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Effects and Impact
• Effects:
The health consequences of PM
• Impact
The sum of all effects in the population, given
the current pollution levels
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Studying Air Pollution Health Effects
is a Research Challenge
• Air pollution
• a complex mixture, not ONE substance
• low concentrations
• everybody is exposed
• Health outcomes
• Unspecific, no ‘air pollution disease’
• multi-causal, multi-pathway

EPIDEMIOLOGY
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Investigating Air Pollution
– With epidemiologic methods: difficult to
assess effects of single pollutants!
– We use single pollutants as indicators
of the mixture
– PM10 and finer particles: important
health relevant indicator !
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Long-term effects of air pollution
– Exposure over years or life-time
– Effects occur late (after years)
– Effects may be chronic
Requires mostly studies in very large
populations, observed over years
and decades !
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Typical Long-term effects of urban air
pollution
– Lower pulmonary function
– Chronic respiratory symptoms
increased
– Lung cancer
– Life expectancy decreased
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Lung Cancer and Traffic related Air Pollution in
Stockholm
Nyberg et al. (Epidemiology 2000; 11:487-957)
– All > 1’000 lung cancer cases, 1985-1990
– Residential exposure modeling for past 30 years
– NO2 as a surrogate for carcinogens from traffic
exhaust
Results:
–Those with lung cancer had higher 10-yrsexposure to traffic related air pollution
–highest exposure group, 20-30 years ago:
40% higher risk for lung cancer (95%CI:0-100%)
UN
Mortality (adjusted Relative Risk) and longterm mean pollution (PM2.5)
Harvard Six-City Cohort Study, Dockery et al, NEJM 1993; 329 (24):1753-9
Relative Risk
1.30
1.25
1.20
1.15
1.10
1.05
1.00
0
10
20
30
40
mean PM2.5
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Total Mortality: Smokers, Exsmokers, and Air Pollution
(Harvard Six City Cohort Study, Dockery et al, New Engl J Med 1993)
3
Relative Risk
2.5
2
1.5
1
0.5
0
Smoking
Ex-Smoking Air Pollution
Short-term effects of Air Pollution
Hospital admission
Emergency visits
Death counts,
Pollution
Time
Period of
exposure
Time to
event
Period of
events
SHORT PERIODS
SHORT PERIODS
Days or weeks
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Typical short-term effects
100%
90%
Death
80%
Hospital
70%
Emergency room
60%
Visit to the doctor
50%
40%
30%
20%
10%
Restricted activity
Medication
Symptoms
Reduced lung function, Disturbance
0%
Number of susceptible
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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 (g / m3)
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The APHEA 2 Study in Europe
Acute effects of particulate pollution on respiratory
admissions
(includes Milano and Roma)
Atkinson RW et al; Am J Respir Crit Care Med 2001; 164 (10): 186066)
% change per 10 g/m3 increase in PM10
(fixed effects single pollutant model)
Asthma, age 0-14:
+1.2% (0.2-2.3)
Asthma, age 15-64:
+1.1% (0.3-1.8)
COPD + asthma, 65+ yr +1.0% (0.4-1.5)
All respiratory, 65+
+0.9% (0.6-1.3)
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The MISA Study – an italian example for shortterm effects of air pollution
Torino, Milano, Verona, Ravenna, Bologna, Firenze, Roma, Palermo
Biggeri et al; Epidemiologia & Prevenzione 2001; 25(2)
% change (and 95th CI) per 10 g/m3 increase in
PM10
(random effects model)
Total daily mortality:
+1.27% (0.62-1.92)
Hospital Admissions:
–Cardiac diseases
+1.15% (0.62-1.68)
–Respiratory diseases +2.41% (1.72-3.11)
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Annual Cases (and %) attributed to Air Pollution
Austria, France, and Switzerland (>50% are traffic related)
Outcome
Death (adults 30 yrs.)
Hospital Admissions
(cardio-respiratory causes)
Chronic Bronchitis
(incidence in adults)
Bronchitis Episodes
(children)
Restricted Activity
Days (adults)
Asthma attacks
Cases
Attribut. %
40‘600
~6 %
(24‘600-56'900)
48’000
(17’300–79’100)
47'100
(4’300-93'500)
543'000
(239’500-981'600)
30.5 mill.
