Staff Publications

Staff Publications

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    'Staff publications' is the digital repository of Wageningen University & Research

    'Staff publications' contains references to publications authored by Wageningen University staff from 1976 onward.

    Publications authored by the staff of the Research Institutes are available from 1995 onwards.

    Full text documents are added when available. The database is updated daily and currently holds about 240,000 items, of which 72,000 in open access.

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    Adolescent health in the Eastern Mediterranean Region: findings from the global burden of disease 2015 study
    Azzopardi, Peter ; Cini, Karly ; Kennedy, Elissa ; Sawyer, Susan ; Elbcheraoui, Charbel ; Charara, Raghid ; Khalil, Ibrahim ; Moradi-Lakeh, Maziar ; Collison, Michael ; Afifi, Rima A. ; Al-raiby, Jamela ; Krohn, Kristopher J. ; Daoud, Farah ; Chew, Adrienne ; Afshin, Ashkan ; Foreman, Kyle J. ; Kassebaum, Nicholas J. ; Kutz, Michael ; Kyu, Hmwe H. ; Liu, Patrick ; Olsen, Helen E. ; Smith, Alison ; Stanaway, Jeffrey D. ; Wang, Haidong ; Ärnlöv, Johan ; Ahmadkiadaliri, Aliasghar ; Alam, Khurshid ; Alasfoor, Deena ; Ali, Raghib ; Alizadeh-Navaei, Reza ; Al-Raddadi, Rajaa ; Altirkawi, Khalid A. ; Alvis-Guzman, Nelson ; Anber, Nahla ; Antonio, Carl Abelardo T. ; Anwari, Palwasha ; Artaman, Al ; Asayesh, Hamid ; Barker-Collo, Suzanne L. ; Bedi, Neeraj ; Beghi, Ettore ; Bennett, Derrick A. ; Bensenor, Isabela M. ; Bhutta, Zulfiqar A. ; Butt, Zahid A. ; Castañeda-Orjuela, Carlos A. ; Catalá-López, Ferrán ; Charlson, Fiona J. ; Geleijnse, Johanna M. ; Vos, Theo - \ 2018
    International Journal of Public Health 63 (2018). - ISSN 1661-8556 - p. 79 - 96.
    Adolescent health - Burden of disease - Eastern Mediterranean Region

    Objectives: The 22 countries of the East Mediterranean Region (EMR) have large populations of adolescents aged 10–24 years. These adolescents are central to assuring the health, development, and peace of this region. We described their health needs. Methods: Using data from the Global Burden of Disease Study 2015 (GBD 2015), we report the leading causes of mortality and morbidity for adolescents in the EMR from 1990 to 2015. We also report the prevalence of key health risk behaviors and determinants. Results: Communicable diseases and the health consequences of natural disasters reduced substantially between 1990 and 2015. However, these gains have largely been offset by the health impacts of war and the emergence of non-communicable diseases (including mental health disorders), unintentional injury, and self-harm. Tobacco smoking and high body mass were common health risks amongst adolescents. Additionally, many EMR countries had high rates of adolescent pregnancy and unmet need for contraception. Conclusions: Even with the return of peace and security, adolescents will have a persisting poor health profile that will pose a barrier to socioeconomic growth and development of the EMR.

