Improving air quality in North Carolina: beyond respiratory health effects

Transcription

1 Improving air quality in North Carolina: beyond respiratory health effects Julia Kravchenko, MD, PHD Assistant Professor, Department of Surgery, Duke University School of Medicine October 27-28, 2016 Museum Hotel, Durham, NC

2 Study Rationale The risks from air pollution are now far greater than previously thought or understood, particularly for heart disease and strokes (Dr. Maria Neira, Director of WHO s Department for Public Health, Environmental and Social Determinants of Health, 2014). WHO 2014 report on health and ar pollution: Outdoor air pollution-caused deaths: 40% ischemic heart disease; 40% stroke; 11% chronic obstructive pulmonary disease (COPD); 6% - lung cancer; and 3% acute lower respiratory infections in children.

3 Study Rationale Although geographic variations of mortality and lifespan in the US exist, they remain not fully explained by demographic, socioeconomic (SES), behavioral, and access-to-medical-care factors (Murrey et al, 2006; Marengoni et al., 2011, Preston, Ho, 2010). Example from our study: Death hazard ratios for the 112 U.S. cities showed a correlation between air pollution and residents of the U.S. states with the highest vs. the lowest cardiovascular life expectancy. disease (CVD) mortality: for addition to higher respiratory deaths, increase of PM 2.5 level was associated with increase in heart disease and stroke deaths (Zanobetti, Swartz, Environ Health Perspect 117(6)). The association between air quality and health outcomes in the general population have been reported even for air pollutant levels that remained within air quality standards, i.e. there is no safe threshold (Brook et al., Circulation 121(21): ).

4 We also reported that improving air quality was associated with lower death rates of emphysema, asthma, and pneumonia in NC residential population (Kravchenko et al, Intern J COPD 9: ). In North Carolina: Study Rationale CVD causes almost 30% of all deaths, heart disease is the 2 nd and stroke is the 4 th leading cause of death. (Source: The burden of cardiovascular disease in in NC. Update 2012).

5 What is known about CVD and air quality? CVD trends in NC The role of air quality changes in CVD morbidity and mortality in NC? Note: BP blood pressure; CHD coronary heart disease; CCU coronary care unit; EMS/CPR emergency medical service/cardiopulmonary resuscitation. (Source: Havlik, Feinleib, Bethesda, MD: Dept of Health Education and Welfare). Air pollutants dynamics in NC

6 CVD in Healthy North Carolina 2020

7 CVD in Healthy North Carolina 2020

8 Other factors related to CVD in Healthy North Carolina 2020

9 Source: In 2014 in North Carolina - heart disease death per 100,000 was US rate was 167.0, - stroke death rate per 100,000 was 43.0 US rate was (Source: American Heart Association, American Stroke Association)

10 Our data: CVD mortality trends in North Carolina, age 65+, Legend: Black years old Red years old Blue 85+ years old

11 Our data: CVD hospitalization trends in North Carolina, age 65+, Legend: Black years old Red years old Blue 85+ years old Age-adjusted Discharge Rate CVD hospital discharge rates in North Carolina, ,000 2,500 2,000 1,500 1, Total Males Females 0 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 Year Source: The burden of cardiovascular disease in North Carolina. September 2012 update. Justus-Warren.

12 Dynamics of categorical air pollutants in North Carolina, by seasons, Winter Summer Zanobetti, Swartz, Environ Health Perspect 117(6))

13 In NC, multiple policies addressed air quality over last two decades. The Federal Clean Air Act requires EPA to set the National Ambient Air Quality Standards (NAAQS): - these standards are established for maximum allowable concentrations of criteria pollutants in outdoor air, - they are set at a level that protects public health with an adequate margin of safety. We hypothesized that cumulative effects of Federal and State acts and regulations benefited the health of local population by reducing cardio- and cerebrovascular, as well as respiratory morbidity and mortality. We also understand that socioeconomic (SES) and behavioral factors, and medical care improvements contribute to disease trends and must be considered in analysis. Timeline of key federal and North Carolina state-specific air regulations and actions. Gray: the acts and regulations that had a major impact on air quality in North Carolina.

