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Established seller since Seller Inventory LQ Shipped from UK. Condition: Brand New. In Stock. Seller Inventory x Items related to Chronic Diseases in the year Scenarios on Chronic Publisher: Springer , This specific ISBN edition is currently not available. View all copies of this ISBN edition:. Synopsis About this title Aims and approach In order to chart the way for long-tenn policies in the field of public health, the Dutch government needs to have the best possible insight into potential future trends and the problems to which these could give rise.

Buy New Learn more about this copy. About AbeBooks. Customers who bought this item also bought. Stock Image. Published by Springer, Netherlands New Paperback Quantity Available: Seller Rating:. In addition to the retrospective mortality studies identified above, the committee reviewed a cross-sectional study of Norwegian cable-plant workers exposed to oil mist or kerosene vapors Skyberg et al. Seven cases of pulmonary fibrosis were found in 25 workers compared with one case in the control group. In a followup study of those workers Skyberg et al.

Smoking and exposure to asbestos were possible confounders in both studies. Asthma is the most commonly reported occupational lung disease in most industrialized countries, and trends from long-standing surveillance in Finland and the UK show little change in incidence of occupational asthma over the last 10 years Meyer et al. Four cohort studies of refinery workers Kaplan ; Rushton and Alderson ; Wong et al. All the SMRs were below 1. The committee reviewed two case reports of asthma due to prolonged exposure to kerosene vapor from accidental domestic oil storage-tank spills Todd and Buick and exposure to aviation fuel in an aircraft-engine mechanic Makker and Ayres Six adults and three children were exposed to kerosene vapor, and one adult and the three children developed asthma that persisted for 3 years after the incident.

A year-old aircraft-engine mechanic reported being exposed to both high concentrations of aviation-fuel vapors and jet-stream emissions from aircraft engines. He developed symptoms almost immediately on beginning his job and was diagnosed with asthma within 4 years. The man reported that his symptoms improved when he was away from work for periods of at least 2 or 3 days. A review article by Rodriguez de 1a Vega et al. The authors found that Rushton and Alderson and Wong et al. Two of the three studies found no increased risk, however, one study found an SMR of 1. Three studies Kaplan ; Wong et al.

The healthy-worker effect probably contributed to the results. A fairly extensive literature describes results of cohort studies designed to examine mortality in workers in the petroleum industry Table 5. Most of the studies indicate a healthy-worker effect, which complicates interpretation of their results. The committee divided the epidemiologic literature of respiratory effects and exposure to combustion products into four general types: studies of Gulf War veterans exposed to oil-well fires, community air pollution studies, occupational studies, and studies of biomass fuel, which is burned for heating or cooking primarily in developing countries.

Each part of this section begins with the most robust primary studies that is, studies with strong methods and exposure information , and continues with mortality studies and support studies that add weight to the primary evidence but are not as methodologically robust. Key primary studies used to draw conclusions are also depicted in tables Tables 5.

Most studies reported on more than one respiratory condition. TABLE 5. In February , retreating Iraqi forces set fire to more than oil wells. Fires burned over a month period, until November , exposing thousands of US troops to combustion products.

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Several studies of US Gulf War veterans exposed to oil-well fires stand out from most other Gulf War studies by virtue of their focus on a narrow set of respiratory health outcomes and on a single type of exposure smoke from oil-well fires and their exposure validation on the basis of models of troop unit movements in relation to air-monitoring data. The vast majority of Gulf War health studies focused on multiple health outcomes, multiple exposures, and self-reporting of exposures without validation.

The studies summarized below examined long-term respiratory effects as veterans were surveyed after their deployment to the Persian Gulf. The first indication of possible long-term effects was from an uncontrolled study conducted in Germany, four weeks after deployment, which found that Army veterans that had been stationed near the fires reported coughing more frequently than before the war Petruccelli et al.

All studies discussed below are summarized in Table 5. Cowan et al. The DOD registry was established for active-duty Gulf War military who wished to receive a comprehensive physical examination. Cases of asthma were defined by physical examination conducted by military physicians ICDCM [Clinical Modification] codes and Exposure to smoke from oil-well fires was estimated by linking troop. National Oceanic and Atmospheric Administration NOAA researchers modeled exposure on the basis of meteorologic and ground-station air-monitoring data Draxler et al.

