air pollution and health - evidence, impacts and policy options - dr carlos dora

Public health and environment 1 |

Air Pollution and Health –

Evidence, impacts and policy

options: the future direction of

clean air policy

Dr Carlos Dora

Coordinator

Department of Public Health and Environment

Key messages for mini-campaign


2 in 3 deaths are from NCDs

Cardiovascular disease, mainly heart

disease, stroke

Cancer

Chronic respiratory diseases

Diabetes

Injuries

Today Enormous Burden of NCDs

Costs: Trillions of U$ dollars


Vulnerable (urban, older) populations

are growing rapidly


Risk factors for NCDs most often

considered:

• Tobacco

• Physical inactivity

• Diet (fat, sugar, fiber…)

• Excess use of alcohol


PM<10mm – Coarse

PM<2.5mm – Fine

PM<1mm – Ultrafine

Medgadget .com

Air Pollution is a major risk to NCDs

Substantial new evidence showing that particles smaller than 2.5mm

penetrate deep into the lungs and effect the body more systematically

leading to diseases like stroke, heart disease, in addition to the

cancers, COPD and pneumonia/URLI.


Lungs exposed to tobacco and to Indoor air

pollution

Pathology slides - Courtesy Prof. Saldiva, São Paulo, Brazil


“Review of evidence on health aspects of air

pollution - REVIHAAP”, WHO 2013 selected conclusions on PM (A1)

Confirm and strengthen results form the 2005 WHO Guidelines on

Air Quality and Health.

–New studies on short- and long-term effects;

–Long-term exposures to PM2.5 are a cause of

cardiovascular mortality and morbidity;

–More insight on physiological effects and plausible

biological mechanisms linking short- and long-term PM2.5

exposure with mortality and morbidity;

–Studies linking long-term exposure to PM2.5 to several new

health outcomes (e.g. atherosclerosis, adverse birth

outcomes, childhood respiratory disease).

7


Meta-analysis of the association between long-term

exposure to PM2.5 and cardiovascular mortality

1.00 2.00 1.15

Study %

weight

RR (95%CI)

per 10 µg/m3

Ho

ek e

t a

l, E

nvH

ea

lth

20

13

8

2002

2011

2011

2011

2012

2013

2012

2011

2007

2008

Pub.

year


Mortality and long-term exposure to PM2.5

Ce

sa

ron

i e

t a

l. E

HP

2013

c= % increase in risk per 10

µg/m3

c=10

%

c=6% c=4%

AQG EU LV

9

Results of a cohort study in Rome

(1.3 million adults followed from

2001 to 2010)

PM2.5: 3-dimensional Eulerian model (1x1 km)


Carotid artery wall thickness (=risk of atherosclerosis)

and long-term PM2.5 exposure

AQG EU LV

Bauer et al, JACC 2010

% c

hange

in a

rtery

wall

thic

kness

Home outdoor PM2.5 (µg/m3)

10

Heinz Nixdorf RECALL study, Ruhr region, Germany


Long term O3 exposure and risk of

death due to respiratory causes ACS cohort of 448 thousand adults followed for 18 years

11 Jerrett et al, NEJM 2009

RR per 10 ppb = 1.040 (95% CI

1.010 - 1.067)

(2-pollutant model with O3 and

PM2.5)


Short-term exposure to ozone, mortality and hospital

admissions European cities in the APHENA study

Outcome

Per cent increase in deaths/admissions (95% CI)

per 10 µg/m3 increment in daily maximum

1-hour ozone concentrations

Single pollutant Adjusted for PM10

All-cause mortality a 0.18 (0.07–0.30) 0.21 (0.10–0.31)

Cardiovascular mortality: 75

years and older a

0.22 (0.00–0.45) 0.21 (-0.01–0.43)

Cardiovascular mortality:

younger than 75 years a

0.35 (0.12–0.58) 0.36 (0.10–0.62)

Respiratory mortality b 0.19 (-0.06–0.45) 0.21 (-0.08–0.50)

Cardiac admissions: older than

65 years a

-0.10 (-0.46–0.27) 0.64 (0.36–0.91)

Respiratory admissions: older

than 65 years b

0.19 (-0.28–0.67) 0.32 (0.05–0.60)

