Les facteurs « environnementaux » intra-utérins prédisposant

Progetto SINPHONIE
Dr Isabella ANNESI-MAESANO
Direttore di Ricrerca INSERM
Responsabile Equipe EPAR: Epidémiologie des maladies Allergiques et Respiratoires
UMR-S 1136 Institut Pierre Louis d’Epidémiologie et Santé Publique INSERM et UPMC Sorbonne
Universités, Faculté de Médecine Saint Antoine, Paris
[email protected]
Roma 23.II.2015
Scuola e Salute
Un vero problema di sanità pubblica
• Popolazione esposta importante
• Scuola fonte potenziale di esposizione
all’inquinamento atmosferico ed altri rischi
Roma 23.II.2015
Contesto societale
http://donnees.banquemondiale.org
• Le cifre per l'UE-28 per il 2011 indicano che 93.7 milioni di alunni e
studenti erano scritti nel sistema di istruzione, dalla scuola primaria a
studi post-laurea . Inoltre, 15,4 milioni di bambini erano arruolati
nell’istruzione pre-primaria. (Dati 2014 (ultimi dati))
• Durante il periodo scolastico, i bambini possono trascorrere fino a un
terzo del loro tempo in edifici scolastici
 circa 160-180 giorni a scuola, 1280-1440 ore in media, 960-1.080 ore di
lezione nel casiso dei bambini di età 7-10 anni in Francia
Roma 23.II.2015
Pollution à
l’école
Ameublement
Décoration
Activités
Peinture,
Ménage
Combustion
Chauffage (s’il y
en a)
Bâtiment :
Âge, conception,
équipement,
maintenance,
désordre de
construction
Ventilation
Bio effluents,
bactéries,
moisissures
Comme tous les locaux clos, l’école n’est pas à
l’abri de la pollution atmosphérique de
l’intérieur des locaux en raison des activités
exercées et des caractéristiques des locaux,
ainsi que par le biais du transfert d’air en cas
de ventilation naturelle (ouverture des
Roma 23.II.2015
fenêtres), de celle de l’extérieur des locaux.
Pollution à
l’école
Air
extérieur
Transfer
Ameublement
Décoration
Activités
Peinture,
Coloriage,
Ménage…
Combustion
Chauffage (s’il y
en a)
Bâtiment :
Bio effluents,
bactéries,
moisissures
Réactivité
Âge, conception,
équipement,
maintenance,
désordre de
construction
Ventilation
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Contesto scientifico
• Pochi studi sugli effetti dell’ambiente scolastico sulla
santé degli occupanti (studenti, professori, bidelli)
– Pochi studi in popolazione generale
– Pochi studi basati su misure oggettive di parametri
ambientali
– Pochi studi basati su misure oggettive di parametri di
salute
– Pochi studi di intervento
Roma 23.II.2015
SINPHONIE, « une première » in Europa:
Effetti della qualità dell’aria sulla salute
degli studenti e dei professori
Eva Cobsod (REC, Budapest), Eduardo Oliveira Fernades (INEGI, Porto)
Isabella Annesi-Maesano, Corinne Mandin, CSTB/OQAI
Paolo Carrer
Piersante Sestini
Giovanni Viegi
E tutti gli altri collaboratori
Roma 23.II.2015
Objectifs
•
Suite à la déclaration de Parme sur l’environnement et la santé
(mai 2010)
•
64 millions d’étudiants de la maternelle à l’Université et près de
5 millions d’enseignants en EU
•
Mieux identifier les effets de l’environnement scolaire (air
intérieur, air extérieur, hygiène) sur la santé des enfants et des
enseignants
•
Constituer un réseau européen et développer des pratiques
communes pour la mesure de la QAI dans les écoles
Roma 23.II.2015
Un consortium de partenaires
unique
37 instituts partenaires
23 pays participants
54 villes
311 classes
5175 enfants (dont 264 dans
kindergartens)
1223 professeurs
Roma 23.II.2015
Organisation globale
Revue bibliographique
Etudes de terrain
Environnement intérieur
Environnement extérieur
Evaluation des effets sur la
santé
Base de données QAI
Evaluation des risques sanitaires