Only Army personnel were included in the study because their location data were more precise. Self-reported symptoms of bronchitis and asthma wheezing and coughing vs control symptoms of major depression and injury. For modeled exposure, adjusted ORs for symptom groups, including control symptoms, near 1. Case-control study of cases of asthma vs 2, controls; DOD registry Army personnel only. Cumulative exposure: OR 1. Self-selected population, pre-exposure asthma status unknown, active-duty military Army only. Hospitalizations — for any cause, major ICDCM diagnoses and specific diagnoses related to oil-well fires such as asthma, ischemic heart disease, and emphysema.

With Cox modeling, three of 25 models showed increase in adjusted risk of hospitalization, but no dose-response relationship; when nonexposed and exposed, were compared, none of the adjusted risk ratio for postwar hospitalization. Limited to DOD hospitals, exposures unknown except for oil-well smoke, outpatient data not available. The seven categories were collapsed into two exposed and nonexposed because of relatively small numbers. Self-reported oil-well fire smoke exposure was associated with a higher risk of asthma OR [odds ratio] 1.

In addition, modeled cumulative smoke exposure was related to a greater risk of asthma OR 1. For both exposure metrics, there was evidence of a linear exposure-response trend. Smoking appeared to modify the effect—the effect of oil-well fire smoke exposure was observed among never and former smokers but not among current smokers. Study strengths include the objective exposure assessment and use of physician-diagnosed asthma on the basis of clinical evaluations.

Limitations include the self-selection into the DOD registry, which could have introduced selection bias; for example, if the cohort was enriched in persons who both experienced exposure and have respiratory conditions, the risk estimate could be biased upward. Moreover, the study examined prevalent-asthma cases, so a higher incidence of asthma cannot be distinguished from exacerbation or recrudescence of pre-existing disease.

The study did not ask about chronic bronchitis or other respiratory effects. In contrast, the population-based Iowa cohort of 1, Gulf War veterans found no association between oil-well fire exposure and the risk of asthma Lange et al. Five years after the war, veterans were asked about their exposures and current symptoms. Exposure was modeled with an approach similar to that of Cowan et al. Cases of asthma were defined by questions assessing wheezing and chest tightness.

Cases of bronchitis were assessed by self-reported cough and phlegm production. Both questions pertained to symptoms in the preceding month, so it is not possible to determine whether symptoms were chronic. Self-reported exposure to oil-well fires was associated with a greater risk of asthma and bronchitis. There was no statistical association, however, between modeled exposure and the risk of asthma or bronchitis, when sex, age, race, military rank, smoking history, military service, and level of preparedness for war were controlled for.

The three higher exposure quartiles were associated with a similar risk of asthma and bronchitis compared with the lowest-exposure quartile all ORs near 1. The correlation between self-reported exposure and modeled exposure was moderate range of 0. The authors ascribed the different results for self-reported vs objective exposure measurement to recall bias.

Study strengths include the population-based sampling: findings probably can be generalized to all military personnel in the Persian Gulf; however, the study speaks to the outcome of asthma symptoms rather than an asthma diagnosis. Chronic bronchitis also was not defined with the standard epidemiologic definition, so it was impossible to distinguish between acute and chronic symptoms.

Gray et al. Because of the absence of denominator data, the authors compared proportional morbidity ratios PMRs of hospitalization discharge diagnoses 14 diagnostic categories from ICD-9 in Gulf War vs nondeployed veterans. PMRs of most disease categories were not increased; however, those of respiratory diseases were increased in veterans PMR 1.

Among respiratory diseases, the authors reported increases in asthma, but no data were shown. The study was of hospitalizations, so no data were collected on individual self-reported exposures. In a historical cohort study of , active-duty Gulf War veterans, Smith et al. Exposure was estimated by using troop location data and estimated smoke that is, PM concentrations based on NOAA modeling Draxler et al.

Six exposure categories were created by using average daily exposure and length-of-exposure data Table 5. Hospitalizations were examined for the period —, including admissions for any cause, major ICDCM diagnoses, and nine specific diagnoses presumed to be related to oil-well fires. If a subject was hospitalized before the war with one of the specific diagnoses, the subject was excluded from further analysis. The study examined hospitalizations only in DOD hospitals because of the availability of data.

Active-duty personnel are rarely hospitalized outside the DOD medical system whereas veterans and National Guard and reserve personnel often use other hospitals. There was no association between exposure to oil-well fires and the risk of hospitalization for asthma RR [relative risk] 0. Because most adults who have asthma or chronic bronchitis are never hospitalized for the condition, the study would not be expected to have captured most cases. No information was available on smoking or other exposures that may be related to respiratory symptoms, and although there was an increase in the RR between smoke from oil-well fires and emphysema, the CI included the null value RR 1.

