The Health Effects of Air Pollution. Haim Bibi Carmel Medical Center

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1 The Health Effects of Air Pollution on Children Haim Bibi Carmel Medical Center Haifa

2 Why are children at special risk? Physically, children are more vulnerable to air pollution than adults. Their respiratory defenses are not fully formed. Their airways are smaller, and more likely to become blocked when irritated.

3 Why are children at special risk? Children also spend a lot of time outdoors during periods when air pollution is at its highest.

4 Why are Children More Susceptible to Air Pollution Than Adults? Exercising at maximum levels, they may take in 20 percent to 50 percent more air per body weight -- and more air pollution -- than would an adult in comparable activity.

5 Why are Children More Susceptible to Air Pollution Than Adults? Adults exposed to low levels of ozone experience symptoms such as coughing, chest pain and sometimes headaches. h

6 Why are Children More Susceptible to Air Pollution Than Adults? Children may not feel the same symptoms, or at least they do not acknowledge them when asked by researchers. It is currently not known if children actually do not feel the symptoms or if they ignore them while preoccupied with play activities.

7 Why are Children More Susceptible to Air Pollution Than Adults? Symptoms are warning signals s used to trigger protective behavior. Children not perceive these warning signals and might not reduce their activities i i on smoggy days.

8 Why are Children More Susceptible to Air Pollution Than Adults? This probably does not mean that children are less sensitive to air pollution than adults. Studies showed that t children have losses in lung function even when they don t cough or feel discomfort.

9 Air Pollution and Respiratory disease in children What is the clinically relevant impact

10 Air Pollution Indoor & Outdoor OUT DOOR + + INDOOR + - Ozone (O3) Particulate matter {PM10, PM 2.5 (µm in aerodynamic diameter),tsp} cars exhaust house heating and cooking CO NO 2, NO 3, NOX SO2 Black smoke + ++ ETS (environmental tobacco smoke) Domestic animals allergens Mould, Mite, Cockroach

11 Questions: Air pollution data * Toxic level ( Indoor, outdoor and relevancy to the individual) id? * Exposure to few episodes of high doses or recurrent exposures to low doses?

12 Air Pollution data Air pollution: average?, peak?1 hour?, 1 day?, 1 week?, year?, number of peaks? One pollutant? Combination? Short exposure?,long exposure?. Weather conditions?

13 Air quality standards - as a rule different standards in different places. Ozone: [ European ppb (1 hour),50-60 ppb(8 hours average]. USA/EPA/NAAQS [125 ppb (1 hour), 85 ppb (8 hours average)]. NO2: [European] 78 ppb (24 hour average), 53 ppb ( 1 year average). USA/EPA/NAAQS 54 ppb (1 year average)

14 The Blind Men and the Elephant

15 Airway Pathology in Asthma Cartilage Mucous gland BRONCHUS Airway Normal Muscle Layer

16 Airway Pathology in Asthma Reduced airway opening Mucus Asthma Muscle Layer Contracts

17 Health outcome evaluation *Health H parameters that may be analyzed: * Subjective : symptoms * Diagnosis i (physician): i Asthma New cases of asthma or aggravating existing disease, other organs. * Objective : Lung function, Chest X - rays, other objective parameters ( challenge, skin tests etc.)

18 Source of information about the nature of the health effect of air pollutant Consequential end point: Hospital admissions, ER visits (may be dependent on social condition such as access to medical services), school day lost.

20 ETS (Environmental tobacco smoke) Children with asthma, exposure to higher h levels l of ETS was associated with increased frequency of nocturnal symptoms. JAll Allergy Clin Immunol Jul;110(1): ETS is as a major LAWI (lower ETS is as a major LAWI (lower airway irritants) Chest Sep;120(3): Passive smoking increases risks for higher and lower respiratory tract illness but a smoke-free environment improves all these disorders. Eur Respir J Dec;9(12):

21 Daily fluctuations in Air Pollution levels may have been related to: #acute respiratory hospital admissions in children # school and kindergarten absences # decreases in peak lung air flow rates in normal children # and increased medication use in children and adults with asthma.

22 Diesel emissions & Asthma Diesel emissions may also be a problem for asthmatics. Children with asthma who live near roadways with high amounts of diesel truck traffic have more asthma attacks and use more asthma medication

23 Epidemiology-cross-sectional surveys related to traffic exposure and air pollution Increasing pollutant and exposure to traffic emissions exacerbate pre-existing disease, even when taking pollen and mould counts, as well as influenza epidemics into well as influenza epidemics into account.

