Abstract
Objective
Phthalate acid esters (PAEs) have been identified to be associated with children’s health. Present study was conducted to assess associations between PAEs in household dust and childhood rhinitis.
Methods
Based on phase II of CCHH study (China, Children, Home, Health) conducted in Shanghai, China, 266 indoor dust samples were collected from participants’ families. Concentrations of PAEs in dust samples were measured by chemical treatment and gas chromatograph–mass spectrometer. Information about individuals and residences was surveyed by questionnaires. Logistic regression models were applied to obtain the associations between PAEs and childhood rhinitis.
Results
Higher concentrations of benzyl butyl phthalate (BBP) were found in those families with children who had diagnosed rhinitis. Significantly higher concentrations of bis(2-ethylhexyl) phthalate (DEHP) and PAEs with high molecular weight (HMW-PAEs) were found in the positive group of lifetime rhinitis. Using the multiple and ordinal logistic regression models adjusted by covariates, dibutyl phthalate (DBP), DEHP, and HMW-PAEs were found to be significantly associated with diagnosed rhinitis. Boys who exposure to higher concentrations of DBP, DEHP, HMW-PAEs, and total PAEs have significant associations with diagnosed rhinitis compared with girls who exposure to lower concentration of PAEs.
Conclusions
Present observational study indicated that exposure to high concentrations of DBP, DEHP, and HMW-PAEs in house settled dust was a risk factor for rhinitis for children, especially for boys.
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References
Afshari A, Gunnarsen L, Clausen PA, Hansen V (2004) Emission of phthalates from PVC and other materials. Indoor Air 14(2):120–128
Asher MI, Montefort S, Björkstén B, Lai CK, Strachan DP, Weiland SK, Williams H ISAAC Phase Three Study Group (2006) Worldwide time trends in the prevalence of symptoms of asthma, allergic rhinoconjunctivitis, and eczema in childhood: ISAAC phases one and three repeat multicountry cross-sectional surveys. Lancet 368(9537):733–743
Bamai YA, Shibata E, Saito I, Araki A, Kanazawa A, Morimoto K, Nakayama K, Tanaka M, Takigawa T, Yoshimura T, Chikara H, Saijo Y, Kishi R (2014) Exposure to house dust phthalates in relation to asthma and allergies in both children and adults. Sci Total Environ 485:153–163
Bamai YA, Araki A, Kawai T, Tsuboi T, Saito I, Yoshioka E, Shi C, Kishi R (2016) Exposure to phthalates in house dust and associated allergies in children aged 6–12 years. Environ Int 96:16–23
Barrenäs F, Andersson B, Cardell LO, Langston M, Mobini R, Perkins A (2008) Gender differences in inflammatory proteins and pathways in seasonal allergic rhinitis. Cytokine 42(3):325–329
Bekö G, Callesen M, Weschler CJ, Toftum J, Langer S, Sigsgaard T, Høst A, Kold Jensen T, Clausen G (2015) Phthalate exposure through different pathways and allergic sensitization in preschool children with asthma, allergic rhinoconjunctivitis and atopic dermatitis. Environ Res 137:432–439
Bølling AK, Sripada K, Becher R, Bekö G (2020) Phthalate exposure and allergic diseases: review of epidemiological and experimental evidence. Environ Int. https://doi.org/10.1016/j.envint.2020.105706
Bornehag CG, Sundell J, Weschler CJ, Sigsgaard T, Lundgren B, Hasselgren M, Hägerhed-Engman L (2004) The association between asthma and allergic symptoms in children and phthalates in house dust: a nested case-control study. Environ Health Perspect 112(14):1393–1397
