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LESA #826052, VOL 48, ISS 14
Indoor air pollution and respiratory health in elderly
MALEK BENTAYEB, MARZIA SIMONI, DAN NORBACK, SANDRA BALDACCI, SARA MAIO,
GIOVANI VIEGI, AND ISABELLA ANNESI-MAESANO
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Indoor air pollution and respiratory health in elderly
Malek Bentayeb, Marzia Simoni, Dan Norback, Sandra Baldacci, Sara Maio, Giovani Viegi, and Isabella Annesi-Maesano
Journal of Environmental Science and Health, Part A (2013) 48, 1–7
Copyright C
Taylor & Francis Group, LLC
ISSN: 1093-4529 (Print); 1532-4117 (Online)
DOI: 10.1080/10934529.2013.826052
Indoor air pollution and respiratory health in elderly
MALEK BENTAYEB1,2, MARZIA SIMONI3, DAN NORBACK4, SANDRA BALDACCI3, SARA MAIO3,
GIOVANI VIEGI3,5 and ISABELLA ANNESI-MAESANO1,2
1INSERM, UMR S 707, EPAR, Paris, France
2Universit´
e Pierre et Marie Curie, UPMC Univ Paris 06, UMR S 707, EPAR, Paris, France5
3Pulmonary Environmental Epidemiology Unit, CNR Institute of Clinical Physiology, Pisa, Italy
4Department of Medical Science, Uppsala University, Occupational and Environmental Medicine, University Hospital, Sweden
5CNR Institute of Biomedicine and Molecular Immunology, Palermo, Italy
Data on respiratory effects of indoor air pollution in elderly are scanty. The purpose of this review is to summarize current knowledge
on adverse respiratory effects of indoor air pollution in individuals aged over 65 years, by presenting existing epidemiological evidence.
Using MEDLINE database through PubMed, we identified relevant publications published between 1991 and 2011 in English on
respiratory health effects of indoor air pollution in elderly (>65 years). A total of 61 studies were found and after application of
the inclusion criteria: (i) epidemiologic studies published in English in peer-reviewed journals between January 1991 and December
2011, (ii) study population with age over or equal 65 years, and (iii) outcome of respiratory symptoms and disease with the exclusion
of lung cancer, 33 relevant publications were selected. Most of them showed significant relationships between exposure to major
indoor air pollutants and various short-term and long-term respiratory health outcomes such as wheezing, breathlessness, cough,
phlegm, asthma, COPD, lung cancer and more rarely lung function decline. The most consistent relationship is found between
chronic obstructive pulmonary disease (COPD) and environmental tobacco smoke (ETS). Further studies in the elderly population
are needed in order to define causal relationships between exposures to indoor air pollution and underlying mechanisms in this
sub-population.
10
15
20
Keywords: Aged, environment, epidemiology, indoor air pollution, lung disease.
Introduction
The main challenge for the future in industrialized coun-
Q1
Q2
tries is the aging of the population. The U.S. National In-
stitute on Aging indicated in the report “An Aging World:
25
2008” that “The number of people older than 65 will dou-
ble to 14% from 7% of the world’s population in the next
30 years, rising to 1.4 billion by 2040 from about 506 mil-
lion in the middle of 2008”. People tend to develop chronic
Q3
conditions as they age. Among chronic diseases that affect30
elderly individuals, cardiopulmonary diseases and cancer
are predominant,[1,2] followed up by diabetes and kidney
failure. Chronic Obstructive Pulmonary Disease (COPD)
as well as asthma accelerate lung function decline and in-
crease frequency of mortality.[3,4] The occurrence of almost35
inevitable chronic diseases at older ages conduce to better
investigate and understand the health consequences of ex-
Address correspondence to Isabella Annesi-Maesano, EPAR
UMR S 707, INSERM & UPMC Paris Univ 06, Medical School
Pierre et Marie Curie Site Saint-Antoine, 27, rue Chaligny,
75571 Paris, CEDEX 12, France; E-mail: isabella.annesi-
maesano@inserm.fr
Received March 10, 2013.
posure to various risk factors, including environmental risk
factors such as air pollution.
Recently, we published a systematic review of respiratory 40
health effects of outdoor air pollution in elderly indicating
the existence of statistically significant short-term and al-
though less frequently long-term adverse effects of various
outdoor air pollutants on cardiopulmonary morbidity and
mortality in elderly.[5] Consistent evidence exists on the fact 45
that the elderly exposed to outdoorair pollution experience
more hospital admissions for asthma and COPD and more
COPD mortality than the rest of the population.
