Moshammer H, Fletcher T, Heinrich J, Hoek G, Hruba F, Pattenden S, Rudnai P, Slachtova H, Speizer FE, Zlotkowska R, Neuberger M (2010): Gas cooking is associated with small reductions in lung function in children. Eur Respir J 36: 249–254.
Abstract
ABSTRACT: Inconsistent effects of gas cooking on lung function have been reported. In a previous study from Austria, we demonstrated a significant, though small, reduction of lung function parameters in children living in homes with gas stoves. We used a larger international database to check if this finding can be generalised.
To study the relative impact of cooking with gas on lung function parameters of primary school children in a wide range of geographical settings, we analysed flow and volume data of ,24,000 children (aged 6–12 yrs) from nine countries in Europe and North America.
Exposure information was obtained by comparable questionnaires and spirometry according to an American Thoracic Society/European Respiratory Society protocol. Linear regressions were used, controlling for individual risk factors and study area. Heterogeneity between study-specific results and mean effects were estimated using meta-analytical tools.
On average, gas cooking reduced lung function parameters. Overall effects were small (-0.1–0.7%) and only significant for forced vital capacity and forced expiratory volume in 1 s. There was some indication that allergic children were more affected by gas cooking.
Under current housing conditions, gas cooking is associated with only small reductions in lung function.

Moshammer H, Bartonova A, Hanke W, van den Hazel P, Koppe J, Krämer U, Ronchetti R, Sram RJ, Wallis M, Wallner P, Zuurbier M (2006): Air pollution: A threat to the health of our children. Acta Pædiatrica Suppl 453:93-105.
Background/methods: Current air pollution levels pose a threat to the health of children starting from conception. The scientific evidence is presented for mortality, morbidity, and sub-clinical effects. The first section deals with exposure data, the following sections with the evidence of health effects from epidemiology and toxicology leading to recommendations.
Results: Improved air quality reduces the number of infants’ deaths as well as disease and pain.
Conclusions: Medical doctors have a responsibility to know the facts and to advise their patients. Doctors when visiting their patients’ homes should be aware of the possibly grave impact of the indoor environment for the respiratory health of their patients. They should recognize and advise the parents on problems associated with environmental tobacco smoke, poor ventilation, mould growth, and maintenance of heating installations. With regard to outdoor air pollution, doctors could serve as role models and also advise their patients and parents on environmentally friendly behaviour. Such behaviour not only calls for personal commitment but also for the right infrastructure to be provided (e.g. public transport, district heating). Doctors should be proactive in the community and in their country as advocates for a healthier environment for our children.

Moshammer H, Hutter H-P, Hauck H, Neuberger M (2006): Low levels of air pollution induce changes of lung function in a panel of schoolchildren. Eur Respir J; 27:1138-1143.
Abstract
In search of sensitive screening parameters for assessing acute effects of ambient air pollutants in young schoolchildren, the impact of 8-h average air pollution before lung function testing was investigated by oscillatory measurements of resistance and spirometry with flow– volume loops.
At a central elementary school in Linz, the capital of Upper Austria, 163 children aged 7–10 yrs underwent repeated examinations at the same time of day during 1 school year, yielding a total of 11–12 lung function tests per child. Associations to mass concentrations of particulate matter and nitrogen dioxide (NO2) measured continuously at a nearby monitoring station were tested, applying the Generalised Estimating Equations model.
Reductions per 10 mg?m-3 (both for particles and for NO2) were in the magnitude of 1% for most lung function parameters. The most sensitive indicator for acute effects of combustion-related pollutants was a change in maximal expiratory flow in small airways. NO2 at concentrations below current standards reduced (in the multipollutant model) the forced expiratory volume in one second by 1.01%, maximal instantaneous forced flow when 50% of the forced vital capacity remains to be exhaled (MEF50%) by 1.99% and MEF25% by 1.96%. Peripheral resistance increased by 1.03% per 10 µg/m3 of particulate matter with a 50% cut-off aerodynamic diameter of 2.5 mm (PM2.5). Resistance is less influenced by the child’s cooperation and should be utilised more often in environmental epidemiology when screening for early signs of small airway dysfunction from urban air pollution, but cannot replace the measurement of MEF50% and MEF25%. In the basic model, the reduction of these parameters per 10 µg/m3 was highest for NO2, followed by PM1, PM2.5 and PM10, while exposure to coarse dust (PM10–PM2.5) did not change end-expiratory flow significantly.
All acute effects of urban air pollution found on the lung function of healthy pupils were evident at levels below current European limit values for nitrogen dioxide. Thus, planned reduction of nitrogen dioxide emission (Euro 5; vehicles that comply with the emission limits as defined in Directive 99/96/EC) of 20% in 2010 would seem to be insufficient.