Bornehag CG, Sundell J, Hagerhed-Engman L, Sigsggard T, Janson S, Aberg N, DBH Study Group (2005) ‘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 15:48–55
Bosetti C, McLaughlin JK, Tarone RE, Pira E, La Vecchia C (2008) Formaldehyde and cancer risk: a quantitative review of cohort studies through 2006. Ann Oncol 19(1):29–43
Bousquet J, Cauwenberge PV, Khaltaev N (2001) Allergic rhinitis and its impact on asthma. J Allergy Clin Immunol 108(5):S147–S334
Bråbäck L, Hjern A, Rasmussen F (2004) Trends in asthma, allergic rhinitis and eczema among Swedish conscripts from farming and nonfarming environments. A nationwide study over three decades. Clin Exp Allergy 34:38–43
Brozek G, Lawson J, Szumilas D, Zejda J (2015) Increasing prevalence of asthma, respiratory symptoms, and allergic diseases: Four repeated surveys from 1993–2014. Respir Med 109(8):982–990
Burgos-Aceves MA, Abo-Al-Ela HG, Faggio C (2021) Physiological and metabolic approach of plastic additive effects: immune cells responses. J Hazard Mater. https://doi.org/10.1016/j.jhazmat.2020.124114
Cai J, Liu W, Hu Y, Shen L, Huang C (2017) Household environment, lifestyle behaviors, and dietary habits in relation to childhood atopic eczema in Shanghai, China. Int Arch Occup Environ Health 90(1):141–159
Chen W, Mempel M, Schober W, Behrendt H, Ring J (2008) Gender difference, sex hormones, and immediate type hypersensitivity reactions. Allergy 63(11):1418–1427
Choi H, Schmidbauer N, Sundell J, Hasselgren M, Spengler J, Bornehag CG (2010) Common household chemicals and the allergy risks in pre-school age children. PLoS ONE. https://doi.org/10.1371/journal.pone.0013423
Duty SM, Silva MJ, Barr DB, Brock JW, Ryan L, Chen ZY, Herrick RF, Christiani DC, Hauser R (2003) Phthalate exposure and human semen parameters. Epidemiology 14(3):269–277
Ehlayel MS, Bener A (2008) Duration of breast-feeding and the risk of childhood allergic diseases in a developing country. Allergy Asthma Proc 9(4):386–391
Fagan JK, Scheff PA, Hryhorczuk D, Ramakrishnan V, Ross M, Persky V (2001) Prevalence of asthma and other allergic diseases in an adolescent population: association with gender and race. Ann Allergy Asthma Immunol 86(2):177–184
Fang L, Christina N, Karoline J, Cui XX, Sun JQ, Teng YB, Tian EZ, Wu X, Li Z, Mo JH, Schauer JJ, Black M, Bergin M (2019) Toxic volatile organic compounds in 20 homes in Shanghai: concentrations, inhalation health risks, and the impacts of household air cleaning. Build Environ 15:309–318
Fröhlich M, Pinart M, Keller T, Reich A, Cabieses B, Hohmann C, Postma DS, Bousquet J, Antó JM, Keil T, Roll S (2017) Is there a sex-shift in prevalence of allergic rhinitis and comorbid asthma from childhood to adulthood? A meta-analysis. Clin Transl Allergy 7:44
Froidure A, Shen C, Pilette C (2016) Dendritic cells revisited in human allergic rhinitis and asthma. Allergy 71(2):137–148
Grize L, Gassner M, Wüthrich B, Bringolf-Isler B, Takken-Sahli K, Sennhauser FH, Stricker T, Eigenmann PA, Braun-Fahrländer C, Swiss Surveillance Programme on Childhood Allergy and Respiratory symptoms with respect to Air Pollution (SCARPOL) team (2010) Trends in prevalence of asthma, allergic rhinitis and atopic dermatitis in 5–7 year old Swiss children from 1992 to 2001. Allergy 61(5):556–562
Guo Y, Wang L, Kannan K (2014) Phthalates and parabens in personal care products from china: concentrations and human exposure. Arch Environ Contam Toxicol 66(1):113–119
Hansen JS, Larsen ST, Poulsen LK, Nielsen GD (2007) Adjuvant effects of inhaled mono-2-ethylhexyl phthalate in BALB/cJ mice. Toxicology 232(1–2):79–88
