Children's Health and the Environment

Definition and scope

Environmental health includes all aspects of human health and disease that are influenced by factors in the environment, ranging from the direct pathological effects of chemicals, radiation and some biological agents to the effects (often indirect) on health and wellbeing of the broad physical, psychological, social and environment.

For most relationships the relationships and underlying mechansims are not straightforward. The vulnerability of individuals and communities to environmental health threats depends on age and health status, genetic factors, diet and well-being.

Children are especially vulnerable to environmental threats in many ways especially in the fields of air pollution, unsafe drinking water, accidents and chemicals.

Burden of disease

The environmental burden of disease represents the amount of disease (morbidity) and mortality that can be attributed to environmental risks. The results of international studies on the environmental contribution to the overall burden of disease vary widely, with estimates ranging from about 2 to 20%. Recent studies for the European situation attribute 2-6% of European mortality and morbidity to environmental factors.

The World Health Organisation (WHO) estimated (2006) the impact of the environment on child health in the European Region as more than 24% of deaths and 22% of disease in children under the age of 14.

Some causes and consequences

Indoor and outdoor air pollution, unsafe water conditions, lead exposure and injuries are the most important environmental risk factors in 0-19 year old children.

Air pollution

Very young children, probably including unborn babies, are particularly sensitive to air pollutants. The evidence is sufficient to infer a causal relationship between particulate air pollution and deaths from respiratory complaints in the post-neonatal period.

Road traffic injuries

Children and young people are particularly vulnerable to road traffic injuries Estimates suggest that each year road traffic incidents cause as many as 6400 deaths in children in the european region aged 0–14 years and up to 37 000 in young people aged 15–24 years.

Chemicals

Infants and children are especially vulnerable to the acute, sub-acute and chronic effects of ingestion of chemical hazards. Infants consume twice the amount of food per unit of body weight as adults. Moreover, developing organs and tissues are more susceptible to the toxic effects of certain chemicals. Chemical hazards that give most concern are toxic metals (lead, methylmercury, cadmium, arsenic) and some persistent organic pollutants (POPs), notably dioxin-like compounds. The highest risks in food for children are not contaminants or added chemicals, but unhealthy food choices including snack foods with too much fat, sugar and salt.

Opportunities for prevention

Preventive measures include reduction of emission of air pollutants, reduction of noise exposure, traffic safety measures and healthy behaviour.

Current legislation related to the emission of air pollutants is expected to reduce impacts by around one third. Further reduction, down to around 50% of those estimated for current pollution levels, could be achieved by implementing all currently feasible emission reduction measures (the maximum feasible reduction scenario).

Approaches on reducing road traffic injuries include legislation on, for example, the setting and enforcing of speed limits, and programmes seeking to raise awareness and influence attitudes and behaviour. Measures include the incorporation of safety features into land use and transport planning; setting and enforcing appropriate speed limits; enactment of laws requiring seat belts and child restraints for all motor vehicle occupants; enactment of laws requiring cyclists and drivers of motorized two-wheelers to wear helmets; enactment of legislation setting blood alcohol concentration limits for drivers; and revision of the road infrastructure to improve traffic safety and to provide safer cycling and pedestrian routes and traffic calming.

In the European Region, the World Health Organisation (WHO) is helping countries to develop and strengthen their food safety programmes. This includes harmonizing legislation with Codex Alimentarius guidelines and EU policies, strengthening food control services and promoting quality assurance systems. The WHO food safety programme also supports countries in building and updating skills for the safety analysis, monitoring and management of food.

Link to the European Environment and Health Information System (ENHIS)

The information in this EUphocus comes from the ENHIS project. In this project a comprehensive information and knowledge system is developed that will help to identify and prioritize wide-spread environmental health problems in the Member States, to enable monitoring of the effects of actions taken, and to contribute to building advocacy and communication strategies.

Children's Health and the Environment includes the major aspects of children's health, influenced by factors in the environment, ranging from the direct pathological effects of chemicals, radiation and some biological agents to the effects (often indirect) on health and wellbeing of the broad physical, psychological, and social environment. Children are especially vulnerable to environmental threats in many ways, especially in the fields of air pollution, unsafe drinking water, accidents and poisons.

