The Health Effects of Air PollutionAsian Science in a Global Context

“PAPA Program”

Robert O’Keefe, Vice PresidentRobert O’Keefe, Vice PresidentHealth Effects InstituteHealth Effects Institute

CAI-Asia China Project Inception Workshop CAI-Asia China Project Inception Workshop Beijing, ChinaBeijing, ChinaOctober, 2005October, 2005

The Health Effects of Air Pollution: Asian Science in a Global Context

• Health Effects InstituteHealth Effects Institute• A brief introduction A brief introduction

• Health Burden of Air Pollution in Asia Health Burden of Air Pollution in Asia • ““PAPA” Program – Chinese Studies PAPA” Program – Chinese Studies • Key Pollutants and Health Effects Key Pollutants and Health Effects • Health Benefits of Interventions Health Benefits of Interventions • Priority PollutantsPriority Pollutants

The Health Effects Institute

• Founded in 1980 to provide impartial, high-quality science Founded in 1980 to provide impartial, high-quality science on health effects of air pollutionon health effects of air pollution

• Joint and balanced core funding fromJoint and balanced core funding from• Government (U.S. EPA)Government (U.S. EPA)• Industry (28 worldwide auto)Industry (28 worldwide auto)• Also partnerships with CAI-Asia, WHO, CARB, Vietnam Also partnerships with CAI-Asia, WHO, CARB, Vietnam

Government, Oil, Chemical industry, Hewlett foundation, othersGovernment, Oil, Chemical industry, Hewlett foundation, others

• Independent Board and Expert Science Committees Independent Board and Expert Science Committees oversee and review all researchoversee and review all research

• High level international experts (China India Thailand)High level international experts (China India Thailand)• Over 250 studies, scientific reviews, reanalysis Over 250 studies, scientific reviews, reanalysis

• Relevant to regulationRelevant to regulation• North & South America, Europe, Asia North & South America, Europe, Asia • CO, particulate matter, ozone, SO2, NO2, diesel exhaust, CO, particulate matter, ozone, SO2, NO2, diesel exhaust,

benzene, butadiene, manganese, metals, MTBE, others benzene, butadiene, manganese, metals, MTBE, others

The Problem: Air Pollution in Asia: High Levels in Many Cities (2000-2001)

Source: Benchmarking Report on Air Quality in Asian cities Stage 2, 2004 (forthcoming)

SPM Limit = 90 µg/m3 (WHO, 1979)

0

50

100

150

200

250

300

350

400

Bangk

ok

Busan

Chong

qing

Colom

bo

Hong

Kong

Jaka

rta

Kolkat

a

Man

ila

Mum

bai

New D

elhi

Osaka

Pune

Singap

ore

Seoul

Shang

hai

Tokyo

con

cen

trat

ion

in

µg

/m3

SO2 NO2 SPM PM10

PM10 Limit = 50 µg/m3 (USEPA, 1997)

SO2 Limit = 50 µg/m3 (WHO, 1999)

NO2 Limit = 40 µg/m3 (WHO, 1999)

Excess Deaths from Selected Environmental Factors

(WHO Global Burden of Disease)

Particular Challenge: Many Sources of Air Pollution in Asia

• CombustionCombustion• Agricultural burningAgricultural burning• Brick KilnsBrick Kilns• VehiclesVehicles• Trash burningTrash burning• FactoriesFactories• Power generationPower generation• Cooking in slumsCooking in slums• Other area sourcesOther area sources

• Non-CombustionNon-Combustion• Agricultural cultivationAgricultural cultivation• Street sweepingStreet sweeping• Windblown sandWindblown sand• Unpaved roadsUnpaved roads• Paved roads (asbestos, Paved roads (asbestos,

rubber etc)rubber etc)• ConstructionConstruction

Health Effects

• Different Pollutants have Different EffectsDifferent Pollutants have Different Effects

• Carbon Monoxide - circulatory system, heartCarbon Monoxide - circulatory system, heart• Ozone - respiratory system, lungOzone - respiratory system, lung• Lead - nervous system, brainLead - nervous system, brain• PM - lung, potential effects on heartPM - lung, potential effects on heart• Diesel Exhaust - PM contributor, respiratory, cancer Diesel Exhaust - PM contributor, respiratory, cancer • Sulfur Dioxide – impaired respiratory function, PM ContributorSulfur Dioxide – impaired respiratory function, PM Contributor• Nitrogen Dioxide – lung irritant. ozone contributorNitrogen Dioxide – lung irritant. ozone contributor• Air Toxics – cancer, reproductive, neurotoxic Air Toxics – cancer, reproductive, neurotoxic • There are potential effects of the mixtureThere are potential effects of the mixture