12

a lag 0-1 results; b lag 1 results Katsouyanni et al 2009


REVIHAAP: Indoor, occupational and commuting

exposures vary more than exposure to OAP

•In the absence of tobacco smoke:

Commuting can increase exposures to PM, NO2, CO and

benzene, and is a major contributor to the exposure to UFP, BC

and metals (Fe, Ni and Cu in the underground);

Ambient air dominates population exposures to NO2 (not gas

appliances), PM2.5, BC, O3, CO and SO2 (also BaP, As, Cd, Ni and

Pb);

The high end of the individual exposures to PM10-2.5 and

naphthalene originate from indoor sources and commuting;

Solid fuel fired indoor fireplaces and stoves, where used in

suboptimal conditions, dominate the high end of the exposures to

PM2.5, BC, UFP, CO, benzene and BaP of the affected individuals.

13


IARC 2012 finding: Diesel a carcinogen

LONDON/GENEVA (Reuters) - The air we breathe is laced with cancer-causing substances and is being officially classified as carcinogenic to humans, the World Health Organization's cancer agency said on Thursday.


Ischemic and thrombotic effects of diluted diesel

exhaust inhalation in men with coronary heart

disease

Myocardial ischemia during 15-minute

exercise-induced stress and exposure to

diesel exhaust or filtered air in 20

subjects

Mill

s e

t a

l, N

EJM

2007

15


Deaths attributed to HAP + Outdoor Air

Pollution

~ 7 million deaths globally in 2012

AP a main RF for around 1/5 of NCDs


Estimating human exposure to air

pollution

Burden of disease is estimated from:

1. Air pollution concentrations & human exposure

2. Evidence from epidemiology about the health impacts of

air pollution

1. Diseases affected

2. Disease response to levels of AP (dose-response curves)

3. Baseline disease rates

4. Counterfactual – e.g. zero pollution, lowest existing

levels.


Estimates of outdoor air pollution exposures

used by WHO for BOD estimates

Brings together existing data from:

1. Urban ground monitoring stations – pollutant

concentrations

2. Satellite remote sensing (sparsely covereed areas)

3. Estimates of air pollution levels based on emissions

from sectors (e.g. transport, industry, power production,

etc.)

Mathematical models - combining information from monitoring, from

satellite remote sensing, chemical transport models to fill gaps and improve

estimates


Burden is from household as well as

ambient air pollution

Indoor Air Pollution ~50% of all pneumonia deaths among children under 5

~30% of all COPD (Chronic obstructive pulmonary disease) deaths

~18% of disease & deaths from ischaemic heart disease

Outdoor Air pollution ~22 % of disease & deaths from ischaemic heart disease

~15 % of deaths from pneumonia in children under 5

~5% of COPD deaths – (from ambient ozone pollution)

Air pollution also is a factor in: Cancers, Asthma (ozone), Cataracts,

Adverse pregnancy outcomes, TB

(WHO, 2009/Lim, Lancet, 2012)


4.3 million deaths were attributed to

household air pollution exposure in 2012

• Over half of deaths from

childhood pneumonia are

attributed to the exposure to

HAP

• 88% of these deaths are to non-

communicable diseases like

cardiovascular disease and

chronic obstructive pulmonary

disease (COPD).

534,000

12%

272,000

6%

928,000

22% 1,462,000

34%

1,096,000

26%

ALRI

Lung cancer

COPD

Stroke

IHD


HAP Exposure, 2012

• 2.9 billion people

exposed or…

• 42% of the global

population

• % exposed has

decreased, but the

absolute # exposed

has remained

relatively constant


Existing WHO Air Quality Guidelines (AQG)

• Global update (ambient)

2005:

– PM2.5, PM10

– Chapter on IAP

• Indoor AQG:

– Dampness and Mould:

2009

– Selected pollutants: 2010

– Household fuel

combustion: this project


New Air Quality

Guidelines:

for fuels and technologies

used for cooking, heating

and lighting in the home:

1. Don't use Kerosene

2. Don't use Coal

3. Use only very

efficient cookstoves (following emission rates

provided by WHO)

4. Use clean fuels – LPG,

Biogas, ethanol…


Household air pollution data base

(WHO)

• Data from over 800 household surveys

• Survey information about fuels and technologies used for

cooking,

• Now adding questions on heating, lighting, stacking

• Base for estimates of IAP and related mortality

(Lim S et al, Lancet, 2012)


Energy solutions that work in

your context

• Test them to check they are clean

– Using the emission rates given in the guidelines

• Evaluate actual use and satisfaction of user

– To avoid fuel stacking

• Evaluate health benefits and air pollution

reductions in a sample of users/non users

– To demonstrate costs and benefits


Extensive Evidence Reviews

• Fuel use: Global; for cooking, heating & lighting

• Emissions: range of technology & fuel options, how

relate to AQG

• Levels: HAP and exposure

• Health impacts of HAP: risk for pneumonia, COPD,

lung cancer, etc., including exposure-response.