Several other studies of smoke from oil-well fires in the Persian Gulf were less methodologically robust. A cohort study of Gulf War veterans evaluated self-reported combustion exposure but examined pulmonary symptoms only as a broad class; asthma and bronchitis were not specifically evaluated Proctor et al. Finally, an ecologic study of Kuwaiti residents found no increase in the rate of asthma hospitalization after the Gulf War Al-Khalaf Community air-pollution studies typically evaluate the health effects of routinely measured air pollutants, such as nitrogen oxides NO x , sulfur dioxides, particles of various sizes for example, PM 10 , PM 2.

Some of the studies used single-location measures or community averages of air pollutants to characterize exposures of residents of each study community, and a few estimated exposure of individual residents on the basis of interpolation of ambient monitoring data.

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The Adventist Health Smog study, a prospective cohort study, began in by following a cohort of 6, Seventh-Day Adventists SDAs in areas of California with varied air-pollution magnitudes. The following studies of incidence of respiratory outcomes were based on the SDA cohort.

Each study used similar methods and confounding and bias controls. Study subjects were over 25 years old, baptized members of the SDA church, non-Hispanic and white, had lived within 5 miles of their permanent residence for more than 10 years, and resided in San Francisco, the Los Angeles Basin, or San Diego.

Participants were studied for respiratory and other health outcomes. Respiratory outcomes were studied in a subcohort of nearly 4, people. Three respiratory outcomes were analyzed according to responses to a item symptom questionnaire: asthma, chronic bronchitis, and overall airway obstructive disease AOD.

AOD included asthma, chronic bronchitis, and emphysema there were so few cases of emphysema that it was not analyzed separately. Exposure to air pollutants was determined for each participant on the basis of ambient monitoring sites in — by interpolating residential ZIP codes and work-location history. The precision of interpolating concentrations was verified. In , each study participant completed a detailed demographic and lifestyle questionnaire about smoking, occupation, hours spent in driving on highways, and other topics.

In and , each participant completed standardized respiratory-symptoms questionnaires American Thoracic Society, ATS to ascertain self-reported symptoms of chronic respiratory disease. Most analyses controlled for age, sex, previous smoking, occupational exposure to tobacco smoke, AOD before the age of 16 years, and education. Overall, study findings are informative, particularly because they focus on incident, rather than prevalent, respiratory disease. Study limitations include self-reporting of respiratory symptoms, varying specificity in measures of exposure, and coexposures to ozone and photochemical oxidants.

The following paragraphs summarize a series of four reports about the incidence of respiratory outcomes covering various. PM 10 and PM 2. Asthma self-reporting was validated with information from medical charts. Abbey et al. Confounding variables included in the analysis were education, sex, possible symptoms in , and years worked with a smoker. The mortality results in the SDAs are summarized in a later section on air-pollution mortality findings.


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Self-reported respiratory symptoms, as noted above, were grouped into asthma, chronic bronchitis, and AOD any of asthma, chronic bronchitis, and emphysema. In the same report, mean concentration and average annual exceedance frequencies of , , , and parts per billion ppb were not associated with new cases of any respiratory outcomes, although a possible association between ozone and exceedances of ppb and new cases of asthma point estimate RR 1. An elevated risk in men not women was associated with ozone and exceedances of ppb and new cases of asthma point estimate RR 1.

Because of multicollinearity, the analyses were unable to show whether TSP or ozone was more strongly associated with new cases of asthma ozone and TSP correlation 0. There was no association between SO 2 and respiratory symptoms; however, the average ambient concentrations were low. There also was no association between nitrogen dioxide NO 2 and each of the respiratory outcomes Abbey et al. Another report by Abbey et al. The year cumulative exposure to SO 4 particles was determined for each participant in — Multivariate analysis was conducted for AOD, chronic bronchitis, and asthma for new cases of disease, persistent prevalence that is, symptoms in both and , and change in severity of symptoms from to The year mean ambient concentration of SO 4 particles was strongly associated with the development of definite asthma RR 2.

Working with a smoker and having AOD before the age of 16 years were strongly associated with asthma. Finally, Abbey et al. Exposure to PM 2. Mean PM 2. While the majority of epidemiologic studies of morbidity and mortality associated with community air pollution are time series ecologic design, the committee focused on cross-sectional or case-control studies of air pollution. The time series studies examine daily mortality or morbidity, while the focus for the committee is on long-term health effects.

A population-based study in France examined the relationship between SO 2 concentration and asthma Baldi et al. A random sample of adults 25—59 years old who resided for at least 3 years during — in 24 areas of seven French towns were selected. Air pollution was measured over the same 3 year period by pollution-monitoring stations subjects lived within meters of a station.

