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   Abstract
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ARTICLES Table of Contents   
Year : 2003  |  Volume : 5  |  Issue : 19  |  Page : 41-50
Respiratory and dermatological diseases in children with long-term exposure to road traffic immissions

1 Umweltbundesamt a.D, Berlin, Germany
2 Bundesministerium für Gesundheit und Soziale Sicherung, Dienstsitz Berlin, Germany
3 Practising paediatrician in the district of Osterode/Harz, Germany
4 ENT-specialist, Osterode/Harz, Germany

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  Abstract 

The pathogenesis of allergies can be stimulated by adjuvant effects - i.e. air pollutants such as NO 2 and particles from diesel exhausts as well as noise - the latter especially during night-time. During sleep, noise signals which are associated with danger (i.e. lorry noise) have the potential to trigger stress reactions even if the noise level is low. Increases of cortisol in the first half of the night seem to play an important role. In a blind interview study, the combined effects of chronic exposure to traffic related air pollution and noise, upon the risk of skin and respiratory diseases in children were studied. All children between 5-12 years, who had consulted one of two participating paediatricians were included in the study. The paediatricians diagnoses of 400 children were analysed together with their parents answers regarding the density of road traffic on their street and several confounding factors. Multiple regression analyses resulted in relative risks of asthma, chronic bronchitis and neurodermitis, which increased significantly with increasing traffic load. A comparison with the literature on such effects caused by air pollution alone, showed that traffic noise during the night might have an adjuvant effect on the pathogenesis of the mentioned diseases.

Keywords: Asthma, bronchitis, neurodermitis, air pollution, traffic noise

How to cite this article:
Ising H, Lange-Asschenfeldt H, Lieber G F, Weinhold H, Eilts M. Respiratory and dermatological diseases in children with long-term exposure to road traffic immissions. Noise Health 2003;5:41-50

How to cite this URL:
Ising H, Lange-Asschenfeldt H, Lieber G F, Weinhold H, Eilts M. Respiratory and dermatological diseases in children with long-term exposure to road traffic immissions. Noise Health [serial online] 2003 [cited 2019 Nov 15];5:41-50. Available from: http://www.noiseandhealth.org/text.asp?2003/5/19/41/31699

  Introduction Top


"Allergies are on the advance. More than 25% of all children are affected. The increase is most probably to be ascribed to the life-style of modern civilisation."(Amler et al. 2001). This statement is based on literature associating air pollutants and the prevalence of allergic diseases in children. Integrating the accumulated knowledge, Kiinzli et al. (2001) summarised as follows: "Based upon the findings in research of the past two decades it has to be assumed that the air pollution of our time induces adverse health effects." He calculated the increased risk of bronchitis due to air pollution to be OR=1.31 per 10µg PM 10 .

In a special review on environment and health, the German Council of Environmental Advisors (Der Rat von Sachverstandigen fur Umweltfragen, 1999) has made the following statement on environmental noise-related health effects: "Noise acts as a stress factor and as such has the potential of facilitating diseases which are partially caused by stress as a co-factor."

During sleep, noise, in association with danger such as lorry noises can, even at low levels, induce cortisol level increases. Recent investigations have opened a discussion whether cortisol level increases in the first half of the night may have an adverse effect on the immune system and consequently be an adjuvants in the development of allergic diseases.

In agreement with this hypothesis, stress hormone increases during sleep were observed even with low noise levels. For example, Evans et al. (2001) examined children with relatively low road traffic exposures (day and night mean outdoor noise level Ldn > 60 dB) compared to children who lived in quiet surroundings (mean day and night outdoor noise level Ldn < 50 dB). In the children's night urine, increases in free cortisol and cortisol metabolites were found.

In a pilot field study with children, stress hormone excretion was measured in the first and the second half of the night. The results indicated an impairment of the normal rhythm of nocturnal cortisol excretion in children living on a street with a high traffic load as compared to less exposed children. The endocrine dysfunctions were correlated with restless sleep, difficulties returning to sleep after awakening during the night, as well as to bronchial asthma and allergy prevalence. Children diagnosed with bronchial asthma or an allergy were found to have significantly higher excretion rates of cortisol metabolites but no increase of free cortisol in the first half of the night as compared with the second half (Ising et al. 2002). These results indicate that lorry noise at night could be detrimental to health even at indoor levels which up to now have been rated as not interfering with healthy sleep (Interdisziplinarer Arbeitskreis fur Larmwirkungsfragen beim Umweltbundesamt, 1982).


