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Background: Exposure to green spaces is associated with improved mental health and may reduce risk of suicide. Here, we investigate the association between long-term exposure to residential surrounding greenness and sui-cide mortality. Methods: We used data from the 2001 Belgian census linked to mortality register data (2001-2011). We included all registered individuals aged 18 years or older at baseline (2001) residing in the five largest urban areas in Belgium (n = 3,549,514). Suicide mortality was defined using the tenth revision of the World Health Organi-sation International Classification of Diseases (ICD-10) codes X60-X84, Y10-Y34, and Y870. Surrounding greenness was measured using the Normalized Difference Vegetation Index (NDVI) within a 300 m and 1,000 m buffer around the residential address at baseline. To assess the association between residential surrounding greenness and suicide mortality, we applied Cox proportional hazards models with age as the underlying time scale. Models were adjusted for age, sex, living arrangement, migrant background, educational attainment, neighbourhood socio-economic position. We additionally explored potential mediation by residential outdoor nitrogen dioxide (NO2) concentrations. Finally, we assessed potential effect modification by various socio-demographic characteristics of the population (sex, age, educational attainment, migrant background, and neighbourhood socio-economic position). Associations are expressed as hazard ratios and their 95% confidence intervals (CI) for an interquartile range (IQR) increase in residential surrounding greenness. Results: We observed a 7% (95%CI 0.89-0.97) and 6% (95%CI 0.90-0.98) risk reduction of suicide mortality for an IQR increase in residential surrounding greenness for buffers of 300 m and 1,000 m, respectively. Further-more, this association was independent of exposure to NO2. After stratification, the inverse association was only apparent among women, and residents of Belgian origin, and that it was stronger among residents aged 36 or older, those with high level of education, and residents of most deprived neighbourhoods. Conclusion: Our results suggest that urban green spaces may protect against suicide mortality, but this beneficial effect may not be equally distributed across all strata of the population.

Background: Residing close to green spaces might reduce diabetes mellitus (DM) risk; however, evidence for diabetes mortality is limited. Moreover, individual and neighbourhood social factors may determine DM risk. Exposure to green spaces may also depend on socioeconomic position (SEP). This study examined the associations between residential greenness and diabetes-related mortality, and the role of the social environment in these associations. Methods: We used the 2001 Belgian census linked to mortality register data for the period 2001-2014. We included individuals aged 40-79 years old and residing in the five largest Belgian urban areas at baseline. Exposure to residential greenness was assessed with surrounding greenness using the Normalized Difference Vegetation Index (NDVI) within 500-m of residence (objective indicator), and perceived neighbourhood greenness (subjective indicator). We conducted mixed-effects Cox proportional hazards models to obtain hazard ratios (HR) for diabetes-related mortality per interquartile range (IQR) increments of residential greenness. We assessed effect modification by social factors through stratification. Results: From 2,309,236 individuals included at baseline, 1.2% died from DM during follow-up. Both residential greenness indicators were inversely associated with diabetes-related mortality after adjustment for individual social factors. After controlling for neighbourhood SEP, the beneficial association with surrounding greenness disappeared [HR 1.02 (95%CI:0.99,1.06)], but persisted with perceived neighbourhood greenness [HR 0.93 (95%CI:0.91,0.95)]. After stratification the inverse associations with perceived neighbourhood greenness were strongest for women, the lowest educated, and individuals residing in least deprived neighbourhoods. Conclusions: Our findings suggest that an overall positive perception of neighbourhood green spaces reduces independently the risk of diabetes-related mortality, regardless of the neighbourhood social environment. Nevertheless, neighbourhood SEP may be a strong confounder in the associations between diabetes-related mortality and greenness indicators derived from satellite images. Perception factors not captured by objective measurements of green spaces are potentially relevant in the association with DM, especially among disadvantaged groups.

Background Living in greener areas is associated with slower cognitive decline and reduced dementia risk among older adults, but the evidence with neurodegenerative disease mortality is scarce. We studied the association between residential surrounding greenness and neurodegenerative disease mortality in older adults. Methods We used data from the 2001 Belgian census linked to mortality register data during 2001–2014. We included individuals aged 60 years or older and residing in the five largest Belgian urban areas at baseline (2001). Exposure to residential surrounding greenness was assessed using the 2006 Normalized Difference Vegetation Index (NDVI) within 500-m from residence. We considered all neurodegenerative diseases and four specific outcomes: Alzheimer’s disease, vascular dementia, unspecified dementia, and Parkinson’s disease. We fitted Cox proportional hazard models to obtain hazard ratios (HR) and 95% confidence intervals (CI) of the associations between one interquartile range (IQR) increment in surrounding greenness and neurodegenerative disease mortality outcomes, adjusted for census-based covariates. Furthermore, we evaluated the potential role of 2010 air pollution (PM2.5 and NO2) concentrations, and we explored effect modification by sociodemographic characteristics. Results From 1,134,502 individuals included at baseline, 6.1% died from neurodegenerative diseases during follow-up. After full adjustment, one IQR (0.22) increment of surrounding greenness was associated with a 4–5% reduction in premature mortality from all neurodegenerative diseases, Alzheimer’s disease, vascular and unspecified dementia [e.g., for Alzheimer’s disease mortality: HR 0.95 (95%CI: 0.93, 0.98)]. No association was found with Parkinson’s disease mortality. Main associations remained for all neurodegenerative disease mortality when accounting for air pollution, but not for the majority of specific mortality outcomes. Associations were strongest in the lower educated and residents from most deprived neighbourhoods. Conclusions Living near greener spaces may reduce the risk of neurodegenerative disease mortality among older adults, potentially independent from air pollution. Socioeconomically disadvantaged groups may experience the greatest beneficial effect.

