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Transcript of Dr Ian Mudway - IAPSC · PM 2.5 air pollution & life expectancy in the US Pope et al, N Engl J Med,...
Findings of the WHO REVIHAAP Study:Areas of Consensus and Contention
Dr Ian [email protected]
R: Review of EVI: EVIdence onH: HealthA: Aspects ofA: AirP: Pollution
It all begins with a book.....
WHO project jointly financed by WHO and EC
Evidence review in response to 24 key policy
questions from the EC
Particulate matter PM2.5 and PM10 (7 questions)
Ground-level ozone (4 questions)
Other air pollutants (NO2, SO2, metals, PAHs) and
their mixtures (10 questions)
General questions
New evidence on health effects post 2005
Concentration response functions & thresholds
Policy implications
Critical data gaps
This can’t be summarised in 20 minutes
Scientific Advisory Committee H. Ross Anderson, United Kingdom
Bert Brunekreef, The Netherlands
Aaron Cohen, United States
Klea Katsouyanni, Greece
Daniel Krewski, Canada
Wolfgang G. Kreyling, Germany
Nino Künzli, Switzerland
Xavier Querol, Spain
AuthorsRichard Atkinson, United Kingdom
Lars Barregård, Sweden
Tom Bellander, Sweden
Rick Burnett, Canada
Flemming Cassee, The Netherlands
E. de Oliveira Fernandes, Portugal
Francesco Forastiere, Italy
Bertil Forsberg, Sweden
Susann Henschel, Ireland
Gerard Hoek, The Netherlands
Stephen T Holgate, United Kingdom
Nicole Janssen, The Netherlands
Matti Jantunen, Finland
Frank Kelly, United Kingdom
Nino Kunzli, Switzerland
Timo Lanki, Finland
Inga Mills, United Kingdom
Ian Mudway, United Kingdom
Mark Nieuwenhuijsen, Spain
Bart Ostro, United States
Annette Peters, Germany
David Phillips, United Kingdom
C. Arden Pope III, United States
Regula Rapp, Switzerland
Gerd Sällsten, Sweden
Evi Samoli, Greece
Peter Straehl, Switzerland
Annemoon van Erp, United States
Heather Walton, United Kingdom
Martin Williams, United Kingdom
External reviewers Joseph Antó, Spain
Alena Bartonova, Norway
Vanessa Beaulac, Canada
Michael Brauer, Canada
Hyunok Choi, United States
Bruce Fowler, United States
Sandro Fuzzi, Italy
Krystal Godri, Canada
Patrick Goodman, Ireland
Dan Greenbaum, United States
Jonathan Grigg, United Kingdom
Otto Hänninen, Finland
Roy Harrison, United Kingdom
Peter Hoet, Belgium
Barbara Hoffmann, Germany
Phil Hopke, United States
Fintan Hurley, United Kingdom
Barry Jessiman, Canada
Haidong Kan, China
Thomas Kuhlbusch, Germany
Morton Lippmann, United States
Robert Maynard, United Kingdom
Sylvia Medina, France
Lidia Morawska, Australia
Antonio Mutti, Italy
Tim Nawrot, Belgium
Juha Pekkanen, Finland
Mary Ross, United States
Jürgen Schneider, Austria
Joel Schwartz, United States
Frances Silverman, Canada
Jordi Sunyer, Spain
Observers Markus Amann, IIASA
Arlean Rhode, CONCAWE
Wolfgang Schoepp, IIASA
André Zuber, European Commission
WHO Secretariat (ECEH Bonn)
Marie-Eve Héroux
Michal Krzyzanowski
Svetlana Cincurak
Kelvin Fong
Elizabet Paunovic
Helena Shkarubo
The Team
“Toxicology & clinical studies areIrrelevant to the setting of population based AQGs”
“How many more epidemiological studies do we
need to perform?”
Association Features
Strength of Association
Specificity of Association
Consistency of Association
Other Evidence
Coherence of Theory
Biological Plausibility
Analogy
Exposure / Outcome
Temporal Sequence
Dose Response
Reversibility(Experiment)
Bradford Hill’s Criteria for Inferring Causality
Why both these positions are wrong
Epi.
Epi.
Epi. Epi.
Epi.
Tox.
Tox.
Tox.
Tox.
Tox.
Tox.
Benefits of improved air quality
Increased volume of evidence Broader range of evidence
Role of fractions / components / sources
Recent developments in the evidence of the health effects of traffic pollutants – PM2.5
We have a much better understandingof the magnitude of the problem
Lim et al. LANCET (2012)
Ambient air pollution (PM2.5):
Globally:
- 3.1 million deaths
- ~ 3.0% of all DALYs
In Western, Central and Eastern Europe:
- 430,000 premature deaths;
- over 7 million years of healthy life lost Lim et al. LANCET (2012)
Meta-analysis of the association between long-term exposure to PM2.5 and all-cause mortality
Hoek et al, EnvHealth 2013
These are all, by and large, associations derived from old cohorts exposed to
historic levels of air pollution.
What do they tell us about contemporary exposures?
