Outdoor Air Pollution and Population Health in China

Haidong Kan, M.D., Ph.D. School of Public Health, Fudan University

Shanghai, Chinakanh@fudan.edu.cn

5th International Conference on Environmental and Occupational

MedicineApr. 9, 2010

Outline

Ambient air pollution levels in China

Air pollution epidemiologic studies in China

Health burden of air pollution in China

Co-benefits of GHGs reduction in China

Summary

Air pollution levels in China

Outline

“Pollution in China” – by LU Guang

Estimated PM10 Concentration in World Cities (pop=100,000+)

Source: World Bank

Annual PM10 levels in 30 provincial capitals of China (μg/m3， 2004)

0

20

40

60

80

100

120

140

PM10 SO2 NO2

Chinese cities Nationwide(2004)

China National Air QualityStandard for residentialareas

WHO Global Air QualityGuideline

US National Ambient AirQuality Standards

Kan et al, CVD Prevention & Control, 2009

Comparison of the PM10/SO2/NO2 levels in Chinese cities and International/National Air Quality Standards

(annual average)

Kan et al, Env Int, 2007; Guo et al, Sci Total Environ, 2009

0 20 40 60 80 100 120 140

Beijing (2004-2006)

Shanghai (2005)

WHO Interim Target 1

WHO Interim Target 2

WHO Interim Target 3

US NAAQS

WHO Global AQG

Comparison of the PM2.5 levels in Shanghai, Beijing and International/National Air Quality Standards

Fine particle: PM2.5

Energy production and emissions of SO2 and dust in China, 1998 - 2008

Zhang et al, Lancet, 2010

Air pollution epidemiologic studies in China

Outline

A summary of air pollution epidemiologic studies in China

Short-term exposure studies: Time-series/case crossover studies

Single-city analysis: Beijing, Hong Kong, Shanghai, Shenyang, Taiyuan, Wuhan, etc.

Multi-city analysis: PAPA, CAPES Panel study: Beijing

Long-term exposure study Cross-sectional study: several Cohort study: ONE only

Intervention study Beijing Olympics Hong Kong

Public Health and Air Pollution in Asia (PAPA)

http://www.healtheffects.org/international.htm

Shanghai

Wuhan

Hong Kong

Bangkok

Short-term exposure: Time-series

Results: comparison between PAPA cities

BK had the biggest but less precise ER than the others

PM10: Health effects Levels

Wong et al, EHP, 2008

Traffic-originated particles has the largest health hazard!

% Increase in Daily Deaths by Specific PM2.5 Sources: Six Cities Study (1979-1988)1

Source factor % increase 95% CI

Crustal (Si) -2.3 -5.8, 1.2

Motor vehicles (Pb) 3.4 1.7, 5.2

Coal (Se) 1.1 0.3, 2.0

1 % increase in daily deaths associated with 10 ug/m3 increase in mass concentration from source;

Laden et al, EHP, 2000.

Source factor % increase 95% CI

Crustal (Si) -2.3 -5.8, 1.2

Motor vehicles (Pb) 3.4 1.7, 5.2

Coal (Se) 1.1 0.3, 2.0

1 % increase in daily deaths associated with 10 ug/m3 increase in mass concentration from source;

Laden et al, EHP, 2000.

Similar ERs across cities, but less precise in BK

Wong et al, EHP, 2008; Kan et al, Env Res, 2010

SO2: Health effects Levels

Results: comparison between PAPA cities

Wong et al, EHP, 2008

NO2: Health effects Levels

Results: comparison between PAPA cities

Wong et al, EHP, 2008

O3: Health effects Levels

Results: comparison between PAPA cities

PM10, concentration-response curve

WHO AQG

China National Standard II

Public Health and Air Pollution in Asia (PAPA)

http://www.healtheffects.org/international.htm

Shanghai

Wuhan

Hong Kong

Bangkok

Short-term exposure: Time-series

CAPES

China Air Pollution and Health Effects Study

A new multi-city time-series study in Mainland China

Supported by China Ministry of Environmental Protection PIs: Haidong Kan and Bingheng Chen