    Higher milk intake increases fracture risk : confounding or true association?
    Sahni, S. ; Soedamah-Muthu, S.S. ; Weaver, C.M. - \ 2017
    Osteoporis International 29 (2017)8. - ISSN 0937-941X - p. 2263 - 2264.
    Global shifts in aging and increased life expectancy puts demands on health systems. [1] As age-related chronic diseases, osteoporosis and low bone mass are major public health threats [2, 3]. Milk is a good source of bone-specific nutrients [calcium, vitamin D (when fortified), protein, magnesium, potassium, phosphorus]. Studies have reported beneficial associations between milk and bone mineral density [4, 5, 6, 7, 8, 9, 10]. However, data on mortality [11, 12, 13, 14, 15] and fracture risk are conflicting [14, 16, 17, 18, 19], with studies reporting beneficial [13, 16], neutral [8, 11, 12, 15, 17, 18, 19], and adverse associations [14]. The largest study [14] on milk intake, fractures and mortality has contributed to controversies surrounding potential benefits of these foods for bone health and longevity. Michaelsson et al. [14] examined milk intake in two large Swedish cohorts. Primary outcomes included mortality, incident fracture, hip fracture over follow-up (women, 20.1 years; men, 11.2 years). In women, ≥3 glasses of milk/day was associated with 93% increased risk of mortality compared with <1glass (200 ml). For every glass of milk, fracture and hip fracture risk was 2–9% higher in women. Cheese and fermented milk showed a 10–15% lower fracture and mortality risk in women. Overall, ≥3 glasses of milk/day was associated with higher mortality in adults and with higher fracture incidence in women. The biological rational included high levels of D-galactose in milk (also found in cheese and fermented milk), which increases oxidative stress and chronic low grade inflammation in animal models. This mechanism is unsubstantiated by other studies. This study has raised several issues. The highest relative risks were in women with high milk intake (9% of the population). These women, aged >50 when the study started were followed for 20 years. At age 70, people are likely to die from multiple causes and not due to milk intake perse. These women were at increased risk of comorbidities, prone to dietary changes pursuant to age, loss of spouse, and changes in living arrangement. Furthermore, baseline vitamin D status was missing, and Charlson’s comorbidity index does not account for diabetes, hypertension, or hypercholesterolemia separately. The high risk associations became weaker if only baseline (compared to two repeated measures) milk intake was associated with mortality risk. The FFQ had limited food items and was not validated for milk. The conclusion disagrees with a recent meta-analysis of 29 prospective cohort studies on milk and mortality that found no association [15]. Large cohort studies provide valuable information on diet-disease relationships. However, the question about true associations or confounded results cannot yet be answered. Validated measurements should be utilized, and a detailed assessment of confounders including vitamin D status are necessary to answer important questions related to milk intake and its effect on fracture and mortality. Large intervention studies of other under-studied dairy foods (yogurt and cheese) would clarify nutritional equivalency of dairy foods in order to optimize bone health. An emerging area of fermented dairy foods, microbiome and aging, could provide valuable insights into the unexplored mechanisms via which dairy foods may affect aging in general and skeletal aging in particular.
    Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015
    Forouzanfar, Mohammad Hossein ; Afshin, Ashkan ; Alexander, Lily T. ; Ross Anderson, H. ; Bhutta, Zulfiqar ; Biryukov, Stan ; Brauer, M. ; Burnett, Richard ; Cercy, Kelly ; Charlson, Fiona J. ; Geleijnse, J.M. - \ 2016
    The Lancet 388 (2016)10053. - ISSN 0140-6736 - p. 1659 - 1724.
    The Global Burden of Diseases, Injuries, and Risk Factors Study 2015 provides an up-to-date synthesis of the evidence for risk factor exposure and the attributable burden of disease. By providing national and subnational assessments spanning the past 25 years, this study can inform debates on the importance of addressing risks in context.

    We used the comparative risk assessment framework developed for previous iterations of the Global Burden of Disease Study to estimate attributable deaths, disability-adjusted life-years (DALYs), and trends in exposure by age group, sex, year, and geography for 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks from 1990 to 2015. This study included 388 risk-outcome pairs that met World Cancer Research Fund-defined criteria for convincing or probable evidence. We extracted relative risk and exposure estimates from randomised controlled trials, cohorts, pooled cohorts, household surveys, census data, satellite data, and other sources. We used statistical models to pool data, adjust for bias, and incorporate covariates. We developed a metric that allows comparisons of exposure across risk factors—the summary exposure value. Using the counterfactual scenario of theoretical minimum risk level, we estimated the portion of deaths and DALYs that could be attributed to a given risk. We decomposed trends in attributable burden into contributions from population growth, population age structure, risk exposure, and risk-deleted cause-specific DALY rates. We characterised risk exposure in relation to a Socio-demographic Index (SDI).

