Troeger C et al.2018. Estimates of the global, regional, and national morbidity, mortality, and aetiologies of lower respiratory infections in 195 countries, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Infect Dis 18: 1191–1210.
Rudan I, Boschi-Pinto C, Biloglav Z, Mulholland K, Campbell H , 2008. Epidemiology and etiology of childhood pneumonia. Bull World Health Organ 86: 408–416.
Apelberg BJ, Aoki Y, Jaakkola JJ , 2001. Systematic review: exposure to pets and risk of asthma and asthma-like symptoms. J Allergy Clin Immunol 107: 455–460.
Chen CM, Tischer C, Schnappinger M, Heinrich J , 2010. The role of cats and dogs in asthma and allergy: a systematic review. Int J Hyg Environ Health 213: 1–31.
Gorman J, Cook A, Ferguson C, van Buynder P, Fenwick S, Weinstein P , 2009. Pet birds and risks of respiratory disease in Australia: a review. Aust N Z J Public Health 33: 167–172.
Ho LA, Kuschner WG , 2012. Respiratory health in home and leisure pursuits. Clin Chest Med 33: 715–729.
Konradsen JR et al.2015. Allergy to furry animals: new insights, diagnostic approaches, and challenges. J Allergy Clin Immunol 135: 616–625.
Hofmaier S , 2014. Allergic airway diseases in childhood: an update. Pediatr Allergy Immunol 25: 810–816.
Busse WW, Lemanske RF Jr , Gern JE , 2010. Role of viral respiratory infections in asthma and asthma exacerbations. Lancet 376: 826–834.
Gern JE, Busse WW , 2002. Relationship of viral infections to wheezing illnesses and asthma. Nat Rev Immunol 2: 132–138.
Abdulrazzaq YM, Bener A, DeBuse P , 1995. Pet ownership in the UAE: its effect on allergy and respiratory symptoms. J Asthma 32: 117–124.
Kalyoncu AF et al.1994. Prevalence of childhood asthma and allergic diseases in Ankara, Turkey. Allergy 49: 485–488.
Hakanen E et al.2018. Urban environment predisposes dogs and their owners to allergic symptoms. Sci Rep 8: 1–9.
Lødrup Carlsen KC et al.2012. Does pet ownership in infancy lead to asthma or allergy at school age? Pooled analysis of individual participant data from 11 European birth cohorts. PLoS One 7: e43214.
Brunekreef B, Von Mutius E, Wong GK, Odhiambo JA, Clayton TO , 2012. Early life exposure to farm animals and symptoms of asthma, rhinoconjunctivitis and eczema: an ISAAC Phase Three Study. Int J Epidemiol 41: 753–761.
Myers KP, Setterquist SF, Capuano AW, Gray GC , 2007. Infection due to 3 avian influenza subtypes in United States veterinarians. Clin Infect Dis 45: 4–9.
Gray GC, McCarthy T, Capuano AW, Setterquist SF, Alavanja MC, Lynch CF , 2008. Evidence for avian influenza A infections among Iowa’s agricultural workers. Influenza Other Respir Viruses 2: 61–69.
Puzelli S et al.2005. Serological analysis of serum samples from humans exposed to avian H7 influenza viruses in Italy between 1999 and 2003. J Infect Dis 192: 1318–1322.
Crow R, Mutyara K, Agustian D, Kartasasmita CB, Simões EAF , 2021. Risk factors for respiratory syncytial virus lower respiratory tract infections: evidence from an Indonesian cohort. Viruses 13: 331.
Delahoy MJ et al.2018. Pathogens transmitted in animal feces in low- and middle-income countries. Int J Hyg Environ Health 221: 661–676.
Penakalapati G et al.2017. Exposure to animal feces and human health: a systematic review and proposed research priorities. Environ Sci Technol 51: 11537–11552.
Turner JC et al.2017. Insight into live bird markets of Bangladesh: an overview of the dynamics of transmission of H5N1 and H9N2 avian influenza viruses. Emerg Microbes Infect 6: e12.
Biswas PK, Giasuddin M, Chowdhury P, Barua H, Debnath NC, Yamage M , 2018. Incidence of contamination of live bird markets in Bangladesh with influenza A virus and subtypes H5, H7 and H9. Transbound Emerg Dis 65: 687–695.
