ENCUENTRO
Retos para la mejora de la calidad del aire Los efectos en la salud de la contaminaci贸n atmosf茅rica Jordi Sunyer CREAL 20/9/2012
Beijing Olympic games (2008) 500
Air Pollution Index (API)
400
Shutdown of 300 steel factories in the city of Tangshan (90 miles from Beijing)
300
300,000 high-polluting vehicles banned
200
Shutdown of 40 factories in the city of Tianjin (70 miles from Beijing)
Odd-even licence plate restriction
Beijing 2008's Olympics
100
0 15May
22May
29May
5Jun
12Jun
19Jun
26Jun
3Jul
10Jul Date
By Aymeric Ung, InVS
17Jul
24Jul
31Jul
7Aug
14Aug
21Aug
28Aug
4Sep
Lin W, Acute respiratory inflammation in children and black carbon in ambient air before and during the 2008 Beijing Olympics. Environ Health Perspect. 2011;119:1507-12
Beijing Olympic games (2008): the health impact • Rich DQ, Association between changes in air pollution levels during the Beijing Olympics and biomarkers of inflammation and thrombosis in healthy young adults. JAMA. 2012;307:2068-78. • Huang W, Inflammatory and Oxidative Stress Responses of Healthy Young Adults to Changes in Air Quality during the Beijing Olympics. Am J Respir Crit Care Med. 2012 Aug 30
NIH library Pubmed air pollution AND health papers/year
10000 1000 100 10 1 19761980
20062010
Mechanisms by which exposure to PM damages our health Health Effects of Fine Particles: Lines that Connect (Pope et Dockery 2006)
Particulate matter (PM) e.g.:
PM2.5
i.e. Ø
≤ 2.5 μm
Impact by PM size
Ultrafine particles (UFP) promote early atherosclerosis and systemic oxidative stress
(Araujo, 2008, Brook 2010)
Placas en las arterias despu茅s exposici贸n a New York PM en ratolins Sun et al, JAMA Dec 2005
Porque mejorar la calidad del aire? • Efectos agudos o a corto plazo • Efectos crónicos • Lecciones de las Intervenciones
Porque no mejoramos la calidad del aire? • Fuentes • El papel de los médicos y otros profesionales
Nuevos estudios
01 /0 1/ 20 03 01 /0 2/ 20 03 01 /0 3/ 20 03 01 /0 4/ 20 03 01 /0 5/ 20 03 01 /0 6/ 20 03 01 /0 7/ 20 03 01 /0 8/ 20 03 01 /0 9/ 20 03 01 /1 0/ 20 03 01 /1 1/ 20 03 01 /1 2/ 20 03 01 /0 1/ 20 04 01 /0 2/ 20 04 01 /0 3/ 20 04 01 /0 4/ 20 04 01 /0 5/ 20 04 01 /0 6/ 20 04 01 /0 7/ 20 04 01 /0 8/ 20 04 01 /0 9/ 20 04 01 /1 0/ 20 04 01 /1 1/ 20 04 01 /1 2/ 20 04
Death per day 80
3
Death per day
120
140
120
60 100
40 80
60
20 40
20
0 0
Time
PM10 (ug/m )
Mortalidad diaria y contaminación atmosfèrica: anàlisis de series temporales Total mortality and PM10 concentration vs time Barcelona 2003-2004 PM10 (ug/m3) 200
100 180
160
Example: Time-series analysis APHEA: daily mortality and air pollution Katsouyanni et al, Epidemiology 2001 • • • • •
29 European cities >43 mill. Inhabitants > 5 years of data Total death (excluding external causes) Daily: PM10, black smoke, SO2, O3, NO2 • Investigate city-specific causes of heterogeneity of effects across Europe (two-stage model)
Percent increase in daily mortality (95% CI) per 10Îźg/m3 PM10 The European APHEA Study
-1%-1
Percent increase in mortality
0% 0
1%1
2% 2
Katsouyanni et al, Epidemiology 2001; 12 (5): 52131
Cambridge1.ppt
Admisiones en urgencias por enfermedad pulmonar obstructiva crònica en función niveles diarios de contaminación atmosférica en Barcelona
Daily COPD Emergency addmissions
Sunyer et al, Am J Epidemiol 1991
Winter
Summer 20
30
40
50
Black Smoke concentrations in μg/m3
60
Acute effects of urban pollution in asthmatic children • Inflammatory markers in exhaled air and nasal lavage (Berhane 2011) • Peak flow values (O‘Connor 2008) • Daily symptoms (Andersen 2008) • Asthma medication (Gent 2003) • Hospital admissions (Iskandar 2011)
Parallel contributions of past days’ 1hr-maxima of NO2 (in units of 50 µg/m3 ) to current day’s mortality (cubic polynomial lag models) (Schindler, Künzli, Ackermann-Liebrich; 2001)
Zurich Basel Geneva
1,03