    Between 1990 and 2015, global exposure to unsafe sanitation, household air pollution, childhood underweight, childhood stunting, and smoking each decreased by more than 25%. Global exposure for several occupational risks, high body-mass index (BMI), and drug use increased by more than 25% over the same period. All risks jointly evaluated in 2015 accounted for 57·8% (95% CI 56·6–58·8) of global deaths and 41·2% (39·8–42·8) of DALYs. In 2015, the ten largest contributors to global DALYs among Level 3 risks were high systolic blood pressure (211·8 million [192·7 million to 231·1 million] global DALYs), smoking (148·6 million [134·2 million to 163·1 million]), high fasting plasma glucose (143·1 million [125·1 million to 163·5 million]), high BMI (120·1 million [83·8 million to 158·4 million]), childhood undernutrition (113·3 million [103·9 million to 123·4 million]), ambient particulate matter (103·1 million [90·8 million to 115·1 million]), high total cholesterol (88·7 million [74·6 million to 105·7 million]), household air pollution (85·6 million [66·7 million to 106·1 million]), alcohol use (85·0 million [77·2 million to 93·0 million]), and diets high in sodium (83·0 million [49·3 million to 127·5 million]). From 1990 to 2015, attributable DALYs declined for micronutrient deficiencies, childhood undernutrition, unsafe sanitation and water, and household air pollution; reductions in risk-deleted DALY rates rather than reductions in exposure drove these declines. Rising exposure contributed to notable increases in attributable DALYs from high BMI, high fasting plasma glucose, occupational carcinogens, and drug use. Environmental risks and childhood undernutrition declined steadily with SDI; low physical activity, high BMI, and high fasting plasma glucose increased with SDI. In 119 countries, metabolic risks, such as high BMI and fasting plasma glucose, contributed the most attributable DALYs in 2015. Regionally, smoking still ranked among the leading five risk factors for attributable DALYs in 109 countries; childhood underweight and unsafe sex remained primary drivers of early death and disability in much of sub-Saharan Africa.

    Declines in some key environmental risks have contributed to declines in critical infectious diseases. Some risks appear to be invariant to SDI. Increasing risks, including high BMI, high fasting plasma glucose, drug use, and some occupational exposures, contribute to rising burden from some conditions, but also provide opportunities for intervention. Some highly preventable risks, such as smoking, remain major causes of attributable DALYs, even as exposure is declining. Public policy makers need to pay attention to the risks that are increasingly major contributors to global burden.
    Global, regional, and national disability-adjusted life-years (DALYs) for 315 diseases and injuries and healthy life expectancy (HALE), 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015
    Kassebaum, N.J. ; Arora, Megha ; Barber, R.M. ; Bhutta, Zulfiqar ; Brown, J. ; Carter, Austin ; Casey, Daniel C. ; Charlson, Fiona J. ; Coates, M. ; Coggeshall, M.S. ; Geleijnse, J.M. - \ 2016
    The Lancet 388 (2016)10053. - ISSN 0140-6736 - p. 1603 - 1658.
    Healthy life expectancy (HALE) and disability-adjusted life-years (DALYs) provide summary measures of health across geographies and time that can inform assessments of epidemiological patterns and health system performance, help to prioritise investments in research and development, and monitor progress toward the Sustainable Development Goals (SDGs). We aimed to provide updated HALE and DALYs for geographies worldwide and evaluate how disease burden changes with development.

    We used results from the Global Burden of Diseases, Injuries, and Risk Factors Study 2015 (GBD 2015) for all-cause mortality, cause-specific mortality, and non-fatal disease burden to derive HALE and DALYs by sex for 195 countries and territories from 1990 to 2015. We calculated DALYs by summing years of life lost (YLLs) and years of life lived with disability (YLDs) for each geography, age group, sex, and year. We estimated HALE using the Sullivan method, which draws from age-specific death rates and YLDs per capita. We then assessed how observed levels of DALYs and HALE differed from expected trends calculated with the Socio-demographic Index (SDI), a composite indicator constructed from measures of income per capita, average years of schooling, and total fertility rate.