Chakraborty A et al.2017. Mild respiratory illness among young children caused by highly pathogenic avian influenza A (H5N1) virus infection in Dhaka, Bangladesh, 2011. J Infect Dis 216: S520–S528.
Zambrano LD, Levy K, Menezes NP, Freeman MC , 2014. Human diarrhea infections associated with domestic animal husbandry: a systematic review and meta-analysis. Trans R Soc Trop Med Hyg 108: 313–325.
Parvin T et al.2020. Prospective cohort study of child mouthing of faeces and fomites in Dhaka, Bangladesh (CHoBI7 Program). Trop Med Int Health 25: 976–984.
Monira S et al.2020. Child mouthing of soil and presence of animals in child sleeping spaces are associated with growth faltering among young children in Dhaka, Bangladesh (CHoBI7 Program). Trop Med Int Health 25: 1016–1023.
Berkman DS, Lescano AG, Gilman RH, Lopez SL, Black MM , 2002. Effects of stunting, diarrhoeal disease, and parasitic infection during infancy on cognition in late childhood: a follow-up study. Lancet 359: 564–571.
Walker SP, Chang SM, Powell CA, Simonoff E, Grantham-McGregor SM , 2007. Early childhood stunting is associated with poor psychological functioning in late adolescence and effects are reduced by psychosocial stimulation. J Nutr 137: 2464–2469.
Tarleton JL, Haque R, Mondal D, Shu J, Farr BM, Petri WA Jr , 2006. Cognitive effects of diarrhea, malnutrition, and Entamoeba histolytica infection on school age children in Dhaka, Bangladesh. Am J Trop Med Hyg 74: 475–481.
Bhutta ZA et al.2013. Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost? Lancet 382: 452–477.
Weisz AJ et al.2012. Abnormal gut integrity is associated with reduced linear growth in rural Malawian children. J Pediatr Gastroenterol Nutr 55: 747–750.
George CM et al.2015. Fecal markers of environmental enteropathy are associated with animal exposure and caregiver hygiene in Bangladesh. Am J Trop Med Hyg. 93: 269–275.
Headey D, Hirvonen K , 2016. Is exposure to poultry harmful to child nutrition? An observational analysis for rural Ethiopia. PLoS One 11: e0160590.
George CM et al.2021. Effects of a water, sanitation and hygiene mobile health program on diarrhea and child growth in Bangladesh: a cluster-randomized controlled trial of the CHoBI7 mobile health program. Clin Infect Dis 73: e2560–e2568.
George CM et al.2019. Formative research for the design of a scalable water, sanitation, and hygiene mobile health program: CHoBI7 mobile health program. BMC Public Health 19: 1028.
National Institute of Population Research and Training , ICF , 2020. Bangladesh Demographic Health Survey, 2017–18. Available at: https://dhsprogram.com/pubs/pdf/FR344/FR344.pdf. Accessed November 30, 2021.
World Health Organization , 2014. Integrated Management of Childhood Illness (IMCI), revised. Geneva, Switzerland, WHO.
Shanmuganatham K et al.2013. Antigenic and molecular characterization of avian influenza A(H9N2) viruses, Bangladesh. Emerg Infect Dis 19: 1393–1402.
Ansari WK et al.2016. Surveillance, epidemiological, and virological detection of highly pathogenic H5N1 avian influenza viruses in duck and poultry from Bangladesh. Vet Microbiol 193: 49–59.
Negovetich NJ et al.2011. Live bird markets of Bangladesh: H9N2 viruses and the near absence of highly pathogenic H5N1 influenza. PLoS One 6: e19311.
Nasreen S et al.2015. Highly pathogenic avian influenza A(H5N1) virus infection among workers at live bird markets, Bangladesh, 2009–2010. Emerg Infect Dis 21: 629–637.
Shanta IS et al.2017. Raising backyard poultry in rural Bangladesh: financial and nutritional benefits, but persistent risky practices. Transbound Emerg Dis 64: 1454–1464.
Shortridge KF et al.1998. Characterization of avian H5N1 influenza viruses from poultry in Hong Kong. Virology 252: 331–342.