Short-term exposure: Time-series

CAPES cities

上海杭州

桂林

天津太原

沈阳

福州

广州

西安

鞍山乌鲁木齐

SO2 NOx PM10

PM2.5 CO VOCs

Spatial Distribution of Emissions in China, 2005

Panel study

Wu et al, EHP, 2009

Association of Heart Rate Variability in Taxi Drivers with Marked Changes of Particulate Air Pollution in Beijing in 2008

Short-term exposure

Among PM10, PM2.5: significant

effects on daily mortality;

PM10-2.5: NO significant health effects

PM10: PM2.5 vs. PM10-2.5

Kan et al, Environ Int, 2007

Short-term exposure

Interaction between pollutants

Chen et al, Biomed Environ Sci, 2007

Higher PM10 significantly increased the effect of O3 on total mortality;

O3 also increased the effect of PM10.

Short-term exposure

Visibility and mortality risk

Huang et al, Sci Total Environ 2009

Short-term exposure

Modifiers of air pollution acute health effects

Season: warm vs. cool Gender: male vs. female Age SES

Sensitive sub-population

Kan et al, EHP, 2008

Short-term exposure

Warm season Cool season

Total mortality PM10 0.21 (0.09, 0.33) 0.26 (0.22, 0.30)

SO2 0.79 (0.16, 1.42) 1.41 (0.98, 1.83)

NO2 0.88 (0.34, 1.42) 1.61 (1.21, 1.99) *

O3 0.22 (-0.08, 0.52) 1.18 (0.52, 1.83) *

Cardiovascularmortality

PM10 0.26 (0.00, 0.51) 0.30 (0.20, 0.40)

SO2 0.56 (-0.44, 1.55) 1.46 (0.84, 2.07)

NO2 0.76 (-0.09, 1.62) 1.77 (1.19, 2.33)

O3 0.26 (-0.22, 0.74) 1.35 (0.41, 2.28) *

Respiratorymortality

PM10 -0.21 (-0.82, 0.41) 0.79 (0.47, 1.11) *

SO2 -0.31 (-2.06, 1.43) 3.05 (2.04, 4.07) *

NO2 -1.01 (-2.50, 0.48) 3.34 (2.40, 4.28) *

O3 0.09 (-0.75, 0.92) 0.39 (-1.19, 1.97)

Warm (May-Oct) and cold (Nov-Apr) seasons

Kan et al, EHP, 2008

Short-term exposure

Warm (May-Oct) and cold (Nov-Apr) seasons

Cao et al, Sci Total Environ, 2009

Short-term exposure

Female vs. male

Female Male

PM10 0.33 (0.18, 0.47) 0.17 (0.03, 0.32)*

SO2 1.05 (0.61, 1.49) 0.85 (0.43, 1.27)

NO2 1.10 (0.69, 1.50) 0.88 (0.49, 1.27)

O3 0.40 (0.03, 0.76) 0.19 (-0.16, 0.54)*

Kan et al, EHP, 2008

Short-term exposure

Young vs. old5-44 45-64 65+

PM10 0.04 (-0.52, 0.59)

0.17 (-0.11, 0.44)

0.26 (0.14, 0.38)

SO2 1.20 (-0.47, 2.87)

0.22 (-0.60, 1.03)

1.00 (0.65, 1.35)

NO2 0.52 (-1.02, 2.06)

0.64 (-0.11, 1.39)

1.01 (0.69, 1.33)

O3 -0.08 (-1.39, 1.24)

0.47 (-0.19, 1.12)

0.32 (0.03,0.61)