relative risk
1,02 1,01 1 0,99 0,98 0,97 0
-1
-2
-3 day
-4
-5
-6
Urban PM fractions and health effects Perez et al.2009 Odds ratio per 10 ug/m3* Respiratory mortality
Cardiovascular mortality
Cerebrovascular mortality
PM10-2.5
Not significant
1.059 (1.026-1.094) Lag1
1.098 (1.030-1.171) Lag1
PM2.5-1
1.206 (1.028-1.416) Lag2
Not significant
Not significant
1.028 (1.000-1.058) Lag1
1.063 (1.004-1.124) Lag1
Fraction
PM1
Not significant
*Only maximum lag effect for tri-pollutant model presented
Efectos respiratorios de exposición al tráfico diesel en asmáticos (en Londres)
Oxford Street D
D
Busos diesel per Oxford Street
R OXFO
T STREE
STRE ET
NORTH CARRIAGE DRIVE
eL Th W ate r
NE K LA
Subjects enter here
W CA EST DR RR IV IAG E E
Round Pond
PAR
Old Police House & Rangers Lodge
g on
Kensington Palace
The Serpentine
SOUTH C ARRIAGE
DRIVE
Hyde Park sense tràfic
EET STR
HAR ORC
NT REGE
McCreanor et al, New England J Medicine 2007; 357:2348
La función pulmonar (FEV1) disminuie considerablement durante un paseo por la ruta de los autobuses diesel (Oxford Street) McCreanor et al, NEJM 2007 2
Hyde Park
% cambio en la FEV1
0
Oxford Street
-2
-4
-6
p < 0,001
-8
-10 0
1
2
3
4
5
Hores (desde el inici de l’exposició)
6
7
Presence of carbon in airway macrophages in healthy children exposed to traffic Kulkarni et al. (NEJM 2006)
Figure 1. Representative Images of Carbon in Airway Macrophages from Healthy Children. Panel A shows a macrophage with no carbon. Increasing levels of carbon are shown in Panels B through E.
Carbon in airway macrophages impairs lung function in healthy children Kulkarni et al. (NEJM 2006)
WHO review 2005 â&#x20AC;&#x2DC;Substantial evidence suggested that the inflammatory processes associated with exposure to traffic pollutants contributed to an increase respiratory symptomsâ&#x20AC;&#x2122;
Are there chronic effects (average exposure for one year or more) beyond the short-term effects • • • • •
Onset asthma Lung function growth decline Atherosclerosis Mortality Life expectancy
The USC Childrenâ&#x20AC;&#x2122;s Health Study in 12 communities
Lung development during 8 years NEJM 2004; 351:1057
Grade
# Kids
1993
4th
1,759
10
7th
900
13
10th
900
16
4th
2,000
94
95
96
97
98
99
00
01
02
03
04
18 18 18 10
18
Southern California
0
RR=1.4
RR=1.0
-1
s(big3dist, 3)
Asthma risk
1
Association between residential distance to busy roads and childhood asthma
00
100 100
200 200
300 300
400 400
500 500 meters
Distance to busy road big3dist
McConnell et al, EHP2010
Traffic proximity and exposure
Beckerman et al. 2008
Birth cohorts on asthma: Long follow-up after exposure at early life • Germany (GINI & LISA), n=3066 at six years, doctor diagnosed asthma OR=1.56 (1.032.37) (Morgenstern V, AJRCCM 2008) • Holland (PIAMA), n=3583 at 4 years, doctor diagnosed asthma OR=1.32 (1.04-1.69) (Brauer M, ERJ 2008; Gehring 2010)
• Sweeden (BAMSE), n=3515 at 4 years, persistent wheeze OR=1.60 (1.09-2.36) (Nordling E, Epidemiology 2009)
• East Boston, n=413 at 18 years doctor diagnosed asthma OR=1.63 (1.14-2.33) (Clougherty JE, EHP 2007)
Life-time course of lung function (e.g. forced expiratory capacities such as FEV1 and FVC) 100% normal at age 20
Disability Death 0
20
80
Repeated FEV1 during 8 years in the CHS (Gauderman NEJM 2004; 351:1057)
% of persons at age 18 with FEV1 < 80% by PM2,5 (Gauderman, NEJM 2004)
PM2,5
Changes in ambient PM2.5 correlated with change in lung function development (FEV1) FEV1 growth rate (ml per year)
Avol et al., Am J Respir Crit Care Med 2001
cleaner -40 -20
0
dirtier +20 +40
change in PM10 (Îźg/m3)
Lung function growth in Mexico (Rojas-Martinez R, AJRCCM 2007) • • • • •
Cohort at age 8 (n=3170) Followed during three years Spirometry every 6 months Attended 39 schools near 10 stations An IQR on PM10 -> annual deficit in FEV1 of 11 ml in girls and 15 in boys.