Effective action is crucial and should be based on systematic reviews of interventions designed to prevent and reduce risk, whenever this information is available, and be built on existing experience and best practices. Effective action also requires multisectoral approaches, such as those needed to ensure clean air, safe food and water, safe industrial products and safe and supportive human settlements.

The focus is first and foremost on actions that are associated with a substantial reduction of the disease burden in children and that are feasible and effective within a reasonable time frame.

Environmental burden of disease

Environmental hazards such as air pollutants, noise and chemicals can cause illness, disability or even death. The results of international studies on the environmental burden of disease vary widely, with estimates ranging from about 2 to 20% of the total disease burden caused by environmental exposures (ENHIS). These differences are mainly due to differences in methodology (e.g. which risk factors are included) and partly related to actual differences in environmental conditions.

In 2006, the World Health Organisation (WHO) estimated that in the WHO European Region as much as 14-19% of disease is caused by environmental exposures that can be averted (WHO, 2006d).

It is important to recognise that these percentages refer to a selected set of the currently known environmental risk factors for which quantification of health impacts is possible. In addition, disease burden calculations are a simplification of a very complex reality consisting of combined exposures to different risk factors by different pathways.

Children's burden of disease

Environmental exposures are known to be important contributors to the global burden of disease among children and adolescents, but there are still gaps in our knowledge about the magnitude and regional distribution of the environmental burden. Child-specific data are only available for specific environmental factors.

Children have a special vulnerability to environmental pollution, because their body is still developing. Furthermore, their specific exposure patterns make them subject to higher exposures.

WHO calculated the impact of the environment on child health in the European Region. The results show that indoor and outdoor air pollution, unsafe water conditions, lead exposure and injuries are important risk factors in 0-19 year old children (WHO, 2004f). The report further estimates that more than 24% of deaths and 22% of disease in children under the age of 14 is caused by environmental exposures. Well-targeted interventions can prevent much of this environmental risk and save thousand lives a year.

Gastrointestinal diseases

Gastrointestinal infection (infectious intestinal disease) comprises a variety of communicable diseases, which gain entry by and/or affect the gastrointestinal tract. Environmental factors such as drinking and bathing water pollution or food contamination are among major determinants.

In the European Region the mortality of diarrhoeal disease attributable to poor water quality, sanitation and hygiene in children aged 0–14 years is estimated at 13 548 (5.3% of all deaths) (WHO, 2004f).

Cardiovascular diseases

Cardiovascular diseases (CVDs) are the main cause of illness and premature death in the world, almost equally in men and women. The causes of CVDs are well established and well known. The most important include unhealthy diet, physical inactivity and tobacco use. Outdoor and indoor air pollution are among the environmental determinants of CVDs. Addressing these risk factors would provide a great potential for prevention.

Respiratory diseases

Respiratory diseases include chronic respiratory diseases, such as asthma, chronic obstructive pulmonary disease (COPD) and lung cancer, as well as acute respiratory infections. Tobacco smoke is the principal risk factor for these diseases. Other risk factors include heavy exposure to air pollution (from indoor and outdoor sources) and occupation-related exposure.

It is estimated that exposure to tobacco smoke increases the number of asthma episodes in children aged under 14 years by 6 to 10%, depending on the current smoking prevalence in each country (WHO, 2007). For air pollution, WHO estimated that throughout the Region around 700 deaths annually from acute respiratory infections in children aged 0–4 years can be attributed to PM10 exposure (WHO, 2007b).

Cancers

Cancer remains one of the biggest causes of death in Europe. 40% of cancer can be prevented. Tobacco use is the single largest preventable cause of cancer in the world. Environmental hazards such as air, water and food contamination, radiation, occupational exposures and unsafe buildings are also among the causes of cancer.

The overall estimate of lung cancer that can be attributed to radon is approximately 9% for Europe with attributable risk estimates ranging from about 3% of lung cancer deaths in the Netherlands or the United Kingdom to 21% in the Czech Republic (WHO, 2007q).

Overweight and obesity

Excess body weight and obesity in children and young people are on the rise in Europe. Inadequate nutrition and lack of physical activity are important risk factors. A high body mass index (BMI) in adolescence predicts elevated adult mortality and cardiovascular disease rates, even if the excess body weight is lost.

