Workgroup report: developing environmental health indicators for european children: world health organization working group.

Approximately a quarter of the global burden of disease can be attributed to environmental factors (Pruss-Ustun and Corvalan 2006). Children < 5 years of age bear > 40% of this burden [Smith et al. 1999; World Health Organization (WHO) 2002a]. Contaminated air, food, and drinking water are particular environmental factors affecting children in developing regions of the world (Abalak et al. 2001; Smith et al. 2000). An estimated 1.7 million deaths per year globally are attributed to unsafe water, sanitation, and hygiene; nine of 10 of these deaths occur in children, and nearly all of these occur in developing countries (Pruss-Ustun and Corvalan 2006). Although the traditional infectious disease threats to children's health have largely been controlled in most industrialized countries by advances in water treatment, immunizations, waste disposal, and the provision of adequate food (Suk et al. 2003), diseases such as asthma and cancers including leukemia, learning disabilities, and congenital malformations are increasing in children in western Europe (Landrigan et al. 1998; Richardson et al. 2005; Simoni et al. 2005). Even if most of the deterministic processes leading to these diseases are multifactoral, there is increasing evidence that these diseases are influenced by environmental factors. Exposure to air pollution, lead, chemicals, and noise has been shown to impair children's health and their cognitive development (Bellinger 2004; Niemann et al. 2005; Schwartz 2004). Despite the fact that the European Region contains some of the world's wealthiest countries, widening health inequalities remain the principal determinant of mortality (Anonymous 2005), illustrated by the fact that almost 140 million (16%) people in the WHO European Region do not have a household connection to a drinking-water supply, 85 million (10%) do not have improved sanitation, and > 41 million (5%) do not have access to a safe drinking-water supply (Anonymous 2005). From a burden perspective, injury is responsible for 23% of all deaths and 19% of disability-adjusted life-years (DALYs) in 0to 19-year-olds in the WHO European Region and has the largest environmental burden for children compared with outdoor/indoor contaminants, water sanitation and hygienic issues, or lead contaminants (Valent et al. 2004)

The Fourth Ministerial Conference on Environment and Health, held in Budapest, Hungary, in June 2004 ("The Budapest Conference"), focused on "the future for our children," recognizing the need to address the rights of children, their health, and their particular vulnerability toward environmental risks, as well as to respond to emerging environmental concerns. The Declaration from the conference reaffirmed that the Environment and Health Information System (EHIS) is an essential tool for policy making relevant to children's environmental health (WHO Regional Office for Europe 2004b).

The Budapest Conference through its Declaration adopted the Children's Environment and Health Action Plan for Europe (CEHAPE), an international instrument negotiated with member states to develop and manage environmental health indicators. CEHAPE sets four regional priority goals (RPGs) that encapsulate key themes for action on children's health in relation to environmental factors: a) gastrointestinal health related to safe water and adequate sanitation; b) healthy and safe transport, mobility, and home environment to reduce injuries and enhance physical activity; c) respiratory health and clean air; and d) health through environment free of hazardous chemicals, physical, and biological factors.

Although the RPGs do not explicitly cover social indicators, the CEHAPE recognizes that these factors are critical in determining a child's possible increased exposure or vulnerability to a number of environmental factors.

Reliable information is essential for prioritizing actions related to environmental exposures and their health effects as well as for monitoring the effectiveness of the actions taken. Currently, this information is widely scattered and difficult to obtain on international and national levels. Where it does exist, its contents and format are often inappropriate for international comparisons, for policy support, or for public communication. Providing decision makers with appropriate information regarding health effects attributable to environmental risks is of crucial importance. They require information about the issues of concern and an indication of the hazards and the risks that need to be addressed (Briggs 2003). Such information should enable them to assess the implications of their decisions, compare the potential effects of different decisions and choices, and ultimately develop effective prevention strategies (Corvalan et al. 2000). Such information includes environmental quality guidelines based on epidemiologic and toxicologic studies (e.g., WHO air quality guidelines; WHO 2006a). Overall, the information needs to be clear, concise, relevant, and powerful (Briggs 2003).

WHO has been coordinating the development of methods and tools for a pan-European EHIS to support policy making since 1999. In particular, the development of environmental health indicators--the EHIS central element--has been significantly advanced through a series of projects in collaboration with relevant international organizations. The project Development of Environment and Health Indicators for European Union (EU) countries (ECOEHIS), co-funded by the Directorate-General for Health and Consumer Protection of the European Commission (EC) and coordinated by WHO, was a part of this process and resulted in the proposal of 17 core indicators under six themes for monitoring the EU population's exposure to environmental hazards, their health effects, and related policy actions (WHO Regional Office for Europe 2004a; Kim et al. 2005).

The Declaration from the Budapest Conference reaffirmed that the EHIS is an essential tool for policy making relevant to children's environmental health. The development and application of indicators focusing on children's environmental health and facilitating monitoring and evaluation of the environmental health risks and the effect of interventions has become a significant objective (WHO Regional Office for Europe 2004b).

An international project, Implementing Environment and Health Information System in Europe (ENHIS), co-funded by the EC and coordinated by the WHO Regional Office for Europe, developed a prototype of an evidence-based system to support children's health and environmental policies in the European Region. Among the key products is a core set of children's environmental health indicators to monitor the implementation of the CEHAPE with a prototype pan-European EHIS. Here we report the process and products of the ENHIS project related to developing children's environmental health indicators.

