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  • 101. Götschi, Thomas
    et al.
    Hazenkamp-Von Arxb, Marianne E
    Heinrich, Joachim
    Bono, Roberto
    Burney, Peter
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Jarvis, Deborah
    Maldonado, Jose
    Norbäck, Dan
    Stern, Willem B
    Sunyer, Jordi
    Torén, Kjell
    Verlato, Giuseppe
    Villani, Simona
    Künzli, Nino
    Elemental composition and reflectance of ambient fine particles at 21 European locations2005In: Atmospheric Environment, ISSN 1352-2310, E-ISSN 1873-2844, Vol. 39, no 32, p. 5947-5958Article in journal (Refereed)
    Abstract [en]

    We sampled fine particles (PM2.5) over a 1-year period at 21 central urban monitoring sites in 20 cities of the European Community Respiratory Health Survey (ECRHS). Particle filters were then analysed for elemental composition using energy dispersive X-ray fluorescence spectrometry and reflectance (light absorption). Elemental analyses yielded valid results for 15 elements (Al, As, Br, Ca, Cl, Cu, Fe, K, Mn, Pb, S, Si, Ti, V, Zn). Annual and seasonal means Of PM2.5, reflectance, and elements show a wide range across Europe with the lowest levels found in Iceland and up to 80 times higher concentrations in Northern Italy. This pattern holds for most of the air pollution indicators. The mass concentration of S did constitute the largest fraction of the analysed elements Of PM2.5 in all locations. The crustal component varies from less than 10% up to 25% across these cities. Temporal correlations of daily values vary considerably from city to city, depending on the indicators compared. Nevertheless, correlations between estimates of long-term exposure, such as annual means, are generally high among indicators Of PM2.5 from anthropogenic sources, such as S, metals, and reflectance. This highlights the difficulty to disentangle effects of specific sources or PM constituents in future health effect analyses using annual averages.

  • 102. Götschi, Thomas
    et al.
    Sunyer, Jordi
    Chinn, Susan
    de Marco, Roberto
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Occupational and Enviromental Medicine.
    Gauderman, James W
    Garcia-Esteban, Raquel
    Heinrich, Joachim
    Jacquemin, Bénédicte
    Jarvis, Deborah
    Ponzio, Michela
    Villani, Simona
    Künzli, Nino
    Air pollution and lung function in the European Community Respiratory Health Survey.2008In: International journal of epidemiology, ISSN 1464-3685, Vol. 37, no 6, p. 1349-58Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The association of long-term air pollution and lung function has not been studied across adult European multi-national populations before. The aim of this study was to determine the association between long-term urban background air pollution and lung function levels, as well as change in lung function among European adults. METHODS: Forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC) and the ratio thereof (FEV1/FVC) were assessed at baseline and after 9 years of follow-up in adults from 21 European centres (followed-up sample 5610). Fine particles (PM(2.5)) were measured in 2000/2001 using central monitors. RESULTS: Despite sufficient statistical power no significant associations were found between city-specific annual mean PM(2.5) and average lung function levels. The findings also do not support an effect on change in lung function, albeit statistical power was insufficient to significantly detect such an association. CONCLUSIONS: The inability to refuse the null hypothesis may reflect (i) no effect of urban air pollution on lung function or (ii) inherent biases due to the study design. Examples of the latter are lack of individual-level air quality assignment, not quantified within-city contrasts in traffic-related pollution, or the heterogeneity of the studied populations and their urban environments. Future studies on long-term effects of air pollution on lung function could increase statistical power and reduce potential misclassification and confounding by characterizing exposure on the level of individuals, capturing contrasts due to local sources, in particular traffic.

  • 103.
    Hagenbjörk-Gustafsson, Annika
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Tornevi, Andreas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Andersson, Eva M
    Johannesson, Sandra
    Bellander, Tom
    Merritt, Anne-Sophie
    Tinnerberg, Håkan
    Westberg, Håkan
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Sallsten, Gerd
    Determinants of personal exposure to some carcinogenic substances and nitrogen dioxide among the general population in five Swedish cities2014In: Journal of Exposure Science and Environmental Epidemiology, ISSN 1559-0631, E-ISSN 1559-064X, Vol. 24, no 4, p. 437-443Article in journal (Refereed)
    Abstract [en]

    Environmental levels of airborne carcinogenic and related substances are comparatively better known than individual exposure and its determinants. We report on a personal monitoring program involving five Swedish urban populations. The aim of the program was to investigate personal exposure to benzene, 1,3-butadiene, formaldehyde, and nitrogen dioxide (NO2). The measurements were performed among 40 inhabitants during seven consecutive days, in one urban area each year, during 2000-2008. The estimated population exposure levels were 1.95 μg/m(3) for benzene, 0.56 μg/m(3) for 1,3-butadiene, 19.4 μg/m(3) for formaldehyde, and 14.1 μg/m(3) for NO2. Statistical analysis using a mixed-effects model revealed that time spent in traffic and time outdoors contributed to benzene and 1,3- butadiene exposure. For benzene, refueling a car was an additional determinant influencing the exposure level. Smoking or environmental tobacco smoke were significant determinants of exposure to NO2, benzene, and 1,3-butadiene. Those with a gas stove had higher NO2 exposure. Living in a single-family house increased the exposure to formaldehyde significantly. In a variance component model, the between-subject variance dominated for 1,3-butadiene and formaldehyde, whereas the between-city variance dominated for NO2. For benzene, the between-subject and between-cities variances were similar.

  • 104.
    Hagenbjörk-Gustafsson, Annika
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Tornevi, Andreas
    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.
    Field validation of the Ogawa diffusive sampler for NO(2) and NO(x) in a cold climate2010In: Journal of Environmental Monitoring, ISSN 1464-0325, E-ISSN 1464-0333, Vol. 12, no 6, p. 1315-24Article in journal (Refereed)
    Abstract [en]

    A small-scale field trial in Umeå, Sweden with Ogawa samplers and a chemiluminescence instrument indicated that the NO(2) concentration was underestimated with respect to the reference monitor, if calculated according to the manufacturer's Ogawa sampling protocol. By co-locating Ogawa samplers and reference monitors at six sites in two Swedish cities, uptake rates were determined for NO(2) and NO(x) better applicable to the Swedish conditions and climate. The concentrations of NO(2) and NO(x) calculated according to the instruction manual of the sampler and using the field-determined uptake rates were compared with values derived from chemiluminescence monitors for each week over which samples were taken. When calculated according to the manufacturer's suggested protocol, the Ogawa sampler underestimated the NO(2) concentrations by 9.1% on average for all samples (N = 53), with respect to the reference monitor. In contrast, NO(x) concentrations were overestimated by a mean value of 15% for all samples (N = 45). By using the field determined uptake rates for the calculation of NO(2) and NO(x) a better estimation of the concentrations was obtained. The ratio between concentrations determined with the Ogawa samplers and chemiluminescence monitors was then 1.02 for all measurements of NO(2) and 1.00 for NO(x). Precision, expressed as the mean coefficient of variation, was 6.4% for six, 6-replicate measurements of NO(2) and 3.7% for five, 6-replicate measurements of NO(x).

  • 105.
    Hagenbjörk-Gustavsson, Annika
    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.
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Hälsorelaterad miljöövervakning. Cancerframkallande ämnen i tätortsluft: personlig exponering och bakgrundsmätningar i Umeå 20132014Report (Other academic)
    Abstract [sv]

    Undersökningen kartlägger allmänbefolkningens exponering via luften för vissa cancerframkallande ämnen (bensen, 1,3-butadien, formaldehyd) och kvävedioxid. Undersökningen genomfördes i centrala Umeå under hösten 2013, och inkluderade totalt 40 slumpvis utvalda personer i åldrarna 20-50 år.

    Mätningarna upprepades på 20 personer. Utöver de personburna mätningarna genomfördes även stationära mätningar på två platser utomhus, samt för partiklar även inomhus hos 20 deltagare. Deltagarfrekvensen var 66% och medelåldern var 35 år. Den personliga medianhalten för bensen och 1,3-butadien var 1,4 μg/m3 respektive 0,2 μg/m3 vilket är något lägre än halterna år 2001. Bensenhalten överskrider lågrisknivån (1,3 μg/m3), medan halten 1,3-butadien ligger i nedre kanten av lågriskintervallet. Det fanns en signifikant korrelation mellan den personliga exponeringen för bensen och 1,3-butadien (rs=0.50, p=<0.01). Medianhalten för formaldehyd var 12 μg/m3, och halterna var högre bland de som bodde i villa jämfört med lägenhet. Medianhalten kvävedioxid var 12 μg/m3. PM2.5 mättes utomhus i urban bakgrund samt hemma hos deltagare under två dygn. Medianvärdet för inomhusmätningarna av PM2.5 var högre än motsvarande halt vid mätningarna 2007 (1,9 μg/m3). PM2,5 filtren analyserades även på sitt innehåll av polycykliska kolväten och halterna inomhus var lägre jämfört med halterna utomhus, och var klart lägre än den fastställda lågrisknivån.

  • 106. Hastan, D
    et al.
    Fokkens, W J
    Bachert, C
    Newson, R B
    Bislimovska, J
    Bockelbrink, A
    Bousquet, P J
    Brozek, G
    Bruno, A
    Dahlén, S E
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Gunnbjörnsdóttir, M
    Kasper, L
    Krämer, U
    Kowalski, M L
    Lange, B
    Lundbäck, B
    Salagean, E
    Todo-Bom, A
    Tomassen, P
    Toskala, E
    van Drunen, C M
    Bousquet, J
    Zuberbier, T
    Jarvis, D
    Burney, P
    Chronic rhinosinusitis in Europe: an underestimated disease. A GA²LEN study2011In: Allergy. European Journal of Allergy and Clinical Immunology, ISSN 0105-4538, E-ISSN 1398-9995, Vol. 66, no 9, p. 1216-1223Article in journal (Refereed)
    Abstract [en]

    Background:  Chronic rhinosinusitis (CRS) is a common health problem, with significant medical costs and impact on general health. Even so, prevalence figures for Europe are unavailable. In this study, conducted by the GA2LEN network of excellence, the European Position Paper on Rhinosinusitis and nasal Polyps (EP3OS) diagnostic criteria are applied to estimate variation in the prevalence of Chronic rhinosinusitis (CRS) for Europe.

    Method:  A postal questionnaire was sent to a random sample of adults aged 15–75 years in 19 centres in Europe. Participants reported symptoms of CRS, and doctor diagnosed CRS, allergic rhinitis, age, gender and smoking history. Definition of CRS was based on the EP3OS diagnostic criteria: the presence of more than two of the symptoms: (i) nasal blockage, (ii) nasal discharge, (iii) facial pain/pressure or (iv) reduction in sense of smell, for >12 weeks in the past year – with at least one symptom being nasal blockage or discharge.

    Results:  Information was obtained from 57 128 responders living in 19 centres in 12 countries. The overall prevalence of CRS by EP3OS criteria was 10.9% (range 6.9–27.1). CRS was more common in smokers than in nonsmokers (OR 1.7: 95% CI 1.6–1.9). The prevalence of self-reported physician-diagnosed CRS within centres was highly correlated with the prevalence of EP3OS-diagnosed CRS.

    Conclusion:  This is the first European international multicentre prevalence study of CRS. In this multicentre survey of adults in Europe, about one in ten participants had CRS with marked geographical variation. Smoking was associated with having CRS in all parts of Europe.

  • 107.
    Hedman, Linnéa
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Andersson, Martin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Bjerg, Anders
    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.
    Environmental risk factors related to the incidence of wheeze and asthma in adolescence2015In: Clinical and Experimental Allergy, ISSN 0954-7894, E-ISSN 1365-2222, Vol. 45, no 1, p. 184-191Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Asthma is common among adolescents, but there are few population-based studies on the risk factors for incident asthma and wheeze at this age group OBJECTIVE: To study risk factors for incident asthma and wheeze in adolescence.

