Child care centre and home exposures among preschool children in singapore and their associations with asthma, allergies and respiratory symptoms

CHILD CARE CENTRE AND HOME EXPOSURES AMONG PRESCHOOL CHILDREN IN SINGAPORE AND THEIR ASSOCIATIONS WITH ASTHMA, ALLERGIES AND RESPIRATORY SYMPTOMS ZURAIMI BIN MOHAMED SULTAN NATIONAL UNIVERSITY OF SINGAPORE 2008 CHILD CARE CENTRE AND HOME EXPOSURES AMONG PRESCHOOL CHILDREN IN SINGAPORE AND THEIR ASSOCIATIONS WITH ASTHMA, ALLERGIES AND RESPIRATORY SYMPTOMS ZURAIMI BIN MOHAMED SULTAN B.Sc., (Chem & Mat Sci), NUS M.Bldg.Sc., NUS A THESIS SUBMITTED FOR THE DEGREE OF DOCTOR OF PHILOSOPHY DEPARTMENT OF BUILDING NATIONAL UNIVERSITY OF SINGAPORE 2008 _ ACKNOWLEDGEMENTS I would like to thank Profs Cheong Hin Fatt and George Ofori for allowing me to pursue this work in the Department of Building and Mrs Elias Ismail from the Ministry of Community, Youth and Sports for the support, assistance and encouragement in soliciting the participation of the child care centers in this project Special thanks are reserved for my supervisor A/Prof Tham Kwok Wai for the guidance and support in this research There are many people that helped me throughout the course of this work; Prof David Koh in matters relating medical epidemiology and manuscript drafting; Dr Gerald Koh who provided advice relating asthma and allergies from a clinician’s point of view; Dr Chew Fook Tim who assisted, guided and advised in matters relating to allergen measurements and asthma epidemiology; Dr Ong Tan Ching who assisted in the allergen analyses; A/Prof Ooi Peng Lim who assisted in the questionnaire development and epidemiological analyses; Prof Claude-Alain Roulet in providing the TGD software and advice in ventilation measurements; A/Prof Chan Yiong Huak in biostatistical analyses Profs Jan Sundell and CarlGustaf Bornehag in advice relating to the study design and Dr Linda Hagerhed-Engman in support, information sharing and advice in research design and analyses Thank you all very much I am indebted to my sampling and data-entry team comprising of students from National University of Singapore, Singapore Polytechnic and Nanyang Polytechnic; Loh Ting Tuan, Tan Su Shan; Lin Su Qing; Moshood Fadeyi, Adeline Phang, Khairulizwan, Guo Dian Yang, Teresa Lim, Low Ming Fui and Tan Mei Xi I acknowledge the tremendous help of the participating child care center principals, licensees, teachers, maintenance workers and parents of children Without them, this work will not have been successful I also wish to express my sincere appreciation and gratitude to everyone who, in one way or another, have contributed to the successful completion of this thesis Special acknowledgement is reserved for my family; for their love, understanding, support and patience -facing long hours away from me throughout the course of this work Above all, I thank the Almighty God i _ TABLE OF CONTENTS Acknowldegments …………………………………………………………………… i Table of Contents ………………………………………………………………………ii Summary ……………………………………………………………………………… x List of Tables………………………………………………………………………… xii List of Figures ………………………………………………………………………….xvii List of Symbols ……………………………………………………………………… xx List of Publications Arising out of Thesis …………………………………………… xxii Introduction 1.1 Background 1.2 Asthma, Allergies and Respiratory Infections 1.2.1 Asthma and Allergies 1.2.2 Respiratory Infections 1.2.3 Worldwide Trends and Current Hypotheses 1.3 Indoor Air: Exposures and Risk Factors 1.3.1 Dampness 1.3.2 Chemicals 1.3.2.1 Environmental Tobacco Smoke (ETS) 1.3.2.2 Building Materials and Finishes Emissions 1.3.2.3 Outdoor Traffic Emissions 1.3.3 Home or CCC Indoor Risk Factors? 