24 Epidemiology - West Germany more NOX + (Western life style) East Germany high SO2 and particulate pollution. Asthma, AWH, atopy more in the West. Childhood bronchitis higher in the East.

25 Epidemiology - Initiation of asthma Cross sectional surveys related to air pollution: Asthma symptoms wheeze and cough more prevalent in areas of high pollution.

26 asthma attacks The levels of air pollution even well below current U.S. government air quality standards d linked with increased ER visits for asthma among children.(jama 2003)

27 Epidemiology Pollution associated wheeze is a different phenotype of wheezing. More closely related to infectious triggers and irritative nonspecific airway inflammation than with atopy related asthmatic than with atopy related asthmatic wheezing phenotype.

28 Epidemiology Genetic Prone Beta 2 adrenergic gene (ADRB2) # 5q31 Tumor necrotizing factor alfa (TNF-a) # 6p21 Glutathione S transferase P1 (GSTP1) # 11q13 Interleukine 9 receptor (IL9R) # Xq28 Yq12 Interleukine eu e receptor alpha a (IL4RA) # 16p12

29 Environment weather and pulmonary symptoms The major factors found to be associated with ER visits of asthmatic children were high h NOx, high h SO2, and high barometric pressure. Negative correlation was found between ER visits of asthmatic children and ozone concentrations. Garty BZ, et al.schneider Children's Medical Center of Israel, Petah Tiqva Ann Allergy Asthma Immunol Dec;81(6):563

30 Environment weather and pulmonary symptoms The particularly l highh number of ER visits at the beginning of the school year and the Jewish holidays was probably associated with an increase in the number of viral infections and/or emotional stress. Garty BZ, et al

32 Prediction of Emergency Department Visits for Respiratory Symptoms Using an Artificial Neural Network* Haim Bibi,Amir Nutman, et al. (CHEST 2002; 122: ) Peak 7 days average Tem RH Brp So2 Nox Tem RH Brp So2 Nox Input Layer Hidden Layer 25 neurons... Output Layer Cough* + Asthma*

33 ANN and air pollution The relative weight of the input parameters Peak value one day before ER visit Average of 7 days before ER visit Temperature 9% 10% Relative Humidity 11% 10% Barometric Pressure 10% 11% SO2 10% 9% NOX 10% 10%

34 Our experience Difference in lung function among school children in communities in Israel (Peled R. Bibi H. Arch Environ Health 2001) school children school children ( 5 different communities) school children Substantial differences in lung function across the different communities. Some association with air pollution was demonstrated.

35 What can you do to protect your kids? Keep track of air pollution levels. l If air quality unhealthy, limit the time of outdoors vigorous play. Plan the most strenuous activities for the early morning hours, before ozone levels climb. Keep all outdoor activities as far as possible from busy roadways and other sources of pollution.

36 What can you do to protect your kids? If your child does have asthma, learn to recognize what ti triggers the attacks, and help plan to avoid those substances.

37 What can you do to protect your kids? Make your indoor environment "lung healthy. " Keep it smoke-free and cleaned regularly to reduce dust and insect pests. Fix any leaks or moisture problems that might cause mold growth..

38 Air Quality Weather Conditions Health Information Good (green) Cool summer temperatures Windy and/or cloudy Recent rain or cool front None Moderate (yellow) Mild summer temperatures Light/moderate winds High pressure system, or partly cloudy skies Extremely sensitive individuals, usually with respiratory disease, may need to limit prolonged exertion outdoors Unhealthy for Sensitive Groups (orange) Temperatures upper 80 s or above Light winds Sunny skies People with respiratory disease and other sensitive individuals should limit prolonged exertion outdoors Unhealthy (red) Hazy, hot and humid People with respiratory disease and other sensitive individuals should avoid exertion outdoors. Others should limit prolonged or vigorous exercise. Very Unhealthy to Hazardous Continuing hot stagnant weather (these levels usually occur only in most polluted areas of the country) People with respiratory disease and other sensitive individuals should avoid outdoor activity. Others should limit or avoid exertion.

40 . Despite our knowledge regarding airborne pollution we have no succeeded in devising successful strategies t to reduce the risk. There is a lot to be done and health care providers should have major role in this act.

Asthma and Air Pollution

Asthma and Air Pollution Health Effects Workshop Nov. 6, 2008 Joann Held with thanks to: Dave Brown Asthma and Airways Asthma Physiology A chronic disease that affects airways. The inside walls of airways