Geographic clustering of data was taken into account by using random effects. Limitations include the cross-sectional design and the use of self-reported asthma; strengths include the population-based sampling and direct air-pollution monitoring. Karakatsani et al. Residents of greater Athens completed a questionnaire, which was used to recruit participants who reported a history of COPD, chronic bronchitis, emphysema, or respiratory symptoms including chronic productive cough for 3 months per year for 2 years.

The same number of age- and sex-matched controls without respiratory conditions or symptoms was selected. Air pollution was ascertained retrospectively on the basis of average long-term concentrations of black smoke and NO 2 recorded at 14 monitoring stations for the decade — Boroughs were classified into quintiles of NO 2 concentration.

Residential and employment histories were used to calculate time-weighted averages for each subject. Subjects who resided in rural areas or other cities were assigned to categories based on their presumed pollution exposure. Conditional logistic regression revealed an association between the highest quartile of estimated exposure during the preceding 5 years and the risk of COPD OR 1.

Study strengths include the population-based recruitment of cases and controls, the attempt to confirm the diagnosis of COPD with physician examination, the objective exposure assessment, and statistical control for sociodemographic and smoking variables. The study had several limitations: There was a lack of uniform criteria for diagnosing COPD; although exposure was objectively ascertained, the lack of monitoring data on subjects who lived outside greater Athens. In a population-based sample of adults aged 40 years or older, investigators studied the relation between regional SO 2 concentration in the Osaka prefecture in Japan and the prevalence of self-reported chronic bronchitis Tsunetoshi et al.

Average SO 2 concentrations for a 3-year period before the study began were noted. The researchers found a moderate relationship between chronic-bronchitis prevalence and regional average SO 2 when they controlled for age and smoking mean prevalence increased 1. There was no relationship between regional SO 2 and the prevalence of reduced 1-second forced respiratory volume FEV 1. Limitations include the use of an exposure measurement based on averaging SO 2 over a long time 3 years before the study and the lack of control for socioeconomic status SES or other exposures.

A population-based, cross-sectional study of 18, people 20—44 years old evaluated the relationship between regional mean annual NO 2 concentration and asthma prevalence across Italy De Marco et al. Asthma prevalence was measured with a question asking whether the respondent had had an attack of asthma during the preceding 12 months. Higher ambient NO 2 was associated with a greater risk of asthma attacks, when climate, age, sex, smoking, social class, season, and type of contact telephone vs mail were controlled for OR per standard-deviation increment in NO 2 1.

The confidence interval did not exclude absence of an association. Study strengths include the population-based sampling and objective exposure measurement. A population-based study in western Australia compared cases of asthma that required hospitalization with population-based controls Hunt and Holman Residential SO 2 was estimated with a validated model based on meteorologic data and industry emissions data. There was no relation between mean residential SO 2 and risk of asthma hospitalization OR 0. A major limitation for the committee in interpreting the data for purposes of its charge is that asthma hospitalizations could reflect either incident disease or exacerbation of pre-existing disease.

In addition, most asthma patients are never hospitalized for the disease, so hospitalization is a poor measure of disease causation. Mortality studies of respiratory outcomes are, for purposes of this report, often difficult to interpret and inconclusive. One reason is that many mortality studies use composite ICD codes instead of minor groupings or individual codes, which would have greater specificity.

A second is that because asthma and chronic bronchitis are rarely fatal, mortality studies tend to be insensitive to any relationship between an environmental or occupational exposure and long-term respiratory effects. Finally, although emphysema is the respiratory effect that is the exception because it can be fatal, most emphysema deaths are related to cigarette-smoking.

Garshick et al. Veterans who lived within 50 meters of a major roadway were compared with those who lived more than meters away. By virtue of their age mean age They were drawn from the general population of southeastern Massachusetts, and they had not been treated in a VA medical center in the year before being surveyed.

Estimates of individual exposure were based on current residential address without information on residential history linked to road type and traffic-count data in a geographic information system. Living near a major roadway appeared to be associated with increased reporting of persistent wheeze OR 1. Self-reports of physician-diagnosed asthma or COPD defined as chronic bronchitis or emphysema were analyzed as confounders and effect modifiers. Associations were adjusted for cigarette-smoking, age, and occupational exposure to dust.

The authors noted that limitations of the study include lack of information on duration of residence at each address and information about home exposure to NO x from cooking or heating. Zhang et al. A study of parents of schoolchildren was performed on 4, adults who resided in four school districts of three major cities.