14 NC population: 65 years and older. Diseases: Myocardial infarction (ICD-9: 410, ICD-10: I21-I22) Ischemic heart disease (IHD) (ICD-9: , ICD-10: I20-I25) Arterial hypertension (ICD-9: ; ICD-10: I10-I15) Stroke (ICD-9: ; ICD-10: I60-I63) Cerebrovascular disease (ICD-9: , ICD-10: I60-I69): for addition to stroke includes transient cerebral ischemia, cerebral seizure, encephalopathy, late effects of cerebrovascular disease (hemi- /monoplegia, hemiparesis, other paralytic syndrome), etc. Datasets: Data and study design Individual level data on disease-specific mortality and hospital admissions in NC: The State Inpatient Database (H-CUP SID data on disease-specific hospital admissions), State Center for Health Statistics, Vital Statistics-Death, UNC Dataverse. The U.S. Environmental Protection Agency (EPA) datafiles on air quality for criteria air pollutants (i.e., for which the National Ambient Air Quality Standards (NAAQS) have been set), The Centers for Disease Control and Prevention Behavioral Risk Factor Surveillance System (BRFSS) survey for adult smoking prevalence, age group specific. Approach: County level analysis. We analyzed the association between month-to-month over time changes of age-specific death rates of each disease and month-to-month over time dynamics of air pollutant levels. Analyses were adjusted by age group specific smoking prevalence, SES characteristics (income and education), and seasonal fluctuations of disease-specific deaths (i.e., for monthly death rates). Note: Socioeconomic factors and changes in medical care did not fluctuate month to month significantly in studied counties.

15 Heart diseases: correlations between the death and hospitalization rates and air pollutants levels, age 65+ years old, multivariate analysis adjusted by smoking prevalence, median income, and seasonal deaths and hospitalization fluctuations. Per 1 unit of air pollutant measurement. Disease Myocardial infarction (ICD-9: 410, ICD-10: I21- I22) Arterial hypertension (ICD-9: ; ICD-10: I10-I15) Ischemic heart disease (IHD) (ICD-9: , ICD-10: I20-I25) Criteria pollutant, unit of measurement Disease rate changes Mortality Changes of disease-specific deaths among all causes of deaths Disease rate changes Hospitalization Changes of disease-specific hospitalization among all causes of hospitalization CO, ppb -0.13% -0.08% -0.03% n/s SO 2, ppb -7.9% -3.4% n/s n/s PM 10, µg/m 3-2.0% -1.6% n/s n/s PM 2.5, µg/m 3-5.5% -3.9% -2.3% -0.8% CO, ppb n/s n/s -0.05% n/s SO 2, ppb n/s +8.0% n/s +2.7% PM 10, µg/m 3 n/s +1.6% n/s n/s PM 2.5, µg/m 3 n/s n/s -1.3% n/s CO, ppb -0.11% -0.06% -0.1% -0.06% SO 2, ppb -7.3% -3.1% -4.5% -3.3% NO 2, ppb -2.3% n/s -3.3% -3.0% PM 10, µg/m 3-1.6% -1.3% -1.2% -0.9% PM 2.5, µg/m 3-4.0% -2.7% -4.2% -2.9% EHSP Fall Forum Note: - The results shown are significant after applying Bonferroni correction (p value <10-6 ), *n/s non-significant. 2016

16 Cerebrovascular diseases: correlations between the death and hospitalization rates and air pollutants in NC, age 65+ years old, multivariate analysis adjusted by smoking prevalence, median income, and seasonal death and hospitalization fluctuations. Per 1 unit of air pollutant measurement. Disease Cerebrovascular disease (ICD-9: , ICD-10: I60-I69) for addition to stroke includes transient cerebral ischemia, cerebral seizure, encephalopathy, late effects of cerebrovascular disease (hemi- /monoplegia, hemiparesis, other paralytic syndrome), etc. Stroke (ICD-9: ; ICD-10: I60-I63) Criteria pollutant, unit of measurement Disease rate changes Mortality Changes of diseasespecific deaths among all causes of deaths Disease rate changes Hospitalization Changes of diseasespecific hospitalization among all causes of hospitalization CO, ppb -0.09% -0.04% -0.03% n/s SO 2, ppb -7.5% -3.6% n/s n/s PM 10, µg/m 3-1.4% -1.1% n/s n/s PM 2.5, µg/m 3-4.0% -2.4% -1.8% n/s CO, ppb -0.08% n/s -0.02% n/s SO 2, ppb -10.7% -6.8% n/s n/s PM 10, µg/m 3-2.3% -1.8% n/s n/s PM 2.5, µg/m 3-5.2% -3.3% -1.5% n/s EHSP Fall Forum Note: - The results shown are significant after applying Bonferroni correction (p value <10-6 ), *n/s non-significant. 2016

17 Is CVD prevalent in younger population in NC? Percentage of CVD Deaths African- American Males <65 years 65+ years 25.9 White Males 24.8 African- American Females 10.4 White Females Percentage of total CVD deaths in NC by age group, (Data Source: Centers for Disease Control and Prevention, National Center for Health Statistics. Compressed Mortality File, CDC WONDER Online Database, 2011.) Percentage of Hospitalizations <65 years 65+ years Female Male Total Percentage of CVD hospitalizations in NC by age group, (Data Source: North Carolina Division of Public Health, State Center for Health Statistics. North Carolina Inpatient Provisional Hospital Discharges, Produced by: State Center for Health Statistics, 06/08/2012.)

