Environmental burden of disease in Europe: assessing nine risk factors in six countries.

BACKGROUND: Environmental health effects vary considerably with regard to their severity, type of disease, and duration. Integrated measures of population health, such as environmental burden of disease (EBD), are useful for setting priorities in environmental health policies and research. This review is a summary of the full Environmental Burden of Disease in European countries (EBoDE) project report. OBJECTIVES: The EBoDE project was set up to provide assessments for nine environmental risk factors relevant in selected European countries (Belgium, Finland, France, Germany, Italy, and the Netherlands). METHODS: Disability-adjusted life years (DALYs) were estimated for benzene, dioxins, secondhand smoke, formaldehyde, lead, traffic noise, ozone, particulate matter (PM2.5), and radon, using primarily World Health Organization data on burden of disease, (inter)national exposure data, and epidemiological or toxicological risk estimates. Results are presented here without discounting or age-weighting. RESULTS: About 3-7% of the annual burden of disease in the participating countries is associated with the included environmental risk factors. Airborne particulate matter (diameter ≤ 2.5 µm; PM2.5) is the leading risk factor associated with 6,000-10,000 DALYs/year and 1 million people. Secondhand smoke, traffic noise (including road, rail, and air traffic noise), and radon had overlapping estimate ranges (600-1,200 DALYs/million people). Some of the EBD estimates, especially for dioxins and formaldehyde, contain substantial uncertainties that could be only partly quantified. However, overall ranking of the estimates seems relatively robust. CONCLUSIONS: With current methods and data, environmental burden of disease estimates support meaningful policy evaluation and resource allocation, including identification of susceptible groups and targets for efficient exposure reduction. International exposure monitoring standards would enhance data quality and improve comparability.

Application of the maximum cumulative ratio (MCR) as a screening tool for the evaluation of mixtures in residential indoor air.

The maximum cumulative ratio (MCR) method allows the categorisation of mixtures according to whether the mixture is of concern for toxicity and if so whether this is driven by one substance or multiple substances. The aim of the present study was to explore, by application of the MCR approach, whether health risks due to indoor air pollution are dominated by one substance or are due to concurrent exposure to various substances. Analysis was undertaken on monitoring data of four European indoor studies (giving five datasets), involving 1800 records of indoor air or personal exposure. Application of the MCR methodology requires knowledge of the concentrations of chemicals in a mixture together with health-based reference values for those chemicals. For this evaluation, single substance health-based reference values (RVs) were selected through a structured review process. The MCR analysis found high variability in the proportion of samples of concern for mixture toxicity. The fraction of samples in these groups of concern varied from 2% (Flemish schools) to 77% (EXPOLIS, Basel, indoor), the variation being due not only to the variation in indoor air contaminant levels across the studies but also to other factors such as differences in number and type of substances monitored, analytical performance, and choice of RVs. However, in 4 out of the 5 datasets, a considerable proportion of cases were found where a chemical-by-chemical approach failed to identify the need for the investigation of combined risk assessment. Although the MCR methodology applied in the current study provides no consideration of commonality of endpoints, it provides a tool for discrimination between those mixtures requiring further combined risk assessment and those for which a single-substance assessment is sufficient.

Utilitarian cycling in Belgium: a cross-sectional study in a sample of regular cyclists.

BACKGROUND: For an accurate estimation of health benefits and hazards of utilitarian cycling, a prospective collection of bicycle usage data (exposure) is fundamental. Individual and environmental correlates are necessary to guide health promotion and traffic safety issues. Firstly, this study aims to report on utilitarian bicycle usage in Belgium, using a prospective data collection in regular adult commuter cyclists. Secondly, the association is explored between the individual variation in bicycle usage and individual and environmental correlates. METHODS: 1187 regular adult cyclists filled out travel diaries prospectively. Multivariate linear regression with Stepwise selection (SMLR) models studied the association between exposure and individual and environmental correlates. RESULTS: Higher age and availability of cycle paths have a positive association with bicycle usage to work. Women cycle significant less compared with men, and so do cyclists with 'poor' or 'average' health. Living in an urban crown (opposed to city center) and living in Flanders (opposed to Brussels or Wallonia) is associated with significantly more cycling. CONCLUSIONS: Utilitarian cycling is related to regional differences, level of urbanization of the place of residence, availability of bicycle paths, and gender. These findings are useful in estimating health benefits and hazards of utilitarian cycling among regular Belgian cyclists.

A prospective cohort study on minor accidents involving commuter cyclists in Belgium.

