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This fact sheet gives a comparative assessment of national policies on unintentional injuries (excluding road traffic injuries (RTIs)) based on responses to the ENHIS-2 survey of 23 countries in the WHO European Region. The indicator is defined as a score indicating the extent to which different policies are implemented. The results are interpreted in the context of public health and policy implications, followed by an assessment of the situation in the WHO European Region.

Key message

National policy efforts in the Region to reduce unintentional injuries in children and adolescents are moderate as measured by the indicator scores, i.e. the level of political commitment to reduce and prevent such injuries. All reporting countries have some policies but there is no consistent pattern and the level of implementation varies between them. The ultimate impact of policy measures can only be assessed through health outcome indicators, particularly mortality and morbidity data.

Figures

Presentation of data

Fig. 1 shows the total score for implementation of the 12 policies in the reporting countries. A higher index reflects wider scope and comprehensiveness of the policies.

Table 1 shows the proportion of the countries surveyed which have implemented and enforced each of the policies to a high (score of 2), medium or low degree. Policies that are most frequently implemented and enforced relate to (i) child-resistant packaging of non-pharmaceutical products with the potential to poison or cause corrosive injuries and (ii) prohibition on the sale of fireworks to children. Those least often implemented include legislation on child-resistant packaging of pharmaceuticals, working smoke detectors in all dwellings, a safe pre-set temperature for water heaters, barrier fencing for private and public pools, and the use of drawstrings in children’s clothing.

Fig. 1. Degree of implementation of 12 national policies aimed at the reduction of unintentional injuries in selected countries, 2006

Note. See below under Description of data. The total score for degree of implementation is the sum of the scores for each policy: 0 = no policy; 1 = partly implemented or enforced; 2 = substantially implemented or enforced.

Source: ENHIS-2 project countries and countries volunteering data.

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Table 1. Proportion of countries implementing and enforcing 12 policies for preventing and reducing unintentional injuries across reporting countries, by mechanism of injury, 2006

The proportion of countries was calculated for those scoring 2 for a given policy. The percentages are grouped as: low = <50% of countries, medium = 50–69% of countries, high ≥70% of countries.

Source: ENHIS-2 project countries and countries volunteering data.

Rationale

Unintentional injuries from falls, drowning, poisoning, fires and choking constitute a major cause of morbidity and mortality in children and adolescents. Protective measures can reduce this and the adoption and enforcement of adequate legislation and standards are likely to increase the effectiveness of such measures. This action indicator gives a snapshot of efforts to reduce unintentional injuries in children and adolescents, focusing on 12 policies considered effective in reducing the frequency and severity of unintentional injuries.

Health and environment context

A review of the health and environmental context is provided in ENHIS-2 fact sheet 2.2 on mortality in children and adolescents from unintentional injuries (falls, drowning, fires and poisoning) (1). In brief, unintentional injuries cause a considerable burden of illness in children and young people and are strongly linked to environmental conditions in the home and in recreational areas. The rates are particularly high among children and adolescents from poor or minority group backgrounds, which may be due to factors including: less awareness (or knowledge) about, or income available for the purchase of, safety devices such as smoke detectors; greater likelihood of living in older and sub-standard housing without proper play areas; and less supervision, with parents possibly not being able to afford to stay at home or pay for child care (2).

The number and severity of injuries in children can be greatly reduced. The policies in this indicator are recognized as effective measures to reduce injuries, particularly when linked to environmental/product modification and awareness campaigns (3,4).

Policy relevance and context

In 2004, the Fourth Ministerial Conference on Environment and Health adopted the Children’s Health and Environment Action Plan for Europe, which includes four regional priority goals to reduce the burden of environment-related diseases in children. One of the goals (RPGII) aims at reducing mortality and morbidity from injuries, including from RTIs, and at the provision of safe conditions which also facilitate more physical activity among children (5).

In the context of injury prevention, the WHO Regional Committee for Europe has adopted resolution RC55/R9 urging Member States: (a) to give high priority to the prevention of violence and unintentional injury by developing national action plans; (b) to develop injury surveillance; (c) to strengthen their technical and institutional capacities to address the issue of injuries, both in terms of prevention and along the whole continuum of trauma care; (d) to promote research on effective intervention measures and the implementation of evidence-based approaches; and (e) to promote the dissemination and sharing of experience in developing and implementing policies and action to reduce the burden of injury across the Region (6).

The European Union (EU) has introduced legislation to prevent unintentional injuries to children arising from unsafe products and equipment, food and clothing. The General Product Safety Directive creates a general obligation to place only safe products on the market. Some key product groups, such as toys, electrical and gas appliances and personal protective equipment are covered by specific Directives, such as Directive 88/378/EEC on the safety of toys for children aged under 36 months. Voluntary European standards specify technical requirements, such as for the construction, installation and maintenance of playground equipment and for the removal of drawstrings in children’s clothing. Children are protected from unintentional injuries from poisoning by Directive 67/548/EEC regulating the packaging and labelling of dangerous substances and EU Food Law 178/2002, which lays down the general food requirements (7).

Moreover, within the EU, a number of policy framework documents focus on injury prevention. Notably, the European Commission adopted the Communication on Actions for a Safer Europe in May 2006 (8). Following this, Council Recommendation on the prevention of injury and the promotion of safety was adopted, which recommends member states to: (i) develop a national injury surveillance and reporting system; (ii) set up national plans for preventing accidents and injuries by initiating interdepartmental cooperation; and (iii) ensure that injury prevention and safety promotion is introduced in a systematic way in the vocational training of health care professionals (9). The Injury Prevention Programme was established in 1999 and has been part of the Public Health Programme of the Directorate-General for Health and Consumer Protection since 2002 (10). A key tool in injury prevention is the EU injury database, which is a hospital-based surveillance system for injuries intended to provide information on morbidity and the circumstances of their occurrence. Further development of the injury database includes the improvement of the international comparability of data collected through it (11). Finally, the European survey on prevention of unintentional injuries has collected national injury data to improve understanding of existing national policy frameworks (12).

Assessment

Some specific preventive policies have been implemented in all reporting countries but no country has adopted or is fully implementing and enforcing all 12 policies considered in this indicator: that is, no country scored the maximum of 24. Twelve of the countries have clearly stated and implemented half of the policies (Austria, Belgium, Croatia, the Czech Republic, Finland, France, Greece, Italy, Malta, Slovakia, Slovenia and Sweden). There are wide variations in this area.

There are five main mechanisms of injury: drowning, falls, burns and scalds (fires), poisoning, and choking and suffocation. The degree of policy implementation between and within each injury mechanism varies widely: some countries are fully implementing policies only recently adopted, while other policies that were formulated and adopted years ago are not yet being enforced. For example, Belgium is fully enforcing the requirement for barrier fencing for public pools, for which the legislation was adopted during the last ten years, while in Albania this legislation is only being partially implemented even though it was adopted in 1989.

This indicator provides information on the level of policy attention given to unintentional injuries rather than to the impact on health of those policies. The final outcome of policy implementation should be assessed in terms of reduced mortality and morbidity (as in fact sheet 2.2 which recognizes accidental drowning and submersion and accidental poisoning as major causes of death from unintentional injuries). These health findings are not noticeable with this policy indicator: no consistent trend regarding the lack of preventive policies on drowning and poisoning is marked.

Metadata

Name: Policies to reduce unintentional injuries falls, drowning, poisoning, fires and choking in children and adolescents

Definition: Extent to which 12 policies to reduce unintentional injuries are implemented

Code: RPG2_Hous_A1

Data source

Experts working in environmental health and public health institutions dealing with safety policies in the countries.

Description of data

This indicator was developed in collaboration with the Child Safety Action Plan, a project of the European Child Safety Alliance (EUROSAFE). The 12 policies under scrutiny are:

1. legislation requiring barrier fencing for public pools;
2. legislation requiring barrier fencing for private (domestic) pools;
3. policy making water safety education (for example, swimming lessons) a compulsory part of the school curriculum;
4. policy requiring playground equipment and landing surfaces to meet safety standards;
5. legislation requiring a safe pre-set temperature (54 °C) for all water heaters;
6. building codes requiring working smoke detectors in all dwellings;
7. legislation prohibiting the sale of fireworks to children under 18 years of age;
8. legislation requiring child-resistant packaging of pharmaceuticals;
9. legislation requiring child-resistant packaging of non-pharmaceuticals with potential to poison or cause corrosive injuries (such as household cleaners);
10. legislation requiring informative warning labels on products to prevent choking, suffocation and strangulation;
11. legislation prohibiting the use of inedible materials in food products;
12. legislation prohibiting the use of drawstrings in children’s clothing.

The underlying data and descriptive information on existence and level of implementation and enforcement of the 12 policies are given in the ENHIS-2 database.