    Total global DALYs remained largely unchanged from 1990 to 2015, with decreases in communicable, neonatal, maternal, and nutritional (Group 1) disease DALYs offset by increased DALYs due to non-communicable diseases (NCDs). Much of this epidemiological transition was caused by changes in population growth and ageing, but it was accelerated by widespread improvements in SDI that also correlated strongly with the increasing importance of NCDs. Both total DALYs and age-standardised DALY rates due to most Group 1 causes significantly decreased by 2015, and although total burden climbed for the majority of NCDs, age-standardised DALY rates due to NCDs declined. Nonetheless, age-standardised DALY rates due to several high-burden NCDs (including osteoarthritis, drug use disorders, depression, diabetes, congenital birth defects, and skin, oral, and sense organ diseases) either increased or remained unchanged, leading to increases in their relative ranking in many geographies. From 2005 to 2015, HALE at birth increased by an average of 2·9 years (95% uncertainty interval 2·9–3·0) for men and 3·5 years (3·4–3·7) for women, while HALE at age 65 years improved by 0·85 years (0·78–0·92) and 1·2 years (1·1–1·3), respectively. Rising SDI was associated with consistently higher HALE and a somewhat smaller proportion of life spent with functional health loss; however, rising SDI was related to increases in total disability. Many countries and territories in central America and eastern sub-Saharan Africa had increasingly lower rates of disease burden than expected given their SDI. At the same time, a subset of geographies recorded a growing gap between observed and expected levels of DALYs, a trend driven mainly by rising burden due to war, interpersonal violence, and various NCDs.

    Health is improving globally, but this means more populations are spending more time with functional health loss, an absolute expansion of morbidity. The proportion of life spent in ill health decreases somewhat with increasing SDI, a relative compression of morbidity, which supports continued efforts to elevate personal income, improve education, and limit fertility. Our analysis of DALYs and HALE and their relationship to SDI represents a robust framework on which to benchmark geography-specific health performance and SDG progress. Country-specific drivers of disease burden, particularly for causes with higher-than-expected DALYs, should inform financial and research investments, prevention efforts, health policies, and health system improvement initiatives for all countries along the development continuum.
    Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015
    Wang, Haidong ; Naghavi, Mohsen ; Allen, Christine ; Barber, R.M. ; Bhutta, Zulfiqar ; Carter, Austin ; Casey, Daniel C. ; Charlson, Fiona J. ; Chen, Alan Z. ; Coates, M. ; Geleijnse, J.M. - \ 2016
    The Lancet 388 (2016)10053. - ISSN 0140-6736 - p. 1459 - 1544.
    Improving survival and extending the longevity of life for all populations requires timely, robust evidence on local mortality levels and trends. The Global Burden of Disease 2015 Study (GBD 2015) provides a comprehensive assessment of all-cause and cause-specific mortality for 249 causes in 195 countries and territories from 1980 to 2015. These results informed an in-depth investigation of observed and expected mortality patterns based on sociodemographic measures.

    We estimated all-cause mortality by age, sex, geography, and year using an improved analytical approach originally developed for GBD 2013 and GBD 2010. Improvements included refinements to the estimation of child and adult mortality and corresponding uncertainty, parameter selection for under-5 mortality synthesis by spatiotemporal Gaussian process regression, and sibling history data processing. We also expanded the database of vital registration, survey, and census data to 14 294 geography–year datapoints. For GBD 2015, eight causes, including Ebola virus disease, were added to the previous GBD cause list for mortality. We used six modelling approaches to assess cause-specific mortality, with the Cause of Death Ensemble Model (CODEm) generating estimates for most causes. We used a series of novel analyses to systematically quantify the drivers of trends in mortality across geographies. First, we assessed observed and expected levels and trends of cause-specific mortality as they relate to the Socio-demographic Index (SDI), a summary indicator derived from measures of income per capita, educational attainment, and fertility. Second, we examined factors affecting total mortality patterns through a series of counterfactual scenarios, testing the magnitude by which population growth, population age structures, and epidemiological changes contributed to shifts in mortality. Finally, we attributed changes in life expectancy to changes in cause of death. We documented each step of the GBD 2015 estimation processes, as well as data sources, in accordance with Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER).