18 CVD: correlations between the death and hospitalization rates and air pollutants in NC, age years old, multivariate analysis adjusted by smoking prevalence, median income, and seasonal death and hospitalization fluctuations. Per 1 unit of air pollutant measurement. Disease Myocardial infarction (ICD-9: 410, ICD-10: I21-I22) Arterial hypertension (ICD-9: ; ICD- 10: I10-I15) Ischemic heart disease (IHD) (ICD-9: , ICD- 10: I20-I25) Cerebrovascular disease (ICD-9: , ICD-10: I60-I69) Stroke (ICD-9: ; ICD- 10: I60-I63) Criteria pollutant, unit of measurement Disease rate changes Mortality Changes of disease-specific deaths among all causes of deaths Disease rate changes Hospitalization Changes of disease-specific hospitalization among all causes of hospitalization CO, ppb -0.10% n/s n/s n/s SO 2, ppb -8.1% n/s n/s n/s Lower than for people aged 65+ PM 10, µg/m 3-2.1% n/s n/s n/s PM 2.5, µg/m 3-3.9% -2.2% n/s n/s CO, ppb n/s n/s n/s -0.03% SO 2, ppb n/s +6.1% +2.7% +3.0% PM 10, µg/m % +3.4% n/s n/s PM 2.5, µg/m 3 n/s +3.9% n/s n/s CO, ppb -0.07% n/s -0.09% -0.06% SO 2, ppb -5.2% n/s -3.8% -3.6% NO 2, ppb n/s Lower than n/s for people aged % -2.7% PM 10, µg/m 3-1.3% n/s -0.6% -0.7% PM 2.5, µg/m 3-2.4% n/s -3.2% -2.9% CO, ppb -0.06% n/s n/s n/s SO 2, ppb -9.6% -5.2% n/s n/s PM 10, µg/m 3-2.4% -1.3% n/s n/s PM 2.5, µg/m 3-4.7% -2.6% n/s n/s Higher than for people aged 65+ CO, ppb 0.07% n/s n/s n/s SO 2, ppb -12.6% -8.2% n/s +2.2% PM 10, µg/m 3-3.0% -1.8% n/s n/s PM 2.5, µg/m 3-5.3% -3.2% n/s n/s Note: - The results shown are significant after applying Bonferroni correction (p value <10-6 ), *n/s non-significant.

19 Some examples of potential benefits of improved air quality in NC on health of residential population: annual reductions in deaths and hospital admissions since Disease and air pollutant Deaths Hospital admissions Myocardial infarction and PM 2.5 : age IHD and PM 10 : Stroke and PM 2.5 : Stroke average hospital charges per stay in NC, Charges per Stay in 2011 Dollars $30,000 $27,000 $24,000 $21,000 $18,000 Total Males Females $15,000 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 Year Data Source: North Carolina Division of Public Health, State Center for Health Statistics. North Carolina Inpatient Hospital Discharges, age age age age age Coronary heart disease average hospital charges per stay in NC, Charges per Stay in 2011 Dollars $60,000 $55,000 $50,000 $45,000 $40,000 $35,000 $30,000 Total Males Females $25,000 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 Year Data Source: North Carolina Division of Public Health, State Center for Health Statistics. North Carolina Inpatient Hospital Discharges,

20 Study team: The Center for Applied Therapeutics, Department of Surgery, Duke University School of Medicine: H. Kim Lyerly, Julia Kravchenko, Pankaj Agarwal, Sung Han Rhew (post-doc) We thank Igor Akushevich (Associated Professor at SSRI, Duke University) for his help in analysis. We thank for consultations the specialists from the North Carolina Division of Air Quality (Director Sheila Holman) and John Walker and Jesse Bash from the U.S. EPA. We thank Fred and Alice Stanback for supporting this study with a philanthropic donation.

21 Appendix

22 Air pollutants-health associations depend on: Geographic region: summer/winter pollutants levels, measured associations for one season, regional/local differences in PM components. Age-specific population groups. Year/time period when the study was performed. The levels of air pollutants (high, moderate, low).