  Methods Top


The study design followed the principles of a practice based study (Schlaud et al. 2002) while data evaluation was carried out using the methods which are applied for cross-sectional studies. For a given time period, all cases of diverse diseases and the rates of respective treatments were registered (numerator) and evaluated in relation to the total contact rates (denominator), after statistical control for other potential influences.

The study design was developed in co-operation with two paediatricians who have their clinics in the Osterode district of the Harz Mountains. They both had already taken part in a pilot study. In particular, diseases hypothetically associated with road traffic-related immissions and further data were collected from the children's parents by questionnaire.

The following diseases when diagnosed by the paediatricians were documented explicitly: bronchial asthma; chronic bronchitis; allergies verified by case history, a positive prick test, a patch test if necessary, and a blood analysis; neurodermatitis and behavioural disturbances. Diseases hypothetically not associated with road traffic immissions, and other health complaints presented to the physicians, were documented separately: gastro-intestinal or urinary tract infections, otitis media, accidents and orthopaedic cases, and vaccinations. All other health hazards were categorised as "various". The interviews with the young patients' parents were carried out by the paediatrician's nurses after being trained to carry out a questionnaire guided interview.

Beside socio-demographic data (age, sex, highest educational level of both parents), the interviews were primarily concerned with the individual living conditions, construction and design of their homes. The most important exposure variables were the statements made on the traffic load of the street to which the family's home and the children's bedrooms were facing. Other relevant factors were the time period of living in their home and the children's habits of keeping their windows open or closed. Further potential confounding variables included allergy-inducing factors at home such as pets or environmental tobacco smoking (ETS). While these items were obtained from their parents, the children were asked about their annoyances due to road traffic noise at home (categories: little, moderate, severe). For further evaluations, a secondary exposure variable was calculated from the initial questionnaire statements regarding the road traffic load at the home and the child's bedroom. These were gained by asking the following two questions:

1. "Is your home on a street with heavy lorry and motorcar traffic / with moderate motorcar traffic and occasional lorry traffic / with minor motorcar and lorry traffic / or on a rarely used road (in a residential area with no thoroughfare, on a courtyard or garden plot)".

2. " Does your child's bedroom face a main or thoroughfare street with heavy traffic / or a side street with considerable traffic / a moderately used side street / or a rarely used road (in a residential area with no thoroughfare, on a courtyard or garden plot)".

Traffic exposures were rated as "low" if both the home and the child's bedroom were in the two low categories. Mixed traffic exposures were rated as "moderate". An exposure was determined as "high" if both home and bedroom were in the two upper traffic load categories.

The study was conducted from the 1st to the 30th of September 2001. Participation was voluntary, test persons were recruited in the two paediatric clinics by addressing all parents who brought their child to see the doctor for medical treatment or vaccination. Each patient was interviewed only once during the total observation period. Since the nurses did not know the actual cause of consulting the doctor at that point, the interview was rated as a blind test.

Associations between exposures to road traffic immissions and health outcomes were estimated by logistic regression analyses. For estimation of the relative risks, odds ratios and 95%­confidence intervals were calculated (statistical software: SPSS 9.0). For statistical adjustment, the potential confounding factors age, sex, number of household members, ETS, pets in the child's bedroom and the parents' highest educational level were considered in the multiple models.


  Results Top


Thanks to the physicians' motivating influence on their patients a response rate of 100% was reached. A total of 401 children aged 5 to 12 years were diagnosed and interviewed. The age distribution of the children is given in [Table - 1]. Proportionally, girls comprised 47%, boys 53%. Parents with a higher and lower educational level respectively amounted to 25% each. 50% of the parents had completed '0' levels. These figures indicate the highest level of both parents. 34 of the total group had occupied their room for less than a year. In order to avoid confounding of the results by potentially too short immission periods, several of the statistical evaluations were carried out omitting these cases.

According to the parents' rating of the traffic load in their street and the location of rooms in their home, a high traffic load was established for 21% of all homes; in 15% the children's bedrooms faced a main or a thoroughfare street, and in 4% a side street with considerable traffic. The low traffic load category applied to 54%, a medium load to 29%, and a high load to 17% of the total sample.

The prevalence ratios of the physicians' diagnoses or treatments were: a positive allergen skin test in 15% of the total sample, bronchial asthma in 9%, chronic bronchitis in 22.5%, neurodermatitis in 23%, and behavioural disturbances (restlessness) in 21.5%. 16% had otitis media, 13% were treated for gastro­intestinal disorders, 7% for orthopaedic disorders or accidents, 13% were due for vaccination, and 54.5% were treated for "various" other complaints.