Moshammer H, Hoek G, Luttmann-Gibson H, Neuberger M, Antova T, Gehring U, Hruba F, Pattenden S, Rudnai P, Slachtova H, Zlotkowska R, Fletcher T (2006): Parental Smoking and Lung Function in Children. An International Study. Am J Respir Crit Care Med 173: 1255–1263.
Abstract
Rationale: Both prenatal and postnatal passive smoking have been linked with respiratory symptoms and asthma in childhood. Their differential contributions to lung function growth in the general children’s population are less clear.
Objective: To study the relative impact of pre- and postnatal exposure on respiratory functions of primary school children in a wide range of geographic settings, we analyzed flow and volume data of more than 20,000 children (aged 6–12 yr) from nine countries in Europe and North America.
Methods: Exposure information had been obtained by comparable questionnaires, and spirometry followed a protocol of the American Thoracic Society/European Respiratory Society. Linear and logistic regressions were used, controlling for individual risk factors and study area. Heterogeneity between study-specific results and mean effects were estimated using meta-analytic tools.
Main Results: Smoking during pregnancy was associated with decreases in lung function parameters between -1% (FEV1) and -6% maximal expiratory flow at 25% of vital capacity left (MEF25). A 4% lower maximal midexpiratory flow (MMEF) corresponded to a 40% increase in the risk of poor lung function (MMEF < 75% of expected). Associations with current passive smoking were weaker though still measurable, with effects ranging from -0.5% (FEV1) to -2% maximal expiratory flow (MEF50).
Conclusions: Considering the high number of children exposed to maternal smoking in utero and the even higher number exposed to passive smoking after birth, this risk factor for reduced lung function growth remains a serious pediatric and public health issue.

Moshammer H, Hutter H-P, Neuberger M (2006): Gas cooking and reduced lung function in school children. Atmospheric Environment 40: 3349–3354
Abstract
Rationale: Outdoor nitrogen dioxide (NO2) is associated with reduced respiratory health. This could be due to a unique biological effect of this gaseous pollutant or because it serves as a surrogate of fine particles from incineration sources. Cooking with gas in small kitchens produces high concentrations of gaseous irritants (mainly nitrogen dioxide), but not fine particles.
Objectives: To study the relative impact of cooking with gas on lung function parameters in a cross sectional study of school children.
Methods: Nearly all elementary school children (2898 children aged 6–10 years) living in the city of Linz (capital of Upper Austria) underwent lung function testing. In a questionnaire administered simultaneously to their parents, information on household conditions including cooking and tobacco smoke exposure was collected. Impact of cooking with gas on lung function controlling for various confounders was analyzed using loglinear multiple regression. Results: Gas cooking reduced lung function parameters ranging from 1.1% (not significant) for MEF25 up to 3.4% (p ¼ 0:01) for peak expiratory flow (PEF).
Conclusions: Gas stoves can have an adverse impact on children’s respiratory health. Parents and caretakers should be advised to insure good ventilation while and after cooking, especially in small and poorly ventilated rooms. This study adds to the growing evidence that gaseous pollutants from incineration sources affect respiratory health directly.

Moshammer H, Schinko H, Neuberger M (2005): Total pollen counts do not influence active surface measurements. Atmospheric Environment 39: 1551–1555
Abstract
We investigated the temporal association of various aerosol parameters with pollen counts in the pollen season (April 2001) in Linz, Austria. We were especially interested in the relationship between active surface (or Fuchs’ surface) because we had shown previously (Atmos. Environ. 37 (2003) 1737–1744) that this parameter during the same observation period was a better predictor for acute respiratory symptoms in school children (like wheezing, shortness of breath, and cough) and reduced lung function on the same day than particle mass (PM10). While active surface is most sensitive for fine particles with a diameter of less than 100nm it has no strict upper cut-off regarding particle size and so could eventually be incluenced also by larger particles if their numbers were high. All particle mass parameters tested (TSP, PM10, PM1) were weakly (r approximately 0.2) though signigncantly correlated with pollen counts but neither was active surface nor total particle counts (CPC). The weak association of particle mass and pollen counts was due mainly to similar diurnal variations and a linear trend over time. Only the mass of the coarse fraction (TSP minus PM10) remained associated with pollen counts significantly after controlling for these general temporal patterns.

