Conferencia Dr. Monsó. •It is healthy to live and work on a farm? Congreso SEPAR Sevilla 2006

It is healthy to live and workon a farm?

E MonsóHospital Germans Trias i Pujol,

Badalona, Spain.

E MonsóHospital Germans Trias i Pujol,

Badalona, Spain.

ContentContent

• The hygiene hypothesis.

• Exposures and diseases.

• Farming in Europe.

• Enclosed workplaces:

– Greenhouses.

– Confinement buildings.

• The hygiene hypothesis.

• Exposures and diseases.

• Farming in Europe.

• Enclosed workplaces:

– Greenhouses.

– Confinement buildings.

HealthHealth

Hygiene hypothesis

• Early exposure to farmingenvironments is associated with a low incidence of asthma, due to a predominant Th1 inmunologicresponse.

Hygiene hypothesis

• Early exposure to farmingenvironments is associated with a low incidence of asthma, due to a predominant Th1 inmunologicresponse.

HealthHealth

ErnstErnst. AJRCCM 2000. AJRCCM 2000

HealthHealth

IlliIlli. BMJ 2001. BMJ 2001

HealthHealth

DiseaseDiseaseBHR+asthma asthma

• Farmers 2.6(1.3-5.3) 1.7(1.0-3.0)• Agricultural workers 1.8(1.0-3.2) 1.4(1.0-2.0)• Spray painters ..... ....• Cleaners .... ....• Plastics .... ....• Textiles .... ....• ....

KogevinasKogevinas. . LancetLancet 1999;353:1701999;353:170

Work-related diseasesWork-related diseases

• Rinitis.• Asthma.• Organic dust toxic syndrome.• Silo filler’s disease.• Farmer’s lung disease.• Chronic bronchitis.• Lung infection.• COPD.

Work exposuresWork exposures

• Toxic gases– Ammonia, CO2, methane, Hydrogen sulfide, NO2, CO.

• Organic dust– Endotoxin, glucan, mycotoxin.

• Biologic agents– Bacteria, fungi, Mites.

• Inorganic dusts.• Chemicals.• Infectious microorganisms.

• Toxic gases– Ammonia, CO2, methane, Hydrogen sulfide, NO2, CO.

• Organic dust– Endotoxin, glucan, mycotoxin.

• Biologic agents– Bacteria, fungi, Mites.

• Inorganic dusts.• Chemicals.• Infectious microorganisms.

Work environmentsWork environments

• Field work.

• Confinement house.

• Silo.

• Greenhouse.

• Field work.

• Confinement house.

• Silo.

• Greenhouse.

Northamerican/European Study onFarmers’ Lung Health - Design

• Cross-sectional study of the prevalenceof respiratory symptoms in Europeanand Californian farmers.

• Assessment of occupation and region-related risk factors for respiratorysymptoms.

• Cross-sectional study of the prevalenceof respiratory symptoms in Europeanand Californian farmers.

• Assessment of occupation and region-related risk factors for respiratorysymptoms.

Monsó E. Eur Respir J 2003

Work-related diseasesWork-related diseases

• Rinitis.• Asthma.• Organic dust toxic syndrome.• Silo filler’s disease.• Farmer’s lung disease.• Chronic bronchitis.• Lung infection.• COPD.

MethodMethod• Target sample: All subjects who

participated in the studies onrespiratory health in farmers performedin Europe and California in the nineties.

• Random selection from census andcontact by mail, phone or home visit.

• Questionnaire on respiratory symptomsand occupation.

• Target sample: All subjects whoparticipated in the studies onrespiratory health in farmers performedin Europe and California in the nineties.

• Random selection from census andcontact by mail, phone or home visit.

• Questionnaire on respiratory symptomsand occupation.

StatisticsStatistics• Association between respiratory

symptoms, occupation and regionassessed using logistic regression.

– 1) Occupational model created forevery respiratory symptom with socio-demographic factors and type offarming as independent variables.

–2) Regional model including region in every occupational model as a riskfactor.

• Association between respiratorysymptoms, occupation and regionassessed using logistic regression.

– 1) Occupational model created forevery respiratory symptom with socio-demographic factors and type offarming as independent variables.

–2) Regional model including region in every occupational model as a riskfactor.