1.3.4 Indoor Air Quality in CCCs 1.3.5 Indoor Allergens in CCCs 10 1.4 Knowledge Gap Identification 11 1.4.1 Home Indoor Exposures as Risk Factors 11 1.4.2 Traffic Exposure Indoors and Air Conditioning (AC) 12 1.4.3 CCC Indoor Risk Factors 12 1.4.4 IAQ and Ventilation Determinants in CCC 13 1.4.5 Indoor Allergens in CCCs 13 1.5 Objectives 14 1.6 General Research Methodology 15 1.6.1 Overview of Sampling Design 15 ii _ 1.6.2 Conceptual Framework Models 17 1.6.2.1 1.6.2.2 1.7 Linking Indoor Air Quality, Exposure, Ventilation and Health 17 Linking Exposure, Health and Confounders 18 Thesis Outline & Research Program 22 1.7.1 Thesis Outline 22 1.7.2 Thesis vis-à-vis Backdrop of Research Program 23 Indoor Air Quality of CCCs and the Effects of Ventilation Strategies 25 2.1 Introduction 25 2.1.1 Literature Review on CCC Indoor Air Quality (IAQ) 26 2.1.1.1 Physical Characterization 26 2.1.1.2 Chemical Characterization 27 2.1.1.3 Biological Characterization 29 2.1.2 Summary of Literature Review vis-à-vis Tropical Conditions in Singapore – Knowledge Gap Identification 30 2.1.3 Ventilation Strategies as an Important Determinant of IAQ in CCCs 31 2.1.4 Objectives 31 2.2 Materials and Methods 32 2.2.1 CCC Population and Sampling 32 2.2.1.1 Temperature, Relative Humidity and Air Velocity 33 2.2.1.2 Carbon Dioxide, Carbon Monoxide and Ventilation Rates 33 2.2.1.3 Fine Particle (PM2.5) and Ozone 34 2.2.1.4 Airborne Viable Bacteria and Fungi 35 2.2.1.5 Volatile Organic Compounds (VOCs) and Carbonyls 35 2.2.1.6 CCC Characteristics 37 2.2.2 Data analysis 38 2.3 Results 39 2.3.1 Baseline Data 39 2.3.1.1 Temperature, Relative Humidity, Air Velocity and Ventilation Parameters 39 2.3.1.2 CO2, CO, PM2.5 and O3 39 2.3.1.3 Bacteria and Fungi 40 2.3.1.4 Volatile Organic Compounds and Carbonyls 40 2.3.2 Effects of Ventilation Strategies 46 2.3.2.1 Stratified CCC Characteristics 46 iii _ 2.3.2.2 2.3.2.3 CO2, CO, PM2.5 and O3 50 2.3.2.4 Bacteria and Fungi 53 2.3.2.5 2.4 Temperature, Relative Humidity, Air Velocity and Ventilation Parameters 46 Volatile Organic Compounds and Carbonyls 57 Discussion 66 2.4.1 Baseline Data 66 2.4.2 Effect of Ventilation Strategies 68 2.4.3 Strengths, Limitations and Considerations 72 2.5 Conclusion 73 Indoor Allergens in CCCs: Concentrations, Distribution and Determinants 75 3.1 Introduction 75 3.1.1 Literature Review on CCC Indoor Allergens 75 3.1.2 Literature Review on Distributions of Indoor Allergens in CCC 77 3.1.3 Literature Review on Determinants of Indoor Allergens 78 3.1.4 Summary and Identification of Knowledge Gap 80 3.1.5 Objectives 82 3.2 Materials and Methods 82 3.2.1 CCC Population and Sampling 82 3.2.2 Dust Collection Procedures 82 3.2.3 Allergen Extraction 83 3.2.4 Allergen Analysis 83 3.2.4.1 Bead Coupling and Activation 84 3.2.4.2 Bioplex Assays (Der p 1, Fel d 1, Bla g 1, Can f 1, Mus m 1) 85 3.2.4.3 ELISA Assay (Asp f 1, Blo t 5) 85 3.2.5 CCC Characteristics and Indoor Air Quality 86 3.2.6 Data Analysis 86 3.3 Results 87 3.3.1 Summary statistics 87 3.3.2 Concentrations of Allergens in Different Niches 88 3.3.3 Characteristics and Indoor Air Quality of CCCs 95 3.3.4 Bivariate Associations between IAQ in CCCs and Allergens 96 3.3.5 Bivariate Associations between CCC Characteristics and Allergens 97 iv _ 3.3.6 Multivariate Associations between CCC Characteristics and IAQ with Allergens Levels ……………………………………………………………………………………… 97 3.4 Discussion 102 3.4.1 Baseline Data, Comparison and Distributions 102 3.4.2 Associations of Allergens with CCC Characteristics and IAQ 103 3.5 Conclusion 108 On the Associations of CCC Characteristics with Asthma, Allergies and Respiratory Symptoms …………………………………………………………………………………109 4.1 Introduction & Literature Review 109 4.1.1 Health of Children Associated with CCCs Attendance 109 4.1.2 Review Process for Studies on CCC Characteristics Associations with Health 112 4.1.3 Ventilation Strategies and Health 113 4.1.4 Ventilation and Respiratory Symptoms 114 4.1.5 Associations of CCC Dampness with Asthma, Allergies and Respiratory Symptoms ……………………………………………………………………………………….115 4.1.6 Associations of CCC Building Materials with Asthma, Allergies and Respiratory Symptoms 116 4.1.7 Associations of CCC Cleaning and Maintenance with Asthma, Allergies and Respiratory Symptoms 117 4.1.8 Associations of Outdoor Pollution Sources of CCC with Asthma, Allergies and Respiratory Symptoms 117 4.1.9 Summary of Literature Review and and Knowledge Gap Identification 117 4.2 Objective 119 4.3 Methods and Materials 120 4.3.1 CCC Characteristics – Exposure Variables 120 4.3.2 Questionnaire Survey 120 4.3.3 Statistical Analyses 122 4.4 Results 124 4.4.1 Prevalence of Symptoms by CCC Exposures 124 4.4.2 Prevalence Ratio - Ventilation Strategies 143 4.4.3 Prevalence Ratio - Dampness 143 4.4.4 Prevalence Ratio - Building Materials 146 v _ 4.4.5 Prevalence Ratio - Cleaning Frequency and Maintenance 151 4.4.6 Prevalence Ratio - Outdoor Pollution 154 4.5 Discussion 157 4.5.1 Prevalence of Symptoms 157 4.5.2 Ventilation Strategies 157 4.5.2.1 Rhinitis, Eczema and Flexural Rash 158 4.5.2.2 Respiratory Symptoms 159 4.5.2.3 Hybrid Ventilation and Respiratory Symptoms 160 4.5.3 Dampness and Molds 161 4.5.4 Building Materials, Cleaning Frequencies and Outdoor Pollution 162 4.5.4.1 Wall Wood Panels and Respiratory Symptoms 162 4.5.4.2 Recent Painting in CCCs and Chronic Cough 165 4.5.4.3 Plastic Tiles and Blinds 166 4.5.4.4 Traffic and Outdoor Pollution Sources 167 4.5.4.5 CCC Cleaning Frequencies 168 4.5.5 Strengths and Limitations 169 4.6 Conclusions 170 Home Indoor Risk Factors and Asthma and Allergies in Preschool Children 172 5.1 Introduction 172 5.2 Literature Review 172 5.2.1 Home Dampness/Molds and Children’s Asthma and Allergies 172 5.2.2 Home ETS exposure and Children’s Asthma and Allergies 174 5.2.3 Home Building Materials and Children’s Asthma and Allergies 175 5.2.4 Indoor Combustion Sources and Children’s Asthma and Allergies 177 5.2.5 Pet Exposures and Children’s Asthma and Allergies 178 5.2.6 Home Air Conditioning 178 5.2.7 Summary and Knowledge Gap Identification 179 5.3 Objectives 180 5.4 Methods and Materials 187 5.4.1 Cross-sectional Design 187 5.4.2 Questionnaire Survey – Health Endpoints 187 5.4.3 Questionnaire survey – Home Exposure Information 188 5.4.3.1 Dampness 188 vi _ 5.4.3.2 ETS 189 5.4.3.3 Floor and Wall Coverings 189 5.4.3.4 Painting and Renovation 189 5.4.3.5 Pet Keeping 190 5.4.3.6 Cooking Fuel 190 5.4.3.7 Air Conditioning 190 5.4.4 Statistical Analysis 190 5.4.5 Partial Validation Studies 191 5.5 Results 192 5.5.1 Dampness 192 5.5.2 ETS 197 5.5.3 Floor and Wall Coverings 202 5.5.4 Renovation and Painting 202 5.5.5 Pet Keeping 208 5.5.6 Cooking Fuel 208 5.5.7 Air Conditioning 208 5.5.8 Partial Validation 208 5.6 Discussion 216 5.6.1 General 216 5.6.2 Home Dampness as a Risk Factor 216 5.6.3 Home ETS as a Risk Factor 218 5.6.4 Home Wall Paper as a Risk Factor 220 5.6.5 Other Factors 221 5.6.6 Home Risk Factors versus CCC Risk Factors 222 5.6.7 Limitations of Study 223 5.7 Conclusions 223 Home Air-conditioning, Traffic Exposure and Asthma and Allergies in Preschool Children …………………………………………………………………………………………… 224 6.1 Literature Review 224 6.1.1 Background 224 6.1.2 Asthma and Allergies and Traffic Exposures 224 6.1.3 Traffic-Related Exposures, Indoor Environments and Air-Conditioning 225 6.1.4 The Singapore Context and Identification