• Burns and poisoning: risks, burden and interventions

• Intervention impacts: HAP/exposure in routine use

• Adoption at scale: barriers and enablers,

costs/benefits, finance


Model linking emissions to air quality

Inputs:

• Emission rates:

– PM2.5

– CO

• Kitchen volume

• Air exchange

rate

• Duration of use

(hours per day)

Outputs:

• Predicted

average

concentrations

of:

– PM2.5

– CO

Assumes uniform mixing of pollutants and air in kitchen


Focus on emissions reductions – why?

• Outdoor indoor

• Evidence base stronger

than for other approaches

• Implementation practicality

– via design, production,

standards, etc

• Some options (clean fuels),

are relatively independent

of user behaviour.


3.7 million deaths were attributed to

ambient air pollution exposure in 2012

Breakdown of by disease

~21 % of all deaths from

ischaemic heart disease (IHD)

~23% of all deaths due to stroke

~13 % of all deaths to chronic

obstructive pulmonary disease

(COPD)


Urban Air Quality Data (WHO) 1600 cities, but sparse coverage for Africa, Latin America, Middle East

– no coverage in rural areas


First World Health

Assembly Resolution on

Air Pollution and Health

7 million deaths a year due to household and

ambient air pollution


The resolution:

• key role health authorities in raising awareness about

the potential to save lives and reduce health costs, if air

pollution is addressed effectively.

• Need for strong cooperation between different sectors

and integration of health concerns into all national,

regional and local air pollution-related policies.

• It urges Member States to develop air quality

monitoring systems and health registries to improve

surveillance for all illnesses related to air pollution;

• It urges Member States to strengthen international

transfer of expertise, technologies and scientific data

in the field of air pollution.


Asks the WHO Secretariat:

• To build capacity to implement the "WHO air quality guidelines"

and "WHO indoor air quality guidelines;

• Regularly update the WHO guidelines

• Compile and analyse data on air quality, health

• Conduct cost-benefit assessment of mitigation measures;

• disseminate evidence-based best practices on effective indoor and

ambient air quality interventions and policies related to health

• Advance research into air pollution’s health effects and

effectiveness.

• Propose a road map for an enhanced global response by the

health sector that reduces the adverse health effects of air pollution.


collaborate, as appropriate, with relevant international, regional and

national stakeholders, to compile and analyse data on air

quality, with particular emphasis on health

related aspects of air quality

to create, enhance and update, in cooperation with relevant United Nations

agencies and programmes a public information tool of WHO analysis,

including policy and cost-efficiency

aspects, of specific and available clean air technologies to address the

prevention and control of air pollution, and its impacts on health;

advise and support tools to assist the health and other

sectors at all levels of government, especially the local level and in urban

areas, taking into account different sources of pollution in tackling air

pollution and their health effects;

raise awareness of the public health risks of air pollution and the

multiple benefits of Improved air quality, in particular in the

context of the discussions on the post

- 2015 development agenda cooperation with relevant United Nations agencies


Focus on the sources of AP: Energy-efficient

homes reduce air pollution & other housing risks

such as...

