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Effects of the Home Environment on Respiratory Symptoms of a General Population Sample in Middle Italy Dr. Giovanni Viegi a b
a b
, Sandra Baldacci d
Pede & C. Giuntini
, Laura Carrozzi a b
a b
, Paola Modena
, Paolo Paoletti
a b
a b
, Mariella Vellutini
, Marzia Pedreschi
a b
a b
, Emilio Diviggiano c
, Umberto Mammini , Cinzia Di
a b
a
CNR Institute of Clinical Physiology , University of Pisa , Pisa, Italy
b
2nd Medical Clinic , University of Pisa , Pisa, Italy
c
CNR Computer Center (CNUCE) , University of Pisa , Pisa, Italy
d
Occupational Medicine Service , USL 5 Media Valle del Serchio Bagni di Lucca Regione, Toscana, Italy Published online: 03 Aug 2010.
To cite this article: Dr. Giovanni Viegi , Laura Carrozzi , Paolo Paoletti , Mariella Vellutini , Emilio Diviggiano , Sandra Baldacci , Paola Modena , Marzia Pedreschi , Umberto Mammini , Cinzia Di Pede & C. Giuntini (1992) Effects of the Home Environment on Respiratory Symptoms of a General Population Sample in Middle Italy, Archives of Environmental Health: An International Journal, 47:1, 64-70, DOI: 10.1080/00039896.1992.9935946 To link to this article: http://dx.doi.org/10.1080/00039896.1992.9935946
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Effects of the Home Environment on Respiratory Symptoms of a
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General Population Sample in Middle Italy
ClOVANNl VlEGl LAURA CARROZZI PA010 PAOLETTI MARIELLA VELLUTINI EMlLlO DlVlCGlANO SANDRA BALDACCI PAOLA MODENA MARZIA PEDRESCHI CNR Institute of Clinical Physiology and 2nd Medical Clinic UMBERTO MAMMINI CNR Computer Center (CNUCE) University of Pisa Pisa, Italy ClNZlA DI PEDE Occupational Medicine Service US1 5 Media Valle del Serchio Bagni di Lucca Regione TOScana, Italy C. GlUNTlNl CNR Institute of Clinical Physiology and 2nd Medical Clinic University of Pisa Pisa, Italy
ABSTRACT. The effects of home environment characteristics were evaluated in a multistage, stratified, cluster sample (N = 3 866) of the general population who lived in the district of Pisa (middle Italy). Each subject completed a standardized interviewer-administered questionnaire that contained questions about respiratory symptomddiseases and risk factors (e.g., type of heating, fuels used for cooking and heating). Cough and asthma were significantly more frequent in men who did not smoke and who did not use natural gas for cooking and heating. Attacks of shortness of breath accompanied by wheeze, wheeze, dyspnea, and cardiovascular conditions in female nonsmokers were associated with use of a stove or forced-air circulation for heating; the type of fuel used did not affect this result. Multiple logistic models, which accounted for independent effects of age, smoking status, pack-years, childhbod respiratory illness, education, zone of residence, and work exposure to dusts, chemicals, or fumes, showed significantly increased odds ratios for (a) cough and phlegm in males (associated with bottled gas for cooking), (b) wheeze and shortness of breath with wheeze in females (associated with the use of a stove or forced-air circulation). These results, which confirm our previous observations in an unpolluted rural area of north Italy, indicate that characteristics of the home environment, as assessed by questionnaire, may be linked to mild adverse health effects, i.e., respiratory symptoms, in the general population. The results also identify the need to better characterize the dose-response relationship in indoor air pollution monitoring studies that include subsamples of this population. 64
Archives of Environmental Health
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DURING THE PAST 10 y, interest in the health effects of indoor air pollution has increased. Most people spend the majority of their time indoors, and many pollutants can be detected in various rooms-especially in the kitchen.'-' However, few epidemiological sutveys have investigated these effects. Studies of children" found that the use of gas for cooking or heating was associated with an increased prevalence of cough, wheeze, acute respiratory infections, history of respiratory illness prior to age 2 y, and rate of hospitalization, compared with the use of electric stoves for cooking or heating. The increased prevalence rate of chronic cough and phlegm in adults is related to gas cooking."" Unvented space (forced-air) heaters, especially those that use kerosene, are also harmf~1.l~ In a recent review on the adverse health effects of indoor the authors recornmended that pollutants thought to be responsible for these effects, i.e., mainly nitrogen oxides (NOJ, sulfur dioxide (SOz),carbon monoxide (CO),and particulates CTSP), be monitored. However, such measurements are not simple, nor are they sufficiently inexpensive to be applied in large-scale epidemiologic surveys; therefore, most published reports are based on assessment of exposure by questionnaire. In a previous report," we described, for the first time in Italy, the relationship between exposure to various sources of indoor pollution, as assessed by a standardized interviewer-administered questionnaire, and respiratory symptoms in a general population sample in the rural unpolluted area of Po Delta (northern Italy). Fuels that were different from natural gas, e.g., bottled gas, kerosene, coal, or oil, and heating appliances that differed from central heating (i.e., water-heat transfer) were associated with an increased prevalence of chronic cough, phlegm, wheeze, dyspnea, rhinitis, and cardiovascular disturbances. On the basis of this information, we considered it worthwhile to analyze the data of a lar e-scale epidemiological survey in Pisa (middle Italy).' The survey was originally planned to assess the health effects of outdoor air pollution, which resulted from heavily used highway and industrial settings. The aim of this study was to determine if the fuel for cooking or for heating, and type of heating, are associated with increased prevalence rates of respiratory symptoms in a general population sample in an urbansuburban environment.
Q
Materials and methods The sampling method, population characteristics, air pollution monitoring data, and the CNRquestionnaire were described previ~usly.'~~' Briefly, two populations were studied from 1985 through 1988: (1) individuals in the suburban zone of Cascina, where most exposures resulted from heavily used highways; and (2) individuals in the urban zone of Pisa who were also exposed to fumes from surrounding industry. There were outdoor low values of So, and considerable levels of TSPl5; concentrations of both pollutants were higher in these two areas JanuarylFebruary1992 [Vd. 47 (No.l)]
than in Po Delta," and they were higher in Pisa than in Cascina. In Pisa, the mean annual TSP level approached the National Air Quality Standard of 150 &mJ. The target population numbered 48 662 and included 59 census sections, of which 29 were in Pisa and 28 were in Cascina. Age and sex distribution were similar in the two areas. In Cascina, the main activities were manufacturing and small-scale industry; administration and trading were the main activities in Pisa, where sub jects were more educated. In the current study, the population sample of 3 866 individuals (77%of eligible subjects, 5-90 y of age) was a family-based, multistage, stratified, cluster design. Stratification was performed according to age and socioeconomic characteristics. Information for these indicators was collected from the most recent national census data for the aforementioned 59 census sections. Family clusters were selected randomly from each stratum. Each subject completed the CNR questionnaire, which was developed by the Italian National Research Council (CNR) and patterned after the questionnaire developed by the American National Heart and Lung Institute (now NHLBI)." Mothers provided answers for children who were less than 10 y of age; subjects who were 10 y of age and older answered personally. The following symptoms were considered in the analysis: (1) chronic cough (or phlegm), which was characterized by cough (or phlegm production) for as many as 3 mo of the year for at least 2 y; (2) wheeze (unrelated to the common cold); (3) attacks of shortness of breath ackompanied by wheeze (unrelated to the common cold); (4) dyspnea, defined by shortness of breath when hurrying on level ground or walking up a slight incline; and (5) rhinitis that resulted from hay fever or from any allergy that made the nose runny or stufi (unrelated to the common cold). Emphysema, Table l.--QUestions Regarding the Home Environment A. What kind of heating do you have at home? 1. Forced-air circulation 2. Central heating (water-heat transfer) 3. Stove 4. None 6. If there is heating, which is the main fuel you use for heating? 1. Natural gas 2. Bottledgas 3. Electricity 4. Kerosene 5. wood 6. Coal or oil 7. Other C. Which is the main fuel you use for cooking?. 1. Natural gas 2. Bottledgas 3. Electricity 4. wood 5. Coal or oil 6. Other *Kerosene was omitted from item C because, in Italy, it is never used for cooking.