BACKGROUND: The available evidence for positive associations between urban trees and human health is mixed, partly because the assessment of exposure to trees is often imprecise because of, for instance, exclusion of trees in private areas and the lack of three-dimensional (3D) exposure indicators (e.g., crown volume). OBJECTIVES: We aimed to quantify all trees and relevant 3D structural traits in Brussels (Belgium) and to investigate associations between the number of trees, tree traits, and sales of medication commonly prescribed for mood disorders and cardiovascular disease. METHODS: We developed a workflow to automatically isolate all individual trees from airborne light detection and ranging (LiDAR) data collected in 2012. Trait data were subsequently extracted for 309,757 trees in 604 census tracts. We used the average annual age-standardized rate of medication sales in Brussels for the period 2006 to 2014, calculated from reimbursement information on medication prescribed to adults (19-64 years of age). The medication sales data were provided by sex at the census tract level. Generalized log-linear models were used to investigate associations between the number of trees, the crown volume, tree structural variation, and medication sales. Models were run separately for mood disorder and cardiovascular medication and for men and women. All models were adjusted for indicators of area-level socioeconomic status. RESULTS: Single-factor models showed that higher stem densities and higher crown volumes are both associated with lower medication sales, but opposing associations emerged in multifactor models. Higher crown volume [an increase by one formula presented ] was associated with 34% lower mood disorder medication sales [women, formula presented (95% CI: formula presented ); men, formula presented (95% CI: formula presented )] and with 21-25% lower cardiovascular medication sales [women, formula presented (95% CI: formula presented ); men, formula presented (95% CI: formula presented )]. Conversely, a higher stem density (an increase by one formula presented ) was associated with 28-32% higher mood disorder medication sales [women, formula presented (95% CI: 0.284, 0.361); men, formula presented (95% CI: 0.243, 0.319)] and with 20-24% higher cardiovascular medication sales [women, formula presented (95% CI: 0.169, 0.236); men, formula presented (95% CI: 0.206, 0.273)]. DISCUSSION: We found a trade-off between the number of trees and the crown volumes of those trees for human health benefits in an urban environment. Our results demonstrate that conserving large trees in urban environments may not only support conservation of biodiversity but also human health. https://doi.org/10.1289/EHP9924.

Background: Ambient air pollution exposure has been associated with higher mortality risk in numerous studies. We assessed potential variability in the magnitude of this association for non-accidental, cardiovascular disease, respiratory disease, and lung cancer mortality in a country-wide administrative cohort by exposure assessment method and by adjustment for geographic subdivisions. Methods: We used the Belgian 2001 census linked to population and mortality register including nearly 5.5 million adults aged >= 30 (mean follow-up: 9.97 years). Annual mean concentrations for fine particulate matter (PM2.5), nitrogen dioxide (NO2), black carbon (BC) and ozone (O-3) were assessed at baseline residential address using two exposure methods; Europe-wide hybrid land use regression (LUR) models [100x100m], and Belgium-wide interpolation-dispersion (RIO-IFDM) models [25x25m]. We used Cox proportional hazards models with age as the underlying time scale and adjusted for various individual and area-level covariates. We further adjusted main models for two different area-levels following the European Nomenclature of Territorial Units for Statistics (NUTS); NUTS-1 (n = 3), or NUTS-3 (n = 43). Results: We found no consistent differences between both exposure methods. We observed most robust associations with lung cancer mortality. Hazard Ratios (HRs) per 10 mu g/m(3) increase for NO2 were 1.060 (95%CI 1.0421.078) [hybrid LUR] and 1.040 (95%CI 1.022-1.058) [RIO-IFDM]. Associations with non-accidental, respiratory disease and cardiovascular disease mortality were generally null in main models but were enhanced after further adjustment for NUTS-1 or NUTS-3. HRs for non-accidental mortality per 5 mu g/m(3) increase for PM2.5 for the main model using hybrid LUR exposure were 1.023 (95%CI 1.011-1.035). After including random effects HRs were 1.044 (95%CI 1.033-1.057) [NUTS-1] and 1.076 (95%CI 1.060-1.092) [NUTS-3]. Conclusion: Long-term air pollution exposure was associated with higher lung cancer mortality risk but not consistently with the other studied causes. Magnitude of associations varied by adjustment for geographic subdivisions, area-level socio-economic covariates and less by exposure assessment method. (C) 2021 Published by Elsevier B.V.

BACKGROUND: Residential green space has been associated with mental health benefits, but how such associations vary with green space types is insufficiently known. OBJECTIVE: We aimed to investigate associations between types and quantities of green space and sales of mood disorder medication in Belgium. METHODS: We used aggregated sales data of psycholeptics and psychoanaleptics prescribed to adults from 2006 to 2014. Generalized mixed effects models were used to investigate associations between relative covers of woodland, low-green, grassland, and garden, and average annual medication sales. Models were adjusted for socio-economic background variables, urban-rural differences, and administrative region, and included random effects of latitude and longitude. RESULTS: Urban census tracts were associated with 9-10% higher medication sales. In nationwide models, a 10% increase in relative cover of woodland, garden, and grass was associated with a 1-2% decrease in medication sales. The same association was found for low green but only for men. In stratified models, a 10% increase in relative cover of any green space type in urban census tracts was associated with a decrease of medication sales by 1-3%. In rural census tracts, no protective associations between green space and mood disorder medication sales were observed, with the exception of relative woodland cover for women (-1%), and low green was associated with higher medication sales (+6-7%). CONCLUSIONS: Taken together, these results suggest that living in green environments may be beneficial for adult mental health. Woodland exposure seemed the most beneficial, but the amount of green space was more important than the type. Results underline the importance of conserving green space in our living environment, for the conservation of biodiversity and for human health. ispartof: Environmental Reserach vol:211 ispartof: location:Netherlands status: published

Background: Residing in greener areas may decrease the burden of chronic diseases, but the association with cancer is unclear. We studied the associations between residential green spaces and site-specific cancer mortality in urban Belgium. Methodology: We linked the 2001 Belgian census, register mortality data for 2001-2014, and environmental information (green spaces and air pollution) at baseline residence (2001). We included residents from the largest Belgian urban areas aged >= 30 years at baseline. Exposure to residential green spaces was assessed using the Normalized Difference Vegetation Index (NDVI), Urban Atlas, and perceived neighbourhood greenness (from the census). We used Cox proportional hazards models to obtain hazard ratios (HR) and their 95 % confidence intervals (95 %CI) of the mortality risk from lung, colorectal, breast (in women) and prostate cancer (in men) per interquartile range increment in residential green spaces. We further analyzed the role of outdoor air pollution and effect modification by age and socioeconomic position (SEP) in main associations. Results: 2,441,566 individuals were included at baseline. During follow-up, 1.2 % died from lung cancer, 0.6 % from colorectal cancer, 0.8 % from breast cancer, and 0.6 % from prostate cancer. After adjustment, higher exposure to green spaces was associated with a reduced mortality risk from lung cancer and breast cancer [e.g., for NDVI within 300 m, HR:0.946 (95 %CI:0.924,0.970), and HR:0.927 (95 %CI:0.892,0.963), respectively], but not with colorectal or prostate cancer mortality. For the latter, a suggestive hazardous effect of green spaces was found. Air pollution seemed to have only a marginal role. Beneficial effects of greenspace were generally stronger in < 65-year-old, but no clear trend by SEP was found. Conclusions: Our findings suggest that residing in green areas could decrease mortality risk from lung and breast cancer, potentially independent from air pollution. Future studies should consider different indicators of greenspace exposure and investigate potential pathways underlying the associations.

