1st annual meeting of the health impact of...

1

14/04/2015

1st Annual meeting of the

Health Impact of Environmental Hazards HPRU

Professor Frank Kelly

King’s College London

HPRU Structure

Director: Prof Frank Kelly (King’s College London)

Administrator: Angela Lewis

Imperial College lead:

Prof Paul Elliott

Theme I

Dr Anna Hansell

Dr Tony Fletcher

Theme II

Prof Tim Gant

Prof David Phillips

PHE lead:

Prof Tim Gant

Theme III

Dr Simon Bouffler

Dr Mireille Toledano

Theme IV

Dr Heather Walton

Dr Rachel Smith

THEME 2:

THEME 3:

THEME 4:

Health Impact of Environmental Hazards

THEME 1: Epidemiological assessment of low level environmental exposures

Modes and mechanisms of toxicity

Health impact of low dose non-ionising and ionising radiation

Health effects of noise and air pollution including nanoparticles

2

GovernanceExternal Advisory Board

Chairman: Prof Roy Harrison (University of Birmingham)

Theme I

Dr Judy Qualters

(US CDC)

Theme II

Prof Heather Wallace

(University of Aberdeen)

Theme III

Prof Hans Kromhout

(Utrecht

University)

Theme IV

Prof Bob Maynard

(University of Birmingham)

Simon Birkett – lay member(Clean Air in London)

Prof Sari Kovats – cross

HPRU representative

Plenary Session I – (15 minute presentations and 5 minute discussion) 10:15 - 10:20 Epidemiological assessment of low level environmental exposures Tony Fletcher 10:20 - 10:40 Carbon monoxide studies Becky Ghosh 10:40 - 11:00 Health impacts from bioaerosols from waste composting facilities Anna Hansell 11:00 - 11:20 Cluster guidelines/Rapid Inquiry Facility Becky Close / Anna Hansell 11:20 - 11:35 Tea/Coffee break 11:35 - 11:40 Modes and Mechanisms of Toxicity Tim Gant 11:40 - 12:00 Epigenetic effects of chemical exposure / Bioaerosols, aeroallergens and complex mixtures Tim Gant 12:00 - 12:15 Mechanisms of chemical effects in response to aeroallergens Martin Leonard 12:15 - 12:30 Foetal Exposures Tim Marczylo 12:30 - 12:45 Toxicokinetics Matt Puncher 12:45 - 13:00 Genotoxicity of air pollutants David Phillips

13:00 - 14:00 Lunch

Imperial

College London

King’s College London

Noise

Small

area

Photo

biology

Key features

• 55 investigators across

7 Departments in 3

Institutions

• Established work programmes & funding in

place for new studies

Air

Pollution

Public

Health England

NP’sTox

Radiation

Non–

ionising

radiation


Our strategy is to combine:

� Large-scale epidemiological enquiry

(small-area, cohorts)

� Establish/develop exposure models

� Advance biomarker research

exposure/early effects/disease

� Toxicology/mechanisms

� Hierarchical statistical approaches

� Inference at individual level

through to population and policy

Exposure

Biomarkers

of exposureBiomarkers of early effects

Disease

Environmental

Modelling

Integrated Environmental

Monitoring


14/04/2015

Patient and Public Involvement & Engagement

PPI Objectives

To make research available to people in their ‘own backyard’ by forging links

with local communities.

Develop good practice guidance for researchers and scientists on engaging

the community in translational research.

Expand communication of research activities and findings

PPI Strategic Oversight Group (SOG)

Mireille Toledano (Lead)Ian Mudway (Deputy Lead)

