1 INDOOR AIR POLLUTION Children's Health and the Environment WHO Training Package for the Health Sector World Health Organization TRAINING.

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INDOOR AIR POLLUTION

Children's Health and the EnvironmentWHO Training Package for the Health Sector

World Health Organization

www.who.int/ceh

TRAINING FOR THE HEALTH SECTORTRAINING FOR THE HEALTH SECTOR [Date …Place …Event…Sponsor…Organizer] [Date …Place …Event…Sponsor…Organizer]

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Indoor Air Pollution Indoor Air Pollution

LEARNING OBJECTIVESLEARNING OBJECTIVESTO UNDERSTAND, RECOGNIZE AND KNOW:TO UNDERSTAND, RECOGNIZE AND KNOW:

Hazards of indoor air pollution to children’s health

Different toxicants in indoor air, according to sources, settings and activities

Characteristics and issues relating to indoor air pollution in industrialized and developing countries

How to recognize, assess and address health effects

How to prevent exposure to indoor air contaminants

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OUTLINEOUTLINE

Scope of the problem of indoor air pollution Scope of the problem of indoor air pollution Particulate matterParticulate matter Carbon monoxideCarbon monoxide Secondhand tobacco smokeSecondhand tobacco smoke PesticidesPesticides SolventsSolvents Volatile organic compoundsVolatile organic compounds Biological pollutantsBiological pollutants

- Mites- Mites- Allergens- Allergens- Moulds- Moulds

Built environmentBuilt environment Radon Radon AsbestosAsbestos OccupationOccupation--related contaminantsrelated contaminants

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CHILDREN’S UNIQUE VULNERABILITYCHILDREN’S UNIQUE VULNERABILITY

Inhale more pollutants per kilogram of body weight than Inhale more pollutants per kilogram of body weight than do adultsdo adults

Because airways are narrower, irritation can result in Because airways are narrower, irritation can result in proportionately greater airway obstructionproportionately greater airway obstruction

WHO

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SMALLER AIRWAYS MORE VULNERABLESMALLER AIRWAYS MORE VULNERABLE

www.vh.org/pediatric/provider/pediatrics/ElectricAirway/Diagrams/AirwayDIaneterEdema.jpg

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DEPOSITION OF POLLUTANTS IN RESPIRATORY TRACTDEPOSITION OF POLLUTANTS IN RESPIRATORY TRACT

CDC

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SIZE MATTERSSIZE MATTERS

Coarse particles (2.5–10 Coarse particles (2.5–10 micrometres) deposited in micrometres) deposited in the upper respiratory tract the upper respiratory tract and large airwaysand large airways

Fine particles (< 2.5 Fine particles (< 2.5 micrometres) may reach micrometres) may reach terminal bronchioles and terminal bronchioles and alveolialveoli

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RESPIRATORY DEVELOPMENT:RESPIRATORY DEVELOPMENT:CONTINUES THROUGH LINEAR GROWTHCONTINUES THROUGH LINEAR GROWTH

10 X 106 Alveoli300 X 106 Alveoli (age 8)

Growth/structure • Second-hand tobacco smoke• Particulates• Ozone

Function• Indoor air quality• Ambient ozone

Dieter,t 2000

2 to 82 to 8

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0 20000 40000 60000 80000 100000 120000 140000 160000

Underweight

Unsafe water, sanitation and hygiene

Indoor smoke from solid fuels

Zinc deficiency

Vitamin A deficiency

Iron deficiency

Unsafe sex

Lead exposure

Climate change

Unsafe health care injections

Ambient air pollution

Alcohol

Illicit drugs

Attributable burden of disease 0–4 years

1000 DALY

World Health Report 2002

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CHILDREN’S INDOOR EXPOSURECHILDREN’S INDOOR EXPOSURE

Level of economic development is a key factorLevel of economic development is a key factor

Developing and industrialized countriesDeveloping and industrialized countries Rural and urban areasRural and urban areas Local climateLocal climate Architecture/ventilationArchitecture/ventilation

In urban areas, children In urban areas, children

may spend most of their time indoors.may spend most of their time indoors.

Most exposure to air contaminants occurs Most exposure to air contaminants occurs

inside homes and schools.inside homes and schools.

