Reflections on the history of indoor air science, focusing on the last 50 years.

The scientific articles and Indoor Air conference publications of the indoor air sciences (IAS) during the last 50 years are summarized. In total 7524 presentations, from 79 countries, have been made at Indoor Air conferences held between 1978 (49 presentations) and 2014 (1049 presentations). In the Web of Science, 26 992 articles on indoor air research (with the word "indoor" as a search term) have been found (as of 1 Jan 2016) of which 70% were published during the last 10 years. The modern scientific history started in the 1970s with a question: "did indoor air pose a threat to health as did outdoor air?" Soon it was recognized that indoor air is more important, from a health point of view, than outdoor air. Topics of concern were first radon, environmental tobacco smoke, and lung cancer, followed by volatile organic compounds, formaldehyde and sick building syndrome, house dust-mites, asthma and allergies, Legionnaires disease, and other airborne infections. Later emerged dampness/mold-associated allergies and today's concern with "modern exposures-modern diseases." Ventilation, thermal comfort, indoor air chemistry, semi-volatile organic compounds, building simulation by computational fluid dynamics, and fine particulate matter are common topics today. From their beginning in Denmark and Sweden, then in the USA, the indoor air sciences now show increasing activity in East and Southeast Asia.

Phthalate metabolites in urine samples from Beijing children and correlations with phthalate levels in their handwipes.

UNLABELLED: Little attention has been paid to dermal absorption of phthalates even though modeling suggests that this pathway may contribute meaningfully to total uptake. We have concurrently collected handwipe and urine samples from 39 Beijing children (5-9 years) for the purpose of measuring levels of five phthalates in handwipes, corresponding concentrations of eight of their metabolites in urine, and to subsequently assess the contribution of dermal absorption to total uptake. In summer sampling, DEHP was the most abundant phthalate in handwipes (median: 1130 µg/m(2) ), while MnBP was the most abundant metabolite in urine (median: 232 ng/ml). We found significant associations between the parent phthalate in handwipes and its monoester metabolite in urine for DiBP (r = 0.41, P = 0.01), DnBP (r = 0.50, P = 0.002), BBzP (r = 0.48, P = 0.003), and DEHP (r = 0.36, P = 0.03). Assuming that no dermal uptake occurred under clothing-covered skin, we estimate that dermal absorption of DiBP, DnBP, BBzP, and DEHP contributed 6.9%, 4.6%, 6.9%, and 3.3%, respectively, to total uptake. Assuming that somewhat attenuated dermal uptake occurred under clothing-covered skin, these estimates increase to 19%, 14%, 17%, and 10%. The results indicate that absorption from skin surfaces makes a meaningful contribution to total phthalate uptake for children and should be considered in future risk assessments. PRACTICAL IMPLICATIONS: This study indicates that children's hands acquire substantial amounts of various phthalates. The levels measured in handwipes, although higher, are somewhat representative of levels on other body locations. Via dermal absorption, as well as hand-to-mouth activity, phthalates on hands and other body locations contribute to the overall body burden of these compounds. Dermal absorption from air and contact transfer from surfaces is expected to occur for many SVOCs commonly found indoors (e.g. bisphenols, synthetic musks, organophosphates). However, the dermal pathway has often been neglected in exposure assessments of indoor pollutants. Knowledge regarding phthalates and other SVOCs in handwipes can facilitate our understanding of risks and aid in the mitigation of adverse health effects resulting from indoor exposures. To make progress toward these goals, further studies are necessary, including investigations of phthalate level variability in skinwipes collected at different locations on the body and the impact of clothing on dermal absorption from air.

CO2 generation rate in Chinese people.

UNLABELLED: Carbon dioxide (CO2 ) metabolically produced by humans has been widely used as a tracer gas for determining ventilation rates in occupied rooms. Among other necessities, the method requires good estimates of human CO2 generation rates. An empirically derived equation is widely used to calculate the CO2 generation rate. However, there are indications that this equation is not valid for young Chinese people. In this study, we measured the CO2 generation rate of 44 young Chinese people at two typical activity levels, quiet sitting and relaxed standing. We found that the commonly used empirical equation overpredicted CO2 generation rates, but could be corrected with a factor of 0.75 for Chinese females and of 0.85 for Chinese males. The variance for measured CO2 sitting was much smaller than for standing, and hence, we concluded that sitting yields more precise CO2 generation estimates. The relative contributions of sex, height, weight, and metabolic rate were analyzed. We concluded that the error in estimating metabolic rate is responsible for most of the difference in measured generation of CO2 from the empirical equation's predictions. PRACTICAL IMPLICATIONS: The tracer gas method using CO2 generated by people is widely used to calculate ventilation rate. However, the empirically derived equation that is normally used to estimate CO2 generation rate is not suitable for young Chinese people at rest. To estimate the CO2 generation rate in Chinese people under low-activity conditions, the empirical equation should be multiplied by correction factors of 0.75 and 0.85 for females and males, respectively.