THEME 1: Tony Fletcher

THEME 2: Toby Athersuch

THEME 3: Antony Young

THEME 4: Rachel Smith

Epidemiological assessment of low level environmental exposures

Modes and mechanisms of toxicity

Health impact of low dose non-ionising and ionising radiation

Health effects of noise and air pollution including nanoparticles

Ge

ne

ral P

ub

lic

Pa

tien

t G

rou

ps

Go

ve

rnm

ent

NG

Os


3

Dissemination

Potential synergies with

other HPRU’s

• Environmental Change & Health

• Emergency Preparedness and Response

• Chemical and Radiation Threats and Hazards

Strategic need for HPRU

� Environmental exposures major

determinants of human health and disease

� Individual and small-area studies needed

to investigate environmental health

problems of national importance

� New technologies and approaches offer

unprecedented opportunities to

understand pathways and mechanisms

linking environmental exposures to

disease

� Skills shortages in key strategic areas to

deal with the explosion of (big) data

� Requires new integrated multidisciplinary

approaches to research, training and

capacity building

Childhood cancers near mobile phone

masts

12/11/2014

Theme 1 Overview

Theme 1: Epidemiological assessment of low

level environmental exposures Lead: Anna Hansell (Imperial); Deputy lead: Tony Fletcher (PHE)

Presenter: Tony Fletcher (PHE)

Theme 1 (Epidemiology)

Objective: To use epidemiology and surveillance to identify and quantify associations between disease and low level environmental exposures.

Principles underlying Theme 1 work programme:• Selection of specific exposures – widespread exposures

but with uncertainty of disease burden: potentially large impact. First phase CO and bioaerosols

• Selection of methodological focuses – developing science relevant to policy issues: responding to clusters and risk communication, improved hazard identification and risk

assessment• Partnership strengths – Building on and developing

existing research and collaborations in the team

4

Theme 1 Years 1-2

Project 1 Carbon monoxide

studies

14-15 15-16 16-17

Project 2 Bioaerosols from waste

composting facilities

Project 3 Cluster guidelines/

Rapid Inquiry Facility


14-15 15-16 16-17

Project 2 Bioaerosols

Project 3 Cluster guidelines/RIF

To be presented in

more detail

Theme 1 Years 2-3


14-15 15-16 16-17

Project 2 Bioaerosols

Project 3 Cluster guidelines/RIF

Project 4 Water fluoridation: health

monitoring report for England.

Project 6 Spatial uncertainty in

public health data

Project 5 Epi evidence for health

effects of low level exposures

Project 7 Exposure to emissions

from incinerators.

Theme 1 Years 2-3

14/04/2015

Accidental non-fire related Carbon Monoxide poisoning in England

(2001-2010)

Lead: Rebecca Ghosh (Imperial); Deputy lead: Giovanni Leonardi (PHE)

Presenter: Rebecca Ghosh

Carbon Monoxide (CO) emissions

• CO is a common, potentially fatal, colourless, odourless and tasteless gas that results from the incomplete combustion of fuels.

• CO poisoning can cause sudden collapse, loss of consciousness and

death with high levels of exposure

• Symptoms include headaches,

drowsiness, cheat pains, nausea &

neurological effects depending on level and duration of exposure.

Aims

• To quantify the of the morbidity burden due to accidental non-fire related CO poisoning in England in:

1) the context of other admissions to hospital for CO poisoning

2) to describe these admissions by region, sex, age and deprivation.

• To provide a baseline for future routine surveillance of

CO morbidity

• To help target educational and other interventions to

reduce CO exposures

5

Hospital Episode Statistics inpatient data (2001-2010)

• Primary diagnosis using ICD-10:

• Accidental CO poisoning - T58: Toxic effect of carbon monoxide +

X47: accidental poisoning by and exposure to other gases and vapours

• Compared with:– intentional CO poisoning (T58+X67: intentional self-poisoning by and

exposure to other gases and vapours)

– Unknown intent: (T58+Y17: poisoning by and exposure to other gases and vapours, undetermined intent or no additional external cause code.)

• Non-fire related accidental CO poisoning= T58+X67

excluding:– X00-X09: exposure to smoke, fire and flames

– T20-T32: burns and corrosions

– Y26: exposure to smoke fire and flames, undetermined intent

Methods

• Accidental CO admissions compared to other CO

admissions for each sex

• Crude rates by cause of CO poisoning over time

calculated (using Census based population estimates

as denominator).

• Data analysed by region, month, age group and area-

level deprivation (Carstairs).

