ORGANISATION MONDIALE DE LA SANTÉ BUREAU RÉGIONAL DE L'EUROPE
WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR EUROPE WELTGESUNDHEITSORGANISATION REGIONALBÜRO FÜR EUROPA
ВСЕМИРНАЯ ОРГАНИЗАЦИЯ ЗДРАВООХРАНЕНИЯ ЕВРОПЕЙСКОЕ РЕГИОНАЛЬНОЕ БЮРО
EUROPEAN CENTRE FOR ENVIRONMENT AND HEALTH BONN OFFICE
ESTABLISHMENT OF ENVIRONMENT AND HEALTH INFORMATION SYSTEM SUPPORTING POLICY-MAKING IN EUROPE
ENHIS 2
Grant Agreement SPC 2004124 between The European Commission, DG Sanco and World Health Organization, Regional Office for Europe
FINAL TECHNICAL IMPLEMENTATION REPORT 1 NOVEMBER 2005 – 31 OCTOBER 2007
© WHO ECEH, Bonn, December 2007 The views expressed in this report can in no way be taken to reflect the official opinion of the European Community or of the World Health Organization
LIST OF CONTENTS EXECUTIVE SUMMARY .....................................................................................................
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Introduction .........................................................................................................
7
1. Detailed description of activities conducted WORK PACKAGE 1 PROJECT COORDINATION ................................................................... WORK PACKAGE 2 DISSEMINATION OF RESULTS .............................................................. WORK PACKAGE 3 DETERMINE INFORMATION NEEDS OF POLICIES .................................... WORK PACKAGE 4 UPDATE CORE SET OF EH INDICATORS ............................................... WORK PACKAGE 5 METHODS FOR INFORMATION GENERATION ........................................ . WORK PACKAGE 6 SUPPORT TO THE NETWORK OF COLLABORATING CENTRES ................. . WORK PACKAGE 7 INTEGRATE HEALTH IMPACT ASSESSMENT ......................................... . WORK PACKAGE 8 INFORMATION MAINTENANCE, ANALYSIS AND REPORTING .................... .
9 11 13 15 17 18 20 22
2. Manpower for the execution of the activities ...............................................
25
3. Beneficiaries involved ....................................................................................
49
4. Countries involved ..........................................................................................
50
5. Achievement of objectives .............................................................................
52
ANNEX 1: List of ENHIS 2 partners and national collaborators................
57
ANNEX 2: Results of ENHIS 2 project implementation ...............................
62
Annex 2.1. Outcomes of ENHIS 2 implementation
…...…………………. 63
WORK PACKAGE 2 .........................................................................................................
64
LIST OF PUBLICATIONS .......................................................................................................
65
WORK PACKAGE 3 .........................................................................................................
70
METHODOLOGY FOR IDENTIFICATION OF INFORMATION NEEDS FOR POLICIES ....................................... GUIDELINES FOR GENERATING INFORMATION FOR POLICY SUPPORT ....................................................
71 101
WORK PACKAGE 5 .........................................................................................................
108
INVENTORY OF AVAILABLE SURVEYS FOR EH INDICATORS; CHILDREN’S EH INFORMATION FOR NEW SURVEYS 109
WORK PACKAGE 6 .........................................................................................................
120
USER’S MANUAL OF THE COMMUNICATION AND INFORMATION EXCHANGE PLATFORM SHAREPOINT ...... SET OF NATIONAL FACT SHEETS .........................................................................................................
121 125
WORK PACKAGE 7 .........................................................................................................
219
REPORT ON THE HIA OF INDOOR AIR QUALITY: RESULTS AND ASSESSMENT OF FEASIBILITY .................. REPORT ON THE HIA OF NOISE:: RESULTS AND ASSESSMENT OF FEASIBILITY ....................................... REPORT ON THE HIA OF DRINKING WATER POLLUTION ........................................................................
220 245 267
WORK PACKAGE 8 .........................................................................................................
306
FINAL TECHNICAL REPORT ................................................................................................................
307
Annex 2.2. Excerpts from country reports …...……………………………. 390 AUSTRIA ........................................................................................................................ BULGARIA ...................................................................................................................... CZECH REPUBLIC........................................................................................................... ESTONIA ........................................................................................................................
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391 391 392 392
FINLAND ........................................................................................................................ FRANCE ........................................................................................................................ GERMANY...................................................................................................................... GREECE ........................................................................................................................ HUNGARY ...................................................................................................................... ITALY............................................................................................................................. LITHUANIA ..................................................................................................................... NETHERLANDS ............................................................................................................... POLAND ........................................................................................................................ PORTUGAL .................................................................................................................... ROMANIA ...................................................................................................................... SLOVAKIA ..................................................................................................................... SLOVENIA ..................................................................................................................... SPAIN ............................................................................................................................
393 394 395 395 396 397 397 398 398 400 400 401 401 402
Annex 2.3 Technical meeting reports ........................................................
404
FIRST COORDINATION MEETING (BONN, 15-16 DECEMBER 2005) ..................................... MID-TERM REVIEW MEETING (GRANADA, 9-10 OCTOBER 2006)........................................ FINAL PROJECT MEETING (PRAGUE, 12-14 SEPTEMBER 2007).........................................
405 420 441
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EXECUTIVE SUMMARY The project “Establishment of environment and health information system supporting policy making in Europe – ENHIS 2”, co-funded under Grant Agreement SPC 2004124, aimed at setting up and starting the operation of a comprehensive information and knowledge system (ENHIS) enabling analysis of environmental health (EH) situation to support relevant policies in Europe, focusing on those addressing children. It was implemented in the period 1 November 2006 – 31 October 2007 by a consortium of twenty-two partner institutions from 18 countries (Austria, Bulgaria, Czech Republic, Estonia, Finland, France, Germany, Greece, Hungary, Italy, Lithuania, Netherlands, Poland, Portugal, Romania, Slovakia, Slovenia and Spain) and WHO. The French Agency for Environmental and Occupational Health and Safety (AFSSET, France) and the European Commission Joint Research Centre (EC JRC) acted as project collaborators. WHO/Europe (ECEH Bonn) coordinated the project. Previously implemented projects, co-sponsored by the EC DG Sanco (ENHIS - Grant Agreements SPC 2003112 and ECOEHIS – Grant Agreement SPC 2002300) provided basis for the current work. ENHIS 2 project was organized in eight work packages (WP) each of them implemented by WP leader and selected project partners. •
WP1: Overall project coordination assuring good communication and collaboration among all partners (leader: WHO);
•
WP2: Dissemination of the results, coordinating and facilitating publication of the results achieved by the work (leader: WHO);
•
WP3: Determine information needs of environmental health policies (leader: KTL Finland);
•
WP4: Update the core set of environmental health indicators (leader: WHO);
•
WP5: Develop and apply methods for generating information from existing national and international data bases, and surveys (leader: IPHB, Romania);
•
WP6: Support to the network of collaborating centres: maintain communication links and information exchange infrastructure (leader: KOZPONT, Hungary);
•
WP7: Develop and test methods for health impact assessment (HIA) of indoor air quality and noise in partner countries (leader: InVS, France);
•
WP8: Build progressively the system by implementing key technical infrastructure elements (leader: RIVM, Netherlands).
The most important achievement of the ENHIS 2 project is the integration of policy analysis, data on various health and environment aspects and tools for assessment and reporting. The project was able to link diverse sources of information and various technical disciplines, and formulated succinct, policy-relevant messages suitable for various user groups – including general public, environmental and health managers, decision-makers and scientists. The outputs of the project include 26 Indicator Fact Sheets covering four Regional Priority Goals of the Children Environment and Health Action Plan for Europe (CEHAPE), agreed by the 4th Ministerial Conference on Environment and Health in Budapest. The assessments presented by the fact sheets, and accessible both as formatted documents and through ENHIS web site www.enhis.org created by the project, are based on the most recent reviews of
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ENHIS 2: Final Technical Implementation Report
scientific evidence and on the most reliable data from existing data bases. Other project results include: •
Policy analysis conducted by ENHIS 2 serves to identify the format and contents of the information needs and define the policy-relevant indicators according to the methodology developed by the ENHIS projects. An inventory of EU and national policies in the context of CEHAPE RPGs was also created and is available through the www.enhis.org . The information needs and gaps for each thematic policy area contribute to the “Policy context and relevance” section of the fact sheets.
•
Environmental health indicators serve as the main tools for monitoring the situation and trends in countries and for communicating with a wide range of users. The indicators focus on environmental factors most relevant to health, health outcomes most influenced by the environment, and policy action deemed to reduce and prevent the risks. A core set of 26 indicators was selected during a process involving multiple working groups and consultations, using the criteria of scientific credibility, a focus on children’s EH and relevant policy action such as CEHAPE, and feasibility. ENHIS methodological guidelines for the indicators giving the rationale, definition, required data elements, calculation method, data sources, interpretation and policy-relevance are integrated in the system. An information base has been created for the 26 children’s EH indicators using international databases, case studies based on surveys in selected countries and examples of child-specific policies.
•
Methods and tools allowing the use of information from existing national and international data bases were developed, tested and applied in creation of the ENHIS data base. More than 15 data bases were accessed. The hands-on guidelines are a part of methodological documentation available on the ENHIS web site.
•
The network of partner-institutions is an important mechanism for the operation of ENHIS, currently involving 25 project partners and collaborating institutions. The ENHIS network has provided substantial input for information gathering and data flows for the 26 indicators, in particular to case studies on specific environmental health issues related to the four CEHAPE RPGs, as well as examples of national policy activities. The network members were responsible for the preparation of 23 indicator-based fact sheets, thus strengthening existing capacities for EH information processing, analysis and reporting. Establishment of the SharePoint platform has facilitated the exchange of information and networking. The network members from 7 countries prepared national analysis using ENHIS approaches, demonstrating its applicability and usefulness on national level.
•
Health impact assessment methods were developed and applied to selected EH risk factors for outdoor (PM10 particles and ozone) and indoor (ETS and mould and dampness in the home) air pollution. An on-line software tool prepared in the framework of the project, HIAir, facilitates health impact assessment for European cities. The assessment results were integrated into the indicator fact sheets and are accessible through www.enhis.org. Methods and guidelines on HIA for other factors, such as noise, were prepared and published, and will facilitate implementation of HIA when appropriate data sets are available.
•
The web-based platform serving as the main tool for information dissemination. It brings together data, indicators and related trends in time and space, fact sheets describing the situation for each indicator and showing the potential health benefits of action and ENHIS 2: Final Technical Implementation Report
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interventions, and links to relevant information resources. Users can access and search the information-base on a theme of their particular interest at http://www.enhis.org. They could select various environmental health issues, specific health effects of the environment, as well as country information for each of 53 WHO/Euro Member States. Users can access the analysis of environment and health policies or retrieve information on methods and tools used in the system. •
Reporting methods and tools for indicator fact sheets and periodic indicator-based assessments were designed for decision-makers. They provide evidence clearly and concisely to support the development of action which benefits public health and the environment, and to track the progress of its implementation. Standard and clear format of the fact sheets facilitate evaluation of various issues and respond to the needs of various users. The fact sheets have been prepared for the 26 indicators. Following an evaluation and revision process, they have been integrated into the information base. ENHIS web site as well as the indicator-based assessment report were published to provide the framework for effective dissemination of EH information in the future. The methods can be used for further expansion of the thematic scope of the system as well as for national applications.
The experiences of the project serve also for identification of the gaps in evidence and information on environment and health, necessary for evidence-based and accountable policy making in Europe. The expertise and capacities built by the project in the partner institutions will serve in the maintenance and further development of the European and national systems. ENHIS methods will be used to increase system coverage to all Member States of WHO/Euro. The achievements of the ENHIS 2 project provide a solid basis for the operation of the system in the future. Its next challenge is to produce information support for the 5th Ministerial Conference on Environment and Health to be held in Italy, in 2009.
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INTRODUCTION Project objectives The project aimed at setting up and starting the operation of a comprehensive information and knowledge system (ENHIS) enabling analysis of environmental health (EH) situation to support relevant policies in Europe, focusing on those addressing children. The system was to be based on a set of EH Indicators developed and updated by the project, use health impact assessment methods and contribute to the European Community Health Information System. The ENHIS 2 project has been developed taking stock of the experiences and products of the ENHIS project implemented in 2004-2005 under the grant agreement SPC2003112. Specific objectives were: • • • •
To put into operation 'core' environmental health indicators developed and tested throughout a consensus-building process based on ECOEHIS, ENHIS and previous WHO-coordinated projects; To create an inventory of current policies and interventions relevant to the children's health and the environment and assess their information needs; To build software tools for data retrieval and query and web-portal enhancing the IT system infrastructure and streamlining data reporting; To develop and apply health impact assessment methods for selected aspects of indoor air pollution and noise.
Working Process and Methods Consortium of twenty-two partner institutions from 18 MS (Austria, Bulgaria, Czech Republic, Estonia, Finland, France, Germany, Greece, Hungary, Italy, Lithuania, Netherlands, Poland, Portugal, Romania, Slovakia, Slovenia, Spain), together with the French Agency for environmental and occupational health and safety (AFSSET, France), WHO/Europe and the European Commission Joint Research Centre (EC JRC), implemented the project (see Annex 1 for partner information and contact data). ENHIS 2 project was organized in eight work packages (WP) each of them implemented by WP leader and selected project partners. •
WP1: Overall project coordination assuring good communication and collaboration among all partners;
•
WP2: Dissemination of the results, coordinating and facilitating publication of the results achieved by the work;
•
WP3: Determine information needs of environmental health policies;
•
WP4: Update the core set of environmental health indicators;
•
WP5: Develop and apply methods for generating information from existing national and international data bases, and surveys;
•
WP6: Support to the network of collaborating centres: maintain communication links and information exchange infrastructure;
•
WP7: Develop and test methods for health impact assessment (HIA) of indoor air quality and noise in partner countries;
ENHIS 2: Final Technical Implementation Report
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•
WP8: Build progressively the system by implementing key technical infrastructure elements;
ENHIS SharePoint and regular meetings assured internal communication and coordination within the project. Major decisions were made at the coordination and review meetings gathering representatives of all partners. WHO European Centre for Environment and Health, Bonn Office, acted as the project coordinator. It also led the dissemination of the results as well as was responsible for the update of the core set of environmental health indicators i.e. was responsible for work packages 1, 2, and 4. This report summarizes the project implementation during the duration of all project period (from 1 November 2005 to 31 October 2007) and has been prepared in accordance with the reporting requirements as stipulated in the Annex III of the ENHIS 2 project contract. The report also presents the results achieved throughout the ENHIS 2 project implementation and documents and resources used by each partner for the work package implementation. Most of the project products are published on the web-site created in the framework of the project and being one of its products (www.enhis.org ). Technical reports on the activities and the results of the ENHIS 2 implementation which are not published on the ENHIS web-site are enclosed in the section “Outcomes of ENHIS-2 implementation” in Annex 2.1 of the present report. They are available on the ENHIS SharePoint as well on request from
[email protected]. Reports on activities conducted in each of the countries involved, describing how the project results were made available in the country are presented as well.
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1. DETAILED DESCRIPTION OF ACTIVITIES CONDUCTED This section describes activities of each work package and their outcomes. It also provides a brief evaluation of the contribution of the work package to the achievement of the project objectives. Work Package 1 Project Coordination Lead Partner: WHO European Centre for Environment and Health, Bonn Office, WHO-DK Activities 1. Overall planning and organization of the work The scope of the ENHIS 2 work and deliverables were determined vis-à-vis the project objectives. The plan of work was adjusted in view of preparation of an assessment report using the ENHIS 2 methods and tools for the Intergovernmental Mid-term Review (IMR). Vienna on 13 to 15 June 2007. 2. Coordination and maintaining communication for the project implementation Coordination was implemented both on technical and administrative ‘levels’ under the responsibility of WHO. Coordination of the technical work included maintaining links among the work packages and regular exchange of information about the work progress. Communication was maintained through emails, contacts as well as through the common project office - the ENHIS SharePoint. Three meetings related to work organization and progress evaluation were convened with WHO responsible for the logistics, the scientific preparation and publication of the reports. One editorial meeting has been convened with WHO responsible for the scientific preparation to assure timely and quality deliverable of the indicator-based assessment report for the IMR. Two web editorial workshops have been convened to advance the contents and the functionality of the ENHIS web at the same time supporting capacity building in disseminating EH information on the web. Six WP meetings on specific technical issues related to ENHIS 2 implementation were held with WHO involvement in the scientific preparation and in reporting. The reports of the three meetings related to the overall work organization i.e. the first coordination, mid-term and final one are enclosed in the Annex 2.3 “Technical meeting reports”. The reports from all other meetings are published on the ENHIS SharePoint and available on request. 3. Reporting to EC DG Sanco and interaction with international organizations ENHIS-2 progress has been regularly reported at the meetings of Working Party on HealthEnvironment (http://ec.europa.eu/health/ph_information/implement/wp/environment/events_environment_en.htm). Special meetings were held, with the organizational support of EC DG Sanco, with the EC DG Eurostat (Luxembourg, 16 February 2006) and EEA (Copenhagen, 5 May 2006) to reach early agreement between the data-holder agencies and the project. 4. Meetings 4.1. First Coordination Meeting (Bonn, 15-16 December 2005) gathered all twentytwo ENHIS-2 partners and representatives of institutions having expressed willingness for involvement in the project as from the EC DG Sanco, EC DG JRC and EEA. The Meeting agreed on the activities and responsibilities for each of the work packages and partners, and synchronized the work among them. In particular, all the partners agreed to advance the entire implementation process so that the CEHAPE assessment report ENHIS 2: Final Technical Implementation Report
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will be presented at the mid-term Intergovernmental mid-term review meeting (Vienna, 13-15 June 2007). The meeting report is published on http://www.euro.who.int/EHindicators/Methodology/20060201_4 4.2. Two joint WP2 and WP8 technical meetings were held involving participants from RIVM and WHO in Bilthoven, Netherlands on 8 March 2006 and in Bonn on 29 March 2006, respectively. The objectives were to prepare a joint WP2 and WP8 work plan for the development of ENHIS IT infrastructure specifying the tasks, responsibilities and timelines. WP2 was focusing on the database and data retrieval and WP8 – predominantly on the web-based platform. 4.3. WP7 technical meeting (Granada, 20-21 April 2006) gathered WP7 partners to agree on the approach for the development of an integrated software tool for health impact assessment of air quality using routinely collected data. 4.4. WP3 technical meeting (Bonn, 29 May 2006) gathered ENHIS 2 WP3 partners, the EC DG JRC and WHO team implementing projects to review existing governance instruments (laws, standards and guidelines) in the different Member countries of WHO European Region. The objectives were to reach an agreement on a common approach and questionnaire for children’s EH policy review across Europe. 4.5. Joint WP4, WP5 and WP6 technical meeting (Vienna, 26-27 June 2006) on updating the core set of children’s environmental health indicators. The meeting gathered WP4, WP5 and WP6 partners, representatives of network collaborating centres and of institutions involved in ENHIS-2 on voluntary basis. The objectives were to evaluate the pilot testing and update the core set of feasible and policyrelevant environmental health indicators to address children and general population. 4.6. ENHIS 2 mid-term review meeting (Granada, 09-10 October 2006) gathered all project partners, participating network centres and representatives of EC DG Sanco, EC DG JRC and EEA. The objectives were to evaluate the progress of the 1st year implementation as well as the status of the preparation of the products for the upcoming intergovernmental meeting and to plan the activities for the next period. Summary report is published on http://www.euro.who.int/document/EHI/ENHIS2_mtg_rpt_Oct_2006.pdf. 4.7. WP7 satellite meeting (Bonn, 24 January 2007) gathered WP7 partners to agree on integration of HIA assessment in selected EH indicator fact sheets. 4.8. ENHIS 2 editorial meeting (Bonn, 25-26 January 2007) gathered all project partners, participating network centres, as well as experts volunteering to be involved in the preparation of the indicator-based assessment and reporting. It evaluated the indicator fact sheets to be disseminated on the web and used in the preparation of the report. The assessment report “Children’s health and the environment in Europe: a baseline assessment” was reviewed and the inputs and actions needed to advance its preparation – decided. 4.9. Two web editorial workshops (Bonn, 8-10 May and 23-25 October 2007) convened by WHO gathered collaborators from four and six partner institutions. Participants had training on web content management system and advanced the ENHIS web. 4.10. ENHIS-2 final meeting (Prague, 12-14 September 2007) gathered all project partners, participating network centres and representatives of EC DG Sanco and EEA. 10
ENHIS 2: Final Technical Implementation Report
The objectives were to evaluate the deliverables vis-à-vis the objectives, to decide on the necessary follow-up actions for finalization of the deliverables by the end of October 2007 and reporting to EC DG Sanco within the three months after project termination. Feedback from potential future users of ENHIS, provided through the project partner served as a basis for the meeting to plan the work on the system in the final stage of the project. Outcomes: • Work plan ensuring synchronization among the work packages and partners and timely delivery of the products approved by all partners; • Twelve meetings carried out and reports – published, in particular the coordination meeting, mid-term review and final meetings as set in the contract; • Mid-term activity report prepared in accordance with the reporting requirements and accepted by the EC DG Sanco. • Final activity report prepared in accordance with the reporting requirements and submitted to the EC DG Sanco. Outcomes vs. deliverables: D1.1 D.1.2 D.1.3 D.1.4.
Report from the coordination meeting Report from the mid-term review meeting Mid term activity report Final activity report
Bonn, 15-16 December 2005 http://www.euro.who.int/EHindicators/Methodology/20060201_4 Granada, 09-10 October 2006 http://www.euro.who.int/document/EHI/ENHIS2_mtg_rpt_Oct_2006.pdf. Delivered to EC in January 2007, http://ec.europa.eu/health/ph_projects/2004/action1/docs/action1_2004_inter_24_e n.pdf Delivered to EC in January 2008
Evaluation: WP1 achieved the tasks set in the contract ensuring a smooth implementation of the project as well as timeliness and quality of the deliverables. All meetings as planned in Table 2.2, Annex I of the Contract – implemented.
Wok Package 2. Dissemination of Results Lead Partner: WHO European Centre for Environment and Health, Bonn Office, WHO-DK Partners involved: All project partners Activities 1. Preparation of the CEHAPE indicator-based assessment report. The report “Children’s health and the environment in Europe: a baseline assessment” is a concerted effort of all project partners and many contributors, coordinated by WHO. As the most recent data are from 2005, the assessment provides baseline spatial and time patterns of the health-environment situation in the WHO European region, focusing on children’s health and relevant policy. It demonstrates the use of EH information system established through the ENHIS projects in policy-relevant ENHIS 2: Final Technical Implementation Report
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monitoring and reporting. The assessment has been published as a WHO monograph and the results have been widely disseminated at several international forums, in particular at the intergovernmental mid-term review meeting (Vienna, 13-15 June 2007). 2. Establishment and update of the ENHIS website The www.enhis.org has been progressively developed as a platform for access and dissemination of indicators, assessments and reports using various reporting techniques (e.g. fact sheets). The information has been expanded to cover key environmental health determinants and related policies and can be accessed by country or by environmental health topic according to different levels of detail. An ENHIS logo was designed. The ENHIS web also contains key methodological guidelines on indicators, information retrieval, health impact assessment and reporting. More about the contents and functionality of the ENHIS web platform is reported under WP8. To ensure timely release of the ENHIS website two web editorial workshops were convened involving 4 and 6 partner-institutions: participants were provided training for working with web content management system and uploaded information. The ENHIS SharePoint http://enhis.ecehbonn.euro.who.int/default.aspx has been reorganized and extensively used by the project partners for exchange of data and information, e-networking and as a common project domain. More on the ENHIS SharePoint is reported under WP6. 3. Publication and dissemination of ENHIS fact sheets The 26 indicator-based assessments prepared within WP4 were supplied with a uniform leaflet-type layout and published as a set of “Facts on children’s health and the environment in Europe”. They were disseminated at the Intergovernmental midterm review meeting (Vienna, 13-15 June2 007). 4. Presentations made at international and national conferences Based on the materials prepared by the project, numerous presentations and lectures were prepared for various audiences. In particular, the ENHIS results were used for one of the plenary presentations at the IGM as well as for a presentation at the 10th Health Forum Gastein (Parallel Forum 3: Healthy Environments). The results were also presented at the meetings of the European Environment and Health Committee as well as of the Working Party on Health and the Environment of EC DG Sanco. Several presentations were made at the annual conferences of the International Society of Environmental Epidemiology and on the 4th International Conference on Children’s Health and the Environment of the INCHES network. List of publications is given in Annex 2.1 of this report, section on WP2 results. Presentations at the national forums are listed in the reports from individual countries. Outcomes • Indicator-based CEHAPE assessment report “Children’s health and the environment in Europe: a baseline assessment” Dalbokova, D, Krzyzanowski, M, Lloyd, S. (eds) World Health Organization, Copenhagen, 2007 ISBN 978 92 890 7297 7 available at www.euro.who.int/document/E90767.pdf; paper copy is enclosed • The ENHIS web site www.enhis.org - a web-based information service providing updated information on EH indicators and related analysis, showing trends in time and space, as well as access to fact sheets describing the situation and policy effects. • The collection of indicator-based assessments in a ready to disseminate format is available at www.euro.who.int/EHindicators/Publications/qryIndicatorbasedAssessments; a paper copy is enclosed 12
ENHIS 2: Final Technical Implementation Report
Outcomes vs. deliverables: D.2.1 D.2.2 D.2.3 D.2.4.
Establish and maintain ENHIS web page Report summarizing mid-term project results CEHAPE assessment report Final project report
Web page released in Sept 2006. Updates in Nov 2006, June, Sept 2007. www.enhis.org Publication of the collection of 26 indicator Fact Sheets (May 2007) available on www.euro.who.int/EHindicators/Publications/qryIndicatorbasedAssessments “Children’s health and the environment in Europe: a baseline assessment” www.euro.who.int/document/document/E90767.pdf Delivered to EC in January 2008 (see Annex 2)
Evaluation: WP2 achieved the tasks set in the contract. The indicator based CEHAPE assessment report and the ENHIS web www.enhis.org are major products of the project demonstrating the comprehensive European EH information system based on existing data in international databases. The products highlight the System use in validating, evaluating or supporting action undertaken and identify areas where resources and interventions are needed. The ENHIS products received a strong positive resonance at the IMR meeting (http://www.euro.who.int/IMR2007) thus revealing their usefulness and at the same time shaping future work directions. Work Package 3. Determine information needs of policies Lead Partner: Institute of Public Health, Kuopio, Finland (KTL-FI) Partners involved: WHO, IMPIZS, KOZPONT, FCSAI, SZU, NSPH, VASC, APAT, IPHB, MOHBG Collaborating partners: AFSSET, EC DG JRC Activities 1. Overall planning and organization of the work The scope of the ENHIS-2 WP3 work was delineated as to develop and test methodology for the identification of information needs for environmental health policies, in particular for the policies concerning children. The network of collaborating centres (NCC) contributed to the methodology development and its application for information gathering. 2. Development of an assessment framework for policy evaluation The framework includes: • requirements for defined policy objectives, • specification of policy scientific foundations and establishment of its implementation and follow up programme, • evaluation of the policy’s achievements in relation to its objectives, • feedback for policy adjustment if necessitated by the evaluation. These criteria serve, in turn, to for the identification of policy information needs. 3. Development and testing of the methodology for policy evaluation A comprehensive policy evaluation questionnaire was developed, tested, revised and applied for the assessment of national policies reflecting the four CEHAPE Regional Priority Goals in 18 countries. Seven EH topics are covered: air quality, chemical food ENHIS 2: Final Technical Implementation Report
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safety, water and sanitation, mobility and transport, UV and ionizing radiation, noise and housing. The results are summarised in a database and policy evaluation report. Based on the evaluation, four policies were selected and evaluated in depth in four countries: Bulgaria and Spain on environmental tobacco smoke, Finland – on radon and Italy – on traffic. The results of these evaluations have been reported. 4. Preparation of guidelines for generating information for policy support on the basis of the experience gained in the testing phase. Outcomes •
Methodology for identification of information needs of EH policies integrating a policy questionnaire and extended up-to-date EH policy information database. The database is accessible from the KTL web site at www.ktl.fi/portal/english/research__people___programs/environmental_health/research/air_p ollution/research_projects/enhis/ (linked to www.enhis.org). The methodology for
•
•
identification of policy information needs is presented in the section on ENHIS-2 outcomes (Annex 2.1 of this report, section on WP3 results) and is available on the SharePoint and otherwise on request to
[email protected]. Annual assessment of policy information needs with children’s relevant EH policy in the focus from 18 ENHIS-2 partner countries is available on line-by topic at www.enhis.org/object_class/enhis_policy_assessments_by_environmental_health_i.html. The four national policy case evaluation reports are accessible at www.enhis.org/object_class/enhis_National_level.html and also at http://www.enhis.org/object_class/enhis_enhis2_country_profiles.html. Guidelines for generating information for environmental health policy support are presented in the section on ENHIS-2 outcomes (Annex 2.1 of this report, section on WP3 results) and are available on the SharePoint for ENHIS partners and otherwise on request to
[email protected].
Outcomes vs. deliverables: D.3.1 D.3.2 D.3.3 D.3.4
Methodology for identification of information needs for policies Annual assessment of new information needs Guidelines for generating information for environmental health policy support Annual assessment of new information needs – part 2
Methodology prepared, tested and applied. See the report in Annex 2.1 Available on www.enhis.org Guidelines prepared, tested and applied. Published on ENHIS SharePoint. See the report in Annex 2.1 Available on www.enhis.org
Evaluation WP3 achieved its objectives. The methodology for identification of information needs in environmental health policy-making enhances the knowledge and understanding of the existing EH policies across Europe, in particular the format, objectives, rationale and follow-up mechanisms. The assessment of information needs of European and national policy enables identifying gap areas where improved monitoring and/ or further research is needed to increase policy accountability concerning population health.
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ENHIS 2: Final Technical Implementation Report
The guidelines for generating information for policy support facilitate harmonization of national EH policy. Finally the work contributes to increased policy relevance of the indicators and the results feed in the policy context and relevance of the indicator factsheets. Work Package 4. Update core set of EH indicators Lead partner: WHO European Centre for Environment and Health, Bonn Office, WHO-DK Partners involved: OEBIG, KTL-FI, NAPH, SZU, VASC, APAT, IPHB, MOHBG, FCSAI, INVS, KOZPONT, IZVA, IMPIZS, TKS, DGDS, NSPH Collaborating partners: EC DG JRC Activities 1. Development of protocol for pilot testing of the indicators The protocol was developed to cover indicator generation from international databases together with meta-data (data-about-data) information. It also included preparation of information to support indicator data such as analysis/ assessment, key message and graphical presentation; Primary data sources for the children’s EH indicators have been identified using a set of quality criteria and in particular to ensure greater country coverage and time completeness. Approach for resolving priority data gaps using case studies of volunteering country survey results has been developed as well. This work has been conducted in collaboration with WP5; 2. Conduct pilot testing Following the protocol for pilot testing and according to the available expertise in the ENHIS network of collaborating centres (WP6) teams were built to retrieve the information for assigned indicators. The pilot study was evaluated at a joint WP4, 5 and 6 technical meeting (Vienna, 26-27 June 2006) and a ‘core’ set of twenty-six EH indicators for general population and children was selected; 3. Preparation of indicator fact sheets The pilot testing teams (WP6) prepared the data for indicator fact sheets following the guidelines developed by WP8. The fact sheets present assessment of the situation per indicator, the scientific basis and policy context in a standardized and clear format which allow effective use and re-use of information. After evaluation and revision process they were included in the ENHIS information-base. The pilot testing and preparation of fact sheets proved a good capacity building effort for the network of collaborating centres. The experience gained serves national public health reporting capacity (more details in WP6 report); 4. Update of methodology for core set of indicators; define extended set of indicators and their methodology Final methodology sheets were prepared for 26 indicators using requirements from data retrieval and fact sheet preparation. The methodology for the extended set builds on the work done by the first phase of the ENHIS and by ECOEHIS projects.
ENHIS 2: Final Technical Implementation Report
15
Outcomes •
•
• •
Protocol for pilot testing of the indicators – developed and implemented The protocol is published in the interim project report, under the section “Results of the first year of ENHIS-2 implementation, WP4 (p. 98-123 at http://ec.europa.eu/health/ph_projects/2004/action1/docs/action1_2004_inter_24_en.pdf). Selected 26 indicators as a “core” set to become the core of the ENHIS information base: accessible on www.enhis.org (more details reported under WP8). Indicator fact sheets have been published as WHO documents on WHO web www.euro.who.int/EHindicators/Publications/qryIndicatorbasedAssessments Extended set defined together with methodology The methodology for the extended set has been integrated with that for the core set to form the methodological guidelines Methodology guidelines for a set of environmental health indicators are published on www.enhis.org/object_class/enhis_about_indicators.html
Outcomes vs. deliverables: D.4.1
D.4.2
D.4.3
D.4.4
Protocol for pilot testing of selected CEH indicators Summary evaluation of the tested indicators based on pilot study Definition of core set of indicators and their methodology Definition of extended set of indicators and their methodology
Published in ENHIS-2 Interim report, p. 98 – 123 http://ec.europa.eu/health/ph_projects/2004/action1/docs/action1_2004_inter_24_en.pdf
Published in ENHIS-2 Interim report, p. 125-129 http://ec.europa.eu/health/ph_projects/2004/action1/docs/action1_2004_inter_24_en.pdf
Methodology sheets for 26 core indicators available in Part A of the Methodological Guidelines available through www.enhis.org/object_class/enhis_about_indicators.html Methodology sheets for 16 indicators available in Part B of the Methodological Guidelines available through www.enhis.org/object_class/enhis_about_indicators.html
Evaluation WP4 fulfilled its objectives. The core set of indicators has been updated to cover key EH risks focusing on children’s health and the environment. The EH information base was established to enable up-to-date and targeted access by different users. The core set provides a stable and manageable basis for indicator-based assessments. The extended set defined by the project is also of policy-relevance but needs further developments and harmonization. It also requires new data flows, possibly as a result of future implementation of regulations and related reporting.
16
ENHIS 2: Final Technical Implementation Report
Work Package 5 Methods for information generation Lead partner: Partners involved:
Institute of Public Health Bucharest, Romania (IPHB) WHO, IMPIZS, INVS, TKS, VASC, DGDS, MOHB, SZU, FCSAI
Activities 1. Definition of organizational framework for exchange of relevant data Activities focused on defining organizational approaches for access and exchange of data available in the international databases and included identification of primary data source; development of the protocol for pilot testing of the indicators (in collaboration with WP4) and reaching early agreements with European data-provider agencies. EC DG Sanco assistance and the meeting (Luxembourg, 16 February 2006) gathering ENHIS-2 and the relevant Commission services such as EC DG Eurostat, JRC and EEA facilitated the implementation. 2. Retrieval of information available in the international databases Within the pilot testing of the indicators, the ENHIS network of collaborating centres (WP6) were guided for the actual data retrieval thus strengthening its capacity for preparation of the information. At the same time, an inventory of data sets necessary for the core indicators, which are available in international databases, was prepared. 3. Definition of information necessary for children’s environment and health to be collected by surveys During the pilot testing an inventory of the available survey methods was prepared. On the basis of the pilot testing evaluation and consequent selection of the core set of EH indicators at the joint WP4, WP5 and WP6 meeting (Vienna, 26-27 June 2006), the information necessary to be collected by surveys was defined. These include 12 indicators from the extended set for which data are not available from existing international surveys and therefore special survey(s) have to be developed and implemented for their generation. 4. Development of a comprehensive hands-on guidance A practical tool has been prepared to serve national and international reporting on EH tested by the ENHIS network and revised upon the feedback. It includes an inventory of the data sets available in international databases and supports generation of the core set of EH indicators addressing both general population and children. The user is provided with a step-by-step guidance for data and meta-data retrieval necessary for the core set of indicators as well as with recommendations for possible graphical presentation and analysis of the indicators. Outcomes • Hands-on guidance for retrieving information from international data sources and surveys which implies organizational approaches to data retrieval is published on www.enhis.org/object_class/enhis_about_indicators.html • Inventory of international data sources together with data availability for the children’s EH indicators for all the 53 Member States of WHO/European Region is integrated in Annex 2 of the CEHAPE indicator-based assessment report (pp.116-121 at www.euro.who.int/document/document/E90767.pdf) • Inventory of available survey methods for the core set of indicators and the information needed to be collected by new surveys for the extended set is presented in the section on ENHIS-2 results (Annex 2.1 of this report, section on WP5 results) and ENHIS 2: Final Technical Implementation Report
17
available on the SharePoint
[email protected]
and
otherwise
on
request
from
Outcomes vs. deliverables: D.5.1
D.5.2 D.5.3 D.5.4
Definition of organizational framework for exchange of relevant data available in international data bases Inventory of available survey methods for CEH indicators Data sets necessary for core indicators available in international data bases Definition of information necessary for CEH to be collected by surveys
Hands-on guidance for retrieving information from international data www.enhis.org/object_class/enhis_about_indicators.html Available in Annex 2.1 – WP5 Inventory of international data sources – Annex 2 of www.euro.who.int/document/document/E90767.pdf Available in Annex 2.1 – WP5
Evaluation WP5 fully achieved the objectives set in the contract. The core information retrieved covers the 53 Member States of the European Region of WHO. The hands-on guidelines – a comprehensive practical tool on how to generate, present and analyse indicators provide useful guidance in setting a national health and environment information system according to European harmonized methodology. Defining the information necessary for children’s EH assessments to be collected by surveys enables setting priorities for data systems and statistical activities. Work Package 6 Support to the network of collaborating centres (NCC) Lead partner: National Institute of Environmental Health, Budapest, Hungary (KOZPONT) Partners involved: WHO, IMPIZS, INVS, FCSAI, TKS, IZVA, LOEGD, OEBIG, NAPH, SZU, NSPH, VASC, APAT, IPHB, DGDS, MOHBG, ASPB Collaborating partners: EC DG JRC Activities 1. Expansion of the network of collaborating centres to include all ENHIS-2 partners Using the ENHIS SharePoint platform, communication and information exchange links were established among all ENHIS-2 project partners and partner institutions collaborating on a voluntary basis The SharePoint was reorganized to serve ENHIS-2 project and to increase its user-friendliness (in collaboration with WP2). Support was provided to the new partners in using this platform and user manual was prepared for the purpose; 2. Synchronization of the network activities ensuring contribution of the network to all ENHIS 2 WPs Through joint planning of activities, coordination and information exchange the network contributed to EH policy evaluation (WP3), implementation of the pilot testing (WP4), testing of hands-on-guidance (WP5), to health impact assessment (WP7) and evaluation of the ENHIS web usefulness (WP8). At the same time it enabled strengthening the network and also building partnership; 18
ENHIS 2: Final Technical Implementation Report
3. Implementation of the pilot testing of the children’s EH indicators Activities include coordination of information retrieval and data flows, indicator generation together with all information elements, testing the indicator methodology (WP4) and the guidelines for information retrieval (WP5) and preparation of indicator fact sheets according to the guidelines developed by WP8. Information generation for the 4 children-specific policy indicators required coordination of an extended network of more than 30 institutions. The activities significantly contributed to capacity building and training for the network to become the “backbone” of the European and national environmental health information systems; 4. Preparation of input to indicator based assessment report Besides contribution to preparation of the core information-base the network provided input to the assessment report, which includes case studies on specific environmental health issues (e.g. blood lead in children) related to the four CEHAPE regional priority goals as well as examples of national policy actions. The network also contributed to writing the thematic chapters of the CEHAPE assessment report; 5. Preparation of national fact sheets Seven partner institutions (SZU-Czech Republic; TKS-Estonia; KOZPONT-Hungary; VASC-Lithuania; IMPIZS-Poland; IPHB-Romania; NAPH-Slovakia) applied the methodology and the expertise gained and prepared 10 national fact sheets. These address children’s environmental health and safety issues related to respiratory health, exposure to outdoor airborne particles, road traffic injuries, blood lead, public water supply, and safe recreational water environments. Preparation of the national topicspecific assessments enhanced the establishment of information exchange mechanisms in the countries, strengthening partnership and involvement of relevant actors and promoting the ENHIS. It also contributed to the national capacity building. Outcomes • Operational communication and information exchange links with all the partners network: a key resource of the ENHIS system The network involves 20 partner-institutions and 6 collaborating institutions; the SharePoint user’s manual is presented in Annex 2.1 of this report, the section on WP6 results, and is available on request to
[email protected]; • Pilot testing of indicators implemented and creation of ENHIS information base The information is available at www.enhis.org -> “Environment and health issues” and “Health effects of the environment”; 26 international fact sheets - at www.euro.who.int/EHindicators/Publications/qryIndicatorbasedAssessments • Contribution to international indicator report provided “Children’s health and the environment in Europe: a baseline assessment” Dalbokova, D, Krzyzanowski, M, Lloyd, S. (eds) World Health Organization, Copenhagen, 2007 ISBN 978 92 890 7297 7 at www.euro.who.int/document/document/E90767.pdf • Set of 10 national indicator fact sheets prepared; the English abstract of the fact sheets are published on http://www.enhis.org/object_class/enhis_enhis2_country_profiles.html (select “National assessment”) and a web-link is given to the full text published on the partner institution web-site in national language. The full text is presented in the Annex 2.1 of this report, the section on WP6 results
ENHIS 2: Final Technical Implementation Report
19
Outcomes vs. deliverables: D.6.1
D.6.2
D.6.3
D.6.4
Communication and information exchange links with all NCC established and operational Pilot study of indicators defined by WP4 implemented in the partner countries Contributions to international indicator report Set of national fact sheets
SharePoint platform used by 20 partner institutions and 6 collaborating institutions. Manual in Annex 2.1 WP6 Information on 26 indicators generated with contributions from the NCC available on www.enhis.org Experts from all partner institutions actively contributing to preparation of the “Children’s health and the environment in Europe: a baseline assessment” at www.euro.who.int/document/document/E90767.pdf Set of 10 national r fact sheets prepared; English abstracts on http://www.enhis.org/object_class/enhis_enhis2_country_profiles.html
Evaluation WP6 fully achieved the objectives to build a solid European resource for putting the ENHIS methods and tools in operation while maintaining their relevance for the countries as well as to assure national capacity building and training. Work Package 7 Integrate Health Impact Assessment (HIA) Lead partner: Partners involved: ASPB, EASP
Institute of Public Health Surveillance, Saint Maurice, France (InVS) WHO, FCSAI, LOEGD, SZU, NSPH, VASC, APAT, IPHB, MOHBG,
Activities 1. Development and testing methods for health impact assessment (HIA) of indoor air pollution and noise focusing on children. The following risk factors were selected based on criteria evidence, public health importance, availability of information/ indicator and amenability to intervention: environmental tobacco smoke (ETS), solid fuel use, mould and dampness, indoor radon, traffic-related noise, blood lead level. Activities included literature review, identification of HIA methods together with specification of data needs and development of estimation algorithms. Six feasibility studies were conducted to address each selected risk factor. 2. Preparation of guidelines and HIA reports Guidelines were prepared for HIA of each of the six selected risk factors; reports were prepared for HIA of the following risk factors: ETS covering majority of the EU countries; mould and dampness, traffic noise and blood lead level at sub-national level. HIA of radon and solid fuel use are considered not feasible and information sheets on the public health importance and available scientific evidence were prepared for them instead of HIA reports. 3. Conducting health impact assessment of urban air pollution Based on methodology developed in previous EC projects, a software tool HIAir1.0 – web-based application for on-line calculation of health impact estimates of urban air 20
ENHIS 2: Final Technical Implementation Report
pollution was prepared. HIA of children’s exposure to outdoor airborne particles PM10 was conducted in majority of EU countries (together with WP6). 4. Conducting qualitative health impact assessment of drinking water pollution Taking stock of earlier work in particular the ENHIS project and involving WP6 guidelines for HIA of chemical and microbiological water pollution were prepared. The guidelines integrate several practical examples of estimating health risks of drinking water contaminants such as nitrates, trihalomethanes and microbiological pollution. 5. Preparation of relevant inputs to the project reports and dissemination Inputs on HIA were provided to indicator-based assessments/ fact sheets, in particular on children’s exposure to ETS, to outdoor airborne particles PM10 as well as to the CEHAPE assessment report chapter 3 “Clean air for health”. In collaboration with WP8 and WP2 HIA reports and guidelines for the above-mentioned six risk factors, urban air (PM10) and drinking water pollution were prepared and disseminated on the ENHIS web. Outcomes •
• •
HIA guidelines and reports/ case studies for the eight risk factors available on the ENHIS web http://www.enhis.org/object_class/enhis_healthimpactassessment.html. Detailed reports on feasibility of HIA of dampness and mould, indoor radon and traffic noise in children as well as guidelines on HIA of drinking water pollution are presented in Annex 2.1 in this report, section on WP7 results, are available on the SharePoint, and otherwise on request to
[email protected]. Health Impact Assessment of Urban Air Pollution (HIAir) software V 1.0 (on www.enhis.org/object_class/enhis_healthimpactassessment.html -> www.hiair.eu/) including on-line guidelines on how to perform the assessment and method limitations The fact sheets www.euro.who.int/EHindicators/Publications/qryIndicatorbasedAssessments and the CEHAPE assessment report www.euro.who.int/document/document/E90767.pdf.
Outcomes vs. deliverables: D.7.1 D.7.2 D.7.3 D.7.4 D.7.5
Methodological guidelines for HIA for IAQ focussing on children Report on HIA on IAQ Methodological guidelines for HIA of noise focusing on children HIA of noise completed by selected local collaborators Report from HIA of ambient air quality and water quality completed by selected collaborators
Guidelines and reports/ case studies for the 8 risk factors available on the ENHIS web http://www.enhis.org/object_class/enhis_healthimpactassessment.html Reports on HIA of ETS and on feasibility of HIA for dampness and mould and radon available in Annex 2.1 WP7 Sumamry on http://www.enhis.org/object_class/enhis_healthimpactassessment.html Reports on feasibility of HIA for noise available in Annex 2.1 WP7. Summary on http://www.enhis.org/object_class/enhis_healthimpactassessment.html Case study available on http://www.enhis.org/object_document/o4824n27773.html Health Impact Assessment of Urban Air Pollution (HIAir) software; Reports in Annex 2.1 WP7
Evaluation: WP7 fully achieved the objectives and tasks set in the contract. Methods and tools were developed for health impact assessment and integrated in the ENHIS system thus ENHIS 2: Final Technical Implementation Report
21
enabling evaluation of different policy options to reduce exposure to environmental health risk factors and assessment of new policy strategies. Health impacts of environmental tobacco smoke and outdoor airborne particles were assessed at European scale. Case studies and qualitative assessments at national/ regional scale were delivered on health impacts of dampness and mould, traffic noise, blood lead in children and drinking water pollution. Knowledge and expertise on health impact assessment of risk factors related to main environmental media and more importantly on reporting the results has increased and priority information needs to improve our assessments – highlighted. Work Package 8 Information maintenance, analysis and reporting Lead partner: National Institute for Public Health and the Environment, Bilthoven, Netherlands (RIVM) Partners involved: WHO, KTL, KOZPONT, INVS, IZVA, OEBIG, SZU, VASC, IPHB, MOHB Activities: 1. Development and implementation of key IT infrastructure elements The work builds on earlier projects and has benefited from close synergy with EUPHIX project 1 and includes the following: • Data exchange module (DEM) to support raw data collection, pre-processing and entry in the ENHIS database. The first DEM version comprised prototypes for five selected “test” (called “leading”) indicators. Based on the experience, an automatic data retrieval module was not developed for several reasons. Those include the diversity of the current IT data systems’ technologies, the necessity of involvement of EH expert in manual data validation, and related costs which would considerably outweigh the available resources of the project and any potential benefits. The tool developed comprises a collection of standardized spreadsheets for raw data collection and stored procedures as a part of the ENHIS database for the input of processed data; • Meta-data base on the data elements for the core indicators comprises the information necessary for assuring the consistent data management of the ENHIS database; • ENHIS web www.enhis.org: a structured information resource, integrating Content Management System (CMS) and database and allowing editing by authorized editors and presenting data from the underlying database. 2. Implementing the ENHIS web functionalities for a functional EH information service A specialized software ASP.net for the search function allowing accessing both the web content and the indicator data was integrated together with a graphics tool. To enable input of information and maintenance and updating of web contents by trained non-IT specialists, a Content Management System (CMS) “NetWriter” was integrated as well. The ENHIS website has been continuously evolving (in collaboration with WP2) based on the inputs from WP3-5 and WP7 and the feedback from the network of
1
EUPHIX web site http://www.euphix.org/object_document/o4581n27010.html
22
ENHIS 2: Final Technical Implementation Report
collaborating centres (WP6) with five releases since September 2006 2 and a final release in December 2007. The content of the website includes: a. Summary information for 8 environmental health issues, including comparative assessment of policy in 18 EU countries and links to relevant indicators b. Summary information for 7 environment-related health issues, including links to relevant indicators c. Detailed and structured information for 26 indicators, including interactive interfaces to indicator data in the ENHIS database and graphs d. 54 country profiles e. Health Impact Assessments f. Link to HIAir tool (WP7) g. Information about environment and health policies (national and international, including policy reviews for environmental health issues) h. Indicator methodology sheets and information retrieval guidelines i. Guidelines for preparation of indicator fact sheets j. Guidelines for writing web-texts k. Information about environment and health in Europe l. General project information m. Possibilities to export selected indicator data in Microsoft Excel format n. Search function for the web texts and the ENHIS database 3. Development of user’s manual and description of software tools The software is described in a technical report. The user manual for the ENHIS CMS is provided within the system and was accompanied by several sessions of trainings within WP2 and the network (WP6). 4. Development of guidelines for indicator-based report and other reporting tools Guidelines were developed for indicator-based assessments called fact sheets which aggregate the data, assessment and reporting per indicator. Guidelines were also developed for web-texts, charts and graphs, an overall publishing on the web. 5. Preparation of inputs to the CEHAPE assessment report Input was provided to the CEHAPE assessment report, in particular development of the outline and review of chapters as well as of selected fact sheets. Outcomes • Web-site available at two synonymous locations: http://www.ENHIS.org and http://www.ENHIS.net; • User’s manual and full technical documentation of the ENHIS web and the software is presented in Annex 2.1 of this report, section on WP8 results and is available on request to
[email protected]; • Guidelines for preparation of indicator fact-sheets and web-texts http://www.enhis.org/object_class/enhis_Environment_and_health_indicators.html; • CEHAPE assessment report – at www.euro.who.int/document/document/E90767.pdf
2
1st release in September 2006, 2nd in November 2006, 3rd - June 2007, 4th - September, and 5th - Dec 2007
ENHIS 2: Final Technical Implementation Report
23
Outcomes vs. deliverables: D.8.1 D.8.2
D.8.3 D.8.4 D.8.5
Data exchange module, ver 1 ready for testing Guidelines on indicators based report and other reporting tools Meta-data base for core indicators User manual and description of software tools Data exchange module, version 2
IT infrastructure developed and used to create 1st version of www.enhis.org in Sept 2006 Guidelines available on http://www.enhis.org/object_class/enhis_Environment_and_health_indicators.html Meta data on each of 26 indicators available on www.enhis.org (by indicator) Available in Annex 2.1 WP8 IT infrastructure developed and used to create consecutive versions of www.enhis.org in 2007
Evaluation: WP8 fully achieved its objectives: the ENHIS web site was established as a useful information resource on health and the environment allowing effective dissemination of the ENHIS methods and results. Methodology for analysis and reporting of current EH situation and trends in the context of policy put in place was prepared and applied, and capacity for using it – strengthened.
24
ENHIS 2: Final Technical Implementation Report
2. MANPOWER FOR EXECUTION OF ACTIVITIES Table 1 presents the manpower by partner institution together with the professional category level, daily rate and associated costs. Both the staff and persons working under subcontracting are listed. Table 1. Manpower involvement Partner Institution WHO-DK
Name
Professional level/ Cat
TOTAL
WHO-DK
Staff
Number of days
Unit/ rate, €
Total cost, €
1,826.69
625,546.36
911
438,897.61
M. Krzyzanowski
Project Coordinator (P5)
105.00
708.00
74,340.00
D. Dalbokova
Senior Scientist (TL P4)
380.00
514.11
195,360.19
R. Bertollini
Director (D1)
4.00
794.00
3,176.00 10,620.00
R. Aertgeerts
Regional Advisor (P5)
15.00
708.00
F. Racioppi
Senior scientist (P4)
15.00
596.00
8,940.00
N. Besbelli
Senior scientist (P4)
20.00
596.00
11,920.00
R. Kim
Senior scientist (P4)
20.00
596.00
11,920.00
M. Braubach
Scientist (P1)
30.00
496.00
14,880.00
L. Nemer
Scientist (P3)
30.00
496.00
14,880.00
H. Takasawa
Scientist (P2)
30.00
496.00
14,880.00
V. Taylor-Gee
Web Manager (P4)
4.00
596.00
2,384.00
N. di Tanno
Technical Officer (C6)
40.00
496.00
19,840.00 7,440.00
S. Kahlmeier
Scientist (P3)
15.00
496.00
D. Sethi
Scientist (P4)
15.00
496.00
7,440.00
C. Schweizer
Scientist (P2)
5.00
496.00
2,480.00
W. Maus
IT administrator (C5)
20.00
201.07
4,021.35
C. Gapp
Informatics Specialist (P3)
40.00
660.58
13,211.54
C. Pasztor
Programme assistance C4
75.00
165.71
12,428.07
A. Rhein
Programme assistance C5
8.00
250.00
2,000.00
40.00
168.41
W. Williams WHO-DK
Programme assistance C4
Sub-contracted
915.69
6,736.46 186648.85
RIVM (E. Lebret)
Junior res./experts (Knol, Nugteren, van Overveld)
99.00
189.44
18,754.77
Hajo Zeeb
Medium level researcher
5.00
205.39
1,026.96
Rosemary Bohr
Editor
37.50
125.39
4,702.21
M.J. Carroquino
Medium level researcher
10.00
164.95
1,649.47 1,314.57
K. Pond
Medium level researcher
8.00
164.32
K. Polanska
Junior researcher
5.00
128.27
641.34
J. Tuomisto
Senior researcher
7.00
232.98
1,630.83
B. Kuna
Medium level researcher
7.00
167.74
1,174.20
J. Heinrich
Medium level researcher
10.00
184.08
1,840.81
O. Solevag
Medium level researcher
10.00
181.03
1,810.30
I. Miettinen
Medium level researcher
5.00
167.74
838.72
Laziosanita (C. Clini)
Medium level researchers (S. Farchi, Dr Camilloni)
20.00
166.40
3,328.02
F. Kozisek
Medium level researcher
20.00
166.40
3,328.02
20.00
166.40
3,328.02
RIVM (E. Lebret)
Medium level researcher Senior researcher (E. van Kempen)
20.00
184.84
3,696.87
G. Paludan-Mueller
Technical designer
13.00
138.33
1,798.34
U. HaverinenShaughnessy
ENHIS 2: Final Technical Implementation Report
25
RIVM (E. Lebret)
Senior res. (Staatsen), junior researchers/experts (Knol, van Overveld, Nugteren, Scheurs, de Bruin)
S. Lloyd
Junior researcher
C. Stiller
Senior researcher
K. Patja
A. Ramirez
Senior researcher Scientist/info procurement (P3) External expert / junior researcher
Wendy Williams
Secretarial assistance (C4)
C. Gapp
MOHBG-BG
TOTAL Staff
4,326.42
2.00
228.80
457.60
20.00
184.07
3,681.44
143.94
267.00
38,431.35
78.64
267.00
20,997.02
141.61
191.00
27,047.78 10,824.00
451.00
10,824.00
Senior researcher (Cat. 1)
79.00
24.00
1,896.00
Sevdalina Topalova
Senior researcher (Cat. 1)
17.00
24.00
408.00
Ivan Kupov
Senior researcher (Cat. 1)
77.00
24.00
1,848.00
Masha Gavrailova
Senior responsible (Cat. 1)
75.00
24.00
1,800.00
Hristina Mileva
Senior responsible (Cat. 1)
65.00
24.00
1,560.00
Irina Kovacheva
Senior responsible (Cat. 1)
65.00
24.00
1,560.00
Nana Nikolova
Senior responsible (Cat. 1)
35.00
24.00
840.00
Maria Nenova
Senior responsible (Cat. 1)
22.00
24.00
528.00
Dimitar Dimitrov
Senior responsible (Cat. 1)
8.00
24.00
192.00
Georgi Uzunov
Senior responsible (Cat. 1)
8.00
24.00
192.00
TOTAL
146.3 Staff
123,951.07
146.3
92,614.80
A van Overveld
Junior expert
10.70
573.00
6,131.10
A Knol
Junior expert
34.70
573.00
19,883.10
B Staatsen
Senior researcher (Cat. 1)
36.20
800.00
28,960.00
DJ Griffioen
Junior expert
9.60
573.00
5,500.80
R Nugteren
Junior expert
21.40
573.00
12,262.20
C Ameling
Junior expert
1.00
573.00
573.00
J de Bruin
Junior expert
9.50
573.00
5,443.50
R Schreurs
Junior expert
6.70
573.00
3,839.10
A Roedig
Junior expert
3.30
573.00
1,890.90
O vd Kuij
Junior expert
4.90
573.00
2,807.70
R van Leeuwen
Junior expert
1.50
573.00
859.50
T van Alphen
Junior expert
4.00
573.00
2,292.00
E Lebret
Senior scientist (Cat. 1)
2.50
800.00
2,000.00
0.30
573.00
C Vros RIVM-NL
Junior expert Sub-contracted
n/a
171.90 31,336.27
Be Value
Website programming Editing texts website
n/a n/a
9,002.35
Text editor Be Value
Website programming
n/a
3,717.56
Be Value
Website programming
n/a
471.24
Be Value
Website programming
n/a
12,409.32
Be Value
Website programming
n/a
3,570.00
TOTAL
ASPB-ES
26
40,843.79
110.93
Momchil Sidjimov
RIVM-NL
ASPB-ES
210.54
39.00
451.00
MOHBG-BG
RIVM-NL
194.00
Staff
2,165.80
159.70
38,078.00
159.70
38,078.00
M. Gonzalez-Cabré
Senior res (cat 1)
80.00
320.00
N. Valero
junior expert
67.70
140.00
9,478.00
R. San José
Assistance
12.00
250.00
3,000.00
ENHIS 2: Final Technical Implementation Report
25,600.00
EASP-ES
TOTAL
EASP-ES
Staff Senior responsible (Cat. 1)
123.00
287.92
35,414.16
Alejandro López Ruiz
IT expert (Cat. 1)
123.00
275.70
33,911.10
Julia Gómez Ruiz
Secretarial assistance
22.00
153.00
3,366.00
Sub-contracted IT expert / design web page
Solinsur Informática S.L,U
IT expert / web page development
Miguel Angel Espinosa
Guidelines/database revision/literature revision
Juan Pedro Arrebola
Guidelines/database revision/literature revision
TOTAL Staff
6,023.90
245.00
112.00
27,440.01
68.00
136.34
9,271.12
192.00
136.34
26,177.28 18,221.99
163.00
11,979.51
Senior responsible (Cat. 1)
29.00
106.14
3,078.06
F. Kozisek
Medium level researcher
16.00
76.84
1,229.44
L. Skalova
Medium level researcher
2.00
70.74
141.48
P. Pumann
Junior expert
5.00
55.42
277.10
A. Batariova
Junior expert
5.00
43.17
215.85
J. Kratenova
Medium level researcher
20.00
72.84
1,456.80
V. Puklova
Medium level researcher
86.00
64.89
5,580.78
Sub-contracted
73.17
6,242.48
K. Knetl
Technical director
3.00
316.24
948.72
H. Sebakova
Senior responsible (Cat. 1)
9.00
111.11
999.99
J. Kubina
Medium level researcher
23.00
85.22
1,960.06
F. Kozisek
Medium level researcher
2.64
76.85
202.88
P. Pumann
Junior expert
2.74
55.42
151.85
L. Skalova
Medium level researcher
1.43
70.74
101.16
A. Batariova
Junior expert
2.35
43.17
101.45
J. Kratenova
Medium level researcher
1.39
72.84
101.25
V. Puklova
Medium level researcher
15.62
64.89
1,013.58
K. Zgafas
Technical manager
10.00
56.83
568.30
B. Suk
Technical manager
2.00
46.62
TOTAL Staff Juri Ruut Staff
93.24
62.00
4,650.00
62.00
4,650.00
Project leader (cat 1)
TOTAL
APAT-IT
62.00
75.00
4,650.00
659.00
68,332.00
179.00
28,252.48
Ernesto Vocaturo
Senior res (cat 1)
44.00
415.42
Jessica Tuscano
Junior expert
31.00
83.09
2575.79
Sonja Luce
Secretarial assistance
55.00
66.5543
3660.49
Giorgia Lisi
Secretarial assistance
49.00
76.28
APAT-IT
Sub-contracted
480.00
18,278.48
3737.72 40,079.52
Robert Usala
Junior expert
240.00
96.69
23,205.60
Silvia Giardina
Junior expert
240.00
70.31
16,873.92
TOTAL
415.07
NSPH-GR
Staff
49,900.00
308.57
N. Kasitris
Project leader (Cat. 1)
G. Zervas
Senior engineer (Cat. 2) Environmental chemist (Cat. 2)
Olga Cavoura NSPH-GR
164.00
R. Kubinova
TKS-EE
NSPH-GR
68,912.31
36.73
236.17
SZU-CZ
APAT-IT
541.73
Aficonta S.L.
SZU-CZ
TKS-EE
141,603.57 72691.26
Piedad Martín-Olmedo
EASP-ES
SZU-CZ
809.73 268.00
Sub-contracted
32,500.00 100.00
143.07
14,307.00
58.57
75.00
4,393.00
150.00
92.00
13,800.00
106.50
17,400.00
A. Katsiri
Project main investigator
67.50
200.00
13,500.00
I. Damikouka
Junior Environmental
10.00
100.00
1,000.00
ENHIS 2: Final Technical Implementation Report
27
Chemist
IMPISZ-PL
A. Damikouka
Junior Water Engineer
I. Mantziaras
Policy expert
TOTAL
IMPIZS-PL
Staff
158.00
9,450.00 94.50
60.00
5,670.00
47.00
60.00
2,820.00
Zbigniew Rudkowski
Senior
5.00
100.00
500.00
Aleksandra Barwicka
Secretarial assistance
2.00
40.00
80.00
Marzena Strzelec
Secretarial assistance
9.50
40.00
380.00
11.00
50.00
550.00
3.30
100.00
330.00
9.90
100.00
990.00
0.80
60.00
48.00
23.00
60.00
1,380.00
11.50
60.00
690.00
Sub-contracted
59.5 Junior expert / translations Scientists / senior researcher Scientists / senior researcher
K. Rzepka
Scientists / translation Scientist / medium level researcher Scientist / medium level researcher
M. Strzelec K. Zagalski Catering national workshop 25/10/07
4,220.12
232.12
TOTAL
113.71
KTL-FI
Staff
33,799.54 113.71
33,799.54
Eva Kunseler Piipp, Anna-Maija
Medium level researcher Secretarial assistance
54.81 1.50
319.98 176.69
17,538.09 265.04
Jokinen, Sanna-Maria
Secretarial assistance
31.60
180.23
5,695.41
Jantunen, Matti
National official
25.80
399.26
TOTAL
VASC-LT
Staff
10,301.00
488.00
16,104.00
406.00
12,824.00
Ingrida Zurlyte
Senior researcher (Cat. 1)
139.00
40.00
5,560.00
Liuda Ciesiuniene
Junior expert
57.00
22.00
1,254.00
Natalija Sliachtic
Junior expert
12.00
22.00
264.00
Viktorija Andreikenaite
Secretarial assistance
27.00
16.00
432.00
Aida Laukaitiene
Medium level researcher
62.00
35.00
2,170.00
Roma Bartkeviciute
Medium level researcher
10.00
35.00
350.00
Vytautas Silickas
Senior researcher (Cat. 1)
10.00
40.00
400.00
Genadijus Jonauskas
Medium level researcher
14.00
35.00
490.00
Regina Burbiene
Medium level researcher
10.00
35.00
350.00
D. Bagdanaviciute
Junior expert
12.00
22.00
264.00
Daiva Beciene
Secretarial assistance
40.00
16.00
640.00
Ramune Meiziene
National official
13.00
50.00
VASC-LT
Sub-contracted R. Zidelyte
82.00 Translator
TOTAL Staff
82.00
40.00
Senior res. (Cat 1)
Charlotte Wirl
Junior expert
TOTAL
16,800.00 4.00
420.00
1,680.00
54.00
280.00
15,120.00
182.00
IZVA-SL
Staff dr.Peter Otorepec
18,999.45
182.00 Senior res. (Cat 1)
3,280.00 16,800.00
58.00
Gerhard Fülöp
650.00 3,280.00
58.00
OEBIG-AT
28
1,900.00 13,670.12
Medium / responsible
D. Jarosinska
IZVA-SL
100.00
217.5
Medium
J. Hałuszka
OEBIG-AT
19.00
1,000.00
Beata Dąbkowska
A. Anczyk
VASC-LT
100.00
Maja Muszyńska Graca
IMPIZS-PL
KTL-FI
10.00
18,999.45 48.80
165.13
8,058.34
Katarina Bitenc
Analyst Researcher
54.60
73.80
4,029.48
Boštjan Krek
Analyst Researcher
33.80
73.03
2,468.47
Pia Vračko
Researcher
37.80
105.39
3,983.74
Laura Šušteršič Zorn
Secretarial assistance
7.00
65.63
459.41
ENHIS 2: Final Technical Implementation Report
FCSAI-ES
TOTAL
FCSAI-ES
NAPH-SK
Staff
236,097.04
735.98
236,097.04
Alejandro Ramírez
Medium level researcher
113.94
325.00
37,030.36
María José Carroquino
Medium level researcher
90.88
325.00
29,537.14
Elena Boldo
Senior researcher
329.16
291.00
95,784.54
Manuel Posada
National official
43.00
490.00
21,070.00
Luís Soldevilla
Senior researcher
29.00
490.00
14,210.00
María Jose Carroquino
Med level res. (3/7/0731/10/07)
101.00
355.00
35,855.00
Cristina Campos
Secretarial assistance
20.00
90.00
1,800.00
Juana Rubio
Secretarial assistance
9.00
90.00
TOTAL
NAPH-SK
Staff
810.00
286.00
18,314.54
246.00
10,940.00
Mrs Halzlova
Senior researcher (Cat. 1)
26.00
125.00
3,250.00
Mrs MikulcikovaEstokova
Medium level researcher
40.00
40.00
1,600.00
Ms Slovakova
Medium level researcher
120.00
40.00
4,800.00
Mr Jajcaj
Software administrator
10.00
39.00
390.00
Mrs Savinova
Junior expert
30.00
30.00
900.00
Ms Slovakova
Secretariat
20.00
25.00
NAPH-SK
Sub-contracted
40.00
500.00 7,374.54
Eduard Chalas
Expert on Police Headquarters of SR
1.25
83.93
104.91
Milos Janousek
Medical Doctor, UVZ SR
1.25
83.93
104.91
Vladimir Jurina
Head of Department of Radiation Protection
1.25
83.93
104.91
Martin Kapasny
Director of Regional Office of Public Health - Zilina
2.50
83.93
209.83
6.25
83.93
524.56
2.50
83.93
209.83
Kvetoslava Koppova
INVS-FR
735.98
Elena Mogonova
Medical Doctor, RUVZ BB Expert on Bathing Water Quality, Public Health Authority
Katarina Slotova
Expert on Indoor Air Quality, RUVZ BB
5.00
83.93
419.65
Rudolf Haas
External Programmer
10.00
284.80
2,847.97
Stanislav Bandzi
External Interpreter
10.00
284.80
2,847.97
TOTAL
INVS-FR
Staff
504.00
214,680.85
504.00
214,680.85
G. Brücker
Director (Cat.1)
1.00
645.80
645.80
M. Ledrans
Director of Environmental Health Unit (Cat.1) (on the 1st year of the program)
1.00
425.65
425.65
G.Salines
Director of Environmental Health Unit (Cat.1) (on the 2nd year of the program)
2.00
450.98
901.96
S.Medina
Project leader (Cat.1)
200.00
499.33
99,866.73
A.Le Tertre
senior statistician (Cat.1)
80.00
427.15
34,172.18
K..De Proft
Admin and Financial Assistant (Cat.3)
60.00
168.75
10,125.27
F. Dor
Epidemio /monitoring unit Indoor Air (Cat.1) (on the 1st year of the program)
15.00
483.56
7,253.33
Ph. Bretin
Epidemio (Cat.1) (on the 2nd year of the program)
40.00
523.75
20,949.93
P. Germonneau
Epidemio /monitoring unit Noise (Cat.1) (on the 1st year of the programme)
10.00
335.86
3,358.62
ENHIS 2: Final Technical Implementation Report
29
Epidemio (Cat.1) (on the 2nd year of the program)
O. Catelinois
KOZPONT-HU
60.00
454.12
20.00
240.54
TOTAL
369.00 Staff
4,810.72 24,195.00
312.50
21,935.00
A. Paldy
senior researcher
62.00
100.00
6,200.00
P. Rudnai
senior researcher
30.00
100.00
3,000.00
M.Benyi
senior researcher
11.00
100.00
1,100.00
T.Malnasi
medium level researcher
120.00
60.00
7,200.00
M. Varró
medium level researcher
17.00
60.00
1,020.00
B.Somogyi
junior expert
31.00
50.00
1,550.00
E. Novak
junior expert
20.50
50.00
1,025.00
K.Balintfy
Secretarial assistance
21.00
40.00
840.00
computer assistant
56.50
40.00
2,260.00
Sub-contracted
56.50
TOTAL
LOEGD-DE
Staff
2,260.00
322.00
85,240.00
158.00
44,240.00
Dr Rainer Fehr
Senior res
12.50
360.00
4,500.00
Dr Odile Mekel
Senior res
111.00
300.00
33,300.00
Heinrich Huhmann
Researcher
11.50
300.00
3,450.00
Adelheid Kraft
Secretarial assistance
23.00
130.00
LOEGD-DE
Sub-contracted
164.00
Thomas Classen
Junior expert
Sarah Sierig
Junior expert
TOTAL
IPHB-RO
Staff
2,990.00 41,000.00
94.00
250.00
70.00
250.00
23,500.00 17,500.00
818.00
22,580.00
766.00
20,770.00
Adriana Galan
Project leader
240.00
20.00
4,800.00
Aurelia Marcu
Senior responsible (Cat. 1)
131.00
40.00
5,240.00
Emilia Niciu
Head of EH Unit
5.00
40.00
200.00
Cristian Talea
Director
55.00
30.00
1,650.00
Bogdan Stolica
Director
55.00
30.00
1,650.00
Florin Popovici
Head of Epidemiology Unit
10.00
40.00
400.00
Alexandra Cucu
Senior (Cat. 1)
143.00
30.00
4,290.00
Cristina Chirita
Junior expert
62.00
20.00
1,240.00
Constanta Proca
Financial assistance
10.00
20.00
200.00
Maria Radulescu
Secretarial assistance
40.00
20.00
800.00
Steluta Harabagiu
Secretarial assistance
10.00
20.00
200.00
Carmen Lazar
Secretarial assistance
5.00
20.00
IPHB-RO
Sub-contracted
52.00
100.00 1,810.00
Daniel Mihai
Scientists / info proc (STP P2)
27.00
30.00
810.00
Eugenia Bratu
Senior res (cat A)
25.00
40.00
1,000.00
TOTAL
523.00
DGDS-PT
Staff
35,956.00
256.00
L. Farrapa
Secretarial assistance
A. Tavares
Head of Env. Health Unit
C. Amaral
Med level researcher
P. Diegues
Med level researcher
C. Weigert
Med. Level researcher
DGDS-PT
30
27,247.04
Epidemio (Cat.1) Junior epidemiologist (Cat.2)
E. Baranyi
DGDS-PT
4,923.64
P. Pirard
KOZPONT-HU
IPHB-RO
328.24
M. Pascal KOZPONT-HU
LOEGD-DE
15.00
Sub-contracted
19,724.00 106.00
49.00
10.00
109.00
1,090.00
130.00
96.00
12,480.00
5.00
96.00
480.00
5.00
96.00
267.00
5,194.00
480.00 16,232.00
E.Casimiro
Medium level researcher
62.00
96.00
5,952.00
R.Vilão
Medium level researcher
5.00
96.00
480.00
R. Cardoso
Assistant
200.00
49.00
9,800.00
ENHIS 2: Final Technical Implementation Report
GRAND TOTAL P-D
1,741,065.00
9385.57
Eight tables – 2.1 to 2.8 present for each work package the manpower involved, specifying the activities executed and days by each person.
