TESTIMONY OF LEONARDO TRASANDE, MD, MPP ASSOCIATE PROFESSOR OF - PDF document

TESTIMONY OF LEONARDO TRASANDE, MD, MPP ASSOCIATE PROFESSOR OF PEDIATRICS, ENVIRONMENTAL MEDICINE AND POPULATION HEALTH, NYU SCHOOL OF MEDICINE ASSOCIATE PROFESSOR OF HEALTH POLICY, NYU WAGNER SCHOOL OF PUBLIC SERVICE ASSOCIATE PROFESSOR, NYU STEINHARDT SCHOOL OF CULTURE, EDUCATION AND HUMAN DEVELOPMENT US ENVIRONMENTAL PROTECTION AGENCY CLEAN AIR SCIENTIFIC ADVISORY COMMITTEE 26 MARCH 2014

Members of the Clean Air Scientific Advisory Committee, I am grateful for the opportunity to speak to you today. My name is Leonardo Trasande; I am an Associate Professor of Pediatrics, Environmental Medicine and Population Health at NYU School of Medicine. I also hold faculty appointments at NYU’s Wagner School of Public Service, Steinhardt School of Education, Culture and Human Development, and its Global Institute for Public Health. I also serve on the Executive Committee of the Council for Environmental Health of the American Academy of Pediatrics. I am here to speak today to the urgent need to protect children’s health by recommending an 8- hour average primary standard for ozone of 60 ppb or below. Children have long been known to be uniquely vulnerable to the effects of air pollution. Alveolar growth expands from 24 million at birth to 257 million at age 4, 1 and the greater permeability of the epithelial layer heightens the effect of air pollutant exposures. 2 Their greater resting minute ventilation results in increased exposure compared with adults. 3 In the lungs phagocytosis of particulate matter can produce alveolar inflammation. Air pollutants are known immunotoxicants, 4-6 reducing immune clearance of lower respiratory tract infections, and adverse effects have been described on early lung development. 7 The evidence for ozone as a contributor to childhood respiratory disease is extremely strong. Ozone in particular has long been known to induce asthma exacerbations in children, and in one

well characterized population-based cohort study in California, exposure to ozone was associated with the development of asthma. 8 During the 1996 Atlanta Olympics, restrictions of vehicular volume decreased peak morning traffic by 23%, reduced ozone levels by 28%, and emergency visits for asthma in children decreased 42%. Emergency room visits for other conditions did not reduce, suggesting the effect was highly specific. 9 Exposure at 60 ppb has been associated with pulmonary inflammation in healthy young adults. Compared with a control group exposed to ozone free air, reductions in the forced expiratory value within the first second were substantial and significant, and acute inflammation was noted in the airways by measuring white blood cells in the sputum. 10 Such a study cannot readily be conducted in children due to the fact that they cannot produce sputum, and given the findings in adults, repeating a study that might produce more than minimal risk would require stronger justification for repeating the study in a vulnerable population, under the section of the Code for Federal Regulations (45 CFR 46) that sets rules for review human subjects research. Given the findings of this carefully conducted study in young adults, a 60 ppb threshold is at minimum required to protect children from the health effects of air pollution. Given the known biological bases for children’s vulnerability to air pollution, the effects of ozone on lung capacity and inflammation in the lungs is likely to be stronger at 60 ppb, and the effects are likely to occur at lower levels. Indeed, EPA’s own Integrated Science Assessment with respect to ozone concludes that chronic ozone exposure is associated with childhood asthma hospital admissions in multiple studies with mean annual 8-hour maximum ozone concentrations of less than 41 ppb. The same report also notes that positive associations of acute ozone exposure with respiratory