Method for indicator calculation

This indicator is computed as the sum of scores given to 12 policies. The score for each policy has a range from 0 to 2: 0 = no policy, 1 = existing legislation, clearly stated and partially implemented or enforced, 2 = existing legislation, clearly stated and substantially implemented or enforced. The maximum score is 24.

Geographical coverage

Albania, Austria, Belgium, Bulgaria, Croatia, the Czech Republic, Estonia, Finland, France, Greece, Hungary, Italy, Lithuania, Malta, the Netherlands, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden and Uzbekistan.

Period of coverage

Snapshot in 2006.

Frequency of update

Data quality

The total score of this composite policy indicator needs to be interpreted with care. Countries with the same indicator score do not necessarily have the same policies and the same level of implementation. In addition, since the definitions are semi-quantitative, it is difficult to get a precise assessment of the actual implementation and coverage of the programmes. The administrative arrangements in countries may also have some effect (for example, whether there is a federal or unitary administration). As a result of these limitations it is important to examine each of the indicator’s components in addition to the overall score when interpreting results and drawing conclusions. Direct comparisons of scores between countries without examination of the individual components are discouraged.

It would be useful to continue monitoring developments in EU policy framework documents and consequent national policy responses. A more objective measurement of implementation would be helpful, since the policy data in this fact sheet reflect the broad and subjective assessment of representative experts from each participating country. In addition, more structured assessments, focusing on specific determinants of implementation and enforcement, would help to make this process more objective.

For more information on meta data and calculation of this indicator, please refer to the methodology .

References

1. WHO European Centre for Environment and Health. Mortality in children and adolescents from unintentional injuries (falls, drowning, fires and poisoning). Copenhagen, WHO Regional Office for Europe, 2007 (ENHIS-2 project, Fact sheet No. 2.2).
2. Grossman DC. The history of injury control and the epidemiology of child and adolescent injuries. The Future of Children, 2000, 10(1):23–52 (http://www.futureofchildren.org/usr_doc/Unintentional_Injuries.pdf, accessed 13 April 2007).
3. MacKay M et al. Child safety good practice guide: Good investments in unintentional child injury prevention and safety promotion. Amsterdam, European Child Safety Alliance, 2007 (http://www.eurosafe.eu.com/csi/eurosafe2006.nsf/wwwPage?readform&context=5030339C670A38A3C125718500364505&action=showliterature&lit=DF9FC5A3E70AACBFC125719D002BE34D).
4. Schieber RA, Gichrist J, Sleet DA. Legislative and regulatory strategies to reduce childhood unintentional injuries. The Future of Children, 2000, 10:111–136 (http://www.futureofchildren.org/usr_doc/Unintentional_Injuries.pdf, accessed 13 April 2007).
5. Children’s Environment and Health Action Plan for Europe [web site]. Copenhagen, WHO Regional Office for Europe, 2006 (http://www.euro.who.int/childhealthenv/policy/20020724_2, accessed 13 April 2007).
6. WHO Regional Committee for Europe resolution EUR/RC55/R9 on prevention of injuries in the WHO European Region. Copenhagen, WHO Regional Office for Europe, 2006 (http://www.euro.who.int/Governance/resolutions/2005/20050922_1, accessed 8 April 2007).
7. Vincenten J, Farquhar B. A guide to child safety regulations and standards in Europe. Amsterdam, European Consumer Safety Association, European Child Safety Alliance, 2003, (http://www.eurosafe.eu.com/csi/eurosafe2006.nsf/wwwPage?readform&context=5030339C670A38A3C125718500364505&action=showliterature&lit=17CBB1F9FB973029C1256D5700463DC5, accessed 13 April 2007).
8. Communication from the Commission to the European Parliament and the Council on Actions for a Safer Europe. Brussels, European Commission, 2006 (COM(2006) 328 final, 2006; http://ec.europa.eu/health/ph_determinants/environment/IPP/documents/com_328_en.pdf, accessed 10 April 2007).
9. Council Recommendation on the prevention of injury and the promotion of safety. Brussels, Commission of the European Communities, 2006 (COM(2006) 329 Final; http://ec.europa.eu/health/ph_determinants/environment/IPP/documents/com_329_en.pdf, accessed 13 April 2007).
10. Programme of community action in the field of public health (2003–2008) [web site]. Brussels, Commission of the European Communities, Directorate-General for Health and Consumer Protection, 2007 (http://ec.europa.eu/health/ph_programme/programme_en.htm, accessed 13 April 2007).
11. EU injury database [online database]. Brussels, Commission of the European Communities, Directorate-General for Health and Consumer Protection, 2007 2006 (https://webgate.cec.eu.int/idb, accessed 13 April 2007).
12. Shields N et al. National responses to preventing violence and unintentional injuries. Copenhagen, WHO Regional Office for Europe, 2006 (http://www.euro.who.int/document/e89258.pdf, accessed 13 April 2007).

European Child Safety Alliance [web site]. Amsterdam, European Association for Injury Prevention and Safety Promotion, 2007 (www.childsafetyeurope.org, accessed 13 April 2007).

Vincenten J. Priorities for child safety in the European Union: Agenda for action. Amsterdam, European Consumer Safety Association, European Child Safety Alliance, 2004 (http://www.childsafetyeurope.org/csi/ecsa.nsf/index/injurythemes/$file/2004whitebook.pdf, accessed 13 April 2007).

Presentation from the Third International Conference on Children’s Health and Environment, 2004 (www.pinche.hvdgm.nl/icche/presentations/vincenten_j.pdf, accessed 13 April 2007).

Good practice websites:

Unintentional injuries in childhood. The Future of Children, 2000, 10(1) (www.futureofchildren.org/pubs-info2825/pubs-info.htm?doc_id=69724, accessed 13 April 2007).

Best Practices Overview [web site]. Seattle WA, Harborview Injury Prevention and Research Center, 2007 (http://depts.washington.edu/hiprc/practices/index.html, accessed 13 April 2007).

Authors: Jennifer Grad, WHO European Centre for Environment and Health, Bonn, Germany; Eva Kunseler, National Public Health Institute, Kuopio, Finland.

This fact sheet reports on unintentional injury mortality in children and adolescents from falls, drowning, poisoning and fires in the 53 countries of the WHO European Region. Data are drawn from the WHO revised global burden of disease 2002 estimates (1) and the European mortality database (2). These data are interpreted taking the public health, environmental and policy contexts into account, followed by an assessment of the situation in the WHO European Region.

Key message

Falls, drowning, fires and poisoning are some of the leading causes of death following unintentional injury in children and adolescents in the Region. Cause-specific rates vary greatly across the Region and are generally lowest in western Europe and highest in some eastern European countries and members of the Commonwealth of Independent States (CIS). Importantly, evidence-supported means exist to reduce this burden, and a combination of legislation, environmental modification and educational approaches is desirable.

Figures

Presentation of data

Fig. 1 shows the proportion of deaths attributable to various causes of unintentional injury in children and adolescents aged 0–19 years in the Region. The chart reveals the three leading causes of unintentional injuries to be road traffic injuries (see ENHIS-2 fact sheet 2.1 on mortality from road traffic injuries (RTIs) in children and young people (4); this topic is not covered further in this fact sheet), drowning and poisonings.

Fig. 2A–2D show European countries with more than one million inhabitants ranked by age-standardized mortality rate for specific causes of unintentional injury in children for 2003 (or latest available year). They show that a cluster of countries from the CIS and the Baltic region report the highest mortality rates for cause-specific unintentional injuries.

Fig. 1. Proportion of deaths from unintentional injuries by cause in the group aged 0–19 years, WHO European Region, 2002

Source: Revised global burden of disease 2002 estimates (1).

Fig. 2. Standardized mortality rates for cause-specific unintentional injuries in the group aged 1-19 years, WHO European Region, 2003

2A. Drowning and submersion

Note. Data for Denmark, Georgia, Italy and Tajikistan are for 2001; data for Sweden are for 2002; all rates are standardized by age.

Source: WHO European mortality database (2).

2B. Poisoning

Note. Data for Denmark, Italy and Tajikistan are for 2001; data for Sweden are for 2002; all rates are standardized by age.

Source: WHO European mortality database (2).

2C. Accidental falls

Note. Data for Denmark, Georgia, Italy and Tajikistan are for 2001; all rates are standardized by age.

Source: WHO European mortality database (2).

2D. Exposure to smoke, fire and flames

Note. Data for Denmark, Georgia, Italy and Tajikistan are for 2001; data for Sweden are for 2002; all rates are standardized by age.

Source: WHO European mortality database (2).

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Rationale

A clear picture of the current situation would enable decision-makers at European and national level to develop evidence-based policies, plan effective interventions and monitor programmes in order to improve the protection of children and adolescents from injuries in settings at and around their homes, playgrounds, schools and workplaces. The ultimate aim would be to monitor progress towards regional priority goal II (RPGII) of the Children’s Health and Environment Action Plan for Europe (CEHAPE) on the reduction in childhood mortality from unintentional injuries (3).