• The empirical Bayes smoothed relative risk of CO

poisoning at local authority/district level was mapped unadjusted and adjusted for deprivation.

Carbon monoxide admissions (2001-

2010, England) by sex and cause

1 Combination of “T58+Y17 – Undetermined intent” and T58 with no intent code provided 2 Difference between sexes statistically significant : Χ2 p<0.001, 3p=0.0034 Of these 571were admissions with T58 but no other intent code5 Of these 362 were admissions with T58 but no other intent code

Accidental-X47 n

(%)

Intentional-X67 n

(%)Unknown 1 n (%) Total n (%)

Including fire related codes

Female 1184 (47.4) 389 (17.9) 265 (41.5) 1838 (34.6)

Male 1316 (52.6)2 1785 (82.1)2 373 (58.5)2 3474 (65.4)

Total 2500 (100) 2174 (100) 638 (100)4 5312 (100)

Excluding fire related codes

Female 1164 (47.3) 389 (17.9) 174 (40.7) 1727 (34.1)

Male 1299 (52.7)2 1782 (82.1)2 254 (59.3)3 3335 (65.9)

Total 2463 (100) 2171 (100) 428 (100)5 5062 (100)

Carbon monoxide admissions (2001-

2010, England) by sex and cause

1 Combination of “T58+Y17 – Undetermined intent” and T58 with no intent code provided 2 Difference between sexes statistically significant : Χ2 p<0.001, 3p=0.0034 Of these 571were admissions with T58 but no other intent code5 Of these 362 were admissions with T58 but no other intent code

Accidental-X47 n

(%)

Intentional-X67 n

(%)Unknown 1 n (%) Total n (%)

Including fire related codes

Female 1184 (47.4) 389 (17.9) 265 (41.5) 1838 (34.6)

Male 1316 (52.6)2 1785 (82.1)2 373 (58.5)2 3474 (65.4)

Total 2500 (100) 2174 (100) 638 (100)4 5312 (100)

Excluding fire related codes

Female 1164 (47.3) 389 (17.9) 174 (40.7) 1727 (34.1)

Male 1299 (52.7)2 1782 (82.1)2 254 (59.3)3 3335 (65.9)

Total 2463 (100) 2171 (100) 428 (100)5 5062 (100)

CO hospital admission rates over time

0.00

0.20

0.40

0.60

0.80

1.00

Ra

tes

of

Ad

mis

sio

ns

pe

r

10

0,0

00

Female admission ratesANFR (T58+X47 - excluding fire codes)

Intentional (NFR T58+x67 excluding fire codes)

Unknown intent (NFR - T58+Y17 or no code, excluding fire codes)

0.00

0.20

0.40

0.60

0.80

1.00

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Ra

tes

of

Ad

mis

sio

ns

pe

r

10

0,0

00

Years

Male admission rates

Accidental non-fire related (ANFR) CO hospital admission rates per 100,000 person

years by government office region 2001-2010

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

South

East

London East of

England

North

West

South

West

West

Midlands

Yorkshire

and The

Humber

East

Midlands

North

East

Ra

te p

er

10

0,0

00

Government Office Regions

Female

Male

6

Smoothed relative risk of ANFR CO hospital admissions

ANFR CO hospital admissions by month of admission

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

Pe

rce

nta

ge

of

tota

l a

dm

issi

on

s

Month of Admission

females males

Rate of ANFR CO hospital admissions by age groups

0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40

1.60

Ra

te p

er

10

0,0

00

Age groups

Female rate

Male rate

ANFR CO hospital admissions by Carstairs quintiles

0%

5%

10%

15%

20%

25%

Pe

rce

nta

ge

of

Ad

mis

sio

ns

Carstairs Quintiles

females

males

Summary

DeathsDeaths

Serious injuries

Accident and Emergency

visits

Primary care consultations

Community level poisoning

ONS mortality (40 deaths per year)

HES inpatients (250 Hospital admissions per

year)

HES A&E (4000 per year)

General Practice data

Local schemes (e.g.

Hackney homes)?