People spend 80–90% of their time indoors. Due to re-
duced outdoor activities the elderly people spend even more 50
time in their homes and thereafter are potentially more
exposed to indoor air pollutants (environmental tobacco
smoke (ETS), volatile organic compounds (VOCs), partic-
ulate matter (PM), carbon monoxide (CO), formaldehyde,
nitrogen dioxide (NO2)...) than the rest of the popula- 55
tion.[6,7] Indoor air pollutants observed in investigations
having dealt with elderly.
Although there is increased evidence of adverse respi-
ratory health effects of these indoor air contaminants in
the general population, epidemiological studies on sus- 60
ceptible subpopulations such as elderly are scarce. Health
2Bentayeb et al.
effects of indoor air pollution in general population is
today well-documented and various studies have shown
evidence that indoor air pollution increases the risk of
chronic obstructive pulmonary diseases, acute respiratory
65
symptoms, atopic sensitization, bronchial hyperresponsive-
ness, respiratory cancer, infectious diseases, and irritation
phenomena.[8–10]
Conservative estimates show that between 1.5 million
and 2 million deaths per year could be attributed to indoor
70
air pollution, and significant part of the deaths occurring
due to COPD.[11] However, among elderly population these
studies are sparse. The purpose of this work is to summarize
current knowledge on adverse respiratory effects of indoor
air pollution in individuals aged over 65 years, by presenting
75
existing epidemiological evidence.
Methods
MEDLINE database through PubMed was searched for
epidemiological studies on respiratory health effects of in-
80
door air pollutants in elderly. The MeSH(Medical Sub-
jects Headings) terms “elderly” (or >65 years), “Air Pol-
lution, Indoor,” “asthma,” “COPD,” “chronic bronchitis”
and “pneumonia” were used. Inclusion criteria for studies
were: (i) epidemiologic studies published in English in peer-
85
reviewed journals between January 1991 and December
2011, (ii) study population with age over or equal 65 years,
and (iii) outcome of respiratory symptoms and disease with
the exclusion of lung cancer. 61 studies were identified and
after application of the inclusion criteria the relevant publi-
90
cations (n =33) were selected manually by reviewing titles,
abstracts, and reference lists.
Results were categorized by exposure. Studied indoor
atmospheric chemical pollutants included: environmental
tobacco smoke (ETS), PM10, (particles of aerodiameter95
<10 µm), PM2.5 (fine particles, particles of aerodiameter
<2.5 µm), nitrogen dioxide (NO2), volatile organic com-
pounds (VOC) and biological pollutants such as allergens,
dust mite and molds. In this review, we summarize findings
from the main publications on the impacts of specific in-
100
door air pollutants on respiratory health in elderly people
indicating authors, year of publication, population, sam-
ple size, design and analysis, health outcome, confusion
factors taken into account, and measures of association.
Further details were presented in a recent chapter on the
105
link between ageing and respiratory diseases.[6]
Results
Exposure
Elderly people are likely to spend most of their time within
their place of residence where they are exposed to air Total
110
Suspended Particles (TSP), i.e., PM10, (particles of aerodi-
ameter <10 µm), PM2.5 (fine particles, particles of aero-
diameter <2.5 µm), biomass, O3,NO
2,CO,SO
2,VOC
(aldehydes, ketones, esters...), allergens, microorganisms
and ETS.[12–17] VOC are common indoor air pollutants. 115
Sources of indoor air pollution include: fuel combustion
for cooking, heating, tobacco smoking, paints, glues, pol-
ishes, pesticides and building products.[18]
Among the VOC, formaldehyde is found in numerous
construction materials and commonly used products (some 120
insulation materials, certain fitted carpets and textiles,
some glues, disinfectants and other household products...).
