    Abstract [en]

    A large number of studies have analysed air pollution effects on hospital admissions for respiratory diseases. Not so many have dealt with effects on emergency room visits. We have studied the associations between ambient pollution levels and emergency visits for asthma and Chronic Obstructive Pulmonary Disease (COPD) at seven hospitals in Greater Stockholm. Data on daily numbers of respiratory emergency visits, including ICD codes, were obtained from registers kept by the County council. We studied the period 1998-2002. Air pollution data were obtained from the main monitoring station, indicating the urban background concentration of PM10 (TEOM), NO2 and ozone. The daily pollen concentration from one measurement site in the city was also used. Weather data (temperature, relative humidity) were collected from an official weather station at the City airport. The mean concentration was 59 μg/m3 for ozone, 17 μg/m3 for NO2 and 16 μg/m3 for PM10. The mean daily number of emergency visits was 12 for asthma and 3 for COPD. Data were analysed using generalised additive models assuming an overdispersed Poisson model, and estimated using a quasi-likelihood approach. For asthma autoregressive terms were added to the model. We adjusted for season, day of week and weather. If the model was improved, we included also a pollen variable (asthma) and the number of influenza visits. The first analysis has been focussed on the effect of the mean air pollution levels during the last two days (lag 01). We used both single pollutant models, two pollutant models and finally a full model with the three pollutants included simultaneously. Ozone was significant in all COPD models, while the other pollutants never had any significant associations. In the full model the ozone effect was 3% per 10 μg/m3. For all asthma no pollutant had any significant effect, but for the largest subgroup (J45.9; unspecified asthma, here representing two thirds of the asthma visits) ozone significantly increased the number of visits. The estimate was about 2% per 10 μg/m3 in all models. These coefficients are rather high in comparison with other studies, but not high when compared with the ozone effect on respiratory hospital admissions in Stockholm. We conclude that ozone from an health point of view is an important air pollutant in this area.

  • 46.
    Forsberg, Bertil
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Stjernberg, Nils
    Falk, M
    Lundbäck, B
    Wall, Stig
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Air pollution levels, meteorological conditions and asthma symptoms1993In: European Respiratory Journal, ISSN 0903-1936, E-ISSN 1399-3003, Vol. 6, no 8, p. 1109-1115Article in journal (Refereed)
    Abstract [en]

    We wanted to assess relations between the daily occurrence of asthma symptoms and fluctuations of air pollution concentrations and meteorological conditions. In a panel of 31 asthmatic patients residing in the town of Piteå in northern Sweden, severe symptoms of shortness of breath, wheeze, cough and phlegm were recorded in an asthma diary together with suspected causes. Sulphur dioxide, nitrogen dioxide, black smoke, relative humidity and temperature were used to evaluate the relationship to the environment. By using multivariate analyses, we found that daily variations in the particulate pollution levels, indicated by black smoke levels below the criteria limits, had significant effects on the risk of developing severe symptoms of shortness of breath. This association was stronger among 10 subjects, who had at least five incident days with severe shortness of breath. Meteorological conditions were not significant in the multivariate models. Cough and phlegm did not show significant relationships to any environmental condition that was evaluated. Only one-third of the subjects reported, at least once during the study, symptoms believed to be related to air pollutants, although we found significant correlations between the pollution levels and the frequency of pollution-related symptoms. We conclude that an association has been established for black smoke as pollutant and shortness of breath as respiratory symptom, and that in certain asthmatics, effects were occurring at lower particulate levels than suggested previously.

  • 47.
    Forsberg, Bertil
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Stjernberg, Nils
    National Institute for Working Life, Umeå, Sweden.
    Linné, R
    Landskrona Hospital, Landskrona, Sweden.
    Segerstedt, Bo
    Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE).
    Wall, Stig
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Daily air pollution levels and acute asthma in southern Sweden1998In: European Respiratory Journal, ISSN 0903-1936, E-ISSN 1399-3003, Vol. 12, no 4, p. 900-905Article in journal (Refereed)
    Abstract [en]

    This study aimed to investigate the association between daily air pollution levels and the occurrence of acute respiratory signs and symptoms among people with asthma or asthma-like problems.

    Thirty eight subjects in the southern Swedish city of Landskrona kept a daily diary for 10 weeks. The daily prevalence of symptoms, supplementary bronchodilator use and peak flow deviations were compared with measurements of environmental nitrogen dioxide (NO2), sulphur dioxide, temperature and humidity in the city.

    The occurrence of severe asthma, both during the day and during the evening, was significantly positively associated with the concurrent 24 h average concentration of NO2, which never exceeded 72 microg x m(-3). A correlation of borderline significance was found between the use of on-demand medication and the NO2 level. However, peak flow deviations were not associated with air pollution or weather conditions, which may be explained by the beneficial effect of bronchodilators used by 28 of the subjects.