Ercumen A, Prottas C, Harris A, Dioguardi A, Dowd G, Guiteras R , 2020. Poultry ownership associated with increased risk of child diarrhea: cross-sectional evidence from Uganda. Am J Trop Med Hyg 102: 526–533.
Hossain MB, Khan JR , 2020. Association between household livestock ownership and childhood stunting in Bangladesh: a spatial analysis. J Trop Pediatr 66: 248–256.
Kaur M, Graham JP, Eisenberg JNS , 2017. Livestock ownership among rural households and child morbidity and mortality: an analysis of Demographic Health Survey data from 30 sub-Saharan African countries (2005–2015). Am J Trop Med Hyg 96: 741–748.
Schmidt WP, Cairncross S, Barreto ML, Clasen T, Genser B , 2009. Recent diarrhoeal illness and risk of lower respiratory infections in children under the age of 5 years. Int J Epidemiol 38: 766–772.
Ashraf S, Huque MH, Kenah E, Agboatwalla M, Luby SP , 2013. Effect of recent diarrhoeal episodes on risk of pneumonia in children under the age of 5 years in Karachi, Pakistan. Int J Epidemiol 42: 194–200.
Rodríguez L, Cervantes E, Ortiz R , 2011. Malnutrition and gastrointestinal and respiratory infections in children: a public health problem. Int J Environ Res Public Health 8: 1174–1205.
Parvin T et al.2021. Fecal contamination on the household compound and in water sources are associated with subsequent diarrhea in young children in urban Bangladesh (CHoBI7 Program). Am J Trop Med Hyg 105: 261–266.
Fournié G et al.2013. Interventions for avian influenza A (H5N1) risk management in live bird market networks. Proc Natl Acad Sci USA 110: 9177–9182.
Oberhelman RA et al.2006. An intervention-control study of corralling of free-ranging chickens to control Campylobacter infections among children in a Peruvian periurban shantytown. Am J Trop Med Hyg 74: 1054–1059.
Rimi, Nadia Ali et al., 2016. Understanding the failure of a behavior change intervention to reduce risk behaviors for avian influenza transmission among backyard poultry raisers in rural Bangladesh: a focused ethnography. BMC Public Health 16: 1–15.
Kuhl J et al.2021. Formative research for the development of baby water, sanitation, and hygiene interventions for young children in the Democratic Republic of the Congo (REDUCE program). BMC Public Health 21: 427.
Luby SP et al.2005. Effect of handwashing on child health: a randomised controlled trial. Lancet 366: 225–233.
McGuinness SL et al.2018. Effect of hygiene interventions on acute respiratory infections in childcare, school and domestic settings in low- and middle-income countries: a systematic review. Trop Med Int Health 23: 816–833.
Rabie T, Curtis V , 2006. Handwashing and risk of respiratory infections: a quantitative systematic review. Trop Med Int Health 11: 258–267.
World Health Organization , 2005. Effects of Air Pollution on Children's Health and Development. Geneva, Switzerland: WHO.
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There is limited evidence on the association between animal ownership and respiratory illness among young children in low- and middle-income countries. In this study, we examined the association between animal ownership and respiratory illness among children younger than 5 years of age enrolled in a prospective cohort study in urban Bangladesh. This prospective cohort study enrolled 884 participants younger than 5 years of age in Dhaka, Bangladesh. At baseline, trained research assistants administered caregivers of children younger than 5 years of age a questionnaire on household animal ownership. Animal ownership was defined as owning chickens, birds other than chickens, cats, and dogs. Respiratory surveillance was conducted monthly for children based on caregiver-reported coughing, rapid breathing, and difficulty breathing in the past 2 weeks during the 12-month study period. At baseline, 48% of children (424 of 884) had reports of coughing, 5% (40 of 884) had difficulty breathing, 3% (25 of 884) had rapid breathing, and 49% (431 of 884) had reports of any of these three respiratory symptoms. Seventeen percent of children (151 of 884) resided in a household that owned an animal. Children residing in households reporting bird ownership had a significantly greater odds of coughing (odds ratio, 1.14; 95% CI, 1.02–1.28) and any of the three respiratory symptoms in the past 2 weeks (odds ratio, 1.14; 95% CI, 1.02–1.28). Household bird ownership was associated with respiratory illness in young children. These findings suggest that interventions aiming to reduce young children’s exposure to domestic animals should extend to include birds other than chickens.