Methods

A working group comprised a core group of international experts representing each of the technical areas identified by the RPGs, plus a network of invited experts in each of the fields. This group carried out the following tasks: determine the needs of current and future environmental health policies; define the scope and target of the indicators; produce the methodologic guidelines for each of the indicators; pilot test the indicators and then further refine the indicators; and select a core set of indicators for pilot implementation. During the process, the group was concerned primarily with the need to select reliable indicators for which there was evidence in published literature that a clear health link exists between the environmental exposure and health outcome, while allowing comparison in the framework of the implementation of the CEHAPE. However, the group was mindful of the need not to place too much of a reporting burden on countries and therefore, where possible, to prioritize indicators for which routine monitoring and published data were readily available in most countries.

The indicators were designed to a) enable monitoring of children's environmental health risks, their determinants, and effects of the intervention; b) provide appropriate information to countries to monitor the state of children's environmental health, allow trends to be established, and support national policies and action programs; c) provide a sustainable basis for reporting and dissemination of evidence-based information (i.e., there is a policy need plus there is an established link between the exposure and health outcome) on children's environmental health, avoiding duplication and ensuring continuity; and d) provide a basis for improvement of existing monitoring and surveillance systems by pointing out priority data gaps in order to inform policy-making decisions.

Overall process of development of the indicators. Based on these criteria the process of development of the indicators was initiated. To present the links between environment, health outcomes, and actions the DPSEEA framework developed by Corvalan et al. (1996) was used. This framework defines driving forces (D), that lead to pressures on the environment (P), which in turn change the state of the environment (S), resulting in human exposures (Ex) and then to health effects (E). Actions (A) can be taken at any point during the chain to mitigate health effects.

The scope of indicators developed for the current project focused on exposure, health effects, and policy actions within the conceptual framework of cause-effect proposed by WHO (1999). The process of development is detailed in the following sections and summarized in Figure 1.

Initial selection of candidate indicators. The working group undertook to assess the information needs of European environmental health policies by identifying the requirements of relevant legislation and guidelines such as the Protocol on Water and Health (WHO Regional Office for Europe 2004c). This was done through the development of a questionnaire on current and planned children's environmental and health policies at EU and domestic levels for the creation of an inventory. The questionnaire was sent to national collaborating centers of the ENHIS project and was completed by public health and environmental officials or national experts in the existing policies. The topics that were identified as policy priorities from this process were water and sanitation, noise, air pollution [including environmental tobacco smoke (ETS)], housing (including injuries), transport, and radiation. Social determinants were also considered important but these are not included in the key themes of CEHAPE, and it was eventually decided not to include social indicators in the project.

To address the assessment of the information needs of European environmental health policies, the working group reviewed the scientific literature of the links between environmental factors and health effects, and proposed a series of indicators of relevance to the RPGs regardless of data availability and existence of methodology sheets.

The review of the policy needs identified topic areas for which no clear regulatory framework exists. Examples include drinkingwater safety, ensuring safe transport and mobility, counteracting obesity, and indoor air quality. The policy measures with clear legal and regulatory context are dedicated mainly to environmental protection and improvement of environmental quality. Furthermore, these policies do not cover the range of harmful health effects, particularly on children's health, resulting from exposure to a regulated environmental substance.

These considerations guided the working group to select environmental public health thematic issues for which policy indicators needed to be developed. The working group sought to develop policy indicators to provide a snapshot of the measures put in place in countries to reduce and prevent hazardous exposures and related health effects in children. At the same time, the analysis of the policy indicators would identify policy gaps--areas not addressed by current policy measures.

Policy indicators were conceived as a composite index across a set of policy actions using a simple equal-weight linear model. To obtain the index, each individual policy measure was scored with the following options: 0 = not existing, 1 = partly existing, 2 = clearly stated and implemented across the country.

Because there is no consensus nor many systematic reviews on policy actions' interventions, the working group checked international health regulation documents to select the policy components for the composite measure. These included the WHO Framework Convention on Tobacco Control (WHO 2003a), European Strategy for Tobacco Control (WHO Regional Office for Europe 2002), First Action Plan for Food and Nutrition Policy (WHO Regional Office for Europe 2001), European Child Safety Alliance (2004b), Child Safety Action Plan Project (European Child Safety Alliance 2004a), and the CEHAPE program and related table of actions (WHO Regional Office for Europe 2005).

This process resulted in 164 indicators (including those that had already been tested in the ECOEHIS project). The phase of reducing the number of indicators then began through a series of expert working group consultations. Initially, indicators that had already been tested and recommended by the ECOEHIS project and could be adjusted to meet the requirements of CEHAPE were selected. In addition, new indicators that corresponded to emerging policy and health priorities covered by the RPG action items of the CEHAPE were selected and developed. The proposed indicators were screened according to their policy relevance, health relevance, and potential data availability, including a review of published literature linking environmental factors and health outcomes as well as using the results from the policy questionnaire described above.

We assessed each indicator in terms of its credibility (i.e., based on a knowledge link between environment and health taking into account uncertainties), basic information on the definition, calculation method, interpretation, and potential data sources. The process and contents of assessments were recorded. There is scientific uncertainty in environmental health that needs to be reduced. During the process of selecting the indicators, we screened published literature to assess the scientific credibility of the available data. Within these criteria, the indicators were either set aside or accepted for development. This assessment reduced the number of proposed indicators to 116.

Methodology sheets. To ensure the information collected on the proposed indicators was consistent and user friendly, we adopted a template for a methodology sheet used in the ECOEHIS project (Table 1).

Table 1. Template of the methodology sheet used to define the
indicators.
    Indicator       Position in DPSEEA chain

Issue               Specification of the environmental health
                    issue as stated in the  CEHAPE regional
                    priority goals to  which the indicator relates

Justification for   Describe the importance of this indicator
this indicator      in terms of the priorities  of children's
                    environmental  health considering the
                    magnitude,  severity, amenability, and
                    public concerns of the problem, with special
                    attention to CEHAPE action item.

