Health Disparities Northeast Air Pollution Control Conference 2012

Transcription

1 Role of Air Quality on Health and Health Disparities Northeast Air Pollution Control Conference 2012 Sumita B. Khatri, MD, MS Co-Director, Asthma Center Respiratory Institute Cleveland Clinic 1

2 Photo: Danny Wilcox Frazier/Redux All it takes to control asthma is the right medication, clean air, and a reasonably stress-free life. But for millions of children caught up in the epidemic, none of those things are anywhere within reach. By Sara Corbett 2

3 Images from the Hazecam 10/29/09-8 am 10/29/09-4pm PM ug/m3 PM2.5 6 ug/m3 Average for the day = 30 ug/m 3 3

4 Cleveland has an asthma and air pollution problem problem. Children have a diagnosis of asthma: 6-8%. Children in East Side of Cleveland (grs 2-5): 22-26% of children have a diagnosis off asthma. th 14% of children miss school for breathing problems like asthma. > 16% of children have GCAC 2006 symptoms of asthma (no diagnosis). 4

5 Sobering statistics on the burden of asthma. People age 18 and over with current asthma (2006)...16 million. People under age 18 with an asthma attack in past 12 months (2004) million. Total cost of asthma (2007)...$19.7 billion. 5

6 During , National Health Interview Survey (NHIS) Proportion of asthma in US increased from 7.3% to 8.2% 20 to 25 million people (12%) Children % Whites % Blacks % Hispanics % Non-Hispanic black children % Children 9.6% vs. adults 7.7% 6

7 Factors contributing to asthma disparities: I. Health care inequities. II. Poor housing/ environmental factors. III. Social and psychosocial stressors. Bryant-Stephens

8 Poor Housing/Environmental Factors. Indoor and outdoor exposures pose problems. Indoor exposures increase in the inner city Overcrowding, housing density, poor conditions, crime. 8

9 Top Polluters in Cleveland. 9

10 Cuyahoga County air toxics emission i inventory (2002) 64% of emissions from mobile sources (vehicles). Primary air toxics released are volatile organics benzene and formaldehyde Primary contributors of non-mobile sources Metal wood-products chemicals-related auto manufacturing industries waste disposal activities. 10

11 Outline Introduction Background on air quality. Health Effects/associations. ti Disparities in the morbidity of asthma. Personal and regional initiatives. 11

12 Children are at higher health risk from air pollution. Lungs are still developing. More time outdoors. More asthma and allergies. Indoor pollutant/exposures from adult behaviors. 12

13 Older adults are also at higher health risk from air pollution. Heart disease. Congestive heart failure. Ath Asthma. Emphysema and bronchitis (COPD). 13

14 What is the evidence? 14

15 Increase in prevalence of allergic airways disease has been linked to increase in air pollution. Children in 24 schools within 400 meters of highways. (Netherlands). Children with more exposure to truck traffic-related pollution: -were more sensitive to allergens. - had more respiratory symptoms. - Janssen

16 Children s Health Study revealed associations of poor air quality with decreased d lung development. Lung function of 1759 children were followed over 8 years, ages Lung growth was lower in association with exposures to nitrogen dioxide and PM

17 A measure of lung function Community-Specific Average Growth in FEV1 among Girls and Boys During the Eight-Year Period from 1993 to 2001 Plotted against Average Nitrogen Dioxide (NO2) Levels from 1994 through Gauderman NEJM

18 Cardiac ischemia relates to PM 38 patients with coronary disease / 10 days Ambulatory EKGs to look for ST depression. Positive associations of hourly ST depression with combustion related aerosols and gases. Exposure to combustion related pollutants (traffic related) increase risk of myocardial ischemia. Delfino et al EHP

19 NEJM Study Each 10 ug/m 3 increase in particular matter pollution (2.5) was associated with 24% increase in risk of cardiac event and 76% increase in the risk of death from cardiovascular disease. 19

20 NEJM Study-January 2009 Fine-Particulate t Air Pollution and Life Expectancy in the United States. PM2.5 A reduction in exposure to ambient levels contributed to measurable improvements in life expectancy. Decrease of 10 ug/m 3 associated with increase of year. 20

21 More recently, data have emerged to support associations between air pollution and INCIDENCE of asthma. Five prospective studies support a modest increase in risk for air pollution with clinical symptoms of asthma. 21

22 Children s Health Study demonstrate higher risk of asthma when children play outdoor sports during high ozone season. California 3535 children without asthma. Pollutants evaluated: ozone, particles, acids, and NOx. Children who played 3 or more sports in higher ozone areas were at 80% increased risk of developing/being diagnosed d with asthma. McConnell Lancet