65
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chronic bronchitis, their combination, asthma, and cardiovascular conditions were taken into account if diagnosis was confirmed by a physician. Questions (Table 1) were asked about the home environment, of which most pertained to type of heating and type of fuel used for cooking. Subjects were defined as nonsmokers if they had never smoked any kind of tobacco regularly. Those who currently smoked at least one cigarette a day were classified as smokers. Exsmokers included those who had formerly smoked regularly until 6 mo or more prior to the examination (because there were so few, they were not accounted for in the univariate analysis). Statistical analyses were performed on an IBM 3081 at the University of Pisa Computer Center (CNUCE) and on a personal computer (PC/AT) at the University of Arizona, and the routines of the Statistical Package of the Social Sciences (SPSS) were used. The chi-square test was used to assess the difference in prevalence rates of symptoms. The role of different risk factors in determining respiratory symptomsldiseases were accounted for with multiple logistic regression models as follows: age (0 = < 20y, 1 = 21-40y, 2 41-60y, 3 = 60+ y); childhood respiratory problems (0 = absent, 1 = present); work exposure to dusts, chemicals, or fumes (0 a b sent, 1 present); education (1 did not graduate high school, 0 = college or college graduate); and zone of residence (0 = Cascina, 1 = Pisa). In the separate model for smokers, pack-years were also included (0 less than 10, 1 = 11-20, 2 21-30, 3 = 30+). The logistic models were run four times for each symptom/ disease to insure that the effects of the following were considered separately: fuel for cooking (0 = natural gas, 1 = other); fuel for heating (0 natural gas, 1 = other); type of heating (0 central, 1 = stove or forced-air circulation); and the variable ALLNATGAS (0 central heating fueled by natural gas-used also for cooking, 1 = forced-air circulation or stove fueled by bottled gas, wood, kerosene, coal or oil [no natural gas used for cooking]). Unless stated otherwise, all relationships were considered significant at p < .05.
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9
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-
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- -
Results Of the 3 729 subjects for whom information on cooking fuel was obtained, 67% used natural gas, 30% used bottled gas, 1% used wood, and 1% used “other” fuels, including electricity. With regard to heating fuel, 65% of the 3 714 used natural gas, 13% used coal or oil, 7% used kerosene, 7% used wood, 2% used bottled gas, 2% used electricity, and 4% indicated that they used other sources. Type of heating information revealed that 67% of 3 678 used central heating (water-heat transfer), 29% used a stove, and only 3% used forced-air circulation. We eliminated from analysis the few subjects who used electricity for heating and cooking and the 20 subjects who indicated that they had no heat in their home. We have preliminarily analyzed, by chi-square distrib~tion,’~ the effects of single sources of indoor pollution. Cough and asthma were significantly more fre66
quent in (a) male nonsmokers who used bottled gas for cooking and in (b) male nonsmokers who used kerosene, bottled gas, wood, coal, or oil for heating than in individuals who used natural gas. Females who were nonsmokers and who used a stove for heating had higher prevalence rates of wheeze, attacks of shortness of breath accompanied by wheeze, dyspnea, and cardiovascular conditions than those using central heating. Subsequently, we have tried to take a more logical approach to the analysis because, in this context, technologies tend to be highly associated. Therefore, interaction terms should most closely approach empirical reality. Distribution of subjects with respect to fuels used for heating and cooking and type of heating used is shown in Table 2, and subjects are categorized by sex and smoking status. In male and female smokers and nonsmokers, the interactive category, “central natural gas heat with natural gas cooking,” described the largest single group. There were only three other groups that were suitable for comparisons: (1) stove or forced-air circulation-natural gas used for heating and cooking; (2) central (not natural) gas heat-bottled gas used for cooking; and (3) stove or forced-air circulation that used (not natural) gas heat-bottled gas was used for cooking. The main characteristics of the subjects are reported in Table 3. The only significant difference found was for females: females who used stoves for heating were slightly older than those who used .central heating. Borderline differences in males were found for mean age and number of smokers. In nonsmoking males, significantly higher prevalence rates of chronic cough and diagnosed asthma (Table 4) were found for those who used no natural gas heating fuels and who used bottled gas for cooking (regardless of the type of heating used). No significant differences were noted for smokers. Regardless of the type of fuels used for heating or cooking, significantly higher frequencies of wheeze, attacks of shortness of breath accompanied by wheeze, dyspnea, and cardiovascular conditions were found in female nonsmokers (Table 5) who used a stove or forced-air circulation to heat their home. Less consistent results were found for female smokers; significantly higher prevalence rates of chronic cough and dyspnea occurred if these individuals used a stove or forced-air circulation for heating and if they used natural gas for heating and cooking. Stratification of the population by age ( < 20 y, 20-64 y, and > 64 y) did not impart relevant information. Because the groups were small in number, no statistically significant relationships emerged from the chi-square test. The results of multiple logistic models, which accounted for independent effects of other risk factors (i.e., age; smoking; pack-years; exposure to dusts, chemicals, or fumes in the workplace; childhood respiratory problems; education; and zone of residence) are shown in Table 6. The use of bottled gas was significantly related to higher odds ratios for (a) cough in Amhi-
of EnvironmentalHealth
of Subjects according to Interadan of Indoor Pollution Soumr, by
Tabk 2.-Didributkn Scx and Smdring
Natural gas Subjects and indoor pollution sources
-
Male nonsmokers (n 613) Central heat No central heat Male smokers (n 623) Central heat No central heat Female nonsmokers (n 1 326) Central heat No central heat Female smokers (n 623) Central heat No central heat
-
-
-
- -
NG
BC
31 7
3 2
1
96 295
8
0
94
2
601 213
1 62 74
16 11
101 61
4 0
18 7
99
2
90
2 6
9 3
4 1
34 21
210 21 1
8 11
5 2
0
11 5
57 53
0
1
1
-
natural gas, BC bottled gas. Central heat no central heat stove or forced-air circulation.
