1. SEARCH School Environment And Respiratory health of CHildren an international research project within the Indoor Air Quality in European Schools. Preventing and reducing respiratory diseases Programme Péter Rudnai, Éva Vaskövi, Mihály János Varró, Margherita Neri, Éva Csobod National Institute of Environmental Health, Budapest, Hungary, Regional Environmental Center for Central and Eastern Europe, Country Office Hungary, Szentendre, Hungary

2. OBJECTIVES to identify the exposure level in combination with building characteristics and occupants behaviour and activities to evaluate the relationship between measured concentrations and possible emission sources to assess the childrens respiratory health to assess the associations between the school environment and the childrens (respiratory) health to make recommendations for improving the quality of school environment

3. STUDY DESIGN: cross-sectional Exposure assessment measurement of the indoor air quality in the school questionnaire on the class-room and the time spent there questionnaire on the school building and its maintenance questionnaire on the home environment Health assessment symptom questionnaire (cough, wheeze, asthma dg, allergy) with questions on confounding factors (environmental tobacco smoke, previous health problems, home environment, life-style and socio-economic status of the family, etc.) lung function measurement

4. ALBANIA BOSNIA - HERZEGOVINA HUNGARY ITALY SERBIA SLOVAKIA Coordination: REC and NIEH, Budapest PARTICIPATING COUNTRIES

5. CountryTown number School number Class number Albania31035 Bosnia31040 Hungary41043 Italy9 1313 45 Serbia71044 Slovakia21040 Total: 28 63 247 SAMPLING SITES

6. INDOOR classroom, in the breathing zone OUTDOOR ambient air, closest to the window of the classroom SAMPLING PLACES

7. CountryBeginning date End date Albania22/01/200804/04/2008 Bosnia24/12/200717/04/2008 Hungary05/11/200729/02/2008 Italy 11/02/200823/04/2008 Serbia28/01/200809/05/2008 Slovakia03/12/200714/03/2008 SAMPLING PERIOD

8. INDOOR AIR MEASUREMENTS CHEMICAL: CO 2, CO, PM 10 (real-time monitoring during school-time, 1 day/classroom) NO 2, BTEX, HCHO (integrated (passive) sampling for 3-5 days, depending on the number of classrooms ) PHYSICAL: T, RH (real-time monitoring during school-time, 1 day/classroom)

9. Protocol for field work Training and consultation The same portable monitors and passive samplers Blank samples Passive samples were collected by the countries and analysed by one laboratory Samples transportation were performed in compliance with the same protocol QUALITY ASSURANCE

10. INDOOR CONCENTRATIONS

11. PM 10

12. NO 2

13. HCHO

14. BENZENE

15. TOLUENE

16. ETHYL-BENZENE

17. XYLENES

18. Prevalence of respiratory symptoms and allergy among 5,242 school children in the 6 countries

19. Distribution of children and classes in schools with various traffic density nearby Distribution of children Distribution of classes

20. Percentage of children in schools with polluting establishments in the neighbourhood

21. Prevalence of symptomatic children in schools with or without industry in the neighbourhood aOR= 1.34 (95% CI.:1.03-1.75) aOR=1.36 (95% CI.:1.04-1.78) aOR=1.32 (95% CI.: 1.04-1.69) adjusted for age, gender, country, industry close to home

22. Prevalence of children with chronic ear-ache in schools with industry and/or heavy traffic around *aOR=1.61 (1.15-2.25) *Adjusted for age, gender, traffic and industry near home and country

23. Prevalence of children with or without regular day / night cough in classes with PM 10 concentrations 80 µg/m 3 or above * p<0.05 ** aOR = 1.32 (1.06 – 1.66) ** adjusted for age, gender, parental chronic bronchitis, serious chest disease in the first 2 years of life and country

24. Prevalence of children woken up by wheeze at night and mean benzene concentrations measured in the classroom *** p<0.001 aOR* = 1.47 (1.04-2.08) *adjusted for age, gender, parental asthma, smoking during pregnancy, serious chest diseases in the first 2 years of life and country