    METHOD: Within the Obstructive Lung Disease In Northern Sweden (OLIN) studies, a cohort of 3430 school children (age 7-8y) was recruited in 1996. In the present study, this cohort was followed from age 12 to 19y. At baseline (age 12y), 3151 participated and skin prick tests (SPT) were performed. The cohort was resurveyed annually and risk factors for the cumulative incidence of asthma and wheeze from age 12 to19y were analysed using multivariate Cox regression.

    RESULTS: Female sex (wheeze: HR1.4 95%CI 1.2-1.6; asthma: HR1.8 95%CI1.2-2.5) and a positive SPT to cat, dog or horse at baseline (wheeze: HR 1.6 95%CI 1.2-2.1; asthma: HR2.3 95%CI 1.4-4.0) were significantly associated with the cumulative incidence of wheeze and asthma. Increasing numbers of siblings were inversely related to the incidence of wheeze (HR0.9 95%CI 0.8-0.97) and asthma (HR0.8 95%CI 0.7-0.97). Parental asthma was related to the incidence of asthma (HR 1.8 95%CI 1.2-2.6) while ever smoking (HR 2.0 95%CI 1.6-2.4) and house dampness (HR 1.3 95%CI 1.1-1.6) were risk factors for the incidence of wheeze. Maternal ETS exposure increased the risk of incident asthma in non-sensitized subjects (HR 1.9 95%CI 1.0-3.7).

    CONCLUSION AND CLINICAL RELEVANCE: Several environmental risk factors related to the incidence of asthma and wheeze in adolescence were identified and may be possible targets for intervention and prevention.

  • 108.
    Hedman, Linnéa
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Andersson, Martin
    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.
    Lundbäck, B
    Rönmark, Eva
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Incidence of wheeze and asthma in adolescence in relation to environmental factorsManuscript (preprint) (Other academic)
  • 109.
    Hedman, Linnéa
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Bjerg, Anders
    Sundberg, Sigrid
    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.
    Both environmental tobacco smoke and personal smoking is related to asthma and wheeze in teenagers2011In: Thorax, ISSN 0040-6376, E-ISSN 1468-3296, Vol. 66, no 1, p. 20-25Article in journal (Refereed)
    Abstract [en]

    Background: Environmental tobacco smoke (ETS) has been reported as a significant risk factor for childhood asthma. Among adults, personal smoking is a major cause of respiratory symptoms and diseases. The effects of these exposures on the prevalence of asthma and wheeze among teenagers are less well known.

    Objective: The aim was to study the independent and combined effects of ETS and personal smoking on the prevalence of asthma and wheeze in teenagers.

    Methods: A longitudinal study of asthma and allergic diseases in schoolchildren has been in progress in Northern Sweden since 1996. All children aged 7–8 years in three municipalities were invited and 3430 (97%) participants have been followed by annual questionnaires. At the age 16–17 years, 82% of the initial participants took part in the 2005 survey.

    Results: Prevalence of physician-diagnosed asthma, ever wheeze and current wheeze was significantly higher among those exposed to maternal ETS and among daily smokers. In multivariate analyses, maternal ETS was a significant risk factor for physician-diagnosed asthma and ever wheeze (OR 1.3–1.5) and personal daily smoking for current wheeze (OR 2.0). ORs for asthma and ever wheeze were highest among daily smokers who were also exposed to maternal ETS with ORs of 1.7 and 2.5, respectively. A significant dose–response association between number of cigarettes/day and the prevalence of wheeze was also found.

    Conclusions: Both ETS and personal smoking were significantly related to asthma and wheeze in teenagers. Maternal ETS exposure was associated with lifetime symptoms, but daily smoking among the teenagers was more strongly related to current symptoms.

  • 110.
    Helleday, Ragnberth
    et al.
    Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Pulmonary Medicine.
    Segerstedt, Bo
    Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Occupational and Enviromental Medicine.
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Occupational and Enviromental Medicine.
    Mudway, Ian
    Nordberg, Gunnar
    Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Occupational and Enviromental Medicine.
    Bernard, Alfred
    Blomberg, Anders
    Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Pulmonary Medicine.
    Exploring the time dependence of serum clara cell protein as a biomarker of pulmonary injury in humans.2006In: Chest, ISSN 0012-3692, E-ISSN 1931-3543, Vol. 130, no 3, p. 672-675Article in journal (Refereed)
  • 111. Henschel, Susann
    et al.
    Atkinson, Richard
    Zeka, Ariana
    Le Tertre, Alain
    Analitis, Antonis
    Katsouyanni, Klea
    Chanel, Olivier
    Pascal, Mathilde
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Medina, Sylvia
    Goodman, Patrick G
    Air pollution interventions and their impact on public health2012In: International Journal of Public Health, ISSN 1661-8556, E-ISSN 1661-8564, Vol. 57, no 5, p. 757-768Article, review/survey (Refereed)
    Abstract [en]

    INTRODUCTION: Numerous epidemiological studies have found a link between air pollution and health. We are reviewing a collection of published intervention studies with particular focus on studies assessing both improvements in air quality and associated health effects. METHODS: Interventions, defined as events aimed at reducing air pollution or where reductions occurred as a side effect, e.g. strikes, German reunification, from the 1960s onwards were considered for inclusion. This review is not a complete record of all existing air pollution interventions. In total, 28 studies published in English were selected based on a systematic search of internet databases. RESULTS: Overall air pollution interventions have succeeded at improving air quality. Consistently published evidence suggests that most of these interventions have been associated with health benefits, mainly by the way of reduced cardiovascular and/or respiratory mortality and/or morbidity. The decrease in mortality from the majority of the reviewed interventions has been estimated to exceed the expected predicted figures based on the estimates from time-series studies. CONCLUSION: There is consistent evidence that decreased air pollution levels following an intervention resulted in health benefits for the assessed population.

  • 112. Holm, M
    et al.
    Kim, J-L
    Lillienberg, L
    Storaas, T
    Jögi, R
    Svanes, C
    Schlünssen, V
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Gíslason, T
    Janson, C
    Torén, K
    Incidence and prevalence of chronic bronchitis: impact of smoking and welding. The RHINE study2012In: The International Journal of Tuberculosis and Lung Disease, ISSN 1027-3719, E-ISSN 1815-7920, Vol. 16, no 4, p. 553-557Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To investigate the prevalence and incidence rate of chronic bronchitis (CB) in relation to smoking habits and exposure to welding fumes in a general population sample.

    METHODS: Subjects from Northern Europe born between 1945 and 1971 who participated in Stage 1 (1989-1994) of the European Community Respiratory Health Survey were mailed a respiratory questionnaire in 1999-2001 (the RHINE study); 15 909 answered the questionnaire and gave complete data on smoking. CB was defined as chronic productive cough of at least 3 months a year for 2 consecutive years. The questionnaire comprised an item about age when CB started and items about exposure to welding fumes. The incidence of CB was retrospectively assessed for the observation period 1980-2001.

    RESULTS: CB had a prevalence of 5.4%, and was associated with current smoking and welding exposure. The incidence rate of CB was 1.9 per 1000 person-years, and was increased in relation to welding exposure (low exposure HR 1.4, 95%CI 1.1-1.8; high exposure HR 2.0, 95%CI 1.6-2.7) and in relation to smoking (HR 2.1, 95%CI 1.8-2.5).

    CONCLUSION: Smoking and occupational exposure to welding fumes are both associated with an increased risk of CB.

  • 113. Holm, Mathias
    et al.
    Schiöler, Linus
    Andersson, Eva
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Gislason, Thorarinn
    Janson, Christer
    Jogi, Rain
    Schlünssen, Vivi
    Svanes, Cecilie
    Torén, Kjell
    Predictors of smoking cessation: a longitudinal study in a large cohort of smokers2017In: Respiratory Medicine, ISSN 0954-6111, E-ISSN 1532-3064, Vol. 132, p. 164-169Article in journal (Refereed)
    Abstract [en]

    Background: There are few studies on predictors of smoking cessation in general populations. We studied the smoking cessation rate in relation to several potential predictors, with special focus on respiratory and cardiovascular disease.

    Methods: Smokers (n = 4636) from seven centres in Northern Europe, born between 1945 and 1973, who answered a questionnaire in 1999–2001 (the RHINE study) were followed up with a new questionnaire in 2010–2012. Altogether 2564 answered the questionnaire and provided complete data on smoking. Cox regression analyses were performed to calculate hazard ratios (HRs).

    Results: A total of 999 subjects (39%) stopped smoking during the study period. The smoking cessation rate was 44.9/1000 person-years. Smoking cessation was more common with increasing age, higher education and fewer years of smoking. Asthma, wheeze, hay fever, chronic bronchitis, diabetes and hypertension did not significantly predict smoking cessation, but smokers hospitalized for ischaemic heart disease during the study period were more prone to stopping smoking (HR 3.75 [2.62–5.37]).

    Conclusions: Successful smoking cessation is common in middle-aged smokers, and is associated with few smoking years and higher education. A diagnosis of respiratory disease does not appear to motivate people to quit smoking, nor do known cardiovascular risk factors; however, an acute episode of ischaemic heart disease encouraged smoking cessation in our study population.

  • 114. Jacquemin, B
    et al.
    Sunyer, J
    Forsberg, B
    Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Occupational and Enviromental Medicine.
    Aguilera, I
    Briggs, D
    Götschi, T
    Heinrich, J
    Torén, K
    Vienneau, D
    Künzli, N
    Association between annoyance and individuals' values of nitrogen dioxide in a European setting.2008In: Journal of epidemiology and community health, ISSN 1470-2738, Vol. 62, no 5, p. e12-Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: Annoyance caused by air pollution has been proposed as an indicator of exposure to air pollution. The aim of this study was to assess the geographical homogeneity of the relationship between annoyance and modelled home-based nitrogen dioxide (NO2) measurements. METHODS: The European Community Respiratory Health Survey II was conducted in 2000-1, in 25 European centres in 12 countries. This analysis included 4753 subjects (from 37 in Tartu, Estonia, to 532 in Antwerp, Belgium) who answered the annoyance question and with available outdoor residential NO2 (4399 modelled and 354 measured) including 20 cities from 10 countries. Annoyance as a result of air pollution was self-reported on an 11-point scale (0, no disturbance at all; 10, intolerable disturbance). Demographic and socioeconomic factors, smoking status and the presence of respiratory symptoms or disease were measured through a standard questionnaire. Negative binomial regression was used. RESULTS: The median NO2 concentration was 27 microg.m(-3) (from 10 in Umeå, Sweden, to 57 in Barcelona, Spain). The mean of annoyance was 2.5 (from 0.7 in Reykjavik, Iceland, to 4.4 in Huelva, Spain). NO2 was associated with annoyance (ratio of the mean score 1.26 per 10 microg.m(-3), 95% CI 1.19 to 1.34). The association between NO2 and annoyance was heterogeneous among cities (p for heterogeneity <0.001). CONCLUSIONS: Annoyance is associated with home outdoor air pollution but with a different strength by city. This indicates that annoyance is not a valid surrogate for air pollution exposure. Nevertheless, it may be a useful measure of perceived ambient air quality and could be considered a complementary tool for health surveillance.

  • 115. Jacquemin, B
    et al.
    Sunyer, J
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Aguilera, I
    Bouso, L
    Briggs, D
    de Marco, R
    García-Esteban, R
    Heinrich, J
    Jarvis, D
    Maldonado, J A
    Payo, F
    Rage, E
    Vienneau, D
    Künzli, N
    Association between modelled traffic related air pollution (NO2) and asthma score in ECHRS.2009In: European Respiratory Journal, ISSN 0903-1936, E-ISSN 1399-3003, Vol. 34, no 4, p. 834-842Article in journal (Refereed)
    Abstract [en]

    The aim of this analysis is to study the association between air pollution and asthma among adults. For this goal, a previously developed "asthma score" was used.Persons aged 25-44 years were randomly selected (1991-1993) and followed up (2000-2002) within the European Community Respiratory Health Survey (ECRHS-I and II). The asthma score was defined from 0 to 5, based on positive answers to symptoms reported for the last 12 months: wheeze/breathlessness, chest tightness, dyspnoea at rest, dyspnoea after exercise, and woken by dyspnoea. Participants' home addresses were linked to outdoor modelled NO2 estimates for 2001. Negative binomial regression was used to model the asthma score.The score from ECRHS-II was positively associated with NO2 (Ratio of the Mean asthma Score (RMS) 1.23, 95% Confidence Intervals (CI): 1.09-1.38 for an increase of 10 microg.m(-3)). After excluding participants with asthma and symptoms at baseline, the association remained (RMS 1.25, 95%CI: 1.05-1.51) and was particularly high among those reporting a high score in ECRHS-II. The latter probably reflects incident cases of asthma.Our results suggest that traffic-related pollution causes asthma symptoms and possibly asthma incidence in adults. The asthma score offers an alternative to investigate the course and aetiology of asthma in adults.