Housing risks

• Indoor/outdoor air pollution

• Damp, mould & allergens

• Poor indoor ventilation

• Planning, transport access

• Urban waste, sanitation & water

• Heat Island

• Storms/flooding

Health impacts

• Chronic/acute respiratory disease

• Allergies, respiratory disease

• Respiratory disease

• Physical inactivity, NCDs, traffic injuries

• Water and sanitation-borne disease

• Strokes

• Injuries/poverty


« Improved

insulation saved

0.26 months of

life per person »

(UK Warm Front

Programme)

Housing that is good for health

Reduction of

respiratory

illness by 9% to

20% and

increase of

individual

productivity

between 0.48%

and 11% with

natural

ventilation

startegies

« Reduced

wheezing, days-off

school, doctors'

visits were reported

by occupants of

insulated homes

« (NZ Insulation

study)

Photo 1

(graphic, table,

map, etc) zone


Health co-benefits in housing

Energy-efficient heating, cooling and natural ventilation

can reduce strokes and respiratory illness as well as

TB and vector-borne diseases;

A focus on slums /sub-standard housing - where needs

are greatest/benefits could be multiplied

Solar hot water heating - India

Slum in Mexico City


Light a billion lives – solar substitutes kerosene, India

Solar hot water heating is an fast-growing, popular technology in

Turkey, China, South Africa, Middle East, etc.

China is mass marketing next-generation solar PV & passive. Below

passive solar "combi" hot water space heating raised night-time

winter temperatures from 6-8º C lows in village near Beijing

Health co-benefits in energy


Cape Town, South Africa's Kuyasa neighborhood slum upgrade: First

to be financed by UN Clean Development Mechanism (CDM). Solar

hot water systems, sewage and insulation (below) will help reduce

heat-related, respiratory and waterborne diseases.

Health Impact Assessment of urban innovations can demonstrate health benefits and enhance global support and financing for scale-up


A significant fraction of NCDs is attributable to

exposure to traffic-related air pollution

Source: APHEKOM


Gain in life expectancy (months) in 25 Aphekom cities for a

decrease in PM2.5 to WHO AQG (10 μg/m3) (age 30+)


•

Better fuels and engines help, but

private vehicle transport increases

congestion, injuries, pollution, and

physical inactivity.

Rapid transit/NMT improves access

to schools, jobs & services for poor,

children, women, elderly & disabled,

improving equity. It can reduce injury,

cardiovascular disease & support

healthy physical activity.

Cycling to work reduced premature

mortality by 30% among commuter

groups in Shanghai & Copenhagen.

'Healthy' urban transport can reduce chronic

disease, injuries and improve health equity


Evidence: Health outcomes directly linked to type of

urban infrastructure investment

Infrastructure for different travel modes (including presence and proximity of infrastructure)

Increased walking, cycling or active transport

94,133,138,144,146,147,154,175,223–229

Less active transport179

Increased physical activity

104,154,155,160,176,184,223,228,230–239

Reduced BMI or obesity

111,118,119,165,224,234,238–240

Reduced air pollution-related effects234

Improved reported health status224

Reductions in specific health problems222,224

More infrastructure facilitating walking (including general assessments of “walkability” of neighbourhoods as well as presence of specific features, e.g. pavements)

Lower mortality / higher life expectancy47


94,136–139,141,144,171,175,241–243

More infrastructure facilitating cycling


27,104,157,159,161,184,244


44,133,140,146

Less walking, cycling or active transport 89,94,150,152,179,245


103,140,157,159,182

Reduced BMI or obesity113,117

More infrastructure facilitating public transport use

Reduced air pollution-related effects246


245,247

Less infrastructure facilitating car travel (including parking, motorways)

Reduced BMI or obesity73

Review of

studies on

infrastructure

investment,

physical

activity and

health –

WHO/Health in Green

Economy

(forthcoming)


Effectiveness of interventions - BCA:

WHO tool for estimating health economic

gains from cycling

HEAT for cycling and user guide from

www.euro.who.int/transport/policy/20070503_

1

http://www.euro.who.int/transport/policy/20070503_1





Access to clean/sustainable energy in

Health Care

• Adopt energy efficient medical technologies

• Substitute diesel generators for sustainable sources (solar, hydro…)

• Access to sustainable transport

• Energy efficient buildings …

Solar suitcase powering a health

care facility in Nigeria.

Solar powered refrigerator in

Vietnam.


A vision of

health &

equity in

Sustainable

Development


Preventing disease – addressing their route causes in

the environment and in development


Global Platform on Air Quality and Health

• To ensure best estimates of human exposure to air pollution will continue to

be regularly available for Burden of Disease estimates, as well as to ensure

accountability, transparency and wide access of these results worldwide.

• Established in January 2014,

• A wide collaboration with international agencies including UNECE, WMO,

UNEP, JRC, IIASA, World Bank, space research agencies (e.g. NASA,

JAXA), as well as national agencies and research institutions.