Chronic Obstructive Pulmonary Disease (COPD) in Women - UCLAMDCHAT

The self-reported symptoms ascertained were cough, phlegm, wheeze, and persistent cough and phlegm PCP, an indicator of chronic bronchitis. Exposure to air pollution was determined on the basis of ambient air pollution data from monitoring stations in each district. A separate report covered findings on schoolchildren, but this young population is not relevant to Gulf War veterans. NOx were assessed to estimate long-term exposure to outdoor air pollution. The differences for SO 2 and NO x were less pronounced. The findings suggest that increased TSP concentration is associated with increased symptoms.

Physician-diagnosed asthma and bronchitis showed inconsistent trends. For bronchitis acute or chronic , ORs for mothers followed the same trend as respiratory symptoms Lanzhou OR 9. A limitation of the study is that it did not associate air-pollution concentrations themselves with health outcomes; it only associated residence in some regions with health outcomes. The authors cautioned that nonmeasured between-city factors may have been responsible for the associations.

In an ecologic study in Sweden Bjornsson et al. There was no difference in the prevalence of self-reported asthma. Although Gotborg was more polluted, there were also differences in climate and SES that could have accounted for the findings. An ecologic study evaluated the relation between short-term SO 2 peaks and emergency-department visits for asthma in low income neighborhoods in New York City in — Goldstein and Weinstein Limitations include the lack of control for confounding factors, such as smoking and sociodemographic characteristics, and the likelihood that emergency-department visits reflected exacerbation of pre-existing asthma rather than incident asthma cases.

Two other studies compared the prevalence of asthma or chronic bronchitis among geographic regions that had different air-pollution magnitudes. The geographic areas probably differ in other important ways, such as sociodemographic characteristics of the inhabitants, smoking prevalence, and allergen exposure. Because there were no specific measurements of air pollution, it is difficult to draw any inferences from the studies Papageorgiou et al. The Woods et al. The self-reported-exposure measure is suspect, however, in that persons who have respiratory disease may be more likely to remember and report perceived air-pollution annoyance.

An ecologic study in Brisbane, Australia, examined the association between weekly smoke density coefficient of haze and admissions to the casualty department of the Royal Brisbane Hospital at night Derrick Hastings and Jardine evaluated the association between measured particulate air pollution and upper respiratory disease rates in soldiers deployed to Bosnia in — No specific information on asthma, chronic bronchitis, or COPD was presented. Zelikoff et al. Additionally, several studies for example, Aditama ; Kunii et al.

Domestic gas-stove use releases NO 2 , a potential respiratory irritant, into the indoor environment Samet et al. Many epidemiologic studies examining the effects of gas-stove use have focused on healthy members of the adult population Dow et al. In those studies, the effect of gas stove exposure on the development of respiratory symptoms, including asthma symptoms and pulmonary function impairment has been inconclusive. The city of Rotorua, New Zealand, is above a geothermally active area with substantial hydrogen sulfide H 2 S exposure. A series of studies by Bates et al.

The impetus for the studies was a World Health Organization report that recommended research in Rotorua to take advantage of the natural conditions to study the health effects of H 2 S. Bates et al. Rotorua has a higher density of Maori residents than other areas of New Zealand. In a subsequent report, Bates used hospital-discharge data over a 3-year period — to calculate standardized incidence ratios SIRs for respiratory and other diseases and subgroupings in Rotorua residents. Exposure was designated as high, medium, and low on the basis of area of residence where H 2 S was mapped outdoors with passive sampling.

The authors had no information on smoking and SES as potential confounders. In a third report, Bates et al. No exposure groups were designated. CORD was not increased. A major limitation of the series of Bates studies for purposes of the present report is the grouping of respiratory diseases without specifying whether they were asthma, bronchitis, COPD, or individual conditions. Additionally, the Bates studies were the only epidemiologic studies of H 2 S found by the committee that examined long-term health outcomes. Due to the paucity of literature, the committee did not make a separate conclusion on H 2 S.

Osterman et al. Individual exposures were to respirable dust and to SO 2 at relatively low concentrations less than 1.


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Exposures were estimated based on the basis of job-specific measurements and linkage to worker-specific job titles and employment duration. Average duration of employment was 14 years. The estimates included a measure of cumulative exposure, average exposure, and most recent exposure. It is notable that the plant had been closed in the 6 months preceding the study, so the evaluation of outcome probably occurred after an exposure-free interval. Respiratory symptoms were ascertained with a translated version of the ATS respiratory-disease questionnaire. Lung function was also measured and reported separately Osterman et al.