Home dampness, childhood asthma, hay fever, and airway symptoms in Shanghai, China: associations, dose-response relationships, and lifestyle's influences.

Numerous studies of associations between dampness and respiratory diseases have been conducted, but their implications remain inconclusive. In this study of 13,335 parent-reported questionnaires (response rate: 85.3%), we analyzed associations between home dampness and asthma and related symptoms in 4- to 6-year-old children in a cross-sectional study of Shanghai. Indicators of home dampness were strongly and significantly associated with dry cough, wheeze, and rhinitis symptoms. In the current residence, children with visible mold spots (VMS) exposure had 32% higher risk of asthma (adjusted OR, 95% CI: 1.32, 1.07-1.64); damp clothing and/or bedding (frequently) was strongly associated with dry cough (1.78, 1.37-2.30); condensation on windows was strongly associated with hay fever (1.60, 1.27-2.01). In the early-life residence, VMS or damp stains (frequently) were strongly associated with dry cough (2.20, 1.55-3.11) and rhinitis ever (1.57, 1.11-2.21). Associations between dampness and diseases among children with or without family history of atopy were similar. The total number of dampness indicators had strong dose-response relationships with investigated health outcomes. Actions, including opening windows of the child's room at night and cleaning the child's room frequently, could potentially mitigate 25% of home VMS, thereby preventing more than 1.5% of attributable risk of the studied symptoms.

Children's health and its association with indoor environments in Danish homes and daycare centres - methods.

UNLABELLED: The principle objective of the Danish research program 'Indoor Environment and Children's Health' (IECH) was to explore associations between various exposures that children experience in their indoor environments (specifically their homes and daycare centers) and their well-being and health. The targeted health endpoints were allergy, asthma, and certain respiratory symptoms. The study was designed with two stages. In the first stage, a questionnaire survey was distributed to more than 17,000 families with children between the ages of 1 and 5. The questionnaire focused on the children's health and the environments within the homes they inhabited and daycare facilities they attended. More than 11,000 questionnaires were returned. In the second stage, a subsample of 500 children was selected for more detailed studies, including an extensive set of measurements in their homes and daycare centers and a clinical examination; all clinical examinations were carried out by the same physician. In this study, the methods used for data collection within the IECH research program are presented and discussed. Furthermore, initial findings are presented regarding descriptors of the study population and selected characteristics of the children's dwellings and daycare centers. PRACTICAL IMPLICATIONS: This study outlines methods that might be followed by future investigators conducting large-scale field studies of potential connections between various indoor environmental factors and selected health endpoints. Of particular note are (i) the two-stage design - a broad questionnaire-based survey followed by a more intensive set of measurements among a subset of participants who have been selected based on their responses to the questionnaire; (ii) the case-base approach utilized in the stage 2 in contrast to the more commonly used case-control approach; (iii) the inclusion of the children's daycare environment when conducting intensive sampling to more fully capture the children's total indoor exposure; and (iv) all clinical examinations conducted by the same physician. We recognize that future investigators are unlikely to fully duplicate the methods outlined in this study, but we hope that it provides a useful starting point in terms of factors that might be considered when designing such a study.

Predicted risk of childhood allergy, asthma, and reported symptoms using measured phthalate exposure in dust and urine.