Respiratory Symptoms

Smoking Rhinitis Asthma Chronic bronchitis ODTS

CaliforniaEurope* *

* p<.001* p<.001

Results 1aSociodemography and Symptoms

California Europe pN 1839 7188 Age, mean (SD) 55 (13) 48 (13) <.001Gender(women), n (%) 181 (10) 1246 (17) <.001Current smoking, n (%) 212 (11) 1602 (22) <.001Former smoking, n (%) 600 (33) 1329 (18) <.001Rhinitis, n (%) 440 (24) 910 (12) <.001Asthma, n (%) 86 (5) 203 (3) <.001Chronic bronchitis, n (%) 80 (4) 770 (11) <.001ODTS, n (%) 50 (3) 877 (12) <.001

Animal exposure

Swine Beef/Veal Dairy Poultry Sheep Rabbit

CaliforniaEurope

* p<.001* p<.001

Results 1bAnimal Exposure

California Europe p

Swine, n (%) 40 (2) 2337 (32) <.001Beef/Veal, n (%) 381 (21) 3987 (55) <.001Dairy, n (%) 136 (7) 4037 (56) <.001Poultry, n (%) 89 (5) 692 (10) <.001Sheep, n (%) 105 (6) 522 (7) <.05Rabbit, n (%) 8 (1) 212 (3) <.001One or more, n (%) 584 (32) 6009 (84) <.001

California Europe p

Swine, n (%) 40 (2) 2337 (32) <.001Beef/Veal, n (%) 381 (21) 3987 (55) <.001Dairy, n (%) 136 (7) 4037 (56) <.001Poultry, n (%) 89 (5) 692 (10) <.001Sheep, n (%) 105 (6) 522 (7) <.05Rabbit, n (%) 8 (1) 212 (3) <.001One or more, n (%) 584 (32) 6009 (84) <.001

Crop exposure

Grain Vegetables Tomatoes Root crops Oil plants Fruits Nuts Flowers

CaliforniaEurope

* p<.001* p<.001

Results 1cCrop Exposure

California Europe pGrain, n (%) 180 (10) 3754 (52) <.001Vegetables, n (%) 63 (3) 943 (13) <.001Tomatoes, n (%) 82 (5) 516 (7) <.001Root crops, n (%) 59 (3) 1801 (25) <.001Oil plants, n (%) 47 (3) 1235 (17) <.001Fruits/berries, n (%) 878 (47) 563 (8) <.001Nuts, n (%) 490 (26) 287 (4) <.001Flowers, n (%) 89 (5) 311 (4) <.001

Results 2aRisk factors-Animal farming

Adjusted OR (95CI)Rhinitis Asthma

Swine 0.65 (0.56-0.76) ------Beef/Veal 1.13 (0.97-1.31) ------Dairy 0.55 (0.47-0.64) 0.80 (0.62-1.03)Poultry 1.30 (1.06-1.60) 1.90 (1.34-2.68)Sheep ------ ------Rabbit 1.27 (0.88-1.85) ------

Results 2bRisk factors-Animal farming

Adjusted OR (95CI)Chron. bronchitis ODTS

Swine 1.22 (1.03-1.43) ------

Beef/Veal ----- 0.76 (0.64-0.90)

Dairy ----- 1.32 (1.11-1.57)

Poultry ----- 1.25 (0.99-1.59)

Sheep 1.27 (0.98-1.66) 1.31 (1.01-1.69)

Rabbit 1.68 (1.13-2.50) 1.89 (1.30-2.75)

Swine 1.22 (1.03-1.43) ------

Beef/Veal ----- 0.76 (0.64-0.90)

Dairy ----- 1.32 (1.11-1.57)

Poultry ----- 1.25 (0.99-1.59)

Sheep 1.27 (0.98-1.66) 1.31 (1.01-1.69)

Rabbit 1.68 (1.13-2.50) 1.89 (1.30-2.75)

Results 2cRisk factors-Crop farming

Grain 1.13 (1.00-1.29) ------Vegetables 0.77 (0.61-0.97) 0.52 (0.32-0.83)Tomatoes 0.77 (0.57-1.04) ------Root crops ------ 1.28 (0.94-1.75)Oil plants ------ ------Fruits/berries 1.30 (1.10-1.54) ------Nuts 1.23 (1.00-1.51) ------Flowers 1.29 (0.98-1.70) 1.71 (1.06-2.77)