Health and environment context

There is a direct relationship between childhood mortality from drowning, poisoning, falls and fires and the environment. Unsafe environments, whether the home, the playground, or recreational waters, are associated with increased risks of drowning, fires and falls.

Specific factors leading to injuries may include unsafe building design in the home and school, unsafe furnishings, unsafe toys and products such as baby-walkers, and unsafe storage and packaging of toxic materials.

Environmental modification based on evidence of what works could therefore be used as part of a multifaceted programme of interventions to bring down the relentless daily loss of children’s lives from unintentional injuries. Behaviour modification may be an essential part of such programmes. Evidence of the effectiveness of a number of interventions has recently been reviewed (5). Effective interventions include programmes to install smoke alarms to reduce the risk of fire and to fit window bars to stop deaths from falls, as well as supportive home visits which may facilitate behavioural or environmental changes that in turn lead to a reduction in hazards in the home. Child-resistant closings on packaging are highly effective in reducing the number of children’s deaths from poisoning: fatal episodes in the United Kingdom fell by 85% following their introduction. The installation of rubber or bark surfacing in playground areas has been associated with lower rates of childhood injuries.

A major finding of policy effectiveness assessments is that legislation, environmental modification and educational approaches all have a part to play in preventing or reducing childhood injuries, and their interactive effects are encouraging. Nevertheless, there should be closer examination of the effectiveness and cost-effectiveness of interventions across the range of injuries incurred by children, because some areas are under- or even unexplored. In this connection, WHO has recently highlighted key elements for the development of effective home safety strategies in order to create physically safer environments and reduce the number of unintentional injuries in the home (6).

Socioeconomic determinants play an important role in childhood injuries. For example, deprived families are more likely to live in poor neighbourhoods which are unsafe, to resort to unsafe behaviour such as poor supervision of children, to have less access to safety equipment such as fire alarms because of their cost, to be associated with risk factors such as harmful alcohol use, and to have poorer access to good emergency medical services (6).

Deaths due to unintentional injuries are only the tip of the iceberg: for each death in children aged 0–14 years from unintentional injuries at home or at leisure, there are estimated to be 160 hospital admissions and 2000 visits to emergency departments (7). Projecting this for drowning, poisoning, falls, fires and other injuries (excluding RTIs) in children aged 0-14 years at the European level suggests that they result in around 3 million hospital admissions and 37 million emergency department visits per year in this age group alone. Further, injuries can have long-term physical and psychological consequences for children, with serious effects on their health in later life (6). It is only in relatively recent years, however, that organized efforts have been made to improve the collection of data on non-fatal outcomes of injuries, notably by the development of the European Union (EU) injury database (8). Finally, there is need for further work on the cost to society of unintentional injuries so that the cost-effectiveness of action can be adequately assessed.

Policy relevance and context

The EU has several policy instruments, ranging from directives to non-legally binding standards and recommendations, which address unintentional injuries. These are presented and discussed in greater detail in ENHIS-2 fact sheet 2.6 on policies to reduce unintentional injuries from falls, drowning, poisoning and fires in children and adolescents (9), which also describes the current situation related to the implementation of policies on prevention of unintentional injuries in children in some European countries participating in the WHO Environment and Health Information System (ENHIS) project.

In 2004, the Fourth Ministerial Conference on Environment and Health adopted the CEHAPE, which includes four regional priority goals to reduce the burden of environment-related diseases in children. One of the goals (RPGII) aims to reduce mortality and morbidity from injuries, including from RTIs, and to ensure the provision of safe conditions which also facilitate more physical activity among children (3). Further, in 2006 the WHO Regional Committee for Europe adopted a resolution (RC55/R9) on the prevention of injuries in the Region (10).

Assessment

This indicator should be interpreted with some caution as the quality and completeness of the data probably vary between countries. Furthermore, the data only refer to one year, which is not necessarily indicative of the long-term situation. Even so, this indicator, in combination with that on policies to reduce unintentional injuries from falls, drowning, poisoning and fires in children and adolescents, is essential for monitoring this important problem in Europe. Unintentional injuries from drowning, poisoning, fires and falls remain a threat to children’s health and this indicator shows that further concerted action needs to be taken.

RTIs are the major cause of death (37%) from unintentional injuries in children and adolescents aged 0-19 years (4).

Accidental drowning and submersion (Fig. 1) is the second most important cause (15% of deaths), associated with an estimated 6854 deaths in 2002 (1). The highest mortality rates were evident in Kazakhstan, Kyrgyzstan, Latvia, the Russian Federation and Uzbekistan (Fig. 2A), where the rates are more than twice the European average (3.1 per 100 000 for 1–19-year-olds in 2003 (2). Rates were considerably lower in countries such as Italy, Slovenia and the United Kingdom.

Accidental poisoning (Fig. 1) is the third most important cause, implicated in 8% of deaths. Kazakhstan (Fig. 2B) had a rate five times higher than the European average (1.3 per 100 000 for 1–19-year-olds in 2003 (2). The data for Kazakhstan may, however, be more or less biased due to peculiarities in the coding of underlying causes. High rates were also evident in the Russian Federation and Ukraine.

Falls (Fig. 1) were implicated in 5% of deaths from unintentional injury in the group aged 0-19 years; the highest rates were seen in Belarus, Kazakhstan and the Russian Federation (Fig. 2C).

Exposure to smoke, fire and flames (Fig. 2D) is an important cause of death in children aged 1–19 years, notably in Azerbaijan, Belarus, Latvia and the Russian Federation, where the rates are more than twice the European average (0.9 deaths per 100 000 for 1-19-year-olds in 2003 (2). The lowest rates were seen in Armenia, the Czech Republic and Switzerland.

Overall, some of the intercountry differences observed may be due to the different attention given to safety, differing regulatory capacity, varying quality of housing and public building stock (particularly in view of the economic downturn experienced in some countries), and the loss of social safety networks in some countries undergoing economic and political transition.

Metadata

Name: Mortality in children and adolescents from unintentional injuries (falls, drowning, fires and poisoning)

Definition: Cause-specific child mortality rates per 100 000 population for unintentional injuries not related to traffic accidents

Code: RPG2_Hous_E1

Data source

European mortality database for age-specific and standardized rates (2)

Revised global burden of disease 2002 estimates (1).

Description of data

Cause-specific child mortality rates per 100 000 population for unintentional injuries, not related to RTIs, by sex and by age group.

Deaths are reported by countries every year from national registers of births and deaths. The national population estimates used by WHO are those of the United Nations Population Division 2002 revision (11).

Method for indicator calculation

Numerator: deaths stratified by: age, gender, unintentional injuries (ICD-10 codes below or equivalent ICD-9 codes):

• drowning (ICD 9 BTL: E521; ICD 10: W65–W74)
• falls (ICD 9 BTL: E50; ICD 10: W00–W19)
• burns (ICD 9 BTL: E51; ICD 10: X00–X09)
• poisoning (ICD 9 BTL: E48; ICD 10: X40–X49).

Denominator: total resident population stratified by: age, gender and socioeconomic status if available.

Data stratification specified in the methodology sheet: by male, female and total in the age groups <1, 1–4, 5–14, 15–24 and 1–19 years.

Age-standardized death rates are already calculated within the European mortality database released in January 2007, using the direct method and standard European population structure. Mortality rates have been calculated by the WHO Regional Office for Europe using the data on deaths by cause/age/sex and mid-year population by age/sex reported annually by the Member States.

Geographical coverage

The European mortality database should provide data for all 53 countries within the Region. Data are, however, missing for Andorra, Bosnia and Herzegovina, Monaco, Montenegro, San Marino, Serbia and Turkey. Belgium and Turkmenistan reported very old data (before 1998), which have not been considered in this fact sheet.

Period of coverage

For most of the countries in the Region, time series cover 1997–2004.

Frequency of update

Annually.

Data quality

These data should be interpreted with caution as there may be considerable differences in quality and completeness. Under-reporting or deaths attributed to incorrect underlying causes in some countries lead to the size of the problem being underestimated. Further, data presented in this fact sheet refer to only one year, which does not allow for possible annual fluctuations.

The quality and completeness of the data reported are still matters of concern, and improvements appear particularly necessary with respect to non-fatal outcomes of injuries.

For more information on meta data and calculation of this indicator, please refer to the methodology .