Roma 23.II.2015
Bonnes pratiques et recommandations
pour améliorier la QAI dans les écoles
Overall Organisation
WP1 - Management and coordination
WP2 - Background
WP3 - Assessment of outdoor/indoor school environment
WP3.1 - Characterization of the school buildings
WP3.2 - Physical and chemical measurements
WP3.3 - Measurements of biological contaminants
WP3.4 - Environment context and modeling
WP4 - Assessment of health outcomes
WP4.1 - Clinical field survey
WP4.2 - Clinical tests and noninvasive biomarkers
WP5 - Data management, cross analysis and database
WP6 - Health risk assessment
WP7 - Risk management and development of guidelines/ recommendations
WP8 - Communication and dissemination
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METODI
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Etude principale : mesures (1)
– Composés chimiques
gazeux :
Composés ciblés (5 capteurs passifs) :
o dioxyde d’azote
o ozone
o composés organiques volatils (COV)
o aldéhydes
o radon
Analyse différée en laboratoire
– Particules :
o Mesure gravimétrique des PM2,5
o Comptage en nombre,
diamètre entre 0,3 à 20 µm,
évaluation concentration massique
en PM10
Roma 23.II.2015
Etude principale : mesures (2)
Prélèvements de poussières pour l’analyse des moisissures, bactéries, endotoxines
et allergènes d’animaux (chat, chien, cheval, acariens)
Aspiration des poussières sur les
surfaces et rebords de portes et
fenêtres
Aspiration des poussières au sol
+ mesure en continu : température, humidité relative et CO2
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Système de collecteur passif
pour la récupération des
poussières sédimentables
(4 semaines en place)
Etude principale : questionnaires
–
Questionnaires à distribuer :
o Questionnaire « santé » aux enfants 
o Questionnaire sur la santé des enfants et descriptif de l’environnement
domestique à mettre dans le carnet de liaison pour les parents (retour via
l’école sous enveloppe) 
–
Questionnaires à compléter par chaque enseignant :
o Questionnaire « santé » 
o Questionnaire descriptif de la classe 
o Ouverture des fenêtres pendant la semaine de mesure 
o et Absentéisme des enfants pendant l’hiver 
–
Tests de calcul et de logique à faire avec les enfants (4 fois 10 minutes) ⑦
–
Audit technique du bâtiment et des classes complété par l’enquêteur ⑧
Roma 23.II.2015
Secondary study: clinical tests
Santé
- Nasal patency of
schoolchildren
- Break-up time
- Exhaled Nitric Oxide
- Inflammatory cytokines in
Nasal Lavage
- Inflammatory cytokines in
Exhaled Breath
Condensate
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RISULTATI
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Chemical air pollutants in European classrooms
Pollutants
Formaldehyde1
Benzene1
Naphthalene1
Limonene1
NO21
PM2.51
Ozone1
CO2
T3CE1
T4CE1
Radon3
WHO guidelines for indoor air
[EU-INDEX]
[French ANSES]
[Maximum allowable concentration Netherlands]
[Guideline value Flemish Indoor Decree]
Short-term
Long-term
100 [30] [50] [120]
[20]
200 [200]
25
100 (outdoors)
100* [100]* [30]*
-
10 [10] [10] [10]
no safe level [10] [20] [10]
10
[450]
40 [40] [135]
10 [10] [15]
23**
250
167***
Mean
Median
Min-Max
CV%
15
4
2
38
14
44
8
1
3
1
205
12
2
DL
9
11
37
3
DL
DL
DL
101
1.0 - 66
DL - 38
DL - 31
DL - 672
DL - 88
4 - 250
DL - 142
DL - 122
DL - 126
DL - 81
DL - 9190
67
141
223
211
73
78
202
815
419
436
327
SD: Standard Deviation; Min : minimum ; Max : maximum ; CV: Coefficient of Variation; T3CE: Trichloroethylene;
T4CE:tetrachloroethylene ;
1 µg/m3 ; 2 ppm (parts per million) ; 3 Bq/m3 ; 4 % 5 °C; 6 /hr