Authors’ addresses: Tahmina Parvin, Md. Sazzadul Islam Bhuyian, Ismat Minhaj Uddin, Md. Tasdik Hasan, Fatema Zohura, Jahed Masud, Shirajum Monira, Munirul Alam, and ASG Faruque, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh, E-mails: tparvin@icddrb.org, sazzadul.islam@icddrb.org, ismat.minhaj@icddrb.org, tasdikhdip@yahoo.com, fzohura@icddrb.org, jahed@icddrb.org, smonira@icddrb.org, munirul@icddrb.org, and gfaruque@icddrb.org. Elizabeth D. Thomas, Kelly Endres, Jamie Perin, and Christine Marie George, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, E-mails: liz.thomas@jhu.edu, kendres4@jhu.edu, jperin@jhu.edu, and cgeorg19@jhu.edu. Daniel Leung, Division of Infectious Diseases, University of Utah School of Medicine, Salt Lake City, UT, E-mail: daniel.leung@utah.edu.
Troeger C et al.2018. Estimates of the global, regional, and national morbidity, mortality, and aetiologies of lower respiratory infections in 195 countries, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Infect Dis 18: 1191–1210.
Rudan I, Boschi-Pinto C, Biloglav Z, Mulholland K, Campbell H , 2008. Epidemiology and etiology of childhood pneumonia. Bull World Health Organ 86: 408–416.
Apelberg BJ, Aoki Y, Jaakkola JJ , 2001. Systematic review: exposure to pets and risk of asthma and asthma-like symptoms. J Allergy Clin Immunol 107: 455–460.
Chen CM, Tischer C, Schnappinger M, Heinrich J , 2010. The role of cats and dogs in asthma and allergy: a systematic review. Int J Hyg Environ Health 213: 1–31.
Gorman J, Cook A, Ferguson C, van Buynder P, Fenwick S, Weinstein P , 2009. Pet birds and risks of respiratory disease in Australia: a review. Aust N Z J Public Health 33: 167–172.
Ho LA, Kuschner WG , 2012. Respiratory health in home and leisure pursuits. Clin Chest Med 33: 715–729.
Konradsen JR et al.2015. Allergy to furry animals: new insights, diagnostic approaches, and challenges. J Allergy Clin Immunol 135: 616–625.
Hofmaier S , 2014. Allergic airway diseases in childhood: an update. Pediatr Allergy Immunol 25: 810–816.
Busse WW, Lemanske RF Jr , Gern JE , 2010. Role of viral respiratory infections in asthma and asthma exacerbations. Lancet 376: 826–834.
Gern JE, Busse WW , 2002. Relationship of viral infections to wheezing illnesses and asthma. Nat Rev Immunol 2: 132–138.
Abdulrazzaq YM, Bener A, DeBuse P , 1995. Pet ownership in the UAE: its effect on allergy and respiratory symptoms. J Asthma 32: 117–124.
Kalyoncu AF et al.1994. Prevalence of childhood asthma and allergic diseases in Ankara, Turkey. Allergy 49: 485–488.
Hakanen E et al.2018. Urban environment predisposes dogs and their owners to allergic symptoms. Sci Rep 8: 1–9.
Lødrup Carlsen KC et al.2012. Does pet ownership in infancy lead to asthma or allergy at school age? Pooled analysis of individual participant data from 11 European birth cohorts. PLoS One 7: e43214.
Brunekreef B, Von Mutius E, Wong GK, Odhiambo JA, Clayton TO , 2012. Early life exposure to farm animals and symptoms of asthma, rhinoconjunctivitis and eczema: an ISAAC Phase Three Study. Int J Epidemiol 41: 753–761.
Myers KP, Setterquist SF, Capuano AW, Gray GC , 2007. Infection due to 3 avian influenza subtypes in United States veterinarians. Clin Infect Dis 45: 4–9.
Gray GC, McCarthy T, Capuano AW, Setterquist SF, Alavanja MC, Lynch CF , 2008. Evidence for avian influenza A infections among Iowa’s agricultural workers. Influenza Other Respir Viruses 2: 61–69.
