«Il contributo dell`inquinamento outdoor alla qualità dell`aria indoors

Iconvegno Ambiente e Salute
ISS Roma 5-6.XII.2011
«Il contributo dell’inquinamento outdoor
alla qualità dell’aria indoors: possibili
effetti sulla salute»
Dr Isabella ANNESI-MAESANO
Directeur de Recherche INSERM
Responsable Equipe EPAR
Isabella.annesi-maesano@inserm.fr
EPAR: Epidémiologie des Maladies
Allergiques et Respiratoires
UMRS-707 INSERM & UPMC Paris VI
Faculté de Médecine Saint Antoine
27, rue Chaligny 75012 Paris
www.epar.fr
EPAR
Outline
• Context
• Indoor air pollutants and sources
• Outdoor air pollutants contribution to indoor air
quality
• Levels at the population level
• Exposure at the population level
• Health effects
(both allergic and respiratory)
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EPAR
Outline
• Context
• Indoor air pollutants and sources
• Outdoor air pollutants contribution to indoor air
quality
• Levels at the population level
• Exposure at the population level
• Health effects
(both allergic and respiratory)
Main pollutants
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Indoor air. Why?
Indoor environments contribute significantly to human
exposure to air pollutants (3 billions people are exposed to
biomass).
Conservative estimates show that between 1.5 and 2 million
deaths per year could be attributed to indoor air pollution,
and significant part of the deaths occurring because of
COPD and lung cancer overall among women and of
respiratory infections (1 million)
Today, indoor air pollution is globally ranked 10th as
preventable risk factor causing burden of disease.
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Which risk for indoor air pollution
compared to outdoor air pollution?
• Individuals spent more time indoors than
outdoors (up to 90%)
• More indoor air pollutants than outdoor air
pollutants (about 5000 air pollutants indoors)
• Concentrations of some indoor air pollutants
higher than concentrations of outdoor air
pollutants.
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Indoor air pollution – When, where and how?
 Individuals spent up to 90% of their time indoors:
– Dwellings, colleges, nursing homes…
– Working place, school, university
– HORECA: hotels, restaurants, cafés
– Hobbies and “loisirs” : discos, swimming pools, fitness centers…
– Vehicles, transports...
 Exposure to indoor air pollution depends on:
 Dose
 Length of exposure
 Activities (physical activity, sleep, work, cleaning activities…): 0,5
m3/hour at rest vs. 1,2 m3/h during activities
 Window of exposure (children are different form elderly)
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EPAR
Tabagisme
passif
PM
NO2
Biomasse bois charbon
COV
INDOOR AIR POLLUTANTS
AND SOURCES
CO2
Acariens
Virus et bactéries
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Moisissures
EPAR
Les polluants atmosphériques chimiques
 Phase gazeuse :
• Dioxyde de soufre : SO2
• Oxydes nitriques  dioxyde d’azote (NO2)
• Monoxyde de Carbone (CO)
• COV = composants organiques volatiles
• radon
 Phase particulaire :
• PM (particulate matter)
• Contaminants:
HAP, métaux, contaminants biologiques (LPS)
Corps carboné
Hydrocarbures
polyaromatiques
adsorbés (HAP)
Sulfates
et traces
métalliques
•Taille:
De 0 .1µm: translocation vers des organes distaux
(Elder & Oberdorster, COEM,2006)
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Les polluants atmosphériques biologiques
 Allergènes
• Acariens
• Phanères
• Animaux domestiques
• Animaux nuisibles
• Moisissures
• Pollens
 Agents infectieux
• Virus
• Bactéries
 Produits dérivés de:
• moisissures
• pollens
Acariens
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Moisissures
EPAR
Main indoor pollutants and related sources
Pollutants
Sources
CO
CO2
NO2
PM
SO2
ETS
VOCs
Radon
Combustion
Anthropogenic pollutants
Unvented Gas/Kerosene heaters
Biomass (wood/coal) for heating/cooking
Tobacco use
ETS
Wood (fireplaces)/Gas ranges-pilot lights
New furnitures, solvents, painting,
adhesives, insulation, cleaning products,
materials for offices
Building materials, water
Allergens
Dust, beds, carpets
Acarides (house dust mites)
Pets (cats, dogs) dundruff, birds, insects
(cockroaches), rodents
Dampness
Moulds
Plants
Pollens
Virus, bacteria
Biological contaminants
COx=Carbon Oxides, NO2 = Nitrogen dioxide, PM = Particulate Matter, SO2 = Sulphur Dioxide, ETS = Environmental Tobacco Smoke, VOCs = Volatile Organic
Compounds (Aldehydes, Formaldehyde, Aliphatic halogenated/aromatic Hydrocarbons, Benzene, Terpene, Xilene.....)
