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					  Indoor Air Pollution and Children's Environmental Health




               INDOOR AIR POLLUTION
             & ENVIRONMENTAL HEALTH

                             Y Amitai
                            May 26 2009




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                   LEARNING OBJECTIVES
             TO UNDERSTAND, RECOGNIZE AND KNOW



  The hazards to children’s health in indoor air

  The sources for different toxicants in air indoors,
   according to different settings and activities

  How to prevent exposure to indoor air
   contaminants


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                 CHILDREN ARE NOT LITTLE ADULTS
             INDOOR AIR POLLUTION MAY BE MORE DANGEROUS


             1. Higher exposure
             2. Metabolism
             3. Susceptibility
             4. Life expectancy
             5. Political standing




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               RESPIRATORY DEVELOPMENT:
               CONTINUES THROUGH LINEAR GROWTH



                                                           Growth
                                                           • ETS
                                                           • Particulates
                                                           • Ozone
                    10 X 106 Alveoli
                                       300 X 106 Alveoli
                                         (age 8)           Function
                                                           • IAQ
                                                  18       • Ambient O3

Dieter, 2000


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                    CHILDREN’S INDOOR EXPOSURE


         Level of economic development a Key Factor
          Different issues developing and industrial
          Rural and urban


         Urban areas:
          Children may spend most of
           their time indoors.

              most exposure to contaminants may come         WHO
         from air and environment inside homes and schools.

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                    CHILDREN’S INDOOR EXPOSURE


             How long children spend time indoors is influenced by:
             Geographic region:
                Seasons and temperature
                Urban or rural area

             Development level of the region
             Socio-economical factors
             Cultural aspects

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             HOMES SHOULD BE HEALTHY PLACES

                                             The homes of poor children
                                             may be unhealthy places:

                                              2,000,000 deaths ARI in < 5 y.o.

                                              Rising trends of “wheezing”


                                            WHO



  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
 Second-hand smoke is a major concern
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        ADVERSE HEALTH EFFECTS OF AIR POLLUTANTS

             Acute:

              Irritation of the mucous membranes of eyes, nose and
               throat
              Cough, wheeze, chest tightness
              Increased airway responsiveness to allergens
              Increase of acute respiratory illness:
                 cold, pneumonia, otitis media

              Tracheobronchitis
              Exacerbations of asthma
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        ADVERSE HEALTH EFFECTS OF AIR POLLUTANTS


             Chronic:

             Long term decrease in lung growth
             Impairment of pulmonary function
             Increase susceptibility to chronic obstructive lung
              diseases, including asthma




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                          INDOOR AIR QUALITY

             Influenced by:

              Outdoor air pollution: vehicles and plants
              Tobacco and second-hand smoke
              Inadequate heating and cooking sources
              Confined and poor ventilated spaces
              Crowding houses and insufficient living space
              Level of Economic Development
              Customs and Habits


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                ENVIRONMENT AND POLLUTION

Indoors environment also reflects outdoor air quality
and pollution:

 Industrial or agricultural regions
 Treatment of industrial effluents and domestic residues
 Solid waste management
 Clandestine industries

 Chemical accidents and spills


                                       WHO                   11
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      COMBUSTION PRODUCTS: CO AND PARTICULATES

             Carbon Monoxide, Nitrogen Dioxide, Sulphur
             dioxide, Nitrogenated compounds, Particulates.

                    Sources:
                    Gas stoves and appliances
                    Wood and coal stoves
                    Gas and propane engines
                    Fireplaces
                    Tobacco smoke
                    Candles and incense

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                     INADEQUATE COOKING SOURCES


             The cooking stoves produce heavy smoke with fine particles,
             CO and polycyclic aromatic compounds (PAHs).
             These substances are linked to ARIs, asthma and cancer.