Although all symptoms occurred more frequently in current smokers For cumulative SO 2 exposure, the highest exposure over 3 ppm-years had OR The strong SO 2 -symptom associations persisted and were almost identical with those obtained from regression models that did not include a dust variable. There was no evidence of a dust-SO 2 interaction. The association was more closely related to exposure concentration rather than to duration. A similar dose-dependent association was observed between SO 2 exposure and chronic wheeze. The associations with respirable dust were generally negative.


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  4. Because the study measured symptoms only 6 months after cessation of exposure, it is not known whether they were reduced or eliminated after a longer exposure-free period. In a companion article, Osterman et al. No effects of a dust-SO 2 interaction were seen. Studies of respiratory-system mortality in particular occupations are often difficult to interpret. Other studies examine occupations that entail exposure to chemicals of uncertain relevance to Gulf War veterans, including studies of urban firefighters Aronson et al.

    Although most mortality studies had negative results, three found higher mortality from emphysema Maizlish et al. A separate analysis of the ACS prospective study found that emphysema mortality was not meaningfully increased among workers exposed to diesel exhaust, after adjustment for the effects of smoking Boffetta et al. A large study of firefighters in 27 states over 5, The effects of occupational exposure to engine exhaust were studied in Copenhagen street-cleaners in comparison with a similar number of cemetery workers Raaschou-Nielsen et al. Environmental monitoring confirmed that street cleaners had higher average exposures to air pollutants except ozone than did cemetery workers, but similar wages and similar exertion.

    Cemetery workers were younger and less likely to smoke cigarettes. The study did not indicate whether the symptom questionnaire was sent after an exposure-free interval, but the likelihood is that there was no interval, inasmuch as this was a study of current workers. The study found, after adjustment for age and smoking, that street-cleaners were at higher risk for chronic bronchitis OR 2.

    Asthma and chronic bronchitis were defined on the basis of responses to the standard questionnaire by the British Medical Research Council. The average duration of employment was 5—9 years. A limitation of the study is the potential for nonmeasured differences between the two types of workers that could confound the exposure-outcome relationships.

    Occupational exposure to diesel-exhaust emissions was associated with increased self-reported symptoms of cough and sputum and with lower pulmonary function in coal miners vs matched controls Reger et al. When disparities in various health characteristics between workers in or at diesel-using mines and their matched controls were related to an index of diesel exposure, they showed no noteworthy trends. Although a pattern consistent with early airway disease was shown, factors other than diesel may be responsible inasmuch as exposure duration and concentrations were low.

    The respiratory health of workers at five salt mines was evaluated with a questionnaire and spirometry Gamble and Jones ; no direct exposure measurements were available. Comparisons within the study population showed a dose-related association of phlegm and diesel-exhaust exposure, no noteworthy trend for cough and dyspnea, and no association with spirometry was seen. The factory also emitted azodicarbonamide, which has been associated with occupational asthma. Investigators evaluated clerical and industrial workers in four engineering factories in Brisbane, Australia Smithurst and Williams Although cough and phlegm were more common among industrial than clerical workers, there was no specific evaluation of exposure to combustion products.

    There also was no statistical control for potentially confounding variables, such as SES. A study of 1, men 22—54 years old living in Norway found that self-reported occupational exposure to SO 2 was associated with a greater decline in FEV 1 from initial examination — to followup — Investigators demonstrated a decline in FEV 1 after occupational diesel-exhaust exposure, but the decline normalized after an exposure-free period of 3 days Ulfvarson et al.

    Several other morbidity studies assessed occupational exposures but were limited by lack of exposure information or other features. One study Fleming and Charlton found that. Occupational exposure to engine exhaust was not associated with adult asthma in a study in Sweden Toren et al.

    Other studies are limited in that they did not provide specific estimates of exposure to combustion products but rather studied exposures to a composite category for example, vapors, gas, dust, or fumes Flodin et al. Some studies have assessed the effect of forest firefighting on various intermediate measures or indexes of pulmonary function rather than on respiratory diseases themselves.

    Most forest-firefighter studies, however, did not examine effects on lung function after an exposure-free period. An exposure-free period is important for distinguishing between reversible, short-term outcomes and long-term outcomes. In one study that had an exposure-free period of 2. Liu et al. Crews worked full-time in May—November.

    Findings were independent of smoking. The duration of the exposure-free interval between fire exposure and testing appears to have been at most 2 weeks, so it is difficult to determine whether effects are short-term effects, which may reverse, or long-term effects. A prospective study of 1, urban firefighters in — found no exposure-related decline in pulmonary function. A study of retirees from the same urban fire department did not find appreciably reduced respiratory function that was unrelated to smoking Musk et al.