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EPAR
Main indoor pollutants and related sources
Pollutants
Sources
CO
CO2
NO2
PM
SO2
ETS
VOCs
Radon
Combustion
Anthropogenic pollutants
Unvented Gas/Kerosene heaters
Biomass (wood/coal) for heating/cooking
Tobacco use
ETS
Wood (fireplaces)/Gas ranges-pilot lights
New furnitures, solvents, painting,
adhesives, insulation, cleaning products,
materials for offices
Building materials, water
Allergens
Dust, beds, carpets
Pets (cats, dogs) dundruff, birds, insects
(cockroaches), rodents
Dampness
Plants
Virus, bacteria
ETS is the largest contributor
to indoor particulate matter
(PM), accounting for even
50%-90% of the total PM
Moulds
concentration.
Pollens
Acarides (house dust mites)
Biological contaminants
COx=Carbon Oxides, NO2 = Nitrogen dioxide, PM = Particulate Matter, SO2 = Sulphur Dioxide, ETS = Environmental Tobacco Smoke, VOCs = Volatile Organic
Compounds (Aldehydes, Formaldehyde, Aliphatic halogenated/aromatic Hydrocarbons, Benzene, Terpene, Xilene.....)
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I.Simoni,
Annesi-Maesano
Viegi, Annesi-Maesano ERS
White Book Update (in press)
EPAR
Source de polluants de l’air intérieur
Réactivité
Combustion
Cuisine,
Chauffage
Bio effluents,
bactéries,
moisissures
Bâtiment
Equipement
Ameublement
Décoration
Activités
Bâtiment
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Tabac,
Bricolage,
Ménage
EPAROQA
Courtoisie
Source de polluants de l’air intérieur
Réactivité
Bâtiment
Equipement
Combustion
Cuisine,
Chauffage
Ameublement
Décoration
Bio effluents,
bactéries,
moisissures
Activités
Bâtiment :
Ventilation
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Tabac,
Bricolage,
Ménage
Radon
EPAROQA
Courtoisie
Main indoor pollutants and related sources
Also outdoor contrbution
Pollutants
Sources
CO
CO2
NO2
PM
SO2
ETS
VOCs
Radon
Combustion
Anthropogenic pollutants
Unvented Gas/Kerosene heaters
Biomass (wood/coal) for heating/cooking
Tobacco use
ETS
Wood (fireplaces)/Gas ranges-pilot lights
New furnitures, solvents, painting, adhesives,
insulation, cleaning products, materials for
offices
Building materials, water
Allergens
Dust, beds, carpets
Acarides (house dust mites)
Pets (cats, dogs) dundruff, birds, insects
(cockroaches), rodents
Dampness
Moulds
Plants
Pollens
Virus, bacteria
Biological contaminants
COx=Carbon Oxides, NO2 = Nitrogen dioxide, PM = Particulate Matter, SO2 = Sulphur Dioxide, ETS = Environmental Tobacco Smoke, VOCs = Volatile Organic Compounds (Aldehydes,
Formaldehyde, Aliphatic halogenated/aromatic Hydrocarbons, Benzene, Terpene, Xilene.....)
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EPAR
How outdoor contribution to indoor
air quality is estimated?
• Through Indoors/Outdoors ratio =
indoor concentration (µg/m3)/outdoor concentration(µg/m3)
• I/O > 1 indoor concentrations higher than outdoor
concetration
• I/O < 1 outdoor concentration higher than indoor
concentration
• I/O = 1 no difference
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Important to identify
outdoor contribution to
indoor air qualty in view
of prevention
EPAR
How outdoor contribution to indoor
air quality is estimated?
•
•
•
•
O3: I/O = 0,06 - 0,39 (Annesi-Maesano, Chao, Mi)
NO2: I/O = 0,54 - 1,4 (Annesi-Maesano, Chao, Lee, Baek)
PM: I/O = 0.78 - 1.08 (Annesi-Maesano, Cavallo, Morawska).
VOCs (acetaldeide, formaldeide...): I/O > 1 (up to 15) (Cavallo,
Annesi-Maesano).
