Retos para la mejora de la calidad del aire

Los efectos en la salud de la contaminación atmosférica

Jordi Sunyer

CREAL 20/9/2012

ENCUENTRO

Beijing Olympic games (2008)

By Aymeric Ung, InVS

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Beijing 2008's Olympics

Odd-even licence plate restriction

300,000 high-polluting vehicles banned

Shutdown of 300 steel factories in the city of Tangshan (90 miles from Beijing)

Shutdown of 40 factories in the city of Tianjin (70 miles from Beijing)

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

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10

100

1000

10000

1976-1980

2006-2010

Health Effects of Fine Particles: Lines that Connect (Pope et Dockery 2006)

Mechanisms by which exposure to PM damages our health

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 después exposición 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

Total mortality and PM10 concentration vs timeBarcelona 2003-2004

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ay

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PM10

(ug/

m3 )

Death per day PM10 (ug/m3)

Mortalidad diaria y contaminación atmosfèrica: anàlisis de series temporales

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

10μg/m3 PM10 The European APHEA

Study

Katsouyanni et al, Epidemiology 2001; 12 (5): 521-

31

Cambridge1.ppt

0 1 2-1

Percent increase in mortality-1% 0% 1% 2%

Admisiones en urgencias por enfermedad pulmonar obstructiva crònica en función niveles diarios de

contaminación atmosférica en Barcelona Sunyer et al, Am J Epidemiol 1991

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Summer

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ly C

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erge

ncy

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sion

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Black Smoke concentrations in μg/m3 20 30 40 50 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)

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0,99

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1,01

1,02

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day

rela

tive

risk

ZurichBaselGeneva

Urban PM fractions and health effects Perez et al.2009

Odds ratio per 10 ug/m3*

Fraction 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

PM1 Not significant 1.028

(1.000-1.058) Lag1

1.063 (1.004-1.124)

Lag1

*Only maximum lag effect for tri-pollutant model presented

Oxford Street

Hyde Park sense tràfic

OXFORD STREET

REGEN

TSTREET

ORCH

ARDSTREET

OXFORD STREET

REGEN

TSTREET

ORCH

ARDSTREET

Efectos respiratorios de exposición al tráfico diesel en asmáticos (en Londres)

McCreanor et al, New England J Medicine 2007; 357:2348

Busos diesel per Oxford Street

Kensington Palace

Round Pond

The Serpentine

The Long Water

Old Police House & Rangers Lodge

WES

T CAR

RIAGE

DRIVE

SOUTH CARRIAGE DRIVE

NORTH CARRIAGE DRIVEPAR

K LANESubjects

enter here

Kensington Palace

Round Pond

The Serpentine

The Long Water

Old Police House & Rangers Lodge

WES

T CAR

RIAGE

DRIVE

SOUTH CARRIAGE DRIVE

NORTH CARRIAGE DRIVEPAR

K LANESubjects

enter here

La función pulmonar (FEV1) disminuie considerablement durante un paseo por la ruta

de los autobuses diesel (Oxford Street) McCreanor et al, NEJM 2007

Hyde Park

Oxford Street

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Hores (desde el inici de l’exposició)

% c

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o en

la F

EV1

p < 0,001

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 ‘Substantial evidence suggested that the

inflammatory processes associated with exposure to traffic pollutants contributed to an increase respiratory symptoms’

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 Children’s Health Study in 12 communities

Grade # Kids 1993 94 95 96 97 98 99 00 01 02 03 04

4th 1,759 10 18

7th 900 13 18

10th 900 16 18

4th 2,000 10 18

Lung development during 8 years NEJM 2004; 351:1057

big3dist

s(bi

g3di

st, 3

)

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-10

1

Distance to busy road 0 100 200 300 400 500 meters

Asth

ma

risk

RR=1.0

Southern California Association between residential distance to busy roads

and childhood asthma

McConnell et al, EHP2010

RR=1.4

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 (1.03-2.37) (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)

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Disability

Death

100% normal at age 20

Repeated FEV1 during 8 years in the CHS (Gauderman NEJM 2004; 351:1057)

PM2,5

% of persons at age 18 with FEV1 < 80% by PM2,5 (Gauderman, NEJM 2004)

Changes in ambient PM2.5 correlated with change in lung function development (FEV1)

Avol et al., Am J Respir Crit Care Med 2001

FEV1

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wth

rate

(m

l pe

r yea

r)