    Urban-firefighter studies, however, are probably less relevant to Gulf War veterans see above than are studies of rural firefighters, because of the nature of the materials in urban fires. Several studies evaluated the effects of exposure to products of biomass fuel combustion for heating or cooking, which includes combustion of wood, dung, and agricultural residue. The homes in question often do not have a separate kitchen or a way to vent fumes. The studies assessed exposure by self-reporting of duration of cooking-fuel use and, in some cases, by measurement of air quality at the time of the survey.

    On the basis of survey items about 10 cooking fuels, the author classified cooking-smoke exposure as high only biomass fuels , medium a mix of biomass and cleaner fuels, such as kerosene, petroleum gas, biogas, or electricity , and low only cleaner fuels. The risk was also increased for the medium group mixed fuels vs clean fuels OR 1. The asthma results were stronger for women OR 1. The strengths of the study are its population-based design, thorough ascertainment of fuel use, and control for confounding.

    Limitations include the cross-sectional design and the use of a self-reported definition of asthma that did not require symptoms or a physician diagnosis. No information is available on duration of exposure. Albalak et al. The villages were similar, except that one used indoor cooking and the other outdoor cooking. They were given a Spanish translation of the British Medical Research Council questionnaire for chronic bronchitis.

    Measured kitchen PM 10 was substantially higher in the indoor-cooking village; total daily integrated PM 10 exposure based on a time-budget analysis was also much higher. The outdoor-cooking village had a lower risk of chronic bronchitis, after adjustment for age, sex, and exclusion of smokers OR 0. The villages were similar in a variety of socioeconomic indicators.

    The validation of exposure with direct ambient-air monitoring specifically PM 10 is a strength of the study.

    Summary of Notifiable Diseases United States,

    Although duration of residence was not reported, air monitoring was carried out over a month period, and a case of chronic bronchitis was identified by uninterrupted cough for at least 3 months over 2 years. They had reported a range of 2. There were four different groups: people who had tuberculosis, interstitial lung disease, or ear nose and throat ENT conditions sinusitis, otitis media, or deviated nasal septum and healthy visitors of hospitalized patients with no respiratory symptoms or pulmonary function impairment.

    The primary exposure was to wood smoke while cooking. The selection of controls that had tuberculosis or interstitial lung disease is suspect because such subjects may differ from persons who have chronic airway disease in a variety of important ways. In analyses that used the other control groups, wood-smoke exposure was associated with a greater risk of chronic bronchitis without chronic airway obstruction than in ENT controls OR 3.

    The analysis controlled for age, cigarette-smoking, region of origin, income, education, and place of residence. Wood-smoke exposure was not associated with the risk of chronic airway obstruction without chronic bronchitis. Wood-smoke exposure was associated with a greater risk of chronic airway obstruction plus chronic bronchitis compared with ENT controls OR 5. Cumulative lifetime exposure the product of average hours per day of exposure and years of exposure was also linearly related to a greater risk of chronic bronchitis only than in the ENT or visitor controls.

    Findings in the tuberculosis and interstitial-lung-disease control groups are difficult to interpret, because these conditions could be related to wood-smoke exposure; alternatively, the conditions, because they are severe diseases, might reduce the likelihood of cooking and consequent exposure. In addition, wood-smoke exposure could be a cause of the ENT conditions and result in a bias toward the null value in the analyses. The small sample resulted in imprecise estimates with wide confidence intervals.

    A study in the hill region of Nepal evaluated 1, people Pandey They reported exposure to domestic smoke produced by burning firewood, straw, and other biomass fuels, and. The cross-sectional prevalence of chronic bronchitis increased with hours spent near the fireplace. In women, chronic bronchitis was observed among smokers, ex-smokers, and never smokers. In men, it was observed in all groups except nonsmokers. However, the study did not control for SES. Quereshi randomly selected two villages in Kashmir. In Gujjar, inhabitants live in single-room hutments and burn firewood in a mud hearth for cooking and heating.

    In Wahidpora, living conditions are better; kerosene stoves, gas stoves, and electric heaters are more commonly used. The SES was lower in Gujjar, and the prevalence of cigarette-smoking was also lower. The prevalence of chronic bronchitis was higher in Gujjar Among Gujjar residents, the prevalence of chronic bronchitis increased with average hours spent near the fireplace no statistical testing was performed.

    In a pooled analysis of both villages, the prevalence of chronic bronchitis among women but not men varied with hours spent near the fireplace. A major limitation of the study is the lack of control for confounding variables, such as cigarette-smoking and SES, both within and between villages.