• I/O > 1 for VOCs, acetaldehydes, certain allergens, moulds…
• I/O < 1 for NO2, SO2, radon
• I/O = 1 for PM in the absence of indoor sources
Few studies estimated the relationship between I/O and NO2 e O3.
OR=1.23 e 1.27 between NO2 and wheezing and asthma and 0.83
between O3 and breathlessness confirming the origin of the
pollutants.
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EPAR
Indoor air exposure exposure
and health effects
How many are exposed to indoor air
exposure?
How many are diseased because of
indoor air exposure?
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Indoor air exposure exposure
and health effects
How many are exposed to indoor air
exposure?
How many are diseased because of
indoor air exposure?
What are the diseases related to indoor
air pollution?
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EPAR
Pyramids of health effects of indoor air
pollution
Cancer
Severity
Chronic diseases: asthma, COPD…
Lung function decline
Acute effects: infections
Symptoms, BHR or NHR
Sub-clinical effects/Intermediate
phenotypes (inflammation…)
Proportion of the touched
population
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EPAR
POLLUTANT BY POLLUTANT
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Particulate matter
PM
Oberdorster,
2005 (modifiée)
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EPAR
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Africa (Smith)
Asia(Smith)
Chile(Caceres)
China-rural(Pan)
ITA-3(Simoni 2003b)
ITA-2(Simoni 2003b)
ITA-1(Maroni)
Costa Rica(Lee)
GRE(Gotschi)
CZEC(Gotschi)
USA-2(Neas)
MEX(Cortez-Lugo)
HOL(Janssen)
USA-1(Wallace)
100
95
90
85
80
75
70
65
60
55
50
45
40
35
30
25
20
15
10
5
0
FRA(Zmirou)
UK(Gee)
SWI(Gotschi)
FIN-2(Janssen)
FIN-1 (Gotschi)
USA-Retir(Evans)
PM 2.5 µg/m3
INDOOR PM2.5 CONCENTRATION
PM10
threshold byUSEPA(1997
ref)
both total and
respirable PM
EPAR
Current biomass/solid fuel use
Africa
Asia
Latin America
Rural
Urban
90%
89%
60%
68%
40%
20%
About 50% of world's households burn these products for cooking in
open fire or with inefficient stoves in poorly ventilated rooms. It occurs
especially in developing countries, where the production of PM and CO
(good proxy for PM2.5) by biomass combustion is dramatically high.
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EPAR
Biomass fuel
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EPAR
Biomass fuel
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Biomass fuel
Never smoker women exposed
domestically
to
biomass
developed COPD with clinical
characteristics, quality of
life, and increased mortality
similar in degree to that of
tobacco smokers.
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EPAR
Biomass fuel
Orozco-Levy et al have evidenced that biomass fuel
may be a risk factor for COPD also in Europe. In
their Spanish case-control study in women,
exposure to wood or charcoal smoke was associated
with COPD after adjusting for age and smoking.
The association between length of exposure and
COPD suggested a dose-response pattern.
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6 Cities Studies
(I. Annesi-Maesano et al. THORAX)
Concentrations of PM2.5, NO2, and VOCs were objectively assessed in 401
randomly chosen classrooms in 108 primary schools attended by 6,590
children (10.4, ±0.7 years) in the French 6 Cities Study.
From
outdoors
XXX
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Substance
VGAI proposées
Formaldéhyde
Monoxyde de carbone
Benzène
Fine particules
NO2
CO2
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- VGAI court terme : 50 µg.m-3 pour une exposition de 2h
- VGAI long terme : 10 µg.m-3 pour une exposition supérieure
à un an
VGAI court terme :
- 10 mg.m-3 pour une exposition de 8 h
- 30 mg.m-3 pour une exposition d’1 h
- 60 mg.m-3 pour une exposition de 30 min
- 100 mg.m-3 pour une exposition de 15 min
- VGAI court terme : 30 µg.m-3 pour une exposition d’une
journée à 14 jours
- VGAI intermédiaire : 20 µg.m-3 pour une exposition de plus
de deux semaines à un an
- VGAI long
terme :
XXX
-3
* 10 µg.m pour une exposition supérieure à un an
* 0,2 µg.m-3 pour une exposition vie entière correspondant à
un excès de risque de 10-6
* 2 µg.m-3 pour une exposition vie entière correspondant à un
excès de risque de 10-5
10 µg.m-3 en moyenne sur année (OMS)
40 μg/m3
guideline of ASHRAE (1000 ppm)
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EPAR
6 Cities Studies
(I. Annesi-Maesano et al. THORAX (submitted))
Exposure levels are below standards
NO2: low=≤23.7 µg/m3, medium=]23.7;31.6], high=>31.6 µg/m3
PM2.5 : low=≤12.2 µg/m3, medium=]12.2;17.5], high=>17.5 µg/m3
Formaldehyde: low=≤19.1 µg/m3, medium=]19.1;28.4], high=>28.4 µg/m3
XXX
Acetaldehyde: low=≤6.5 µg/m3, medium=]6.5;9.9], high=>9.9 µg/m3
Acrolein: low=limit of detection, medium=]LD;1.55], high=>1.55 µg/m3
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EPAR
6 Cities Studies
(I. Annesi-Maesano et al. THORAX (submitted))
Children exposure to PM2.5, NO2, and VOCs assessed in 401 randomly
chosen classrooms in 108 primary schools attended by 6,590 children in
the French 6 Cities Study.
