Outline Recognition Historical Perspective Deadly episodes U.S. - PDF document

2/27/2017 Disclosure Ambient Air Pollution and Health: Epidemiologic Bench to Bedside • I am the Physician Member of the California Air Resources Board John R. Balmes, MD University of California, San Francisco and Berkeley Outline Recognition • Historical Perspective • Deadly episodes • U.S. Air Quality Regulation (Donora, Meuse Valley, London) – “Criteria” Pollutants • Outdoor Air Pollution – What Do We Know – New Evidence • Household Air pollution – What Do We Know – New Evidence 1

2/27/2017 Air Quality Regulation in the U.S. EPA Criteria Pollutants • Ozone • Clean Air Act (1963) • Nitrogen Dioxide • U.S. EPA (1970) • Particulate Matter • National Ambient Air Quality Standards • Sulfur Dioxide • Carbon Monoxide • Lead • The EPA also regulates “ hazardous ” air pollutants (HAPS) primarily because of adverse reproductive or cancer effects; the current list includes 188 chemicals. Outdoor Air Pollution • Multiple sources • Mixture of gases and particulate matter • Traffic ‐ related air pollution 2

2/27/2017 Outdoor Air Pollution Outdoor Air Pollution • Increased contribution • Increased contribution to the Global Burden to the Global Burden of of Disease (2013 Comparative Risk Disease (2010 Assessment, Lancet , 2015) Comparative Risk • 14% of new cases and 15% of exacerbations of Assessment, Lancet , 2012) childhood asthma attributed to TRAP in a • Rapidly increasing study of 10 European cities ( Eur Respir J , 2013) pollution in mega ‐ cities • Rapidly increasing pollution in mega ‐ cities of of the developing the developing world world Global Burden of Disease and Household Air Pollution Comparative Risk Assessment 2013 • 40% of the world’s population cooks with solid fuels ALRI • Increased risk of low birth weight and pneumonia in children COPD • Increased risk of chronic obstructive pulmonary disease (COPD), lung cancer, cataracts, cardiovascular disease in adults • Major contributor to ambient air pollution in developing countries GBD 2013 Risk Factors Collaborators. Lancet 2015 Dec 5;380(10010):2287-323 3

2/27/2017 Outdoor Air Pollution Known Health Ozone Effects ‐‐ Respiratory • Prototypic • Asthma and Chronic Obstructive Pulmonary oxidant Disease (COPD) pollutant – Exacerbations • Major source: – New ‐ onset motor vehicle • Respiratory infections (pneumonia) emissions • Increased pulmonary mortality • Photochemistry during sunny • Lung cancer afternoons Ozone: Health Effects • Respiratory symptoms, lower lung function, airway inflammation in healthy individuals • Asthma – Exacerbations – New onset • Mortality Am J Respir Crit Care Med 2010;182:307 ‐ 16. 4

2/27/2017 Chronic Exposure to Ozone and Mortality Nitrogen Dioxide (NO 2 ) ( Jerrett at al. NEJM 2009) • Oxidant gas • Sources: combustion of fossil fuels – Motor vehicle emissions – Power plants • Marker of traffic emissions Nitrogen Dioxide: Health Effects • Decreased lung function growth • Asthma – Exacerbation – New ‐ onset Gauderman et al. NEJM 2004;351:1057 ‐ 1067 N Engl J Med 201;372:905 5

2/27/2017 Early ‐ life Exposure to Nitrogen dioxide (NO2) Am J Respir Crit Care Med 2013;188:309 ‐ 318 N Engl J Med 201;372:905 Particle Size Particulate Matter (PM) Hair cross section (60  m) • PM is a mixture, including particles of differing origin (combustion, crustal, biological) and varying size. • Multiple sources – Ultrafines (PM <0.1 ): Fossil fuel combustion – PM 2.5 : Fossil fuel combustion – PM 10 ‐ 2.5 : Road dust and crustal material PM0.1 PM2.5 Human Hair PM10 (0.1  m ) (2.5  m ) (10  m ) (60  m diameter) 6

2/27/2017 Particle deposition Particulate Matter: Health Effects • Asthma – Exacerbation – New ‐ onset • Decreased lung function growth • Mortality – Ischemic heart disease • Lung cancer An Association between Air Pollution and Mortality in Six U.S. Cities Thorax 2014;69(7):660 ‐ 5. Dockery et al. N Engl J Med 1993;329:1753 ‐ 1759 7

