1. Does outdoor or indoor air pollution cause more respiratory disease? Evidence from the Central European Study on Air Pollution and Respiratory Health (CESAR Study). Central European Study of Air Pollution and Respiratory Health Tony Fletcher, London School of Hygiene and Tropical Medicine, London. UK Brunekreef B, Houthuijs D, Fabianova E, Lebret E, Leonardi G, Gurzau E, Nikiforov B, Rudnai P, Volf J, Zejda J.

2. CESAR National Research Teams Bulgaria : National Centre of Hygiene, Bojidar Nikiforov Czech Republic: Regional Institute of Hygiene Ostrava, Jaroslav Volf Hungary: National Institute of Public Health, Alan Pintér and Peter Rudnai Poland: Institute of Occupational Medicine and Environmental Health, Jan Zejda Romania: Environmental Health Center, Eugen Gurzau Slovakia: Regional Specialized Institute of Public Health Banska Bystrica, Eleonorá Fabiánová United Kingdom: LSHTM, Tony Fletcher, Giovanni Leonardi and Sam Pattenden The Netherlands: WAU, : Bert Brunekreef and Gerard Hoek The Netherlands: RIVM, Erik Lebret, Annelike Dusseldorp and Danny Houthuijs

3. CESAR - AIMS: Central European Study of Air Pollution and Respiratory Health Establish comparable base-line data on: children’s respiratory health air pollution, including PM10 and PM2.5 environment and health risk perceptions Investigate effects on respiratory health of: air pollution indoor and other risks factors Capacity building: (epidemiological) research methods introduction of QA/QC methods

4. Central European Study of Air Pollution and Respiratory Health 1994-1997EC - PHARE Programme 1999-2000EC - INCO Copernicus European Funding for CESAR:

5. Study characteristics  Cross-sectional study among children aged 7 - 11 year in 6 countries  Four (five) study areas per country: 25 study areas  Selection of study areas within countries based on differences in air pollution levels and in dominant local sources  Participation of about 1,000 children per study area  Current concentration of PM10 and PM2.5 measured in all study areas  Assessment of respiratory health endpoints and potential confounders at individual level

6. CESAR Study areas Central European Study of Air Pollution and Respiratory Health

7. Methods 24 hour sampling, once every six days, during Nov 1995 - Oct 1996 background sampling site Harvard impactors with cut-off points at 2.5 and 10 µm preparation and analysis in one central laboratory per country Questionnaire respiratory symptoms and conditions: based on items from WHO, ISAAC and ATS in children 7 - 11 years old Base-line pulmonary function test (FVC and FEV 1 ) in children age 9 - 11 Information on risk factors and potential confounders collected by questionnaire

8. Questionnaire based health endpoints Cough on most days for at least 3 months consecutively in the last autumn-winter season Any cough symptom over life time (combination) Any wheeze symptom in the last 12 months (combination) Any wheeze symptom over lifetime (combination) Bronchitis doctor diagnosed, ever Bronchitis in last 12 months Asthma doctor diagnosed, ever Asthma attacks in last 12 months Medication use for a breathing trouble in last 12 months

9. Risk factors in model Age, sex country current # of smokers in the home use of gas range or oven for heating in winter use of unvented gas, oil or kerosene heater ever moisture stains or mould in the home over lifetime of child Furniture with chipboard Reported frequency of traffic passing the house Consumption of fruit, vegetables and fish education of the mother occupation of the father Parental history of wheeze, asthma, inhalant allergy, eczema or hay fever

10. Statistical analyses Assessment of current annual average concentrations for PM10, PM2.5 and coarse fraction Two stage regression of area-specific means/logits after adjustment for potential individual confounders Random effects models at taking into account within country correlations for estimating pollution effect Attributable fraction: calculation of attributable fractions from logistic regression models

11. Numbers in study total population: 20271 3470 (1 Country) dropped for lack of PM data 2899 dropped for missing values in one or more variables in the models subjects used in these analyses: 13902

12. CESAR - 25 Study areas Central European Study of Air Pollution and Respiratory Health Bulgaria Sofia suburbThermal power station Sofia centreTraffic VratzaChemicals, AssenovgradMetallurgical Czech Republic Ostrava centreLocal heating, traffic Ostrava -VitkoviceIron works, power, coke Ostrava - Poruba No local sources Ostrava - RadvaniceIron works, coke oven Hungary CegledNo local sources DorogLocal heat., power plant, pharmac. EgerLocal heat., intense traffic, agric. TataLocal heating, moderate traffic TatabanyaLocal heating, coal/ oil power Poland Kedzierzyn - KozleChemical plant KielceClean, recreational area PszczynaClean area SwietochlowiceMetallurg., coal, chemical Romania BucharestTraffic, local heating PloiestiPetrochemical, chemicals Baja MareMetallurgical industry Tirgu MuresChemical industry Slovakia Banska Bystrica suburb No local sources Banska Bystrica centre Traffic, cement plant Zilina Chemical, paper factories Bratislava Traffic, local heating

14. Cough and PM2.5 by study area any cough symptoms ever (%) PM2.5-concentration (µg/m3) 3040506070 0 20 40 60 B B B B C C C C H H H H H P P P P S S S S

15. Wheeze and PM2.5 by study area any wheeze symptoms ever (%) PM2.5-concentration (µg/m3) 3040506070 10 20 30 40 50 B B B B C C C C H H H H H P P P P S S S S

16. Example of some risk factors for Wheeze: Prevalence, Odds ratios and Attributable fractions

17. Conclusions Central European Study of Air Pollution and Respiratory Health attributable fractions are a helpful indicator for interpreting these results and could be used more widely parental history of respiratory illness and indicators of socioeconomic status are important contributors to symptom prevalence air pollution is more important for some symptoms than indoor combustion sources, ETS or dampness the presence of chipboard furniture is very prevalent and appears to be associated with substantial attributable fractions for some symptoms