XXX
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EPAR
6 Cities Studies
(I. Annesi-Maesano et al. THORAX (submitted))
Relationship between air pollution in classrooms and current asthma (7%)
XXX
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EPAR
6 Cities Studies
(I. Annesi-Maesano et al. THORAX (submitted))
Relationship between air pollution in classrooms and current AR (7%)
XXX
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EPAR
OQAI
COV
Observatoire de la qualité de l’air
(October 2003 – December 2005)
28 Polluants
4 confort parameters (CO2, T,
RH, ventilation)
Questionnaires for hinhabitants
and on the dwellings
Standardised questionnaire
• 710 dwellings
• Representative sample
• 567 included in the survey
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EPAR
VOCs related to asthma and rhinitis
COV
Billionnet et Annesi-Maesano
Env Res 2011
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EPAR
VOCs related to asthma and rhinitis
Rhinitis
Asthma
Billionnet et Annesi-Maesano
Env Res 2011
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BIOLOGICAL POLLUTANTS
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0
I. Annesi-Maesano
30 % de logements
infestés en Ile de France
USA (Brunekreef 1989)
CAN (Dales 1991)
CHI (Li 1996)
ITA (Simoni 1998)
Hong Kong (Leung 1998)
HOL (Brunekreef 1989)
SWE (Norbak, Engvall 2001)
POL (Jedrikowski 1998)
FIN (Kilpelainen 2001)
UK (Williamson 1997)
Taiwan (Yang 1997)
60
RUS (Spengler 2002)
ITA (Simoni 2005)
Moisissures
Prévalence résidentielle de moisissures/humidité
50
40
% 30
20
10
Adapted from
EPAR
Mould
2007
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Exposure to molds according to the fungal index based on MVOC
at home in controls (N=51) and cases, defined as lifetime asthmatics
(N=44) or current asthmatics (N=28) and adjusted odds ratio*. FERMA
MOULDS ARE MORE THAN ONLY ALLERGENS
Lifetime asthma
Exposure (%)
Adjusted Odds Ratio
Exposure (%)
Adjusted Odds Ratio
Cases Controls
OR (CI 95%)
Cases Controls
OR (CI 95%)
70.5 49.0‡
1.92
[0.75; 4.96]
75.0 49.0‡
3.38
[1.16; 9.90]
Urban
55.0
58.3
Rural
83.3† 52.0‡
0.95
[0.23; 4.0]
4.37
[1.38; 13.79]
1.70
[0.29; 9.85]
7.54
[1.64; 34.72]
All
population
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Current asthma
46.2
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46.2
87.5 52.0‡
†
EPAR
Allergens
References
Pollutant concentrations at school
Indoor
Associated health effects
Outdoor
Figures are OR, CI 95 % if not otherwise stated
Dog allergen (can f1)
Current wheeze α : 1,14**[1-1,31]
Breathlessness day α: 2,51**[1,08-5,85]
Median [range]
Kim et al.
Cat allergen (ng/g dust) : 860 [<200-4700]
2005
Dog allergen (ng/g dust) : 750 [<200-6200]
Horse allergen (equ cx)
_
Current wheeze β : 1,14**[1-1,31]
Current asthma β : 1,17**[1-1,37]
Horse allergen (U/g dust) : 945 [<200-31 000]
Current wheeze § : 1,26**[1,01-1,57]
Breathlessness daytime § : 1,31**[1,01-1,7]
Current asthma § : 1,3**[1-1,68]
Mean [range]
Smedje et al.