Table 2.1 Activities executed by the manpower for WP1 Partnerinstitution TOTAL
WHO-DK
Name
Activities executed
605
TOTAL
405
STAFF
TOTAL Management and coordination of the project implementation
75
D. Dalbokova
Technical management and coordination of the project Preparation of project technical and activity reports
120
C. Pasztor
Assistance to the project management and coordination Organizational preparation of the project meetings
60
A. Rhein
Assistance to the project management and coordination
8
Wendy Williams
TOTAL Assistance to the project management and coordination Organizational preparation of the project meetings
10 TOTAL
Masha Gavrailova
Coordination and management of the activities
10 TOTAL Coordination and management of the activities
2
B Staatsen
Coordination and management of the activities
8
TOTAL
10 TOTAL Coordination and management of the activities
10 TOTAL
R. Kubinova
Coordination and management of the activities
10 TOTAL
Piedad Martin Olmedo
Coordination and management of the activities
10
STAFF
APAT-IT
10 10
TOTAL
Juri Ruut
10 10
TOTAL STAFF
TKS-EE
10 10
TOTAL STAFF
EASP-ES
10
A Knol
STAFF Manuel GonsalezCabre
SZU-CZ
10 10
TOTAL STAFF
ASPB-ES
142 142
TOTAL STAFF
RIVM-NL
263
M. Krzyzanowski
SUB-CONTRACTED
MOHBG-BG
Days
WP1
TOTAL Coordination and management of the activities
TOTAL
10 10
10
ENHIS 2: Final Technical Implementation Report
31
STAFF
TOTAL
Ernesto Vocaturo
NSPH-GR
Coordination and management of the activities
TOTAL
10
STAFF
TOTAL
N. Kasitris
IMPIZS-PL
Coordination and management of the activities
10 TOTAL Coordination and management of the activities
10 TOTAL
Matti Jantunen
Coordination and management of the activities
10 TOTAL
Ingrida Zurlyte
Coordination and management of the activities
10 TOTAL
Charlotte Wirl
Coordination and management of the activities
10 TOTAL
Peter Otorepec
Coordination and management of the activities
10 TOTAL
Manuel Posada
Coordination and management of the activities
10 TOTAL
Katarina Halzlova
Coordination and management of the activities
10 TOTAL
Sylvia Medina
Coordination and management of the activities
10 TOTAL
Anna Paldy
Coordination and management of the activities
10 TOTAL
Odile Mekel
Coordination and management of the activities
10 TOTAL
Adriana Galan
Coordination and management of the activities
10 10
TOTAL
10
STAFF
TOTAL
Antonio Tavares
32
10 10
TOTAL STAFF
DGDS-PT
10 10
TOTAL STAFF
IPHB-RO
10 10
TOTAL STAFF
LOEGD-DE
10 10
TOTAL STAFF
KOZPONT-HU
10 10
TOTAL STAFF
INVS-FR
10 10
TOTAL STAFF
NAPH-SK
10 10
TOTAL STAFF
FCSAI-ES
10 10
TOTAL STAFF
IZVA-SL
10 10
TOTAL STAFF
OEBIG-AT
10 10
TOTAL STAFF
VASC-LT
10 10
TOTAL STAFF Maja Muszyńska Graca
KTL-FI
10 10
Coordination and management of the activities
ENHIS 2: Final Technical Implementation Report
10 10
Table 2.2 Activities executed by the manpower for WP2 Partnerinstitution TOTAL
WHO-DK
Name
Days 1091
TOTAL STAFF M. Krzyzanowski
TOTAL Preparation of the indicator-based assessment report Topic-specific input to the report Chapter 3 on health and air quality Dissemination of the ENHIS system and products
481 234 17
D. Dalbokova
Preparation of the indicator-based assessment report: coordination Topic-specific input to the report Chapters 2 and 4 Scientific review and editing of the report Input to the development of ENHIS web Dissemination of the ENHIS system and products
80
R. Bertollini
Dissemination of the ENHIS system and products
4
R. Aertgeerts
Dissemination of ENHIS indicators Topic-specific input to the report, Chapter 1
9
F. Racioppi
Topic-specific input to the Report Chapter 2
10
R. Kim
Topic-specific input to the report chapter 4 on child labour
5
N. Besbelli
Topic-specific input to the report chapter 4 on chemical EH hazards and safety Dissemination of the ENHIS report and related products
7
M. Braubach
Topic-specific input to the report chapter 3 on indoor air quality information Topic-specific input to the Report: case studies of child-specific policy actions Topic-specific input to the Report chapter 1: information on water and health Dissemination of ENHIS results on WHO web
10
N. Di Tanno
Dissemination of ENHIS at IMR Input to the ENHIS web structure and navigation
10
S. Kahlmeier
8
D. Sethi
Topic-specific input to the Report Chapter 2 section mobility and physical activity Topic-specific input to the Report Chapter 2
W. Maus
Dissemination of the ENHIS results on WHO web
5
C. Gapp
Development of ENHIS web
15
L. Nemer H. Takasawa V. Taylor-Gee
7 5 4
10
C. Pasztor
Administrative support to preparation of the report
5
W. Williams
Administrative support to preparation of the report and its dissemination
23
SUB-CONTRACTED
TOTAL
247
Rosemary Bohr
Editing of 25 fact sheets
38
M.J. Carroquino
Verification of coverage of EU policy documents in all the fact sheets
10
O. Solevag
10
I. Miettinen
Contribution to policy section of chapter 3 and review all policy sections of the Report Preparation of the fact sheet on outbreaks of water-borne diseases
F. Kozisek
Preparation of HIA of drinking water pollution
20
U. HaverinenShaughnessy S. Lloyd
Review and input to HIA of mould and dampness
20
Scientific revision on the CEHAPE assessment report and fact sheets
39
Final revision of the section on childhood leukaemia of the CEHAPE assessment report Contribution to HIA of environmental tobacco smoke
2
C. Stiller K. Patja
EASP-ES
Activities executed
WP2
5
20
H. Zeeb
Contribution to the CEHAPE assessment report section on UV radiation
5
A. Ramirez
Gathering information on case studies related to children’s EH issues for the Report; Information processing and analysis
79
TOTAL
10
STAFF
TOTAL
Piedad Martín-Olmedo
Contribution to the preparation and revision of Chapter 1 (clean water) and Chapter 3 ( clean air and health) of the CEHAPE assessment report
ENHIS 2: Final Technical Implementation Report
10 10
33
NSPH-GR
TOTAL
50
STAFF
TOTAL
N. Kasitris
Coordination of national activities
10
Olga Cavoura
Reporting
20
SUB-CONTRACTED A. Katsiri
VASC-LT
TOTAL Contribution to chapter 1 of the CEHAPE assessment report
103 TOTAL
Ingrida Zurlyte
50
Liuda Ciesiuniene Aida Laukaitiene
Preparation of dissemination materials on national level
9
Daiva Beciene
Technical assistance for project activities
16
R. Zidelyte
TOTAL Contribution to translation and editing English and Lithuanian texts related to the WP activities
TOTAL
6
Input to the national dissemination activities on public health reporting
2
National dissemination activities on ENHIS
4
58
TOTAL TOTAL
58
Peter Otorepec
Technical management of the national activities in ENHIS project, Preparing National CEHAP report
20
Boštjan Krek
Cooperation on HIA on air pollution and drinking water pollution Preparing National CEHAP report
15
Pia Vračko
Elaborating of HIA document on Chemical Pollution Preparation of National CEHAP report
20
Laura Šušteršič Zorn
Secretarial assistance
3
49
TOTAL TOTAL
49
Alejandro Ramírez
Revision of ENHIS 2 deliverables Organization of a National meeting for presentation of ENHIS results
20
María José Carroquino
Review of ENHIS 2 deliverables Organization of a National meeting for presentation of ENHIS results
24
Manuel Posada
Organization of a National meeting for presentation of ENHIS results
5
126
TOTAL STAFF
TOTAL
126
Katarina Halzlova
Coordination and management of national activities
16
Milada MikulcikovaEstokova Gabriela Slovakova
Input to the national dissemination activites
10
Creation of national fact sheet on bathing water quality Preparation of information about drinking and recreational water Input to ENHIS web
50
Technical support for SharePoint and the web-page
10
Mr Jajcaj
34
9
Charlotte Wirl
STAFF
IPHB-RO
9
Gerhard Fülöp
STAFF
NAPH-SK
19
6
TOTAL STAFF
FCSAI-ES
69
Contribution to development of fact sheets and editorial work on factsheets; involvement in dissemination activities Technical management of national activities Technical support on fact-sheets development
SUB-CONTRACTED
IZVA-SL
20 20
TOTAL STAFF
OEBIG-AT
30
Mrs Savinova
Preparation of information for ENHIS web
30
Ms Slovakova
Secretarial assistance
10
208
TOTAL
ENHIS 2: Final Technical Implementation Report
STAFF
TOTAL
183
Adriana Galan
Preparation of the fact sheet on CEHAPE RPGII; revision of fact sheets; Revision of Chapter 2 of the CEHAPE assessment report
40
Alexandra Cucu
Preparation of fact sheets; revision of Chapter 1 of the CEHAPE assessment report Review of relevant national policies
143
SUB-CONTRACTED Eugenia Bratu
TOTAL Literature review for the national fact sheets
25 25
Table 2.3 Activities executed by the manpower for WP3 Partnerinstitution TOTAL WHO-DK
Name
Activities executed
1414.96
TOTAL
21
STAFF
MOHBG-BG
TOTAL
21
D. Dalbokova
Input to the development of framework for assessment of policy information needs Review of the guidelines and assessment results
10
L. Nemer
Input to policy assessment with child-specific legislation
8
N. di Tanno
Input to publication of assessment on the ENHIS web
3
TOTAL
378
STAFF
APAT-IT
Days
WP3
TOTAL
378
Momchil Sidjimov
Contribution to development of questionnaire on policies to reduce & ban passive smoking
29
Sevdalina Topalova
Information gathering for the policy database and country information for two policy indicators.
17
Ivan Kupov
Implementation of a case study on ETS incl. “on field” measurements of CO concentrations in indoor air of public closed areas belonging to the hospitality sector, as well as CO concentrations in expired air of the employees; Analyzes and reporting.
77
Masha Gavrailova
Management of the overall input to WP3 Contribution with information on the relevant national EH policies
65
Hristina Mileva
Technical advice on national policy analysis Information gathering for the policy database and information needs for 5 national policies
52
Irina Kovacheva
Information gathering for the policy database and information needs for 5 national policies
65
Nana Nikolova
Information gathering for the policy database and information needs for 2 national policies
35
Maria Nenova
Support and input to the organizational management of the national activities and financial aspects of the ENHIS 2 implementation in the country
22
Dimitar Dimitrov
Preparation of a national case study
8
Georgi Uzunov
Input to data retrieval for national policies
8
TOTAL
245
STAFF
TOTAL
53
Ernesto Vocaturo
Technical management of the national working group contributing to WP3
12
Jessica Tuscano
Drawing up questionnaires in collaboration with national experts; Preparation of technical input reports
11
Sonja Luce
Administrative support
10
Giorgia Lisi
Secretarial assistance
20
SUB-CONTRACTED
ENHIS 2: Final Technical Implementation Report
TOTAL
192
35
NSPH-GR
Roberta Usala
Administrative support and secretarial assistance
96
Silvia Giardina
Administrative support and secretarial assistance
96
TOTAL
72
STAFF
TOTAL
58
N. Kasitris
Technical management of the national working group contributing to WP3
18
Olga Cavoura
Assessing information on content, goals and implementation degree of EH policies in Greece for policy questionnaire
40
SUB-CONTRACTED I. Mantziaras
IMPIZS-PL
TOTAL Collecting information on content, goals and implementation degree of EH policies in Greece for policy questionnaire regarding water policies and air pollution
TOTAL
43.5
STAFF
TOTAL Completion of the policy questionnaire for Poland Information retrieval on environment and health policies in Poland
10
Zbigniew Rudkowski
Information on EH policies in Poland
4
M. Strzelec
Input and assessment of the information retrieved on EH policies in Poland
TOTAL
Piipp,o Anna-Maija
Planning and implementation of the technical activities Coordination of various inputs of the partners and preparation of technical reports Technical support for reporting
54.81 1.5
Technical assistance for reporting. Financial and travel arrangements
31.6
Technical management of WP3, planning of activities and reporting
15.8
TOTAL
6 TOTAL Collection of information for the EH policy questionnaire
SUB-CONTRACTED R. Zidelyte
2 2
TOTAL Contribution to translation and editing of English and Lithuanian texts related to WP3
TOTAL
4 4
20
STAFF
TOTAL
Charlotte Wirl
Implementation of WP3 activities in Austria: identifying relevant experts, providing support and ensuring input on EH policies in Austria
TOTAL
20 20
106
STAFF
TOTAL
106
Alejandro Ramírez
Support to WP3 activities in Spain
13
María José Carroquino
Coordination of national inputs to the EH policy database Preparation of case study on the national tobacco control policy
25
Manuel Posada
Coordination of WP3 activities in Spain
10
Luís Soldevilla
29
Cristina Campos
Technical management of the national working group on WP3 and input to reporting Administrative support
Juana Rubio
Secretarial assistance
9
TOTAL
20
16.25
STAFF
36
103.71
Jantunen, Matti
D. Bagdanaviciute
NAPH-SK
15
Jokinen, Sanna-Maria
STAFF
FCSAI-ES
15
103.71 TOTAL
Eva Kunseler
OEBIG-AT
14.5
TOTAL
STAFF
VASC-LT
28.5
Maja Muszyńska Graca Beata Dąbkowska
SUB-CONTRACTED
KTL-FI
14 14
TOTAL
ENHIS 2: Final Technical Implementation Report
10
Mrs MikulcikovaEstokova
Input to data retrieval for national policies
SUB-CONTRACTED
KOZPONT-HU
TOTAL Identification of information needs of national policies on injuries
1.25
Milos Janousek
Identification of information needs of national policies on radiation
1.25
Vladimir Jurina
Identification of information needs of national policies on radiation
1.25
Martin Kapasny
Identification of information needs of national policies on chemical safety
2.5
TOTAL
40.5 TOTAL
A. Paldy T. Malnasi E. Novak
Contribution to the assessment of information needs on EH policies in Hungary Contribution to the assessment of information needs on EH policies in Hungary Collection of information on policies in Hungary
TOTAL TOTAL
Heinrich Huhmann
Literature search and documentation
SUB-CONTRACTED Thomas Classen
10 10 20.5
3 3
TOTAL Conducting the survey on EH policies in North-Rhine Westphalia
15 15
TOTAL
141
STAFF
DGDS-PT
40.5
18
STAFF
IPHB-RO
6.25
Eduard Chalas
STAFF
LOEGD-DE
10
TOTAL
141
Aurelia Marcu
Review of relevant policies and input to the questionnaire for RO
131
Florin Popovici
Review of relevant policies and input to the questionnaire for RO
10
TOTAL
204
STAFF
TOTAL
103
L. Farrapa
Secretarial assistance
53
C. Amaral
Background material for the ENHIS policy indicators Planning and technical management of the WP3 working group
40
P. Diegues
Background material for the ENHIS policy indicators
5
C. Weigert
Background materials for the ENHIS policy indicators
5
SUB-CONTRACTED
TOTAL
101
E.Casimiro
Case study on chemicals and human bio-monitoring
31
R. Cardoso
Technical assistance with information processing
70
Table 2.4 Activities executed by the manpower for WP4 Partnerinstitution TOTAL WHO-DK
Name
Activities executed
Days
WP4
1720
TOTAL
260
STAFF
TOTAL
M. Krzyzanowski
Topic-specific input to air quality and health indicator methodology; Preparation of fact sheet on children’s exposure to outdoor airborne particles
ENHIS 2: Final Technical Implementation Report
203 8
37
D. Dalbokova
Development of the protocol for pilot testing of the indicators; Coordination of various inputs to the indicator development and application; Preparation of guidelines for methodology of a set for EH indicators; Coordination of the preparation of indicator fact sheets; Scientific review of the fact sheets
80
R. Aertgeerts
Topic-specific input to the indicator methodology and harmonization with UNECE/ WHO water and health protocol
6
F. Racioppi
Topic-specific input to the indicator methodology and harmonization with UNECE/WHO THE PEP; Scientific review of 2 fact sheets
5
N. Besbelli
Topic-specific input to the indicator methodology and international data sources for human bio-monitoring; Input to the preparation of fact sheets on chemical hazards indicators
10
R. Kim
Input to the preparation of the fact sheet on work injuries in children
8
M. Braubach
Preparation of the fact sheets on mould and dampness exposure ;Input to the fact sheets on housing safety policies
20
L. Nemer
Input to the preparation of the fact sheets on children’s environmental tobacco smoke exposure and policies
10
H. Takasawa
Input to the preparation of the fact sheets on children’s environmental tobacco smoke exposure and policies
25
S. Kahlmeier
Input to the preparation of the fact sheet on physical activity
7
D. Sethi
Review of the fact sheets on injuries in children
5
C. Schweizer
Review of the fact sheet on ETS exposure
5
W. Williams
Secretarial assistance
14
SUB-CONTRACTED
MOHBG-BG
TOTAL Input to FS for RPG1
8
K. Polanska
Input to fact sheet on work injuries
5
J. Tuomisto
Contribution to 2 fact sheets on chemical hazards in food
7
B. Kuna
Revision of fact sheet on asthma and allergies in children
7
J. Heinrich
Revision of fact sheet on asthma and allergies in children
10
Laziosanita (C. Clini)
Revision of FS on RPG2
20
TOTAL
54
STAFF
SZU-CZ
TOTAL Contribution to FS on RPG3
45
Hristina Mileva
Case study on PbB in BUL
9
TOTAL
120 TOTAL Coordination of the national Working Group activities and of pilot testing
L. Skalova
Background materials for ENHIS policy indicators
2
P. Pumann
Cooperation on HIA on drinking water pollution
5
A. Batariova
Case study on Blood lead level in children in CZ
5
V. Puklova
Collaboration on the fact sheets on RPG3
19
45 TOTAL
44
J. Kubina
Elaborating of index indicators reflecting the degree of EH policies implementation in CZ
23
L. Skalova
Background materials for ENHIS policy indicators
1
A. Batariova
Testing data availability for indicator POPs in human milk in CZ
2
V. Puklova
Testing data availability for indicators Bathing water management and Waterborne diseases in CZ
16
B. Suk
Technical support
2
TOTAL
12
STAFF Juri Ruut
TOTAL Contribution to FS on RPG1
12 12
TOTAL
217
STAFF
38
76
R. Kubinova
SUB-CONTRACTED
APAT-IT
54
Momchil Sidjimov
STAFF
TKS-EE
57
K. Pond
TOTAL
ENHIS 2: Final Technical Implementation Report
49
Jessica Tuscano
Screening of data, indicator implementation
10
Sonja Luce
Adm support
10
Giorgia Lisi
Adm support
SUB-CONTRACTED
NSPH-GR
Screening of data, indicator implementation
84
Silvia Giardina
Screening of data, indicator implementation
84
TOTAL
148 TOTAL Technical management
18
G. Zervas
Background material for policy implementation
40
Olga Cavoura
Contribution to the FS on RPG1
50 TOTAL
Contribution to the FS on RPG1
25
A. Damikouka
Elaborating of index indicators reflecting the degree of EH policies implementation in Greece
10
I. Mantziaras
Testing data availability for indicators
5
TOTAL
36 TOTAL
Maja Muszyńska Graca
29
Preparation of FS for RPG2
18
Beata Dąbkowska
Preparation of FS for RPG2
10
Zbigniew Rudkowski
Preparation of FS for RPG2
SUB-CONTRACTED
1 TOTAL
7
M. Strzelec
Sect assistance
4
K. Zagalski
Extraction of data for POL
3
TOTAL
150
STAFF
TOTAL
116
Ingrida Zurlyte
Technical management of VASC activities in the ENHIS2 project; contributed to methodology sheets refinement for core and extended set of indicators
39
Aida Laukaitiene
Contribution to refinement of methodological sheet of 2 indicators from core set and 4 indicators from extended set
26
Roma Bartkeviciute
Contributed with information for EH policy indicators
10
Vytautas Silickas
Contributed with information for EH policy indicators
10
Regina Burbiene
Contributed with information for EH policy indicators
10
Daiva Beciene
Technical assistance for project activities
14
Ramune Meiziene
Contributed with information for EH policy indicators
SUB-CONTRACTED R. Zidelyte
7 TOTAL
Contribution to translation and editing English and Lithuanian texts related to the WP activities
TOTAL
34 34
41
STAFF
FCSAI-ES
40
A. Katsiri
STAFF
IZVA-SL
108
N. Kasitris
SUB-CONTRACTED
VASC-LT
168
Roberta Usala
STAFF
IMPIZS-PL
29 TOTAL
TOTAL
41
dr.Peter Otorepec
Contribution to FS on RPG3 and RPG4
19
Pia Vračko
Contribution to FS on RPG4
18
Laura Šušteršič Zorn
Secretarial assistance
4
TOTAL
111
STAFF
TOTAL
Alejandro Ramírez
Selection of the core set of indicators (feasibility and pilot study). Updating the core of indicators. Preparation of indicator fact sheets in RPG2. Participation in the preparation of documents for publication
ENHIS 2: Final Technical Implementation Report
111 56
39
NAPH-SK
María José Carroquino
Selection of the core set of indicators (feasibility and pilot study). Updating the core of indicators. Preparation of indicator fact sheets in RPG2. Participation in the preparation of documents for publication.
53
Manuel Posada
Coordination of partner activities
2
TOTAL
114
STAFF
TOTAL
Mrs MikulcikovaEstokova
Retrieval of data and testing indicators
10
Ms Slovakova
Collection of data for Outbreaks of WBD; Cooperation on FS for RPG1 and RPG4
70
SUB-CONTRACTED Kvetoslava Koppova
KOZPONT-HU
TOTAL
6
Elena Mogonova
Information for FS RPG1
3
Katarina Slotova
Information for FS RPG4
5
Rudolf Haas
Translation of FS
10
Stanislav Bandzi
IT support
10
TOTAL
111 TOTAL review of international assessment report
5
P. Rudnai
production of blood lead level fact sheet
26
M. Benyi
testing methods of data collection
11
T. Malnasi
contribution to the production of fact sheets: Policies to reduce children’s exposure to tobacco smoke methodology review and update
40
Computer assistant
29
E. Baranyi
29
TOTAL
17
STAFF Dr Odile Mekel
Sarah Sierig
9
TOTAL
8
9
Support to indicators development and review
8
TOTAL
20
STAFF
TOTAL
Adriana Galan
Refining indicator methodology
20 20
TOTAL
309
STAFF
TOTAL
L. Farrapa
Secretarial assistance
C. Amaral
Background info for policy indicators
SUB-CONTRACTED
40
TOTAL Support to indicators development and review
SUB-CONTRACTED
DGDS-PT
82
A. Paldy
SUB-CONTRACTED
IPHB-RO
34
Contribution to FS RPG4
STAFF
LOEGD-DE
80
53 90 TOTAL
E.Casimiro
Case study on POPs in human milk
R.Vilão
Background material for policy indicators
R. Cardoso
Technical assistance
ENHIS 2: Final Technical Implementation Report
143
166 31 5 130
Table 2.5 Activities executed by the manpower for WP5 Partnerinstitution TOTAL
Name
Activities executed
458.0
WHO-DK
TOTAL
WHO-DK
D. Dalbokova
15
ASPB-ES
TOTAL
Staff
TOTAL
15
Input to the preparation of the hands-on guidance for information retrieval
15
5
Staff
TOTAL
N. Valero
SZU-CZ
Search availability of air pollution data and ETS exposure in international databases
TOTAL TOTAL
V. Puklova
Input to the hands-on-guidance for data retrieval; data availability for indicators for WHO/European region countries
TOTAL
Juri Ruut
TOTAL
15
Input to the hands-on guidance for data retrieval for bathing water quality; testing data availability
15
TOTAL
22
Sub-contracted A. Katsiri
IMPIZS-PL
TOTAL Contribution to data retrieval from international data sources
46 TOTAL Revision of the hands-on guidance for data retrieval
22
Beata Dąbkowska
Revision of the hands-on guidance for data retrieval
12
Aleksandra Barwicka
Secretarial assistance
2
Marzena Strzelec
Secretarial assistance
10
TOTAL
19 TOTAL
Ingrida Zurlyte
Contribution to data retrieval and check for RPG1 core set of indicators and amendments for finalization of hands-on guidance document
TOTAL
19 19
27
Staff
KOZPONT-HU
46
Maja Muszyńska Graca
Staff
FCSAI-ES
13 22
TOTAL Staff
VASC-LT
10 10
15
Staff
NSPH-GR
5 5
10
STAFF
TKS-EE
Days
WP5
TOTAL
27
Alejandro Ramírez
Review and feedback on the hands-on guidance
5
María José Carroquino
Input to the preparation of the hands-on guidance; verification and revision of the guidance document
21
Manuel Posada
Review and feedback on the hands-on guidance
1
TOTAL
20
Staff
TOTAL
20
A. Paldy
Testing hands-on guidelines, data accessibility
5
T. Malnasi
Testing hands-on guidelines, data accessibility
15
ENHIS 2: Final Technical Implementation Report
41
IPHB-RO
TOTAL
279
Staff
TOTAL
252
Adriana Galan
WP5 coordination, preparation of technical and activity reports for WP5; data retrieval and check RPG2 core set of indicators
150
Cristina Chirita
Information retrieval from international data sources, contributes to the preparation of the ENHIS database
62
Maria Radulescu
Editorial work for the hands-on guidance
40
Sub-contracted Daniel Mihai
TOTAL Data retrieval analysis
27 27
Table 2.6 Activities executed by the manpower for WP6 Partnerinstitution TOTAL WHO-DK
Name
Activities executed
WP6
1090.0
TOTAL
104.00
STAFF
MOHBG-BG
TOTAL Cooperation in the organization of production of fact sheets and national fact sheets, update methodologies
60
N. Besbelli
Chemical safety expertise
3
N. di Tanno
Information support
3
W. Maus
Technical IT support
15
C. Gapp
Coordination of IT activities
10
C. Pasztor
Secretarial support
10
W. Williams
Secretarial support
3
TOTAL
9 TOTAL Production of fact sheets on Infant mortality from respiratory diseases; Proportion of children living in homes using solid fuels
5
Hristina Mileva
Data analysis and reporting
4
TOTAL
20 TOTAL
Juri Ruut
Contribution to questionnaire on RPG2 & RPG4
162 TOTAL
42
Ernesto Vocaturo
Coordination of working group
12
Jessica Tuscano
Screening of policy information; data collection.
10
Sonja Luce
Administrative support
SUB-CONTRACTED
20 TOTAL
120
Roberta Usala
Screening of policy information; data collection.
60
Silvia Giardina
Screening of policy information; data collection.
60
TOTAL
87.6
STAFF
42
20 20
TOTAL STAFF
NSPH-GR
9
Momchil Sidjimov
STAFF
APAT-IT
104
D. Dalbokova
STAFF
TKS-EE
Days
TOTAL
ENHIS 2: Final Technical Implementation Report
87.6
IMPIZS-PL
N. Kasitris
Co-author of the 2nd chapter of international assessment report, Production of fact sheet on Wastewater treatment and access to improved sanitation; Review and update of methodology No 1.1., 1.2., 1.3., 1.5., 1.7;Data collection on 4 policy indicators; Organization of the fulfilment of national policy assessment
G. Zervas
Dissemination of ENHIS results
18.6
Olga Cavoura
Dissemination of ENHIS results
30
TOTAL
80
STAFF
TOTAL
Maja Muszyńska Graca Beata Dąbkowska
A. Anczyk
28
Dissemination of ENHIS results; Preparation of national FS
14 TOTAL
Translation of ENHIS material; assistance with national workshop Analysis of EH situation, RPG3
3.3
D. Jarosinska
Analysis of EH info in Poland
9.9
K. Rzepka
Translation of ENHIS material;
0.8
M. Strzelec
Update of policy relevance of Air_E2 FS in PL
4
K. Zagalski
Identification of data sources on injuries and accidents
9
TOTAL
174 TOTAL Contribution to collection information on national EH policies; to revision on national fact sheet
21
Liuda Ciesiuniene
Collection of information and presentation for the national fact sheet
38
Natalija Sliachtic
Checking possibilities to contribute with national data to the case studies related to water
7
Viktorija Andreikenaite
Technical assistance for project activities
27
Aida Laukaitiene
Development of the national fact sheet
26
Daugale Bagdanaviciute Daiva Beciene
Contribution to development of national fact sheet
10
Technical assistance for project activities
10
R. Zidelyte
TOTAL Contribution to collection information on national EH policies; revision of national fact sheet
TOTAL TOTAL
Charlotte Wirl
Production of fact sheet on Prevalence of asthma and allergies in children; Review and update of methodology No. 3.1., 3.11.; Data collection on 4 policy indicators; Organization of the fulfilment of national policy assessment
TOTAL
20 20
38.4
STAFF
TOTAL
38.4
Katarina Bitenc
Testing feasibility and applicability of indicators
19.6
Boštjan Krek
Testing feasibility and applicability of indicators
18.8
TOTAL
8
STAFF
NAPH-SK
35 35
20
STAFF
FCSAI-ES
139
Ingrida Zurlyte
SUB-CONTRACTED
IZVA-SL
38 11
J. Hałuszka
STAFF
OEBIG-AT
42
Dissemination of ENHIS results Preparation of national FS
SUB-CONTRACTED
VASC-LT
39
TOTAL
8
Alejandro Ramírez
Pilot study on indicators; National meeting on ENHIS
3
María José Carroquino
Pilot study onindicators; National meeting on ENHIS
3
Manuel Posada
coordinating pilot study of indicators
2
TOTAL
20
STAFF
TOTAL
ENHIS 2: Final Technical Implementation Report
20
43
Mrs MikulcikovaEstokova Ms Slovakova
KOZPONT-HU
Hands-on data retrieval; testing data availability in SVK
10
Secretarial assistance
10
TOTAL
178
STAFF
TOTAL coordination of network, producing national factsheet, dissemination of the results of ENHIS at national level
27
P. Rudnai
contribution to production of national factsheet on prevalence of asthma and allergy
4
T. Malnasi
contribution of building the network, and its coordination, production of guidelines for SharePoint, ,and the national factsheet, organising the activity of national factsheet preparation of other members
50
M. Varró
contribution of the preparation of national factsheet
17
B. Somogyi
contribution to the adjustment of SharePoint
31
K. Balintfy
technical support
21
SUB-CONTRACTED E. Baranyi
LOEGD-DE
TOTAL IT assistant
28 28
TOTAL
29
STAFF
TOTAL
18
Dr Rainer Fehr
Supporting network at the meetings
5
Dr Odile Mekel
Network building in NRW
13
SUB-CONTRACTED
IPHB-RO
150
A. Paldy
TOTAL
11
Thomas Classen
Network building in NRW
2
Sarah Sierig
Network building in NRW
9
TOTAL
160
STAFF
TOTAL
Adriana Galan
Prepared/retrieved info the files to feed EHIS database, developed a Romanian fact sheet
160 20
Emilia Niciu
Contributed to the preparation of Vienna meeting
5
Cristian Talea
Coordinated the dissemination of results at national level
55
Bogdan Stolica
Coordinated the dissemination of results at national level; revised the Romanian Fact Sheet
55
Constanta Proca
Financial assistance
10
Steluta Harabagiu
Financial assistance
10
Carmen Lazar
Personnel assistance
5
Table 2.7 Activities executed by the manpower for WP7 Partnerinstitution TOTAL WHO-DK
Name
Activities executed
2198.6
TOTAL
22
STAFF
TOTAL
M. Krzyzanowski
44
Days
WP7
Contribution to HIA technical reports on outdoor air pollution
22.0 5.0
D. Dalbokova
Contribution to HIA technical reports on ETS
5.0
R. Kim
Contribution to HIA technical reports on noise
7.0
L. Nemer
Contribution to HIA technical reports on ETS
5.0
ENHIS 2: Final Technical Implementation Report
ASPB-ES
TOTAL
144.7
STAFF
EASP-ES
TOTAL Technical advise on HIA outdoor air pollution reports
70.0
N. Valero
Preparation of technical reports on outdoor air pollution; Contribution to the HIAir software and guidelines; Test for Barcelona; PM case study
62.7
R. San José
Preparation of technical reports on outdoor air pollution
12.0
TOTAL
779.7
STAFF
TOTAL Epidemiological coordination for the development of the HIAir software; Test for Seville; Collaboration on HIA technical reports on drinking water pollution; PM case study
93.00
Alejandro López Ruiz
Information Technology coordination for the development of the HIAir software
123.0
Julia Gómez Ruiz
Secretarial work
Software development
36.7
Software development
245.0
International Database revision on air quality and health data for HIA calculations
68.0
Contribution to the HIAir software and guidelines; Test for Seville; preparation of technical reports on outdoor air pollution
192.0
TOTAL
81.0 TOTAL
67.0
F. Kozisek
Preparation of HIA technical reports on drinking water pollution
16.0
J. Kratenova
Case study on HIA of damp and moulds and respiratory symptoms in children
20.0
V. Puklova
Preparation of HIA technical reports on mould and dampness
31.0
SUB-CONTRACTED
TOTAL
14.0
F. Kozisek
Preparation of HIA technical reports on drinking water pollution
2.6
J. Kratenova
Case study on HIA of damp and moulds and respiratory symptoms in children
1.4
K. Zgafas
Secretarial assistance
10.0
TOTAL
25.0
STAFF
TOTAL
25.0
Ernesto Vocaturo
Coordination of working group
10.0
Sonja Luce
Secretarial assistance
15.0
TOTAL
10.0
SUB-CONTRACTED A. Katsiri
FCSAI-ES
541.7
Solinsur Informática S.L,U Miguel Angel Espinosa
STAFF
NSPH-GR
22.0 TOTAL
Aficonta S.L.
Juan Pedro Arrebola
APAT-IT
238.0
Piedad Martín-Olmedo
SUB-CONTRACTED
SZU-CZ
144.7
M. Gonzalez-Cabré
TOTAL Case-study on HIA of drinking water pollution
10.0 10.0
TOTAL
422.1
STAFF
TOTAL
422.1
Alejandro Ramírez
Preparation of technical reports on feasibility of HIA on Solid Fuel Use
15.9
Elena Boldo
WP7 technical co- management; Elaborate and review guidelines to develop the HIA methodology for environmental risk factors; Preparation of HIA technical reports on ETS; Contribute to the development of HIAir (online routine tool to conduct HIA on outdoor air pollution)
329.2
Manuel Posada
Technical advise on all HIA activities conducted in WP7; Contribute to the coordination and implementation of HIA in collaboration with the network of national centres
12.0
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45
María Jose Carroquino
INVS-FR
Preparation of HIA technical reports on Blood lead levels; Development of methodology for HIA study on blood lead levels
TOTAL
494.0
STAFF
LOEGD-DE
65.0
TOTAL
494.0
G.Brücker
General management / supervision
M.Ledrans
General management / supervision
1.0 1.0
G.Salines
General management / supervision
2.0
S.Medina
WP7 leader: coordination and review of all HIA activities within WP7
190.0
A.Le Tertre
Biostatistical supervision of the HIAir applications
80.0
K..De Proft
Adminsitrative assistant
60.0
F.Dor
Expert for indoor air phase one
15.0
Ph.Bretin
Expert for HIA blood lead levels
40.0
P.Germonneau
Expert for noise phase one
10.0
O.Catelinois
Expert for HIA radon in dwellings
15.0
P.Pirard
Preparation of technical reports on feasibility of HIA on radon in dwellings
60.0
M.Pascal
Review of final WP7 deliverables
20.0
TOTAL
243.0
STAFF
TOTAL
118.0
Dr Rainer Fehr
Supervising HIA feasibility study on road traffic noise
7.5
Dr Odile Mekel
Coordination of HIA technical reports on road traffic noise; Development of methodology for HIA study on road traffic noise
79.0
Heinrich Huhmann
Research assistance
8.5
Adelheid Kraft
Secretarial assistance
23.0
SUBCONTRACTED
TOTAL
125.0
Thomas Classen
Preparation of HIA technical reports on road traffic noise until 01-04-2007
77.0
Sarah Sierig
Preparation of HIA technical reports on road traffic noise since 01-042007
48.0
Table 2.8 Activities executed by the manpower for WP8 Partnerinstitution TOTAL WHO-DK
Name
Activities executed
785.10
TOTAL
518.94
STAFF
TOTAL
D. Dalbokova
Information outline Input to the organization of information for web publishing
24.00
C. Gapp
Development of ENHIS database and data exchange module
15.00
TOTAL
369.94
RIVM (E. Lebret)
Information supply, editing
99.00
RIVM (E. Lebret)
Information supply, editing
20.00
G. Paludan-Mueller
Information supply, editing
13.00
RIVM (E. Lebret)
CMS development
194.00
C. Gapp
Data model and architecture
143.94
TOTAL
136.43
STAFF
46
49.00 10.00
N. di Tanno
Sub-contracted
RIVM-NL
Days
WP8
TOTAL
136.43
A van Overveld
Website design, CMS, text editing, factsheet editing, guidelines development
10.70
P Fischer
Database management
0.63
ENHIS 2: Final Technical Implementation Report
A Knol
EASP-ES
Website design, CMS, text editing, factsheet design, guidelines development; WP project management
32.70
D Houthuijs
IT support
0.25
Irene van Kamp
IT support
1.25
B Staatsen
Text editing and harmonization, factsheet editing, guidelines development; WP project management
28.20
DJ Griffioen
Database module developer
9.60
R Nugteren
CMS and database programming, CMS training, website development
21.40
C Ameling
Web site release
1.00
J de Bruin
Web site release, CMS training
9.50
R Schreurs
Web site development and web site release
6.70
A Roedig
CMS training
3.30
O vd Kuij
Website release
4.90
R van Leeuwen
Website release
1.50
T van Alphen
IT support
4.00
E Lebret
Information supply, editing
2.50
C Vros
Information supply, editing
0.30
TOTAL
10.00
STAFF
TOTAL
Piedad Martín-Olmedo
SZU-CZ
Commenting and testing the web page
15.74 TOTAL
V. Puklova
Data retrieval support
Sub-contracted
TOTAL
3.00
P. Pumann
Data retrieval support
2.74
TOTAL
5.00 TOTAL Support for darta retreival to the ENHIS web pages
15.00 TOTAL
15.00
N. Kasitris
Technical management of the NSPH activities in ENHIS project
5.00
Olga Cavoura
Support for darta retreival to the ENHIS web pages
10.00
TOTAL
3.00
Staff
TOTAL
Maja Muszyńska Graca Beata Dąbkowska
3.00
Content supply web site
2.00
Content supply web site
1.00
TOTAL
26.00
Staff
TOTAL
26.00
Genadijus Jonauskas
Support for data retreival to the ENHIS web pages
14.00
Ramune Meiziene
Support for data retreival to the ENHIS web pages
6.00
Mrs Savinova
OEBIG-AT
5.00 5.00
TOTAL Staff
VASC-LT
5.74
Data retrieval support
Juri Ruut
IMPIZS-PL
10.00 10.00
K. Knetl
Staff
NSPH-GR
10.00
TOTAL Staff
TKS-EE
10.00
6.00
TOTAL
2.00
Staff
TOTAL
Gerhard Fülöp
Commenting and testing the web page
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2.00 2.00
47
IZVA-SL
TOTAL
35.00
Staff
35.00
Katarina Bitenc
FCSAI-ES
Support for data retrieval to the ENHIS web pages
TOTAL
3.00
Staff
KOZPONT-HU
TOTAL Content supply web site
María José Carroquino
Content supply web site
1.00
Manuel Posada
Content supply web site
1.00
1.00
TOTAL
10.00 TOTAL
10.00
A. Paldy
Commenting and testing the web page
5.00
T. Malnasi
Commenting and testing the web page
5.00
TOTAL
5.00
Sub-contracted Sarah Sierig
48
3.00
Alejandro Ramírez
Staff
LOEGD-DE
35.00
TOTAL Support for data retrieval to the ENHIS web pages
ENHIS 2: Final Technical Implementation Report
5.00 5.00
3. BENEFICIARIES INVOLVED Table 3 below provides an overall assessment of the actual situation of the partners’ involvement in each of the eight work packages. In ‘bold’ are the person-days (P-D) for those work packages for which the corresponding partner institution is the WP leader. The number of the person-days per WP and partner institution reflects the total person-days i.e. both of the staff and the sub-contracted. It can be noted that all partners have been actively involved in the project implementation and have contributed to the preparation of both methodological deliverables as well as of the information products. Some partners have indicated that they have also contributed to work, which has not been charged to the project. Example is KTL-FI contribution to the policy context and relevance of the indicator fact sheets under WP2 and WP4. In addition the contribution of the collaborating partners AFSSET and EC DG JRC is not shown on the table. Considerable number of partner-institutions has been actively participating in the network of collaborating centres. Their involvement and the networking have been instrumental to advance the indicator-based assessment and reporting and the web platform for information dissemination. Table 3: Beneficiaries involved, work distribution Person-days charged WP1
WP2
WP3
WP4
WP5
WP6
WP7
WP8
WHO-DK MOHBG-BG RIVM-NL ASPB-ES SZU-CZ EASP-ES TKS-EE APAT-IT NSPH-GR IMPIZS-PL KTL-FI VASC-LT OEBIG-AT IZVA-SL FCSAI-ES NAPH-SK INVS-FR KOZPONT-HU LOEGD-DE IPHB-RO DGDS-PT
405 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10
481
21 378
260 54
15
104 9
22
519
Sum WP
605
1091
Sum partner
Partner institution
136 120
5 10
145 81 780
10
50
103 6 58 49 126
12 217 148 36
22 46
150
19
106 16
41 111 114
27
41 18 141 204
111 17 20 309
1415
1720
245 72 44 104 6 20
15
20 162 88 80 174 20 38 8 20
25 10
422
16 10 5 15 3 26 2 35 3
494
208
20
243
10 5
279
178 29 160
458
1090
2222
785
ENHIS 2: Final Technical Implementation Report
1827 451 146 160 237 810 62 659 415 219 114 488 58 182 736 286 504 370 322 818 523 9386
49
4. COUNTRIES INVOLVED This section summarizes the activities conducted to make available the results in each of the countries involved. More details can be found in Annex 2.2 which contains excerpts from the reports prepared by the ENHIS 2 partner institutions on dissemination activities in the country. Partner institutions conducted activities on the dissemination of the ENHIS results in each of the eighteen countries involved. They used for the purpose variety of communication channels and mostly convening meetings or seminars involving regional and local public health professionals. The stakeholder involvement depended on the organization and infrastructure of the country health system. For example, in Austria the meeting gathered representatives from the federal provinces dealing with public health reporting and the social insurance; in Bulgaria, Estonia, Germany – NRW, Slovakia, Slovenia – professionals from regional inspectorates and local health authorities. In several countries (e.g. Austria, Czech Republic, Finland, Greece, Hungary, Spain, Slovakia, Slovenia, etc) ENHIS results were disseminated at multisectorial meetings. Together with EU policy processes the Budapest process and the CEHAPE action programme were important drivers in Austria, Lithuania, Poland and Slovenia. All those events highlighted the benefits in providing a harmonized methodology and good practice examples in policy-oriented monitoring and reporting. Concrete recommendations and follow-up actions focus on the implementation of the ENHIS methods e.g. indicators, health impact assessment, policy analysis, and tools in a national context (Bulgaria, Czech Republic, Estonia, Germany – NRW) as well as strengthening relevant inter-institutional mechanisms (Austria, Czech Republic, Spain). The three ENHIS 2 partner institutions from Spain have joined their efforts and organized a common meeting involving professionals and policy makers at different administrative levels to set implementation of the ENHIS system as a priority action of the National EH Action Plan. The need for training of the public health professionals, and in particular those involved in preparation of the EH information for national use, with ENHIS methods and tools has been emphasized. It is worth mentioning the IPHB (Romania) experience in conducting a training workshop on health impact assessment introducing the ENHIS methods and the HIAir tool in the framework of WHO collaborative project. ENHIS methods have been incorporated in postgraduate training module for the public health specialization in the National School of Public Health at the Athens University. In most of the countries the ENHIS benefits were demonstrated using the information-base i.e. the indicators and related fact sheets, the baseline assessment report on children’s health and the environment and the ENHIS web. In order to best demonstrate the country use of ENHIS partner institutions in Czech Republic, Estonia, Hungary, Italy, Lithuania, Poland, Portugal, Romania, Slovakia and Slovenia have prepared national indicator-based assessments applying the ENHIS methods. The Public Health Institute (KTL) in Finland has convened a workshop on indoor radon involving policy-makers from the Ministry of Environment, of Social Affairs and Health, the Radiation and Nuclear Safety Authority and the municipal health authority of Tampere to evaluate gaps and information needs for the policy development, implementation and evaluation using ENHIS methodology. ENHIS results have been disseminated at several national forums to reach scientific and professional communities. They have also been communicated at relevant international 50
ENHIS 2: Final Technical Implementation Report
forums e.g. the International Society for Environmental Epidemiology, and details are given in Annex 2.1, the section of work package 2 (WP2). Two more country examples come from Belgium and the United Kingdom collaborating on ENHIS on a voluntary basis. In follow-up of meeting to discuss the baseline assessment report and the country profiles on ENHIS indicators held in Belgium after the IMR a working group has been established to deal with EH indicators with the Scientific Institute of Public Health at the core. The Health Protection Agency is leading a collaborative initiative with the West Midlands Public Health Observatory and local and regional government to pilot the ENHIS indicators focusing on the local dimension as a basis for a national system which will enable comparison between and within HPU geographies. All partner-institutions have used the WWW technology to disseminate the ENHIS programme and achievements. All institution web-sites have a brief explanatory text in national language and link to the www.enhis.org. The KTL (Finland) web-site hosts the policy information database created within ENHIS 2. The international indicator-based assessments have been translated to national language (e.g. in Slovakia) and other countries plan to do so and to publish them on the institution web-sites together with the national fact sheets.
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5. ACHIEVEMENT OF OBJECTIVES The most important achievement of the ENHIS 2 project is the integration of policy analysis, data on various health and environment aspects and tools for assessment and reporting. The project was able to link diverse sources of information and various technical disciplines, and formulated succinct, policy-relevant messages suitable for various user groups – including general public, environmental and health managers, decision-makers and scientists. The outputs are based on the most recent reviews of scientific evidence and on the most reliable data from existing data bases. At the same time, the requirement to limit the additional data collection for the purpose of the system was fulfilled. The system is supporting with information the four Regional Priority Goals of the Children Environment and Health Action Plan for Europe (CEHAPE), agreed by the 4th Ministerial Conference on Environment and Health in Budapest, and is open for further topics of policy and scientific interest. The work on the project involved wide group of partners from public health, environmental management and academic institutions in EU countries, and provided a framework for participation in the system to other WHO/Euro member states. Active participation of the partners in the project provided good opportunity for capacity building and the basis for a sustainable continuation of the network in the future. The developments were assessed from technical point of view at 8 key meetings involving experts from 8-29 countries. Policy relevance of the work was reviewed through the discussions with the representatives of the Member States at the meetings of the Working Party on Health and Environment, of CEHAPE Task Force and of the European Environment and Health Committee. Presentation of the results at high-level public health conferences, including Intergovernmental Midterm Review meeting involving high level representatives of all WHO/Euro Member States, confirmed the direction of the work. Publication of WHO documents, journal articles, presentations at national and international conferences increased visibility of the project and its methods. The web-site created by the project becomes a standard information resource of public health professionals. The following paragraphs document achievement of specific objectives set in point 1.4 of the Grant Agreement, Annex 1. •
Policy analysis conducted by ENHIS 2 serves to identify the format and contents of the information needs and define the policy-relevant indicators according to the methodology developed by the ENHIS projects. An inventory of EU and national policies in the context of CEHAPE RPGs was also created and is available through the www.enhis.org . The information needs and gaps for each thematic policy area contribute to the “Policy context and relevance” section of the fact sheets.
•
Environmental health indicators serve as the main tools for monitoring the situation and trends in countries and for communicating with a wide range of users. The indicators focus on environmental factors most relevant to health, health outcomes most influenced by the environment, and policy action deemed to reduce and prevent the risks. A core set of 26 indicators was selected during a process involving multiple working groups and consultations, using the criteria of scientific credibility, a focus on children’s EH and relevant policy action such as CEHAPE, and feasibility. ENHIS methodological guidelines for the indicators giving the rationale, definition, required data elements, calculation method, data sources, interpretation and policy-relevance are integrated in the system. An information base has been created for the 26 children’s EH indicators using
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ENHIS 2: Final Technical Implementation Report
international databases, case studies based on surveys in selected countries and examples of child-specific policies. •
Methods and tools allowing the use of information from existing national and international data bases were developed, tested and applied in creation of the ENHIS data base. More than 15 data bases were accessed. The hands-on guidelines are a part of methodological documentation available on the ENHIS web site.
•
The network of partner-institutions is an important mechanism for the operation of ENHIS, currently involving 25 project partners and collaborating institutions. The ENHIS network has provided substantial input for information gathering and data flows for the 26 indicators, in particular to case studies on specific environmental health issues related to the four CEHAPE RPGs, as well as examples of national policy activities. The network members were responsible for the preparation of 23 indicator-based fact sheets, thus strengthening existing capacities for EH information processing, analysis and reporting. Establishment of the SharePoint project has facilitated the exchange of information and networking. The network members from 7 countries prepared national analysis using ENHIS approaches, demonstrating its applicability and usefulness on national level.
•
Health impact assessment methods were developed and applied to the selected EH risk factors for outdoor (PM10 particles and ozone) and indoor (ETS and mould and damp in the home) air pollution. The assessment results were integrated into the indicator fact sheets. Methods and guidelines on HIA for other factors, such as noise, were prepared and published, and will facilitate implementation of HIA when appropriate data sets are available.
•
Information is disseminated via a web-based platform which brings together data, indicators and related trends in time and space, fact sheets describing the situation for each indicator and showing the potential health benefits of action and interventions, and links to relevant information resources. Users can access and search the information base on a theme of their particular interest at http://www.enhis.org . It should be emphasized that the electronic infrastructure and in particular data- and meta-data (“data-about-data”) base and data exchange modules require further development and specialized resources for their maintenance and update in the future.
•
Reporting methods and tools for indicator fact sheets and periodic indicator-based assessments were designed for decision-makers. They provide evidence clearly and concisely to support the development of action which benefits public health and the environment, and to track the progress of its implementation. Standard and clear format of the fact sheets facilitate evaluation of various issues and respond to the needs of various users. The fact sheets have been prepared for the 26 indicators. Following an evaluation and revision process, they have been integrated into the information base. ENHIS web site as well as the indicator-based assessment report were published and provide the framework for effective dissemination of EH information in the future.
The table below lists the output indicators specified in point 1.5 of the Grant Agreement, Annex 1, and compares the ENHIS 2 results with the target indicator values. The table documents that the target values for all but one indicator were met or exceeded. The exception is the lack of HIA results on noise due to the lack of necessary data on population exposure to noise in European data bases. The feasibility study, conducted in the framework of WP7 (full report available in Annex 2.1, section on WP7 results and summary is published on ENHIS 2: Final Technical Implementation Report
53
http://www.enhis.org/object_document/o4824n27773.html) concludes that the necessary data should be available when the reporting required by the Environmental Noise Directive is implemented. Output indicator title Guidelines for generating information for policy support
Target value WHO document published
Result achieved Available on the ENHIS SharePoint and on request from
[email protected]. (see Annex 2.1)
Methodology for children- 10 indicators specific EH core indicators
Methodology for 26 core indicators and 16 indicators from extended set published on www.enhis.org
Methods to retrieve information from international data bases and surveys
10 data bases accessible
15 data bases accessible. Methodology published on www.enhis.org
Perform pilot testing of the system by the member states
16 MS complete the test
System applied to all 53 WHO/Euro MS, with an active participation of partners from 18 MS
Assess the health impacts of indoor air pollutants and noise
15 cities complete HIA
Software tools for data exchange operational and supporting report prepared
Data for 15 indicators in the system
HIA of indoor air pollution (ETS) completed for 27 countries 3 . HIA for noise based on routinely collected data – found to be currently not feasible. This status will be changed by the reporting obligations of the Environmental Noise Directive, which entered into power in 2007. Data for 26 indicators in the system, with 18 indicators covering more than 20 countries
Indicator based CEHAPE assessment report
WHO document published
“Children’s health and the environment in Europe: a baseline assessment” Dalbokova, D, Krzyzanowski, M, Lloyd, S. (eds) World Health Organization, Copenhagen, 2007 ISBN 978 92 890 7297 7 available at www.euro.who.int/document/document/E90767.pdf; paper copy is enclosed
The comparisons of the project outcomes with deliverables specified by the Grant Agreement, annex 1, part 3 of each of the Work Packages, confirming fulfilment of contractual obligations, are listed in Section 1 “Detailed description of activities”. In addition to the objectives stated in the Grant Agreement, ENHIS-2 project contributed to identification of several recommendations for the future work on information system in Europe, leading to an improvement of the support to the policy making. In particular, the following issues were identified: •
Scientific evidence and monitoring data.
3
The following countries: Austria, Bulgaria, Croatia, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Ireland, Italy, Latvia, Lithuania, Netherlands, Norway, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden, Switzerland, The former Yugoslav Republic of Macedonia, and United Kingdom.
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ENHIS 2: Final Technical Implementation Report
In several cases, the availability of data or feasibility of their collection for wide populations influenced the definition of the indicator. As a consequence, some became less specific. For example, “Access to public water supply and improved drinking-water sources”, which focuses on the proportion of the population connected to a public water supply, is a rather crude indicator of population exposure to chemical or biological contaminants through the water actually drunk. The indicator is justified by the fact that water from public supply systems is regularly controlled and treated to avoid contamination, and that its availability reduces health risks due to water contamination. However, there remains a possibility that the public supply is contaminated, or that people use other water sources, for example to avoid water charges: the indicator cannot pick this up. Specificity and sensitivity of the indicator could be improved using better monitoring or special surveys, but a principle of the current system is to use data from existing sources which cover a large part of the Region systematically. For the policy action summarized by action indicators, the scientific evidence on effectiveness is rather weak. The definitions created by the project are often based on expert evaluation of the intentions of the action, rather than through systematic analysis of the impact on health risks. Evaluation of such impact is, however, not often possible as the necessary information is rarely collected. Studies producing data on the impact of interventions and policies would allow validation of the indicator and enhance assessments of the effectiveness of action. Future application of the EH information system could be policy analysis using both policy and outcome indicators, although the high level of data aggregation might make such analysis difficult. •
Information from international surveys, in particular related to the following topics: o Water-borne diseases and their outbreaks (surveillance systems needs to be harmonized and extended) o Asthma and allergies (expansion of ISAAC methodology to other populations) o Exposure to ETS and mould (increase coverage of countries; repeat surveys periodically) o Exposure to POPs and heavy metals (increase coverage of population by (bio) monitoring) o Specific risks in school environments
•
Generation of data specific to children. Few monitoring systems provide child-specific data, especially those relevant to the exposure and action indicators. Therefore, in several cases, data pertaining to the general population was used as a proxy in the current data base of ENHIS.
•
Analysis on national level. The European system is designed to provide intercountry comparisons, where the units of analysis are countries. However, if data are available at sub-national level, similar analyses can be carried out within countries, meaning that action can be focused on problem areas and its effectiveness assessed with greater specificity. For national use, the system might need to be supplemented by additional, country-specific indicators, which correspond better with the particular needs of a country and its policies. If such additional indicators are demonstrated to be useful, this may encourage the collection of similar data in other areas of the Region leading to a possible expansion in the scope of the system.
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55
Future steps The achievements of ENHIS-2 project provide a solid basis for the operation of the system in the future. Its next challenge is to produce information support for the 5th Ministerial Conference on Environment and Health to be held in Italy, in 2009. This will require the update of the data base reflecting the recent changes in the indicators contained by the system. Further challenges include the need to expand the system to the WHO/Euro member states beyond the European Union, the need to develop indicators for the newly emerging policy areas, such as the health aspects of the climate change, as well as expansion of the indicatorbased reporting within the Member States. WHO/Euro will remain active in these areas providing the nucleus to the network created by the ENHIS projects. It is expected that several other projects related to the above listed issues will involve the network members consolidating the resources for further improvement of information capacities related to environment and health in Europe.
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ANNEX 1 Table 1: List of ENHIS 2 Partner-institutions and focal points TABLE 1a. List of ENHIS 2 Partner Institutions Country Austria Organization Gesundheit Österreich GmbH (ÖBIG) http://www.goeg.at http://www.oebig.org Name of the project leader Gerhard Fülöp / team member Charlotte Wirl Address Stubenring 6, A-1010 Wien Telephone +43 1 515 61 163 e-mail
[email protected] Fax +43 1 513 8472 Country Bulgaria Organization Ministry of Health (MOHBG) http://www.mh.government.bg Name of the project leader Masha Gavrailova / team member Hristina Mileva Address 5 Sveta Nedela Sa. Sofia 1000 Telephone +35 92 93 01 183 e-mail
[email protected] Fax +35 92 98 83 413 Country Czech Republic Organization Statni Zdravotni Ustav (SZU) http://www.szu.cz Name of the project leader Ruzena Kubinova / team member Vladimira Puklova Frantisek Kosicek Address Šrobárova 48, 142 00 Prague 10 Telephone +420 267 082 622 e-mail
[email protected] Fax +420 271 731 699 Country Estonia Organization Tervisekaitseinspektsioon (TKS) http://www.tervisekaitse.ee Name of the project leader Juri Ruut Address Gonsiori Str 29, 15027 Tallin Telephone + 37 26 26 91 51 e-mail
[email protected] Fax Country Finland Organization Kansanterveyslaitos (KTL) http://www.ktl.fi Name of the project leader Matti Jantunen / team member Eva Kunseler, Ilkka Miettinen Address POBox 95, FIN 70701 Kuopio Telephone +358 17 201 340 e-mail
[email protected] Fax +358 17 201 184 Country France Organization Institut de Veille Sanitaire (InVS) http://www.invs.sante.fr Name of the project leader Sylvia Medina / team member Philippe Pirard, Alain le Tertre Address 12 rue du Val d`Osne 94415 Saint Maurice Telephone +33 1 41 79 67 56 e-mail
[email protected] Fax +33 1 41 79 67 68 Country Germany Organization Landesinstitut für den Öffentlichen Gesundheitsdiesnt des Landes Nordrhein-Westfalen (LÖGD) http://www.loegd.nrw.de Name of the project leader Rainer Fehr
/ team member Address Telephone e-mail Fax Country Organization Name of the project leader / team member Address Telephone e-mail Fax Country Organization Name of the project leader / team member Address Telephone e-mail Fax Country Organization Name of the project leader / team member Address Telephone e-mail Fax Country Organization Name of the project leader / team member Address Telephone e-mail Fax Country Organization Name of the project leader / team member Address Telephone e-mail Fax Country Organization Name of the project leader / team member Address Telephone e-mail Fax
58
Odile Mekel Westerfeldstrasse 35-37, 33611 Bielefeld +49 521 80 07 253
[email protected] +49 521 80 07 299 Greece Ethniki Scholi Dimosias Ygeias Eidikos Logariasmos Erevnon – National School of Public Health (NSPH) http://www.nsph.gr Aleksandra Katsiri Olga Cavoura Leoforos Alexandras 196, 11521 Athens +30 21 07 72 27 97
[email protected] +30 21 07 72 28 99 Hungary Fodor Jozsef Orszagos Kozegeszegugyi Kozpont (KOZPONT) http://efrirk.antsz.hu/oki Anna Paldy Tibor Malnasi Gyáli út 2-6, Budapest, 1097 +36-1-476-1215
[email protected] +36-1-476-1215 Italy Agenzia per la Protezione dell Ambiente e per I Servizi Tecnici (APAT) http://www.apat.gov.it Luciana Sinisi Ernesto Vocaturo Via Vitalioano Brancati, 48, 00144, Rome +39 06 50 07 25 95
[email protected] +39 06 80 07 25 96 Lithuania Valstybinis aplinkos Sveikatos Centras (VASC) http://vasc.sam.lt Ingrida Zurlyte Aida Laukaitiene, Genadius Jonauskas Kalvariju str 153, LT-08221 Vilnius +37 05 247 7340
[email protected] +37 05 273 7397 Netherlands Rijksinstituut Voor Volksgezondheid en Milieuhygiene (RIVM) http://www.rivm.nl Anne Knol Brigit Staatsen, Rutger Nugteren, Annemiek van Overveld A. van Leeuwenhoeklaan 9, 3720 BA Bilthoven +31 30 274 2915
[email protected] +31 30 274 4451 Poland Instytut Medycyny Pracy I Zdrowia Srodowiskowego (IMPIZS) http://www.imp.sosnowiec.pl Maja Muszynska-Graza Beata Dabkowska 13 Koscielna, 41-200 Sosnowiec + 48 32 2660885 (ext. 208)
[email protected] + 48 32 2661124
ENHIS 2: Final Technical Implementation Report
Country Organization Name of the project leader / team member Address Telephone e-mail Fax Country Organization Name of the project leader / team member Address Telephone e-mail Fax Country Organization Name of the project leader / team member Address Telephone e-mail Fax Country Organization Name of the project leader / team members Address Telephone e-mail Fax Country Organization Name of the project leader / team member Address Telephone e-mail Fax Organization Name of the project leader Address Telephone e-mail Fax Organization Name of the project leader / team member Address Telephone e-mail Fax
Portugal Direcção Geral Da Saúde (DGDS) http://www.dgs.pt Paulo Diegues Claudia Weigert Alameda D. Afonso Henriques, 45, 1049-005 Lisbon +35 12 13 17 97 42
[email protected] +35 12 13 17 97 27 Romania Institute of Public Health Bucharest (IPHB) http://www.ispb.ro Adriana Galan Christina Chirita 1-3 dr Leonte str. Bucharest +40212249226 or +40213144259/ +4021 3072666
[email protected] +4021 2249226(IPH) Slovakia Úrad Verejného Zdravotnictva Slovenskej Republiky – National Authority of Public Health of Slovak Republic (NAPH) http://www.uvzsr.sk Katarina Halzlova Gabriela Slovakova 826 45 Bratislava
[email protected] Slovenia Institut Za Varovanje Zdravja Republike Slovenije (IZVA) National Institute of Public Health http://www.ivz.si/ Peter Otorepec Katarina Bitenc, Pia Vracko Trubarjeva 2, 1000 Ljubljana +386 (1244) 1488
[email protected] +33 (91) 387 7895 Spain Agència De Salut Pública De Barcelona (ASPB) http://www.aspb.cat Manuel González-Cabre Natalia Valero Placa Lesseps 1, 08023 Barcelona +34 932384545 (ext 269)
[email protected] +34-93-2173197 Escuela Andaluza de Salud Pública (EASP) Piedad Martin Olmedo Campus Universitario de Cartuja, Cuesta del Observatorio, 4, P.O. Box 2070, Granada 18080 +34 95 80 27 400
[email protected] +34 95 80 27 503 Fundación para la Cooperatión y Salud International Carlos III (FCSAI) http://www.isciii.es Manuel Posada de la Paz Elena Boldo, Maria-Jose Carroquino, A. Ramirez, L Soldevilla-Benito Sinesio Delgado, 6, 28029 Madrid +34 91 387 78 03
[email protected] +34 91 387 78 95
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Table 1b. List of ENHIS-2 Partners contributing on a voluntary basis Country Organization Name of the project leader / team member Address Telephone e-mail Fax Country Organization Name of the project leader Address Telephone e-mail Fax Country Organization Name of the project leader/ team member Address Telephone e-mail Fax Organization Name of the project leader/ team member Address Telephone e-mail Fax
Organization Name of the project leader/ team member Address Telephone e-mail Fax Organization Name of the project leader Address Telephone e-mail Fax
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France Agence Française de sécurité sanitaire de l’ennvironment et du travail (AFSSET) http://www.afsset.fr Salma Elreedy Clara Galand 27, 31 av. Général Leclerc 94704 Maisons Alfort Cédex +33 (1) 56 29 56 47
[email protected] Sweden National Board of Health and Welfare Sociastyrelsen http://www.socialstyrelsen.se Ing-Mary Olsson 106 30 Stockholm +46 (-8) -555 532 96
[email protected] United Kingdom UK Health Protection Agency (HPA) http://www.hpa.org.uk Centre for Radiation, Chemical & Environmental Hazards, Chemical Hazards & Poisons Division Patrick Saunders Lorraine Stewart Childton, Didcot, Oxfordshire OX11 ORQ + 44 121 414 3985
[email protected] +44 121 414 3827 European Child Safety Alliance http://www.childsafetyeurope.org Joanne Vincenten Morag Mackay P.O. Box 75169 1070 AD Amsterdam, Netherlands +31 (20) 511 4529
[email protected] European Commission Joint Research Centre http://ec.europa.eu/dgs/jrc Institute for Environment and sustainability Peter Part Andreas Skouloudis T.P. 441, Via E. Fermi 1, I-21020 Ispra (Va.) Italy +39 0332 786427
[email protected] +39 0332 785236 European Environment Agency http://www.eea.europa.eu Dorota Jarosinska Kongens Nytorv 6, DK-1050 Copenhagen K +45 (33) 36 7107
[email protected] +45 (3336) 7128
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WHO Personnel WHO European Centre for Environment and Health, Bonn office http://www.euro.who.int/ecehbonn Michal Krzyzanowski & Dafina Dalbokova Nida Besbelli, Matthias Braubach, Rokho Kim Christian Gapp Winfried Maus Andrea Rhein, Christine Pasztor, Wendy Williams
Project Coordination Topic-specific input ENHIS infrastructure development IT system administration Administrative assistance
WHO European Centre for Environment and Health, Rome office http://www.euro.who.int/ecehrome Roger Aertgeerts Leda Nemer; Sonja Kahlmeier Francesca Racioppi; Dinesh Sethi; Christian Schweizer; Hiroko Takasawa WHO Headquarters, Geneva http://www.who.int/ Fiona Gore
Topic specific input
Public Health and Environment
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ANNEX 2
RESULTS OF ENHIS 2 PROJECT IMPLEMENTATION
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Annex 2.1 Outcomes of ENHIS 2 implementation by Work Package
This section presents the outcomes of work packages that are not published on the ENHIS web-site. They are available on the SharePoint for the ENHIS partners and in general on request from
[email protected]
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WORK PACKAGE 2 (WP2) RESULTS
LIST OF PUBLICATIONS by the ENHIS 2 partners disseminating the project results
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LIST OF PUBLICATIONS Books, articles and WHO documents Krzyzanowski M., Dalbokova D., (Coordinators of the ENHIS project), European Environment and Health Information system (ENHIS), 1st release, Bilthoven, Netherlands, RIVM (web host), 2007, http://www.enhis.org World Health Organization, Regional Office for Europe, Children’s Health and the Environment in Europe: a Baseline Assessment, D. Dalbokova, M. Kryzanowski, S. Lloyd (eds.) Monograph ISBN 978 92 890 7297 7 Copenhagen, 2007 http://www.euro.who.int/document/E90767.pdf World Health Organization, Regional Office for Europe Facts on children’s health and the environment in Europe, Fact sheets, WHO, Copenhagen, 2007, http://www.euro.who.int/EHindicators/Publications/qryIndicatorbasedAssessments World Health Organization Regional Office for Europe, Report of the 21st meeting of the European Environment and Health Committee, Oslo, Norway, 15-16 May 2006 http://www.euro.who.int/Document/EEHC/REPORT_EEHC_Oslo%20_20_9_06.pdf World Health Organization Regional Office for Europe, Report of the 4th Meeting of the CEHAPE Taskforce (Limassol, Cyprus, 16-17 October 2006) http://www.euro.who.int/Document/EEHC/CEHAPE_Cyprus_4th_Mtg.pdf World Health Organization Regional Office for Europe, Report of the Intergovernmental Midterm Review Meeting on implementation of the Budapest Declaration (Vienna, 13-15 June 2007) http://www.euro.who.int/Document/EEHC/IMR_Vienna_mtgrep_en.pdf
Peer-reviewed journal articles, book chapters, other reports Dalbokova D. on behalf of ENHIS group, ‘Environment and health information systems in Europe and WHO collaborative projects’, WHO CC of Air Quality Management and Air Pollution Control, UBA Newsletter, 37, June 2006, 4-9 (http://www.umweltbundesamt.de/whocc/archiv/Newsletter37.pdf) Pond K., Kim R., Dalbokova D., Krzyzanowski M., Developing Environmental Health Indicators for European Children, Environmental Health Perspectives on line, NIEHS, USA, 2007, http://www.ehponline.org Pond K, Kim R, Carroquino M, Pirard P, Gore F, Cucu A , Nemer L, MacKay M, Smedje G, Georgellis A, Dalbokova D, Krzyzanowski M. Workgorup Report: Developing Environmental Health Indicators for European Children. Environmental Health Perspectives, 2007, 115, 9, 1376-1382
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Abstracts, proceedings, short communications Aertgeerts R., Pond, K, Kay, Kim R, D, Dalbokova D, Development of water and sanitation indicators to monitor children’s health, Joint Conference of the International Society for Environmental Epidemiology (ISEE) and Exposure Analysis (ISEA) Paris, France, 2-6 September, 2006, Paris, France, 2-6 September, 2006, Epidemiology, Vol 17, No 6, November supplement 2006, p S181, MAB1-PD-06 Besbelli, N, ‘Reporting on children’s health and chemicals – a case study of POPs in human milk (Europe) 4th International Conference on Children’s Health and the Environment (Vienna, 10-12 June 2007), Journal of Environmental Medicine, 2007, 10, 1, S1, 32 http://inchesnetwork.net/p27.pdf Boldo E. et al, ‘Necesidades de información para cuantificar el impacto en salud por contaminación del agua de consumo en Europa, Proyecto ENHIS’ Presentation at Sociedad Española de Epidemiologia, Logroño, 5 October, 2006 Boldo E. et al, ‘Assessing the implementation of health impact assessment ofr drinking-water pollution in European countries,’ Poster presentation at Joint Conference of the International Society for Environmental Epidemiology (ISEE) and Exposure Analysis (ISEA) Paris, France, 2-6 September, 2006, Paris, France, 2-6 September, 2006, Epidemiology, 17, 6 Suppl November 2006, S446. Boldo E., et al, ‘ENHIS project: availability of drinking-water information for health impact assessment purposed in 9 European countries,’ Poster presentation at Joint Conference of the International Society for Environmental Epidemiology (ISEE) and Exposure Analysis (ISEA), Paris, France, 2-6 September, 2006, Epidemiology, 17, 6 Suppl November 2006, S446. Boldo E. et al, ‘Towards the quantification of health impacts caused by drinking-water pollution in European countries,’ Poster presentation at Joint Conference of the International Society for Environmental Epidemiology (ISEE) and Exposure Analysis (ISEA), Paris, France, 2-6 September, 2006, Epidemiology, 17, 6 Suppl November 2006, S447. Boldo, E, Oeberg, M, Medina, S, Valero, N, Patja, K, Posada, M, et al, ‘Impact of environmental tobacco smoke (ETS) on sudden infant death syndrome (SIDS) in European children’, 19th Conference of the International Society for Environmental Epidemiology (ISEE), Mexico City, 5-9 September 2007, Salud Publica de Mexico, 2007, 49, 4, 304, E690 Boldo, E, Medina, S, Oeberg, M, Puklova, V, Valero, N, Posada, M, et al, ‘Assessing health impact of environmental tobacco smoke (ETS) on asthma episodes in European children’, 19th Conference of the International Society for Environmental Epidemiology (ISEE), Mexico City, 5-9 September 2007, Salud Publica de Mexico, 2007, 49, 4, 305, E690 Cambra, K, et al, ‘Health impact assessment of PM10 air pollution on postneonatal mortality in 31 European cities,’ Poster presentation at Joint Conference of the International Society for Environmental Epidemiology (ISEE) and Exposure Analysis (ISEA), Paris, France, 2-6 September, 2006, Epidemiology, Vol.17, No 6, November supplement 2006, p. S106, SM4PD-07 66
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Carroquino M.J. et al, ‘Development of indicators for Regional Priority Goal II of Children’s Environment and Health Action Plan for Europe,’ Poster discussion at Joint Conference of the International Society for Environmental Epidemiology (ISEE) and Exposure Analysis (ISEA), Paris, France, 2-6 September, 2006, Epidemiology, 17, 6 Suppl November 2006, S179. Cavoura O, Katsiri A, Katsiris N, Dalbokova D, ‘An Environmental Health information system – assessment of the situation in Greece’, 10th International Conference on Environmental Science and Technology, Kos Island, Greece, 5-7 September 2007, in CEST2007: A-183-190, (Sep 2007), www.gnest.org/cest/ Dalbokova, D. ‘Environmental public health indicators and health-environment information system: experiences from Europe’, Presentation at Third National Tracking Conference of the US CDC National Environmental Health Tracking Program, Atlanta, 9-11 August 2006 (http://www.cdc.gov/nceh/tracking/tracks06/home.htm) Dalbokova D., Kim R., et al. Developing environmental health indicators for European children, Joint Conference of the International Society for Environmental Epidemiology (ISEE) and Exposure Analysis (ISEA) Paris, France, 2-6 September, 2006, Paris, France, 2-6 September, 2006, Epidemiology, Vol. 17, No. 6, November Suppl 2006, p. S106, MAA2-PD03 Dalbokova D. et al, ‘Development of environment and health indicator system in Europe,’ Poster presentation at Joint Conference of the International Society for Environmental Epidemiology (ISEE) and Exposure Analysis (ISEA), Paris, France, 2-6 September, 2006, Epidemiology, Vol. 17, No. 6, November Suppl 2006, p. S448, P-567. Dalbokova, D. Krzyzanowski, Gore, F. on behalf of ENHIS 2 partners, ‘Reporting on indicators: lessons from ‘Children’s health and the environment in Europe – a baseline assessment’, 19th Conference of the International Society for Environmental Epidemiology (ISEE), Mexico City, 5-9 September 2007, Salud Publica de Mexico, 2007, 49, 4, E400 Dalbokova, D, ‘CEHAPE indicator-based report “Children’s health and the environment in Europe: a baseline assessment” and information support to policy actions’, 4th International Conference on Children’s Health and the Environment (Vienna, 10-12 June 2007), Journal of Environmental Medicine, 2007, 10, 1, S1, 25 http://inchesnetwork.net/p28.pdf Dalbokova, D, ‘Development of environmental health information system in Central and Eastern Europe’, International Conference and central and Eastern European Chapter Meeting of International Society for Environmental Epidemiology (Celadna, Czech Republic, 26-29 November 2007), http://isee.zuova.cz/, Central European Journal of Public Health, S 2007, 15, S9 Hanninen, O, ‘European approach to environmental health indicators: ENHIS’, 7th Valamo Conference on Environment and Health – Approaches to Benefit-Risk Analysis (Valamo, Finland, 5-7 December 2007) http://www.ktl.fi/attachments/english/events/valamo/who_enhis.pdf Gonzalez-Cabré M., et al. Health impact assessment of ozone on mortality in 30 European cities, Joint Conference of the International Society for Environmental Epidemiology (ISEE) ENHIS 2: Final Technical Implementation Report
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and Exposure Analysis (ISEA) Paris, France, 2-6 September, 2006, Paris, France, 2-6 September, 2006, Epidemiology, Vol 17, No 6, November supplement 2006, p S254, P-020 Gore, F. and Dalbokova, D. ‘The global initiative on children’s environmental health indicators – shaping priorities for action’, 19th Conference of the International Society for Environmental Epidemiology (ISEE), Mexico City, 5-9 September 2007, Salud Publica de Mexico, 2007, 49, 4, E400 Jantunen, M, Kunseler, E, ‘Towards a comparative assessment of policy actions on children’s health and the environment: a case study within WHO-coordinated ENHIS project’, 4th International Conference on Children’s Health and the Environment (Vienna, 10-12 June 2007), Journal of Environmental Medicine, 2007, 10, 1, S1, 95 http://inchesnetwork.net/p31.pdf Kim R., Dalbokova D., et al. Development of indicators to monitor regional priority goal IV of children’s environment and health action plan for Europe, Joint Conference of the International Society for Environmental Epidemiology (ISEE) and Exposure Analysis (ISEA), Paris, France, 2-6 September, 2006, Epidemiology, Vol.17, No 6, November supplement 2006, p. S167, MAA2-PD-06 Kubinova, R, Puklova, V, Implementation of the Environmental Health Information System in Czech Republic, International Conference and central and Eastern European Chapter Meeting of International Society for Environmental Epidemiology (Celadna, Czech Republic, 26-29 November 2007), http://isee.zuova.cz/past_celadna/session3/10_kubinova.pdf, Central European Journal of Public Health, S 2007, 15, S9 Kunseler, E, Jantunen, M, Dalbokova, D, ‘Exposure indicators in WHO ENHIS project’, 17th Annual Conference of the International Society of Exposure Analysis (Durnham/ Research Triangle Park, North Carolina, 14-18 October 2007), http://secure.awma.org/events/ISEA/ Málnási T., Páldy A., ‘Environmental health indicators of the European Environmental Health Information System (ENHIS) for evaluation of environmental factors influencing children’s health,’ Presentation at 2nd Forum of Young Hygienists, Szeged, Hungary, 1-3 June 2006. Málnási T., Páldy A., ‘Environmental health indicators of the European Environmental Health Information System (ENHIS) for evaluation of environmental factors influencing children’s health ,’ Poster presentation at XXXVI. Annual Meeting of the Hungarian Society of Hygiene, Siófok, Hungary, 3-5 October 2006. Malnasi, T, Paldy, A, ‘Evaluation of the Hungarian situation of indoor and outdoor air pollution and the respiratory diseases of children by the tools of the European environment and health information system (ENHIS)’, International Conference and central and Eastern European Chapter Meeting of International Society for Environmental Epidemiology (Celadna, Czech Republic, 26-29 November 2007), http://isee.zuova.cz/past_celadna/session3/04_malnasi.pdf, Central European Journal of Public Health, S 2007, 15, S16 Páldy A, ‘Analysis of the environmental health situation of children in the mirror of the European Environmental Health Information System (ENHIS),’ Presentation at 2nd Forum of Young Hygienists, Szeged, Hungary, 1-3 June 2006. 68
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Paldy A. et al, ‘Health impact assessment of PM10 on mortality and morbidity in children in central-eastern European cities,’ Presentation at International Conference on Environmental Epidemiology & Exposure (ISEE), Paris, France, 2-6 September, 2006, Epidemiology, Vol 17, No 6, November supplement 2006, p S131, SAA5-O-07 Páldy A., Málnási T., ‘Evaluation of policies on prevention of children’s non-traffic accidents with the help of the tools of the European Environmental Health Information System (ENHIS),’ Presentation at XXXVI. Annual Meeting of the Hungarian Society of Hygiene, Siófok, Hungary, 3-5 October 2006. Paldy, A, Malnasi, T, Sandor, R, ‘Assessment of physical activity and obesity in children according to Regional Priority Goal of CEHAPE at national and regional level based on environmental health indicator system, 4th International Conference on Children’s Health and the Environment (Vienna, 10-12 June 2007), Journal of Environmental Medicine, 2007, 10, 1, S1, 133 Pirard, P, Doré, J-F, Zeeb, H, Kunseler, E. ‘CEH policy indicators: a case study of UV radiation’, 4th International Conference on Children’s Health and the Environment (Vienna, 10-12 June 2007), Journal of Environmental Medicine, 2007, 10, 1, S1, 32 http://inchesnetwork.net/p29.pdf Pirard, P, Kunseler, E, Zeeb, H, Vracko, P, Dalbokova, D, ‘DPSEEA use in an environment and health information system: UV and melanoma in Europe’, 19th Conference of the International Society for Environmental Epidemiology (ISEE), Mexico City, 5-9 September 2007, Salud Publica de Mexico, 2007, 49, 4, 397, E710 Ramirez, A, Carroquino, M, Kim R., Nemer L., Posada, M, Dalbokova D., Development of the indicator “policies to prevent childhood obesity” to monitor children’s health, Joint Conference of the International Society for Environmental Epidemiology (ISEE) and Exposure Analysis (ISEA), Paris, France, 2-6 September, 2006, Epidemiology, Vol 17, No 6, November supplement 2006, p S180, MAB1-PD-05 Smedje G, Kim, R, Gore, F, Dalbokova, D, Krzyzanowski, M, ‘Development of air pollution and respiratory diseases indicators to monitor implementation of Children’s Environment and Health Action Plan for Europe,’ Poster discussion at Joint Conference of the International Society for Environmental Epidemiology (ISEE) and Exposure Analysis (ISEA), Paris, France, 2-6 September, 2006, Epidemiology, 17, 6 Suppl November 2006, S166. Smedje G, Kim, R, Gore, F, Dalbokova, D, Krzyzanowski, M, ‘Development of indicators for Regional Priority Goal of Children’s Environment and Health Action Plan for Europe,’ Poster discussion at Joint Conference of the International Society for Environmental Epidemiology (ISEE) and Exposure Analysis (ISEA), Paris, France, 2-6 September, 2006, Epidemiology, 17, 6 Suppl November 2006, S449.