                                   WHO                                     13
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                  PARTICULATES FROM SOLID FUEL


             Solid Fuels comprise only 10-15% of fuel used

             Nearly One Half of the World Population uses
              Solid Fuels for cooking and heating homes

             Combustion produces hundreds of toxic
              chemicals which concentrate inside homes




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                                 Attributable burden of disease 0-4 years

                                 Illicit drugs
                                     Alcohol
                       Ambient air pollution
               Unsafe health care injections
                            Climate change
                             Lead exposure
                                 Unsafe sex

                             Iron deficiency
                        Vitamin A deficiency
                             Zinc deficiency
               Indoor smoke from solid fuels
        Unsafe water, sanitation and hygiene
                               Underweight

                                                 0   20000   40000   60000   80000 100000 120000 140000 160000


                                                                                                 1000 DALY
                                                                                          World Health Report 2002   15
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             CARBON MONOXIDE: THE "SENSELESS KILLER"
      MOST COMMON CAUSE OF INDOOR EXPOSURE MORTALITY

   CO is a colorless, odorless gas formed by incomplete burn of
    carbon-based fuels.

   CO affinity to HB is 240-270 times greater than Oxygen:

   Fetal Hb has higher affinity for CO

   CO causes a leftward shift of oxyhemoglobin dissociation curve:

   Intoxication results in tissue hypoxia

   Multiple organ systems are affected:


                                          www.cdc.gov/nceh/airpollution/carbonmonoxide/checklist.htm   16
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                    CARBON MONOXIDE: SOURCES


            Gas, Kerosene and wood stoves, charcoal grill
            Room and water heaters
            Fireplace, furnace
            Leaking chimneys and vents
            Vehicle emissions in closed garage
            Tobacco smoke



                                            www.epa.nsw.gov.au/woodsmoke/heateruse.htm
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                          PREVENTION

 Keep fuel-burning
  appliances in good
  working condition
 Heating systems,
  chimneys and vents
  checked regularly
 Never burn charcoal
  indoors
 Never leave a car
  running in a garage
 Install CO detectors
  for added safety
26/01/2011
                                   www.firstalert.com/index.asp?pageid=82   18
   Indoor Air Pollution and Children's Environmental Health
 Colleman-Phox et al. Arch Pediatr Adolesc Med. 2008 ;162:963-8.
 Use of a fan during sleep and the risk of sudden infant death syndrome.
 OBJECTIVE: To examine the relation between room ventilation during sleep and
  SIDS. DESIGN: case-control study. SETTING: 11 California counties.
 PARTICIPANTS: Mothers of 185 infants with a confirmed SIDS diagnosis and 312
  controls. Intervention: Fan use and open window during sleep.
 RESULTS: Fan use during sleep was associated with a 72% reduction in SIDS risk
  AOR, 0.28;
 ( 95% CI, 0.10-0.77). The reduction in SIDS risk seemed more pronounced in:
 Warmer room temperatures , a greater reduction in SIDS risk (AOR, 0.06; 95% CI,
  0.01-0.52) compared with cooler room temperatures (0.77; 0.22-2.73).
 In infants placed in the prone / side sleep position (AOR, 0.14; 95% CI, 0.03-0.55) vs
  supine (0.84; 0.21-3.39).
 In infants who shared a bed with an individual other than their parents (AOR, 0.15;
  95% CI, 0.01-1.85) vs with a parent (0.40; 0.03-4.68).
 In infants not using pacifiers (AOR, 0.22; 95% CI, 0.07-0.69)
 CONCLUSION: Fan use may be an effective intervention for further decreasing SIDS
  risk in infants in adverse sleep environments.
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                  CO POISONING CAN KILL:
 POISONOUS EVEN TO HEALTHY PEOPLE AT HIGH LEVELS IN THE AIR

 Symptoms:                            Diagnosis:
  Headache, dizziness, fatigue        Measurement of COHb
  Nausea, vomiting                       non-smokers 1 – 3 %
  Irritability                           smokers 3 – 8%
  Sleepiness, confusion,              Pulse oxymeter, ABG not
   disorientation                       useful
  Irregular breathing, dyspnea       Treatment:
  Unconsciousness, coma               Remove patient from CO
  Death                                source
  Delayed neuropsychological          Support and monitoring
   sequelae
                                       Oxygen 100%
                                       Hyperbaric Oxygen         20
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                     SECOND-HAND SMOKE
                      SCOPE OF THE PROBLEM

  Children whose mothers smoke have an estimated 70% more
   respiratory problems than children whose mothers do not smoke.