References

1. Revised global burden of disease (GBD) 2002 estimates [web site]. Geneva, World Health Organization, 2007 (http://www.who.int/healthinfo/bodgbd2002revised/en/index.html).
2. European mortality database [online database]. Copenhagen, WHO Regional Office for Europe, 2007 (http://www.euro.who.int/InformationSources/Data/20011017_1, accessed 6 April 2007).
3. Children’s Environment and Health Action Plan for Europe. Declaration. Fourth Ministerial Conference on Environment and Health, Budapest, 23–25 June 2004 (EUR/04/5046267/6; http://www.euro.who.int/document/e83335.pdf, accessed 16 March 2007).
4. WHO European Centre for Environment and Health. Mortality from road traffic injuries in children and young people. Copenhagen, WHO Regional Office for Europe, 2007 (ENHIS-2 fact sheet No. 2.1).
5. Health Evidence Network. How can injuries in children and older people be prevented? [web site] Copenhagen, WHO Regional Office for Europe, 2004 (http://www.euro.who.int/HEN/Syntheses/injuries/20041016_1, accessed 7 April 2007).
6. Sethi D et al. Injuries and violence in Europe. Why they matter and what can be done. Copenhagen, WHO Regional Office for Europe, 2006 (www.euro.who.int/document/E88037.pdf, accessed 7 April 2007).
7. Rogmans W. Les accidents domestiques et de loisirs des jeunes de moins de 25 ans dans l’Union europeenne: defies pour demain. Santé publique, 2000, 12:283–298.
8. EU injury database [online database]. Brussels, European Commission, Directorate-General for Health and Consumer Protection, 2006 (https://webgate.cec.eu.int/idb, accessed 7 April 2007).
9. WHO European Centre for Environment and Health. Policies to reduce unintentional injuries from falls, drowning, poisoning and fires in children and adolescents. Copenhagen, WHO Regional Office for Europe, 2007 (ENHIS-2 fact sheet No. 2.6).
10. WHO Regional Committee for Europe resolution EUR/RC55/R9 on prevention of injuries in the WHO European Region. Copenhagen, WHO Regional Office for Europe, 2006 (http://www.euro.who.int/Governance/resolutions/2005/20050922_1, accessed 8 April 2007).
11. World population prospects. The 2002 revision. New York, United Nations, Population Division, 2003 (http://www.un.org/esa/population/publications/wpp2002/WPP2002-HIGHLIGHTSrev1.PDF, accessed 8 April 2007).

Authors: Adriana Galan, Institute of Public Health, Bucharest, Romania; Sara Farchi, Public Health Agency of Lazio Region, Rome, Italy.

This summary presents an assessment of the estimated radon levels and proportion of dwellings with annual mean levels of radon above 400 Bq.m^-3 for existing dwellings and above 200 Bq.m^-3 for future dwellings in 11 European countries.

Key message

Average radon levels in dwellings vary widely within and between countries. In most countries the world average of 40 Bq.m^-3 is exceeded (1). Countries with mainly sedimentary soils (e.g. Germany, the Netherlands, Poland and the United Kingdom) present lower or equivalent averages, whereas those with old granite soils (e.g. Austria, the Czech Republic and Finland) are more prone to radon emissions. If a common action level of 200 Bq.m^-3 were to be defined, Austria, the Czech Republic and Finland would have to take remedial measures for more than 10% of the houses, as against under 3.5% in countries with sedimentary soil.

Figures

Presentation of data

Fig. 1 shows the estimated arithmetic mean of indoor radon in each country, based on a review of national surveys carried out by the European Commission Joint Research Centre (JRC). There is almost 10 times the difference between the minimum (20 Bq.m^-3), found in the Netherlands and the United Kingdom, and the maximum (120–140 Bq.m^-3) reported for the Czech Republic and Finland. The maps also display those countries with insufficient or unreliable data.

Fig. 2 and 3 show the percentage of radon measurements higher than 200 Bq.m^-3 and 400 Bq.m^-3. The countries with the highest mean radon levels also have the highest percentage of housing stock above these levels, indicating a higher proportion of houses requiring remedial action.

Fig 1. Estimated annual mean radon levels in dwellings, selected European countries

Source: Dubois (2).

Fig. 2. Estimated proportion of dwellings with radon levels ≥200 Bq.m^-3, selected European countries

Source: Dubois (2).

Fig. 3. Estimated proportion of dwellings with radon levels ≥400 Bq.m^-3, selected European countries

Source: Dubois (2).

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Rationale

The presence of radon in dwellings is an important indicator of the exposure of the population at the beginning and in the course of the process of reducing indoor radon. Considering the linear exposure/response relationship between radon and lung cancer risk, the arithmetic mean is the most relevant indicator to assess the impact on public health.

The radon action levels of 200 and 400 Bq.m-3 allow for international comparisons, since most of the countries comply with the European guideline of 400 Bq.m^-3 for existing houses and 200 Bq.m^-3 for future dwellings.

The 200 Bq.m^-3 measurement enables a reliable comparison of the proportion of houses that exceed this level in different geographical areas since it is less sensitive to variability from the size of the samples than the 400 Bq.m^-3 measurement.

Health and environment context

Radon is a radioactive gas coming from soils (mainly granites) and accumulating in houses. Radon concentration in air is measured as the number of transformations per second in a cubic metre of air (Bq.m^-3). One Becquerel corresponds to the transformation (disintegration) of one atomic nucleus per second.

Radon contributes up to 40% of the dose of ionizing radiation received by the population. Studies of cohorts of uranium miners clearly show a linear relation between exposure to radon and risk of lung cancer (3,4). This relation is modified by age, time since exposure and duration of exposure. Pooled analyses of key studies in China, Europe and North America have confirmed that radon in homes contributes substantially to the occurrence of lung cancers worldwide. On the basis of these studies, the International Agency for Research on Cancer (IARC) and the US National Toxicology Program have classified radon as a human carcinogen. There is also discussion of plausible leukemogenicity of radon (5).

Recent findings from case-control studies on lung cancer and exposure to radon in homes completed in many countries allow for substantial improvements in risk estimates and, by pooling the studies, for further consolidation of knowledge. The consistency of the findings from the latest European and North American pooled studies clearly points to a need for global action (6,7). The recent pooled analysis of key European studies estimated that the risk of lung cancer increases by 16% per 100 Bq.m^-3 increase in radon concentration. The dose–response relation seems to be linear without evidence of a threshold, meaning that the lung cancer risk increases proportionally with increasing radon exposure. Furthermore, the new results show that if a threshold exists, it should not be higher than 150 Bq.m^-3.

With these results and an estimated exposure mean for 29 European countries of 59 Bq.m^-3, 9% of deaths from lung cancer per year in Europe were estimated to be attributable to exposure to indoor radon. The pooling studies agree on the magnitude of the risk estimates.

In order to reduce the disease burden associated with radon, it is important that national authorities use methods and tools based on solid scientific evidence and sound public health policy. Mapping and distribution indicators can help to assess the level of burden yet to be expected for radon effects. Most countries have adopted national radon programmes to identify zones of higher concentration and provide information to the public.

On the base of the new epidemiological results, WHO has developed a programme on public health aspects of radon exposure (8). This project is one of the high priority activities of the WHO radiation programme.

Policy relevance and context

There is no regulation or directive in Europe concerning radon. Instead, in 1990 the European Commission issued recommendation 90/143/Euratom on the protection of the public against indoor exposure to radon. This recommendation defined 400 Bq.m^-3 as the level for considering remedial action in existing dwellings and 200 Bq.m^-3 as the reference level for new dwellings (9). It has served as a reference for the development of policies against radon exposure in many countries. Although the recommendation sets the framework policy on indoor radon, there are diverse approaches in Europe: some countries do not have any regulations and many others have adopted an indoor radon level within the range 200–400 Bq.m^-3 as the level for action or the reference level for new buildings. Only a few responsible authorities have developed detailed legislation specifying levels above which financial support for mitigation can be provided.

Radon levels in indoor air can be lowered in a number of ways, from sealing cracks in floors and walls to increasing the ventilation rate of the building. Under-floor sump and extraction methods are considered to be the most efficient. Prevention of radon exposure in new buildings can be implemented through appropriate provisions in the construction phase. National building codes cover the issue of exposure to natural radiation in building construction and ventilation sections.

In addition, all European Union member states already have or are drawing up provisions for implementing basic safety standards for the health protection of the general public, and workers in particular, in case of a significant increase in exposure due to natural radiation sources (including radon) in work places, as laid down in Title VII of Council Directive 96/29/Euratom (10).

In 2006, the JRC launched the Radioactivity Environmental Monitoring (REM) project (11) with the aim of improving the collection, evaluation and harmonization of environmental radioactivity concentrations and the modelling of the migration of radioactivity in the environment. A central activity of REM is the monitoring and mapping of indoor radon (12).

In 1995, WHO set up the International Radon Project (8) in which over 20 countries have formed a network of partners to identify and promote programmes that reduce the health impact of radon. The Project will review recommendations for levels of action and provide evidence-based recommendations for radon policies and radon programmes in countries. The project will also develop tools for radon communication.

Assessment

There are clearly huge differences between countries in terms of exposure to radon in dwellings in Europe. Countries with mainly sedimentary soils have low radon gas concentrations indoors. In our sample this concerns Germany, the Netherlands, Poland and the United Kingdom. Countries with large amounts of granite or uranium-rich soils generally have very high levels of radon.