WHO

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INDOOR AIR QUALITYINDOOR AIR QUALITY

Indoor air quality is influencedIndoor air quality is influenced byby::

Outdoor air pollution: vehicles and industrial plants

Secondhand tobacco smoke

Fuels used for heating and cooking

Confined and poorly ventilated spaces

Overcrowded homes and insufficient living space

Customs, habits, traditions

Level of economic development: Industrialized ≠ developing countries

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2 000 000 deaths from ARI in < 5 yr olds (½ due to solid fuel use)

Rising trends of “wheezing”

Coal and biomass fuel: a major source of indoor air pollution

Suspended particulate matter increases the risk of acute respiratory infections

CO and other toxic gases may impair development and health

Secondhand tobacco smoke a major concern

HOMES OF POOR CHILDREN MAY BE UNHEALTHY HOMES OF POOR CHILDREN MAY BE UNHEALTHY

WHO

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ADVERSE HEALTH EFFECTS OF AIR POLLUTANTSADVERSE HEALTH EFFECTS OF AIR POLLUTANTS

Acute:Acute:

Irritation of the mucous membranes (eyes, nose, throat)

Cough, wheeze, chest tightness

Increased airway responsiveness to allergens

Increased incidence of acute respiratory illness: "cold", pneumonia, otitis media

Tracheobronchitis

Exacerbation of asthma

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ADVERSE HEALTH EFFECTS OF AIR POLLUTANTSADVERSE HEALTH EFFECTS OF AIR POLLUTANTS

ChronicChronic::

Long-term exposure decreases lung growth

Impairment of pulmonary function

Increased susceptibility to chronic obstructive lung diseases, including asthma

Other

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ENVIRONMENT AND POLLUTIONENVIRONMENT AND POLLUTION

Indoor environments also reflect Indoor environments also reflect outdooroutdoor air quality air quality

Industrial or agricultural activities

Treatment of industrial effluents and domestic residues

Traffic

Solid waste management

Cottage industries

Chemical incidents and spills

WHO

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INDOOR AIR POLLUTION ALSO AFFECTS OUTDOOR AIR INDOOR AIR POLLUTION ALSO AFFECTS OUTDOOR AIR QUALITYQUALITY

Nigel Bruce/ITDG

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COMBUSTION PRODUCTSCOMBUSTION PRODUCTS

SourcesSources

Gas stoves and appliances

Wood and coal stoves

Gas and propane engines

Fireplaces

Tobacco smoke

Candles and incense

Mosquito coils

Combustion productsCombustion products

Carbon monoxide (CO)

Nitrogen dioxide (NO2)

Sulfur dioxide (SO2)

Nitrogenated compounds (NOx)

Particulate matter (PM)

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SMOKY COOKING FUELSSMOKY COOKING FUELS

Open fire cooking stoves produce heavy smoke containing:Open fire cooking stoves produce heavy smoke containing:

Fine particles Carbon monoxide (CO) Polycyclic aromatic hydrocarbons (PAHs)

Strongly linked to pneumonia Suggested link to low birth weight In adults: chronic obstructive

pulmonary disease, lung cancer

WHO

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HOUSEHOLD ENERGY, IAP AND HEALTHHOUSEHOLD ENERGY, IAP AND HEALTH

3 billion people rely on solid fuels

Solid fuels comprise 10--15% of the total fuels used worldwide

Cooking and heating

levels indoor air pollution

Most concern: particulate matter and carbon monoxide

Women and children heavily exposed

Dung Wood Agricultural residues Charcoal Coal

Nigel Bruce/ITDG

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Level of particulates in home using biofuel: >1000 µg/m3

(24 hr mean)

Can reach 10 000 µg/m3 PM10 (if using an open fire)

EPA: 50 µg/m3 PM10 annual mean

Women and young children have greatest exposure

INDOOR AIR POLLUTION LEVELS ARE VERY HIGHINDOOR AIR POLLUTION LEVELS ARE VERY HIGH

Nigel Bruce/ITDG

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Gordon, WHO, 2004

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AGE DISTRIBUTION OF GLOBAL BURDEN OF DISEASE AGE DISTRIBUTION OF GLOBAL BURDEN OF DISEASE ATTRIBUTABLE TO SOLID FUEL USEATTRIBUTABLE TO SOLID FUEL USE

Age group (yrs)

Attributable mortality

Attributable DALYs

0–4 56 83 5–14 0 0 15–59 5 8 60+ 38 9

Young children at high risk due to:

Lung immaturity

High exposure to IAP: nearly 1 million children under 5 yrs die every year due to

solid fuel use!