23 Further studies Multi-pollutant approach. PM components analysis (organic and non-organic components). Socioeconomic and access-to-medical-care characteristics (e.g., the Health and Retirement study, the National Cancer Data Base) as co-factors. Temperature (average and heat/cold waves) and humidity as co-factors. Medicare datafiles used for analysis of disease incidence, prevalence, and treatment effectiveness in persons aged 65+ years old. Urban/rural area as co-factor. Analyses on datasets with available individual records on smoking and obesity (with information of duration and severity of exposure to be available). Extend the study to other U.S. states. Investigate the data on genetics and how it interrelates with environmental exposures (e.g., using the Health and Retirement Study).

24 Sensitivity analysis Scenario 1: potential effect of ICD codes changes (from ICD-9 to ICD-10). Scenario 2: seasonal fluctuations of air pollutants and mortality during summer and winter. Scenario 3: only underlying causes of deaths contributed to the causespecific death rates.

25 Air pollutant Measurements of air pollutant levels Number of monitored sites Number of monthspecific measurements NO SO CO PM PM counties for ozone measurements 11 counties for NO 2 22 counties for SO 2 16 counties for CO 37 counties for PM 2.5 and PM 10

26 The Clean Air Act requires EPA to set the National Ambient Air Quality Standards (NAAQS): they are established by EPA for maximum allowable concentrations of criteria pollutants in outdoor air. The standards are set at a level that protects public health with an adequate margin of safety. Gaseous air pollutants: Sulfur dioxide (SO 2 ): 1-hour averaging time (AT) 75 parts per billion (ppb) Nitrogen dioxide (NO 2 ): 1-hr AT 100 ppb, annual AT 53 ppb Carbone monoxide (CO): 8-hr AT 9 parts per million (ppm), 1-hr AT 35 ppm Particulate matters: PM 10 : 24-hr AT 150 µg/m 3, PM 2.5 : 24-hr AT 35 µg/m 3 The "WHO Air quality guidelines" provide an assessment of health effects of air pollution and thresholds for health-harmful pollution levels. PM μg/m 3 annual mean 25 μg/m 3 24-hour mean PM μg/m 3 annual mean 50 μg/m 3 24-hour mean NO 2 40 μg/m 3 annual mean 200 μg/m 3 1-hour mean SO 2 20 μg/m 3 24-hour mean 500 μg/m 3 10-minute mean 2016 EHSP Fall Forum

27 Clean Smokestacks Act In June 2002, the N.C. General Assembly enacted the Clean Smokestacks Bill, officially titled the Air Quality/Electric Utilities Bill (SB 1078), which requires significant actual emissions reductions from coalfired power plants in North Carolina. Under the act, power plants must reduce their nitrogen oxide emissions by 77% in 2009 and sulfur dioxide emissions by 73% in Source: NC Division of Air Quality, at

28 association between the trends of death rates and dynamics of air pollutants in NC: estimates and percent of decrease of death rates with decreasing of air pollutant levels by 1 unit of measurements. Population aged 65+, considering smoking prevalence and seasonal deaths fluctuations (not shown here). Disease Ozone SO 2 NO 2 CO PM 10 PM 2.5 Myocardial infarction n/s *, p< % Angina pectoris n/s *, p< % Heart failure n/s *, p< % Cerebrovascular , *, diseases p<0.01 p< % -0.47% Emphysema n/s *, p< % Asthma n/s *, p< % Acute upper n/s *, p<0.001 respiratory -1.61% infections * Significant after applying Bonferroni correction , p< % n/s , p< % *, p< % , p< % , p< % n/s *, p< % *, p< % *, p< % *, p< % *, p< % *, p< % *, p< % *, p< % , p< % , p< % n/s n/s *, p< % *, p< *, p< % -1.2% n/s *, p< % *, p< % , p< % n/s , p< % Note: Disease-specific death rate (number of deaths per 100,000 population) decreased by a factor that can be calculated based on the estimates presented in Table. For example: if PM 2.5 level will decrease by 1.0 µg/m 3, then cerebrovascular death rate can be predicted to decrease by 1.2% (a factor of (exp(0.0117)-1)x100%=( )x100%= 1.2%).

29 Percentage increase (and 95% CI) in relative risk of mortality associated with long-term PM 2.5 exposure: cardiopulmonary mortality (Pope, Dockery, Air&Waste Manag Assoc 56: ). 18% (6.0-32) Dockery et al, % (6.5-33) Krewski et al, % (13-44) Laden et al, % (6.7-17) Pope et al, % (7.4-17) Krewski et al, % (8-15) Pope et al, %-14% Dockery et al, % (6-90) Chen et al, % (1-73) Miller et al, 2004 Agreement with other studies 95% (9-251) near major roads, Hoek et al, 2002 Arterial hypertension ( ), myocardial infarction (410), other ischemic heart diseases (411, 413, 414), conduction disorders and cardiac dysrhythmias (426, 427), heart failure (428), peripheral vein diseases( , 456, 459), aneurysm/arterial embolism/thrombosis ( , 447, 557) references Stroke ( , 348), stroke with complications (438, 342, 344) 5-8 references

