EXPOSOMICS - Enhanced exposure assessment and OMIC profiling for high priority environmental exposures in Europe.

EXPOsOMICS is a multicenter study, performed in 5 study areas in Italy, Spain,
Switzerland, the United Kingdom and the Netherlands from the end of 2013 until
the end of 2014. Every center will perform the same Personal Exposure
Monitoring (PEM) procedures, followed by biological sample collection. The
EXPOsOMICS study will be performed in a subsample of an existing cohort, where
a blood sample is available from the moment of cohort inclusion.

This application for the Medical Ethical Committee covers the procedures in the
Netherlands, where the Institute for Risk Assessment Sciences (IRAS), part of
Utrecht University, is the only center involved in implementation of the study.
Subjects will be recruited from the cohorts EPIC-Morgen and EPIC-Prospect,
together referred as EPIC-NL.


A considerable number of longitudinal cohorts in both children and adults have
explored associations between non-genetic risk factors and health outcomes
using detailed information on major risk factors, confounders, and health
outcomes (Brunekreef, 2002; Van Roosbroeck, 2008a; Van Roosbroeck, 2008b;
Kaufman, 2012). The assessment of environmental exposure in such studies is
often not optimal resulting in uncertainties in the quantification of exposure
and associated health risks. The quality of exposure assessment approaches can
be improved by improving the quality of traditional approaches focused on
assessment of concentrations in the environment (air, water). In addition,
assessment of biological markers that reflect the human body*s response to
exposure might contribute as well.

The exposome concept, which refers to the comprehensive description of lifelong
environmental (i.e. non-genetic) exposure history, has been proposed to draw
attention to the critical need for more complete environmental exposure
assessment in epidemiological studies (Wild, 2005; Rappaport, 2010; Wild,
2011). The exposome refers to the individual exposure to multiple stressors in
critical periods of life. The current challenge is to apply the concept in
observational studies (Wild, 2011), as exposures are difficult to characterize
since they significantly vary in space and time.

This project is designed to move the field forward by collecting data on the
individual external exposome (by repeated personal exposure monitoring of key
pollutants including real-time monitoring of activity and location) and the
individual internal exposome (by profiling large sets of biological molecules
for new and integrated biomarkers), in relationship to air pollution exposure.
To improve quality of assessment of relationships, differences in short-term
perturbations and long-term or natural progression in biomarker levels will be
analyzed using an archived blood sample, requested from the cohort*s biobank.

Developed tools will improve the quality of air pollution exposure estimates
for epidemiological studies, eventually resulting in reduced uncertainty in
disease risk assessment.
This study is among the first attempts to apply the exposome concept in large
scale human studies. A unique feature of the project is the integration of both
external and internal detailed measurements. Though personal monitoring studies
have been performed before (Kaur, 2005; Briggs, 2008; Boogaard, 2010; Dons,
2012), there are very few on assessing long-term air pollution exposures
(Aldgate, 2007; Van Roosbroeck, 2007) and none that included ultrafine
particles (UFPs).

This multidisciplinary study will create significant new information regarding:
1. Validity of standard exposure assessment approaches in assessing individual
exposure to key air pollutants, including ultrafine particles
2. Relationships between external and internal markers of exposures, resulting
in potential new biomarkers of air pollution exposure
3. Acute effects of air pollution through more detailed exposure assessment

The primary objective is to improve prediction of individual disease risk
related to air pollution, by characterizing the internal and external exposome
related to air pollution in Europe. The specific research questions are:
1. Can novel biomarkers of exposure for major outdoor air pollutants be
identified through characterization of the internal exposome using untargeted
OMIC analyses (corrected for variations in OMIC levels in archived blood sample
from cohort*s biobank, due to long-term or natural progression) and detailed
assessment of the external exposome using personal exposure monitoring?
2. Can novel biomarkers of exposure for major outdoor air pollutants be
identified in target tissue for air pollution, such as the nose and the mouth?
3. What is the agreement between modelled exposure to air pollution and
measured personal exposure of key particulate pollutants (external exposome)?
4. Does short-term exposure to outdoor air pollutants affect lung function and
blood pressure?