• Carbon Dioxide and Carbon Particles - climate changeCarbon Dioxide and Carbon Particles - climate change

PAPA Program• Partnership with CAI-ASIAPartnership with CAI-ASIA to understand & communicate the health effects of to understand & communicate the health effects of

air pollution in Asiaair pollution in Asia• Published Published Scientific ReviewScientific Review and and Meta AnalysisMeta Analysis of what is known today of what is known today

about health effects in Asian citiesabout health effects in Asian cities• New! Periodic New! Periodic updating compendium of Asian studiesupdating compendium of Asian studies (140-+260) (140-+260) • Series of epidemiological studiesSeries of epidemiological studies in 8 Asian cities in 8 Asian cities

• Understand local impactUnderstand local impact• Combine to provide Asia-wide understandingCombine to provide Asia-wide understanding

• Regular CommunicationRegular Communication of results to policy makers of results to policy makers • Build capacityBuild capacity of local scientists of local scientists• Publish a CPublish a Comprehensive Assessmentomprehensive Assessment of the state of air pollution and of the state of air pollution and

health across Asian cities health across Asian cities • Initiate new science to Initiate new science to understand intersection of poverty air pollution understand intersection of poverty air pollution

and healthand health

• Overall Goal:Overall Goal:• Quality science to inform key Asian regulatory & policy decisionsQuality science to inform key Asian regulatory & policy decisions

PAPA Literature Review: PAPA Literature Review: Health Effects of Outdoor Air Health Effects of Outdoor Air Pollution in Developing Countries of AsiaPollution in Developing Countries of Asia

• Systematic identification of 140 peer-Systematic identification of 140 peer-reviewed Asian studies 1980-2003 (over reviewed Asian studies 1980-2003 (over 60 from China) 60 from China)

• Special focus on studies of daily changes Special focus on studies of daily changes in air pollution and healthin air pollution and health

• Conduct first ever Asian meta analysis” Conduct first ever Asian meta analysis” 28 “time series” studies evaluated in 28 “time series” studies evaluated in depth effects in Asia and to assess depth effects in Asia and to assess relative to Westrelative to West

• Identify knowledge gaps to guide future Identify knowledge gaps to guide future research research

• Now being updated with many recent Now being updated with many recent studies, made web accessible,studies, made web accessible,

Epidemiologic Studies of Air Pollution in Asia 1980–2003

Tokyo (5)

Kuala Lampur (1)

Jakarta (2)

Hong Kong (16)

Seoul (9)

Singapore (5)

Delhi (5)

Mumbai (5)(Bombay)

Chongqing (3)

Beijing (11)

Shenyang (4)

Taiwan (28)

Bangkok (6)

Datong (2)

Osaka (1)

Guangzhou (2)

Shanghai (2)

Chang Mai (1)

Chandigarh (1)

Lanzhou (1)

Wuhan (1)

Inch’on (2)

Semarang (1)

Yokohama (1)

Lucknow (1)

Tripura (1)

Kushiro (1)

Chiba (1)

Ulsan (2)

PAPA Studies in China -Literature Review-Current Analyses in Chinese Cities

Literature Review: China Studies

• Seventy-eight studies in mainland, Hong Kong, and Taipei, China- Seventy-eight studies in mainland, Hong Kong, and Taipei, China- range of pollutants \ effectsrange of pollutants \ effects• 26 cross-sectional26 cross-sectional

• 34-4000 subjects: infants, children, adults34-4000 subjects: infants, children, adults• TSP, PMTSP, PM1010, SO, SO22, NOx, CO, NOx, CO• Acute and chronic respiratory illness, lung functionAcute and chronic respiratory illness, lung function

• 20 time series20 time series• 1,000-millions of subjects1,000-millions of subjects• Total and cause-specific mortality, unscheduled hospital visits, hospital Total and cause-specific mortality, unscheduled hospital visits, hospital

admission, sudden infant death admission, sudden infant death • TSP, SOTSP, SO22, PM, PM1010 /PM /PM2.52.5