Hauser R, Meeker JD, Duty S, Silva MJ, Calafat AM (2006) Altered semen quality in relation to urinary concentrations of phthalate monoester and oxidative metabolites. Epidemiology 17(6):682–691
He M, Inoue KI, Yoshida S, Tanaka M, Takano H, Sun GF, Ichinose T (2013) Effects of airway exposure to di-(2-ethylhexyl) phthalate on allergic rhinitis. Immunopharmacol Immunotoxicol 35(3):390–395
Holgate ST, Djukanović R, Casale T, Bousquet J (2010) Anti-immunoglobulin E treatment with omalizumab in allergic diseases: an update on anti-inflammatory activity and clinical efficacy. Clin Exp Allergy 35(4):408–416
Hou J, Sun Y, Wang P, Zhang Q, Kong X, Sundell J (2021) Associations between ventilation and children’s asthma and allergy in naturally ventilated Chinese homes. Indoor Air 31(2):383–391
Hsu NY, Lee CC, Wang JY, Li YC, Chang HW, Chen CY, Bornehag CG, Wu PC, Sundell J, Su HJ (2012) Predicted risk of childhood allergy, asthma, and reported symptoms using measured phthalate exposure in dust and urine. Indoor Air 22(3):186–199
Hu Y, Liu W, Huang C, Cai J, Shen L, Zou ZJ, Sundell J (2015) Home dampness, childhood asthma, hay fever, and airway symptoms in Shanghai, China: associations, dose-response relationships, and lifestyle’s influences. Indoor Air 24(5):450–463
Hu D, Wang YX, Chen WJ, Zhang Y, Li HH, Xiong L, Zhu HP, Chen HY, Peng SX, Wan ZH, Zhang Y, Du YK (2017) Associations of phthalates exposure with attention deficits hyperactivity disorder: a case-control study among Chinese children. Environ Pollut 229:375–385
Huang LP, Lee CC, Fan JP, Kuo PH, Shih TS, Hsu PC (2014) Urinary metabolites of di(2-ethylhexyl) phthalate relation to sperm motility, reactive oxygen species generation, and apoptosis in polyvinyl chloride workers. Int Arch Occup Environ Health 87(6):635–646
Huang C, Liu W, Hu Y, Zou ZJ, Zhao ZH, Shen L, Weschler LB, Sundell J (2015) Updated prevalences of asthma, allergy, and airway symptoms, and a systematic review of trends over time for childhood asthma in Shanghai, China. PLoS ONE. https://doi.org/10.1371/journal.pone.0121577
Huang HC, Lin FC, Wu MF, Nfor ON, Hsu SY, Lung CC, Ho CC, Chen CY, Liaw YP (2019) Association between chronic obstructive pulmonary disease and PM2.5 in Taiwanese nonsmokers. Int J Hyg Environ Health 222(5):884–888
Hulin M, Simoni M, Viegi G, Annesi-Maesano I (2012) Respiratory health and indoor air pollutants based on quantitative exposure assessments. Eur Respir J 40(4):1033–1045
Kanazawa A, Saito I, Araki A, Takeda M, Ma M, Saijo Y, Kishi R (2010) Association between indoor exposure to semi-volatile organic compounds and building-related symptoms among the occupants of residential dwellings. Indoor Air 20(1):72–84
Khan M, Khan MA, Shabbir F, Rajput TA (2013) Association of allergic rhinitis with gender and asthma. J Ayub Med Coll Abbottabad 25(1–2):120–122
Kim MA, Yon DK, Jee HM, Kim JH, Park J, Lee SW, Sung M, Sheen YH, Han MY (2020) Association of phthalates with nasal patency and small airway dysfunction in first-grade elementary school children. Allergy 75(11):2967–2969
Kimber I, Dearman RJ (2010) An assessment of the ability of phthalates to influence immune and allergic responses. Toxicology 271(3):73–82
Klepeis NE, Nelson WC, Ott WR, Robinson JP, Tsang AM, Switzer P, Behar JV, Hern SC, Engelmann WH (2001) The national human activity pattern survey (NHAPS): a resource for assessing exposure to environmental pollutants. J Expo Anal Environ Epidemiol 11(3):231–252
Koike E, Inoue KI, Yanagisawa R, Takano H (2009) Di-(2-ethylhexyl) phthalate affects immune cells from atopic prone mice in vitro. Toxicology 259(1–2):54–60