29% of the children slept with their windows closed in summer compared to 76% in the wintertime. Only 4% felt severely annoyed by traffic noise in the daytime, 3% at night, while 15% were moderately annoyed in the daytime, 7% at night. The relative frequencies of children severely or moderately annoyed in relation to traffic load are listed in [Table - 2]. Of all children with a "low exposure" 26% felt annoyed in the daytime, and 13% at night. The corresponding ratios were 36% and 42% in the "moderate exposure" category, and 38% and 45% in the "high exposure" category.

In the wintertime, 29% of the children with a "low exposure" slept with their windows open, but only 19% of the "moderately" and 18% of the "highly" exposed children. In summer, 75% of the "low exposure" children and 74% of the "moderate exposure" children, but only 51% of the "highly" exposed ones slept with their windows open.

In [Table - 3], absolute and relative frequencies of all diagnosed diseases and respective treatments are given in relation to the road traffic loads stated in the questionnaires. As regards health effects hypothetically associated with road traffic immissions (bronchial asthma, chronic bronchitis, positive allergen skin tests, neurodermatitis, behavioural disturbances), the findings gave more or less clear evidence for increasing treatment rates with increasing traffic loads. As regards the rates of treatments for diseases not associated with road traffic immissions according to hypothesis, no relationship was observed but rather a tendential decline of treatment rates.

In the "low exposure" group, the habit of keeping windows open or closed had a significant effect on the prevalence of chronic bronchitis. In the group of children sleeping summer and/or winter with their windows open, 5.3% suffered from chronic bronchitis as compared with 14.6% in the group of those who principally slept with their windows closed.

There was no such relationship with any other disease.

In [Table - 4], odds ratios corresponding with those in [Table - 3] are given for the different diseases and respective treatments in relation to the children's traffic exposures stated in the questionnaires. The lowest traffic load category is used as a reference category

(relative risk = 1) for all higher exposure rates. The odds ratio results are adjusted for the above mentioned confounding factors.

Solely in children with a positive allergen skin test no significant relationship was found with diseases hypothetically associated with road traffic immissions. The prevalence of treatments for neurodermatitis was significantly higher already in the "moderately exposed" group (OR = 3.0), reaching an OR = 3.7 in the "high exposure" group. A tendential relationship was also discernible between bronchial asthma and traffic load, but reached significance only in the "high exposure" group (OR = 3.4). The analysis of chronic bronchitis yielded exceedingly high risk ratios of 5.3 for "moderately" and of 10.8 for "highly" exposed children. Behavioural disturbances showed a tendency towards significant increases in the "high exposure" group (OR = 3.4).

Whereas vaccinations had to be excepted, the rates of the other road traffic-related diseases and treatments showed, in the majority of cases, an odds ratio below 1, with only a few being significant. As an example, for the group of "moderately" exposed children with orthopaedic complaints a low risk ratio of OR = 0.24 emerged. The "various" health effects showed a tendency towards declining treatment rates with increasing road traffic loads, just below significance (OR = 0.81 and OR = 0.57).

[Table - 5] shows the associations between control variables and diagnosed diseases as calculated in the multiple analysis models (odds ratios or significance values*). The age effect refers to the increase in risk per year of age. For dichotomous variables the following reference categories were chosen: sex / girls; ETS / non-smoking household members; pets / no pets in the home.

The dummy-variables "0 level" and "grammar school level" stand for the effects of the parents' highest educational level compared with just 10 years of schooling.

With increasing age groups an increased risk of bronchial asthma and of positive allergen skin tests emerged. Girls showed a greater tendency towards allergies than boys. Behavioural disturbances were more frequent in children from households with ETS. In children from families with a high educational level (grammar school) there were less treatments connected with chronic bronchitis and gastro-intestinal disorders.

Finally, [Table - 6] shows the influence of the duration of using the same bedroom on the combined relative risk of respiratory and dermatological diseases. Compared with the total sample, the odds ratios are for the most part slightly higher in the subgroup of children who had lived in their room for at least a year, but there was no substantial difference.


  Discussion Top


For a period of one month, all patient-physician interviews in two paediatric clinics were evaluated. Thanks to highly motivated doctors, nurses and patients, none of the addressed parents refused participation in the study. The questionnaires contained very few missing answers, so that only 8 out of 401 participating children's data had to be excluded from multiple regression analyses. The results were adjusted for a number of potential confounders. The list of control variables certainly was not complete. For instance, potential hereditary effects on the health outcomes in question were not considered. Any such involuntarily omitted co­variables may therefore have biased some of the results.