Cooking is also a source of immediate VOC emissions
according to the cooking method (fossil fuel, oil, wood
or kerosene stove ...) and the food cooked (acrolein de- 125
rived from oil and fat heating reactions). Elderly with co-
morbidities, because of their difficulty in getting outdoors,
may be exposed to high levels of indoor air pollution.[7]
Furthermore, respiratory co-morbidities can put elderly at
higher risk of indoor air pollution effects.[6] 130
Indoor exposure to air pollutants has scarcely been as-
sessed objectively in elderly and mostly in the frame of
investigations having target all the adult population in gen-
eral. In elderly Koreans, PM10 and PM2.5 levels were as-
sessed objectively.[19] Recently, quasi-ultrafine (quasi-UF) 135
particulate matter (PM0.25, particles of aerodiameter <
0.25 µm) and its components were measured in indoor
and outdoor environments at four retirement communities
in Los Angeles Basin, California, as part of the Cardio-
vascular Health and Air Pollution Study (CHAPS).[20] The 140
average indoor/outdoor ratios of most of the measured
polycyclic aromatic hydrocarbons (PAHs), hopanes, and
steranes were close to or slightly lower than 1, thus re-
flecting the possible impact of outdoor sources on indoor
PAHs, hopanes, and steranes. 145
Conversely, indoor n-alkanes and n-alkanoic acids were
likely to be influenced by indoor sources. Although elderly
generally spend most of their time indoors, a major portion
of the PM0.25 particles they are exposed to comes from
outdoor mobile sources. An attempt to assess real exposure 150
was brought through an PM2.5 exposure index (computed
as product of concentration and daily exposure time) in
Italian elderly.[7] One study has assessed VOC metabolites
in elderly.[21] Regarding biocontaminants, Weiss et al. as-
sessed home allergen exposure in older adults participating 155
in the Normative Aging Study.[22] A Swedish survey on
adult population (>18 years) assessed exposure to moulds
through damp or mouldy odour at home.[23] Building
dampness may lead to emission of odorous or irritation
compounds from micro-organisms or chemical degrada- 160
tion of building materials, such as formaldehyde (VOC).
Respiratory health effects
There have been few investigations on the effects of indoor
air pollution in elderly (Table 1).[24] They have been limited
Respiratory health in the elderly 3
Table 1. Associations of respiratory diseases with exposure to indoor air pollutants in the elderly.
Study
Population
sample
investigated Health outcome
Pollutants (unit of
measures) Measures of associations
Ng et al.[31] 1008 women
aged 20–74 yrs
Malaysia
Chronic cough
Chronic phlegm
Breathlessness on
exertion
Wheezing
ETS Rate Ratios:
3.01 (1.13–8.03)
2.29 (0.94–5.59)
1.83 (1.30–2.58)
2.69 (1.23–5.88)
Jedrychowski
et al.[35]
1,544 women
over 65 yrs
Poland
Asthma
Dyspnea
Gas stoves for cooking
Gas stoves for cooking
ETS
ORs associated with changes
in pollutant:
Never smoked: 2.8 Smoked : 2.4
Never smoked: 7.2
Never smoked : 2.2
Weiss et al.[22] 40 subjects
Aged 20–74 yrs
Boston
Change on lung
function
Cockroach allergens
Bla g1
Bla g2
Regression coefficient associated
with changes in pollutant
−79.8 mL/yr, p=0.0006
−40.81 mL/yr, p=0.0004
Mishra[38] 38,595 Subjects
over 60 yrs
India
Asthma Gas stoves for cooking OR associated with changes in
pollutant:
Woman: 1.83 (1.32–2.53)
Men: 1.46 (1.14–1.88)
Eisner et al.[30] 1,057 Subjects
over 55 yrs
USA
COPD ETS OR associated with changes in
pollutant
1.55 (1.09–2.21)
Skorge et al.[40] 1148 subjects
aged 61–82 yrs
Cough with phlegm
Chronic cough
Dyspnea
Moulds OR associated with time of
exposure to moulds:
1.7 (1.0–2.64)
2.0 (1.17–2.48)
2.3 (1.35–3.85)
Eisner et al.[33] 1,057 subjects
over 55 yrs
USA
Pulmonary
function
Cardiovascular
mortality
Second-hand smoke
(SHS)
SHS at home
SHS at work
SHS at home
Decline of FEV1(mL/s) per
10-year cumulative exposure:
−15 (−29 to −1.3)
−41 (−55 to −28)
RR per 10 years of home
exposure:
1.11 (1.00 to 1.24)
Lee et al.[19] 154 Subjects
over 65 yrs
South Korea
Change for an
acute effects of
pollutants on
lung function
PM10 (µg/m3)
PM2.5 (µg/m3)
PEFR change in daily mean
concentrations of pollutants
−0.39 L/min (−0.63; −0.14)
0.54 L/min (−0.89; −0.19)
Liu et al.[46] 3286 women
40 to 70 yrs
China
COPD Biomass fuel
combustion
SO2(µg/m3)
NO2(µg/m3)
PM10 (µg/m3)
CO (µg/m3)
OR associated with changes in
pollutant
1.80 (1.04 to 3.11)
1.28 (0.79 to 2.09)
1.10 (0.93 to 1.30)
1.01 (0.98 to 1.04)
Osman et al.[27] 148 Subjects
over 60 yrs
United Kingdom
Hospital admission:
COPD
NO2(ppb)
PM2.5 (µg/m3)
Endotoxin
P- value associated with
changes in pollutant
P-value =0.002
P-value =0.22
P-value =0.49
Yin et al.[32] 20 430 Subjects
over 50 yrs
China
COPD ETS OR associated with changes in
pollutant
1.48 (1.18–1.85)
COPD: Chronic Obstructive Pulmonary Disease, ETS: Environmental Tobacco Smoke, SO2: Sulphur dioxide, NO2: Nitrogen dioxide, PM10:
suspended particulates of aerodynamic diameter less than 10 µm, CO: Carbon monoxide.