30 References 1. Brook RD et al. Particulate matter air pollution and cardiovascular disease an update to the scientific statement from the American heart association. Circulation 2010;121(21): Pope 3rd C et al. Lung cancer and cardiovascular disease mortality associated with ambient air pollution and cigarette smoke: shape of the exposure-response relationships. Environ Health Perspect 2011;119(11): Dominici F et al. Fine particulate air pollution and hospital admission for cardiovascular and respiratory diseases. JAMA 2006;295(10): Peng RD et al. Emergency admissions for cardiovascular and respiratory diseases and the chemical composition of fine particle air pollution. Environ Health Perspect 2009;117(6): Hoek G et al. The association between air pollution and heart failure, arrhythmia, embolism, thrombosis, and other cardiovascular causes of death in a time series study. Epidemiology 2001;12(3): Hendryx M. Mortality from heart, respiratory, and kidney disease in coal mining areas of Appalachia. International Archives of Occupational and Environmental Health 2009;82(2): Chan C-C et al. Urban air pollution and emergency admissions for cerebrovascular diseases in Taipei, Taiwan. European Heart Journal 2006;27(10): Block ML et al. Air pollution: mechanisms of neuroinflammation and CNS disease. Trends in Neurosciences 2009;32(9): Kravchenko J et al. Long-term dynamics of death rates of emphysema, asthma, and pneumonia and improving air quality. International Journal of Chronic Obstructive Pulmonary Disease 2014, 9: Ngo L et al. The Effects of Short-term Exposure on Hospital Admissions for Acute Lower Respiratory Infections in Young Children of Ho Chi Minh City, Viet Nam. Epidemiology 2011;22(1):S228-S Zanobetti A, Schwartz J. Air pollution and emergency admissions in Boston, MA. Journal of Epidemiology and Community Health 2006;60(10): Lin H-H et al. Tobacco smoke, indoor air pollution and tuberculosis: a systematic review and meta-analysis. PLoS Medicine 2007;4(1):e Brauer M et al. Air pollution and development of asthma, allergy and infections in a birth cohort. European Respiratory Journal 2007;29(5): Spickett JT et al. Climate change and air quality: the potential impact on health. Asia-Pacific Journal of Public Health 2011;23(Suppl2):37S-45S. 15. Brauer M et al. Air pollution from traffic and the development of respiratory infections and asthmatic and allergic symptoms in children. American Journal of Respiratory and Critical Care Medicine 2002;166(8): Brook RD et al. The relationship between diabetes mellitus and traffic-related air pollution. Journal of Occupational and Environmental Medicine 2008;50(1): Pearce EN, Braverman LE. Environmental pollutants and the thyroid. Best Practice & Research Clinical Endocrinology & Metabolism 2009;23(6): Bernard SM et al. The potential impacts of climate variability and change on air pollution-related health effects in the United States. Environmental Health Perspectives 2001;109(Suppl2): Castaño-Vinyals G et al. Air pollution and risk of urinary bladder cancer in a case-control study in Spain. Occupational and Environmental Medicine 2008;65(1): Vineis P, Husgafvel-Pursiainen K. Air pollution and cancer: biomarker studies in human populations. Carcinogenesis 2005;26(11): Gauderman WJ et al. Association of improved air quality with lung development in children. The New England Journal of Medicine 2015, 372(10): Kalkbrenner et al. Perinatal exposure to hazardous air pollutants and autism spectrum disorders at age 8. Epidemiology 2010, 21(5): Dockery DW, Ware JH. Cleaner air, bigger lungs. The New England Journal of Medicine 2015, ):

31 Figure Coronary Heart Disease: Average Hospital Charges per Stay, N.C., Charges per Stay in 2011 Dollars $60,000 $55,000 $50,000 $45,000 $40,000 $35,000 $30,000 $25,000 Total Males Females '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 Year Coronary Heart Disease: ICD-9-CM codes ; Principal diagnosis only. Data Source: North Carolina Division of Public Health, State Center for Health Statistics. North Carolina Inpatient Hospital Discharges, Produced by: State Center for Health Statistics, 06/08/2012. Charges adjusted to 2011 dollars using the Bureau of Labor Statistics Consumer Price Index tables for Medical Care for years , U.S. city average, not seasonally adjusted. The Burden of CVD in N.C. September, 2012 N.C. Justus-Warren Heart Disease & Stroke Prevention Task Force