Green space could influence adult cognition and childhood neurodevelopment , and is hypothesized to be partly driven by epigenetic modifications. However, it remains unknown whether some of these associations are already evident during foetal development. Similar biological signals shape the developmental processes in the foetal brain and placenta.Therefore, we hypothesize that green space can modify epigenetic processes of cognition-related pathways in placental tissue, such as DNA-methylation of the serotonin receptor HTR2A. HTR2A-methylation was determined within 327 placentas from the ENVIRONAGE (ENVIRonmental influence ON early AGEing) birth cohort using bisulphite-PCR-pyrosequencing. Total green space exposure was calculated using high-resolution land cover data derived from the Green Map of Flanders in seven buffers (50 m-3 km) and stratified into low (a priori chosen covariables. For an IQR increment in total green space within a 1,000 m, 2,000 m and 3,000 m buffer the methylation of HTR2A increased with 1.47% (95%CI:0.17;2.78), 1.52% (95%CI:0.21;2.83) and 1.42% (95%CI:0.15;2.69), respectively. Additionally,, we found 3.00% (95%CI:1.09;4.91) and 1.98% (95%CI:0.28;3.68) higher HTR2A-methylation when comparing residences with and without the presence of nature in a 50 m and 100 m buffer, respectively. The methylation status of HTR2A in placental tissue is positively associated with maternal green space exposure. Future research is needed to understand better how these epigenetic changes are related to functional modifications in the placenta and the consequent implications for foetal development.

Background: Temperature may trigger the risk of suicide, however, the extent and shape of the associations show geographical variation. Here, we investigate the short-term effects of temperature on suicide deaths occurring in Brussels between January 1st, 2002 and December 31st, 2011. Methods: We conducted a bidirectional time-stratified case-crossover study with cases being suicide deaths occurring among Brussels residents aged 5 years or older. Cases were matched by day of the week with control days from the same month and year. The exposure was the daily average temperature measured at the Uccle station (Brussels) and obtained from the Belgian Royal Meteorological Institute. We combined conditional logistic regression with distributed lag non-linear models (DLNM) to obtain one week (lag 0-6) cumulative risk ratios (RR) and their 95% confidence intervals (CI) for the effects of moderate and extreme cold (5th and 1st percentiles of temperature, respectively) and moderate and extreme heat (95th and 99th percentiles of temperature, respectively), relative to the median temperature. Results: In total, 1891 suicide deaths were included. The median temperature was 11.6 degrees C, moderate and extreme cold temperatures were 0 and -3.1 degrees C, respectively, and moderate and extreme high temperatures were 20.9 and 24.4 degrees C, respectively. The cumulative risk of suicide mortality was almost twice higher among lags 0 to 6 for both moderate and extreme heat, relative to the period median temperature (e.g. moderate heat RR = 1.80 CI:1.27-2.54). No statistically significant associations were observed for cold temperatures. Conclusions: In Brussels, a western European city with temperate climate, high temperatures may trigger suicide deaths up to one week later. In the context of climate change, adaptation strategies must take into consideration the effects of temperature on mental health.

Climate change leads to more days with extremely hot temperatures. Previous analyses of heat waves have documented a short-term rise in mortality. The results on the relationship between high temperatures and hospitalisations, especially in vulnerable patients admitted to nursing homes, are inconsistent. The objective of this research was to examine the discrepancy between heat-related mortality and morbidity in nursing homes. A time-stratified case-crossover study about the impact of heat waves on mortality and hospitalisations between 1 January 2013 and 31 December 2017 was conducted in 10 nursing homes over 5 years in Flanders, Belgium. In this study, the events were deaths and hospitalisations. We selected our control days during the same month as the events and matched them by day of the week. Heat waves were the exposure. Conditional logistic regression models were applied. The associations were reported as odds ratios at lag 0, 1, 2, and 3 and their 95% confidence intervals. In the investigated time period, 3048 hospitalisations took place and 1888 residents died. The conditional logistic regression showed that odds ratios of mortality and hospitalisations during heat waves were 1.61 (95% confidence interval 1.10-2.37) and 0.96 (95% confidence interval 0.67-1.36), respectively, at lag 0. Therefore, the increase in mortality during heat waves was statistically significant, but no significant changes in hospitalisations were obtained. Our result suggests that heat waves have an adverse effect on mortality in Flemish nursing homes but have no significant effect on the number of hospitalisations. ispartof: INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH vol:18 issue:20 ispartof: location:Switzerland status: published