Moshammer H, Neuberger M (2004): Lung cancer and dust exposure: results of a prospective cohort study following 3260 workers for 50 years. Occup Environ Med 61:157–162.
Abstract
Aims:To study the lasting health impact of occupational dust exposure on life expectancy and specific causes of death. Methods: Male Viennese workers, selected at age >40 (mean 54) years during preventive check-ups between 1950 and 1960, were followed prospectively until death. Half of them (1630) were exposed at work to (non-fibrous) particulates, while the non-exposed workers were matched for year, age, and smoking status at the start of observation. Results: Average life expectancy of those exposed was 1.6 years less than that of those non-exposed. Only a small part of this decrease in life expectancy (hazards ratios in brackets) was related to acknowledged occupational diseases such as silicosis and silicotuberculosis (67.12). Chronic obstructive lung disease (1.82) and cancer of the lung (1.42) and stomach (1.77) were found more frequently among those exposed. Conclusions: Results support the hypothesis that high exposure to insoluble particulates such as silica in the metal, glass, ceramics, and stone industries promotes bronchial cancer and chronic obstructive pulmonary disease. The finding of an increased incidence of stomach cancer might be related to particles swallowed after clearance from the airways.

Moshammer H, Neuberger M (2003): The active surface of suspended particles as a predictor of lung function and pulmonary symptoms in Austrian school children. Atmospheric Environment 37: 1737-1744
Abstract
At a central elementary school in the capital of Upper Austria children aged 7–10 years underwent repeated respiratory health checkups (questionnaires, diaries, spirometry). Between March and May 2001 the daily means of the signals of a diffusion charging sensor, measuring the "active surface" of suspended particles, and a photoelectric aerosol sensor, measuring the particle-bound polycyclic aromatic hydrocarbons, were related to spirometric results of the total 164 children examined and to the daily symptom scores of a susceptible subgroup. Significant reductions of forced vital capacity (p=0.006) and forced expiratory volume in the first second (p=0.001) and significant increases of wheezing (p=0.001), shortness of breath (p=0.041), cough in the evening (p=0.031) and at night (p=0.018) were found with increase of "active surface" of suspended particles measured at the adjacent outdoor monitoring station, but not with the increase of particle-bound polycyclic aromatic hydrocarbons. Monitoring "active surface" of particles with diameters of about 10 nm–1 m by means of a diffusion charging sensor might provide additional information in surveillance of particulate matter for prevention of acute effects on respiratory health.

Hutter HP, Moshammer H, Kundi M, Wallner P, Neuberger M (2002): Moulds in housing: visual inspection and spore counts comparison - implications for future strategies in the public health setting. Central European Journal of Public Health 10(3): 93-96
Summary:
Objectives. Among the problems of health related to living conditions presented to a public consulting centre for environmental medicine in Vienna, the main point at issue was damp housing and mould growth. On answering this demand indoor exposure to fungal spores was identified by visual semi-quantitative assessment of fungal growth on the one hand and quantitative measurement of viable spores on the other hand. The validity and practicability of this approach was investigated.
Method: We applied these two simple methods in a standardised form and compared the results in a field study, which has been conducted between 1995 and 1999. In 197 rooms in Viennese flats (183 of which were claimed to be “mouldy”) fungal spore concentrations were measured by RCS-impactor and Rose-Bengal-agar. Outdoor measurements were taken simultaneously outside the buildings and were used for reference.
Results: Independent classification of visible growth of mould in flats correlated significantly (r=0.635; p<0.0001) with the ratio of indoor/outdoor concentration of fungal spores. Conclusions. It is usually possible to classify the severity of the problem just by local inspection. Visible plaques should always be an indication for sanitary measures. However, spore counting is indicated for quantifying health relevant exposures, for scientific comparisons and in documentation and follow up such as for litigation purposes. Quantitative data bear more credibility and so help to prove the need of sanitation.