• Yearly meetings to update on progress and results.

• Task forces to provide improvements in methods and outputs from one year

to the next.

First year – improvements in data integration and statistical fusion, (using data from

monitors, atmospheric transport models and satellite remote sensing).

– First database of source apportionment studies (n=500)


Second year: • Data fusion: Global air quality data as a result of fusion from various data sources,

report on progress and work ahead,

• Emission sources information, including from emission inventories and source

apportionment

• Exposure-risk relationship: Integrated dose-response functions that relate levels of

air pollution indoors and outdoors to a range of diseases, report on progress and work

ahead.

• Surface monitoring: key air pollution indicators to be monitored, minimum data sets

for health purposes; systematic data collection and display;

• Automated Data acquisition, portable monitors etc. quality of outputs form different

sources,

• Household air pollution: exposure assessment, progress in IAP data, availability of

exposure data from Europe

New task forces proposed: • Data fusion and synthesis – further improvements

• Models for integrating Household and Ambient Air Polluton exposure estimates

• Guidance on the collection of ground measurement data.

• Guidance on source apportionment studies.


Establishment of a web-based resource providing access/

web linkage to:

• Results from the platform – methods, tools, results

• Tools for estimating health impacts from air pollution at local level

• Exposure-response functions

• Air quality databases:

– WHO ambient air quality in cities,

– WHO household air pollution database,

– Joint ambient/ household air pollution (future)

• Analysis of trends.

• Burden of disease estimates.

• Awareness raising and communication tools.

• Collection of cost-effective interventions/ best practices to address

air pollution and health.


Priorities for addressing the health impacts of air pollution

1. Indicators for SDGs linking health, air pollutants and its sources (Note to UN Statistics Divison)

2. Road map for implementing the WHA resolution on air pollution and health

3. Targeted actions/early wins – Global Platform AQH, implementation of IAQ guidelines


Health indicators for Post-2015

Sustainable Development WHO related health to SD policies,

through the

• Defining health-relevant indicators

for sustainable development goals (EB 136/30)

•Convened consultation on health

indicators for Rio + 20

themes/disseminated through civil

society/government partners at the

conference

•Constributions to the UN Statistics

Commission 2015-2016


SDG 11: cities

Goal 11 Make cities and human settlements

inclusive, safe, resilient and sustainable.

Target 11.7 By 2030, reduce the adverse per capita environmental

impact of cities, including by paying special attention to

air quality, municipal and other waste management.


Target Current Indicator Recommended update to indicator

11.7 Level of ambient particulate

matter (PM10 and PM2.5)

Annual mean levels of fine particulate

matter (i.e. PM2.5) air pollution in cities

(population weighted)


Data sources

• WHO urban air quality data base – 1600 cities

• Global platform air quality and health –

cooperation with many partners, facilitated by

WHO, currently improving estimates for many

more cities, synthesizing data from:

– Satellite remote sensing

– Emission inventories and source apportionment studies

– Air pollutant transport models

– Ground level monitoring of air quality


SDG 7: Energy Goal 7 Ensure access to affordable, reliable, sustainable, and

modern energy for all

Target 7.1 By 2030, ensure universal access to affordable, reliable

and modern energy services

Target Indicators currently

proposed

Recommended update to

indicator

7.1 7.1.1 Percentage of

population with electricity

access

n/a

7.1.2 Percentage of

population with primary

reliance on non-solid

fuels (%)

Percentage of population

with primary reliance on

clean fuels and technologies

at the household level*

* Recommandation 4 WHO guidelines


Recommendation 4:

– Household combustion of kerosene is

discouraged

Rationale:

– High levels of emissions of PM and other

health-damaging emissions.

– Epidemiologic studies suggest links to

tuberculosis, cancer, respiratory disease,

adverse birth outcomes, etc., but are not

of adequate consistency/quality.

– Kerosene use carries substantial risks of

burns and poisoning.


Recommendation 1:

For 90% of homes to meet the WHO

AQGs for PM2.5, emission rates should

not exceed the emission rate targets

(ERTs) set out on the right.