Background: Epidemiological studies suggest that residing close to green space reduce mortality rates. We investigated the relationship between long-term exposure to residential green space and non-accidental and cardio-respiratory mortality. Methods: We linked the Belgian 2001 census to population and mortality register follow-up data (2001-2011) among adults aged 30 years and older residing in the five largest urban areas in Belgium (n = 2,185,170 and mean follow-up time 9.4 years). Residential addresses were available at baseline. Exposure to green space was defined as 1) surrounding greenness (2006) [normalized difference vegetation index (NDVI) and modified soiladjusted vegetation index (MSAVI2)] within buffers of 300 m, 500 m, and 1000 m; 2) surrounding green space (2006) [Urban Atlas (UA) and CORINE Land Cover (CLC)] within buffers of 300 m, 500 m, and 1000 m; and 3) perceived neighborhood green space (2001). Cox proportional hazards models with age as the underlying time scale were used to probe into cause-specific mortality (non-accidental, respiratory, COPD, cardiovascular, ischemic heart disease (IHD), and cerebrovascular). Models were adjusted for several sociodemographic variables (age, sex, marital status, country of birth, education level, employment status, and area mean income). We further adjusted our main models for annual mean (2010) values of ambient air pollution (PM2.5, PM10, NO2 and BC, one at a time), and we additionally explored potential mediation with the aforementioned pollutants. Results: Higher degrees of residential green space were associated with lower rates of non-accidental and respiratory mortality. In fully adjusted models, hazard ratios (HR) per interquartile range (IQR) increase in NDVI 500 m buffer (IQR: 0.24) and UA 500 m buffer (IQR: 0.31) were 0.97 (95%CI 0.96-0.98) and 0.99 (95%CI 0.98-0.99) for non-accidental mortality, and 0.95 (95%CI 0.93-0.98) and 0.97 (95%CI 0.96-0.99) for respiratory mortality. For perceived neighborhood green space, HRs were 0.93 (95%CI 0.92-0.94) and 0.94 (95%CI 0.91-0.98) for non-accidental and respiratory mortality, respectively. The observed lower mortality risks associated with residential exposure to green space were largely independent from exposure to ambient air pollutants. Conclusion: We observed evidence for lower mortality risk in associations with long-term residential exposure to green space in most but not all studied causes of death in a large representative cohort for the five largest urban areas in Belgium. These findings support the importance of the availability of residential green space in urban areas. This work was supported by the GRESP-HEALTH project which was funded by the Belgian Science Policy Office BELSPO [grant number BR/ 143/A3/GRESP-HEALTH]. Mariska Bauwelinck is funded by an individual PhD grant supported by the Research Foundation - Flanders (FWO) [grant number 11A9718N]. Lidia Casas is recipient of a postdoctoral fellowship of the Research Foundation Flanders (FWO) [grant number 12I1517N]. The authors thank Frederik Priem from the Department of Geography of the Vrije Universiteit Brussel (VUB) for his support in obtaining and processing satellite imagery and land use data. Next, we acknowledge IRCEL-CELINE (Belgian Interregional Environment Agency) for providing the ambient air pollution estimates. We are very grateful to Massimo Stafoggia and Matteo Scortichini for their help in carrying out and interpreting the mediation analysis. Further, we recognize the support of Statbel (Directorate-general Statistics – Statistics Belgium) for geocoding the census data and facilitating data linkages as well as the help of Johan Surkyn from Interface Demography VUB with data management. Computational resources and services were provided by the Shared ICT Services Centre funded by the Vrije Universiteit Brussel, the Flemish Supercomputer Center (VSC) and the Research Foundation - Flanders (FWO). We are grateful for the fruitful exchanges with the reviewers, which substantially helped improving this study.

Background Microbial exposures in early childhood direct the development of the immune system and their diversity may influence the risk of allergy development. We aimed to determine whether the indoor microbial diversity at early-life is associated with the development of allergic rhinitis and inhalant atopy. Methods The study population included children within two birth cohorts: Finnish rural-suburban LUKAS (N = 312), and German urban LISA from Munich and Leipzig study centers (N = 248). The indoor microbiota diversity (Chao1 richness and Shannon entropy) was characterized from floor dust samples collected at the child age of 2–3 months by Illumina MiSeq sequencing of bacterial and fungal DNA amplicons. Allergic rhinitis and inhalant atopy were determined at the age of 10 years and analyzed using logistic regression models. Results High bacterial richness (aOR 0.19, 95%CI 0.09–0.42 for middle and aOR 0.12, 95%CI 0.05–0.29 for highest vs. lowest tertile) and Shannon entropy were associated with lower risk of allergic rhinitis in LISA, and similar trend was seen in LUKAS. We observed some significant associations between bacterial and fungal diversity measured and the risk of inhalant atopy, but the associations were inconsistent between the two cohorts. High bacterial diversity tended to be associated with increased risk of inhalant atopy in rural areas, but lower risk in more urban areas. Fungal diversity tended to be associated with increased risk of inhalant atopy only in LISA. Conclusions Our study suggests that a higher bacterial diversity may reduce the risk of allergic rhinitis later in childhood. The environment-dependent heterogeneity in the associations with inhalant atopy – visible here as inconsistent results between two differing cohorts - suggests that specific constituents of the diversity may be relevant.

Introduction: During early childhood, neuronal networks are highly susceptible to environmental factors. Previous research suggests that green space exposure is beneficial for cognitive functioning. Here, we investigate the associations between residential green space exposure and behavioral problems and cognitive development in children aged four to six years. Method: We included children participating in the ENVIRONAGE birth cohort. Residential green spaces were calculated based on high-resolution land cover data within several buffers (50-1,000 m) around the residence. The children's behavior was assessed with the Strengths and Difficulties Questionnaire (SDQ) among 411 children. In addition, to evaluate cognitive function, 456 children completed four tasks of the Cambridge Neuropsychological Test Automated Battery (CANTAB). We used multivariate logistic and linear regression models while accounting for potential confounders and covariables. Results: An interquartile (IQR) increase of residential green space within 50 m was associated with a 38% (95% CI: 56;14) lower odds of a child having hyperactivity problems. Additionally, we found a beneficial influence of residential green space in close proximity (50-100 m) on the attention and psychomotor speed, represented by the Motor Screening Task. For example, we found a decrease of 0.45 (95% CI: -0.82;-0.09) pixel units from target center with an IQR increase of residential green space in a 50 m buffer. In addition, we observed an improved visual recognition/working memory, represented by the Delayed Matching to Sample Task within all included buffers (50-1000 m). For example, we observed a decrease of 4.91% (95 %CI: -7.46;-2.36) probability of an error occurring if the previous trial was correct and a 2.02% (95 %CI: 0.08; 3.97) increase of correct trials with an IQR increase of green space within a 100 m buffer. Conclusion: This study provides additional indications for a beneficial influence of green space exposure on the development of behavioral problems and cognitive function as young as four years of age. This investigation is supported by the EU research council “project ENVIRONAGE” (ERC-2012-StG 310890) and Flemish Scientific Fund (G073315N/G048420N). Lidia Casas is recipient of a post-doctoral fellowship a of the Research Foundation Flanders (FWO), grant number 12I1517N. Esm´ee M Bijnens holds a fellowship from the Marguerite-Marie Delacroix foundation. The authors thank all children and parents for taking part in the study. Graphical abstract was created with BioRender.com.