                    State the evidence linking exposure,effect,
                    and policy actions. Specify actions. Specify
                    actions. Specify how this indicator can
                    effectively monitor the achievement or
                    actions of CEHAPE regional priority goals

                    Quote the relevant part from CEHAPE as
                    a key justification, followed by a summary
                    of scientific evidence and policy effectiveness
Definition of       Detailed technical definition of the indicator.
indicator           If there are subindicators, provide their
                    definitions.
Underlying          Definition of all terms and concepts involved in
definitions and     describing and constructing the indicator
concepts

Specification of    List data elements needed to construct
data needed         the indicator

Data sources,       Outline potential sources of data, and comment
availability,       on their quality and characteristics in
and quality         terms of the indicator. Where
                    indicator. Where appropriate, indicate ways of
                    obtaining data that are not readily available

Computation         Specify how the indicator is computed: i.e.,
                    how the data are analyzed/processed to
                    construct the indicator. Where relevant, express
                    the computation process mathematically, and
                    define the terms used

Units of            Specify the units of measurement used in
measurement         presenting the indicator

Scale of            Specify the potential scales of application or
application         level of aggregation. The scale specified
                    refers to the area across which the across
                    which the indicator can be used; for
                    geographic comparisons, the indicator might
                    be developed at lower levels of aggregation.

                    Definitions: local (within a city or community);
                    regional (within a subnational region);
                    national (for a country); international
                    (across several countries or globally)

Interpretation      Describe how the indicator may be interpreted
                    in relation to the issue(s) specified

Linkage with other  Describe the relationship between this and
indicators          other indicators relating to the issue(s)
                    specified, listing all indicators and their
                    position in the DPSEEA chain

Related data,       List similar or related indicators, proposed
indicator sets,     or developed as part of other indicator

websites            sets List and briefly explain any international
Policy/regulatory   policy or regulations in the forms of
context             declaration, action plan, framework, treaty,
                    directives related the issue that this indicator
                    is dealing with

Reporting           Describe whether the reporting ofthe data
obligations         elements for this indicator is obliged
                    for the member states by the international
                    legislations or constitutions

Through the development of methodology sheets for each indicator, it became apparent that in the case of 44 indicators there were insufficient data available to continue development. These indicators were put aside, despite being considered potentially useful for the future.

To avoid duplication and assure continuity of developmental work, we reviewed the indicators tested and proposed in the ECOEHIS project for their relevance to children's environmental health. Eleven indicators from the core indicators selected in the ECOEHIS project were adopted on the basis of their relevance to children's health and the availability of data.

Adjustment and screening of the indicators. Further review of the indicators was undertaken by member states and technical experts, until a final list of 29 core indicators was produced. The primary reason for rejecting proposed core indicators at this stage was unavailability of data from international sources. Nine indicators that were rejected from the core set were retained for future use and were termed "extended set." These indicators were deemed highly relevant to children's health, but at present the required data to compute the indicator do not exist.

Before finalization of the 29 core indicators, the experts were still uncertain about the feasibility and applicability of eight indicators that had not been evaluated in the ECOEHIS project. It was decided that these indicators should undergo an evaluation process in the countries represented in ENHIS (Austria, the Czech Republic, Finland, France, Germany, Hungary, the Netherlands, Poland, Romania, Spain). Four of these were action indicators and four were exposure indicators. The indicators screened were policies to promote safe mobility and transport for children; policies to reduce child unintentional injury unrelated to traffic accidents; policies to reduce child obesity; children living in homes using a hazardous source of fuel for cooking and heating; children living in proximity to heavily trafficked roads; children going to school with indoor air problems; actions to reduce children's exposure to ultraviolet (UV) radiation; blood lead levels in young children. It was not deemed necessary to evaluate the indicators that had been developed for or adapted from the ECOEHIS project because these had already been tested. Details of the process taken to test the indicators selected for the ECOEHIS project are discussed by the WHO Regional Office for Europe (2004a).

The request to evaluate the indicators was sent to officials from the ministry of health and/or environment in the participating countries together with the methodology sheet and the contact data of the national partner institution. The questionnaire that accompanied the methodology sheets focused on four criteria of evaluating indicators and data elements: data quality, usefulness (combined as one category in Table 2 and described as understandability) data availability, and policy relevance (Table 2). The responses were collected using the questionnaire from April to June 2005.

Table 2. Summary of screening results.

                    Austria    Czech     France  Hungary
                               Republic

Policies to
promote safe
mobility and
transport for
children

Data availability      X         X         X        X

Understandability      X         X         X        X

Policy relevance       X         X         X        X

Policies to reduce
children's
unintentional
injury unrelated
to traffic
accidents

Data availability      X         X         X        X

Understandability      X         X         X

Policy relevance       X         X         X        X

Policies to reduce
child obesity

Data availability      X         X         X        X

Understandability      X         X         X        X

Policy relevance       X         X         X        X

Children living at
home using a
hazardous source
of fuel for
cooking or
heating

Data availability                                   X

Understandability                X         X        X

Policy relevance       X         X         X        X

Children living in
proximity to
heavily trafficked
roads

Data availability                                   X

Understandability      X         X         X        X

Policy relevance       X         X         X        X

Children going to
schools with
indoor air
problems

Data availability

Understandability                          X        X

Policy relevance       X                   X        X

Actions to reduce
children's
exposure to UV

Data availability      X         X         X        X

Understandability      X         X                  X

Policy relevance       X         X         X        X

Blood lead levels
in young children

Data availability                          X

Understandability      X         X         X        X

Policy relevance       X                   X        X

                    Netherlands  Poland  Romania  Spain

Policies to
promote safe
mobility and
transport for
children

Data availability        X         X        X       X

Understandability        X                  X       X

Policy relevance         X                  X       X

Policies to reduce
children's
unintentional
injury unrelated
to traffic
accidents