Grain 1.13 (1.00-1.29) ------Vegetables 0.77 (0.61-0.97) 0.52 (0.32-0.83)Tomatoes 0.77 (0.57-1.04) ------Root crops ------ 1.28 (0.94-1.75)Oil plants ------ ------Fruits/berries 1.30 (1.10-1.54) ------Nuts 1.23 (1.00-1.51) ------Flowers 1.29 (0.98-1.70) 1.71 (1.061.71 (1.06--2.77)2.77)

Results 2dRisk Factors-Crop Farming

Grain 1.42 (1.21-1.67) 2.15 (1.82-2.53)Vegetables ------ ------Tomatoes ------ ------Root crops ------ 1.51 (1.28-1.77)Oil plants 1.49 (1.22-1.81) 1.66 (1.39-1.98)Fruits/berries 0.90 (0.72-1.12) 0.81 (0.64-1.01)Nuts 0.55 (0.40-0.77) ------Flowers 1.67 (1.22-2.27) 1.75 (1.29-2.38)

ResultsRisk Factors-Farming

Crops Animals

Grain SwineVegetables Beef/VealTomatoes DairyRoot crops PoultryOil plants SheepFruits/berries RabbitsNutsFlowers

Crops Animals

Grain SwineVegetables Beef/VealTomatoes DairyRoot crops PoultryOil plants SheepFruits/berries RabbitsNutsFlowers

Results 4aEurope-California . Regional risk factors

Non-smokers Adjusted OR (95CI)Sociodemograph. Occupational mod.

Rhinitis 0.56 (0.47- 0.65) 0.58 (0.47-0.71)Asthma 0.96 (0.68- 1.35) 0.95 (0.67-1.35)Chronic Br. 4.19 (3.08- 5.70) 3.61 (2.64-4.95)ODTS 7.93 (5.76-10.93) 4.14 (2.81-6.09)

Non-smokers Adjusted OR (95CI)Sociodemograph. Occupational mod.

Results 4bEurope-California . Regional risk factors

Smokers Adjusted OR (95CI)Sociodemograph. Occupational m.

Results 5a - EuropeChronic bronchitis and indoor work

Chronic bronchitisODTS Adjusted OR (95CI)

yes noNon-smokers 28% 7% 5.17 (4.21- 6.34)Smokers 40% 11% 4.28 (3.01- 6.10)

Chronic bronchitisODTS Adjusted OR (95CI)

Results 5b - EuropeChronic bronchitis and indoor work

Chronic bronchitisConfinement building Adjusted OR (95CI)

Results 5c - EuropeChronic bronchitis and indoor work

Chronic bronchitisgreenhouse Adjusted OR (95CI)

yes no

Non-smokers 15% 9% 1.59 (1.02- 2.48)Smokers 14% 15% 0.98 (0.45- 2.12)

Chronic bronchitisgreenhouse Adjusted OR (95CI)

yes no

Non-smokers 15% 9% 1.59 (1.02- 2.48)Smokers 14% 15% 0.98 (0.45- 2.12)

Results 6aNon-smoking animal farmers

n=112Former smoking, n (%) 28 (25.0)Chronic bronchitis, n (%) 36 (32.1)

in former smokers, n (%) 6 (5.4)in never smokers, n (%) 30 (26.8)

Chronic bronchitis+COPD, n (%) 11 (10.7)in former smokers, n (%) 3 (11.1)in never smokers, n (%) 8 (10.5)

n=112Former smoking, n (%) 28 (25.0)Chronic bronchitis, n (%) 36 (32.1)

in former smokers, n (%) 6 (5.4)in never smokers, n (%) 30 (26.8)

Chronic bronchitis+COPD, n (%) 11 (10.7)in former smokers, n (%) 3 (11.1)in never smokers, n (%) 8 (10.5)

Conclusions - 1Conclusions - 1

• The prevalence of chronic bronchitisand ODTS is higher in European than in Californian farmers.

• The high prevalence of chronicbronchitis and ODTS in Europeanfarmers depends on the type offarming practiced in the region and ismainly related to work inside animal confinement buildings.

• The prevalence of chronic bronchitisand ODTS is higher in European than in Californian farmers.

• The high prevalence of chronicbronchitis and ODTS in Europeanfarmers depends on the type offarming practiced in the region and ismainly related to work inside animal confinement buildings.

BackgroundBackground

The European Farmers’ Studydemonstrated that the cultivation offlowers and ornamental plants is a riskfactor for bronchial asthma and workinginside greenhouses increases this risk.