Green space may improve cardiovascular (CV) health, for example by promoting physical activity and by reducing air pollution, noise and heat. Socioeconomic and environmental factors may modify the health effects of green space. We examined the association between residential green space and reimbursed CV medication sales in Belgium between 2006 and 2014, adjusting for socioeconomic deprivation and air pollution. We analyzed data for 11,575 census tracts using structural equation models for the entire country and for the administrative regions. Latent variables for green space, air pollution and socioeconomic deprivation were used as predictors of CV medication sales and were estimated from the number of patches of forest, census tract relative forest cover and relative forest cover within a 600 m buffer around the census tract; annual mean concentrations of PM2.5, BC and NO2; and percentages of inhabitants that were foreign-born from lower- and mid-income countries, unemployed or had no higher education. A direct association between socioeconomic deprivation and CV medication sales [parameter estimate (95% CI): 0.26 (0.25; 0.28)] and inverse associations between CV medication sales and green space [–0.71 (–0.80; –0.61)] and air pollution [–1.62 (–1.69; –0.61)] were observed. In the regional models, the association between green space and CV medication sales was stronger in the region with relatively low green space cover (Flemish Region, standardized estimate –0.16) than in the region with high green space cover (Walloon Region, –0.10). In the highly urbanized Brussels Capital Region the association tended towards the null. In all regions, the associations between CV medication sales and socioeconomic deprivation were direct and more prominent. Our results suggest that there may be an inverse association between green space and CV medication sales, but socioeconomic deprivation was always the strongest predictor of CV medication sales. The authors acknowledge the Intermutualistisch Agentschap – L’Agence Intermutualiste (IMA-AIM) for providing the medication sales data, Charlotte Vanpoucke (IRCEL-CELINE) and Wouter Lefebvre (VITO) for providing air pollution data, Esmeé Bijnens (U Hasselt) for aggregating air pollution data, Rafael Costa for contributing to the preparation of socioeconomic data and dr. Maissa Rayyan (MD, KU Leuven) for providing medical background information on CVD medication. The icons in the graphical abstract were made by Freepik from www.flaticon.com and are used under a Flaticon Basic License (with attribution). ispartof: Science Of The Total Environment vol:712 ispartof: location:Netherlands status: published

Background: Mitochondria are sensitive to air pollutants due to their lack of repair capacity. Changes in mitochondrial DNA copy number (mtDNAcn) or content is a proxy of mitochondrial damage and has been associated with recent exposure to traffic-derived air pollutants, nitrogen dioxide (NO2) and black carbon (BC). Inhaled BC can be phagocytosed by airway macrophages (AMs), and its amount in AM reflects personal exposure to traffic-related air pollution. Objectives: The present study investigated the relation between the internal marker AM BC and ambient NO2 concentration and examined the associations of mtDNAcn with NO2 and AM BC. Methods: A panel of 20 healthy retired participants (10 couples) living in Belgium underwent repeated assessments of health and air pollution exposure at 11 time points over one year. We increased exposure contrast temporarily by moving participants for 10 days to Milan, Italy (high exposure) and to Vindeln, Sweden (low exposure). Personal exposure to NO2 was measured during 5 consecutive days prior to each assessment time point. The amount of BC was assessed by image analysis in AMs retrieved from induced sputum collected at 7 time points. Blood mtDNAcn was determined by qPCR at each time point. Associations between AM BC and NO2, and of mtDNAcn with NO2 and AM BC were estimated using linear mixed effect models adjusted for covariates and potential confounders. Results: Mean concentrations of 5-day average NO2 were higher in Milan (64 mu g/m(3)) and lower in Vindeln (4 mu g/m(3)) than Belgium (26 mu g/m(3)). Each 10 mu g/m(3) increment in NO2 exposure during the last 5 days was associated with 0.07 mu m(2) (95% CI: 0.001 to 0.012) increase in median area of AM BC. A 10 mu g/m(3) increase in NO2 was associated with 3.9% (95% CI: 2.2 to 5.5%) decrease in mtDNAcn. Consistently, each 1 mu m(2) increment in median area of AM BC was associated with 24.8% (95% CI: 6.8 to 39.3%) decrease in mtDNAcn. Conclusion: In this quasi-experimental setting involving moving persons to places with high and low ambient air pollution, we found changes in AM BC according to ambient air pollution levels measured during the previous 5 days. Both higher ambient NO2 and the internal lung BC load, paralleled mitochondrial compromises as exemplified by lower mtDNA content This work was supported by the Fund for Scientific Research (FWO-Vlaanderen, G.0165.03).We acknowledge donations from vzw Compostela (a non-profit organization for elderly care). Both Lidia Casas and Bram Janssen hold a post-doctoral fellowship of the Research Foundation Flanders (FWO). The mitochondrial DNA work was supported by a grant from the European Research Council (ERC-2012-StG 310898).

Background: The influence of outdoor green space on microbial communities indoors has scarcely been investigated. Here, we study the associations between nearby residential green space and residential indoor microbiota. Methods: We collected settled dust from 176 living rooms of participants of the ENVIRONAGE birth cohort. We performed 16S and ITS amplicon sequencing, and quantitative PCR measurements of total bacterial and fungal loads to calculate bacterial and fungal diversity measures (Chao1 richness, Shannon and Simpson diversity indices) and relative abundance of individual taxa. Green spaces were estimated within 50m and 100m buffers around the residential address. We defined total residential green space using high-resolution land-cover data, further stratified in low-growing (height3m). We used land-use data to calculate the residential nature. We ran linear regression models, adjusting for confounders and other potential determinants. Results are expressed as units change for an interquartile range (IQR) increase in residential green space and their 95% confidence intervals (CI). Results: After adjustment, we observed statistically significant associations between the indoor microbial diversity indices and nearby residential green space. For bacteria, the Shannon index was directly associated with residential nature (e.g. 0.08 units increase (CI:0.02,0.13) per IQR increase in nature within a 50m buffer). Fungal diversity was directly associated with high-growing residential green and inversely with low-growing green. For example, an IQR increase in high-growing green within a 50m buffer was associated with increases in 0.14 (CI:0.01,0.27) and 0.02 (CI:0.008,0.04) units in the Shannon and Simpson indices, respectively. Conclusions: Nearby green space determines the diversity of indoor environment microbiota, and the type of green differently impacts bacterial and fungal diversity. Further research is needed to investigate in more detail possible microbial taxa compositions underlying the observed changes in indoor microbiota diversity and to explore their contribution to beneficial health effects associated with green space exposure.