of Knowledge Gap 227 vii _ 6.2 Objectives 228 6.3 Methods 228 6.3.1 Questionnaires 228 6.3.1 Partial Validation Studies 230 6.4 Results 230 6.5 Discusssion 239 6.6 Conclusions 242 Final Remarks 243 7.1 Conclusion 243 7.2 Review and Achievement of Objectives and Findings 243 7.2.1 First Objective 243 7.2.2 Second Objective 244 7.2.3 Third Objective 245 7.2.4 Fourth Objective 246 7.2.5 Fifth Objective 247 7.3 Implications and Recommendations 248 References 252 A Appendix Indoor Air Quality (IAQ) 291 A.1 Comparability of Instruments and Techniques– Results of Collocated Measurements 291 A.1.1 Instruments Measuring Carbon Dioxide (CO2) 291 A.1.2 Instruments Measuring Carbon Monoxide (CO) 292 A.1.3 Instruments Measuring Fine Particles (PM2.5) 292 A.1.4 Instruments Measuring Ozone (O3) 293 A.1.5 Air Exchange Rates Measurements Using CO2 and SF6 as Tracer Gases 293 A.2 Detection Limits of Measurements 294 A.2.1 Bacteria and Fungi 294 A.2.2 VOCs and Carbonyls 294 A.2.3 Allergens 294 A.3 Paired Measurements 296 A.3.1 Bacteria and Fungi 296 A.3.2 VOCs and Carbonyls 296 viii Appendix Figure A.15 Kirby Dust Sampling Apparatus Figure A.16 ELISA System 301 Appendix Figure A.17 Bioplex MicroArray System 302 Appendix B APPENDIX CHILD CARE CENTER BUILDING INSPECTION SHEET 303 Appendix CCC BUILDING CHECKLIST INTERVIEWER: CCC ID: CCC Name: Previous tenant: No of Occupants: CCC Age: MAIN BUILDING CHARACTERITICS CATEGORY CTRL CITY OUTR CITY ESTATE SUBRUBAN COMMENTS SMALL LOCAL STRT LOCAL STRT EXPRESSWAY NONE COMMENTS LIGHT MEDIUM HEAVY Type of place/location CATEGORY Traffic type CATEGORY COMMENTS Traffic density CATEGORY FACTORY DUMP CAR PARK CONSTR NONE COMMENTS Other pollution CATEGORY VOID DCK COM OFF BGL/TRC OWN OTHERS COMMENTS > 800 CAPACITY Building type CATEGORY < 100 100 < 200 200 < 500 500 < 800 Floor area (m2) CATEGORY 1-3 4-5 6-10 > 10 COMMENTS No of rooms CATEGORY COMMENTS Storey CATEGORY NONE 15 COMMENTS Plant units BUILDING VENTILATION CHARACTERITICS CATEGORY ACMV HB NV AC COMMENTS Type of ventilation CATEGORY AGE Age of ventilation system CATEGORY YES/NO Mechanical Fans CATEGORY CATEGORY no of hours COMMENTS NO OF HOURS COMMENTS NO OF HOURS COMMENTS Ventilation time CATEGORY Fan time YES/NO AC CATEGORY AC time CATEGORY ASHRAE 30-50% ASHRAE 50-80% HEPA OTHERS COMMENTS Filter standard 304 Appendix CATEGORY HEPA ESP UV O3 OTHERS COMMENTS Standalone air cleaner CATEGORY MONTHS COMMENTS Last change / maintain air filter CATEGORY YES/NO CATEGORY Windows Opened YES/NO COMMENTS F/A near Sources CATEGORY CENTRAL LOCAL BOTH NONE COMMENTS Temperature control BUILDING SURFACES CHARACTERITICS CATEGORY MURAL GYPSUM WOOD CONCRETE COMMENTS CARPET (PART/FULL) PVC (VINYL) WOOD CERAMIC/C ONCRETE COMMENTS Wall surfaces CATEGORY Floors m2 Estimated floor covered area CATEGORY PRESSED WOOD MAT Shelves PLASTIC COMMENTS m2 Estimated shelf area CATEGORY YES/NO Curtains BLINDS TEXTILE COMMENTS m2 Estimated curtain area CATEGORY PRESSED WOOD MAT Tables PLASTIC COMMENTS m2 Estimated table area CATEGORY MIN WOOL CONC WOOD OTHERS COMMENTS YES/NO COMMENTS Ceiling materials CATEGORY YES/NO Recently renovated (< yr) CATEGORY Recently painted (1 yr) MAINTENANCE CHARACTERISTICS CATEGORY 2X DAILY DAILY 2-4X WEEKLY WEEKLY > WEEKLY COMMENTS Floor cleaning CATEGORY DAILY 2-4X WEEKLY WEEKLY MONTHLY >6 MONTHLY COMMENTS Shelf cleaning CATEGORY X DAILY DAILY 2-4X WEEKLY WEEKLY COMMENTS DAILY 2-4X WEEKLY WEEKLY > WEEKLY COMMENTS Toilet cleaning CATEGORY Mattress cleaning 305 Appendix CATEGORY WEEKLY MONTHLY ≤6 MONTHLY > MONTHLY COMMENTS ≤MONHTLY COMMENTS Curtains cleaning CATEGORY DAILY 2-4X WEEKLY WEEKLY Toys cleaning DAMP & MOLD CHARACTERISTICS CATEGORY YES/NO Visible