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Note: NG
Type of heating fuel Non-natural gas Type of cooking fuel Other NG BG Other
1
Tabk 3.--Msm
central heating (water-heat transfer),
Values of Age and Smvking Characteristii
I
Number of subjects Age (y) Smokers (%) Pack-yean
-
3
612 37.2 (21.3) 48.2 24.4 (20.8)
Male groups II 111
200 35.1 (21.0) 49.5 24.1 (18.9)
190 38.1 (22.1) 49.5 26.5 (21.O)
IV
151 41.Ot (21.9) 59.6t 25.3 (18.9)
I 763 45.4 (20.7) 21.2 9.5 (8.6)
Female groups II 111
267 40.8 (20.4) 21.3 7.7 (7.2)
287 48.8 (21.1) 25.8 10.8 (9.9)
IV
264 48.41 (22.5) 20.1 9.3 (8.9)
Notes: Values within parentheses are the standard deviations. Group I used central heating fueled by natural gas and cooked with natural gas; Group It used non-natural gas central heating and cooked with bottled gas; Group 111
used a stove or forced-air heating fueled by natural &as and cooked witti natural gas; and Group IV used nonnatural gas stove or forced-air heating and cooked with bottled gas. *p < .01 (analysis of variance for age; chi-square for smokers). t.1 > p > .05(analysis of variance). I
male nonsmokers and (b) cough and phlegm in male smokers, compared with respective groups who used natural gas for cooking fuel. The use of a stove or forced-air circulation to heat the home was significantly associated with increased odds ratios for wheeze and attacks of shortness of breath accompanied by wheeze in females, c o m p p d with the use of central heating (water-heat transfer). The interaction terms were considered, and the use of noncentral heating and nonnatural-gas fuels was significantly associated with increased odds ratios for cough in male nonsmokers, compared with use of central heating and natural-gas fuels. Rhinitis and cardiovascular conditions were not associated with any indoor variable in either sex. Discussion
A mild association between sources of indoor pollution and increased prevalence rates of respiratory
symptoms was found in a large sample of the general population who lived in an urban-suburban area of middle Italy. All of the symptoms noted are among the adverse health effects of air pollution, which are stated in the American Thoracic Society guideline.20An a s s ciation between the use of gas and an increased frequency of respiratory symptoms was found previously in E ~ rope~and , ' ~ in the United Statesc" (subjects who relied on electricity for cooking and heating were used as controls). Electricity is seldom used for cooking or for heating in Italy; therefore, in our study, we included, as controls, subjects who used natural gas. We hypothesized that natural gas poses less health risks to subjects, compared with the health effectsof bottled gas and other fuels. Also, in Italy, natural gas is utilized in newer appliances. The findings of this study accord with the results of the Po Delta survey," in which we described higher 67
prevalence rates of chronic cough, phlegm, dyspnea, and cardiovascular disturbances that were associated with the use of fuels (other than natural gas) or the use of a stove. However, in the Po Delta sample, the trend was more consistent than in the Pisa sample. In addition to the possible qualitative and quantitative differences that result from exposure to cigarette smoke (active and passive) and to indoor pollution, we have to consider the effect of outdoor pollution in Pisa, which was linked to the presence of significantly higher prevalence rates than were found in the Po Delta sur~ey.'~ The association between symptoms and sources of indoor pollution did not strengthen as the subjects'
Table 4.-Prevalence Indoor Exposure
ages increased, and we cannot conclude that a duration effect of indoor exposure exists. jedrychowski et aI.,'* however, studied a larger cohort of elderly women in Cracow (N 560, 65+ y of age), and more specific questions were included in the survey; a dose-response relationship between chronic chest symptoms (mainly phlegm) and time spent in the kitchen was estab1ished. If type of fuel used for cooking was considered, univariate analysis revealed mild effects (i.e., increased frequency of cough and asthma) of only bottled gas in the male nonsmokers; multivariate analysis disclosed an association between type of fuel (excluding natural gas)
-
Rates (%) of Respiratory Symptoms in Males, by Smoking Status and Groups of
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Nonsmokers
Subjects (n) Chronic cough Chronic phlegm Wheeze SOBWHZ Asthma Emphysema Chronic bronchitis Dyspnea Rhinitis Heart disorders
Smokers
I
II
111
IV
31 7 3 4 10 8 5 3 1 8 21 4
101 8 7 10 11 13
96
61 1 o* 5 10 10 7* 2 3 10 12 3
1
5 8 15 5 4 1
2 8 16 1
8 19 7
-
I
II
111
IV
295 32 29 39 8 6 10 13 35 15 8
99 38 31 36
94 35 31 38 5 5 14 12 33 11 9
90 36 34 29 8 8 12 10 33 12 7
7 7 6 9 35 16
5
~~
~
Notes: SOBWHZ r i c k s of shortness of breath accompanied by wheeze. Group I used central heating fueled by natural gas and cooked with natural gas; Group II used non-natural gas central heating and cooked with bottled gas; Group 111 used a stove or forced-air heating fueled by natural gas and cooked with natural gas; and Group IV used non-natural gas stove or forced-air heating and cooked with bottled gas. *p < .05 (chi-square).
Table 9.-Prevalence Indoor Exposure
Rates (%) of Respiratory Symptoms in Females, by Smoking Status and
I Subjects (n) Chronic cough Chronic phlegm Wheeze SOBWHZ Asthma Emphysema Chronic bronchitis Dyspnea Rhinitis Heart disorders
600
6 2 10 6
5 2 1 33 17 13
Nonsmokers II Ill
210 4 1 6 4 6
-
1 24 14
5
21 3 7 1 14 11 8 2 1 43 16 17
Smokers IV
21 1 7 1 14' ' 8 7 1 3 39* 14 139
I
II
111
IV
162 19 17 23 6 6 6 4 30 17 6
57
74 30 16 30 10 5 5 8 49 20 5
53 15' 14t 19t 6 8 8 4 23* 13 6
11
4 12 9 4 4 2 33 28 2
-
Notes: SOBWHZ attacks of shortness of breath accompanied by wheeze. Group I used central heating fueled by natural gas and cooked with natural gas; Group II used non-natural gas central heating and cooked with bottled gas; Group 111 used a stove or forced-air heating fueled by natural gas and cooked with natural gas; and Group IV used non-natural gas stove or forced-air heating and cooked with bottled gas. *p c .05 (chi-square). t.1 > p > .05 (chi-square). *p < .001 (chi-square). c .01 (chi-square).