Monsó E. Am J Respir Crit Care Med 2000; 162: 1246Monsó E. Am J Respir Crit Care Med 2000; 162: 1246

European Farmers’ StudyEuropean Farmers’ Study

5.4% asthma prevalence in flower growers

OR (95%CI) for asthma

Flower growing 2.1 (1.1-3.9)

Greenhouse work 2.1 (0.9-4.5)

farmers with other cultivations as the reference

5.4% asthma prevalence in flower growers

OR (95%CI) for asthma

Flower growing 2.1 (1.1-3.9)

Greenhouse work 2.1 (0.9-4.5)

farmers with other cultivations as the reference

Monsó E. Am J Respir Crit Care Med 2000; 162: 1246Monsó E. Am J Respir Crit Care Med 2000; 162: 1246

Flower greenhouseFlower greenhouse

AimAim

To determine the prevalence and theetiology of occupational asthma in cropfarmers cultivating flowers and/orornamental plants inside greenhouses.

Method - 1Method - 1Target populationTarget population

•Determination of a representativesubsample from the population ofgreenhouse flower and/or ornamental plant growers who participated in theEuropean Farmers’ Study.

•Selection of a random sample of 40 growers from this subsample for thepresent study.

•Determination of a representativesubsample from the population ofgreenhouse flower and/or ornamental plant growers who participated in theEuropean Farmers’ Study.

•Selection of a random sample of 40 growers from this subsample for thepresent study.

Method - 2Method - 2MeasurementsMeasurements

• Greenhouse characteristics• Air contaminants.• Symptoms and occupational exposure.• Spirometry and reversibility testing. • Workplace bronchial provocation

challenge for subjects reportingwheezing and/or asthma last year.

• Skin testing with workplace allergens.

• Greenhouse characteristics• Air contaminants.• Symptoms and occupational exposure.• Spirometry and reversibility testing. • Workplace bronchial provocation

challenge for subjects reportingwheezing and/or asthma last year.

• Skin testing with workplace allergens.

Method - 3Method - 3Skin testingSkin testing

•Common allergens (Dermatophagoides, mixed trees, mixed grass, mixed graminae, Parietaria, cat and dog hair).

•Workplace allergens:

• Moulds: Alternaria, Cladosporium, Aspergillusand Penicillium.

• Flowers: Gladiolus, Hyacintus, Narcissus, Solidago, Chrysantemum and Heliantus.

• Spider mite.

•Common allergens (Dermatophagoides, mixed trees, mixed grass, mixed graminae, Parietaria, cat and dog hair).

•Workplace allergens:

• Moulds: Alternaria, Cladosporium, Aspergillusand Penicillium.

• Flowers: Gladiolus, Hyacintus, Narcissus, Solidago, Chrysantemum and Heliantus.

• Spider mite.

Results - 1Results - 1Population samplePopulation sample

•73/85 greenhouse flower and/orornamental plant growers participating in the European Farmers’ Study worked in Spain (86%) and were the targetpopulation.

•39 growers from the random sample of40 subjects from the target populationparticipated in the study (97.5%).

•73/85 greenhouse flower and/orornamental plant growers participating in the European Farmers’ Study worked in Spain (86%) and were the targetpopulation.

•39 growers from the random sample of40 subjects from the target populationparticipated in the study (97.5%).

Population samplePopulation sample

GreenhouseGreenhouse areaarea

Results - 2Results - 2Sociodemography and symptomsSociodemography and symptoms

Age, m (SD) 48.6 (10.2)Gender (m/f) 35/4Smoking, n (%) 18 (46.2)Flower growers, n (%) 25 (64.1)Ornamental plant growers, n(%) 14 (35.9)Wheezing last year, n (%) 12 (30.8)Nasal allergies last year, n(%) 12 (30.8)Asthma attacks last year, n (%) 3 (7.7)

Greenhouse air contamination by moulds

Cladosp. Penicil. Botryu. Acremon. Asperg. Alternar. Geotric. Other Non-ident.