UNLABELLED: The associated risk of phthalate exposure, both parent compounds in the home and their metabolites in urine, to childhood allergic and respiratory morbidity, after adjusting for exposures of indoor pollutants, especially bioaerosols, was comprehensively assessed. Levels of five phthalates in settled dust from the homes of 101 children (3-9 years old) were measured, along with their corresponding urinary metabolites. Other environmental risk factors, including indoor CO2, PM2.5, formaldehyde, 1,3-ß-D-glucan, endotoxin, allergen and fungal levels, were concomitantly examined. Subject's health status was verified by pediatricians, and parents recorded observed daily symptoms of their children for the week that the home investigation visit took place. Significantly increased level of benzylbutyl phthalate, in settled dust, was associated with test case subjects (allergic or asthmatic children). Higher levels of dibutyl phthalate and its metabolites, mono-n-butyl phthalate, and mono-2-ethylhexyl phthalate were found to be the potential risk factors for the health outcomes of interest. Similarly, indoor fungal exposure remained a significant risk factor, especially for reported respiratory symptoms. The relative contribution from exposure to phthalates and indoor biocontaminants in childhood allergic and respiratory morbidity is, for the first time, quantitatively assessed and characterized. PRACTICAL IMPLICATIONS: For asthmatic and allergic children living in subtropical and highly developed environments like homes in Taiwan, controlling environmental exposure of phthalates may be viewed as equally important as avoiding indoor microbial burdens, for the management of allergy-related diseases. It is also recognized that multidisciplinary efforts will be critical in realizing the true underlying mechanisms associated with these observations.

Ventilation and dampness in dorms and their associations with allergy among college students in China: a case-control study.

To study the associations between dorm environment and occupants' health, a nested case-control study on 348 college students was carried out in 2006-2007 at Tianjin University, China. Two hundred and twenty-three dorm rooms where the 'cases' and 'controls' resided were inspected. Measured variables were ventilation rate, air temperature, and relative humidity indoors. Allergic symptoms in the last 12 months were self-reported by occupants. Adjusted odds ratios (AORs) of a 'localized moldy smell/moisture indicator' in 'special places' (e.g., in a room corner or close to the radiator under the window) for wheezing was 3.56 [95% Confident Interval (CI): 1.56-8.14] and for rhinitis 2.81 (95% CI: 1.32-5.97). The AOR of a low air change rate (below the median value of 0.7/h) for wheezing was 2.28 (95% CI: 1.38-3.75) and for dry cough 2.26 (95% CI: 1.08-4.75). The prevalence of students with allergic symptoms in dorm rooms decreased with increasing ventilation rate. The combination of a 'localized moldy/moisture indicator' and a low air change rate significantly increased the AOR of case status to 13.35 (95% CI: 3.73-47.83), compared to the reference condition with no-dampness and high ventilation rate (above the median). This supports the hypothesis that ventilation rate is an effect modifier for moisture problems and indoor pollutants.

Ventilation rates and health: multidisciplinary review of the scientific literature.

UNLABELLED: The scientific literature through 2005 on the effects of ventilation rates on health in indoor environments has been reviewed by a multidisciplinary group. The group judged 27 papers published in peer-reviewed scientific journals as providing sufficient information on both ventilation rates and health effects to inform the relationship. Consistency was found across multiple investigations and different epidemiologic designs for different populations. Multiple health endpoints show similar relationships with ventilation rate. There is biological plausibility for an association of health outcomes with ventilation rates, although the literature does not provide clear evidence on particular agent(s) for the effects. Higher ventilation rates in offices, up to about 25 l/s per person, are associated with reduced prevalence of sick building syndrome (SBS) symptoms. The limited available data suggest that inflammation, respiratory infections, asthma symptoms and short-term sick leave increase with lower ventilation rates. Home ventilation rates above 0.5 air changes per hour (h(-1)) have been associated with a reduced risk of allergic manifestations among children in a Nordic climate. The need remains for more studies of the relationship between ventilation rates and health, especially in diverse climates, in locations with polluted outdoor air and in buildings other than offices. PRACTICAL IMPLICATIONS: Ventilation with outdoor air plays an important role influencing human exposures to indoor pollutants. This review and assessment indicates that increasing ventilation rates above currently adopted standards and guidelines should result in reduced prevalence of negative health outcomes. Building operators and designers should avoid low ventilation rates unless alternative effective measures, such as source control or air cleaning, are employed to limit indoor pollutant levels.

Reflections on the state of research: indoor environmental quality.