-40 -20 0 +20 +40 change in PM10 (μg/m3)

cleaner dirtier

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)

0 20 80 A

Disability

Death

100% normal at age 20

smoking

Annual mean PM10 and expiratory capacity (FVC) in the 8 SAPALDIA areas

Ackermann-Liebrich et al, AJRCCM 1997; 155 (1):122-129

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PM10 annual mean (µg / m3)

FVC

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© Nino li

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 li

EXPOSURE SURFACE, PM2.5

Home outdoor PM2.5 is associated with CIMT Künzli et al, Env Health Perspect 2005

35 30 25 20 15 10 0.9

1.0

1.1

1.2

1.3

• Portage, W • Topeka, KS

• Waterown, MA (Boston)

• Harriman, TN (Knoxville) • St. Louis, MO

• Stebenville, OH

Long-term mortality. 6 cities, Dockery 1993

EL ESTUDIO DE LAS 6 CIUDADES: PM2.5 –MORTALITAT (Dockery , NEJM 1993)

Bold: PM2.5 1974-89 Cursive: 1990-98

Mortalitat Cardiovascular en el seguiment de l’estudi 6-Cities Study

Laden et al, AJRCCM 2006

Diesel exhaust exposure chamber

Mills et al, New England Journal of Medicine, 2007 (13.Sept)

1 hora exposición en una cámara 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

5 10 15 20 25 30 35 5 7 9

11 13 15 17 19 21 23 25

Montana

Payerne Langnau

Rheintal

Biel

Lugano

Genf

Zürich Bern

Anières

PM10 µg/m3 Braun-Fahrländer; Am JRespir Crit Care Med 1997

Chronic cough and annual pollution in Swiss children 1993

Lugano

Geneve

Montana

Lugano Basel

Davos

1991 2002

PM10

ann

ual m

ean

PM decline in Swiss cities after traffic intervention 1993-2001

Anieres

BernBiel

Genf

Langnau

Lugano

Montana

Pay erneZuerich

-8-6

-4-2

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-20 -15 -10 -5 0Decline of PM10 between 1993 and 2001 in μg/m3

Across nine Regions of SwissSchool Children Study Change in prevalence vs change in PM10

Bayer-Oglesby et al., Env Health Perspect, 2005

Schindler et al. 2009

Reduction among adults Reduction of chronic cough-SAPALDIA

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

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Decrease in Mean Annual PM10 (µg/m3)

Mea

n A

nnua

l Dec

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in F

EV

1 (m

l/yr)

Prohibición del carbón en Dublín, 1990

Reduccció Fums negres: - 35.6 %

SO2: - 11.3%

Reducció Mort cardiovascular: - 10.3%

Mort respiratòria: -15.5%

valor mig

valor mig

4,4 /dia

3,8 /dia

Clancy et al., Lancet 2002 1991

Health benefits air pollution control (pubmed n=455)

• .

La normativa de la UE (NO2, PM10) i la salut

Nivell UE

Nivell OMS

Exposició actual mitjana anual

~50 µg/m3

40 µg/m3

20 µg/m3

-10 µg/m3

-30 µg/m3

Mortality WHO scenario

Indicator Mean (95% CI) % of total cases

(95% CI)

Deaths per year 3.500 (2.200-4.800) 12% (7%-16%)

Of which

Death due to acute exposure per year 520 (350-690) 2% (1%-2%)

Infant deaths per year 15 (7-22) 13% (6%-19%)

Morbidity per year WHO scenario

Indicator Mean (95% CI) % of total cases

(95% CI)

Respiratory

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%)

Hospitalizations

Respiratory causes 1.150 (630-1.670)) 3% (2%-5%)

Cardiovascular causes 620 (310-930) 2% (1%-3%)

Beneficis econòmics de reduir la contaminació atmosfèrica

(Euros/any)

PM1 composition in Barcelona (Pérez N, 2010)

Estimating impact of traffic exposure Population distribution from roads >10,000 vehicle/day

% de días que exceden los estándards de calidad del aire en Los Ángeles - 1976 a

2002

1976 1990 2002

75%

50%

25%

http://www.ersnet.org/publications/air-quality-and-health.html

• 20 països

• 40 àrees d’estudi

• 2008 - 2012

ESCAPE

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

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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 neuro-

cognitivo?

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.

jsunyer@creal.cat

Gràcies