23 Ohio ER visit Medicaid claims from in Cleveland, Cincinnati, and Columbus. Nitrogen dioxide, ozone and sulfur dioxide levels were associated with ED asthma episodes. The link is present regardless of economic or social status. 23

24 Ozone: Good up High, Bad Nearby Stratospheric: 6-30 miles above Earth s surface. Absorbs harmful UV radiation from the sun. 24

25 Ozone is a seasonal pollutant. Ground-level ozone Vehicle emissions. Other pollutants (cars, refineries). Local weather/ sun radiation. Baseline ppb. High ozone season: May-Sept. Low Ozone season: Dec- Feb. US EPA Standards for Ozone Ozone (ppm) 0.12 (1h) (8h) ** **the 3-year average of the fourth-highest daily maximum 8-hour average ozone concentrations measured at each monitor within an area over each year must not exceed ppm 25

26 The major reactions involved in the regulation of ozone concentration in photochemical smog. 1) NO NO + O 2 2) O 2 + O O 3 3) O 3 + NO NO 2 + O 2 26

27 National vs. Cleveland Average Ozone Levels

28 Asthma is a chronic inflammatory disease of the airways. Episodes of cough, wheeze, shortness of breath with activity. Triggers make it worse- allergies (hay fever, dust), upper respiratory infections, odors, emotions, tobacco smoke. 28

29 Asthmatics are particularly susceptible to poor air quality. Less allergen needed to cause an asthma response if individuals were primed with ozone exposure. Jorres et al. 1996; Koren et al Worse airway inflammation and increased reactivity to allergen occur in asthmatics after ozone exposure. Yost et al. 1999; Mudway et al. 2000;Peden, Ambient ozone levels l correlate with eosinophilia and airway inflammation in asthma. Khatri et. al

30 Air pollution has been associated with increased asthma medication use, visits to ERs and hospital admissions. Ozone (and dno2) associated with ihdeath hin asthma (Spain). Sunyer 2002 ER visit with asthma increased by 21.3% on days after ozone levels were exceedingly gy high (India). Pande 2002 ER visit 5% higher and increased asthma medication use during high ozone times (US). Wilson 2005, Ostro

31 Exposure to ozone also affects healthy people. Dose and duration-dependent decreases in airflow for the first hrs after exposure Some tolerance over time to effects. Persistent changes in the asthmatics. More affects when high rate of respiration (more inhaled pollution). Appears to be a dose response. 31

32 Particulate Matter (PM) is the component of air pollution most consistently associated with adverse health effects. Mixture of solid and liquid particles of different origin size and composition. From breakdown of rocks, soil, and dust. Fine particles from combustion of fuels used in vehicles, power plants, and industries, wood-burning. Categorized by size: PM10 (less than 10 um in diameter) Coarse PM2.5 (less than 2.5 um) Fine Ultrafine particles (<0.1 um) Ultrafine 32

33 PM is the component of air pollution most consistently tl associated with adverse health effects. US EPA Standards for PM (24 h) (annual) PM 10 (ug/m 3 ) 150 revoked PM 2.5 (ug/m 3 ) 35* (was 65)** 15 **3-year average of fthe 98th percentile of f24h 24-hour concentrations ti must not exceed 35 µg/m3 3-year average of the weighted annual mean PM2.5 must not exceed 15.0 µg/m3 33

34 National trends for PM are improving. 34

35 Tremont monitor demonstrates levels recently fell below standards d for PM

36 Mean monthly PM10 levels correlated with adult % asthma visits (R=0.34, p<0.01) but not with % pneumonia visits/month (R=0.03, p=0.79). ma visits/ mo % Asth / mo monia visits % Pneu Averaged Mean Monthly PM10 levels (ug/m3)

37 Utah Valley Steel Mill and Harvard 6 Cities Studies. Utah Valley steel mill study linked increased morbidity in asthmatics 8-72 yrs old to PM concentrations, hospitalizations, lung function and respiratory symptoms, school absences and mortality. Pope 1989 Harvard Six Cities and American Cancer Society (ACS) prospective cohort studies that reported long-term PM exposure was associated with respiratory illness in children and cardiopulmonary mortality in adults. Pope and Dockery JAWMA

38 Diesel exhaust particulate (DEP) Accounts for most of airborne PM in largest cities. Carbonaceious core with HMW organic compounds are adsorbed. Effects exerted by activities of chemical agents such as polyaromatic hydrocarbons (PAH) which get deposited on mucosa of airways. 38