UNLABELLED: More than 30 years after the First International Indoor Climate Symposium, ten researchers from the USA, Slovakia, Sweden, and Denmark gathered to review the current status of indoor environmental research. We initiated our review with discussions during the 1-day meeting and followed that with parallel research and writing efforts culminating with internal review and revision cycles. In this paper, we present our choices for the most important research findings on indoor environmental quality from the past three decades followed by a discussion of the most important research questions in our field today. We then continue with a discussion on whether there are research areas for which we can 'close the book' and say that we already know what is needed. Finally, we discuss whether we can maintain our identity in the future or it is time to team up with new partners. PRACTICAL IMPLICATIONS: In the early years of this field, the accumulated knowledge was small and it was possible for any researcher to acquire a complete understanding. To do so has become impossible today as what we know has grown to exceed the learning capacity of any person. These circumstances challenge us to work collectively to synthesize what we do know and to define clearly what remains to be learned. If we fail to do these things well, we risk repeating research without memory, an inefficiency that we cannot afford.

PVC--as flooring material--and its association with incident asthma in a Swedish child cohort study.

UNLABELLED: The Dampness in Buildings and Health study (DBH) started in the year 2000 in Värmland, Sweden, with a baseline questionnaire sent to all children (n = 14,077) aged 1-6. Five years later, a follow-up questionnaire was sent to the children who were 1-3 years at baseline. A total of 4779 children participated in both the baseline and the follow-up studies and constitute the study population in this cohort study. The aim of this study was to examine the association between exposure to PVC-flooring in the child's and parent's bedroom in homes of children aged 1-3 and the incidence of asthma, rhinitis, and eczema during the following 5-year period. Adjusted analyses showed that the incidence of asthma among children was associated with PVC-flooring in the child's bedroom (AOR 1.52; 95% CI 0.99-2.35) and in the parent's bedroom (1.46; 0.96-2.23). The found risks were on borderline of significance and should therefore be interpreted with caution. There was further a positive relationship between the number of rooms with PVC-flooring and the cumulative incidence of asthma. PVC-flooring was found to be a stronger risk factor for incident asthma in multifamily homes when compared with single-family houses and in smoking families compared with non-smoking families and in women. PRACTICAL IMPLICATIONS: These longitudinal data from the DBH study found an association between the presence of PVC-flooring in the home and incident asthma in children. However, earlier results from the DBH study have shown that PVC-flooring is one important source for phthalates in indoor dust, and exposure to such phthalates was found to be associated with asthma and allergy among children. This emphasizes the need for prospective studies that focus on the importance of prenatal and neonatal exposure to phthalates in the development of asthma and allergy in children.

Culturable mold in indoor air and its association with moisture-related problems and asthma and allergy among Swedish children.

UNLABELLED: In a nested case-control study with 198 children with asthmatic and allergic symptoms (cases) and 202 healthy controls in Värmland, Sweden, we have investigated the relationship between mold spore exposure (mean colony-forming unit) indoor and (i) different indexes of moldy odor indoor (observed by professional inspectors and reported by parents), (ii) visible signs of dampness in the homes of the children (observed and reported), and (iii) doctor-diagnosed asthma/allergy in children. No association was found between the spore concentration indoor and moldy odor and signs of visible dampness in the homes. When a semi-quantitative method in distinguishing between moldy houses or non-moldy houses was used, there were no significant differences between the observed indexes of moldy odor or visible signs of dampness (both observed and reported). No association could be found between the spore concentration in indoor air and asthma/allergy in the children. PRACTICAL IMPLICATIONS: Mold spore exposure indoor have been suggested as a possible explanation for airway problems such as asthma and allergy among people living in buildings with moisture-related problems. However, this investigation could not find any associations between the spore concentrations in indoor air and signs of dampness and moldy odor reported by parents or observed by professional inspectors. Neither was there any association between the indoor spore concentration and asthma/allergy among children. With these results, there is no reason for one-time air sampling of mold colony-forming unit (CFU) in indoor air of homes to identify risk factors for asthma/allergy in children living in Scandinavian countries.

Dampness in dorm rooms and its associations with allergy and airways infections among college students in China: a cross-sectional study.

UNLABELLED: A cross-sectional study was carried out at Tianjin University campus, China, from February 21 to June 10, 2006, to survey the association between dampness in dorms, and allergy and airways infections among college students. The health and dampness conditions were self-reported by 3436 students living in 1511 dorm rooms located in 13 buildings on the campus. The buildings were selected according to their positions, construction periods and occupant densities. The symptoms involved wheezing, dry cough during night, rhinitis, eczema, cold/flu, ear inflammation, pneumonia and tuberculosis. The indoor moisture signs were mould/damp spots on walls, ceilings and floors; suspected or ever happened water damage; condensation on windowpane in winter and odours perceived by subjects themselves. There was a significant positive association between condensation and dry cough. Eczema was often reported in rooms with moisture problem. Dampness was a significant risk factor for common cold. PRACTICAL IMPLICATIONS: Dampness problems in dorms of Chinese students are a risk factor for allergic symptoms, and hence there is a need for dorm environment improvement. Health problems related to ventilation and microbiology problems in dorms should be further studied.