    Globally, life expectancy from birth increased from 61·7 years (95% uncertainty interval 61·4–61·9) in 1980 to 71·8 years (71·5–72·2) in 2015. Several countries in sub-Saharan Africa had very large gains in life expectancy from 2005 to 2015, rebounding from an era of exceedingly high loss of life due to HIV/AIDS. At the same time, many geographies saw life expectancy stagnate or decline, particularly for men and in countries with rising mortality from war or interpersonal violence. From 2005 to 2015, male life expectancy in Syria dropped by 11·3 years (3·7–17·4), to 62·6 years (56·5–70·2). Total deaths increased by 4·1% (2·6–5·6) from 2005 to 2015, rising to 55·8 million (54·9 million to 56·6 million) in 2015, but age-standardised death rates fell by 17·0% (15·8–18·1) during this time, underscoring changes in population growth and shifts in global age structures. The result was similar for non-communicable diseases (NCDs), with total deaths from these causes increasing by 14·1% (12·6–16·0) to 39·8 million (39·2 million to 40·5 million) in 2015, whereas age-standardised rates decreased by 13·1% (11·9–14·3). Globally, this mortality pattern emerged for several NCDs, including several types of cancer, ischaemic heart disease, cirrhosis, and Alzheimer's disease and other dementias. By contrast, both total deaths and age-standardised death rates due to communicable, maternal, neonatal, and nutritional conditions significantly declined from 2005 to 2015, gains largely attributable to decreases in mortality rates due to HIV/AIDS (42·1%, 39·1–44·6), malaria (43·1%, 34·7–51·8), neonatal preterm birth complications (29·8%, 24·8–34·9), and maternal disorders (29·1%, 19·3–37·1). Progress was slower for several causes, such as lower respiratory infections and nutritional deficiencies, whereas deaths increased for others, including dengue and drug use disorders. Age-standardised death rates due to injuries significantly declined from 2005 to 2015, yet interpersonal violence and war claimed increasingly more lives in some regions, particularly in the Middle East. In 2015, rotaviral enteritis (rotavirus) was the leading cause of under-5 deaths due to diarrhoea (146 000 deaths, 118 000–183 000) and pneumococcal pneumonia was the leading cause of under-5 deaths due to lower respiratory infections (393 000 deaths, 228 000–532 000), although pathogen-specific mortality varied by region. Globally, the effects of population growth, ageing, and changes in age-standardised death rates substantially differed by cause. Our analyses on the expected associations between cause-specific mortality and SDI show the regular shifts in cause of death composition and population age structure with rising SDI. Country patterns of premature mortality (measured as years of life lost [YLLs]) and how they differ from the level expected on the basis of SDI alone revealed distinct but highly heterogeneous patterns by region and country or territory. Ischaemic heart disease, stroke, and diabetes were among the leading causes of YLLs in most regions, but in many cases, intraregional results sharply diverged for ratios of observed and expected YLLs based on SDI. Communicable, maternal, neonatal, and nutritional diseases caused the most YLLs throughout sub-Saharan Africa, with observed YLLs far exceeding expected YLLs for countries in which malaria or HIV/AIDS remained the leading causes of early death.

    At the global scale, age-specific mortality has steadily improved over the past 35 years; this pattern of general progress continued in the past decade. Progress has been faster in most countries than expected on the basis of development measured by the SDI. Against this background of progress, some countries have seen falls in life expectancy, and age-standardised death rates for some causes are increasing. Despite progress in reducing age-standardised death rates, population growth and ageing mean that the number of deaths from most non-communicable causes are increasing in most countries, putting increased demands on health systems.
    Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990–2015 : a systematic analysis for the Global Burden of Disease Study 2015
    Vos, Theo ; Allen, Christine ; Arora, Megha ; Barber, R.M. ; Bhutta, Zulfiqar ; Brown, Alexandria ; Carter, Austin ; Casey, Daniel C. ; Charlson, Fiona J. ; Chen, Alan Z. ; Geleijnse, J.M. - \ 2016
    The Lancet 388 (2016)10053. - ISSN 0140-6736 - p. 1545 - 1602.


    Non-fatal outcomes of disease and injury increasingly detract from the ability of the world's population to live in full health, a trend largely attributable to an epidemiological transition in many countries from causes affecting children, to non-communicable diseases (NCDs) more common in adults. For the Global Burden of Diseases, Injuries, and Risk Factors Study 2015 (GBD 2015), we estimated the incidence, prevalence, and years lived with disability for diseases and injuries at the global, regional, and national scale over the period of 1990 to 2015.