  Pneumonia and hospitalization in the first year is 38% more
   frequent in children when the mother smokes.

  Infant mortality was 80% higher in children born to women who
   smoked during pregnancy compared with children of nonsmokers.

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

  Infants of mothers who smoke have almost 5 times the risk of
   sudden infant death syndrome (SIDS) than infants of mothers
   who do not smoke.
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                  CLINICAL EFFECTS OF SMOKE


             Respiratory tract illness
             Asthma
             Middle ear effusions
             Prenatal complications and low birth weight
             Fire-related injuries
             Sudden Infant Death Syndrome
             Cancer


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      THE LIFE CYCLE OF THE EFFECTS OF SMOKING ON
                         HEALTH
                                                       Asthma
                                                       Otitis Media            Influences
                                                       Fire-related Injuries   to Start
                                                                               Smoking
             SIDs
             RSV/Bronchiolitis
             Meningitis                    Childhood

                                 Infancy                Adolescence


                                    In utero                                    Nicotine Addiction
                                                   Adulthood


             Low Birth Weight
             Stillbirth
                                                   Cancer
                                                   Cardiovascular Disease
                                                   COPD



               Aligne, 1997
                                                                                                     23
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                         PESTICIDES - EXPOSURE


 Spraying of pesticides at home and in schools
  increases exposure to children due to
         Higher concentrations near the floor
         Persistence in some surfaces, such as carpets and soft toys
         Overuse and misuse of pesticides


 Children activities contribute to inhalation of pesticides
         Crawling
         Playing close to the floor
         Hand-to-mouth and Object-to-mouth activities


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                                       INSECTICIDES
  Classes commonly used for insect control indoors:
   Pyrethroids: very allergenic
   Cholinesterase inhibitors: neurotoxicants, neurodevelopmental
    toxicants
   Hydramethylnone (relatively new)
   Insect repellents (DEET)
   Mosquito Coils

  Health Effects:
   Acute poisoning usually related to accidental ingestion in children
   Allergic and general symptoms are common due inhalation
              Headache, nausea, vomiting
              Cough, rhinitis, bronchitis, asthma and other allergic symptoms
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                                   MOSQUITO COILS

     Household use in Asia, Africa, South America
             Major Active Ingredient –pyrethrins
                 0.3-0.4% of mass of coil
                 ―Inert‖ ingredients >99% of mass of coil


             Long-term exposures linked to epidemiologically
                 Increased asthma, persistent wheeze in children


             Smoke tested contained particulates, all < 1 micron
                 PAHs, carbonyls including formaldehyde
                 Burning 1 coil  PM25 as if burning 75-137 cigarettes
                         Same amount of formaldehyde as 51 cigarettes
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       SOLVENTS AND VOLATILE ORGANIC COMPOUNDS

   Alkanes, Aromatic Hydrocarbons, Alcohols, Aldehydes, Ketones.


   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 spray, perfumes


                                                 www.epa.gov/oppfead1/cb/10_tips/   27
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   VOLATILE ORGANIC COMPOUNDS: HEALTH EFFECTS

             Acute:
              Eye and respiratory tract irritation
              General: headache, dizziness, loss of coordination, nausea,
               visual disorders
              Allergic reactions, including asthma and rhinitis


             Chronic:
              Damage to liver, kidney, hematological and central nervous
               systems
              Some may cause cancer in humans

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                              FORMALDEHYDE

             Sources: Differ by Level of Development
             Developing Countries
                Use of Solid Fuels indoors
                Mosquito Coils

             Industrialized Countries
                  Household cleaners and deodorizers
                  Glues and resins
                  Tobacco smoke
                  Some carpeting and carpet backing
                  Some furniture and dyed materials
                  Pressed wood products
                  Urea formaldehyde insulating foam (UFFI)
                  Others
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                  FORMALDEHYDE: HEALTH EFFECTS

