From toxic emissions to health effectsFrom toxic emissions to health effects… …

Health effects of air pollution Health effects of air pollution in Krakow populationin Krakow populationResults of epidemiological Krakow studyResults of epidemiological Krakow study

Krystyna Szafraniec, Agnieszka Kiełtyka, Marta RzepeckaKrystyna Szafraniec, Agnieszka Kiełtyka, Marta Rzepecka

Nikolaos Stilianakis, Yoannis DrossinosNikolaos Stilianakis, Yoannis Drossinos

Anette Borowiak, Luisa Marelli, Herdis Laupsa, Robert PiątekAnette Borowiak, Luisa Marelli, Herdis Laupsa, Robert Piątek

Joanna Niedziałek, Jose JimenezJoanna Niedziałek, Jose Jimenez

BackgroundBackground

Human responses to air Human responses to air pollutantspollutants

ExposureExposure Health outcomeHealth outcome

Confounding factorsConfounding factors

Short-termShort-term AcuteAcute

Long termLong term Chronic Chronic

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BackgroundBackground

Air pollution health effects pyramidAir pollution health effects pyramid

adapted from WHO

BackgroundBackground

1. While exposure is common, the risk tend to be low

2. Misclassifaction of exposure - personal exposure to air pollution differ substantially from ambient data

3. Exposure is multifactorial

4. Adverse health effects of environmental pollutants are generally nonspecific

Difficulties in air pollution epidemiology:Difficulties in air pollution epidemiology:

BackgroundBackground

How big is particular health How big is particular health problem?problem?

Measures of risk:

RR (relative risk), β-coefficient

Attributable Proportion

AimAim

To investigate the health effect caused by particulate matter air pollution in adult population with special attention given to the indoor exposure related to type of apartment’s heating

Study Study DesignDesign

Type of investigation:eepidemiological cross-sectional studypidemiological cross-sectional study

Sampling method: purposive sampling based on exposure status

(type of apartment’s heating system)

Research tools: structured questionnaires onstructured questionnaires on - personal characteristics - health status - daily activity - housing conditions lung functions measure by spirometry testslung functions measure by spirometry tests

Study Study DesignDesign

Health outcomes: • general health status measured by no. of chronic conditions and SF-36 questionnaire • symptoms and diseases of respiratory system (chronic cough, chronic bronchitis, asthma, allergy) • functional status of the lung (FVC, FEV1, PEF,…)

Indicators of exposure:Indoor air pollution:Indoor air pollution:

• measurements of indoor air quality (20 apartments)• type of apartment’s heating system (coal stoves vs. central heating)• gas appliances• indoor environment (ETS,dampness, pets)

Outdoor air pollution:Outdoor air pollution:• on site measurements of outdoor PM10 for 20 apartments• modelled ambient air quality (PM10) in other apartment’s locations

Study ParticipantsStudy Participants

I I 97 97 196 196 IIII 22 22 45 45 IIIIII 11 11 22 22 IVIV 14 14 32 32 VV 9 9 21 21 VIVI 9 9 20 20 VIIVII 4 4 10 10 VIIIVIII 11 11 28 28 IXIX 4 4 7 7 XX 4 4 13 13 XIXI 30 30 70 70 XIIXII 12 12 26 26 XIIIXIII 50 50 96 96 XIVXIV 3 3 7 7 XVXV 8 8 20 20 XVIXVI 10 10 19 19 XVIIXVII 1 1 4 4XVIIIXVIII 9 9 21 21

TotalTotal 308 308 657657

82% of coal heated apartments 82% of coal heated apartments was located in the districts I and was located in the districts I and

XIIIXIII

District Apartments SubjectsDistrict Apartments Subjects

Characteristics of the study populationCharacteristics of the study population

Gender

55.344.7

0 10 20 30 40 50 60 70 %

MalesFemales

Education

19.9

42.0

21.9

16.2

universityhighvocationalprimary

Occupational status16.0

24.0

7.614.0

13.4

12.2

12.8

blue collarwhite collarstudentretiredpensionerunemployedother

Age

12.553.2

34.4

0 10 20 30 40 50 60 70 %

<3535-65>65

Home environment (1)Home environment (1)

Central heatingCoal stoves

Gas stoveElectric applianceMunicipal supply

Home environment (2)Home environment (2)

Environmental Tobacco Smoke

Regular smoking in 174 (56.5%) apartments

147 (37%) non-smoking persons is exposed to ETS in their own 147 (37%) non-smoking persons is exposed to ETS in their own apartments ! !apartments ! !