In the proposed study, forty (40) subjects from five European study areas will
perform three 24 hour Personal Exposure Monitoring (PEM) sessions, spread over
one year (total 160 adults and 40 children). In Italy, the Netherlands,
Switzerland and the United Kingdom adults from existing cohorts will be
included, whereas in Spain children will be included. In the remainder of this
protocol we will discuss only the four adult cohorts, focusing the Dutch
situation, since this application to the METC only covers work in the
Netherlands.
In the Netherlands forty (40) subjects, aged 50-70 , will be selected from the
EPIC-NL cohort, where a blood sample is available at study baseline (mid
1990*s).

All eligible volunteers, based on EPIC-NL records, will receive a Letter of
Recruitment (including study details and Letter of Agreement) and a Screening
Questionnaire (SQ). Interested volunteers will be asked to fill out the SQ and
the Letter of Agreement and send this back to IRAS, Utrecht University. Based
on data from the SQ, final eligibility will be concluded.

When eligible, subjects will be visited by a fieldworker (a) to determine
whether the subject is motivated to participate, (b) to explain the setup of
the study and show the backpack and belt with air monitors, (c) to answer the
subject*s questions. When the subject agrees with procedures, the subject will
fill out a Baseline Questionnaire (BQ). The fieldworker will record home and
outdoor characteristics in a Home Characterization Form (HCF) and an Outdoor
Characterization Form (OCF). When finishes, (provisional) appointments will be
made for all three 24h PEM sessions.

During a PEM session, a fieldworker will visit the subject*s home address to
distribute PEM devices. The subject will carry a backpack and a belt with PEM
monitors for fine and ultrafine particles for a period of 24 hours, while
performing daily activities. Simultaneously, the same set of air pollution
monitors will run outdoors at the subject*s home address. During the 24 hour
PEM session, the subject will fill out a PEM Session Questionnaire (PSQ) on
smoke and fine dust exposure, a Time-Activity Diary (TAD) on past 24h
activities and a Food Questionnaire (FQ) on food intake in the past 48h. At the
end of each PEM session, a nurse and a fieldworker will visit the subjects home
address. The nurse will collect a blood sample for OMIC analyses (20 ml),
perform a blood pressure measurement, a spirometry test and collect two buccal
scrapes, two nasal swabs, and health data in the Health Questionnaire (HQ). The
fieldworker will shut down and check PEM devices.
Biological samples will be transported to a center, processed and stored at -80
degrees Celsius.

When all PEM sessions are finished, fresh blood samples (used for long and
short-term perturbations of the biomarker response), archived blood sample from
the cohort*s biobank (used for correction for variations in biomarker levels
due to long-term or natural progression of the biomarker response), and buccal
scrapes and nasal swabs (to assess biomarker levels in target tissues) will be
sent for OMIC analysis. Metabolomics, Adductomics, Transcriptomics,
Epigenomics, and Proteomics analyses will be applied on these samples to detect
systemic biomarkers, relevant for air pollution exposure. All analyses for a
specific OMIC technology will be conducted in the same laboratory for all five
study areas.

Spirometry and blood pressure measurements will be conducted to get more
detailed information on direct respiratory and cardiovascular effects of air
pollution. These effect have been bescribed in literature, but the methods of
this study provides the opportunity to investigate these effects in more depth.

The healthy participants in this study may experience minor physiological
discomfort, related to the PEM sessions (n=3) or the collection of biological
samples (n=3, at the end of each PEM session). Performing the PEM sessions may
cause slight discomfort because of the attention that is required to correctly
fulfill the carrying of the pumps, but previous studies including up to six
repeats have not identified this as an important issue. Collecting blood may be
unpleasant, and may provoke a hematoma that usually disappears fast. The risk
associated to collecting blood is small. Performing spirometry may induce short
term dizziness, because a maximal respiratory effort is made. Symptoms usually
disappear fast.
The collection of cells from the nose and the mouth can cause a mild
irritation. This usually disappears fast and does not lead to any health risk
for the subject.

Subjects* privacy will be guarded by storing the data encrypted on a protected
server at IRAS. A unique Subject ID, consisting of a 3 number code, is created
for each eligible volunteer, based in SQ data. Personal information from the
Letter of Agreement will be processed at IRAS, protected by professional
secrecy. The Subject ID will be used for all computer files, forms, tubes and
filters. Researchers and fieldworkers, performing measurements, processing
samples or analyzing filters, will not have the possibility to trace subject*s
name or home address. When samples are shipped to partners, again only the
Subject ID will be used on all files and tubes. Individual data will under no
circumstances be communicated. Procedures are in place to ensure compliance
with professional secrecy and confidentiality. Each person involved in data
entry and analysis is bound to respect these rules.