          Eye, nose and throat irritation
              Watery eyes and burning sensation
              Wheezing and coughing
          Difficulty breathing
          Skin rash
          Severe allergic reactions, including asthma
          May be sensitizer
          May cause cancer

         Prevention:
          Reduce exposure
          Adequate ventilation while using household products
          Maintain moderate temperature and humidity levels
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                     BIOLOGICAL POLLUTANTS

     Biological pollutants are or were living organisms:
     Animal dander, dust mite, molds, infectious agents, pollen


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


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                                     DUST MITES

          Feed on human dander
          Prefer warm, humid environments
          Sources:
              Bedding, Carpets, Upholstery, Stuffed toys


         Prevention:
          Encasing mattress and pillows
          Hot water washing of bedding
              Greater than 130 F kills mite
          Frequent vacuuming / damp mopping                 CDC

          Decreasing clutter
          Remove carpeting

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                              ANIMAL ALLERGENS

      Dogs most common household pet—allergy uncommon
      Cats most allergenic: 6 million people with allergies to cats
      Birds harbor dust mites
      Cockroach feces are important cause of asthma morbidity

     Prevention:
      Avoidance
              Allergens persist many months after source removed
      Frequent cleaning of environment and pet
      Adequate ventilation
      Dust and moisture control
      Air filtration

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                                MOLD


        Health effects correlated with damp indoor spaces
        Symptoms more common among atopic persons

             Allergies and nonspecific symptoms are common,
                             infections are rare.




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                             MOLD-RELATED DISEASES

              Airway and conjunctival irritation
                 Eye irritation, cough, sore throat,
              Headache
              Difficulty concentrating
              Hypersensitivity reactions:
                 Asthma
                 Allergic rhinitis
              Infections:
                 Thrush (candidiasis)
                 Systemic infections (immunosupression)
              Acute toxicity:
                 Pulmonary hemorrhage in infants

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             CHEMICAL AGENTS ELABORATED BY MOLDS


             Mycotoxins are associated with human disease and
             cause acute and chronic effects.

              Mycotoxins
                 Tricothecenes
                 Ochratoxins and citrinin
                 Aflatoxins


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


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                     INDOOR AIR QUALITY:
                      BUILT ENVIRONMENT


               Housing materials:
                   Asbestos, wood preservative, paints and others


               Ventilation
               Heating
               Air conditioning



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                    SICK BUILDING SYNDROME

     What is this Syndrome?
      Building occupants experience acute discomfort not related to
       specific illness
      Effects appear to be linked to time spent in a building
      Cause of symptoms is unknown
      Most complaints relieved soon after leaving the building


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

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                     SICK BUILDING SYNDROME


             Causes:
             Inadequate building design
             Occupant activities
             Remodeled buildings operating in manner
              inconsistent with its original design
             Inadequate ventilation
             Inadequate maintenance
             Chemical and biological contaminants

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                      SICK BUILDING SYNDROME


 Symptoms:                                Solutions:
        Headache                           Pollutant source removal
        Eye, nose or throat irritation     Increase ventilation
        Dry cough                          Air cleaning: filters
        Dry or itchy skin                  Education and
        Difficulty in concentrating         communication
        Fatigue
        Sensitivity to odors


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                              RADON

 Radon 222 is a radioactive gas released from soil and rocks during
  natural decay of Uranium and Thorium
 Considered second leading cause of lung cancer, may enhance
  risk of cancer in smokers
 Geology of the area can predict potential high levels in soil and
  water
 Radon concentrations indoors depend on construction aspects:
  building materials; cracks or pores in concrete floor and walls;
  floor-wall joints; loose pipe penetration; air pressure of a house
  lower than the surrounding soil, and others
 Highest level in basements and ground floor

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                     RADON MITIGATION SYSTEM


             A - Gas Permeable Layer
             B - Plastic Sheeting
             C - Sealing and Caulking
             D - Vent Pipe
             E - Junction Box



      It is recommended that homes be
      tested for radon below third floor.
                                                www.epa.gov/iaq/radon/construc.html