Respiratory symptomsRespiratory symptoms

17.8

13.2

13.5

11.1

9.6

7.8

0.0 5.0 10.0 15.0 20.0

Chronic cough

Chronic phlegm

Wheezing

Breathlessnessduring the day

Chronicbronchitis

Asthma

%

Reported prevalence (%) of respiratory symptoms

Which of the symptoms are caused by PM pollution?Which of the symptoms are caused by PM pollution?

General health status (1)General health status (1)

13.2

29.9

56.9

34.3

41.7

24

0.0

10.0

20.0

30.0

40.0

50.0

60.0

Excellent/ very good Good Fair/ Poor

%

Coal stoves

Central heating

Subjective evaluation of health statusSubjective evaluation of health status

OR=3.2, 95%CI: 2.1-4.8, pOR=3.2, 95%CI: 2.1-4.8, p << 0.001 0.001 adjusted for age, gender, education, smoking

General health status (2)General health status (2)

Chronic conditionsChronic conditions OROR 95%CI95%CI1 Chronic respiratory diseases 1.4 0.8 – 2.5

2 Hypertension 1.4 0.8-2.0

3 Serious disease such as cancer 1.7 0.8-2.2

4 Peptic or duodenal ulcer or serious intestinal disorders for at least 3 mo.

1.7 1.04-2.7

5 Liver diseases, bile stones or cholecystitis (excluding tumors)

1.6 0.94-2.6

6 Diabetes 1.6 0.7-3.5

7 Thyroid diseases 2.3 1.1-4.8

8 Diseases of nervous system 3.4 1.4-8.4

9 Persisting back pain for at least 3 months or hernia (excluding possible spine ostheoporosis)

1.3 0.9-2.1

10 Rheumatism or other arthralgia (including arthritis or other serious bone diseases)

1.9 1.2-3.0

11 Migraine or other chronic pain in a head

1.4 0.9-2.2

12 Atopic dermatitis or eczema 0.5 0.3-1.1adjusted to age, gender, education, smoking

Exposure AssessmentExposure Assessment

Indoor air pollutionIndoor air pollution• type of heating (coal vs. non-coal)• time span of burning coal (in minutes)• time span of cooking on a gas stove (in minutes)• ETS• estimated indoor concentration based on statistical model derived from indoor-outdoor measurements campaign

Outdoor air pollutionOutdoor air pollution• outdoor concentration based on modelled PM10 data for apartment locations on ‘average winter day’

winter PM10 average: 42.7 winter PM10 average: 42.7 µµg/mg/m33 (SD (SD 30.6) 30.6)

Chronic coughChronic bronchitis

RR 95%CI p RR 95%CI p

Type of heating

0-central1-coal

1.88 (1.1-3.32) 0.023 2.24 (1.05-4.75) 0.036

Stove doors kept open

No exposure

1.0 1.0

<60 min

1.22(0.53-2.79)

0.631 1.88 (0.66-5.12) 0.235

>60 min

2.12(1.20-

3.72)0.009 2.35 (1.08-5.54) 0.031

Using gas oven

0-no, 1-yes1.30

(0.81-2.06)

0.272 2.07 (1.13-3.76) 0.017

Multivariate logistic regression models on respiratory Multivariate logistic regression models on respiratory symptoms and some indoor sources of air pollutionsymptoms and some indoor sources of air pollution

adjusted to age, gender, education, smoking habit

Indoor – respiratory Indoor – respiratory symptomssymptoms

Multivariate regression models on Multivariate regression models on spirometryspirometry measurements measurements and some indoor sources of air pollutionand some indoor sources of air pollution

1/ Dummy variable: 0 vs. <60min, 0 vs. >60 min Adjusted for age, gender, education, BMI, height, occupational exposure

Indoor – spirometry (1)Indoor – spirometry (1)

FVC FVC <70%expected

95%CI p RR 95%CI p

Heating0-central1-coal

-0.08 -0.21; 0.050.23

51.36 0.87; 2.14

0.175

Stove doors kept open1

<60 min

-0.11 -0.30; 0.090.28

81.86 0.98; 3.52

0.057

>60 min

-0.07 -0.21; 0.070.32

21.22 0.76; 1.98

0.406

Cooking on gas oven (10 min.interval)

-0.01 -0.3; 0.010.34

51.07 1.01; 1.14

0.028

Multivariate Multivariate linear linear regression models on regression models on spirometryspirometry measurements measurements and some indoor sources of air pollutionand some indoor sources of air pollution