An accidental misclassification of the road traffic load would have had a conservative effect. A bias in information could have occurred if parents of children with a positive health outcome had made incorrect traffic load-related statements, either in an effort to "achieve" something or to make environmental factors responsible for their child's disease.

The study design does itself imply a conservative bias insofar as for the evaluation of a single health outcome all other patient-physician contacts were used as a reference. These included all those patients who saw their doctor due to a disease, which was according to the hypothesis also associated with road traffic immissions (bronchial asthma, chronic bronchitis, a positive allergen skin test, neurodermatitis, behavioural disturbances).

In agreement with the hypothesis, logistic regression analyses yielded significant increases in almost all treatment rates with increasing traffic load. The only exception was the frequency of positive allergen skin test results. Since this test may be considered as the only objective test result of the study, it might be concluded that any significant findings were biased since they resulted from the physicians' subjective diagnoses. The indisputable diagnosis of asthma, chronic bronchitis and neurodermatitis is evident.

The relative risk of asthma found to be 3.0 for "highly exposed" children exceeds the findings given in the literature regarding the effects of air pollutants. In a U.S. literature overview (Committee of the Environmental and Occupational Health Assembly of the American Thoracic Soc., 1996) the frequency increase in asthma is given as a 2-3% fine particle increase per PM 10 10 !g/m 3 . A Taiwan study (Guo et al. 1999) has verified an increased asthma prevalence in pupils along with wide-range increases in road traffic-related air pollutants, especially of carbon monoxide and nitrogen dioxide.

The relative risk of chronic bronchitis, found in the present study to be 5.3 for the moderate exposure and 10.8 for the high exposure group, are apparently too high. Also, in contrast to the literature, no significant association was found with ETS. However our result is in qualitative agreement with the results of a Swiss study (Braun-Fahrlander et al. 1997) on 6 to 15 year olds. The highest risk of bronchitis was 2.17 after comparing highly exposed persons from among 10 communities with persons from the least exposed community. The same tendency has been observed in the parallel decline of air pollutants and non-asthmatic respiratory symptoms in 5-14 year old children in former East Germany (Heinrich 2000). In two cross­sectional studies, performed at a three-year interval, a decrease in total suspended particles (TSP) of a mean concentration of 22.9 or 8 !g/m 3 was assessed in three regions. In parallel, the prevalence of bronchitis decreased significantly to about one half. The relative risk was 0.55. According to Kunzli (2001) the prevalence of chronic bronchitis in children under 15 years of age living in non-polluted areas (yearly mean PM = 5-10 !g/m 3 ) has been established between 1.6 (for Austria) and 2.35 (for France). However, in these countries the proportion of people enjoying such a clean air is less than 1%. For children under the age of 15 the relative risk of chronic bronchitis is given as 1.31 per increase of 10 ig/m 3 . Here PM 10 serves as an indicator of mixed air pollutants. It has so far not been established whether, from the pathophysiological point of view, the fine particle fraction constitutes the crucial damage factor (Kunzli et al. 2001). A survey of the literature on the relationship between fine particle concentrations and respiratory diseases is given in (Peters et al. 1998).

Outdoor fine particle concentrations account for 42% of indoor concentrations. Therefore, outdoor air pollution has a major effect on air quality in the children's bedrooms which they use for almost half of their time. Since in the present study the road traffic load was documented for each single child's bedroom, a closer relationship between traffic immission loads and health outcome rates was to be expected than from mean values of an entire community. City-centred measuring points in Berlin yielded overall assessments of 36 ig/m 3 , but representative values of 50 ig/m 3 for right­on-the-street PM 10 (Mucke et al. 2001).

The present study was primarily performed in two spas and neighbouring villages in the Osterode district of the Harz Mountains. The low exposure housing areas may therefore be rated as non-polluted. The high exposure children lived along a thoroughfare with heavy day and night lorry traffic (Ising et al. 2002). Taking a rough estimate, PM 10 for "low exposure" children may be rated at 7.5 ig/m 3 , and at 50 ig/m 3 for "high exposure" children. Consequently, the risk of chronic bronchitis due to PM 10 would be 3.1 according to (Kunzli et al. 2001).

