Indoor habits of children aged 5 to 10 years learning at the public basic schools of Lisbon-city, Portugal

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1 Indoor habits of children aged 5 to 10 years learning at the public basic schools of Lisbon-city, Portugal Issmat R. Khan 1, Maria do Carmo Freitas 1, Isabel Dionísio 1 and Adriano M. G. Pacheco 2 1 Reactor-ITN (Technological and Nuclear Institute), Estrada Nacional 10, 2686 Sacavém Portugal 2 CERENA-IST (Technical University of Lisbon), Av. Rovisco Pais 1, Lisboa Portugal Corresponding ikhan@itn.pt SUMMARY In this work, 36 basic schools of Lisbon city, Portugal followed a questionnaire of the ISAAC - International Study of Asthma and Allergies in Childhood Program. The questionnaire contains questions to identify children with respiratory diseases (wheeze, asthma and rhinitis) as well as their nutrition habits, ingested medication, environmental aspects, among others. The questioned children are 5 to 10 years old, and the answers are from June to December The results are from 995 children inquired who have shown 26.7% with wheezing symptoms, 9.2% with asthma, and 26.2% with rhinitis. The results obtained are compared with the results, interpretations and correlations obtained in the ISAAC 2002 program, which questioned to 7 years old children from the basic schools of Lisbon-city from November 2002 till March INTRODUCTION Children s exposure to air pollution is a very important issue mainly because children immune system is not fully developed, as well as their lungs. Consequently their response to pollution from traffic in urban areas, particles and other combustion sources are different to those observed by adults [1]. In addition, children spend more time outside, where the concentrations of our pollution are generally higher. The effects of air pollution in children with respiratory problems might be even higher than recognised. Overall, evidence for effects of air pollution on children has been growing, and effects are seen at concentrations that are common today. Although many of these associations seem likely to be causal, others require additional investigation [1]. The aim of this work is to identify the children with respiratory problems with ages between 5 to 10 years, studying in the basic schools of the Lisbon city. It will be followed by other studies which will relate air pollution, with acute episodes of respiratory diseases in the same population. The identification was made by simple core questionnaires which followed other identification study ISAAC - International Study of Asthma and Allergies in Childhood. ISAAC was formed in 1991 to facilitate research into asthma, allergic rhinitis and eczema by promoting a standardised methodology. ISAAC developed from a merging of two multinational collaborative projects each investigating variations in childhood asthma at the population level. It was a unique project which has attracted worldwide interest and unprecedented large scale participation. The aims of ISAAC were to describe the prevalence and severity of asthma, rhinitis and eczema in children living in different centres and to make comparisons within and between countries [2]. The study has included the city of Lisbon, and the results of this work will be compared with the results obtained in this 2002 international study.

2 The first part of the questionnaire identifies children with wheeze symptoms. Wheeze is a continuous, coarse, whistling sound produced in the respiratory airways during breathing. For wheezes to occur, some part of the respiratory tree must be narrowed or obstructed, or airflow velocity within the respiratory system is higher. Wheezing is commonly experienced by persons with a lung disease. The aim of the second part of the questionnaire is to identify asthmatic children, a chronic disease of the respiratory system in which the airway occasionally constricts, becomes inflamed, and is lined with excessive amounts of mucus, often in response to one or more triggers. These acute episodes may be triggered by such things as exposure to an environmental stimulant (or allergen), cold air, exercise or exertion, or emotional stress. In children, the most common triggers are viral illnesses such as those that cause the common cold. This airway narrowing causes symptoms such as wheezing, shortness of breath, chest tightness, and coughing. Between episodes, most patients feel fine. The symptoms of asthma, which can range from mild to life threatening can usually be controlled with a combination of drugs and environmental changes. The third part aims to identify children with rhinitis symptoms and hay fever. Rhinitis is the medical term describing irritation and inflammation of the nose. The primary symptom of rhinitis is a runny nose. It is caused by chronic or acute inflammation of the mucous membrane of the nose due to viruses, bacteria or irritants. The inflammation results in excessive mucous production producing a runny nose, nasal congestion and post-nasal drip. Hay fever is caused by pollens of specific seasonal plants in people who are allergic to these substances. When these symptoms are caused by pollens, the allergic rhinitis is commonly known as "hay fever", after the fact it is most prevalent during haying season. Allergies are caused by an oversensitive immune system, leading to a not direct immune response. Allergy occurs when the immune system reacts to substances (allergens) that are generally harmless and in most people do not cause an immune response. As noted above, hay fever involves an allergic reaction to pollen. A virtually identical reaction occurs with allergy to mould, animal dander, dust, and similar inhaled allergens. Particulate matter in polluted air and chemicals which can normally be tolerated can greatly aggravate the condition. The ISAAC work concludes that there are several factors which might trigger acute episodes, or on other hand, be protective about respiratory systems diseases. The last part of the questionnaire, follows this principle as described in the ISAAC studies, and gathers the information about these factors, so that later conclusions can be found. METHODS It has been established a contact with the ISAAC coordinator in Portugal Dr. José Eduardo Rosado Pinto, prior to the study start. This contact lead to the elaboration of the questionnaires based on the ISAAC study. The next step involved the contact with all the basic schools in the city of Lisbon, to present the project and to get authorization to deliver the questionnaires to the students. The questionnaires were delivered from June 2006 to the participating schools. At the same time oral presentation to the teachers and meetings with the school coordinators took place to explain the main targets to be achieved, and to motivate the filling of the questions and improve the number of students with answers. The distribution of the schools in the Lisbon city is shown in fig. 1

