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Nearly a quarter of the global disease burden and premature mortality is expected to be caused by environmental exposures, and the environmental health burden in children is even larger. Among the most hazardous environmental risk factors are tobacco smoke and ambient air pollution. Also temperature extremes have been linked to different adverse health outcomes, which is a concern because of the expected increase in extreme weather events due to climate change. It is well accepted that prenatal and postnatal exposure to second-hand tobacco smoke has detrimental effects on fetal and child health. However, evidence that smoke-free legislations are associated with health benefits early in life was limited before 2013. Also early life health effects of ambient temperature and air pollution are a relatively novel research domain. The number of studies investigating the association between temperature and preterm birth is limited, and results are inconclusive. Concerning fetal growth, evidence for adverse effects of air pollution is cumulating, but results are inconsistent with respect to the exposure window. Finally, although animals may serve as useful sentinels for the effects of environmental exposures on human health, epidemiological findings for human have seldom been replicated in animal populations. In this dissertation, we used population-level registry data to investigate health effects of different environmental exposures and to evaluate the health impact of preventive public health measures, including health outcomes in newborns and in the older segment of the population. The specific objectives of this dissertation were: 1. The assessment of potential public health benefits of smoking policies, focusing on health outcomes in early and in later life. For this purpose, we studied the impact of the stepwise implementation of smoke-free legislation in Belgium on the risk of preterm birth and on the risk of mortality due to acute myocardial infarction. 2. The investigation of the association between environmental exposures and adverse birth outcomes. First, we examined the risk of preterm birth in relation to ambient temperature by investigating potential heat and cold effects. Second, we studied fetal growth in relation to maternal exposure to PM10. For the latter, we focused on birth weight and small-for-gestational-age and we assessed potential effect modification by pregnancy duration and potential non-linearity in the exposure-response shape. 3. The exploration of the use of dairy cattle populations as comparative models of human health risks. For this purpose, we investigated the association between dairy cow mortality and ambient O3, PM10, NO2 and temperature, accounting for harvesting and delayed effects. ; Men schat dat bijna een kwart van de globale ziektelast en vroegtijdige sterfte veroorzaakt wordt door blootstelling aan omgevingsfactoren, en de impact van het milieu op de gezondheid van kinderen is zelfs nog groter. Tabaksrook en luchtverontreiniging behoren tot de meest schadelijke omgevingsblootstellingen. Ook blootstelling aan zeer lage of hoge buitentemperaturen kan leiden tot verscheidene nadelige gezondheidseffecten, wat een probleem vormt in de context van de verwachte toename in extreme weersomstandigheden door de klimaatsverandering. Het is algemeen aanvaard dat prenatale en postnatale blootstelling aan tabaksrook schadelijk zijn voor de gezondheid van de foetus en het kind. Toch was er vóór 2013 nog bijna geen wetenschappelijk bewijs dat rookvrije wetgevingen al vroeg in het leven gezondheidswinst opleveren. Ook het onderzoek naar perinatale gezondheidseffecten van omgevingstemperatuur en luchtverontreiniging is relatief nieuw. Slechts een beperkt aantal studies onderzocht het verband tussen temperatuur en vroeggeboortes, en de resultaten zijn niet eenduidig. Hoewel er groeiend wetenschappelijk bewijs is dat blootstelling aan luchtverontreiniging schadelijk is voor de groei van de foetus, zijn de resultaten van studies inconsistent wat betreft de periode van de zwangerschap waarin de foetus het meest gevoelig is aan zulke blootstelling. Hoewel dieren kunnen gebruikt worden als rolmodellen voor de effecten van milieufactoren op de gezondheid van de mens, werden epidemiologische bevindingen bij de mens slechts zelden bevestigd in dierenpopulaties. In dit proefschrift gebruikten we registergegevens op populatieniveau om de gezondheidseffecten van verscheidende milieufactoren te onderzoeken en om de impact van preventieve volksgezondheidmaatregelen te evalueren. Hiervoor keken we naar gezondheidsuitkomsten in pasgeborenen en in een ouder deel van de populatie. De specifieke doelstellingen van dit proefschrift waren: 1. Een inschatting maken van mogelijke gezondheidsvoordelen ten gevolge van rookwetgevingen, gericht op aandoeningen zowel vroeg als later in het leven. Hiervoor onderzochten we de impact van de stapsgewijze invoering van het rookverbod in België op het risico op vroeggeboorte en op het risico op sterfte door een hartaanval. 2. Het onderzoeken van het verband tussen omgevingsblootstellingen en negatieve zwangerschapsuitkomsten. Om te beginnen bestudeerden we de effecten van lage en hoge buitentemperaturen op het risico op vroeggeboorte. Daarnaast gingen we na of er een verband is tussen foetale groei en blootstelling van de moeder aan luchtverontreiniging. Hiervoor keken we naar geboortegewicht en naar het risico om te licht te zijn rekening houdend met de zwangerschapsduur ("small-for-gestational-age"). We keken ook naar mogelijke effect modificatie door zwangerschapsduur en mogelijke nietlineariteit in het verband tussen blootstelling en uitkomst. 3. De exploratie van het gebruik van melkkoeien als vergelijkende modellen voor menselijke gezondheidsrisico's. Hiervoor onderzochten we de associatie tussen sterfte bij melkkoeien en concentraties van ozon (O3), fijn stof (PM10) en stikstofdioxide (NO2) in de buitenlucht. Daarnaast keken we ook naar de effecten van extreme buitentemperaturen. In de analyses hielden we rekening met mogelijke "harvesting" en vertraagde blootstellingseffecten.