The wide variations also lead to very different health impacts in countries. As mentioned before, the overall estimate of lung cancer that can be attributed to radon is approximately 9% for Europe. Based on the methodology used in the European pooling study, attributable risk estimates range from about 3% of lung cancer deaths in the Netherlands or the United Kingdom to 21% in the Czech Republic. The public health gain due to remedial action for levels above 200 Bq.m^-3, as well as the cost–effectiveness of such action, would also differ greatly between countries.

At present it is impossible to assess the time trends of radon. Improvements in insulation techniques in the context of energy crises may have in fact led to an increase in radon levels in dwellings. Action programmes to reduce radon levels in old and new dwellings may have led to a reduction below certain guidelines, or to changes in radon distribution. The current indicator could serve as a starting point for making an initial assessment at the outset of radon programme activities.

The estimated arithmetic mean in regions or countries would be a good indicator in following up modifications to buildings or other activities aimed at lowering radon levels in dwellings. Monitoring of the proportion of dwellings with radon levels above the point at which action is required will enable the effectiveness of programmes targeted at extreme levels to be evaluated.

The indicator provides a good picture of the discrepancy concerning radon problems between countries and of the proportion of dwellings with levels above the European guidelines. It thus serves a baseline reference for future comparison. Countries with continuing radon programmes can use the information as interim monitoring results.

Metadata

Name: Radon levels in dwellings

Definition: Estimated annual mean of radon levels in dwellings and proportion of dwellings with levels above 200 Bq.m^-3 and 400 Bq.m^-3

Code: RPG4_RadEx1

Data source

The information comes from the JRC campaign to collect nationally available information for radon mapping in 34 European countries. The focal points in the country institutions in the relevant radon areas answered a questionnaire produced by the JRC. More information about the database used for each country is available on the European Forum on Radon Mapping web site (12).

Description of data

The indicator consists of a presentation per country of three important key values of the distribution of annual radon level in dwellings:

• estimated arithmetic mean of radon concentration
• estimated percentage of dwellings with annual mean levels of radon above 200 Bq.m^-3
• estimated percentage of dwellings with annual mean levels of radon above 400 Bq.m^-3.

Method for indicator calculation

The estimated values are given by institutions which deal with indoor radon and maintain information about radon distribution over the country. The survey reference has been quoted as well as its period, the number of dwellings concerned and the method of sampling (Table 1).

Note: In the United Kingdom, around 500 000 dwelling measurements have been taken but they were not random and are not used as reference data for the assessment of radon distribution in dwellings.

Geographical coverage

Austria, the Czech Republic, Finland, France, Germany, Hungary, the Netherlands, Poland, Romania, Spain and the United Kingdom.

Period of coverage

The data were collected in 2005 but the results concern widely differing periods between countries.

Frequency of update

Not specified yet.

Data quality

It is important to stress that the radon measurements were not made with a standardized protocol in all countries. In some countries the sample was selected randomly on a national basis, so that the results can be directly extrapolated in order to generate estimates. In others, the samples were not randomly selected and corrections were needed to estimate the radon distribution. Some countries relied on information from regional campaigns and did not give precise descriptions of the methodology used to assess the estimated distribution. Direct comparisons between results are, therefore, to be viewed with great caution.

Radon levels are susceptible to change with modifications to buildings or the renewal of the building stock, or the efficiency of regional or national action programmes. Regular national surveys or targeted surveys of new buildings or buildings of concern are, therefore, necessary to assess the evolution or efficiency of a policy. Coordination between countries is necessary to promote the use of national (and/or regional) survey protocols with a minimum set of standard criteria allowing for direct comparisons. Furthermore, as radon levels are strongly linked to local geological characteristics, the ideal scale to assess and compare radon distribution would be the regional one. Regional mapping based on a standardized assessment protocol could be an excellent tool for making comparisons.

For more information on meta data and calculation of this indicator, please refer to the methodology .

Table 1. Sampling table

Note: In the United Kingdom, around 500 000 dwelling measurements have been taken but they were not random and are not used as reference data for the assessment of radon distribution in dwellings

References

1. Report of the United Nations Scientific Committee on the Effects of Atomic Radiation. New York, United Nations, 2000 (http://daccessdds.un.org/doc/UNDOC/GEN/N00/587/20/IMG/N0058720.pdf?OpenElement, accessed 4 April 2007).
2. Dubois G. An overview of radon surveys in Europe. Luxembourg, Office for Official Publications of the European Communities, 2005 (EUR 21892 EN).
3. Lubin J, Boice JD, Edling JC et al. Radon and lung cancer risk: A joint analysis of 11 underground miner studies. Bethesda, MD, US National Institutes of Health, 1994.
4. Lubin JH, Boice JD, Edling C et al. Radon-exposed underground miners and inverse dose-rate (protraction enhancement) effects. Health Physics, 1995, 69:494-500.
5. Belson M, Kingsley B, Holmes A. Risk factors for acute leukemia in children: a review. Environmental Health Perspectives, 2007, 115:138-145.
6. Darby S et al. Radon in homes and risk of lung cancer: collaborative analysis of individual data from 13 European case-control studies. British Medical Journal, 2005, 330(7485):223.
7. Krewski D et al. Residential radon and risk of lung cancer: a combined analysis of 7 North American case-control studies. Epidemiology, 2005, 16(2):137-145.
8. International Radon Project [web site]. Geneva, World Health Organization, 2007 (http://www.who.int/ionizing_radiation/env/radon/en/, accessed 4 April 2007).
9. Commission recommendation on the protection of the public against indoor exposure to radon (90/143/Euroatom). Brussels, Commission of the European Communities, 1990 (http://ec.europa.eu/energy/nuclear/radioprotection/doc/legislation/90143_en.pdf, accessed 4 April 2007).
10. Council Directive 96/29/Euratom laying down basic safety standards for the protection of the health of workers and the general public against the dangers arising from ionizing radiation. Brussels, Commission of the European Communities, 1996 (http://ec.europa.eu/energy/nuclear/radioprotection/doc/legislation/9629_en.pdf, accessed 4 April 2007).
11. Radioactivity Environmental Monitoring project [web site]. Brussels, European Commission, Joint Research Centre, 2006 (http://rem.jrc.cec.eu.int/, accessed 4 April 2007).
12. European Forum on Radon Mapping [web site]. Brussels, European Commission, Joint Research Centre, 2005 (http://radonmapping.jrc.it/index.php?id=36, accessed 4 April 2007).

Radon and cancer. Geneva, World Health Organization, 2005 (Fact sheet No. 291; http://www.who.int/mediacentre/factsheets/fs291/en/ , accessed 4 April 2007).

For this indicator, a feasibility study has been carried out: HIA for Exposure to radon in dwellings during childhood

Author: Philippe Pirard, National Institute of Public Health Surveillance, Paris, France.

This summary presents the proportion of children living in homes where solid fuel is used for cooking and heating. It provides information about related health risks, the policy relevance and context and an assessment of the situation in the WHO European Region. Suggestions for further monitoring and information on underlying data are also provided.

Key message

Solid fuel use in homes in the 52 Member States of the WHO European Region in 2004 varied from below 5% to over 70%, even though the regional average of 16% was relatively low compared with other regions. The geographical pattern shows a gradual increase from west to east of the Region. Studies suggest that the WHO Air Quality Guideline limit of 20 μg/m3 for annual PM10 (1) is exceeded in most homes where solid fuel is used, pointing to a substantial public health problem in the Region.

Figures

Presentation of data

Fig. 1 presents the value of the indicator for the latest available year for the European Member States plus Liechtenstein. It is assumed that exposure to solid fuel combustion among children is equal to the exposure among the total population.

Fig. 1. Proportion of children aged 0−14 years living in homes using solid fuels, WHO European Region plus Liechtenstein, 2004

Note. The actual proportion of children aged 0−14 years living in homes where solid fuels are used is under 5% in Andorra, Austria, Belgium, Cyprus, the Czech Republic, Denmark, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Israel, Italy, Kazakhstan, Liechtenstein, Lithuania, Luxembourg, Malta, Monaco, the Netherlands, Norway, Poland, Portugal, San Marino, Slovakia, Spain, Sweden, Switzerland, Turkmenistan and the United Kingdom.

Source: World health statistics (2).

Download Excel sheet with Figure Data

Rationale

The indicator provides a general measure of exposure to pollutants from indoor combustion sources, in particular with respect to fine particles. In terms of children’s health, epidemiological studies demonstrate that the risk for child morbidity and mortality due to pneumonia is higher in households that use solid fuel than in households using liquid or gaseous fuels.

Health and environment context

Cooking and heating with solid fuels, such as dung, wood, agricultural residues, grass, straw, charcoal and coal, is a major source of indoor air pollution. The indoor smoke comprises a variety of health-damaging pollutants, such as particles (complex mixtures of chemicals in solid form and droplets), carbon monoxide, nitrogen oxides, sulfur oxides, formaldehyde and carcinogens, such as benzo[a]pyrene and benzene. Small particles with a diameter of 10 µm or less (PM10) are able to penetrate deep into the lungs. The smallest particles with a diameter of 2.5 µm or less (PM2.5) appear to have the greatest health-damaging potential.