The purpose of this study is to gain insight into bicycle accidents. Bicycle accident data and weekly exposure data were prospectively collected for one year to calculate the incidence rate (IR) of bicycle accidents. An accident was included if it occurred during utilitarian cycling, resulting in an acute injury with corporal damage. If an accident occurred, a detailed questionnaire was filled out to collect detailed information about its circumstances and consequences. A sample of 1087 regular (≥2 cycling trips to work a week) adult (40±10 years) cyclists was analyzed. Over the 1-year follow-up period, 20,107 weeks were covered, accumulating 1,474,978 cycled kilometers. Sixty-two participants were involved in 70 bicycle accidents, of which 68 were classified as 'minor'. The overall IR for the 70 accidents was 0.324 per 1000 trips (95% CI 0.248-0.400), 0.896 per 1000 h (95% CI 0.686-1.106) and 0.047 per 1000 km (95% CI 0.036-0.059) of exposure. Brussels-capital region is the region with the highest IR (0.086; 95% CI 0.054-0.118), with a significantly (P<0.05) higher IR compared to Flanders (0.037; 95% CI 0.025-0.050). Injuries were mainly caused by 'slipping' (35%) or 'collision with a car' (19%). The accidents caused abrasions (42%) and bruises (27%) to the lower (45%) and upper limbs (41%). Police, hospital emergency department or insurance companies were involved in only 7%, 10% and 30% of the cases, respectively. It is noteworthy that 37% of the participants indicated that they could have avoided the accident. In order to decrease the number of accidents, measures should be taken to keep cycling surfaces clean and decrease the number of obstacles on bicycle infrastructure. Roads and intersections need to be built so that the collisions between cars and bicycles are decreased to a minimum. Car drivers and cyclists should pay more attention towards each other. Underreporting of minor bicycle accidents in Belgium is confirmed, and is higher than expected. Reliable accident statistics, taking into account exposure, are needed to decide which road safety measures are the most effective. The 'safety in numbers' principle is also applicable for minor bicycle accidents.

The costs of breast cancer prior to and following diagnosis.

This retrospective incidence-based cost-of-illness analysis aims to quantify the costs associated with female breast cancer in Flanders for the year prior to diagnosis and for each of the 5 years following diagnosis. A bottom-up analysis from the societal perspective included direct health care costs and indirect costs of productivity loss due to morbidity and premature mortality. A case-control study design compared total costs of breast cancer patients with costs of an equivalent standardised population with a view to calculating the additional costs that can be attributed to breast cancer. Total average costs of breast cancer amounted to 107,456 per patient over 6 years. Total costs consisted of productivity loss costs (89% of costs) and health care costs (11% of costs). Health care costs did not vary with age at diagnosis. Health care costs of breast cancer patients converged with those of the general population at 5 years following diagnosis. Patients with advanced breast cancer stadia had higher health care costs. Cost estimates provided by this analysis can be used to determine priorities for, and inform, future research on breast cancer. In particular, attention needs to be focussed on decreasing productivity loss from breast cancer.

Commuting by bike in Belgium, the costs of minor accidents.

Minor bicycle accidents are defined as "bicycle accidents not involving death or heavily injured persons, implying that possible hospital visits last less than 24 hours". Statistics about these accidents and related injuries are very poor, because they are mostly not reported to police, hospitals or insurance companies. Yet, they form a major share of all bicycle accidents. Official registrations underestimate the number of minor accidents and do not provide cost data, nor the distance cycled. Therefore related policies are hampered by a lack of accurate data. This paper provides more insight into the importance of minor bicycle accidents and reports the frequency, risk and resulting costs of minor bicycle accidents. Direct costs, including the damage to bike and clothes as well as medical costs and indirect costs such as productivity loss and leisure time lost are calculated. We also estimate intangible costs of pain and psychological suffering and costs for other parties involved in the accident. Data were collected during the SHAPES project using several electronic surveys. The weekly prospective registration that lasted a year, covered 1187 persons that cycled 1,474,978 km. 219 minor bicycle accidents were reported. Resulting in a frequency of 148 minor bicycle accidents per million kilometres. We analyzed the economic costs related to 118 minor bicycle accidents in detail. The average total cost of these accidents is estimated at 841 euro (95% CI: 579-1205) per accident or 0.125 euro per kilometre cycled. Overall, productivity loss is the most important component accounting for 48% of the total cost. Intangible costs, which in past research were mostly neglected, are an important burden related to minor bicycle accidents (27% of the total cost). Even among minor accidents there are important differences in the total cost depending on the severity of the injury.