Pollution and urbanization: effects on respiratory health

Catherine H. Miele, MDJohns Hopkins Pulmonary and Critical Care

chooper5@jhmi.edu

Disclosures

• No relevant disclosures

Outline

• Background:

– Air pollution and respiratory health

• Our studies in Peru

– COPD

– Chronic Bronchitis

Pollution in urban centers

Components of air pollution• Particulate matter• Sulfur oxides• Oxidants (ozone)• Carbon monoxide• Hydrocarbons• Nitrogen oxide• Lead • Heavy metals• Plastic debris

Size classification of particulate matter

Brooke et al Circulation 2004

UPPER AIRWAYSCoarse particles (10 um)

AlveoliFine particles (1 um)

Alveoli

Ultrafine particles (100 nm)

LOWER AIRWAYFine particles (2.5 um)

Air pollution and respiratory disease

Rice et al AJRCCM 2014

Traffic related pollution is associated with worse baseline lung function

Air pollution and respiratory disease

Rice et al AJRCCM 2014

Traffic related pollution is associated accelerated lung function decline

CRONICAS Cohort Study

• Longitudinal, population based

• Age and sex-stratified, adults ≥35y

• Excluded: pregnancy, active TB

PERU

COLOMBIA

BRAZIL

BOLIVIA

ECUADOR

Lima

0 mPuno

3825 m

Sites

Tumbes

0 m

Lima (Urban) Puno (Urban)

Tumbes (Semi-urban) Puno (Rural)

Methods

• Collected demographics, past medical history, family history, respiratory symptoms, smoking, biomass fuel use

• Spirometry

• Prevalence of COPD: FEV1/FVC < 70%

• Prevalence of Chronic Bronchitis base on:

– cough and phlegm production

12

COPD and Chronic Bronchitis

Prevalence in Peru

Miele et al COPD 2015

Risk Factors for COPD

across all sites in women (N=1487)

Prevalence ratio 95% CI P

Age per 10 years 2.51 1.86-3.38 <0.001

High altitude vs. sea-level 1.44 1.05-1.99 0.02

Smoking per 10 pack years 2.39 0.59-9.63 0.22

Post-treatment pulmonary tuberculosis 7.02 3.63-13.59 <0.001

Asthma 2.30 1.12-4.72 0.02

Urbanization

Urban 1.00

Semi-Urban 0.66 0.53-0.82 <0.001

Rural 1.71 1.47-1.99 <0.001

Biomass use at least once daily 2.22 1.02-4.81 0.04

Wealth Index

Low 1.00

Middle 1.78 0.52-6.00 0.36

High 1.44 0.54-3.86 0.47

Risk Factors for COPD across all sites in

men (N=1443)` Prevalence ratio 95% CI P

Age per 10 years 1.65 1.42-1.92 <0.001

High altitude vs. sea-level 1.13 1.06-1.21 <0.001

>10 pack-years of smoking 1.80 1.40-2.32 <0.001

Post-treatment pulmonary tuberculosis 3.12 2.02-4.83 <0.001

Asthma 2.16 1.11-4.23 0.02

Urbanization

Urban 1.00

Semi-Urban 0.52 0.43-0.64 <0.001

Rural 1.01 0.74-1.37 0.97

Biomass use at least once daily 1.08 0.55-2.11 0.82

Wealth Index

Low 1.00

Middle 1.02 0.69-1.52 0.91

High 0.68 0.39-1.19 0.18

Population Attributable Risks - Lima

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

TB Asthma Biomass FuelUse Daily

Smoking atleast 10 pack

years

PA

R

Men

Women

Jaganath et al Respiratory Research 2015

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

TB Asthma Biomass FuelUse Daily

Smoking atleast 10 pack

years

PA

R

Men

Women

Jaganath et al Respiratory Research 2015

Population Attributable Risks – Rural Puno

Risk factors associated with chronic bronchitis (N=2,947)

Odds ratio 95% CI P

Age per 10 years 1.23 1.09-1.40 0.001

Gender male vs. female 1.28 0.94-1.75 0.13

Hypertension 1.15 0.79-1.69 0.45

BMI ≥ 25 kg/m2 1.02 0.72-1.44 0.91

Asthma 2.99 1.81-4.56 <0.001

Post-treatment tuberculosis 1.74 0.95-3.20 0.08

Smoking per 10 pack years 0.86 0.61-1.23 0.42

Air pollution exposure

Daily biomass fuel use 2.00 1.30-3.07 <0.01

Urban dwelling 3.34 2.18-5.11 <0.001

High Wealth Index 0.83 0.59-1.17 0.29

High altitude 1.39 1.00-1.92 0.05

Miele et al COPD 2015

Urbanization accelerates lung function declineFEV

1 FVC

High altitude

Urbanization

BMI (IQR)

Chronic bronchitis

Hypertension

Biomass

Smoke

-6 -4 -2 0 2 -6 -4 -2 0 2

Miele et al unpublished

Change per year (𝑚𝐿/𝑚2

𝑦𝑟)

Summary

• Pollution is one of many risk factors contributing to poor health in urban slums

• There is strong data that indoor and outdoor air pollution directly affect lung disease

Air pollution and risk for heart disease

Evaluating pollution and markers for cardiovascular disease

• Framingham Offspring and Third Generation Cohorts

• 5,112 participants (2,731 (53%) women, mean age 49±14 years).

• Higher average PM2.5 exposure was associated with increased markers of cardiovascular disease.

Wilker EH et al AJC 2014

Air pollution and risk for heart disease

• Decreased markers of cardiovascular risk with increased distance from major road.

• Decreased markers of cardiovascular risk with decreased PM2.5 exposure

Wilker EH et al AJC 2014