• 11 cohort / 3 panel11 cohort / 3 panel• 20- thousands of subjects20- thousands of subjects• Birth outcomes, serum CO, lung function, respiratory symptoms, illness-Birth outcomes, serum CO, lung function, respiratory symptoms, illness-

related school absencerelated school absence• 7 case-control7 case-control

• Urban, occupational smoke, industrial pollutionUrban, occupational smoke, industrial pollution• Birth outcomes, lung cancerBirth outcomes, lung cancer

NEW: PAPA Review Updated, Extended

• PAPA Review extended to include 2003-2005 PAPA Review extended to include 2003-2005 and additional early studies and additional early studies

• Refined search methods yieldRefined search methods yield doubledouble number of Asian studies (130-260) number of Asian studies (130-260)

• Chinese studies increase from 36 to 74Chinese studies increase from 36 to 74• HEI web-based comprehensive study HEI web-based comprehensive study

summary, statistics and citation underwaysummary, statistics and citation underway• New analyses of data plannedNew analyses of data planned• New resource for policy makers in early 2006New resource for policy makers in early 2006

New PAPA Studies: China

Daily MortalityDaily Mortality• Hong Kong SARHong Kong SAR

• 1996-2002)1996-2002)• ShanghaiShanghai

• 2002-20052002-2005• WuhanWuhan

• 7/2000-6/20047/2000-6/2004

Pilot CohortPilot Cohort• GuangzhouGuangzhou

• 2004 2004

Combined analysis to provide Asia profileCombined analysis to provide Asia profile

Hong Kong Time-Series Study

• Team: Dr. CM Wong, Hong Kong UniversityTeam: Dr. CM Wong, Hong Kong University• Population sizePopulation size

• 6.8 million6.8 million• Major Pollutants & SourcesMajor Pollutants & Sources

• PM, SOPM, SO22, NOx, NOx• Traffic (vehicle, marine vessel, aircraft), industry, power Traffic (vehicle, marine vessel, aircraft), industry, power

generation, generation, • Data sourcesData sources

• Daily monitored PMDaily monitored PM1010, SO, SO22, NO, NO22, 8-hr O, 8-hr O33

• Health data: total and cause-specific mortality, hospital Health data: total and cause-specific mortality, hospital admissionadmission

• Temperature, humidity, holidays, etc.Temperature, humidity, holidays, etc.• EndpointsEndpoints

• Common: Daily deaths Common: Daily deaths • Unique: Tuberculosis & Impact of pollution interventionUnique: Tuberculosis & Impact of pollution intervention

Shanghai Time-Series Study

• Team: Dr. HD Kan, Fudan UniversityTeam: Dr. HD Kan, Fudan University• Period: 2002-2005Period: 2002-2005• Population sizePopulation size

• Total 16.7 million, including 7million in urban area and 4 million mobile Total 16.7 million, including 7million in urban area and 4 million mobile populationpopulation

• Major pollutants and sourcesMajor pollutants and sources• PM, SOPM, SO22, NOx, NOx• Traffic (vehicle), industry, power generation, home fuel useData Traffic (vehicle), industry, power generation, home fuel useData

sourcessources• Pollutant data: Pollutant data:

• daily PMdaily PM1010, SO, SO22, NO, NO22, O, O33, PM, PM2.52.5

• Health data: total and cause-specific mortalityHealth data: total and cause-specific mortality• Weather, influenza etcWeather, influenza etc

• Endpoints:Endpoints:• Common: Daily mortalityCommon: Daily mortality• Unique: Aged local population, large mobile population, rapid increase Unique: Aged local population, large mobile population, rapid increase

of motor vehicleof motor vehicle• Increased cardiac, cancer and respiratory diseases death Increased cardiac, cancer and respiratory diseases death

Wuhan Time-Series Study

• Team: Dr. ZM Qian, Penn State UniversityTeam: Dr. ZM Qian, Penn State University• Period: 7/2000-6/2004Period: 7/2000-6/2004• Population sizePopulation size

• 7.5 million including 4.3 million in urban area7.5 million including 4.3 million in urban area• Major pollutants and sourcesMajor pollutants and sources

• PM, SOPM, SO22, NOx, NOx• Traffic, coal burning, industryData sourcesTraffic, coal burning, industryData sources

