Jordi Sunyer

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