  • 116. Jacquemin, Bénédicte
    et al.
    Sunyer, Jordi
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Aguilera, Inmaculada
    Briggs, David
    García-Esteban, Raquel
    Götschi, Thomas
    Heinrich, Joachim
    Järvholm, Bengt
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Jarvis, Debbie
    Vienneau, Danielle
    Künzli, Nino
    Home outdoor NO2 and new onset of self-reported asthma in adults2009In: Epidemiology, ISSN 1044-3983, E-ISSN 1531-5487, Vol. 20, no 1, p. 119-126Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Few studies have investigated new onset of asthma in adults in relation to air pollution. The aim of this study is to investigate the association between modeled background levels of traffic-related air pollution at the subjects' home addresses and self-reported asthma incidence in a European adult population. METHODS: Adults from the European Respiratory Health Survey were included (n = 4185 from 17 cities). Subjects' home addresses were geocoded and linked to outdoor nitrogen dioxide (NO2) estimates, as a marker of local traffic-related pollution. We obtained this information from the 1-km background NO2 surface modeled in APMoSPHERE (Air Pollution Modelling for Support to Policy on Health and Environmental Risk in Europe). Asthma incidence was defined as reporting asthma in the follow-up (1999 to 2001) but not in the baseline (1991 to 1993). RESULTS: A positive association was found between NO2 and asthma incidence (odds ratio 1.43; 95% confidence interval = 1.02 to 2.01) per 10 microg/m. Results were homogeneous among centers (P value for heterogeneity = 0.59). CONCLUSIONS: We found an association between a marker of traffic-related air pollution and asthma incidence in European adults.

  • 117. Jacquemin, Bénédicte
    et al.
    Sunyer, Jordi
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Occupational and Enviromental Medicine.
    Götschi, Thomas
    Bayer-Oglesby, Lucy
    Ackermann-Liebrich, Ursula
    de Marco, Roberto
    Heinrich, Joachim
    Jarvis, Deborah
    Torén, Kjell
    Künzli, Nino
    Annoyance due to air pollution in Europe.2007In: International Journal of Epidemiology, ISSN 0300-5771, E-ISSN 1464-3685, Vol. 36, no 4, p. 809-20Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Annoyance due to air pollution is a subjective score of air quality, which has been incorporated into the National Environmental monitoring of some countries. The objectives of this study are to describe the variations in annoyance due to air pollution in Europe and its individual and environmental determinants. METHODS: This study took place in the context of the European Community Respiratory Health Survey II (ECRHS II) that was conducted during 1999-2001. It included 25 centres in 12 countries and 7867 randomly selected adults from the general population. Annoyance due to air pollution was self-reported on an 11-point scale. Annual mean mass concentration of fine particles (PM(2.5)) and its sulphur (S) content were measured in 21 centres as a surrogate of urban air pollution. RESULTS: Forty-three per cent of participants reported moderate annoyance (1-5 on the scale) and 14% high annoyance (> or =6) with large differences across centres (2-40% of high annoyance). Participants in the Northern European countries reported less annoyance. Female gender, nocturnal dyspnoea, phlegm and rhinitis, self-reported car and heavy vehicle traffic in front of the home, high education, non-smoking and exposure to environmental tobacco smoke were associated with higher annoyance levels. At the centre level, adjusted means of annoyance scores were moderately associated with sulphur urban levels (slope 1.43 microg m(-3), standard error 0.40, r = 0.61). CONCLUSIONS: Annoyance due to air pollution is frequent in Europe. Individuals' annoyance may be a useful measure of perceived ambient quality and could be considered a complementary tool for health surveillance.

  • 118. James, Anna
    et al.
    Janson, Christer
    Malinovschi, Andrei
    Holweg, Cecile
    Alving, Kjell
    Ono, Junya
    Ohta, Shoichiro
    Ek, Alexandra
    Middelveld, Roelinde
    Dahlén, Barbro
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Izuhara, Kenji
    Dahlén, Sven-Erik
    Serum periostin relates to type-2 inflammation and lung function in asthma: data from the large population-based cohort Swedish GA(2)LEN2017In: Allergy. European Journal of Allergy and Clinical Immunology, ISSN 0105-4538, E-ISSN 1398-9995, Vol. 72, no 11, p. 1753-1760Article in journal (Refereed)
    Abstract [en]

    Background: Periostin has been suggested as a novel, phenotype-specific biomarker for asthma driven by type-2 inflammation. However, large studies examining relationships between circulating periostin and patient characteristics are lacking and the suitability of periostin as a biomarker in asthma remains unclear.

    Aim: To examine circulating periostin in healthy controls and subjects with asthma from the general population with different severity and treatment profiles, both with and without chronic rhinosinusitis (CRS), in relation to other biomarkers and clinical characteristics.

    Methods: Serum periostin was examined by ELISA in 1091 subjects aged 17-76 from the Swedish GA(2)LEN study, which included 460 asthmatics with/without chronic rhinosinusitis (CRS), 97 individuals with CRS only, and 203 healthy controls. Clinical tests included measurement of lung function, FeNO, IgE, urinary eosinophil derived neurotoxin (U-EDN) and serum eosinophil cationic protein (S-ECP), as well as completion of questionnaires regarding respiratory symptoms, medication and quality of life.

    Results: Although median periostin values showed no differences when comparing disease groups with healthy controls, multiple regression analyses revealed that periostin was positively associated with higher FeNO, U-EDN and total IgE. In patients with asthma, an inverse relationship with lung function was also observed. Current smoking was associated with decreased periostin levels, whereas increased age and lower BMI related to higher periostin levels in subjects both with and without asthma.

    Conclusion: We confirm associations between periostin and markers of type-2 inflammation, as well as lung function, and identify novel constitutional factors of importance to the use of periostin as a phenotype-specific biomarker in asthma.

  • 119.
    Jansson, Sven-Arne
    et al.
    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.
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Löfgren, Curt
    Lindberg, Anne
    Lundbäck, Bo
    The economic consequences of asthma among adults in Sweden.2007In: Respiratory Medicine, ISSN 0954-6111, E-ISSN 1532-3064, Vol. 101, no 11, p. 2263-70Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: Asthma is a common disease in most countries. The objective of this study was to estimate the societal costs for subjects with asthma. METHODS: Telephone interviews regarding resource utilization were made in a representative sample of 115 randomly selected subjects with asthma derived from a large population study of obstructive airway diseases. Direct and indirect costs were measured, and the costs were also transformed with the estimated prevalence of asthma in Sweden. RESULTS: Average annual costs were SEK 15919 (USD 1592; EUR 1768) per subject with asthma in the ages between 25 and 56 years. The direct and indirect costs were SEK 4931 (31.0%) and SEK 10988 (69.0%), respectively, and were highly dependent of age and disease severity. Assuming that the prevalence is representative for Sweden as a whole, the asthmatics would amount to 226000 in the ages between 25 and 56 years, corresponding to an overall prevalence in Sweden of 6-7%. The total costs of asthma for the society amounted thus to SEK 3.7 billion in these ages. CONCLUSIONS: The total costs of asthma for the society could be estimated at 3.7 billion SEK in the age range of 25-56 years, and thus approximately twice as high in the whole population of Sweden. The costs were strongly dependent on disease severity and increasing age.

  • 120. Jarvis, D
    et al.
    Newson, R
    Lotvall, J
    Hastan, D
    Tomassen, P
    Keil, T
    Gjomarkaj, M
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Gunnbjornsdottir, M
    Minov, J
    Brozek, G
    Dahlen, SE
    Toskala, E
    Kowalski, ML
    Olze, H
    Howarth, P
    Krämer, U
    Baelum, J
    Loureiro, C
    Kasper, L
    Bousquet, PJ
    Bousquet, J
    Bachert, C
    Fokkens, W
    Burney, P
    Asthma in adults and its association with chronic rhinosinusitis: the GA(2) LEN survey in Europe2012In: Allergy. European Journal of Allergy and Clinical Immunology, ISSN 0105-4538, E-ISSN 1398-9995, Vol. 67, no 1, p. 91-98Article in journal (Refereed)
    Abstract [en]

    Background: The prevalence of asthma and its association with chronic rhinosinusitis (CRS) have not been widely studied in population-based epidemiological surveys.

    Methods: The Global Allergy and Asthma Network of Excellence (GA2LEN) conducted a postal questionnaire in representative samples of adults living in Europe to assess the presence of asthma and CRS defined by the European Position Paper on Rhinosinusitis and Nasal Polyps. The prevalence of self-reported current asthma by age group was determined. The association of asthma with CRS in each participating centre was assessed using logistic regression analyses, controlling for age, sex and smoking, and the effect estimates were combined using standard methods of meta-analysis.

    Results: Over 52 000 adults aged 18–75 years and living in 19 centres in 12 countries took part. In most centres, and overall, the reported prevalence of asthma was lower in older adults (adjusted OR for 65–74 years compared with 15–24 years: 0.72; 95% CI: 0.63–0.81). In all centres, there was a strong association of asthma with CRS (adjusted OR: 3.47; 95% CI: 3.20–3.76) at all ages. The association with asthma was stronger in those reporting both CRS and allergic rhinitis (adjusted OR: 11.85; 95% CI: 10.57–13.17). CRS in the absence of nasal allergies was positively associated with late-onset asthma.

    Conclusion: Geographical variation in the prevalence of self-reported asthma was observed across Europe, but overall, self-reported asthma was more common in young adults, women and smokers. In all age groups, men and women, and irrespective of smoking behaviour, asthma was also associated with CRS.

  • 121. Jarvis, Debbie
    et al.
    Newson, Roger
    Janson, Christer
    Corsico, Angelo
    Heinrich, Joachim
    Anto, Josep M
    Abramson, Michael J
    Kirsten, Anne-Marie
    Zock, Jan Paul
    Bono, Roberto
    Demoly, Pascal
    Leynaert, Bénédicte
    Raherison, Chantal
    Pin, Isabelle
    Gislason, Thorarinn
    Jogi, Rain
    Schlunssen, Vivi
    Svanes, Cecilie
    Watkins, John
    Weyler, Joost
    Pereira-Vega, Antonio
    Urrutia, Isabel
    Gullón, Jose A
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Probst-Hensch, Nicole
    Boezen, H Marike
    Martinez-Moratalla Rovira, Jesús
    Accordini, Simone
    de Marco, Roberto
    Burney, Peter
    Prevalence of asthma-like symptoms with ageing2018In: Thorax, ISSN 0040-6376, E-ISSN 1468-3296, Vol. 73, no 1, p. 37-48Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Change in the prevalence of asthma-like symptoms in populations of ageing adults is likely to be influenced by smoking, asthma treatment and atopy.

    METHODS: The European Community Respiratory Health Survey collected information on prevalent asthma-like symptoms from representative samples of adults aged 20-44 years (29 centres in 13 European countries and Australia) at baseline and 10 and 20 years later (n=7844). Net changes in symptom prevalence were determined using generalised estimating equations (accounting for non-response through inverse probability weighting), followed by meta-analysis of centre level estimates.

    FINDINGS: Over 20 years the prevalence of 'wheeze' and 'wheeze in the absence of a cold' decreased (-2.4%, 95% CI -3.5 to -1.3%; -1.5%, 95% CI -2.4 to -0.6%, respectively) but the prevalence of asthma attacks, use of asthma medication and hay fever/nasal allergies increased (0.6%, 95% CI 0.1 to 1.11; 3.6%, 95% CI 3.0 to 4.2; 2.7%, 95% CI 1.7 to 3.7). Changes were similar in the first 10 years compared with the second 10 years, except for hay fever/nasal allergies (increase seen in the first 10 years only). Decreases in these wheeze-related symptoms were largely seen in the group who gave up smoking, and were seen in those who reported hay fever/nasal allergies at baseline.