Future work

• Use of other national NHS datasets – complete picture for the UK:

• Following CO admissions through the hospital system:

– Linking inpatients back to A&E records

– Outcome of the patient (sent home, died in hospital, died within 30 days of returning home)

7

Deliverables and milestones Theme 1, Project 1

• Analysis of hospital admissions – paper submission. Completed. Paper published March 2015 in Journal of

Public Health.

• Joint workshop between HPRU/Institute de Veille

Sanitaire in Paris to compare French/English approaches in environmental public health CO

surveillance. April 2016.

• Assessment of A&E presentations of those subsequently

diagnosed with CO poisoning on hospital admission. By end March 2016.

Further information

www.nihr.ac.uk

Rebecca E. Ghosh; Rebecca Close; Lucy J. McCann; Helen Crabbe; Kevin Garwood; Anna L. Hansell; Giovanni

Leonardi. Analysis of hospital admissions due to accidental non-fire-related carbon monoxide poisoning

in England, between 2001 and 2010 Journal of Public Health 2015; doi: 10.1093/pubmed/fdv026

• The research was funded by the National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Health Impact of Environmental Hazards at King’s College London in partnership with Public Health England (PHE). The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR, the Department of Health or Public Health England.

• Hospital Episode Statistics data are copyright © 2013, Re-used with the permission of the Health and Social Care Information Centre. All rights reserved.

• Population data used were supplied by the Office for National Statistics (ONS), derived from the Census.

Acknowledgements

14/04/2015

Health impacts from

bioaerosols from waste composting facilities

Lead: Anna Hansell (Imperial); Deputy lead: Tim

Gant (PHE)

Presenter: Anna Hansell

Background

• Bioaerosols are airborne biological particles,

microbial fragments and constituents of cells

• Increasing number of large-scale composting

facilities producing bioaerosols

• EA currently hold a precautionary stance

(bioaerosol concentrations must be attained at

certain concentrations by 250m)

• Limited evidence on health effects

1. Systematic Review Study

Aim• To systematically review occupational and community

studies measuring concentrations of bioaerosols and/or assessing health effects associated with bioaerosol

emissions within and nearby composting facilities

Search Strategy• Methods developed based on PRISMA and MOOSE

criteria• Search conducted across 6 electronic databases

8

*The majority of toxicological studies were non-human lab-based studies

1

10

100

1,000

10,000

100,000

1,000,000

10,000,000

100,000,000

Measu

red

Asp

erg

illu

s f

um

igatu

s

co

ncen

trati

on

-lo

g s

cale

(C

FU

/m3)

Background Indoor Shredding Turning Screening Downwind

Occupational Exposure Studies

• 51 studies• Wide variability in measured concentration on site

Community Exposure Studies• 13 studies• Concentrations generally reduce with distance, although

some remain elevated

1

10

100

1,000

10,000

100,000

1,000,000

10,000,000

100,000,000

-1000 -500 0 500 1000 1500

Me

as

ure

d to

tal b

ac

teri

a

co

nc

en

tra

tio

n (

cfu

/m3)

Distance measurement was taken from site (m)

Occupational Health Studies

Community Health Studies

• 12 Studies• 1 experimental, 2 quasi-experimental, 1 cohort study, 6

cross-sectional, 1 lab based, 2 case reports,• Upper respiratory symptoms generally reported

• 6 Studies• 1 panel based, 3 cross-sectional,1 lab based, 1 case

report • Provided limited evidence of increased exposure levels

at distances greater than 200m to 300m• 2 of 3 cross sectional studies used self-report

questionnaires - prone to bias

Quantitative Quality Assessment

• 13 epidemiological studies assessed for bias

• Bespoke quality assessment tool developed assessing:– Study design - Exposure

– Selection - Outcome Assessment

– Responder - Sample Size

– Confounder - Analytical

• Score of 1-4 where 4 = low bias

– Scores ranged 13 to 25 (highest possible score = 32)

• Generally samples sizes were low, with a high risk of response bias

Author

(Year)

Risk of BiasStudy

Design

Selec-

tion

Respon-

der

Confounder Exposure

Ass.

Outcome

Ass.