AbstractDeaths from air pollution in the UK are higher by a factor of 10 than from car crashes, 7 for drug-related deaths and 52 for murders, and yet awareness seems to be lacking in local government. We conducted an 18-year retrospective cohort study using routinely collected health care records from Ninewells Hospital, Dundee, and Perth Royal Infirmary, in Tayside, Scotland, UK, from 2000 to 2017. Hospitalisation events and deaths were linked to daily nitric oxides (NOX, NO, NO2), and particulate matter 10 (PM10) levels extracted from publicly available data over this same time period. Distributed lag models were used to estimate risk ratios for hospitalisation and mortality, adjusting for temperature, humidity, day of the week, month and public holiday. Nitric oxides and PM10 were associated with an increased risk of all hospital admissions and cardiovascular (CV) admissions on day of exposure to pollutant. This study shows a significant increase in all cause and CV hospital admissions, on high pollution days in Tayside, Scotland.

Deaths from air pollution in the UK are higher by a factor of 10 than from car crashes, 7 for drug-related deaths and 52 for murders, and yet awareness seems to be lacking in local government. We conducted an 18-year retrospective cohort study using routinely collected health care records from Ninewells Hospital, Dundee, and Perth Royal Infirmary, in Tayside, Scotland, UK, from 2000 to 2017. Hospitalisation events and deaths were linked to daily nitric oxides (NOX, NO, NO2), and particulate matter 10 (PM10) levels extracted from publicly available data over this same time period. Distributed lag models were used to estimate risk ratios for hospitalisation and mortality, adjusting for temperature, humidity, day of the week, month and public holiday. Nitric oxides and PM10 were associated with an increased risk of all hospital admissions and cardiovascular (CV) admissions on day of exposure to pollutant. This study shows a significant increase in all cause and CV hospital admissions, on high pollution days in Tayside, Scotland. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s11356-021-16544-0.

Objective To investigate the incidence of preterm delivery in the Belgian population after implementation of smoke-free legislation in three phases (in public places and most workplaces January 2006, in restaurants January 2007, and in bars serving food January 2010). Design Logistic regression analyses on routinely collected birth data from January 2002 to December 2011. Setting Flanders, Belgium. Population All live born singleton births delivered at 24-44 weeks of gestation (n=606 877, with n=448 520 spontaneous deliveries). Main outcome measures Preterm birth (gestational age <37 weeks). Results We found reductions in the risk of preterm birth after the introduction of each phase of the smoking ban. No decreasing trend was evident in the years or months before the bans. We observed a step change in the risk of spontaneous preterm delivery of -3.13% (95% CI -4.37% to -1.87%; P<0.01) on 1 January 2007 (ban on smoking in restaurants), and an annual slope change of -2.65% (-5.11% to -0.13%; P=0.04) after 1 January 2010 (ban on smoking in bars serving food). The analysis for all births gave similar results: a step change of -3.18% (-5.38% to -0.94%; P<0.01) on 1 January 2007, and an annual slope change of -3.50% (-6.35% to -0.57%; P=0.02) after 1 January 2010. These changes could not be explained by personal factors (infant sex, maternal age, parity, socioeconomic status, national origin, level of urbanisation); time related factors (underlying trends, month of the year, day of the week); or population related factors (public holidays, influenza epidemics, and short term changes in apparent temperature and particulate air pollution). Conclusion Our study shows a consistent pattern of reduction in the risk of preterm delivery with successive population interventions to restrict smoking. This finding is not definitive but it supports the notion that smoking bans have public health benefits from early life.

Objective To investigate the incidence of preterm delivery in the Belgian population after implementation of smoke-free legislation in three phases (in public places and most workplaces January 2006, in restaurants January 2007, and in bars serving food January 2010).