Data availability        X         X        X       X

Understandability        X         X        X       X

Policy relevance         X         X        X       X

Policies to reduce
child obesity

Data availability        X         X        X       X

Understandability                  X        X       X

Policy relevance         X         X        X       X

Children living at
home using a
hazardous source
of fuel for
cooking or
heating

Data availability

Understandability        X                  X

Policy relevance                              X

Children living in
proximity to
heavily trafficked
roads

Data availability        X

Understandability        X         X        X

Policy relevance         X         X        X

Children going to
schools with
indoor air
problems

Data availability

Understandability                             X

Policy relevance                              X

Actions to reduce
children's
exposure to UV

Data availability        X         X

Understandability        X         X        X       X

Policy relevance                              X       X

Blood lead levels
in young children

Data availability                  X

Understandability        X         X                  X

Policy relevance         X                            X
Table 3. Core and extended indicators related to CEHAPE regional
priority goal I.

                      Origin and
                    international
  Indicator title     data source,    Definition of
    (and type)      if available    the indicator

Core indicators

Wastewater          Adapted from   Percentage of
treatment           ECOEHIS        the child
(exposure)                         population
                                   served by
                                   sewage
                                   connected to a
                                   wastewater
                                   treatment
                                   facility that
                                   produces a
                                   regulated
                                   effluent
                                   discharge
                                   monitored by
                                   the competent
                                   authorities, or
                                   to an
                                   alternative
                                   safe local
                                   wastewater
                                   disposal
                                   system, e.g.,
                                   septic tank

Recreational water  Adapted from   Proportion of
quality             ECOEHIS        identified
(exposure)                         bathing waters,
                                   falling under
                                   the EU bathing
                                   water directive
                                   definition (CEC
                                   1976)

Drinking-water      Adapted from   Proportion of
compliance          ECOEHIS        the
(exposure)                         drinking-water
                                   samples
                                   analyzed from
                                   regulated
                                   public supplies
                                   that fail to
                                   comply with the
                                   Escherichia
                                   coliparameter
                                   of the EU
                                   drinking-water
                                   directive (CEC
                                   1998)

Safe drinking       Adapted from   Proportion of
water               ECOEHIS        the child
(exposure/policy)                  population with
                                   continuous
                                   access to an
                                   adequate amount
                                   of safe
                                   drinking water
                                   in the home

Management of       Adapted from   Percentage of
bathing waters      ECOEHIS        identified
                                   bathing waters
                                   which are
                                   covered by
                                   management
                                   systems as
                                   described by
(policy)                           WHO (2003b)

Water safety plans  Adapted from   Proportion of
(policy)            ECOEHIS        the child
                                   population
                                   served by a
                                   potable water
                                   supply covered
                                   by a 'water
                                   safety plan' as
                                   described by
                                   WHO (2006b)

Extended set of
indicators

Reliability of the  New            Percentage of
water supply (exposure)            the child
                                   population who
                                   have access to
                                   a reliable
                                   water supply

Outbreaks of        New            Number of
waterborne                         outbreaks of
diseases in                        fecal--oral
children (health)                  water-related
                                   illness in the
                                   child
                                   population
                                   reported
                                   separately for
                                   drinking-water
                                   and
                                   recreational
                                   waters

Incidence of        New            The incidence
priority diseases                  of key
in children (health)               water-related
                                   infections in
                                   the child
                                   population

Results

Screening in participating member states. Table 2 shows a summary of the results of the screening process in eight participating member states. The results revealed lack of data in four areas related to air pollution: the protection of children from air pollutants derived from cooking and heating facilities; the protection of children living in proximity to heavily trafficked areas; the protection of children going to schools with indoor air problems; and the protection of children from exposure to heavy metals such as lead (expressed as blood lead levels in young children). In addition, limited data were available in relation to the indicators on actions to reduce children's exposure to UV. However, their relevance to policy in Europe was considered to be high.

Core set of indicators. Tables 3--6 show the final set of children's environmental health indicators according to the RPGs. The core indicators were deemed policy relevant and readily available from international data sources with sufficient quality and comparability. The eight indicators listed under "extended set" were retained for future development and use.

Table 4. Core and extended indicators related to CEHAPE regional priority goal II.

                     Origin
                       and
Indicator title  data        Definition of
  (and type)     source, if  the indicator
                 available

Core
indicators

Child mortality  Amended     Child mortality
from traffic     from        from traffic
accidents        ECOEHIS     accidents by
(health)                     age group and
                             by mode of
                             accident

Policies for     Child       Existence and
safe             Safety      actual
transportation   Action      enforcement of
for children     Plan        legislation and
(policy)         (European   regulations
                 Child       establishing
                 Safety      requirements
                 Alliance    for safe
                 2004a)      mobility and
                             transport for
                             children

Children's       Amended     Data available
mortality due    from        from the WHO
to               ECOEHIS     Mortality
unintentional    Child       Database (WHO
injuries not     Action      Safety      2005).
related to       Plan        Cause-specific
traffic                      child
accidents                    mortality
(health)                     rates per
                             100,000
                             population for
                             unintentional
                             injuries not
                             related to
                             traffic
                             accidents