Low home ventilation rate in combination with moldy odor from the building structure increase the risk for allergic symptoms in children.

UNLABELLED: There are consistent findings on associations between asthma and allergy symptoms and residential mold and moisture. However, definitions of 'dampness' in studies are diverse because of differences in climate and building construction. Few studies have estimated mold problems inside the building structure by odor assessments. In a nested case-control study of 400 Swedish children, observations and measurements were performed in their homes by inspectors, and the children were examined by physicians for diagnoses of asthma, eczema, and rhinitis. In conclusion, we found an association between moldy odor along the skirting board and allergic symptoms among children, mainly rhinitis. No associations with any of the allergic symptoms were found for discoloured stains, 'floor dampness' or a general mold odor in the room. A moldy odor along the skirting board can be a proxy for hidden moisture problem inside the outer wall construction or in the foundation construction. There are indications that such dampness problems increase the risk for sensitization but the interpretation of data in respect of sensitization is difficult as about 80% of the children with rhinitis were sensitized. Furthermore, low ventilation rate in combination with moldy odor along the skirting board further increased the risk for three out of four studied outcomes, indicating that the ventilation rate is an effect modifier for indoor pollutants. PRACTICAL IMPLICATIONS: This study showed that mold odor at the skirting board level is strongly associated with allergic symptoms among children. Such odor at that specific place can be seen as a proxy for some kind of hidden moisture or mold problem in the building structure, such as the foundation or wooden ground beam. In houses with odor along the skirting board, dismantling of the structure is required for an investigation of possible moisture damage, measurements, and choice of actions. In homes with low ventilation in combination with mold odor along the skirting board, there was even a higher risk of health effects. This emphasizes the need for the appropriate remediation as this is an ever increasing problem in poorly ventilated houses that are damp.

Dampness at dorm and its associations with allergy and airways infection among college students in China: a cross-sectional study.

UNLABELLED: A cross-sectional study was carried out at Tianjin University campus, China, from February 21 to June10, 2006, to survey the association between dampness in dorms and allergy and airways infection among college students. The health and dampness condition were self-reported by 3436 students living in 1511 dorm rooms located in 13 buildings on the campus. The buildings were selected according to their positions, construction periods and occupant densities. The allergy and airways infection symptoms involved wheezing, dry cough during night, rhinitis, eczema, cold/flu, ear inflammation, pneumonia and tuberculosis. The indoor moisture signs were mould/damp spots on walls, ceilings and floors; suspected or ever happened water damage; condensation on windowpane in winter and odours perceived by subjects themselves. This study showed there was significantly positive association between condensation and dry cough. Eczema was often reported in rooms with suspected moisture problem. Dampness was a significantly risk factor for common cold. PRACTICAL IMPLICATIONS: This paper indicated that dampness problem at dorms of Chinese students was a risk factor in irritating allergic symptoms, and hence there is a need for dorm environment improvement. The ventilation and microbiology problems in dorm environment corresponding to dampness should be further studied, especially when it is associated to occupants' health.

Nitric oxide in exhaled and aspirated nasal air as an objective measure of human response to indoor air pollution.

UNLABELLED: The concentration of nitric oxide (NO) in exhaled and aspirated nasal air was used to objectively assess human response to indoor air pollutants in a climate chamber exposure experiment. The concentration of NO was measured before exposure, after 2, and 4.5 h of exposure, using a chemiluminescence NO analyzer. Sixteen healthy female subjects were exposed to two indoor air pollutants and to a clean reference condition for 4.5 h. Subjective assessments of the environment were obtained by questionnaires. After exposure (4.5 h) to the two polluted conditions a small increase in NO concentration in exhaled air was observed. After exposure to the reference condition the mean NO concentration was significantly reduced compared to pre-exposure. Together these changes resulted in significant differences in exhaled NO between exposure to reference and polluted conditions. NO in nasal air was not affected by the exposures. The results may indicate an association between polluted indoor air and subclinical inflammation. PRACTICAL IMPLICATIONS: Measurement of nitric oxide in exhaled air is a possible objective marker of subclinical inflammation in healthy adults.