Mortality and long-term PM2.5 exposure Results of a Canadian cohort study (2.1 million adults, 1991-2001)
Non accidental
Cardiovascular
Ischemic heart disease
Cerebrovascular
Crouse et al, EHP 2012
AQG
Mortality and long-term exposure to PM2.5
Results of a cohort study in Rome (1.3 million adults followed from 2001 to 2010)
EULV
AQG
4% per 10 mg/m3 6% per 10 mg/m3 10% per 10 mg/m3
Cesaroni et al, EHP 2013
Improvements in PM10 (& PM2.5) reduces respiratory symptoms
SAPALDIA Study, Schindler et al, 2009
New Cough Persistent Cough
New Wheeze Persistent Wheeze
7,019 subjects with detailed baseline examinations in 1991 and a follow-up interview in 2002
PM2.5 air pollution & life expectancy in the US
Pope et al, N Engl J Med, 2009
Reduction in PM2.5, 1980-2000 (μg/m3)
Ch
ange
in li
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xpec
tan
cy, 1
98
0-2
00
0 (
yr)
Assessed associations between life expectancy and fine-particulate air pollution in 51 U.S. metropolitan areas, comparing data for the period from the late 1970s to the early 1980s with matched data for the period from the late 1990s to the early 2000s
Black Carbon – a better health indictor? Toxic component or source indicator?
Janssen et al, Environ Health Perspect, 2011
Estimated county- and season-specific relative risks (RR) of cardiovascular and respiratory hospitalization associated with PM2.5 components in 106 U.S. counties for the years 1999 through 2005
Systematic review and meta-analysis of health effects of BC compared with PM mass based on data from time-series studies and cohort studies that measured both exposures
We already know quite a lot about traffic & traffic-derived pollutants
Mortality
Asthma and Respiratory - Children
Asthma and Respiratory - Adults
All-cause and Cardiovascular mortality
Asthma onset and prevalenceAsthma is more common in children living in the street buffers with the highest concentrations of traffic-related pollution
Exacerbation of asthma symptomsChildren living in hot spots of traffic-related pollution experience more symptoms and exacerbations
Adult-onset of asthma (one study)
Exacerbation of asthma symptoms (few studies)
Hospitalisation rates
Association with Traffic Air Pollution Exposure
Sufficient
Sufficient
Sufficient
InsufficientSuggestive but not sufficient
Insufficient
Health Outcome
Respiratory Symptoms
Living in proximity to high concentration of traffic air pollution may be associated with reduced lung function
Suggestive but not sufficient
Association Features
Strength of Association
Specificity of Association
Consistency of Association
Other Evidence
Coherence of Theory
Biological Plausibility
Analogy
Exposure / Outcome
Temporal Sequence
Dose Response
Reversibility(Experiment)
Inferring Causality for PM2.5
As concluded by REVIHAPP – PM2.5
• Additional support for the effects of short- and long-term exposure to PM2.5 on both mortality and morbidity.
• Long term exposure to PM2.5 is a cause of both cardiovascular mortality and morbidity.
• More insight has been gained into physiological effects and plausible biological mechanisms of the detrimental effects of PM2.5.
• Additional studies linking long-term exposure to PM2.5 to several new health outcomes including atherosclerosis, adverse birth outcomes and childhood respiratory disease
• Possible links between long-term PM2.5 exposure and neurodevelopment and cognitive function as well as other chronic disease conditions such as diabetes.
• Black carbon, secondary organic aerosols, and secondary inorganic aerosols may provide valuable metrics for the effects of mixtures of pollutants from a variety of sources.
• Short-term exposures to coarse (including crustal material) and ultrafine particlesare associated with adverse respiratory and cardiovascular health effects, including premature mortality.
Forest plot for cardiac hospital admissions studies NO2 with and without adjusting for PM10
NO2 SINGLE ESTIMATES
Wong et al 2002 [London]
Wong et al 2002 [Hong Kong]
Moolgavkar 2000 [Cook County, USA]
NO2 CONTROLLING FOR PM10
Wong et al 2002 [London]
Wong et al 2002 [Hong Kong]
Moolgavkar 2000 [Cook County, USA]
0.0 0.5 1.0 1.5 2.0 2.5 3.0
Percentage change for a 10 unit change
Long-term exposure – mortality in multi-pollutant models
• Jerrett, 2009: Toronto Effects of NO2 not PM2.5, NO2
effect remained after adjustment for traffic proximity
• Hart, 2011: Truck drivers NO2 and SO2 rather than PM10
and PM2.5 (smoking adjustment only in a subset)
• Cesaroni, 2013: Rome effect independent of PM2.5 and traffic density (indirect control for smoking)
Association Features
Strength of Association
Specificity of Association
Consistency of Association
Other Evidence
Coherence of Theory
Biological Plausibility
Analogy
Exposure / Outcome
Temporal Sequence
Dose Response
Reversibility(Experiment)
Inferring Causality for NO2
As concluded by REVIHAPP – NO2
• Many new studies document associations between day-to-day variations in NO2 concentration and variations in mortality, hospital admissions, and respiratory symptoms.
• Studies have now been published, showing associations between long-term exposure to NO2 and mortality and morbidity.
• Both short- and long-term studies have found these associations with adverse effects at concentrations at or below the current EU limit values.
• The results of these new studies provide support for updating the 2005 global update of the WHO air quality guidelines which could result in lower guideline values.
• Toxicology remains non-coherent.
The results of the WHO – EC project “Review of evidence on health aspects of air
pollution - REVIHAAP”
http://www.euro.who.int/__data/assets/pdf_file/0004/193108/REVIHAAP-Final-
technical-report-final-version.pdf
• 1000’s new health studies, reviews (2006-2014)
• NPACT study (2013); ESCAPE (2013)
• REVIHAAP (July 2013); HRAPIE (Dec 2013)
• HEI Ultrafines report (2013)• WHO Black Carbon report
(2012)• IARC Diesel exhaust report
(2013)• WHO Burden of disease
report (March 2014)