Policies to                 (European Existence and
reduce                       Child enforcement of
children's                   Safety legislation and
mortality due                regulations
unintentional                aimed at
injuries not                 reducing child to
related to                   injury
traffic                      Alliance
accidents                    2004a)


          New. Data
        found in
(policy)         HBSC

Prevalence of    (Currie et  Percentage of
overweight and   al. 2004)   adolescents
obesity in                   15--19 years of
                             age who are
                             adequate
                             weight,
                             overweight, or
                             obese,
adolescents      New. Data   where adequate
(health)         available   weight is
                 in HBSC     defined as a
                             BMI < 25
                             kg/[m.sup.2],
                             overweight is
                             defined as a
                             BMI 25--30
                             kg/[m.sup.2],
                             obesity is
                             defined as a
                             BMI of &ge; 30
                             kg/[m.sup.2]

Percentage of    (Currie et  The percentage
physically       al. 2004)   of children
active                       reporting to be
children                     physically
                             active for 1
                             hr/day at least
                             3 times
(exposure)       New         per week

Policies to                  Composite index
reduce                       of the
childhood                    willingness and
obesity                      commitment to
(policy)                     implement a
                             national
                             strategy to
                             prevent obesity
                             in accordance
                             with the WHO
                             Global Strategy
                             on Diet,
                             Physical
                             Activity and
                             Health (WHO
                             2004) and the
                             WHO Food and
                             Nutrition
                             Action Plan for
                             the WHO
                             European
                             Region,
                             2000--2005 (WHO
                             Regional Office
                             for Europe
                             2001)

Extended set of  New
indicators

Mode of child                Percentage of
transportation               children going
to school                    to school by
                             different
                             modes
(exposure)

Abbreviations: BMI, body mass index; HBSC, Health Behaviour in
School-aged Children study.
Table 5. Core and extended indicators related to CEHAPE
regional priority goal III.

   Indicator (and       Origin and        Definition of the
        type)            data source,           indicator
                       if available

Core indicators

Policies to reduce    Adapted from    This indicator is aimed at
tobacco smoke         ECOEHIS         constructing a composite
exposure in           indicator       index of capability for
children                              implementing
(policy)                              policies to reduce smoking
                                      and exposure to ETS in
                                      children and adolescents

Prevalence of         New             Prevalence (%) of children
allergies and asthma                  with asthma in age groups
in                                    (years) 0--4, 5--9,
children (health)                     10--14, 15--19 of total
                                      population of children in
                                      the respective age group
                                      Prevalence (%) of allergy
                                      toward house dust mites,
                                      pollens, furry animals,
                                      and molds

Infant mortality due  New             Annual mortality rate due
to respiratory                        to respiratory diseases in
diseases (health)                     children > 1 month and
                                      < 1 year of age

Children's exposure   Adapted from    [PM.sub.10]: Child
to air pollutants     ECOEHIS         population-weighted annual
(exposure)            indicator       mean PM10 concentration
                                      [PM.sub.2.5]: Child
                                      population-weighted annual
                                      mean [PM.sub.2.5]
                                      concentration
                                      [O.sub.3]: Child
                                      population-weighted
                                      annual mean (of
                                      maximum daily 8 hr
                                      means) [O.sub.3]
                                      concentration
                                      [NO.sub.2]: Child
                                      population
                                      distribution of
                                      exceedance hours of
                                      air quality limit
                                      values
                                      [SO.sub.2]: Child
                                      population
                                      distribution of
                                      exceedance days of
                                      air quality values

Children living in    Adapted from    Percentage of children
homes with dampness   ECOEHIS         0--4, 5--9, 10--14, 15--19
problems (exposure)   indicator       years old living in damp
                                      housing
                                      This indicator uses the
                                      Eurostat SILC (variable
                                      HH040) on dampness-related
                                      problems such as a)
                                      leaking roof, b) damp
                                      walls/floors/foundations,
                                      and c) rot in window
                                      frames or floor; all of
                                      which could lead to or
                                      represent mold growth

Children exposed to   New             Percentage of children
tobacco smoke                         0--4, 5--9, 10--14 years
(exposure)                            old daily exposed to ETS
                                      Percentage of smokers
                                      among children 10--14,
                                      15--19 years old

Children living in    New. Data from  Percentage of children
homes using solid     international   0--4, 5--9, 10--14 years
fuels (exposure)      surveys, e.g,   old living in households
                      dung, gas,      using: coal, wood,
                      demographic     or kerosene as
                      and health      the main source of heating
                      surveys         and cooking fuel
                      (Measure DHS
                      2007), world
                      health
                      statistics
                      (WHO 2006c),
                      and censuses.
                      Data also
                      available from
                      the Millennium
                      Indicator
                      Database (UN
                      2006) and
                      Eurostat
                      (2007)

Children living in    New             Percentage of children
proximity to                          0--4, 5--9, or 10--14
heavily                               years old living in
trafficked roads                     proximity to heavily
(exposure)                           trafficked roads

Extended set of
indicators

Hospital admissions   New             No. of hospital admissions
and emergency room                    or emergency room visits
visits due to asthma                  for asthma per 1,000
in children                           children by age
(health)                              group

Children going to     New             Percentage of children
schools with indoor                   going to schools or day
air                                   care centers with moisture
problems (exposure)                   damage or mold
                                      growth during the year
                                      Percentage of
                                      children going to
                                      schools and day care
                                      centres with a
                                      ventilation < 7
                                      L/sec per person

Abbreviations: ETS, environmental tobacco smoke; [PM.sub.2.5],
[PM.sub.10], particulate matter < 2.5 or 10 [micro]m in aerodynamic
diameter.
Table 6. Core and extended indicators related to CEHAPE regional priority goal IV.