4Bentayeb et al.
to few air pollutants and they support the hypothesis that165
indoor air pollution might be more harmful for the elderly
than for the rest of the population. The most considered
factor has been ETS also called second-hand smoke or
passive smoking. Various respiratory health effects have
been related to exposure.
170
ETS
ETS remains the main source of indoor air suspension
particles. In Europe, 10 to 50% of adults are exposed to
ETS.[25,26] Osman et al. found a significant association be-
tween high concentrations of PM2.5 (the more numerous175
smoking individuals, the higher indoor levels) and adverse
health outcome in the elderly with COPD.[27] In a syn-
thesis of existing publications, Simoni et al. examined the
association between ETS and respiratory health in the el-
derly. A significant relationship was found between ETS,
180
on the one hand, and asthma, COPD and chronic respi-
ratory symptoms, on the other hand with odds-ratio (OR)
(in exposed vs. unexposed individuals) ranging from 1.45
(95% CI 1.21–1.80) to 1.97 (95% CI 1.33–2.92), 1.68 (95%
CI 1.17–2.34) to 5.63 (95% CI 4.63–6.85) and 1.35 (95% CI
185
0.71–2.44) to 4.50 (95% CI 3.41–5.97), respectively.[28]
The length of ETS exposure and the considered diseases
were heterogeneous and limited in the reviewed studies.
More information is derived by successive studies. Jaakkola
et al. showed a significant relationship between ETS expo-
190
sure and asthma (OR ranging from 1.45 to 1.47 in exposed
vs. unexposed subjects), COPD (1.68 to 5.63), and chronic
respiratory symptoms (1.45 to 4.5).[29] Eisner et al. con-
ducted a study on subjects aged 55 to 75 years, investigating
the relationship between life exposure to ETS and risk of
195
developing COPD. After adjustment for age, gender, race,
smoking history, level of study, marital status and occupa-
tional exposure, the risk for COPD was significant for ETS
exposure at home and in the workplace.[30]
In a population of 2,868 non-smoker adult women, 31%200
of whom aged 60 to 75 years; Ng et al. investigated the rela-
tionship between ETS-related indoor air pollution and the
risk of increasing respiratory symptoms. Women exposed
to ETS had significantly higher prevalence of chronic cough
and phlegm, breathlessness on exertion, and wheezing.[31]
205
With the aim of studying the relationship between ETS and
the risk of developing COPD in China, Yin et al. found a
significant OR of 1.48 (95% CI 1.18–1.85) in 20,430 subjects
aged more than 50 years.