1/ Dummy variable: 0 vs. <60min, 0 vs. >60 min Adjusted for age, gender, education, BMI, height, family history of asthma, occupational exposure

Indoor – spirometry (2)Indoor – spirometry (2)

PEF PEF%

95%CI p RR 95%CI p

Heating0-central1-coal

-20.2 -37.1; -3.30.019

-3.8 -7.4; -0.30.035

Stove doors kept open1

<60 min

-5.19 -30.2;-19.8 0.68 0.47 -4.8; 5.70.861

>60 min

-25.4 -43.3; -7.3 0.006

-5.2 -9.0;-1.50.006

Stove doors kept open (continuous with 10 min unit of time)

-1.1 -2.1; -0.060.034

-0.26 -0.5; -0.030.024

Outdoor modelled PM10 exposure & respiratory Outdoor modelled PM10 exposure & respiratory symptomssymptoms

0

0.05

0.1

0.15

0.2

0.25

0.3

Chronic cough Chronic phlegm Chronicbronchitis

40 - 49.9 50 -59.9 60 - 69.9 70+

Proportion of chronic cough, phlegm and bronchitis according to modelled PM10

exposure levels

adjusted to type of heating system, age, gender, smoking status, occupational exposure and educational level

Outdoor modelled PM10 exposure & spirometryOutdoor modelled PM10 exposure & spirometry

80

85

90

95

100

40 - 49.9 50 -59.9 60 - 69.9 70+

Means of Peak Expiratory Flow as percent of predicted values according to modelled PM10 exposure levels

PEF%

adjusted to type of heating system, age, gender, smoking status, occupational exposure, educational level and family history of asthma

Outdoor modelled PM10 exposure & indoor heatingOutdoor modelled PM10 exposure & indoor heating

Proportion of respiratory symptoms according to type of heating system

adjusted to PM10 level, age, gender, smoking status, occupational exposure and educational level adjusted to PM10 level, age, gender,

smoking status, occupational exposure, educational level and family history of asthma

Means of Peak Expiratory Flow as percent of predicted values according to type of heating

system

Population Attributable ProportionPopulation Attributable Proportion

Risk attributed to PM10 Risk attributed to PM10 greater than 50greater than 50g/mg/m3 3

in population of Krakówin population of Kraków

Risk attributed to using Risk attributed to using coal-burning stovescoal-burning stoves

in population of Krakówin population of Kraków

Distribution of PM10 - Winter 2004/2005

02468

1012141618

Exposure categories (µg/m3)

Num

ber

of d

ays

Health Impact AssessmentHealth Impact Assessment

Winter 2004/2005: 1.12.2004-31.03.2005: 122 122 daysdays

Minimum 13

Percentile 5 23

Percentile 25 42

Median 70

Percentile 75 114

Percentile 95 190

Percentile 98 267

Maximum 414

Daily mean 88

Standard error 67

PM10 distribution:PM10 distribution:

119 days PM10 > 20 µg/m3

79 days PM10 > 50 µg/m3

Health Impact AssessmentHealth Impact Assessment

Winter 2004/2005: 1.12.2004-31.03.2005: 122 122 daysdays

Hospital admissions from respiratory conditions (ICD10: J00-J99)Hospital admissions from respiratory conditions (ICD10: J00-J99)

Age: 15 and aboveAge: 15 and above

2614 cases

≈ 22 cases daily

How many cases is attributed to air How many cases is attributed to air pollution ?pollution ?

Distribution of daily PM10 levels and associated respiratory admissions (%)

Health Impact AssessmentHealth Impact Assessment

How many cases is attributed to air How many cases is attributed to air pollution ?pollution ?

Short-term effects of PM10 on rShort-term effects of PM10 on respiratory admissionsespiratory admissions

Number of attributable cases for different scenarios of PM10 reduction

HIA findingsHIA findings

 Scenario: all daysall days NAC 95% CI

above 20 above 20 µµg/mg/m33 to 20 to 20 µµg/mg/m33

180.6 95.7 271.7

above 50 above 50 µµg/mg/m33 to 50 to 50 µµg/mg/m33

113.0 60.0 169.5

7%7%

4.34.3%%

The Study was partially done in the

Chair of Epidemiology and Preventive Medicine of the Jagiellonian University Medical College

and is continued in

Epidemiology and Population Studies DepartmentInstitute of Public Health of the same University

contact: dr Krystyna Szafraniec mygomola@cyf-kr.edu.plmygomola@cyf-kr.edu.pl