2/27/2017 et al. European Heart Journal 2015;36:83 ‐ 93 Newby DE, et al. European Heart Journal 2015;36:83 ‐ 93 Fine ‐ Particulate Air Pollution and Life Traffic Expectancy in the United States • Mixed emissions – Gases (CO, SO 2 , NO 2 ) – VOCs – PM – Road dust Pope et al. N Engl J Med 2009;360:376 ‐ 386. 8

2/27/2017 Traffic: Health Effects • Asthma • Decreased lung function growth Environ Health Perspect 2010;118:1021–1026 New Health Effects Environ Health Toxicol 2015;30:e2015011. • Adverse birth outcomes – Low birth weight – Preterm birth – Birth defects Birth • Cognitive development and decline Weight • Obesity and Diabetes – Oxidative stress – Systemic inflammation 9

2/27/2017 Preterm Birth Jerrett et al., Prev Med 2010 Polycyclic Aromatic Hydrocarbons (PAHs) • PAHs are formed by incomplete combustion of carbon ‐ containing materials (wood, coal, diesel, gas; also cooked food and tobacco smoke) Jerrett et al., Environ Health 2014 10

2/27/2017 Air Pollution and Diabetes • Several studies have shown associations between diabetes in adults and exposure to traffic ‐ related air pollution (TRAP) • Evidence also building for children – Two studies have shown associations between ozone and type 1 diabetes (Hathout et al., Pediatr Diabetes 2006; Malmquist et al., Environ Res 2015*) *also NO 2 – Three recent studies of minority children in Los Angeles have shown associations with glucose dysregulation and TRAP (Gilliland and colleagues, Diabetes Care 2016; Pediatr Obes 2016; Diabetes 2017) Rundle et al., Am J Epidemiol 2012 Potential Mechanism • Air pollution can induce oxidative stress and systemic inflammation • PM 2.5 induced adipose tissue inflammation and insulin resistance in a mouse model of diet ‐ induced obesity (Sun et al. Circulation 2009) Environ Int 2017 Jan 30 11

2/27/2017 Suspected Effects ‐‐ Neurological Risk Modifiers • Age • Cognitive development in children • Sex • Accelerated cognitive decline in adults • Race/ethnicity • Socioeconomic status • Neurodegenerative disease (e.g., Parkinson’s • Neighborhood Disease and Alzheimer’s Disease) • Stress • Diet • Obesity • Diabetes • Other exposures (e.g., tobacco smoke, biomass smoke, occupational vapors, dusts, fumes) PNAS 2009;106:12406 ‐ 11. Environ Health Perspect 2007;115:1140 ‐ 6 12

2/27/2017 Air Pollution Exposure Inequality Inequality Curve • People of color and low SES have – Greater exposures to outdoor air pollution – Disproportionate proximity to polluting land uses and toxic emissions • Poor communities have more health ‐ damaging factors and less health ‐ promoting amenities – More fast food and liquor stores – Less green space and recreational programs Environ Sci Technol 2009;43:7626–34. Research Needs • Better understanding of impacts of extrinsic neighborhood factors on observed air pollution ‐ health effects associations – poverty, unemployment, segregation, crime, foodscape, built environment • Better understanding of air pollution ‐ stress interactions – biological mechanisms – biomarkers • Methods to characterize and model cumulative impacts Environ Sci Technol 2009;43:7626–34. 13

2/27/2017 Health Effects of Climate Change Ozone Increases with Higher Temperatures Capitman and Tyner, 2011 Source: American Lung Association in California Land Use, Climate Change and Public Health Issue Brief , 2009 53 The Major Sources of Smog and Soot also Heat Waves and Ozone Contribute to Greenhouse Gases and Aerosols • During the heat waves in Europe in summer 2003 there were thousands of excess deaths above the seasonal average. • Epidemiological studies suggest that 20 ‐ 50% of the total excess deaths could be attributed to elevated O 3 and particle levels that occurred during the heat waves. (Filleul et al.;Johnson et al.) 55 56 14

2/27/2017 Conclusions • Improved air quality will have a major impact on Thank you public health – Strong governmental policies required – Transportation and energy production should move away from combustion of fossil fuel – Such an approach is needed to mitigate climate change Question 1 Question 2 • Which of the following have been associated • Which of the following is not considered a with exposure to air pollution? component of traffic ‐ related air pollution? a) Diabetes a) Nitrogen oxides b) Asthma b) PM2.5 c) Stroke c) Ozone d) Low birth weight d) Carbon monoxide e) All of the above 15

2/27/2017 Question 3 • Which of the following is not true? a) Ozone is a secondary pollutant for which exposure is regional b) Nitrogen oxides are primary pollutants that are precursors for the generation of ozone c) Climate change will lead to increased ambient ozone d) Ozone exposure has been associated with low birth weight 16