  Indicator title       Origin and      Definition of
                     data source,     the indicator
                     if available

Core indicators
Children exposed    New. Noise map  Percentage of
to harmful noise    available in    children going
at                  2008            to primary or
                                    secondary
                                    schools located
                                    in places that
                                    are
school (exposure)   according to    considered to be
                    EU directive    exposed to
                    on              transport (road,
                                    rail, and
                                    aircraft) noises
                                    > 55 dB (A)
                    environmental   average during
                    noise (CEC      school hours
                    2002)

Actions to reduce   New             This is a
children's                          composite index
exposure to                         of national
                                    efforts to
                                    improve
                                    protection of
                                    children
                                    against

UV (policy)                         UV exposure
Incidence of        Adapted from    Incidence of
melanoma (health)   ECOEHIS. Data   melanoma by age
                                    periods of 5
                                    years, among
                                    children and
                                    adults up to
                                    45-50
                    available from  years of age
                    International
                    Agency for
                    Research on
                    Cancer

Incidence of        New             Annual incidence
childhood leukemia                  rate of
(health)                            leukemia

Work injuries       New. Data       Incidence rate
among employees     available       of work
                    from            accidents with
                                    victims < 18
                                    years of age per
                                    100,000 workers
< 18 years of   EUROSTAT        According to the
age (health)        (Eurostat       severity, there
                    2007)           are two
                                    subindicators:
                                    Nonfatal work
                                    injuries with
                                    > 3 days'
                                    absence from
                                    work Fatal work
                                    injuries

Children's          New. Data       Dietary exposure
exposure to         available from  assessment to
chemical hazards    WHO             potentially
                                    hazardous
                                    chemicals
                                    monitored in
                                    children's food
in food             (2007)          Global
(exposure/policy)                   Environmental
                                    Monitoring
                                    System/Food
                                    Contamination
                                    Monitoring and
                                    Assessment
                                    Programme
                                    (GEMS/Food)

Persistent organic  New. Data       Concentrations
pollutants in       available from  of dioxins and
                    WHO             polychlorinated
                                    biphenyls in
                                    human milk fat
                                    (expressed as
human milk          (2007)          WHO toxicity
(exposure)                          equivalents in
                                    pg/g) in pooled
                                    samples using
                                    standardized
                                    collection and
                                    analytical
                                    protocols
                                    established by
                                    WHO

Blood lead levels   New             Average of blood
in children                         lead levels
                                    ([micro]g/dL) in
                                    children < 6
                                    years of age
(exposure)                          Percentage of
                                    children < 6
                                    years of age
                                    with elevated
                                    blood lead
                                    levels (> 10
                                    [micro]g/dL)

Extended set of
indicators

Radon levels in                     Distribution of
schools                             annual radon
(exposure)                          levels in
                                    classrooms and
                                    inhabited rooms
                                    of
                                    kindergarten,
schools, and
colleges

                                    Estimated
                                    arithmetic mean,
                                    median of radon
                                    concentration
                                    Estimated
                                    percentage (and
                                    number) of
                                    classrooms and
                                    other rooms with
                                    annual mean
                                    levels
                                    of radon >
                                    200, 400
                                    Bq/[m.sub.3]
                                    Specified at the
                                    national or
                                    regional level

Children with                       Proportion of
hearing loss and                    children with
reporting                           hearing loss due
                                    to noise
tinnitus (health)

Discussion

The indicators developed in this project met a specific task identified by the Budapest Declaration: to address the environmental factors that most affect the health of European children (WHO Regional Office for Europe 2004b). Through the development of these indicators, the project has helped identify and prioritize the environmental health issues that are widespread in the European Region.

The screening process undertaken by eight countries highlighted the national variations in data availability, policy relevance, and priorities. It became clear through this process that even in this small number of member states there are gaps in policies relating to some areas of children's environmental health as well as available data. One such area is indoor air quality. However, indoor air is an important issue with respect to children's environmental health specifically targeted in CEHPAE, and keeping such indicators was considered valuable to encourage efforts to collect relevant data. Although not all of the issues are a priority in all countries, and countries should therefore choose the indicators that best suit their priorities and conditions, including resources, when establishing their own environmental health information system, there is clearly a need to fill these gaps through the development of national or international data collection systems.

The next phase of the project (begun in November 2005) was to implement the indicators in the European Region. This is making it possible to monitor the effect of actions taken to address the environmental health issues affecting children using standardized methodologies for data collection, processing, and dissemination, allowing inter-and intracountry comparisons and time trend analysis.

In the long term, the overall goal is to maintain an active and up-to-date European database of environmental health policies and data, which would facilitate the development of harmonized and science-based environmental health policies across Europe and increase their accountability in population health terms. Differences between national policies will and should remain, but they should be based on different conditions and needs, rather than on the lack of information to assess their effectiveness and accountability.

The environmental health indicators developed in this project can be readily applied in most EU countries in monitoring the implementation of CEHAPE. The indicators will need to be reviewed and updated regularly to maintain flexibility and responsiveness. By outlining the priority data flows in a pan-European EHIS, the core indicators will provide guidelines for the reporting on the progress of realization of four RPGs of the CEHAPE.

The development of environmental health indicators to monitor the trends in the state of European children contributes toward the objectives of the Global Initiative on Children's Environmental Health Indicators launched at the World Summit on Sustainable Development in 2002, initiated by and building on efforts of the U.S. Environmental Protection Agency (WHO 2002b). The indicators developed and made available through the regional pilot surveys as well as information from ongoing international surveys and reporting mechanisms will be part of the comprehensive evidence base toward healthy public policies to better protect the health of our children and the generations to come.