Kolarik B, Bornehag CG, Naydenov K, Sundell J, Stavova P, Nielsen OF (2008) The concentrations of phthalates in settled dust in Bulgarian homes in relation to building characteristic and cleaning habits in the family. Atmos Enviro 42(37):8553–8559
Kuo CH, Hsieh CC, Kuo HF, Huang MY, Yang SN, Chen LC, Huang SK, Hung CH (2013) Phthalates suppress type i interferon in human plasmacytoid dendritic cells via epigenetic regulation. Allergy 68:870–879
Kurukulaaratchy RJ, Karmaus W, Arshad SH (2012) Gender and atopy influences on the natural history of rhinitis. Curr Opin Allergy Clin Immunol 12(1):7–12
Lan Q, Cui KY, Zeng F, Zhu F, Liu H, Chen HL, Ma YQ, Wen JX, Luan TG, Sun GQ, Zeng ZX (2012) Characteristics and assessment of phthalate esters in urban dusts in Guangzhou city. China Environ Monit Assess 184(8):4921–4929
Langer S, Weschler CJ, Fischer A, Bekö G, Toftum J, Clausen G (2010) Phthalate and PAH concentrations in dust collected from Danish homes and daycare centers. Atmos Environ 44(19):2294–2301
Larsen ST, Lund RM, Nielsen GD, Thygesen P, Poulsen OM (2010) Adjuvant effect of di-n-butyl-, di-n-octyl-, di-iso-nonyl- and di-iso-decyl phthalate in a subcutaneous injection model using BALB/c mice. Pharmacol Toxicol 91(5):264–272
Larsson M, Hagerhed-Engman L, Kolarik B, James P, Lundin F, Janson S, Sundell J, Bornehag CG (2010) PVC—as flooring material—and its association with incident asthma in a Swedish child cohort study. Indoor Air 20(6):494–501
Lau YL, Karlberg J (1998) Prevalence and risk factors of childhood asthma, rhinitis and eczema in Hong Kong. J Paediatr Child Health 34:47–52
Li L, Li HS, Song NN, Chen HM (2013) The immunotoxicity of dibutyl phthalate on the macrophages in mice. Immunopharmacol Immunotoxicol 35(2):272–281
Li HL, Song WW, Zhang ZF, Ma WL, Gao CJ, Li J, Huo CY, Mohammed MOA, Liu LY, Kannan K, Li YF (2016) Phthalates in dormitory and house dust of northern Chinese cities: occurrence, human exposure, and risk assessment. Sci Total Environ 565:496–502
Liao CX, Liu W, Zhang JL, Shi WM, Wang X, Cai J, Zou ZJ, Lu RC, Sun CJ, Wang H, Huang C, Zhao ZH (2018) Associations of urinary phthalate metabolites with residential characteristics, lifestyles, and dietary habits among young children in Shanghai, China. Sci Total Environ 616–617:1288–1297
Liu Y, Lee K, Perez-Padilla R, Hudson NL, Mannino DM (2008) Outdoor and indoor air pollution and COPD-related diseases in high- and low-income countries. Int J Tuberc Lung Dis 12(2):115–127
Liu W, Huang C, Hu Y, Zou ZJ, Sundell J (2013) Associations between indoor environmental smoke and respiratory symptoms among preschool children in Shanghai. China Chin Sci Bull 58(034):4211–4216
Marco RD, Cappa V, Accordini S, Rava M, Verlato G (2012) Trends in the prevalence of asthma and allergic rhinitis in Italy between 1991 and 2010. Eur Respir J 39(4):883–892
McGwin G, Lienert J, Kennedy JI (2010) Formaldehyde exposure and asthma in children: a systematic review. Environ Health Perspect 118(3):313–317
Meeker JD (2012) Exposure to environmental endocrine disruptors and child development. Arch Pediatr 166(6):E1-7
Meltzer EO (2016) Allergic rhinitis: burden of illness, quality of life, comorbidities, and control. Immunol Allergy Clin North Am 36(2):235–248
Mimura T, Ichinose T, Yamagami S, Fujishima H, Kamei Y, Goto M, Takada S, Matsubara M (2014) Airborne particulate matter (PM2.5) and the prevalence of allergic conjunctivitis in Japan. Sci Total Environ 487(1):493–499