Sample

Size

Analytical Total

Occupational health studiesLundholm

(1980)2 2 1 1 3 2 1 1 13

Sigsgaard

(1994)2 4 3 2 2 4 1 3 21

Bunger (2000) 2 2 1 2 1 3 2 3 16Douwes (2000) 2 2 1 2 4 3 1 3 18Heldal (2003) 2 1 1 2 2 3 1 2 14Muller (2006) 2 3 3 1 3 3 1 3 19Bunger (2007) 1 3 2 2 2 3 2 3 18van Kampen

(2012)2 2 1 3 1 3 2 4 18

Hambach

(2012)2 2 4 3 1 3 1 3 19

Community health studiesBrowne (2001) 3 3 2 2 3 3 2 3 21Herr (2003) 2 4 1 4 3 3 3 4 24Herr (2003a) 2 2 1 1 2 4 3 3 18Aatamila

(2011) 2 4 3 4 1 4 4 3 25

9

Discussion

Exposure Studies• Heterogeneous in design (wide range of bioaerosols

measured and different sampling techniques adopted)

• Limited details provided (many did not provide background concentrations)

• High variability in measured concentrations on and off site

• Measurement techniques rely on culture methods

• Short term ‘spot’ measurements

Discussion

Health Studies• Short term studies

• Small sample sizes

• No studies on vulnerable populations

• High risk of response bias in studies relying on questionnaire data

• The evidence base is not sufficient to provide quantitative dose-response estimates

Conclusions

• Data remains limited

• Little insight into long-term exposure

• Most health studies performed over short timescales

• No quantitative exposure response estimates

• Qualitative evidence of adverse health outcomes which

supports the current precautionary stance adopted by the Environment Agency

Recommendations for future work

• More detailed and longer term monitoring of bioaerosols

• Improved characterisation of background levels

• An examination of health effects over longer timescales and in larger numbers of individuals

(including potentially sensitive groups) using objective measures

• An initial research focus on respiratory and allergic disease

2. Respiratory admissions near composting sites -pilot study

AimTo conduct a small area study investigating whether higher

rates of respiratory hospital admissions are associated with living in areas near to large-scale waste composting sites

Methods• All sites in England 2008-10 with an outdoor composting

component (n=148)• Respiratory related hospital admissions up to 2500m from

site by distance band and continuously• Statistical analysis completed using a random intercept

hierarchical Poisson regression model

• Results adjusted for age, sex, deprivation, smoking and overdispersion

Results

Distance UnadjustedRR (95% CI)

p-value

Adjusted (for area deprivation and smoking)

RR (95% CI)

p-value

250-750m compared with

1500-2500m

1.05 (0.99-1.11)p=0.08

1.01 (0.95-1.06)p=0.68

750-1500mcompared with

1500-2500m

1.02 (1.00-1.05)p=0.06

1.03 (1.01-1.05)p=0.04

P for trend p=0.01 p=0.10

Log-transformed distance

0.97 (0.94-1.00)p=0.06

0.98 (0.96-1.00)p=0.05

10

Limitations• Could not assess 0-250m band

• Potential exposure misclassification and population location uncertainties

• Unclear temporal relationships with exposure

Conclusions• Detected borderline significant health effects in those

living nearer to site• Supports current Environment Agency (EA)

precautionary stance

Limitations and Conclusions

• Review of exposures and health outcomes, journal submission. Completed. Published 1 April 2015 in Journal of

Toxicology and Environmental Health Part B• Short paper on bioaerosols from intensive farming.

Completion in year 2• Analysis of hospital admissions for respiratory disease.

Paper submission by end December 2015.

• Emissions modelling of bioaerosols from industrial composting sites. Paper submission by end of year 2

(March 2016)


Further information

www.nihr.ac.uk

For further details on cluster guidelines please contact:[email protected], [email protected],

[email protected]

Pearson, C., Littlewood, E., Douglas, P., Robertson, S., Gant,

T.W., and A.L. Hansell. 2015. Exposures and health outcomes

in relation to bioaerosol emissions from composting facilities: A systematic review of occupational and community studies.