Background and objectives: Previous studies have suggested that air pollution is associated with depression and anxiety symptoms. Here, we investigate the association between personal exposure to NO2 and perceived stress and mood in a panel of healthy elderly persons. Methods: In a one-year panel study, we included 20 healthy volunteers (10 male-female couples aged 58-76 years) with air pollution and health parameters measured every two months (120 observations). We measured personal exposure to NO2 in the previous 5 days, perceived stress using the Perceived Stress Scale (PSS) and positive and negative affect with the Positive and Negative Affect Schedule (PANAS). We used linear and Poisson mixed models to evaluate the associations between the health outcomes and NO2 adjusted for age, sex, temperature in the previous 5 days, sunlight in the previous day and physical activity (daily average number of steps on the previous week). Also, the interaction terms between NO2 and physical activity were tested. We report % changes for PSS scores and unit changes (beta) for positive and negative affect, and their 95% confidence intervals (CI), for changes in 10 mu g/m(3) of NO2. Results: After adjustment, an increase by 10 mu g/m(3) in NO2 concentrations was associated with a decrease of 1.3 points in the positive affect (95% CI -2.49 to - 0.17) and an increase of 0.11 points in the negative affect (95% CI 0.02 to 0.20). The association with positive affect was stronger when physical activity was below median value of 9,362 steps per day (beta = -2.68; CI: 4.87 to - 0.49); p-value for interaction was 0.08. No statistically significant associations were observed with perceived stress. Conclusion: Short-term exposure to air pollution may produce non-pathological alterations in mood in healthy elderly population.

Background: Living in green environments has been associated with various health benefits, but the evidence for positive effects on respiratory health in children is ambiguous. Objective: To investigate if residential exposure to different types of green space is associated with childhood asthma prevalence in Belgium. Methods: Asthma prevalence was estimated from sales data of reimbursed medication for obstructive airway disease (OAD) prescribed to children between 2010 and 2014, aggregated at census tract level (n = 1872) by sex and age group (6–12 and 13–18 years). Generalized log-linear mixed effects models with repeated measures were used to estimate effects of relative covers of forest, grassland and garden in the census tract of the residence on OAD medication sales. Models were adjusted for air pollution (PM10), housing quality and administrative region. Results: Consistent associations between OAD medication sales and relative covers of grassland and garden were observed (unadjusted parameter estimates per IQR increase of relative cover, range across four strata: grassland, β = 0.15–0.17; garden, β = 0.13–0.17). The associations remained significant after adjusting for housing quality and chronic air pollution (adjusted parameter estimates per IQR increase of relative cover, range across four strata: grassland, β = 0.10–0.14; garden, β = 0.07–0.09). There was no association between OAD medication sales and forest cover. Conclusions: Based on aggregated data, we found that living in close proximity to areas with high grass cover (grasslands, but also residential gardens) may negatively impact child respiratory health. Potential allergic and non-allergic mechanisms that underlie this association include elevated exposure to grass pollen and fungi and reduced exposure to environmental biodiversity. Reducing the dominance of grass in public and private green space might be beneficial to reduce the childhood asthma burden and may simultaneously improve the ecological value of urban green space. All health data were anonymized by aggregation to census tract level and were used under license of IMA-AIM. The protocol for this study did not require ethics approval. ispartof: Environmental Research vol:189 ispartof: location:Netherlands status: published

The sustainability of cobalt is an important emerging issue because this critical base metal is an essential component of lithium-ion batteries for electric vehicles. More than half of the world’s cobalt mine production comes from the Katanga Copperbelt in DR Congo, with a substantial proportion (estimated at 15–20%) being extracted by artisanal miners. Here we show, in a case study performed in the town of Kolwezi, that people living in a neighbourhood that had been transformed into an artisanal cobalt mine had much higher levels of cobalt in their urine and blood than people living in a nearby control area. The differences were most pronounced for children, in whom we also found evidence of exposure-related oxidative DNA damage. It was already known that industrial mining and processing of metals has led to severe environmental pollution in the region. This field study provides novel and robust empirical evidence that the artisanal extraction of cobalt that prevails in the DR Congo may cause toxic harm to vulnerable communities. This strengthens the conclusion that the currently existing cobalt supply chain is not sustainable. Cobalt is used in rechargeable batteries, and half the world’s supply comes from one district in the Democratic Republic of Congo. This study assesses the sustainability of artisanal mining there, finding much higher levels of cobalt in blood and urine of community members and especially of children.

Background Short-term exposure to ambient air pollution triggers acute cardiovascular events. Here, we evaluate the association of exposure to ambient air pollution with two intermediate cardiovascular endpoints: blood pressure and carotid stiffness. Methods In a one-year panel study, we included 20 healthy volunteers (10 male-female couples aged 59–75 years) with air pollution and health parameters measured every two months at their region of residence (Leuven, Belgium) and twice during two ten-day periods in two locations, one with higher (Milan, Italy) and one with lower (Vindeln, Sweden) air pollution levels (220 observations). We measured blood pressure, carotid arterial stiffness, personal exposure to NO2, and ambient concentrations of PM10, PM2.5, and NO2. We used linear mixed models to evaluate the associations between the health outcomes and the air pollutants. Results Compared with Leuven, exposure to pollutants was higher in Milan and lower in Vindeln, with the highest contrast for NO2 (median 20.7 μg/m3 (IQR:7.4) vs 65.1 μg/m3 (9.0) and 4.5 mg/m3 (0.8), respectively). We did not observe significant associations between either systolic or diastolic blood pressure and variations in air pollution. However, we found significant associations between arterial stiffness and 5 day average exposure to the studied pollutants. The strongest associations were observed for PM10 with carotid distensibility (DC) and compliance (CC) coefficients, and the young elastic modulus (YEM): 4.3% (95%CI:7.0;1.5) increase in DC, 4.7% (95%CI:7.1;2.3) increase in CC and 4.2% (95%CI:1.1;7.3) decrease in YEM for each 10 μg/m3 decreases in PM10. Conclusions Our study suggests that short-term exposure to air pollution results in reductions in carotid elasticity among elderly population. Electronic supplementary material The online version of this article (10.1186/s12940-018-0425-7) contains supplementary material, which is available to authorized users.