Combustion of solid fuels in inefficient stoves under poor ventilation conditions can result in large exposure burdens, particularly for women and young children who spend the major part of their time in the home (3). Of 1.6 million deaths globally related to indoor air pollution from the use of solid fuel, 52% are in children aged under five years. There is consistent evidence that exposure to indoor air pollution increases the risk of pneumonia among children in this age group, and chronic respiratory disease and lung cancer (in relation to coal use) among adults aged over 30 years (4).

There is some evidence for associations between biomass smoke and lung cancer, asthma, cataracts and tuberculosis. On the basis of the few available studies there is suggestive evidence of a link between indoor air pollution and adverse pregnancy outcomes, in particular low birth weight. Tentative evidence exists for associations with ischaemic heart disease and cancers of the nose and throat (5).

While the precise mechanism of how exposure causes disease is still unclear, it is known that small particles and several of the other pollutants contained in indoor smoke cause inflammation of the airways and lungs and impair the immune response. Carbon monoxide also results in systemic effects by reducing the oxygen-carrying capacity of the blood. Other components of indoor air pollution can cause healthy cells to mutate into cancerous ones.

Policy relevance and context

In September 2000, the World Summit of Heads of State established the Millenium Development Goals (MDGs) (6) with the overall objective of encouraging healthy and prosperous development around the world. The seventh MDG calls for environmental sustainability. Within this context WHO has identified the "proportion of the population using solid fuels for cooking" as an indicator for assessing progress towards the integration of the principles of sustainable development into country policies and programmes. In addition, indoor air pollution as a consequence of household energy problems is linked to the achievement of other MDGs, in particular those for reducing child mortality (Goal 4) and improving maternal health (Goal 5).

The WHO European Member States have declared that they will aim to substantially reduce morbidity and mortality from acute and chronic respiratory disorders (7). They plan to do so through developing indoor air quality strategies that take into account the specific needs of children and improving access to healthier and safer heating and cooking systems.

Measures to reduce indoor air pollution and associated health effects range from switching to cleaner alternatives, such as gas, electricity, solar energy or modern biofuels, to improving stoves or hoods that vent health-damaging pollutants to the outside, to changing behaviour patterns. There is an urgent need to investigate the real scale of the problem in Europe and to promote successful and sustainable interventions accordingly.

Assessment

All assessments are based on the indicator as defined for the MDG: percentage of the population using solid fuels. Not all countries have conducted surveys of energy use for cooking and heating. Where no data are available, the indicator is modelled; countries with a gross national income of more than US$ 10 500 are assumed to have made an almost complete transition to cleaner cooking fuels (less than 5% solid fuel use).

According to the WHO regional assessment of the burden of disease related to the use of solid fuels carried out at WHO headquarters in 2006 with health data from 2002, the highest burden lies on children aged under five years living in Eur-B countries (5). The lower number of disability-adjusted life-years (DALYs) per 100 000 in 2006 estimations in Eur-C countries is related to more accurate data on solid fuel use in homes which become available from national surveys.

Taking into account the model that has been applied for estimation, findings would suggest that indoor air pollution from solid fuel combustion is a public health problem in some areas of the Region. The scale of the problem is difficult to ascertain due to the fact that the data reported by many Member States, in particular those in the Eur-C sub-region, do not show the use of solid fuel at household level. However, the estimates that take into account sociodemographic and economic parameters result in noticeable use rates. The projected use of solid fuels in households is higher in the eastern countries than in the west.

In line with the indicator, a burden of disease study was conducted in 2005 which looked at indoor air pollution caused by the use of solid fuels in households (8). This study, which was based on a number of assumptions, provides an estimate of the probable exposure rate to indoor air pollution from solid fuels in the WHO regions. For many of the regions (including the European Region) the exposure data were statistically modelled and all the calculations obtained are, therefore, estimates. According to this study, the estimated burden in the European Region is the highest in the Eur-B sub-region countries (Table 1). The WHO epidemiological sub-regions are defined by geographic location and patterns of child and adult mortality (9).

Table 1. Estimated burden of acute lower respiratory infections in children aged under five years attributable to use of solid fuels at home, 2004 and 2006

^a Serbia and Montenegro became two separate Member States of WHO in September 2006. In this fact sheet the data refer to before that date and relate to the then one country of Serbia and Montenegro.

This indicator should be interpreted with caution, due to the inherent problems associated with the methodology and data used. The indicator does not take into account factors such as stove type, ventilation and behaviour, which are likely to affect exposures and health outcome. Additionally, health outcomes may be confounded by other factors such as socioeconomic status or age.

Metadata

Name: Proportion of children living in homes using solid fuels

Definition: Percentage of children aged 0-4, 5-9 and 10-14 years living in households using coal, wood or dung as the main source of heating and cooking fuel

Code: RPG3_ Hous_Ex3

Data source

World health statistics (2)

Indoor air pollution (10)

Population data: EUROSTAT (11)

Description of data

Data are based on international surveys (e.g. Demographic and Health Surveys, the World Health Survey), censuses and national energy statistics.

Method for indicator calculation

Percentage of general population using solid fuels.

Average population by country and five-year age groups.

The indicator is computed as simple percentages: 100 × Csolid/Ctot, where Csolid is the number of children living in households using coal, wood or dung as the main source of cooking/heating fuel in a given age group, and Ctot is the total number of children in the same age group.

Geographical coverage

Data are available for 52 countries of the WHO European Region. The data for Andorra, Austria, Belgium, Cyprus, the Czech Republic, Denmark, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Israel, Italy, Kazakhstan, Lithuania, Luxembourg, Malta, Monaco, the Netherlands, Norway, Poland, Portugal, San Marino, Slovakia, Spain, Sweden, Switzerland, Turkmenistan and the United Kingdom are estimates.

Period of coverage

A single year (based on current data).

Frequency of update

Depends on availability of new data.

Data quality

Current limitations in the definition and reporting of the indicator should be overcome in order to improve accuracy in estimating health and other impacts and to provide a better basis for designing interventions. At present, data are compiled on a country-by-country basis from different sources. For the majority of the countries this is done through various surveys and censuses. In other countries data come from models using parameters such as proportion of people living in rural areas and the gross national income for the year corresponding to the data surveyed. For upper-middle or high-income countries with a gross national income of more than US$ 10 500 per capita in 2003, the proportion of the population using solid fuels is assumed to be less than 5%. Efforts must continue to improve regular data collection through relevant international and national surveys, such as the Demographic and Health Survey (12), the World Bank Living Standards Measurement Study (13), the United Nations Children’s Fund’s Multiple Indicator Cluster Survey (14), the World Health Survey (15) and national censuses by integrating additional questions on type of cooking stove and kitchen characteristics as well as heating and ventilation practices. Furthermore, given the stark contrast between urban and rural populations, household energy practices should be disaggregated according to place of residence (4).

For more information on meta data and calculation of this indicator, please refer to the methodology .

References

1. Air quality guidelines for Europe, 2nd ed. Copenhagen, WHO Regional Office for Europe, 2000 (WHO Regional Publications, European Series, No. 91; http://www.euro.who.int/air/activities/20050223_3, accessed 2 March 2007).
2. World health statistics 2006. Geneva, World Health Organization, 2007 (http://www.who.int/whosis/whostat2006.pdf, accessed 26 March 2007).
3. Mehta S et al. Modeling household solid fuel use towards reporting of the Millennium Development Goal indicator. Energy for Sustainable Development, 2006, 10(3):36–45 (http://www.who.int/indoorair/mdg/esdmodellingsolidfueluse.pdf, accessed 26 March 2007).
4. Indoor air pollution and health. Geneva, World Health Organization, 2005 (fact sheet No. 292; http://www.who.int/mediacentre/factsheets/fs292/en/index.html, accessed 26 March 2007).
5. Rehfuess E, Mehta S, Prüss-Üstün A. Assessing household solid fuel use: multiple implications for the Millennium Development Goals. Environmental Health Perspectives, 2006, 114(3):373–378 (http://www.ehponline.org/members/2006/8603/8603.html, accessed 26 March 2007).
6. Millennium Development Goals Report 2006. New York, United Nations, 2006 (http://mdgs.un.org/unsd/mdg/Resources/Static/Products/Progress2006/MDGReport2006.pdf, accessed 27 March 2007).
7. Children’s Environment and Health Action Plan for Europe. Declaration. Fourth Ministerial Conference on Environment and Health, Budapest, 23–25 June 2004 (EUR/04/5046267/6; http://www.euro.who.int/document/e83338.pdf, accessed 26 March 2007).
8. Smith KR, Mehta S, Maeusezahl-Feuz M. Indoor air pollution from household use of solid fuels. In: Ezzati M et al., eds. Comparative quantification of health risks: global and regional burden of disease attributable to selected major risk factors, Vol. 2. Geneva, World Health Organization, 2004:1435-1493 (http://ehs.sph.berkeley.edu/krsmith/publications/Chapt 18 IAP from Soid Fuels.pdf, accessed 28 March 2007).
9. The world health report 2002 – reducing risks, promoting healthy life. Geneva, World Health Organization, 2002 (http://www.who.int/whr/2002/en/, accessed 26 March 2007).
10. Indoor air pollution [web site]. Geneva, World Health Organization, 2007 (http://www.who.int/indoorair/en/, accessed 26 March 2007).
11. EUROSTAT [web site]. Brussels, EUROSTAT, 2007 (http://epp.eurostat.ec.europa.eu, accessed 26 March 2007).
12. Demographic and health survey [web site]. Calverton, MD, Measure DHS, 2007 (http://www.measuredhs.com, accessed 26 March 2007).
13. Living standards and measurement survey [web site]. New York, World Bank, 2007 (http://www.worldbank.org/LSMS, accessed 26 March 2007).
14. End decade assessment. Multiple cluster interview survey [online database]. New York, United Nations Children’s Fund, 2007 (http://www.childinfo.org/MICS2/Gj99306k.htm, accessed 26 March 2007).
15. World health survey [web site]. Geneva, World Health Organization, 2007 (http://www.who.int/healthinfo/survey/en/index.html, accessed 26 March 2007)