According to Yin et al., under the hypothesis of causal-
210
ity, the estimated excess of COPD deaths due to ETS in
never smoking Chinese individuals would have been 1.9
million.[32] However, in all these studies ETS exposure was
assessed by self-reported questionnaire, which can lead to
an exposure misclassification. More recently in 2007, a
215
study was published on the relationship between cumu-
lated exposure to ETS (at home andat the workplace) and
the forced expiratory volume in one second (FEV1)inthe
elderly.[33] Both at home and at the workplace, the cumu-
lated ETS exposure (over 10 years) was associated to a 220
decrease of the FEV1. In households with smoker adult
males aged 44 to 77 years, the mortality risk for respiratory
diseases was found significantly higher than in households
without smokers.[34]
Other chemical pollutants 225
Very few data exist on the effects of other pollutants in
elderly. NO2is an air pollutant present in indoor envi-
ronments and its concentrations are affected by outdoor
levels, indoor appliances such as gas stoves (gas stoves are
among the major contributors to indoor NO2exposure) 230
and kerosene heaters, cigarette smoke, and ventilation of
both combustion appliances and indoor and constitute a
hazard for elderly. In a study aiming to assess indoor air
pollution effects of combustion gases on respiratory health
in 1544 women aged 65 or more, Jedrychowski et al. found 235
that the longer the subjects were exposed to pollutants de-
rived from cooking appliances, the more asthma was ex-
acerbated, with OR of 2.8 in never smoking women and
of 2.4 in smoking women (7.2 and 3.3, respectively, for as
exercise-related dyspnea).[35] 240
In one of the rare studies that performed indoor objec-
tive measurements of air pollutants caused by ETS, Lee
et al. examined the adverse effects of PM10 and PM2.5 on
lung function in the elderly.[19] For a rise in the levels of
PM10 and PM2.5, there was observed a decreasing peak ex- 245
piratory flow. These results suggested that particles exert a
negative effect on the health of the most sensitive individu-
als, including the elderly. Study population was composed
of three panel surveys with 61, 47 and 42 subjects so that
there was not enough power to conclude that PM10 and 250
PM2.5 decrease lung function. Other investigations with
more subjects are needed to support these hypotheses.
The use of biomass (wood/coal) for either cooking or
heating affects respiratory health, because of the produc-
tion of PM and CO from biomass combustion is spread 255
worldwide.[7,36,46] In a review describing the link between
biomass fuel and respiratory diseases, Torres-Duque et al.
cited references studying the risks for health outcomes asso-
ciated with solid fuel smoke inhalation in adults aged over
30 years including elderly.[37] In India, Mishra et al. exam- 260
ined the relationship between cooking smoke and asthma
in those aged over 60 years. The risk for asthma in exposed
existed and was greater among women.[38] Asthma was re-
ported by participants and not confirmed by physician or
clinical tests. This could underestimate a real prevalence of 265
asthma.
VOC can induce eye and airways irritations when sub-
jects are exposed to acute or chronic exposures but also
more severe respiratory symptoms and immune dysfunc-
tion. To our knowledge no studies focused on the effects 270
of benzene and VOC in elderly people. However, in a
Respiratory health in the elderly 5
longitudinal panel study of 154 elderly people conducted
in South Korea, the urinary levels of hippuric acid and
methylhippuric acid, which are metabolites of toluene and
xylene, respectively, were significantly associated with re-
275
duction of FEV1, FEV1/forced vital capacity (FVC), and
forced expiratory flow at 25–75% of FVC.[19]
Biological pollutants
Very few surveys have concerned the effects of indoor al-
lergens on respiratory health in the elderly in population-
280
based samples, probably because allergic sensitisation di-
minishes with age. Among the studies cited in a recent
meta-analysis on health effects of mold and dampness,[39]
one study examined the association between molds and res-
piratory symptoms in adults with 1,148 of them aged 61 to
285
82 years. Association was significant for phlegm, chronic
cough and dyspnea.[40]
In addition, a Swedish survey on adult population
(>18 years), which also included subjects >65 years, found
that an exposure of at least 3 years to damp or mouldy
290
odour at home was associated with persistent cough with
OR ranging from 1.32 to 5.86 (95% CI from 1.22 to 6.19).[23]
Few surveys have concerned the effects of other indoor al-
lergens on respiratory health in the elderly. Weiss et al.,
Q4
when investigating the relationship between home allergen295
exposure and decline in FEV1in older adults participat-
ing in the Normative Aging Study, found that cockroach
concentration was a significant predictor of decline in FEV1
(−79.8 mL/yr to −40.81 mL/yr, P<0.001), independently
from the presence/absence of asthma.[17]
300
Another study on adults aged more than 70 years ev-
idenced a positive interaction between smoking and pets
at home in relation to the incidence of asthma: with non-
smoking females as reference, the adjusted OR of smoking
for asthma incidence was 2.50 (95% CI 1.24–5.05) in fe-
305
males who had pets at home and 0.95 (0.49–1.85) in those
who did not.[23]
Discussion
Overall, although the elderly spend most time indoors
where they are easily exposed to poor air quality, there
310
are few data on exposure to indoor air pollutants and re-
lated effects on respiratory health in this age group. Existing
evidence shows that respiratory health of the elderly is af-
fected by ETS, PM and biomass use and possibly by molds.