39 Health effects of PM are related to particle size and composition. Mechanism: Penetrates into airways, induces inflammation. Transition metals in the particles damage airways. Human lung tissue retains PM2.5. Larger particles 5-10 um eliminated by lung defense. 39

40 Mechanisms of pollutant-related health effects. Pulmonary inflammation. Modification of intracellular proteins. Biologic compounds (endotoxin) which induce inflammation Enhancement of allergic airway inflammation Adjuvant effects in immune system. Free radical and oxidative stress. Stimulation of autonomic nervous system. Suppression of alveolar macrophage function. Bernstein et al. Health effects of air pollution, JACI

41 Traffic related air pollution (TRAP)* have more oxidative potential. High Traffic Low Traffic High Traffic Low Traffic High Traffic Low Traffic High Traffic Low Traffic Antioxidant depletion % A PM2.5 PM10 PM2.5 PM10 *(CO, NO2, elemental carbon, PM, benzene) Traffic density is a surrogate marker. King s College London

42 London Oxford St vs. Hyde Park - moderate asthma affected more. Oxford Street : Higher exposures to PM2.5, fine particles, elemental carbon, NO 2 than Hyde Park. Walking 2 hours on Oxford Street: Consistent reductions in FEV 1 (up to 6.1%) and FVC (up to 5.4%). More pronounced than Hyde Park (p< 0.05). Sputum ph lower, higher sputum myeloperoxidase. McCreanor NEJM 2007; 42

43 Hope in face of the data-reduced PM2.5 concentrations associated with lower risk of death. No evidence of safe threshold levels. Any reduction in ambient PM levels is likely to have an effect on public health. Pope and Dockery 2006-JAWMA, Laden 2006-AJRCCM 43

44 Follow up study in 6 cities, total, cardiovascular, and lung cancer mortality associated with PM2.5 and decreases with reduced levels. Figure 2. Estimated adjusted rate ratios for total mortality and PM2.5 levels in the Six Cities Study by period. P denotes Portage, WI (reference for both periods); T = Topeka, KS; W = Watertown, MA; L = St. Louis, MO; H = Harriman, TN; S = Steubenville, OH. A term for Period 1 (1 if Period 2, 0 if Period 1) was included d in the model. Bold letters represent Period 1 ( ) and italicized letters represent Period 2 ( ). In Period 1, PM2.5 (µg/m3) is defined as the mean concentration during , the years where there are monitoring data for all cities (18). In Period 2, PM2.5 is defined as the mean concentrations of the estimated PM2.5 in Laden 2006 Am J Resp Crit Care Med v.173, p667 44

45 What to do when ozone or PM is expected to be highh Conserve electricity, set air conditioner at higher temperature. Choose a cleaner commute: rideshare, public transportation Refuel cars and trucks after dusk. Combine errands and reduce trips. Keep household chemical evaporation to a minimum, or try to delay using them when poor air quality is forecast. Reduce or eliminate fireplace and wood stove use. Avoid using gas-powered lawn and garden equipment. Avoid burning leaves, trash and other materials. 45

46 Reduce Idling. Leaving the car running while stationary. Cleveland City ordinance (Oct 1 st ). No more than 5 min/hr (summer) No more than 10 min/hr winter. Exceptions: Law enforcement /emergency services. Fragile populations. 46

47 Other tips. Indoor air quality household tips Use environmentally safe paints and cleaning products whenever possible. Using gas logs instead of wood. Burn only dry, seasoned wood. Transportation tips properly inflate tires. Follow gasoline refueling instructions for efficient vapor recovery. 47

48 What has worked in Delhi Switch to Compressed Natural Gas (CNG). Counteracted 100,000 vehicles including ~3000 diesel bus retrofits. Low sulfur diesel. Enforcing strict European emission standards early. 500 heavy industries shut down or relocate, allowing time to upgrade to improve energy efficiency and consumption. India: reduced indoor air pollution, reduced biomass combustion. 48

49 Best strategy (active travel and decreased use of motor vehicles) has policy implications: Make road, infrastructure more convenient for pedestrian, cyclists than vehicles. Strict control of HGV. Street design/urban form. Woodcock 2009 Lancet Increase safety, convenience, comfort of walking. Decrease the attractiveness 49 of private motor vehicle use.

50 Summary Air quality has an impact on public health. Good target to help reduce disparities. Affects economy. Awareness is key. Societal and personal change can have an impact on air quality which WILL improve human health. 50

51 References and Resources EPA website (airnow.gov) Health Effects Institute ( Northeast Ohio Areawide Coordinating Agency ( g American Lung Association: ( 51