WHO

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LeadLeadLeadLeadClimate changeClimate change

Perc

ent

Perc

ent a

geage

of to

tal

of t

otal

bu

rden

burd

en (w

ithin

regi

on)

(with

in re

gion

)

1% -1% -

5% -5% - Water, sanitation and hygiene (5.5%)Water, sanitation and hygiene (5.5%)

UnderweightUnderweight

Solid fuel use (3.7 %)Solid fuel use (3.7 %)

Ambient airAmbient air Occupational injuriesOccupational injuries

Developing countriesDeveloping countries(high mortality)(high mortality)

Industrialized countriesIndustrialized countries

Occupational risksOccupational risks

Alcohol Alcohol Tobacco Tobacco

Overweight Overweight Unsafe sexUnsafe sex

Tobacco Tobacco Alcohol Alcohol

Ambient airAmbient air Water, sanitation and hygieneWater, sanitation and hygieneOverweight Overweight Unsafe sexUnsafe sex

Physical Physical inactivityinactivityZinc deficiencyZinc deficiency

GLOBAL BURDEN OF DISEASE ATTRIBUTABLE TO GLOBAL BURDEN OF DISEASE ATTRIBUTABLE TO SELECTED MAJOR RISK FACTORSSELECTED MAJOR RISK FACTORS

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WHAT INTERVENTIONS ARE AVAILABLE TO REDUCE WHAT INTERVENTIONS ARE AVAILABLE TO REDUCE INDOOR AIR POLLUTION FROM SOLID FUELS?INDOOR AIR POLLUTION FROM SOLID FUELS?

- Fuel drying- Fuel drying

- Use of pot lids- Use of pot lids

- Good - Good maintenancemaintenance

- Keeping children- Keeping children away from smoke away from smoke

-Hoods and chimneys-Hoods and chimneys

-Windows, ventilation -Windows, ventilation holes, eaves holes, eaves spacesspaces

-Separate kitchen-Separate kitchen

- Improved stoves- Improved stoves

- Cleaner fuels- Cleaner fuels (kerosene, gas, (kerosene, gas, electricity) electricity)

UserUser behaviourbehaviourHomeHome environmentenvironmentSource of pollutionSource of pollution

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CARBON MONOXIDE: THE "SILENT KILLER"CARBON MONOXIDE: THE "SILENT KILLER"A COMMON CAUSE OF ACUTE AND LETHAL POISONINGA COMMON CAUSE OF ACUTE AND LETHAL POISONING

Colourless, odourless gas formed by incomplete burning of carbon-based fuels

CO’s affinity for Hb is 240––270 times greater than oxygen

Fetal Hb has higher affinity for CO

CO causes a leftward shift of the

oxyhaemoglobin (OHb) dissociation curve

Intoxication results in tissue hypoxia

Multiple organ systems are affectedwww.cdc.gov/nceh/airpollution/carbonmonoxide/checklist.htm

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CARBON MONOXIDE (CO): SOURCESCARBON MONOXIDE (CO): SOURCES

Gas, kerosene, wood stoves and coal Fires, fireplaces, furnaces Leaking chimneys and vents Room and water heaters Vehicle exhaust in closed garage Tobacco smoke

Any place where combustion is incompleteEPA

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www.firstalert.com/index.asp?pageid=82

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PREVENTION OF EXPOSURE TO CO PREVENTION OF EXPOSURE TO CO

Keep fuel-burning appliances in good working condition

Check heating systems, chimneys and vents regularly

Never burn charcoal indoors

Never leave a car running in a closed garage

Consider CO detectors

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CARBON MONOXIDE POISONING CAN KILL CARBON MONOXIDE POISONING CAN KILL

Symptoms:

Headache, dizziness, fatigue, dyspnoea

Nausea, vomiting

Irritability

Sleepiness, confusion, disorientation

Unconsciousness, coma

Death

Delayed neuropsychological sequelae (in survivors)