Archives of EnvironmentalHealth
Table 6.--Significant Associatho of Home Environment Charactetistics with Respiratoy SVmpt-
OR Male nonsmokers Cough Male smokers Cough Phelgm Female nonsmokers Wheeze SOBWHZ
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I
Cooking fuel CI
Type of heating OR CI
(7.10-1.12)
-
1.39 1.42
(1.96498) (2.01-1.00)
-
-
-
1.54 1.72
2.82
-
-
-
ALLNATGAS OR CI
-
2.52
(5.93-1.07)
-
-
-
-
(2.21-1.07) (2.65-1.11)
-
-
-
Notes: OR odds ratio, CI confidence interval, SOBWHZ attacks of shortness of breath accompanied by wheeze, ALLNATCAS exposure to at least one source of indoor pollution versus no exposure. Values were derived from multiple logistic models, which accounted for the independent effeas of age, childhood respiratory problems, work exposure, education, zone of residence, and pack-years (for smokers), compared with subjects absent these risk factors (see text).
used and increased odds ratios for cough and phlegm in males. If bottled gas (mixed propane) rather than natural gas (methane) is used, production of CO and NO1 may be increased. In fact, bottled-gas ovens are generally less efficient than natural-gas ovens, and, in Italy, there is no requirement that they must be checked by an official technician. Also, bottled-gas ovens are probably less ventilated than are natural-gas ovens. The need for objective measurements of indoor pollutants is great. This necessity is further supported by the data of Remijn et al.” and Fischer et al.,= who found, for example, that estimations of historical exposure to indoor NOi, as assessed by questionnaires, were inaccurate. Sub jects who resided in homes in which high concentrations of NO2were measured tended to spend less time in the kitchen. Univariate analyses revealed very few associations between exposure to heating fuel and prevalence of respiratory symptoms. In addition to the absence of precision that exists if exposures are classified by questionnaire, as was noted for cooking fuel, it must be considered, for example, that heating devices may be (a) located in different rooms, (b) placed inside or outside of the home, and (c) operated by different persons who reside in private dwellings and in condominiums. Female nonsmokers who used a stove to heat their home exhibited higher prevalence rates (univariate analysis) of wheeze, attacks of shortness of breath accompanied by wheeze, dyspnea, and cardiovascular conditions, compared with a similar group who used central heating. Multivariate analysis disclosed significantly increased odds ratios for wheeze and attacks of shortness of breath accompanied by wheeze in female nonsmokers who used a stove for forced-air circulation heating, compared with female nonsmokers who used central heating. The different pollutants that result from different types of heating may be responsible for the effects described above. For example, the increased prevalence of dyspnea and cardiovascular conditions might have Janusy/Febmay1992 [Vd. 47 (No. l)]
I
resulted from higher levels of C0.’,2,’3An increase in the concentration of NO, and particulates would lead to an increased prevalence of cough and phlegm.s11 Perhaps the differences in climatic conditions, e.g., ventilation, humidity, temperature, which were a direct result of the type of heat system used, accounted for the findings. Melia et al?3 found a significant positive association between the prevalence of one or more respiratory conditions and relative humidity. More recently, Brunekreef et al.” found significantly increased odds ratios for cough, wheeze, asthma, and other respiratory illnesses, which were associated with at least one questionnaire indicator of home dampness, in children who participated in six-cities study. The analyses presented herein demonstrate that the interactive category, “central natural gas heat with natural gas cooking,” best describes the type of heating and fuel used by the largest single group of the population in middle Italy. This group reported the fewest symptoms, compared &ith other interactive categories in the univariate analyses. However, use of a general dichotomized variable (i.e., at least one exposure to indoor pollution sources, as previously defined with respect to central natural gas heat accompanied by natural gas for cooking) in multiple logistic models did not contribute relevant information to analyses in which the various exposures were considered separately. This supports the importance of achieving the best possible classification of indoor exposure in general population surveys; the inclusion of more specific and more quantitative questions will help achieve this end. In conclusion, our results indicate that the use of a stove or forced-air circulation for heating, combined with the use of cooking fuels other than natural gas, may be associated with mild adverse health e m s , as evidenced by respiratory symptoms. Moreover, these preliminary findings have led us to implement indoor air pollution monitoring studies in subsamples of the general population, especially in susceptible individuals (e.g., individuals with asthma, chronic bronchitis). 69
These studies will be used in our second survey, in which we hope to confirm and better explain the effects of the components in the home environmentwhich, in the current study, were assessed by questionnaire only.
12.
13.
********** The authors thank the nurses, Bruna Belli and Gianna k e r i , for collecting the data, and the thousands of residents of the Pisa district who participate in the study. This work was partially supported by the Italian National Research Council, targeted project "Prevention and Control Disease Factors -SP2," contract number 91.00171.PF41; the Italian Electric Power Authority (ENEL); the Health Department of Toscana Region (contract number 2926 of 06-02-83); and the local administrations of Pisa and Cascina (contract numbers 333931724 of 0810-83 and 39725 of 20/3/87). Dr. Ciovanni Viegi was a recipient of an Italian National Research Council (CNR) fellowship (bando n. 203.4.12 del 1/07/86) at the Division of Respiratory Sciences, University of Arizona, Tucson, U.S.A., since January 1990 to january 1991. Requests for reprints should be sent to: Dr. Giovanni Viegi, CNR Institute of Clinical Physiology, University of Pisa, Via Paolo Savi n. 6, 56100 Pisa, Italy.
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23.
24.
tory effects of household exposures to tobacco smoke and gas cooking on nonsmokers. Environ Int 1982; 8365-70. jedrychowski W, Tobiau-Adamayk 6, Flak E, Mroz E, Comola K. Effect of indoor air pollution caused by domestic cooking on respiratory problems of elderly women. Environ Int 1990; 16 57-60. Berwick M, Leaderer BP, Stolwjik JA, Zagraniski RT. Lower respiratory symptoms in children exposed to NOzfrom unvented combustion sources. Environ Inter 1989; 15:369-74. Viegi C, Paoletti P, Carroui L, Vellutini M, Di Pede F, Giuntini C, Lebowitz MD. Effects of indoor pollutants on respiratory symp toms and lung function of a general population sample in North Italy. Proceedings of the 82nd Annual Meeting & Exhibitionof Air and Waste Management Association, Anaheim, California, June 25-30, 1989; 89-15.7, pp 1-11. Viegi G, Paoletti P, Carroui L, Vellutini M, Diviggiano E, Di Pede C, Pistelli G, Ciuntini C, Lebowitz MD. Prevalence rates of respiratory symptoms in italian general population samples, exposed to different levels of air pollution. Environ Health Penp 1991; 9495-99. Viegi C, Paoletti P, Prediletto R, Carroui L, Fazzi P, Di Pede F, Pistelli C, Ciuntini C, Lebowitz MD. Prevalence of respiratory symptoms in an unpolluted area of Northern Italy. Eur Respir J 1988; 1~311-18. Carrozzi L, Ciuliano G , Viegi G, Paoletti P, Di Pede F, Mammini U, Saracci R, Ciuntini C, Lebowitz MD. The Po River Delta epidemiological study of obstructive lung disease: Sampling methods, environmental and population characteristics. Eur J Epidemiol 1990; 6 191-200. Helsing KJ, Comstock GW, Speizer FE, Ferris BG, Lebowitz MD, Tockman MS, Burrows 6. Comparison of three standardized questionnaires on respiratory symptoms. Am Rev Respir Dis 1979; 120:1221-31. Viegi C, Carrozzi L, Paoletti P, Vellutini M, Diviggiano E, Baldacci S, Modena P, Giuntini C, Lebowitz MD. Effects of home environment on respiratory symptoms of a general population sample in middle Italy. Proceedings of the 5th International Conference on Indoor Air Quality and Climate, Toronto, 29 July-3 August 1990. Vol. 1:399-403. American Thoracic Society. Guideline as to what constitutes an adverse respiratory health effect, with special reference to epidemiologic studies of air pollution. Am Rev Respir Dis 1985; 131566-68. Remijn 6, Fischer P, Brunekreef 6, Lebret E, Boleij JSM, Noij D. Indoor air pollution and its effect on pulmonary function of adult non-smoking women. I. Exposure estimates for nitrogen dioxide and passive smoking. Int J Epidemiol 1985; 14215-20. Fischer P, Remijn 6, Brunekreef 6, Van der Lende R, Shouten J, Quanjer P. Indoor air pollution and its effect on pulmonary function of adult non-smoking women. II. Associations between nitrogen dioxide and pulmonary function. Int J Epidemiol 1985; 14221 -26. Melia RJW, Florey C du Ve, Morris RW, Coldstein BD, John HH, Clark D, Craighead 16, Mackinlay JC. Childhood respiratory illness and the home environment. II. Association between respiratory illness and nitrogen dioxide, temperature and relative humidity. Int J Epidemiol 1982;.11:164-69. Brunekreef 6, Dockery DW, Speizer FE, Ware JH, Spengler ID, Ferris BC. Home dampness and respiratory morbidity in children. Am Rev Respir Dis 1989 140:1363-67.