    INTERPRETATION: European adults born between 1946 and 1970 have, over the last 20 years, experienced less wheeze, although they were more likely to report asthma attacks, use of asthma medication and hay fever. Decrease in wheeze is largely attributable to smoking cessation, rather than improved treatment of asthma. It may also be influenced by reductions in atopy with ageing.

  • 122. Johannessen, Ane
    et al.
    Kuiper, Ingrid Nordeide
    Accordini, Simone
    Bertelsen, Randi Jacobsen
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Gislason, Thorarinn
    Heinrich, Joachim
    Holm, Mathias
    Jögi, Rain
    Kirkeleit, Jorunn
    Malinovschi, Andrei
    Marcon, Alessandro
    Markevych, Iana
    Oudin, Anna
    Schlünssen, Vivi
    Sigsgaard, Torben
    Svanes, Cecilie
    Torén, Kjell
    Janson, Christer
    Long-term air pollution exposure is associated with sick leave 20 years later2018In: European Respiratory Journal, ISSN 0903-1936, E-ISSN 1399-3003, Vol. 52Article in journal (Other academic)
    Abstract [en]

    Background: Little is known on outdoor air pollution in a long-term perspective and societal costs such as sick leave. In the Nordic countries, recent pollution health impact assessments have had to rely on outdated studies.

    Aims: To investigate if air pollution exposure is associated with sick leave 20 years later.

    Methods: We analysed self-reported sick leave (all-cause and respiratory) in 7 466 subjects from Bergen, Gothenburg, Umea, Uppsala in the RHINE3 study in 2010-12. Home addresses were geocoded and linked to annual average concentrations of PM2.5, PM10 and NO2 at RHINE3, 10 years earlier and 20 years earlier, using existing land-use regression (LUR) models. We performed multilevel logistic regression clustered by centre, and adjusted for sex, smoking, education and previous health-related workplace change.

    Results: Age range in RHINE3 was 40-66 yrs, 34% and 4% reported all-cause and respiratory sick leave during the last year. In the adjusted analyses all-cause sick leave was associated with PM2.520 years earlier (OR per interquartile range (IQR) difference (2.6 µg/m³) 1.12 (95%CI 1.01, 1.24)), and borderline with NO2 (OR per IQR diff (8.1 µg/m³) 1.09 (95%CI 0.99, 1.19)). Respiratory sick leave was associated with PM10 20 years earlier (OR per IQR diff (3.92 µg/m³) 1.54 (95%CI 1.06, 2.25)), and borderline with PM2.5 (OR per IQR diff 1.31 (95%CI 0.97, 1.76)). Pollution exposures at present as well as 10 years earlier were not significantly associated with sick leave.

    Conclusions: Air pollution exposure in a general population is associated with sick leave in a 20-year perspective. Our findings suggest that even low air pollution levels such as in Northern Europe have societal costs over time.

  • 123. Johannessen, Ane
    et al.
    Verlato, Giuseppe
    Benediktsdottir, Bryndis
    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.
    Gislason, Thorarinn
    Holm, Mathias
    Janson, Christer
    Jögi, Rain
    Lindberg, Eva
    Macsali, Ferenc
    Omenaas, Ernst
    Real, Francisco Gomez
    Saure, Eirunn Waatevik
    Schlünssen, Vivi
    Sigsgaard, Torben
    Skorge, Trude Duelien
    Svanes, Cecilie
    Torén, Kjell
    Waatevik, Marie
    Nilsen, Roy Miodini
    de Marco, Roberto
    Longterm follow-up in European respiratory health studies: patterns and implications2014In: BMC Pulmonary Medicine, ISSN 1471-2466, E-ISSN 1471-2466, Vol. 14, p. 63-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Selection bias is a systematic error in epidemiologic studies that may seriously distort true measures of associations between exposure and disease. Observational studies are highly susceptible to selection bias, and researchers should therefore always examine to what extent selection bias may be present in their material and what characterizes the bias in their material. In the present study we examined long-term participation and consequences of loss to follow-up in the studies Respiratory Health in Northern Europe (RHINE), Italian centers of European Community Respiratory Health Survey (I-ECRHS), and the Italian Study on Asthma in Young Adults (ISAYA). METHODS: Logistic regression identified predictors for follow-up participation. Baseline prevalence of 9 respiratory symptoms (asthma attack, asthma medication, combined variable with asthma attack and/or asthma medication, wheeze, rhinitis, wheeze with dyspnea, wheeze without cold, waking with chest tightness, waking with dyspnea) and 9 exposure-outcome associations (predictors sex, age and smoking; outcomes wheeze, asthma and rhinitis) were compared between all baseline participants and long-term participants. Bias was measured as ratios of relative frequencies and ratios of odds ratios (ROR). RESULTS: Follow-up response rates after 10 years were 75% in RHINE, 64% in I-ECRHS and 53% in ISAYA. After 20 years of follow-up, response was 53% in RHINE and 49% in I-ECRHS. Female sex predicted long-term participation (in RHINE OR (95%CI) 1.30(1.22, 1.38); in I-ECRHS 1.29 (1.11, 1.50); and in ISAYA 1.42 (1.25, 1.61)), as did increasing age. Baseline prevalence of respiratory symptoms were lower among long-term participants (relative deviations compared to total baseline population 0-15% (RHINE), 0-48% (I-ECRHS), 3-20% (ISAYA)), except rhinitis which had a slightly higher prevalence. Most exposure-outcome associations did not differ between long-term participants and all baseline participants, except lower OR for rhinitis among ISAYA long-term participating smokers (relative deviation 17% (smokers) and 44% (10-20 pack years)). CONCLUSIONS: We found comparable patterns of long-term participation and loss to follow-up in RHINE, I-ECRHS and ISAYA. Baseline prevalence estimates for long-term participants were slightly lower than for the total baseline population, while exposure-outcome associations were mainly unchanged by loss to follow-up.

  • 124. Johansson, Christer
    et al.
    Burman, Lars
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    The effects of congestions tax on air quality and health2009In: Atmospheric Environment, ISSN 1352-2310, E-ISSN 1873-2844, Vol. 43, no 31, p. 4843-4854Article in journal (Refereed)
    Abstract [en]

    The “Stockholm Trial” involved a road pricing system to improve the air quality and reduce traffic congestion. The test period of the trial was January 3–July 31, 2006. Vehicles travelling into and out of the charge cordon were charged for every passage during weekdays. The amount due varied during the day and was highest during rush hours (20 SEK = 2.2 EUR, maximum 60 SEK per day). Based on measured and modelled changes in road traffic it was estimated that this system resulted in a 15% reduction in total road use within the charged cordon. Total traffic emissions in this area of NOx and PM10 fell by 8.5% and 13%, respectively. Air quality dispersion modelling was applied to assess the effect of the emission reductions on ambient concentrations and population exposure. For the situations with and without the trial, meteorological conditions and other emissions than from road traffic were kept the same. The calculations show that, with a permanent congestion tax system like the Stockholm Trial, the annual average NOx concentrations would be lower by up to 12% along the most densely trafficked streets. PM10 concentrations would be up to 7% lower. The limit values for both PM10 and NO2 would still be exceeded along the most densely trafficked streets. The total population exposure of NOx in Greater Stockholm (35 × 35 km with 1.44 million people) is estimated to decrease with a rather modest 0.23 μg m−3. However, based on a long-term epidemiological study, that found an increased mortality risk of 8% per 10 μg m−3 NOx, it is estimated that 27 premature deaths would be avoided every year. According to life-table analysis this would correspond to 206 years of life gained over 10 years per 100 000 people following the trial if the effects on exposures would persist. The effect on mortality is attributed to road traffic emissions (likely vehicle exhaust particles); NOx is merely regarded as an indicator of traffic exposure. This is only the tip of the ice-berg since reductions are expected in both respiratory and cardiovascular morbidity. This study demonstrates the importance of not only assessing the effects on air quality limit values, but also to make quantitative estimates of health impacts, in order to justify actions to reduce air pollution.

  • 125. Johansson, Christer
    et al.
    Lövenheim, Boel
    Schantz, Peter
    Wahlgren, Lina
    Almström, Peter
    Markstedt, Anders
    Strömgren, Magnus
    Umeå University, Faculty of Social Sciences, Department of Geography and Economic History, Economic and social geography.
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Nilsson Sommar, Johan
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Impacts on air pollution and health by changing commuting from car to bicycle2017In: Science of the Total Environment, ISSN 0048-9697, E-ISSN 1879-1026, Vol. 584-585, p. 55-63Article in journal (Refereed)
    Abstract [en]

    Our study is based on individual data on people's home and work addresses, as well as their age, sex and physical capacity, in order to establish realistic bicycle-travel distances. A transport model is used to single out data on commuting preferences in the County Stockholm. Our analysis shows there is a very large potential for reducing emissions and exposure if all car drivers living within a distance corresponding to a maximum of a 30 min bicycle ride to work would change to commuting by bicycle. It would result in > 111,000 new cyclists, corresponding to an increase of 209% compared to the current situation.

    Mean population exposure would be reduced by about 7% for both NOx and black carbon (BC) in the most densely populated area of the inner city of Stockholm. Applying a relative risk for NOx of 8% decrease in all-cause mortality associated with a 10 μg m− 3decrease in NOx, this corresponds to > 449 (95% CI: 340–558) years of life saved annually for the Stockholm county area with 2.1 million inhabitants. This is more than double the effect of the reduced mortality estimated for the introduction of congestion charge in Stockholm in 2006. Using NO2 or BC as indicator of health impacts, we obtain 395 (95% CI: 172–617) and 185 (95% CI: 158–209) years of life saved for the population, respectively. The calculated exposure of BC and its corresponding impacts on mortality are likely underestimated. With this in mind the estimates using NOx, NO2 and BC show quite similar health impacts considering the 95% confidence intervals.

  • 126. Jönsson, Oskar
    et al.
    Andersson, Camilla
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Johansson, Christer
    Air pollution episodes in Stockholm regional background air due to sources in Europe and their effects on human population2013In: Boreal environment research, ISSN 1239-6095, E-ISSN 1797-2469, Vol. 18, no 3-4, p. 280-302Article in journal (Refereed)
    Abstract [en]

    Using air quality measurements, we categorized air pollution according to source sectors in a rural background environment in southern Sweden based on hourly air-mass backward trajectories during 1997-2010. Concentrations of fine (PM2.5) and sum of fine and coarse particulate matter (PM10), accumulation mode particle number, black carbon and surface ozone were 4.0, 3.9, 4.5, 6.8 and 1.3 times higher, respectively, in air masses from the southeast as compared with those in air masses from the cleanest sector in the northwest, consistent with air-mass transport over areas with relatively high emissions of primary particulate matter (PM) and secondary PM precursors. The highest ultrafine particle numbers were associated with clean air from the northwest. We estimate that almost 7.8% and 0.6% higher premature human mortality is caused by PM2.5 and ozone exposure, respectively, when air originates from the southeast as compared with that when air originates from the northwest. Reductions of emissions in eastern Europe would reduce the highest air pollution concentrations and associated health risks. However, since air masses from the southwest are more frequent, emissions in the western part of Europe are more important for annual mean premature mortality.