Incr

ea

sin

g C

OH

b

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MANAGEMENTMANAGEMENT

Diagnosis: Measurement of COHb

nonsmokers 1–3 % smokers 3–8%

Not useful: Pulse oximeter Arterial blood gases

Treatment: Remove patient from

CO source Life support Oxygen 100% Hyperbaric oxygen? Monitoring

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CHRONIC EXPOSURECHRONIC EXPOSURE

Acute or chronic exposure to low levels of carbon monoxide (research in animals and humans):

Linked to development of arteriosclerosis ?Aggravation of cardiovascular diseases ?Poor performance on certain psychomotor tasks Limited exercise capacity

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Can lead mainly to :

Cardiovascular effects.

Central nervous system effects

Increased susceptibility to acute respiratory infections

CHRONIC EXPOSURECHRONIC EXPOSURE

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FIRE INJURIESFIRE INJURIES

From inhaled toxic chemicals and/or thermal burns.

The lungs and airways are affected in these ways: tissue irritation heat damage Asphyxiation potential cyanide poisoning

Make the home safer: Beware of matches and lighters Install smoke alarms Have a home fire escape plan

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SECONDHAND TOBACCO SMOKE SECONDHAND TOBACCO SMOKE

SCOPE OF THE PROBLEMSCOPE OF THE PROBLEM

Children whose mothers smoke:

70% more respiratory problems

Pneumonia and hospitalization in year 1 is 38% higher

Infant mortality is 80% higher

20% of all infant deaths could be avoided if all pregnant smokers stopped by the 16th week of gestation

5 times higher risk of sudden infant death syndrome (SIDS)

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SECONDHAND SMOKE INCREASES RISK OF:SECONDHAND SMOKE INCREASES RISK OF:

Respiratory tract illness Asthma Middle ear effusions Prenatal complications and low birth weight Fire-related injuries Sudden infant death syndrome (SIDS) Cancers (childhood leukemia and others)

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THE LIFE CYCLE OF THE EFFECTS OF SMOKING ON THE LIFE CYCLE OF THE EFFECTS OF SMOKING ON HEALTHHEALTH

SIDsSIDsRSV/BronchiolitisRSV/BronchiolitisMeningitisMeningitis

InfancyInfancy

Low Birth WeightLow Birth WeightStillbirthStillbirth

In uteroIn utero

AsthmaAsthmaOtitis MediaOtitis MediaFire-related InjuriesFire-related Injuries

InfluencesInfluencesto Startto StartSmokingSmoking

Nicotine AddictionNicotine Addiction

CancerCancerCardiovascular DiseaseCardiovascular DiseaseCOPDCOPD

AdulthoodAdulthood

AdolescenceAdolescence

ChildhoodChildhood

Aligne, 1997

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PESTICIDES PESTICIDES

Spraying pesticides at home / school: Higher concentrations near the floor Persistence in some surfaces (carpets, soft toys) Overuse and misuse

Children’s behaviour and inhalation of pesticides Crawling Playing close to the floor Plush toys Hand-to-mouth Object-to-mouth

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PESTICIDES: INSECTICIDESPESTICIDES: INSECTICIDES

Classes commonly used for insect control indoors:Classes commonly used for insect control indoors:

Pyrethroids: allergenic, CNS toxicity at high levels Cholinesterase inhibitors: neurotoxicants,

neurodevelopmental toxicants Insect repellents (DEET) Mosquito coils

Health effects:Health effects:

Acute poisoning Allergic and general symptoms

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MOSQUITO COILSMOSQUITO COILS

Household use in Africa, Asia, South America

Major active ingredient – pyrethrins

Long-term exposures linked to asthma

and wheezing

ehp.niehs.nih.gov/members/2003/6177/6177.html

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SOLVENTS AND VOLATILE ORGANIC COMPOUNDSSOLVENTS AND VOLATILE ORGANIC COMPOUNDS

Alkanes, aromatic hydrocarbons, alcohols, aldehydes, ketonesAlkanes, aromatic hydrocarbons, alcohols, aldehydes, ketones