Short-term exposure

Kan et al, EHP, 2008

Educational level: a measure of SES

Short-term exposure

Kan et al, EHP, 2008

Air pollution and mortality in Beijing

Zhang et al, Sci Total Environ, 2000

Long-term exposure: cross-sectional

Air pollution and lung cancer in Guangzhou

Tie et al, Atmos Environ, 2009

Long-term exposure: cross-sectional

CNHS Air Study

China National Hypertension Survey (CNHS) Baseline survey in 1991 Follow-up visit in 1999 158,666 participants in 17 provinces of China

(including both urban and rural areas)

CNHS Air: a retrospective cohort analysis of outdoor air pollution and mortality in China 90,167 urban participants in 41 Chinese cities

Long-term exposure: cohort study

Previous findings from the CNHS

Gu et al, JAMA, 2006He et al, NEJM, 2005 Gu et al, NEJM, 2009

Long-term exposure: cohort study

CNHS Air cities

Mean Range

TSP 293 135 - 489

SO2 83 13 - 209

NOX 47 11 - 106

Outdoor air pollution levels

(in 1991-1993, μg/m3)

Long-term exposure: cohort study

CNHS Air Results

Each 10 μg/m3 increase in TSP was associated with increased risk of death *: 0.2% for total mortality (p=0.222) 0.8% for cardiovascular mortality

(p=0.003) 0.4% for respiratory mortality (p=0.448) 1.0% for lung cancer mortality (p=0.095)

Long-term exposure: cohort study

* After adjustment for age, gender, smoking (smoking status, age at starting smoking, years smoked, and cigarettes per day), alcohol intake, physical activity, education, hypertension

Comparison with the ACS study

CNHS*: 10 μg/m3 increase of PM2.5 was associated with

- 0.6% ↑ of total mortality - 2.5% ↑ of cardiovascular

mortality- 1.2% ↑ of respiratory

mortality- 3.1% ↑ of lung cancer

mortality

*: assuming PM2.5/PM10≈0.65 and PM10/TSP ≈0.5

ACS:10 μg/m3 increase of PM2.5 was associated with

- 4% ↑ of total mortality - 6% ↑ of cardiopulmonary

mortality- 8% ↑ of lung cancer

mortality

Pope et al, JAMA, 2002

Long-term exposure: cohort study

1.0000

1.0100

1.0200

1.0300

1.0400

1.0500

1.0600

Acute effects Chronic effects

China

WesternCountries

Kan et al, Biomed Environ Sci, 2005

Strengths and limitations of CNHS Air

Strengths Large sample size Detailed individual information on potential

confounders

Limitations TSP only Air pollution exposure on the aggregated city

level, rather than individual level

Long-term exposure: cohort study

Health benefits gained from environmental intervention

Hong Kong Dublin Atlanta Beijing Olympics

Intervention study

1988 1989 1990 1991 1992 1993 1994 1995

020

4060

80

NO2

SO2

O3

PM10

Mic

rogr

am

s pe

r cu

bic

met

re

Year

HALF YEARLY MEAN LEVELSFuel restriction on sulphur

50% reduction in SO2 after the intervention

No change in other pollutants

Hedley et al 2002

Hong Kong: air pollutants 1988 – 95

-6-5

-4-3

-2-1

0

15-64 65+ 15-64 65+ 15-64 65+

Reductions In Deaths After Sulfur Restriction

All causes Cardiovascular Respiratory

% R

educ

tion

in a

nnua

l tre

nd

-1.8%

-2.8%

-1.6%

-2.4%

-4.8%

-4.2%

Typical air pollution in

Beijing Good air quality during the Beijing

Olympics

2008 Beijing Olympic Games

2008 Beijing Olympic Games

Intervention study

Li et al, Sci Total Environ, 2010

Health burden of air pollution in China

Outline

Chinese Burden of Disease from Top 10 Risk FactorsPlus Selected Other Risk Factors