Physical activity levels in children and adolescents are low and decline with age: 11-year-olds are more physically active than 13- and 15-year-olds. Across all the countries in the Health Behaviour in School-aged Children study, about one third of all children (39%) report taking physical activity at a level that meets the current guidelines (WHO, 2007c, see also EUphact overweight).

Injuries

In the WHO European region, the three leading causes of death from unintentional injuries in the age group 0-19 years are road traffic injuries (37%), drowning (15%) and poisonings (8%) (ENHIS).

For road traffic injuries, up to 6400 deaths per year are estimated to occur among children aged 0-14 years and up to 25 500 among young people aged 15-24 years. Some countries show relatively low mortality rates, which indicates that deaths from road traffic injuries are preventable (WHO, 2007d).

Developmental disorders

The central nervous system is particularly vulnerable to toxic effects during early development. Nervous system damage, once incurred during a developmental stage, is likely to be irreversible and may change the affected individual’s quality of life and economic and social success. The extent to which current environmental pollution causes adverse effects on brain development is unknown. The contaminants that have been studied in the greatest detail, such as lead, methylmercury and polychlorinated biphenyls (PCBs), are likely to cause adverse health effects in subgroups of European populations with increased exposures.

Air quality

Emissions from motor vehicles, industry, heating and commercial sources, as well as tobacco smoke or household fuels, pollute the air we breathe. Evidence shows that air pollution at current levels in European cities is responsible for a significant burden of disease, mortality, hospital admissions and exacerbation of symptoms, especially in relation to cardiovascular disease. Very young children and pregnant woman are especially vulnerable to air pollutants.

WHO estimated that in children aged 0-4 years, throughout the European Region, around 700 deaths occur annually from acute respiratory infections that can be attributed to PM10 exposure (WHO, 2007b).

Food safety

Food can be contaminated with chemical or microbiological agents. The strict regulations and measures applied in European countries mean that food is generally safe, but ingestion of contaminated food may still present an important route of exposure. Children are at particular risk of illness, as their bodies are developing and they generally consume more food on a body weight basis than adults.

In most European countries adult intake levels of chemicals in food have been 10–30% of the provisional tolerable weekly intake (PTWI) levels, sometimes higher. The data on intake among children are very patchy. The total intake seems to be lower than in adults, but per kg body weight the intake is higher (WHO, 2007e).

Chemical safety

The number of existing chemicals is very large, and for many of them the health risks are not known. Chemicals can reach our body through different routes (e.g. food, air, water) and cause a variety of health effects. Due to the many ways in which chemicals are used and released, the many exposure routes involved, and the different mixtures of chemicals present, the public health relevance of chemicals can be extremely difficult to assess.

Children are especially sensitive to lead exposure. Elevated blood lead levels (>10ug/l) have been associated with toxicity in the developing brain and nervous system of young children, leading to lower intelligence quotient (IQ). Levels have significantly reduced since the mid-80s, but many children still have levels that may harm their health (WHO, 2007f).

Water and sanitation

Safe drinking water and sanitation are essential for health. Microbial contamination can lead to outbreaks of waterborne diseases. Chemical contamination of drinking water occurs less frequently but may also have health impacts, generally chronic and long-term.

In the eastern part of the Region, the percentage of homes with an adequate supply of piped and safe water remains rather low (ranging from 58% to 80%), albeit rising. There are important disparities between urban and rural areas: only 30–40% of rural households in eastern European countries have access to safe drinking water (WHO, 2007g).

Occupational hazards

Every day at the workplace, employees face health and safety hazards such as accidents, dust, chemicals, noise, violence or stress. The effects range from premature deaths and injuries to occupational diseases such as for example cancer and respiratory disease.

In recent years, a slightly decreasing trend was visible in the standardized incidence rates of work injuries among young workers. A clear decrease could only be noted in a few countries, indicating that overall progress in Europe is not adequate (WHO, 2007h).

UV and ionizing radiation

Various types of radiation can cause negative health effects. Solar radiation is beneficial for our body as a source of vitamin D, however, excessive exposure may pose a threat to health. Ultraviolet (UV) radiation causes premature ageing of the skin and may lead to the development of malignant melanoma. Radon is a gas emitted by certain types of soil and building materials, and can cause lung cancer.