  • 127. Keidel, Dirk
    et al.
    Anto, Josep Maria
    Basagaña, Xavier
    Bono, Roberto
    Burte, Emilie
    Carsin, Anne-Elie
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Fuertes, Elaine
    Galobardes, Bruna
    Heinrich, Joachim
    de Hoogh, Kees
    Jarvis, Debbie
    Künzli, Nino
    Leynaert, Bénédicte
    Marcon, Alessandro
    Le Moual, Nicole
    de Nazelle, Audrey
    Schindler, Christian
    Siroux, Valérie
    Stempfelet, Morgane
    Sunyer, Jordi
    Temam, Sofia
    Tsai, Ming-Yi
    Varraso, Raphaëlle
    Jacquemin, Bénédicte
    Probst-Hensch, Nicole
    The Role of Socioeconomic Status in the Association of Lung Function and Air Pollution: A Pooled Analysis of Three Adult ESCAPE Cohorts2019In: International Journal of Environmental Research and Public Health, ISSN 1661-7827, E-ISSN 1660-4601, Vol. 16, no 11, article id E1901Article in journal (Refereed)
    Abstract [en]

    Ambient air pollution is a leading environmental risk factor and its broad spectrum of adverse health effects includes a decrease in lung function. Socioeconomic status (SES) is known to be associated with both air pollution exposure and respiratory function. This study assesses the role of SES either as confounder or effect modifier of the association between ambient air pollution and lung function. Cross-sectional data from three European multicenter adult cohorts were pooled to assess factors associated with lung function, including annual means of home outdoor NO2. Pre-bronchodilator lung function was measured according to the ATS-criteria. Multiple mixed linear models with random intercepts for study areas were used. Three different factors (education, occupation and neighborhood unemployment rate) were considered to represent SES. NO2 exposure was negatively associated with lung function. Occupation and neighborhood unemployment rates were not associated with lung function. However, the inclusion of the SES-variable education improved the models and the air pollution-lung function associations got slightly stronger. NO2 associations with lung function were not substantially modified by SES-variables. In this multicenter European study we could show that SES plays a role as a confounder in the association of ambient NO2 exposure with lung function.

  • 128. Keune, Hans
    et al.
    Gutleb, Arno C
    Zimmer, Karin E
    Ravnum, Solveig
    Yang, Aileen
    Bartonova, Alena
    Krayer von Krauss, Martin
    Ropstad, Erik
    Eriksen, Gunnar S
    Saunders, Margaret
    Magnanti, Brooke
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    We’re only in it for the knowledge?: a problem solving turn in environment and health expert elicitation2012In: Environmental health, ISSN 1476-069X, E-ISSN 1476-069X, Vol. 11, no Supplement 1, p. S3-Article in journal (Refereed)
    Abstract [en]

    Background: The FP6 EU HENVINET project aimed at synthesizing the scientific information available on a number of topics of high relevance to policy makers in environment and health. The goal of the current paper is to reflect on the methodology that was used in the project, in view of exploring the usefulness of this and similar methodologies to the policy process. The topics investigated included health impacts of the brominated flame retardants decabrominated diphenylether (decaBDE) and hexabromocyclododecane (HBCD), phthalates highlighting di(2-ethylhexyl)phthalate (DEHP), the pesticide chlorpyrifos (CPF), nanoparticles, the impacts of climate change on asthma and other respiratory disorders, and the influence of environment health stressors on cancer induction. Methods: Initially the focus was on identifying knowledge gaps in the state of the art in scientific knowledge. Literature reviews covered all elements that compose the causal chain of the different environmental health issues from emissions to exposures, to effects and to health impacts. Through expert elicitation, knowledge gaps were highlighted by assessing expert confidence using calibrated confidence scales. During this work a complementary focus to that on knowledge gaps was developed through interdisciplinary reflections. By extending the scope of the endeavour from only a scientific perspective, to also include the more problem solving oriented policy perspective, the question of which kind of policy action experts consider justifiable was addressed. This was addressed by means of a questionnaire. In an expert workshop the results of both questionnaires were discussed as a basis for policy briefs. Results: The expert elicitation, the application of the calibrated confidence levels and the problem solving approach were all experienced as being quite challenging for the experts involved, as these approaches did not easily relate to mainstream environment and health scientific practices. Even so, most experts were quite positive about it. In particular, the opportunity to widen one's own horizon and to interactively exchange knowledge and debate with a diversity of experts seemed to be well appreciated in this approach. Different parts of the approach also helped in focussing on specific relevant aspects of scientific knowledge, and as such can be considered of reflective value. Conclusions: The approach developed by HENVINET was part of a practice of learning by doing and of interdisciplinary cooperation and negotiation. Ambitions were challenged by unforeseen complexities and difference of opinion and as no Holy Grail approach was at hand to copy or follow, it was quite an interesting but also complicated endeavour. Perfection, if this could be defined, seemed out of reach all the time. Nevertheless, many involved were quite positive about it. It seems that many felt that it fitted some important needs in current science when addressing the needs of policy making on such important issues, without anyone really having a clue on how to actually do this. Challenging questions remain on the quality of such approach and its product. Practice tells us that there probably is no best method and that the best we can do is dependent on contextual negotiation and learning from experiences that we think are relevant.

  • 129.
    Kriit, Hedi Katre
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Stewart Williams, Jennifer
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Lindholm, Lars
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health.
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Sommar, Johan
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Health economic assessment of a scenario to promote bicycling as active transport in Stockholm, Sweden2019In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 9, no 9, article id e030466Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: To conduct a health economic evaluation of a proposed investment in urban bicycle infrastructure in Stockholm County, Sweden.

    DESIGN: A cost-effectiveness analysis is undertaken from a healthcare perspective. Investment costs over a 50-year life cycle are offset by averted healthcare costs and compared with estimated long-term impacts on morbidity, quantified in disability-adjusted life years (DALYs). The results are re-calculated under different assumptions to model the effects of uncertainty.

    SETTING: The Municipality of Stockholm (population 2.27 million) committed funds for bicycle path infrastructure with the aim of achieving a 15% increase in the number of bicycle commuters by 2030. This work is based on a previously constructed scenario, in which individual registry data on home and work address and a transport model allocation to different modes of transport identified 111 487 individuals with the physical capacity to bicycle to work within 30 min but that currently drive a car to work.

    RESULTS: Morbidity impacts and healthcare costs attributed to increased physical activity, change in air pollution exposure and accident risk are quantified under the scenario. The largest reduction in healthcare costs is attributed to increased physical activity and the second largest to reduced air pollution exposure among the population of Greater Stockholm. The expected net benefit from the investment is 8.7% of the 2017 Stockholm County healthcare budget, and 3.7% after discounting. The economic evaluation estimates that the intervention is cost-effective and each DALY averted gives a surplus of €9933. The results remained robust under varied assumptions pertaining to reduced numbers of additional bicycle commuters.

    CONCLUSION: Investing in urban infrastructure to increase bicycling as active transport is cost-effective from a healthcare sector perspective.

  • 130. Kuiper, Ingrid Nordeide
    et al.
    Svanes, Cecilie
    Abramson, Michael J.
    Benediktsdottir, Bryndis
    Bertelsen, Randi J.
    Dennekamp, Martine
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Gislason, Thorarinn
    Halvorsen, Thomas
    Heinrich, Joachim
    Holm, Mathias
    Janson, Christer
    Jögi, Rain
    Malinovschi, Andrei
    Marcon, Alessandro
    Markevych, Iana
    Moratalla, Jesús M.
    Oudin, Anna
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine. Division of Occupational and Environmental Medicine, Lund University, Sweden.
    Pearce, John L.
    Schlünssen, Vivi
    Vega, Antonio P.
    Johannessen, Ane
    Lung health in adulthood after childhood exposure to air pollution and greenness2018In: European Respiratory Journal, ISSN 0903-1936, E-ISSN 1399-3003, Vol. 52Article in journal (Other academic)
    Abstract [en]

    Background: Little is known on childhood exposure to air pollution and adult chronic respiratory outcomes.

    Aim: To investigate associations between air pollution and greenness in childhood and adult lung health.

    Methods: In selected centres of the RHINESSA study (age 18-52) we analysed the outcomes respiratory symptoms (≥3 symptoms), severe wheeze (wheeze last year with breathlessness, no cold) and late onset asthma (>10 years). We calculated mean annual exposures of PM2.5, PM10, NO2 (µg/m³) and greenness (Normalized Difference Vegetation Index, 100m buffer) from offspring's birth till age 18, categorised into mean exposure <10 years and 11-18 years. We performed multilevel logistic regression clustered by family, stratified by centre and adjusted for childhood passive smoke and parental asthma.

    Results: 12% had ≥3 respiratory symptoms, 7.7% severe wheeze, and 9.4% late onset asthma. Overall estimates: greenness was associated with less respiratory symptoms, PM2.5 and NO2 with more late onset asthma. Exposure <10 years: Greenness was associated with less wheeze in Tartu (OR 0.29, 95%CI 0.11-0.73). PM2.5 (OR 1.22, 95%CI 1.00-1.48) and NO2 (OR 1.06, 95%CI 1.01-1.11) were risk factors for late onset asthma in Bergen. PM10 was a risk factor for respiratory symptoms (OR 1.21, 95%CI 1.04-1.41) in Uppsala and late onset asthma (OR 1.23, 95%CI 1.02-1.45) in Bergen. Exposure 11-18 years: Greenness was protective for respiratory symptoms (OR 0.29, 95%CI 0.10-0.86) and wheeze (OR 0.39, 95%CI 0.19-0.80) in Tartu.

    Conclusions: Childhood exposure to greenness was associated with less respiratory symptoms, while air pollutants were associated with more respiratory symptoms (some centres) and late onset asthma.

  • 131. Kuiper, Ingrid Nordeide
    et al.
    Svanes, Cecilie
    Markevych, Iana
    Heinrich, Joachim
    Halvorse, Thomas n
    Bertelsen, Randi J.
    Holm, Mathias
    Bråbäck, Lennart
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Malinovschi, Andrei
    Janson, Christer
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Toren, Kjell
    Accordini, Simone
    Marcon, Alessandro
    Jarvis, Debbie
    Gislason, Thorarinn
    Benediktsdottir, Bryndis
    Schlunssen, Vivi
    Sigsgaard, Torben
    Johannessen, Ane
    Preconception air pollution exposure and early onset asthma and hay fever in the offspring2019In: European Respiratory Journal, ISSN 0903-1936, E-ISSN 1399-3003, Vol. 54Article in journal (Other academic)
  • 132. Kämpe, Mary
    et al.
    Vosough, Maria
    Malinovschi, Andrei
    Alimohammadi, Mohammad
    Alving, Kjell
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Lötvall, Jan
    Middelveld, Roelinde
    Dahlén, Barbro
    Janson, Christer
    Upper airway and skin symptoms in allergic and non-allergic asthma: results from the Swedish GA2LEN study2018In: Journal of Asthma, ISSN 0277-0903, E-ISSN 1532-4303, Vol. 55, no 3, p. 275-283Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Allergic and non-allergic asthma are viewed as separate entities, despite sharing similarities. The aims of this study were to determine differences in symptoms from the upper airways and the skin in allergic and non-allergic asthma. The secondary aims were to identify childhood risk factors and to compare quality of life in the two asthma groups.

    METHODS: This cohort (age 17-76 years) consisted of 575 subjects with allergic or non-allergic asthma and 219 controls. The participants participated in an interview, spirometry, exhaled nitric oxide (NO), skin prick test and responded to the Mini Asthma Quality of Life Questionnaire.

    RESULTS: Self-reported allergic rhinitis was significantly more common in both allergic and non-allergic asthma (82.3% and 40.7%) compared with the controls. The prevalence of chronic rhinosinusitis (CRS) was similar in both asthma groups. Eczema was significantly more common in both asthmatic groups (72.3% and 59.8%) than controls (47.0%) (p < 0.001 and p = 0.012). Severe respiratory infection in childhood and parental allergy were risk factors for both allergic and non-allergic asthma. Quality of life was significantly lower in non-allergic than allergic asthma (p = 0.01).

    CONCLUSION: Concomitant symptoms from the upper airways and the skin were significantly more common in both allergic and non-allergic asthma. This indicates that non-allergic asthma has a systemic component with similarities to what is found in allergic asthma. There were similarities in the childhood risk factor pattern between the two types of asthma but asthma-related quality of life was lower in the non-allergic asthma group.