REFERENCES

Abalak R, Bruce N, McCraken JP, Smith KR, de Gallardo T. 2001. Indoor respirable particulate matter concentrations from an open fire, improved cook stoves and LPG/open fire, combination in rural Guatemalan community. Environ Sci Technol 35:2650-2655.

[Anonymous]. 2005. Children's health coming of age in Europe [Editorial]. Lancet 366(9491):1052.

Bellinger DC. 2004. Lead. Pediatrics 113:1016-1022.

Briggs A. 2003. Making A Difference: Indicators to Improve Children's Environmental Health. Geneva:World Health Organization. Available: http://www.int/ceh/publications/ ceh1590599/en/index.html [accessed 8 March 2007].

CEC (Council of the European Communities). 1976. Bathing Water Quality. Directive 76/160/EEC. Available: http://ec. europa.eu/water/water-bathing/directiv.html [accessed 27 March 2007].

CEC (Council of the European Communities). 1998. Directive (98/83/EC) on the Quality of Water Intended for Human Consumption. Available: http://eur-lex.europa.eu/ LexUriServ/site/en/oj/1998/l_330/l_33019981205en00320054. pdf [accessed 27 March 2007].

CEC (Council of the European Communities). 2002. Noise: Activities Linked to the Environmental Noise Directive. Available: http://ec.europa.eu/environment/noise/ activities.htm [accessed 26 March 2007].

Corvalan C, Briggs D, Kjellstrom T. 1996. Development of environmental health indicators. In: Linkage Methods For Environment And Health Analysis. General Guidelines. (Briggs D, Corvalan C, Nurminen M, eds). Geneva:World Health Organization, 19-53.

Corvalan C, Briggs D, Zielhuis G. 2000. Decision-Making in Environmental Health: From Evidence to Action. London:E&FN Spon.

Currie C, Roberts, C, Morgan, A, Smith, R, Settertobulte W, Samdal O, et al. 2004. Young People's Health in Context. Health Behaviour in School-aged Children (HBSC) Study: International Report from the 2001/2002 Survey. Copenhagen:WHO Regional Office for Europe. Available: http://www.euro.who.int/InformationSources/ Publications/catalogue/20040518_1 [accessed 30 July 2007].

European Child Safety Alliance. 2004a. Child Safety Action Plan. Available: http://www.eurosafe.eu.com/csi/eurosafe2006. nsf/wwwVwContent/61CE5CD93275507BC1257194004DE694 ?opendocument&context=C695AC19E93E2400C12571770035 3994 [accessed 27 March 2007].

European Child Safety Alliance. 2004b. Priorities for Child Safety in the European Union: Agenda for Action. 2nd ed. Amsterdam:European Child Safety Alliance. Available: http://www.childsafetyeurope.org/csi/ecsa.nsf/index/ injurythemes/$file/2004whitebook.pdf [accessed 27 March 2007].

Eurostat. 2007. Eurostat Data. Available: http://epp.eurostat.ec. europa.eu/ [accessed 27 March 2007].

Kim R, Dalbokova D, Krzyzanowski M. 2005. Development of environmental health indicators for European Union countries. EpiMarker 9(3):1--4.

Landrigan PJ, Carlson JE, Bearer JS, Cranmer CF, Bullard R, Etzel RA, et al. 1998. Children's health and the environment: a new agenda for prevention research. Environ Health Perspect 106:787--794.

Measure DHS. 2007. Demographic and Health Surveys. Available: http://www.measuredhs.com/ [accessed 27 March 2007].

Niemann H, Maschke C, Hecht K. 2005. Noise induced annoyance and morbidity. Results from the pan European LARES-survey. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 48(3):315--328.

Pruss-Ustun A and Corvalan C. 2006. Preventing Disease Through Healthy Environments. Towards an Estimate of The Environmental Burden of Disease. Geneva:World Health Organization. Available: http://www.who.int/quantifying_ ehimpacts/publications/preventingdisease/en/ [accessed 6 December 2006].

Richardson G, Eick S, Jones R. 2005. How is the indoor environment related to asthma? Literature review. J Adv Nurs 52(3):328--339.

Schwartz J. 2004. Air pollution and children's health. Pediatrics 113:1037--1043.

Simoni M, Lombardi E, Berti G, Rusconi F, La Grutta S, Piffer S, et al. 2005. Mould/dampness exposure at home is associated with respiratory disorders in Italian children and adolescents: the SIDRIA-2 Study. Occup Environ Med 62(9):616--622.

Smith KR, Corvalan CF, Kjellstrom T. 1999. How much global ill health is attributable to environmental factors? Epidemiology 10:573--584.

Smith KR, Samet JM, Romieu I, Bruce N. 2000. Indoor air pollution in developing countries and acute lower respiratory infections in children. Thorax 55:518--522.

Suk W, Murray K, Avakian MD. 2003. Environmental hazards to children's health in the modern world. Mutat Res 544:235--242.

UN. 2006. MDGInfo 2006. New York:United Nations Statistics Division. Available: http://mdgs.un.org/unsd/mdg/ News.aspx?ArticleId=18 [accessed 27 March 2007].

Valent F, Little D, Bertollini R, Leda NE, Barbone F, Tamburlini G. 2004. Burden of disease attributable to selected environmental factors and injury among children and adolescents in Europe. Lancet 363(9426):2032--2039.

WHO. 2002a. Report of the International Conference on Environmental Threats to the Health of Children: Hazards and Vulnerability. Bangkok, Thailand, 3--7 March, 2002.