Acute and more rarely chronic respiratory symptoms and
315
diseases (overall in the case of ETS) have been related to
these pollutants in the elderly. However, these data are de-
rived by very heterogeneous investigations and findings are
not conclusive.
Difficulties in finding clear relationships between expo-
320
sures and respiratory health outcomes in elderly may be at-
tributable to measurement errors in expo-sure assessment.
In investigations among elderly, exposure assessment was
based rarely on objective assessments and the hypothesis
was made that these assessments were representative. Sub- 325
jective reports of exposure to sources of air pollutants are
subject to recall and reporting biases. Quantitative assess-
ments of air pollutants concentrations have been limited in
time without taking their temporal-spatial variations. From
the point of view of respiratory health outcomes, hetero- 330
geneous definitions have been used so that comparisons
have been difficult. In addition, a wide variety of respira-
tory health effects have been considered, which cannot be
explained by a unique mechanism.
Last, current findings do not allow defining causal re- 335
lationships between exposure and respiratory health out-
comes in the elderly because of lack of information on
lifetime exposure to air pollution, in particular on intensity
and duration of exposure or age of exposure.
Whether elderly are at higher risk of developing air- 340
pollution related diseases than the rest of the population is
under debate.[5,41] Indoor air pollution may play a special
role in the elderly, since they are likely to spend most of
their time indoors and thus to be more exposed to indoor
air pollutants than the rest of the population. Under the 345
hypothesis that the severity of respiratory diseases may de-
pend on the intensity degree and duration of exposure to
air pollution, the elderly might be at higher risk of suffer-
ing from air-pollution related diseases because of longer
exposure to air pollution than the rest of the population. 350
In addition, the Cardiovascular Health and Air Pollu-
tion Study (CHAPS) showed that indoor-infiltrated parti-
cles from mobile sources are more strongly correlated with
adverse health effects observed in the elderly subjects living
in the studied retirement communities compared with other 355
particles found indoors.[42] Indoor associations were often
stronger for estimated indoor Elemental Carbon, primary
Organic Carbon, and total particle number of outdoor ori-
gin than for uncharacterized indoor measurements.
It has been suggested that altered physiology and toxi- 360
cokinetics (e.g., reduced renal clearance) make elderly peo-
ple potentially more sensitive to air pollution effects due to
reduced capacity for elimination.[43] Potential mechanisms
of action of air pollutants include oxidative stress. In the
longitudinal study conducted in South Korea previously 365
introduced, oxidative stress markers (malondialdehyde and
8-oxo-2-deoxyguanosine) on the same day of spirometric
tests were significantly associated with the metabolites of
VOCs.[21]
In addition, the oxidative stress markers were associated 370
with pulmonary function parameters. This study suggests
that exposure to toluene and xylenes might exert a harmful
effect on pulmonary function by exacerbating oxidative
stress in elderly people. VOCs might impair pulmonary
function through enhancing oxidative stress, especially in 375
the elderly population.
6Bentayeb et al.
Conclusions
To sum up, investigations are still needed to better un-
derstand the links between indoor air pollution and res-
piratory health impairment in elderly. They have to use
380
objective standardized assessments of both exposure and
health outcomes and they have to apply methods allowing
taking exposure to multi-pollutants mixture either through
scores[44] or more sophisticated methods,[45] that is a very
common phenomenon indoors, into account.
385
Indoor residential places for elderly like nursing homes
should be privileged because of the multiple advantages for
studying such effects they offer. In this respect, appropriate
data are expected by the GERIE Study having recruited
600 elderly in 50 nursing homes across Europe. Last, pre-
Q5
390
vention and remediation actions to reduce indoor air pollu-
tion in nursing homes on which there are no data should be
implemented.
Acknowledgment
This work has been supported by Contract no. 2006343 of395
European DG-SANCO. The GERiatric study In Europe
on health effects of air quality in nursing homes is be-
ing carried out by nine research teams in Europe (Isabella
Annesi-Maesano (France) (Principal Investigator), Alfred
Bernard (Belgium), Christina Gratziou (Greece), Franc¸ois
400
Lavaud (France), Dan Norback (Sweden), Piersante Sestini
(Italy), Torben Sigsgaard (Denmark), Gunilla Wieslander
(Sweden), Giovanni Viegi (Italy), Jan Zielinski (Poland).
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