The present state of knowledge about the effect of environment-related air pollution on the risk of neurodermatitis is expressed in an expert interview as follows:

"The role of man-made air pollution particles mainly originating from motorcar exhausts is undisputed. Harmful air substances are generally discussed as inducing allergies. In addition, laboratory tests have indicated that indoor air pollutants may potentially add to aggravation of eczema. Apart from their irritating effect, there is certain evidence for immuno-modulating effects of most of these components as for instance an increase in total IgE. Recent studies have increasingly focused on soot particles from diesel engines and on the outdoor fine particle fractions. The discussion about air pollutants inducing and enhancing neurodermatitis is as yet inconclusive. But a potential influence of indoor nitrogen dioxide sources such as gas ovens as well as motorcar exhausts cannot be denied."(Ring 2001).

As emphasized above, experts (Amler et.al. 2001) see a relationship between the increase in allergies (bronchial asthma, neurodermatitis) and the life-style of Western civilisation, and explicitly add noise to be considered as a serious stress factor. It is a fact that immissions of motor vehicles are part of Western life-style. Stress reactions caused by traffic noises during sleep can exert an adjuvant effect on allergies and bronchitis in children (Ising et al. 2001, Ising et al. 2002). Several publications indicate that normal functioning of the immune system and a normal circadian rhythm of cortisol level (Born 2000) are a prerogative for healthy and restful sleep. Long-term, persisting noises can by way of untimely cortisol releases, particularly in the first half of night, exert an adjuvant effect on allergenic diseases.

As far as is known to us, no investigations have yet been carried out on the effect of combined immissions of traffic-related air pollution and noise on respiratory and dermatological diseases in children. The cited literature (Schupp et al. 1994; Oosterlee et al. 1996; Brunekreef et al. 1997; Kramer et al. 1999; Kunzli et al. 2002 and Committee of the Environmental and Occupational Health Assembly of the American Thoracic Soc., 1996; Guo et al. 1999; Braun­Fahrlander et al.1997; Heinrich et al. 2000) is concerned with air pollutants only. Behavioural disturbances such as restlessness in relation to traffic immissions have to our knowledge not been studied so far. The relative risks of bronchial asthma, neurodermatitis and behavioural disorders found in the present study, ranging from 3 to 4 as a combined effect of traffic-related air pollution and noise, seem plausible. Possibly, the relative risk of chronic bronchitis is somewhat higher than that of asthma and neurodermatitis, but most likely well below 10. It has become clear, however, that the observed effects of combined traffic-polluted air and noise immissions are significantly greater than the effects of motor vehicle exhausts alone.


  Conclusions Top


Long-term combined effects of air pollution from motor vehicle exhausts and traffic noise cause significant and dose-dependant increases of the prevalence of chronic respiratory and dermatological diseases as well as behavioural disturbances like restlessness. According to the literature, increased risks due to air pollution do not completely explain our findings. Traffic noise therefore seems to add substantially to the increased risks. The combined effects traffic exhaust and noise ought to be further investigated in future studies, with the respective immission loads as well as health outcomes being objectively assessed.


  Acknowledgements Top


The authors wish to thank the parents and nurses, who co-operated in this study, as well as the Health Office Osterode/Harz and the District Health Office of Lower Saxony for their help, Dr. Wolfgang Babisch for carrying out the statistical analyses and the Association for Water, Soil and Air Hygiene for financial support of this study.[21]