Damp Stains CATEGORY YES/NO COMMENTS Signs of mold CATEGORY CATEGORY Location MILD MODEST SERIOUS NONE Extent of problem ANIMALS CATEGORY YES/NO Cats CATEGORY YES/NO COMMENTS CATEGORY YES/NO COMMENTS CATEGORY YES/NO COMMENTS CATEGORY YES/NO COMMENTS YES/NO COMMENTS YES/NO COMMENTS Dogs CATEGORY YES/NO Birds cockroach CATEGORY YES/NO Ants mice CATEGORY YES/NO Cats neighbouring CATEGORY Dogs neighbouring YES/NO Birds neighbouring CATEGORY Ants neighbouring CATEGORY cockroach neighbouring YES/NO CATEGORY mice neighbouring 306 Appendix C APPENDIX PARENTS ADMINISTERED QUESTIONNAIRE 307 Appendix Child Care Center: _ Date: _ (dd/mm/yy) Escrow No: _ Questionnaire Survey on Breathing, Nose and Skin Problems in Children Person completing this questionnaire: Mother Father Guardian Child’s Particulars Name: (optional) Gender: Race: M Chinese Type of Housing: F Age: Malay HDB Total monthly family income: Postal code: Date of birth: _(dd/mm/yy) Indian Others Private Apartments/HUDC Below $2000 $2000-3999 Landed Property $4000-5999 $6000 and above Number of people living together (including child): _ Age of child (to the nearest year) when he/she first attended any form of childcare _ years How many brothers and sisters does this child have? or more Is he/she the Was this child ever breastfed? If YES, he/she was breastfed exclusively for 1st born 2nd born 3rd born or higher ? No Yes less than months months and above Was this child born at least one month before his/her due date (premature)? What was the weight of your child when he/she was born? Has a doctor diagnosed this child to be allergic to any food? No Yes How does your child get to the child care center? Walking Public Bus Transport Car Others MRT No Yes kg When choosing a child care for your child, have you refrained from child care centers with air conditioning because of allergic or respiratory diseases? No Yes 10 When choosing a child care for your child, have you refrained from child care centers close to traffic because of allergic or respiratory diseases? No Yes 11 Have you changed child care centers for your child due to allergic or respiratory illness? No Yes 308 Appendix SECTION I Has your child ever had wheezing or whistling in the chest at any time in the past? Yes No IF YOU HAVE ANSWERED “NO” PLEASE SKIP TO QUESTION Has your child had wheezing or whistling in the chest in the last 12 months? Yes No IF YOU HAVE ANSWERED “NO” PLEASE SKIP TO QUESTION How many attacks of wheezing has your child had in the last 12 months? None to to 12 More than 12 In the past 12 months, how often, on average, has your child’s sleep been disturbed due to wheezing? Never woken with wheezing Less than one night per week One or more nights per week In the last 12 months, has wheezing ever been severe enough to limit your child’s speech to only one or two words at a time between breathes? Yes No Has your child ever had asthma? Yes No In the past 12 months, has your child’s chest sounded wheezy during or after exercise? Yes No In the past 12 months, has your child had a dry cough at night, apart from a cough associated with a cold or chest infection? Yes No SECTION II Has your child ever had a problem with sneezing or a runny or blocked nose when he/ she DID NOT have a cold or flu? Yes No IF YOU ANSWERED “NO” PLEASE SKIP TO QUESTION in Section II In the past 12 months, has your child ever had a problem with sneezing or a runny or blocked nose when he/ she DID NOT have a cold or a flu? Yes No IF YOU ANSWERED “NO” PLEASE SKIP TO QUESTION in Section II In the past 12 months, has this nose problem been accompanied by itchy-watery eyes? Yes No Not at all A little A moderate amount A lot In the past 12 