Sources:Sources: Solvents, fabric softeners, deodorizers and cleaning products Paints, glues, resins, waxes and polishing materials Spray propellants, dry cleaning fluids Pens and markers Binders and plasticizers Cosmetics: hair sprays, perfumes

www.epa.gov/oppfead1/cb/10_tips/

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VOLATILE ORGANIC COMPOUNDS: HEALTH EFFECTSVOLATILE ORGANIC COMPOUNDS: HEALTH EFFECTS

Acute:Acute: Irritation of eyes and respiratory tract General: headache, dizziness, loss of coordination, nausea,

visual disorders Allergic reactions, including asthma and rhinitis

Chronic:Chronic: Damage to liver, kidney, blood system and

central nervous system (CNS) Some may cause cancer in humans (formaldehyde)

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FORMALDEHYDEFORMALDEHYDE

Sources: differ according to countrySources: differ according to country

Developing countriesDeveloping countries Use of solid fuels indoors Mosquito coils Furniture (pressed wood)

Industrialized countriesIndustrialized countries Household cleaners and deodorizers Glues and resins Tobacco smoke Carpeting Furniture and dyed materials Pressed wood products Urea formaldehyde insulating foam (UFFI) Others

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FORMALDEHYDE: HEALTH EFFECTSFORMALDEHYDE: HEALTH EFFECTS

Irritation of eyes, nose and throat

Breathing difficulties

Skin rash

Asthma and other allergic reactions

May be a sensitizer

May cause cancer

PreventionPrevention::

Reduce exposure

Provide adequate ventilation

Maintain moderate temperature and humidity levels

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BIOLOGICAL POLLUTANTSBIOLOGICAL POLLUTANTS

Biological pollutants are/were living organisms:

Animal dander, dust mites, moulds, infectious agents, pollen

Sources of biological agents: Water-damaged surfaces and materials Humidifiers and stagnant water Water vapour from cooking and showering Air conditioning systems Mattresses, upholstered furniture and carpets Dirt

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DUST MITESDUST MITES

Feed on human dander Prefer warm, humid environments Sources:

bedding, carpets, upholstery, soft toys

Prevention: Encasing mattress and pillows Washing bedding in hot water Frequent vacuuming / damp mopping Decreasing clutter Removing carpets

CDC

46


ANIMAL ALLERGENSANIMAL ALLERGENS

Cat dander (most allergenic) Dog dander Birds Cockroach parts and faeces

Prevention: Remove animals from indoors

Allergens persist for many months after removal of source Clean environment and pet(s) frequently Ventilate adequately Control dust and moisture

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MOULDSMOULDS

A frequently undetected environmental problem Occur in damp indoor areas Allergies and nonspecific symptoms are common, but

infections are rare

EPA

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MOULD-RELATED DISEASESMOULD-RELATED DISEASES

Airway and conjunctival irritation

Headache

Difficulty in concentrating

Hypersensitivity reactions: asthma, rhinitis

Systemic infections (immunosuppressed child)

Acute exposure associated with pulmonary haemorrhage in infants

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CHEMICAL AGENTS PRODUCED BY MOULDSCHEMICAL AGENTS PRODUCED BY MOULDS

Mycotoxins are associated with human disease andcause acute and chronic effects

Mycotoxins Aflatoxins Tricothecenes Ochratoxins and citrinin Hundreds of others

Glucans (cell wall components) Volatile organic compounds (irritating)

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INDOOR AIR QUALITY: INDOOR AIR QUALITY: BUILDING COMPONENTSBUILDING COMPONENTS

The importance of:The importance of: Materials in houses and schools: Materials in houses and schools:

Asbestos, wood preservatives, paints and others

VentilationVentilation HeatingHeating Use (overuse) and location of electric appliancesUse (overuse) and location of electric appliances Air conditioningAir conditioning

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SICK BUILDING SYNDROMESICK BUILDING SYNDROME

What is this syndrome?