  • 133. Künzli, Nino
    et al.
    Mudway, Ian S
    Götschi, Thomas
    Shi, Tingming
    Kelly, Frank J
    Cook, Sarah
    Burney, Peter
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Occupational and Enviromental Medicine.
    Gauderman, James W
    Hazenkamp, Marianne E
    Heinrich, Joachim
    Jarvis, Deborah
    Norbäck, Dan
    Payo-Losa, Felix
    Poli, Albino
    Sunyer, Jordi
    Borm, Paul J A
    Comparison of oxidative properties, light absorbance, total and elemental mass concentration of ambient PM2.5 collected at 20 European sites.2006In: Environ Health Perspect, ISSN 0091-6765, Vol. 114, no 5, p. 684-90Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Body mass, as well as distribution of body fat, are predictors of both diabetes and cardiovascular disease. In Northern Sweden, despite a marked increase in average body mass, prevalence of diabetes was stagnant and myocardial infarctions decreased. A more favourable distribution of body fat is a possible contributing factor.This study investigates the relative importance of individual food items for time trends in waist circumference (WC) and hip circumference (HC) on a population level. METHODS: Independent cross-sectional surveys conducted in 1986, 1990, 1994 and 1999 in the two northernmost counties of Sweden with a common population of 250,000. Randomly selected age stratified samples, altogether 2982 men and 3087 women aged 25-64 years. Questionnaires were completed and anthropometric measurements taken. For each food item, associations between frequency of consumption and waist and hip circumferences were estimated. Partial regression coefficients for every level of reported intake were multiplied with differences in proportion of the population reporting the corresponding levels of intake in 1986 and 1999. The sum of these product terms for every food item was the respective estimated impact on mean circumference. RESULTS: Time trends in reported food consumption associated with the more favourable gynoid distribution of adipose tissue were increased use of vegetable oil, pasta and 1.5% fat milk. Trends associated with abdominal obesity were increased consumption of beer in men and higher intake of hamburgers and French fried potatoes in women. CONCLUSION: Food trends as markers of time trends in body fat distribution have been identified. The method is a complement to conventional approaches to establish associations between food intake and disease risk on a population level.

  • 134.
    Lagerkvist, Birgitta Json
    et al.
    Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Occupational and Enviromental Medicine.
    Bernard, Alfred
    Blomberg, Anders
    Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Pulmonary Medicine.
    Bergström, Erik
    Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Occupational and Enviromental Medicine.
    Holmstrom, Karin
    Karp, Kjell
    Lundstrom, Nils-Goran
    Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Occupational and Enviromental Medicine.
    Segerstedt, Bo
    Svensson, Mona
    Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Occupational and Enviromental Medicine.
    Nordberg, Gunnar
    Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Occupational and Enviromental Medicine.
    Pulmonary epithelial integrity in children: relationship to ambient ozone exposure and swimming pool attendance.2004In: Environ Health Perspect, ISSN 0091-6765, Vol. 112, no 17, p. 1768-71Article in journal (Refereed)
  • 135. Lee, Jae Young
    et al.
    Kim, Ho
    Gasparrini, Antonio
    Armstrong, Ben
    Bell, Michelle L
    Sera, Francesco
    Lavigne, Eric
    Abrutzky, Rosana
    Tong, Shilu
    Coelho, Micheline de Sousa Zanotti Stagliorio
    Saldiva, Paulo Hilario Nascimento
    Correa, Patricia Matus
    Ortega, Nicolas Valdes
    Kan, Haidong
    Garcia, Samuel Osorio
    Kyselý, Jan
    Urban, Aleš
    Orru, Hans
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health. Institute of Family Medicine and Public Health, University of Tartu, Tartu, Estonia.
    Indermitte, Ene
    Jaakkola, Jouni J K
    Ryti, Niilo R I
    Pascal, Mathilde
    Goodman, Patrick G
    Zeka, Ariana
    Michelozzi, Paola
    Scortichini, Matteo
    Hashizume, Masahiro
    Honda, Yasushi
    Hurtado, Magali
    Cruz, Julio
    Seposo, Xerxes
    Nunes, Baltazar
    Teixeira, João Paulo
    Tobias, Aurelio
    Íñiguez, Carmen
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Åström, Christofer
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Vicedo-Cabrera, Ana Maria
    Ragettli, Martina S
    Guo, Yue-Liang Leon
    Chen, Bing-Yu
    Zanobetti, Antonella
    Schwartz, Joel
    Dang, Tran Ngoc
    Do Van, Dung
    Mayvaneh, Fetemeh
    Overcenco, Ala
    Li, Shanshan
    Guo, Yuming
    Predicted temperature-increase-induced global health burden and its regional variability2019In: Environment International, ISSN 0160-4120, E-ISSN 1873-6750, Vol. 131, article id 105027Article in journal (Refereed)
    Abstract [en]

    An increase in the global health burden of temperature was projected for 459 locations in 28 countries worldwide under four representative concentration pathway scenarios until 2099. We determined that the amount of temperature increase for each 100 ppm increase in global CO2 concentrations is nearly constant, regardless of climate scenarios. The overall average temperature increase during 2010-2099 is largest in Canada (1.16 °C/100 ppm) and Finland (1.14 °C/100 ppm), while it is smallest in Ireland (0.62 °C/100 ppm) and Argentina (0.63 °C/100 ppm). In addition, for each 1 °C temperature increase, the amount of excess mortality is increased largely in tropical countries such as Vietnam (10.34%p/°C) and the Philippines (8.18%p/°C), while it is decreased in Ireland (-0.92%p/°C) and Australia (-0.32%p/°C). To understand the regional variability in temperature increase and mortality, we performed a regression-based modeling. We observed that the projected temperature increase is highly correlated with daily temperature range at the location and vulnerability to temperature increase is affected by health expenditure, and proportions of obese and elderly population.

  • 136. Lee, Whanhee
    et al.
    Bell, Michelle L.
    Gasparrini, Antonio
    Armstrong, Ben G.
    Sera, Francesco
    Hwang, Sunghee
    Lavigne, Eric
    Zanobetti, Antonella
    Coelho, Micheline de Sousa Zanotti Stagliorio
    Saldiva, Paulo Hilario Nascimento
    Osorio, Samuel
    Tobias, Aurelio
    Zeka, Ariana
    Goodman, Patrick G.
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Rocklöv, Joacim
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Hashizume, Masahiro
    Honda, Yasushi
    Guo, Yue-Liang Leon
    Seposo, Xerxes
    Van Dung, Do
    Dang, Tran Ngoc
    Tong, Shilu
    Guo, Yuming
    Kim, Ho
    Mortality burden of diurnal temperature range and its temporal changes: a multi-country study2018In: Environment International, ISSN 0160-4120, E-ISSN 1873-6750, Vol. 110, p. 123-130Article in journal (Refereed)
    Abstract [en]

    Although diurnal temperature range (DTR) is a key index of climate change, few studies have reported the health burden of DTR and its temporal changes at a multi-country scale. Therefore, we assessed the attributable risk fraction of DTR on mortality and its temporal variations in a multi-country data set. We collected time-series data covering mortality and weather variables from 308 cities in 10 countries from 1972 to 2013. The temporal change in DTR-related mortality was estimated for each city with a time-varying distributed lag model. Estimates for each city were pooled using a multivariate meta-analysis. The results showed that the attributable fraction of total mortality to DTR was 2.5% (95% eCI: 2.3-2.7%) over the entire study period. In all countries, the attributable fraction increased from 2.4% (2.1-2.7%) to 2.7% (2.4-2.9%) between the first and last study years. This study found that DTR has significantly contributed to mortality in all the countries studied, and this attributable fraction has significantly increased over time in the USA, the UK, Spain, and South Korea. Therefore, because the health burden of DTR is not likely to reduce in the near future, countermeasures are needed to alleviate its impact on human health.

  • 137. Lillienberg, Linnéa
    et al.
    Andersson, Eva
    Janson, Christer
    Dahlman-Höglund, Anna
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Holm, Mathias
    Gislason, Thorarinn
    Jögi, Rain
    Omenaas, Ernst
    Schlünssen, Vivi
    Sigsgaard, Torben
    Svanes, Cecilie
    Torén, Kjell
    Occupational exposure and new-onset asthma in a population-based study in Northern Europe (RHINE)2013In: Annals of Occupational Hygiene, ISSN 0003-4878, E-ISSN 1475-3162, Vol. 57, no 4, p. 482-492Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: In a large population-based study among adults in northern Europe the relation between occupational exposure and new-onset asthma was studied.

    METHODS: The study comprised 13 284 subjects born between 1945 and 1973, who answered a questionnaire 1989-1992 and again 1999-2001. Asthma was defined as 'Asthma diagnosed by a physician' with reported year of diagnose. Hazard ratios (HR), for new-onset adult asthma during 1980-2000, were calculated using a modified job-exposure matrix as well as high-risk occupations in Cox regression models. The analyses were made separately for men and women and were also stratified for atopy.

    RESULTS: During the observation period there were 429 subjects with new-onset asthma with an asthma incidence of 1.3 cases per 1000 person-years for men and 2.4 for women. A significant increase in new-onset asthma was seen for men exposed to plant-associated antigens (HR = 3.6; 95% CI [confidence interval] = 1.4-9.0), epoxy (HR = 2.4; 95% CI = 1.3-4.5), diisocyanates (HR = 2.1; 95% CI = 1.2-3.7) and accidental peak exposures to irritants (HR = 2.4; 95% CI = 1.3-4.7). Both men and women exposed to cleaning agents had an increased asthma risk. When stratifying for atopy an increased asthma risk were seen in non-atopic men exposed to acrylates (HR = 3.3; 95% CI = 1.4-7.5), epoxy compounds (HR = 3.6; 95% CI = 1.6-7.9), diisocyanates and accidental peak exposures to irritants (HR = 3.0; 95% CI = 1.2-7.2). Population attributable risk for occupational asthma was 14% for men and 7% for women.

    CONCLUSIONS: This population-based study showed that men exposed to epoxy, diisocyanates and acrylates had an increased risk of new-onset asthma. Non-atopics seemed to be at higher risk than atopics, except for exposure to high molecular weight agents. Increased asthma risks among cleaners, spray painters, plumbers, and hairdressers were confirmed.

  • 138. Lindgren, Elisabet
    et al.
    Albihn, Ann
    Andersson, Yvonne
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Olsson, Gert
    Rocklöv, Joacim
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    [Consequences of climate changes for the health status in Sweden. Heat waves and disease transmission most alarming]2008In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 105, no 28-29, p. 2018-23Article in journal (Refereed)
  • 139. Liu, Cong
    et al.
    Chen, Renjie
    Sera, Francesco
    Vicedo-Cabrera, Ana M
    Guo, Yuming
    Tong, Shilu
    Coelho, Micheline S Z S
    Saldiva, Paulo H N
    Lavigne, Eric
    Matus, Patricia
    Valdes Ortega, Nicolas
    Osorio Garcia, Samuel
    Pascal, Mathilde
    Stafoggia, Massimo
    Scortichini, Matteo
    Hashizume, Masahiro
    Honda, Yasushi
    Hurtado-Díaz, Magali
    Cruz, Julio
    Nunes, Baltazar
    Teixeira, João P
    Kim, Ho
    Tobias, Aurelio
    Íñiguez, Carmen
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Åström, Christofer
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Ragettli, Martina S
    Guo, Yue-Leon
    Chen, Bing-Yu
    Bell, Michelle L
    Wright, Caradee Y
    Scovronick, Noah
    Garland, Rebecca M
    Milojevic, Ai
    Kyselý, Jan
    Urban, Aleš
    Orru, Hans
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health. The Institute of Family Medicine and Public Health, University of Tartu, Tartu, Estonia.
    Indermitte, Ene
    Jaakkola, Jouni J K
    Ryti, Niilo R I
    Katsouyanni, Klea
    Analitis, Antonis
    Zanobetti, Antonella
    Schwartz, Joel
    Chen, Jianmin
    Wu, Tangchun
    Cohen, Aaron
    Gasparrini, Antonio
    Kan, Haidong
    Ambient Particulate Air Pollution and Daily Mortality in 652 Cities2019In: New England Journal of Medicine, ISSN 0028-4793, E-ISSN 1533-4406, Vol. 381, no 8, p. 705-715Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The systematic evaluation of the results of time-series studies of air pollution is challenged by differences in model specification and publication bias.