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ENHIS 2
WORK PACKAGE 3 (WP3) RESULTS
METHODOLOGY FOR IDENTIFICATION OF INFORMATION NEEDS FOR POLICIES (Deliverable
3.1)
GUIDELINES FOR GENERATING INFORMATION FOR POLICY SUPPORT (Deliverable
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WP3 Information needs of EH policies Deliverable 3.1
Methodology for identification of information needs for policies
www.ENHIS.org
This document has been developed by a project co-financed by the European Commission - DG Sanco (Grant Agreement SPC 2004124), coordinated by the WHO Regional Office for Europe and involving partner institutions from 18 European countries. The views expressed here do not necessarily reflect the official opinion of the European Commission or of the World Health Organization.
Authors: Eva Kunseler and Matti Jantunen National Public Health Institute, Department of Environmental Health Kuopio - Finland
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Table of contents 1.
INTRODUCTION ...................................................................................74
2.
DEVELOPMENT OF METHODOLOGY................................................76
2.1
Policy text analysis ....................................................................................................................76
2.2
Questionnaire development and implementation ...................................................................76
2.3
Comparative policy assessment................................................................................................77
2.4
Case study development and implementation.........................................................................78
3.
METHOD DEMONSTRATIONS AND USER EXPERIENCES ..............79
3.1
Policy questionnaire ..................................................................................................................79
3.2
Policy case study ........................................................................................................................87
APPENDIX 1 STATEMENTS IN FINNISH RADON POLICY WORKSHOP ...92 APPENDIX 2 QUESTIONNAIRE ON ETS POLICY DEVELOPMENT, IMPLEMENTATION AND FOLLOW-UP IN BULGARIA ................................96
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1. Introduction To enhance the policy-relevance of the Environment and Health Information System and to stimulate accountability in environmental health policy making, the ENHIS project assessed and compared information needs in policy making processes across seven environmental health topic areas. The findings are presented in the ENHIS Assessment report. This methodology report provides and describes the fundamental ENHIS methods developed for the purpose of identification of policy information needs. WHO ECEH Bonn Office has initiated and co-ordinated the effort of developing methodology for the identification of information needs in policy making. The actual development was principally carried out by the Finnish ENHIS and ENHIS-2 partner (KTL) with the help of a number of partners in the work package. The methods can be used as a starting point for method development in future policy assessment studies. Re-inventing the wheel of carrying out environmental health policy assessment would be a needless and time consuming effort, whereas European and national policy experts will benefit from a common policy assessment methodology. Advanced application of the ENHIS methodology would increase the knowledge base about environmental health policy making and ultimately result in one comprehensive, complete and thorough European-wide environmental health policy information system.
Four research methods were developed and applied for different purposes and stages in the process of information needs generation: (i)
literature and policy text analysis;
(ii)
questionnaire development and implementation;
(iii)
comparative analysis;
(iv)
policy case study development and implementation.
The methodology is published in the ‘Methods and tools’ page on the ENHIS website and should as well be communicated in policy expert networks. A user’s experience interface should be created and accordingly managed to improve the ENHIS policy assessment methodology.
The following chapter will discuss the method development process. In succession, the individual research methods are discussed in terms of their purpose and use. Demonstrations
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of the methods are presented in boxes and several user experiences with method application are provided.
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2. Development of methodology The development of the policy assessment methodology started in the ENHIS project in 2004 and continued in the ENHIS-2 project. The steps in method development are listed by method.
2.1
Policy text analysis
For the purpose of writing the policy sections of the indicator factsheets (26 ready factsheets available on http://www.enhis.org), document search and analysis of European and wider international legislation and policy framing documents were carried out. Additional text analysis for the first policy assessment study in WP3 resulted in information on the contents and format of principal international and (pan-) European environmental health policies in the seven topic areas. A listing of the principal policy documents is presented on the ENHIS website. Reflections on these policy findings are structured according to the three policy discourse mechanisms and available in the ENHIS policy assessment report (D3.2 and D3.4).
2.2
Questionnaire development and implementation
Insight into national environmental health policies and the process of environmental health policy development, implementation and follow-up processes in the ENHIS partner countries was retrieved through policy questionnaire implementation. A demonstration of the questionnaire is presented in chapter 3, section 3.1. The process of development is described in subsequent steps:
1
In the ENHIS project (01/11/2004 – 31/10/2005) a questionnaire was developed to review relevant policies, in particular their objectives, health-related accountability mechanisms and evidence-based use. The scope and format of the survey was defined using a selected set of ECOEHIS 1 indicators as the issues of interest. Appropriate policy makers at environment and health ministries as well as ENHIS national focal points were invited to cooperate. The questionnaire responses were collected in a MS Excel © policy information database, which lists detailed information on national environmental health policy documents and policy making processes in the ENHIS partner countries. This database is available on the ENHIS webpage of the Finnish National Public Health Institute.
ECOEHIS focused on the Development of Environment and Health Indicators for European Union Countries.
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2.3
A technical meeting was convened at WHO ECEH Bonn on 29 May 2006 to agree on a common approach and questionnaire for children’s EH policy review across Europe, to be used in the WHO coordinated ENHIS-2 project (01/11/06 – 31/10/07) and another WHO coordinated project co-funded by Health Canada. During this meeting the scope and policy aspects of ENHIS-2 were discussed in detail as well as the essential methods and tools for retrieval of information needs. Reflections and ideas were formulated about priorities and mechanisms to improve policy accountability concerning population health across Europe. The meeting minutes are uploaded on the common project web platform Sharepoint 2 and available on request. Building further upon the ENHIS policy questionnaire (see first bullet), a renewed policy questionnaire was developed in ENHIS-2 framed in the context of the CEHAPE regional priority goals (RPGs) so as to provide a comprehensive structure and clear link to the general child-focused project rationale. The scope of the questionnaire was based on a selected set of ECOEHIS and ENHIS indicators, which resulted in the definition of seven topics of inquiry. The questionnaire topics were organized according to policy description, rationale, accountability and information needs to make a comprehensive assessment of national environmental health policies possible. The wordings in this quite challenging questionnaire were improved in order to lead to the most comprehensive and unambiguous answers possible. The questionnaire and country answers are uploaded on the common project web platform Sharepoint and are available on request. Suggestions from our German partner (Lögd NRW) and the Health Canada project coordinator in WHO plus the lessons learned from the questionnaire implementation process are considered in drafting the final version of the policy questionnaire. ENHIS-2 partners (interviewers) were instructed about the questionnaire implementation procedure in their countries. Technical guidance was provided by email and phone together with a general introductory letter to the policy experts and officials (interviewees). A direct and personal approach of interviewees resulted in more complete and comprehensive outcomes than was achieved in the first questionnaire implementation in ENHIS. In chapter 3, section 3.1 more details about and user experiences from questionnaire implementation are presented. The ENHIS policy information database (available on the ENHIS webpage of the Finnish National Public Health Institute) has been updated and supplemented with the more detailed and complete policy information resulting from the questionnaire responses collected between May and November 2006 and inclusion of results from similar projects (WHO project on Housing and Health Legislation co-funded by French MoH, see http://www.euro.who.int/Housing/Publications and Children´s Health and Environment: Review of Legislation a.k.a. Health Canada Project), information extracted from the EEHC website (EH Progress by country http://www.euro.who.int/eehc/ctryinfo/ctryinfo) and WHO databases for ETS (WHO Tobacco Control Database - Smoke free areas and public transport policies http://data.euro.who.int/tobacco/) and traffic (WHO Alcohol Control Database - Drink Driving policies http://data.euro.who.int/alcohol/). (Partly) completed questionnaires were received from 17 out of the 18 partner countries. The database requires continuous updating and should be professionalized in the near future regarding structure, readability and accessibility.
Comparative policy assessment
The findings listed in the policy information database are evaluated by topic and across countries by means of evaluation questions. The questions are structured according to (i)
2
Online communication tool and common project office
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policy initiation / rationale-setting, (ii) policy formulation / target-setting and (iii) implementation and follow-up to assess the level of accountability in these policy phases. (iv) Gaps and information needs in policy making are explicated per topic as well and further analysed across the topics in the ENHIS policy assessment report (D3.2 and D3.4). Evaluation allows for structured analyses of the policy processes and results in a comparative assessment of their respective levels of accountability. Consequent gaps-and-needs analyses enable comparison of the identified problems and challenges in environmental health policy making. The topicbased policy assessment reports are available on the ENHIS website.
2.4
Case study development and implementation
A demonstration of the policy case evaluation protocol is presented in chapter 3, section 3.2 To achieve more detailed information about information needs policymaking, a small group of four WP3 partners discussed the selection of policy case studies during the ENHIS-2 coordination meeting in Granada, October 2006. The selected policy case studies include one or several key policies in the EH topic areas (e.g. regulation or law), covering issues from all four CEHAPE RPGs.
The Spanish and Bulgarian partners reviewed their tobacco control policies, in particular the actions regulating environmental tobacco smoke exposure. In Italy, the national traffic safety policy was evaluated, whereas Finland critically discussed its indoor radon policy.
Case study implementation involved policy text analysis, expert consultations and discussions among national, regional and local authorities. A policy case evaluation questionnaire was developed to serve as a frame for in-depth evaluation of the policy. Experts provided input to the evaluation document. Discussion between experts, legislative and executive policy authorities gives important insights into the policy making processes. Information needs assessment of the policy case studies is presented in the ENHIS policy assessment report (D3.2 and D3.4). The assessment is structured according to the three principal policymaking phases where environment and health arguments should be explicitly addressed in order to lead to accountable policymaking. The individual policy case reports are presented on the ENHIS website.
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3. Method demonstrations and user experiences
3.1
Policy questionnaire
The policy questionnaire aims at obtaining current information on environmental health policies in place at national level, hereupon providing the data needed for the identification of policy information needs. The full questionnaire is available on the ‘Methods and tools’ page of the ENHIS website.
ENHIS selected seven environmental health policy topics (see figure 1) in the context of the Children’s Environment and Health Action Plan (CEHAPE) and in line with the ENHIS and ECOEHIS 3 indicator topics. Collection of pan-European national policy information will result in a balanced and comprehensive picture of the policy actions for the main environmental health risks across the WHO European Region. The policy information database, available on the ENHIS webpage of the Finnish National Public Health Institute, could serve as the platform for data collection.
Figure 1 demonstrates the core set of environmental health topics in relation to the CEHAPE regional priority goals (RPGs). An extended set of topics is available in addition. In the ENHIS2 exercise we did not distinguish between a core and extended set, and retrieved policy information for all topics. Most partners were not able to retrieve policy information for the complete set of topics due to problems in finding the appropriate contacts at the responsible ministerial agencies, their lack of co-operation related to time restraints and / or difficulties in answering the descriptive questions. Therefore, a shorter listing of environmental health priority issues in a core set is proposed, which is expected to result in more efficient and complete information collection. The extended set of topics receives secondary attention.
3
ECOEHIS focused on the Development of Environment and Health Indicators for European Union Countries.
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Figure 1 Core set of environmental health policy topics
RPG I TOPIC: WATER Subtopic: Drinking water supplies Subtopic: Bathing waters
RPG II TOPIC: HOUSING Subtopic: Hygienic conditions in dwellings Subtopic: Extreme cold Subtopic: Housing safety and accidents
RPG III TOPIC: AIR QUALITY Subtopic: Particulate matter in outdoor air Subtopic: Environmental Tobacco Smoke (ETS)
RPG IV TOPIC: CHEMICAL HAZARDS Subtopic: Chemical hazards in food
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The policy questionnaire was implemented in ENHIS and ENHIS-2. Based on user experiences from ENHIS-2 partners and suggestions from the WHO coordinated Health Canada project, a renewed questionnaire is proposed, drafted in October 2006. Figure 2 displays the questionnaire section on air pollution and its subtopic on environmental tobacco smoke. Questions are similar for each topic and organised in general and specific questions. The general questions ask for the contents and organisational structure of the national policy document and likewise for ensuing policy implementation and follow-up measures. The specific questions ask for more information about the gaps and information needs in policymaking. A questionnaire instruction to the interviewees is displayed in Figure 3. Policy information retrieved from the ENHIS and ENHIS-2 policy studies and other sources are used as reference material. Interviewees save time and efforts by starting from a pre-filled questionnaire. In this respect, the French ENHIS-2 partner wrote the following evaluation remark: “This way of working was quite motivating to the ministerial officials, though very time-consuming for us. We had to send the questionnaire with an explanation to why we needed a more precise answer and subsequently had to phone them to fulfil it.” The policy questionnaire is rather demanding for the interviewers, therefore clear instruction should be provided.
Interviewer guidance for questionnaire implementation in ENHIS-2 project One person from each ENHIS-2 partner country was asked to contribute to policy questionnaire implementation. A guidance letter explained the procedure. First of all, the interviewer had to retrieve the already available national policy information from the ENHIS policy database (accessible at the ENHIS page of the Finnish National Public Health Institute) and check it on completeness and consistency. The questions and responses in need of further elaboration had to be distributed among environment and health experts knowledgeable in the topic area of inquiry. In succession, outside contact with ministerial policy experts was necessary for obtaining more detailed answers, in particular to the specific questions. The interviewers were instructed to contact the respondents preferably face-to-face or directly by phone, which is most likely to result in a co-operative and complete response. This direct approach also allowed for a personalised clarification of the questions by the interviewer, and likewise for focused answers by the interviewees. It was found that answers can best be provided in domestic language and subsequently checked and translated by the interviewer. The chance for interviewer bias this way is rather high.
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Figure 2 Policy questionnaire on environmental health policies: example on environmental tobacco smoke
Subtopic: Environmental Tobacco Smoke (ETS) Right in the end of this topic, please find the previously collected environmental health information from your country, as stated in our database. Feel free to use or refer to this material in completing your contribution. General question 1: Council Recommendation 2003/54/EC a) Describe the principal national policy 4 - law, regulation, guideline – in place to implement Council Recommendation 2003/54/EC related to environmental tobacco smoke. Please provide the following information.
Exact title of the policy;
Brief description of the policy mission (max. 25 words);
Text of the policy, either by web link or attachment (may also be in its original language);
Date when the policy was adopted;
Date of enforcement of the policy;
Responsible authorities at national, provincial/regional and municipal/local policy level.
b) Does the policy have quantitative exposure reduction or health promotion objectives? YES
NO
If YES, please describe. ► c) Does the policy explicitly consider children and their health? YES
NO
If YES, describe and if possible give reference to the passage in the policy text ► d) Describe the policy measures - abatement programme, action plan - in place to enforce the principal national policy. Please provide the following information for each of the policy measures.
Exact title of the policy measure;
Brief description of the measure´ objectives;
Text of the policy measure, either by web link or attachment (may also be in its original language);
4
For the purpose of this questionnaire, a policy refers to a written document endorsed by the government and/or parliament, which includes a set of statements and decisions defining goals, principles, priorities, main directions, obligations and responsibilities for attaining the goals.
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Stakeholders groups - administration, industry, NGO - involved with its implementation;
If 1c) is answered yes, describe how the policy measure explicitly considers children and their health. e) Is there a follow-up programme to monitor or evaluate the actual exposure reduction or health improvement achieved by the implemented policy? YES
NO
If YES, please provide the following information.
Exact title of the programme;
Brief description of the programme´ objective;
Text of the programme, either by web link or attachment (may also be in its original language);
Stakeholders groups - administration, industry, public - involved with its implementation;
If 1c) is answered yes, describe how the policy measure explicitly considers children and their health.
General question 2: Policies in addition to Council Recommendation 2003/54/EC a) Are there national/federal policies - law, regulation, guideline - in place in addition to Council Recommendation 2003/54/EC related to environmental tobacco smoke? YES
NO
If YES, please provide the following information for each of the policies
Exact title of the policy;
Brief description of the policy mission (max. 25 words);
Source – exposure – health rationale of the national/federal policy;
Text of the policy, either by web link or attachment (may also be in its original language)
Date when the policy was adopted;
Date of enforcement of the policy;
Responsible authorities at national, provincial/regional and municipal/local policy level.
b) Does the policy have quantitative exposure reduction or health promotion objectives? YES
NO
If YES, please describe. ► c) Does the policy explicitly consider children and their health? YES
NO
If YES, describe and if possible give reference to the passage in the policy text ► d) Describe the measures - abatement programme, action plan - in place to enforce the national policy.
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Methodology for identification of information needs for policies www.ENHIS.org Please provide the following information for each of the policy measures.
Exact title of the policy measure;
Brief description of the measure´ objectives;
Text of the policy measure, either by web link or attachment (may also be in its original language);
Stakeholders groups - administration, industry, NGO - involved with its implementation.
If 2c) is answered yes, describe how the policy measure explicitly considers children and their health. e) Is there a follow-up programme to monitor or evaluate the actual exposure reduction or health improvement achieved by the implemented policy? YES
NO
If YES, please provide the following information.
Exact title of the programme;
Brief description of the programme´ objective;
Text of the programme, either by web link or attachment (may also be in its original language);
Stakeholders groups - administration, industry, NGO - involved with its implementation.
If 2c) is answered yes, describe how the policy measure explicitly considers children and their health.
Specific question 1: Level of compliance Is there a formal obligation to record and report the level of compliance for particulate matter concentrations in outdoor air with mandatory standards? YES
NO
If YES, please describe.
► Specific question 2: Information input Please indicate your need, either as “Essential”, “Desirable” or “Not necessary”, for (improved) input regarding the following types of EH information in the policy-making process:
Type of EH information
Essential
Desirable
Not necessary
Application of monitoring methods
Identification of actions for policy
Explanation of exposure – health linkage
5
improvement Other: ___________________________
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Specific question 3: Information gaps Are there information gaps in the policy process on environmental tobacco smoke? If yes, please mark in what policy phase (formulation, implementation, accountability 6 ) and, if possible, specify your information needs and ideas for improvement.
Policy formulation ►
Policy implementation ►
Policy accountability ►
Annex: Environmental Health policy information available from (COUNTRY) [see EH policy database]
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Figure 3 Interviewee instruction
Please read the INSTRUCTIONS before completing the questionnaire. This questionnaire aims at obtaining current information on environmental health policies in place at national level, hereupon providing the data needed for the identification of policy information needs. The questionnaire is divided into seven main topic areas: Water, Housing, Air, Chemicals, Traffic, Noise and Radiation. The core set of topics (as listed in the table of contents) requires primary attention, since they are of principal concern in relation to children’s health. The selection of topics is based on the priority goals (RPGs) defined in the WHO Children’s Environment and Health Action Plan for Europe (CEHAPE) of 2004. For each topic, there are general questions asking for information concerning policy description, policy rationale and policy implementation and follow-up. Children are considered as a particular group of interest, therefore questions explicitly request for policy information related to children´s health. A general question is (partially) marked grey when considered irrelevant to the topic of inquiry and for that reason (partially) does not need to be answered. Question wordings might differ slightly between topics to allow for consistency with the topic of inquiry. Specific questions ask for your personal opinion towards policy gaps and information needs in the topic of inquiry. Please read the questions thoroughly and provide complete and consistent answers to the extent possible. This questionnaire has been developed in the ENHIS and ENHIS-2 project (co-funded by the European Commission DG Sanco, grant agreements SPC2003112 and SPC 2004124). The projects started the operation of a comprehensive environment and health (EH) information system in Europe that will help to identify and prioritize widespread environmental health concerns. The information system is available at http://www.enhis.org. Policy relevant information on exposure to environmental hazards, its determinants and health effects, as well as information on policy evaluation is collected in a policy information database (available at the ENHIS page of the Finnish National Public Health Institute), which provides the background source for this questionnaire. The policy information available of your country is inserted under each topic of inquiry. Please check this information on completeness and consistency and refer to this material in completing the questionnaire. Feel free to make use of the policy information for your own purposes, yet keep in mind the database embodies work in progress and therefore may not be distributed. If you have received an electronic version of the questionnaire, feel free to insert your answers (in English or domestic language) directly following each question. If you have received a paper version of the questionnaire and will therefore provide your answers in a separate document, please clearly identify the link to the topic, subtopic and question. Thank you in advance for your contribution. Questions or remarks can be delivered to [CONTACT]
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3.2
Policy case study
The policy case evaluation questionnaire aims to provide the structure for in-depth policy analysis. The policy case evaluation can be carried out as an individual exercise, or can build further upon the policy questionnaire. The evaluation questionnaire was developed in response to the need for more thorough assessment of the policy accountability components. The policy questionnaire responses and subsequent comparative assessment demonstrated a lack of information about the process of policy target setting, implementation and follow-up. ENHIS-2 partners from Bulgaria, Italy, Finland and Spain carried out policy case evaluation with a selected environmental health policy topic. Figure 4 illustrates the policy case evaluation questionnaire for the topic of environmental tobacco smoke. The structure of the policy case evaluation questionnaire is divided into four headings. (i) The background evaluation questions ask for the position and significance of the EH topic in the national policy context. (ii) The subsequent policy evaluation section asks the respondent to thoroughly examine the selected national policy document(s) and to answer the detailed questions. The policy evaluation questions are based on the EH policy questionnaire as presented in figure 2, but include additional focused questions, for example about co-ordination between stakeholders. (iii) Education and awareness activities with respect to the EH topic are evaluated so as to get an insight into public involvement and professional strengthening efforts. (iv) As a result from the previous evaluation sections, the policy gaps and needs for improvement can be evaluated and formulated by the respondent.
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Figure 4 Policy case evaluation questionnaire
Subtopic: Environmental Tobacco Smoke (ETS) Background evaluation ¾ How far is prevention or reduction of ETS exposure seen as a priority in your country? ¾ Does your country face any particular challenges in relation to tobacco smoke and health? ¾ Based on your personal knowledge, how would you describe the overall time trend of the past 25 years in your country in this policy field, and how would you describe the associated socioeconomic (demographic, ethnic) changes in your country? ¾ Is the precautionary approach applied in ETS policy considerations? ¾ Overall, would you say that progress has been made since 2004, on reducing the number of children exposed to tobacco smoke?
Policy evaluation a) Describe the principal national policy 7 related to ETS - law, regulation, guideline - in place to implement European policies, such as Council Recommendation 2003/54/EC, WHO Framework Convention on Tobacco Control Please provide the following information.
• • • • • • • • • •
Exact title of the policy; Brief (historical) description of the underlying European and national policy frame; Brief description of the policy mission; Application domain of the policy e.g. occupational, residential, public indoor spaces; Explanation of policy focus on ETS; Source – exposure – health rationale of the policy; Text of the policy, either by web link or attachment (may also be in its original language); Date when the policy was adopted; Responsible authorities at national, provincial/regional and municipal/local policy level; Schematic display of policy structure and responsible authorities.
b) Does the policy have quantitative exposure reduction or health promotion objectives?
YES
NO
If YES, please describe.
► c) Does the policy explicitly consider children and their health?
YES
NO
If YES, describe and if possible give reference to the passage in the policy text
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d) Describe the policy measures - abatement programme, action plan - in place to enforce the principal national policy. Please provide the following information for each of the policy measures.
• Exact title of the policy measure; • Brief description of the measure´ objectives; • If 1c) is answered yes, describe how the policy measure aims to reduce ETS exposure among children; • Text of the policy measure, either by web link or attachment (may also be in its original language); • To what extent are local authorities, NGOs, research and academic bodies, the media, private industry, and other sectors actively involved with its implementation; • Explanation of coordination system between different stakeholders; • Description of reporting requirements to responsible authorities; • Schematic display of policy measures and responsible authorities e) Is there a follow-up programme to monitor or evaluate the actual exposure reduction or health improvement achieved by the implemented policy?
YES
NO
If YES, please provide the following information.
• Exact title of the programme; • Brief description of the programme´ objective; • If 1c) is answered yes, describe how the follow-up programme measures ETS exposure reduction among children. • What tools are used for policy evaluation, e.g. exposure indicators, cost-benefit analysis; • Text of the programme, either by web link or attachment (may also be in its original language); • To what extent are local authorities, NGOs, research and academic bodies, the media, private industry, and other sectors actively involved with its implementation; • Explanation of coordination system between different stakeholders; • Description of reporting requirements to responsible authorities; • Schematic display of policy follow-up and responsible authorities Education and awareness ¾ Do you have any figures (or estimates) on how many children are affected by ETS exposure in your country? ¾ Do you have any education or awareness programmes among the public, parents, schools, communities or included in professional training related to ETS exposure prevention or reduction? ¾ Are there any relevant national websites, publications or research that you would like to mention?
Identification of policy gaps and needs for improvement 8 ¾ Do you personally think the national policy well enough covers the issue of ETS exposure? ¾ Do you recognise gaps in the policy document? December 2007
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¾ Which challenges and constraints do you identify on this policy issue (such as level of political support, public awareness, policy and institutional framework, finance, technical capacity, adequacy of monitoring systems, etc.)?
Case study protocol The following text describes the steps taken in the ENHIS-2 policy case study implementation. The protocol allows for a comparable and structured process of individual case studies.
Step 1: Select the relevant national policy document(s) for your topic and complete the evaluation questionnaire for the principal ones. (If more documents are selected, answer the questions for either one of them.) Selected policy documents in ENHIS-2 policy study Indoor radon – Finland: Ministerial Order on radon levels, National Building Code and Radiation Act /Decree ETS - Bulgaria: National programme for tobacco smoking constraint 2002 – 2005 and unofficial draft version of the second part of the programme for 2006-2010 ETS – Spain: Tobacco law Traffic – Italy: Italian Plan on Street Security and New Road Code NB: Identify the policy type
Technical standards are actively enforced with proactive controls e.g. drinking water quality standards, traffic safety requirements (e.g. car requirements), radon standards in new and existing buildings A general norm is actively enforced (reactive or proactive e.g. (urban) traffic rules and safety conditions, smoking prohibition in public settings An individual right is passively enforced e.g. indoor radon exposure prevention (mitigation), ETS in private settings, traffic safety behaviour
Step 2: Prepare a list of experts who or institutes that are involved with policy development, enforcement, implementation, monitoring and evaluation at national and regional level. Specify their role in the policy process. Step 3: Ask each of the selected experts to verify and complete the evaluation questionnaire based on their expertise and experience.
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Step 4: Prepare interview questions / workshop statements with the aim to discuss about linkages between steps in the policy process and respective responsibilities of different authorities. Preparation:
Compare evaluation responses Structure interview or workshop according to evaluation questionnaire structure Specify questions / issues for certain experts Ask participating / interviewed experts to prepare an example according to which they can clarify their opinions
NB: Keep in mind possible biases related to interviewees’ attention, ideology, knowledge and analytical strictness in differentiating between the explicit policy documents and typical national problems. More attentiveness results in relatively higher reporting of application problems Depending on ideology, application problems can be weighted arbitrarily Some experts are better informed about application and enforcement issues than others Difficulties in differentiating between problems connected to the respective policy document and application problems of any policy in the same issue area.
Case study implementation in Bulgaria and Finland enfolded also step 4 in the protocol and turned out to lead to most valuable findings: policy statements provide a good means of retrieving expert opinions and in generating discussion if being distributed in workshop setting. The policy statements for a Finnish policy workshop on the indoor radon policy and prepared for a Bulgarian ETS roundtable meeting are available in Appendix 1 and 2 respectively.
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Appendix 1 Statements in Finnish radon policy workshop Please mark if you agree or disagree with the statement and provide your argumentation below
Set of statements - Finnish radon policy framework 1.
The various radon policy documents have a distinctive application domain Agree
Disagree
Argumentation:
2.
The radon policy documents are consistent in their intrinsic aim to reduce indoor radon exposure Agree
Disagree
Argumentation: 3.
Executive policy measures stem from directive policy documents Agree
Disagree
Argumentation:
4.
Each radon policy document explicitly addresses the association between radon sources, indoor radon levels and exposure settings and consequent health effects of exposure Agree
Disagree
Argumentation:
5.
The tasks and responsibilities resulting from the Finnish radon policy are clearly divided among the various directive and executive actors Agree
Disagree
Argumentation:
Set of statements - Radon monitoring system 1.
Radon monitoring requirements are stated in policy documents Agree
Disagree
Argumentation:
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2.
Radon monitoring is systematic and harmonized throughout Finland Agree
Disagree
Argumentation:
3.
Collaboration is successful between different actors involved in radon monitoring Agree
Disagree
Argumentation:
4.
Radon monitoring results are openly communicated to the respective residential population Agree
Disagree
Argumentation: 5.
Measured indoor radon levels that are exceeding the action level require immediate remediation Agree
Disagree
Argumentation:
Set of statements - Health impacts of radon exposure
1.
The Finnish radon policy sets health-based targets Agree
Disagree
Argumentation:
2.
The Finnish radon policy is adjusted in response to new evidence about health implications from exposure to the regulated radon limit levels Agree
Disagree
Argumentation:
3.
Health surveillance of lung cancer incidence is linked to radon monitoring data Agree
Disagree
Argumentation:
4.
The Finnish radon policy recognizes children as vulnerable exposure group
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Disagree
Argumentation: Set of statements - Policy and practice
1.
Guidance documents for mitigation and radon-safe building originate from directive radon policy documents Agree
Disagree
Argumentation:
2.
Guidance and awareness-raising activities are coordinated at national level Agree
Disagree
Argumentation:
3.
Practical experiences at local /executive level find their way up to the national /directive policy level Agree
Disagree
Argumentation:
4.
Policy evaluation and control occur on a formal and regular basis Agree
Disagree
Argumentation:
5.
Policy evaluation involves collaboration between directive and executive actors at national and local levels Agree
Disagree
Argumentation:
Set of statements - Constraints and challenges
1.
The radon policy implementation process is slow Agree
Disagree
Argumentation:
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2.
There is a need for further increasing public awareness on risks of indoor radon and consequent activation to carry out indoor radon measurements and mitigation Agree
Disagree
Argumentation:
3.
Local health authorities should have a continuous focus on indoor radon measurements and mitigation work Agree
Disagree
Argumentation:
4.
There is a need for harmonizing the practices of municipal building authorities Agree
Disagree
Argumentation:
5.
Strengthening the importance of indoor radon regulations is essential for good local policy practice Agree
Disagree
Argumentation:
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Appendix 2 Questionnaire on ETS policy development, implementation and follow-up in Bulgaria Event: ETS round table meeting Sofia, Bulgaria - 30 May 2007
Topic / Idea: Open public debate to formulate feedback about the EC green paper of 30 January 2007 named “Towards a Europe free from tobacco smoke: policy options at EU level” Participants: Experts from ministries, municipalities, NGOs, professional organizations etc.
Introduction The World Health Organization – Environment and Health Centre in Bonn is coordinating a European project to establish an Environment and Health Information System (EHIS) in the WHO 9 European Region . 18 partner countries are involved; the Bulgarian ministry of health delivers the
Bulgarian project member. The project framework is created by the Children’s Environment and Health Action Plan for Europe (CEHAPE). CEHAPE defines priority areas where reduction and prevention of children’s exposure to environmental matters and consequent health effects is necessary. Environmental tobacco smoke is one of these issues. One of the project’s objectives is to evaluate the policy development, implementation and follow-up process for these priority topics at national level.
This questionnaire aims to retrieve your opinion about the Bulgarian environmental tobacco smoke regulations, see listed below. It principally covers the question: To what extent do the existing regulations prevent non-smokers and in particular children from exposure to tobacco smoke and thus prevent or reduce the mortality and morbidity rates that can be attributed to environmental tobacco smoke?
A non-exhaustive listing of the Bulgarian regulations in the area of environmental tobacco smoking:
ETS national strategy (?)
National Programme for tobacco smoking constraint 2002 – 2005 and renewed programme for 2006 – 2010
DECREE No. 329 Dated 08 of December, 2004 for adoption of the Regulations of Conditions and Order of Permitted Smoking as an Exception in Separated Enclosed Areas of Indoor Public Places and Indoor Places of Employment
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LAW ON TOBACCO AND TOBACCO PRODUCTS latest amendment dates from 2 July 2004
We prepared 15 questions which are structured according to three headings: (i) development; (ii) implementation; (iii) follow-up. Please carefully read the questions and mark your response in the provided boxes. Feel free to clarify your answer in the open space below each question.
In succession to this questionnaire you might be invited for an interview where we would like to discuss your responses in more detail.
Thank you very much in advance for your efforts.
ETS policy development
1.
Advertising and selling tobacco products smoke is being constrained and smoking bans are (going to be) in place in public indoor and working environments. These policies indirectly reduce smokers’ and non-smokers’ exposure to environmental tobacco smoke. Is ETS exposure also directly addressed in Bulgarian policies? Yes No Explanation:
2.
Are vulnerable groups, such as asthmatics and children, specifically addressed in Bulgarian 10 ETS-relevant policies ?
Yes No Explanation:
3.
Would you prefer the Bulgarian ETS-relevant policies to be stricter / have a higher potency for enforcement and control? Yes
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4.
The European policy process influences the Member States’ policy development. In the case of ETS, would you say that Bulgaria is active in developing ETS-relevant policies mainly due to European processes or mainly due to national initiatives and pressures? Mainly European pressure Mainly national pressure Explanation:
5.
Do the policies include quantitative exposure reduction or health promotion objectives? Yes No Explanation:
6.
Do you have a clear idea of which Bulgarian authorities are involved with policy development? Yes No Explanation:
7.
If yes, is coordination of responsibilities and tasks between these authorities well-organized? Yes No Explanation:
ETS policy implementation
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Are implementation measures, such as reporting systems and abatement measures, in place to enforce the defined policy objectives? Yes No Explanation:
9.
In general, would you say that the implementation of the Bulgarian ETS-relevant policies is successful? Yes No Explanation:
10. Do you have a clear idea of which Bulgarian authorities are involved with policy implementation? Yes No Explanation:
11. In your opinion, are the targeted users (such as pub owners) of the ETS-relevant policies wellenough informed about and guided in application of implementation requirements? Yes No Explanation:
ETS policy follow-up
12. If the answer to question 5 is ‘yes’, are there tools, such as exposure indicators or monitoring systems in place to assess ETS exposure reduction or consequent health improvement which is attributable to the policy? Yes No Explanation:
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13. Do you have a clear idea of which Bulgarian authorities are involved with policy evaluation? Yes No Explanation:
14. Are you aware of a ‘successful’ education or awareness programme for children and adolescents addressing ETS and aiming for exposure prevention or reduction? Yes No Explanation:
15. Would you like to contribute to a brainstorming session on how to improve the development, implementation and follow-up of ETS policies in Bulgaria? Yes No Explanation:
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WP3 Information needs of EH policies Deliverable 3.3
Guidelines for generating information for policy support
www.ENHIS.org
This document has been developed by a project co-financed by the European Commission - DG Sanco (Grant Agreement SPC 2004124), coordinated by the WHO Regional Office for Europe and involving partner institutions from 18 European countries. The views expressed here do not necessarily reflect the official opinion of the European Commission or of the World Health Organization.
Authors: Eva Kunseler and Matti Jantunen National Public Health Institute, Department of Environmental Health Kuopio - Finland
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Table of contents 1. INTRODUCTION ...................................................................................104 2. GUIDANCE TO METHODOLOGY ........................................................105 3. IDENTIFICATION OF INFORMATION NEEDS IN ENHIS-2 .................106 4. FINAL REMARKS .................................................................................107
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1.
Introduction
This guidance document provides direction for assessment and evaluation of environmental health policy making processes and allows for a structured approach towards specification of information needs for environmental health policy making. Assessment of information needs can for example reveal the need for improved coordination procedures, more transparent policy structures, enhanced methods and tools for policy implementation, follow up and evaluation, evidence-based knowledge and data. Policy making consists of successive and interconnecting phases, each of which requires undertaking of different procedures, actions and approaches towards stakeholder involvement. Accountable policy making refers to clear-cut policy objectives defined, implemented and evaluated by means of effective policy instruments following an organized and coordinated system. Ideally, the policies should be strengthened, modified or changed according to how well or poorly the objectives are met. Figure 1 illustrates the process of accountable policy making. First, concerning an identified hazard (i), the public health objective for the policy is defined in a political deliberation process, involving discussion about the environment-health linkage, social, economic and political upstream determinants, as well as possible interventions. (ii) Science based models are drafted linking health impacts to exposures, further to sources of the hazard and the driving forces behind them. (iii) Quantified exposure objectives can be defined as interim targets, given a trusted dose/response model. Exposure objectives are more directly linked to sources and can be monitored with minimal time lag, which is usually not the case for public health objectives. (iv) Policy formulation continues with evaluation of the policy options and selection of the policy/actions for implementation. (v) Exposure reduction towards meeting the exposure objectives is monitored and the public health benefit can consequently be estimated. Ideally, also the health impacts are observed and evaluated against the overall policy objective.
Figure 1. The accountable policy making process
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In order to evaluate the accountability of and environmental health policy, information is needed to enable the identification, formulation, selection and evaluation of policy objectives with suitable policy instruments and through collaboration among the appropriate legislative and executive authorities. The ENHIS-2 project 1 identified information needs for environmental health policy making in seven environmental health topic areas. The seven topics are divided into several sub topics for a final list of thirteen policy topics. 1. Water – (i) Drinking water; (ii) Bathing waters 2. Traffic accidents (iii) 3. Housing – (iv) Hygienic conditions in dwellings; (v) Violence, crime and vandalism in residential areas; (vi) Extreme cold and heat; (vii) Housing safety and accidents 4. Air Quality – (viii) Particulate matter, ozone, nitrogen dioxide and sulphur dioxide in outdoor air; (ix) Environmental tobacco smoke (ETS) 5. Noise (x) 6. Radiation – (xi) UV radiation; (xii) Indoor radon 7. Chemical hazards in food (xiii) A first assessment of information needs covered the international / (pan-)European policy level and the national policy level. A second assessment of information needs is based on experiences of national officials and experts concerning each step from policy initiation to its evaluation.
The following chapter presents the methodology towards information generation that was developed for and applied in the ENHIS-2 project. The principal information needs identified in ENHIS-2 are highlighted in the third chapter. The final remarks indicate the need for continued information generation for policy support.
2.
Guidance to methodology
In ENHIS-2, information needs in environmental health policy making were identified as part of policy review studies at European and national level involving policy document analysis and interviews with national policy legislatives, executive authorities and professionals in the field. The ENHIS-2 tools for identification of information needs in environmental health policy making are here described from a policy research perspective. For demonstration and exemplification of the method and tool development and application in ENHIS-2, please access to the Methods and tools page on the ENHIS website. (i)
Literature and policy text analysis: Document search and structured analysis of existing legislation at international, European and national policy level helps to improve the knowledge and understanding of environmental health policies across Europe – their formats, objectives, rationale and accountability;
(ii)
Questionnaire development and implementation: A structured questionnaire to national environmental health experts and policy authorities allows for obtaining the necessary information on national environmental health policies, e.g. on the policy development, implementation and follow-up processes. Questionnaire responses are the main data source to identify the policy information needs. It is preferable to have national focal points selecting the right experts and authorities for each policy question and to interview them face-to-face or by phone. The
1
The ENHIS-2 project establishes the Environment and Health Information System for policy support and is supported with EC DG Sanco grant agreement SPC 2004124.
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experience shows that this approach results in a co-operative atmosphere and complete responses; (iii)
Comparative analysis: Evaluation allows for structured analyses of the policy processes and results in a comparative assessment of their respective levels of accountability. Consequent gaps-and-needs analyses enable comparison of the identified problems and challenges in environmental health policy making.
(iv)
Policy case study development and implementation. Policy case evaluation can be carried out as an individual exercise, or built further upon the outcomes of the analyses of the policy questionnaire responses. The evaluation can be carried out as a single expert desk exercise, although stakeholder involvement will lead to more valuable outcomes. Discussion between experts, legislative and executive policy authorities gives important insights into the policy making processes. An evaluation structure allows for systematic assessment of the qualitative policy data.
Information needs for accountable policy making are assessed by comparing the retrieved data to the conceptual framework of accountable policy making (figure 1). Assessment of information needs can for example reveal the need for improved coordination procedures, more transparent policy structures, evidence-based knowledge and data, and enhanced methods and tools for policy implementation, follow up and evaluation. Information needs derived from the first and second assessment studies are specified in the ENHIS-2 assessment report that is available at the policy page of the ENHIS website. The next chapter will highlight the principal information needs, resulting from the ENHIS-2 assessment studies.
3.
Identification of information needs in ENHIS-2
Recognition of gaps in the European and national environment and health policy making processes and consequent identification of the information needs for each policy is a starting point for improved, efficient policy action. Based on the information needs assessments, four major information needs were identified: (i) linking health objectives to policy actions, (ii) validated methods for the evaluation of health impacts of the policies, (iii) strengthened focus on children’s health and (iv) improved integration of policy topic areas through better coordination between policy sectors and legislative and executive actors. i.
Quantified exposure reduction or health improvement targets are seldom defined, which is partially due to insufficient quantitative knowledge on or formulation of the linkage between the identified environmental hazard(s) and their presumed health effects. Still, the formulation should state what is known, acknowledge the uncertainties and point out the additional information needs, otherwise the accountability of the policy cannot be assessed.
ii.
Current policy evaluations, if performed in the first place, typically monitor compliance with hazard or source control objectives without further exposure or health impact assessments. There is however growing public and political demand for the evaluation and comparison of policies in terms of their actual public health benefits.
iii. Only in the policy areas of food, housing and traffic safety are child-specific policy actions formulated and implemented. In certain areas, such as home violence, noise and ETS, children are being recognised as a particular
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vulnerable group. While this recognition is important, without its translation into explicit policy objectives and measures for children’s health it will not result in effective protection. Experts report a need for more data and research about the dose-response relations specific to children and a consequent development of methodology to determine the exposure and health impacts. iv. Throughout the whole environmental health spectrum a major gap exists in joining up individual policy actions into common holistic approaches. In particular, indoor environments contain many different types of hazard sources that should be commonly addressed and interlinked. The ENHIS indicators can play a major role in bringing together data and information on the diverse sources, exposure pathways and routes, and health effects. A major requirement for establishing an integrated environmental health approach is improved co-ordination within and between horizontal and vertical policy levels in all topic areas.
4.
Final remarks
Application of the methodology to identify the information needs in environmental health policy making provides a common assessment framework for policy analyses, improves insight into policy processes and raises awareness and motivation for the development of accountable environmental health policies and actions at European and national level. Policy accountability requires that the policy is assigned quantified and verifiable public health and exposure objectives, the policy is founded on science based dose/response and sourceexposure models, the policy implementation is accompanied with a follow up programme to ensure that its objectives are met, and a feedback process to improve and correct the policy when deemed necessary by the follow up results. Transparency is also an integral element of any accountable policy. For the public, which pays for the policy and would suffer from its failure, an accountable policy will demonstrate that either the expected health benefits are achieved or that an inefficient policy is re-evaluated and corrected.
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ENHIS 2
WORK PACKAGE 5 (WP5) RESULTS
INVENTORY OF AVAILABLE SURVEY METHODS FOR ENVIRONMENTAL HEALTH INDICATORS (Deliverable 5.2) DEFINITION OF INFORMATION NECESSARY FOR THE CEH TO BE COLLECTED BY SURVEYS (Deliverable 5.4)
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WP 5 Methods for generating information from existing data sources Deliverables 5.2 and 5.4
5.2 Inventory of available survey methods for Environmental Health indicators and
5.4 Definition of information necessary for the CEH to be collected by surveys
www.ENHIS.org
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This document has been developed by a project co-financed by the European Commission - DG Sanco (Grant Agreement SPC 2004124), coordinated by the WHO Regional Office for Europe and involving partner institutions from 18 European countries. The views expressed here do not necessarily reflect the official opinion of the European Commission or of the World Health Organization.
Author: Adriana Galan Institute of Public Health, Bucharest, Romania
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Introduction The development and selection of environmental health indicators followed a process involving multiple working groups and consultations, using the criteria of scientific credibility, a focus on children’s EH and relevant policy action such as CEHAPE, and feasibility. To achieve the goals of protecting and promoting the children’s health, the environmental health information system primarily focused on the indicators regarding Exposure (Ex), Health effects (E) and Action (A) in the causal chain framework of DPSEEA. Some of the core indicators, especially those related to health effects (e.g., Outbreaks of water-borne diseases, Prevalence of excess body weight and obesity in children and adolescents, Percentage of physically active children and adolescents, Prevalence of asthma and allergies in children) are not routinely reported at international level in databases like EUROSTAT or WHO-HFA. However, due to their relevance, they were included in the core set of indicators. For these indicators, international surveys were searched and used whenever they were available and matching the definition of the related indicator. A list of available surveys at international level is provided in Table 1. Action indicators (e.g. Policies to promote safe mobility and transport for children; Policies to reduce and prevent unintentional injuries from falls, drowning, poisoning, fires and chocking; Policies to reduce and prevent excess body weight and obesity in children and adolescents; Policies to reduce the excessive exposure of children to ultraviolet radiation) were also included in the core set to evaluate the existing policies at national level for related issues of interest. For these action indicators, special surveys were designed and implemented within EHNIS 2 project, involving all project partner countries, but volunteer countries as well. For indicators that have not yet been addressed by international surveys, like Outbreaks of water-borne diseases, but included in the core set, special case studies were developed, based on data existing at country level, even if not standardised or fully compatible; for this indicator a specific survey is needed. December 2007
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Another number of indicators were included in the Extended set, needing further development and harmonisation. Out of them, 12 are available neither in international databases, nor in international surveys. The list of these indicators is provided in Table 1. Special surveys need to be designed and implemented to collect necessary data to build the indicators.
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Table 1 RPG 1
Inventory of available survey methods for CEH indicators and definition of information for CEH indicators to be collected by new surveys Overview of proposed indicators
No.
Indicator Code
Indicator full name
Definition of indicator
1.1
RPG1_WatSan_E1
Outbreaks of water-borne diseases
1.5
RPG1_WatSan_S2
Drinking water quality
1.6
RPG1_Hous_Ex4
Household hygiene
Number of outbreaks of waterborne diseases attributable to drinking water and bathing water each year; number of cases in the outbreaks. An outbreak of waterborne disease is usually defined as an event meeting two criteria: (i) at least two people have experienced similar illness after exposure to water, and (ii) epidemiological evidence implicates water as the probable source of the illness. Proportion of the drinking water % samples analysed which fail to comply with the EU Directive on the quality of water intended for human consumption Percentage of the population living in % housing with missing hygienic amenities
1.7
RPG1_WatSan_A1
Water safety plans
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Proportion of the population served by a potable water supply covered by a
Unit of measure Number of outbreaks Number of cases
score
Age stratification Children under 18
Children under 18
Category i C
Data collection method National surveillance systems – harmonisation needed
E
Indicator needs further development
E
Survey (EU-SILC of EUROSTAT) – data will be available in the future New survey
E
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‘water safety plan’ as described by WHO (2002)
RPG 2
Overview of proposed indicators
No.
Indicator Code
Indicator full name
Definition of indicator
2.3
RPG2_Hous_E2
Prevalence of excess body weight and obesity in children
2.4
RPG2_Hous_Ex1
Prevalence of excess body weight and obesity in children and adolescents Percentage of physically active children and adolescents
2.5
RPG2_Traf_A1
2.6
RPG2_Hous_A1
2.7
RPG2_Hous_A2
2.9
RPG2_Traf_S1
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Percentage of children who meet the moderate-to-vigorous physical activity guidelines, defined as 60 minutes or more of at least moderate intensity activity on 5 or more days week Degree of implementation of policies aimed at preventing road traffic injuries in children and young people Extent to which 12 policies to reduce unintentional injuries are implemented
Policies to promote safe mobility and transport for children Policies to reduce and prevent unintentional injuries from falls, drowning, poisoning, fires and chocking Policies to reduce and Policies to reduce childhood obesity prevent excess body weight and obesity in children and adolescents Mode of child Percentage of children going to school transportation to school by different modes of transportation: a) car b) walking c) bicycle d) public
Unit of measure %
Age stratification Children aged 11, 13 and 15
Category
%
Children aged 11, 13 and 15
C
Data collection method Health Behaviour in School-aged Children (HBSC) survey HBSC survey
Ordinal score (0-20)
yes
C
ENHIS survey
Ordinal score (0-24)
yes
C
ENHIS survey
Ordinal score (0-24)
yes
C
ENHIS survey
%
children going to school
E
New survey (possibly to be included in the
C
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transport (including school buses)
RPG 3
next phase of HBSC study)
Overview of proposed indicators
No.
Indicator Code
Indicator full name
Definition of indicator
3.1
RPG3_Air_E1
Prevalence of asthma and allergies in children
3.4
RGP3_Air_Ex2
3.8
RPG3_Air_Ex3
3.9
RPG3_Hous_Ex1
Exposure of children to environmental tobacco smoke Proportion of children living in proximity of heavily trafficked roads Crowding
The prevalence rates of symptoms of asthma and allergic rhinoconjunctivites in children aged 6-7 years and 13-14 years Proportion of children exposed to environmental tobacco smoke in their homes Percentage of children aged 0-4, 5-9 or 10-14 living in proximity to heavily trafficked roads Proportion of households living in crowded housing conditions
3.11
RPG3_Air_Ex4
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Children going to schools with indoor air problems
Proportion of children going to schools or day care centres with moisture damage or mould growth during the year. Proportion of children going to schools
Unit of measure %
Age stratification Children of 6-7 and 13-14 years
Category
%
Children of 13-15 C years
GYTS survey
%
0-4, 5-9, 10-14
E
New survey
%
E
%
Children under 19 E years
Survey (EU-SILC of EUROSTAT) – data will be available in the future New survey
C
Data collection method ISAAC survey
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and day care centres with a ventilation < 7 l/s per person
RPG 4
Overview of proposed indicators
No.
Indicator Code
Indicator full name
Definition of indicator
4.3
RPG4_Food_Ex2
Persistent Organic Pollutants (POP) in human milk
4.4
RPG4_Food_Ex1
4.5
RPG4_Chem_Ex1
Exposure of children to chemical hazards in food Levels of lead in children’s blood
Persistent Organic Pollutants (POP) in human milk. POPs are chemicals that remain intact in the environment for long periods, become widely distributed geographically, accumulate in the fatty tissue of living organisms and are toxic to humans and wildlife Dietary exposure to potentially hazardous chemicals in children’s food
4.6
RPG4_Rad_Ex1
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Radon level in dwellings
The level of lead in the blood of children in a community, a region or a country is expressed as the geometric mean of individual blood lead concentrations in micrograms per decilitre (µg/dl) Estimated annual mean of radon levels in dwellings and proportion of dwellings with levels above 200 Bq.m-3 and 400
Unit of measure For dioxins and PCBs: pg/g fat (expressed as WHO TEQs)
Age stratification
Category C
µg/kg bw/day
C
µg/dl
C
Bq.m-3 and %
C
Data collection method WHO coordinated surveys
SCOOP and GEMS/Food Surveys National Surveys; need further harmonization
JRC Survey
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4.8
RPG4_UVrd_A1
4.11
RPG4_Nois_A1
4.12
RPG4_Chem_A1
4.13
RPG4_Chem_A2
4.14
RPG4_Chem_A3
4.15
RPG4_Rad_A1
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Policies to reduce the excessive exposure of children to ultraviolet radiation Policies to reduce exposure to leisure sounds Regulatory requirements for landuse planning
Bq.m-3 Action to reduce the excessive exposure of children to ultraviolet radiation
Composite index of existence and enforcement of regulations to regulate the music levels and insulation Composite index of existence of regulatory requirements for land-use planning around sites containing large quantities of chemicals according to the criteria for upper tier of the European Union ‘Seveso II’ Directive Chemical incidents Composite index of existence of active register register containing information about the source of the accident, the location, estimate of the health outcomes Government Composite index of existence of preparedness instruments for government preparedness to chemical emergencies and population/geographical areas covered. Effective environmental Composite index of existence of monitoring of effective environmental monitoring of radioactivity radiation activity in compliance with national and international quality assurance programmes
Ordinal score
C
ENHIS survey
Ordinal score
E
ENHIS survey (for the future)
score
E
SEVESO survey
score
E
ENHIS survey (for the future)
score
E
ENHIS survey (for the future)
score
E
ENHIS survey (for the future)
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i
C – included in the Core set of indicators E - included in the Extended set of indicators
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ENHIS 2
WORK PACKAGE 6 (WP6) RESULTS
USER’S
MANUAL OF THE COMMUNICATION AND SHAREPOINT INFORMATION EXCHANGE PLATFORM
(Deliverable 6.1) SET OF NATIONAL FACT SHEETS (Deliverable 6.4)
WP6 Support to the network of national collaborating centres Deliverable 6.1
User’s manual of the communication and information exchange platform SharePoint
www.ENHIS.org
This document has been developed by a project co-financed by the European Commission - DG Sanco (Grant Agreement SPC 2004124), coordinated by the WHO Regional Office for Europe and involving partner institutions from 18 European countries. The views expressed here do not necessarily reflect the official opinion of the European Commission or of the World Health Organization.
Author: Tibor Malnasi National Institute of Environmental Health Budapest, Hungary
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ENHIS Common Office site User’s Manual The site was created to ensure effective communication between the project partners and to enable them to get an up-to-date overview of the outcomes and results of the project. The structure of the site The ENHIS Home page was created for the public. It means that besides the project partners, guests also can access the page with password. They can download documents and write comments about the project. Therefore only final documents are stored on this site. There is a Common site for tasks, information and documents that refers more than one Work Package. The Work Packages have their own site (WP1 – WP8), where they can store their working documents and can have conversation about topics that interest the WP members. Navigation The menu can be found on the left side of the page (see below the detailed description of the functions). The link to the Common page and to the pages of the WPs is on the right side of the ENHIS Home page. To go back to the first page of a particular site, click on the ‘Home’ link on the upper right side of the page. To go back to the ENHIS Home page, click on the ‘Up to ENHIS’ link on the upper left side of the page.
Announcements (ENHIS Home, Common) The announcements allow the users to share important information and to write messages. The title, author, date and the first few lines of the announcements appear in the announcement window (e.g. on the first page of the Common site). To view the announcement, open it by clicking on the title. After opening, it can be modified by clicking on the ‘Edit item’ or deleted (‘Delete item’). To add new announcement, click on the ‘Add new announcement’ on the bottom of the page (or on the ‘New item’ button if you have already opened one). Then type the title and the text of the announcement (in the Body field) and also the date of expire can be added (optional). Please note that the format of dates is always Month/Day/Year (e.g. 2/4/2005 means 4th February 2005). After filling in the required fields, always click on the ‘Save and close’ button in order to create a new announcement or save modifications.
Shared documents (ENHIS Home, Common, WPs) This function allows the users to up- and download, store and modify documents. To create folders, click on the ‘New Folder’ button. Type the name of the folder and click on the ‘Save and close’. To upload a document, click on the ‘Upload document’, then click on the ‘Browse’ button, select the document you want to add (a short description is required in the ‘Note’ field) and click on the ‘Save and close’. The documents can be ordered according to type, name, date of modification etc. by clicking on the grey text above the list of the documents. If you want to comment a document, do not modify the document that is on
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the Sharepoint. Create a new document with your comments, amend the original filename with your initials and upload it in the same folder. If you have to modify a document (e.g. fill in a data collection sheet), you can do it in different ways (depending on your system): you can open the file by clicking on the arrow on the right side of the file (it will appear only if you move the mouse on the title) and from the pop-up menu choose ‘Edit in Microsoft Office Excel’ or ‘Edit in Microsoft Office Word’. Then you can modify and save the document. If this does not work, try to open and save the file in the Explorer view (left side of the page). Documents can be opened in the Explorer view if the browser is Internet Explorer 5.0 or greater.
Tasks (Common) The tasks, their status, priority, and deadlines can be seen on this page. To add a new task, click on the ‘New item’. To modify a task, open it by clicking on the title, then click on the ‘Edit item’ or click on the arrow on the right side of the title (move the mouse on the title) and use the pop-up menu. The tasks can be ordered according to title, deadline etc. by clicking on the grey text above the list of the tasks.
Contacts (ENHIS Home, Common) The details (name, e-mail address etc.) of the project partners can be found on this page. The project partners have to add their own details. The followings appear on the ‘Contact’ page: Name, Company (institution), Business Phone, e-mail address and the number of the relevant Work Package. All of the details of a person can be listed by clicking on the last name of the person. E-mail can be sent directly by clicking on the e-mail address. To add a new contact, click on the ‘New contact’ button, then fill in the fields (the required fields are marked with *) and click on the ‘Save and close’. To modify the details, click on the name of the person and then on the ‘Edit item’ or click on the arrow on the right side of the name (move the mouse on the title) and use the pop-up menu.
Discussions (ENHIS Home, Common, WPs) Discussion boards provide a forum for conversing about different topics. You can view discussion comments in either threaded or flat view. Threaded view lets you view comments by conversation. To read the text of and the answer to a comment, click on the ‘+’ on the left side of it. Flat view displays all comments in the order in which they were created. You can open a discussion about a topic by clicking on the ‘New discussion’. To view, edit, reply to or delete a comment, move the mouse on it and click on the arrow on the right side and use the pop-up menu.
Alerts Due to technical difficulties it is not possible to create individual alerts. Every user gets a daily summary about any changes and modifications.
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Set of national fact sheets
www.ENHIS.org
This document has been developed by a project co-financed by the European Commission - DG Sanco (Grant Agreement SPC 2004124), coordinated by the WHO Regional Office for Europe and involving partner institutions from 18 European countries. The views expressed here do not necessarily reflect the official opinion of the European Commission or of the World Health Organization.
Editor: Tibor Malnasi National Institute of Environmental Health Budapest, Hungary
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Table of contents 1. National fact sheets of the Czech Republic 1.1. Prevalence of asthma and allergies in children 1.2. Exposure of children to air pollution (particulate matter) in outdoor air 1.3. Blood lead levels in children
2. National fact sheets of Estonia 2.1. Public water supply and access to improved water sources 2.2. Bathing water quality
3. National fact sheet of Hungary 3.1. Prevalence of asthma and allergies in children
4. National fact sheet of Lithuania 4.1. Mortality from road traffic injuries in children and young people
5. National fact sheet of Poland 5.1. Infant mortality from respiratory diseases
6. National fact sheet of Romania 6.1. Mortality from road traffic injuries in children and young people
7. National fact sheet of Slovakia 7.1. Bathing water quality
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National fact sheets Czech Republic
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Datum: říjen 2007
Prevalence astmatu a alergií u dětí Indikátor Jméno: Definice: Kód:
Prevalence astmatu a alergií u dětí Prevalence astmatu a alergických onemocnění u dětí ve věkových kategoriích 5, 9, 13 a 17 let. RPG3_Air_E1
Úvod Tento Informační list poskytuje přehled o vývoji výskytu (prevalence) astmatu a alergií u dětí v České republice, jakož i o zastoupení jednotlivých alergických diagnóz jednak u dětí celkově a jednak u sledovaných věkových skupin dětí (5,9,13 a 17 let). Údaje pocházejí z pravidelných šetření výskytu alergií prováděných v rámci Systému monitorování zdravotního stavu obyvatelstva ČR ve vztahu k životnímu prostředí. Zahrnuta je také informace o vztahu k životnímu prostředí a existujícím politikám jak v národním, tak v evropském kontextu. Odůvodnění Vzestup počtu alergických onemocnění, a zejména astmatu, byl největší především v 70. – 90. letech 20. století, kdy se uvádělo až zdvojnásobení prevalence v průběhu jedné dekády (1). Astma se v průběhu 90. let 20. století stalo jednou z nejčastějších chronických nemocí vůbec. Výskyt v dětském věku je zřetelně vyšší než u dospělých, a v některých zemích přesahuje v dětské populaci 20% (2). Očekává se, že počet alergických onemocnění bude nadále růst, neboť přibývá lidí citlivých na nejrůznější alergeny. Souhrnný závěr Podle periodicky opakovaného šetření prevalence alergií vzrostl počet alergických dětí za posledních deset let téměř dvojnásobně: ze 17 % v roce 1996 na 32% v roce 2006. Nejčastějším onemocněním je alergická rýma pylová a atopický ekzém; obě tyto alergie činí přes polovinu všech diagnostikovaných alergických onemocnění. V roce 2006 bylo lékařem diagnostikováno astma u 8% dětí, což představuje nárůst o polovinu ve srovnání s rokem 1996.