Incidence rates of asthma, rhinitis and eczema symptoms and influential factors in young children in Sweden.

AIM: To estimate the incidence rates for asthma, rhinitis and eczema symptoms and to investigate the importance of different influential factors for the incidence of these symptoms. METHODS: The Dampness in Building and Health study commenced in the year 2000 in Värmland, Sweden with a parental questionnaire based on an ISAAC protocol to all children in the age of 1-6 years. Five years later a follow-up questionnaire was sent to the children that were 1-3 years at baseline. In total, 4779 children (response rate = 73%) participated in both surveys and constitute the study population in this cohort study. RESULTS: The 5-year incidence of doctor-diagnosed asthma was 4.9% (95% CI 4.3-5.3), rhinitis was 5.7% (5.0-6.4) and eczema was 13.4% (12.3-14.5). However, incidence rates strongly depend on the health status of the baseline population. Risk factors for incident asthma were male gender and short period of breast-feeding. Allergic symptoms in parents were also a strong risk factor for incident asthma, as well as for rhinitis and eczema. CONCLUSION: When comparing incident rates of asthma between different studies it is important to realize that different definitions of the healthy baseline population will give rise to different incident rates.

Effect of alpha-tocopherol and beta-carotene supplementation on the incidence of type 2 diabetes.

AIMS/HYPOTHESIS: Type 2 diabetes is associated with reduced antioxidant defence. Only a few human studies have investigated the role of antioxidants in the pathogenesis of diabetes. This study aimed to examine whether alpha-tocopherol or beta-carotene affected the occurrence of type 2 diabetes. METHODS: In the Alpha-Tocopherol, Beta-Carotene Cancer Prevention (ATBC) Study, a double-blind, controlled trial, 29,133 male smokers aged 50-69 years were randomised to receive either alpha-tocopherol (50 mg/day) or beta-carotene (20 mg/day) or both agents or placebo daily for 5-8 years (median 6.1 years). Baseline serum samples were analysed for alpha-tocopherol and beta-carotene using HPLC. Cases of diabetes were identified from a nationwide Finnish registry of patients receiving drug reimbursement for diabetes. Of 27,379 men without diabetes at baseline, 705 men were diagnosed with diabetes during the follow-up of up to 12.5 years. RESULTS: Baseline serum levels of alpha-tocopherol and beta-carotene were not associated with the risk of diabetes in the placebo group: the relative risk (RR) between the highest and lowest quintiles of alpha-tocopherol was 1.59 (95% CI 0.89-2.84) and that for beta-carotene was 0.66 (95% CI 0.40-1.10). Neither supplementation significantly affected the incidence of diabetes: the RR was 0.92 (95% CI 0.79-1.07) for participants receiving alpha-tocopherol compared with non-recipients and 0.99 (95% CI 0.85-1.15) for participants receiving beta-carotene compared with non-recipients. CONCLUSIONS/INTERPRETATION: Neither alpha-tocopherol nor beta-carotene supplementation prevented type 2 diabetes in male smokers. Serum levels of alpha-tocopherol and beta-carotene were not associated with the risk of type 2 diabetes.

Role of ventilation in airborne transmission of infectious agents in the built environment - a multidisciplinary systematic review.

There have been few recent studies demonstrating a definitive association between the transmission of airborne infections and the ventilation of buildings. The severe acute respiratory syndrome (SARS) epidemic in 2003 and current concerns about the risk of an avian influenza (H5N1) pandemic, have made a review of this area timely. We searched the major literature databases between 1960 and 2005, and then screened titles and abstracts, and finally selected 40 original studies based on a set of criteria. We established a review panel comprising medical and engineering experts in the fields of microbiology, medicine, epidemiology, indoor air quality, building ventilation, etc. Most panel members had experience with research into the 2003 SARS epidemic. The panel systematically assessed 40 original studies through both individual assessment and a 2-day face-to-face consensus meeting. Ten of 40 studies reviewed were considered to be conclusive with regard to the association between building ventilation and the transmission of airborne infection. There is strong and sufficient evidence to demonstrate the association between ventilation, air movements in buildings and the transmission/spread of infectious diseases such as measles, tuberculosis, chickenpox, influenza, smallpox and SARS. There is insufficient data to specify and quantify the minimum ventilation requirements in hospitals, schools, offices, homes and isolation rooms in relation to spread of infectious diseases via the airborne route. PRACTICAL IMPLICATION: The strong and sufficient evidence of the association between ventilation, the control of airflow direction in buildings, and the transmission and spread of infectious diseases supports the use of negatively pressurized isolation rooms for patients with these diseases in hospitals, in addition to the use of other engineering control methods. However, the lack of sufficient data on the specification and quantification of the minimum ventilation requirements in hospitals, schools and offices in relation to the spread of airborne infectious diseases, suggest the existence of a knowledge gap. Our study reveals a strong need for a multidisciplinary study in investigating disease outbreaks, and the impact of indoor air environments on the spread of airborne infectious diseases.