Emissions rate

targets (ERT)

Emission

rate

(mg/min)

Percentage of

kitchens

meeting AQG

(10 µg/m3)

Percentage of

kitchens

meeting AQG

IT-1 (35 µg/m3)

Unvented

Final 0.23 90% 100%

Vented

Final 0.80 90% 100%

Recommendation 2: • Promote clean fuels where and when possible

• For many, it will take time to meet AQGs (especially

PM2.5), so intermediate steps (solid fuel stoves) may be

required

• Solid fuels: test emissions (ref Recommendation #1), use

best possible options

• Monitor use and air pollution (not just laboratory)

Rationale:

– Health evidence: need low levels for

major health benefits (ALRI)

– In practice, solid fuel stoves not

achieving low levels (some vented

wood stoves 35-70 µg/m3)

– Even clean fuel users well above IT-

1 (other sources)

– Based on evidence, requires (near)

exclusive use of clean fuels to

achieve AQG (PM2.5).

Recommendation 3: Unprocessed coal should not be used as a household fuel

Rationale:

– High levels of emissions of PM and other health-damaging emissions.

– Epidemiologic studies suggest links to tuberculosis, cancer, respiratory

disease, adverse birth outcomes, etc., but are not of adequate

consistency/quality.

– Kerosene use carries substantial risks of burns and poisoning.


Data source: WHO household energy data base*:

Population Primarily Relying on Solid fuels for cooking in 2012

• based on over 800 household surveys,

• being upgraded to include: fuels and technologies for lighting, heating and cooking as well as fuel stacking

Used as input to SE4All and other global energy tracking


SDG 3: Health

Goal 3 Ensure healthy lives and promote well-being for all

at all ages

Target 3.9 By 2030, substantially reduce the number of deaths and

illnesses from hazardous chemicals and air, water and soil

pollution from contamination.

Target Current Indicator Recommended update to

indicator

3.9 3.9.1 Population in urban areas exposed

to outdoor air pollution levels above

WHO guideline values

3.9.1. Mean levels of exposure

to ambient air pollution

(population weighted)

Rationale: dicotomous value (WHO guideline levels)

is a good target but a poor measure to track progress,

and annual levels are linked to health

OR: Mean levels of exposure to ambient and indoor air pollution


Alternative SDG 3: Health

Goal 3 Ensure healthy lives and promote well-being for all

at all ages

Target 3.9 By 2030, substantially reduce the number of deaths and

illnesses from hazardous chemicals and air, water and soil

pollution from contamination.

Target Current Indicator Recommended update to

indicator

3.9 3.9.1 Population in urban areas exposed

to outdoor air pollution levels above

WHO guideline values

3.9.1. Mean levels of exposure

to ambient and indoor air

pollution (population weighted)

Using initially both indicators for AAP and IAP, and

later an integrated indicator of AP exposure.


Data sources • WHO urban air quality data base – 1600 cities

• Global platform air quality and health –cooperation with many

partners, facilitated by WHO, currently improving estimates for many

more cities, synthesizing data from:

– Satellite remote sensing

– Emission inventories and source apportionment studies

– Air pollutant transport models

– Ground level monitoring of air quality

• WHO household energy data base:

– based on over 800 household surveys,

– being upgraded to include: fuels and technologies for lighting, heating and

cooking as well as fuel stacking

– Further data integration of all the above under the

global platform on air quality and health – being

prepared


Monitoring and reporting.

Member States commit to redouble their efforts on:

• strengthening international cooperation

• collecting and utilizing data relevant to the health

outcomes of air quality,

• working towards harmonization of health-

related indicators which could be used by

decision makers

• optimize the linkages (of health surveillance)

with monitoring systems of air pollutants


Monitoring and reporting.

request the WHO to:

• provide enhanced cooperation between WHO relevant international regional and national stakeholders,

• compile and analyse data on air quality, with particular emphasis on the health-related aspects of air quality,

• take account of sources of air pollution in tackling their health effects

• cooperate with relevant UN agencies and programmes to create, enhance and update a public information tool of

WHO analysis, including policy and cost-efficiency aspects.


Making the link - Health benefits from Policies to

Mitigate Climate Change and Air Pollution

T

ran

sport

, en

ergy

, la

nd

use

po

lici

es /

Com

bu

stio

n

Air pollution (PM)

Climate change (CO2)

Local/

short term

health

impacts

Global/long

term health

impacts

Climate change (SLCPs)

Injuries, physical activity,

noise, diet,