Life-time course of lung function
(e.g. forced expiratory capacities such as FEV1 and FVC) 100% normal at age 20
smoking
Disability Death 0
20
80
A
Annual mean PM10 and expiratory capacity (FVC) in the 8 SAPALDIA areas Ackermann-Liebrich et al, AJRCCM 1997; 155 (1):122-129
% deviation from predicted
FVC
6 4 2 0 -2 -4 -6 0
10
20
30
40
PM10 annual mean (µg / m3) © Nino
Lung function studies in adults – SAPALDIA (Downs, NEJM 2007) – SALIA (Shikowski T, Respir Med 2005) – Health Survey for England( Forbes, Thorax 2009)
• An increase in 10 μg/m3 was associated with a decrease of 3.4% in FEV1. This may imply an increase of 50% of the population with a FEV1<80%
© Nino
EXPOSURE SURFACE, PM2.5
Home outdoor PM2.5 is associated with CIMT K端nzli et al, Env Health Perspect 2005
EL ESTUDIO DE LAS 6 CIUDADES: PM2.5 –MORTALITAT (Dockery , NEJM 1993) 1.3
• Stebenville, OH
1.2
•(Knoxville) Harriman, TN
• St. Louis, MO
1.1 1.0
• Waterown, MA (Boston)
• Topeka, KS • Portage, W
0.9 10
15
20
25
30
35
Long-term mortality. 6 cities, Dockery 1993
Mortalitat Cardiovascular en el seguiment de lâ&#x20AC;&#x2122;estudi 6-Cities Study Laden et al, AJRCCM 2006
Bold: PM2.5 1974-89 Cursive: 1990-98
Diesel exhaust exposure chamber
Mills et al, New England Journal of Medicine, 2007 (13.Sept)
1 hora exposici贸n en una c谩mara con diesel en 20 supervivents infarto de miocardo (Mills et al, N Engl J Med 2007)
Long-term exposure to air pollution increases the incidence of cardiovascular events and mortality in women Miller et al. (NEJM 2007)
Pope CA. Fine-paticulate air pollution and life expectancy in US. N Engl J Med. 2009
Chronic cough and annual pollution in Swiss children 1993 25 23 21 19 17 15 13 11 Montana 9 7 5 5 10
Genf Anières Lugano Biel Zürich Bern Langnau Payerne
Rheintal
15 20 25 PM10 µg/m3
Braun-Fahrländer; Am JRespir Crit Care Med 1997
30
35
PM10 annual mean
PM decline in Swiss cities after traffic intervention 1993-2001 Lugano
Lugano Basel
Geneve Montana Davos
1991
2002
Change in prevalence vs change in PM10 Across nine Regions of SwissSchool Children Study -15
-5
-10
0
Montana
Zuerich
Pay erne
-6
Bern
Langnau Biel
-4
-2
0
-20
Decline of PM10 between 1993 and 2001 in Îźg/m3
Lugano Anieres
-8
Genf
Bayer-Oglesby et al., Env Health Perspect, 2005
Reduction among adults Reduction of chronic cough-SAPALDIA
Schindler et al. 2009
Decreasing PM10 over 11 years reduced decline in adults' lung function SAPALDIA Swiss Study, Downs et al. (NEJM, 2007) Estimated Effect of Interval Exposure between 1991 and 2002 on Mean Annual Decline in FEV1 0
-5
-10
Mean Annual Decline in FEV1 (ml/yr)
-15
-20
-25
-30
-35
-40
-45
-50 45
40
35
30
25
20
Decrease in Mean Annual PM10 (Âľg/m3)
15
10
5
Prohibición del carbón en Dublín, 1990 Reduccció Fums negres: - 35.6 % SO2: - 11.3%
Reducció Mort cardiovascular: - 10.3% Mort respiratòria: -15.5%
4,4 /dia valor mig
3,8 /dia valor mig
Clancy et al., Lancet 2002
1991
Health benefits air pollution control (pubmed n=455) â&#x20AC;˘ .