Journal of Toxicology and Environmental Health, Part B. Vol 18,

No.1, P.1-27 http://www.tandfonline.com/doi/full/10.1080/10937404.2015.100

9961#abstract

14/04/2015

Theme 1/Project 3:Cluster guidance/Rapid Inquiry

Facility

Lead: Tony Fletcher (PHE); Deputy lead: Anna Hansell (Imperial)

Presenters: Rebecca Close (PHE) & Anna Hansell

Background

• Investigating potential clusters can be difficult and time consuming

• PHE has guidelines available for investigating outbreaks of infectious diseases & unusual illness

• Guidelines for investigating non-infectious disease cluster enquiries is not currently available in England

• Some other countries such as US and the

Netherlands have cluster guidance

Aim of cluster guidance

• The aim is to complete and make available guidelines on investigation of clusters of non-infectious disease

consulting widely in the public health community

• Final guidelines will incorporate:

– Case studies

– Suggested roles and responsibilities

– Guidance on use of the Rapid Inquiry Facility (RIF)

11

The guidance - approach

• Staged approach, comprehensive steps within stages

• Local public health authorities will be responsible for leading and coordinating the cluster investigation

• Directors of Public Health will involve PHECs and other relevant departments

• Three track approach adopted for cluster investigation:

– Health events

– Exposure investigation

– Communication

• Stage 1: Screening

• Stage 2: Assessment (Statistical analysis and check for biologic plausibility)

– 2a: Preliminary evaluation

– 2b: Occurrence evaluation

– 2c: Event evaluation

• Stage 3: Aetiological investigation

– 3a: Feasibility study

– 3b: Aetiological investigation

The guidance - stages

Rapid Inquiry Facility 4.0

A tool that allows users to assess the

relationship between the environment and

health.

– Links spatial and non-spatial data

– Free open source

web platform

Rapid Inquiry Facility 4.0

Disease Mapping

Visualising mortality or morbidity rates and spatial patterns of disease.

• Direct / Indirect standardized rates

• Bayesian Smoothing R-INLA

• Cluster detection

Risk analysis

Initial assessment into whether an environmental risk factor has a

statistical association with a health outcome in a local population.

• Uses Exposure’ bands (modelled/distance and point/area sources)

• Tests whether the risks in the different exposure groups arehomogeneous, or show heterogeneity

• Tests whether the risks display a linear trend with exposure.

Analysis set-up

Disease submission parameters

Visualising results

Disease mapping viewer

12


• Three case studies of previous cluster investigations.

Completed

• Produce cluster guidance for consultation, incorporating

appropriate use of the RIF risk analysis and disease mapping

functions. Completion in June 2015. (PHE lead)

• Evaluation of the cluster guidance implementation.

Submission by December 2016.(PHE lead)

• Enhanced RIF - development of software on cluster analysis

and disease mapping, available as freeware. A beta working

version will be available by March 2016. (Imperial lead)

• Presenting a workshop on the RIF at at least one conference

by March 2016. (ISEE 2015)

Further information

www.nihr.ac.uk

For further details on cluster guidelines please contact: [email protected], [email protected]

[email protected], [email protected]

The RIF is funded by the National Institute for Health Research

Health Protection Research Unit (NIHR HPRU) with Public

Health England (PHE), the US Centers for Disease Control andPrevention (CDC) and the European commission has also

supported previous RIF versions. For more info on the RIF find

us on github:https://github.com/smallAreaHealthStatisticsUnit/rapidInquiryFa

cility

12/11/2014

Theme 1 Overview of outreach

Presenter: Anna Hansell (Imperial)

Theme 1

• Carbon monoxide: Joint workshop planned in Paris with Institute de Veille Sanitaire

• Bioaerosols: Review paper briefing teleconference including industry representatives

– Analyses of this and CO work presented to MRC-PHE Centre Community Advisory Board

• Cluster guidelines / Rapid Inquiry Facility: Work

presented at PHE Applied Scientific Meeting, March 2015

• Two team members have attended training: a PPI

course (PD) and Science and Media Training course (RG)

1st annual meeting of the health impact of...

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