6/21/2019 Air pollution Financial disclosures Air Pollution: Every Breath You Take • 1. Overview, effects on indigenous populations. • None. Christopher Sanford, MD, MPH, DTM&H Christopher Sanford, MD Associate Professor, Family Medicine, Global Health University of Washington, Seattle, WA, USA • 2. Study on travelers and pulmonary function Terry Gordon, PhD Terry Gordon, PhD Professor of Environmental Medicine New York University School of Medicine, New York, NY, USA Dr. Trish Batchelor, FRACGP MPH (Trop Med) Dip CH ACCAM PG Dip Occ Env Med • 3., Managing pollution in expatriates: developing Chief Medical Officer, DFAT a strategy and practical tips for travellers. Australia Trish Batchelor, MD CISTM16, Washington DC, June 2019 1 2 3 Shanghai, China Guangzhou, China, December 2018 4 5 6 Deaths due to air pollution 2 categories of air pollution • WHO: 90% of world population breathes • Per WHO: 7 million deaths/year highly ‐ polluted air. – 40% percent of deaths are due to ischemic heart • 1) Ambient (Outdoor) disease, 40% to stroke, 11% to COPD (chronic • 2) Household (Indoor) obstructive pulmonary disease), and 6% to lung • WHO: air pollution is the most significant • burning of biomass ‐‐ : wood, charcoal, dung, crop residue cancer. environmental threat for cooking fuel, heating, lighting ‐‐ increased exposure in women, young children, who spend • WHO states that air pollution and climate – WHO: Ten Threats to Global Health in 2019 more time near domestic hearth change is one of the Ten Threats to Global https://www.who.int/emergencies/ten ‐ threats ‐ • This presentation will focus on outdoor air to ‐ global ‐ health ‐ in ‐ 2019 Health in 2019 pollution. 7 8 9 1
6/21/2019 A problem in both low ‐ and high ‐ Top 100 cities in the world, air India, China income nations. pollution, PM 2.5 • China: 57 • India: 33 • India and China account for over 50% of • Over 90% of deaths related to air pollution deaths due to air pollution. occur in low ‐ income nations. • Pakistan: 2 • Bahrain: 1 • Of the 25 cities with the worst air pollution, 20 • Bosnia ‐ Herzegovina: 1 • United Arab Emirates: 1 are in India. • Nepal: 1 • Bangladesh: 1 • Afghanistan: 1 • Mongolia: 1 • Kuwait: 1 AirVisual, 2018 https://www.airvisual.com/world ‐ most ‐ polluted ‐ cities 10 11 12 Increasingly, travelers are visiting Health effects of air pollution regions with significant air pollution. • 2017: 1.32 billion tourist arrivals globally • Many areas with significant air pollution are • stroke seeing a marked increase in visitors, e.g., • heart disease International Tourist Arrivals India. • sudden death 1990 2015 – 10.04 million tourist arrivals in India in 2017, a • COPD (chronic obstructive pulmonary disease) 17% increase over the previous year. • asthma World 435 million 1.186 billion • lung cancer • India Tourist Statistics at a Glance: 2018. Ministry of Tourism, Government of India. Advanced 299 million 653 million • other cancers: breast, bladder, liver, pancreas, economies http://tourism.gov.in/sites/default/files/Other/ bile duct, and gall bladder ITS_Glance_2018_Eng_Version_for_Mail.pdf Emerging 136 million (31%) 533 million (45%) economies ‐‐ UNWTO 2016a 13 14 15 Different ways to measure air pollution Air Quality Index (AQI) • In addition to effects on heart and lung function, • 1) Air quality index. (AQI). air pollution has been linked to decreased • Level of pollutant, via a piecewise linear cognitive function and increased crime. function, is converted to a number on a scale • A large study performed in multiple cities in on which values below 100 are good or China linked long ‐ term air pollution to impaired moderate. math and verbal skills; effects were greatest in • If multiple pollutants are measured at a older men with lower educational levels (see monitoring site, then the largest or article by Zhang et al in References). "dominant" AQI value is reported for the location 16 17 18 2