Archives of Envhnmental Health
Archives of Environmental Health: An International Journal Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vzeh20
Effects of the Home Environment on Respiratory Symptoms of a General Population Sample in Middle Italy Dr. Giovanni Viegi a b
a b
, Sandra Baldacci d
Pede & C. Giuntini
, Laura Carrozzi a b
a b
, Paola Modena
, Paolo Paoletti
a b
a b
, Mariella Vellutini
, Marzia Pedreschi
a b
a b
, Emilio Diviggiano c
, Umberto Mammini , Cinzia Di
a b
a
CNR Institute of Clinical Physiology , University of Pisa , Pisa, Italy
b
2nd Medical Clinic , University of Pisa , Pisa, Italy
c
CNR Computer Center (CNUCE) , University of Pisa , Pisa, Italy
d
Occupational Medicine Service , USL 5 Media Valle del Serchio Bagni di Lucca Regione, Toscana, Italy Published online: 03 Aug 2010.
To cite this article: Dr. Giovanni Viegi , Laura Carrozzi , Paolo Paoletti , Mariella Vellutini , Emilio Diviggiano , Sandra Baldacci , Paola Modena , Marzia Pedreschi , Umberto Mammini , Cinzia Di Pede & C. Giuntini (1992) Effects of the Home Environment on Respiratory Symptoms of a General Population Sample in Middle Italy, Archives of Environmental Health: An International Journal, 47:1, 64-70, DOI: 10.1080/00039896.1992.9935946 To link to this article: http://dx.doi.org/10.1080/00039896.1992.9935946
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Effects of the Home Environment on Respiratory Symptoms of a
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General Population Sample in Middle Italy
ClOVANNl VlEGl LAURA CARROZZI PA010 PAOLETTI MARIELLA VELLUTINI EMlLlO DlVlCGlANO SANDRA BALDACCI PAOLA MODENA MARZIA PEDRESCHI CNR Institute of Clinical Physiology and 2nd Medical Clinic UMBERTO MAMMINI CNR Computer Center (CNUCE) University of Pisa Pisa, Italy ClNZlA DI PEDE Occupational Medicine Service US1 5 Media Valle del Serchio Bagni di Lucca Regione TOScana, Italy C. GlUNTlNl CNR Institute of Clinical Physiology and 2nd Medical Clinic University of Pisa Pisa, Italy
ABSTRACT. The effects of home environment characteristics were evaluated in a multistage, stratified, cluster sample (N = 3 866) of the general population who lived in the district of Pisa (middle Italy). Each subject completed a standardized interviewer-administered questionnaire that contained questions about respiratory symptomddiseases and risk factors (e.g., type of heating, fuels used for cooking and heating). Cough and asthma were significantly more frequent in men who did not smoke and who did not use natural gas for cooking and heating. Attacks of shortness of breath accompanied by wheeze, wheeze, dyspnea, and cardiovascular conditions in female nonsmokers were associated with use of a stove or forced-air circulation for heating; the type of fuel used did not affect this result. Multiple logistic models, which accounted for independent effects of age, smoking status, pack-years, childhbod respiratory illness, education, zone of residence, and work exposure to dusts, chemicals, or fumes, showed significantly increased odds ratios for (a) cough and phlegm in males (associated with bottled gas for cooking), (b) wheeze and shortness of breath with wheeze in females (associated with the use of a stove or forced-air circulation). These results, which confirm our previous observations in an unpolluted rural area of north Italy, indicate that characteristics of the home environment, as assessed by questionnaire, may be linked to mild adverse health effects, i.e., respiratory symptoms, in the general population. The results also identify the need to better characterize the dose-response relationship in indoor air pollution monitoring studies that include subsamples of this population. 64
Archives of Environmental Health
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DURING THE PAST 10 y, interest in the health effects of indoor air pollution has increased. Most people spend the majority of their time indoors, and many pollutants can be detected in various rooms-especially in the kitchen.'-' However, few epidemiological sutveys have investigated these effects. Studies of children" found that the use of gas for cooking or heating was associated with an increased prevalence of cough, wheeze, acute respiratory infections, history of respiratory illness prior to age 2 y, and rate of hospitalization, compared with the use of electric stoves for cooking or heating. The increased prevalence rate of chronic cough and phlegm in adults is related to gas cooking."" Unvented space (forced-air) heaters, especially those that use kerosene, are also harmf~1.l~ In a recent review on the adverse health effects of indoor the authors recornmended that pollutants thought to be responsible for these effects, i.e., mainly nitrogen oxides (NOJ, sulfur dioxide (SOz),carbon monoxide (CO),and particulates CTSP), be monitored. However, such measurements are not simple, nor are they sufficiently inexpensive to be applied in large-scale epidemiologic surveys; therefore, most published reports are based on assessment of exposure by questionnaire. In a previous report," we described, for the first time in Italy, the relationship between exposure to various sources of indoor pollution, as assessed by a standardized interviewer-administered questionnaire, and respiratory symptoms in a general population sample in the rural unpolluted area of Po Delta (northern Italy). Fuels that were different from natural gas, e.g., bottled gas, kerosene, coal, or oil, and heating appliances that differed from central heating (i.e., water-heat transfer) were associated with an increased prevalence of chronic cough, phlegm, wheeze, dyspnea, rhinitis, and cardiovascular disturbances. On the basis of this information, we considered it worthwhile to analyze the data of a lar e-scale epidemiological survey in Pisa (middle Italy).' The survey was originally planned to assess the health effects of outdoor air pollution, which resulted from heavily used highway and industrial settings. The aim of this study was to determine if the fuel for cooking or for heating, and type of heating, are associated with increased prevalence rates of respiratory symptoms in a general population sample in an urbansuburban environment.