*: 15 minutes; **: lifetime exposure with acceptable risk at 10-5
***concentration associated with an excess lifetime risk of 1 per 1000 (non-smokers)
Roma 23.II.2015
Formaldehyde, benzene, and PM
in European classrooms by countries
mean: 15 µg/m3 in mean
guideline: 10 µg/m3
mean: 4 µg/m3
guideline: 5 µg/m3
mean: 44 µg/m3 in mean
guideline: 10 µg/m3
= limit values
Roma 23.II.2015
Children’ exposure to air pollution
in European classrooms
Par rapport aux valeurs guide OMS
• PM2.5:
– 13% exposés à > 25 µg/m3 (valeur 24h)
– 85% exposés à > 10 µg/m3 (valeur annuelle)
• Benzène :
– 25% exposés à > 5 µg/m3 (valeur annuelle)
• Formaldéhyde :
– 60% exposés à > 10 µg/m3 (valeur annuelle)
PROBLEMES AVEC CO2 ET VENTILATION
Roma 23.II.2015
mean: 86 µg/gr dust
guideline: 8 µg/gr dust
Ever eczema vs. Cat allergen (high / low)
countryName
RR (95% CI)
Portugal
United
Kingdom
France
Italy
Germany
Malta
Austria
Sweden
Finland
Czech
Republic
Slovakia
Bosnia
Herzegovina
Hungary
Serbia
Albania
Poland
Bulgaria
Estonia
Lithuania
Romania
Cyprus
Greece
I-V Overall (I-squared = 0.0%, p = 0.664)
D+L Overall
0.79 (0.41, 1.51)
0.93 (0.45, 1.91)
1.47 (1.01, 2.16)
1.16 (0.72, 1.85)
2.70 (1.37, 5.32)
1.19 (0.68, 2.06)
0.96 (0.38, 2.44)
0.90 (0.42, 1.91)
1.24 (0.74, 2.08)
0.97 (0.70, 1.36)
1.26 (0.86, 1.85)
1.25 (0.49, 3.21)
0.88 (0.63, 1.24)
1.21 (0.62, 2.36)
0.95 (0.12, 7.44)
0.80 (0.23, 2.79)
1.01 (0.26, 3.95)
1.98 (1.02, 3.87)
1.21 (0.37, 4.01)
0.95 (0.39, 2.32)
1.38 (0.53, 3.64)
(Excluded)
1.15 (1.01, 1.30)
1.15 (1.01, 1.30)
.1
.2
.5
Ever eczema decreased
1
2
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5
10
Ever eczema increased
Events,
Exposed
Events,
Unexposed
%
Weight
(I-V)
11/84
10/44
29/77
23/104
18/60
15/60
6/63
6/14
12/26
30/81
29/75
5/36
38/148
11/73
1/50
3/55
3/83
11/47
4/76
6/75
5/52
0/19
276/1402
28/169
13/53
45/176
34/178
11/99
27/128
12/121
10/21
26/70
75/197
40/130
15/135
74/255
22/176
8/380
10/146
6/168
19/161
7/161
17/202
15/216
0/113
514/3455
3.83
3.08
10.96
7.23
3.48
5.26
1.85
2.82
6.04
14.25
10.84
1.80
14.30
3.56
0.38
1.02
0.86
3.59
1.12
2.01
1.72
0.00
100.00
latitude
longitude
38
51
48
41
52
36
48
59
60
50
48
44
47
44
41
52
42
59
55
44
35
37
-9
0
2
12
13
15
16
18
25
14
17
18
19
20
20
21
23
24
25
26
33
23
Recent (<3 months) health events
in European schoolchildren
Up to 25% (1/5) of children
sick in the year
Prevalence resulting from meta-analysis
Roma 23.II.2015
Recent (< 3 m) health events in
European schoolchildren
Prevalence (%)
Symptom/Disease
EYE
Iirritation
swollen
SKIN
Hand rash
Face rash
Eczema
Hand itch
Face itch
AIRWAYS
Runny nose
Blocked nose
Dry throat
Sore throat
Irritative cough
Shortness of breath
SYSTEMIC
Headache
Nausea
Feel cold / feverish
Feel tired out of sorts
Symptom(s) improve when back at home
Schoolchildren
(N=4,919)
13.4
6.6
6.8
5.7
7.1
8.8
4.9
42.0
46.6
20.6
35.8
29.3
8.6
41.1
17.8
41.2
36.2
Pre-school children
(N=259)
10.2
4.3
9.0
5.1
6.7
8.6
3.5
50.4
56.8
25.0
42.0
45.3
15.0
13.4
10.7
44.5
29.8
All
25.9
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33.2
26.2
13.2
6.5
6.9
5.6
7.0
8.8
4.8
42.5
47.1
20.9
36.2
30.2
8.9
39.6
17.5
41.3
35.8
mean 4 µg/m3 in mean
guideline: 5 µg/m3
Roma 23.II.2015
Indoor biocontaminants
in European classrooms
Biocontaminants
Endotoxin1
PenAsp cells2
Avers cells2
Tviri cells2
Cherb cells2
Aaltr cells2
Strep cells2
Myco cells2
Cat allergen3
Dog allergen3
Horse allergen3
Derp1 allergen3
Derf1 allergen3
For allergic sensitisation:
° 1-2 ng Der p 1/ gr dust
° 2 ng Fel d 1 / gr dust
° 2 ng Can f 1 /gr dust
Mean
Median
Min
Max
CV%
10080.1
726149.3
378.0
301.2