The effect of 12-month enzyme replacement therapy on myocardial perfusion in patients with Fabry disease.

Fabry disease (McKusick 301500) is an X-linked lysosomal storage disorder secondary to deficient alpha-galactosidase A activity which leads to the widespread accumulation of globotriaosylceramide (Gb(3)) and related glycosphingolipids, especially in vascular smooth-muscle and endothelial cells. We have recently shown that the myocardial perfusion reserve of Fabry patients is significantly decreased. Thus, in the present study we investigated, whether it can be improved with enzyme replacement therapy (ERT). Ten patients (7 male, 3 female; mean age 34, range 19-49 years) with confirmed Fabry disease were approved for this uncontrolled, open-label study. Myocardial perfusion was measured at rest and during dipyridamole-induced hyperaemia by positron emission tomography and radiowater. Myocardial perfusion reserve was calculated as the ratio between maximal and resting perfusion. Perfusion measurements were performed before and after 6 and 12 months of ERT by recombinant human alpha-galactosidase A (Fabrazyme, Genzyme). Plasma Gb(3) concentration decreased significantly and the patients reported that they felt better and suffered less pain after the ERT. However, neither resting or dipyridamole-stimulated myocardial perfusion nor myocardial perfusion reserve changed during the ERT. Pretreatment relative wall thickness correlated negatively with posttreatment changes in flow reserve (r = -0.76, p = 0.05) and positively with posttreatment changes in minimal coronary resistance (r = 0.80, p = 0.03). This study shows that 12 months of ERT does not improve myocardial perfusion reserve, although the plasma Gb(3) concentration decreases. However, individual variation in the response to therapy was large and the results suggest that the success of the therapy may depend on the degree of cardiac hypertrophy.

Day-care attendance and increased risk for respiratory and allergic symptoms in preschool age.

BACKGROUND: The reported impact of day-care attendance on respiratory and atopic symptoms has varied between studies from different countries. Regarding to the 'hygiene-hypothesis', day-care attendance may lead to less sensitization later in life, but the question still is whether day-care attendance and subsequent exposure to more frequent early infections is a risk or a protection against future allergic disease or asthma (atopic and nonatopic). METHODS: A cross-sectional postal questionnaire was replied by parents of 10,851 children, aged 1-6 years, in the year 2000 in a Swedish region (DBH-phase 1). The questionnaire focused on respiratory and atopic symptoms, the home environment and information on day care of the children. RESULTS: Children in day care were reported to have more symptoms than children in home care: adjusted odds ratio (AOR) for wheezing last 12 months, AOR 1.33 (CI 95%: 1.12-1.58), cough at night apart from colds last 12 months AOR 1.56 (CI: 1.17-2.07), doctor diagnosed asthma AOR 1.23 (CI: 0.88-1.71), rhinitis last 12 months AOR 1.15 (CI: 0.92-1.44), doctor diagnosed hay fever AOR 1.75 (CI: 0.94-3.23), eczema last 12 months, AOR 1.49 (CI: 1.24-1.79), allergic reactions to foods, AOR 1.27 (CI: 1.07-1.52), >6 colds last 12 months of 2.57 (CI: 2.12-3.12) and ear infection ever AOR 2.14 (CI: 1.87-2.45). The increased risks were mainly seen and reached significance in the youngest group of children, aged 1-4 years. Adjusting and stratification for the number of airway infections last year did not change the risk associated with day-care attendance for allergic diseases. CONCLUSIONS: Attending day care was associated with an increased risk of symptoms related to airways infections as well with eczema and allergic reactions to food. No sign of protection from day-care attendance for allergic diseases was found up to 6 years of age. Multiple airway infections and day-care attendance were found to be independently associated with asthma and allergic symptoms.