Pulmonary exposure to nanoparticles (NPs) has been shown to induce pulmonary as well as cardiovascular toxicity. These effects might be enhanced in elderly subjects as a result of a compromised immunity and/or declined organ functions. To study the adverse in vivo effects of NPs in a model for the elderly, we exposed 18-month-old C75Bl/6 mice to multi-walled carbon nanotubes (MWCNTs) or ZnO NPs by intratracheal instillation once a week during 5 consecutive weeks. Pulmonary and hemostatic toxicity was determined 24 h (T1) and 8 weeks (T2) after the last administration. Both NP types significantly increased the pulmonary macrophages at both time points. The MWCNTs and ZnO NPs also induced a pulmonary influx of neutrophils, which was even larger at T2 compared to T1. All NPs induced only a modest increase of pulmonary IL-1β, IL-6 and KC levels. Both types of NPs also increased blood neutrophils. Red blood cells were not significantly affected. Both NPs significantly increased coagulation factor VIII levels at both time points. Histological analysis revealed the presence of MWCNTs in the alveolar macrophages up to 8 weeks after the last administration and the ZnO NPs induced a pronounced alveolar inflammation. In these 18-month-old mice, NPs caused pulmonary inflammation (without evidence of oxidative stress) accompanied by large increases in coagulation factor VIII up to 8 weeks after the last NP exposure. The persistence of the MWCNTs in the lungs resulted in translocation from the lungs to the left heart and the ZnO NPs induced a fibrosis-like pathology. ispartof: SCIENCE OF THE TOTAL ENVIRONMENT vol:644 pages:907-915 ispartof: location:Netherlands status: published

Developmental exposure to phthalates may be associated with adverse health outcomes but information on the variability and predictors of urinary phthalate metabolite concentrations during pregnancy is limited. We evaluated in Spanish pregnant women (n=391) the reproducibility of urinary phthalate metabolite concentrations and predictors of exposure. We measured mono-(4-methyl-7-hydroxyoctyl) phthalate (7-OHMMeOP), mono-(2-ethylhexyl) phthalate (MEHP), mono-(2-ethyl-5-hydroxyhexyl) phthalate (MEHHP), mono-(2-ethyl-5-oxohexyl) phthalate (MEOHP), mono-(2-ethyl-5-carboxypentyl) phthalate (MECPP), mono-(2-carboxyhexyl) phthalate (MCMHP), mono-benzyl phthalate (MBzP), monoethyl phthalate (MEP), mono-iso-butyl phthalate (MiBP) and mono-n-butyl phthalate (MnBP) in two spot urine samples collected in the first and third pregnancy trimesters. Questionnaires on predictors and food-frequency questionnaires were administered in the first and/or third pregnancy trimesters. Using creatinine-adjusted phthalate metabolite concentrations (log(10)-trasformed) we calculated intraclass correlation coefficients (ICCs). Linear mixed and regression models assessed the associations between predictors and phthalate metabolites. The ICCs ranged from 0.24 to 0.07 and were higher for MBzP, MEP, MiBP, and lower for MEOHP and MEHHP. Overweight, lower education and social class, and less frequent consumption of organic food were associated with higher levels of some phthalate metabolites. The use of household cleaning products (bleach, ammonia, glass cleaners, oven cleaning sprays and degreasing products) at least once per week during pregnancy was associated with 10-44% higher urinary phthalate metabolites. Bottled-water consumption, consumption of food groups usually stored in plastic containers or cans, use of plastic containers for heating food and cosmetic use were not associated with increased concentrations of phthalate metabolites. This large study with repeated phthalate measurements suggests that, in this Spanish setting, sociodemographic and lifestyle factors and household cleaning product use are better predictors of phthalate exposure levels in pregnant women than average water and food consumption and use of plastic containers and cosmetics. (C) 2014 Elsevier GmbH. All rights reserved.

Since we spend most of our time indoors, the characteristics of the indoor environment, and in particular, the characteristics of the microbial environment, have an impact in our health and well-being. The composition of the indoor microbial environment in homes is determined by regional factors like climate, building factors (e.g. ventilation or presence of mould or dampness) or the occupants and their indoor activities (e.g. crowdedness, pet ownership, indoor smoking, cleanliness or use of gas for cooking). The “westernization” process has modified some of these factors leading to changes in the characteristics of the indoor microbial environment and a consequent impact in our health. To date, most studies have investigated the beneficial and negative effects of the indoor microbial environment on respiratory and allergic health, mainly among children. Nevertheless, some recent studies point to a potential impact on mental health. Among children and adults, the exposure to mould or damp at home seems to be a risk factor for the development of asthma and allergies, and may have a negative effect on neuropsychological development and mood disorders. On the other hand, growing up in a farm protects against allergies and asthma. Nevertheless, for children and adults, the health effects of the indoor microbial environment are only consistent in observation/report of indoor moisture damage or when comparing farming vs non-farming homes. When actual measures targeting indoor microbial exposure in (sub-) urban areas are included, the picture becomes less clear and the associations appear inconsistent. Similarly, the presence of mould or dampness at home has been associated with lower cognitive function and with behavioural problems in children. Among adults, living in damp homes may be related with mood disorders. However, the inclusion of actual measures of the indoor microbial environment in human studies does not confirm these associations. Further epidemiological studies are needed to obtain sufficient evidence of the effects of the indoor microbial environment on mental health.

It has been published that hospital adverse events are an important source of morbidity and mortality in different countries and settings. The aim of this study was to evaluate the frequency, magnitude, distribution and degree of preventability of adverse events in the Autonomous Community of Catalonia (Spain). We conducted a retrospective cohort study of 4,790 hospital discharges that were selected by simple random sampling after stratified multistage sampling in 15 hospitals in Catalonia. 38.25% of patients had positive risk criteria (screening phase). We identified 356 cases of adverse events, which represent a 7.4% (95%CI: 6.7% to 8.1%). Of these, 43.5% (155 cases) were considered preventable. This study confirms that adverse events in hospitals in Catalonia are frequent, and generate a significant impact on morbidity and mortality. As in other studies, corroborated that a high proportion of these adverse events are considered preventable. It was possible to identify priority areas to focus improvement efforts.