18 15 13

Results - 3Results - 3

0 30 60 90 120 150 180 210 240 270 300 330 360

Minutes

Control day Greenhouse day

* Decline FEV1 >20%

Workplace bronchial challenge - 1

0 30 60 90 120 150 180 210 240 270 300 330 360

Minutes

* ** Decline FEV1 >20%

0 30 60 90 120 150 180 210 240 270 300 330 360

Minutes

* Decline FEV1 >20%

Results - 4Results - 4Occupational asthma and sensitizationOccupational asthma and sensitization

atopy (n=38) 16 (42.1)

current asthma 5 (12.8)

- occupational 3 (7.7)

- non-occupational 2 (5.1)

atopy (n=38) 16 (42.1)

current asthma 5 (12.8)

- occupational 3 (7.7)

- non-occupational 2 (5.1)

Results - 4Results - 4Sensitization to workplace allergensSensitization to workplace allergens

n=38 n (%)

moulds 7 (18.4)

flowers 8 (21.1)

spider mite 2 (5.3)

one or more allergens 13 (34.2)

n=38 n (%)

moulds 7 (18.4)

flowers 8 (21.1)

spider mite 2 (5.3)

one or more allergens 13 (34.2)

Sensitization to workplace allergen 13/38 (34.2)

Occupational asthma 3/39 (7.7)

Sensitization to moulds (2)/ flowers (2)

Occupational asthma

- Sensitized to workplace allergens 3/13 (23.1)

- Non-sensitized to workplace allergens 0/25 (0.0)

Etiology of occupational asthma

Prevalences n (%)

Results - 5

Conclusions - 2Conclusions - 2•One third of the greenhouse flowerand/or ornamental plant growers are sensitized to workplace moulds and/orflowers.

•The cultivation of flowers and/orornamental plants inside greenhousescauses occupational asthma in almost 8%of the growers, through sensitization toworkplace antigens.

•One third of the greenhouse flowerand/or ornamental plant growers are sensitized to workplace moulds and/orflowers.

•The cultivation of flowers and/orornamental plants inside greenhousescauses occupational asthma in almost 8%of the growers, through sensitization toworkplace antigens.

PigPig farmersfarmers -- LungLung functionfunction declinedecline

IversenIversen. ERJ 2000. ERJ 2000

Method 1Method 1• Never-smoking subjects who participated in the

European Farmers’ Study and worked inside animal confinement buildings (n=105).

Age, mean (SD) 45.1 (11.7)Gender (women), n (%) 21 (20.0)Country

Denmark, n (%) 14 (13.3)Germany, n (%) 65 (61.9)Switzerland, n (%) 20 (19.0)Spain, n (%) 6 (5.7)

• Never-smoking subjects who participated in theEuropean Farmers’ Study and worked inside animal confinement buildings (n=105).

Age, mean (SD) 45.1 (11.7)Gender (women), n (%) 21 (20.0)Country

Denmark, n (%) 14 (13.3)Germany, n (%) 65 (61.9)Switzerland, n (%) 20 (19.0)Spain, n (%) 6 (5.7)

Method - 2Method - 2

MeasurementsMeasurements

• Symptoms and occupational exposure.• Spirometry and reversibility testing.• FEV1 variability in a work day.• Confinement building characteristics.• Air contaminants:

• Carbon dioxide• Ammonia• Dust• Endotoxin

• Symptoms and occupational exposure.• Spirometry and reversibility testing.• FEV1 variability in a work day.• Confinement building characteristics.• Air contaminants:

• Carbon dioxide• Ammonia• Dust• Endotoxin

Type of farmingPig, n (%) 82 (78.1)Beef/Veal, n (%) 32 (30.5)Dairy, n (%) 23 (21.9)Poultry, n (%) 33 (31.4)

Respiratory symptomsWheeze last year, n (%) 58 (55.2)Chronic bronchitis, n (%) 48 (45.7)Wheeze or chronic bronchitis, n (%) 72 (68.6)

Respiratory symptoms - animal farmers

FEV1%, m (SD) 98.5 (21.0)

COPD, n (%) ($) 18 (17.1)mild, n (%) 7 (6.7)moderate/severe, n (%) 11 (10.5)+respiratory symptoms, n (%) 18 (17.1)

FEV1 variability>10%, m (SD) 20 (19.0)increase, n (%) 7 (6.7)decline, n (%) 13 (12.3)

COPD and FEV1 variabilityvariability >10%, n (%) 4 (3.8)variab.>10% + wheeze, n(%) 4 (3.8)