Puzelli S et al.2005. Serological analysis of serum samples from humans exposed to avian H7 influenza viruses in Italy between 1999 and 2003. J Infect Dis 192: 1318–1322.
Crow R, Mutyara K, Agustian D, Kartasasmita CB, Simões EAF , 2021. Risk factors for respiratory syncytial virus lower respiratory tract infections: evidence from an Indonesian cohort. Viruses 13: 331.
Delahoy MJ et al.2018. Pathogens transmitted in animal feces in low- and middle-income countries. Int J Hyg Environ Health 221: 661–676.
Penakalapati G et al.2017. Exposure to animal feces and human health: a systematic review and proposed research priorities. Environ Sci Technol 51: 11537–11552.
Turner JC et al.2017. Insight into live bird markets of Bangladesh: an overview of the dynamics of transmission of H5N1 and H9N2 avian influenza viruses. Emerg Microbes Infect 6: e12.
Biswas PK, Giasuddin M, Chowdhury P, Barua H, Debnath NC, Yamage M , 2018. Incidence of contamination of live bird markets in Bangladesh with influenza A virus and subtypes H5, H7 and H9. Transbound Emerg Dis 65: 687–695.
Chakraborty A et al.2017. Mild respiratory illness among young children caused by highly pathogenic avian influenza A (H5N1) virus infection in Dhaka, Bangladesh, 2011. J Infect Dis 216: S520–S528.
Zambrano LD, Levy K, Menezes NP, Freeman MC , 2014. Human diarrhea infections associated with domestic animal husbandry: a systematic review and meta-analysis. Trans R Soc Trop Med Hyg 108: 313–325.
Parvin T et al.2020. Prospective cohort study of child mouthing of faeces and fomites in Dhaka, Bangladesh (CHoBI7 Program). Trop Med Int Health 25: 976–984.
Monira S et al.2020. Child mouthing of soil and presence of animals in child sleeping spaces are associated with growth faltering among young children in Dhaka, Bangladesh (CHoBI7 Program). Trop Med Int Health 25: 1016–1023.
Berkman DS, Lescano AG, Gilman RH, Lopez SL, Black MM , 2002. Effects of stunting, diarrhoeal disease, and parasitic infection during infancy on cognition in late childhood: a follow-up study. Lancet 359: 564–571.
Walker SP, Chang SM, Powell CA, Simonoff E, Grantham-McGregor SM , 2007. Early childhood stunting is associated with poor psychological functioning in late adolescence and effects are reduced by psychosocial stimulation. J Nutr 137: 2464–2469.
Tarleton JL, Haque R, Mondal D, Shu J, Farr BM, Petri WA Jr , 2006. Cognitive effects of diarrhea, malnutrition, and Entamoeba histolytica infection on school age children in Dhaka, Bangladesh. Am J Trop Med Hyg 74: 475–481.
Bhutta ZA et al.2013. Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost? Lancet 382: 452–477.
Weisz AJ et al.2012. Abnormal gut integrity is associated with reduced linear growth in rural Malawian children. J Pediatr Gastroenterol Nutr 55: 747–750.
George CM et al.2015. Fecal markers of environmental enteropathy are associated with animal exposure and caregiver hygiene in Bangladesh. Am J Trop Med Hyg. 93: 269–275.
Headey D, Hirvonen K , 2016. Is exposure to poultry harmful to child nutrition? An observational analysis for rural Ethiopia. PLoS One 11: e0160590.
George CM et al.2021. Effects of a water, sanitation and hygiene mobile health program on diarrhea and child growth in Bangladesh: a cluster-randomized controlled trial of the CHoBI7 mobile health program. Clin Infect Dis 73: e2560–e2568.
George CM et al.2019. Formative research for the design of a scalable water, sanitation, and hygiene mobile health program: CHoBI7 mobile health program. BMC Public Health 19: 1028.
National Institute of Population Research and Training , ICF , 2020. Bangladesh Demographic Health Survey, 2017–18. Available at: https://dhsprogram.com/pubs/pdf/FR344/FR344.pdf. Accessed November 30, 2021.
World Health Organization , 2014. Integrated Management of Childhood Illness (IMCI), revised. Geneva, Switzerland, WHO.