    A case-control study in Saudi Arabia recruited 50 people who had COPD defined by airflow obstruction with pulmonary-function testing and 71 healthy controls Dossing et al. A serious limitation of the study is the lack of control for smoking, age, SES, and other factors. Cases and controls averaged more than 15 years of wood use, usually beginning in childhood or adolescence.

    Use of wood as a cooking fuel was associated with a greater risk of obstructive airways disease OR 3. A study strength is the use of pulmonary-function testing to define cases. Limitations include the lack of control for SES and the limited evaluation of wood-smoke exposure in multivariate analysis for example, no exposure-response relationship was examined. In addition, the recruitment process in a variety of inpatient and outpatient settings did not clearly result in controls that were comparable with cases.

    Investigators examined the use of planchas wood-burning chimney stoves compared with open wood fires by women in the rural highlands of Guatemala Bruce et al. Although cough and phlegm production were less common among those using planchas, the risk of chronic bronchitis was similar OR 0. The investigators noted that use of planchas was related to other indicators of higher SES, such as radio ownership, spousal employment in business and trade, and cement or tile floors as opposed to dirt floors. The authors commented on the potential for strong confounding in studies that use fuel type as an exposure measure.

    A population-based study in India evaluated 3, nonsmoking women in their homes in villages of Chandigarh in northern India Behera and Jindal Cooking with a chulla—which uses dung, crop residues, and agricultural wastes—was associated with a higher. There was no statistical difference in the prevalence of asthma, but there were very few cases. A major limitation of the study is the lack of control for confounding factors apart from sex and smoking, such as SES.

    Investigators in Finland conducted a mail-based survey of Finnish university students to examine the effect of wood-stove heating during childhood age 0—6 years on the development of asthma and allergic conditions in young adulthood age 18—25 years Kilpelainen et al. There was no association between wood-stove exposure during childhood and ever having a self-reported physician diagnosis of asthma OR 0.

    Study limitations include the cross-sectional survey design and the lack of control for cigarette-smoking. Additional studies have linked biomass-smoke exposure to impaired pulmonary function with spirometry Pandey et al. The committee excluded some reports because they contained no specific information about asthma, chronic bronchitis, or COPD Amoli ; Perez-Padilla et al. Another study was excluded because the statistical analysis could not be clearly interpreted Golshan et al. The series of related studies of Seventh-Day Adventists comprise the only high quality study of asthma incidence related to outdoor air pollution in adults.

    The studies found that new cases of asthma were associated with combustion-product exposure in air pollutants Abbey et al. Although the other key Gulf War study based on the Iowa cohort Lange et al. The study of Mishra also supports an association between biomass combustion and prevalent asthma. Other studies of biomass-fuel combustion and outdoor air pollution support a relationship between combustion exposure and asthma Baldi et al. Chronic bronchitis is defined by symptoms of chronic cough and sputum production. A major prospective study of outdoor air pollution with more than a decade of exposure Abbey et al.

    Supporting findings were reported by five other studies Dennis et al. The study of Gulf War veterans in Iowa of Lange showed no relationship between exposure to oil-well fires and chronic bronchitis, but the standard epidemiologic definition of chronic bronchitis was not used, so acute and chronic bronchitis could not be distinguished. Although the studies reviewed by the committee indicate a probable relationship between long-term over 1 year exposure to combustion products and chronic bronchitis, a key unresolved issue is whether shorter-term exposures less than 1 year can cause the condition.

    The committee found inadequate published data that address the effect of shorter-term combustion-product exposures less than 1 year on the risk of developing chronic bronchitis. A related issue is the exposure-free period after combustion-product exposure. Will chronic bronchitis remit after exposure cessation? If so, how long does it take for symptoms to remit? Only one of the studies in this chapter examined people after an exposure-free period. They found strong symptom-SO 2 associations after adjusting for the effects of dust exposure. The study suggests that chronic-bronchitis symptoms can persist for at least 6 months after cessation of combustion-product exposure, but there are no data from this study or others to indicate whether chronic-bronchitis symptoms might abate thereafter.

    It is instructive to examine the influence of smoking on the natural history of chronic bronchitis. Smoking is the dominant risk factor for chronic bronchitis. It is well known that chronic bronchitis, when defined as mucous hypersecretion, usually remits after smoking cessation Fletcher ; Kanner et al. In the Lung Health Study, most of the people who had COPD defined by airway obstruction and chronic cough had resolution of the cough by a year after sustained smoking cessation Kanner et al.