Q
Materials and methods The sampling method, population characteristics, air pollution monitoring data, and the CNRquestionnaire were described previ~usly.'~~' Briefly, two populations were studied from 1985 through 1988: (1) individuals in the suburban zone of Cascina, where most exposures resulted from heavily used highways; and (2) individuals in the urban zone of Pisa who were also exposed to fumes from surrounding industry. There were outdoor low values of So, and considerable levels of TSPl5; concentrations of both pollutants were higher in these two areas JanuarylFebruary1992 [Vd. 47 (No.l)]
than in Po Delta," and they were higher in Pisa than in Cascina. In Pisa, the mean annual TSP level approached the National Air Quality Standard of 150 &mJ. The target population numbered 48 662 and included 59 census sections, of which 29 were in Pisa and 28 were in Cascina. Age and sex distribution were similar in the two areas. In Cascina, the main activities were manufacturing and small-scale industry; administration and trading were the main activities in Pisa, where sub jects were more educated. In the current study, the population sample of 3 866 individuals (77%of eligible subjects, 5-90 y of age) was a family-based, multistage, stratified, cluster design. Stratification was performed according to age and socioeconomic characteristics. Information for these indicators was collected from the most recent national census data for the aforementioned 59 census sections. Family clusters were selected randomly from each stratum. Each subject completed the CNR questionnaire, which was developed by the Italian National Research Council (CNR) and patterned after the questionnaire developed by the American National Heart and Lung Institute (now NHLBI)." Mothers provided answers for children who were less than 10 y of age; subjects who were 10 y of age and older answered personally. The following symptoms were considered in the analysis: (1) chronic cough (or phlegm), which was characterized by cough (or phlegm production) for as many as 3 mo of the year for at least 2 y; (2) wheeze (unrelated to the common cold); (3) attacks of shortness of breath ackompanied by wheeze (unrelated to the common cold); (4) dyspnea, defined by shortness of breath when hurrying on level ground or walking up a slight incline; and (5) rhinitis that resulted from hay fever or from any allergy that made the nose runny or stufi (unrelated to the common cold). Emphysema, Table l.--QUestions Regarding the Home Environment A. What kind of heating do you have at home? 1. Forced-air circulation 2. Central heating (water-heat transfer) 3. Stove 4. None 6. If there is heating, which is the main fuel you use for heating? 1. Natural gas 2. Bottledgas 3. Electricity 4. Kerosene 5. wood 6. Coal or oil 7. Other C. Which is the main fuel you use for cooking?. 1. Natural gas 2. Bottledgas 3. Electricity 4. wood 5. Coal or oil 6. Other *Kerosene was omitted from item C because, in Italy, it is never used for cooking.
65
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chronic bronchitis, their combination, asthma, and cardiovascular conditions were taken into account if diagnosis was confirmed by a physician. Questions (Table 1) were asked about the home environment, of which most pertained to type of heating and type of fuel used for cooking. Subjects were defined as nonsmokers if they had never smoked any kind of tobacco regularly. Those who currently smoked at least one cigarette a day were classified as smokers. Exsmokers included those who had formerly smoked regularly until 6 mo or more prior to the examination (because there were so few, they were not accounted for in the univariate analysis). Statistical analyses were performed on an IBM 3081 at the University of Pisa Computer Center (CNUCE) and on a personal computer (PC/AT) at the University of Arizona, and the routines of the Statistical Package of the Social Sciences (SPSS) were used. The chi-square test was used to assess the difference in prevalence rates of symptoms. The role of different risk factors in determining respiratory symptomsldiseases were accounted for with multiple logistic regression models as follows: age (0 = < 20y, 1 = 21-40y, 2 41-60y, 3 = 60+ y); childhood respiratory problems (0 = absent, 1 = present); work exposure to dusts, chemicals, or fumes (0 a b sent, 1 present); education (1 did not graduate high school, 0 = college or college graduate); and zone of residence (0 = Cascina, 1 = Pisa). In the separate model for smokers, pack-years were also included (0 less than 10, 1 = 11-20, 2 21-30, 3 = 30+). The logistic models were run four times for each symptom/ disease to insure that the effects of the following were considered separately: fuel for cooking (0 = natural gas, 1 = other); fuel for heating (0 natural gas, 1 = other); type of heating (0 central, 1 = stove or forced-air circulation); and the variable ALLNATGAS (0 central heating fueled by natural gas-used also for cooking, 1 = forced-air circulation or stove fueled by bottled gas, wood, kerosene, coal or oil [no natural gas used for cooking]). Unless stated otherwise, all relationships were considered significant at p < .05.