Cat allergen (ng/g dust) : 131 [<16-391]
1997
Dog allergen (ng/g dust): 921 [<60-3990]
XXX
_
Cat allergen £
Current asthma : 1,8*** [1,3-2,4]
Endotoxin (ng/g dust) : 3 [2-5]
Smedje et al.
2001
Cat allergen (ng/classroom Mean [range]
sample) : 12 [<1-36]
_
Cat allergen+
Dog allergen 48 [<3-286]
Asthma : 1,4** [1,02-1,9]
(ng/classroom sample) :
α
OR for change of coefficient per µg of allergen per sample ; β OR change of coefficient per 1000 U of allergen per g dust ; § OR for
change
of coefficient per 1000 U of allergen per sample ; £ OR
expressed as change of coefficient per 100 ng/g fine dust ; + OR per 10
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ng increase in amount of cat allergen in classroom sample.
EPAR
House dust mite and asthma
• Not linear relationship between HDM
concentrations in the mattress and asthma
at 5 years of age;
• Break point (23.40 µg/d dust ) (due to the
role of others contaminants such as
endotoxins and beta-glucans)
Tovey 2008
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SUSCEPTIBLE GROUPS
• Individuals with co-morbidity (shown in the case of outdoor
air indoor exposure)
• Children
• Elderly
• Individuals socially vulnerable
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ETS
§ Odds ratio (OR) and 95% confidence
interval (CI) from metaanalysis (reference
given in brackets) or, if a summary
estimate is not available, range of OR9s
from individual studies, lung function
parameter data given as effect estimate
(95% CI);
# Causality as judged by the authors.
Meaning of the symbols is the following.
+++ causal relationship established; ++
strong evidence of a causal relationship; +
some evidence of a causal relationship; 0
no clear evidence of a causal relationship.
¶ The difference in forced expiratory
volume in one second (FEV1) level
between the exposed and unexposed,
expressed as a percentage of the level in
the unexposed group. COPD: chronic
obstructive pulmonary disease.
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Indoor air and respiratory health in the
eldelry of OQAI
Elderly more fragile (normal and pathological ageing)
Elderly spend more time inside
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Improve Indoor Air Quality
• Individuals have certain influence e.g. on
–
–
–
–
–
Environmental tobacco smoke (ETS)
Design and construction of buildings (e.g. ventilation)
Household chemicals and other products
Combustion Sources (fireplaces) and cooking
Heating and cooling systems
• Individuals have less influence on
– Environmental (outdoor/general) air pollution (e.g.
automobile exhaust and industry emissions);
– Building materials (e.g. dangerous substances in
existing buildings and in new construction materials)
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Possible Asthma prevention
(as estimated by the Population Attributable Risk)
By eliminating the exposure to.......
Population
ETS
+
Mould
Adults
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+
+
Study
28%
Lee
et al, 2006
Non smokers 10%
women
Simoni
et al, 2007
home indoor pollution
by gas use for
heating/cooking
Children
39%
Lanphear
et al, 2001
home indoor pollution
by gas use for
heating/cooking
Children
5-7%
Battistini
et al, 2000
+
ETS
ETS
Reduction
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EPAR
Possible COPD/respiratory symptoms prevention
(as estimated by the Population Attributable Risk)
By eliminating the exposure to.......
Symptom/
disease
Work exposure to gas/vapours/
fumes/dusts
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+
Mould
+
Reduction
Nonsmokers
women
COPD
Dyspnea
Cough/
Phlegm
ETS
ETS
Population
Simoni
et al, 2007
12%
10%
9%
Adults
COPD
Asthmatic/
Bronchitic
Symptoms
I. Annesi-Maesano
Study
20-31%
Children
16%
Adolescents
18%
Trupin
et al, 2003
Forastiere
et al, 2005
EPAR
Conclusions
•
•
•
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Sebbene sia indiscutibile il fatto che la penetrazione degli inquinanti
outdoors nei locali chiusi dove gli esseri umani trascorrono anche
90% del loro tempo possa provocare danio alla salute degli occupanti,
è difficile separare il contributo dell’inquinamento outdoors alla
qualità dell’aria indoors salvo nel caso di fonti indoors o outdoors ben
identificate.