25. Mean concentrations of pollutants in classrooms with or without water-resistant paint on the wall * p<0.05

26. Prevalence of children with doctor-diagnosed allergy or recently treated for asthma visiting classrooms with wall painted with water resistant (WR) paints ** p<0.01 + aOR= 1.19 (1.001-1.41) ++ aOR= 1.36 (1.04-1.79) + adjusted for age, gender, parental allergy, water resistant paint at home, country ++ adjusted for age, gender, parental asthma, water resistant paint at home, country

27. Prevalence of children with doctor-diagnosed allergies in classrooms with or without plastic floor + aOR: 1.30 (1.09-1.56) 1.33 (1.06-1.68) 1.56 (1.15-2.11) + adjusted for age, gender, parental allergy, plastic floor at home, country

28. Mean concentrations of ethyl-benzene and xylenes in classrooms with or without open windows during cleaning ***p<0.001

29. Mean, maximum and minimum floor surface area per child by country

30. Mean concentrations of some pollutants by crowdedness categories ***p<0.001

31. Prevalence of children with chronic respiratory symptoms in well or poorly ventilated classrooms ***p<0.001 + aOR= 1.30 (1.10-1.54) 1.29 (1.03-1.60) 1.32 (1.06-1.63) 1.39 (1.13-1.72) + adjusted for age, gender, serious chest disease in the first 2 years of life and country

32. Prevalence of children with skin rash and house-dust mite allergy among children in classrooms cleaned with bleach *p<0.05 + aOR = 1.27 (0.99-1.61) 0.71 (0.53-0.95) + adjusted for age, gender, parental allergy and country

33. Prevalence of children with chronic bronchitic symptoms in classrooms with (4.1%) or without air conditioners *p<0.05; **p<0.01; ***p<0.001 + aOR = 0.44 (0.28-0.69) 0.58 (0.33-1.04) 0.43 (0.22-0.87) 0.43 (0.20-0.94) + adjusted for age, gender, serious chest disease during the first 2 years of life and country

34. CONCLUSIONS 1 Site of the school Heavy traffic in the close neighbourhood of the school had an adverse effect on the childrens exposure to most of the measured pollutants Industry in the close neighbourhood of the school had an adverse effect on the childrens exposure to most of the measured pollutants, too. Both heavy traffic and industry in the close neighbourhood of the school were independent determinants of decreased lung function

35. CONCLUSIONS 2 Sources of indoor air pollutants in the classroom Plastic floor was associated with increased prevalence of doctor-diagnosed allergies and decreased lung function. Increased levels of the measured volatile organic compounds and nitrogen-dioxide were found in classrooms with carpets on the floor and these classrooms were associated with increased prevalence of children with woken up by wheeze at night. Increased levels of benzene, xylene and ethylbenzene were measured in classrooms painted with water-resistant paints and these classrooms were associated with increased prevalence of allergies diagnosed and treated by a physician during the last 12 months.

36. CONCLUSIONS 3 Sources of indoor air pollutants in the classroom: CLEANING Broom use for cleaning the classrooms was associated with increased prevalence of children with chronic cough with phlegm and decreased lung function. Use of mop for cleaning was found to be associated with increased prevalence of reported chronic conjunctivitis and decreased lung function. Use of mop with bleach was associated with increased prevalence of skin rash and eczema.

37. CONCLUSIONS 4. Occupancy of the classroom and ventilation Crowdedness was associated with increased levels of carbon-dioxide (CO2), PM10 and benzene measured in the classrooms as well as with higher prevalence of chronic ear-ache among children. Poor natural ventilation during teaching hours was associated with increased levels of CO2 and formaldehyde measured in the classrooms and with increased prevalence of chronic bronchitis and asthmatic symptoms. Decreased prevalence of chronic bronchitis was found among children visiting classrooms equipped with air conditioner

38. RECOMMENDATIONS Schools should be built in places not directly affected by heavy traffic or industry or any other polluting establishments in the neighbourhood. Crowdedness should be avoided in the classrooms. Appropriate ventilation regime of the classrooms should be introduced in order to provide good indoor air quality during the whole period of teaching hours. Floor coverings of the classrooms should be chosen with particular cautiousness to avoid any adverse effects on the respiratory health of children. Use of water-resistant paints in the classrooms should be avoided. Clear instructions for good cleaning practice in schools should be provided and appropriate control should be exerted over their implementation.