• Pollutant data: Pollutant data: • daily PMdaily PM1010, SO, SO22, NO, NO22, O, O33

• Health data: total and cause-specific mortalityHealth data: total and cause-specific mortality• EndpointsEndpoints

• Common: Daily MortalityCommon: Daily Mortality• Unique: Temperature extremes & well distributed SES group Unique: Temperature extremes & well distributed SES group

among study subjects among study subjects

Coordinated Time-Series Analysis

• ObjectivesObjectives

• Develop a common protocol for study design and data analysis Develop a common protocol for study design and data analysis across the citiesacross the cities

• Conduct coordinated analyses for common exposure and health Conduct coordinated analyses for common exposure and health endpointsendpoints

• Understand the Asia relationship to established international Understand the Asia relationship to established international scientific literature on conduct and interpretation of studies of short-scientific literature on conduct and interpretation of studies of short-term exposureterm exposure

• Stimulate the development of routine systems for the recording of Stimulate the development of routine systems for the recording of daily mortality and hospital admissions for health studies daily mortality and hospital admissions for health studies

• Build scientific capacity, establish Asia-wide network of scientistsBuild scientific capacity, establish Asia-wide network of scientists• Initial Results in 2006Initial Results in 2006

Extensive science on air pollution healthExtensive science on air pollution health

effects in developed countries….effects in developed countries….

What do emerging Asian studies tell us?What do emerging Asian studies tell us?

PM Health Effects

• High levels of PM (e.g. 500 High levels of PM (e.g. 500 /m/m33) known to ) known to cause premature deathcause premature death• e.g. London 1952e.g. London 1952

• Recent studies in North and South America, Recent studies in North and South America, Europe, Asia, have found association of PM Europe, Asia, have found association of PM with death at much lower levelswith death at much lower levels• no evidence of a “threshold” (safe level)no evidence of a “threshold” (safe level)

• Recent progress toward identifying biological Recent progress toward identifying biological mechanisms, though not conclusive mechanisms, though not conclusive

PM: Linked to Increased Mortality, Morbidity

• A Number of Epidemiology StudiesA Number of Epidemiology Studies• Acute Effects Acute Effects (black smoke) (black smoke) Long Term Effects Long Term Effects PM 2.5PM 2.5

Europe (APHEA)Europe (APHEA) US (Six Cities)US (Six Cities)

EVIDENCE FROM ASIA:HEI Meta-Analysis of Asian Studies of Daily Mortality/Hospital

Admissions (Public Health and Air Pollution in Asia (PAPA) 2004)

• 28 recent daily time series 28 recent daily time series studies examined in depthstudies examined in depth

• Studies find effects of air Studies find effects of air pollution on rate of death, pollution on rate of death, illnessillness• ~~0.5% increase per 10 0.5% increase per 10

µµg/mg/m33 of PM of PM1010

• High levels of air pollution High levels of air pollution in Asian cities (>100 in Asian cities (>100 µµg/mg/m33), imply a substantial ), imply a substantial public health impactpublic health impact

• Limitations Limitations • Small number of cities Small number of cities • Not geographically Not geographically

representative (poorest, representative (poorest, most polluted countries most polluted countries under-represented)under-represented)

0.460.62

0.49

0

0.2

0.4

0.6

0.8

Percent Increase

US(90 Cities)* Eur(21 Cities)* Asia (4 Cities)

Percent Increase in Mortality per 10 micrograms PM10

* Estimates Using Pre-GAM Results (without revision)

Ozone Health Effects

• Known to cause inflammation in respiratory tractKnown to cause inflammation in respiratory tract• Reduces ability to breathe (lung function) for some Reduces ability to breathe (lung function) for some

peoplepeople• Increases hospitalization for asthma, other lung Increases hospitalization for asthma, other lung

diseasesdiseases• Recent systematic evidence of effects on premature Recent systematic evidence of effects on premature

mortalitymortality• Effects have been demonstrated for short term Effects have been demonstrated for short term

exposure, long term effects are less certainexposure, long term effects are less certain

Ozone Effects on Mortality95 US Cities

(Approximately 0.5% increase in mortality /10ppb)

Evidence from Asia: Ozone and Respiratory Hospital Admissions

(PAPA, 2004)