Discomfort not related to specific illness Effects appear to be linked to time spent inside the building Cause of symptoms is unknown Most complaints relieved soon after leaving the building An evolving area

Building related illness: symptoms of identified illness attributed to airborne contaminants in the building

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Possible causes: Inadequate building design Occupant activities Remodelled buildings operating in a manner

inconsistent with their original design Inadequate ventilation Inadequate maintenance Chemical and biological contaminants

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Symptoms:Symptoms:

Headache Irritation of eyes, nose or

throat Dry cough Dry or itchy skin Difficulty in concentrating Fatigue Sensitivity to odours

Solutions:Solutions:

Remove source of pollutant

Increase ventilation Air cleaning: filters Education and

communication

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RADONRADON

Radioactive gas released from soil and rocks

Second leading cause of lung cancer (in adults)

Geology of the area can predict levels in soil and water

Concentrations indoors depend on construction site and building materials

Highest levels occur in basements and on the ground floor

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RADON MITIGATION SYSTEMRADON MITIGATION SYSTEM

A – Gas-permeable layer A – Gas-permeable layer

B - Plastic sheeting B - Plastic sheeting

C - Sealing and caulkingC - Sealing and caulking

D - Vent pipe D - Vent pipe

E - Junction boxE - Junction box

It is recommended that homes be It is recommended that homes be tested for radon on the lowest tested for radon on the lowest lived-in level – basement or lived-in level – basement or ground floorground floor

www.epa.gov/iaq/radon/construc.html

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RADON IN SCHOOLSRADON IN SCHOOLS

Schools should also be tested for radon:Schools should also be tested for radon: Levels above 4 pCi/L call for action to reduce exposureLevels above 4 pCi/L call for action to reduce exposure

www.epa.gov/radon/pubs/schoolrn.html

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ASBESTOSASBESTOS

Sources:Sources: Used for insulation and as fire-retardant: asbestos cement, floor and roof tiles,

water pipes and others Levels increase if asbestos-containing materials are damaged Levels can be high in clothes of working parents

Health effects:Health effects: No acute toxicity Asbestosis results from occupational exposure Main risk for children: long-term exposure may cause cancer in adulthood

Malignant mesothelioma Lung cancer

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OCCUPATION-RELATED CONTAMINANTSOCCUPATION-RELATED CONTAMINANTS

Parents “take home” exposures related to work: Contaminated clothing, shoes and objects Contaminated skin and exhaled breath Empty containers (pesticide and others)

Children are directly exposed when: Visiting parents’ workplaces Participating in work

Prevention Change work clothes and shower before hugging or playing

with children

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CHILDREN WORKING INDOORSCHILDREN WORKING INDOORS

Child labour and adolescent work: exposure to pesticides, solvents, cleaning agents and other chemicals indoors

Young children employed illegally Unregulated temporary work School-based vocational training Family businesses Cottage industries Indoor smoke from solid fuels (e.g. food stands) Volunteer service projects

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OUTCOME-EFFECTS:- Acute poisonings- Respiratory diseases- Allergies- Developmental

disturbances- Cancer

SUSCEPTIBILITIES:SUSCEPTIBILITIES:

-Lungs still immature

-Higher breathing rate

-More time indoors

-Nutritional status

-Poverty

SUMMARY SLIDESUMMARY SLIDE

HAZARDS:

Particulates,

CO, Solvents,

Pesticides,

Lead, moulds,

Mites, pollen

MEDIUM

Air

SETTINGS:

-Home

-Child care

-School

-Workplace

Playground

Sports placeACTIVITIES

Playing, Studying, Eating, Drinking, Working, Sleeping

(photo credit US NIEHS CERHR logo)

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APPROACHES TO REDUCE INDOOR AIR POLLUTIONAPPROACHES TO REDUCE INDOOR AIR POLLUTION

1. Eliminate or control the sources of pollution Improved stoves Clean fuels (kerosene, gas) Venting stoves for cooking and heating Regular maintenance of cooking, heating and cooling systems Choose non-volatile, non-toxic building materials Maintaining dry homes and schools

2. Ventilation – building design Dilute and remove pollutants through ventilation with outdoor air

3. Air cleaning – NOT air fresheners! Air filters and ionizers may remove some airborne particles Gas adsorbing material is used to remove gaseous contaminants

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OZONE GENERATORS – CAUTIONOZONE GENERATORS – CAUTION

Ozone can be harmful to health Chest pain, coughing, throat irritation

Ozone is ineffective in controlling indoor air pollution below health standards levels NIOSH / OSHA recommends an upper limit of 0.10 ppm ozone