Geneva:World Health Organization. Available: http://www. who.int/docstore/peh/ceh/Bangkok/Bangkokconfreport.pdf [accessed 6 December 2006].

WHO. 2002b. Global Initiative on Children's Environmental Health Indicators. Available: http://www.who.int/ceh/ indicators/globinit/en/ [accessed 30 July 2007].

WHO. 1999. Environmental Health Indicators: Framework and Methodologies. Geneva:World Health Organization. Available: http://whqlibdoc.who.int/hq/1999/WHO_SDE_ OEH_99.10.pdf [accessed 6 December 2006].

WHO. 2003a. WHO Framework Convention on Tobacco Control. Geneva:World Health Organization. Available: http:// www.who.int/tobacco/framework/WHO_FCTC_english.pdf [accessed 27 March 2007].

WHO. 2003b. Guidelines for Safe Recreational Water Environments. Vol 1: Coastal and Freshwaters. Geneva: World Health Organization. Available: http://whqlibdoc. who.int/publications/2003/9241545801.pdf [accessed 30 July 2007].

WHO. 2004. Global Strategy on Diet, Physical Activity and Health. Geneva:World Health Organization. Available: http://www.who.int/dietphysicalactivity/strategy/eb11344/ strategy_english_web.pdf [accessed 27 March 2007].

WHO (World Health Organization). 2005. Mortality Database. Available: http://www3.who.int/whosis/menu.cfm [accessed 27 March 2007].

WHO. 2006a. WHO Air Quality Guidelines for Particulate Matter, Ozone, Nitrogen Dioxide and Sulfur Dioxide. Global Update 2005. Summary of Risk Assessment. Geneva:World Health Organization. Available: http://whqlibdoc.who.int/ hq/2006/WHO_SDE_PHE_OEH_06.02_eng.pdf [accessed 30 July 2007].

WHO. 2006b. Guidelines for Drinking-water Quality. Vol 1: Recommendations. Geneva:World Health Organization. Available: http://www.who.int/water_sanitation_health/ dwq/gdwq0506begin.pdf [accessed 27 March 2007].

WHO. 2006c. World Health Statistics 2006. Geneva:World Health Organization. Available: http://www.who.int/ whosis/whostat2006_toc2intro.pdf [accessed 27 March 2007].

WHO. 2007. WHO SIGHT. Summary Information and Global Health Trends. Copenhagen:World Health Organization. Available: http://sight.who.int/ [accessed 27 March 2007].

WHO Regional Office for Europe. 2001. The First Action Plan for Food and Nutrition Policy. Copenhagen:World Health Organization. Available: http://www.euro.who.int/ Document/E72199.pdf [accessed 27 March 2007].

WHO Regional Office for Europe. 2002. European Strategy for Tobacco Control. Copenhagen:World Health Organization. Available: http://www.euro.who.int/Document/E77976.pdf [accessed 27 March 2007].

WHO Regional Office for Europe. 2004a. Development of Environment and Health Indicators for European Union Countries: Results of a Pilot Study. Available: http://www. euro.who.int/document/E85061.pdf [accessed 6 December 2006].

WHO Regional Office for Europe. 2004b. Fourth Ministerial Conference on Environment and Health, Budapest, Hungary, 23--25 June 2004. Declaration. Available: http:// www.euro.who.int/document/e83335.pdf [accessed 6 December 2006].

WHO Regional Office for Europe. 2004c. Protocol on Water and Health to the 1992 Convention on Protection and Use of Transboundary Waters and International Lakes. Available: http://www.euro.who.int/watsan/waterprotocol/20030523_1 [accessed 6 December 2004].

WHO Regional Office for Europe. 2005. Children's Health and Environment. Developing Action Plans. Copenhagen:World Health Organization. Available: http://www.euro.who.int/ document/E86888.pdf [accessed 30 July 2007].

Address correspondence to R. Kim, WHO European Centre for Environment and Health, HermannEhlers-Strasse 10, D-53113 Bonn, Germany. Telephone: [phone]. Fax: [phone]. E-mail:[e-mail] authors thank the following experts who helped to develop the indicators: D. Kay, R. Aertgeerts, D. Lupulescu, F. Racioppi, M. Martuzzi, J. Pronczuk, G. Moy, D. Sethi, R.C. Vallenas, I. Ivanov, E. Rehfuess, and J. Vincenten.

This work was funded by the European Commission, Directorate-General for Health and Consumer Protection under grant 2003112.

The authors declare they have no competing financial interests.

Received 6 December 2006; accepted 10 May 2007.

KathyPond,RokhoKim,Maria-JoseCarroquino,PhilippePirard,FionaGore,AlexandraCucu,LedaNemer,MoragMacKay,GretaSmedje,AntonisGeorgellis,DafinaDalbokova, and MichalKrzyzanowski (1)Robens Centre for Public and Environmental Health, University of Surrey, Guildford, United Kingdom; (2)WHO European Centre for Environment and Health, Bonn, WHO Regional Office for Europe; (3)Instituto de Salud Carlos III, Madrid, Spain; (4)Institut de Veille Sanitaire, Saint-Maurice, France; (5)WHO headquarters, Geneva, Switzerland; (6)Ministry of Health, Bucharest, Romania; (7)WHO European Centre for Environment and Health, Rome, WHO Regional Office for Europe; (8)European Child Safety Alliance, Amsterdam, The Netherlands; (9)Department of Occupational and Environmental Medicine, Uppsala University Hospital, Uppsala, Sweden; (10)Occupational and Environmental Health Department, Stockholm County Council, Stockholm, Sweden