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Obr. 1 Vývoj prevalence alergických onemocnění u dětí v letech šetření 1996 - 2001 - 2006 40
Alergická onemocnění celkem
Astma 32 %
30 Podíl dětí (%)
25 %
20
17 %
8%
10 5%
4% 0 1996
2001
2006
Zdroj: Systém monitorování zdravotního stavu obyvatelstva ČR ve vztahu k životnímu prostředí Obr. 2
Podíl dětí s alergickým onemocněním v roce 2006
Alergická rýma pylová
12,8
10,9
14,5 12,3 12,7 12,0
Atopický ekzém
Astma
7,2
8,2 9,2
2,9 2,5 3,4
Opakované bronchitidy
Celkem
3,3 2,8 3,7
Celoroční alergická rýma
Dívky Chlapci 6,4 6,9 5,9
Ostatní alergie 0
2
4
6
8
10
12
14
16
Podíl dětí s alergií [%]
Zdroj: Systém monitorování zdravotního stavu obyvatelstva ČR ve vztahu k životnímu prostředí
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Obr. 3
Výskyt alergických onemocnění ve věkových skupinách dětí, 2006
20 Podíl dětí s alergií [%]
18 16
Celkem 35 % Celkem 28 %
Celkem 34 %
Celkem 30 %
14 12 10 8 6 4 2 0 5 let
9 let
13 let Věková skupina
17 let
Atopický ekzém
Alergická rýma pylová
Astma
Opakované bronchitidy
Celoroční alergická rýma
Ostatní alergie
Zdroj: Systém monitorování zdravotního stavu obyvatelstva ČR ve vztahu k životnímu prostředí Prezentace dat Na obr. 1 je zobrazen vývoj prevalence alergických onemocnění v jednotlivých letech šetření. Zvyšuje se počet dětí trpících alergickým onemocněním jak celkově, tak také dětí trpících astmatem. V letech šetření 2001 a 2006 byly zastoupeny všechny vybrané věkové skupiny dětí. V roce 1996 nebyla v souboru dětí zastoupena věková skupina 17 let. Tento fakt však neovlivnil trend vývoje onemocnění ve sledovaných letech. Na obr. 2 je znázorněn výskyt alergických onemocnění podle jednotlivých diagnóz a podle pohlaví. Nejčastější diagnózou je alergická rýma pylová, kterou trpí 13% dětí a atopický ekzém (12% dětí). Chlapci mají významně častěji než dívky respirační formu alergie. Z obr. 3 je zřejmé, že výskyt alergických onemocnění je závislý na věku. Pro mladší děti je typický zejména atopický ekzém, pro starší děti pylová alergická rýma. U této diagnózy je evidentní nárůst s věkem. Výskyt astmatu byl nejvyšší u třináctiletých, a to téměř dvojnásobný ve srovnání s pětiletými. Vztah životního prostředí a zdraví Podle odhadu trpí asi 20% světové populace alergickým onemocněním a astma se v průběhu 90. let 20. století stalo jednou z nejčastějších chronických nemocí vůbec. (3). Současné studie naznačují, že výskyt alergických onemocnění má v Evropě stále rostoucí trend a již není omezen na specifickou sezónu nebo prostředí (4,5). V současné době je třeba brát v úvahu několik hypotéz o příčinách nárůstu astmatu a alergií. Patří sem zvýšení expozice celoročně působících alergenů, vlivy výživy, změny životního stylu a změny v imunologické odpovídavosti. Tyto změny se vyvíjejí v důsledku nedostatečného kontaktu
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s nejrůznějšími mikroorganismy, zvýšené hygieny, zvýšeného používání antibiotik a rozvoje očkování (5). S výskytem astmatu a alergií jsou spojeny špatná kvalita venkovního ovzduší, expozice alergenům ve vnitřním prostředí a stresující životní styl (4). Rostoucí trend ve výskytu astmatu je zřejmý zejména v městském prostředí (6). Používání fosilních paliv a velký objem silniční dopravy ve městech přispívá k senzitivizaci (6,7,8). Současné studie podporují souvislost mezi expozicí znečištěnému ovzduší a exacerbací astmatu, zejména expozicí suspendovaným částicím PM a ozonu (7). Kauzální vztah mezi znečištěním ovzduší jako takovým a výskytem nebo incidencí astmatu však nebyl prokázán. Prokázán byl vztah alergických onemocnění s expozicí alergenům vnitřního prostředí tam, kde je špatná kvalita ovzduší (9). Na té se podílejí například zplodiny hoření, vysoká vlhkost a s ní související výskyt plísní a roztočů, chování domácích zvířat nebo tabákový kouř (10). Expozice tabákovému kouři může způsobit onemocnění astmatem u dětí, které dosud neměly žádné symptomy. Navíc, u již astmatických dětí může tabákový kouř vyvolat astmatický záchvat a celkově zhoršit toto onemocnění (11). Dýchání kouře dokonce snižuje účinnost protiastmatické léčby. Expozice tabákovému kouři v těhotenství je rizikovým faktorem pro obstrukční obtíže dítěte v časném věku (1). Ukazuje se, že existuje souvislost mezi změnami klimatu a rostoucím výskytem astmatu a alergií u dětí. V důsledku vyšších teplot a dřívějšího nástupu jara se zvyšuje množství vzdušných alergenů. Senzibilizace na pylové alergeny se v mnoha částech Evropy během posledních tří dekád téměř zdvojnásobila, zejména u mladých lidí (12). Kontext s politikami Jedním z rozhodujících vlivů na kvalitu života alergika je včasná diagnostika a následná léčba nemoci. Nedostatečná diagnostika astmatu a alergických onemocnění vede k neadekvátní kontrole onemocnění a následně pak k vyšším nákladům na léčení. Klíčovým prvkem v systému péče je úloha praktického lékaře pro děti a dorost, který by si měl být vědom vysoké prevalence astmatu a na tuto diagnózu u pacientů aktivně myslet. Úlohou specialisty-alergologa je především potvrzení diagnózy, doplnění podrobných vyšetření funkce plic, alergologického vyšetření a také řádná edukace nemocného včetně stanovení dlouhodobého plánu péče. Důležité je zvyšovat povědomí lidí o těchto nemocech, o významu včasného a správného léčení a důležitosti rizikových faktorů a rizikového chování (1). Protože také vlivy životního prostředí hrají roli při vzniku onemocnění, medikace není jedinou cestou ke snižování zátěže populace tímto onemocněním. Pozitivní účinky by měly mít i politiky vedoucí ke zlepšení kvality vnitřního i venkovního ovzduší. Mnoho zemí má internetové stránky informující veřejnost o správném chování při prevenci vzniku astmatu a alergií, jako jsou např. praktiky k zabránění množení roztočů nebo upozornění na rizika chovu domácích mazlíčků. Mezníkem v péči o astma bylo založení celosvětové Globální iniciativy pro astma v roce 1992 (GINA, WHO) a vydání Globální strategie péče o astma a jeho prevence. V ČR byla v roce 1996 založena odpovídající národní organizace Česká iniciativa pro astma (ČIPA), která se přihlásila ke strategii GINA dokumentem Strategie diagnostiky, prevence a léčby průduškového astmatu. Jejím posláním jsou cílené edukační aktivity, které prokazatelně zvýšily povědomí o nemoci především u praktických lékařů a pediatrů. Zkušenosti z konce 20. století ukazují, že rozdíl mezi prevalencí příznaků a diagnostikovaným astmatem se významně zmenšil a snížil se i počet dětí, které pro astma potřebují okamžitou a intenzivní
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péči. Začátkem cesty prevence je poznání rizikového jedince a faktorů, které k alergii vedou. Hlavním preventivním opatřením, které účinně chrání před exacerbací a opakovanými příznaky onemocnění je kvalitní preventivní léčba a udržení astmatu pod dobrou kontrolou. Hlavním cílem péče o astmatika je, aby příznaky nemoci byly nejvýše ojedinělé a nezávažné a závažnější exacerbace by měly být zcela vzácné (1). V roce 2004 přijala 4. ministerská konference životního prostředí a zdraví v Budapešti Akční plán zdraví a životního prostředí zaměřený na dětskou populaci v Evropě, která obsahuje čtyři regionální prioritní cíle ke snížení zátěže dětí nemocemi souvisejícími s kvalitou životního prostředí (13). Jeden z cílů (RPC III) je zaměřen na prevenci a snížení respiračních onemocnění v důsledku znečištění vnějšího a vnitřního prostředí, přispívajíce tak ke snižování frekvence astmatických záchvatů. Tento akční plán byl zpracován na národních úrovních v evropských zemích, tedy také ČR. Politický dokument Dlouhodobý program zlepšování zdravotního stavu obyvatelstva ČR - Zdraví pro všechny v 21. století, schválený usnesením vlády v roce 2002, (14) obsahuje v rámci cíle 10 úkol „snížit expozice obyvatelstva zdravotním rizikům souvisejícím se znečištěním vody, vzduchu a půdy látkami mikrobiálními, chemickými a dalšími,…“. Mezi aktivity zajišťující tento úkol patří „soustavně monitorovat a vyhodnocovat ukazatele kvality ovzduší a ukazatele zdravotního stavu“, tedy také výskyt astmatu a alergií v populaci. Této problematiky by se také částečně mohla týkat aktivita „snižovat vliv dopravy na životní prostředí a zdraví obyvatel“. Protože astma je považováno za redukovatelné a preventabilní onemocnění, Akční plán EC v oblasti veřejného zdraví na léta 2003–2008 je zaměřen na hodnocení dopadu možných opatření zdravotní politiky na prevalenci astmatu (15). Ve většině evropských zemí existuje v současné době pylová informační služba (PIS), která sleduje obsah pylu a plísní v ovzduší. Při znalosti kvantitativních a kvalitativních údajů o výskytu pylů v ovzduší celé Evropy je možno následně zpracovat předpovědi pro další období. Zpracované údaje slouží lékařům i pacientům ke zkvalitnění léčby alergií. V současné době monitoruje situaci v Česku 12 stanic. Hodnocení Výskyt astmatu v České republice je odhadován na 5 – 15 % v závislosti na věku dětí a metodikách prováděných studií. Studie z roku 1995 (16) udává výskyt astmatických příznaků u 3 – 5ti-letých dětí v rozmezí 9 – 15 %, a velmi nízkou úroveň diagnostiky nemoci (0,5 – 3,4%). Česká studie provedená v letech 1995 – 1998 podle metodiky Mezinárodní studie astmatu a alergií u dětí (ISAAC), zaměřená na příznaky astmatu přímo uváděné dětmi, zjistila výskyt příznaků u 16% dětí ve věku 13 – 14 let; následné ověření diagnózy astmatu u 5% dětí (17). Studie publikovaná v roce 1997 (18) uvádí rozdílný výskyt astmatu u dětí v Praze (3,8% – 6%) a venkovském okrese Benešov (2,5%). Podle opakovaných studií prevalence alergických onemocnění v rámci Systému monitorování zdravotního stavu obyvatelstva ČR ve vztahu k životnímu prostředí provedených v letech 1996, 2001 a 2006 (19,20,21), měl výskyt lékařem diagnostikovaných alergických onemocnění u dětí v průběhu deseti let stoupající trend: ze 17% na 25% a 32%; z toho astmatických onemocnění bylo 3,7%, 5,2% a 8,2%. Výskyt příznaků astmatu (pískotů při nachlazení) byl v roce 2001 udáván u 9,4% dětí, v roce 2006 již u 14%. V rámci zatím posledního šetření v roce 2006 byl
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vyhodnocen Test kontroly astmatu (ACT) ve skupině 13ti a 17ti-letých astmatiků. Úplná kontrola astmatu byla zjištěna téměř u 50% astmatiků a naopak nedostatečnou kontrolu (příznaky perzistujícího astmatu) mělo 15% astmatiků. Za pozitivní lze považovat fakt, že z celkového počtu 8% dětí s celoživotním výskytem astmatu měla jen asi polovina projevy onemocnění v posledním roce. Poslední opakování studie prevalence alergických onemocnění v roce 2006 (21) prokázalo kouření některého člena v 15% domácností s alergickým dítětem (ve 20% domácností bez alergiků). Za příznivý vývoj lze považovat fakt, že počet kuřáckých domácností byl v roce 2006 ve srovnání s rokem 2001 významně nižší, a to jak u alergiků a astmatiků, tak i celkově. V rámci evropských zemí je nejvyšší výskyt příznaků astmatu v anglofonních zemích (Spojené království, Irsko). Podle třetí fáze mezinárodní studie ISAAC v letech 1999 - 2004 uvádělo v těchto zemích 20% až 25% dětí příznaky astmatu, v posledních letech je rychle dohánějí Rumunsko a Ukrajina, kde došlo k velkému nárůstu výskytu příznaků od posledního šetření ISAAC v letech 1992 1998 (22). Nejnižší výskyt je naopak v Albánii nebo Litvě (do 5%). Rozdíly mezi zeměmi mohou být způsobeny faktory životního stylu, výživovými zvyklostmi, Také socio-ekonomickými rozdíly a faktory životního prostředí či klimatu. povědomí o nemoci může ovlivnit zjišťovaný výskyt nemoci (7,22). Souhrnně zpracované informace o tomto indikátoru pro Evropu lze nalézt na stránkách Evropského centra pro zdraví a životní prostředí Světové zdravotnické organizace (WHO) v rámci Informačního systému zdraví a životního prostředí (23). O datech k indikátoru Zdroj dat Studie prevalence alergických onemocnění v rámci Systému monitorování zdravotního stavu obyvatelstva ČR ve vztahu k životnímu prostředí (19,20,21), jsou organizovány Státním zdravotním ústavem (SZÚ) ve spolupráci se zdravotními ústavy ČR a praktickými dětskými lékaři. Zdrojem dat o výskytu diagnostikovaných alergických nemocnění byl dotazník pro lékaře, zdrojem dat o příznacích astmatu a také faktorech bydlení a životního stylu byl dotazník pro rodiče. Dotazníky byly vyplňovány v době preventivní prohlídky, za přítomnosti rodiče. Při vyplňování dotazníku lékaři uvedli, zda je u dítěte přítomno alergické onemocnění, u alergiků pak slovně označili druh onemocnění a dále uvedli kód onemocnění dle MKN. V dotazníku, který vyplnili rodiče dítěte byla zjišťována přítomnost astmatických příznaků dle metodiky studie ISAAC: „Mělo Vaše dítě v posledních 12 měsících hvízdavé dýchání nebo pískoty při/mimo nachlazení a mimo chřipkové onemocnění? “ Metoda výpočtu indikátoru Data byla převzata ze zdrojových studií (viz Zdroj dat), jako procenta dětí s lékařem diagnostikovaným alergickým onemocněním a zobecněna na dětskou populaci ČR. Geografické pokrytí Studie probíhá opakovaně v 18 městech ČR: Brno, České Budějovice, FrýdekMístek, Hodonín, Jablonec n. Nisou, Jihlava, Karviná, Kladno, Hradec Králové, Mělník, Most, Olomouc, Ostrava, Praha, Sokolov, Ústí n. Labem, Ústí n. Orlicí, Žďár n. Sázavou. Perioda
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První průřezová studie se uskutečnila v roce 1996 a byla zaměřena na populaci dětí ve věku 5, 9 a 13 let. V roce 2001 a 2006 proběhlo ve vybraných městech opakované šetření prevalence alergických onemocnění v populaci 5, 9, 13 a 17ti letých dětí. Frekvence aktualizace Pět let. Kvalita dat Výběr měst pro studii se řídil různorodostí ve velikosti i kvalitě životního prostředí (15000 až 385000 obyvatel + Praha, 1.2 mil), aby byl získán reprezentativní vzorek měst. Velikost skupiny dětí v šetření se řídila odhadem prevalence alergických onemocnění a počtem dětí v jednotlivých věkových skupinách ve vybraných městech. Podle tohoto údaje byl vybrán relevantní počet spolupracujících dětských lékařů v každém městě. Byla sledována vždy buď celá klientela daného věku nebo byl proveden náhodný výběr z ní. Nebyla tedy předpokládána žádná selektivita výběru dětí. Citace 1. Pohunek P., Svobodová T. Průduškové astma v dětském věku. Maxdorf 2007; Praha. ISBN 978-80-7345-118-9 2. Pohunek P. Výskyt bronchiálního astmatu ve světě a u nás. Alergie, Supplementum. 2003; 1: 7-14 3. Prevention of Allergy and Allergic Asthma. Geneva, World Health Organization, 2003 (http://www.worldallergy.org/professional/who_paa2003.pdf, accessed 7 March 2007). 4. Asthma. Geneva, World Health Organization, 2006 (Fact sheet No. 307) (http://www.who.int/mediacentre/factsheets/fs307/en/index.html, accessed 7 March 2007). 5. Špičák V. Hygienická hypotéza – možnost nebo dogma? Alergie. 2005;3:185 189 6. ISAAC Steering Committee. Worldwide variation in prevalence of symptoms of asthma, allergic rhinoconjunctivitis and atopic eczema: ISAAC. Lancet, 1998, 351:1225–1232. 7. WHO European Centre for Environment and Health. Effects of air pollution on children’s health and development - a review of the evidence. Copenhagen, WHO Regional Office for Europe, 2005 (http://www.euro.who.int/document/E86575.pdf, accessed 6 March 2007). 8. Nicolau N, Siddique N, Custovic A. Allergic disease in urban and rural populations: increasing prevalence with increasing urbanization. Allergy, 2005, 60:1357–1360. 9. Bibi H et al. Comparison of positive allergy skin tests among asthmatic children from rural and urban areas living within small geographic area. Annals of Allergy, Asthma and Immunology, 2002, 88:416–420. 10. ISAAC [web site]. International Study of Asthma and Allergies in childhood (http://isaac.auckland.ac.nz/, accessed 9 March 2007). 11. Fact sheet: National survey on Environmental Management of Asthma and Children’s Exposure to Environmental Tobacco Smoke. Washington, DC, United States Environmental Protection Agency, 2005 (http://www.epa.gov/smokefree/pdfs/survey_fact_sheet.pdf, accessed 7 March 2007). 12. Environmental hazards trigger childhood allergic disorders. Copenhagen, WHO Regional Office for Europe, 2003 (Fact sheet EURO/01/03)
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(http://www.euro.who.int/document/mediacentre/fswhde.pdf, accessed 7 March 2007). 13. Children’s Environment and Health Action Plan for Europe. Fourth Ministerial Conference on Environment and Health, Budapest, 23–25 June 2004 (EUR/04/5046267/7) (http://www.euro.who.int/document/e83338.pdf, accessed 2 March 2007). 14. Dlouhodobý program zlepšování zdravotního stavu obyvatelstva ČR - Zdraví pro všechny v 21. století (http://www.szu.cz/Menu1/zdravi21.html, accessed 5 October 2007) 15. Asthma. Brussels, Commission of the European Communities, Public Health Programme (2003–2008) (http://ec.europa.eu/health/ph_information/dissemination/diseases/asthma_en.h tm, accessed 7 March 2007). 16. Bobák M., Koupilová L., Williams HC., Leon DA., Dáňová J., Kříž B. Prevalence astmatu, atopického ekzému a senné rýmy u předškolních dětí. Prakt. Lék. 1995; 75(10):480-485 17. Pohunek P., Slámová A., Zvárová J., Svatoš J. Prevalence průduškového astmatu, ekzému a alergické rýmy u školních dětí v České republice. Čs. Pediat., 1999; 54(2):60 - 68 18. Vondra V., Reisová M., Braniš M., Malý M. Prevalence příznaků bronchiálního astmatu dětí základních škol v pražském obvodu a ve venkovském okrese. Čs. Pediat. 1997;52(11): 827-830 19. Systém monitorování zdravotního stavu obyvatelstva ČR ve vztahu k životnímu prostředí, Souhrnná zpráva za rok 1996, SZÚ Praha 1995. 20. Systém monitorování zdravotního stavu obyvatelstva ČR ve vztahu k životnímu prostředí, Souhrnná zpráva za rok 2001, SZÚ Praha 2002 (http://www.szu.cz/chzp/rep01/szu_02cz.htm). 21. Systém monitorování zdravotního stavu obyvatelstva ČR ve vztahu k životnímu prostředí, Souhrnná zpráva za rok 2001, SZÚ Praha 2007 (http://www.szu.cz/chzp/rep06/szu_07cz.htm). (http://www.euro.who.int/Document/EHI/ENHIS_Factsheet_3_1.pdf) 22. Asher MI et al. Worldwide time trends in the prevalence of symptoms of asthma, allergic rhinoconjunctivitis, and eczema in childhood: ISAAC Phase One and Three repeat multicountry cross-sectional surveys. Lancet, 2006, 368:733– 743. 23. Fact sheet No 3.1 Prevalence of astma and allergies in children. WHO Regional Office for Europe, Copenhagen, 2007 Další • • • • •
informace Česká iniciativa pro astma (www.cipa.cz/) Česká pylová informační služba (http://www.pylovasluzba.cz/home) Alergie, informační internetové stránky (http://www.alergie.cz/) Bez-alergie, informační internetové stránky (http://www.bez-alergie.cz/) World Allergy Organization [web site]. Milwaukee, WI, World Allergy Organization, 2007 (http://www.worldallergy.org/, accessed 7 March 2007). • Environmental Hazards and Health Effects Program. Asthma’s impact on children and adolescents. Atlanta, GA, Centers for Disease Control and Prevention, (http://www.cdc.gov/asthma/children.htm, accessed 7 March 2007). • A plea to abandon asthma as a disease concept. Lancet, 2006, 368:705. • Eder W et al. The asthma epidemic. The New England Journal of Medicine, 2006, 355:2226–2235
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(http://content.nejm.org/cgi/content/full/355/21/2226, accessed 7 March 2007). WHO European Centre for Environment and Health. Exposure of children to environmental tobacco smoke. Copenhagen, WHO Regional Office for Europe, 2007 (ENHIS-2 fact sheet No. 3.4). WHO European Centre for Environment and Health. Children living in homes with problems of damp. Copenhagen, WHO Regional Office for Europe, 2007 (ENHIS-2 fact sheet No. 3.5).
Autoři: MUDr. Jana Kratěnová, RNDr. Vladimíra Puklová Státní zdravotní ústav Praha, Centrum hygieny životního prostředí
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Datum: říjen 2007
Expozice obyvatel suspendovaným částicím ve venkovním ovzduší
Indikátor Jméno: Expozice obyvatel suspendovaným částicím ve venkovním ovzduší Definice: Rozdělení obyvatel měst podle velikosti potenciální expozice suspendovaným částicím, vyjádřené v intervalech ročního imisního limitu Kód: RPG3_Air_Ex2
Úvod Tato informace je založena na průměrných ročních koncentracích suspendovaných částic frakce PM10 ve venkovním ovzduší zjišťovaných na měřících stanicích ve městech v rámci Systému monitorování zdravotního stavu obyvatelstva ČR ve vztahu k životnímu prostředí. Výsledky měření jsou získávány ze sítě měřicích stanic, které provozují zdravotní ústavy v monitorovaných městech, a z vybraných měřicích stanic spravovaných Českým hydrometeorologickým ústavem (ČHMÚ), jejichž umístění vyhovuje požadavkům Systému monitorování. Zahrnuta je rovněž informace o vztahu k životnímu prostředí a vztah k existujícím politikám jak v národním, tak evropském kontextu. Odůvodnění Průměrné dlouhodobé expozice suspendovaným částicím PM10 představují jak riziko chronických účinků znečištění ovzduší na zdraví dětí, jako je poškození vývoje plicních funkcí, tak akutních účinků, například zhoršení projevů astmatu anebo incidence respiračních onemocnění. Koncentrace suspendovaných částic jsou také dávány do souvislosti s rizikem širokého okruhu zdravotních dopadů u dospělých. Souhrnný závěr Alespoň jedno z kritérií překročení ročního imisního limitu pro suspendované částice frakce PM10 bylo v roce 2006 naplněno na více než polovině měřicích stanic zahrnutých do Systému monitorování zdravotního stavu obyvatelstva ČR ve vztahu k životnímu prostředí . Podle odhadu žije téměř 80 % obyvatel monitorovaných sídel v místech, kde byly překročeny podmínky pro splnění pro imisního limitu. Zvýšené zátěži obyvatel České republiky suspendovanými částicemi frakce PM10 lze přisuzovat plošný charakter, měřené hodnoty byly v roce 2006 proti předchozímu roku mírně zvýšené. Kromě průmyslově zatížených lokalit, mezi které patří například Ostrava, Karviná, Ústí nad Labem nebo Liberec, se znečištění ovzduší koncentruje ve
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velkých městských aglomeracích (Praha, Brno, Ostrava), kde je překračován imisní limit u více sledovaných parametrů kvality ovzduší. V souvislosti s celorepublikovým nárůstem intenzity dopravy lze nalézt významně zatížená místa i v ostatních městech, a v souvislosti s nárůstem cen energií a spotřeby pevných paliv v domácnostech i v malých sídlech.
Obr. 1 Rozdělení obyvatel monitorovaných měst (3,36 mil. obyv.) podle potenciální expozice suspendovaným částicím (tj. průměrné roční koncentrace ve městech, v intervalech imisního limitu)
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Zdroj: Systém monitorování zdravotního stavu obyvatelstva ČR ve vztahu k životnímu prostředí, SZÚ Praha Český statistický úřad
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Obr. 2 Vývoj znečištění suspendovanými částicemi frakce PM10 v nejvíce zatížených městech v období 1996 - 2006
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Pozn.: Praha zastoupena jednou městskou částí LH - Imisní limit pro průměrnou roční koncentraci DH - Nejvyšší hodnota průměrné roční koncentrace doporučená WHO
Zdroj: Systém monitorování zdravotního stavu obyvatelstva ČR ve vztahu k životnímu prostředí, SZÚ Praha Prezentace dat Obr. 1 zobrazuje rozdělení obyvatelstva 19ti monitorovaných měst ČR, žijícího v různých hladinách roční průměrné koncentrace PM10, vyjádřené zde jako podíl platného imisního limitu. Do kategorie „nad limit“ spadá obyvatelstvo těch měst, kde byl překročen imisní limit pro roční koncentraci PM10, a také měst, kde byl zjištěn vyšší počet dnů s překročením denního limitu než 35. Z obrázku je patrný postupný nárůst počtu obyvatel exponovaných znečištění ovzduší PM10 překračujícím limitní kritéria a to zejména v důsledku růstu znečištění ve velkých aglomeracích. Obr. 2 ukazuje trend koncentrací PM10 ve vybraných nejvíce zatížených městech s dostatečnou řadou měření v letech 1996 – 2006. Přibližně od přelomu tisíciletí je patrný pozvolný nárůst průměrných koncentrací, přechodný pokles v roce 2004 mohl být způsoben meteorologickými podmínkami. Úroveň WHO doporučené nejvyšší koncentrace PM10 20 µg/m3 byla překročena ve všech městech, také na stanici ČHMÚ Košetice představující venkovské pozadí. Vztah životního prostředí a zdraví Krátkodobě zvýšené denní koncentrace suspendovaných částic PM10 způsobují nárůst celkové nemocnosti i úmrtnosti, zejména na onemocnění srdce a cév, zvýšení kojenecké úmrtnosti, zvýšení výskytu kašle a ztíženého dýchání, zejména u astmatiků (1). Mezi účinky dlouhodobě zvýšených koncentrací patří snížení plicních funkcí u dětí i dospělých, zvýšení nemocnosti na onemocnění dýchacího
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ústrojí a výskytu symptomů chronického zánětu průdušek, zkrácení délky života hlavně z důvodu vyšší úmrtnosti na choroby srdce a cév a pravděpodobně i na rakovinu plic. Tyto účinky suspendovaných částic frakce PM10 bývají uváděny i při průměrných ročních koncentrací nižších než 30 µg/m3. Při chronické expozici suspendovaným částicím frakce PM2,5 se redukce očekávané délky života začíná projevovat již od průměrných ročních koncentrací 10 µg/m3. Na základě nových poznatků upravila Světová zdravotnická organizace v roce 2005 Směrnice kvality ovzduší pro částice v ovzduší (2). Pro jemné částice frakce PM2.5 doporučila nejvyšší hodnoty ročního průměru 10 μg/m3 a hodnoty 25 μg/m3 pro 24-h průměr, který nemá být překročen více než 3 dny v roce. Pro částice frakce PM10 byly odpovídající hodnoty stanoveny na 20 μg/m3 a 50 μg/m3. Vzhledem k dostupnosti údajů bylo numerické vyjádření doporučených hodnot stanoveno na základě studií na dospělých. Nicméně snížením expozice na úroveň doporučených hodnot bude dosaženo snížení rizika negativních zdravotních dopadů jak u dospělých, tak i u dětí. Mnoho epidemiologických studií provedených nejen v Evropě ukazuje na souvislost mezi zdravotními ukazateli u dětí a v současnosti měřenými koncentracemi PM10. Podle analýzy Světové zdravotnické organizace (WHO) založené na údajích z konce 90. let může být asi 700 úmrtí na akutní respirační onemocnění u dětí ve věku 0-4 roky důsledkem expozice suspendovaným částicím v evropském regionu WHO (3). Kvantifikace dopadů částic v ovzduší na nemocnost je složitější a méně přesná, nicméně z předběžné analýzy vyplývá, že snížení expozice PM10 na 20 µg/m3 by mohlo přinést sedmiprocentní pokles výskytu kašle a nových případů onemocnění dolních dýchacích cest, a také dvouprocentní pokles hospitalizací pro respirační onemocnění u dětí do 15 let věku (4). Při snížení koncentrace PM10 o 10 µg/m3 se očekává pokles počtu dní s onemocněním dolních cest dýchacích (sípot, krátký dech, tíže na prsou, kašel) o 1,9 dne ročně na každé dítě ve věku 5-14 let. Ve stejné věkové skupině se odhaduje o 18 % snížený počet dní, ve kterých je nutné použít bronchodilatátor u astmatických dětí (5). Tento dokument je zaměřen na suspendované částice antropogenního původu, jejichž zdrojem do ovzduší je doprava, výroba energie, lokální vytápění a průmysl. Suspendované částice jsou tvořeny směsí pevných a kapalných částic v ovzduší. Tyto částice se liší svým původem, fyzikálními vlastnostmi, chemickým složením apod. Mohou být buď přímo vypouštěny do ovzduší nebo mohou vznikat sekundárně v atmosféře z plynných látek – prekurzorů, zejména oxidů dusíku, amoniaku a některých těkavých organických látek (5). Z hlediska účinků není znám žádný práh koncentrace suspendovaných částic, pod kterým by nemohly být očekávány zdravotní dopady (2). Kontext s politikami Legislativní úprava kvality ovzduší se v ČR opírá zejména o zákon 472/2005 Sb. o ochraně ovzduší a Nařízení vlády 597/2006 Sb. o sledování a vyhodnocování kvality ovzduší. Toto nařízení stanoví pro vybrané polutanty limitní hodnoty, kterých je třeba postupně dosáhnout. Závazné limitní hodnoty koncentrace suspendovaných částic PM10 (40 μg/m3 roční průměr a 50 μg/m3 denní průměr, který nemá být překročen více než 35 dní v roce) vycházejí ze Směrnice Rady Evropské unie 1999/30/EC. Návrh nové direktivy o kvalitě venkovního ovzduší a čistším ovzduší pro Evropu (6) zahrnuje mezní hodnotu koncentrace pro jemné suspendované částice frakce PM2.5 (25 µg/m3) a konkrétní cíle snížení expozice populace PM2.5. Podrobnosti direktivy jsou diskutovány v rámci EU.
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6. environmentální akční plán EU pro životní prostředí vyzval k vypracování strategie týkající se znečištění ovzduší v Evropě pro dosažení takové úrovně kvality ovzduší, která nebude mít za následek významné negativní dopady a rizika pro lidské zdraví a životní prostředí. Tématická strategie o znečištění ovzduší připravená programem Čisté ovzduší pro Evropu (CAFE), byla přijata Evropskou komisí v září 2005. Program stanovil průběžné cíle vztahující se ke zdraví pro zlepšení kvality ovzduší v zemích EU a doporučil modernizaci současné legislativy tak, aby byly více zohledněny nejzávažnější polutanty a aby bylo uděláno více pro integrování aspektů ochrany životního prostředí do jiných politik a programů. Rokem 1999 vystřídala pokles emisí znečišťujících látek stagnace a kvalita ovzduší se začíná spíše zhoršovat. V roce 2004 byl proto usnesením vlády ČR schválen Národní program snižování emisí, v roce 2006 proběhla jeho aktualizace. S ohledem na současný nevyhovující stav kvality ovzduší, a také pro splnění závazků vyplývajících z Tématické strategie o znečišťování ovzduší, byla přijata opatření ke snížení znečišťování ovzduší suspendovanými částicemi, oxidy dusíku a benzo(a)pyrenem. Byl zpracován nový Národní program snižování emisí, zaměřený zejména na dva významné druhy zdrojů emisí suspendovaných částic vytápění a dopravu. V červnu 2007 byl schválen vládou ČR jako Usnesení vlády č. 630/2007 Sb. Dlouhodobý program zlepšování zdravotního stavu obyvatelstva ČR – Zdraví pro všechny v 21. století, schválený usnesením vlády v roce 2002, ukládá v cíli 10 „snížit expozice obyvatelstva zdravotním rizikům souvisejícím se znečištěním vody, vzduchu a půdy …., aktivity koordinovat s cíli, stanovenými v Akčním plánu zdraví a životního prostředí ČR“ a dále „soustavně monitorovat a vyhodnocovat ukazatele kvality ovzduší a ukazatele zdravotního stavu“. V roce 2004 přijali ministři na 4. Ministerské konferenci o zdraví a životním prostředí v Budapešti Evropský akční plán zdraví a životního prostředí pro děti (CEHAPE) (7). Plán obsahuje čtyři regionální cíle ke snížení zátěže dětí nemocemi souvisejících se životním prostředím. Ministři se zavázali implementovat opatření k plnění těchto cílů ve svých zemích. Jedním z cílů (RPG III) je prevence a snížení respiračních onemocnění v důsledku znečištění vnějšího a vnitřního prostředí. Má se tak snížit frekvence astmatických záchvatů, a zajistit, aby děti mohly žít v prostředí s čistým ovzduším. Snížení expozice suspendovaným částicím je zásadní pro dosažení tohoto cíle. Hodnocení Alespoň jedno z kritérií překročení ročního imisního limitu pro suspendované částice frakce PM10 (aritmetický roční průměr nad 40 µg/m3 a/nebo více než 35 překročení 24-hod. limitu 50 µg/m3 za kalendářní rok) bylo v roce 2006 naplněno na více než polovině z 81 měřicích stanic zahrnutých do zpracování. Z analýzy úrovně zátěže v jednotlivých typech městských lokalit vyplývá, že roční střední hodnota koncentrace PM10 se v závislosti na intenzitě okolní dopravy pohybovala v rozsahu od 28 µg/m3 v dopravou nezatížených lokalitách, přes 35 µg/m3 u dopravně středně zatížených, 45 µg/m3 ročního průměru v dopravně extrémně exponovaných místech až po téměř 50 µg/m3 v průmyslem silně exponovaných lokalitách. Porovnání zátěže v jednotlivých typech městských obytných lokalit usvědčuje dopravu jako hlavní příčinu znečištění ovzduší suspendovanými částicemi ve městech. Specifickým případem je ostravsko-karvinská aglomerace, kde je obvyklá kombinace zdrojů (doprava a lokální zdroje) doplněna o vliv významných zdrojů průmyslových. Zvýšené zátěži suspendovanými částicemi
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frakce PM10 v České republice lze stále přisuzovat plošný charakter, měřené hodnoty byly proti roku 2005 opět mírně zvýšené. Na základě dat Systému monitorování lze odhadovat, že téměř 80 % obyvatel monitorovaných sídel žije v místech, kde je překročen imisní limit. Průměrné roční koncentrace suspendovaných částic frakce PM2,5 se v sídlech, kde je měření zavedeno, pohybovaly od 13 do 44 µg/m3. Hodnotu roční mezní hodnoty 25 µg/m3, navrhovanou EU v rámci přípravy nové rámcové direktivy, překročily stanice v Brně, Kladně, Teplicích, Olomouci, Ostravě, Mostě a v Praze 9. Pro hodnocení zdravotního rizika dlouhodobé expozice české populace suspendovaným částicím v ovzduší byly použity závěry americké studie American Cancer Society (8), upravené dodatkem Směrnice pro kvalitu ovzduší v Evropě (2). Vyplývá z nich, že zvýšení roční koncentrace suspendovaných částic PM10 o 10 µg/m3 zvyšuje celkovou úmrtnost exponované populace o 3 %. Lze tak odhadnout, že v roce 2006 se zvýšila celková úmrtnost v ČR v důsledku expozice částicím PM10 v ovzduší zhruba o 5 -13 %, nejvíce v průmyslem zatížené oblasti Ostravsko-Karvinska. Podle vztahů expozice a účinku, publikovaných na základě metaanalýzy výsledků epidemiologických studií (9) může současná imisní situace ve znečištění ovzduší suspendovanými částicemi frakce PM10 přispívat k navýšení výskytu příznaků zánětu průdušek a dalších respiračních symptomů u dětí ze 3% v populaci neovlivněné znečištěným ovzduším na 4 až 17 %. O datech k indikátoru Zdroj dat PM10 data: Databáze Systému monitorování zdravotního stavu obyvatelstva ČR ve vztahu k životnímu prostředí. Demografická data: ČSÚ http://www.czso.cz/ Geografické pokrytí 19 měst v rámci Systému monitorování zdravotního stavu obyvatelstva ČR ve vztahu k životnímu prostředí, kde probíhá měření koncentrace suspendovaných částic frakce PM10. Perioda 1996-2006 Frekvence aktualizace Každoročně Kvalita dat Údaje o koncentracích suspendovaných částic PM10 pocházejí ze sítě měřicích stanic, které provozují zdravotní ústavy v monitorovaných městech, a z vybraných měřicích stanic spravovaných Českým hydrometeorologickým ústavem (ČHMÚ), jejichž umístění vyhovuje požadavkům Systému monitorování. Používané postupy měření vycházejí z ČSN ISO 7708 a EN 12341:1999 „Kvalita ovzduší – Stanovení frakce PM10 v suspendovaných částicích – referenční metoda a polní zkouška k prokázání ekvivalence metod měření“ a EN 14907:2005 „Normalizovaná metoda gravimetrického měření ke stanovení hmotnostní frakce suspendovaných částic frakce PM2,5 ve vnějším ovzduší“.
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Citace 1. WHO Regional Office for Europe (2005). Effects of air pollution on children’s health and development: a review of the evidence. http://www.euro.who.int/document/E86575.pdf 2. WHO Air quality guidelines for particulate matter, ozone, nitrogen dioxide and sulphur dioxide - Global update 2005 (2006). Summary of risk assessment. http://www.who.int/phe/air/aqg2006execsum.pdf 3. Cohen et al. Urban air pollution. In: Ezzati et al, eds. Comparative quantification of heath risks. Volume 2. Edited by WHO 2004: 1353-1433. http://www.who.int/publications/cra/en/ 4. WHO European Centre for Environment and Health. Implementing environment and health information system in Europe. Copenhagen, WHO Regional Office for Europe, 2005 (http://ec.europa.eu/health/ph_projects/2003/action1/docs/2003_1_28_frep_ en.pdf, accessed 7 March 2007). 5. WHO Regional Office for Europe (2006). Health risks of particulate matter from long-range transboundary air pollution. Joint WHO / Convention Task Force on the Health Aspects of Air Pollution. http://www.euro.who.int/document/E88189.pdf 6. Proposal for a Directive of the European Parliament and of the Council on ambient air quality and cleaner air for Europe. Brussels, 21.9.2005, COM(2005) 447 http://ec.europa.eu/environment/air/cafe/pdf/cafe_dir_en.pdf 7. Children’s Environmental Health Action Plan. (2004) Declaration. Fourth Ministerial Conference on Environment and Health. Budapest, 23-25 June 2004. http://www.euro.who.int/document/e83335.pdf 8. Pope CA et al. (2002). Lung cancer, cardiopulmonary mortality, and long-term exposure to fine particulate air pollution. Journal of the American Medical Association, 287:1132–1141. 9. Aunan, K: Exposoure-response Functions for Health Effect of Air Pollutants Based on Epidemiological Findings, Report 1995:8, University of Oslo, Center for International Climate and Enviromental Research Další informace Akční plán zdraví a životního prostředí,NEHAP http://www.szu.cz/chzp/nehap/_nehapcz.htm Zdraví 21 http://www.szu.cz/Menu1/zdravi21.html Souhrn aktuálních poznatků k problematice „prachu“ a prašnosti v ovzduší http://www.szu.cz/chzp/ovzdusi/dokumenty/documents/susp_castice.pdf Aktuální stav ovzduší v ČR http://www.chmi.cz/uoco/act/aim/aregion/aim_region.html COMMUNICATION FROM THE COMMISSION TO THE COUNCIL AND THE EUROPEAN PARLIAMENT. Thematic Strategy on air pollution http://eur-lex.europa.eu/LexUriServ/site/en/com/2005/com2005_0446en01.pdf Council Directive 1999/30/EC of 22 April 1999 relating to limit values for sulphur dioxide, nitrogen dioxide and oxides of nitrogen, particulate matter and lead in ambient air, Official Journal L 163 , 29/06/1999 P. 0041 – 0060, http://eurlex.europa.eu/LexUriServ/LexUriServ.do?uri=CELEX:31999L0030:EN:HTML
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Autoři: RNDr. Bohumil Kotlík, MUDr. Helena Kazmarová, RNDr. Vladimíra Puklová Státní zdravotní ústav Praha, Centrum hygieny životního prostředí
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Datum: říjen 2007
Obsah olova v krvi dětí a dospělých Indikátor Název: Definice:
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Obsah olova v krvi dětí a dospělých Koncentrace olova v krvi dětí ve věku 8-10 let a dospělých ve věku 18-59 let ve vybraných městech ČR, vyjádřená jako střední hodnota koncentrace (medián) jednotlivých koncentrací olova v mikrogramech na litr krve. RPG4_Chem_Ex1
Úvod Tato informace byla zpracována na základě systematického sběru vzorků krve dětí ve věku 8-10 let a dospělých ve věku 18-59 let ve vybraných městech ČR v letech 1996 až 2006 v rámci Systému monitorování zdravotního stavu obyvatelstva ČR ve vztahu k životnímu prostředí. Odůvodnění Olovo je jedním z nejznámějších toxických těžkých kovů. Obsah olova v krvi je vhodným ukazatelem současné expozice populace olovu. Zvýšená expozice olovu představuje zdravotní riziko především pro malé děti, u kterých je obsah olova v krvi 100 µg/l a vyšší spojován s toxickými účinky na vyvíjející se mozek a nervový systém (neurobehaviorální a vývojové změny), a následným poklesem inteligenčního kvocientu (IQ) (1). Výsledky posledních studií však upozorňují na nežádoucí zdravotní důsledky i u dětských populací s obsahem olova v krvi nižším než 100 µg/l; z toho důvodu je třeba prosazovat veškerá dostupná opatření směřující ke snížení zátěže dětí tímto toxickým kovem na nejnižší možnou míru. Souhrnný závěr
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Od roku 1996 je pozorován klesající trend obsahu olova v krvi dětí. Zatímco v roce 1996 mělo 15% vyšetřených dětí obsah olova v krvi větší než 50 µg/l, v roce 2006 byla tato hodnota překročena pouze u 2% dětí. U žádného dítěte nebyla přitom zjištěna zdravotně významná hladina olova v krvi 100 µg/l a vyšší. Pokles obsahu olova v krvi se projevil od roku 2001 i u dospělé populace; obsah olova v krvi nepřekročil v posledních několika letech zdravotně významnou koncentraci 150 μg/l u mužů a 100 μg/l u žen .
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Obr. 1 Vývoj obsahu olova v krvi dětí v letech 1996 až 2006 40
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Pozn.: roky 1996, 1998, 1999 a 2001 – lokality Benešov, Plzeň, Ústí nad Labem, Žďár nad Sázavou rok 2006 – lokality Praha, Liberec, Ostrava, Zlín (Kroměříž a Uherské Hradiště) Zdroj: Systém monitorování zdravotního stavu obyvatelstva ČR ve vztahu k životnímu prostředí
Obr. 2 Distribuce obsahu olova v krvi dětí v roce 1996 a 2006 1996
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Set of national fact sheets www.ENHIS.org Pozn.: rok 1996 – lokality Benešov, Plzeň, Ústí nad Labem, Žďár nad Sázavou rok 2006 – lokality Praha, Liberec, Ostrava, Zlín (Kroměříž a Uherské Hradiště) Zdroj: Systém monitorování zdravotního stavu obyvatelstva ČR ve vztahu k životnímu prostředí
Obr. 3
Vývoj obsahu olova v krvi mužů a žen
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Pozn.: roky 1996 až 2003 – lokality Benešov, Plzeň, Ústí nad Labem, Žďár nad Sázavou rok 2005 – lokality Praha, Liberec, Ostrava, Zlín (Kroměříž a Uherské Hradiště) Zdroj: Systém monitorování zdravotního stavu obyvatelstva ČR ve vztahu k životnímu prostředí
Prezentace dat Obsah olova v krvi dětí byl v rámci biologického monitoringu sledován v období od roku 1996 do roku 2001, u dospělých pak v období 1996 – 2003 v Benešově, Plzni, Ústí n. Labem a Žďáru n. Sázavou. Od roku 2005 je biologický monitoring realizován ve městech Praha, Ostrava, Liberec a Zlín (resp. Kroměříž a Uherské Hradiště). Obr. 1 ukazuje trend v poklesu obsahu olova v krvi dětí souhrnně ve sledovaných městech od roku 1996 do 2001. Chlapci mají vyšší hodnoty obsahu olova v krvi než dívky. Distribuce koncentrace olova v krvi dětí na Obr. 2 znázorňuje posun v obsahu olova v krvi dětí v roce 2006 směrem k nižším hodnotám ve srovnání s rokem 1996. Na Obr.3 je patrný pokles obsahu olova v krvi dospělé populace v průběhu let monitorování, a to v letech 1996-1998 a dále pak v letech 2000-2002. Hodnoty u mužů jsou významně vyšší než u žen.
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Souvislost zdraví a životního prostředí Účinky olova při vyšších expozicích jsou víceméně známy: inhibice některých enzymů, účinky na krvetvorbu (anémie), neurologické účinky, poškození funkce ledvin, imunitních mechanismů apod. Účinky při chronické expozici nízkým koncentracím ze životního prostředí jsou známy zejména u dětí, u kterých byl prokázán negativní vliv na neurobehaviorální funkce a také vývojové změny. Byly rovněž pozorovány účinky na výši krevního tlaku a na kvalitu sluchu. Důkaz o karcinogenitě pro člověka není zatím dostatečný, IARC zařazuje olovo do skupiny 2B, anorganické sloučeniny pak do skupiny 2A. Hlavním antropogenním zdrojem olova do ovzduší jsou spalovací procesy, dříve zejména spalování olovnatého benzínu; zdrojem lokálního zvýšení koncentrací olova v prostředí mohou být slévárny, ocelárny, spalovny odpadů, a také spalování uhlí. Zdrojem olova ve vodách mohou být odpadní vody ze zpracování rud, z barevné metalurgie, z výroby akumulátorů a ze sklářského průmyslu. Do půdy se olovo dostává kromě sedimentace z ovzduší také aplikací čistírenských kalů a průmyslových kompostů do půdy. Nejvýznamnějším plošným zdrojem olova do prostředí bylo spalování alkylovaného olova v pohonných hmotách, které se tak dostalo přes ovzduší do všech složek životního prostředí. U profesionálně neexponované populace se olovo dostává do organismu zejména prostřednictvím potravy. Zdrojem expozice olovu může být také olověné vodovodní potrubí. U malých dětí je nutno počítat i se vstupem olova do organismu požitím prachu a půdních částic kontaminovaných olovem v důsledku ještě nefixovaných hygienických návyků a zvýšené aktivity ruka - ústa. Ke zvýšené vnímavosti dětí přispívá i celá řada dalších faktorů jako vyšší příjem potravy na kg hmotnosti ve srovnání s dospělými, vyšší absorpce olova z gastrointestinálního traktu i vyšší citlivost vůči toxickému působení olova v průběhu vývoje dětského organismu. Epidemiologické studie ukazují, že expozice olovu během časných stádií vývoje dítěte je spojena, kromě jiného, se sníženou schopností učení a dalších neurobehaviorálních funkcí. Provedené studie naznačují, že na každých 100 µg olova na litr krve se snižuje IQ o 1 – 3 body. Na individuální úrovni se může tento pokles jevit malý a nevýznamný, avšak na populační úrovni mohou i malé účinky na mnoha osobách znamenat velkou zátěž pro společnost snížením všeobecné intelektuální úrovně a vyplývajících ekonomických ztrát. Kognitivní schopnost ovlivňuje výkon ve škole, úroveň vzdělání a úspěch na trhu práce (2,3). Pro kontrolu zátěže běžné populace olovem je důležitá existence zdravotně významných limitních hodnot obsahu olova v krvi. V současné době jsou k dispozici limitní hodnoty stanovené Komisí pro biologický monitoring v SRN vymezující dvě pásma zdravotně významných hodnot (označované jako HBM I a II), které jsou odlišné pro muže, ženy v reprodukčním věku a děti. Pokud je obsah olova ve sledované populaci nižší než hodnota HBM I, pak je zdravotní riziko považováno za zanedbatelné. Hodnoty pohybující se v rozmezí HBM I a HBM II signalizují nutnost zvýšené pozornosti, odhalení možných expozičních zdrojů a ověření zvýšeného obsahu olova v krvi častějšími kontrolami. Hladiny v populaci dosahující hodnoty HBM II a vyšší jsou pak jednoznačným signálem pro systémová preventivní opatření. Hodnoty HBM I a II jsou pro ženy v reprodukčním věku a pro děti stanoveny na 100 a 150 µg/l, pro muže a ženy starší 45 let pak 150 a 250 µg/l (4). Předpokládá se však, že limitní hodnota pro dětskou populaci bude na základě současné úrovně poznání snížena.
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Kontext s politikami Dlouhodobý program zlepšování zdravotního stavu obyvatelstva ČR – Zdraví pro všechny v 21. století, schválený Usnesením vlády č. 1046 v roce 2002 (5) ukládá v cíli 10 „snížit expozice obyvatelstva zdravotním rizikům souvisejícím se znečištěním vody, vzduchu a půdy ….“ Expozice olovu souvisí se všemi těmito cestami přívodu. V roce 2004 přijali ministři na 4. Ministerské konferenci o zdraví a životním prostředí Evropský Akční plán zdraví a životního prostředí pro děti (CEHAPE). Plán obsahuje čtyři regionální cíle ke snížení zátěže dětí nemocemi souvisejícími se životním prostředím. Jeden z cílů (RPG IV) se zaměřuje na snížení rizik onemocnění a snížené schopnosti v důsledku expozice nebezpečným chemickým látkám (jako jsou těžké kovy), fyzikální faktory (jako je nadměrné UV záření) a biologické faktory a rizikové faktory v pracovním prostředí během těhotenství, dětství a dospívání (6). V roce 2006 byl schválen na zasedání Řídící rady UNEP/7 Implementační plán Světového summitu udržitelného rozvoje (WSSD) Johannesburgu , 2002, který stanovuje závazek:„… do roku 2020 vyrábět a používat chemické látky způsobem, který by minimalizoval negativní vlivy na lidské zdraví a životní prostředí“. Z tohoto závazku vyplynula příprava Strategického přístupu k mezinárodnímu nakládání s chemickými látkami (SAICM), který obsahuje pět hlavních cílů při zacházení s chemickými látkami během celého období jejich životnosti (7). Mezi aktivity ČR v rámci SAICM se řadí uspořádání Mezinárodního sympozia o nezákonném mezinárodním obchodování s nebezpečnými chemickými látkami v Praze 2006. S aktivitami SAICM souvisí rovněž implementace nové chemické politiky EU REACH (Registrace, evaluace a autorizace chemických látek, www.reach.cz), která představuje nový systém kontroly chemikálií zajišťující, aby se nejpozději od roku 2020 používaly pouze chemické látky se známými vlastnostmi a to způsobem, který nepoškozuje životní prostředí a zdraví člověka. V září 2006 se konalo 5. zasedání Mezivládního fóra pro chemickou bezpečnost (IFCS) v Budapešti. Na tomto zasedání bylo vydáno Prohlášení o rtuti, olovu a kadmiu, které říká, že zdravotní rizika těchto kovů je třeba řešit od globální přes národní po lokální úroveň (8). Fórum také vyzvalo státy a průmysl k vypracování směrnice ohledně bezpečnosti hraček a harmonizace mezinárodních norem, vzhledem k rostoucímu mezinárodnímu obchodu. Deklarace z Brescie o prevenci neurotoxických účinků kovů podpořila revizi expozičních standardů olova a podpořila snižování hladin olova v krvi dětí na koncentraci 50 µg/l celosvětově (9). Tato hladina je navržena jako prozatímní s tím, že může být dále upravováno v příštích letech tak, jak se budou hromadit nové poznatky o toxickém působení olova při stále nižším obsahu v krvi. Sedmý rámcový výzkumný program EU (2006–2013) zdůrazňuje nezbytnost vývoje koherentního přístupu k biomonitoringu v Evropě, nezbytnému k zajištění hodnocení zdravotních rizik a zacházení s nebezpečnými chemickými látkami (10). 4. ministerská konference Životní prostředí pro Evropu, Aarhus 1998 (11), vyústila v podpis politického dokumentu s názvem Deklarace k postupnému vyřazení olovnatého benzinu; úzce souvisí s Celoevropskou strategií postupného vyřazení olovnatého benzinu a Protokolem o těžkých kovech. Tento protokol je součástí Úmluvy o znečišťování ovzduší přecházejícím hranice státu. Cílem Protokolu o těžkých kovech je omezit emise těžkých kovů, které se účastní
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dálkového přenosu škodlivin v atmosféře a o nichž se předpokládá, že mohou mít nepříznivé účinky na lidské zdraví a životní prostředí. V současné době se protokol omezuje na olovo, kadmium a rtuť. V ČR byl prodej olovnatých pohonných hmot zastaven k 1.1 2001. Hodnocení Hladiny olova v krvi jsou dobrým ukazatelem současné a nedávné zátěže olovem z prostředí (vzhledem k relativně krátkému poločasu olova v organismu 28 - 36 dní). Hematologické ani neurologické účinky pravděpodobně nelze očekávat u dospělých při obsahu olova pod 200 µg/l. U dětí však byly některými studiemi prokázány účinky na centrální nervový systém (kognitivní deficit) již při hodnotách kolem 100 –150 µg/l. Dolní limit tohoto rozpětí je proto považován jako hraniční přijatelná hodnota a to pro děti i dospělé. Aby byla zajištěna tato mezní hodnota 100 µg/l alespoň u 98 % sledované populace, hodnota mediánu sledované skupiny osob by neměla přesáhnout 54 µg/l krve. Medián zjištěných individuálních hodnot obsahu olova v krvi dětské populace se v roce 2006 pohyboval v jednotlivých městech monitorování (Praha, Ostrava, Liberec, Kroměříž a Uherské Hradiště) od 23 do 38 µg/l, vyšší hodnoty jsou pozorovány u chlapců ve srovnání s dívkami. I v tomto roce pokračoval sestupný trend obsahu olova v krvi dětí pozorovaný od roku 1996. Zatímco v roce 1996 mělo 84 % dětí obsah olova v krvi pod doporučovanou hranicí 50 µg/l, v roce 2006 to bylo již 97 % dětí; u žádného ze sledovaných dětí nebyla překročena tolerovatelná mezní hodnota 100 µg/l. Je však třeba vzít v úvahu, že se jedná o děti školního věku, zatímco nejvyšší hodnoty se předpokládají u malých dětí ve věku kolem dvou let. Střední hodnota (medián) obsahu olova v krvi dospělé populace klesá postupně v průběhu let monitorování (viz Obr. 3). V zatím posledním roce monitorování (2005) byly zjištěny střední (mediány) hodnoty obsahu olova v krvi mužů 35,4 µg/l a žen 26,6 µg/l, což jsou významně nižší hodnoty než ty, nalezené v roce 1996.Údaje o obsahu olova v krvi korespondují do jisté míry s vývojem koncentrací olova sledovaných v městském ovzduší v rámci Systému monitorování zdraví a životního prostředí. Rychlý pokles do roku 1999 byl následován zpomalením poklesu hodnot až ke stagnaci v posledních několika letech (Odborné zprávy Subsystému I Systému monitorování zdravotního stavu obyvatelstva ČR ve vztahu k životnímu prostředí, http://www.szu.cz/chzp/ovzdusi/mzso/). O datech k indikátoru Zdroj dat Data pocházejí ze Systému monitorování zdraví obyvatelstva ČR ve vztahu k životnímu prostředí, koordinovaného Státním zdravotním ústavem Praha. Odběry biologického materiálu jsou zajišťovány příslušnými zdravotními ústavy v regionech (www.szu.cz). Odběry dospělých probíhají na transfúzních stanicích dobrovolným dárcům krve ve věku 18 – 59 let. Odběry krve dětí probíhaly dříve ve vybraných školách, v posledních letech jsou organizovány za pomoci dětských lékařů. Osoba darující krev k vyšetření obsahu olova je předem informována o účelu studie a s využitím krve pro monitorovací účely vyslovuje písemný souhlas. U dětí je vždy získán písemný souhlas rodičů nebo jejich zákonného zástupce. Základní demografické údaje a informace o životním stylu nutné pro odhad expozice obyvatel sledovaným toxickým látkám jsou zjišťovány stručným dotazníkem.
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Popis dat Data představují střední hodnoty (mediány) individuálních koncentrací olova v krvi. V každé oblasti je zařazeno do šetření vždy zhruba 100 dětí a 100 dospělých dárců krve (Kroměříž a Uherské Hradiště po 50 osobách). Stanovení olova v krvi je prováděno po mineralizaci vzorků metodou atomové absorpční spektrofotometrie AAS. Výpočet indikátoru Indikátor představuje koncentraci olova na litr plné krve. Plošné pokrytí: Od roku 1996 do 2003: Benešov, Plzeň, Ústí n. Labem, Žďár n. Sázavou. Od roku 2005: Praha, Ostrava, Liberec, Kroměříž, Uherské Hradiště. Perioda: 1996–2006. Frekvence: Jednou za rok/dva roky. Kvalita dat: Postup při odběrech vzorků biologického materiálu je pro každý rok definován Standardním operačním postupem (Protokol odběru a manipulace se vzorky). Analyzující laboratoře procházejí soustavnou kontrolou kvality produkovaných dat. Analyzující laboratoře mají akreditaci ČIA a účastní se mezinárodních porovnávacích okružních testů. Citace: 1. Preventing lead poisoning in young children. A statement by the Centers for Disease Control and Prevention. Atlanta, Centers for Disease Control and Prevention, 2005 (http://www.cdc.gov/nceh/lead/Publications/PrevLeadPoisoning.pdf, accessed 2 April 2007). 2. Tong S, von Schirnding YE, Prapamontol T. Environmental lead exposure: a public health problem of global dimensions. Bulletin of the World Health Organization, 2000, 78:1068–1077. 3. Grosse SD et al. Economic gains resulting from the reduction in children’s exposure to lead in the United States. Environmental Health Perspectives, 2002, 110:563–569. 4. Ewers U, Krause C, Schulz C, Wilhelm M. Reference values and human biological monitoring values for environmental toxins. Int. Arch. Occup. Environ. Health, 1999, 72:255-260. 5. Dlouhodobý program zlepšování zdravotního stavu obyvatelstva ČR - Zdraví pro všechny v 21. století http://www.szu.cz/Menu1/zdravi21.html 6. Children’s Environment and Health Action Plan for Europe. Declaration. Fourth Ministerial Conference on Environment and Health, Budapest, 23–25 June 2004 (EUR/04/5046267/6; http://www.euro.who.int/document/e83335.pdf, accessed 16 March 2007). 7. Strategic Approach to International Chemicals Management [web site]. Geneva, United Nations Environment Programme, Division of Technology, Industry, and Economics, 2007 (http://www.chem.unep.ch/saicm/SAICM%20texts/SAICM%20documents.ht m, accessed 2 April 2007).
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8. 9. 10.
11.
Intergovernmental Forum on Chemical Safety [web site]. Geneva, World Health Organization, 2007 (http://www.who.int/ifcs/en/, accessed 2 April 2007). The Declaration of Brescia on Prevention of Neurotoxicity of Metals, 2006 (http://www.ntoxmet.it/declaration.pdf, accessed 2 April 2007). Community Research and Development Information Service (CORDIS). Seventh Research Framework Programme. Brussels, Europa Publications Office 2007 (http://cordis.europa.eu/fp7/home_en.html, accessed 2 April 2007). Životní prostředí pro Evropu – Čtvrtá konference ministrů životního prostředí států regionu EHK OSN http://www.env.cz/osv/edice.nsf/59BF8250286760F5C1256FC000431C26/$f ile/z7zisvprostredi.html
Další informace Evropský informační system zdraví a životního prostředí – internetové stránky (European Environment and Health Information System) http://www.enhis.org/object_class/enhis_home_tab.html Světová zdravotnická organizace - Evropský Informační system zdraví a životního prostředí (WHO- Environment and health information system) http://www.euro.who.int/EHindicators Evropský informační list Hladiny olova u dětí (The fact sheet Blood lead levels in children) http://www.euro.who.int/Document/EHI/ENHIS_Factsheet_4_5.pdf SZÚ, Biologický zprava.html
monitoring
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European Environment and Health Information System (ENHIS)
Indikaatori nimetus: Ühisveevärgid ja ligipääs parendatud veeallikatele Indicator name: Public water supply and access to improved water sources This factsheet is based on issues related to public water supplies reported by Estonia. It also contains information on the environment and health context, the policy relevance and context, and an assessment of the situation. Metadata and references are provided as well. 77% of the Estonian population is supplied by public waterworks. The coverage for urban population is 86%, dropping to 59% for rural population. Most of the waterworks use ground water, only two waterworks in Tallinn and Narva use surface waters. Altogether, there are 1377 public waterworks in Estonia. 2% of them produce more than 1000 m3 per day, serving 64% of the total population. At the same time, the smallest 358 waterworks (28% of the total number) only serve 3780 people (2% of the population). This situation makes very difficult to maintain the required level of control and ensure water safety. With regard to microbiological parameters, in all drinking water supply systems in Estonia water has constantly met the requirements, and no water-borne outbreaks were reported since 1993. With regard to chemical parameters, there were exceedances due to high fluoride levels in
groundwaters and to trihalometanes in the public water supply of Narva City. These exceedances affected approximately 30% of the population. 23% of the population gets its drinking water from individual wells, which are not under official surveillance. A monitoring program should be launched to ensure safety of water. Põhjendus: Indikaator hindab, kuivõrd on täidetud miinimumnõuded tervisele ohutu veevärgivee saamiseks kodudes. Tegemist on vee ja hügieeniga seotud tuumikindikaatoriga. Põhisõnum:
☺
Positiivne trend/oluline paranemine Negatiivne trend/oluline halvenemine
Muutusteta/ olulise paranemiseta -
Oluline osa joogiveetarbijatest saab veevärgi kaudu indikaatornäitajatele või keemilistele näitajatele mittevastavat joogivett. Väikeste veevärkide suur osakaal ei võimalda olukorda tõhusalt parandada. Ligi kolmandik elanikkonnast kasutab kaevuvett, mida ei kontrollita, ja mis kaevude tehnilise seisukorra tõttu ei tarvitse olla tervisele ohutu.
Joonised: Joonis 1. Kvaliteedinõuetele mittevastav joogivesi, 2002-2006
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40
% rahvastikust
35 30
Indikaatornäitajad
25 Keemilised näitajad
20 15
Mikrobioloogilised näitajad
10 5 0 2002
2003
2004
2005
2006
Aasta Allikas: Tervisekaitseinspektsioon []
Jooniste kirjeldus Joonisel 1 on kujutatud nõuetele ühisveevärgist mittevastavat vett saava rahvastiku osakaal Eestis aastatel 2002-2004 mikrobioloogiliste, keemiliste ja indikaatornäitajate osas. Seotus tervise ja keskkonnaga Ohutu joogivesi on üks põhilisemaid tegureid tervise kaitsmisel. Sellest tulenevalt on ühisveevärgist tervisele ohutut vett saava elanikkonna osakaal näitaja, mis mõõdab põhiliste vajaduste rahuldamise määra. Saastunud vesi põhjustab haiguspuhanguid, mis võivad ette tulla isegi majanduslikult arenenud Euroopa maades. Tagajärjed tervisele võivad olla väga tõsised, seejuures on suuremateks riskirühmadeks imikud ja lapsed. Maailma Tervishoiuorganisatsiooni hinnangul põhjustab halvakvaliteediline joogivesi Euroopa regioonis 0..14- aastaste laste hulgas 13 500 kõhulahtisusest tingitud surmajuhtu (5,3% kõigist selle vanuserühma surmadest) [1]. Veevõrgu kaudu levivaid haigestumisi ei ole Eestis esinenud juba 15 aastat, kuid varasematel aastatel on esinenud päris ulatuslikke puhanguid. Suuremad neist on olnud düsenteeriapuhang Ahtmes 1963. aastal, kui haigestus 1254 inimest, ja A-viirushepatiidi puhang Sõmerus 1993. aastal, kui haigestus 614 inimest. Alates 1945. aastast on Eestis olnud üle 150 joogiveega seotud soolenakkushaiguste puhangu: 84 düsenteeria, 31 hepatiiti A, ülejäänud kõhutüüfuse ja paratüüfus B puhangud. Alates 1991. aastast on registreeritud 12 puhangut, kus haigestus 841 inimest. Enamuse veepuhangute põhjustajaks on olnud põhjaveeallikate reostunud vesi [2]. Ehkki suurem osa veepuhangutest on seotud mikrobioloogilise saastusega, võivad tõsised tervisetagajärjed olla ka vee keemilisel saastumisel. Eesti tingimustes on olulisemateks keemilisteks teguriteks fluoriidide liigne sisaldus, mis põhjustab fluoroosi ja luustumishäireid [3]. Poliitiline taust
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2004. aastal võttis IV ministrite keskkonna- ja tervisekonverents vastu Euroopa laste keskkonna ja tervise tegevuskava (Children's Environment and Health Action Plan for Europe ,CEHAPE), millega on ühinenud ka Eesti. Tegevuskavas on toodud neli peamist regionaalset eesmärki laste keskkonnast tingitud haiguskoormuse vähendamiseks. Üks neist eesmärkidest (nr. 1) on suunatud seedeelundkonna haigustest tingitud haigestumuse ja suremuse tunduvale vähendamisele, võttes kasutusele meetmed, “et suurendada majapidamiste hulka, millele on tagatud piisaval hulgal kvaliteetse vee ning sanitaarkaitse olemasolu, vähendades sellega aastaks 2015 ilma puhta veeta ja halbades hügieenitingimustes elavate laste osakalu poole võrra” [4]. Eesti on võtnud joogivee direktiivi 98/83/EÜ [5] nõuded üle Rahvatervise seaduse [6], Veeseaduse [7] ja nende alusel kehtestatud määrustega [8-12]. Veeseadus on raamseadus, mis reguleerib vee kaitse ja kasutamise korraldust Eestis, määrab kindlaks põhikohustused ja tingimused vee kasutamisel, toimingud veevarude ja veekogude valgala kaitseks ning määratleb põhjaveevarude hindamise korra. Rahvatervise seadus sätestab elukeskkonna ja terviseakaitse põhinõuded, s.h selle, et joogivesi peab olema inimeste tervisele ohutu ja vastama kvaliteedinõuetele. Joogivee valdkonda käsitletakse tervikuna, alates veevõtu kohast kuni tarbijani. Joogivee kvaliteedi- ja kontrollinõuded Eestis kasutatavale joogiveele on kindlaks määratud sotsiaalministri ja keskkonnaministri määruste alusel, mis arvestavad täiel määral joogivee direktiivis määratletud eesmärke, kohustusi ning nõudeid. Hinnang Joogiveevarustuseks võetakse pinnavett Tallinnas ja Narvas. Väljaspool Tallinna ja Narvat on ainuke joogiveeallikas põhjavesi. Looduslik põhjavesi on väikese mineraalsusega, veekihi sügavamas anaeroobses osas esineb üldreeglina liigselt rauda, ka mangaani ja väävelvesinikku. Sügavamate veekihtide vee kvaliteet sõltub looduslikest omadustest ning kohati sisaldab normatiividest enam fluoriide, kloriide ja rauaühendeid, Lääne- ja Põhja- Eesti kambriumi-vendi veekompleksi põhjavees täheldati kõrgenenud efektiivdoosi. Uute sügavamate veekihtide kasutuselevõtmine on kaasa toonud mikroelementide kontsentratsiooni kõrgenemise joogivees. Joogiveeallikana kasutatav vesi on väga hästi kaitstud 70-90 m paksuste savikihtidega ja seetõttu on igasuguse reostuse sattumine sügavatesse põhjaveekihtidesse ebareaalne. Kõigis Eesti linnades ja paljudes väikeasulates on veevarustussüsteem. Tervisekaitseinspektsiooni 2004. aasta andmetel [2] kasutab ühisveevärgivett ligikaudu 77% elanikest, kuid elanike hõlmatus ühisveevärgiga on paikkonniti väga erinev. Suuremates linnades kasutab ühisveevärki 86%, maa-asulates 59% elanikkonnast. Elanike hõlmatus ühisveevärgiga on väga erinev (Paides 95%, Türil 66%, Elvas alla 50%, Harjumaa Loo alevikus 100%, kuid Vasalemmas ainult 19%). 2006.a oli Eestis 1237 veevärki. Iseloomulik on väikese tootlikkusega ühisveevärkide rohkus (98%). Üle 1000 m³/ööpäevas vett tootvaid veevärke on 23, mis moodustab 2% kõikidest veevärkidest. Need 23 veevärki teenindavad 842 440 inimest (64% elanikkonnast). Veevärkide arv tootlikkusega vähem kui 100 m³/ööpäevas on 358 (moodustab 28% veevärkidest), ja need teenindavad ainult 3780 inimest, mis moodustab 2,0% elanikkonnast. Väikestel veekäitlejatel on sageli raske korraldada nõutud sagedusega süva- ja
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tavakontrolli ning välja töötada abinõude plaane veekvaliteedi parandamiseks. Seda peegeldab ka nõuetele mittevastavate indikaatornäitajatega vett tarbivate inimeste püsivalt kõrge osakaal viimastel aastatel, olles 27..30% vahemikus. Viimastel aastatel pole esinenud veevärke, kus vesi pidevalt ei vasta mikrobioloogilistele nõuetele. Ajutiste kõrvalekalletega veevärgivett kasutavate elanike osakaal on väga väike, ulatudes viimastel aastatel 0,004%-st (2004. a.) 0,02%-ni (2002. a.). Tervisele ohtlike keemiliste näitajate osas ei vastanud 2006. aastal nõuetele 100 veevärki (8% veevärkidest), mille vett kasutab 27 158 inimest, ehk 2% elanikest. 99 veevärgis on probleemiks kohati esinev liigne (üle 1,5 mg/l) fluori sisaldus ning ühes veevärgis (Narva linna veevärgis) liigne trihalometaanidide sisaldus. 14 veevärgis ületab fluoriidide sisaldus 4 mg/l, sellist vett kasutab 1868 inimest. Need veevärgid asuvad Pärnumaal (7), Jõgevamaal (1), Läänemaal (4), Raplamaal (2) ja Saaremaal (1). Rahvastikust umbes 23% saab joogivee peamiselt individuaalkaevudest, mille üle ei ole järelevalvet. Tervisekaitseinspektsioon uurib individuaalkaevude vett ainult kaebuste korral. Kaevudest 75% on ehitatud üle 20 aasta tagasi, 58% on puhastamata, ja 88% remontimata. Tervisele ohutu veevarustuse tagamiseks oleks otstarbekas läbi viia kaevude uuring. Metaandmed/Metadata Indikaatori definitsioon/ Definition of the indicator Kodus piisavas hulgas ja pidevalt tervisele ohutut joogivett saava rahvastiku osakaal Proportion of population with continuous access to adequate amount of safe drinking water in the home. Indikaatori kood / Indicator code . RPG1_WatSan_Ex1 Public water supply and access to improved water sources. Andmeallikas/ Data source 1. Tervisekaitseinspektsioon/ Health Protection Inspectorate Andmete kirjeldus/ Description of data Indikaatori arvutamiseks kasutatav meetod/ Methodology for indicator calculation Indikaator arvutati järgmiselt: veevärgiga seotud elanikkond/koguelanikkond x 100 The indicator was computed as: connected population/total population x 100 Geograafiline ulatus/ Geographical coverage Eesti Vabariik / Republic of Estonia Ajaline ulatus / Temporal coverage 2002-2006 Täiendamissagedus/ Frequency of update Andmestik uuendatakse igal aastal. Proovivõtmine ja hindamine põhineb direktiivi 98/83/EÜ nõuetel. Data sets are updated every year. Sampling and assessment procedures are carried out according to Directive 98/83/EC. Andmekvaliteet/ Data quality Joogivee kvaliteedi ja veevärgiga ühendatud kohta peab arvestust Tervisekaitseinspektsioon Health Protection Inspectorate is responsible for surveillance of public water supplies and the quality of drinking water. and the quality of bathing waters. Viited 1. Valent F et al. Burden of disease attributable to selected environmental factors and injuries among Europe’s children and adolescents. Geneva, World Health
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Organization, 2004 (WHO Environmental Burden of Disease Series, No. 8;) WWW: http://www.who.int/quantifying_ehimpacts/publications/en/ebd8web.pdf 2. Annus A. Järelevalve joogivee kvaliteedi üle 2006. aastal. Tallinn, Tervisekaitseinspektsioon, 2007 (Tervisekaitseinspektsiooni aastaraamat 2006) WWW: http://www.tervisekaitse.ee/documents/vesi/joogivesi/Joogivesi_2006.pdf 3. Indermitte E, Saava A, Saag M, Russak S. Joogivee fluorisisaldus Eestis, selle tähtsus hambakaariese ja fluoroosi levimuses ning ennetuses. Tartu Ülikooli Kirjastus, 2005 4. Children’s Environment and Health Action Plan for Europe. Declaration. Fourth Ministerial Conference on Environment and Health, Budapest, 23-25 June 2004 (EUR/04/5046267/6) WWW: http://www.euro.who.int/document/e83335.pdf 5. Nõukogu direktiiv 98/83/EÜ, 3. november 1998, olmevee kvaliteedi kohta WWW: http://eurlex.europa.eu/LexUriServ/LexUriServ.do?uri=DD:15:04:31998L0083:ET:PDF 6. Rahvatervise seadus. Vastu võetud 14.06.1995. a seadusega (RT I 1995, 57, 978) WWW: https://www.riigiteataja.ee/ert/act.jsp?id=12890518 7. Veeseadus. Vastu võetud 11.05.1994. a seadusega (RT I 1994, 40, 655) WWW: https://www.riigiteataja.ee/ert/act.jsp?id=12895223 8. Sotsiaalministri 31. juuli 2001.a määrus nr 82 “Joogivee kvaliteedi- ja kontrollinõuded ning analüüsimeetodid” (RTL 2001, 100, 1369) WWW: http://www.riigiteataja.ee/ert/act.jsp?id=12782324 9. Sotsiaalministri 21. detsembri 2002.a määrus nr 152 “Kvaliteedinõuetele mittevastava, kuid tervisele ohutu joogivee müümiseks loa taotlemise, andmise, muutmise, peatamise ja kehtetuks tunnistamise kord” (RTL 2002, 4, 44) WWW: https://www.riigiteataja.ee/ert/act.jsp?id=920754 10. Sotsiaalministri 4. aprilli 2003. a määrus nr 58 “Joogiveeproove võtvate isikute atesteerimise kord“ (RTL 2003, 48, 702) WWW: http://www.riigiteataja.ee/ert/act.jsp?id=562761 11. Sotsiaalministri 2. jaanuari 2003.a määrus nr 1 “Joogivee tootmiseks kasutatava või kasutada kavatsetava pinna- ja põhjavee kvaliteedi- ja kontrollinõuded” (RTL 2003, 9, 100) WWW: https://www.riigiteataja.ee/ert/act.jsp?id=237268 12. Keskkonnaministri 26. märtsi 2002.a määrus nr 18 „Vee erikasutusloa ja ajutise vee erikasutusloa andmise, muutmise ja kehtetuks tunnistamise kord, loa taotlemiseks vajalike materjalide loetelu ja loa vormid“ (RTL 2002, 48, 664) WWW: https://www.riigiteataja.ee/ert/act.jsp?id=998096
Lisateave WWW: Joogivee kvaliteedi andmed Tervisekaitseinspektsiooni kodulehel. http://www.tervisekaitse.ee -> Vesi -> Joogivesi Versioon/ Version Autor: Jüri Ruut, Tervisekaitseinspektsioon,
[email protected] Author: Jüri Ruut, Estonian Health Protection Inspectorate,
[email protected] Faktilehe väljaandmise kuupäev/ Date of production of fact sheet: 01.11.2007 Retsensendid/ Reviewers: Viimase versiooni kuupäev /Date of final revision: 09.01.2008 Toimetusversiooni kuupäev/ Date of editorial revision: 09.01.2008
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European Environment and Health Information System (ENHIS)
Indikaatori nimetus: Suplusvee kvaliteet Indicator name: Bathing Water Quality This factsheet is based on data on bathing water quality reported by Estonia. It also contains information on the environment and health context, the policy relevance and context, and an assessment of the situation. Metadata and references are provided as well. Estonia has been successful in implementing Bathing Water Directive 76/160/EEC. During 2004-2006, sampling schemes were successfully implemented, and the quality of bathing water in freshwater zones was fully compliant with directives. There were noncompliances in one of the bathing sites of the coastal zones.