Fuel for life: Household energy and health. Geneva, World Health Organization, 2006 (http://www.who.int/indoorair/publications/fuelforlife/en/, accessed 26 March 2007).

Study on environmental burden of disease in children: key findings. Copenhagen, WHO Regional Office for Europe, 2004 (Fact Sheet EURO/05/04; http://www.euro.who.int/document/mediacentre/fs0504e.pdf, accessed 15 March 2004).

Authors: Momchil Sidjimov, National Centre for Public Health Protection, Sofia, Bulgaria; Ingrida Zurlytė, State Environmental Health Centre, Vilnius, Lithuania.

This summary is based on self-reported data collected by EUROSTAT on the proportion of households with problems of damp (1, 2). It also contains information on the environment and health context, the policy relevance and context, and an assessment of the situation in the WHO European Region.

Key message

In European countries, exposure to damp in the home varies greatly, ranging between 4% and 40%. In some countries for which data is available over a wider time span, the prevalence of damp homes has slightly increased, but in general there is rather a trend towards exposure reduction.

Differences between countries may be due to a combination of factors including climate characteristics, socioeconomic status, housing characteristics, culture and lifestyle and the existence and effectiveness of related policies (e.g. on ventilation or thermal insulation). Children are particularly susceptible to the health effects of damp, which include respiratory disorders such as irritation of the respiratory tract, allergies and exacerbation of asthma.

Figures

Presentation of data

Fig. 1 shows the proportion of the population in selected European countries living in homes with self-reported problems of damp for 1995, 2001 and 2006. 1995 and 2001 data are based on the EUROSTAT ECHP survey (voluntary survey for the EU 15 between 1995 and 2001), while data for 2006 are based on the ongoing EUROSTAT SILC survey (mandatory for all EU member states with voluntary participation of Norway and Iceland).

Fig. 2 shows the impact of tenure on the perception of damp, based on data from selected European countries for 1997 (ECHP data). More people living in rented accommodation reported problems of damp than home owners. This difference has been found in many surveys of damp and may (to an extent not yet quantified) relate to the responsibility for interventions rather than the real exposure. Data for 2006 will be added as soon as available from SILC.

Fig. 1. Proportion of the total population living in homes with self-reported problems of damp, 1995–2006

1995, 2001: ECHP; 2006: SILC

Source: EUROSTAT ECHP (European Community Household Panel) (1) and EUROSTAT SILC (Statistics on Income and Living Conditions) (2). Date of extraction: 30 September 2008.

Fig. 2. Self-reported problems of damp in the home by housing tenure, 1997

Source: EUROSTAT ECHP (1)

Download Excel sheet with data of the figures

Rationale

This indicator provides an estimate of the proportion of households exposed to damp. The data are not child-specific, and as they are based on household’s reports of such problems, they serve only as an indication of the scale of the problem. International comparisons are difficult and the main message can be derived from trends in national data rather than variations between countries. Exposure to damp in the home is an important risk factor for a number of illnesses, particularly respiratory illnesses; and an indication for the risk of mould growth which may trigger serious health effects as well..

Health and environment context

Dampness and thermal/humidity conditions are of particular concern in European countries with temperate and damp climates. The number of people, activities such as cooking, laundering and bathing, the use of certain fuels for heating and cooking, the indoor temperature and especially the degree of ventilation all affect the amount of water vapour in indoor air. Water leakage due to structural damage may contribute to damp as well.

Damp inside the home induces the growth of moulds, dust mites and various microbial agents and, at the correct temperature, may initiate chemical reactions leading to the release of chemicals from building materials and furnishings. Mould and damp are important risk factors for a variety of illnesses, particularly those of the respiratory and immune systems. Generally, there are four kinds of health problems: allergic illness, irritation of the respiratory tract, infection and toxicological effects. For people that are sensitive to moulds, symptoms such as nasal irritation or congestion, dry or productive cough, wheezing, skin rashes or burning, watery or reddened eyes may occur. Sufferers of severe allergies to moulds may have more serious reactions, such as hay-fever-like symptoms or shortness of breath. Moulds can also trigger asthma attacks in persons with asthma. Individuals with chronic illnesses or those with immune deficiencies are more likely to develop infections from certain moulds.

WHO has concluded that the strongest evidence exists for the association of damp with cough, wheeze and asthma (3). Children, who tend to spend more time than adults in their homes and whose immune systems are still developing, are at increased risk of developing respiratory disorders when living in damp, mouldy housing. The prevalence of asthma, cough and wheezing among children living in homes with problems of damp or mould is 1.4–2.2 times higher than among children living in drier housing conditions (3). According to the currently available evidence, 13% of childhood asthma in the developed countries could be attributable to dampness (4).

Other illnesses associated with exposure to indoor damp include bronchial obstruction, bronchitis, persistent allergic rhinitis and eczema (5-8).

It has been suggested that damp is associated with mental health problems and other types of illness. Depression and the presence of general symptoms such as fatigue, headache, dizziness and difficulty concentrating have been linked to damp, mouldy living conditions (9).

This exposure indicator is closely connected with other housing quality indicators and their effects. Damp is often associated with poor housing and social conditions, poor indoor air quality and inadequate housing hygiene, which includes factors such as overcrowding, low air exchange rate, low indoor temperature and poor insulation. All these factors influence health status.

Reduction of mould and damp in housing can be achieved by a policy framework describing the components and implementation of national plans, and through strengthening the requirements for building standards. Financial incentives and supporting instruments are necessary for the implementation of effective interventions such as the rehabilitation of housing stock.

WHO Guidelines on damp and mould have been suggested, providing both an ovverview of potential health risks of dampo and mould, and a set of recommendations on prevention and mitigation (10).

Policy relevance and context

In 2004, the Fourth Ministerial Conference on Environment and Health adopted the Children’s Health and Environment Action Plan for Europe (CEHAPE), which includes four regional priority goals to reduce the burden of environment-related diseases in children. One of the goals (RPG III) aims at preventing and reducing respiratory diseases due to outdoor and indoor air pollution, thus contributing to a reduction in the frequency of asthmatic attacks and ensuring that children can live in an environment with clean air (11).

Several initiatives, action programmes and declarations within the framework of the United Nations Human Settlements Programme (UN-HABITAT) coordinate international bodies in their efforts to reach the United Nations’ Millennium Declaration. This is achieved by promoting human development as the key to sustaining social and economic progress in all countries.

In January 2006, the EU Stability Pact for South Eastern Europe implemented a cooperation agreement with UN-HABITAT to improve social housing and urban development across the Region (12). This agreement will contribute to economic growth and help countries in the Region achieve essential reforms.

In European countries the problems with damp housing have been addressed partly by technical building codes (usually only applicable to new buildings) and partly by hygiene requirements aiming to ensure that conditions are not hazardous to life, although these frequently fail to include a requirement for protection against excessive humidity.

In addition, many European countries have public health services that carry out health inspections of dwellings according to specific guidelines. In general, existing policies aim to ensure habitable and healthy housing conditions but do not include specific health promotion objectives. Portugal, with one of the higher rates of damp housing according to EUROSTAT, has developed a project on housing and health action plans as a national follow-up to the Fourth Ministerial Conference on Environment and Health (13). This project will enable all the municipalities to develop their own plans, based on a national action plan document. Finland, one of the countries with the lowest exposure to damp housing, addresses dampness in its Land Use and Building Act (132/1999), section 13: Building Codes D2 Indoor Climate and Ventilation of Buildings (2003) (14). The United Kingdom has recently developed a Housing Health and Safety Rating System in which residential buildings are evaluated on the basis of their risk to health, with damp and mould being one of the major issues addressed (15).