3 Figure 1 Distribution of the participating schools in the city of Lisbon, and number of answered questionnaires for each. During this period and till February 2007, the data from the questionnaires were processed to make possible a further statistical treatment. As a first step the data treatment included the validation of the data base by comparing the results processed in two independent databases made by two persons. RESULTS Tables 1 to 10 resume the results obtained by processing the questionnaires as well as the results obtained in on the ISAAC work for comparison. The non valid results were eliminated for each question, and was calculated the total number of answers, the percentages in each question in relation to the total number of answers or in some questions in relation to the number of the positive answers. Table 1 Resume of schools inquiry Inquiries Information ISAAC Number of schools contacted 96 - Number of schools with answers Number of inquiry s Answers from Jun to Dec 2006 Nov 2002 to March 2003 Children with ages between 5 10 years 6 7 years Table 2 Results related with wheezing symptoms Questions in relation with wheezing symptoms Number of children inquired with wheezing symptoms Number of children with wheezing symptoms in the last 12 months Number of days with wheezing symptoms in the last 12 months % in relation to children with wheezing symptoms % in relation to the total number of answers % in relation to the total number of answers % 30.1 % % 11.4% 14.1 % % in relation to children with wheezing symptoms % in relation to the total number of answers 1 to % 8.0% not available 4 to % 2.4% n. a. more then % 0.8% n. a. Weakening because of wheezing symptoms Never % 3.8% n. a. 1 night or less per week % 4.9% n. a. 1 to 2 nights per week % 2.6% n. a. Children with talking limitation because of wheezing symptoms % 2.3% n. a.

4 Table 3 Results related to asthma ASTHMA % in relation to the total number of answers Children with asthma % 7.8 % Table 4 Results related to Rhinitis RHINITIS Children with sneezing crisis, runny nose or nasal congestion not associated with common cold Children with sneezing crisis, runny nose or nasal congestion not associated with common cold in the last 12 months % in relation with children with rhinitis symptoms % in relation to the total number of answers % in relation to the total number of answers % 31.2% % 23.3% 26.2% Table 5 Rhinitis symptoms along the year Months with more nasal % in relation to the total Months with more nasal % in relation to the total problems in the last year number of answers problems in the last year number of answers Jan % Jul. 18 2% Feb. 64 8% Aug. 23 3% Mar % Sep. 68 9% Apr % Oct. 72 9% May 91 12% Nov. 53 7% Jun. 44 6% Dec. 49 6% Table 6 Rhinitis influence in the daily activities Influence of Rhinitis in the daily activities of the children % in relation with children with rhinitis symptoms % in relation to the total number of answers Not affected % 11.2% Low % 7.7% Average % 5.8% High 8 3.0% 0.8% Table 7 Results related with Alimentary Habits a. Meat Eating habits % in relation to the total number of answers More than 3 times a week % 74.6 % 1 or 2 times a week % 21.2 % Never or occasionally % 0.8 % b. Fish More than 3 times a week % 52.8 % 1 or 2 times a week % 38.4 % Never or occasionally % 4.2 % d. Vegetables More than 3 times a week % 50.8 % 1 or 2 times a week % 33.0 % Never or occasionally % 9.1 % i. Butter More than 3 times a week % 58.5 % 1 or 2 times a week % 25.5 % Never or occasionally % 10.1 % j. Margarine More than 3 times a week % 20.0 % 1 or 2 times a week % 26.0 % Never or occasionally % 42.9 %