Neuberger M, Moshammer H, Kundi M (2002): Declining ambient air pollution and lung function improvement in Austrian children. Atmospheric Environment 36: 1733-1736
Abstract
Three thousand four hundred fifty-one Austrian elementary school children were examined (between 2 and 8 times) by spirometry by standardized methods, over a 5 yr period. The districts where they lived were grouped into those where NO2 declined during this period (by at least 0.03 mg/m3 measured as half year means) and those with less or no decline in ambient NO2. In both groups of districts, SO2 and TSP fell by similar amounts over this period. A continuous improvement of MEF25 (maximum exspiratory flow rate at 25% vital capacity) was found in districts with declining ambient NO2. Populations did not differ in respect of anthropometric factors, passive smoking or socioeconomic status. A birth cohort from this study population which was followed up to age 18 confirmed the improved growth of MEF25 with decline in NO2, while the improved growth of forced vital capacity was more related to decline in SO2. This study provides the first evidence that improvements in the outdoor air quality during the 1980s are correlated with health benefits, and suggest that adverse effects on lung function related to ambient air pollution are reversible before adulthood. Improvement of small airway functions appeared to be more dependent on reductions of NO2 than reduction in SO2 and TSP.

Hutter HP, Moshammer H, Wallner P (2001): Determinanten der Zufriedenheit von Patienten mit der Betreuung durch die Umweltmedizinische Beratungsstelle der Stadt Wien. Gesundheitswesen 63(4): 238-241
Zusammenfassung
Die Erhebung der Zufriedenheit von Klienten ist ein wichtiger Aspekt der Evaluierung einer medizinischen Beratungsstelle. Ziel dieser Studie war die Beantwortung der Frage, durch welche Faktoren Zufriedenheit determiniert wird. Diese Ergebnisse sind für eine Weiterentwicklung des Service einer Umweltmedizinischen Beratungsstelle (UMB) besonders wichtig.
Zu diesem Zweck wurde ein anonymisierter Kurzfragebogen an 245 Klienten der UMB verschickt. Dieser enthielt Items zur Zufriedenheit mit der Beratung, zu der Erfüllung der Erwartungen, zu der Lösung der Probleme und zu den noch offenen Problemen sowie die Frage, ob gegebenenfalls wieder die Beratungsstelle in Anspruch genommen werden würde.
Die Rücklaufquote war mit 43 % zufrieden stellend. Die Resultate zeigen trotz weiterhin bestehender ungelöster bzw. nur teilweise gelöster Probleme (71 %) und offener Fragen (38 %) eine hohe Zufriedenheit der Klienten mit der Beratung (78 %). Rund 90 % würden sich erneut an die UMB wenden. Die Beratungsanliegen zeigten keinen signifikanten Einfluss auf die Zufriedenheit. Diese war aber umso höher, je mehr das Problem einer Lösung zugeführt wurde und je mehr Aktivitäten die UMB für den Klienten gesetzt hatte. Es bestätigte sich die Bedeutung einer eingehenden Erstanamnese und des Beratungsgespräches, welche neben dem Ortsaugenschein und evtl. Messungen das Fundament jedes weiteren Schrittes zur Abklärung einer umweltbedingten Problemsituation darstellen.
Determinants of Client Satisfaction with the Medical Consultant and Advisory Board for Environmental Medicine („UMB”) of the City of Vienna
Client satisfaction is a relevant aspect for assessing the efficiency of a Medical Advisory Board. The study presented here aimed at determining the factors that guarantee satisfaction. These findings are essential for the further development of the service of the Advisory Board of the City of Vienna for Environmental Medicine („UMB”).
To this end a brief anonymous questionnaire was sent to 245 clients. This comprised elements evaluating the degree of satisfaction with the consultant service of the Advisory Board, fulfilment rate of expectations, solutions offered for various problems, and whether - if necessary - the „UMB” Advisory Board would be consulted again.
A satisfactory response rate of 43 % was obtained. The results show a high degree of satisfaction among the clients with the consultations (= 78 %) despite unresolved or only partly resolved problems (71 %) and questions that remained open for discussion (38 %). Approximately 90 % of the clients would again consult „UMB” for advice. The reasons for consultation did not show any significant influence on the client satisfaction. However, satisfaction of clients depended on whether or not a solution was found in respect of their problem and on the action taken by „UMB” to solve it.
Summarising the findings, the analyses show that apart from on-the-spot assessment and detailed inspection, comprehensive case histories and interviews are an important basis for further clarification of problems caused by environmental factors.