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                       RADON IN SCHOOLS




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



    Schools also should be tested for radon:
     Levels above of 4 pCi/L recommend action to reduce exposure

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                                        ASBESTOS
    Sources:
     Building construction materials for insulation and as fire-retardant,
      asbestos cement, floor tiles, water pipes and others
     Elevated levels can occur in homes when asbestos-containing
      materials are damaged

    Health Effects:
     NO acute toxicity
     Asbestosis results from occupational exposure
     Main risk for children: may cause cancer in long term exposure
              Lung cancer
              Malignant mesothelioma
                                                                              44
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   OCCUPATIONAL RELATED INDOOR CONTAMINANTS -
                  INCLUDING AIR

             Parents “Take Home Exposures” related to work:
              Contaminated clothing, shoes and skin
              Contaminated exhaled breath
              Bring home empty containers of pesticide and others
                Change work clothes and shower before hugging
                       or playing with your children.
             Children directly exposed when
              Visiting parents workplace
              Participating in work
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               CHILDREN WORKING INDOORS

                           Child labor and adolescent work may
                           result in exposure to pesticides, solvents,
                           cleaning agents and other chemicals-
                           many of these occur indoors and can
                           pollute the air.

                          Young children under illegal employment
                          Unregulated temporary work
                          School-based vocational training
  WHO
                          Family businesses
                          Cottage industries
                          Volunteer service projects


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                                    SUMMARY SLIDE

 HAZARDS:                                                                     SETTINGS:
 Particulates,                                    MEDIA                       -Home
 CO, Solvents,                                     Air                        -Child care
 Pesticides,                                                                  -School
 Lead, etc                                                                    -Work place

                                          ACTIVITIES
                     Playing, Studing, Eating, Drinking, Working, Sleeping


SUSCEPTIBILITIES:                                                     OUTCOME-EFFECTS:
-Lungs still immature                                                 - Acute poisonings
-Higher breathing rate                                                - Respiratory diseases
-More time inside                                                     - Allergies
                                                                      - Development
-Nutritional status                                                       disturbances
-Economic resources           (photo credit US NIEHS CERHR logo)
                                                                      - Cancer
                                                                                               47
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     APPROACHES TO REDUCE INDOOR AIR POLLUTION

    1. Eliminate or control the sources of pollution
                Regular maintenance of cooking, heating and cooling systems
                Choose non-volatile, non-toxic building materials


    2. Ventilation – Building Design
                Dilute and exhaust pollutants through outdoor air ventilation


    3. Air cleaning – NOT air fresheners
                Air filters, ionizers are used to remove airbone particles
                Gas adsorbing material is used to remove gaseous contaminants


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                 OZONE GENERATORS AS AIR CLEANERS

    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

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


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   PREVENTION OF ENVIRONMENT RELATED DISEASES


             Education of:
                Children
                Family
                Health care providers


             Environment policy making
                Community actions


             Research

                                                     WHO     50
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             HEALTH & ENVIRONMENT PROFESSIONALS
                        CRITICAL ROLE


                          Diagnose and Treat
                          Publish, Research
                               Sentinel Cases
                               Community-based Interventions
                          Educate
                               Patients and Families
                               Colleagues and Students
                          Advocate
                          Role Model
              WHO
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                     We hold our future in our hands
                         and it is our children.




             Poster Contest by HRIDAY with support from WHO SEARO

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                                 ACKNOWLEDGEMENTS

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

    First draft prepared by Ligia Fruchtengarten MD (Brazil)

    With the advice of the Working Group on Training Package for Health Care
      Providers: Cristina Alonzo MD (Uruguay); Yona Amitai MD, MPH
      (Israel); Stephan Boese-O’Reilly MD (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: …………………………………..

    WHO CEH Training Project Coordination: Jenny Pronczuk, MD
    Medical Consultant: Katherine M. Shea, MD, MPH, USA
    Technical Assistance: Marie-Noel Bruné, M. Sc.
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  Indoor Air Pollution and Children's Environmental Health


                                                       DISCLAIMER
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