923.5
39.2
42252.7
147504.4
86.5
103.5
80.3
4.9
2.8
7114.0
63154.5
0.0
10.0
268.5
8.0
16914.0
51191.0
0.0
0.0
0.0
0.0
0.0
496.0
1143.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
59000.0
24739120.0
55671.0
72308.0
69322.0
4406.0
1268072.0
6401677.0
1762.0
1745.0
2630.0
337.0
167.0
95.6
382.0
932.8
1440.6
466.2
684.0
238.0
299.9
244.1
215.2
498.5
751.5
713.7
Roma 23.II.2015
For asthma exacerbations:
° 10 ng Der p 1/ gr dust
° 8 ng Fel d 1 / gr dust
° 10 ng Can f 1 /gr dust
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Relationships between chemical air
pollution and recent health events
Formaldeyde
Benzene
Limonene
T3CE
—
—
—
-
Hand itching,
face itching,
blocked nose;
Night dry cough
(<12 mo)
—
Hand itching,
recent eczema;
Ever eczema
—
TC4
-
Hand itching,
sore throat,
wheezing (<30
days), nasal
allergy (<12 mo)
Fine Particles
(PM2.5)
NO2
—
-
Dry throat,
nausea
Eye irritation,
runny nose,
blocked nose,
sore throat,
irritative
cough, feel
cold/feverish,
nausea, feel
tired out of
sorts;
Eye irritation
(< 12 months),
ever eczema
Naphtalene
Hand rash,
hand itching,
face itching,
eye swollen,
headache, sore
throat, feel
tired, feel
cold/feverish
Ozone
Hand itching,
face rash,
recent
eczema, feel
cold/feverish
Roma 23.II.2015
—
—
Feel tired out
of sorts
Ever runny/
blocked nose;
Nasal allergy
(<12 mo),
doctor nasal
allergy, ever
itchy rash (for
6 months),
ever wheeze,
- Face itching, feel
tired out of sorts
Bio-contaminants related to
health outcomes
in European schoolchildren
Schoolchildren
Endotoxin
Eye irritation, dry throat, irritative cough;
Doctor diagnosed asthma, every
runny/blocked nose, nasal allergy, night
dry cough, cough episodes
Fungal species/groups
Penicillium/Aspergillus/Paecilomyces
spp. group
Aspergillus versicolor
Trichoderma viride
Alternaria alternata
Cladosporium herbarum
Bacterial groups
Streptomyces spp.
Mycobacterium spp.
Symptoms improving when home;
ever nasal allergy (↓)
Sore throat, feel cold/feverish
Eye irritation (↓)
Ever runny/blocked nose
Roma 23.II.2015
Asthma at school
• 1,5% of asthma attacks at school, i.e.
100000 children at the European level
– 30000 children with asthma attacks at
school
Roma 23.II.2015
Conclusion
• SINPHONIE provides important data on Indoor air quality (IAQ) in
schools that has been rarely studied.
• In school high levels of PM, volatile organic compounds (VOCs),
allergens and moulds have frequently been measured.
• Schools frequently have severe indoor air problems because of poor
building construction and maintenance, poor cleaning and poor
ventilation (CO2>1000 ppm), and humidity.
• Poor air quality in schools has been related significantly to a large
spectrum of diseases (SICK SCHOOL SYNDROME). Respiratory
health is particularly challenged by air pollutants found in schools
through the inhalation route.
• Allergic individuals could be at higher risk.
• No causality can be assessed.
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MERCI
[email protected]
Roma 23.II.2015
HESE
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Etude HESE: Health Effects of School
Environment
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All disorders were more prevalent in schoolchildren from
classrooms with poor air quality
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Etude HESE: Health Effects of School
Environment
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HESE: Total viable molds distribution
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HESE: Fungal DNA distribution
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