Estonia faces a challenge of implementing a new Bathing Water Directive 2006/7/EC, which is based on new principles of bathing water management. Põhjendus: Pärast Euroopa Liiduga ühinemist on Eesti edukalt rakendanud suplusvee direktiiv 76/160/EMÜ. Uus suplusvee direktiiv 2006/7/EÜ toob endaga kaasa uued nõuded ja põhimõtted. Põhisõnum:
☺
Positiivne trend/oluline paranemine Negatiivne trend/oluline halvenemine
Muutusteta/ olulise paranemiseta -
☺ Vee kvaliteet supelrandades on aastatel 2004-2006 paranenud, proovivõtmise nõuded on täidetud. Ees seisab uue suplusvee direktiiv 2006/7/EÜ [1] rakendamine.
Joonised: Joonis 1. Eesti suplusvee kvaliteet, 2004-2006
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Ebapiisav hulk proove, meri
110,0 100,0
Ebapiisav hulk proove, mageveekogud
90,0 80,0
Kohustuslikud nõuded täitmata,meri
70,0 Kohustuslikud nõuded täitmata, mageveekogud
%
60,0 50,0
Kohustuslikud nõuded täidetud, meri
40,0
Kohustuslikud nõuded täidetud, mageveekogud
30,0 20,0
Soovituslikud nõuded täidetud, meri
10,0 0,0 2004
2005
2006
Soovituslikud nõuded täidetud, mageveekogud
Allikas: European Commission. Bathing water quality. Annual report, 2005 season. [2]
Jooniste kirjeldus Joonis 1 näitab muutusi Eesti suplusvee kvaliteedis aastatel 2004-2006 vastavalt igaaastasele suplusvee kvaliteedi aruandele [2], väljendatuna protsendina suplusrandade üldarvust. Vee kvaliteedile anti hinnang, lähtudes suplusvee direktiiviga 76/160/EMÜ [3] sätestatud kriteeriumidest. Ebapiisava hulga proovide korral ei suudetud järgida proovide võtmise sagedust. Kohustuslikud nõuded loeti mittetäidetuks, kui suplusrand ei vastanud suplusvee direktiivi poolt kehtestatud kohustuslikele nõuetele. Seotus tervise ja keskkonnaga Suplusvesi on olulise tervisekaitselise tähtsusega. On tõestatud, et ebakvaliteetne suplusvesi põhjustab haiguspuhanguid [4], mis võivad hõlmata tuhandeid turiste. Suplusvee kvaliteeti võib halvendada ebapiisav heitvee puhastamine ja põllumajandusreostus, mis toovad kaasa mikrobioloogilise ja keemilise saastumise ning eutrofeerumise. Rahvusvahelistes kirjandusallikates on piisavalt tõendeid, et suplusvesi võib tekitada haigestumist, põhiliselt seedeelundkonna vaevusi, kuid on olemas ka risk nakatuda tõsisemate haiguste tekitajatega, nagu Shigella sonneri, E. coli O157, algloomad ja enteroviirused [5;6]. Maailma Tervishoiuorganisatsioon on hinnanud suplusveest tingitud DALY-meetodil põhinevat haiguskoormust [7] Suurbritannia veekvaliteedi andmetele põhinedes 66 000 aastale [8]. Eestis pole selliseid uuringuid tehtud. Suurema haigestumisriskiga on lapsed ja turistid, kel pole resistentsust kohalike endeemiliste haiguste vastu. Lapsed viibivad vees täiskasvanutest pikemat aega,
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neelates seejuures meelega või tahtmatult ka rohkem vett. [9]. Poliitiline taust 2004. aastal võttis IV ministrite keskkonna- ja tervisekonverents vastu Euroopa laste keskkonna ja tervise tegevuskava (Children's Environment and Health Action Plan for Europe ,CEHAPE), millega on ühinenud ka Eesti. Tegevuskavas on toodud neli peamist regionaalset eesmärki laste keskkonnast tingitud haiguskoormuse vähendamiseks. Üks neist eesmärkidest (nr. 1) on suunatud seedeelundkonna haigustest tingitud haigestumuse ja suremuse tunduvale vähendamisele, võttes kasutusele meetmed, mis tagavad piisaval hulgal kvaliteetse vee ning sanitaarkaitse olemasolu. Euroopa Liidu suplusvee direktiivis 76/160/EMÜ [3] oli määratletud suplusvee kvaliteedi kriteeriumid, ning liikmesriigid on kohustatud läbi viima supelrandade seiret. Nüüdseks on vastu võetud uus Euroopa Parlamendi ja Nõukogu direktiiv 2006/7/EÜ [1], mis kehtestab suplusvee seireks ja majandamiseks uued nõuded, võttes arvesse viimastel aastatel teatavaks saanud teaduspõhised asjaolud. Uue suplusvee direktiivi nõuded on kooskõlas veepoliitika raamdirektiiviga 2000/60/EÜ [10], mille nõuded on rakendatud Veeseadusega [7]. Suplusvee kvaliteedi kriteeriumid on toodud Rahvatervise seadusele põhinevas Vabariigi Valitsuse 25. juuli 2000. a määruses nr 247 ”Tervisekaitsenõuded supelrannale ja suplusveele” [12]. Supelrandade valdajad ei suuda suplusvee kvaliteeti parandada, kui reostaja asub näiteks hoopis naabermaakonnas. Sellise situatsiooni vältimiseks koostatakse igale vesikonnale veemajanduskava vastavalt veepoliitika raamdirektiivile. Lisaks sellele näeb suplusvee direktiiv ette kohustuse koostada reostusallikate hindamisele põhinev majanduskava ka iga supelranna jaoks. Nõuetele mittevastava veekvaliteedi puhuks tuleb ette valmistada meetmed supelranna sulgemiseks või vee kvaliteedi taastamiseks. Uue direktiivi kohaselt on liikmesriigid kohustatud avalikkusele levitama teavet suplusvee kvaliteedi, kaasnevate terviseriskide ja ohutu käitumise kohta. Ülaltoodud põhimõtted on heas kooskõlas Maailma Tervishoiuorganisatsiooni suplusvee majandamise juhenditega [9], mida saab kasutada suplusvee direktiivi nõuete täitmiseks. Hinnang Eesti rannajoone pikkus ja sisevete võrk on pindala, rahvaarvu ja asustustihedust arvestades enamiku Euroopa riikidega võrreldes märkimisväärselt suur, pakkudes suplemiseks ja rannamõnude nautimiseks palju võimalusi, nii ametlikke kui mitteametlikke kohti. Ametlikud supluskohad ja supelrannad moodustavad kõigist võimalikest suplemiseks kasutatavatest veekogudest vaid väga väikese osa. Ametlikes supluskohtades ja randades on tagatud nende korrashoid ning jälgitakse veekvaliteeti. 2006. a. oli supelrandu ja supluskohti kokku 72 (supelrandu - 23 ja supelkohti – 49). Suured kulutused supelrandade korrashoiuks ning kõigi Vabariigi Valitsuse 25. juuli 2000. a määruses nr 247 ”Tervisekaitsenõuded supelrannale ja suplusveele” toodud nõuete (suplusvee kvaliteedi, ranna hoonestuse, sisustuse ning heakorra) täitmiseks on aastate jooksul kaasa toonud supelrandade arvu olulise vähenemise. 2006. a ei vastanud suplusvee kvaliteet nõuetele mikrobioloogiliste näitajate osas 0,8% ja keemiliste näitajate osas 3,66%. Peamiselt ületasid norme mikrobioloogilistest
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näitajatest fekaalsed coli-laadsed bakterid ja fekaalsed streptokokid ning keemilistest/füüsikalistest näitajatest värvus, läbipaistvus ning lahustunud hapniku sisaldus, pH ja ammoonium. 2004. aastal esinenud mittevastavused proovide võtmise osas on kadunud, ka on nüüdseks suudetud tagada kvaliteetne suplusvesi kõigis siseveekogude supelrandades. Mererandades on Euroopa Keskkonnaagentuuri hinnangul nõuetele mittevastavuse põhjuseks ilmastikuolud ning suuremate asulate ligiduses ka fekaalne reostus [2]. Siiski on piiratud ajavahemiku tõttu üldistuste tegemine raskendatud. Varasematel aastatel on probleemiks olnud sinivetikate vohamine, mis võib tekitada tervisehäireid. Sellele probleemile tuleb ka edaspidi tähelepanu pöörata, ehkki 2007. aastal sinivetikate massilist esinemist supelrandades ei täheldatud. Seoses uue Euroopa Parlamendi ja nõukogu direktiivi 2006/7/EÜ jõustumisega laieneb supelrandadega seotud töö maht. Riskidest paremaks arusaamiseks ja nendest tulenevate kvaliteedijuhtimise meetmete rakendamiseks luuakse suplusvee profiilid ehk andmestikud. Juba praegu on kogutud andmed võimaldanud avalikkusele ülevaate andmiseks luua interaktiivsed rakendused Euroopa Liidu tasandil [13] ning kajastada suplusvee kvaliteeti hooaja jooksul üksikasjaliselt ka Tervisekaitseinspektsiooni kodulehel [14] Metaandmed/Metadata Indikaatori definitsioon ja kood/ Definition of the indicator and code Euroopa Liidu suplusvee direktiivi kohustuslikele nõuetele vastava suplusvee osakaal./ Proportion of identified bathing waters, falling under the Bathing Water Directive definition in compliance with the EC mandatory standards. Indikaatori kood / Indicator code RPG1_ WatSan_S1 Recreational Water Quality Andmeallikas/ Data source 1. Bathing Water Quality Annual Report, 2005 bathing season WWW: http://ec.europa.eu/water/water-bathing/report_2006.html Andmete kirjeldus/ Description of data Indikaatori arvutamiseks kasutatav meetod/ Methodology for indicator calculation Suplusvee nõuetele vastavuse indikaator arvutatakse järgmiselt: Suplusvee nõuetele vastavus = 100 * (C / T), kus C on coli-laadsete bakterite sisalduse osas kohustuslikele nõuetele vastavate supelrandade arv; T on seirealuste supelrandade arv. Indicator RWC can be computed as RWC = 100 * (C / T) where: C is the number of bathing waters in compliance with the mandatory coliform standards and T is the total number of bathing waters identified for compliance monitoring Geograafiline ulatus/ Geographical coverage Eesti Vabariik / Republic of Estonia Ajaline ulatus / Temporal coverage 2004-2006
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Täiendamissagedus/ Frequency of update Andmestik uuendatakse igal aastal. Proovivõtmine ja hindamine põhineb direktiivi 76/160/EMÜ nõuetel. Data sets are updated every year. Sampling and assessment procedures are carried out according to Directive 76/160/EEC. Andmekvaliteet/ Data quality Supelrandade ja suplusvee kvaliteedi kohta peab arvestust Tervisekaitseinspektsioon, kes edastab teabe Euroopa on saadaval Euroopa Keskkonnaagentuurile. Täpsed andmed on toodud Euroopa Liidu suplusvee kvaliteedi aruandes. Health Protection Inspectorate is responsible for surveillance of bathing sites and the quality of bathing waters, and delivers the information to EEA. Accurate information is available in the EU bathing water quality report. Viited 1. Euroopa Parlamendi ja nõukogu direktiiv 2006/7/EÜ, 15. veebruar 2006, mis käsitleb suplusvee kvaliteedi juhtimist ja millega tunnistatakse kehtetuks direktiiv 76/160/EMÜ WWW: http://eurlex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:2006:064:0037:0051:ET:PDF 2. European Commission. Bathing water quality. Annual report, 2006 season. Estonia WWW: http://ec.europa.eu/water/water-bathing/report_2007.html 3. Nõukogu direktiiv, 8. detsember 1975, suplusvee kvaliteedi kohta. WWW: http://eurlex.europa.eu/LexUriServ/LexUriServ.do?uri=CONSLEG:1976L0160:20030605:ET: PDF 4. Nichols G. Infection risks from water in natural and man-made environments. Euro Surveill 2006;11(4):76-8 WWW: http://www.eurosurveillance.org/em/v11n04/1104-221.asp 5. Pruss A. Review of epidemiological studies on health effects from exposure to recreational water. International Journal of Epidemiology 1998; 27(1):1-9 6. Pond K. Water recreation and disease. Plausibility of Associated Infections: Acute Effects, Sequelae and Mortality. London: World Health Organization, 2005. 7. World Health Organisation. Guidelines for Drinking-water Quality, Third Edition, Volume 1, Recommendations and Water Safety Plans: Protecting Drinking-water Quality from Catchment to Consumers. Geneva: World Health Organisation, 2005 8. World Health Organisation. Guidelines for safe recreational water environments. Volume 2, swimming pools and similar environments. World Health Organization, Geneva: World Health Organisation, 2006. 9. World Health Organisation. Guidelines for safe recreational water environments. Volume 1, Coastal and fresh waters. World Health Organisation, 2003. WWW: http://www.who.int/water_sanitation_health/bathing/srwe1/en/ 10. Euroopa Parlamendi ja nõukogu direktiiv 2000/60/EÜ, 23. oktoober 2000, millega kehtestatakse ühenduse veepoliitika alane tegevusraamistik WWW: http://eurlex.europa.eu/LexUriServ/LexUriServ.do?uri=DD:15:05:32000L0060:ET:PDF 11. Veeseadus. Vastu võetud 11.05.1994. a seadusega (RT I 1994, 40, 655), jõustunud 16.06.1994. WWW: https://www.riigiteataja.ee/ert/act.jsp?id=12895223 12. Vabariigi Valitsuse 25. juuli 2000. a määrus nr 247 “Tervisekaitsenõuded supelrannale ja suplusveele”. RTI, 64, 407
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WWW: https://www.riigiteataja.ee/ert/act.jsp?id=72214 13. WWW: Bathing water quality. Wandering around in the Atlas. http://ec.europa.eu/water/cgi-bin/bw.pl 14. WWW: Tervisekaitseinspektsiooni andmed suplusvee kohta http://www.tervisekaitse.ee -> Vesi -> Suplusvesi
Lisateave 1. Suplusvee kvaliteedi ülevaade Euroopa Liidu jaoks (ingliskeelne). Eraldi on toodud ka Eesti andmed: WWW: http://ec.europa.eu/water/water-bathing/index_en.html Versioon/ Version Autor: Jüri Ruut, Tervisekaitseinspektsioon,
[email protected] Author: Jüri Ruut, Estonian Health Protection Inspectorate,
[email protected] Faktilehe väljaandmise kuupäev/ Date of production of fact sheet: 01.11.2007 Retsensendid/ Reviewers: Viimase versiooni kuupäev /Date of final revision: 09.01.2008 Toimetusversiooni kuupäev/ Date of editorial revision: 09.01.2008
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National fact sheet Hungary
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Asztmás és allergiás tünetek prevalenciája gyermekeknél Magyarországon Indikátor Megnevezés: Asztma és allergia prevalencia gyermekeknél Definíció: Asztmás és allergiás tünetek prevalenciája 8-9 éves gyermekeknél Kód: RPG3_Air_E1 Bevezetés Jelen összeállítás áttekintést ad a gyermekeket érintő asztma és légúti allergiás megbetegedések magyarországi viszonyairól néhány hazai felmérés eredményei alapján. Tartalmazza ezenkívül a témakörrel kapcsolatos környezet-egészségügyi összefüggéseket, a jogi és szabályozási hátteret, valamint a magyarországi helyzet értékelését. Kulcsüzenet Az allergiás és asztmás tünetek jelentős betegségterhet jelentenek a gyermekek számára az európai országokban [1], így Magyarországon is. Az allergiás és asztmás tünetek összefüggésbe hozhatók – számos tényező mellett – a külső- és belsőtéri levegő minőségével. Az adatok bemutatása Az 1. és 2. ábra a 2005-ben lefolytatott Országos Gyermek Légúti Felmérés (OGYELF) adatait mutatja be megyei bontásban az 5000 fő alatti és 5000 fő fölötti lakosságszámú településeken. Időbeli összehasonlításra ad lehetőséget az, hogy az Országos Környezetegészségügyi Intézetben régóta folynak hasonló felmérések. A 3. és 4. ábra három kiválasztott város asztma és allergia prevalencia értékeit mutatja be az 1996-os CESAR és a 2005-ös OGYELF felmérés eredményei alapján.
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1. ábra: Asztmás tünetek prevalenciája 8-9 éves tanulóknál az OGYELF felmérés alapján (2005) 30
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3. ábra: Asztmás tünetek prevalenciája 8-9 éves tanulóknál 3 kiválasztott városban két felmérés alapján (1996, 2005) 30 CESAR felmérés (1996) OGYELF felmérés (2005) 25
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Környezet-egészségügyi összefüggések Az asztma és allergia számos tényező eredményeként, genetikai és környezeti tényezők komplex interakciója révén alakul ki. A környezeti tényezők közül a legfontosabbak a kül- és beltéri levegőszennyezés, a dohányfüst, az allergének, de szerepet játszanak egyéb hatások is, mint például a táplálkozás, életmód és társadalmigazdasági tényezők. Az anya terhesség alatti dohányzása, valamint a gyermekek dohányfüst expozíciója növeli a különféle légzőszervi betegségek kialakulásának kockázatát, az asztmás tünetek súlyosbodásához vezet. A kültéri szennyezők közül legegyértelműbb egészségi összefüggéseket a szálló por (PM) és az ózon esetén tudtak kimutatni, vagyis ezen szennyezők koncentrációinak növekedése együtt jár az asztmás tünetek gyakoriságának növekedésével és a tünetek erősödésével több epidemiológiai tanulmány szerint. A belsőtéri levegőben levő szennyezőanyagok közül a dohányfüst mellett a tüzelőanyagok elégetéséből származó égéstermékeknek nagy jelentősége van a gyermekek légzőszervi tüneteinek kialakulása szempontjából. A bútorokból, padlószőnyegek ragasztóanyagából (valamint a dohányfüstből) származó formaldehid a felső légutak irritációjához vezethet és egyéb szemben, orrban, torokban jelentkező tüneteket okozhat. Az asztma és az allergiás megbetegedések kialakulása és a tünetek súlyosbodása összefüggésben van a különböző bel- és kültéri allergénekkel. A beltéri allergének közül elsősorban a penészgombák és a háziporatkák jelentenek kockázatot. A lakások szellőztetésnek hiánya, a magas páratartalom révén az allergének koncentrálódhatnak a belsőtéri levegőben. A kültéri levegőben levő virágpor és gombaspórák allergiás reakciót váltanak ki az arra érzékeny személyeknél [2]. Magyarországon a legerősebb allergén a parlagfű (Ambrosia elatior) pollenje. A klímaváltozás egyik lehetséges következménye a növények vegetációs idejének meghosszabbodása, aminek következtében az allergén pollenek évente egyre hosszabb ideig okozhatnak tüneteket. A higiénés hipotézis szerint a „nyugati életstílus” miatt a korai életkorban a fejlődő immunrendszer nem találkozik megfelelő hatásokkal, amely az allergiás megbetegedések kialakulásának kockázatát növelheti. Számos tanulmány szerint a táplálkozási faktorok is hatással lehetnek az allergiás megbetegedések kialakulására, különösen fontos kiemelni az anyatejes táplálás preventív hatását [2]. Jogi és szabályozási vonatkozások 2004-ben a IV. Környezet és Egészség Miniszteri Konferencia Budapesten fogadta el az Európai cselekvési terv a környezetért és a gyermekek egészségéért című dokumentumot (CEHAPE), amely négy regionális elsőbbségi célt határozott meg a gyermekek környezeti eredetű betegségterhének csökkentésére. A célok egyike (III.) a beltéri és kültéri légszennyezés okozta légúti betegségek megelőzésére és csökkentésére irányul, ily módon hozzájárulva az asztmás rohamok gyakoriságának csökkentéséhez annak biztosítása érdekében, hogy a gyermekek tiszta levegőjű környezetben élhessenek [3]. A hazai asztma epidemiológiai adatokat számottevően torzítja az a körülmény, hogy a gyermek asztmásokat nem regisztrálják, ami részben magyarázza, hogy a hazai asztma prevalencia (2%) alacsonyabb az európai átlagnál (3-5%). Az európai adatok általában standardizált epidemiológiai felmérések eredményei alapján születnek, adott esetben élettartam prevalencia adatokat jelentenek, így értelemszerűen magasabbak. A December 2007
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hazai adatok regisztrált és gondozott asztmás betegeket fednek. A tüdőgyógyászati hálózatban nyilvántartott gyermek asztmások számából a valós gyermekkori asztma epidemiológiai adatokra nem lehet következtetni [4]. A lakosságot érintő biológiai eredetű légszennyezettségi paraméterek folyamatos monitorozását az 1991. évi XI. törvény 3. és 4. paragrafusa alapján kezdte meg az ÁNTSZ [5]. Az Aerobiológiai Hálózat az ország területét lefedő 19 állomáson monitorozza 32 növény és 2 gomba légköri pollen illetve spóra koncentrációját. A folyamatosan frissített országos pollenjelentés elérhető az ÁNTSZ honlapján (http://www.antsz.hu), valamint a tömegtájékoztatási eszközökön keresztül. A pollenkoncentrációkra vonatkozó 7 napos előrejelzési adatok a http://www.pollenmonitor.hu oldalon találhatók. A parlagfű Magyarországon az egyik legigénytelenebb és legagresszívebb gyomnövény, amely Észak-Amerikából származik és amelynek allergenitása a legjelentősebb, igen sok embernek okoz panaszokat. A parlagfű leggyakoribb felszaporodási helye, a megbolygatott talajú elhanyagolt parlagterületek. Mivel a parlagfű nemcsak gazdasági, hanem közegészségügyi szempontból is jelentős károkat okoz, a jogszabályok kiemelten kezelik a parlagfű-mentesítést. A parlagfű elleni védekezés jogszabályi alapját a növényvédelemről szóló 2000. évi XXXV. törvény (és annak 2007. évi XVI. törvénnyel történt módosítása) valamint az ehhez kapcsolódó rendeletek jelentik (felsorolásuk a „További információk” között található) [6]. Elemzés, értékelés Az asztmás tünetek gyakorisága 12,3% (Zala megye) és 21,9% (Somogy megye) közötti értékeket mutat. A megyék többségében a kisebb településeken lényegesen magasabb az asztmás tünetek prevalenciája. Az asztmás tünetek gyakorisága országos átlagban 17,1%, az orvos által diagnosztizált asztma 7,2% volt. A nemzetközi adatokkal összehasonlítva [1] a magyar tünetek prevalenciája Magyarországon magasnak számít, bár mind a korcsoport, mind a módszertan különbözik egymástól ezért ezen adatok összehasonlíthatósága igen korlátozott. Az allergiás tünetek gyakorisága tekintetében 18,7% (Vas megye) és 29,3% (Budapest) közötti értékeket tapasztaltak (országos átlag 24,9%) és az esetek többségében a nagyobb lakosságszámú településeken volt magasabb az allergia prevalencia. Az orvos által diagnosztizált allergia gyakorisága általában 5%-kal kisebb, mint a kérdőíves válaszok alapján bemutatott allergiás tünet gyakoriság. Az ISAAC felmérés [1] eredményeivel összehasonlítva (szintén más módszertan és korcsoport) a magyar allergia prevalencia értékek magasnak számítanak a többi európai országhoz viszonyítva. Az asztmás tünetek gyakorisága (3. ábra) Egerben közel 4%-kal volt alacsonyabb az utóbbi felmérésben, Dorogon több mint 4%-kal volt magasabb ez az érték, míg Tatabányán igen kismértékben alacsonyabb értéket tapasztaltak 2005-ben. A légúti allergiás tünetek gyakorisága tekintetében (4. ábra) Egerben és Dorogon növekedés volt tapasztalható (utóbbi esetben több mint duplájára nőtt az esetszám), Tatabányán néhány százalékkal alacsonyabb értéket tapasztaltak 2005-ben. Az indikátor meghatározásához felhasznált adatok 1996-ban az Európai Unió Phare CESAR Programjának támogatásával került sor kérdőíves felmérésre. Az Országos Gyermek Légúti Felmérés (OGYELF, 2005) során December 2007
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a korábbi nemzetközi felmérések (ISAAC, CESAR) kérdéseit magyar viszonyokra dolgozták át és kibővítették és az ország általános iskolás 3. osztályos tanulói (8-9 évesek) részére elküldték. 62 711 megválaszolt kérdőív érkezett vissza. A 2005-ös OGYELF felmérésben – az asztmás tünetek gyakoriságának meghatározása a következő szempontok alapján történt: sípolás/zihálás, száraz éjszaki köhögés, zihálás álomból ébreszt, asztma miatti kezelés – az utolsó 12 hónapban legalább az egyik előfordult. – az allergiás tünetek gyakoriságának meghatározása a következő szempontok alapján történt: parlagfű-, egyéb virágpor-, állati szőr/toll-, penészgomba-, élelmiszer/étel-, gyógyszer-allergia közül legalább az egyik előfordul. Felhasznált irodalom 1. Prevalence of asthma and allergies in children. Fact sheet No. 3.1. ENHIS, WHOEuro http://www.enhis.net 2. Children's health and environment: A review of evidence. A joint report from the European Environment Agency and the WHO Regional Office for Europe, Edited by: G. Tamburlini, O.S. von Ehrenstein, R. Bertollini, European Environment Agency, 2002 http://reports.eea.europa.eu/environmental_issue_report_2002_29/en/eip_29.pdf 3. Európai cselekvési terv a környezetért és a gyermekek egészségéért, IV. Környezet és Egészség Miniszteri Konferencia, Budapest, 2004. június 23-25. http://efrirk.antsz.hu/oki 4. A pulmonológiai intézmények 2006. évi epidemiológiai és működési adatai, Országos Korányi Tbc és Pulmonológiai Intézet, 2007. http://www.koranyi.hu 5. 1991. évi XI. törvény az egészségügyi hatósági és igazgatási tevékenységről 6. Almási Gy.: Parlagfű kézikönyv. Parlagfűmentes Magyarországért Tárcaközi Bizottság, 2007 http://www.nepegeszseg.net 7. Országos pollenjelentés, Országos Környezetegészségügyi Intézet http://efrirk.antsz.hu/oki 8. Országos pollen-előrejelzés http://www.pollenmonitor.hu 9. Virágh Z.: Védd egészségedet és környezetedet, OKK-OKI, Budapest, 2005 10. Rudnai P., Virágh Z., Varró M.J.: Az allergia prevalenciája és kockázati tényezői 7-11 éves gyermekek körében végzett környezetepidemiológiai vizsgálataink alapján. Környezeti Ártalmak és a Légzőrendszer XV. kötet (Szerk.: Szabó Tibor, Bártfai Imre, Somlai János) Hévíz, 2005., 229-236. old. 11. P. Rudnai, M.J. Varró, Z. Virágh: Associations between respiratory symptoms of school-children and their mother’s smoking during pregnancy. In: (W.A. Jedrychowski, F.P. Perera and U. Maugeri eds.) Vulnerability of the Fetus and Infant
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to Ambient Pollutants and Reduced Food Intake in Pregnancy. Jagiellonian University Press, Krakow, 2007, pp. 115-121
További információk 1. A parlagfű elleni védekezés hatósági tennivalóit előíró jogszabályok (http://www.nepegeszseg.net): i. A növényvédelemről szóló 2000. évi XXXV. törvény és annak 2007. évi XVI. törvénnyel történt módosítása, ii. A növényvédelmi bírság tételes mértékéről szóló 187/2006. (IX. 5.) Korm. rendelet, iii. A növényvédelmi tevékenységről szóló 5/2001. (I. 16.) FVM rendelet, iv. A növényvédelmi közérdekű védekezés költségei megállapításának és igénylésének részletes szabályairól szóló 160/2005. (VIII. 16.) Korm. rendelet, v. A növényvédelmi igazgatás szervezetéről szóló 335/2006. (XII. 23.) Korm. rendelet, vi. A közigazgatási hatósági eljárás és szolgáltatás általános szabályairól szóló 2004. évi CXL. törvény Szerzők: Málnási Tibor, Páldy Anna, Rudnai Péter, Szabó Eszter, Varró Mihály János (Országos Környezetegészségügyi Intézet). Az értékelőlap elkészítésének dátuma: 2007. szeptember 10.
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National fact sheet Lithuania
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Rodiklio duomenų lapas 1
Vaikų ir jaunimo mirtingumas dėl eismo įvykių keliuose (2007 m. lapkritis) Rodiklio apibrėžimas: 0–24 metų amžiaus vaikų ir jaunimo mirtingumas nuo sužalojimų eismo įvykių metu 100 tūkstančių gyventojų. Įvadas Šis rodiklis parodo gyventojų nuo 0 iki 24 metų amžiaus mirtingumą dėl eismo įvykių Lietuvoje. Rodikliui apskaičiuoti panaudoti Statistikos departamento prie Lietuvos Respublikos Vyriausybės duomenų bazės ir kasmetinių leidinių „Demografijos metraštis“ ir „Mirties priežastys“ duomenys. Taip pat pateikiama informacija apie aplinkos ir sveikatos kontekstą, politikos svarbą bei situacijos vertinimą Lietuvoje. Pagrindinė žinia
☹
Eismo įvykiai yra pirmaujanti vaikų ir jaunimo mirties priežastis Lietuvoje. Pagal
žuvusiųjų eismo įvykiuose skaičių Lietuva užima pirmąją vietą Europos Sąjungoje. Per pastaruosius penkerius metus šis skaičius išaugo net 18 proc. Šis faktas įpareigoja atsakingas Lietuvos valstybės institucijas nedelsiant imtis prevencinių priemonių saugaus transporto politikos ir traumatizmo prevencijos srityse. Pagrindimas Mirtingumas dėl eismo įvykių keliuose yra pirmaujanti jaunimo ir vaikų (5-24 m. amžiaus) priežastis Europoje. 2006 m. Lietuvos keliuose žuvo 899 žmonės [2]. Iš jų 221 neturintys 25 metų, per pastaruosius penkerius metus šis skaičius išaugo net 18 proc. (2001 m. – 188 mirties atvejai) [2]. Apie 30 vaikų, kurių amžius nuo 0 iki 14 metų, kasmet žūsta autoavarijose. Nuo 15 iki 24 metų amžiaus šis skaičius siekia iki 168 jaunuolių (2002–2006 metų vidurkis) [2]. Mirties atvejų skaičių galima sumažinti susivienijant ir koncentruojant valstybės institucijų bei pilietinės visuomenės pastangas, taikant priemones, kurios sumažintų pagrindinius rizikos veiksnius. Šis rodiklis atspindi tikslingų priemonių poveikį ir efektyvumą mažinant vaikų ir jaunimo mirtingumą dėl eismo įvykių. Remiantis užsienio mokslininkų atliktais tyrimais, matome, kad daugelis išsivysčiusių šalių pasižymi savo puikiais laimėjimais vaikų mirčių skaičiaus nuo sužalojimų mažinimo srityje, pvz., Švedijoje, įgyvendinus eismo saugos stiprinimo 1
Šis duomenų lapas parengtas įgyvendinant PSO Europos regiono biuro ENHIS2 projektą, laikantis projekte naudoto duomenų lapo turinio ir formos: Fact sheet No. 2.1. May 2007, Code:RPG2_Traf_E1 [19].
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priemones, mirtys eismo nelaimėse per 35 m. sumažėjo net 77 proc. Nemažai autorių, siūlo taikyti žinomus, veiksmingus būdus, pvz.: saugios aplinkos kūrimas, mokymas, švietimas ir įstatymų galią turinčių priemonių tobulinimas, vaikų saugos kėdučių ir saugos diržų automobilio viduje bei dviratininkų šalmų naudojimas, greičio reguliavimas, alkoholio vartojimo vairuotojams apribojimas, greičio matavimo kameros, transporto priemonių ir kelių dizaino tobulinimas, vairavimo kultūros lygio kėlimas – tai yra veiksmingos priemonės, stiprinančios eismo saugą. Tarptautiniai sužalojimų prevencijos ir saugos stiprinimo ekspertai kartu su Pasaulio sveikatos organizacija rekomenduoja, kad ypač svarbu sukurti nacionalinę eismo saugos strategiją ir numatyti veiksmų planą [22]. Lietuvoje būtina toliau plėtoti, tobulinti, koordinuoti visapusišką profilaktinę vaikų ir jaunimo sužalojimų bei saugos stiprinimo veiklą, diegti kompleksines programas, naudoti teigiamą kitų šalių patirtį šioje srityje. Eismo sauga turi tapti prioritetiniu šalies tikslu [21, 22]. Pateikiami duomenys 1 pav. rodo išorinių mirtingumo priežasčių pasiskirstymą Lietuvoje 2006 m., vaikų ir jaunimo 0–24 m. amžiaus grupėje. 2 pav. pavaizduotas žmonių iki 25 metų amžiaus standartizuoto mirtingumo rodiklio (SMR) dėl eismo įvykių pasiskirstymas pagal Europos regiono šalis. Duomenys pateikti tų šalių, kuriose gyvena daugiau nei 1 milijonas gyventojų. Standartizuotas mirtingumo rodiklis yra trijų pastarųjų metų vidurkis paimtas iš PSO mirtingumo duomenų bazės. Pažymėtina, kad Standartizuoto mirtingumo rodiklio dinamika nepriklauso nuo pajamų lygio šalyje [19]. 3 pav. atsispindi 0-24 metų amžiaus vaikų ir jaunimo mirtingumo, dėl eismo įvykių Lietuvos keliuose kitimo tendencijų pasiskirstymas pagal lytį 1998–2006 m. 4 pav. parodo, kaip pasiskirsto mirtingumas nuo eismo įvykių Lietuvoje (2001–2005 m. duomenų vidurkis) pagal amžius grupes. 5 pav. pavaizduota, kaip keičiasi mirtingumo dėl eismo įvykių Lietuvos keliuose priežasčių struktūra, keičiantis amžiaus grupėms (0–4, 5–9, 10–14, 15–19, 20–24 metai). Išvestas 2001–2005 metų mirtingumo duomenų vidurkis. 6 pav. palyginami 0–24 metų amžiaus vaikų ir jaunimo mirtingumo dėl eismo įvykių keliuose visoje Lietuvoje ir apskrityse 2006 m. duomenys.
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1 pav. Traumos dėl eismo įvykių– pagrindinė Lietuvoje vaikų ir jaunimo 0–24 m. amžiaus išorinė mirties priežastis 2006 m.
18% 5%
44%
22% 1% transporto įvykiai atsitiktinis paskendimas savižudybės kitos išorinės priežastys
8%
2% nukritimai atsitiktinis apsinuodijimas alkoholiu nužudymai
Duomenų šaltinis: Statistikos departamentas prie LRV [1].
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2 pav. Vaikų ir jaunuolių 0–24 amžiaus standartizuotas mirtingumo rodiklis PSO Europos regione, 2002–2004 m. vidurkis Russian RusijosFederation Federacija Lithuania Lietuva Latvia Latvija Portugal Portugalija Greece Graikija Belgium Belgija Kazakhstan Kazachstanas Croatia Kroatija Belarus Baltarusija Ukraine Ukraina France Prancūzija Italija Italy Slovėnija Slovenia Ispanija Spain Lenkija Poland Estija Estonia Čekija Czech Republic Moldova Republic of Moldova Austrija Austria Danija Denmark Slovakija Slovakia Rumunija Romania Vokietija Germany Bulgarija Bulgaria Vengrija Hungary Kirgizija Kyrgyzstan Norvegija Norway Suomija Finland Šveicarija Switzerland Albanija Albania Izraelis Israel Airija Ireland Olandija Netherlands Jungtinė United Karalystė Kingdom Švedija Sweden Turkmėnija Turkmenistan Uzbekija Uzbekistan Makedonija TFYR Macedonia* Gruzija Georgia Armėnija Armenia Azerbaidžanas Azerbaijan Tadžikija Tajikistan 0
2
4
6
8
10
12
14
16
Deaths 100100 000000 population Mirtiesper atv.sk. gyv.
Duomenų šaltinis: PSO Europos regiono biuro ENHIS projekto metu sukurtas duomenų lapas Nr.2.1. [19].
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3 pav. 0–24 metų amžiaus vaikų ir jaunimo mirtingumas dėl eismo įvykių Lietuvos keliuose 1998–2006 m. 35
atv. sk. 100 tūkst. vaikų ir jaunuolių
30 25 20
0-24 visi 0-24 vyrai 0-24 moterys
15 10 5 0 1998
1999
2000
2001
2002
2003
2004
2005
2006
m etai
Duomenų šaltinis: Statistikos departamentas prie Lietuvos Respublikos Vyriausybės [1, 2].
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4 pav. Mirtingumas dėl eismo įvykių Lietuvos keliuose pagal amžiaus grupes (2001–2005 metų vidurkis) 20-24
amžiaus grupės
15-19
10-14
5-9
0-4
0
5
10
15
20
25
30
35
40
atv.sk. 100 tūkst. vaikų ir jaunuolių
Duomenų šaltinis: Statistikos departamentas prie Lietuvos Respublikos Vyriausybės [1].
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5 pav. Mirtingumas dėl eismo įvykių Lietuvos keliuose pagal priežastis ir amžiaus grupes (2001–2005 metų vidurkis) 30
atv.sk. 100 tūkst vaikų ir jaunuolių
25
20 Pėstieji Dviratininkai
15
Važiavę motociklu Važiavę automobiliu
10
5
0 0-4
5-9
10-14
15-19
20-24
am žiaus grupės
Duomenų šaltinis: Statistikos departamentas prie Lietuvos Respublikos Vyriausybės [1, 2].
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6 pav. 0–24 metų amžiaus vaikų ir jaunimo mirtingumas dėl eismo įvykių keliuose Lietuvoje ir apskrityse 2006 m. Šiaulių apskritis Utenos apskritis Panevėžio apskritis Marijampolės apskritis Klaipėdos apskritis Alytaus apskritis Lietuva Vilniaus apskritis Kauno apskritis Telšių apskritis Tauragės apskritis 0
5
10
15
20
25
atv.sk.100 tūkst. vaikų ir jaunuolių
Duomenų šaltinis: Statistikos departamentas prie Lietuvos Respublikos Vyriausybės [2].
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30
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Sveikatos ir aplinkos analizė Augant ekonomikai Lietuvoje, didėja mobilumo poreikis bei galimybės. Besiplėtojanti transporto sistema didina neigiamą poveikį aplinkai bei sukelia nepageidaujamas eismo saugos problemas. Skausmingas Lietuvos visuomenei yra didelis traumatizmas bei žūtys keliuose, ypač vaikų ir jaunų žmonių. Lietuvos keliuose 2006 m. žuvo 899 žmonės, iš jų 221 0–24 metų amžiaus. Iki 14 metų vaikų – 38 mirtys, 15–24 metų jaunuolių – net 183 mirtini atvejai [2]. Milijonui Lietuvos gyventojų tenka 223 mirtys keliuose, tai daugiau nei dvigubai viršijo ES vidurkį (86 mirtys keliuose mln. gyventojų) [4]. Vaikai ir jaunimas yra labiau pažeidžiami autoavarijų metu dėl skirtingų fizinių bei psichologinių charakteristikų. Eismo įvykio metu vaikų sužalojimo rizika yra didesnė dėl galvos ir kūno proporcijos, tai nulemia rimtesnius galvos sužeidimus. Mažesnis ūgis sudaro sąlygas kitų gyvybiškai svarbių organų sužeidimams. Be to, 33 proc. vaikų patiria potrauminį stresą. Jaunų motociklų vairuotojų ir keleivių mirtys taip pat sudaro didelę dalį visų mirčių autoavarijose dalį. Transporto ir kelių tyrimo instituto duomenimis, nelaiminguose eismo įvykiuose absoliučiai pirmauja vairuotojai-kaltininkai, kurių vairavimo stažas yra tik vieneri metai [3]. Didėjant vairavimo stažui, autoavarijų skaičius stabiliai mažėja. Taip yra dėl ribotos patirties ir rizikingų veiksmų, neretai ir alkoholio vartojimo. Tai gali būti priežastis, kad daugiau itin skaudžių nelaimių, kuriose žūsta žmonės, įvyksta būtent naktį, nors sužeidžiama daugiau dieną įvykusiose autoavarijose. Pagal Valstybinę saugaus eismo automobilių keliais 2005–2010 m. programą, patvirtintą Lietuvos Respublikos Vyriausybės 2005 m. liepos 8 d. nutarimu Nr. 759, numatytas strateginis tikslas – siekti iki 2010 metų per pusę sumažinti Lietuvos eismo įvykiuose žuvusių žmonių skaičių palyginti su 2004 metais. Siekiant to, svarbu sukurti transporto infrastruktūrą, kuri turėtų atitikti realias eismo intensyvumo bei greičio sąlygas konkrečiuose transporto judėjimo ruožuose. Tam būtinas kelių saugumo vertinimas, kelių saugumo auditas, transporto srautų valdymas, saugos patikrinimas. Europos Sąjungos šalyse kelių teisingas projektavimas ir infrastruktūra padeda išvengti trečdalio mirtinų autoįvykių keliuose [4]. Norint įvykdyti siekius, taip pat svarbu užtikrinti transporto priemonių šiuolaikinius saugos reikalavimus, dažnesę jų techninę priežiūrą. Labai svarbūs veiksniai – visuomenės eismo saugos kultūros lygio kilimas, bausmės už pažeidimą neišvengiamumas, švietimas eismo saugos srityje (tai įtakoja iki 30 proc. eismo įvykių) [4]. Situacija politikoje ir jos svarba Lietuvoje eismo saugos problemos sprendžiamos kompleksiškai: teisinėmis, administracinėmis, inžinerinėmis, švietėjiškomis priemonėmis bei atliekant mokslo tiriamuosius darbus. Saugaus eismo politiką Lietuvoje formuoja Lietuvos Respublikos susisiekimo ministerija. Siekiant užtikrinti eismo saugą kartu su Susisiekimo ministerija dirba Vidaus reikalų ministerija, Švietimo ir mokslo ministerija, Sveikatos apsaugos ministerija, savivaldybės, kitos valstybinės institucijos, visuomeninės organizacijos bei mokslo institucijos. Valstybės politikos įgyvendinimą saugaus eismo užtikrinimo srityje kontroliuoja nuolat veikianti Saugaus eismo komisija. Vyriausybės
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patvirtintą Komisiją sudaro valstybinio administravimo ir savivaldybių administravimo subjektai, nevyriausybinių organizacijų atstovai [6]. Gerinant eismo saugą mūsų šalyje, 2000 m. buvo priimtas Lietuvos Respublikos saugaus eismo automobilių keliais įstatymas, kurio pagrindinis uždavinys – koordinuoti visų už eismą atsakingų institucijų darbą, reglamentuoti ir užtikrinti saugų eismą automobilių keliais [7]. 2000 metais Lietuvos Respublikos Vyriausybė patvirtino Valstybinę traumatizmo profilaktikos 2000–2010 metų programą. Šios programos 2006–2007 m. priemonių plane buvo numatytos edukacinės ir kvalifikacijos kėlimo priemonės vaikų traumatizmo keliuose profilaktikos srityje [8]. Į šios programos 2007–2008 metų priemonių planą siūloma įtraukti teisinį dviratininkų šalmų naudojimo reglamentavimą. Europos Komisijos 2001 m. patvirtintoje Baltojoje knygoje užsibrėžtas tikslas – žuvusiųjų eismo įvykiuose skaičių iki 2010 m. sumažinti dvigubai, suvienodinant baudų dydžius, nustatant papildomas priemones saugiam eismui užtikrinti, diegiant naujas ir pažangias technologijas. Šį tikslą pakartotinai užsibrėžė Europos šalių susisiekimo ministrai 2003 m. spalio mėn. priėmę Veronos deklaraciją [6]. Lietuva kaip ir kitos Europos valstybės, kaip ir Europos Komisija deda pastangas eismo saugai gerinti. Lietuva siekdama išsaugoti žmonių gyvybes keliuose bei įgyvendinti Veronos deklaracijoje užsibrėžtus tikslus stengiasi pasiekti esminę pažangą saugaus eismo srityje. 2004 metais Ketvirtojoje aplinkosaugos ir sveikatos apsaugos ministrų Konferencijoje Budapešte, kurioje dalyvavo ir Lietuvos sveikatos apsaugos minstras, buvo priimtas Europos vaikų aplinkos sveikatinimo veiksmų planas [9, 10]. Lietuvos Respublikos visuomenės sveikatos priežiūros įstatymas [11] reglamentuoja palankios žmonių sveikatai aplinkos gerinimą bei žmogaus veiklos neigiamo poveikio sveikatai mažinimą. Įstatymas taip pat reglamentuoja vaikų sveikatos saugos įgyvendinimą užtikrinant įstatymų ir kitų teisės aktų nustatytas vaikų ugdymo sąlygas ugdymo įstaigose bei vaikų apsaugą nuo fizinę bei psichinę sveikatą žalojančio poveikio [11]. Lietuvos Respublikos Vyriausybės nutarimu Nr. 1950 „Dėl kelių eismo taisyklių patvirtinimo“ buvo reglamentuotas vaikų automobiliuose vežimas: jaunesnius kaip 12 metų ir žemesnius kaip 150 cm vaikus leidžiama vežti ant priekinės lengvojo automobilio, autobuso sėdynės ar sunkvežimio kabinoje tik specialiose jų ūgiui ir svoriui pritaikytose sėdynėse; vežamus ant galinės automobilio sėdynės 3 metų ir vyresnius vaikus leidžiama prisegti saugos diržu, skirtu suaugusiesiems, arba naudoti kitas prisegimo sistemas; jaunesnius kaip 3 metų vaikus leidžiama vežti ant galinės automobilio sėdynės tik specialiose jų ūgiui ir svoriui pritaikytose sėdynėse. Šiuo Lietuvos Respublikos Vyriausybės nutarimu draudžiama vežti motociklais (išskyrus priekaboje) vaikus iki 12 metų bei važiuoti motociklu ar mopedu neužsisegus saugos šalmų. Taip pat šis nutarimas draudžia visoms transporto priemonėms gyvenamojoje zonoje važiuoti didesniu kaip 20 km/h greičiu, o gyvenvietėse leidžiama važiuoti ne didesniu kaip 50 km/h greičiu [12]. Taip pat Lietuvos Respublikos Vyriausybė 2005 m. liepos 8 d. nutarimu Nr. 759 patvirtino Valstybinę saugaus eismo automobilių keliais 2005–2010 m. programą (toliau – Programa), kurios paskirtis – sudaryti sąlygas kryptingam ir ilgalaikiam saugaus eismo gerinimui, numatyti ir realizuoti atitinkamas priemones, padėsiančias sumažinti avaringumą keliuose. Strateginis šios programos tikslas – siekti iki 2010 metų per pusę sumažinti eismo įvykiuose žuvusių žmonių skaičių palyginti su 2004 December 2007
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metais. Įvertinus pagrindines avaringumo priežastis ir siekiant šioje Programoje numatytų tikslų, iki 2010 metų numatytos prioritetinės veiklos kryptys: 1) žmogaus (eismo dalyvio) elgsenos srityje; 2) kelių infrastruktūros srityje; 3) transporto priemonių saugos gerinimo srityje; 4) įstatyminės bazės tobulinimo srityje. Programos vykdytojai – Susisiekimo ministerija, Vidaus reikalų ministerija, Švietimo ir mokslo ministerija, Sveikatos apsaugos ministerija. Pagal šią Programą, Policijos departamentas prie Vidaus reikalų ministerijos vykdo saugos diržų, šalmų ir vaikiškų saugos kėdučių naudojimo kontrolę, renka ir teikia Saugaus eismo komisijai informaciją, Susisiekimo ministerija leidžia informacinius leidinius apie vaikų saugumo priemones automobilyje bei rengia informacines saugaus eismo kompanijas, taip pat švietėjiškas pėsčiųjų ir dviratininkų saugos akcijas, skatinančias atšvaitų ir drabužių su šviesą atspindinčiomis medžiagomis dėvėjimą; Švietimo ir mokslo ministerija rengia ir leidžia saugaus eismo programas I–VIII klasių mokiniams bei saugaus eismo mokymo metodinę medžiagą I–XII klasių mokiniams ir užtikrina saugaus eismo apmokymo procesą, taip pat organizuoja kursus saugaus eismo mokytojams, o Susisiekimo ministerija – Lietuvos moksleivių konkursą „Saugokime jaunas gyvybes keliuose“ ir propaguoja visuomenei kultūringą elgesį keliuose, smerkdama agresyvų vairavimą. Remiantis šia programa yra parengtas „pakopų sistemos“ vairavimo teisių išdavimo projektas [13]. 2003 metais Lietuvoje priimta 2003–2012 metų Valstybinė švietimo strategija. Ji reglamentuoja valstybės, apskričių bei savivaldybių švietimo planų, atitinkančių konkrečias nuostatas, tarp kurių – saugaus kelio į mokyklą užtikrinimas, sudarymą [14]. Valstybės ir savivaldybių švietimo įstaigos ir visuomenės sveikatos priežiūros įstaigos organizuoja vaikų sveikatos saugą ir už ją atsako, moko sveikos gyvensenos įgūdžių. Lietuvos Respublikos švietimo įstatyme apibrėžti valstybės įsipareigojimai visuomenei švietimo srityje bei ugdymo turinys – integruota žinių, įgūdžių, gebėjimų, vertybinių nuostatų sistema [15]. Lietuvos Respublikos sveikatos apsaugos ministerija koordinuoja Pasaulio sveikatos organizacijos (PSO) chartijos „Transportas, aplinka ir sveikata“ (toliau – Chartija) įgyvendinimą Lietuvoje, kuri vykdoma pagal PSO ir Jungtinių Tautų ekonominės komisijos Europai Europos Programą „Transportas, aplinka ir sveikata“(THE PEP) [16, 18]. Chartijos įgyvendinimas Lietuvoje buvo patvirtintas Lietuvos Respublikos sveikatos apsaugos ministro, aplinkos ministro ir susisiekimo ministro 2005 m. liepos 1 d. įsakymu Nr. V-564/D1-339/3-312 „Dėl Pasaulio sveikatos organizacijos chartijos „Transportas, aplinka ir sveikata“ įgyvendinimo Lietuvoje“. Atitinkamų ministerijų sekretoriai pagal jų administruojamą sritį vykdo šio įsakymo kontrolę ir užtikrina, kad informacija apie pasiektą pažangą, įgyvendinant chartijos nuostatas, kasmet būtų teikiama Chartijos įgyvendinimo Lietuvoje koordinavimo grupei. Šiuo įsakymu ministrai įsipareigojo skatinti saugų ir aplinkai palankų mobilumą, kuriant saugią infrastruktūrą ir tinklus, įgyvendinant eismo valdymo priemones, nustatant greičio ribas, tinkamas vietos sąlygoms bei suprojektuojant kelius ir gyvenvietes atsižvelgiant į pėsčiųjų ir dviratininkų poreikius [17]. Vertinimas
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Vaikų ir jaunuolių mirtingumas dėl keliuose patirtų traumų Lietuvoje yra labai didelis. Nagrinėjant 0–24 m. vaikų ir jaunimo išorines mirties priežastis, paaiškėja, kad pagrindinė mirties priežastis vaikystėje ir paauglystėje yra autotransporto įvykiai. 2006 m. duomenimis, tai sudaro net 44 proc. visų išorinių mirties priežasčių. Nelaimingi atsitikimai keliuose yra opi problema atsižvelgiant į žymų jaunuolių prarastų gyvenimo metų skaičių dėl ankstyvos mirties ir sunkų išgyvenusiųjų neįgalumą. Tai paveikia net tik aukas, jų šeimas, bet ir visą visuomenę. Apskaičiuota, kad nuostoliai dėl nelaimingų atsitikimų keliuose per metus sudaro 3 proc. bendrojo šalies BVP, t.y. vien per 2005 metus Lietuva prarado 2,1 mlrd. Lt. Nuostoliai dėl eismo įvykių per metus sudaro 10 proc. metinio Lietuvos biudžeto [4]. Skaičiuojant mirtingumo rodiklį paaiškėja, kad 100 000-ių 0–24 metų vaikų ir jaunimo tenka net 20,45 žuvusių eismo įvykiuose. Apie 30 vaikų, kurių amžius nuo 0 iki 14 metų, kasmet žūsta autoavarijose. Jaunuolių nuo 15 iki 24 metų amžiaus šis skaičius siekia iki 168 [2]. 15–24 metų amžiaus grupė yra absoliuti lyderė lyginant visas amžiaus grupes pagal eismo įvykių, kuriuose sužeidžiami ar žūsta žmonės, skaičių [3]. Išanalizavus vaikų ir paauglių mirtingumo dėl atsitiktinių sužalojimų (nudegimų, paskendimų, transporto įvykių) tendencijas Lietuvoje per 35 metus (1971–2005 m.), pastebėta, jog 15-19 metų paauglių mirtingumas nuo eismo įvykių Lietuvoje statistiškai patikimai didėja, ypatingai berniukų tarpe [21]. Toks 15–24 metų jaunuolių mirties atvejų išaugimas siejamas su automobilių vairavimo pradžia. Jei 10–14 metų amžiaus grupėje jau pasitaiko motociklininkų mirčių, tai 15–19 metų, o dar daugiau 20–24 metų jaunų žmonių žūsta automobilių sukeltuose autoįvykiuose, net 84 proc. žuvusiųjų yra vyrai. Nagrinėjant žuvusiuosius pagal lytį, nustatyta, kad 0–24 metų berniukai ir jaunuoliai autoavarijose žūsta net 3 kartus dažniau nei to paties amžiaus mergaitės ir jaunuolės. Lyginant mirtingumą Lietuvos apskrityse, matyti, kad 0–24 metų amžiaus asmenų atskirų apskričių rodikliai gerokai skiriasi, o visų amžiaus grupių mastu rodikliai gana panašūs. Galbūt tai galima paaiškinti jauno amžiaus žmonių skaičiaus ir eismo intensyvumo skirtumais apskrityse. Duomenys, kuriais grindžiamas rodiklis Duomenų šaltinis Mirtingumo duomenys dėl eismo įvykių paimti iš Statistikos departamento prie Lietuvos Respublikos Vyriausybės duomenų bazės ir jo leidinio „Mirties priežastys“ 1998–2006 m.; vidutinio metinio gyventojų skaičiaus duomenys iš šio departamento leidinio „Demografijos metraštis“ 1998–2006 m. [1, 2]. Duomenų apibūdinimas Mirtys dėl eismo įvykių Lietuvoje 1998–2006 metais pagal lytį, amžiaus grupę, priežastį. TLK-10 kodai V01-V79. Vidutinis metinis gyventojų skaičius pagal lytį, amžiaus grupę. Duomenų prieinamumas Ruošiant šią apžvalgą, nepavyko pasinaudoti Lietuvos sveikatos informacijos centro sveikatos rodiklių sistema „Lietuvos vaikų ir jaunimo sveikata“, nes nėra December 2007
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duomenų apie vaikų iki 10 metų amžiaus mirtingumą dėl eismo įvykių. Be to, paskutiniai prieinami duomenis yra tik 2005 metų. Taip pat šioje rodiklių sistemoje nėra mirtingumo pagal eismo įvykio priežastį rodiklių. Statistikos departamento prie Lietuvos Respublikos Vyriausybės internete skelbiamoje duomenų bazėje taip pat nepavyko rasti duomenų apie mirtingumą dėl eismo įvykių keliuose ir vidutinio metinio Lietuvos gyventojų skaičiaus rodiklio. Lietuvos policijos eismo priežiūros tarnybos internetiniame puslapyje informacija apie nukentėjusius ir žuvusius eismo įvykiuose pateikiama gana išsamiai ir operatyviai, tačiau nėra duomenų, reikalingų 0–24 m. amžiaus grupės mirtingumui apskaičiuoti. Duomenų apie šią amžiaus grupę nepavyko rasti ir Lietuvos automobilių kelių direkcijos prie Susisiekimo ministerijos internetiniame puslapyje. Atsižvelgiant į aukščiau išvardytas priežastis, mirtingumo rodikliai buvo specialiai atskirai apskaičiuoti šiai apžvalgai parengti. Absoliutūs mirties atvejų skaičiai 1998–2005 metais pagal amžiaus grupes, lytį, TLK-10 kodus V01-V79 buvo paimti iš Statistikos departamento prie Lietuvos Respublikos Vyriausybės kasmetinio leidinio “Mirties priežastys”. 2006 metų analogiški duomenys gauti elektroniniu paštu iš Statistikos departamento prie Lietuvos Respublikos Vyriausybės, nes 2006 metų leidinys dar nėra išleistas. 1998–2006 m. vidutinis metinis gyventojų skaičius pagal amžiaus grupes ir lytį buvo paimtas iš Statistikos departamento prie Lietuvos Respublikos Vyriausybės kasmetinio leidinio „Demografijos metraštis“. Išvadoms apie vairavimo stažo, paros laiko įtaką eismo įvykiams, 15–24 metų amžiaus grupės išskirtinumą padaryti buvo pasinaudota leidinio „2003–2006 metų eismo įvykių statistika Lietuvoje“, kurį rengiant dalyvavo Lietuvos automobilių kelių direkcija prie Susisiekimo ministerijos ir Transporto ir kelių tyrimo institutas, medžiaga [3]. Rodiklio apskaičiavimo metodas Rodiklis parodo 0–24 metų vaikų ir jaunų žmonių, žuvusių dėl eismo įvykių keliuose mirčių skaičių, tenkantį 100 000 atitinkamos amžiaus grupės gyventojų. Skaičiuojamas pagal formulę: 100 000 * (Mt / P), čia: Mt – mirusių vaikų ir jaunimo skaičius dėl eismo įvykių keliuose, skirstomas pagal amžiaus grupę (0–24, 0–4, 5–9, 10–14, 15–19, 20–24), lytį, transporto priemonę (pėstieji, važiavę dviračiu, motociklu, automobiliu). P – vaikų ir jaunimo skaičius skirstomas pagal atitinkamą skaitikliui amžiaus grupę (0–24, 0–4, 5–9, 10–14, 15–19, 20–24) ir lytį. Rodiklio stebėjimo vietovės Lietuva, Alytaus apskritis, Kauno apskritis, Klaipėdos apskritis, Marijampolės apskritis, Panevėžio apskritis, Šiaulių apskritis, Tauragės apskritis, Telšių apskritis, Utenos apskritis, Vilniaus apskritis. Rodiklio analizės laikotarpis Analizuoti 1998–2006 metų mirtingumo dėl eismo įvykių Lietuvos keliuose duomenys. LITERATŪRA:
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1. Demografijos metraštis. Statistikos departamentas prie Lietuvos Respublikos Vyriausybės, 1998–2006 m., Vilnius. 2. Mirties priežastys. Statistikos departamentas prie Lietuvos Respublikos Vyriausybės, 1998–2006 m., Vilnius. 3. 2003–2006 metų eismo įvykių statistika Lietuvoje. Lietuvos automobilių kelių direkcija prie Susisiekimo ministerijos, VĮ Transporto ir kelių tyrimo institutas . 4. Ignotas P. Automobilių parko atnaujinimo įtaka eismo saugai. Pranešimas Lietuvos Respublikos Seime konferencijoje „Dramos keliuose“ 2007 06 27. 5. Meižienė R. Sužalojimų kelių eismo įvykių metu profilaktika. Pranešimas Lietuvos Respublikos Seime konferencijoje „Dramos keliuose“ 2007 06 27. 6. Lietuvos Respublikos susisiekimo ministerijos tinklalapis http://www.transp.lt . 7. Lietuvos Respublikos saugaus eismo automobilių keliais įstatymas (Žin., 2000, Nr. 92-2883). 8. Lietuvos Respublikos Vyriausybės 2006 m. kovo 16 d. nutarimas Nr.258 „Dėl Valstybinės traumatizmo profilaktikos 2000–2010 m. programos įgyvendinimo 2006– 2007 m. priemonių plano patvirtinimo“ (Žin., 2006, Nr. 31-1091). 9. White Paper. European transport policy for 2010: time to decide. Luxembourg, Office for Official Publications of the European Communities, 2001 (http://ec.europa.eu/transport/white_paper/documents/doc/lb_texte_complet_en.pdf, accessed 10 April 2007). 10. Children’s Environment and Health Action Plan for Europe. Fourth Ministerial Conference on Environment and Health, Budapest, 23–25 June 2004 (EUR/04/5046267/6; http://www.euro.who.int/document/e83338.pdf, accessed 16 March 2007). 11. Lietuvos Respublikos visuomenės sveikatos priežiūros įstatymas (Žin., 2002, Nr.56-2225). 12. Lietuvos Respublikos Vyriausybės 2002 m. gruodžio 11 d. nutarimas Nr. 1950 „Dėl Kelių eismo taisyklių patvirtinimo“ (Žin., 2003, Nr. 7-263). 13. Lietuvos Respublikos Vyriausybės 2005 m. liepos 8 d. nutarimas Nr.759 „Dėl Valstybinės saugaus eismo automobilių keliais 2005–2010 metų programos patvirtinimo“ (Žin., 2005, Nr. 84-3117). 14. Lietuvos Respublikos Seimo 2003 m. liepos 4 d. nutarimas Nr.IX-1700 „Dėl Valstybinės švietimo strategijos 2003–2012 metų nuostatos (Žin., 2003, Nr.71-3216). 15. Lietuvos Respublikos švietimo įstatymas (Žin., 1991, Nr. 23-5930). 16. Transport, Health and Environment Pan-European Programme - The PEP. Transport-related health effects with a particular focus on children. Geneva, World Health Organization and United Nations Economic Commission for Europe, 2004 (http://www.unece.org/doc/ece/ac/ece.ac.21.2002.9.e.pdf, accessed 10 April 2007). 17. Lietuvos Respublikos sveikatos apsaugos ministro, Lietuvos Respublikos aplinkos ministro, Lietuvos Respublikos susisiekimo ministro 2005 m. liepos 11 d. įsakymas Nr.V-564/D1-339/3-312 „Dėl Pasaulio sveikatos organizacijos chartijos „Transportas, aplinka ir sveikata“ įgyvendinimo Lietuvoje“ (Žin., 2005, Nr. 87-3276). 18. PSO ir Jungtinių Tautų Ekonominės Komisijos Europai Europos Programos „Transportas, aplinka ir sveikata (THE PEP) vykdomojo komiteto tinklapis. http://www.thepep.org/en/commitee/committee.htm . 19. „Mortality from road traffic injuries in children and young people” Copenhagen, WHO Regional Office for Europe, 2007 (ENHIS fact sheet 2.1)
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(http://www.euro.who.int/Document/EHI/ENHIS_Factsheet_2_1.pdf, accessed 03 November 2007). 20. „Policies to promote safe mobility and transport for children “Copenhagen, WHO Regional Office for Europe, 2007 (ENHIS fact sheet 2.5) (http://www.euro.who.int/Document/EHI/ENHIS_Factsheet_2_5.pdf, accessed 03 November 2007). 21. B. Strukčinskienė, A. Šereivienė, N. Strazdienė. Vaikų ir paauglių mirtingumo dėl atsitiktinių sužalojimų (nudegimų, paskendimų, transporto įvykių) tendencijos Lietuvoje per 35 metus. Sveikatos mokslai, 2007 m. birželis, Nr. 3 (50). ISSN 13926373. http://www.sam.lt. 22. B. Strukčinskienė, A. Šereivienė, A.Martinkėnas, N. Strazdienė. Mirtys nuo eismo įvykių 0–19 metų vaikų ir paauglių grupėje: 1971–2005 metų longitudinė duomenų analizė Lietuvoje. Sveikatos mokslai, 2007 m. birželis, Nr. 3 (50). ISSN 1392-6373. http://www.sam.lt. Autoriai: A. Laukaitienė, L. Ciesiūnienė, D. Bagdanavičiūtė, Valstybinis aplinkos sveikatos centras. Recenzentai: B. Strukčinskienė, Klaipėdos universitetas; E. Skrodenis, Transporto ir kelių tyrimo institutas.
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National fact sheet Poland
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Umieralność niemowląt z powodu chorób układu oddechowego Wskaźnik Nazwa: Umieralność niemowląt z powodu chorób układu oddechowego Definicja: Częstość zgonów z powodu chorób układu oddechowego w ciągu roku w grupie dzieci starszych niż 1 miesiąc i młodszych niż 1 rok Kod: RPG3_Air_E2
Wprowadzenie Niniejsze opracowanie stanowi pierwszą próbę oceny umieralności w okresie wczesnego dzieciństwa z powodu chorób układu oddechowego w Polsce z uwzględnieniem zmian zachodzących w czasie. Zawiera również informacje na temat potencjalnych środowiskowych czynników ryzyka oraz istniejących w tym zakresie strategii, polityk i regulacji prawnych. Uzasadnienie Wskaźnik pozwala na pośrednią ocenę szkodliwego wpływu czynników środowiskowych na zdrowie w szczególnie wrażliwej grupie wiekowej. Umieralność niemowląt z powodu chorób układu oddechowego zależy od wielu różnych czynników, włączając stopień zanieczyszczenia powietrza atmosferycznego i wewnątrz pomieszczeń. Wiadomość kluczowa Obserwuje się wyraźne różnice w zakresie umieralności niemowląt z powodu chorób układu oddechowego w różnych regionach kraju. Zróżnicowanie to nie odpowiada jednak rozkładowi zanieczyszczeń powietrza atmosferycznego na terenie Polski. Prezentacja danych Ryc. 1 pokazuje dane na temat umieralności niemowląt z powodu chorób układu oddechowego w poszczególnych województwach w roku 2006. Dane pochodzą z Głównego Urzędu Statystycznego [1]. Wartość średnia dla całego kraju wynosi 0.13. Ryc. 2 prezentuje zmiany w zakresie częstości zgonów niemowląt z powodu chorób układu oddechowego w poszczególnych województwach latach 1999 2006.
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Ryc.1. Umieralność niemowląt w okresie ponoworodkowym z powodu chorób układu oddechowego w poszczególnych województwach w roku 2006. Lubelskie Małopolskie Świętokrzyskie Lubuskie Mazowieckie Podkarpackie Wielkopolskie Pomorskie Zachodniopomorskie Łódzkie Warmińsko-mazurskie Podlaskie Kujawsko-pomorskie Śląskie Dolnośląskie Opolskie 0
0,05
0,1
0,15
0,2
0,25
0,3
0,35
Żródło: Główny Urząd Statystyczny [1].