-
-
9
-
-
-
- -
Results Of the 3 729 subjects for whom information on cooking fuel was obtained, 67% used natural gas, 30% used bottled gas, 1% used wood, and 1% used “other” fuels, including electricity. With regard to heating fuel, 65% of the 3 714 used natural gas, 13% used coal or oil, 7% used kerosene, 7% used wood, 2% used bottled gas, 2% used electricity, and 4% indicated that they used other sources. Type of heating information revealed that 67% of 3 678 used central heating (water-heat transfer), 29% used a stove, and only 3% used forced-air circulation. We eliminated from analysis the few subjects who used electricity for heating and cooking and the 20 subjects who indicated that they had no heat in their home. We have preliminarily analyzed, by chi-square distrib~tion,’~ the effects of single sources of indoor pollution. Cough and asthma were significantly more fre66
quent in (a) male nonsmokers who used bottled gas for cooking and in (b) male nonsmokers who used kerosene, bottled gas, wood, coal, or oil for heating than in individuals who used natural gas. Females who were nonsmokers and who used a stove for heating had higher prevalence rates of wheeze, attacks of shortness of breath accompanied by wheeze, dyspnea, and cardiovascular conditions than those using central heating. Subsequently, we have tried to take a more logical approach to the analysis because, in this context, technologies tend to be highly associated. Therefore, interaction terms should most closely approach empirical reality. Distribution of subjects with respect to fuels used for heating and cooking and type of heating used is shown in Table 2, and subjects are categorized by sex and smoking status. In male and female smokers and nonsmokers, the interactive category, “central natural gas heat with natural gas cooking,” described the largest single group. There were only three other groups that were suitable for comparisons: (1) stove or forced-air circulation-natural gas used for heating and cooking; (2) central (not natural) gas heat-bottled gas used for cooking; and (3) stove or forced-air circulation that used (not natural) gas heat-bottled gas was used for cooking. The main characteristics of the subjects are reported in Table 3. The only significant difference found was for females: females who used stoves for heating were slightly older than those who used .central heating. Borderline differences in males were found for mean age and number of smokers. In nonsmoking males, significantly higher prevalence rates of chronic cough and diagnosed asthma (Table 4) were found for those who used no natural gas heating fuels and who used bottled gas for cooking (regardless of the type of heating used). No significant differences were noted for smokers. Regardless of the type of fuels used for heating or cooking, significantly higher frequencies of wheeze, attacks of shortness of breath accompanied by wheeze, dyspnea, and cardiovascular conditions were found in female nonsmokers (Table 5) who used a stove or forced-air circulation to heat their home. Less consistent results were found for female smokers; significantly higher prevalence rates of chronic cough and dyspnea occurred if these individuals used a stove or forced-air circulation for heating and if they used natural gas for heating and cooking. Stratification of the population by age ( < 20 y, 20-64 y, and > 64 y) did not impart relevant information. Because the groups were small in number, no statistically significant relationships emerged from the chi-square test. The results of multiple logistic models, which accounted for independent effects of other risk factors (i.e., age; smoking; pack-years; exposure to dusts, chemicals, or fumes in the workplace; childhood respiratory problems; education; and zone of residence) are shown in Table 6. The use of bottled gas was significantly related to higher odds ratios for (a) cough in Amhi-
of EnvironmentalHealth
of Subjects according to Interadan of Indoor Pollution Soumr, by
Tabk 2.-Didributkn Scx and Smdring
Natural gas Subjects and indoor pollution sources
-
Male nonsmokers (n 613) Central heat No central heat Male smokers (n 623) Central heat No central heat Female nonsmokers (n 1 326) Central heat No central heat Female smokers (n 623) Central heat No central heat
-
-
-
- -
NG
BC
31 7
3 2
1
96 295
8
0
94
2
601 213
1 62 74
16 11
101 61
4 0
18 7
99
2
90
2 6
9 3
4 1
34 21
210 21 1
8 11
5 2
0
11 5
57 53
0
1
1
-
natural gas, BC bottled gas. Central heat no central heat stove or forced-air circulation.
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Note: NG
Type of heating fuel Non-natural gas Type of cooking fuel Other NG BG Other
1
Tabk 3.--Msm
central heating (water-heat transfer),
Values of Age and Smvking Characteristii
I
Number of subjects Age (y) Smokers (%) Pack-yean
-
3
612 37.2 (21.3) 48.2 24.4 (20.8)
Male groups II 111
200 35.1 (21.0) 49.5 24.1 (18.9)
190 38.1 (22.1) 49.5 26.5 (21.O)
IV
151 41.Ot (21.9) 59.6t 25.3 (18.9)
I 763 45.4 (20.7) 21.2 9.5 (8.6)
Female groups II 111
267 40.8 (20.4) 21.3 7.7 (7.2)
287 48.8 (21.1) 25.8 10.8 (9.9)
IV
264 48.41 (22.5) 20.1 9.3 (8.9)
Notes: Values within parentheses are the standard deviations. Group I used central heating fueled by natural gas and cooked with natural gas; Group It used non-natural gas central heating and cooked with bottled gas; Group 111
used a stove or forced-air heating fueled by natural &as and cooked witti natural gas; and Group IV used nonnatural gas stove or forced-air heating and cooked with bottled gas. *p < .01 (analysis of variance for age; chi-square for smokers). t.1 > p > .05(analysis of variance). I
male nonsmokers and (b) cough and phlegm in male smokers, compared with respective groups who used natural gas for cooking fuel. The use of a stove or forced-air circulation to heat the home was significantly associated with increased odds ratios for wheeze and attacks of shortness of breath accompanied by wheeze in females, c o m p p d with the use of central heating (water-heat transfer). The interaction terms were considered, and the use of noncentral heating and nonnatural-gas fuels was significantly associated with increased odds ratios for cough in male nonsmokers, compared with use of central heating and natural-gas fuels. Rhinitis and cardiovascular conditions were not associated with any indoor variable in either sex. Discussion
A mild association between sources of indoor pollution and increased prevalence rates of respiratory
symptoms was found in a large sample of the general population who lived in an urban-suburban area of middle Italy. All of the symptoms noted are among the adverse health effects of air pollution, which are stated in the American Thoracic Society guideline.20An a s s ciation between the use of gas and an increased frequency of respiratory symptoms was found previously in E ~ rope~and , ' ~ in the United Statesc" (subjects who relied on electricity for cooking and heating were used as controls). Electricity is seldom used for cooking or for heating in Italy; therefore, in our study, we included, as controls, subjects who used natural gas. We hypothesized that natural gas poses less health risks to subjects, compared with the health effectsof bottled gas and other fuels. Also, in Italy, natural gas is utilized in newer appliances. The findings of this study accord with the results of the Po Delta survey," in which we described higher 67
prevalence rates of chronic cough, phlegm, dyspnea, and cardiovascular disturbances that were associated with the use of fuels (other than natural gas) or the use of a stove. However, in the Po Delta sample, the trend was more consistent than in the Pisa sample. In addition to the possible qualitative and quantitative differences that result from exposure to cigarette smoke (active and passive) and to indoor pollution, we have to consider the effect of outdoor pollution in Pisa, which was linked to the presence of significantly higher prevalence rates than were found in the Po Delta sur~ey.'~ The association between symptoms and sources of indoor pollution did not strengthen as the subjects'
Table 4.-Prevalence Indoor Exposure
ages increased, and we cannot conclude that a duration effect of indoor exposure exists. jedrychowski et aI.,'* however, studied a larger cohort of elderly women in Cracow (N 560, 65+ y of age), and more specific questions were included in the survey; a dose-response relationship between chronic chest symptoms (mainly phlegm) and time spent in the kitchen was estab1ished. If type of fuel used for cooking was considered, univariate analysis revealed mild effects (i.e., increased frequency of cough and asthma) of only bottled gas in the male nonsmokers; multivariate analysis disclosed an association between type of fuel (excluding natural gas)
-
Rates (%) of Respiratory Symptoms in Males, by Smoking Status and Groups of
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Nonsmokers
Subjects (n) Chronic cough Chronic phlegm Wheeze SOBWHZ Asthma Emphysema Chronic bronchitis Dyspnea Rhinitis Heart disorders
Smokers
I
II
111
IV
31 7 3 4 10 8 5 3 1 8 21 4
101 8 7 10 11 13
96
61 1 o* 5 10 10 7* 2 3 10 12 3
1
5 8 15 5 4 1
2 8 16 1
8 19 7
-
I
II
111
IV
295 32 29 39 8 6 10 13 35 15 8
99 38 31 36
94 35 31 38 5 5 14 12 33 11 9
90 36 34 29 8 8 12 10 33 12 7
7 7 6 9 35 16
5
~~
~
Notes: SOBWHZ r i c k s of shortness of breath accompanied by wheeze. Group I used central heating fueled by natural gas and cooked with natural gas; Group II used non-natural gas central heating and cooked with bottled gas; Group 111 used a stove or forced-air heating fueled by natural gas and cooked with natural gas; and Group IV used non-natural gas stove or forced-air heating and cooked with bottled gas. *p < .05 (chi-square).