    The results of this study confirm those of some earlier studies and suggest that aggravation of asthma is related to daily variations in air quality, as indicated by relatively low ambient concentrations of nitrogen dioxide. These results also indicate that it may be appropriate to examine severe asthma symptoms separately.

  • 48.
    Forsberg, Bertil
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Stjernberg, Nils
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Wall, Stig
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    People can detect poor air quality well below guideline concentrations: a prevalence study of annoyance reactions and air pollution from traffic1997In: Occupational and Environmental Medicine, ISSN 1351-0711, E-ISSN 1470-7926, Vol. 54, no 1, p. 44-48Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: Motor vehicle exhaust fumes are the main source of atmospheric pollution in cities in industrialised countries. They cause respiratory disease and annoy people exposed to them. The relation between ambient exposure to air pollution mainly from motor vehicles and annoyance reactions in a general population was assessed. Also, the importance of factors such as age, sex, respiratory disease, access to the use of a car, and smoking habits on the reporting of these reactions was studied.

    METHODS: A postal questionnaire was sent out in 55 urban areas in Sweden that had nearly identical air quality monitoring stations of the urban air monitoring network. From each area, 150 people aged 16-70 were randomly selected. The questionnaire contained questions on perception of air quality as well as a question on how often exhaust fumes were annoying.

    RESULTS: Six-monthly nitrogen dioxide concentrations correlated consistently with the prevalence of reported annoyance related to air pollution and traffic exhaust fumes. Black smoke and sulphur dioxide had no significant effects. The frequency of reporting annoyance reactions was higher among people with asthma, women, and people with lack of access to a car.

    CONCLUSIONS: In this study town dwellers could detect poor air quality at concentrations well below current guidelines for outdoor air pollution. This suggests that questionnaire studies have a place in monitoring air quality.

  • 49.
    Forsberg, Bertil
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Environmental Medicine.
    Stjernberg, Nils
    Wall, Stig
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Prevalence of respiratory and hyperreactivity symptoms in relation to levels of criteria air pollutants in Sweden1997In: European Journal of Public Health, ISSN 1101-1262, E-ISSN 1464-360X, Vol. 7, no 3, p. 291-296Article in journal (Refereed)
    Abstract [en]

    Our knowledge of the adverse health effects from exposure to low levels of air pollution is still insufficient. Early indicators, such as respiratory symptoms, need more attention. We made use of the fact that possible weak effects can be detected more easily when the relevant exposure and other determinants are well controlled. A postal questionnaire was sent to random samples of inhabitants registered as residing in the Vicinity of 55 centrally located air quality monitoring stations in Swedish towns. There were 6,109 questionnaires (76%) returned. Multivariate analyses with confounding control were used to examine the effects of different levels of criteria pollutants on the prevalence of symptoms. The ranges of the half year values were 9-32 and 2-16 mu g/m(3) for nitrogen dioxide and sulphur dioxide respectively. Logistic regression analyses showed higher risks for respiratory problems such as coughs, throat irritation and nose irritation among the persons most exposed, The associations were most obvious for nitrogen dioxide exposure among women. The suggested effects of air pollution exposure cannot be medically evaluated today but they are nevertheless interesting since they are found within common levels usually considered to be safe.

  • 50.
    Forsberg, Bertil
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Wahlgren, Chatrin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Lundström, Nils-Göran
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Jonsson, Lennart
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Eldningsvanor inom några studieområden i Västerbotten2014Report (Other academic)
    Abstract [sv]

    I syfte att få bättre underlag om vedeldningens omfattning och emissioner har en eldningsvaneundersökning genomförts i fyra områden inom Västerbotten. Undersökningen baseras på en besöksintervju genomförd av två personer vilka följt ett formulär med frågor och standardiserat sina klassificeringar av de intervjuades svar av mer öppen karaktär. Intervjuerna har genomförts i fyra områden med bebyggelse av olika ålder: Vännäs (kommuncentra), Vännäsby, Sävar och Tavleliden/Tomtebo (villaförort i Umeå). På dessa platser har partikelmätningar i en punkt genomförts inom ramen för ett annat projekt, och kortvariga sotmätningar genomförts på fler platser. Hushåll till intervjuerna utvaldes utifrån att de enligt sotarregistret har någon form av ved- , flis- eller pelletseldning. Totalt intervjuades 176 hushåll, endast ett två ytterligare var tillfrågade och avböjde. Studien visar anläggningarnas användningsgrad, bl.a. bränsleförbrukning per år, vilket kan användas för att beräkna utsläppsmängder. För pannor fanns dock inget samband mellan hög sotnings-frekvens enligt sotarregistren och hög vedförbrukning per år enligt intervjuerna. De som har fjärrvärme som huvudsakligt uppvärmningssätt använder sin kamin/lokaleldstad mindre än den som i huvudsak värmer bostaden med el. Utsläpps- och haltberäkningar kan ta hänsyn till denna kunskap.

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