months, how much did this nose problem interfere with your child’s daily activities: Has your child ever had allergic rhinitis? Yes No Don’t know 309 Appendix SECTION III Has your child ever had an itchy rash which was coming and going for at least six months? Yes No IF YOU HAVE ANSWERED “NO” PLEASE SKIP TO QUESTION in Section III Has your child had this itchy rash at any time in the last 12 months? Yes No IF YOU HAVE ANSWERED “NO” PLEASE SKIP TO QUESTION in Section III Has this itchy rash at any time affected any of the following places: The folds of the elbows, behind the knees, in front of the ankles, under the buttocks, or around the neck, Yes cheeks, ears or eyes? No At which age did this itchy rash first occur? Under year Age 2-4 years Age or more Don’t know Has this rash cleared completely at any time during the last 12 months? Yes No In the past 12 months, how often, on average, has your child been kept awake at night by this itchy rash? Never in the last 12 months Less than one night per week One or more nights per week Has your child ever had eczema? No Yes Don’t know SECTION IV If your child has or ever had asthma, please answer the following questions If your child has “NO” asthma, please skip this section and go to section V In the past 12 months, how often, on average, has your child experienced asthma attacks in the daytime? Not at all Less frequently than monthly 1-3 times a month 1-3 times a week 4-6 times a week Every day In the past 12 months, how often, on average, have your child experienced asthma attacks in the night? Not at all Less frequently than monthly 1-3 times a month 1-3 times a week 4-6 times a week Every day In the past 12 months, how many days (or part days) of school has your child missed because of wheezing or asthma? None to to 10 More than 10 310 Appendix In the past 12 months, how many times has your child visited a General Practitioner’s clinic or Specialist's Clinic for asthma (e.g a wheezy episode and regular asthma checkup)? None to visits to 12 visits More than 12 visits In the past 12 months, how many times has your child visited the Accident & Emergency Department in any hospital for asthma (e.g a wheezy episode and regular asthma checkup)? None to visits to 12 visits More than 12 visits In the past 12 months, how many times has your child been admitted to hospital because of wheezing or asthma? None to times to times or more SECTION V In the past 12 months, does this child usually have a cough with colds/flu? Yes No If YES: Does this child cough at most days (4 or more days a week) for as much as months or more a year? Yes No In the past 12 months, does this child usually seem congested (full of phlegm) in the chest or bring up phlegm with colds/flu? Yes No If YES: Does this child seem congested or bring up phlegm, sputum, or mucus from his/her chest on most days (4 or more days a week) for as much as months or more a year? Yes No In the past 12 months, does this child get attacks (increased) cough, chest congestion, or phlegm lasting for week or more each year? Yes No In the past 12 months, how often does this child gets a cold? Daily to times per week to times per month less than day per month In the past 12 months, how often does this child gets middle ear infection? Daily to times per week to times per month less than day per month Has this child been diagnosed with any of the following illness? If yes, please state the AGE when he/she was first diagnosed and the number of TIMES the illness has re-occurred till now a Bronchiolitis If YES, it has occurred No Only once Yes, 1st diagnosed at age _ 2-3 times or more Don’t know b Bronchitis If YES, it has occurred No Only once Yes, 1st