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0,4
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Średnia liczba zgonów niemowląt w okresie ponoworodkowym z powodu chorób układu oddechowego na 1000 urodzeń żywych
Ryc.2. Rozkład częstości zgonów z powodu chorób układu oddechowego wśród niemowląt w okresie ponoworodkowym w poszczególnych województwach w latach 1999−2006 0,8 0,7 0,6 0,5 0,4 0,3 0,2 0,1 0 1999
2000
2001
Dolnośląskie Lubuskie Mazowieckie Podlaskie Świętokrzyskie Zachodniopomorskie
2002
2003
Kujawsko-pomorskie Łódzkie Opolskie Pomorskie Warmińsko-mazurskie
2004
2005
Lubelskie Małopolskie Podkarpackie Śląskie Wielkopolskie
Żródło: Główny Urząd Statystyczny [1]. Przedstawienie danych za okres wcześniejszy niż 1999 stwarza pewne problemy. W roku 1999 miała miejsce w Polsce reforma administracyjna, w wyniku której zmienił się podział terytorialny kraju. Dodatkowo, dane dotyczące umieralności za lata 1997 i 1998 nie są dostępne w związku z okresowym brakiem sprawozdawczości w zakresie kodów rozpoznań ICD-10, spowodowanym trwającymi w tych latach strajkami lekarzy. Kontekst środowiskowy i zdrowotny Choroby układu oddechowego są najbardziej powszechną przyczyną zachorowalności dzieci w krajach uprzemysłowionych [2]. Grupą największego ryzyka są w tym zakresie niemowlęta i małe dzieci do 2 roku życia [3]. Główną tego przyczyną są właściwości fizjologiczne (dojrzewanie układu odpornościowego dzięki doświadczeniu po przebyciu zakażeń), aktywność wysiłkowa w tym okresie życia (szczególnie nieostrożność w stosunku do potencjalnego zakażenia), skokowe a nie stopniowe przystosowywanie się małych dzieci do przebywania w zbiorowiskach, a nawet sposób żywienia w pierwszych miesiącach życia. Ostre zapalenia dolnych dróg oddechowych (tzn. zapalenia płuc) powodują najwięcej poważnych zachorowań i zgonów, choć ich częstość jest niewielka w porównaniu z banalnymi zapaleniami dróg oddechowych [2]. Istotny wzrost
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częstości występowania obu rodzajów tych zapaleń w sezonie zimowym, tj. w okresie gdy narasta zanieczyszczenie powietrza [4], sugeruje, że właściwości środowiska mogą stanowić poważny czynnik ryzyka. Badania wykazały pozytywny związek pomiędzy stopniem zanieczyszczenia powietrza a umieralnością dzieci z powodu chorób układu oddechowego. Wzrost liczby zgonów może wskazywać na wzrost poziomu zanieczyszczeń powietrza atmosferycznego oraz powietrza pomieszczeń zamkniętych i odwrotnie, zmniejszenie umieralności – lepszą jakość powietrza [5]. Tego rodzaju interpretacje powinny być jednak dokonywane z ostrożnością. Związek pomiędzy umieralnością noworodków i stopniem zanieczyszczenia powietrza nie jest prosty. W grupie chorób układu oddechowego wyróżnia się wiele jednostek chorobowych o różnej etiologii, w tym spowodowane przez zanieczyszczenia i alergeny w powietrzu atmosferycznym i powietrzu pomieszczeń zamkniętych (m. in. produkty spalania paliw stałych w gospodarstwie domowym, dym tytoniowy i kurz) [6]. Istotne znaczenie mają również dieta, styl życia i czynniki społeczne wykazując działanie synergistyczne. Odniesienie do regulacji prawnych i strategii W 2004 roku podczas IV Ministerialnej Konferencji „Zdrowie i Środowisko” przyjęto program Środowisko i Zdrowie Dziecka: Plan Działań dla Europy /CEHAPE/ sygnowany także przez Polskę, w którym zawarte zostały regionalne cele priorytetowe ukierunkowane na zmniejszenie obciążenia chorobami związanymi z czynnikami środowiskowymi. Jeden z celów priorytetowych (RPG III) dotyczy zapobiegania i redukcji zachorowalności na choroby układu oddechowego z powodu zanieczyszczenia powietrza atmosferycznego i pomieszczeń zamkniętych [7]. Poniżej przedstawione dyrektywy Unii Europejskiej mają na celu osiągnięcie ostatecznego celu europejskiej polityki czystego powietrza, która ma doprowadzić do osiągnięcia takich poziomów jakości powietrza, które nie będą powodowały wzrostu istotnych ujemnych skutków zdrowotnych ani zagrożenia dla zdrowia ludzi i stanu środowiska naturalnego. •
• • •
Dyrektywa Ramowa dotycząca Jakości Powietrza 96/62/EC [8] związana z oceną i zarządzaniem jakością powietrza ustala standardy zawartości pyłu zawieszonego, NO2, SO2, i O3 w powietrzu (uzupełniona Dyrektywą 2002/3/EC), jak również ustala powszechnie stosowane metody i kryteria oceny stopnia zanieczyszczenia powietrza. Dyrektywa Rady 1999/30/EC [9] odnosi się do stężenia dopuszczalnego pyłu zawieszonego, NO2, NOx, oraz ołowiu w powietrzu. Dyrektywa 2002/3/EC [10] odnosi się do stężenia dopuszczalnego benzenu i CO w powietrzu. Dyrektywa 2002/3/EC odnosi się do stężenia O3 w powietrzu [11].
Dodatkowym uzupełnieniem jest Szósty Społeczny Program Działania utworzony w celu rozwoju strategii tematycznej dotyczącej zanieczyszczenia powietrza, a którego główny cel to „uzyskanie takiego poziomu jakości powietrza, który nie stwarza zagrożenia dla środowiska naturalnego i zdrowia człowieka” [12]. Ta strategia, przygotowana przez Program „Czyste Powietrze dla Europu” przyjęta została w 2005 r. Ustanowiono wtedy tymczasowe cele do realizacji w sferze zdrowia środowiskowego, związane z jakością powietrza w Krajach Członkowskich Unii Europejskiej oraz zalecono modernizację działań legislacyjnych poprzez
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koncentrację na najbardziej inwazyjnych źródłach zanieczyszczeń oraz włączanie czynników środowiskowych do innych ustaw i programów [13]. WHO opublikowała pierwsze wytyczne dotyczące jakości powietrza dla Europy w 1987 r.: „:Air quality guidelines” (druga edycja w 2000 r.) [14]. Po częściowej aktualizacji w 2006 r. opublikowano najnowszą wersję wytycznych dotyczących jakości powietrza [15]. Zgodnie z dokonaną przez WHO oceną obciążenia chorobami (burden of disease) w skali globalnej ponad 2 miliony przedwczesnych zgonów rocznie można przypisać: zanieczyszczeniom powietrza w gospodarstwach domowych oraz używaniu stałego paliwa (ok. 1,5 milionów notowanych zgonów) oraz zanieczyszczeniu powietrza w środowisku miejskim (ok. 800 tys. notowanych zgonów)[6]. W 2007 r. w Polsce uchwałą numer 90/2007 przyjęty został przez Radę Ministrów Narodowy Program Zdrowia [16] na lata 2007 – 2015, który zakłada zmniejszenie narażenia na czynniki szkodliwe w środowisku życia i pracy oraz ich skutków zdrowotnych (cel operacyjny 6). Wśród efektów oczekiwanych do 2015 r. wymienia się m.in. zmniejszenie wielkości emisji do atmosfery niebezpiecznych substancji oraz ich prekursorów a także zmniejszenie narażenia na ponadnormatywne stężenia zanieczyszczeń powietrza atmosferycznego i powietrza wewnątrz pomieszczeń przeznaczonych na pobyt ludzi. W wyniku podjętych działań planuje się zmniejszenie wskaźnika umieralności z powodu chorób układu oddechowego w stosunku do roku 2005. Ministerstwo Środowiska w drodze ustaw i rozporządzeń szczegółowo reguluje kwestie jakości powietrza zarówno atmosferycznego jak i wewnątrz pomieszczeń, w tym dopuszczalne poziomy emisji zanieczyszczeń powietrza, alarmowe poziomy niektórych substancji w powietrzu, marginesy tolerancji dla dopuszczalnych poziomów niektórych substancji, wymagania w zakresie prowadzenia pomiarów wielkości emisji, zakres i sposób przekazywania informacji dotyczących zanieczyszczenia powietrza. Akty prawne dotyczące ochrony powietrza w Polsce. 1. Prawo ochrony środowiska. Ustawa z dn. 27.04.2001 z późniejszymi zmianami 24.02.2006; 26.04.2007 (Dz.U. 2001.62.627) [17], 2. Rozporządzenie Ministra Środowiska z dn 6.06.2002 w sprawie oceny poziomów substancji w powietrzu (Dz.U. 2002.87.798) [18], 3. Rozporządzenie Ministra Środowiska z dn 6.06.2002 w sprawie dopuszczalnych poziomów niektórych substancji w powietrzu, alarmowych poziomów niektórych substancji w powietrzu oraz marginesów tolerancji dla dopuszczalnych poziomów niektórych substancji (Dz.U. 2002.87.796) [19], 4. Rozporządzenie Ministra Środowiska z dn 13.06.2003 w sprawie wymagań w zakresie prowadzenia pomiarów wielkości emisji (Dz.U. 2003.110.1057) [20], http://www.lex.com.pl/serwis/du/2003/1057.htm 5. Rozporządzenie Ministra Środowiska z dn 5.12.2002 w sprawie wartości odniesienia dla niektórych substancji w powietrzu (Dz.U. 2003.1.12) [21], http://www.lex.com.pl/serwis/du/2003/0012.htm 6. Rozporządzenie Ministra Środowiska z dn 26.11.2002 w sprawie zakresu i sposobu przekazywania informacji dotyczących zanieczyszczenia powietrza (Dz.U. 2002.204.1727) [22], http://www.lex.com.pl/serwis/du/2002/1727.htm
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7. Ustawa o Państwowej Inspekcji Ochrony Środowiska z dn. 20.07.1991 (Dz.U. 1991.77.335) [23]. http://www.lex.com.pl/serwis/ Ocena W roku 2006 średnia liczba zgonów noworodków z powodu chorób układu oddechowego w Polsce wynosiła 2,2% zgonów noworodków ze wszystkich przyczyn, a współczynnik zgonów niemowląt z powodu chorób układu oddechowego (liczba zgonów niemowląt na 1000 urodzeń żywych) ukształtował się na poziomie 0,13‰. Obserwuje się duże zróżnicowanie współczynnika zgonów niemowląt z powodu chorób układu oddechowego w poszczególnych województwach na terenie kraju od 0 w województwach lubelskim, małopolskim i świętokrzyskim do 0,35‰ w województwie opolskim, obserwowane różnice nie korespondują jednak z rozkładem zanieczyszczeń powietrza atmosferycznego w Polsce. Należy również podkreślić, że na podstawie uśrednionych danych rocznych nie można wykazać zmian sezonowych, tj. krótkotrwałych pików w poziomach zanieczyszczeń powietrza, których oddziaływanie na układ oddechowy powodujące wzrost liczby i ciężkości zaburzeń, a nawet śmiertelność, jest udowodnione. Bezwzględna liczba zgonów niemowląt z powodu chorób układu oddechowego w poszczególnych województwach jest niska (średnio 3,25), co obniża silę wskaźnika dla mniejszych obszarów (regionów kraju, województw). Zastosowanie wskaźnika poziomu umieralności niemowląt z powodu chorób układu oddechowego jako indykatora zanieczyszczenia powietrza [5] wydaje się być nieprecyzyjne ze względu na małą czułość, a zwłaszcza jego niską swoistość wobec potencjalnego wpływu wielu czynników zaburzających. Swoistość proponowanego obiektywnego wskaźnika może podnieść wprowadzenie w analizowanej grupie 2 przedziałów wiekowych, tj.: 1-6 m-ca życia i 7-12 m-ca życia. Czułość proponowanego wskaźnika może podnieść również analiza hospitalizacji, a nawet częstości rejestracji ambulatoryjnej zachorowań w terenie.
Dane niezbędne do obliczenia wskaźnika Źródło danych Główny Urząd Statystyczny (1). Opis danych Roczna liczba zgonów dzieci w wieku 28–364 dni z powodu chorób układu oddechowego i liczba urodzeń żywych. Metoda obliczania wskaźnika Liczba zgonów na 1000 urodzeń żywych jest obliczana przez podzielenie rocznej liczby zgonów dzieci w wieku 28-364 dni z powodu chorób układu oddechowego [LZ] przez liczbę urodzeń żywych [LUŻ] w danym roku i pomnożenie wyniku przez 1000: RPG3_Air_E2=[LZ] / [LUŻ] x 1000 Zasięg geograficzny 16 województw.
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Zakres czasowy 1999-2006. Częstotliwość aktualizacji roczna Jakość danych Dane gromadzone są przez Główny Urząd Statystyczny na podstawie statystyk przekazywanych z Urzędów Statystycznych na terenie poszczególnych województw. Działają one w oparciu o Ustawę o Statystyce Publicznej z dnia 29 czerwca 1995r. z późniejszymi zmianami. Niniejsze opracowanie prezentuje najnowsze dostępne dane za lata 1999-2006. Piśmiennictwo Główny Urząd Statystyczny, http://www.stat.gov.pl/gus/. Technical Working Group on Priority Diseases. Baseline report on respiratory health in the framework of the European environment and health strategy. Brussels, Commission of the European Communities, 2003 (COM (2003)338 final), http://ec.europa.eu/environment/health/pdf/respiratory_health.pdf. 3. Hałuszka J., Ronchetti R., Pisiewicz K.: Pneumonologia wieku dziecięcego – wczoraj, dziś, jutro (Pol). Sympozjum – Medyczne Czasopismo Zjazdowe 1/99. XXVI Ogólnopolski Kongres Pediatrów 06-09.1999, 22-27. 4. Donaldson G.C., Keatinge W.R.: Excess Winter Mortality: Influenza or Cold Stress? BMJ 2002; 324: 89-90. 5. WHO European Centre for Environment and Health. Effects of air pollution on children’s health and development - a review of the evidence. Copenhagen, WHO Regional Office for Europe, 2005, http://www.euro.who.int/document/E86575.pdf. 6. Indoor air pollution [web site]. Geneva, World Health Organization, 2007, http://www.who.int/indoorair. 7. Children’s Environment and Health Action Plan for Europe. Fourth Ministerial Conference on Environment and Health, Budapest, 23–25 June 2004 (EUR/04/5046267/7) http://www.euro.who.int/document/e83338.pdf. 8. Council Directive 96/62/EC of 27 September 1996 on ambient air quality assessment and management. Official Journal of the European Union, L296, 21.11.1996 http://europa.eu/scadplus/leg/en/lvb/l28031a.htm. 9. Council Directive 1999/30/EC of 22 April 1999 relating to limit values for sulphur dioxide, nitrogen dioxide and oxides of nitrogen, particulate matter and lead in ambient air. Official Journal of the European Union, L163/41, http://eur29.6.1999, lex.europa.eu/LexUriServ/site/en/oj/1999/l_163/l_16319990629en00410060. pdf. 10. Directive 2000/69/EC of the European Parliament and of the Council of 16 November 2000 relating to limit values for benzene and carbon monoxide in ambient air. Official Journal of the European Union, L313/12, 13.12.2000, http://eurlex.europa.eu/LexUriServ/site/en/oj/2000/l_313/l_31320001213en00120021. pdf. 11. Directive 2002/3/EC of the European Parliament and of the Council of 12 February 2002 relating to ozone in ambient air. Official Journal of the http://eurEuropean Union, L67/14, 9.3.2002, 1. 2.
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lex.europa.eu/LexUriServ/site/en/oj/2002/l_067/l_06720020309en00140030. pdf. 12. Decision No 1600/2002/EC of the European Parliament and of the Council of 22 July 2002 laying down the Sixth Community Environment Action Programme. Official Journal of the European Union, L242, 10.9.2002 (http://europa.eu.int/eur-lex/en/archive/2002/l_24220020910en.html, accessed 6 March 2007). 13. Proposal for a directive of the European Parliament and of the Council on ambient air quality and cleaner air for Europe. Brussels, 21.9.2005, COM(2005) 447 (http://ec.europa.eu/environment/air/cafe/pdf/cafe_dir_en.pdf, accessed 6 March 2007). 14. Air quality guidelines for Europe, 2nd ed. Copenhagen, WHO Regional Office for Europe, 2000 (WHO Regional Publications, European Series, No. 91; http://www.euro.who.int/air/activities/20050223_3, accessed 2 March 2007). 15. WHO air quality guidelines for particulate matter, ozone, nitrogen dioxide and sulphur dioxide. Global update 2005. Summary of risk assessment. Geneva, World Health Organization, 2006 (http://www.who.int/phe/air/aqg2006execsum.pdf, accessed 6 March 2007). 16. Narodowy Program Zdrowia http://www.mz.gov.pl/wwwfiles/ma_struktura/docs/zal_urm_npz_90_150520 07p.pdf 17. Prawo ochrony środowiska. Ustawa z dn. 27.04.2001 z późniejszymi zmianami 24.02.2006; 26.04.2007 [Dz.U. 2001.62.627] http://www.lex.com.pl/serwis/du/2001/0627.htm 18. Rozporządzenie Ministra Środowiska z dn 6.06.2002 w sprawie oceny poziomów substancji w powietrzu [Dz.U. 2002.87.798] http://www.lex.com.pl/serwis/du/2002/0798.htm 19. Rozporządzenie Ministra Środowiska z dn 6.06.2002 w sprawie dopuszczalnych poziomów niektórych substancji w powietrzu, alarmowych poziomów niektórych substancji w powietrzu oraz marginesów tolerancji dla dopuszczalnych poziomów niektórych substancji [Dz.U. 2002.87.796] http://www.lex.com.pl/serwis/du/2002/0796.htm 20. Rozporządzenie Ministra Środowiska z dn 13.06.2003 w sprawie wymagań w zakresie prowadzenia pomiarów wielkości emisji [Dz.U. 2003.110.1057] http://www.lex.com.pl/serwis/du/2003/1057.htm 21. Rozporządzenie Ministra Środowiska z dn 5.12.2002 w sprawie wartości odniesienia dla niektórych substancji w powietrzu [Dz.U. 2003.1.12] http://www.lex.com.pl/serwis/du/2003/0012.htm 22. Rozporządzenie Ministra Środowiska z dn 26.11.2002 w sprawie zakresu i sposobu przekazywania informacji dotyczących zanieczyszczenia powietrza [Dz.U. 2002.204.1727] http://www.lex.com.pl/serwis/du/2002/1727.htm 23. Ustawa o Państwowej Inspekcji Ochrony Środowiska z dn. 20.07.1991 [Dz.U. 1991.77.335] http://www.lex.com.pl/serwis/
Autorzy Maja Muszyńska-Graca Beata Dąbkowska
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National fact sheet Romania
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Mortalitatea prin accidente de trafic la copii si tineri in ROMANIA Indicator Nume: Definiţie: Cod:
Mortalitatea prin accidente de trafic la copii si tineri Rata mortalitatii la copii prin accidente de trafic RPG2_Traf_E1
Introducere Acest indicator descrie mortalitalitatea prin accidente de trafic (AT) la persoane din grupa de varsta 0-24 ani, in Romania, datele fiind extrase din baza de date de mortalitate “Health for all mortality” a OMS (1) sau din datele raportate de Directia Politiei Rutiere (2). Prezentul Fact Sheet mai contine informatii legate de contextul de mediu şi sanatate si despre relevanta si contextul politic. Este de asemenea prezentata o evaluare a situatiei din Romania. Justificare Asa cum reiese din datele raportate de OMS, AT reprezinta principala cauza de deces la copiii si tinerii din grupa de varsta 5–24 ani din regiunea europeana OMS. S-au estimat aproximativ 6400 decese anual la grupa de varsta 0-14 ani si 25500 in randul tinerilor de 15-24 ani din Regiune (3). Numarul de decese ar putea fi redus prin eforturi concertate ale institutiilor si societatii civile si prin implementarea unor masuri eficace de interventie asupra principalilor factori de risc. In consecinta, acest indicator reflecta impactul si eficacitatea masurilor menite sa reduca AT si sa le previna prin asigurarea sigurantei rutiere. Mesaj cheie AT reprezinta principala cauza de deces la copiii si tinerii din Regiune, iar valorile mortalitatii sunt inacceptabil de mari. Intre valorile cele mai mici si cele mai mari ale ratelor de mortalitate prin AT in Regiune exista o diferenta de 8 ori. Romania se plaseaza pe la mijlocul acestui clasament european cu o rata de 8 decese la 100000 populatie 0-24 ani (4), dar fenomenul trebuie tinut in continuare sub supraveghere mai ales datorita stilului agresiv de conducere al tinerilor sub 25 de ani, ceea ce a cauzat accidente extrem de grave in ultimii ani. Un fapt încurajator este acela ca ratele mai scazute de mortalitate atinse de unele tari indica faptul ca decesele prin AT sunt prevenibile. Acest lucru subliniaza necesitatea mentinerii unor politici de siguranta a transportului si a unor strategii de preventie care si-au dovedit eficacitatea in Romania. Prezentarea datelor Fig. 1 prezinta ratele standardizate de mortalitate (SMR) prin AT la grupele de varsta 0-14 ani, 15-29 si la persoanele sub 20 de ani in Romania, pentru perioada 1998-2004. SMR prezentate in grafic se bazeaza pe datele care au fost disponibile în baza de date de mortalitate “health for all mortality” a OMS (1). Sunt puse in evidenta variatii destul de mici ale SMR in Romania, dar, lucru ingrijorator, cu o tendinta de crestere din anul 2004.
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Fig. 2 prezinta dinamica AT in populatia generala si consecintele lor, in perioada 1999-2006. Trebuie subliniat faptul ca incepand cu anul 2005 se observa o crestere semnificativa (de aproximativ 2.5 ori) a numarului absolut de AT fata de anii anteriori, dar acest lucru se datoreaza introducerii in baza de date a Politiei rutiere (incepand cu 24.02.2005) si a accidentelor cu raniti usor, pana la acel moment raportandu-se numai accidentele grave. Graficul arata ca numarul de raniti grav este in usoara scadere din 1999, numarul deceselor neavand o tendinta clara in ultimii ani. Fig. 1. SMR prin accidente de trafic la copii si tineri, pentru grupele de varsta 0– 14, 15-29 si 1-19 ani, in Romania, 1998 - 2004 18
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Sursa: WHO health for all mortality database, Januarie 2007 (1).
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Fig. 2. Dinamica accidentelor de trafic si a consecintelor lor, Romania, 1999 2006 25000
numar absolut
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Sursa: IGP, Politia Rutiera (2).
Sanatatea si mediul in contextul general Se estimeaza ca, la nivel mondial, s-au inregistrat in 2002 aproximatix 1.2 millione decese prin AT. Zece la suta dintre acestea au avut loc in Regiunea europeana a OMS, unde AT reprezinta principala cauza de deces la copiii si tinerii din grupa 5–24 ani. Estimarile arata ca, in fiecare an, AT cauzeaza 6400 decese la copiii de 0–14 ani si pana la 37 000 la tinerii de 15–24 ani, 5% si respectiv 33% din totalul deceselor (3). In Romania, in anul 2002, AT au cauzat 142 de decese la copiii de 0-14 ani si 251 la tinerii de 15-24 ani, 2.5% si respectiv 12% din totalul deceselor (5). Copiii si tinerii sunt foarte vulnerabili in special la accidentele de trafic rutier deoarece au alte caracteristici fizice si psihice decat adultii. Copiii sub 10 ani nu au inca dezvoltate abilitatile de a se descurca in trafic si de aceea sunt deseori implicati in accidente de trafic ca pietoni. Ei sunt la risc mai inalt in conditii de trafic intens sau rapid, de vizibilitate redusa sau atunci cand soferii nu sunt atenti la pietoni si biciclisti. In caz de accident copiii sunt cei mai vulnerabili. Raportul inaltime-greutate le creste riscul de traumatisme craniene, iar inaltimea mica le creste probabilitatea de lovituri ale partilor vitale la coliziune. Mai mult, accidentele de trafic conduc la tulburari de stress post-traumatice la 33% dintre copii. Dintre soferii si motociclistii implicati in accidente de trafic, un numar disproportionat de mare sunt tineri. Acest lucru se datoreaza unei combinatii de experienta limitata, tendinta de a se implica
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in comportamente riscante si o vulnerabilitate crescuta la efectele consumului de alcool (6). Conditiile de mediu ar parea sa contribuie semnificativ la accidentele de trafic in Europa, cu o fractiune atribuibila medie estimata la 25%. In ceea ce priveste mortalitatea prin AT, 35% (44 000 decese anual) ar putea fi atribuite conditiilor de mediu. Acest lucru subliniaza importanta unor politici si practici adecvate de utilizare a terenurilor; de proiectare a drumurilor, a structurii si densitatii urbane; si armonizarea designului drumurilor cu vehiculele in circulatie (7). Relevanta si contextul politic O puternica responsabilitate politica si un leadership proactiv sunt necesare pentru adoptarea unei abordari cuprinzatoare a sigurantei rutiere. Aceste masuri sunt discutate in detaliu in cadrul fact sheet Nr. 2.5 (realizat in proiectul ENHIS-2) despre politici de promovare a sigurantei mobilitatii si a transportului pentru copii la nivel european (8). Cateva politici au fost dezvoltate in Regiune, ceea ce constituie un punct de referinta in abordarea AT. In 2004, a 4-a Conferinta Ministeriala de Mediu si Sanatate a adoptat Planul de Actiune pentru Europa pentru Sanatate si Mediu pentru Copii, care include patru obiective regionale prioritare pentru reducerea poverii bolilor legate de mediu la copii (9). Romania a semnat acest document. Unul dintre obiective (RPG II) isi propune reducerea mortalitatii si morbiditatii prin traumatisme, incluzand accidentele de trafic, si sa asigure conditii de siguranta care pot facilita mai multa activitate fizica in randul copiilor. In incercarea de a imbunatati securitatea drumurilor, Uniunea Europeană (UE) si noile state membre, printre care si Romania, si-au propus un obiectiv ambitios de a injumatati numarul de accidente de trafic pana in 2010. Situatia securitatii traficului in Romania este mai putin favorabila decat media UE, dar in ultimii ani, problemele legate de securitatea drumurilor au capatat o mai mare importanta pentru decidentii romani. Aceasta schimbare se datoreaza in parte presiunilor exercitate de organisme internationale precum UE si Banca Mondiala, dar poate fi atribuita si cresterii nivelului de constientizare a publicului asupra importantei securitatii drumurilor. Coordonarea la nivel national a activitatilor legate de securitatea drumurilor este sarcina Consiliului Interministerial pentru Siguranta Rutiera (CISR). A fost creat in 1995, dar, prin HOTARAREA nr. 750 din 14 iulie 2005 privind constituirea consiliilor interministeriale permanente, CISR a fost preluat in cadrul Consiliului interministerial pentru dezvoltare regionala, infrastructura, amenajarea teritoriului si turism. Are in subordine comisii: • Comisia pentru Supravegherea Circulaţiei Rutiere; • Comisia pentru Infrastructură şi Semnalizarea Rutieră; • Comisia pentru Transporturi Rutiere de Mărfuri de Persoane şi Transporturi Combinate; • Comisia pentru Vehicule Rutiere; si • Comisia pentru Factorul Uman în Siguranţa Circulaţiei. (10) Inceput in 2001, Parteneriatul “Securitatea globală a drumurilor”-Romania (GRSPRomania) activeaza ca a sasea comisie a CISR, in vederea extinderii activitatilor de parteneriat guvern-afaceri-societate civila si este unul dintre cele patru programe Business Partners for Development - BPD ale Băncii Mondiale. Principalele directii de actiune ale GRSP cu impact direct asupra securitatii transportului sunt:
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• •
• • •
imbunatatirea informarii participantilor la trafic imbunătăţirea Siguranţei participanţilor la trafic: educatie rutiera pentru scolari (reguli de circulatie si prim-ajutor, pregatire practica, laboratoare mobile) incurajarea portului centurii de siguranta imbunatatirea infrastructurii rutiere (imbunatatirea semnalizării pentru ‘puncte negre’) imbunatatirea sigurantei vehiculelor rutiere activitati din sfera sanatatii: Ziua Mondiala a Sanatatii, 7 aprilie 2004: O.M.S., Ministerul Sanatatii, Crucea Rosie, D.P.R., C.I.S.R., G.R.S.P. România introducerea la scara nationala a managementului integrat al apelurilor de urgenta 112 dupa modelul SMURD Mures
Inspectoratul General al Politiei Romane a lansat in 2005 „Programul partenerial de prevenire si combatere a accidentelor rutiere”, avand drept scop reducerea numarului accidentelor mortale cu 5%, cu o perioada de derulare cuprinsa intre 19 ianuarie – 31 iulie 2006. Principalele obiective ale programului au fost: constientizarea opiniei publice asupra dinamicii si consecinţelor accidentelor rutiere; diminuarea numarului accidentelor rutiere care au drept cauza viteza excesiva; diminuarea numarului accidentelor rutiere care au drept cauza indisciplina pietonilor; dezvoltarea colaborarii cu alte institutii care au atributii in domeniu. Principalii parteneri ai programului au fost: Inspectoratul General al Politiei Romane (IGP); Ministerul Transporturilor, Constructiilor si Turismului; CISR; Ministerul Educatiei si Cercetarii; Asociatia Romana pentru Transporturi Rutiere Internationale; Uniunea Nationala a Transportatorilor Rutieri din Romania; Automobil Clubul Roman; Asociatia Victimelor Accidentelor de Circulatie; Asociatia pentru Promovarea Sigurantei Auto; 3 M Romania; PETROM OMV Romania; Renault Nissan Romania; VESTA Investment; Administratia Publica Locala; Massmedia. Impactul pozitiv al programului s-a materializat in: reducerea cu 556 (12,66%) a numărului victimelor accidentelor de circulaţie fata de perioada corespunzatoare a anului precedent; diminuarea cu 176 (-13,05%) a numărului persoanelor decedate in accidente rutiere, din care 21% minori si tineri; scaderea cu 475 (-12,70%) a numarului accidentelor rutiere cu consecinte grave. Acest program din 2006 s-a continuat si in 2007 tot sub forma de „Program partenerial de combatere a accidentelor rutiere” si s-a desfasurat sub sloganul “STOP Accidentelor - Viata are Prioritate”. Obiectivele acestui nou program au fost reducerea cu 5% atat a numarului de persoane decedate cat si a celor raniti grav in urma accidentelor. Grupurile tinta au fost pietonii si tinerii conducatori auto. Datorita acestui program s-a organizat în Romania prima Saptamana Mondiala a Sigurantei Rutiere, in perioada 23 - 29 aprilie 2007. Ce s-a realizat prin acest program: • o ampla campanie mediatica pentru prevenirea si combaterea accidentelor rutiere, desfasurata cu sprijinul posturilor de radio si televiziune, materializata in 2 spoturi video si 2 audio • proiectul “Info - Trafic”, prin care conducatorii auto vor fi informati permanent asupra condiţiilor de trafic • tiparituri tematice cu caracter educativ-preventiv (pliante, afise, brosuri, fluturasi, autocolante)
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Partenerii programului au fost in principiu acceasi din programul din 2006, la acestia adaugandu-se Primaria Municipiului Bucuresti si o serie de companii private. Indicatorii de mortalitate prin AT sunt de un real ajutor in evaluarea de politici, tinand cont de rezultatul asteptat (reducerea mortalitatii prin AT), prin furnizarea de standarde de comparare si prin stabilirea unei situatii de pornire de la care se poate monitoriza progresul in viitor. Evaluarea de situatie In Romania, la fel ca si in celelalte tari europene, cei mai afectati de consecintele accidentelor de trafic sunt tinerii din grupa de varsta 15-29 ani, mortalitatea prin AT la aceasta grupa reprezentand 12% din totalul deceselor (5). Incepand cu 1998, mortalitatea prin accidente de trafic a avut o tendinta descrescatoare pentru tinerii din grupele de varsta 0-14 si 1-19 pana in anul 2003, dupa care au inceput din nou sa creasca (Figura 1). Tendinta este asemanatoare si pentru grupa de varsta 15-29 ani, numai ca rata de mortalitate a inceput sa creasca incapand cu 2002. Analiza dinamicii AT raportate de IGP arata un nivel relativ stationar al consecintelor accidentelor de trafic. Un aspect incurajator este acela ca in 2006 a scazut numarul persoanelor decedate si al celor raniti grav in urma accidentelor (vezi Grafic 2), poate si datorita eforturilor sustinute din ultimii ani (2005-2007) de promovare a sigurantei rutiere si de combatere a accidentelor de trafic. Tot datele raportate de IGP pun in evidenta disparitati geografice in ceea ce priveste numarul de accidente de trafic si consecintele acestora. Astfel, in 2006, cele mai multe accidente s-au petrecut in Bucuresti (11594), Prahova (3732), Constanta (3591), Brasov (3477) si Timis (3241), zone turistice si cu un trafic extrem de intens; media accidentelor pe judet in anul 2006 a fost de 2000. (11) Aceste date pun in evidenta faptul ca, desi in unele judete au avut loc mai putine accidente, gravitatea lor a fost deosebita prin aceea ca s-a soldat cu decese si raniri grave. AT la copii constituie o povara importanta a bolii datorita numarului considerabil de ani de viata pierduti prin deces prematur si, de multe ori prin handicapuri
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severe si pe viata la supravietuitori. Acestea, impreuna cu impactul devastator asupra vietii victimelor si a familiilor lor si pierderea productivitatii, au ca rezultat costuri mari pentru societate: se estimeaza ca ATR induc costuri care reprezinta aproximativ 2% din PIB (12). Datele care au stat la baza indicatorului Sursa datelor Datele pentru ratele standardizate de mortalitate prin accidente de trafic se gasesc in baza de date OMS “health for all mortality” (lansata in ianuarie 2007, cu rate specifice pe grupe de varsta si rate standardizate) (1). Statisticile sunt asamblate de OMS. Datele utilizate pentru a ilustra povara relativa a mortalitatii la copii prin accidente de trafic se regasesc in sistemul statistic al OMS, baza de date privind povara globala a bolilor (lansata in ianuarie 2005 pentru cifre absolute) (3). Datele pentru accidentele de trafic in populatia generala a Romaniei sunt raportate de IGP (2). Descrierea datelor Indicatorul de mortalitate pentru “rate standardizate de mortalitate, accidente de trafic, la 100 000” se bazeaza pe datele din baza de date OMS “health for all mortality” (editia ianuarie 2007). Include urmatoarele definitii: codurile ICD-9 BTL: B47; codurile ICD-9: 800–848; codurile ICD-10: V01–V99; lista 175 a fostului URSS: 160–162; lista 1 prescurtata de mortalitate ICD-10: 1096; lista cu 65 de cauze a EUROSTAT: 60. Datele pentru Romania au fost selectate din aceasta baza de date. Indicatorul referitor la numarul de accidente de trafic raportat de IGP si-a modificat definitia incepand cu anul 2005. Din februarie 2005 sunt luate in considerare si accidentele soldate cu raniri usoare, nu numai accidentele cu consecinte grave ca pana atunci. Metoda de calcul a indicatorului Indicatorul reprezinta SMR la copiii si tinerii din grupa 1–19 de ani care au decedat ca rezultat al accidentelor de transport, la 100 000 persoane. Rata standardizata dupa varsta este calculata utilizand metoda directa si structura de populatie standard a Europei. Ratele de mortalitate au fost calculate de Oficiul Regional OMS pentru Europa utilizand date de mortalitate pe cauze/varsta/sex si populatia la jumatatea anului pe varsta/sex, raportate anual de catre statele membre OMS. Trebuie remarcat ca ratele de mortalitate pentru unele tari pot fi distorsionate datorita subraportarii deceselor, mai ales in republicile din Asia centrala, tarile din Caucaz si unele tari din regiunea balcanica. Acoperirea geografica Datele referitoare la Romania din baza de date a OMS acopera numai nivelul national. Datele raportate de IGP acopera si nivelul judetean, dar nu ofera date stratificate dupa grupe de varsta. Acoperirea temporala 1989 – 2004 pentru datele OMS. 1999 – 2006 pentru datele IGP.
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Frecventa reactualizarii Anual pentru ambele surse de date. Calitatea datelor Calitatea datelor de mortalitate raportate de Romania este buna. Pot sa apara probleme de raportare atunci cand se analizeaza problema consecintelor nefatale ale traumatismelor rezultate din accidente. Bibliografie 1. European mortality database [online database]. Copenhagen, WHO Regional Office for Europe, 2007 (http://www.euro.who.int/InformationSources/Data/20011017_1, accesat 6 Aprilie 2007). 2. IGP – Politia Rutiera, (www.politiaromana.ro/DPR/Statistici/accidente_pe_an.jpg accesat 11 Octombrie 2007) 3. Global burden of disease database [online database]. Geneva, World Health Organization, 2002 (http://www3.who.int/whosis/mort/table1.cfm?path=whosis,mort,mort_tabl e1&language=english, accesat 6 Aprilie 2007). http://www.enhis.org/object_document/o4742n27385.html 4. 5. WHO statistical information system [online database]. Geneva, World Health Organization, 2007 (http://www.who.int/whosis/database/mort/table1_process.cfm, accesat 6 Aprilie 2007). 6. Transport, Health and Environment Pan-European Programme - The PEP. Transport-related health effects with a particular focus on children. Geneva, World Health Organization and United Nations Economic Commission for Europe, 2004 (http://www.euro.who.int/Document/trt/PEPSynthesis.pdf), accesat 6 Aprilie 2007). 7. Prüss-Üstün A, Corvalán C. Preventing disease through health environments: Towards an estimate of the environmental burden of disease. Geneva, World Health Organization, 2006 (http://www.who.int/quantifying_ehimpacts/publications/preventingdisease. pdf, accesat 6 Aprilie 2007). 8. WHO European Centre for Environment and Health. Policies to promote safe mobility and transport for children. Copenhagen, WHO Regional Office for Europe, 2007 (ENHIS-2 fact sheet No. 2.5 http://www.enhis.org/object_document/o4725n27385.html, accesat 6 Aprilie 2007). 9. Children’s Environment and Health Action Plan for Europe. Fourth Ministerial Conference on Environment and Health, Budapest, 23–25 June 2004 (http://www.euro.who.int/document/e83338.pdf, accesat 2 Martie 2007). 10. www.arr.ro/cisr/cisr_rom.ppt accesat 11 Octombrie 2007 accesat 11 Octombrie 2007 11. IGP – Politia Rutiera, (www.politiaromana.ro/DPR/Statistici/accidente_pe_judet.jpg accesat 11 Octombrie 2007) 12. Transport safety performance in the EU: A statistical overview. Brussels, European Transport Safety Council, 2003 (http://www.etsc.be/oldsite/statoverv.pdf, accessed 6 April 2007).
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Autori: Adriana Galan, Institutul de Sanatate Publica Bucuresti; Aurelia Marcu, Institutul de Sanatate Publica Bucuresti; Alexandra Cucu, UMF Carol Davila Bucuresti.
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National fact sheet Slovakia
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Národný Fact Sheet
Kvalita vôd na kúpanie v jednotlivých krajoch SR Indikátor Meno: Definícia: Kód:
Kvalita vôd na kúpanie v jednotlivých krajoch SR Podiel identifikovaných kúpacích oblastí vymedzených smernicou o vodách na kúpanie, ktoré spĺňajú povinné stanovené limity v zmysle Európskej komisie. RPG1_WatSan_S1
Úvod Výsledná správa zahŕňa dáta o kvalite vôd na kúpanie v jednotlivých krajoch v Slovenskej republike. Obsahuje aj environmentálny a zdravotný kontext, politickú relevanciu a vyhodnotenie situácie v rámci jednotlivých regiónov v Slovenskej republike. Zdôvodnenie V Slovenskej republike sme implementovali smernicu o vodách na kúpanie 76/160/EEC na národnej úrovni v roku 2004. Keďže údaje bolo možné získať na základe jednotnej metodiky aj za jednotlivé kraje Slovenskej republiky prostredníctvom regionálnych úradov verejného zdravotníctva, kvalitu vôd na kúpanie bolo možné zhodnotiť nielen na medzinárodnej ale i na národnej úrovni. Metodika hodnotenia kvality vôd na kúpanie v jednotlivých krajoch, ktorá bola použitá pri vypracovaní tohto fact sheetu bola v plnom rozsahu rovnaká ako to bolo pri hodnotení kvality vôd na kúpanie na medzinárodnej úrovni. Kľúčová správa
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Kvalita vôd na kúpanie v sledovanom období sa zlepšila takmer vo všetkých krajoch Slovenskej republiky. Ukazovatele kvality vody na kúpanie v prírodných lokalitách na Slovensku majú podľa národnej legislatívy prísnejšie limitné hodnoty ako sú odporúčané hodnoty európskej smernice o vodách na kúpanie. Nepriaznivá situácia v kvalite vôd na kúpanie hodnotená v roku 2004, kde boli vzorky vyhodnotené ako nevyhovujúce vzhľadom na ich nedostatočný počet, napr. z dôvodu rekonštrukcie lokality. Lokalita sa tak hodnotila z pohľadu európskej smernice ako nevyhovujúca, i keď vzorku nebolo možné v danej lokalite odobrať. Prezentácia údajov Graf 1 znázorňuje tendenciu kvality vôd na kúpanie v Slovenskej republike v období od roku 2004 do roku 2006. Graf 2 poukazuje na výsledky kvality vôd na kúpanie v jednotlivých krajoch Slovenskej republiky v roku 2005. Kvalita vôd je vyjadrená percentuálne z celkového počtu kúpacích oblastí, pričom počet kúpacích oblastí v Slovenskej republike bol v roku 2005 v počte tridsaťdeväť (kúpacie oblasti kontrolované v súlade so smernicou o vodách na kúpanie). Parametre kvality vôd na kúpanie vychádzajú zo smernice Európskej Únie o kvalite vôd na kúpanie 76/160/EEC.
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Oblasti s nedostatočným odberom vzoriek nespĺňali požadovanú frekvenciu vzorkovania v sledovanej oblasti. Záväzné požiadavky neboli dodržané v kúpacích oblastiach, kde sledované lokality nespĺňali povinné kritériá stanovené smernicou o vodách na kúpanie.
Graf. 1. Kvalita vôd na kúpanie v Slovenskej republike, 2004–2006
Zdroj: ÚVZ SR
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Graf. 2. Kvalita vôd na kúpanie v jednotlivých krajoch SR, 2005
Zdroj: ÚVZ SR
Graf 2 znázorňuje tendenciu kvality vôd na kúpanie v jednotlivých krajoch Slovenskej republiky v roku 2005. Hodnotenie kvality vody na kúpanie bolo v súlade so smernicou o vodách na kúpanie a v jednotlivých krajoch sa hodnotili len kúpacie oblasti, ktoré boli vyhlásené za vody vhodné na kúpanie. Vzhľadom na rozdielny počet kúpacích oblastí v jednotlivých krajoch sa percentuálne hodnotenie výrazne odlišovalo. Pokiaľ v Trenčianskom kraji je za vyhlásenú kúpaciu oblasť vyhlásená len 1 oblasť a v tejto oblasti nebol dostatočný odber vzoriek, celý Trenčiansky kraj bol tak vyhodnotený ako 100% vzoriek s nedostatočným odberom. V porovnaní s Banskobystrickým krajom, kde bolo vyhlásených v roku 2005 desať kúpacích oblastí, tvorilo percentuálne nedostatočné vzorkovanie 30% zo všetkých vzoriek, aj keď bol tento počet zistený pri vyššom počte kúpacích lokalít a to v počte 3. Z komplexného zhodnotenia kvality vôd na kúpanie v grafe 2 však podľa dodržanej metodiky WHO vyplýva, že najhoršia situácia v kvalite vôd na kúpanie v roku 2005 sa vyskytla v Nitrianskom kraji a najlepšia situácia bola v Žilinskom kraji. Zdravotný a environmentálny kontext Bezpečná voda na kúpanie je významným faktorom vo verejnom zdravotníctve. Nevyhovujúca kvalita vody na kúpanie môže byť príčinou vzniku epidémií spôsobených z vody vrátane mnohých turistov rovnako ako domáceho obyvateľstva (1). Veď napríklad v roku 2000 sme zaznamenali na Slovenku až 3 prípady vzniku epidémií, ktoré vypukli v dôsledku kontaminovanej vody, zatiaľ čo v roku 2005 sa už žiadny podobný prípad nevyskytol.
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V súčasnosti kvalitu vôd vhodných na kúpanie takmer vo všetkých lokalitách ohrozujú znečistené odpadové vody z priľahlých rekreačných objektov. Množstvo súkromných rekreačných chát nie je pripojených na verejnú kanalizáciu, majú nedostatočne izolované žumpy a septiky, alebo v blízkosti vodného zdroja používajú latríny. Čistiarne odpadových vôd niektorých obcí sú vyústené do tokov vlievajúcich sa do vodných nádrží, alebo sú dokonca vyústené priamo do vodnej nádrže. Zdrojom mikrobiologického znečistenia vôd vhodných na kúpanie často bývajú aj ich prítoky, ktoré pretekajú sídlami s nevybudovanou verejnou kanalizáciou, toky znečistené ropnými látkami z cestnej dopravy a odpadovými vodami z poľnohospodárskej výroby. Znečistenie tiež pochádza z neupravených skládok odpadu, zo splaškov pôdy z okolitých poľnohospodárskych pozemkov, z prebiehajúcich ťažobných prác na štrkoviskách a z divokej rekreácie bez zariadení na osobnú hygienu a pod. (7). V mnohých zdrojoch literatúry je uvedené, že kontakt s rekreačnou vodou je spojený s rôznymi ochoreniami, primárnymi gastrointestinálnymi symptómami a taktiež údaje o počte epidémií naznačujú, že je tu vyššie riziko závažnejších ochorení ako Shigella sonneri, Escherichia coli O157 infekcie, protozoálnych parazitov a enterických vírusov (2,3). Zhodnotením celkových príčin spôsobených nevyhovujúcou rekreačnou vodou sa odhaduje, že infekčné gastroenteritické ochorenia predstavujú až 66 000 DALYs "rokov života“ v zhoršenom prostredí (DALYs) (4). Rast populácie môže byť vyšším rizikom ochorení vrátane mladých ľudí a turistov ktorí nemajú vytvorenú imunitu na podmienky lokálne súvisiace s endemickými chorobami. Deti sa zvyčajne zdržiavajú dlhšiu dobu vo vode na kúpanie a tým sú viac ako dospelí vystavení riziku vzniku ochorenia alebo zranenia vo vode (5). Riziko vzniku ochorení vyplýva i z vysokej koncentrácie rekreantov na prírodných lokalitách najmä v letnom období.
Politická relevancia a kontext Vody vhodné na kúpanie sú definované v zákone č.364/2004 o vodách a o zmene zákona Slovenskej národnej rady č. 372/1990 Zb. o priestupkoch v znení neskorších predpisov (vodný zákon). Základné požiadavky na vodu na kúpanie a jej kvalitu ustanovuje §19 zákona č.355/2007 Z.z. o ochrane, podpore a rozvoji verejného zdravia a o zmene a doplnení niektorých zákonov. V procese príprav pre legislatívny schvaľovací proces je návrh nového aproximačného nariadenia vlády Slovenskej republiky pre problematiku prírodných kúpalísk. Pripravovaný návrh vychádza z nariadenie vlády Slovenskej republiky č. 252/2006 o podrobnostiach o prevádzke kúpalísk a podrobnostiach o požiadavkách na kvalitu vody kúpalísk, vody na kúpanie a jej kontrolu, ktoré bolo platné do 1.9.2007 ako vykonávací predpis k zákonu č. 126/2006 o verejnom zdravotníctve a o zmene a doplnení niektorých zákonov. Toto nariadenie i zákon boli v súlade so Smernicou Rady č. 76/160/EEC o kvalite vody určenej na kúpanie. 24. 3. 2006 vstúpila do platnosti nová európska smernica 2006/7/ES pre vody na kúpanie, ktorej vybrané ustanovenia sú členské štáty Európskej únie povinné transponovať do svojej legislatívy do 24. 3. 2008. Zákon č.355/2007 Z.z. o ochrane, podpore a rozvoji verejného zdravia a o zmene a doplnení niektorých zákonov a návrh nového aproximačného nariadenia sú v súlade so Smernicou Rady č. 76/160/EEC o kvalite vody určenej na kúpanie a plne zohľadňujú požiadavky na zapracovanie vybraných ustanovení novej smernice 2006/7/ES o riadení kvality vody určenej na kúpanie.
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Na Slovensku je okolo 70 prírodných lokalít, ktoré sú počas letnej turistickej sezóny (LTS) využívané na kúpanie. Ich počet sa každoročne mení v súvislosti s technickým stavom a pripravenosťou prírodných kúpalísk na sezónu. Tá sa spravidla začína 15. júna a končí 15. septembra. 38 lokalít bolo krajskými úradmi životného prostredia vyhlásené všeobecne záväznými vyhláškami za vody vhodné na kúpanie a sú sledované podľa kritérií európskej legislatívy (Smernica Rady 76/160/EEC) (7). Kvalitu vody na kúpanie na Slovensku monitoruje Úrad verejného zdravotníctva Slovenskej republiky (ÚVZ SR) a 36 regionálnych úradov verejného zdravotníctva (RÚVZ). Sleduje sa 30 ukazovateľov kvality vody na kúpanie. Kvalita vody na kúpaliskách sa začína kontrolovať približne 2 týždne pre začiatkom LTS (letnej turistickej sezóny) a v priebehu sezóny v dvojtýždňových intervaloch. Na lokalitách s neorganizovanou rekreáciou, ktoré tradične využíva na kúpanie malý počet ľudí sa vykonávajú len orientačné kontroly kvality vody na kúpanie na začiatku sezóny a pokiaľ to situácia vyžaduje, tak i v priebehu sezóny. Na základe výsledkov monitoringu Slovenská republika od roku 2004 vypracováva Správu Slovenskej republiky o kvalite vody na kúpanie, ktorú Európskej komisii predkladá SAŽP. Monitorovanie okrem toho, že zásadným spôsobom ovplyvňuje získavanie primárnych informácií, prináša aj podklady pre prípravu legislatívy a riešenie konkrétnych situácií v praxi. Vyhodnotenie Od roku 2004 do roku 2006 sa situácia v oblasti kvality vôd na kúpanie v Slovenskej republike zlepšila, aj keď počet jednotlivých kúpacích oblastí, v ktorých sa robil monitoring na základe smernice o vodách na kúpanie sa znížil (Graf 1). Kým v roku 2004 bolo hodnotených až 67 kúpacích oblastí, v roku 2006 to bolo 38 oficiálne vyhlásených kúpacích oblastí. V percentuálnom porovnaní nedodržaných povinných štandardov v kvalite vôd na kúpanie sa situácia zlepšila, kým v roku 2004 nezodpovedalo povinným kritériám až 31,3 % kúpacích oblastí, v roku 2006 to bolo už len 5% kúpacích oblastí. Čo sa týka nedostatočného vzorkovania, v roku 2004 bolo celkovo 16% kúpacích oblastí, kde nebol odobratý dostatočný počet vzoriek, zatiaľ čo v roku 2006 boli už všetky kúpacie oblasti sledované podľa frekvencie stanovenej v smernici o vodách na kúpanie. Podkladové údaje pre indikátor Zdroj údajov Úrad verejného zdravotníctva SR (6). Regionálne úrady verejného zdravotníctva SR Popis údajov Dáta o kvalite vôd na kúpanie sú dostupné v správach pre Európsku komisiu za roky 2004, 2005, 2006. Dáta zahŕňajú: Rok; názov jednotlivých krajov SR a kód krajov z územného hľadiska rozpracovaný na NUTS 3; celkový počet kúpacích oblastí; C(G):percento kúpacích oblastí, ktoré boli s súlade s záväznými (povinnými) hodnotami; C(I): percento kúpacích oblastí, ktoré boli v súlade s odporúčanými (smernými) hodnotami; NB: percento kúpacích oblastí, kde bolo kúpanie zakázané; NC: percento kúpacích
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oblastí , ktoré nevyhoveli stanoveným kritériám; NF: percento kúpacích oblastí s nedostatočným vzorkovaním.
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Metodika výpočtu indikátora Indikátor môže byť vyčíslený ako RWC = 100 × (C/T), kde C je počet kúpacích oblastí spĺňajúcich povinné koliformné štandardy a T je celkový počet vôd na kúpanie v súlade s dodržaným monitoringom. Geografické pokrytie Bratislavský kraj, Trnavský kraj, Trenčiansky kraj, Žilinský kraj, Bansko-Bystrický kraj, Nitriansky kraj, Prešovský kraj a Košický kraj. Pokryté časové obdobie 2004–2006. Frekvencia aktualizácie Výročné správy za Slovenskú republiku. Odber vzoriek a samotné vyhodnotenie je v súlade so smernicou EÚ 76/160/EEC. Kvalita údajov Presné informácie o kvalite vôd na kúpanie v odobratých vzorkách v rámci krajov poskytujú regionálne úrady verejného zdravotníctva SR Úradu verejného zdravotníctva SR každoročne počas letnej kúpacej sezóny. Referencie 15.
16. 17.
18.
19.
20. 21.
Nichols G. Infekčné riziká z prírodných vôd a umelo vytvoreného prostredia. Eurosurveillance,2006,11(4):76–78 (http://www.eurosurveillance.org/em/v11n04/1104-221.asp, prístupné 20 marec 2007). Pruss A. Preskúmanie epidemiologických štúdií o zdravotných účinkoch z expozície rekreačnou vodou. Medzinárodný epidemiologický časopis, 1998, 27:1–9. Pond K. Rekreácia pri vode a ochorenia. Prijateľnosť pridružených ochorení s: akútne účinky, následné choroby a mortalita. Londýn, IWA Publishing, 2005 (http://www.who.int/water_sanitation_health/bathing/recreadis.pdf, prístupné 12 september 2007). Shuval H. vyhodnotenie globálneho výskytu talasogenických ochorení: infekčné ochorenia ľudí zapríčinené znečistením oidpadových vôd v morskom prostredí. Časopis o vode a zdraví, 2003, 01(2):53-64. (http://www.iwaponline.com/jwh/001/0053/0010053.pdf prístupné 26 marec 2007). odporúčania pre bezpečné prostredie rekreačných vôd. Ženeva, Svetová zdravotnícka organizácia, 2003 (http://www.who.int/water_sanitation_health/bathing/srwe1/en/ , prístupné 20 marec 2007). Európska komisia Kvalita vôd určených na kúpanie máj 2006 Kúpacia sezóna 2005, Súhrnná správa s.12-14 ISBN 92-79-01349-1 Renáta Grófová, Elena Matisová 2006 Kvalita vôd vhodných na kúpanie s slovenskom a európskom kontexte Enviromagazín 1/2006 s.17-18
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Ďalšie informácie Zákon č. 355/2007 o ochrane, podpore a rozvoji verejného zdravia a o zmene a doplnení niektorých zákonov http://www.zbierka.sk/zz/predpisy/default.aspx?PredpisID=207606&FileName=zz 07-00355-0207606&Rocnik=2007 Zákon o vodách č.364/2004 a o zmene zákona Slovenskej národnej rady č. 372/1990 Z.z. http://www.zbierka.sk/zz/predpisy/default.aspx?PredpisID=18006&FileName=04z364&Rocnik=2004 Smernica o vode na kúpanie č. 76/160/EEC Autor: Gabriela Slováková, Úrad verejného zdravotníctva SR
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ENHIS 2
WORK PACKAGE 7 (WP7) RESULTS
REPORT ON THE HIA OF INDOOR AIR QUALITY: RESULTS AND ASSESSMENT OF METHODS FEASIBILITY
(Deliverable 7.2) REPORT ON THE HIA OF NOISE: RESULTS AND ASSESSMENT OF METHODS FEASIBILITY (Deliverable
7.4)
REPORT ON THE HIA OF DRINKING WATER POLLUTION
(Deliverable 7.5)
WP7 Health Impact Assessment Deliverable 7.2
Report on the HIA of indoor air quality: results and assessment of methods feasibility
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This document has been developed by a project co-financed by the European Commission - DG Sanco (Grant Agreement SPC 2004124), coordinated by the WHO Regional Office for Europe and involving partner institutions from 18 European countries. The views expressed here do not necessarily reflect the official opinion of the European Commission or of the World Health Organization.
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List of Authors
WP7 Lead Partner Sylvia Medina French Institute for Public Health Surveillance (InVS) St. Maurice - France
Contributing authors Vladimira Puklova Jana Kratenova State Health Institute (SZU) Prague - Czech Republic Phillipe Pirard French Institute for Public Health Surveillance (InVS) St. Maurice - France
Reviewers Ulla Haverinen National Public Health Institute Kuopio - Finland Elena Boldo Alejandro Ramirez Institute of Health Carlos III Foundation for International Cooperation and Health (ISCIII) Madrid - Spain Odile Mekel Sarah Sierig Institute of Public Health North Rhine-Westphalia (LOEGD) Bielefeld - Germany Natalia Valero Manuel Gonzalez-Cabré Public Health Agency (ASPB) Barcelona - Spain Alain Le Tertre Olivier Catelinois Sylvia Medina French Institute for Public Health Surveillance (InVS) St. Maurice – France
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Hajo Zeeb Institute for Medical Biostatistics, Epidemiology and Informatics (IMBEI) Mainz - Germany
Table of Contents FEASIBILITY OF HIA ON THE HEALTH EFFECTS OF EXPOSURE TO DAMPNESS AND MOULDS AT HOME – CHILDREN AS TARGET POPULATION .......................... 225 IS IT POSSIBLE TO CONDUCT A HEALTH IMPACT ASSESSMENT OF CHILDREN EXPOSED TO INDOOR RADON (AT SCHOOL AND AT HOME) FOR EUROPEAN COUNTRIES? ......................................................................................................... 236
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Feasibility of HIA on the health effects of exposure to dampness and moulds at home – children as target population Authors: Vladimira Puklova, Jana Kratenova (SZU) Reviewers: Ulla Haverinen (KTL), Elena Boldo (ISCIII), Odile Mekel (LOEGD), Sarah Sierig (LOEGD), Alejandro Ramirez (ISCIII), Natalia Valero (ASPB), Manuel Gonzalez-Cabré (ASPB), Alain Le Tertre (InVS) and Sylvia Medina (InVS)
Abstract There is sufficient evidence that excessive dampness/moulds at homes is an important risk factor namely for respiratory illness. For dampness itself, the WHO has concluded that the strongest evidence exists for the association with cough, wheeze and asthma. A limited information exists on households suffering from dampness problems in European countries, and for HIA purposes this information is unsuitable. Therefore, it was not feasible to conduct HIA on damp induced health effects on children at the European scale. Moreover, data on health effects has not been an object of reporting in the inter-country comparable form. Until employing a standard methodology for exposure assessment across the European Region, making between-country comparisons based on Eurostat data or specific survey data is problematic. On a case study from the Czech Republic we tested an approach of using data from a large cross-sectional survey (2001) focused on the health outcomes resulting from inadequate housing, providing both exposure and health data needed for HIA. The estimated share of diagnosed asthma cases consequent to the exposure of children to damp/moulds at homes amounted to 4%, the share of wheeze and dry nocturnal cough was 7% and 3%, respectively. Extrapolating these figures to the Czech child population in the relevant age group, about 3100 asthma cases could be attributable to dampness/moulds occurrence at homes in the Czech Republic. The attributable number of children with wheeze would be 4500 and the number of children suffering from night cough 570. The results may serve as directory information for the national policy makers who wish to estimate the relevance of the damp household problems and the need for housing stock reconditioning.
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1. Introduction The objective of one of the ENHIS2 project work packages (WP7) was to examine the feasibility of quantification the health effects in consequence of the children’s exposure to damp/moulds at home in European countries. Dampness and thermal/humidity conditions are of particular concern in European countries with temperate and damp climates. Dampness inside the home induces the growth of moulds, dust mites and various microbial agents and, at the proper temperature, it may cause the release of chemicals from building materials and furnishings. Dampness and moulds are important risk factors for a variety of illnesses, particularly those of the respiratory and immune systems. Damp can cause asthma aggravation and asthma development. For people that are sensitive to moulds, symptoms such as nasal irritation or congestion, dry or productive cough, wheezing, skin rashes or burning, watery or reddened eyes may occur. Sufferers of severe allergies to moulds may have more serious reactions, such as hay-feverlike symptoms or shortness of breath. For dampness itself, the WHO has concluded that the strongest evidence exists for the association with cough, wheeze and asthma.(1) Children, who tend to spend more time than adults in their homes, and whose immune systems are still developing, are at increased risk of developing respiratory disorders when living in damp, mouldy housing. The odds ratio of having respiratory diseases/disorders among children living in homes with damp/mould problems is 1.4 – 2.2 times higher than among children living in adequate housing conditions.(1,2) Roughly estimated, 13% of childhood asthma may be attributable to dampness in Europe.(3) For additional information about the issue see the fact sheets RPG3_Air_E1 “Prevalence of asthma and allergies in children” and RPG3_Hous_Ex2 “Children living in homes with problems of damp” http://www.euro.who.int/EHindicators/Publications/20070604_1 and the WHO web pages Housing and Health http://www.euro.who.int/Housing.
2. Policy background In 2004, the 4th Ministerial Conference on Environment and Health adopted the Children’s Health and Environment Action Plan for Europe (CEHAPE), which includes four regional priority goals to reduce the burden of environment-related diseases in children. One of the goals aims at preventing and reducing respiratory diseases due to outdoor and indoor air pollution and thus contributing e.g. to a reduction of the asthmatic attacks frequency. In the European countries, the problems with damp housing have been addressed partly by Technical Building Codes, which are usually relevant only for new buildings. Dampness issues may also be partly addressed by hygienic requirements aiming to ensure non-hazardous conditions, but currently they do not often deal with the dampness issues. The responsibility to avoid or reduce damp is largely left to the individual or household.(4) There were derived several basic findings in the frame of the Housing and Health programme of the WHO (http://www.euro.who.int/Housing), and the project Housing and Health Regulations in Europe, respectively: each country has its own priorities and its own specificities for developing its regulatory framework for housing and the degree to which the regulations are December 2007
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compulsory is very different from country to country. Health requirements are often not clearly stated. 3. Availability of HIA component parts 3.1 Exposure-response functions The central estimates of exposure response functions (ORs) resulting from a meta-analysis conducted by Fisk et. al. (8) for several respiratory and asthma-related health outcomes and presence of dampness or moulds at homes are as follows: ORs ranged from 1.34 to 1.75 for total population, with a slightly higher values for children (wheeze OR 1.53, cough OR 1.75) than those for adults (wheeze OR 1.39, cough OR 1.52). For diagnosed asthma, no study dealing with children was included into this meta-analysis. The conclusions of the ‘Report on the WHO technical meeting on quantifying disease from inadequate housing’,(1) Bonn Nov 2005 were that “perhaps the strongest evidence exists on the association of dampness with cough, wheeze and on asthma; there is evidence on both onset of new asthma cases and increased asthma symptoms on previously sensitized individuals.” According to the recommendation of this document, the suggested most reliable and evidence-based health outcomes are cough, wheeze and asthma and the suggested OR interval lags between 1.4 and 2.2, based on literature review. (2) In the Second technical meeting on quantifying diseases from inadequate housing, Nov 2006 in Bonn,(3) the OR 2 was suggested for the purpose of estimating the burden of disease (asthma) from dampness at homes in European children. The suggested OR is based on three essential references to casecontrol and cohort studies, respectively.(5,6,7) The specific ORs derived from the cross-sectional case study fits well the interval cited above and was used for the population attributable risk and the number of attributable cases calculations.
3.2 Exposure data Data on number of children exposed to dampness/moulds at homes is not object of routine reporting. In the European scale, only very rough estimates could be drawn from the number of households with dampness problems from the Eurostat database. Data on exposure to damp in the home was routinely collected through Eurostat by the European Community Household Panel (ECHP) until 2001 (voluntary participation by EU countries).(9) The ECHP was a ‘longitudinal‘ survey that involved annual interviews with participant households (around 80 000 across the EU). The ECHP was replaced in 2003 by data collection under Statistics on Income and Living Conditions (SILC) regulations, which is mandatory for all EU countries and will provide data in a similar format (percentage of population living in damp housing). According to the statement in the Eurostat Yearbook 2006-07, during the transition period to full country coverage under EUSILC, no information is being compiled by Eurostat. Nevertheless, the data from such reporting are, according to some experts, considered not scientifically accurate for inter – country comparison for many reasons, for example, the data relies on subjective resident’s evaluation. Self-reported exposure data are rather considered to December 2007
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provide an indication of national trends in the scope of the problem for national policy makers. In case of using specific surveys as a data source for HIA, the limitation, in addition to subjective resident’s evaluation (which is used for exposure assessment in most studies), lies also in non-uniformity of data due to variable study designs and exposure definitions, and therefore results in non-comparable outputs. The ascertained prevalence of dampness therefore reflects the subjective view of the resident as well as the exposure definition used dampness/damp spots/moisture/moulds/odour of moulds/condensation on the windows/damp floor, leakage, rot etc. There are also various targeted places with damp/moulds presence in question in the studies – the total household, only living areas, living room and child-room, only child-room etc. The source of data for HIA could be large international surveys on housing quality and exposure to damp, resp., such as the LARES project (Large Analysis and Review of European Housing and Health Status) (10) or ECRHS - European Community Respiratory Health Survey, involving also home inspections in the frame of the health risks determination. (11) These studies involve both the exposure data and respiratory diseases/symptoms prevalence data as well, gained by the unified methodology. Nevertheless, ECHRS study deals with the adult population exposure. The data from LARES study has been analyzed by a group of experts so far, the results were not available for our case study. On the national level, there exists data from particular surveys on population exposure to inadequate housing, including damp e.g. in Finland (study on prevalence of moisture problems in Finnish houses in 5 cities), (12) Czech Republic (moisture/damp in homes, 5 cities), (13) and Germany (5,530 randomly selected apartments and houses) (14). There are number of surveys conducted, which are targeted on children’s exposure to damp/moulds at homes. Such study is e.g. The German Environmental Survey (GerES IV – 1,800 children – moulds occurrence in homes). (15) The studies dealing with children are mostly focused not only on exposure assessment, but also on the research of association between exposure and health. Therefore, they involve data on the health effects prevalence and the derived exposureresponse function as well. In principle, such studies could be suitable for HIA purposes in case of large ones representative for a defined country (region/city) and population group, e.g. DBH study in Sweden (a cross-sectional questionnaire investigation involving 10 851 children 1-6 years of age in Vaermland county), (16) or SIDRIA2 study in Italy.(17) Noncomparability of the inter-study results due to differences in study design have to be emphasized.
3.3 Health outcomes data Data on incidence of the relevant health outcomes in children (asthma, chronic or night cough, wheezing etc.) in a defined area (country, region, city) could be available from national statistics on followed up patients for selected allergic diseases. The disadvantage of this source is in low accessibility in English language. Furthermore, such data are not considered to reflect the real situation; their using is limited due to different sources of reporting (paediatricians, allergologists, and hospitals) and inadequacies in diagnostics. December 2007
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More realistic data source could be studies on respiratory diseases/symptoms prevalence like the internationally standardized questionnaire survey International Study of Asthma and Allergies in Childhood (ISAAC). The data available for a set of “ISAAC countries” stem from the periods 1993-96 and 1999 - 2004, for the age groups 6-7 and 13-14 years. (18, 19) Out of ISAAC group of countries (centres), also other studies have been conducted with aid of ISAAC methodology in some countries (e.g.(20), (21)). Such surveys investigate not only respiratory disease/symptoms but also risk factors including those of inadequate housing - damp/moulds at home, or direct associations between respiratory health and damp/moulds exposure. These surveys could serve as HIA data source for a defined child population in case of representative sample for defined area/s (region/city). In principle, these are the cross-sectional studies investigating the prevalence of respiratory diseases/symptoms in association with the indoor characteristics. Example of such studies could be regularly repeated survey on asthma and allergies prevalence among children in 18 cities in the Czech Republic (22, 23), or the SIDRIA2 study on respiratory symptoms/diseases prevalence (together with exposure data), involving 20 016 children (mean age 7 years) and 13,266 adolescents (mean age 13 years) conducted in Italy, or the study from Vaermland county, Sweden, both cited already in chapter 3.2.
4. Feasibility of performing HIA An approach of combining the international database (exposure) data and international/national survey (health) data, was rejected due to limitations in inter-country comparisons both for exposure and health data. We tested an approach of using data from a large cross-sectional survey (focused on the health problems resulting from inadequate housing), which covers spatially representative child population. Such study provides both exposure and health data needed for HIA purposes. Nevertheless, thereby the limitation of subjective resident’s view was not avoided, Also the selection of the exposure-response function was considered problematic: whether a specific function derived from the cross-sectional study, or a function derived from the casecontrol study. An optimal approach would be using an exposure-response function from a case-control study with similar design and level of control of confounding factors used in the cross-sectional survey in question. As a case study of such approach we applied a Czech prevalence survey on asthma and allergies in children. As the health effect of exposure to damp/moulds the diagnosed asthma by collaborating paediatricians was chosen. The paediatricians have been regularly trained for proper and unified asthma diagnostics. However, the results are not comparable with those obtainable from other similar studies from the reasons described in the chapter 3.2.
5. HIA method
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The case study was compiled based on the national survey on the child population (5 – 17 years of age) conducted in 2001 and repeated in 2006 in 18 cities in the Czech Republic (N=7,769 and N= 7,075, respectively) on prevalence of asthma and allergies in relation to the living conditions and lifestyle. The survey is a component part of the Czech Environmental Health Monitoring System (http://www.szu.cz/chzp/rep06/szu_07cz.htm). Eighteen cities varying in size and in outdoor air quality (with 15 000 to 385 000 population + Prague, 1.2 mil) were selected to obtain representative data on the prevalence of allergic diseases in children. The size of population sample was determined based on estimated prevalence of allergic diseases in CZ and a number of children in particular age groups in the cities. According to this number, the relevant amount of paediatricians was identified in each city. The whole clientele of the doctor was always examined; it was assumed that the clientele by a paediatrician was nowise selective. The data were obtained from medical records of 54 and 61, respectively, paediatricians and questionnaires filled by parents during the obligatory preventive check-ups. Parent’s reported presence of damp signs and moulds in the household served as an indicator of exposure. The wording of the question was following: Damp spots or moulds in the household: a) recently (yes, no) , b) in the first two years of the child’s life (yes, no). The doctor–diagnosed asthma cases based on the paediatricians reports was chosen as a health effect. The exposure-response relations processed by logistic regression and expressed by odds ratio (OR) between the population exposed to a factor and that non-exposed were adjusted for confounding factors that could influence the disease/symptoms prevalence. These were age, gender, family history, smoking in dwelling, pet presence and city. The tests of statistical significance were performed at the 0.05 significance level. The population attributable risk (PAR) was computed, which measures the possible reduction in disease prevalence in the target population when the reputed risk factor is removed: PAR=100*Pe(OR-1)/Pe(OR-1)+1, where Pe = proportion of population exposed, OR = odds ratio between the population exposed and unexposed. The number of cases of the asthma cases attributable to exposure to damp/moulds at home was estimated according to the computation followed: A=N*Ip*PAR, where N = number of children in the relevant age group, Ip = prevalence rate of the health effect, PAR = population attributable risk. The population attributable risk (PAR) and the number of attributable cases of the selected health effect was calculated, using the specific exposure-response function (OR) derived from the cross-sectional study, which fits well the OR range 1.4 – 2.2 according to the recommendation of the „Report on the WHO technical meeting on quantifying disease from inadequate housing“, 2005 (1), based on literature review.(2) As a supplementary information, the range of number of attributable health effect cases was calculated using this exposureeffect function interval. December 2007
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6. Results of the case study In 2001, doctor-diagnosed asthma was recorded in 5.1 % of children. In 2006, there occurred a marked increase in prevalence of asthma: it was diagnosed in 8.3% of children. In both studies, boys suffered from asthma more frequently than girls. Current exposure to damp/moulds at home was reported in 7.6% of cases in 2001. In 2006, the rate of exposed children to damp/moulds had not changed significantly, and it was 7.3%. According to the estimate, about 4% of asthma cases in children could be a consequence of the reported exposure to damp/moulds at home. Extrapolating these figures to the whole Czech child population in the relevant age group, about 3,080 (range, 660 to 6,290) asthma cases could be attributable to reported dampness/moulds at homes in the Czech Republic, which means about 220 (range, 50 to 440) cases per 100,000 children in this age group (see Tab. 6.1). Like in other similar studies (e.g. (17), (24)), there was also found early exposure in the first years of child’s life to be highly important for later asthma development. Based on findings from the first study period, by avoiding this early exposure it would later abate almost 10% of asthma cases in children, which represents 500 (range, 280 – 770) cases per 100,000 children. Tab. 6.1 Estimated population attributable risk (PAR) and estimated number of asthma cases attributable to reported damp/moulds exposure at home in the Czech child population (5 – 17 years of age), ORs derived from the survey (2001) Prevalence Prevalence rate of asthma in the sample rate of exposure % of children % Recent exposure Exposure in first two years of life
Adjusted OR (95% CI)
PAR %
Number of attributable cases+
Number of attributable cases per 100,000 children
7.6
5.1 (7.8*)
1.58 (1.12 – 2.24)
4.2
3,080 (660 – 6,290)
220 (50 - 440)
9.9
5.1 (9.5*)
2.10 (1.58 – 2.80)
9.8
7,170 (3960 – 11,040)
500 (280 – 770)
*- asthma prevalence in the group of exposed children + - based on OR central estimates and 95% CI intervals Tab. 6.2 Estimated number of asthma cases in children attributable to reported damp/moulds exposure in both study periods, used OR interval 1.40 – 2.20
PAR %
Number of attributable cases
Number of attributable cases per 100,000 children
I. study period 2001
3.0 – 8.4
2,150 – 6,100
150 - 430
II. study period 2006
2.8 – 8.1
3,320 – 9,440
240 - 670
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The results of the repeated study in 2006 confirmed this findings on early exposure. Nevertheless an association between exposure and asthma was found inferior, which was possibly influenced by an increase of asthma prevalence rate in the group of non-exposed children in 2006. As additional information and to enable assessing the time trend for both study periods, the number of asthma cases attributable to exposure to dampness/moulds was also calculated using the exposure-effect function interval based on the literature review on the relevant studies OR 1.4 – 2.2,(2). The attributable risks (PARs) are essentially similar for both study periods due to similar reported exposure prevalence but the number of attributable cases increased in the second study period compared to the first period as the total asthma prevalence increased in 2006 (see Tab. 6.2).