Naydenov K, Melikov A, Markov D, Stankov P, Bornehag CG, Sundell J (2008) A comparison between occupants’ and inspectors’ reports on home dampness and their association with the health of children: the ALLHOME study. Build Environ 43(11):1840–1849
Orecchio S, Indelicate R, Barreca S (2013) The distribution of phthalate esters in indoor dust of Palermo (Italy). Environ Geochem Health 35(5):613–624
Philippat C, Bennett DH, Krakowiak P, Rose M, Hwang HM, Hertz-Picciotto I (2015) Phthalate concentrations in house dust in relation to autism spectrum disorder and developmental delay in the childhood autism risks from genetics and the environment (CHARGE) study. Environ Health 14:56
Pinart M, Keller T, Reich A, Fröhlich M, Cabieses B, Hohmann C, Postma DS, Bousquet J, Antó JM, Keil T (2017) Sex-related allergic rhinitis prevalence switch from childhood to adulthood: a systematic review and meta-analysis. Int Arch Allergy Immunol 172(4):224–235
Rudel RA, Camann DE, Spengler JD, Korn LR, Brody JG (2003) Phthalates, alkylphenols, pesticides, polybrominated diphenyl ethers, and other endocrine-disrupting compounds in indoor air and dust. Environ Sci Technol 37(20):4543–4553
Rumchev K (2004) Association of domestic exposure to volatile organic compounds with asthma in young children. Thorax 59:746–751
Saikia N, Mathur HB, Agarwal HC (2010) Phthalates in toys. Bull Environ Contam Toxicol 86(6):621–626
Sakhi AK, Sabaredzovic A, Cequier E, Thomsen C (2017) Phthalate metabolites in Norwegian mothers and children: levels, diurnal variation and use of personal care products. Sci Total Environ 599:1984–1992
Sathyanarayana S, Karr CJ, Lozano P, Brown E, Calafat AM, Liu F, Swan SH (2008) Baby care products: possible sources of infant phthalate exposure. Pediatrics 121(2):e260-268
Schlesselman JJ (1974) Sample size requirements in cohort and case-control studies of disease. Am J Epidemiol 99(6):381–384
Shi WM, Lin ZJ, Liao CX, Zhang JL, Liu W, Wang XY, Cai J, Zou ZJ, Wang H, Norbäck D, Kan HD, Huang C, Zhao ZH (2018) Urinary phthalate metabolites in relation to childhood asthmatic and allergic symptoms in Shanghai. Environ Int 121:276–286
Shirinde J, Wichmann J, Voyi K (2015) Environmental tobacco smoke and the risk of eczema symptoms among school children in South Africa: a cross-sectional study. BMJ Open. https://doi.org/10.1136/bmjopen-2015-008234
Sioen I, Fierens T, Holderbeke MV, Geerts L, Bellemans M, Maeyer MD, Servaes K, Vanermen G, Boon PE, Henauw SD (2012) Phthalates dietary exposure and food sources for Belgian preschool children and adults. Environ Int 48:102–108
Skoner DP (2001) Allergic rhinitis: definition, epidemiology, pathophysiology, detection, and diagnosis. J Allergy Clin Immunol 108(1 Suppl):S2-8
Small P, Keith PK, Kim H (2018) Allergic rhinitis. allergy asthma. Clin Immunol 14:51–51
Smit LAM, Lenters V, Høyer BB, Lindh CH, Pedersen HS, Liermontova I, Jönsson BAG, Piersma AH, Bonde JP, Toft G, Vermeulen R, Heederik D (2015) Prenatal exposure to environmental chemical contaminants and asthma and eczema in school-age children. Allergy 70(6):653–660
Stelmach I, Majak P, Jerzynska J, Podlecka D, Stelmach W, Polańska K, Ligocka D, Hanke W (2015) The effect of prenatal exposure to phthalates on food allergy and early eczema in inner-city children. Allergy Asthma Proc 36(4):72–78
Tagiyeva N, Sheikh A (2014) Domestic exposure to volatile organic compounds in relation to asthma and allergy in children and adults. Expert Rev Clin Immunol 10(12):1611–1639