symptoms have generally been documented with mean 8-hour maximum concentrations of less than 69 ppb. 11 Much is made about the economic impact of lowering air pollution for industry, but little is mentioned about the substantial economic benefits of pollution prevention in children. And so I would like to focus the remainder of my testimony here. In 2011, we conducted an analysis of the costs of pediatric disease attributable to environmental factors, and found that air pollution contributed $2.2 billion in preventable costs (2008 dollars) related to exacerbations of asthma. While the costs examined all outdoor air pollutants together, the major driver of these costs was ozone. What is also striking was the comparison of these costs to an estimate of environmentally attributable asthma costs in 1997. Adjusting the previous estimate for inflation, we found that air pollution attributable costs were $3.0 billion, suggesting a substantial, 30% drop in annual costs. 12 While asthma management changed in the interceding period from to emphasize less expensive, outpatient care, the majority of this decrease can be attributed to more stringent National Ambient Air Quality Standards and the 1990 Clean Air Act Amendments. The economic benefits of these interventions will continue for generations to come, as new cohorts of children are born and exposed to less ozone. Ozone may also contribute to preventable health care utilization in the first days after birth. We analyzed a large nationally representative sample of US births in 2000, 2003 and 2006 and examined relationships between average of air pollutants in the month of birth and health care utilization during the birth hospitalization. Despite the greater daily variability which could have clouded associations of ozone with utilization, a $964 increase in costs was found for each ppm

in ozone levels. No threshold of association was identified. 13 While further study, with enhanced control for confounding, improved exposure assessment, and examination of exposures across multiple time windows in pregnancy, is needed, this study suggests substantial economic benefits to reduction in ozone levels at or below 60 parts per billion. In summary, ozone contributes substantially to childhood disease and morbidity at current levels of exposure. Setting an NAAQS standard at or below 60 ppb would produce substantial health and economic benefits, for generations of children to come. Thank you for the opportunity to speak to you today.

References 1. Dunnil M. Thorax. 1962;17:329. 2. Committee on Environmental Health. Ambient Air Pollution: Health Hazards to Children. Pediatrics. December 1, 2004 2004;114(6):1699-1707. 3. Trasande L, Thurston GD. The role of air pollution in asthma and other pediatric morbidities. J Allergy Clin Immunol. Apr 2005;115(4):689-699. 4. Davila DR, Romero DL, Burchiel SW. Human T Cells Are Highly Sensitive to Suppression of Mitogenesis by Polycyclic Aromatic Hydrocarbons and This Effect Is Differentially Reversed by α -Naphthoflavone. Toxicology and Applied Pharmacology. 8// 1996;139(2):333-341. 5. Hong X, Liu C, Chen X, et al. Maternal exposure to airborne particulate matter causes postnatal immunological dysfunction in mice offspring. Toxicology. 4/5/ 2013;306(0):59- 67. 6. Ward EC, Murray MJ, Lauer LD, House RV, Irons R, Dean JH. Immunosuppression following 7,12-dimethylbenz[a]anthracene exposure in B6C3F1 mice. I. Effects on humoral immunity and host resistance. Toxicology and Applied Pharmacology. 9/15/ 1984;75(2):299-308. 7. Martinez FD. The Origins of Asthma and Chronic Obstructive Pulmonary Disease in Early Life. Proc Am Thorac Soc. May 1, 2009 2009;6(3):272-277. 8. McConnell R, Berhane K, Gilliland F, et al. Asthma in exercising children exposed to ozone: a cohort study. The Lancet. 2002;359(9304):386-391. 9. Friedman MS, Powell KE, Hutwagner L, Graham LRM, Teague WG. Impact of Changes in Transportation and Commuting Behaviors During the 1996 Summer Olympic Games in Atlanta on Air Quality and Childhood Asthma. Vol 285: Am Med Assoc; 2001:897- 905. 10. Kim CS, Alexis NE, Rappold AG, et al. Lung Function and Inflammatory Responses in Healthy Young Adults Exposed to 0.06 ppm Ozone for 6.6 Hours. American Journal of Respiratory and Critical Care Medicine. 2011/05/01 2011;183(9):1215-1221. 11. USEPA. Integrated Science Assessment of Ozone and Related Photochemical Oxidants (Final Report). Available at http://cfpub.epa.gov/ncea/isa/recordisplay.cfm?deid=247492#Downloaddeid=247492#Do wnload (Accessed 12 March 2014). 2013. 12. Trasande L, Liu Y. Reducing The Staggering Costs Of Environmental Disease In Children, Estimated At $76.6 Billion In 2008. Health Affairs. May 1, 2011 2011;30(5):863-870. 13. Trasande L, Wong K, Roy A, Savitz DA, Thurston G. Exploring prenatal outdoor air pollution, birth outcomes and neonatal health care utilization in a nationally representative sample. J Expos Sci Environ Epidemiol. 05//print 2013;23(3):315-321.