7. Discussion A limitation of the HIA calculation based on self-reported exposure data is significant, as a subjective element and many influencing factors play a role. The results of HIA performed in the case study could serve as general information for the national policy makers on the relevance of the dampness problems in homes, and on the seriousness of the demands on the housing stock reconditioning. The results cannot be compared within those obtainable from other similar cross-sectional studies due to the non-uniform study designs and methodologies used. The LARES study represents a possible source for inter-city comparable data. It involves eight European cities, in which independent house inspections have been applied within exposure assessment. The data is still under analysis by a group of experts and will be available soon. With respect to health data, criteria for asthma diagnosis and methodology of surveys are crucial points for the results. Officially reported asthma prevalence in national statistics (records from practitioners and /or allergologists, or hospital admissions data) differs from survey figures based on parent’s questionnaire and from self-reported data by school-children. The official data on asthma prevalence are also suited to be underestimated.(19) Therefore, doctor-diagnosed asthma from the cooperating regularly in diagnostics trained paediatricians to utmost ensure the representative outputs were used. Questionable is also the choice of the optimal exposure-response function– specific one from the cross-sectional study itself, or a function derived from other study optimal from the view of exposure-response function investigation, i.e. case control or cohort study. In the presented case study, both the derived respective odds ratios and the range of ORs from the literature review were used for calculations. It should be kept in mind that the exposure and health data stem from a cross-sectional study and therefore cannot imply the causal relationships among the presented risk factor (exposure to damp/moulds) and health effect precisely. Moreover, it is apparent that the strenght of association between exposure and effects differed even in the equally conducted studies from different time periods, which could be more likely caused by the character of the particular cross-sectional study data than by changing importance of the followed-up risk factor. As a supplementary information, the range of number of attributable health effect cases was calculated, using the exposure-effect function interval based on studies published OR 1.4 – 2.2, supported by the Report from WHO Technical meeting, 2005.(1) It should be kept in mind that the most proper would be using an exposure-response function December 2007
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from the case-control study that would have used similar design as the Czech study, i.e. doctor diagnosed asthma, parent reporting exposure (although exposure data obtained from independent home inspections would be more reliable), and the same level of control of confounding factors. Another limitation can be seen in targeting the urban child population; the occurrence of damp/mould problems and respiratory diseases/symptoms could be somehow different in the countryside. Last, not least, the association between reported damp/moulds exposure and health is still under debate. According to some experts there is consistent evidence showing that dampness exacerbates pre-existing respiratory conditions such as asthma, but it is not clear whether it also causes this disease. Mould exposure has been suggested to play a role, but current knowledge about indoor mould exposure and asthma may still be considered limited.(25)
9. Recommendations It is likely that domestic exposure to damp is an underestimated problem. The lack of policies on the housing standard combined with the large number of organisations and authorities responsible for housing policy make housing stock reconditioning a challenge. For non-EU countries, standardized procedures to collect data on inadequate housing are required.(4) The exposure data should be available from 2006 based on the Statistics on Income and Living Conditions (SILC) which is mandatory for all EU countries and will provide data on percentage of people living in households with damp problems. It is intended to be reliable and comprehensive exposure data for good indication of national trends. Without applying a standard methodology for exposure assessment across the European Region, making betweencountry comparisons is problematic as well as performing HIA. Household interview surveys (HIS) can be used to produce estimates of the number of dwellings/people affected by damp/moulds, e.g. by refining the dampness evaluation module or by combining the HIS survey with the LARES inspections methodology. (4) In order to quantify the health related effects, additional information should be collected from national surveys based on standardised methodology.(4) Acknowledgment: The authors highly appreciate the effort of Mrs. Ulla Haverinen-Shaughnessy (KTL Finland) in kindly providing the support by continuous expert advice regarding the objective issue and in help with valuable editorial remarks to the final formulation of the feasibility study outputs. Further information: www.ENHIS.org (Summary information sheet and HIA Guidelines on dampness) References 1. Report on the WHO technical meeting on quantifying disease from inadequate housing, Bonn, Nov 2005. http://www.euro.who.int/Housing/20060519_2
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2. Bornehag CG, Blomquist G, Gyntelberg F, Järvholm B, Malmberg P, Nordvall L, Nielsen A, Pershagen G, Sundell J. Dampness in buildings and health. Nordic interdisciplinary review on the scientific evidence on associations between exposure to “dampness” in buildings and health effects (NORDDAMP). Indoor Air 2001;11: pp 72-86 3. WHO second technical meeting on quantifying disease from inadequate housing, Bonn, November 2006. 4. ENHIS2 Fact Sheet 3.5. RPG3_Hous_Ex1: Children living in homes with problems of damp, WHO Bonn, 2007, http://www.euro.who.int/Document/EHI/ENHIS_Factsheet_3_5.pdf 5. Williamson IJ, Martin CJ, McGill G, Monie RDH, Fennerty AG. Damp housing and asthma: a casecontrol study. Thorax 1997;52:229-234 6. Wickman M, Melen E, Berglind N, Lennart Nordvall S, Almqvist C, Kull I, Svartengren M, Pershagen G. Strategies for preventing wheezing and asthma in small children. Allergy 2003;58:742-747 7. Pekkanen J, Hyvärinen A, Haverinen-Shaughnessy U, Korppi M, Putus T, Nevalainen A. Moisture damage and childhood asthma – a population-based incident case-control study. Eur Resp J 2007, 29: 509-515. 8. Fisk W.J., Lei-Gomez Q., Mendell M.J.: Meta-analyses of the associations of respiratory health effects with dampness and mold in homes, Indoor Air 2007, 17; pp 284 – 296. 9. http://epp.eurostat.cec.eu.int/portal/page?_pageid=1090,30070682,1090_30298591&_dad=portal&_sc hema=PORTAL (under “Living conditions and welfare”) 10. WHO/Europe - Housing and health - Housing and health survey, The LARES project (Large Analysis and Review of European housing and health Status). Preliminary overview of LARES findings. www.euro.who.int/Housing/activities/20020711_1 11. European Community Respiratory Health Survey, http://www.ecrhs.org/ 12. Nevalainen A. et al. – Prevalence of moisture problems in Finnish houses. Indoor air 4 (Suppl) 45 – 49 13. Environmental Health Monitoring System in the Czech Republic, Summary Report 2003, http://www.szu.cz/chzp/rep04/html_an/ka05_04.htm 14. Brasche Sabine; Bischof Wolfgang : Daily time spent indoors in German homes-baseline data for the assessment of indoor exposure of German occupants. Friedrich-Schiller-University Jena, Institute of Occupational, Social and Environmental Medicine, Department of Indoor Climatology, Jena, Germany. International journal of hygiene and environmental health 2005, 208; (4); p247-53. 15. http://www.umweltbundesamt.de/survey-e/us03/uprog.htm 16. Bornehag C G; Sundell J; Hagerhed-Engman L; Sigsggard T; Janson S; Aberg: 'Dampness' at home and its association with airway, nose, and skin symptoms among 10,851 preschool children in Sweden: a cross-sectional study. Indoor air 2005, 15 Suppl 10, 48-55. 17. Simoni M. et al,: Mould/dampness exposure at home is associated with respiratory disorders in Italian children and adolescents: the SIDRIA-2 Study. Occupational and Environmental Medicine, 62, 2005, pp. 616-622. 18. The International Study of Asthma and Allergies in childhood (ISAAC), I. phase (1992/1998) and the III. phase (1999/2004), http://isaac.auckland.ac.nz/Index.html 19. Asher MI et al. Worldwide time trends in the prevalence of symptoms of asthma, allergic rhinoconjunctivitis, and eczema in childhood: ISAAC Phase One and Three repeat multicountry crosssectional surveys. Lancet, 2006, 368:733–743. 20. Stipic-Markovic Asja; Pevec Branko; Radulovic Pevec Mira; Custovic Adnan; Predovic Jurica : Allergic diseases in relationship with environmental factors in a population of school children in Zagreb, Croatia.Department of Clinical Immunology, Pulmology, and Rheumatology, University Hospital Sueti Duh Zagreb, Croatia. Arhiv za higijenu rada i toksikologiju Croatia 2004, 55; (2-3); p221-8. 21. Pohunek P., Slámová A.: Prevalence of bronchial asthma and other allergic symptoms in school children in the Czech Republic (In Czech, with English Summary) http://www.tigis.cz/alergie/ALERG199/09Pohoun.htm 22. Environmental Health Monitoring System in the Czech Republic, Summary Report 2001, NIPH Prague 2002, http://www.szu.cz/chzp/rep01/szu_02an/ka02_04.htm
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23. Environmental Health Monitoring System in the Czech Republic, Summary Report 2006, NIPH Prague 2007, In Press. 24. Fosberg B., Pekanen J. et al.: Childhood asthma in four regions in Scandinavia, risk factors and avoidance effects. International Journal of epidemiology, 26, 1997, pp. 610 – 619. 25. Douwes J., Pearce N.: Is Indoor Mold Exposure a Risk Factor for Asthma? American Journal of Epidemiology, 2003, 158, no 3, pp 203-206.
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Is it possible to conduct a Health Impact Assessment of children exposed to indoor radon (at school and at home) for European countries?
Author: Philippe PIRARD, InVS Reviewers: Hajo Zeeb (IMBEI), Olivier Catelinois (InVS), Alejandro Ramirez (ISCIII), Elena Boldo (ISCIII), Sylvia Medina (InVS)
1. Study question in general terms Radon-222 the radioactive gas present in soils and rocks throughout the world arises naturally from the decay of uranium-238, which is present throughout the earth’s crust. It has a half life of four days, allowing it to diffuse through soil and into the air before decaying by emission of an alpha particle into a series of short lived radioactive progeny. Two of these, polonium218 and polonium-214, also decay by emitting alpha-particles (Darby 2005). This gas makes non impression on our senses. Radon concentration in air is measured as the number of transformations per second in a cubic metre of air (Bq.m-3). One Becquerel corresponds to the transformation (disintegration) of one atomic nucleus per second. Concentrations are low outdoors but can build up indoors, were we spend 90% of our lives. They can be very variable from one house to a close other one. Levels go from a few Bq.m-3 to thousands of Bq.m-3. In Europe the mean dwelling radon levels are very variable from one country to the other. They are above the world mean of 40 Bq.m-3 (Fig. 1) in most of them. Only countries with mainly sedimentary soils present lower or equivalent means (e.g. Netherlands, UK, Germany, and Poland). Countries with old granite soils are more prone to radon (e.g. France, Finland, Czech Rep., Austria) (WHO ENHIS factsheet 2007). There is very few information on radon levels in schools in Europe and it’s not yet possible to know if they are higher or lower than in dwellings. In many countries exposure at home to short lived radioactive disintegration products of the chemically inert gas radon-222 is responsible for about half of all non-medical exposure to ionising radiation. If inhaled, radon itself is mostly exhaled immediately. Its short lived progeny, however, which are solid, tend to be deposited on the bronchial epithelium, thus exposing cells to alpha irradiation (Darby 2005). The highest concentrations to which workers have been routinely exposed occur underground, particularly in uranium mines. Studies of exposed miners have consistently found associations between radon and lung cancer (Laurier 2005). More than fifteen cohort studies on miners provided convincing results on the risk of lung cancer death. They allowed to quantify the exposure-risk relationship, and demonstrated the importance of modifying factors of this relationship, especially age and time since exposure (NRC-BEIR VI 1999). Today, the quality
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of dosimetric estimates and the possibility to reconstruct the individual history of mining exposures provide the basis for more accurate estimates of risks associated with low levels protracted radon exposures. Recent findings from case-control studies on lung cancer and exposure to radon in homes completed in many countries allow for substantial improvement in risk estimates and for further consolidation of knowledge by pooling these studies. The consistency of the findings from the latest European and North American pooled studies clearly point to a need for global action (Darby 2005). The recent pooled analysis of key European studies estimated that the risk of lung cancer increases by 16% per 100 Bq.m-3 of increase in radon concentration. The exposure-response relation seems to be linear without evidence of a threshold, meaning that the lung cancer risk increases proportionally with increasing radon exposure. Furthermore the new results show that if a threshold existed it could not be higher than 150 Bq.m-3. Figure 1. Estimated national annual arithmetic mean of dwelling radon levels in Europe.
Source: Dubois G. (2005) An Overview of Radon Surveys in Europe. EUR 21892 EN, EC.
On the base of the epidemiological studies and experimental studies the IARC has classified radon as a certain lung carcinogen (IARC 2001) Extrapolation from these studies suggests that in many countries residential radon, which involves lower exposure in much larger numbers of people, could cause a substantial minority of all lung cancers (Darby 2005). This is of practical relevance because radon concentrations
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in existing buildings can usually be reduced at moderate cost—for example, by increasing underfloor ventilation—while low concentrations can usually be ensured at reasonable or low cost in new buildings—for example, by installing a radon proof barrier at ground level. Prevention of radon exposure in newly constructed buildings can be implemented through appropriate building provisions in the construction phase. In order to reduce the disease burden associated with radon, it is important that national authorities have methods and tools based on solid scientific evidence for a sound public health policy. There are therefore strong considerations in favour of making HIA and cost effective studies in order to delineate policies against radon exposure. To do that many scenarios have to be indented and assessed. Impact of children’s exposure to radon at school or at home are two are of them. 2. Policy context Most countries have adopted a radon concentration of 200–400 Bq.m-3 for indoor air as an Action or Reference Level above which mitigation measures should be taken to reduce the level in homes. Other countries have chosen higher or lower Action Levels. The choice of Action Levels generally has been based on the concept of acceptable risk, i.e. these levels are thought to represent population health risks similar to other everyday risks. There is no regulation, no directive in Europe concerning radon. Nevertheless the European Commission has issued the recommendation of 21 February 1990 on the protection of the public against indoor exposure to radon (90/143/Euratom). This recommendation defines 400 Bq.m-3 as the reference level for consideration for remedial action in existing dwellings and 200 Bq.m-3 as the reference level for new dwellings. This recommendation served as a reference for the development of policies against radon exposure in many countries. WHO Geneva has established the International Radon Project in which over 20 countries have formed a network of partners to identify and promote programmes that reduce the health impact of radon. http://www.who.int/ionizing_radiation/env/radon/en/index.html The project will review recommendations for action levels and provide evidence-based recommendations for radon policies and radon programmes in countries. The key elements of the Radon project include: •
Developing evidence-based public health guidance for Member States to formulate policy and advocacy strategy, and implementing methods for radon measurements and mitigation.
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Identification of a risk model for radon-associated lung cancer and estimation of the global burden of disease (GBD) associated with exposure to radon,
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Development of tools for radon risk communication
3. Methods
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Health Impact Assessment (HIA) has been well described in the literature and has been successfully used to improve the knowledge of the potential impact of certain risk factors on the health of a given population. Health Impact Assessment is defined as a combination of procedures, methods and tools by which a policy, program or project may be judged as to its potential effects on the health of a population, and the distribution of those effects within the population (WHO 1999). It can be structured in four steps. The first one (hazard identification) is the analysis of effects related in science publication linked to exposure to a product or a physical agent. The second one is the analysis of the available information of the quantitative association between the hazard and the outcome frequency (exposure response function analysis). It is crucial information for calculation of the number of cases attributable. The exposure-response function is, in fact, the key contribution of epidemiological studies to Health Impact Assessment (WHO 2000). The third (exposure analysis) and the fourth (risk characterisation) one are respectively the use of available data on the distribution of exposure and the assessment of the frequency of the effect in a population attributable to this exposure considering the concentration response function. It allows in fact estimates derived from studies in a population (the evidentiary population) to estimate impacts in another (the target population). Such assessments assume that the effect estimates in the evidentiary population are transferable to the target population. The validity of this assumption implicitly requires that the two populations be similar with regard to factors that influence the magnitude of the effect estimates, such as sensitivity to carcinogenesis, physiological or behavioural factors, exposure to other cofactors (tobacco, dust in mines…). 4. Results Hazard identification There is sufficient evidence to consider indoor radon cumulated exposure as a lung cancer carcinogen for humans whatever the exposure moment. The IARC considers it has a lung cancer carcinogen based on evidence from experimental, miner cohort, and indoor casecontrol studies (IARC 2001). On the other side, there is non sufficient information to prove a causal relationship between leukaemia and exposure to radon (Laurier 2001, Evrard 2005, Evrard 2006). If some dosimetric models (Kendall 2002) show that radon can cause a certain amount of exposure of the myolopoïetic cells, epidemiologic studies don’t show a clear relationship. The correlations found in some miner cohort studies are probably due to external radiations or uranium dust inhalation (Laurier 2001). Some ecological studies on leukaemia in children and find positive relationships, but the relation is not found up to now in case control studies. Analysis of the availability of exposure response functions The analysis of the availability of the exposure response functions (ERFs) will therefore only concern lung cancer. There is sufficient evidence to propose an exposure–response relationship between the risk of dying of lung cancer and indoor radon cumulated exposure during adulthood. Results and ERF models issued from cohort miner studies and case – control studies are considered compatible and very close. For example cohort miner studies
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assess 19% to 31% of increase of risk per 100 Bq.m-3 of mean exposure between 5 and 34 years before whereas case-control studies give an assessment of 16% (5%-31%) /100Bq.m-3 (Darby 2005). These results are a strong element of validation of the models proposed by the US National Research Committee that have been implemented in the base of the results of a joint analysis of all miner cohort studies (NRC-BEIRVI 1999) and proposed to assess the lifelong risk of lung cancer of the general population due to lifelong indoor radon exposure. Unfortunately there is a lack of available data to assess the health impact attributable to indoor radon exposure during childhood. No study approaches the issue directly. Data on young miners (teenagers) exposed to radon in mines in China don’t stress any different relation from what has been observed during adulthood exposure. But they are no epidemiological studies that checked any potential relationship between exposure during childhood and risk of lung cancer. Some considerations are for a stronger relationship with childhood exposure such as a growing pulmonary tissue for children or a higher breath rate compared to body mass. Other considerations are for a weaker relationship since the model of miners clearly shows that risk lessens with growing of time since exposure and that lung cancer are very few before 50 years old. Furthermore, to be really relevant a risk assessment should take into account the variability and the evolution of future exposure to tobacco. Indeed, this factor interacts with radon and is a very strong determinant of lung cancer. This is why the experts consulted on this issue generally don’t dare to cross the bridge of extrapolation between these two populations. Analysis of the population exposure JRC provides estimations of arithmetic mean for concentrations in European homes, country per country for at least 10 of them. The quality of these estimations varies considerably between countries and data are not all comparable, but this can represent a first benchmark of the radon concentrations in dwellings allowing the assessment of exposure to indoor radon in the corresponding countries (Dubois 2005). The report from the United Nations Scientific Committee on the Effects of Atomic Radiation provides estimates of mean radon concentrations in dwellings for 29 European countries, with a population weighted average of 59 Bq/m3. (UNSCEAR 2000) Risk characterisation Applying the exposure-response function to all-life exposure in Europe (mean exposure of 59 Bq/m3) (UNSCEAR 2000) (Darby 2005) allows estimating that about 9% of death by lung cancer in Europe is attributable to exposure to radon in dwellings. The BEIR VI model allows also calculating the health burden of specific periods of life of exposure. It would be therefore possible to calculate the % of lung cancer death attributable to childhood exposure at home or at school provided information on radon distributions at homes or at school is available and taking into account the hypothesis of the distribution of children among dwellings (NRC-BEIR VI 1999).
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Table 1: Synthesis of science evidence and expertise on radon health impact Attributable risk of lung cancer due to radon exposure Hazard identification: scientific evidence Adulthood exposure: strong Scientific evidence : Linear relationship between cumulated exposure to radon during adulthood and risk of lung cancer based on epidemiological studies of persons exposed during adulthood (cohort miner studies, case control studies). Childhood exposure : lack of data Scientific evidence: not enough because of lack of data. Supporting a relationship: no statistical difference in the relationship between exposure of teenagers and adults in miner studies, physiological susceptibility. Not supporting a relationship: very few lung cancers before 50y of age – decrease of the relationship in miner cohort studies with lag between exposure and age attained. Solutions: Lifetime cohort research exposure during childhood and lung cancer risk; Research on lung cancer genetic signature of exposure to ionizing radiation. Dose response-function Adulthood exposure: reliable functions Percent increase of risk per 100 Bq.m-3 of mean exposure between 5 and 34 years before: cohort-miner studies (low rate) : (19%-31%)/100 Bq.m-3 - case-control studies : 16%(5%-31%) /100Bq.m-3 Two BEIRVI models: taking into account period of exposure, age at risk, duration of exposure or rate Childhood exposure: no specific and reliable functions Extrapolation from BEIRVI models. Supporting a relationship: Chinese studies Not supporting a relationship: different physiologic susceptibility, unknown future tobacco exposure. Exposure data Adulthood exposure: problems with representativeness National sample studies in European countries: mean of 59 Bq.m-3 in 29 countries (UNSCEAR 2000). Childhood exposure: Problems of representativeness Knowledge on distribution of children in risk areas: houses, schools Attributable risk Adulthood exposure: reliable estimate Nine percent of deaths by lung cancer attributable to radon mean lifetime exposure in Europe. Childhood exposure: considered not reliable (if use of the BEIRI VI model : approximately 10% of the lifetime attributable risk)
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Attributable risk of leukaemia due to radon exposure Scientific evidence Adulthood exposure: scarce and contradictory, non proven Supporting a relationship: dosimetric considerations, Not supporting a relationship: cohort miner studies (no relationship or linked probably due to external radiations or uranium dust inhalation). Childhood exposure : insufficient evidence Supporting a relationship: dosimetric considerations, ecological positive relationships (validity for causality???), Not supporting a relationship: no case control studies in favour. Solutions : case-control study with reliable exposure assessment (glass decays) Dose response-function Not available Exposure data National sample studies in European countries (mean of 59 Bq.m-3 in 29 countries) Attributable risk Not reliable 5. Recommendations More epidemiological studies are necessary to assess the issue of childhood radon exposure effects (leukaemia during childhood or lung cancer during adulthood). They will be unfortunately confronted to methodological difficulties. There is therefore a need for expert review on the specific topic of extrapolation of the exposure response functions from adult exposure to children exposure. We strongly stress the need for addressing a specific focus on the effects on health of childhood exposure to radon by the expert committees such as the International Radon Project coordinated by the WHO Geneva http://www.who.int/ionizing_radiation/env/radon/en/index.html, or the European Community research project ALPHARISK. One specific question would be the relevance of applying the BEIRVI exposure response function to children exposure at school or at home. If considered available the introduction of the scenario of specific exposures during childhood would be of high interest in a cost–efficiency study, among others. Considering the exposure assessment issue, it is obvious that radon measurements have not been made with a similar standardised protocol across countries. Direct comparisons between results therefore have to be interpreted with great caution. Furthermore, radon levels are susceptible to change with modification of buildings, renewal of the building stocks, or efficiency of regional or national action programs. Therefore regular national surveys or targeted surveys on new buildings or buildings concerned by action campaigns are necessary
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to assess the evolution or efficiency of a policy. Coordination between countries is necessary to promote the use of national (and or regional) surveys protocols with a minimum set of standard criteria allowing direct comparisons. Furthermore, as radon levels are strongly linked to local geologic characteristics, regional mapping based on a standardized assessment protocol would be an ideal tool to compare radon distributions. As in dwellings, radon measurement campaigns should be done in schools and other buildings receiving children in order to assess this non negligible source of exposure for children (around 11% of their annual time budget in France). Some considerations on the distribution of children among regions and buildings at high potential of radon would facilitate the assessment of exposure of children to indoor radon. Further information: www.ENHIS.org (Summary information sheet and HIA Guidelines on indoor radon)
References General: http://www.who.int/ionizing_radiation/env/radon/en/index.html. Radon and Leukaemia • • • •
Evrard AS, Hemon D, Billon S, Laurier D, Jougla E, Tirmarche M, Clavel J. Childhood leukaemia incidence and exposure to indoor radon, terrestrial and cosmic gamma radiation. Health Phys. 2006 Jun;90(6):569-79. Evrard AS, Hemon D, Billon S, Laurier D, Jougla E, Tirmarche M, Clavel J. Ecological association between indoor radon concentration and childhood leukaemia incidence in France, 1990-1998. Eur J Cancer Prev. 2005 Apr;14(2):147-57. Kendall GM, Smith TJ. Doses to organs and tissues from radon and its decay products. J Radiol Prot 2002; 22: 389-406. Laurier D, Valenty M, Tirmarche M. Radon exposure and the risk of leukemia: a review of epidemiological studies. Health Phys. 2001 Sep;81(3):272-88. Review.
Radon and lung cancer • • •
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IARC 2001 International Agency for Research on Cancer. IARC monographs on the evaluation of carcinogenic risks to humans. Vol 78. Ionizing radiation. Part 2: Some internally deposited radionuclides. Lyons: IARC, 2001 NRC 1999 National Research Concil. Health Effects of Exposure to Radon: BEIR VI. 1999. Darby S, Hill D, Auvinen A, Barros-Dios JM, Baysson H, Bochicchio F, Deo H, Falk R, Forastiere F, Hakama M, Heid I, Kreienbrock L, Kreuzer M, Lagarde F, Makelainen I, Muirhead C, Oberaigner W, Pershagen G, Ruano-Ravina A, Ruosteenoja E, Rosario AS, Tirmarche M, Tomasek L, Whitley E, Wichmann HE, Doll R. Radon in homes and risk of lung cancer: collaborative analysis of individual data from 13 European case-control studies. British Medical journal. 2005 Dessau JC, Gagnon F, Lévesque B, Prévost C, Leclerc J-M, Belles-Isles JC. 2005. Le radon au Québec - Évaluation du risque à la santé et analyse critique des stratégies d’intervention. INSPQ, 118 p. + annexes.
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Radon exposure data (Source JRC) •
• •
UNSCEAR 2000 Report of the United Nations Scientific Committee on the Effects of Atomic Radiation. New York, United Nations, 2000 Sources and Effects of Ionizing Radiation. UNSCEAR 2000 Report to the General Assembly, with Scientific Annexes. Vol I: Sources. New York: United Nations, 2000. (http://daccessdds.un.org/doc/UNDOC/GEN/N00/587/20/IMG/N0058720.pdf?OpenElement, accessed 4 April 2007). Dubois G. An overview of radon surveys in Europe. Luxembourg, Office for Official Publications of the European Communities, 2005 (EUR 21892 EN). WHO-ENHIS 2007 WHO ENHIS factsheet indicator : exposure to radon in European countries: ”Radon levels in dwellings”. http://www.enhis.org/object_document/o4723n27388.html.
Methodological considerations •
•
WHO 1999 WHO European Centre for Health Policy. Health Impact Assessment. Main concepts and suggested approach. Gothenburg Consensus Paper. WHO, 1999. WHO 2000 World Health Organization. Evaluation and use of epidemiological evidence for
environmental health risk assessment. Guideline Document. WHO, Copenhagen 2000.
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WP7 Health Impact Assessment Deliverable 7.4
Report on the HIA of noise: results and assessment of methods feasibility
www.ENHIS.org
This document has been developed by a project co-financed by the European Commission - DG Sanco (Grant Agreement SPC 2004124), coordinated by the WHO Regional Office for Europe and involving partner institutions from 18 European countries. The views expressed here do not necessarily reflect the official opinion of the European Commission or of the World Health Organization.
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List of Authors
WP7 Lead Partner Sylvia Medina French Institute for Public Health Surveillance (InVS) St. Maurice - France
Principal authors Odile Mekel Sarah Sierig Thomas Claßen Institute of Public Health North Rhine-Westphalia (LOEGD) Bielefeld - Germany
Reviewers Elise van Kempen Danny Houthuijs National Institute for Public Health and the Environment (RIVM) Bilthoven - The Netherlands Sylvia Medina French Institute for Public Health Surveillance (InVS) St. Maurice - France Rainer Fehr Institute of Public Health North Rhine-Westphalia (LOEGD) Bielefeld - Germany
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Feasibility study of HIA on road traffic noise induced health effects on children Authors: Odile Mekel (LOEGD), Sarah Sierig (LOEGD) and Thomas Claßen (LOEGD) Reviewers: Elise van Kempen (RIVM), Danny Houthuijs (RIVM), Sylvia Medina (InVS)
Abstract Environmental noise and especially road traffic noise has a high impact on the European population, affecting approximately 32 % of the population with noise levels exceeding 55 dB(A). Exposure to road traffic noise is associated e.g. with cardio-vascular disease, annoyance, sleep-disturbance, stress related somatic effects, and impacts on cognitive performance. One of the major effects of environmental noise is annoyance. Quantitative exposure-responsefunctions (ERFs) are known for adults but have not yet been studied in detail for children. Under the assumption that ERFs derived for adults are valid for children, adult ERFs were used after some adjustments and further evaluation. It was not feasible to conduct a HIA on health effects in children induced by road traffic noise for all of the European member states due to a lack of suitable noise pollution data. The available data are mainly from the 1990s and are normally based on calculations that differ from those currently done in the Member States for implementation of the EU Directive 2002/49/EC. But unfortunately these new results were not available yet. For exploring the feasibility of applying quantitative HIA methods for road traffic noise in children, case studies in two cities in North Rhine-Westphalia (NRW) were performed. Based on exposure distribution data of road traffic noise in children (0 – 14 yrs) in these cities and the ERFs, the number of children highly annoyed and highly sleep disturbed by road traffic noise was estimated. The exposure distribution in our case studies varies by city. 17 – 34 % of the children is likely to be exposed to noise levels of more than 60 dB(A) during the day, and 21 – 34 % to noise levels of more than 50 dB(A) at night. From the total child population (0 – 14 years) in the two cities (> 30 000 children) more than 2500 children are estimated to be highly annoyed by road traffic noise, and over 1500 children are estimated to be highly disturbed during sleeping time. Scenario analyses were performed illustrating the health gains that could be achieved by noise abatement measures. For the two cities our exposure-based calculations were considered to be are a good estimate of the local situation. It is not possible to extrapolate the findings to the whole of NRW or of Germany due to the spatial and regional differences in exposure and population structure. In comparison with similar data from other countries (the Netherlands, Norway, Sweden) our findings seem to be plausible. Improved exposure assessment of road traffic noise as well as studies on exposure-responserelationship for health effects in children induced by road traffic noise should help reducing uncertainties in the quantification of health effects.
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Table of Contents ABSTRACT.................................................................................................................3 GLOSSARY ................................................................................................................4 1. STUDY QUESTION ...............................................................................................5 2. POLICY CONTEXT................................................................................................5 3. DESCRIPTION OF PARAMETER USED ..............................................................6 4. METHODS .............................................................................................................7 5. RESULTS ............................................................................................................10 6. ASSESSMENT ....................................................................................................14 7. RECOMMENDATIONS........................................................................................16 8. ACKNOWLEDGEMENTS....................................................................................16 REFERENCES ..........................................................................................................17 ANNEX ......................................................................................................................19
Glossary END ERF HIA Noise levels until the introduction of the END Lday Lnight Lday-night (LDN) Noise levels introduced by the END Lday Lnight Levening Lday-evening-night (LDEN)
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EU Directive 2002/49/EC - Environmental Noise Directive exposure-response-function Health Impact Assessment noise level for daytime (6-22 h) noise level for night-time (22-6 h) 24 hr averaged measure noise level for daytime (7-19 h) noise level for night-time (23-7 h) noise level for the evening (19-23) 24 hr averaged measure
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1. Study question In the framework of the ENHIS-2 project co-financed by the European Commission – DG Sanco and coordinated by WHO/Europe the purpose of this study was to assess the feasibility of conducting a Health Impact Assessment (HIA) on health effects in children induced by road traffic noise at European level. Children living in the proximity of heavily trafficked roads (go to indicator Children living in the proximity of heavily trafficked roads) may be exposed to high ambient air pollutant concentrations and high noise levels. Noise exposure at community levels is associated with various health effects. The major effect of environmental noise is annoyance [1]. Beside annoyance, exposure to road traffic noise (the most predominant noise source) is associated with e.g. sleep-disturbance, cardiovascular disease, stress related somatic effects, and impacts on concentration and cognitive performance [1- 4]. Valid quantitative exposure-response-functions (ERFs) are known for annoyance, sleep disturbance, cardiovascular disease, and cognition [1]. For annoyance and sleep disturbance, ERFs are known for adults [1, 5, 6, 7] but have not yet been studied in detail for children. Regarding the exposure to noise, children can be defined as a more sensitive group than adults, because - noise may affect them in critical development periods, - their coping repertoire may be less developed and - they are not able to control their environment [1, 8]. But studies on child specific health effects of noise are rare and partly inconsistent [1, 3, 8, 9]. Most studies investigating children’s exposure to traffic-related noise mainly focussed on the effects of exposure to aircraft noise [10, 11]. Only a few studies have investigated the effects of children‘s exposure to road traffic noise [9, 12]. Although the findings of studies on children’s exposure to traffic noise are difficult to interpret and not consistent, they indicate that road traffic noise related annoyance in children seems to be comparable to noise related annoyance in adults [10, 13]. For sleep disturbance conclusive evidence is still missing. Nevertheless, the studied literature about children indicates that there is a causal relationship between road traffic noise and sleep disturbance for children, too [9]. The assessed health outcomes in this HIA study are therefore annoyance and sleep disturbance, even though the results for sleep disturbance must be discussed in particular. 2. Policy context Environmental noise (“noise from all sources except noise at the industrial workplace” [4]) has a high impact on the European population. As one of the main sources of environmental noise, road traffic noise affects approximately 32 % of the European Union’s population with noise levels exceeding 55 dB(A) daytime. 13 % of the European population are exposed to levels of road traffic noise of more than 65 dB(A) daytime [14, 15]. The WHO ECEH estimates environmental noise becoming one of the major environmental health issues, which concerns policy-makers as well as the public [16]. A reason for the increase of road traffic related noise is an increase of the extent of road traffic in Europe. EUROSTAT-Data support this assumption: from 1995 to 2004, the number of cars per inhabitant in the EU-25 increased from 394 to 463 per 1000 inhabitants.
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Due to the increasing transport demands in all EU member states (MS), noise and especially road traffic related noise is an increasing issue, not only in major cities but also in rural areas with heavily trafficked roads crossing. To handle this issue, the EU introduced the EU Directive 2002/49/EC (Environmental Noise Directive- END) [17] which requests the MS to produce so called noise maps for cities with more than 250 000 inhabitants as well as for heavily trafficked roads (> 6 million vehicles per year) until the end of June 2007. Noise maps include the estimated number of exposed population at different noise levels. In a tiered approach by 2012, MS are obliged to produce noise maps for all of the cities with more than 100 000 inhabitants (“agglomerations”), major roads (> 3 million vehicles per year) as well as for airports and major railways. Based on these maps, the MS have to set up and implement noise reduction plans. Beside harmonising the EU noise assessment methodology (using noise level L(DEN) as one common indicator), one of the goals of the END is to require MS to make their noise maps publicly available and to communicate about the situation of regional noise exposure. As a link between those exposure-maps and possible health effects is still missing, HIA results may be a useful element in this communication process. 3. Description of parameters used Exposure The ENHIS2-indicator “children living in the proximity of heavily trafficked roads” (for further description see fact sheet “Children in proximity of heavily trafficked roads” by Skouloudis 2006) does not focus on noise exposure directly. Hence the indicator had to be modified for the assessment of the feasibility of conducting a HIA on health effects in children induced by road traffic noise. Instead of the given indicator we use the more expedient indicator “population exposed to various noise level ranges by road traffic noise” for assessing the exposure. More precisely, road traffic noise exposure distributions for children (0-14 years) are used (i.e., number of children exposed to different noise levels due to traffic), and in addition road traffic noise exposure data in general population are used to verify the consistency of the applied methodology. Noise exposure data are not yet collected routinely at country level. There is much variation in the current EU estimations of noise levels and in the estimation of number of people exposed. Implementation of the END will reduce this variation due to harmonisation of the noise assessment methodology. Regarding noise exposure, estimated (by modelling) noise levels are usually reported. Until the introduction of the END, noise levels were expressed for daytime (Lday, 6-22 hr), nighttime (Lnight, 22-6 hr) as well as for a 24 hour equivalent (Lday-night/DN). To take into account the sensitive period for rest and relaxation during the evening, the END introduces following time-averaging periods: Lday (7-19 hr), Levening (19-23 hr) and Lnight (23-7 hr). Member States are allowed to vary the time intervals by one or two hours. The 24 hr averaged measure is called Lday-evening-night (LDEN). The calculation formula is presented in the annex (Figure A3), calculation methods and formulas are laid down in the END [17]. As the preparation of the noise exposure data according to the END is still ongoing and not yet available, we use the noise exposure levels as reported before introduction of the END.
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Outcomes Data on annoyance and (self-reported) sleep disturbance are not collected on a routine basis but measured by standardised questions in population health surveys or specific epidemiologic studies (e.g. RANCH [11]). A definition of annoyance is given in the WHO-Guidelines for community noise [4]: “annoyance is a feeling of displeasure associated with any agent or condition, known or believed by an individual or group to adversely affect them”. The WHO community noise guidelines present guidelines for settings where most children spend part of their time. For avoiding annoyance a noise level LAeq of 55 dB(A) for noise from external sources for outdoor playgrounds is recommended. LAeq is a value of continuously measured sounds during a defined time period, in this case during playing time. As exposure-effect relations for road traffic noise and sleep disturbance are only available for adult populations [7], we use them very cautiously to get an impression of the effects of road traffic noise in children. In the WHO-Guidelines for community noise no specific night noise levels for children are given. But for bedrooms in preschools a LAeq of 30 dB(A) during sleeping-time is recommended to avoid sleep disturbance. In our case studies we only use the outcomes “highly annoyed” and “highly sleep disturbed” for an “at least” – approach, because we do not want to overestimate the effects. Furthermore we want to avoid a discussion on whether mild annoyance is counted as a health issue. 4. Methods Following the “Recommendations for the use of epidemiological data for Health Impact Assessment” (WHO Guidelines on evaluation and use of epidemiological evidence for environmental health risk assessment, chapter 4.3; http://www.euro.who.int/document/e68940.pdf [18]), we assessed the feasibility of conducting a HIA on health effects in children induced by road traffic noise. In an exposure-based approach [6, 7] the number of children which are highly annoyed by road traffic noise as well as the number of children highly sleep disturbed can be estimated by combining the exposure distribution with the exposure-response-function (ERF). Due to the lack of suitable noise pollution data on European level, it was not feasible to conduct a HIA on a European level. The available data are mainly from the 1990s and are normally based on calculations that differ from those currently done in the member states for implementation of the EU Directive 2002/49/EC (END) [17]. Unfortunately these new data were not available yet. For further discussion of possible reasons for the lack of data see chapter 6 (assessment). We examined which data on children were available on a regional level in North RhineWestphalia (NRW). It was not possible to get state-wide exposure data. Five cities in NRW were chosen for case-studies and asked for exposure distribution data of road traffic noise in children (0 – 14 yrs). Two of the cities (city A & city B) supported us with data 1 . Data for exposure
1
The colleagues from the environmental agency of city A preferred to remain anonymous.
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The cities A and B provided data on traffic noise exposure levels for the requested age groups in their populations. The data on traffic noise exposure levels in both cities were based on noise modelling. In these models the noise levels are usually calculated via geographical models of the regarded area including information about buildings and their height, zoning maps, and the distribution of road traffic during 24 hours (based on traffic census) with special regard to lorries. Additionally the type of paving was included in the modelling for city B; they gave a penalty of up to 3 dB(A) for noisy paving. In the modelling for city A the starting phases of cars at traffic lights were included. The noise levels estimated by these models reflect the highest noise level at 4 metres height at the outdoor façade. Total numbers of people exposed to different noise levels per 5 dB classes at daytime (Lday, 622 hour), at night-time (Lnight, 22-6 hour) and during 24 hours (LDN) (city B only) were provided. As the noise levels were determined (e.g. modelled) before introduction of the END, these noise levels were not yet reported as LDEN. In case study A, we did not receive data about L(DN). Therefore we had to calculate the L(DN) from L(day) and L(night): Table 1 Calculation of L(DN) % of people exposed day-night = (% of people exposed at daytime * 16/24) + (% people exposed at night-time * 8/24)
It is not possible to equate the day-level with the night level, because of the increased sensitivity in night-times. In line with the recommendations of the END, we shifted the data of people exposed at night within 10 dB(A) before calculating the L(DN), e.g., we subsumed the day’s 40-45 dB(A) class with the night’s 50-55 dB(A) class and so on. Data for health outcomes; exposure-response-functions The chosen ERFs were derived by Miedema & Vos [5], Miedema & Oudshoorn [6] and Miedema et al. [7]. These ERFs are generally accepted and recommended for adults [3, 19, 20]. Even though there are no special ERFs for children, there are indications that road traffic noise related annoyance in children seems to be comparable to noise related annoyance in adults (see chapter 1). For sleep disturbance a causal relationship between road traffic noise and sleep disturbance in children is at least probable. Therefore adults ERFs were used for children in our case-study. In which way differences in children’s and adults’ annoyance- or sleep disturbance- ERFs lead to under- or overestimations has to be discussed. The exposure-response-function for annoyance is based on pooled data from 26 datasets from studies mainly in Western Europe. After establishing curves for each dataset showing the percentage of people highly annoyed (HA) as a function of L(DN), the authors combined all curves to one curve [5]. For sleep disturbance the ERF is based on pooled data from 15 datasets [7, 20]. In the derived exposure-response-functions, annoyance and sleep disturbance both are divided into three categories, dependent on their severity: “lowly annoyed (LA)” and “lowly sleep disturbed (LSD)”, “annoyed (A)” and “sleep disturbed (SD)”, “highly annoyed (HA)” and “highly sleep disturbed (HSD)”. In an exposure-based approach the number of children which are highly annoyed by road traffic noise as well as the number of children which are highly sleep disturbed are estimated by combining the exposure distribution with the ERF. December 2007
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The proportion of the exposed people (in percent) for L(DN), who are highly annoyed (HA) or highly sleep disturbed (HSD) at a certain noise level can be estimated with the following equations. For calculations with the L(DEN), this formula is not valid and a different formula needs to be used [6]. Table 2 Formulas for calculating the percentage of highly annoyed or highly sleepdisturbed people by road traffic noise for L(DN) Health outcome
ERF
Ref. -4
3
-2
2
% HA
9.994*10 (LDN-42) - 1.523*10 (LDN-42) + 0.538 (LDN-42)
[5],[6]
% HSD
20.8 - 1.05 Lnight + 0.01486 (Lnight)²
[7]
HA = highly annoyed people HSD = highly sleep disturbed people
For annoyance this ERF is only valid in the range of L(DN) > 45 dB(A) and L(DN) < 75 dB(A), because the authors of the ERF excluded exposures below 45 dB(A) and over 75 dB(A) [5, 6]. For sleep disturbances, the ERF is valid in the range of > 40 dB(A) – 70 dB(A) because extrapolations to lower exposure (40-45 dB(A)) and higher exposure (65-70 dB(A)) are possible in this case [7]. In these ranges, we calculated the percentage of the people highly annoyed (complete tables in annex, Table 5 and 6): − for LDN (between 45 and 75 dB(A)): LDN 45 dB(A) = 1.5 % of exposed people are highly annoyed; LDN 47.5 dB(A) = 2.66 % HA; LDN 50 dB(A) = 3.84 %, etc. − for Lnight (between 40 and 70 dB(A)): Lnight 40 dB(A) = 0.00 % of exposed people are highly sleep disturbed; Lnight 42.5 dB(A) = 0.27 %, Lnight 45 dB(A) = 3.64 %, etc. Due to the fact that the ERFs are only valid in the described ranges we had to make some assumptions. The proportion of children exposed to noise levels < 45 dB(A) or 40 dB(A) or > 75 dB(A) or 60 dB(A) was set to the noise level 45 dB(A) or 75 dB(A) or 65 dB(A) respectively. Consequences of these assumptions will be discussed in chapter 6. After calculating these percentages of HA and HSD we subsumed the single values to categories (45 - 50 dB(A), 50 - 55 dB(A) etc.) by taking the mean of the associated single values. In this way we calculated the HA and HSD children per noise level category by combining the number of exposed children in each category with the appropriate percentage value. The total number of HA and HSD children per city is derived by summing up the numbers over all categories. To assess one possible variation of our results we estimated the confidence intervals of the expected annoyance and the expected sleep disturbance in our case studies making use of the 95 % confidence intervals of the ERFs [5-7]. Data points of the confidence intervals were kindly provided by the authors of the exposure-response functions [5-7]. Participating countries, cities, regions Case study City A: City A has a municipal area of approximately 123 km², about 7.7 km² (6 %) of this area are used for traffic. This city is a core city in an urbanised area, a typical situation for about 9 % of the cities in North Rhine-Westphalia (NRW) [29]. From the 52 538 inhabitants in 2007, 8 589 (16 %) were children between 0-14 years of age.
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Case study City B: With its municipal area comprising about 91 km², city B is located in western NRW as part of the largest industrial area in NRW. About 12 km² (13 %) of the municipal area are used for traffic, e.g. roads. City B is a core city in a highly-compressed urban agglomeration. This situation is typical for about 4 % of the NRW cities [29]. In the year 2007, 171 160 inhabitants were living in city B, 22 050 (13 %) of them were children between 0-14 years of age. Comparisons of the method and results Based on data of the general population exposed to different noise levels (over 24 hours averaged values) in the Netherlands [3, 21], Norway 2 [22], and in Sweden [23] the number of highly annoyed people was calculated to evaluate our results. As for Germany exposure distribution data for the night was available, the number of highly sleep disturbed people was calculated additionally [30]. Scenarios Based on the results of the case studies, we assumed noise exposure levels not exceeding 50 dB(A) at night and 60 dB(A) daytime (scenario 1). These values are threshold values for noise exposure in residential areas according to the 16. BImSchV (German regulation on noise pollution due to road and railroad traffic) [28]. In a second scenario we examined the effect of decreasing noise levels. We calculated a scenario with a decrease of 5 dB(A) for both cities. An assessment conducted by the German Federal Environmental Agency showed that the use of low-noise asphalt may lead to a noise reduction of about 7 dB(A) [24]. As we do not know in which ranges this value may vary we chose 5 dB(A) to avoid overestimating the effects. 5. Results Exposure levels The percentage of children exposed to the different road traffic noise related noise levels (day and night) has been determined for both cities (see Figure A1 and A2 in the annex). In comparison, the exposure distribution of road traffic noise in children (0 – 14 yrs) in the HIA case study for the two cities in North Rhine-Westphalia varies per city. 17 – 34 % of the children is exposed to noise levels of more than 60 dB(A) during the day, and 21 – 34 % are exposed to noise levels of more than 50 dB(A) at night. Comparing the two cities, the road traffic noise exposure is higher in city B. Hence there are proportionally more children in city B exposed to road traffic noise exposure at higher levels than in city A (see Figure A1 and A2, annex). Calculation of health impacts Based on the exposure levels, for the health outcomes „high annoyance“ and „high sleep disturbance“ the number of affected children was calculated. While there seems to be only a minor difference in sleep disturbance between the two cities, the estimated percentage of highly annoyed children in city B is twice as much as in city A. In comparison with city A, 2
Data about people exposed to different noise levels collected by the joint questionnaire of EUROSTAT and OECD-Organisation for Economic Co-operation and Development
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the proportion of highly annoyed children in the noise level classes higher than 55 dB(A) is quite high (see Figure 1). Table 3 Estimated number of highly annoyed or highly sleep disturbed children by road traffic noise in city A and B with the appropriate confidence intervals (CI) Health outcome Annoyance Highly annoyed children (%) Highly annoyed children (n)
City A
B
5.4 (3.97-6.53) 471 (345-569)
10.06 (7.9-12.22) 2217 (1742-2695)
4.60 (3.27-7.45) 395 (281-640)
5.21 (3.65-8.17) 1149 (804-1802)
Sleep disturbance Highly sleep disturbed children (%) Highly sleep disturbed children (n) CI = Confidence interval
3
For the total child population in the two cities of approximately 31 000 (30 759) children in the age up to 14 years, 2 700 children are estimated to be highly annoyed by road traffic noise, and 1 500 children are estimated to be highly disturbed during sleeping time. A detailed picture about the estimated distribution of highly annoyed and highly sleep disturbed children is shown in Figures 1 and 2. The 95 % lower and upper confidence limits of the expected annoyance in our case studies are presented in Table 3, too. For sleep disturbance they are only available in the range between 45 dB(A) and 65 dB(A). The accumulation of HA or HSD children in the lowest exposure categories in Figures 1 and 2 and in the highest exposure category in Figure 1 may be caused by the ranges, in which the ERFs can be applied. The numbers of children exposed to noise levels lower than 40 dB(A) or 45 dB(A) and higher than 70 or 75 dB(A) had to be subsumed to these values. Consequences of these assumptions on possible under- and overestimations of health effects are discussed in chapter 6.
3
for sleep disturbance only in the range between 45 dB(A) and 65 dB(A)
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Figure 1: Estimated number of children (per 1000) highly annoyed by road traffic noise, by noise level category in two NRW cities 30 City A City B
children [n/ 1000]
25 20 15 10 5 0 ≤ 45
> 45 - 50
> 50 - 55
> 55 - 60
> 60 - 65
> 65 - 70
> 70 - 75
> 75
noise level day-night [dB(A)]
Figure 2: Estimated number of children (per 1000) highly sleep disturbed by road traffic noise, by noise level category in two NRW cities 16 City A
14
City B children [n]/1000
12 10 8 6 4 2 0 ≤ 40
> 40 - 45
> 45 - 50
> 50 - 55
> 55 - 60
> 60 - 65
> 65 - 70
> 70
noise level night [dB(A)]
Comparisons of findings Our findings are comparable to the results of the calculations we made with data from the Netherlands, Sweden, Norway, and Germany (sources: [3; 21-23; 30]). Calculated with the method described in chapter 4, there are approximately 2 % of the people living in the
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Netherlands highly annoyed because of road traffic noise. These include adults as well as children. With the same method we calculated that approximately 3.1 % of the people living in Sweden and 3.4 % of the people living in Norway may be regarded as highly annoyed because of road traffic noise in the year 2003. The percentage of highly annoyed people varies per city. While in Stockholm (S) and Oslo (N) 7.6 % and 7 % of the inhabitants are estimated to be highly annoyed, the proportion of highly annoyed people in Gothenburg (S) and Akershus (N) is only 3.5 % and 2.8 %. And also with the same method we calculated approximately 8.9 % of the people living in Germany as highly annoyed because of road traffic noise. 7.8 % of the people living in Germany are estimated as highly sleep disturbed due to road traffic noise. Scenarios: We calculated the proportion of highly annoyed and highly sleep-disturbed children in the two cities with a noise exposure not exceeding 50 dB(A) in the night and 60 dB(A) daytime (Table 4). In a second scenario, we calculated the situation of the highly annoyed and highly sleep disturbed children in the two cities with the assumption of a noise level decreasing for 5 dB(A) in each noise level category (Table 5). The results show a clear decrease of the outcomes in both cities for both scenarios. Table 4 HIA scenario analysis 1 – noise exposure is not exceeding 50 dB(A) (at night) and 60 dB(A) (daytime) Current situation Health outcome
City A
Annoyance Highly annoyed children (%) Highly annoyed children (n) Sleep disturbance Highly sleep disturbed children (%) Highly sleep disturbed children (n)
B
Exposure reduction measure 1 City A B
Potential health gain / Difference City A B
5.4 471
10.1 2217
4.4 381
7.2 1576
19.1* 90
28.9* 641
4.6
5.2
3.7
4.0
19.2*
26.3*
395
1149
319
847
76
302
* Proportion (in %) of the HA or HSD children which can be avoided by the exposure reduction
measure
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Table 5 HIA scenario analysis 2 - a 5 dB(A) decrease for all categories Current situation Health outcome Annoyance Highly annoyed children (%) Highly annoyed children (n) Sleep disturbance Highly sleep disturbed children (%) Highly sleep disturbed children (n)
City
Exposure reduction measure 2 City A B
Potential health gain / Difference City A B
A
B
5.4 471
10.06 2217
3.36 292
6.22 1372
38.0* 179
38.1* 845
5.21
3.44
3.77
25.3*
27.7*
4.60 395
1149
295
831
100
318
* Proportion (in %) of the HA or HSD children which can be avoided by the exposure reduction
measure
6. Assessment Limitations of results It was not feasible to conduct a HIA on health effects in children induced by road traffic noise for all European member states, because of the lack of suitable data. Reasons for missing suitable data are manifold: − while waiting for implementing the END, there was no further collecting of noise exposure data in many member states. E.g., the EEA project TERM (Towards a transport and environment reporting mechanism for the EU) provides data about the TERMindicator noise-induced annoyance and shows the population exposed to road traffic noise in Europe [14, 25]. Unfortunately, the data were not updated and are only referring to the EU-15. Latest year of available data is 1999. It is questionable to what extent they can be transferred to the EU-25 or the EU-27; − often there is no relation (spatial or temporal) between available data about exposure or about health outcomes on EU level; − there is no focus on children in the reported road traffic noise exposure data; − reported data do not fulfil the required definitions. E.g., information about exposure to road traffic noise is given by the joint questionnaire of EUROSTAT and OECD (Organisation for Economic Co-operation and Development), which contains data about people exposed to different noise levels. These data are available for Norway and Sweden, but the reported exposure levels are not clear; − no differentiation between noise sources. For the two cities used for our case-study, our exposure-based calculations seem to be a good estimate. Even though it is not possible to extrapolate these findings to the whole area of North Rhine-Westphalia or Germany due to the spatial and regional differences in exposure and population structure, there are some cities which are comparable to the cities in our case study (a total of 13 % of the cities in NRW) [29]. In these comparable cities approximately 5 million inhabitants (5 095 226) were living (28 % of the inhabitants of NRW) in 2006.
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In comparison with results of the calculations for Germany, our case study findings seem to be plausible, even if the exposure data for Germany is not complete. We estimated 5 % and 10 % of children highly annoyed in our case studies, for Germany we calculated approximately 9 % of the people highly annoyed. For sleep disturbance, we estimated 5 % for both cities, and 8 % for Germany. The comparison with results from the Netherlands supports our findings, too. Even though there are only 2 % of the people living in the Netherlands highly annoyed by traffic noise (whereas we estimated 5 % and 10 % of children highly annoyed), it has to be noted that in the Netherlands the whole country (including rural areas without heavily trafficked roads) was examined, while we were looking only at cities as was done for the comparison with Norway (3.4 %) and Sweden (3.1 %), too. Furthermore the comparison with Norwegian and Swedish cities shows a bigger proportion of highly annoyed people (Gothenburg, Stockholm, Oslo, except Akershus). The second difference is, that while in the countries compared (the Netherlands, Norway, Sweden) adults and children were examined, we focussed on children only. For the data from Norway and Sweden there may be an underestimation of the percentage of HA people, because numbers of people exposed to noise levels 45 - 50 2.67 > 50 - 55 5.19 > 55 - 60 8.53 > 60 - 65 13.43 > 65 - 70 20.64 > 70 - 75 30.01 > 75 37.08
Table 7 Percentage of highly sleep disturbed persons calculated after the ERF for single noise level values and resulting classified values HIGH SLEEP DISTURBANCE Calculation of percentage of sleep disturbance for single values Noise level night (Lnight) % highly sleep disturbed (22-6 h) [dB(A)] 40.0 0.00 42.5 0.27 45.0 3.64 47.5 4.45 50.0 5.45 52.5 6.63 55.0 8.00 57.5 9.56 60.0 11.30 62.5 13.22 65.0 15.33 67.5 20.39 70.0 25.06
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HIGH SLEEP DISTURBANCE Calculation of percentage of annoyance per category Noise level night (Lnight) % highly sleep disturbed (22-6 h) [dB(A)] ≤ 45 3.64 > 45 - 50 4.51 > 50 - 55 6.69 > 55 - 60 9.62 > 60 - 65 13.28 > 65 15.33
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Figure A1: Road traffic exposure distribution (daytime) for children (0-14 years) in two cities in NRW 50
children [%]
45 40
City A
35
City B
30 25 20 15 10 5 0 ≤ 40
> 40 - 45 > 45 - 50
> 50 - 55
> 55 - 60 > 60 - 65
> 65 - 70 > 70 - 75
> 75 - 80
noise level day (6-22 h) [dB(A)]
Figure A2: Road traffic exposure distribution (night-time) for children in two cities in NRW
children [%]
50 45
City A
40
City B
35 30 25 20 15 10 5 0 ≤ 35
> 35 - 40 > 40 - 45 > 45 - 50 > 50 - 55 > 55 - 60 > 60 - 65 > 65 - 70 > 70 - 75 > 75 - 80
noise level night (22-6 h) [(dB(A)]
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Figure A3
Calculation formula of Lden. Source: END [10]
The day-evening-night level Lden in decibels (dB) is defined by the following formula
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This document has been developed by a project co-financed by the European Commission - DG Sanco (Grant Agreement SPC 2004124), coordinated by the WHO Regional Office for Europe and involving partner institutions from 18 European countries. The views expressed here do not necessarily reflect the official opinion of the European Commission or of the World Health Organization.
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List of Authors
WP7 Lead Partner Sylvia Medina French Institute for Public Health Surveillance (InVS) St. Maurice - France
Principal authors Franticek Kozisek State Health Institute (SZU) Prague - Czech Republic
Reviewers Sylvia Medina French Institute for Public Health Surveillance (InVS) St. Maurice - France Elena Boldo Institute of Health Carlos III Foundation for International Cooperation and Health (ISCIII) Madrid - Spain Odile Mekel Institute of Public Health North Rhine-Westphalia (LOEGD) Bielefeld - Germany
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QUALITATIVE AND QUANTITATIVE HEALTH IMPACT ASSESSMENT ON DRINKING WATER POLLUTION How to understand and use data on drinking water quality and health Abstract: Water utility managers and health or water authority officers are supposed to understand the meaning of data on drinking water quality in terms of health risks to be able to accept appropriate strategy to respond monitoring results. However, it was shown by recent study that even water professionals and public health and environmental specialist do not often understand the meaning of water monitoring data. This paper describes routine data on water quality and health and provides basic information and examples what experience or conclusion may be obtained from these data and when quantitative or only qualitative health impact assessment may be used. Principles of derivation of limit values are explained as well as possible lessons got from non-compliance or different meaning and purpose of drinking water parameters. In the case that numerical data on water quality are available the basics of quantitative health risk assessment are outlined, e.g. how to calculate safe limit value for derogation or accident cases or how to assess carcinogenic potency of drinking water.
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Table of Contents 1. INTRODUCTION ..................................................................................... 272 2. ROUTINE DATA ON WATER QUALITY AND HEALTH ........................ 272 2.1 Compliance data.............................................................................................. 272 2.2 Data on water quality ...................................................................................... 273 2.3 Data on water-borne outbreaks ..................................................................... 274
3. INITIAL CONSIDERATION ON DATA QUALITY AND RELIABILITY ... 275 4. DATA ON COMPLIANCE OR NON-COMPLIANCE............................... 275 4.1 Different meaning and purpose of drinking water parameters ................... 276 4.2 Derivation of limit values................................................................................ 277 4.3 Evaluation of non-compliance with chemical health-related parameter limit values .......................................................................................................................... 279 4.4 Evaluation of non-compliance of microbiological parameters................... 279
5. NUMERICAL DATA ON WATER QUALITY ........................................... 282 5.1 Microbiological parameters............................................................................ 282 5.2 Chemical parameters ...................................................................................... 282 5.2.1 5.2.2 5.2.3 5.2.4
Health risk assessment from non-compliance .....................................................282 Assessment of importance of threshold chemicals exposure from drinking water284 Assessment of carcinogenic potency of drinking water .......................................286 Assessment of safe temporary limit in case of accident or emergency ...............287
6. NUMBER OF WATER-BORNE OUTBREAKS ....................................... 288 7. DATA ON SUPPLIES NOT UNDER (REGULAR) MONITORING?........ 290 8. CONCLUSIONS ...................................................................................... 291 9. REFERENCES ........................................................................................ 293 ANNEX A Meaning, health risks and main sources of pollution of parameters included in the Council Directive on the quality of water intended for human consumption (98/83/EC) ................................................................................. 294 ANNEX B Extended list of suitable parameters available and its relevance and purpose of use in separate parts of the supply system. Adapted from TECHNEAU document Monitoring and control of drinking water quality. Selection of keyparameters [5] ................................................................................................. 300 ANNEX C Parametric values, exposure limits (total daily intake = TDI) and associated cancer risk of parameters included in the Council Directive 98/83/EC ..... 303
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1. Introduction Policy makers usually get several typical sets of data which are supposed to characterize drinking water (DW) safety or health impact of DW pollution. These data are generated periodically from national/regional/local reporting systems of various levels of completeness, preciseness, and reliability. Correct understanding and interpretation of data and the need for an appropriate strategy for responding to monitoring results are essential aspects of the risk management process and key consideration for the effective collection and use and monitoring data.
2. Routine data on water quality and health Most usual kinds of these data includes compliance of DW monitoring results in respect to national or international standards, numerical data on DW quality in given zone or territory, and numbers of water-borne outbreaks reported.
2.1 Compliance data Compliance (or non-compliance) of DW monitoring results in relation to the limit values set for respective parameters (indicators), usually expressed as percentage per given period. Data come from (public) water supplies which are under regular and obligatory control and publicly available. Usually synthesis results for all supplies or selection of supplies are available. Results may be presented together for all parameters (see Figure 1) or individually for each parameter, either in figure (see Figure 2) or table forms (see Table 1). Figure 1 Example of data on drinking water quality expressed as summary data on non-compliance: % samples taken in zones failing to meet European and National standards in period of 19912005. Data from all public water supplies (population supplied about 58 million), United Kingdom [1]. Note: some of the standards changed with effect from 1 January 2004
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Figure 2 Example of data on drinking water quality expressed as summary data on non-compliance for selected parameters: percentage of results exceeded the limit values. Data from all public water supplies in 2006 (population supplied 9.5 million), Czech Republic
Escherichia coli Coliform. bact. Arsenic
> 5000
< 5000
Nitrate Pesticides total Odour Iron
0
2
4
6
8
10
12
excessed limit value %
Table 1 Example of data on drinking water quality expressed as summary data on non-compliance for selected parameters: number and percentage of results exceeded the limit values (LV) + number of results under limit of quantification (LOQ). Data from all public water supplies, Czech Republic 2006 Parameter Arsenic Coliform. bact. Escherichia coli Iron Nitrate Odour Pesticides total
Number of analyses 5709 32679 32326 32044 31459 29112 3931
LV
>LV %
4451 1 1 9851 1921 1230 0
55 1854 546 2704 1214 129 23
0,96 5,67 1,69 8,44 3,86 0,44 0,59
2.2 Data on water quality Data on DW quality for given period from given territory (country, region) or from selected supplies, usually expressed as mean or median concentration, minimum and maximum values found, standard deviations, quantiles, or other results of statistical analysis, and finally number of samples analysed (or collected in database) for all or some of the parameters monitored. See Table 2 for example.
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Table 2 Example of data on drinking water quality expressed as summary data on numbers/concentrations for selected parameters. Data from all public water supplies in 2006, Czech Republic Parameter
Unit
Minim. value
Maxim. value
Average
Geometric mean
Median
Quantile 10%
90%
Number of analyses
Arsenic Coliform bact. Escherichia coli
µg/l CFU/ 100ml CFU/ 100ml
< 0,001
81
1,158
0,635
0,5
0,25
2,5
5709
0
> 700
0,942
0,000
0
0
0
32679
0
298
0,219
0,000
0
0
0
32326
Iron
mg/l
< 0,003
10,7
0,098
0,053
0,05
0,015
0,2
32044
Nitrate
mg/l
< 0,01
149,8
18,048
11,057
13,1
2,5
39,6
31459
2.3 Data on water-borne outbreaks Usually expressed as number of water-borne outbreaks per year or other given period. For example see Figure 3. Beside the outbreaks, some countries are able to report also the numbers of sporadic cases of (notifiable) diseases caused/transmitted by water, but its reliability in term of completeness is questionable. Figure 3 Example of data on health impact of drinking water quality expressed as total number of waterborne outbreaks (46) reported in specific period (1998-2005), analyzed according to the causes. Data from Finland [2]
11
Noroviruses Campylobacters
21 Chemicals Rotavirus
1
Unknown
2
11
What information, experience or conclusion may be obtained from these data?
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3. Initial consideration on data quality and reliability Before starting to evaluate any collection on data on water quality, we have to raise and (try to) answer several basic questions, which have pivotal position for subsequent evaluation and conclusions we would like to present: • How reliable are data on water quality produced by the laboratories? Have these laboratories introduced analytical quality control system that is subject from time to time to external control? Does the system include also sampling? • Are there monitoring plans and sampling strategies (policy)? Is a selection of monitoring sites and sampling frequency representative for all supply network monitored? Is sampling policy primarily focused on water quality on the tap, as consumed by consumers, or on water quality in distribution (pipe) network in front of the buildings supplied? • Are there any significant imbalances in the amount of data from different water supplies, which may introduce bias 1 into the survey design? For instance, if majority of all data come from big supplies run by professionals (utility) that showed very few samples with the presence of indicator bacteria, this may be very unrepresentative of community-managed small supplies in rural areas. • Are all data (results) obtained from routine monitoring included in the database, or any pre-selection of data, e.g. on utility level, may exist? If there is any data selection, what is its nature and purpose – may it influence a representativeness of the survey? • What is population coverage of the survey assessed? Are all public water supplies included? Are there data on private water supplies? Then the coverage may vary according to the proportion of households connected to public water supplies – e.g. from 54.2 % in Romania to 99.9 % in the Netherlands [3]. If the survey is based on data collected from selected supplies – what is such population coverage and are selected zones representative for all supplies or not? In some cases only supply zones with population above 5000 are included, which may present quite different picture of DW quality in comparison with smaller supplies or zones. If we are not sure about data quality, accordingly we have to be very careful in interpretation and making any conclusions. Similarly if population coverage is limited, we should clearly state what percentage or part of the population we are going to speak about and what we know or do not know about the rest.
4. Data on compliance or non-compliance If water analysis, sampling, monitoring representativeness and data collection are reliable and all monitoring results are available, 100 % compliance rate is rather rare and sometimes even little suspicious. Even in properly operated supplies with water of high quality, occasional limit exceedances may be found which does not necessarily mean any breach of water safety, but rather sampling or analysis error or e.g. incidental bacteria occurrence – repeated analysis then usually shows acceptable results. If summary data show low non-compliance – e.g. < 1-2 % - we should know if such quite favourable situation indicating only random exceedances is relevant to all supply zones monitored or if most zones are even better and the rate is influenced by few supply zones showing repeated or continuous non-compliance. We have to ask for more detail analysis of data and supply zones showing distribution of population according to maximum relative number of 1
Bias is deviation of results or inferences from the truth, or processes leading to such deviation.
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analyses with non-compliance of one parameter. For example: while data from the Czech Republic shows total figures for all supply zones with less than 1% non compliance for all limit values and 0.05 % non compliance for maximal limit values, from Figure 4 we know that almost 6.4 million (67 %) population were supplied with water from the distribution systems in which no exceedance of any maximum limit value was recorded in given period. In contrast, at least one of the maximum limit values was exceeded in all samples analyzed for the given parameter in 219 mostly smallest distribution systems supplying altogether more than 56,000 (0.6 %) population (Czech Republic, data from 2006 [4]). Figure 4 Example of data on drinking water quality expressed as distribution of population (%) according to maximal relative number of analyses exceeding maximum limit value of the same parameter. Data from all public water supplies in 2006, Czech Republic Parameters (Maximum limit value)
1%
never 32%
occasionally - up to 50 % often - above 50 % 67%
If water quality in particular supply shows 99-100% compliance, we can conclude that water is safe in agreed way (through accepted regulation). It would be highly improbable (although not entirely impossible 2 ) that such water causes any health damage. If non compliance (i.e. exceedance of limit value) is real, repeatedly found and long lasting, we can say that water does not conform to regulatory requirements, but before to conclude about possible health risk, we have to know: Which parameter is not in compliance and how much and how often was the limit exceeded? It is because not all parameters and not all limit values are of direct health relevance. It is necessary to consider the meaning of each parameter assessed. 4.1 Different meaning and purpose of drinking water parameters The list of 48 parameters/indicators included in European Drinking Water Directive 3 (DWD) and additional ones included in respective national regulations represents mixture of parameters of various nature, purpose and health relevance. Many of them have been traditionally used just for operational control (e.g. pH value, oxidisability, or chlorine residual), filtration efficiency control (e.g. colony counts), corrosion control (conductivity, natural constituents of water like sulphate, chloride or hardness), or as chemical indicator for faecal pollution (e.g. ammonia or chloride, where even manifold limit exceedance of the parameter it2
E.g. due to pathogens which presence is not indicated through current system of faecal indicators – see hereafter for explanation – or due to chemical substances which are not monitored. 3 Council Directive 98/83/EC of 3 November 1998 on the quality of water intended for human consumption.
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self does not represent any health risk in very most cases). For most of the parameters any sudden change in concentration (e.g. from ¼ to ½ of the limit value) is more important and risky than permanent exceedance of the limit caused by geological natural conditions. Although such parameters/indicators have not direct health impact, possible non compliance and especially any abnormal change should be carefully investigated, because they may rapidly indicate presence of health risk, which (for the moment) cannot be found through other routine health related parameters used. There are other parameters which ensure acceptability of water or may cause rejection of water by consumers (turbidity, taste, colour, odour, including some causes like iron or manganese), but even waters that look or smell unpleasant may be safe to drink. Above mentioned indicator parameters are listed in the Annex I, part C, while health related parameters are listed in the Annex I, part A and B of the DWD. There is a list of all DWD parameters and indicators and their meanings, health risks, and main sources of pollution in the ANNEX A. An identification of the source of pollution is important for consequent health risk assessment as it indicates about nature of contamination and possibly duration of exposure (temporary versus permanent), about stability or fluctuation the concentrations found in time and within the zone – the closer is source of pollution to consumer´s tap, the bigger fluctuation of the values measured we can expect. Regarding the parameters where non-compliance is mostly caused by the materials used in domestic plumbing system (e.g. copper or lead), it is not possible to identify what part of the population supplied from the respected supply zone may be affected by such non-compliance if we have only summary results. There is another recent and critically evaluated list of the DWD parameters as well as other suitable parameters available and its relevance and purpose of use in separate parts of the supply system (catchments or source water control, treatment control, distribution conditions control, or consumer´s tap water quality control) in the ANNEX B. For details check the source document [5]. It is obvious from the Annex B that the parameters controlled in various parts of the supply system have different informative value. 4.2 Derivation of limit values Two approaches to the derivation of guideline or limit values for health-related chemicals are used according to the type of their effect: one for “threshold chemicals” (see Box 1) and the other for “non-threshold chemicals”, i.e. mostly genotoxic carcinogens (see Box 2). Box 1: Threshold chemicals
For most kinds of toxicity, it is believed that there is a dose below which no adverse effect will occur. For chemicals that give rise to such toxic effects, a tolerable daily intake 4 (TDI) should be derived as follows, using the most sensitive end-point in the most relevant study, preferably involving administration in DW. The TDI is an estimate of the amount of a substance in food and DW, expressed on a body weight basis (mg/kg or μg/kg of body weight), that can be ingested over a lifetime without appreciable health risk. As TDIs are regarded as representing a tolerable intake for a lifetime, they are not so precise that they cannot be exceeded for short periods of time. Short-term exposure to levels exceeding the TDI is not a cause for concern, provided the individual’s intake averaged over longer periods of time does not appreciably exceed the level set. The large uncertainty factors generally involved in establishing a TDI (see below) serve to provide assurance that exposure exceeding the TDI for short periods is unlikely to 4
Analogous parameter developed and used by US EPA is called Reference dose (RfD) for oral intake.