6/21/2019 The EPA (Environmental Protection 2) Specific pollutants US Clean Air Act Agency) lists six “Criteria Air Pollutants” • PM 2.5 • Requires EPA (Environmental Protection • Particulate matter (PM) Agency) to set National Ambient Air Quality • PM 10 – PM 2.5 Standards (NAAQS). – PM 10 • ozone level • Ozone (ground ‐ level) • NAAQS are currently set for six “Criteria Air • etc. • Carbon monoxide Pollutants.” • Nitrogen dioxide • Sulfur dioxide • Lead EPA (Environmental Protection Agency) Criteria Air Pollutants, https:// www.epa.gov/criteria ‐ air ‐ pollutants accessed 9 May 2019 19 20 21 Particulate matter Why does size matter? Particulate matter • Particulate matter (PM) • Decreases lung function. – PM 2.5 • Increases risk of sudden death. – PM 10 • Lung CA (IARC [Int’l Agency for Research on Cancer] Group 1 carcinogen) • Suspended solid or liquid matter • Worsens asthma. • Source: – Anthropogenic—burning fossil fuels – Natural—dust storms, fires 23 22 23 24 Particulate matter, 2013 study PM 2.5 PM 2.5 , standards (in μ g/m 3 ) • 312,944 people, in nine European countries WHO EU US India • no safe level of particulates daily 25 35 40 • for every increase of 10 μ g/m 3 in PM 10 , PM 2.5 the lung cancer rate rose 22%. μ g/m 3 • smaller PM 2.5 ‐‐ stronger correlation ‐‐ 36% increase in lung cancer per 10 μ g/m 3 annual 10 25 12 60 PM 2.5 μ g/m 3 – Raaschou ‐ Nielsen O, et al. Air pollution and lung cancer incidence in 17 European cohorts: prospective analyses from the European Study of Cohorts for Air Pollution Effects Schulz J., et al. Adressing Global Mortality from PM 2.5, Environmental Science & (ESCAPE) Lancet Oncol. 2013;14(9):813–822. Technology , 2015. 25 26 27 3
6/21/2019 Ozone and relative mortality rate Ground ‐ level ozone (O 3 ) Ground ‐ level ozone (O 3 ) (cont.) (Not to be confused with “good ozone,” which is in the • stratosphere 10 ‐ 50 km [6 ‐ 31 miles] above the earth). • Causes chest pain, coughing, throat irritation, and airway inflammation • Created by chemical reactions between oxides of • Reduces lung function. nitrogen (NOx) and volatile organic compounds (VOC) • Worsens bronchitis, emphysema, asthma. • Occurs when pollutants emitted by cars, power plants, industrial boilers, refineries, chemical plants, etc. chemically react in the presence of sunlight. US EPA. Ground ‐ level ozone basics https://www.epa.gov/ground ‐ level ‐ ozone ‐ pollution/ground ‐ level ‐ ozone ‐ basics Jerrett, et al. Long ‐ Term Ozone Exposure and Mortality. N Engl J Med 2009; Accessed 9 May 2019 360:1085 ‐ 1095. 28 29 30 Carbon monoxide (CO) Carbon monoxide (CO) (cont.) Nitrogen dioxide (NO 2 ) • Released when something is burned. • Reduces the amount of oxygen that blood can • “Nitrogen dioxide (NO 2 ) is one of a group of highly reactive gases known as oxides of nitrogen or transport • Greatest sources of CO to outdoor air: cars, nitrogen oxides (NO x ). Other nitrogen oxides include trucks and other vehicles or machinery that nitrous acid and nitric acid. NO 2 is used as the burn fossil fuels. • At low concentrations: indicator for the larger group of nitrogen oxides.” – Can cause fatigue in healthy people – Can exacerbate angina in those with heart disease • NO 2 is produced by burning of fuel: emissions from cars, trucks and buses, power plants, and off ‐ road equipment. US EPA. Basic Information about NO 2 https://www.epa.gov/no2 ‐ pollution/basic ‐ information ‐ about ‐ no2#What%20is%20NO2 Accessed 9 May 2019 31 32 33 Sulfur dioxide Nitrogen dioxide (cont.) Sulfur dioxide (cont.) • Associated with respiratory symptoms and disease, • SO 2 is the sulfur oxide (SO x ) of greatest concern • Aggravates respiratory diseases, including difficulty in breathing, and premature death and is used as the indicator for the larger group asthma. • People with asthma, particularly children, are sensitive to of gaseous sulfur oxides these effects of SO 2 . • Long ‐ term exposure elevates risk of asthma, • Sources: • High concentrations of SO 2 lead to the formation of other and increases susceptibility to respiratory – primary: burning of fossil fuels by power plants and sulfur oxides (SO x ) which can react with compounds in the atmosphere to form particulate matter (PM) other industrial facilities illnesses. – lesser: industrial processes such as extracting metal • At increased risk for health effects of NO 2 : from ore; natural sources such as volcanoes; and • Environmental: Contributes to acid rain. locomotives, ships and other vehicles and heavy • At high concentrations, gaseous SOx can harm trees and children, the elderly, those with asthma. equipment that burn fuel with a high sulfur content. plants by damaging foliage and decreasing growth. US EPA. Sulfur Dioxide (SO 2 ) Pollution https://www.epa.gov/so2 ‐ pollution/sulfur ‐ dioxide ‐ basics#what%20is%20so2 Accessed 9 May 2019 34 35 36 4
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