High concentrations are used to decontaminate unoccupied spaces from chemical and biological contaminants or odours

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EDUCATION AND ADVOCACYEDUCATION AND ADVOCACY

Education of:Education of: Children Family and community Health care providers

Environment policy-makingEnvironment policy-making Framework Convention on Tobacco Control Clean indoor air regulations Community actions

ResearchResearch

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CRITICAL ROLES OF HEALTH & ENVIRONMENT CRITICAL ROLES OF HEALTH & ENVIRONMENT PROFESSIONALSPROFESSIONALS

WHO

Diagnose and treatDiagnose and treat

Do research and publishDo research and publish• Detect sentinel cases• Inspire community-based interventions

EducateEducate• Patients and families• Colleagues and students

AdvocateAdvocate

Provide good role modelProvide good role model

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POINTS FOR DISCUSSIONPOINTS FOR DISCUSSION

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First draft prepared by Ligia Fruchtengarten MD (Brazil)

With the advice of the Working Group on Training Package for the Health Sector: Cristina Alonzo MD (Uruguay); Yona Amitai MD MPH (Israel); Stephan Boese-O’Reilly MD MPH (Germany); Irena Buka MD (Canada); Lilian Corra MD (Argentina), PhD (USA); Ruth A. Etzel MD PhD (USA); Amalia Laborde MD (Uruguay); Ligia Fruchtengarten MD (Brazil); Leda Nemer TO (WHO/EURO); R. Romizzi MD (ISDE, Italy); S. Borgo MD (ISDE, Italy).

Reviewers: S. Bhave MD (India); S. Boese-O’Reilly MD MPH (Germany); Y. Amitai MD MPH (Israel), E. Rehfuess (WHO), I. Buka MD (Canada)

Reviewer 2008: Ruth A. Etzel, MD, PhD (USA)

Update: July 2008WHO CEH Training Project Coordination: Jenny Pronczuk MDMedical Consultant: Katherine M. Shea MD MPH, USATechnical Assistance: Marie-Noel Bruné MSc.

ACKNOWLEDGEMENTSACKNOWLEDGEMENTS

WHO is grateful to the US EPA Office of Children’s Health Protection for the financial support WHO is grateful to the US EPA Office of Children’s Health Protection for the financial support that made this project possible and for some of the data, graphics and text used in preparing that made this project possible and for some of the data, graphics and text used in preparing

these materials.these materials.

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DISCLAIMERDISCLAIMER The designations employed and the presentation of the material in this publication do not imply the expression of any The designations employed and the presentation of the material in this publication do not imply the expression of any

opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.represent approximate border lines for which there may not yet be full agreement.

The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.

The opinions and conclusions expressed do not necessarily represent the official position of the World Health The opinions and conclusions expressed do not necessarily represent the official position of the World Health Organization.Organization.

This publication is being distributed without warranty of any kind, either express or implied. In no event shall the World This publication is being distributed without warranty of any kind, either express or implied. In no event shall the World Health Organization be liable for damages, including any general, special, incidental, or consequential damages, Health Organization be liable for damages, including any general, special, incidental, or consequential damages, arising out of the use of this publicationarising out of the use of this publication

The contents of this training module are based upon references available in the published literature as of the last The contents of this training module are based upon references available in the published literature as of the last update. Users are encouraged to search standard medical databases for updates in the science for issues of particular update. Users are encouraged to search standard medical databases for updates in the science for issues of particular interest or sensitivity in their regions and areas of specific concern.interest or sensitivity in their regions and areas of specific concern.

If users of this training module should find it necessary to make any modifications (abridgement, addition or deletion) to If users of this training module should find it necessary to make any modifications (abridgement, addition or deletion) to the presentation, the adaptor shall be responsible for all modifications made. The World Health Organization disclaims the presentation, the adaptor shall be responsible for all modifications made. The World Health Organization disclaims all responsibility for adaptations made by others. All modifications shall be clearly distinguished from the original WHO all responsibility for adaptations made by others. All modifications shall be clearly distinguished from the original WHO material.material.

1 INDOOR AIR POLLUTION Children's Health and the Environment WHO Training Package for the Health Sector World Health Organization TRAINING.

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