 
  References Top

1.Amler R. Bergmann K, Bilger,J., et al (2001), Potsdam Declaration: "Children and Health"; Umweltmed Forsch Prax 6 (4), 190-192.  Back to cited text no. 1    
2.Born, J., Fehm, H. (2000) The euroendocrine recovery function of sleep. Noise & Health; 7:25-37  Back to cited text no. 2    
3.Braun-Fahrlander C. Vuille J.C. Sennhauser F.H. Neu U. Kunzle T. Grize L. Gassner M. Minder C. Schindler C. Varonier H.S. Wuthrich B.(1997). Respiratory health and long-term exposure to air pollutants in Swiss schoolchildren. SCARPOL Team. Am.J.Respir.Crit.Care Med.155 (3):1042-1049  Back to cited text no. 3    
4.Brunekreef B. Jansen NAH, Hartog J. (1997), Air pollution from truck traffic and lung function in children living near motorways. Epidemiology; 298-303.  Back to cited text no. 4    
5.Committee of the Environmental and Occupational Health Assembly of the American Thoracic Soc. (1996). Health effects of outdoor air pollution. Am J. Respir.Crit. Care Med. 153(1):3-50  Back to cited text no. 5    
6.Der Rat von Sachverstandigen fur Umweltfragen 1999 Umwelt und Gesundheit - Risiken richtig einschatzen. Sondergutachten. Metzler-Poeschel. Stuttgart  Back to cited text no. 6    
7.Evans, G., Lercher, P., Meis, M., Ising, H., Kofler, W. (2001) Typical Community Noise Exposure and Stress in Children. J. Acoust. Soc. Am. 109 (3) 1023-1027  Back to cited text no. 7    
8.Guo Y.L. Lin Y.C. Sung F.C. Huang S.L. Ko Y. C. Lai J.S. Su H.J. Shaw C.K.Lin R. S. and Dockery D.W. (1999) Climate, traffic-related air pollutants, and asthma prevalence in middle-school children in Taiwan. Environmental Health Perspectives 107:1001-1006  Back to cited text no. 8    
9.Heinrich J. Hoelscher B. Wichmann H.E. (2000) Decline of ambient air pollution and respiratory symptoms in children. Am. J. respir. Crit. Care Med. 161(6): 1930-1936  Back to cited text no. 9    
10.Interdisziplinarer Arbeitskreis fMr Larmwirkungsfragen beim Umweltbundesamt (1982), Beeintrachtigung des Schlafs durch Larm. Z. Larmbekampfung 29,13-16  Back to cited text no. 10    
11.Ising H. Kruppa B. Babisch W. Gottlob D. Guski R. Maschke C. Spreng M. (2001). Kapitel VII-1 Larm, In: Wichmann, Schlipkoter, Fulgraff (eds.) Handbuch der Umweltmedizin. Erg. Lfg.7/01 Ecomed, Landsberg.  Back to cited text no. 11    
12.Ising H. Ising M. (2002) Chronic cortisol increases in the first half of the night caused by road traffic noise. Noise & Health, 4;16, 13-21  Back to cited text no. 12    
13.Kramer U., Koch T., Ranft U. (1999), Traffic-related air pollution is associated with atopy in children living in urban areas. Epidemiology 1999.  Back to cited text no. 13    
14.Kunzli N., Kaiser R. Seethaler R. (2001), Luftverschmutzung und Gesundheit: Quantitative Risikoabschatzung. Umweltmed Forsch Prax 6 (4), 202­212.  Back to cited text no. 14    
15.Maschke C., Ising H., Hecht K. (1997): Schlaf - nachtlicher Verkehrslarm - StreB - Gesundheit: Grundlegen und aktuelle Forschungsergebnisse. Teil II Bundesgesundheitsblatt 40, 86-95.  Back to cited text no. 15    
16.Mucke H.-G. Koch T. Ranft U. (2001) Kapitel VIII-1.3.1 Kraftfahrzeugverkehr - Belastungssituation. In: Wichmann, Schlipkoter, Fulgraf (eds.) Handbuch der Umweltmedizin. Erg. Lfg.3/01 Ecomed, Landsberg  Back to cited text no. 16    
17.Oosterlee A, Drijver M, Lebret E, et al. (1996), Chronic respiratory symptoms in children and adults living along streets with high traffic density. J Occup Environ Med 53, 241-77.  Back to cited text no. 17    
18.Peters A. Schulz H. Kreyling W.G. Wichmann H.-E.(1998) Kapitel VI-2 Staub und Stauinhaltsstoffe/Feine und ultrafeine Partikel. In: Wichmann, Schlipkoter, Fulgraf (eds.) Handbuch der Umweltmedizin. Erg. Lfg.10/98 Ecomed, Landsberg  Back to cited text no. 18    
19.Ring J. (2001) Neue Entwicklungen in der Erforschung des atopischen Ekzems.www.fachklinikum­borkum.de/report/maerz01/8.html  Back to cited text no. 19    
20.Schlaud M. Swart E. (2002) Kapitel III-2.3.3 Beobachtungspraxen. In: Wichmann, Schlipkoter, Fulgraf (eds.) Handbuch der Umweltmedizin. Erg. Lfg.02 Ecomed, Landsberg  Back to cited text no. 20    
21.Schupp A. Kaaden R. Islam M.S. Kreienbrock L. Porstmann F. Rosenlehner R. Spix C. Stiller T. und Wichmann H.E., (1994) EinfluB verkehrsabhangiger Immissionen auf die Empfindlichkeit der Atemwege bei Kindern in Duisburg. Allergologie 17,12 S. 591-597  Back to cited text no. 21    

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    Tables

  [Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5], [Table - 6]

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