(25.7-37.3 mill)
~2%
~ 12 %
~ 30 %
~ 12 %
1.04 mill.
(0.54–1.54 mill.)
Künzli et al, Lancet 2000; 356: 795-801
~6%
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Impatto del PM10 in tre studi:
3 nazioni, Tirolo, 8 città italiane
A/F/CH
Südtirol
8 Città
24 g/m3
15-20 g/m3
~50 g/m3
Mortalità
6%
3-5 %
2-8 %
Ammissioni osp. (cardio-
2%
1-2 %
2-4 %
12%
7-11 %
2-22 %
30%
17-28 %
18-33 %
Giorni con attività
ridotta
12%
6-11 %
13-16 %
Attachi d‘asma
6%
3-5 %
8-9 %
Concentrazione media
resp)
Bronchite chronica
Bronchite (bambini)
Conc. di riferimento 7.5 g/m3 30 g/m3
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Effects of PM10 on daily respiratory admissions (age 65+) are
stronger on days with high ozone
Atkinson et al, APHEA 2
(Am J Respir Crit Care Med 2001; 164 (10): 1860-66)
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Aumento percentuale della
mortalità giornaliera (e limiti di
confidenza al 95%) associato
ad un aumento di 10μg/m3 nel
livello di PM10
Dati dello studio Europeo
APHEA
-1%-1
Percent increase in m ortality
0%
0
1%
1
2%
2
Katsouyanni et al,
Epidemiology 2001; 12 (5): 52131
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Epidemiologic (hospital admiss. in children, pneumonia),
toxicological and human broncho-alveolar effects of PM10 in
120 the Utah Valley, with Steal mill on/off/on
PM10
40
20
0
Neutrophils in BAL
Proteins in BAL
IL-8 in BAL
% of 1986 60
Pneumonia
80
Total cells (rat)
100
Steal mill ON (1986) Steal mill OFF (1987) Steal mill ON (1988)
Epidemiology: Pope et al, Arch Env Health, 1991;46:
90
Toxicology:
Dye et al, Env Health Perspect, 2001; 109 (suppl
3):395
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Human Experiment: Ghio & Devlin, Am J Respir Crit Care Med, 2001; 164:704
Do these small effects matter ?
Che cosa è l‘impatto di questi effetti piccoli?
% increase (and 95% CI) per 10 g/m3 change in PM10
Mortality
4.3 % (2.6-6.1)
Hospital admissions (cardio-resp.)
1.3 % (0.1-2.5)
Chronic bronchitis (adults)
9.8 % (0.9-19.0)
Bronchitis episodes (children)
Restricted activity days
Asthma attacks (children & adults)
30.6 % (13.5-50.2)
9.4 % (7.9-10.9)
4.0 % (1.9-6.2)
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Inquinamento atmosferico
Effetti a breve termine sulla salute dell’uomo
% increase (and 95% CI) per 10 g/m3 change in PM10
 Mortality
4.3 % (2.6-6.1)
 Hospital admissions (cardio-resp.)
1.3 % (0.1-2.5)
 Chronic bronchitis (adults)
9.8 % (0.9-19.0)
 Bronchitis episodes (children)
30.6 % (13.5-50.2)
 Restricted activity days
9.4 % (7.9-10.9)
 Asthma attacks (children & adults)
4.0 % (1.9-6.2)
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Fonte: ARPA
Fonte: ARPA
Fonte: ARPA
Air pollution related health costs (EUROs)
per capita
~600 EUR per persona, all‘anno
Sommer et al, OECD Report, 2000
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Inquinamento atmosferico
Costi correlati agli effetti sulla salute dell’uomo
~600 Euro per persona all‘anno
(Sommer et al, OECD Report, 2000)
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Conclusion
• Air pollution has adverse effects on
health
• Evidence is strongest for short-term
effects; long-term effects should be better
investigated, in Europe
• PM’s are an important aspect of air
pollution, but other pollutants and the
mixture may be relevant, too
• The impact on public health is
substantial, in Italy and Europe
• Some ‘experimental evidence’ that
improvements in air quality lead to health
benefits very fastly (short-term effects)
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