5 Table 7(cont.) Results related with Alimentary Habits Eating habits % in relation to the total number of answers l. Potatoes More than 3 times a week % 63.5 % 1 or 2 times a week % 29.3 % Never or occasionally % 2.2 % m. Milk More than 3 times a week % 86.5 % 1 or 2 times a week % 7.2 % Never or occasionally % 1.0 % o. Fast food/hamburgers More than 3 times a week % 4.1 % 1 or 2 times a week % 20.4 % Never or occasionally % 67.8 % Table 8 Results about Breastfeeding Breastfeeding % in relation to the total number of answers Children that have been breastfeed % 82.2 % Table 9 Results related with medicines and environmental aspects % in relation to the total number of answers Paracetamol Administration % in relation to the total number of answers Paracetamol ministration in the first 12 months of life % 78.1 Paracetamol ministration in the last 12 months % in relation to the total number of answers At least once a month % % At least once a year % 73.9 % Never % 5.1 % Antibiotics administration % in relation to the total number of answers Children with antibiotics ministration in the first 12 months of life % 53.6 % Lorries traffic near home % in relation to the total number of answers All day long % 6.4 % Frequently % 23.9 % Rarely % 50.2 % Never % 16.8 % Table 10 Results related to parents smoking habits Smoking habits % In relation to the total smokers % In relation to the total number of answers % In relation to the total smokers % In relation to the total number of answers Smoking mothers % 26.7 % Less than 10 cigarettes/day % 14.7 % 10 to15 cigarettes/day % 4.9 % 15 to 20 cigarettes/day % 5.6 % More than 20 cigarettes/day % 1.0 % Smoking Fathers % 42.0 % Less than 10 cigarettes/day % 11.0 % 10 to15 cigarettes/day % 6.6 % 15 to 20 cigarettes/day % 15.3 % More than 20 cigarettes/day % 6.0 % Smoking Mothers in the first year of age of the children % 17.8 %

6 Table 10(cont.) - Results related to parents smoking habits Less than 10 cigarettes/day % 10 to15 cigarettes/day % 15 to 20 cigarettes/day % More than 20 cigarettes/day % As mentioned before, the ISAAC study found some risk and protective factors for the respiratory diseases studied. These factors are given in the tables 11 and 12, as well as the results obtained with our inquiries: Table 11 Results relative to wheeze protective and risk factors WHEEZE Eating habits Factor Protective Risk Results from this work Fish More than 3 times a week 52.9 % 52.8 % Margarine More than 3 times a week 12.5 % 20.0 % Meat More than 3 times a week 85.4 % 74.6 % Milk More than 3 times a week 94.5 % 86.5 % Potatoes More than 3 times a week 50.2 % 63.5 % Fast Food More than 3 times a week 4.0 % 4.1 % Medicines Paracetamol At least once a month (recently) 19.0 % 17.0 % Antibiotics In the first year of age 49.5 % 53.6 % Environment Lorries Traffic All day long 7.4 % 6.4 % Smoking Smoking Mother Now 35.0 % 26.7 % Smoking Mother First year of Age 25.9 % 17.8 % Table 12 - Results relative to asthma protective and risk factors ASTHMA Factor Protective Risk Eating Habits Results from This work Milk More than 3 times a week 94.5 % 86.5 % Antibiotics Medicines In the first year of age Environment 49.5 % 53.6 % Lorries Traffic All day long 7.4 % 6.4 %