This study aimed to describe the residential use of insecticides in a birth cohort in Spain. Study subjects were 2 456 women enrolled into the INMA (Environment and Childhood) birth cohort followed prospectively during pregnancy and in the early postnatal period. The women were recruited at the beginning of their pregnancy between 2003 and 2008 in four regions of Spain. Socio-demographic, environmental and lifestyle information was obtained at two interviews during pregnancy, one at the first (mean:13.8 +/- 2.6 weeks of gestation) and the other at the third trimester (mean: 33.3 +/- 23 weeks of gestation). Information about prenatal use of indoor and outdoor insecticides (type, timing, place of application, place of storage) was obtained from the second interview. In a 3rd interview (mean: 16.2 +/- 6.9 months of age of children), information about postnatal indoor and outdoor insecticide use was obtained. Regression models examined the association between demographic and lifestyle factors and pesticide use to determine which characteristics predicted use prenatally and postnatally. Fifty-four percent of women reported using indoor insecticides during pregnancy, 45% in their bedroom and 47% elsewhere in the house. Plug-in devices were the most frequent application methods used in the pregnant woman's bedroom and insecticide sprays elsewhere in the house. The maternal factors related to prenatal use of indoor insecticides were parity, country of birth, educational level, region of residence, having a garden or yard with plants, and living near an agricultural area. These products continued to be used postnatally, although 20% of the women stopped using them. Foetuses and children are especially vulnerable to pesticide exposure; thus knowing how pesticides are used during pregnancy and infancy may be a starting point for the study of their potential effects on health as well as useful for designing preventive actions. (C) 2013 Elsevier B.V. All rights reserved.

Background: Inflammation is a key factor in the pathogenesis of respiratory diseases. Early life exposure to microbial agents may have an effect on the development of the immune system and on respiratory health later in life. In the present work we aimed to evaluate the associations between early life microbial exposures, and fractional exhaled nitric oxide (FeNO) at school age. Methods: Endotoxin, extracellular polysaccharides (EPS) and beta(1,3)-D-glucan were measured in living room dust collected at 2-3 months of age in homes of participants of three prospective European birth cohorts (LISA, n = 182; PIAMA, n = 244; and INMA, n = 355). Home dampness and pet ownership were periodically reported by the parents through questionnaires. FeNO was measured at age 8 for PIAMA and at age 10/11 for LISA and INMA. Cohort-specific associations between the indoor microbial exposures and FeNO were evaluated using multivariable regression analyses. Estimates were combined using random-effects meta-analyses. Results: FeNO at school age was lower in children exposed to endotoxin at age 2-3 months (beta-0.05, 95% confidence interval (CI) -0.10;-0.01) and in children with reported dog ownership during the first two years of life (GM ratio 0.82, CI 0.70-0.96). FeNO was not significantly associated with early life exposure to EPS, beta(1,3)-D-glucan, indoor dampness and cat ownership. Conclusion: Early life exposure to bacterial endotoxin and early life dog ownership are associated with lower FeNO at school age. Further studies are needed to confirm our results and to unravel the underlying mechanisms and possible clinical relevance of this finding., This work was supported by the European Commission as part of HITEA (Health Effects of Indoor Pollutants: Integrating microbial, toxicological and epidemiological approaches), Grant agreement no. 211488 under the Seventh Framework Programme, Topic ENV.2007.1.2.1.1. Indoor air pollution in Europe: An emerging environmental health issue.r The LISAplus study was funded by the BMBF (Federal Ministry of Education and Research), the Helmholtz Center Munich and the UFZ Leipzig. The PIAMA study is supported by The Netherlands Organization for Health Research and Development; The Netherlands Organization for Scientific Research; The Netherlands Asthma Fund; The Netherlands Ministry of Spatial Planning, Housing, and the Environment; and The Netherlands Ministry of Health, Welfare, and Sport. The INMA-Menorca study was funded by Fondo de Investigacion Sanitaria, ISCIII, Ministerio de Sanidad y Servicios Sociales, Spain (Grants 97/0588, 00/0021-2, G03/176, PI061756 and PS0901958), EC Contract QLK4-CT-2000-00263 and Fundacio Roger Torne (Barcelona, Spain).

Background: Phthalate and phenol exposure is prevalent among the general population and of potential concern for pregnant women and children because of their suspected susceptibility to endocrine effects. Objectives: To evaluate the extent of exposure to several phthalates and phenols in a sample of Spanish pregnant women – according to their individual characteristics (age, social class, education, and body mass index) – and children who participated in the INMA — Infancia y Medio Ambiente (Environment and Childhood) project. Methods: One spot urine sample was taken during the third trimester of pregnancy from 120 pregnant women and from 30 4-year old children belonging to 5 Spanish birth cohorts, and analyzed for 11 phthalate metabolites and 9 phenols. Results: Three metabolites of di(2-ethylhexyl) phthalate, mono-2-ethyl-5-carboxypentyl phthalate, mono-2-ethyl-5-hydroxyhexyl phthalate, and mono-2-ethyl-5-oxohexyl phthalate; two metabolites of dibutyl phthalates, mono-isobutyl phthalate and mono-n-butyl phthalate; monoethyl phthalate (MEP), the main metabolite of diethyl phthalate; and two phenols, methyl paraben (M-PB) and 2,5-dichlorophenol were detected in the urine samples of all women. The highest urinary concentrations were for MEP and M-PB. Urinary concentrations of all phthalate metabolites and of 2,4-dichlorophenol, 2,5-dichlorophenol, and bisphenol A were lower in the pregnant women than in the children. Among women, a positive relationship with social class and education was shown for most of the phthalate metabolites and phenols. Almost all phthalate metabolites varied by region even after adjusting for social class and education. Conclusions: Phthalate and phenol exposures are prevalent in a group of pregnant women and young children, two susceptible populations, and these exposures might be positively related to social class. Keywords: Phthalate, Phenol, Pregnancy, Children, Social class, Exposure

Aims: The aim of this study was to compare two treatment options for choroidal neovascularisation (CNV) secondary to age-related macular degeneration (AMD): (1) bevacizumab administered once a month for 3 months and thereafter as needed (loading dose (LD)); and (2) bevacizumab administered as needed, after the first injection (pro re nata (as needed) (PRN)). Methods: Fifty consecutive patients were enrolled in this prospective study. The first 25 patients were included in the LD group and the last 25 patients in the PRN group. In both groups, the need for re-treatment was based on the presence of persistent or recurrent macular oedema, subretinal fluid or pigment epithelial detachment on optical coherence tomography scans. Results: At the 6-month follow-up, mean visual acuity improved by 13.7 letters (p