Un solo studio (Mi) ha stimato la relazione tra gli outcomes sanitari ed
il rapporto I/O per NO2 e O3. La stima degli odds-ratio (1.23 e 1.27 tra
NO2 e sibili e crisi d’asma e 0.83 tra O3 e difficoltà di respiro)
confermava la prevenienza degli inquinanti.
La ventilazione dei locali chiusi e i comportamenti di prevenzione degli
individui devono essere preconizzati per ridurre le concentrazione e
quindi l’esposizione.
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EPAR
Conclusions
•
•
•
Indoor air pollution is ubiquitous (various pollutants in various
environments (house, school, work…))
Individuals exposed to variable indoor concentrations of air pollution
(dose, activities, interactions/synergy, individual susceptibility…)
Exposure to indoor air pollution varies as a function of geography,
setting (rural vs. urban) climate (warm vs. cold countries)
– Several components for a unique pollutant (house
dust mite, moulds…)
– Emerging problem (cleaning product, phtalates…)
•
Indoor air associated with respiratory and allergic diseases ( although
dose-effect relationship not identified) , which could explain their
augmentation in the past decades
 PUBLIC HEALTH PROBLEM
• Few guidelines and standard proposed
• Importance of the ventilation
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1000 fois merci
I. Annesi-Maesano
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Pollution de l’air intérieur et
santé respiratoire en Auvergne (FERMA)
COV
©http://histgeo.ac-aix-marseille.fr
30km
20mi

Études cas-témoin nichées


Milieu urbain : 63 enfants (31/32)
Milieu rural : 51 enfants (27/24)
Clermont-Ferrand
Hulin Indoor Air
2011
ISS.XII.2011
I. Annesi-Maesano
EPAR
Proportion d’enfants fortement exposés
Rural
Urbain
Proportion (%)
70
60
**
50
**
40
30
20
10
0
Aldéhydes
NO
NO2
2
PM
PM2.5
2.5
BTX
Répartition différente entre milieu urbain et rural
** Répartition différente entre les 2 milieux (χ2)
ISS.XII.2011
I. Annesi-Maesano
EPAR
Indoor air pollution and asthma.
FERMA
COV

Associations en milieu
urbain

Associations en milieu
rural
Odds Ratio
Odds Ratio
Acétaldéhyde
Estimation
IC 95%
2.6
[1.0;6.7]
Propanal
3.3
[1.0;11.3]
Toluène
2.6
[1.0;6.8]
Estimation
IC 95%
Formaldéhyde
6.0
[1.3;27.6]
Acétaldéhyde
2.8
[0.9;9.1]
Hexanal
3.0
[0.9;10.0]
NO2
2.2
[1.0;5.2]
Associations significatives

ISS.XII.2011
Plus d’enfants asthmatiques dans les domiciles pollués
 Relations différentes entre les 2 milieux
I. Annesi-Maesano
Indoor
EPAR
House
dust mites
ISS.XII.2011
I. Annesi-Maesano
EPAR
Viable bacteria
References
Pollutant concentrations at school (CFU/m3) Mean
Associated health effects
(SD)/mean/mean [range]
Indoor
Figures are OR, CI 95 % if not otherwise stated
Outdoor
- Nocturnal
Kim JL et al.
1 170 (1 520) 2 200 (4 510)
2007
breathlessness # :
0,92** [0,87-0,98]
- Doctor diagnosed
0,97* [0,94-1]
asthma # :
Reporting of at least one asthmatic symptom
Smedje et al.
2000
Installation of a new ventilation
and the reporting of more asthmatic symptoms in
system later : 450
_
1995 than in 1993 were less common among the
No new ventilation system : 470
143 pupils who attended schools with new
ventilation systems.
Natural Ventilation : 736 (1325)
Zuraimi et al.
2007
104 Child Care
Centers, Sing.
Hybrid ventilation : natural + air
Lower prevalence for most asthma and
conditioning : 759 (1139)
2000
Smedje et al.
2001
743 (1189)
Air conditioned and mechanical
ventilation : 341 (642)
Air-conditioned : 593 (1067)
Norback et al.
663 (1260)
1500 [280-
6800]
730 [5018000]
allergy, and respiratory symptoms in children
705 (1340)
attending NV CCCs.
769 (1384)
_
_
_
_
# OR expressed as change of coefficient per 10²/m
3 ; * P ≤ 0.1 / ** p ≤ 0.05 / *** p ≤ 0.001
ISS.XII.2011
I. Annesi-Maesano
EPAR