    METHODS: We evaluated the associations of inhalable particulate matter (PM) with an aerodynamic diameter of 10 μm or less (PM10) and fine PM with an aerodynamic diameter of 2.5 μm or less (PM2.5) with daily all-cause, cardiovascular, and respiratory mortality across multiple countries or regions. Daily data on mortality and air pollution were collected from 652 cities in 24 countries or regions. We used overdispersed generalized additive models with random-effects meta-analysis to investigate the associations. Two-pollutant models were fitted to test the robustness of the associations. Concentration-response curves from each city were pooled to allow global estimates to be derived.

    RESULTS: On average, an increase of 10 μg per cubic meter in the 2-day moving average of PM10 concentration, which represents the average over the current and previous day, was associated with increases of 0.44% (95% confidence interval [CI], 0.39 to 0.50) in daily all-cause mortality, 0.36% (95% CI, 0.30 to 0.43) in daily cardiovascular mortality, and 0.47% (95% CI, 0.35 to 0.58) in daily respiratory mortality. The corresponding increases in daily mortality for the same change in PM2.5 concentration were 0.68% (95% CI, 0.59 to 0.77), 0.55% (95% CI, 0.45 to 0.66), and 0.74% (95% CI, 0.53 to 0.95). These associations remained significant after adjustment for gaseous pollutants. Associations were stronger in locations with lower annual mean PM concentrations and higher annual mean temperatures. The pooled concentration-response curves showed a consistent increase in daily mortality with increasing PM concentration, with steeper slopes at lower PM concentrations.

    CONCLUSIONS: Our data show independent associations between short-term exposure to PM10 and PM2.5 and daily all-cause, cardiovascular, and respiratory mortality in more than 600 cities across the globe. These data reinforce the evidence of a link between mortality and PM concentration established in regional and local studies. (Funded by the National Natural Science Foundation of China and others.).

  • 140. Ljungman, Petter L S
    et al.
    Andersson, Niklas
    Stockfelt, Leo
    Andersson, Eva M
    Sommar, Johan
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Eneroth, Kristina
    Gidhagen, Lars
    Johansson, Christer
    Lager, Anton
    Leander, Karin
    Molnar, Peter
    Pedersen, Nancy L
    Rizzuto, Debora
    Rosengren, Annika
    Segersson, David
    Wennberg, Patrik
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Barregard, Lars
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Sallsten, Gerd
    Bellander, Tom
    Pershagen, Göran
    Long-Term Exposure to Particulate Air Pollution, Black Carbon, and Their Source Components in Relation to Ischemic Heart Disease and Stroke2019In: Journal of Environmental Health Perspectives, ISSN 0091-6765, E-ISSN 1552-9924, Vol. 127, no 10, article id 107012Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Long-term exposure to particulate matter (PM) in ambient air has been associated with cardiovascular mortality, but few studies have considered incident disease in relation to PM from different sources.

    OBJECTIVES: We aimed to study associations between long-term exposure to different types of PM and sources, and incident ischemic heart disease (IHD) and stroke in three Swedish cities.

    METHODS: ), and black carbon (BC) from road wear, traffic exhaust, residential heating, and other sources in Gothenburg, Stockholm, and Umeå. Registry data for participants from four cohorts were used to obtain incidence of IHD and stroke for first hospitalization or death. We constructed time windows of exposure for same-year, 1- to 5-y, and 6- to 10-y averages preceding incidence from annual averages at residential addresses. Risk estimates were based on random effects meta-analyses of cohort-specific Cox proportional hazard models.

    RESULTS: exposure from residential heating.

    DISCUSSION: Few consistent associations were observed between different particulate components and IHD or stroke. However, long-term residential exposure to locally emitted BC from traffic exhaust was associated with stroke incidence. The comparatively low exposure levels may have contributed to the paucity of associations.

  • 141.
    Lodge, Caroline J.
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine. Allergy and Lung Health Unit, Centre for Epidemiology and Biostatistics, School of Population and Global Health, University of Melbourne, Melbourne, Vic., Australia; Murdoch Children’s Research Institute, Royal Children’s Hospital, Parkville, Melbourne, Vic., Australia.
    Bråbäck, Lennart
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Lowe, Adrian J.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine. Allergy and Lung Health Unit, Centre for Epidemiology and Biostatistics, School of Population and Global Health, University of Melbourne, Melbourne, Vic., Australia; Murdoch Children’s Research Institute, Royal Children’s Hospital, Parkville, Melbourne, Vic., Australia.
    Dharmage, S. C.
    Olsson, David
    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.
    Grandmaternal smoking increases asthma risk in grandchildren: a nationwide Swedish cohort2018In: Clinical and Experimental Allergy, ISSN 0954-7894, E-ISSN 1365-2222, Vol. 48, no 2, p. 167-174Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: There is growing interest in exposures prior to conception as possible risk factors for offspring asthma. Although partially supported by evidence from limited human studies, current evidence is inconsistent, and based on recall of exposure status.

    OBJECTIVE: We aimed to investigate grandmaternal smoking during pregnancy and the risk of asthma in grandchildren using prospectively collected population-based data.

    METHODS: Information on grandmaternal and maternal smoking during pregnancy and grandchild use of asthma medications was collected from national Swedish registries. Associations between grandmaternal smoking during pregnancy (10-12 weeks), and asthma medication use in grandchildren were investigated using generalized estimating equations. Ages at which asthma medications were prescribed classified childhood asthma into never, early transient (0-3years), late onset (3-6 years) and early persistent (0-3 and 3-6 years) phenotypes.

    RESULTS: From 1982 to 1986, 44,583 grandmothers gave birth to 46,197 mothers, who gave birth to 66,271 grandchildren (born 1996-2010). Children aged 1-6 years had an increased asthma risk if their grandmothers had smoked during pregnancy, with a higher risk for more exposure (10+ cigs/day; adjusted OR 1·23; 1·17, 1·30). Maternal smoking did not modify this relationship.

    CONCLUSIONS & CLINICAL RELEVANCE: Children had an increased risk of asthma in the first six years of life if their grandmothers smoked during early pregnancy, independent of maternal smoking. Importantly this exhibited a dose-response relationship and was associated with a persistent childhood asthma phenotype. These findings support possible epigenetic transmission of risk from environmental exposures in previous generations. 

  • 142.
    Lowe, Adrian
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Braback, Lennart
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Ekeus, Cecilia
    Hjern, Anders
    Fosberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    The association between maternal obesity and childhood asthma - an analysis based on swedish sib-pairs2011In: Internal Medicine Journal - Special Issue: 22nd Australasian Society of Clinical Immunology and Allergy (ASCIA) Annual Scientific Meeting, Sydney Convention & Exhibition Centre, Darling Harbour, NSW, 7 - 9 September 2011, Carlton, Vic.: Blackwell Science , 2011, Vol. 41, no Suppl. 4, p. 11-11Conference paper (Refereed)
    Abstract [en]

    Background: The prevalence of both asthma and obesity have increased inwesternised countries over recent decades. It has been proposed that maternalobesity during pregnancy may induce a pro-infl ammatory intrauterineenvironment, which may increase the child’s risk of asthma and allergicdisease. Sib-pair analysis is a powerful technique for assessing the possibilitythat an exposure is causal for an outcome.

    Methods: The study population comprised all children born between 1998and 2005 in Stockholm (n = 99,830 born to 43,103 separate mothers)registered on the Swedish Medical Birth Registry. Maternal BMI was typicallymeasured typically at 8–10 weeks post conception. Use of asthma medications(either inhaled corticosteroids or montelukast) was recorded inthe Swedish Prescription Registry between July 2005 and February 2011. Conditional logistic regression models were used to assess the effect ofchanging maternal BMI on asthma medication use within sibling pairsmatched for age. Adjustment was made for maternal smoking during pregnancy,pregnancy complications, the child’s gender and other potentialconfounders.

    Results: There were 4,311 children with siblings with discordant asthmamedication use between 5 and 9 years of age. There was a trend for childrenborn to obese mothers (30–34.9 kg/m2) to have an elevated risk (aOR = 1.53,95% CI = 0.88–2.65) of asthma medication use when compared to theirmatched sibs. Children born to very obese mothers (BMI > 35 kg/m2) hada much greater risk of asthma than their siblings (aOR = 4.45, 95%CI = 1.79–11.05).

    Conclusion: Maternal early pregnancy obesity is associated with increasedrisk of asthma in the child. These associations are unlikely to be due to sharedgenetic or other familial risk factors for obesity and asthma, as the reportedassociations are based on a sib-pair analysis. Maternal obesity, or changes inlifestyle factors that lead to it, appear to cause an increase risk of childhoodasthma.

  • 143.
    Lowe, Adrian
    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.
    Ekeus, Cecilia
    Hjern, Anders
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Maternal obesity during pregnancy as a risk for early-life asthma2011In: Journal of Allergy and Clinical Immunology, ISSN 0091-6749, E-ISSN 1097-6825, Vol. 128, no 5, p. 1107-1109Article in journal (Refereed)
  • 144.
    Lowe, Adrian J
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Ekeus, Cecilia
    Karolinska Institute, Stockholm, Sweden.
    Bråbäck, Lennart
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Rajaleid, Kristiina
    Karolinska Institute, Stockholm, Sweden.
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Hjern, Anders
    National Board of Health and Welfare and Karolinska Institutet, Stockholm, Sweden.
    Impact of Maternal Obesity on Inhaled Corticosteroid Use in Childhood: A Registry Based Analysis of First Born Children and a Sibling Pair Analysis2013In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 8, no 6, p. e67368-Article in journal (Refereed)
    Abstract [en]

    Background: It has been proposed that maternal obesity during pregnancy may increase the risk that the child developsallergic disease and asthma, although the mechanisms underpinning this relationship are currently unclear. We sought toassess if this association may be due to confounding by genetic or environmental risk factors that are common to maternalobesity and childhood asthma, using a sibling pair analysis.

    Methods: The study population comprised a Swedish national cohort of term children born between 1992 and 2008 tonative Swedish parents. Maternal body mass index (BMI) was measured at 8–10 weeks gestation. Unconditional logisticregression models were used to determine if maternal obesity was associated with increased risk of inhaled corticosteroid(ICS) in 431,718 first-born children, while adjusting for potential confounders. An age-matched discordant sib-pair analysiswas performed, taking into account shared genetic and environmental risk factors.

    Results: Maternal over-weight and obesity were associated with increased risk that the child would require ICS (forBMI$35 kg/m2, aOR = 1.30, 95%CI = 1.10–1.52 compared with normal weight mothers) in children aged 6–12 years. Similareffects were seen in younger children, but in children aged 13–16 years, maternal obesity (BMI$30) was related to increasedrisk of ICS use in girls (aOR = 1.28, 95%CI = 1.07–1.53) but not boys (OR = 1.05, 95%CI = 0.87–1.26). The sib-pair analysis,which included 2,034 sib-pairs older than six years who were discordant for both ICS use and maternal BMI category, failedto find any evidence that increasing maternal weight was related to increased risk of ICS use.

    Conclusion: Maternal obesity is associated with increased risk of childhood ICS use up to approximately 12 years of age, butonly in girls after this age. These effects could not be confirmed in a sib pair analysis, suggesting either limited statisticalpower, or the effects of maternal BMI may be due to shared genetic or environmental risk factors.

  • 145.
    Lowe, Adrian J
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Murdoch Children’s Research Institute; Centre for Molecular, Environmental, Genetic and Analytic Epidemiology, School of Population Health, The University of Melbourne.
    Olsson, David
    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. Department of Research and Development, Västernorrland County Council.
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Pollen exposure in pregnancy and infancy and risk of asthma hospitalisation: a register based cohort study2012In: Allergy, Asthma & Clinical Immunology, ISSN 1710-1484, E-ISSN 1710-1492, Vol. 8, no 1, article id 17Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: A seasonal effect of month of birth and risk of allergic disease has been suggested by numerous studies. Few studies have directly measured pollen exposures at different points during pregnancy and in early life, and assessed their effects on risk of respiratory disease outcomes.