diagnosed at age _ 2-3 times or more Don’t know c Pneumonia If YES, it has occurred No Only once Yes, 1st diagnosed at age _ 2-3 times or more Don’t know d Croup (larygotracheobronchitis) If YES, it has occurred No Only once Yes, 1st diagnosed at age _ 2-3 times or more Don’t know 311 Appendix Parents’ Particulars Highest level of education completed by child’s mother: Primary Secondary (‘O’ or ‘A’ levels’) Highest level of education completed by child’s father: Primary Tertiary (Diploma, Degree or higher) Secondary (‘O’ or ‘A’ levels’) Tertiary (Diploma, Degree or higher) Does anyone living with the child smoke cigarettes in the presence of the child in the home? Yes No Please state the number of people living in the household who smoke cigarettes in the home, including parents: _ Does the child’s father (or male guardian) smoke cigarettes in the home? Yes If YES, please state the number of cigarettes the child’s father (or male guardian) smoke each day in the home: 1-10 cigarettes 11-20 cigarettes No Does the child’s mother (or female guardian) smoke cigarettes in the home? Yes No If YES, please state the number of cigarettes the child’s mother (or female guardian) smoke each day in the home: 1-10 cigarettes 11-20 cigarettes Did the child’s mother (or female guardian) smoke cigarettes during the child’s first year of life? Yes No Has the mother ever been diagnosed with a Asthma b Allergic rhinitis (Sensitive Nose) c Eczema / Atopic Dermatitis(Sensitive Skin) Yes Yes Yes No No No Don’t know Don’t know Don’t know Has the father ever been diagnosed with a Asthma b Allergic rhinitis (Sensitive Nose) c Eczema / Atopic Dermatitis(Sensitive Skin) Yes Yes Yes No No No Don’t know Don’t know Don’t know Home Particulars Has the child lived at the present residence the whole of his/her life? Yes No, lived for: How old is the age of your residence? year 2-3 years more than 10 years 4-5 years less than or equal to 10 years In which room does the child sleep most of his/her sleeping time? Child’s own room Sharing room with siblings Parent’s room State what kind of flooring material there is in the different rooms Child’s room Vinyl flooring Wood flooring Wall to wall Carpet Parent’s room Vinyl flooring Wood flooring Wall to wall Carpet Living room Vinyl flooring Wood flooring Wall to wall Carpet State what kind of wall types there is in the different rooms Child’s room Parent’s room Living room Wall paper Wall paper Wall paper Wooden panel Wooden panel Wooden panel Normal concrete wall Normal concrete wall Normal concrete wall Ceramic Tiles Ceramic Tiles Ceramic Tiles Others Others Others Linoleum Tiles Linoleum Tiles Linoleum Tiles Don’t know Don’t know Don’t know 312 Appendix State what kind of ventilation you rely on in the different rooms? Child’s room Open window Air-conditioning unit Parent’s room Open window Air-conditioning unit Living room Open window Air-conditioning unit Have any major renovations been done to the residence? a) If YES, when was it done? 12 months ago Others Others Others Yes Earlier Don’t know Don’t know Don’t know No Not known b) If YES, was the renovation an action taken due to problems with damp and mold in the residence? Yes No Have any of the rooms stated below been repainted during the past 12 months? Child’s room Yes No Don’t know Earlier Parent’s room Yes No Don’t know Earlier Living room Yes No Don’t know Earlier Have you ever notice any visible mould on the floor, walls or ceiling in any of the rooms stated below? Child’s room Yes No Don’t know Parent’s room Yes No Don’t know Living room Yes No Don’t know 10 Have you ever notice any visible damp stains on the floor, walls or ceiling in any of the rooms