Tickner JA, Schettler T, Guidotti T, McCally M, Rossi M (2001) Health risks posed by use of Di-2-ethylhexyl phthalate (DEHP) in PVC medical devices: a critical review. Am J Ind Med 39(1):100–111
Torfi Y, Bitarafan N, Rajabi M (2015) Impact of socioeconomic and environmental factors on atopic eczema and allergic rhinitis: a cross sectional study. EXCLI J 14:1040–1048
Valero A, Justicia JL, Antón E, Dordal T, Navarro AM (2011) Epidemiology of allergic rhinitis caused by grass pollen or house-dust mites in Spain. Am J Rhinol Allergy 25(4):e123-128
Vermeulen R, Jnsson BAG, Lindh CH, Kromhout H (2005) Biological monitoring of carbon disulphide and phthalate exposure in the contemporary rubber industry. Int Arch Occup Environ Health 78(8):663–669
Wang HY, Zheng JP, Zhong NS (2006) Time trends in the prevalence of asthma and allergic diseases over 7 years among adolescents in Guangzhou city. Zhong Hua Yi Xue Za Zhi 86:1014–1020 ((In Chinese))
Wang XK, Tao W, Xu Y, Feng JT, Wang FH (2014) Indoor phthalate concentration and exposure in residential and office buildings in Xi’an, China. Atmos Environ 87:146–152
Xu ZN, Xiong X, Zhao YH, Xiang W, Wu CX (2020) Pollutants delivered every day: phthalates in plastic express packaging bags and their leaching potential. J Hazard Mater 384:12128
Yao TC, Chang SW, Chang WC, Tsai MH, Liao SL, Hua MC, Lai SH, Yeh KW, Tseng YL, Lin WC, Tsai HJ, Huang JL (2017) Exposure to tobacco smoke and childhood rhinitis: a population-based study. Sci Rep 7(1):10–30
Yon DK, Hwang S, Lee SW, Jee HM, Sheen YH, Kim JH, Lim DH, Han MY (2019) Indoor exposure and sensitization to formaldehyde among inner-city children with increased risk for asthma and rhinitis. Am J Respir Crit Care Med 200(3):388–393
Zhang Y, Zhang L (2014) Increasing prevalence of allergic rhinitis in China. Allergy Asthma Immunol Res 6(2):105–113
Zhang Y, Zhang L (2019) Increasing prevalence of allergic rhinitis in China. Allergy Asthma Immunol Res 11(2):156–169
Zhang YH, Zheng LX, Chen BH (2006) Phthalate exposure and human semen quality in Shanghai: a cross-sectional study. Biomed Environ Sci 19(3):205–209
Zhang FY, Krafft T, Zhang DS, Xu J, Wang WY (2012a) The association between daily outpatient visits for allergic rhinitis and pollen levels in Beijing. Sci Total Environ 417:39–44
Zhang MH, Xue JL, Zhao H, Gong YD, Fang MS (2012b) The detection and significance of total serum IgE in allergic rhinitis. Chin J Lab Diagn 16:6 ((In Chinese))
Zhang Q, Lu XM, Zhang XL, Sun YG, Zhang ZD (2013) Levels of phthalate esters in settled house dust from urban dwellings with young children in Nanjing, China. Atmos Environ 69:258–264
Funding
This work was support by National Natural Science Foundation of China (No.51708347); National key research and development program National Natural Science Foundation of China (No.2017YFC0702700); Shanghai Sailing Program (No.17YF1412800).
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All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by JL Zhang, RC Lu, ZJ Zou, and W Liu. The first draft of the manuscript was written by JL Zhang. Writing—review and editing, project administration, and supervision were performed by CJ Sun and C Huang. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.
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Zhang, J., Sun, C., Lu, R. et al. Association of childhood rhinitis with phthalate acid esters in household dust in Shanghai residences. Int Arch Occup Environ Health 95, 629–643 (2022). https://doi.org/10.1007/s00420-021-01797-6
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DOI: https://doi.org/10.1007/s00420-021-01797-6