La normativa de la UE (NO2, PM10) i la salut Exposició actual mitjana anual ~50 µg/m3 -10 µg/m3
Nivell UE
-30 µg/m3
Nivell OMS
40 µg/m3 20 µg/m3
Mortality WHO scenario Indicator Deaths per year
Mean (95% CI)
% of total cases (95% CI)
3.500 (2.200-4.800)
12% (7%-16%)
520 (350-690)
2% (1%-2%)
15 (7-22)
13% (6%-19%)
Of which Death due to acute exposure per year Infant deaths per year
Morbidity per year WHO scenario Mean (95% CI)
% of total cases (95% CI)
Chronic bronchitis adults
5.100 (550-8.500)
25% (3%-41%)
Acute bronchitis children
31.100 (17.500-40.500)
49% (28%-64%)
Asthma attacks adults
41.500 (21.000-60.500)
11% (6%-16%)
Asthma attacks children
12.400 (6.400-15.200)
11% (6%-14%)
1.150 (630-1.670))
3% (2%-5%)
620 (310-930)
2% (1%-3%)
Indicator
Respiratory
Hospitalizations Respiratory causes Cardiovascular causes
Beneficis econòmics de reduir la contaminació atmosfèrica (Euros/any)
PM1 composition in Barcelona (PĂŠrez N, 2010)
Estimating impact of traffic exposure Population distribution from roads >10,000 vehicle/day
% de dﾃｭas que exceden los estﾃ｡ndards de calidad del aire en Los ﾃ］geles - 1976 a 2002
75% 50% 25%
1976
1990
2002
http://www.ersnet.org/publications/ air-quality-and-health.html
ESCAPE • 20 països • 40 àrees d’estudi
• 2008 - 2012
PM2.5 (Absorbance)
Jordi Sunyer April 2012
Objective To discover the neurodevelopmental (cognitive, behavioral, and neurostructural) effects of urban air pollution (UFP traffic).
Pollutants: (1) school at t in, (2) school at t out and (3) continuous at fixed site
• Continuous:
– EC – UFP counts – Mass: PM1, 2.5, 10
• Daily average: – PM2.5, mass and Patterns of metals
• Weekly average: – Mass OC and Patterns of metals • PM0.2 • PM0.2-2.5 • PM2.5-10
13 - N indoor vs outdoor 50000 45000 40000 35000
Indoor
30000 25000 20000 15000 10000 5000 0 0
10000
20000
30000
40000
50000
60000
Outdoor
32 - N indoor vs outdoor 45000 40000 35000
Indoor
30000 25000 20000 15000 10000 5000 0 0
10000
20000
30000
40000
50000
Outdoor
60000
70000
80000
90000
Que sabemos? Efectos agudos: • Exacerbación: MPOC, asma, insuficiència coronària, diabetis • Incremento urgèncias (respiratorias, cardiacas, vasculares), absentismo escolar y laboral • Incremento mortalidad • Efectos sobre ritmo cardiaco, función vascular, inflamación bronquial y sistémica, coagulación, función pulmonar • Relación linial sin umbral
Que sabemos? Efectos a largo pplazo: – Aterosclerosis – Inflamación bronquial y disminución función pulmonar – Mortalidad cardio-respiratoria y cáncer de pulmón – Relación distancia a ‘busy roads’ – Intervención: reducción sintomas respiratorios, mejora función pulmonar, mejora de la esperanza de vida
Que no sabemos? • Que elementos en el PM y en que fracción son los más tóxicos? • Cuales son las mezclas más tóxicas? • Afecta el crecimiento intra-uterino? • Existen factores protectores o promotores? • Causa alzheimer? • Produce un retardo en el desarrollo neurocognitivo?
Conclusiones • La contaminación urbana y principalmente las partículas finas y ultrafinas de origen mayoritario en el tráfico, afecta la salud de todos los ciudadanos. . • Los profesionales tenemos de actuar como lobby para reducir la contaminación del aire.
GrĂ cies
jsunyer@creal.cat