Table 9.-Prevalence Indoor Exposure
Rates (%) of Respiratory Symptoms in Females, by Smoking Status and
I Subjects (n) Chronic cough Chronic phlegm Wheeze SOBWHZ Asthma Emphysema Chronic bronchitis Dyspnea Rhinitis Heart disorders
600
6 2 10 6
5 2 1 33 17 13
Nonsmokers II Ill
210 4 1 6 4 6
-
1 24 14
5
21 3 7 1 14 11 8 2 1 43 16 17
Smokers IV
21 1 7 1 14' ' 8 7 1 3 39* 14 139
I
II
111
IV
162 19 17 23 6 6 6 4 30 17 6
57
74 30 16 30 10 5 5 8 49 20 5
53 15' 14t 19t 6 8 8 4 23* 13 6
11
4 12 9 4 4 2 33 28 2
-
Notes: SOBWHZ attacks of shortness of breath accompanied by wheeze. Group I used central heating fueled by natural gas and cooked with natural gas; Group II used non-natural gas central heating and cooked with bottled gas; Group 111 used a stove or forced-air heating fueled by natural gas and cooked with natural gas; and Group IV used non-natural gas stove or forced-air heating and cooked with bottled gas. *p c .05 (chi-square). t.1 > p > .05 (chi-square). *p < .001 (chi-square). c .01 (chi-square).
Archives of EnvironmentalHealth
Table 6.--Significant Associatho of Home Environment Charactetistics with Respiratoy SVmpt-
OR Male nonsmokers Cough Male smokers Cough Phelgm Female nonsmokers Wheeze SOBWHZ
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I
Cooking fuel CI
Type of heating OR CI
(7.10-1.12)
-
1.39 1.42
(1.96498) (2.01-1.00)
-
-
-
1.54 1.72
2.82
-
-
-
ALLNATGAS OR CI
-
2.52
(5.93-1.07)
-
-
-
-
(2.21-1.07) (2.65-1.11)
-
-
-
Notes: OR odds ratio, CI confidence interval, SOBWHZ attacks of shortness of breath accompanied by wheeze, ALLNATCAS exposure to at least one source of indoor pollution versus no exposure. Values were derived from multiple logistic models, which accounted for the independent effeas of age, childhood respiratory problems, work exposure, education, zone of residence, and pack-years (for smokers), compared with subjects absent these risk factors (see text).
used and increased odds ratios for cough and phlegm in males. If bottled gas (mixed propane) rather than natural gas (methane) is used, production of CO and NO1 may be increased. In fact, bottled-gas ovens are generally less efficient than natural-gas ovens, and, in Italy, there is no requirement that they must be checked by an official technician. Also, bottled-gas ovens are probably less ventilated than are natural-gas ovens. The need for objective measurements of indoor pollutants is great. This necessity is further supported by the data of Remijn et al.” and Fischer et al.,= who found, for example, that estimations of historical exposure to indoor NOi, as assessed by questionnaires, were inaccurate. Sub jects who resided in homes in which high concentrations of NO2were measured tended to spend less time in the kitchen. Univariate analyses revealed very few associations between exposure to heating fuel and prevalence of respiratory symptoms. In addition to the absence of precision that exists if exposures are classified by questionnaire, as was noted for cooking fuel, it must be considered, for example, that heating devices may be (a) located in different rooms, (b) placed inside or outside of the home, and (c) operated by different persons who reside in private dwellings and in condominiums. Female nonsmokers who used a stove to heat their home exhibited higher prevalence rates (univariate analysis) of wheeze, attacks of shortness of breath accompanied by wheeze, dyspnea, and cardiovascular conditions, compared with a similar group who used central heating. Multivariate analysis disclosed significantly increased odds ratios for wheeze and attacks of shortness of breath accompanied by wheeze in female nonsmokers who used a stove for forced-air circulation heating, compared with female nonsmokers who used central heating. The different pollutants that result from different types of heating may be responsible for the effects described above. For example, the increased prevalence of dyspnea and cardiovascular conditions might have Janusy/Febmay1992 [Vd. 47 (No. l)]
I
resulted from higher levels of C0.’,2,’3An increase in the concentration of NO, and particulates would lead to an increased prevalence of cough and phlegm.s11 Perhaps the differences in climatic conditions, e.g., ventilation, humidity, temperature, which were a direct result of the type of heat system used, accounted for the findings. Melia et al?3 found a significant positive association between the prevalence of one or more respiratory conditions and relative humidity. More recently, Brunekreef et al.” found significantly increased odds ratios for cough, wheeze, asthma, and other respiratory illnesses, which were associated with at least one questionnaire indicator of home dampness, in children who participated in six-cities study. The analyses presented herein demonstrate that the interactive category, “central natural gas heat with natural gas cooking,” best describes the type of heating and fuel used by the largest single group of the population in middle Italy. This group reported the fewest symptoms, compared &ith other interactive categories in the univariate analyses. However, use of a general dichotomized variable (i.e., at least one exposure to indoor pollution sources, as previously defined with respect to central natural gas heat accompanied by natural gas for cooking) in multiple logistic models did not contribute relevant information to analyses in which the various exposures were considered separately. This supports the importance of achieving the best possible classification of indoor exposure in general population surveys; the inclusion of more specific and more quantitative questions will help achieve this end. In conclusion, our results indicate that the use of a stove or forced-air circulation for heating, combined with the use of cooking fuels other than natural gas, may be associated with mild adverse health e m s , as evidenced by respiratory symptoms. Moreover, these preliminary findings have led us to implement indoor air pollution monitoring studies in subsamples of the general population, especially in susceptible individuals (e.g., individuals with asthma, chronic bronchitis). 69
These studies will be used in our second survey, in which we hope to confirm and better explain the effects of the components in the home environmentwhich, in the current study, were assessed by questionnaire only.
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********** The authors thank the nurses, Bruna Belli and Gianna k e r i , for collecting the data, and the thousands of residents of the Pisa district who participate in the study. This work was partially supported by the Italian National Research Council, targeted project "Prevention and Control Disease Factors -SP2," contract number 91.00171.PF41; the Italian Electric Power Authority (ENEL); the Health Department of Toscana Region (contract number 2926 of 06-02-83); and the local administrations of Pisa and Cascina (contract numbers 333931724 of 0810-83 and 39725 of 20/3/87). Dr. Ciovanni Viegi was a recipient of an Italian National Research Council (CNR) fellowship (bando n. 203.4.12 del 1/07/86) at the Division of Respiratory Sciences, University of Arizona, Tucson, U.S.A., since January 1990 to january 1991. Requests for reprints should be sent to: Dr. Giovanni Viegi, CNR Institute of Clinical Physiology, University of Pisa, Via Paolo Savi n. 6, 56100 Pisa, Italy.
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