stated below? Child’s room Yes No Don’t know Parent’s room Yes No Don’t know Living room Yes No Don’t know 11 Is your residence near a road (not more than 100m: about length of a football field)? If YES, what floor is your residence on? 1-3 storeys 4-8 storeys If YES, describe the traffic density Light Medium 12 What type of fuel/stove you use for cooking? Gas stove Solid Fuel Electric stove Yes > storeys Heavy No Others/Don’t know 13 How often you vacuum clean, sweep or mop (wet) the floor in the child’s room? Every day Twice weekly Weekly Monthly 14 How often you change the mattress cover in the child’s room? Every day Twice weekly Weekly Monthly 15 In the past 12 months, did you have cats at home? or did you have dogs at home? or did you have birds at home? Less frequent Less frequent Yes Yes Yes No No No 16 Have you got rid of any furred animals/pets due to allergic illness in the family? Yes No 17 Have you refrained from getting any furred animals/pets due to allergic illness in the family? Yes No 18 Are there any furred animals/pets that the child regularly meets at friends, relatives or others? Yes No Thank you for taking the time to complete this questionnaire The information you have provided is confidential 313 Appendix D APPENDIX HOME INSPECTION SHEET 314 Appendix HOME CHECKLIST INSPECTOR: HOME ID: Date: _ (dd/mm/yy) Did you observe ash tray in these places? Child’s room Comments: _ Living room Parent’s room Kitchen State what kind of flooring material there is in the different rooms Child’s room Vinyl flooring Wood flooring Wall to wall Carpet Parent’s room Vinyl flooring Wood flooring Wall to wall Carpet Living room Vinyl flooring Wood flooring Wall to wall Carpet Comments: _ State what kind of wall types there is in the different rooms Ceramic Tiles Ceramic Tiles Ceramic Tiles Child’s room Wall paper Wooden panel Normal concrete wall Parent’s room Wall paper Wooden panel Normal concrete wall Living room Wall paper Wooden panel Normal concrete wall Comments: _ State what kind of ventilation in the different rooms? Others Others Others Linoleum Tiles Linoleum Tiles Linoleum Tiles Don’t know Don’t know Don’t know Child’s room Open window Air-conditioning unit Others Parent’s room Open window Air-conditioning unit Others Living room Open window Air-conditioning unit Others Comments: _ Did you observe any visible mould on the floor, walls or ceiling in the different rooms? Child’s room Yes No Parent’s room Yes No Living room Yes No Comments: _ Did you observe any visible damp stains on the floor, walls or ceiling in the different rooms? Child’s room Yes No Parent’s room Yes No Living room Yes No Comments: _ What type of fuel/stove is used for cooking? Gas stove Solid Fuel Electric stove Comments: _ Is residence near a road? Yes No What floor is the residence on? 1-3 storeys Describe the traffic density outside the residence Light Comments: _ Did you observe any cat/s in the home? Did you observe any dog/s in the home? Did you observe any bird/s in the home? Comments: _ Others 4-8 storeys Medium > storeys Heavy Yes Yes Yes No No No 315 .. .CHILD CARE CENTRE AND HOME EXPOSURES AMONG PRESCHOOL CHILDREN IN SINGAPORE AND THEIR ASSOCIATIONS WITH ASTHMA, ALLERGIES AND RESPIRATORY SYMPTOMS ZURAIMI BIN MOHAMED SULTAN... linking traffic exposures to asthma and allergies among preschool children in Singapore is lacking in the literature Most research works linking traffic exposures and asthma and allergies among children. .. environments in CCCs and homes in the tropics for preschool children KEYWORDS Indoor Air Quality (IAQ); Child Care Centers (CCCs); Homes; Preschool Children; Asthma and Allergies; Respiratory Symptoms; Exposures;