Lung function - animal farmers

($) GOLD criteria

Confinement building

Area (m2 ) 168 (110-300)Temperature (ºC) 18.0 (15.7-20.0) Humidity (%) 81.3 (73.5-87.2)CO2 (ppm) 1500 (1000-2000)Ammonia (ppm) 10.0 (5.0-17.0) Total dust (mg/m3) 5.6 (2.3-9.4)Endotoxin (ng/m3) 85.9 (35.3-275.4)

Building characteristics - Air contaminants

expressed as median (interquartile range)

COPD, n (%)

≤median >median Crude OR(95%CI) p

Measurement

Area (m2 ) 10 (18.9) 8 (15.4) 0.78 (0.28-2.17) >0.25

Temperature (ºC) 8 (14.8) 10 (19.6) 1.40 (0.50-3.89) >0.25

Relative humidity (%) 7 (13.2) 11 (21.2) 1.76 (0.62-4.97) >0.25

COPD and building characteristics

COPD, n/n total (%) Adjusted OR(95%CI)

CO2First quartile 5/29 (17.2) 1.00Second quartile 8/32 (25.0) 1.08 (0.34-3.43) Third quartile 4/20 (20.0) 0.54 (0.17-1.69)Fourth quartile 1/24 (4.2) 0.18 (0.02-1.44)

AmmoniaFirst quartile 3/28 (10.7) 1.00Second quartile 8/32 (25.0) 1.82 (0.48-7.00)Third quartile 3/21 (14.3) 0.86 (0.30-2.48)Fourth quartile 4/24 (16.7) 1.32 (0.35-4.89)

COPD and indoor contaminants - 1

n=76 COPD, n/n total (%) Adjusted OR(95%CI)

Total dustFirst quartile 1/17 (5.9) 1.00Second quartile 2/21 (9.5) 2.96 (0.34-25.98)Third quartile 2/19 (10.5) 3.70 (0.79-17.27)Fourth quartile 6/19 (31.6) 4.16 (1.01-17.14)

EndotoxinFirst quartile 1/19 (5.3) 1.00Second quartile 3/19 (15.8) 4.03 (0.46-35.52)Third quartile 3/18 (16.7) 1.98 (0.50-7.87)Fourth quartile 4/20 (20.0) 1.15 (0.23-5.59)

COPD and indoor air contaminants - 2

Conclusions - 3

•COPD in never-smoking farmers workinginside animal confinement buildings mayreach moderate severity.

•Indoor exposure to organic dust in theworkplace is related to COPD, and show a dose-response relationship.

•Endotoxin exposure is marginally related to COPD.

Final conclusionsFinal conclusions• The prevalence of chronic bronchitis is

higher in European than in Californianfarmers.

• Chronic bronchitis in Europe is relatedto work inside animal confinementareas and greenhouses.

• The prevalence of chronic bronchitis ishigher in European than in Californianfarmers.

• Chronic bronchitis in Europe is relatedto work inside animal confinementareas and greenhouses.

Final ConclusionsFinal Conclusions•One third of the greenhouse flowergrowers are sensitized to workplacemoulds and/or flowers.

•The cultivation of flowers insidegreenhouses causes occupational asthmain almost 8% of the growers, throughsensitization to workplace antigens.

•One third of the greenhouse flowergrowers are sensitized to workplacemoulds and/or flowers.

•The cultivation of flowers insidegreenhouses causes occupational asthmain almost 8% of the growers, throughsensitization to workplace antigens.

Final Conclusions

•COPD in never-smoking farmers working

inside confinement buildings is significant.

•Indoor exposure to organic dust in the

workplace is related to COPD

Epidemiología de la enfermedad

Ramón Magarolas Rosa ReinónSandra Cabrera Sandra AlonsoMarc Schenker Cathy SaikiKatja Radon Elena RiuDennis Nowak Martin IversenBrigitta Danuser Josep Morera

Hospital Germans Trias i Pujol, Badalona, SpainUniversity of California, Davis, California, USAI Poliklinik Arbeits-Umweltmedizin, Munchen, Germany

Ramón Magarolas Rosa ReinónSandra Cabrera Sandra AlonsoMarc Schenker Cathy SaikiKatja Radon Elena RiuDennis Nowak Martin IversenBrigitta Danuser Josep Morera

Hospital Germans Trias i Pujol, Badalona, SpainUniversity of California, Davis, California, USAI Poliklinik Arbeits-Umweltmedizin, Munchen, Germany

Conferencia Dr. Monsó. •It is healthy to live and work on a farm? Congreso SEPAR Sevilla 2006

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