Shanmuganatham K et al.2013. Antigenic and molecular characterization of avian influenza A(H9N2) viruses, Bangladesh. Emerg Infect Dis 19: 1393–1402.
Ansari WK et al.2016. Surveillance, epidemiological, and virological detection of highly pathogenic H5N1 avian influenza viruses in duck and poultry from Bangladesh. Vet Microbiol 193: 49–59.
Negovetich NJ et al.2011. Live bird markets of Bangladesh: H9N2 viruses and the near absence of highly pathogenic H5N1 influenza. PLoS One 6: e19311.
Nasreen S et al.2015. Highly pathogenic avian influenza A(H5N1) virus infection among workers at live bird markets, Bangladesh, 2009–2010. Emerg Infect Dis 21: 629–637.
Shanta IS et al.2017. Raising backyard poultry in rural Bangladesh: financial and nutritional benefits, but persistent risky practices. Transbound Emerg Dis 64: 1454–1464.
Shortridge KF et al.1998. Characterization of avian H5N1 influenza viruses from poultry in Hong Kong. Virology 252: 331–342.
Ercumen A, Prottas C, Harris A, Dioguardi A, Dowd G, Guiteras R , 2020. Poultry ownership associated with increased risk of child diarrhea: cross-sectional evidence from Uganda. Am J Trop Med Hyg 102: 526–533.
Hossain MB, Khan JR , 2020. Association between household livestock ownership and childhood stunting in Bangladesh: a spatial analysis. J Trop Pediatr 66: 248–256.
Kaur M, Graham JP, Eisenberg JNS , 2017. Livestock ownership among rural households and child morbidity and mortality: an analysis of Demographic Health Survey data from 30 sub-Saharan African countries (2005–2015). Am J Trop Med Hyg 96: 741–748.
Schmidt WP, Cairncross S, Barreto ML, Clasen T, Genser B , 2009. Recent diarrhoeal illness and risk of lower respiratory infections in children under the age of 5 years. Int J Epidemiol 38: 766–772.
Ashraf S, Huque MH, Kenah E, Agboatwalla M, Luby SP , 2013. Effect of recent diarrhoeal episodes on risk of pneumonia in children under the age of 5 years in Karachi, Pakistan. Int J Epidemiol 42: 194–200.
Rodríguez L, Cervantes E, Ortiz R , 2011. Malnutrition and gastrointestinal and respiratory infections in children: a public health problem. Int J Environ Res Public Health 8: 1174–1205.
Parvin T et al.2021. Fecal contamination on the household compound and in water sources are associated with subsequent diarrhea in young children in urban Bangladesh (CHoBI7 Program). Am J Trop Med Hyg 105: 261–266.
Fournié G et al.2013. Interventions for avian influenza A (H5N1) risk management in live bird market networks. Proc Natl Acad Sci USA 110: 9177–9182.
Oberhelman RA et al.2006. An intervention-control study of corralling of free-ranging chickens to control Campylobacter infections among children in a Peruvian periurban shantytown. Am J Trop Med Hyg 74: 1054–1059.
Rimi, Nadia Ali et al., 2016. Understanding the failure of a behavior change intervention to reduce risk behaviors for avian influenza transmission among backyard poultry raisers in rural Bangladesh: a focused ethnography. BMC Public Health 16: 1–15.
Kuhl J et al.2021. Formative research for the development of baby water, sanitation, and hygiene interventions for young children in the Democratic Republic of the Congo (REDUCE program). BMC Public Health 21: 427.
Luby SP et al.2005. Effect of handwashing on child health: a randomised controlled trial. Lancet 366: 225–233.
McGuinness SL et al.2018. Effect of hygiene interventions on acute respiratory infections in childcare, school and domestic settings in low- and middle-income countries: a systematic review. Trop Med Int Health 23: 816–833.
Rabie T, Curtis V , 2006. Handwashing and risk of respiratory infections: a quantitative systematic review. Trop Med Int Health 11: 258–267.
World Health Organization , 2005. Effects of Air Pollution on Children's Health and Development. Geneva, Switzerland: WHO.
Past two years | Past Year | Past 30 Days | |
---|---|---|---|
Abstract Views | 2405 | 622 | 19 |
Full Text Views | 92 | 22 | 0 |
PDF Downloads | 70 | 20 | 0 |