    We estimated incidence and prevalence by age, sex, cause, year, and geography with a wide range of updated and standardised analytical procedures. Improvements from GBD 2013 included the addition of new data sources, updates to literature reviews for 85 causes, and the identification and inclusion of additional studies published up to November, 2015, to expand the database used for estimation of non-fatal outcomes to 60 900 unique data sources. Prevalence and incidence by cause and sequelae were determined with DisMod-MR 2.1, an improved version of the DisMod-MR Bayesian meta-regression tool first developed for GBD 2010 and GBD 2013. For some causes, we used alternative modelling strategies where the complexity of the disease was not suited to DisMod-MR 2.1 or where incidence and prevalence needed to be determined from other data. For GBD 2015 we created a summary indicator that combines measures of income per capita, educational attainment, and fertility (the Socio-demographic Index [SDI]) and used it to compare observed patterns of health loss to the expected pattern for countries or locations with similar SDI scores.


    We generated 9·3 billion estimates from the various combinations of prevalence, incidence, and YLDs for causes, sequelae, and impairments by age, sex, geography, and year. In 2015, two causes had acute incidences in excess of 1 billion: upper respiratory infections (17·2 billion, 95% uncertainty interval [UI] 15·4–19·2 billion) and diarrhoeal diseases (2·39 billion, 2·30–2·50 billion). Eight causes of chronic disease and injury each affected more than 10% of the world's population in 2015: permanent caries, tension-type headache, iron-deficiency anaemia, age-related and other hearing loss, migraine, genital herpes, refraction and accommodation disorders, and ascariasis. The impairment that affected the greatest number of people in 2015 was anaemia, with 2·36 billion (2·35–2·37 billion) individuals affected. The second and third leading impairments by number of individuals affected were hearing loss and vision loss, respectively. Between 2005 and 2015, there was little change in the leading causes of years lived with disability (YLDs) on a global basis. NCDs accounted for 18 of the leading 20 causes of age-standardised YLDs on a global scale. Where rates were decreasing, the rate of decrease for YLDs was slower than that of years of life lost (YLLs) for nearly every cause included in our analysis. For low SDI geographies, Group 1 causes typically accounted for 20–30% of total disability, largely attributable to nutritional deficiencies, malaria, neglected tropical diseases, HIV/AIDS, and tuberculosis. Lower back and neck pain was the leading global cause of disability in 2015 in most countries. The leading cause was sense organ disorders in 22 countries in Asia and Africa and one in central Latin America; diabetes in four countries in Oceania; HIV/AIDS in three southern sub-Saharan African countries; collective violence and legal intervention in two north African and Middle Eastern countries; iron-deficiency anaemia in Somalia and Venezuela; depression in Uganda; onchoceriasis in Liberia; and other neglected tropical diseases in the Democratic Republic of the Congo.


    Ageing of the world's population is increasing the number of people living with sequelae of diseases and injuries. Shifts in the epidemiological profile driven by socioeconomic change also contribute to the continued increase in years lived with disability (YLDs) as well as the rate of increase in YLDs. Despite limitations imposed by gaps in data availability and the variable quality of the data available, the standardised and comprehensive approach of the GBD study provides opportunities to examine broad trends, compare those trends between countries or subnational geographies, benchmark against locations at similar stages of development, and gauge the strength or weakness of the estimates available
    Group Report: Magnitudes and geographical variations and uncertainties of properties of tropospheric and stratospheric aerosols and their forcing.
    Lelieveld, J. ; Crutzen, P.J. ; Grassl, H. ; Heintzenberg, J. ; Jaenicke, R. ; Kaufman, Y.J. ; Kiehl, J.T. ; Penner, J.E. ; Rodhe, H. ; Schult, I. ; Tegen, I. - \ 1995
    In: Aerosols forcing of climate / Charlson, R.J., Heintzenberg, J., John Wiley and Sons - p. 334 - 348.
    Multiphase atmospheric chemistry: implications for climate.
    Charlson, R.J. ; Lelieveld, J. - \ 1994
    In: Proc. IGAC Conf. Global atmospheric-biospheric chemistry, R. Prinn (ed.). Eilat, Israel. Massachusetts Inst. Technol. Cambridge, Mass. USA - p. 57 - 69.
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