Children are those most at risk from excess exposure to UV radiation, e.g. due to still developing skin protection mechanisms. Worldwide, the incidence of melanoma has been increasing, also in younger age groups. Moreover, many people increase their exposure through artificial sources in solariums. Raising awareness and encouraging skin protection are the most effective preventive strategies (WHO, 2007i).

Housing

Several environmental factors present indoors can cause negative health effects. Examples of such factors are indoor air quality (polluted for example by use of solid fuels), noise, humidity and mould growth, temperature, presence of hazardous substances (for example asbestos, lead and radon), hygiene and sanitation, and overcrowding. An unsafe household can cause unintentional injuries such as falls, drowning, poisoning, fires and choking.

The amount of people living in homes with self-reported problems of dampness varies greatly among countries, ranging between 10% and 30% (WHO, 2007j).

Solid fuel use in homes in the WHO European Region in 2004 varied from below 5% to over 70%. The geographical pattern shows a gradual increase from west to east of the Region (WHO, 2007k).

Mobility and transport

Transport can directly lead to health problems (injuries and death), but also indirectly (through air pollution, noise and climate change related to emissions from traffic, but also through reduced physical activity).

Increased motorized transport can lead to more road traffic injuries, which are the main cause of death among young people, especially males, and a major cause of physical disability, especially among the youngest. Motorized transport is also an important factor in the reduction of physical activity, such as for example walking and cycling. Low levels of physical activity contribute to the ongoing epidemic of overweight and obesity.

Current environmental health policy situation

The implementation of effective environmental health policy can lead to significant improvements in health and environmental conditions. National policies may both benefit a country and contribute more widely to the global situation. The key players at European level are the European Commission and WHO/Europe. At the national level, the approach to environmental health issues varies by country. Environmental health cuts across different sectors and ministries, and policy making involves many stakeholders in planning and consultation.

The degree of policy harmonization among 17 countries (Austria, Bulgaria, Czech Republic, Germany, Spain, Finland, France, Greece, Hungary, Italy, Lithuania, The Netherlands, Poland, Portugal, Romania, Slovenia, Slovak Republic) varies by theme. In cases where coherent EU legislative policy frameworks exist, such as for water and outdoor air, national environmental health policies are well harmonized. However, when coherent frameworks are lacking, as for traffic and indoor air, there is less inter-country harmonization. International efforts which seek to strengthen international policy frameworks may provide impetus towards greater harmonization. Policy is poorly harmonized for nationally regulated themes such as housing issues or UV radiation. These themes are currently dealt with in national strategies and action plans, which nevertheless encompass a more or less similar focus or strategy in different countries.

Most countries in the European Region are committed to develop children’s environment and health action plans (CEHAPs). See ENHIS for more information.

European Commission SCALE and Environment and Health Action Plan

The European Commission (EC) introduced the European Environment and Health Strategy in 2003, identifying the need to scale up efforts to protect human health, particularly for the most vulnerable groups in society. This approach, known as ‘SCALE’ (Science, Children, Awareness, Legislation and Evaluation) focuses on child diseases that are linked to environmental factors. In relation to the Strategy, the EC DG Sanco Programme of Community Action in the field of Public Health (2003 – 2008) supports research activities in the field of environmental health. The EU Health Portal includes environmental health data and information about related activities at European and international scale.

In 2004, the European Environment and Health Action Plan 2004-2010 was presented. It was designed to provide the EU with the scientific information needed to reduce the adverse health impacts of specific environmental factors and to enhance cooperation between actors in the environment, health and research fields. The three main themes of the Action Plan are: improving the information chain; filling the knowledge gap; and, reviewing policies and improving communication.

Air quality

At international level, outdoor air and its main pollutants are subject to diverse policy initiatives. In the EU, outdoor air quality is regulated by overarching EC environmentally-oriented Directives, which define air quality standards as well as common methods and criteria for assessment and management of the pollutant levels.