0% 1% 2% 3% 4% 5% 6% 7%

Climate change

Unsafe sex

Physical inactivity

Lead (Pb) pollution

Urban outdoor air pollution

Unsafe water/sanitation

Cholesterol

Low fruit & vegetables

Road traffic accidents*

Overweight

Indoor smoke from solid fuels

Occupational hazards (5 kinds)

Underweight

Tobacco

Blood pressure

Alcohol

Percent of All DALYs in 2000

Smith et al., 2005. Derived from WHO data

Chinese burden of disease from top 10 risk factors plus selected other risk factors

Outdoor air pollution

Economic analysis: national

3.8% of GDP

1.2% of GDP

Estimation of the economic cost of health impacts due to PM10 exposure in Shanghai in 2000

Health outcomes mean (95% CI) Premature death 787.8 Chronic bronchitis 91.9 Respiratory Hospital admission 2.9

Cardiovascular Hospital admission 2.9

Outpatient visits (internal medicine) 4.0

Outpatient visits (pediatrics) 0.4 Acute bronchitis 3.7 Asthma attack(<15) 0.3

Total 893.8*

* Accounting for 1.62% of Shanghai GDP in 2000

Kan and Chen, Sci Total Environ, 2004

Chinese Burden of Disease from Top 10 Risk FactorsPlus Selected Other Risk Factors

0% 1% 2% 3% 4% 5% 6% 7%

Climate change

Unsafe sex

Physical inactivity

Lead (Pb) pollution

Urban outdoor air pollution

Unsafe water/sanitation

Cholesterol

Low fruit & vegetables

Road traffic accidents*

Overweight

Indoor smoke from solid fuels

Occupational hazards (5 kinds)

Underweight

Tobacco

Blood pressure

Alcohol

Percent of All DALYs in 2000

Smith et al., 2005. Derived from WHO data

Chinese burden of disease from top 10 risk factors plus selected other risk factors

Climate change

Total yearly worldwide, US, Chinese, and western European CO2 emissions (left) and per-head yearly CO2 emissions (right)

Zhang et al, Lancet, 2010

Modifiers of the temperature-mortality association in Shanghai

Ma et al, submittedKan et al, Env Res, 2007

Huang et al, Sci Total Environ, 2010

Diurnal temperature range (DTR)

Easterling DR et al, Science, 1997, 277: 364-367

Ancillary benefits of low-carbon policy

Low carbon policy

Acting Locally While Thinking Globally

Greenhouse Gases Emission

(global effect)

Air Pollutants Emission

Air Quality Changes

(local effect)

Population Exposure

Health Outcomes

Solar hot water heater in China

Solar powered Christmas tree

Low carbon life

Endpoints EE GAS WIND SO2b SO2c

Premature death 9870 22210 23100 27280 27340Chronic bronchitis

20700 46330 48160 56770 56890

Respiratory Hospital admission

5057 12030 12560 15150 15190

Cardiovascular Hospital admission

2537 6075 6347 7672 7691

Outpatient visits (internal medicine)

348600 844200 882700 1072000 1074000

Outpatient visits (pediatrics)

36210 87620 91620 111200 111500

Acute bronchitis 659700 1478000 1537000 1812000 1816000Asthma attack 13580 29590 30700 35860 35930

Summary Strong evidence that ambient

air pollution is associated with adverse health effects in Chinese populations

Current air quality standard in China can not fully protect population health

Low-carbon policy will play an active role in the reduction of air pollutant emission, improvement of air quality and the promotion of public health Kan et al, EHP,

2009

Acknowledgement Fudan Univ.: Bingheng Chen, Weimin Song US NIH/NIEHS: Stephanie J. London Shanghai CDC: Guixiang Song, Lili Jiang Shanghai Environmental Monitoring Center:

Guohai Chen Peking Univ. : Wei Huang Graduate Students: Renjie Chen, Wenjuan

Ma, Chunxue Yang

THANK YOU FOR YOUR ATTENTION

hdkan@shmu.edu.cn