The differences between countries may, to some extent, be due to the existence and implementation of policies for preventing damp in homes. The responsibility for avoiding or reducing damp is largely left to the individual or household. With free housing markets, households that are vulnerable due to socioeconomic status are likely to be at risk, as they will be restricted to low-quality housing and be likely to suffer from greater problems.

An additional risk factor for damp and mould has emerged in recent years with the trend towards energy efficiency in the housing stock, leading to more tight houses and - especially in rehabilitated buildings - the reduction of air exchange rates which may result in increased indoor pollution and dampness problems.

Assessment

The assessment of national data is difficult as country data is available for different time periods. For the old EU members (EU 15), the indicator shows a trend towards a decreasing exposure to damp in most of the countries with data, but this does vary strongly between countries and for some countries, the prevalence did increase in 2006. For the new EU members (and Norway / Iceland), data has only been collected by SILC so no trend can be given. However, the data for 2006 show that the eastern European members of the EU have on average much higher number of damp homes than the old members.

Children are more susceptible than adults to exposure to indoor air pollution, including moulds and bacteria which are increased by excessive damp (16,17). Good evidence to support this is available from a number of studies in Finland, Germany, Italy and Sweden which have focused on asthma and allergic symptoms among small children and their parents (18–20).

The lack of binding policies on housing standards, combined with the large number of organizations and authorities responsible for housing policy, make the rehabilitation of housing stock a challenge. In this context, international forums should support the development and implementation of national intersectoral policies on specific action aimed at improving the housing stock. In non-EU countries there is a need for standardized procedures to collect these data.

Metadata

Name: Homes with problems of damp

Definiton: Data on the exposure of the population to damp in the home

Code: RPG3_Hous_Ex2

Data source

EUROSTAT ECHP database, specifically the variable on housing problems with damp (1); and EUROSTAT SILC database, variable HH040 on damp problems in housing (2).

Description of data

Data on exposure to damp in the home were routinely collected through EUROSTAT by the ECHP from 1995 until 2001 (EU countries participated voluntarily). Since 2004, new data are available based on the new framework regulation EU Statistics on Income and Living Conditions (EU-SILC), which is mandatory for all EU countries and provides data in a similar format (percentage of population living in damp housing). For comparison reasons, the years 1995, 2001 and 2006 have been selected.

Method for indicator calculation

Original data provided by EUROSTAT.

Geographical coverage

For ECHP data: voluntary participation of countries belonging to the EU before May 2004. For SILC data: all EU countries (with Romania and Bulgaria starting data collection in 2007) and Norway / Iceland.

Period of coverage

For ECHP data: 1994–2001.

For SILC data: 2004 and continuing.

Frequency of update

Annual, although access to the data may be delayed.

Data quality

Weaknesses: both the ECHP and EU-SILC data rely on subjective assessments made by residents and are not, therefore, scientifically accurate. No direct link to health effects can be made and only EU countries are included. Finally, international comparisons may suffer from many influencing factors and therefore be limited. Although the SILC survey tool was developed using ECHP question formats, there may stil be some method-related data variations for individual countries so comparison of ECHP and SILC data may have restrictions.

Strengths: the data are collected according to consistent methodology, will be available for all EU countries (plus Norway / Iceland) on an annual basis and will provide a good indication of national trends.

For more information on meta data and calculation of this indicator, please refer to the methodology .

References

1. Europe in figures – EUROSTAT yearbook 2006–07. 4. Living conditions and welfare. EUROSTAT - The Statistical Office of the European Communities, 2007 (http://www.euro.who.int/air/activities/20070716_1, accessed 12 March 2007).
2. Survey on Income and Living Conditions (SILC) Questionnaire Manual 2008. (http://www.cso.ie/eusilc/documents/Copy%20of%20silc_manual_2008.pdf , accessed 20 October 2008).
3. Report on the WHO technical meeting on quantifying disease from inadequate housing. Copenhagen, WHO Regional Office for Europe, 2006 (http://www.euro.who.int/Housing/20060519_2, accessed 12 March 2007).
4. WHO second technical meeting on quantifying disease from inadequate housing. Copenhagen, WHO Regional Office for Europe, 2007 (http://www.euro.who.int/Document/HOH/EBD_report.pdf, accessed 15 March 2007).
5. Brunekreef B. et al. Associations between questionnaire reports of home “dampness” and childhood respiratory symptoms. The Science of the Total Environment, 1992, 127:79–89. Cited in Bornehag CG et al. Dampness in Buildings and Health, Nordic interdisciplinary Review of the Scientific Evidence on Associations between Exposure to “Dampness” in Buildings and Health Effects (NORDDAMP). Indoor Air, 2001, 11:72–86.
6. Jaakkola JJK, Hwang Bing-Fang, Jaakkola N. Home dampness and molds, parental atopy, and asthma in childhood: a six-year population-based cohort study. Environmental health perspectives, 2005, 113:357-361.
7. Bornehag CG et al. 'Dampness' at home and its association with airway, nose, and skin symptoms among 10 851 preschool children in Sweden: a cross-sectional study. Indoor air, 2005, 15(Suppl 10):S48-55.
8. WHO European Centre for Environment and Health. The LARES project (Large Analysis and Review of European housing and health Status). Preliminary overview. Copenhagen, WHO Regional Office for Europe, 2006 (http://www.euro.who.int/Housing/activities/20020711_1, accessed 13 March 2007).
9. Shenassa ED, Daskalakis C, Liebhaber A, Braubach M, Brown M.: Dampness and mold in the home and depression: An examination of possible pathways. American Journal of Public Health, 2007, 97(10):1893-1899
10. WHO Report on Development of WHO guidelines for indoor air quality: dampness and mould. report on a working group meeting, Bonn, Germany, 17-18 October 2007. (http://www.euro.who.int/air/activities/20070510_2, accessed 20 October 2008)
11. Children’s Environment and Health Action Plan for Europe. Fourth Ministerial Conference on Environment and Health, Budapest, 23–25 June 2004 (EUR/04/5046267/7) (http://www.euro.who.int/document/e83338.pdf, accessed 2 March 2007).
12. UN-HABITAT signs new social housing improvement programme for southeast Europe. Nairobi, United Nations Human Settlements Programme, 2006 (http://www.unhabitat.org/content.asp?cid=1483&catid=5&typeid=6&subMenuId=0, accessed 15 March 2007).
13. Declaration. Fourth Ministerial Conference on Environment and Health, Budapest, 23–25 June 2004 (EUR/04/5046267/6) (http://www.euro.who.int/document/e83335.pdf, accessed 16 March 2007).
14. Land Use and Building Act (132/1999), section 13: Building Codes D2 Indoor Climate and Ventilation of Buildings (2003) (http://www.ymparisto.fi/download.asp?contentid=33667&lan=EN, accessed 13 March 2007).
15. Housing Health and Safety Rating System. London, Communities and Local Government, 2007 (http://www.communities.gov.uk/index.asp?id=1152820, accessed 13 March 2007).
16. Flynn et al. Indoor air pollutants affecting child health. Schaumburg, IL, American College of Medical Toxicology. 2000 (http://www.acmt.net/content/resources/monographs/IndoorAirPolution.pdf.
17. de Garbino JP, ed. Children’s health and the environment. Geneva, World Health Organization, 2004 (http://libdoc.who.int/publications/2005/9241562927_eng.pdf, accessed 12 March 2007).
18. Wickman M et al. Strategies for preventing wheezing and asthma in small children. Allergy, 2003, 58:742–747.
19. Simoni M et al. Mould/dampness exposure at home is associated with respiratory disorders in Italian children and adolescents: the SIDRIA-2 Study. Occupational and environmental medicine, 2005, 62:616–622.
20. German Environmental Survey 2003/06 (GerES IV) for Children. Dessau, Umweltbundesamt, 2006 (http://www.umweltbundesamt.de/survey-e/us03/uprog.htm, accessed 12 March 2007).

WHO European Centre for Environment and Health. Prevalence of asthma and allergies in children. Copenhagen, WHO Regional Office for Europe (ENHIS-2 fact sheet No. 3.1).

EU Stability Pact for South Eastern Europe [web site]. Brussels, Special Coordinator of the Stability Pact for South Eastern Europe, 2007 (http://www.stabilitypact.org/, accessed 13 March 2007).

For this indicator, a feasibility study has been carried out: HIA for children living in homes with mould and dampness

Authors: Alexandra Cucu, Senior Lecturer, University of Medicine and Pharmacology “Carol Davila”, Bucharest, Romania; Matthias Braubach, WHO European Centre for Environment and Health, Bonn, Germany.

First update: Matthias Braubach, WHO European Centre for Environment and Health, Bonn, Germany