Women generally live longer than men, but women's longer lives are not necessarily healthy lives. The aim of this article is to describe the pattern of gender differences in expected years with and without activity limitations across 25 EU countries and to explore the association between gender differences and macro-level factors. We applied to the Eurostat life table's data from the Statistics of Income and Living Conditions Survey to estimate gender differences in life expectancy with and without activity limitations at age 50 for 2005. We studied the relationship between the gender differences and structural indicators using meta-regression techniques. Differences in years with activity limitations between genders were associated with the life expectancy (LE) and the size of the gender difference in LE. Gender difference in years with activity limitations were larger as the gross domestic product, the expenditure on elderly care and the indicator of life-long learning decreased, and as the inequality in income distribution increased. There was evidence of disparity in the associations between the more established EU countries (EU15) and the newer EU10 countries. Among the EU15, gender differences were positively associated with income inequality, the proportion of the population with a low education and the men's mean exit age from labour force. Among the EU10, inequalities were smaller with increasing expenditure in elderly care, with decreasing poverty risk and with decreasing employment rate of older people. The association between structural indicators and the gender gap in years with activity limitations suggests that gender differences can be reduced.

BACKGROUND: Quality improvement (QI) initiatives such as accreditation, public reporting, inspection and pay-for-performance are increasingly being implemented globally. In Flanders, Belgium, a government policy for acute-care hospitals incorporates aforementioned initiatives. Currently, questions are raised on the sustainability of the present policy. OBJECTIVE: First, to summarise the various initiatives hospitals have adopted under government encouragement between 2008 and 2019. Second, to study the perspectives of healthcare stakeholders on current government policy. METHODS: In this multi-method study, we collected data on QI initiative implementation from governmental and institutional sources and through an online survey among hospital quality managers. We compiled an overview of QI initiative implementation for all Flemish acute-care hospitals between 2008 (n = 62) and 2019 (n = 53 after hospital mergers). Stakeholder perspectives were assessed via a second survey available to all healthcare employees and a focus group with healthcare policy experts was consulted. Variation between professions was assessed. RESULTS: QI initiatives have been increasingly implemented, especially from 2016 onwards, with the majority (87%) of hospitals having obtained a first accreditation label and all hospitals publicly reporting performance indicators, receiving regular inspections and having entered the pay-for-performance initiative. On the topic of external international accreditation, overall attitudes within the survey were predominantly neutral (36.2%), while 34.5% expressed positive and 29.3% negative views towards accreditation. In examining specific professional groups in-depth, we learned 58% of doctors regarded accreditation negatively, while doctors were judged to be the largest contributors to quality according to the majority of respondents. CONCLUSIONS: Hospitals have demonstrated increased efforts into QI, especially since 2016, while perceptions on currently implemented QI initiatives among healthcare ...

Retinal arteriolar narrowing increases with age and predict adverse cardiovascular outcomes. Telomere length keeps track of the division of somatic cells and is a biomarker of biological age. We investigated to what extent retinal arteriolar diameters are associated with biological age, as captured by leukocyte telomere length (LTL). In 168 randomly selected Flemish participants from the family-based population study FLEMENGHO (mean age, 46.2 years) at baseline, of whom 85 underwent a follow-up examination (median, 4.1 years), we post-processed nonmydriatic retinal photographs and measured LTL. In men only, central retinal arteriolar equivalents (CRAE) and arteriole-to-venule ratio (AVR) were associated with LTL with stronger associations at higher age and body mass index. In men aged 57.6 years (75th percentile) a 20% shorter LTL was associated with a decrease in CRAE of 4.57µm. A 20% shorter LTL was associated with a decrease of 5.88µm in CRAE at a BMI of 29.9kg/m2 (75th percentile). Similar associations were observed between AVR and LTL. In women, no retinal microvascular traits were associated with LTL. Retinal arteriolar narrowing in men but not in women is associated with biological age. Our fndings support the idea that avoiding overweight contributes to maintaining a healthier microcirculation. ; The European Union [HEALTH-F7-305507 HOMAGE] and the European Research Council, Advanced Researcher Grant [2011-294713-EPLORE] and Proof-of-Concept Grant [713601-uPROPHET] and the Fonds voor Wetenschappelijk Onderzoek Vlaanderen, Ministry of the Flemish Community, Brussels, Belgium [G.0881.13 and G.088013] currently support the Studies Coordinating Centre in Leuven. Telomere measurements were funded by the European Research Council [ERC-2012-StG.310898] and by the Fonds voor Wetenschappelijk Onderzoek Vlaanderen, Ministry of the Flemish Community, Brussels, Belgium [G073315N and G073409N]. Dr Cox is a postdoctoral fellow of the Fonds voor Wetenschappelijk Onderzoek Vlaanderen, Ministry of the Flemish Community, Brussels, Belgium supported by grant 12Q0517N. The authors gratefully acknowledge the contribution of the nurses working at the examination center (Linda Custers, Marie-Jeanne Jehoul, Daisy Thijs, and Hanne Truyens) and the clerical staff at the Studies Coordinating Centre (Vera De Leebeeck, Yvette Piccart, and Renilde Wolfs).