    METHODS: Pollen exposure was calculated for the first and last 12 weeks of pregnancy and the first 12 weeks of infancy for all children conceived by women residing in Stockholm, Sweden, between 1988 and 1995. Hospital admission data for respiratory conditions in the first year of life was also collected.

    RESULTS: Out of 110,381 children, 940 had been hospitalised for asthma by 12-months of age. Pollen levels showed both marked seasonal variations and between year differences. Exposure to high levels of pollen in the last 12 weeks of pregnancy was associated with an increased risk of asthma hospitalisation (aOR = 1.35, 95% CI = 1.07-1.71 for highest quartile versus remaining infants). Exposure to high levels of pollen in the first three months of life was associated with a reduced risk (aOR = 0.76, 95% CI = 0.59-0.98) but only in children of heavy smoking mothers.

    CONCLUSIONS: High levels of pollen exposure during late pregnancy were somewhat unexpectedly associated with an elevated risk of hospitalisation for asthma within the first year of life.

  • 146.
    Lowe, Dianne
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine. Centre for Health Communication and Participation, School of Public Health & Human Biosciences, La Trobe University, Victoria, Australia.
    Ebi, Kristie L.
    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.
    Factors Increasing Vulnerability to Health Effects before, during and after Floods2013In: International journal of environmental research and public health, ISSN 1660-4601, Vol. 10, no 12, p. 7015-7067Article in journal (Refereed)
    Abstract [en]

    Identifying the risk factors for morbidity and mortality effects pre-, during and post-flood may aid the appropriate targeting of flood-related adverse health prevention strategies. We conducted a systematic PubMed search to identify studies examining risk factors for health effects of precipitation-related floods, among Organisation for Economic Co-Operation and Development (OECD) member countries. Research identifying flood-related morbidity and mortality risk factors is limited and primarily examines demographic characteristics such as age and gender. During floods, females, elderly and children appear to be at greater risk of psychological and physical health effects, while males between 10 to 29 years may be at greater risk of mortality. Post-flood, those over 65 years and males are at increased risk of physical health effects, while females appear at greater risk of psychological health effects. Other risk factors include previous flood experiences, greater flood depth or flood trauma, existing illnesses, medication interruption, and low education or socio-economic status. Tailoring messages to high-risk groups may increase their effectiveness. Target populations differ for morbidity and mortality effects, and differ pre-, during, and post-flood. Additional research is required to identify the risk factors associated with pre- and post-flood mortality and post-flood morbidity, preferably using prospective cohort studies.

  • 147.
    Lowe, Dianne
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Ebi, Kristie L
    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.
    Heatwave early warning systems and adaptation advice to reduce human health consequences of heatwaves2011In: International Journal of Environmental Research and Public Health, ISSN 1661-7827, E-ISSN 1660-4601, Vol. 8, no 12, p. 4623-4648Article in journal (Refereed)
    Abstract [en]

    Introduction: With climate change, there has been an increase in the frequency, intensity and duration of heatwave events. In response to the devastating mortality and morbidity of recent heatwave events, many countries have introduced heatwave early warning systems (HEWS). HEWS are designed to reduce the avoidable human health consequences of heatwaves through timely notification of prevention measures to vulnerable populations.

    Objective: To identify the key characteristics of HEWS in European countries to help inform modification of current, and development of, new systems and plans.

    Methods: We searched the internet to identify HEWS policy or government documents for 33 European countries and requested information from relevant organizations. We translated the HEWS documents and extracted details on the trigger indicators, thresholds for action, notification strategies, message intermediaries, communication and dissemination strategies, prevention strategies recommended and specified target audiences.

    Findings and Conclusions: Twelve European countries have HEWS. Although there are many similarities among the HEWS, there also are differences in key characteristics that could inform improvements in heatwave early warning plans.

  • 148. Lytras, Theodore
    et al.
    Kogevinas, Manolis
    Kromhout, Hans
    Carsin, Anne-Elie
    Antó, Josep M
    Bentouhami, Hayat
    Weyler, Joost
    Heinrich, Joachim
    Nowak, Dennis
    Urrutia, Isabel
    Martinez-Moratalla, Jesús
    Gullón, José Antonio
    Pereira-Vega, Antonio
    Raherison-Semjen, Chantal
    Pin, Isabelle
    Demoly, Pascal
    Leynaert, Bénédicte
    Villani, Simona
    Gislason, Thorarinn
    Svanes, Cecilie
    Holm, Mathias
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Norbäck, Dan
    Mehta, Amar J
    Probst-Hensch, Nicole
    Benke, Geza
    Jogi, Rain
    Torén, Kjell
    Sigsgaard, Torben
    Schlünssen, Vivi
    Olivieri, Mario
    Blanc, Paul D
    Vermeulen, Roel
    Garcia-Aymerich, Judith
    Jarvis, Deborah
    Zock, Jan-Paul
    Occupational exposures and 20-year incidence of COPD: the European Community Respiratory Health Survey.2018In: Thorax, ISSN 0040-6376, E-ISSN 1468-3296, Vol. 73, no 11, p. 1008-1015Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Occupational exposures have been associated with an increased risk of COPD. However, few studies have related objectively assessed occupational exposures to prospectively assessed incidence of COPD, using postbronchodilator lung function tests. Our objective was to examine the effect of occupational exposures on COPD incidence in the European Community Respiratory Health Survey.

    METHODS: General population samples aged 20-44 were randomly selected in 1991-1993 and followed up 20 years later (2010-2012). Spirometry was performed at baseline and at follow-up, with incident COPD defined using a lower limit of normal criterion for postbronchodilator FEV1/FVC. Only participants without COPD and without current asthma at baseline were included. Coded job histories during follow-up were linked to a Job-Exposure Matrix, generating occupational exposure estimates to 12 categories of agents. Their association with COPD incidence was examined in log-binomial models fitted in a Bayesian framework.

    FINDINGS: 3343 participants fulfilled the inclusion criteria; 89 of them had COPD at follow-up (1.4 cases/1000 person-years). Participants exposed to biological dust had a higher incidence of COPD compared with those unexposed (relative risk (RR) 1.6, 95% CI 1.1 to 2.3), as did those exposed to gases and fumes (RR 1.5, 95% CI 1.0 to 2.2) and pesticides (RR 2.2, 95% CI 1.1 to 3.8). The combined population attributable fraction for these exposures was 21.0%.

    INTERPRETATION: These results substantially strengthen the evidence base for occupational exposures as an important risk factor for COPD.

  • 149. Lytras, Theodore
    et al.
    Kogevinas, Manolis
    Kromhout, Hans
    Carsin, Anne-Elie
    Antó, Josep Maria
    Bentouhami, Hayat
    Weyler, Joost
    Heinrich, Joachim
    Nowak, Dennis
    Urrutia, Isabel
    Martínez-Moratalla, Jesús
    Gullón, José Antonio
    Vega, Antonio Pereira
    Raherison Semjen, Chantal
    Pin, Isabelle
    Demoly, Pascal
    Leynaert, Bénédicte
    Villani, Simona
    Gíslason, Thorarinn
    Svanes, Øistein
    Holm, Mathias
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Norbäck, Dan
    Mehta, Amar J
    Probst-Hensch, Nicole
    Benke, Geza
    Jogi, Rain
    Torén, Kjell
    Sigsgaard, Torben
    Schlünssen, Vivi
    Olivieri, Mario
    Blanc, Paul D
    Watkins, John
    Bono, Roberto
    Buist, A Sonia
    Vermeulen, Roel
    Jarvis, Deborah
    Zock, Jan-Paul
    Occupational exposures and incidence of chronic bronchitis and related symptoms over two decades: the European Community Respiratory Health Survey2019In: Occupational and Environmental Medicine, ISSN 1351-0711, E-ISSN 1470-7926, Vol. 76, no 4, p. 222-229Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: Chronic bronchitis (CB) is an important chronic obstructive pulmonary disease (COPD)-related phenotype, with distinct clinical features and prognostic implications. Occupational exposures have been previously associated with increased risk of CB but few studies have examined this association prospectively using objective exposure assessment. We examined the effect of occupational exposures on CB incidence in the European Community Respiratory Health Survey.

    METHODS: Population samples aged 20-44 were randomly selected in 1991-1993, and followed up twice over 20 years. Participants without chronic cough or phlegm at baseline were analysed. Coded job histories during follow-up were linked to the ALOHA Job Exposure Matrix, generating occupational exposure estimates to 12 categories of chemical agents. Their association with CB incidence over both follow-ups was examined with Poisson models using generalised estimating equations.

    RESULTS: 8794 participants fulfilled the inclusion criteria, contributing 13 185 observations. Only participants exposed to metals had a higher incidence of CB (relative risk (RR) 1.70, 95% CI 1.16 to 2.50) compared with non-exposed to metals. Mineral dust exposure increased the incidence of chronic phlegm (RR 1.72, 95% CI 1.43 to 2.06). Incidence of chronic phlegm was increased in men exposed to gases/fumes and to solvents and in women exposed to pesticides.

    CONCLUSIONS: Occupational exposures are associated with chronic phlegm and CB, and the evidence is strongest for metals and mineral dust exposure. The observed differences between men and women warrant further investigation.

  • 150. Makowska, Joanna S
    et al.
    Burney, Peter
    Jarvis, Debbie
    Keil, Thomas
    Tomassen, Peter
    Bislimovska, J
    Brozek, Grzegorz
    Bachert, Claus
    Baelum, Jesper
    Bindslev-Jensen, Carsten
    Bousquet, Jean
    Bousquet, Philippe J
    Kai-Håkon, Carlsen
    Dahlen, Sven Eric
    Dahlen, Barbro
    Fokkens, Wytske J
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Gjomarkaj, Mark
    Howarth, Peter
    Janson, Christer
    Kasper, Lukas
    Kraemer, Ursula
    Louiro, Carlos
    Lundback, Bo
    Minov, Jordan
    Nizankowska-Mogilnicka, Ewa
    Papadopoulos, Nikos
    Sakellariou, Alexandros G
    Todo-Bom, Ana
    Toskala, Elina
    Zejda, Jan E
    Zuberbier, Torsten
    Kowalski, Marek L
    Respiratory hypersensitivity reactions to NSAIDs in Europe: the global allergy and asthma network (GA2LEN) survey2016In: Allergy. European Journal of Allergy and Clinical Immunology, ISSN 0105-4538, E-ISSN 1398-9995, Vol. 71, no 11, p. 1603-1611Article in journal (Refereed)
    Abstract [en]

    Background: Nonsteroidal anti-inflammatory drugs (NSAIDs) are among the most prevalent drugs inducing hypersensitivity reactions. The aim of this analysis was to estimate the prevalence of NSAID-induced respiratory symptoms in population across Europe and to assess its association with upper and lower respiratory tract disorders.

    Methods: The GA2LEN survey was conducted in 22 centers in 15 European countries. Each of 19 centers selected random samples of 5000 adults aged 15–74 from their general population, and in three centers (Athens, Munich, Oslo), a younger population was sampled. Questionnaires including questions about age, gender, presence of symptoms of asthma, allergic rhinitis, chronic rhinosinusitis, smoking status, and history of NSAID-induced hypersensitivity reactions were sent to participants by mail. Totally, 62 737 participants completed the questionnaires.

    Results: The mean prevalence of NSAID-induced dyspnea was 1.9% and was highest in the three Polish centers [Katowice (4.9%), Krakow (4.8%), and Lodz (4.4%)] and lowest in Skopje, (0.9%), Amsterdam (1.1%), and Umea (1.2%). In multivariate analysis, the prevalence of respiratory reactions to NSAIDs was higher in participants with chronic rhinosinusitis symptoms (Odds Ratio 2.12; 95%CI 1.78–2.74), asthma symptoms in last 12 months (2.7; 2.18–3.35), hospitalization due to asthma (1.53; 1.22–1.99), and adults vs children (1.53; 1.24–1.89), but was not associated with allergic rhinitis.

    Conclusion: Our study documented significant variation between European countries in the prevalence of NSAID-induced respiratory hypersensitivity reactions, and association with chronic airway diseases, but also with environmental factors.

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