The Air Quality Framework Directive 96/62/EC covers existing and new air quality legislation. The Directive covers the revision of previously existing legislation and the introduction of new air quality standards for previously unregulated air pollutants, setting the timetable for the development of daughter directives on a range of pollutants. The atmospheric pollutants considered include pollutants governed by exisiting ambient air quality objectives (sulphur dioxide, nitrogen dioxide, particulate matter, lead and ozone), along with benzene, carbon monoxide, poly-aromatic hydrocarbons, and cadmium.

Chemical and food safety

Food is potentially an important source of human exposure to chemicals. In order to ensure adequate standards of food safety and quality, the Food and Agricultural Organization (FAO) and WHO have developed the Codex Alimentarius, which has been an international reference for health authorities and food control officials since 1963. Within the WHO European Region, the WHO food safety programme helps countries develop and strengthen their own programmes, including the harmonization of legislation with Codex Alimentarius guidelines and European Union policies.

Water and sanitation

For water and sanitation, overarching EC environmentally-oriented Directives define microbial standards. In addition, international frameworks focus on ensuring drinking water quality from a health perspective.

Council Directive 98/83/EC on the quality of drinking water is set to protect the health of consumers in the European Union and to ensure drinking water is clean and has an acceptable appearance (in terms of taste, odour and colour)

Council Directive 2006/7/CE and 76/160/EEC concerning the quality of bathing water sets binding microbiological standards in the receiving waters where bathing is practiced by large numbers.

UNECE Protocol on Water and Health (1999) aims to ensure there is adequate safe drinking water and sanitation for everyone, and to protect waters used for drinking effectively..

The WHO Guidelines for drinking-water quality introduced the concept of Water Safety Plans (WSP). At present, no European country has legal instruments which require the implementation of WSP. Most countries will wait for revision of the Drinking Water Directive to introduce the WSP concept.

Mobility and transport

The European Road Safety Action Programme was developed with the aim of significantly improving road safety by 2010. Traffic policies focus on vulnerable groups such as children and the elderly, and also pedestrians, young cyclists and young drivers. In order to move towards sustainable and ‘healthy’ transport, integrated action by various stakeholders and sectors is needed – these reach across traffic, environment, health, and economics. The European Road Safety Charter comprises a formal undertaking towards collective co-operation.

The programme sets out specific measures and reaffirms the overall goal of halving the number of road accident victims by 2010. It aims to encourage road users to improve their behaviour, to make vehicles safer, and to improve road infrastructure.

Housing

The EU’s Stability Pact for South Eastern Europe established co-operation with UN Habitat to improve social housing and urban development across the region. Initiatives, action programmes and declarations within the United Nations Human Settlements Programme are aimed at reaching the UN Millennium Goals.

On the European scale, housing safety and accidents are addressed by the Communication on Actions for a Safer Europe and the proposed Council Recommendation on the Prevention of Injury and the Promotion of Safety. The Council Recommendation describes the burden of injuries in the EU and recommends that member states develop national injury surveillance and reporting systems and national action plans for preventing accidents and injuries, initiating interdepartmental co-operation.

Residential indoor air quality is not covered by European policies. A declaration recognizing the indoor environmental risk factors of private dwellings, schools and other public buildings may provide impetus.

Ultraviolet radiation

The Montreal Protocol on Substances that Deplete the Ozone Layer. Adopted on 16 September 1987, provides the framework for legislation on UV exposure prevention.

The WHO INTERSUN programme recommendations, such as sun bed protection programmes in schools and the existence of a national specific website dedicated to UV exposure and skin cancer prevention, can serve as a framework for a European action plan to reduce excessive UV exposure.

Indoor radon

The EC recommendation on the protection of the public against indoor radon exposure (90/143/Euratom) defines a reference level of 400 Bq.m-3 for existing buildings and 200 Bq.m-3 for new buildings. Above this level, remedial action should be taken.

The WHO International Radon Project (IRP) focuses on the development of evidence-based public health guidance for Member States to formulate policy and advocacy strategies, including the establishment of radon action levels.

Life expectancy

Healthy life expectancy

Cancer survival

Overweight

Smoking

Smoking policies

Lung cancer

COPD

Health-EU Portal Environmental Health

ENHIS European Environment and Health Information System

Authors: Van Overveld A, Van Alphen T (RIVM, Bilthoven the Netherlands)

Editors: Nugteren R, Kramers PGN (RIVM, Bilthoven, the Netherlands)