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have any deleterious effects upon health. However, consideration should be given to any potential acute effects that may occur if the TDI is substantially exceeded for short periods of time. TDI = (NOAEL or LOAEL)/UF where: NOAEL = no-observed-adverse-effect level LOAEL = lowest-observed-adverse-effect level UF = uncertainty factor
The NOAEL (no-observed-adverse-effect level) is defined as the highest dose or concentration of a chemical in a single study, found by experiment or observation, that causes no detectable adverse health effect. Wherever possible, the NOAEL is based on long-term studies, preferably of ingestion in drinking-water. If a NOAEL is not available, a LOAEL (lowest-observed-adverse-effect level) may be used, which is the lowest observed dose or concentration of a substance at which there is a detectable adverse health effect. When a LOAEL is used instead of a NOAEL, an additional uncertainty factor is normally applied. Uncertainty (or safety) factors are applied to derive the TDIs or ADIs (acceptable daily intakes) for food additives, pesticides and environmental contaminants. The reason is to cover all main sources of scientific uncertainties: interspecies variation (animals to humans) if animal study is used, intraspecies variation (individual variations within species), adequacy of studies or database, and nature and severity of effect. The derivation of these factors (each may get value in range of 1 to 10) requires expert judgement and careful consideration of the available scientific evidence.
The guideline value (GV) is then derived from the TDI as follows: GV = (TDI x bw x P)/C where: bw = body weight (default assumption for body weight of adults is 60 kg) P = fraction of the TDI allocated to drinking-water (the values generally vary from 10% of TDI for substances for which exposure from food is probably the major source to 80% for substances for which exposure is primarily through DW) C = daily DW consumption (default assumption for consumption by an adult is 2 litres of water per day) For more details see the WHO Guidelines for drinking-water quality [6].
The list of the DWD parameters with parametric (limit) values, TDIs or corresponding level of cancer risk is provided in the ANNEX C. Box 2: Non-threshold chemicals
In the case of compounds considered to be genotoxic carcinogens, guideline values are normally determined using a mathematical model. Although several models exist, the linearized multistage model was generally adopted. Guideline values are presented as the concentrations in DW associated with an estimated upper-bound excess lifetime cancer risk of defined level. For example, the WHO Guidelines for drinking water quality present the guideline values based on the cancer risk of 10-5 (or one additional cancer per 100 000 of the population ingesting DW containing the substance at the guideline value for 70 years). The parametric values of non-threshold chemicals included in the DWD are mostly based on the cancer risk of 10-6, i.e. one order more strict values. However, all these values must be regarded as rough estimates of cancer risk. For more details on model assumptions and calculation see the WHO Guidelines for drinking-water quality [6].
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4.3 Evaluation of non-compliance with chemical health-related parameter limit values Even the breach of the limit value of chemical health-related parameter does not necessarily pose any health risk, because: • the limits are usually set with considerable margin of safety – see for the principles of setting the limit values of health related parameters (e.g. for tetrachloroethene and trichloroethene with limit value 10 μg/l, the safe concentration for temporal exposure is 200 μg/l for infants and 1000 μg/l for adults); • the limit is based on organoleptic basis: e.g. some volatile organic compounds like the xylenes have the limit value based on taste and odour about one order more strict than health-based limit; • the limit value is set by political decision: for example this is the case of most pesticides for which the DWD sets uniform limit value 0,1 µg/l, which is expression of political decision that the pesticides should not be present in DW (even in low, toxicologically safe concentration). As from simple information on non-compliance we are not able to estimate the extent of exceedance (and the dose received), we have to identify the group of parameters where even little exceedance of the limit may cause harm effect (mostly for sensitive subpopulations) and when we can indicate health risks from any non-compliance. These parameters are: • nitrate and nitrite which may cause infant methaemoglobinaemia (acute effect); • copper which may cause gastrointestinal problems at some sensitive children or adults (acute effect); • sulphates in presence of high magnesium contents which may cause diarrhoea at some consumers not adapted to the source (acute effect); • lead which may cause subencephalopathic neurological and behavioural effects if foetus, infant or very young children with developing neurological system are exposed (chronic effect); • fluoride which may cause dental fluorosis (mottled teeth) at some children (chronic effect); • arsenic ? (there are significant uncertainties regarding the risk assessment for arsenic carcinogenity whether even low concentrations about the limit value represent risk or not). In theory, in case of accident and gross contamination we could expect acute health problems from most chemical substances – even of relatively low toxicity, but these situations are very rare. 4.4 Evaluation of non-compliance of microbiological parameters Evaluation of microbiological parameters seems to be more difficult and one have to understand the system used at the first (see Box 3 for the principle of current microbiological quality monitoring).
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Box 3: Microbiological quality of drinking water
Principles of current microbiological quality monitoring There are a wide variety of micro-organisms that may be found in water. These include those that are pathogenic and those that are not pathogenic. Some of the non-pathogenic micro-organisms may lead to other problems in water supplies such as taste and odour, which may be of particular importance to users of the supply as an indicator of safety and may influence their selection of water for consumption. However, the principal concern for microbiological quality is the potential contamination by pathogens. Pathogens tend to be classified according to their group or family and include bacteria, helminths, protozoa and viruses. Although it is known that pathogens cause disease, the routine monitoring of pathogens is generally not undertaken for several reasons. For many pathogens there is a lack of analytical tools available and where these do exist they are often expensive and difficult to perform. Individual pathogens cannot be guaranteed to be present in all untreated or unprotected waters as this depends on whether the faeces (or other materials e.g. medical wastes) from an infected person or animal are present in the water. Therefore failure to observe a particular pathogen cannot be taken to imply an absence of other pathogens. Furthermore, it is desirable to have a means of detecting contamination before there is a significant public health risk in order to ensure actions can be taken to prevent a major outbreak of disease. As a result of the issues raised above and because most water-borne pathogens are derived from faeces, it is usual practice to use indicator organisms, usually bacteria, for the analysis of microbiological quality of DW. There are a number of indicator micro-organisms that may be used in drinking water quality monitoring programmes. The organisms listed in the DWD are: Escherichia coli (E. coli), enterococci, Clostridium perfringens, and coliform bacteria. Critique of the indicator-based approach The principal current indicators used do have serious limitations. The relationship between pathogens and indicator bacteria is not simple, the range of pathogenic organisms is large, and their nature is broad and many do not bear many similarities with the indicator organisms. The weaknesses of current indicators in predicting health risks has been noted as there is evidence of infection by waterborne pathogens when indicators are not present in water. It has been suggested that whilst the current suite of indicators of microbiological quality have provided a useful tool in prevention of epidemics, they provide far less information about endemic disease, particularly where the disease agents are viruses. The data from these studies suggests that the current indicator bacteria are not adequate alone to predict pathogen presence. The limitations in the use of the current indicators indicate weakness in the application and interpretation of the results of analysis rather than the imperfections of the system itself. The original development of standards for water quality based on indicator bacteria in the early 20th Century were designed to verify treatment system performance (in particular slow sand filtration and disinfection). The bacterial indicators were only one mechanism of verification of water quality and were supported by sanitary surveys of water supplies and monitoring of treatment plant operation. However, over time, the basis of legally enforceable measures of water quality has increasingly focused of numerical limit values for faecal indicator bacteria. Support for continued use of the indicators There are strong arguments that can be made for continued use of indicator bacteria as the principal method for monitoring the microbiological quality and thus, indirectly, the likelihood of pathogen presence in DW supplies. A recent review of microbial indicators concluded that the use of the standard indicators has done much to improve health and their abandonment due to recognized weaknesses is unjustified and likely to be counter-productive to health. Adapted from Howard et al. (2003)
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The interpretation of the results of indicator bacteria analysis in the context of standards illustrates profound misconceptions of the meaning of the absence, presence and numbers of faecal indicator bacteria. Many people in water and health sectors still equate an absence of faecal indicator bacteria with an absence of pathogens. As noted in the box this may not be true given the evidence of water-borne infections resulting from DW meeting current standards. Furthermore, many professionals also seem to equate the presence of faecal indicator bacteria with confirmation of the presence of pathogens. However, it may also not be true – in reality it merely implies that the risk of pathogen presence has increased, as there is evidence of recent faecal contamination. Any attempt to translate the findings of monitoring that describe a risk (which is an inherently probabilistic approach) into a certainty, means the principal flaw in the use of indicator bacteria. Such an approach inherently contains some degree of potential for false positive and false negative results in relation to pathogen presence [7]. Moreover, one also has to take into account two other important facts: what does it mean in reality the absence of faecal indicator bacteria in terms of “zero” results (e.g. 0 CFU/100 ml) and the relativity of any result in microbiological analysis of water relating to the method used. If we consider confidence intervals (e.g. 95% CI), then the results of coliforms 0 CFU means 0.0 – 3.7 CFU, 1 CFU means 0.1 – 5.6, 2 CFU means 0.2 – 7.2, etc. [8]; or the results 1 CFU means < 1 – 6 CFU, 2 CFU means < 1 – 7 CFU, 3 CFU means < 1 – 9 CFU etc. [9]. As bacteria are not homogenously distributed in water, but usually clustered, there may be the large variability in bacterial densities across a drinking water supply. For example coliform densities in some regions of the drinking water supply where coliforms are not detected in 100-ml volumes may vary by as much as 108-fold. The 0/100-ml samples may therefore provide a false sense of security if the operator does not know how close each zero sample was to registering a coliform or how many of the 0/100-ml samples were close to registering coliforms [10].
If we consider the nature of microbiological analysis, we know that we do not look for absolute number of bacteria of selected groups of bacteria in water, but just for certain part of it which is strictly defined by the standard method agreed. If we use little modified method or even another method – in terms different cultivation medium, way of inoculation, incubation temperature or time – we should get totally different results from the same water sample. Not speaking about another key role of the sampling method. What should be the lessons learned? a) Any figures in microbiological analysis of water are relative and defined by the method used. b) Any result – either positive or negative finding of indicator bacteria – does not provide absolute information on the presence or absence of health risk; it just expresses the probability of the risk: the relative numbers of faecal indicators in a water supply are more important than simple presence, as increasing numbers of indicator bacteria implies that the risk of pathogen presence increases. c) Key assessment action may be done only on the level of the single zone, taking account the results of other parameters (do other results, either microbiological or chemical, support non-compliance finding?) and information from sanitary survey or local investigation of water supply.
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d) If indicator bacteria are isolated and other results or complementary information from sanitary survey (accident source pollution, treatment failure, pipe break, etc.) confirm the result, the proper investigation of the cause of non-compliance should be done to select the most appropriate remedial action.
5. Numerical data on water quality 5.1 Microbiological parameters Not even real data on microbial water quality in terms of numbers of CFU found in routine monitoring allow to assess health risk precisely – see above for comments on evaluation of non-compliance of bacterial faecal indicators. The assessment will be in any case qualitative: lower or decreasing versus higher or increasing risk of infection. Although there have been already developed the methods for quantitative health impact assessment (HIA) related to biological pollution of drinking water, the information available and needed for the calculation is still very limited. So far, the lack of available exposureresponse functions for each potential pathogen in water and especially the lack of data on real occurrence of pathogens in water supplies hinders scientific progress on HIA development and its routine use in practice. Basic principles and more details of quantitative microbial risk assessment (QMRA) can be found in special literature [6] or websites [11].
5.2 Chemical parameters If numerical or concentration data on each health related parameter are available, various kinds of quantitative health risk assessments are possible. Some examples follow.
5.2.1 Health risk assessment from non-compliance In case of non-compliance of threshold chemicals we can calculate average daily dose (ADD) consumed and through comparison with tolerable daily intake (see Box 1) to assess whether one can expect health risk or not (and for what age-specific population 5 ). In case of noncompliance of non-threshold chemicals we can calculate lifetime average daily dose (LADD) consumed and with help of cancer slope factor 6 we can assess whether level of cancer risk 7 is still acceptable or not. These assessments should be made obligatory before any derogation 8 is granted to ensure that such derogation does not constitute a potential danger to human health. Some countries established and published maximum acceptable values of chemical parameters listed in the DWD for the purpose of derogation, for example Germany [12]. The method of calculation of ADD and health risk is shown in Box 4.
5
Based on usual body weight of each age group. Cancer slope factor is practical expression of exposure (dose) - response function for carcinogenic substances in the low-dose region. When low-dose linearity cannot be assumed, the slope factor is the slope of the straight line from 0 dose (and 0 excess risk) to the dose at 1 % excess risk. An upper bound on this slope is usually used instead of the slope itself. The units of the slope factor are usually expressed as 1/(mg/kg-day). 7 Individual lifetime cancer risk. 8 Temporary agreement with non-compliance of chemical parameter – see Article 9 (Derogations) of the Drinking Water Directive (98/83/EC). 6
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Box 4: Method of calculation of quantitative health risk assessment from non-compliance
The first step is to assess the exposure, which is calculated as so called average daily dose (ADD) for non-cancer risk or threshold chemicals, usually averaged for one year of exposure, but shorter period is also possible, or so called lifetime average daily dose (LADD) for cancer risk or non-threshold chemicals; as follows: ADD (LADD) = CW x IR x EF x ED/ BW x AT where: CW = chemical concentration in water (mg/l) IR = ingestion rate (litres/day) EF = exposure frequency (days/year) ED = exposure duration (years) BW = body weight (kg) AT = averaging time (period over which exposure is averaged – days); when assessing toxic effect then AT = ED x 365; when assessing carcinogenic effect, we average dose for whole assumed life time (70 years) or AT = 70 x 365, then we get LADD (lifetime average daily dose)
If chemical substance assessed is volatile and one can assume not only exposure from ingestion, but from inhalation, too (e.g. when water is used for bathing or showering), ADD from inhalation exposure may be calculated and than added to oral ADD. To be precise, also ADD from food may be calculated or estimated (if known) to receive total exposure. The second step or assessment of probability of the risk of toxic effect of given substance (non-cancer risk) is calculated by mean of so called hazard quotient (HQ): HQ = ADD/TDI If HQ value is less than 1, we do not expect any risk of toxic effect.
Level of risk from the exposure to carcinogenic substance(s) is determined as so called individual lifetime cancer risk (ILCR), which is calculated through formula: ILCR = LADD x CSF where LADD see above CSF = cancer slope factor (factors for individual substances may be found in various databases e.g. IRIS – see http://www.epa.gov/iris/)
From the ILCR we can calculate annual population cancer risk (APCR) that expresses annual risk of cancer cases occurrence in specific exposed population, or average number of additional cases of cancer (caused by DW exposure) per year: APCR = ILCR x number of people exposed / 70 (years). Acceptable level of cancer risk is defined by political decision on national (regional, EU...) level.
As an example of such approach we can use the case study producing estimates for Health Risk Assessment (HRA) and Environmental Burden of Disease (EBD) due to higher arsenic content in DW which was conducted in one French region (Puy de Dôme).The study was developed within the project “Implementing Environment and Health Information System in Europe” (ENHIS). Both carcinogenic (skin cancer) and toxic effect (vascular complication) from As exposure were evaluated.
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The results for HRA showed that, for lifetime exposure under normal (mean) exposure patterns, there would be an increase of 11.8 skin cancers per 100,000 in the exposed general population over 70 years. For an extreme (P95) water ingestion, this number would be 29 cases per 100,000 in general population. According to the percentages of children (10 251 children in total) exposed to the different arsenic concentration ranges in the study area, a total increase of 0.4 cases (4.3 cases per 100,000) above the number of expected skin cancers for children would be predicted for a normal daily intake. When an extreme DW intake (1.06 L/day for this age group) was considered, the increase would be up to one child (12.1 cases per 100,000) in the same period. Regarding chronic toxic hazard, the HQ values exceeded 1 and indicated potential occurrence of skin diseases and vascular complications in general population and adult age groups (>15 years old) for arsenic concentrations higher than 30 µg/l and normal DW intake. In the case of children (body weight 30.2 kg), HQ >1 were obtained even under lower arsenic concentrations (> 20 µg/l), suggesting that negative health effects for smaller children could be relevant and more significant than for adults. Risk for developing negative health effects for children and adults could be especially important under the worst-case scenario (extreme ingestion rate). The toxicity thresholds in this case was exceeded (HQ > 1) when population consumed water with an arsenic concentration higher than 11 µg/l. Regarding another approach to health impact assessment – Environmental Burden of Disease – the DALYs (Disability Adjusted Life Years 9 ) were calculated. The number of DALYs attributable to skin cancer related to arsenic oral exposure under normal ingestion rate (IR) in Puy de Dôme population was of 2.2 and 594 DALYS for morbidity or mortality, respectively. Results were more than double for both health outcomes when extreme IR was considered. For details on exposure assumptions and calculation methods see original text [13]. Generally there is a rule that smaller unit of analysis we are going to evaluate (e.g. one water supply zone), usually more detail information is available and the better health impact or health risk assessment can be done!
5.2.2 Assessment of importance of threshold chemicals exposure from drinking water In case of compliance of health related parameters (threshold chemicals) we can assess, how important is drinking water as a source of exposure for some chemical pollutant: through calculation of average daily dose we can identify the share (%) how DW can contribute to tolerable daily intake of respective chemical substance. Comparing this contribution with other routes of exposure (air or food), we can identify priority for risk management measures, if needed. Method of calculations: If we want to evaluate the situation in population supplied from one water supply zone, we calculate average daily dose (ADD) for respective chemical – see above – and from the formula (ADD/TDI) ∗ 100 we know how intake from DW consumption draws off tolerable daily intake (TDI). If we want to evaluate the situation in whole population supplied from public water supply, we have to calculate at first the share for every water supply zone, to combine this figure with number of inhabitants supplied from the zone, and finally to sum up all these data from all zones to get country-wide overview. See example in Table 3 and Figure 5. 9
For details see website of the International Burden of Disease Network (www.ibdn.net).
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Table 3 Exposure of population to selected contaminants from drinking water ingestion expressed as % of exposure limit (TDI or ADI) according to the size of supply (population more or less than 5000). Data from all public water supplies in 2006, Czech Republic. Daily water consumption of 1 litre considered; both median and quantile 90 concentrations used for calculation % exposure limit (TDI) Size of the zone (population) more than 5000 persons less than 5000 persons Parameter median quantile 90 median quantile 90 Arsenic
< Names in ‘bold’
Task is being completed (will be available at SharePoint as soon as it is ready) Update needed after production at the first stage of the ENHIS project Leaders/ responsible
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Annex 3 Distribution of tasks Subject Environment & Health Indicators Health Impact Assessment (incl HIA tool, etc) Policy (incl RPGs, etc) About ENHIS Disclaimer Contact Lay out and LOGO Topic introductions
Writer done done Natalia Valero Eva Kunseler, WHO WHO
Christian Gapp
WHO WHO David Barrett
Final approval WHO WHO WHO WHO WHO WHO WHO WHO
Air quality
Michal Krzyzanowski
Matti Jantunen
WHO
Ionizing and non-ionizing Radiation Chemicals Water and Sanitation Traffic Housing Noise Other risk factors
Philippe Pirard Nida Besbelli (WHO) Alexandra Katsiri & Olga Cavoura Maria Carroquino, Sara Farchi Mathias Braubach Brigit Staatsen RIVM
Matti Jantunen, Marco Martuzzi Jouko Tuomisto Frantisek Kosicek Francesca Racioppi, RIVM RIVM Odile Mekel
WHO WHO WHO WHO WHO WHO WHO
All fact-sheet writers need to write a key message for the website! English editing from communication point to be done by Ralf Sudhoff (WHO), Harmonisation of web texts to be done by RIVM
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Editor (content) RIVM WHO RIVM?? Matti
Annex 4 Consolidated work plan for the 2nd year of project implementation Task Changes in the budget sent to WHO/ WP 1 Contributions to interim technical & financial reports sent to WHO/ WP 1 Interim reports sent to EC Indicator fact sheets (preliminary drafts) First draft CEHAPE indicator-based assessment report 1st version of the web service available to EEHC & EC DG Sanco WP HE Comments / reviews to the 1st version 2nd Draft of the assessment report and version 2 of the web-service ready Methodology for identifying policy information needs and annual assessment report ready International data sets for the core set of indicators Expansion of web-service & functionalities Contribution on HIA from selected indoor air and noise risk factors on children to indicator fact-sheets & CEHAPE assessment report 3rd Draft CEHAPE report & Version 3 of web service available to EEHC Final draft CEHAPE assessment report Routine HIA tool upgraded Hands-on guidance for information generation Meta-data base for the core indicators, user manual and software documentation Core set of indicators and methodology Qualitative HIA of drinking water pollution ENHIS web service launch CEHAPE assessment report published Set of National indicator fact-sheets Report on HIA according to the reporting guidelines Assessment of new policy information needs Extended set of EH indicators methodology Definition of children’s EH information to be collected by surveys WP products completed in draft version WP products finished Final project report
Responsible WP (WP involved) All partners Partners, WP leaders
Date 31 Oct 2006 27 Nov 2006
WHO/WP 1
31 Dec 2006
WP 4 (WP 3, 5, 6) WP 2 (WP 3, 4, 6) WP 8 (WP 6)
30 Oct 2006 22 Nov 2006 22 Nov 2006
WP 2 and WP 8 (WP4)
15 Dec 2006 17 Jan 07
WP 3
17 Jan 07
WP 5 WP 8 WP 7
17 Jan 07 25 Jan 07 10 Feb 07
WP 2 and WP 8
15 Feb 07
WP 2 WP 7 WP 5 WP 8 & WP 2
15 March 20 Apr 07 25 Apr 07 30 Apr 07
WP 4 WP 7 WP 2 and WP 8 WP 2 WP 6 WP 7 WP 3 WP 4 WP 5
30 Apr 07 30 Apr 07 1 June 07 1 June 07 1 June 07 25 Aug 07 25 Aug 07 1 Sept. 07 1 Sept 07
WP 3 , 4, 5, 6, 7, 8 WP 2, 3 , 4, 5, 6, 7, 8 WHO/ WP 1
1 Sept 2007 31 Oct 2007 31 Jan 2008
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Technical meetings to be conducted in the 2nd year of project implementation Meeting Technical meeting on feasibility of HIA
WP involved WP 7
Editorial meeting (CEHAPE indicator-based assessment report and web-service) HIA: satellite meeting Workshop on methods Workshop on EH policy accountability Technical meeting on air pollution and drinking water assessments … Final meeting
WP2, WP3,4,5,6,7 & 8
Date End Dec. 06 – early Jan 07 Week 22-26 Jan 07
WP 7 WP 4,5,6,8 & 7 WP3 and EC DG JRC WP 7
After 15 March 07 April-May 07? Early April 07
WP 1 to 8
Week 17-21 Sept 07
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WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR EUROPE WELTGESUNDHEITSORGANISATION REGIONALBÜRO FÜR EUROPA
ORGANISATION MONDIALE DE LA SANTÉ BUREAU RÉGIONAL DE L'EUROPE ВСЕМИРНАЯ ОРГАНИЗАЦИЯ ЗДРАВООХРАНЕНИЯ
ЕВРОПЕЙСКОЕ РЕГИОНАЛЬНОЕ БЮРО
EUROPEAN CENTRE FOR ENVIRONMENT AND HEALTH BONN OFFICE
ESTABLISHMENT OF ENVIRONMENT AND HEALTH INFORMATION SYSTEM SUPPORTING POLICY-MAKING IN EUROPE ENHIS-2 Grant Agreement SPC 2004124 between The European Commission, DG Sanco and World Health Organization, Regional Office for Europe
FINAL MEETING Prague, Czech Republic 12-14 September 2007
SUMMARY REPORT © WHO ECEH, Bonn, September 2007
Background WHO European Centre for Environment and Health is coordinating a project “Establishment of Environmental Health Information System Supporting Policy Making: ENHIS-2”, co-financed by EC DG Sanco and the partner institutions from 18 member states. The project aims to start the operation of a comprehensive information and knowledge system that will help to identify and prioritise common and widespread environmental health problems, make possible monitoring the effects of policies and actions taken, facilitate inter-country comparisons and time trends analysis and ensure timely access to information and its effective dissemination. The meeting was convened to evaluate the progress of the second year of the project implementation and to plan the activities to finish all deliverables. Participants reviewed the deliverables with respect to policy analysis, health impact assessment, indicator generation and building the IT system infrastructure. In particular, the meeting evaluated the deliverables of each work package vis-à-vis the objectives and decided on the necessary follow-up actions for finalization of the deliverables to EC DG Sanco by the end of October 2007. The tasks and responsibilities for preparation of the final technical report to be submitted to EC DG Sanco within the three months after project termination were also agreed upon. The meeting gathered all ENHIS-2 project partners, participating network centres, as well as experts from institutions volunteering to be involved in the project. It was attended by 44 participants (see list of participants in Annex 1). Ruzena Kubinova chaired the meeting, Michal Krzyzanowski co-chaired it and Piedad Martín-Olmedo acted as rapporteur. The proposed agenda and programme were accepted. Dr. Jaroslav Volf, Director of The National Institute of Public Health in Prague gave a warm welcome for the host Institution, encouraging participants to make progress in the directions of how to use information for policy makers, and in finding the approaches for the dissemination of information to best support public health promotion programmes. MEETING OBJECTIVES • • •
To evaluate progress and status of ENHIS2 deliverables to date; To agree on the tasks for finalization of the ENHIS 2 deliverables and for preparation of final implementation report to EC To recommend follow-up activities for continued Member States’ involvement in the system operation and national use
Summary of the meeting discussion The main points of the discussion are outlined below. The meeting consisted of plenary discussions on the main issues and small working groups composed to agree on actions for the preparation of the main products. REPORTING AND EVALUATION OF FINDINGS AND PLANNED DELIVERABLES
Work package 2: presented by Dafina Dalbokova Objectives and deliverables according to contract:
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Summary of results achieved and some tasks •
• • •
•
D2.1. SharePoint http://enhis.ecehbonn.euro.who.int: used for the exchange of data and information and is being actively used by more and more partners. The full functionalities e.g. revision of documents, activity monitoring, etc have not been implemented. It is also not very easy to search for specific information. These limitations are related to the different operating systems of the users. D2.1. ENHIS web-site http://www.enhis.org: the information is progressively expanded and becomes more and more visited; necessary to discuss and plan the web maintenance and update D2.2. Report summarizing mid-term project results: duly delivered to EC DG Sanco and accepted D2.3. CEHAPE assessment report is ahead of schedule. A concerted effort of all partners and many contributors, it was distributed and presented at the Intergovernmental Mid-term Review meeting (Vienna, 13-15 June 2007) and to international forums of the environmental epidemiology and public health (e.g. INCHES, ISEE 2007, etc) and has received a strong positive resonance. The report as official WHO publication will be featured by EEA at the upcoming 6th Ministerial Conference on environment for Europe (Belgrade, 10-12 October 2007) D2.4. guidelines for preparation of final report are discussed below
Questions and suggestions from coordination and partners: • • • • • •
All partners are encouraged to use the ENHIS products in possible national or international meetings; All possible publications will be reported in the final report as part of the dissemination activities; Each partner should include a link to the ENHIS site in their own web sites; The “Environmental Health Perspectives” journal has a call for papers on children’s health; publications are encouraged to be submitted; Possible publications should be announced on the SharePoint, with title, list of authors, and a brief description of the aim of the paper. A common paragraph for the acknowledgement of possible articles under ENHIS project has been agreed below.
Work package 3: presented by Eva Kunseler Objectives: • Stimulate the development of accountable environmental health policies at pan–European level. •
Enhance the policy-relevance of the Environment and Health Information System.
•
Improve knowledge and understanding of the existing environmental health policies across Europe – their format, objectives, rationale and accountability.
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Identify gaps and consequent information needs in the policy process, e.g. a specification of the weaknesses in policy accountability for public health.
•
Stimulate the harmonisation of national environmental health policies through sharing and comparing formulations, experiences, successes and failure.
Deliverables according to contract: • • • •
D3.1 Methodology for identification of information needs for policies D3.2 Annual assessment of new information needs – Part I D3.3 Guidelines for generating information for policy support D3.4 Annual assessment of new information needs – Part II
WP3 progress: •
D3.1. Methodology report – In final stage: description and exemplification of the policy assessment and evaluation methodology throughout the following tools: i. EH policy questionnaire ii. EH policy information database iii. Comparative assessment frame iv. EH policy case studies
•
D3.2 & D3.4. Policy assessment report – In final stage: Assessment on European and national EH policies resulting from document analysis and policy questionnaire responses;
•
D3.3. Generating information for policy support: case examples – In progress;
•
Updating policy page on www.enhis.org – To be started
Work to be done to finalize tasks according to contract: •
Based on discussion following the presentation, it was decided to reorganize the deliverable reports and put emphasis on the method development, implementation and reporting of the information needs assessment. Information needs assessment follows from policy assessment and gaps-andneeds analysis; the current reports describe these preceding exercises in too much detail.
•
Finalization of Case studies: a. All: Assessing the accountability level of the EH policy cases following the policy phases: policy initiation, formulation and implementation b. Spain, Bulgaria and Lithuania: Gather examples of lessons learned and policy recommendations to make possible a thorough information needs assessment for each case study.
•
Policy page on www.enhis.org: a. Methods and tools for policy information generation: Link to be included on Methods & tools page b. National policy assessment by topic and by country: Link to policy assessment sections (pdf) and policy database (excel format) c. Policy accountability analysis following the three policy phases including gaps-and-needs analysis: To be updated and elaborated on EH policy page d. Case examples – good policy practices and recommendations: To be included on EH policy page
Questions and suggestions from coordination and partners:
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• • • •
•
It is necessary to prepare guidelines to properly fulfil deliverable 3.3. If not possible, provide arguments; Crosscheck country policy information with WHO web map in order to avoid double key-messages: already done; Consider summarizing the experience gained on how to create an integrated EH policy approach avoiding non-effective individual policy actions and lack of coordination at the horizontal and vertical policy levels; Specific country policy assessment was not objective of the contract. Therefore, efforts should be concentrated in reporting the methodological tools, emphasising the information that is necessary to be compiled for a proper policy assessment. Lessons from the analysis could be presented as examples, and the case studies - published after 1st November as individual publications; Concentrate efforts for discussion on how to present the results, both in the final report, and also on www.enhis.org.
Work package 4: presented by Dafina Dalbokova
Finalisation of the work •
Deliverable D4.3: a. Extract from the fact sheets the sections for meta-data; rationale; health and environment context; policy relevance and context and some of the references b. Integrate them in the methodology format c. Replace the existing file on www.enhis.org
•
Deliverable D4.4: d. Select the extended set of indicators by taking the indicators beyond the 26 core indicators and reviewing the ENHIS and ECOEHIS methodology sheets; Note: For the core set follow up with ECHI, ECHIM and EUPHIX projects -> assure harmonization and avoid duplication e. Collate the corresponding methodology ensuring consistency with the templates f. Publish the results on www.enhis.org
Questions and suggestions from coordination and partners: • The extended set of indicators should be covered in the same way as the core set of indicators. • Keep the names of the core set of indicators. • Provide clear information about the source of data for each indicator.
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• •
Revise the ENHIS and ECOEHIS methodology for the core set of indicators Assure the coordination with ECHI, ECHIM and EUPHIX using also the upcoming WP health and environment meeting
Work package 5: presented by Adriana Galan Objectives according to contract: Develop and apply methods allowing the use of information from existing national/international data bases and surveys. Deliverables according to contract: • D 5.1 Definition of organizational framework for exchange of relevant data available in international databases • D 5.2 Inventory of available surveys methods for CEH indicators • D 5.3 Data sets necessary for the core indicators available in the international databases • D 5.4 Definition of information necessary for CEH to be collected by surveys Summary of results achieved • A comprehensive Hands-on guidance intended to be a practical tool in supporting data retrieval for generating EH indicators (both for general population and children population-CEHAPE-RPGs). Indicators were classified into 2 categories: core set and extended set; for the indicators included in the core set have been retrieved in international databases or surveys, and fact sheets were developed for each of them. Indicators included in the extended set need special surveys to collect the necessary data or need further methodological development. • An inventory of data sets necessary for the core indicators available in the international databases has been created; • Inventory of indicators necessary for children’s environmental health to be collected by special surveys is under way. Some problems for the future • Hands-on guidance has to be continuously maintained and updated due to frequent changes of data sources, web links or homepages revision; in some cases new relevant databases are launched by different agencies or projects providing valid information for EH information system • Update of case studies – are national data sources going to be used in the future? • Which will be the mechanisms to continue the cooperation between ENHIS partners? • What mechanisms will be followed to extend the ENHIS network? Questions and suggestions from coordination and partners: • Hands-on guidance will be uploaded on the www.enhis.org • Keep the names of core indicators and make clear that there are differences among country survey systems • Deliverables have been accomplished properly.
Work package 6: presented by Anna Paldy Objectives according to contract: • Test the developed methods by the partner countries collecting information and preparing international reports on selected issues • Expand the network of national collaborating centres (NCC) including all partners, promoting: Communication links Information exchange structures Deliverables according to contract:
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• • • •
D 6.1: Communication and information exchange links with all NCC. D 6.2: Pilot study of indicators defined by WP4 implemented in the partner countries. D 6.3: Contribution to international indicator reports D 6.4: Prepare a set of national indicator fact sheets, with the following aims: To prepare around 10 national fact sheets in national languages and publish it on the national websites; To present/ disseminate the fact sheets at national level involving relevant stakeholders
Summary of results achieved • D 6.1: The Sharepoint web-site ensured effective information exchange and communication between members of the network (over 91 users); • D 6.2: Completed in the beginning of 2007; • D 6.3: Centres of excellence have been selected from the network members to prepare subjectspecific sections of the international report Children’s Health and the Environment in Europe: a Baseline Assessment which was presented at the IMR in Vienna, 13-15 June 2007; • D 6.4:A process has been set and process and possible national fact-sheets would be produced as follows: Bulgaria not yet decided Czech Republic Exposure of children to air pollution (PM) in outdoor air is completed; maybe one more fact sheet would be feasible, Estonia not yet decided Lithuania “Mortality from road traffic injuries in children and young people” Hungary “Prevalence of asthma and allergies in children (completed in Hungarian)” and a second fact sheet on child obesity planned to be prepared; Poland “Infant mortality due to respiratory diseases” Romania “Mortality from road traffic injuries in children and adolescents” Slovakia “Bathing water quality” Slovenia “Bathing water quality” (completed?) Spain not yet decided. Questions and suggestions from coordination and partners: • It is very important to extent the experience achieved at European level to the national levels. Therefore, preparation of national sheets is encouraged. In order to do so, WP6 should define the set of those fact sheets that are almost ready or could be finished by 1st November as a deliverable, and the rest of possible fact sheets proposed will be finished later on as an extended work. • Romania is organizing a workshop by December 2007where ENHIS will be promoted and several fact sheets will also be prepared in the next year. In this way, countries could prepare small report on national experiences on application of ENHIS.
Work package 7: presented by Odile Mekel Objectives according to contract: • Using information gathered in ENHIS project on indicators, analyse the feasibility of health impact assessment (HIA) of risk factors in indoor air and noise pollution with a focus on children’s health; • Develop software for HIA of outdoor air pollution (HIAir); • Conduct HIA of ambient air and drinking water pollution Summary of results achieved • 7 HIA feasibility studies by the following partner institutions: For indoor air: Radon in dwellings (InVS); Children living in homes with Solid Fuel Use (ISCII); Children living in homes with mould and dampness (SZU); Children exposed to ETS (ISCIII) For noise: Children in proximity to traffic (noise) (LÖGD) For outdoor air: Children’s exposure to outdoor PM10 (ASPB, EASP, InVS)
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• •
The health impact assessment of ETS and outdoor PM10 have been conducted for majority of EU countries, the one of blood lead level, mould and dampness, and noise –at sub-national level. HIA was not feasible for radon and solid fuel use. Methodological guidelines for health impact assessment Software HIAir 1.0 as a web application for on-line HIA calculations on urban air pollution.
Questions and suggestions from coordination and partners: • Needs to present a qualitative approach to HIA of drinking water pollution (consult with F. Kosicek about it). Discuss in the group a positive way to report a task that can’t be achieved • Include assumptions for HIA of environmental tobacco smoke calculations. • Graphics on reduction of sudden infant death syndrome (SIDS) with reduction of smoking prevalence in selected countries i.e. health gains • For final report, include a limited number of individual HIA calculations for out door air pollution.
Work package 8: presented by Christian Gapp Objectives according to contract: Prepare and test methodology for analysis and reporting of current EH situation and policy effectiveness assuring effective dissemination of EH information and risk communication Summary of results achieved • Guidelines for indicator-based reporting developed and applied in the preparation of fact sheets and assessment report; • Key IT infrastructure elements in particular important progress on the ENHIS web site which has been presented at the IMR and received a positive resonance. Feedback has been received from future users and recently the following functionalities and contents have been added: Search function Web version of country ranking table, based on the indicators All indicator data used are in the database • Technical documentation for the ENHIS web is under way • The current work includes: Finalization of the overview by country pages Edit texts about data retrieval in the methodology page (A. Galan) and correct mistakes; References to the external web pages to be converted into direct links (RIVM) Update all new texts in CMS and decide and include new pictures New database and web-site release by RIVM Include links to relevant pages in EUPHIX: RIVM Fix of printing problems on EH issues pages: RIVM by end 07 Questions and suggestions from coordination and partners: • Cross-check of products and deliverables contracted. Particularly, include guidelines for indicatorbased reporting and for fact sheets in the methodology pages; • State very clearly in the final report for the EC, that development of a software tool for automatic download of data from international data sources was not practical • The most important task is access to the excel files with the data to enable the users making their own analysis; • The country profile on indicators should also contain the policy assessment – adding one more level to the country profile to incorporate a link to the country policy assessment prepared by WP3 - and some links to the burden of disease by country as well as country map from the WHO EEHC website; • The country profile on indicators should also incorporate a link to the environmental indicators (country “scorecards” from the EEA State of the Environment report, 2005)
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DISCUSSION ON FINALIZATION OF TECHNICAL WORK BY WORK PACKAGE
WP3 Finalization The group discussed the interpretation of the deliverables reflected in the current report contents. It was concluded that the perspective of the reports is to be changed: instead of presenting the policy assessment findings in terms of accountability, the information needs for achieving accountable policymaking should be described. These information needs are retrieved as result from the WP3 policy assessment exercises in the ENHIS 2 countries and the five case studies in particular. This change of perspective has implications for the contents of each deliverable report, described successively below. Report on D 3.1 currently includes a description and exemplification of the methodology: – EH policy questionnaire – EH policy information database – Comparative assessment frame – EH policy case studies To be done: Re-writing the report from the perspective of information needs generation, thus explaining the purpose of the four policy tools in the light of information needs retrieval. Responsible partner: KTL (WP3 lead partner) Deadline: 31 October Report on D 3.2 and D 3.4 currently includes the assessment of European and national EH policies resulting from document analysis and policy questionnaire responses To be done: Re-writing the report from the perspective of information needs retrieval. The introduction should include a more extensive text about the information needed for accountable EH policymaking. Subsequently, the method application process is described, followed by a Results chapter: information needs retrieved from EH policy questionnaire implementation, document analysis and case study implementation respectively. The topic-based policy assessment findings as such should be published on the ENHIS website. The concluding chapter should include reflection on the collected information gaps and needs for the accountability assessment of environmental health policy making. Responsible partners: KTL (WP3 lead partner) re-writes the report. The Bulgarian and Lithuanian partners finish their policy case evaluations. All principal partners (Spain, Italy, Finland, Bulgaria, Lithuania) analyse the accountability level of their cases and consequent information gaps & needs. The Finnish radon policy case analysis will serve as a framework for the other partners. Deadline: Finnish radon policy case analysis prepared and distributed to other partners by 1 October. The other partners finish and analyse their case studies by 19 October. Re-writing of the deliverable report 3.2 and 3.4 is to be finished by 31 October Report on D 3.3 currently includes experiences from national policy officials and experts with policy initiation, formulation and implementation in five EH policy topic areas. To be done: Considerable revision needed. The deliverable report should have a general character and cover only 3-4 pages in total and be written as guidelines aimed for policy support. First, the concept of accountable policymaking and related information needs should be briefly introduced. Guidance for policy support in generating accountable EH policies should be based on the results of the national policy assessment findings and case studies organised along the accountable policymaking steps. This deliverable is to be presented as working paper, since it is expected to raise considerable discussion and possibly further elaboration. Responsible partner: KTL (WP3 lead partner) Deadline: 31 October ENHIS website currently contains a policy page with policy assessment findings organised by topic and policy information about the international and EU policy frameworks in environmental health topics. To be done: Re-writing policy page; create policy section on Methods & tools page; uploading policy assessment sections in PDF file; uploading policy case studies in PDF file; make EH policy information database accessible for users; etc. Responsible partner: KTL (WP3 lead partner) and WP8 Deadline: Editorial week from 22- 26 October in WHO, Bonn.
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WP4 finalization On deliverable D 4.3 Definition of the core set of EH indicators and their methodology Work to be done: Decide which sections of the methodology sheets to be amended Responsible of the work: authors of the fact sheets from the ENHIS 2 partners; Deadline: 30th September. Work to be done: Amend the existing methodology sheets for the 26 indicators using the fact sheets prepared. Responsible of the work: All the authors of the fact sheets that are part of ENHIS. Deadline: 30th October Work to be done: Write a background section specifying the criteria on selection of the core set and the process (possibly add a short Annex) Responsible of the work: WHO/D. Dalbokova Deadline: 25th October. Work to be done: Compile the document together Responsible of the work: WHO/D. Dalbokova; Deadline: 3rd November. Work to be done: Replace the existing methodology sheet file on the ENHIS web with this file Responsible of the work: WHO/C. Gapp; Deadline: In the first week of November. On deliverable D 4.4 Definition of extended set of indicators and their methodology Work to be done: Preparation of a list of extended indicators Responsible of the work: authors of the fact sheets from the ENHIS 2 partners; Deadline: 05 October. Work to be done: Preparation of a short background Responsible of the work: WHO/ D. Dalbokova; Deadline: 25th October. Work to be done: Amendment of the methodology sheets for the selected indicators ensuring consistency of the methodology templates (those of ENHIS). Responsible of the work: Group of the core set (see above); Deadline: 30th October. Work to be done: To compile the whole document. Responsible of the work: WHO/ D. Dalbokova; Deadline: 3rd November. Work to be done: Upload the file on the web. Responsible of the work: WHO/ C. Gapp; Deadline: 5th November.
WP5 finalization On deliverables D 5.1 and D 5.3 Work to be done: Revise the hands-on guidelines first section and upload it on the SharePoint. Responsible of the work: WP5 Leader/ Adriana Galan; Deadline: 20th September. Work to be done: Partners of WP 5 to fill-in the meta-data section and the graphs of the fact sheets in the 3rd section of the guidelines. Responsible of the work: Partners of WP 5; Deadline: 15th October. Work to be done: Write a short background. Responsible of the work: ISPB/ Adriana Galan; Deadline: 25 October. Work to be done: To finalize and upload on the ENHIS web Responsible of the work: ISPB/ Adriana Galan and WHO/ Christian Gapp Deadline: 3rd November. On deliverables D 5.2 and D 5.4
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Work to be done: Compile the inventory existing surveys for the core set (check WHO doc). Responsible of the work: ISPB/ Adriana Galan Deadline: 15th October. Work to be done: Compile the list of necessary survey for CEH assessment. Responsible of the work: ISPB/ Adriana Galan Deadline: 15th October. Work to be done: Prof. van Oyen to review the document i.e. inventory+list. Responsible of the work: Herman vay Oyen Deadline: 21st October. Work to be done: Write a short background. Responsible of the work: WP5/ Adriana Galan Deadline: 25th October. Work to be done: To finalize the document and upload it to ENHIS web (WHO/ C. Gapp). Responsible of the work: WP5/ A. Galan, I. Zurlyte, V. Puklova and C. Gapp Deadline: 5th November.
WP6 finalization WP6 decided to produce the following national fact sheets: Bulgaria (definite answer by 20 September); the indicator will also be defined. Czech Republic reported that they will produce 3 fact sheets • Exposure of children to air pollution (PM) in outdoor air – completed • Levels of lead in children’s blood will be completed as well • Public water supply and access to improved water sources Estonia considers preparation of the following 3 fact sheets • Mortality from road traffic injuries in children and young people • Public water supply and access to improved water sources • Bathing water quality Lithuania: Mortality from road traffic injuries in children and young people Hungary considers preparing 2 fact sheets • Prevalence of asthma and allergies in children (completed) • Prevalence of excess body weight and obesity in children and adolescents Poland: Infant mortality due to respiratory diseases Romania: Mortality from road traffic injuries in children and adolescents Slovakia: Bathing water quality Slovenia: Bathing water quality (to be confirmed) Spain: (definite answer by 20 September); the indicator will also be defined. Schedule for producing the national fact sheet: a. Drafting the fact sheet till 31. 10 b. Peer-review of fact sheet involving of relevant stakeholders: 15.11 c. Finalization of fact sheet 20.11 d. Publishing the fact sheet on your institute’s web-site 20.11 e. Evaluation of the national assessment (fact sheet): a meeting involving potential users from Ministry of Health, Regional Public Health centres and services: 1-day & should be organised in October or in the first half of November due to financial reasons f. Technical reporting: a short summary on experiences and lessons by early Dec 07 The draft version of the fact sheet in national language should be ready by 31 October and uploaded on the SharePoint. The final version should be put on the national web till 20 November. An English summary should be produced put on the ENHIS website together with a link to the national webpage. Members of the network, who prepare a national fact sheet, should organize a national meeting to disseminate the national fact sheet as well as the information on ENHIS in October. Each partner of the network should put at least a link on their own website to the ENHIS website.
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WP7 finalization •
•
•
•
It is stated as a deliverable, that several partners will produce a qualitative – quantitative assessment for drinking water case studies. In this way, Frantisek Kozisek (FK) will provide a Czech case study and send it to Elena Boldo, Piedad Martin-Olmedo, Sylvia Medina and Odile Mekel by 1st October 2007. This information will be forwarded to Matti Jantunen so a Finish colleague can provide a case study too. HIAir web tool: The two-user profiles proposed in the meeting (users, and advanced users) is accepted. Advance user will have a security loop that check user identity. Advance users will be only professionals working at governmental institutions on Public Health and Environment and University. All ENHIS contributors are invited to comment on the way to present the text explaining HIA findings, and provide feedback to Piedad Martin-Olmedo. Deadline: 1st October. Documents delivered by WP7: Communication sheets on HIA on the ENHIS web. Long papers included methodological guidelines. Send all to Sylvia Median by 1st October. Final editing at WP 7 October meeting. Scientific Papers: possible options include an overall paper on the WP7 results, specific papers on nonfeasibility of HIA of some risk factors, HIA case studies. Authors, who initiate a scientific paper, will put their ideas on the sharepoint under WP2 with the following information: title, authors, small paragraph with the main objectives, and invitation to other co-authors.
WP8 finalization •
Enter fact sheet data (Excel sheets used for the fig.) (C. Gapp, R. Nugteren)
•
Country profile page: (C. Gapp + editorial group) o
add link to WHO EBD
o
add link to EEHC maps top-level page
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Update partners page (N. Di Tanno based on input from A. Paldy about names for main contributors)
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New page for list of ENHIS products (C. Gapp + editorial group based on input from DDA)
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Link to CEHAPE report (C. Gapp + editorial group)
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Create navigation bar on top of country profile page (C. Gapp + editorial group)
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Upload abstracts of 7 national fact sheets in country profile page (C. Gapp + editorial group)
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Link 7 national fact sheets in country profile page (C. Gapp + editorial group)
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Re-writing policy page; create policy section on methods & tools page; upload and link policy assessment sections in pdf file; upload and link policy case studies in pdf file; make EH policy information database accessible for users. A number of changes are proposed (see WP3 section and WP3 finalization), to be fine tuned before and during the editorial week in Bonn in October. (E. Kunseler + editorial group)
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Additional work to include products of WP7 will be required, to be clarified with WP7 team (O. Mekel in coordination with C. Gapp + editorial group)
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Replace the existing methodology sheet file on the ENHIS web with updated file (WHO/C. Gapp, first week of November)
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Replace methodology sheets for the selected indicators with amended version (WHO/C. Gapp, first week of November, based on input from WP4)
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Upload revised hands-on guidelines (WP5) (WHO/C. Gapp, first week of November, based on input from WP5)
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(On deliverables D 5.2 and D 5.4) Upload the inventory existing surveys for the core set + the list of necessary survey for CEH assessment. (WHO/C. Gapp, first week of November, based on input from WP5)
A workshop to finalize the www.enhis.org according to the abovementioned would be convened in Bonn, Monday- Friday 22-26th October 2007. Shorter assignments possible (less than 3 days) with core days: Tuesday-Thursday; volunteers are welcome and should contact C. Gapp. In addition to the abovementioned already planned items: • • • • • •
Fix of printing problems on EH issues pages: RIVM by end 07 Edit texts about data retrieval in the methodology page (A. Galan) and correct mistakes; References to the external web pages to be converted into direct links (RIVM) Update all new texts in CMS and decide about new pictures New database and web-site release by RIVM Include links to relevant pages in EUPHIX: RIVM
Activities on dissemination of ENHIS – WP2 Aim of this session: share proposals by WPs about dissemination of ENHIS results • • • • •
N. Di Tanno presented preliminary figures on dissemination and impact of ENHIS results (web visits, download of fact sheets, presentation at IMR) C. Gapp presented a list of requests and tasks for the ENHIS website. Changes to be implemented by 31st October. E. Kunseler (WP3) proposed new information to be added under policy actions: methodological tool, case studies, tables with policy information-databases Anna Paldy (WP6), added a list of contributors from the different partner institutions. Each partner should send to A. Paldy (WP 6 Leader) by 25 September, its list of contributors to the project. Information about ENHIS dissemination activity/ event in the country which has been held or is planned to take place should be sent to WHO/D. Dalbokova by the end of September. The note should contain the partners/stakeholders involved, the context of the event e.g. EU EH Action Plan, CEHAPE, etc and scope of the event (national fact sheet, country profile on indicators, etc)
The formula for authorship in future papers and publications has been discussed. M. Krzyzanowski proposed different possibilities for authorship acknowledgement in papers. •
•
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PROPOSAL 1: Authorship Funded by EC DG Sanco, Grant SPC 2004124. Contribution of ENHIS2 project partners is acknowledged (full list of partners available on www.enhis.org) and “indicator-based report” WHO, 2007 (link to the on-line version) PROPOSAL 2: Authors on behalf of the ENHIS project Acknowledgements: Funded by EC DG Sanco, Grant SPC 2004124. Contribution of ENHIS2 project partners is acknowledged (full list of partners available on www. enhis.org) and “indicator-based report” WHO, 2007 (link to the on-line version) Footnote: Partner institutions (and leaders of the ENHIS teams): Institution 1 (Leader XX), Institution 2 (leader XX), … PROPOSAL 3: Authors and leaders by Institution. Acknowledgements: Funded by EC DG Sanco, Grant SPC 2004124. Contribution of ENHIS2 project participants is acknowledged (full list of partners available on www.enhis.org) and “indicator-based report” WHO, 2007 (link to the on-line version)
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It was agreed that very specific articles will follow proposal 1; national papers too. For more general articles where everybody has contributed somehow, all partners should be authors (proposal 2).
CURRENT EU HEALTH INFORMATION STRUCTURE AND FUTURE DEVELOPMENTS The following presentation refers to a conference call with V. Sinclari in the morning of 14th September. DISCLAIMER: The following information was produced for a meeting organized by the World Health Organization and represents the views of its author on the subject. These views have not been adopted or in any way approved by the Commission and should not be relied upon as a statement of the Commission's or Health & Consumer Protection DG's views. The European Commission does not guarantee the accuracy of the data included in this paper, nor does it accept responsibility for any use made thereof.
Objectives and structure Objective: To develop a sustainable health monitoring system able to provide access to reliable, up-to-date and comparable information. The frame work of this System is the Public Health Programme 2003-2008. Actors include: • DG SANCO/PHA (Public Health Agency): to manage and implement the PHP • DG Employment: data/information on health and safety at work • Eurostat/Member States: to gather data on mortality, health status and health care • Networks created under PHP’s projects • Community agencies such as ECDC (Diseases, Stockholm), EMCDDA (Drugs, Lisbon), EU-OSHA (Health and Safety, Bilbao) or EEA (Copenhagen) • Other international organisations: WHO, IARC, OCDE Main aspects of the information strand The information strand of the EU public health programme concentrates on: • Developing and defining health indicators • Disseminating information on health on the basis of comparable methods of collection in the form of reports and analysis • Improving information to the citizens and to policy makers by means of reports and internet sources • Increasing the evidence basis for policy making The Priorities are defined yearly. Operating structures • Network of Competent Authorities (NCA): monitors and advises on the implementation of the information strand • Five Working Parties: indicators, environment and health, lifestyles, mortality and morbidity, health systems • Network of Working Party Leaders: advises the NCA on direction and methodology to implement actions • Three Task Forces: major and chronic diseases and rare diseases (under WP Morbidity and Mortality), health expectancies (work on health expectancy indicators and Healthy Life Years indicator) • Steering Committee of the European Health Survey System: makes recommendations on the coordination of EHSS activities Dissemination of data/information Data and information is disseminated in different ways: • Conferences/events: e-Health 2007, Rare Diseases 2007, Children’s Health 2007 • Publications • Project reports • DG SANCO website • EU Health Portal
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Environment and Health Information • Health and Environment Strategy and Action Plan 2003-2010. It is being reviewed regarding the main principles; focus on children and elderly, Climate change and nanotechnology. • Health and Environment Information. Review–November2006 (14 tasks) • E&H Action Plan Mid term Review (June2007) • Working Party Health and Environment (twice/year) – 22nd November 2007 • Projects (ECOHEIS, ENHIS) The Future of Health Information • New Public Health Programme (2008-2013) • Commission Communication on a EU Health Information System • Eurostat Regulation on Health Statistics Objectives of the New Plan Health Programme Final adoption expected by end of the year, covering a period of 2008-2013. Three main objectives • To improve citizen’s health security • To promote health including the reduction of inequalities • To generate and disseminate health information and knowledge Main Actions under the New Plan Health Programme Actions related to health information and knowledge (Annex) 1. Exchange knowledge and best practice • Exchange best practice on health issues within the PHP scope • Support cooperation to enhance application of best practice within Member States including supporting European Reference Networks, where appropriate 2. Collect, analyse and disseminate health information: • Further develop a sustainable health monitoring system with mechanisms for comparable data and information and indicators • Ensure coordination and follow-up on cancer registries • Collect data on health status and policies • Develop the statistical element of the system in cooperation with the Community Statistical Programme (Eurostat) • Develop mechanisms for analysis and dissemination (health reports, Health Portal, conferences) • Develop information, consultation and participatory mechanisms involving stakeholders, citizens and policymakers • Prepare regular reports on health status including qualitative and quantitative analysis • Provide analysis and technical assistance in support of the development or implementation of policies or legislation related to the scope of the Programme The Work Plan- 2008 • Suggestions for priorities prepared by SANCO C2 (see Annex 2) • Further consultation and input: SeptemberDecember2007 • Decision by Programme Committee: December2007 • Work Plan expected to be published in February2008 Communication on EU Health Information System Objectives • Establish a clear framework for the future organisation and management of the EU health information and knowledge system • Define clear responsibilities and competencies for each actor contributing to the EU health information and knowledge system • Define a common framework of indicators and information sources: ECHI, ENHIS (health and environment), ISARE (regional health)…to be adopted as standard frameworks • Define common mechanisms for collection and comparability of data
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• • •
Establish a procedure for creation and recognition of disease registers Create a EU health reporting system establishing timetable and general objectives of Commission health reports Set up a European Committee on Standards and Health Information to ensure good governance of the system
Expected adoption: 2009 Framework for implementation: PHP 2008-2013, Community Statistical Programme, Framework Programme for R&D (FP7) Expected effects of the Communication • Increased and improved availability of health information and knowledge to policy-makers, public health experts, the scientific community and the public • Higher quality of data concerning public health issues • Increased relevance of information thanks to links with public concerns • Improve deficiency thanks to reasonable costs for higher quality and relevance of information Regulation on Health Statistics Objective: To establish a common framework for systematic production of Community statistics on public health and health and safety at work Domains covered • Health status and health determinants • Health care • Causes of death • Accidents at work, occupational diseases and other work-related health problems and illnesses Expected adoption: 2008 EU Health Information on the Web DG SANCO: http://ec.europa.eu/health/ph_information/information_en.htm EU Health Portal: http://health.europa.eu Public Health Executive Agency: http://ec.europa.eu/phea/index_en.html Comments after the presentation V. Siclari requested also to revise the ENHIS homepage so it is clearly stated that ENHIS is funded by the European Commission but it is not a direct products. Currently it is included in the disclaimer but should be more directly visible. M. Krzyzanowski and N. Di Tanno agreed to implement this to allow linking the ENHIS site from the EU health portal. They also agreed to provide her with some text to build the link. A list of preliminary orientations for priorities to be included in Work Plan 2008 would be provided by V. Sinclari after the meeting, and uploaded to the ENHIS SharePoint.
WHO PROPOSAL TO DG SANCO 2007 CALL- MICHAL KRZYZANOWSKI
Agreement between WHO and EC: on demand of the Member Sates in order to ensure fair competition, 5% of the total funding is allocated for WHO activities. As a result the proposal “Climate, environment and health action plan and information system (CEHAPIS), funded with 500000 € for 24 months. It is not a collaborative project; there will not be formal partners. The main objectives under this project will be: • To develop strategic framework addressing public health system response to CC in Europe and identify adequate public health actions at international, national and local levels. • To maintain the Environment and Health information system and expand its scope to enable monitoring and assessment of EH issues related to CC
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Prepare an assessment of Environment and Health (EH) status and trends, including those related to climate change, for the 5th Ministerial Conference on EH Ensure adequate communication of results of the project and of actions required to relevant stakeholders and Member States.
Although WHO/EURO strategy for 2008-13 is not yet formally announced, it is possible to present the main objectives related to health Information system (WHO Strategic Objective 8 for 2008-13): • EH information system facilitating monitoring of EH risks (incl. MDGs, risks considered by relevant conventions and addressing various populations at risk) updated annually for all EURO MS and supporting evidence-based assessment for the WHO/Europe region and individual MS. • Support provided to development of national EH information systems including surveillance, analysis and reporting, and strengthening EH decision-making • Information support provided to the EH process in Europe, integrating risk assessment, analysis of trends in exposures and health effects, assessment of policies and actions as well as presenting scenarios of health risks for Europe Expectations: to create collaboration with several projects funded by EU or not, to create a common platform and doing so, avoid individual and non-homogeneous approaches. Ideas for collaborative projects include: a. Development of national EH Info system compatible with ENHIS-RIVM, PL b. Sustainable model of EH information system, links with EUPHIX and sub-national level c. Development of methods (e.g. HIA, …), communication strategies, d. HIA-BoD and evaluation, interpretation, link with policy decisions, actions…(LöGD, KTL) e. ENHIS-based reports and assessments. f. Info related to climate change - NSPH g. Capacity Building – networks for education on EH – ISPB, EASP (P. Martin-Olmedo) Record of Partners’ Comments M Posada: Is it possible to send the proposal to DG Research instead of DG SANCO? ENHIS maintenance doesn’t fit in the schedules of EC DG Research. On the other hand, INTARESE is a big consortium related to Information System funded already by DG Research. R. Fehr: HIA means different things to different people. In ENHIS, the interpretation seems to be: HIA aims at identifying the fraction of burden of disease which is attributable to certain factors such as noise or indoor air pollution. This HIA interpretation is legitimate and useful. Common public health practice, however, implies another, broader HIA interpretation which means: the prospective impact assessment of policies, plans, programs and projects (“PPPP”). The question is if the ENHIS group is interested in extending its current HIA approach in this direction. R. Nugteren: How ENHIS products (e.g. web) are going to be maintained? M.Krzyzanowski: It is been currently discussed; links to EUPHIX should be kept. However, it is also important to take these actions to the national level. A. Katsiri: Is climate change to be included in the new proposals? School of Public Health would be very interested in participation. M.Krzyzanowski: WHO project is going to be very small; satellite projects are needed; EU is very keen in this topic. Proposals in this line are encouraged. C. Gapp: Will ENHIS remain focus in the future on children or it will extent to the whole population? M.Krzyzanowski: No expansion to new indicators is expected although climate change needs a specific approach. E Kunseler: New proposal related to HIA in the line to burden of diseases, DALYs calculations, what it is needed, how to improved the quantitative assessments … M.Krzyzanowski: Try to work together for a common proposal.
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Dorota Jarosinka : EEA is working on climate change matters. Take into account this option. There is also a call for IT experts related to health issues, focuses on Working about the specific platform, open source technology, …, Adriana Galan proposes a network for capacity building and education programmes on E&H. Piedad Martin-Olmedo supports this idea, and will collaborate in the creation of the network. Odile Mekel: Training is not only a need specific in Western Europe. She suggests joining other current networks. Ingrida Zurlyte: There is a DG SANCO project on HIA in the new EU Member states and accession countries (HIA-NMAC), where there is a WP related to capacity building. With respect to training and future directions on HIA it might be useful to consider results and recommendations of the HIA-NMAC project.
POSSIBLE FUTURE DEVELOPMENTS ENHIS maintenance Keep the network alive Data update and expansion Periodic update of the websites Periodic surveys New developments Capabilities –have to absorb EH research results Sustainable editorial system Linkage Better integration Adds tools such as HIA More integration on health determinants Scenarios (a dream?) On-line access to the national and sub-national EH information An updated repository on policies is kept On-line, real-time monitoring of stressors and pollutions forecasts available Citizens can subscribe services (pollen, others) Activities needed Call for partners Identify sources of funding (eranet?) DGs RIVM is decided to lead this proposal … Large discussion about the influence of the WHO as coordinator in the MS. M: Krzyzanowski emphasized on using all the possibilities to pressure to the DGSANCO for get funding. Member States can use several mechanisms because they have the power and the influence
REPORTING ENHIS-2 RESULTS ACTIVITIES TO EC (SEE ANNEX III- REPORTING REQUIREMENTS OF THE CONTRACT) -- PRESENTED BY D. DALBOKOVA
Reporting requirements are presented in Annex III of the ENHIS 2 Contract, the section about ‘Final implementation report’. Annex I contains the description of the work. The reporting requirements are outlined below.
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WP Leaders to report briefly on the activities: Enlist them with a concise description justifying how they lead/ led to achievement of the objectives & deliverables. For example: "... The tool/guidelines ... was prepared ... They are available at www.enhis.org”
Annex II B contained the detailed budget (Tables). Each partner should complete the Tables and send them to WHO/ D. Dalbokova Table 1: Professional involved in the project with name, professional cat., number of rate (EUROS), total cost. This Table will go to the financial report too Name
Professional level/ Cat.
Days,
Unit
Number of days Unit/ rate, € Total cost, €
For example, Dafina Dalbokova
P4
329
586.00
192794.00
………
….
…..
…..
…….
Table 2: Name, Function (e.g: senior scientist), level cat (e-g P4), WPs where has been involved, activities conducted ( a brief description), Days. The Table will go to the implementation report Name
Function
Level/Cat
WP
Activities conducted
Days
For example
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Dafina Dalbokova Senior Scientist P4
1
4
Project technical 100 management; Preparation of technical & activity reports; Coordination of 70 technical input on indicators
Each partner has to make a summary of 1 paragraph describing the activities of the institution and send it to WHO/ D.Dalbokova.
Each partner will make a brief summary explaining how ENHIS results/products have been made available in the country. Specify the communication strategies elaborate to disseminate the results of the project (seminars, contact with politicians, etc.). Spain will provide one paragraph only.
Each WP leader has to make a summary explaining how WP objectives have been achieved. WHO will prepare the summary for the ENHIS 2. Deadlines for reporting 1 Dec 07 Technical: - WP leaders: - Each partner:
Financial: - Each partner: 20 Dec 07 Technical: - WP leaders: Financial: - Each partner:
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Activity report (Annex III: 2.1) Activities of each person involved (Annex III: 2.2) Partner’s contribution (Annex III: 2.3) How the results were made available in each country (Annex III: 2.4) Financial report (according to Annex IIA and IIB) (not signed)
Achievement of objectives (Annex III: 2.5) Financial report (according to Annex IIA and IIB) (signed)
Financial reporting: Wendy Williams will provide a specific template to do so. The reporting will be done according to the amended budget submitted in December 2006. It is possible to exceed by 10 % a certain budget line at the expenses of any other budget line. If it is not possible to use all money, it is necessary to return the exceed money. Each partner will still have to receive 20% of the total budget. However, the financial report needs to fulfil the total 100%. Our institutions will have to provide the extra 20% that will be covered later on. Points to consider: In the man-power-reporting, it is not necessary to follow initial WP time allocation. It is better to do it according to real final involvement. The time assigned to different issues should follow a logical approach. Try not to be inconsistent between man-power-reporting and financial report. Outline of three points on how to report the type of activities to disseminate ENHIS results at national level has been published on the SharePoint. Money under travel expenses can be used to attend national congresses where ENHIS results will be presented as part of dissemination activities, but not to international congresses.
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Annex 1 List of participants Austria Ms Charlotte Wirl Gesundheit Osterreich GmbH A-1010 Vienna
Belgium Prof Herman Van Oyen Scientific Institute of Public Health B-1050 Brussels Dr Reginald Moreels Federal Public Health Service B-1060 Brussels
Bulgaria Dr Momchil Sidjimov National Centre for Public Health Protection 1431 Sofia
Czech Republic Ms Ruzena Kubinova National Institute of Public Health 100 42 Prague 10 Dr Vladimira Puklova National Institute of Public Health 100 42 Prague 10
Estonia Mr Jüri Ruut Health Protection Inspectorate 10617 Tallinn
Finland Prof Matti Jantunen National Public Health Institute 70210 Kuopio Ms Eva Kunseler National Public Health Institute 70210 Kuopio
Germany Dr Rainer Fehr Institute of Public Health NRW (LOEGD) 33602 Bielefeld
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Dr Odile Mekel Institute of Public Health NRW (LOEGD) 33602 Bielefeld Ms Sarah Sierig Institute of Public Health NRW (LOEGD) 33602 Bielefeld
Greece Ms Olga Cavoura National School of Public Health 11521 Athens Ms Alexandra Katsiri National School of Public Health 11521 Athens
Hungary Dr Anna Paldy National Institute of Environmental Health H-1097 Budapest
Ireland Ms Siobhan McEvoy Department of Health & Children Dublin 2
Italy Dr Ernesto Vocaturo APAT 00144 Rome
Lithuania Ms Aida Laukaitiene State Environmental Health Center LT-08221 Vilnius Ms Ingrida Zurlyte State Environmental Health Center LT-08221 Vilnius
Netherlands Mr Rutger Nugteren National Institute for Public Health and the Environment (RIVM) 3721 BA Bilthoven
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Poland Mr Edmund Anczyk Institute of Occupational Medicine and Environmental Health 41-200 Sosnowiec Ms Beata Dabkowska Institute of Occupational Medicine and Environmental Health 41-200 Sosnowiec Dr Pawel Gorynski National Institute of Hygiene 00-791 Warsaw Dr Maja Muszynska-Graca Institute of Occupational Medicine and Environmental Health 41-200 Sosnowiec
Portugal Mr Paulo Diegues Directorate General of Health 1049-005 Lisbon Ms Claudia Weigert Directorate General of Health 1049-005 Lisbon
Romania Mrs Adriana Galan Institute of Public Health Bucharest 050463 Bucharest
Slovakia Ms Katarina Halzlova Public Health Authority of the Slovak Republic 826 45 Bratislava Dr Martin Kapasny Regional Authority of Public Health (SZU) 011 71 Zilina Mrs Gabriela Slovakova Public Health Authority of the Slovak Republic 826 45 Bratislava
Spain Ms Elena Isabel Boldo Pascua Instituto de Salud Carlos III 28029 Madrid Dr Maria José Carroquino Saltó Instituto de Salud Carlos III 28029 Madrid
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Mr Manuel Gonzalez-Cabré Public Health Agency of Barcelona (ASPB) 08023 Barcelona Mr Alejandro Lopez Ruiz Andalusian School of Public Health (EASP) Granada 18080 Ms Piedad Martin Olmedo Andalusian School of Public Health (EASP) Granada 18080 Dr Manuel Posada de la Paz Instituto de Salud Carlos III 28029 Madrid Mr Alejandro Ramirez-Gonzalez Instituto de Salud Carlos III 28029 Madrid Dr Luis Soldevilla Benito Instituto de Salud Carlos III 28029 Madrid Ms Natalia Valero Munoz Public Health Agency of Barcelona (ASPB) 08023 Barcelona
United Kingdom of Great Britain and Northern Ireland Dr Lorraine Stewart Health Protection Agency B15 2SQ Birmingham Observers Dr Dorota Jarosinska European Environment Agency 1050 Copenhagen K Denmark
Ms Viviana Siclari European Commission L-2920 Luxembourg World Health Organization Regional Office for Europe Dr Dafina Dalbokova Ms Nicoletta di Tanno Dr Christian Gapp Dr Michal Krzyzanowski Ms Wendy Williams
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ANNEX 2 PRELIMINARY ORIENTATIONS FOR PRIORITIES TO BE INCLUDED IN WORK PLAN 2008 Viviana Siclari, EC DG Sanco DISCLAIMER: This paper was produced for a meeting organized by the World Health Organization and represents the views of its author on the subject. These views have not been adopted or in any way approved by the Commission and should not be relied upon as a statement of the Commission's or Health & Consumer Protection DG's views. The European Commission does not guarantee the accuracy of the data included in this paper, nor does it accept responsibility for any use made thereof.
PRIORITY LEVEL 1: * Pilot European Health Examination Survey in 11/15 Member States * Activities related to forthcoming Commission Communication on rare diseases (codification and classification of rare diseases, registers, networks of action, Scientific assistance to Task Force) * Activities related to forthcoming Commission Communication on the health effects of climate change (cold spells, health effects of flooding, airborne allergens, vector-borne infectious diseases) * E-health - Development of a protected web platform for multimedia content and communication; a web-based template for medical information with a minimum set of fields for emergency care and continuation of treatment; interactive multimedia software for patient education; templates for e-Prescription and discharge letter and others. Promote e-Health tools and training for health professionals. Report on eHealth in Europe. PRIORITY LEVEL 2: * Upgrade the European Injury Database (IDB) with enhanced means of data interpretation for consumer safety and to harmonise national injury surveillance instruments on fatalities. * Development of comparable registers of diseases - in particular cancer, cardiovascular diseases, vision impairment, hearing loss, rheumatic diseases, Autism Spectrum Disorders and neurodegenerative diseases not covered by existing actions. Feasibility study for certification of morbidity registries. * Health indicators - Dissaggregation of the Healthy Life Year indicator by diseases and linking mortality to census data on socioeconomic status. Development of the ECHI system to cover a broad range of health indicators from all MSs. * Other health surveys - Analysis of health survey data for child and adolescent population (less than 15 years), contribution to the World Mental Health Survey, implementation of SANCO modules in Eurobarometer survey, further development of existing European Union Health Surveys Information Database. * Health reporting - to include young people's health, men's health and use of Assisted Reproductive Technologies. * Health care quality - analysis of mortality rates and preventive health care interventions in relation to health system performance.
Preliminary orientations for the priorities to be included in the work plan 2008 are available. DG SANCO would welcome remarks and input from ENHIS members on the priorities listed above. Please circulate the note among members. They can send their comments to the following email address:
[email protected]
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This report was produced by a contractor for Health & Consumer Protection Directorate General and represents the views of the contractor or author. These views have not been adopted or in any way approved by the Commission and do not necessarily represent the view of the Commission or the Directorate General for Health and Consumer Protection. The European Commission does not guarantee the accuracy of the data included in this study, nor does it accept responsibility for any use made thereof.