Hutter HP, Wallner P, Moshammer H, Kundi M (2001): Zur Ableitung von Richtwerten für hochfrequente elektromagnetische Felder. Bundesgesundheitsbl - Gesundheitsforsch - Gesundheitsschutz 44 (5): 498-503

Moshammer H, Hutter HP, Wallner P, Kundi M (2001): Zur toxikologischen Ableitung von Richtwerten für Luftschadstoffe in Innenräumen. Gesundheitswesen 63(10): 625-631
Zusammenfassung
Beim österreichischen Umweltministerium (jetzt: Bundesministerium für Land- und Forstwirtschaft, Umwelt und Wasserwirtschaft) wurde ein Arbeitskreis zur Festlegung von Innenraumluft-Richtwerten eingerichtet. Ihm gehören Vertreter verschiedener Disziplinen (Ärzte, Toxikologen, Messtechniker, Juristen) an. In der konstituierenden Sitzung wurde beschlossen, sich bei der Ableitung von Richtwerten prinzipiell an ein einheitliches Schema zu halten und man einigte sich zunächst auf jenes, welches die deutsche Ad-hoc-AG vorgelegt hat. In den interdisziplinären Diskussionen zeigte sich jedoch, dass zusätzlicher Definitionsbedarf besteht, da die Vertreter aus den verschiedenen Fachrichtungen die Begriffe und Prinzipien des Schemas unterschiedlich interpretieren.
Insbesondere zeigte sich Klärungsbedarf bei der Abgrenzung zu anderen Luftgrenzwerten (Außenluft- und Arbeitsplatz-Grenzwerte) und bei der Festlegung des Anwendungsbereiches. Es erwies sich als notwendig, die Definition der Richtwerte I und II klarer herauszuarbeiten und v. a. detailliert darzulegen, wie eine Über- bzw. Unterschreitung eines der Richtwerte im Einzelfall zu bewerten ist und welche Maßnahmen einzuleiten sind.
Abstract
At the Austrian Ministry for Environment (now: Federal Ministry for agriculture and forestry, environment and water management) a working group was established to propose indoor air guideline values. This consists of representatives of different disciplines, such as physicians, toxicologists, engineers and lawyers. Already in the constituent meeting it was decided to employ a set pattern for establishing toxicologically sound guideline values. It was then agreed to use the pattern proposed by the German ad-hoc-working team. The interdisciplinary discussions, however, demonstrated the need for additional clarification, since representatives of different disciplines obviously interpret the various terms and principles differently.
In particular, there is a need for discussing in detail the relation between the guideline values for indoor air to other air quality standards (outdoor air and workplace) and to specify their scope and application, especially the need to describe in greater detail what should be done in case either guideline value I or II was exceeded.

Hutter HP, Wallner P, Moshammer H, Kundi M, Neuberger M (2001): Stille Opfer des Straßenverkehrs (Letter). Wiener Klinische Wochenschrift 113 (22): 894

Adrian S, Ataniyazova O, Mazhitova Z, Moshammer H, Prindull G, Zetterström R (2001): Continuing progressive detoriation of the environment in the Aral Sea Region. Disasterous effects on mother and child health. Acta Paediatrica 90: 589-591
Abstract:
Scientists, non-governmental experts (NGOs) and governmental officials from the Central Asian Republics and an international group of invited scientists and NGO representatives participated in a workshop on the disastrous health problems in the Aral Sea Region. Various serious problems were reported in more than 20 presentations. Particular emphasis was put on the way in which adverse environmental factors such as contaminated water and food have contributed to the deterioration of human health, particularly that of mothers and children.
Conclusion: There is an urgent request that the international community assists local scientists to develop programmes to improve the health of the population in the Aral Sea Region.

Moshammer H, Neuberger M (2000): Sex ratio in the children of the Austrian chloracne cohort. The Lancet Volume 356 Issue 9237 Page 1271