7 DISCUSSION The results obtained in the questionnaires give a good estimate about the respiratory diseases on the urban area of Lisbon, for the children with 5 to 10 years old. The number of inquiries was lower than the ISAAC study, but pretended to gather information about the population in the same area. The results given are good information of the respiratory diseases for children in the urban city of Lisbon, for a population with a special concern due to their greater risk for these diseases. Although not exactly the same, the results obtained are comparable to the ISAAC study in 2002, which had a bigger population inquired. For this reason we consider our results acceptable and a good snapshot of the respiratory problems in the area studied. We found 26.7 % (266) of children with wheezing symptoms from which 42.5 % (113) had the symptoms in the last 12 months and with about 30% (80) having 1 to 3 days of illness in the same period. Again for the children that have recognized having this respiratory disease, 18.4 % (53) have wakened up at night at least once in the last year with wheeze and 6.8% (23) had talking limitation again because of the symptoms. Comparing the results found with the ISAAC study for this respiratory disease, we find a very close percentage, although slightly minor in our Inquiry from The results show 9.2 % (92) of asthmatic children with ages from 5 to 10 years in the city of Lisbon. This is a significant result for a chronic disease that might be trigged by an environmental stimulant. This fact reveals the importance of a more detailed study relating asthma (and other respiratory diseases) with atmospheric pollution. In addition the comparison with the ISAAC results from 2002/2003 show a slightly increase of the presence of this disease in For rhinitis the results obtained are lower then in the ISAAC study, 26.9 % (268) and 31.2% respectively. The majority of these children had rhinitis in the last year, corresponding to 86.6% (238). According to the results obtained for rhinitis, the months where the disease is more evident are March, April and May, and in lower percentage January. This fact confirms the seasonal prevalence of this respiratory problem, more present in the spring months. In addition 21.6 % (59) of the children inquired with rhinitis had an average affection of the daily activities. For hay fever, we found in our results the same percentage as in the ISAAC study: 2.6% (26). We recognize this percentage could be slightly higher because part of the population inquired could not identify this disease with the related symptoms and therefore did not answer the question. The results obtained about the eating habits of the children are similar which is expectable as the eating habits should not change in a 5 year period. This is important when relating the risk and protective factors with the results obtained. Since the similarities of this study with the ISAAC 2002, we can conclude that the factors referred in table 11 and 12 may be applicable to the population studied. The majority of the children of Lisbon have been breastfeed corresponding to 81.5 % (811). The result was very close to the result of the ISAAC questionnaire in %. For medicines given to children, our results show a big decrease of Paracetamol administration in the first 12 months of life, and in fewer amounts of antibiotics as well, in comparison with ISAAC results.

8 The children living with frequent Lorries traffic near home is significant: 23.3 % (232), and similar to what was obtained in 2002 (23.9%) In terms of the smoking habits, it is important to refer the increase in the number of smoking mothers (26.7 in 2002/2003 to 35.0% in 2006), the increase in the number of smoking mothers in the first year of the children (17.8% in 2002/2003 to 25.9% in 2006) and a slightly decrease on the number of smoking fathers (42.0% in 2002/2003 to 39.4% in 2006). As referred before, table 11 give the main protective and risk factors found in the ISAAC study for wheeze. For the results found in our work, we can consider important risk factor eating fish more than 3 times per week. This corresponds to 52.9% of children only more 0.1% than in the ISAAC study. We also consider important as a risk factor the ministration of antibiotics in the first year of age. It was found 49.5% of the children which is also close to the 53.6% in the ISAAC study. In terms of protective factors, we found 85.4% of children eating meat more than 3 times a week (74.6% in the ISAAC study) and 94.5% drinking milk more than 3 times a week (86.5% in the ISAAC results). This can be considered the main protective factors for wheeze because of the higher percentage of answers and because the results are close to the results of the 2002/2003 study. As we can observe in table 12 for asthma, the same considerations made for wheeze referring antibiotics in the first year of age as a risk factor and eating meat more then 3 times a week as a protective factor can also be taken for asthma. The results found show the importance and the presence of common respiratory diseases in the city of Lisbon, in the same way ISAAC study in 2002 had shown. The percentages were lower than the ISAAC study in 2002 for wheeze and rhinitis which may show a decrease of these respiratory problems in the city. In opposite, there is an increase of the number of asthmatic children. The data presented will be used in future studies and the main objective is to monitor episodes respiratory problems with atmospheric pollution. AKNOWLDGMENTS The authors wish to thank Susana Sarmento and Rita Veloso for the contribution on the data introduction of the questionnaires. This research was subsidized by European Community Found FEDER trough the project POCI2010/AMB/55878/2004 approved by FCT and POCI REFERENCES 1. Joel Schwartz, Air Pollution and Children s Health, Paediatrics, Vol. 113 No. 4 April M.I. Asher, U. Keil, H.R. Anderson, R. Beasley, et al: International study of asthma and allergies in childhood (ISAAC): Rationale and methods, European Respiratory Journal, 1995, 8, I. R. Khan, M. C. Freitas, A. M. G. Pacheco, Particulate matter levels in Portugal (mainland and islands). A preliminary study for outdoor/indoor environment in basic schools Proceedings of the Clima 2007 WellBeing Indoors, Helsinki, Finland, June 2007 (This conference). 5. J. Zhang, W. Hu, F. Wei, G. Wu, LR. Korn, R.S. Chapman, Children s respiratory morbidity prevalence in relation to air pollution in four Chinese cities, Environmental Health Perspectives, set 2002, 110-9

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