Sulfur Dioxide

• Emitted from fossil fuel combustion Emitted from fossil fuel combustion • especially from coal burning facilities, high sulfur fuelsespecially from coal burning facilities, high sulfur fuels

• Can impair breathing in asthmatic children and adultsCan impair breathing in asthmatic children and adults• Has been associated, along with PM, withHas been associated, along with PM, with

• increased aggravation of heart and lung diseaseincreased aggravation of heart and lung disease

• premature mortalitypremature mortality

• Recent study in Hong Kong (Lancet 2002) has found:Recent study in Hong Kong (Lancet 2002) has found:• substantial reductions in SO2 emissions can result in substantial reductions in SO2 emissions can result in

measurable improvements in mortality and illness measurable improvements in mortality and illness

sulfate

s(s

ulfa

te)

2 4 6 8 10 12 14 16

-0.1

0.0

0.1

0.2

Sulfate(g/m3)

Rel

ativ

e ri

sk o

f m

orta

lity

(re

sidu

als)

Effects of Sulfate on Premature MortalitySource: HEI Reanalysis of the American Cancer Society Study (Krewski 2000)

Acute Evidence from Asia

SO2 and All Cause Mortality

PAPA Review

Health Benefits of Emission Health Benefits of Emission Reductions Reductions

In Asia: Hong Kong Fuel Sulfur Reduction(A.J. Hedley et al Lancet 8\2002)

-July 1, 1999 Hong Kong Environmental Protection -July 1, 1999 Hong Kong Environmental Protection Department restricted sulfur content of fuels to .05% Department restricted sulfur content of fuels to .05% (by weight)(by weight)

-Many fuel sources affected (e.g. industrial, vehicles) -Many fuel sources affected (e.g. industrial, vehicles)

-Near term impact-Near term impact- ambient SO2 levels- ambient SO2 levels- health- health

-Adjusted for seasonality, other factors-Adjusted for seasonality, other factors

1988 1989 1990 1991 1992 1993 1994 1995

020

4060

80

NO2

SO2

O3

PM10

Mic

rogr

am

s pe

r cu

bic

met

re

Year

AIR POLLUTANT CONCENTRATIONS 1988 - 95 IN HONG KONG HALF YEARLY MEAN LEVELS

Fuel restriction on sulfur

50% reduction in SO2 after the intervention

No change in other pollutants

-6-5

-4-3

-2-1

0

15-64 65+ 15-64 65+ 15-64 65+

REDUCTIONS IN DEATHS AFTER SULFUR RESTRICTION

All causes Cardiovascular Respiratory

% R

educ

tion

in a

nnua

l tre

nd

-1.8%

-2.8%

-1.6%

-2.4%

-4.8%

-4.2%

Conclusions

• Many pollutants of concernMany pollutants of concern• CO, SO2, PM, NOx. Lead, Air Toxics (including metals), Ozone (VOX\CO, SO2, PM, NOx. Lead, Air Toxics (including metals), Ozone (VOX\

Nox)Nox)• Progress made in some areas Progress made in some areas

• Many SourcesMany Sources• Combustion, Non CombustionCombustion, Non Combustion• Regional differences exist, depending on fuels, weather patterns, Regional differences exist, depending on fuels, weather patterns,

industrial profile, SES, suggesting both general and regionally specific industrial profile, SES, suggesting both general and regionally specific prioritiespriorities

• PAPA, WHO others document effects in both Western and, PAPA, WHO others document effects in both Western and, increasingly, in Asian population increasingly, in Asian population

• Greater monitoring, source characterization needed Greater monitoring, source characterization needed • To inform health impact assessment, control measures, especially in To inform health impact assessment, control measures, especially in

highly populated areas highly populated areas • However, several pollutants of concern common across sectors, However, several pollutants of concern common across sectors,

regions, regions,

Potential Priorities

• Pollutants associated with morbidity, mortality and found in Pollutants associated with morbidity, mortality and found in urban, rural areas at high levels urban, rural areas at high levels • ParticulatesParticulates

• Also recommend additional monitoring, for PM10, 2.5Also recommend additional monitoring, for PM10, 2.5• SO2SO2

• Contributes to sulfate formation, SO2 also respiratory irritant, some Contributes to sulfate formation, SO2 also respiratory irritant, some mortality evidencemortality evidence

• Of concern but less studied in AsiaOf concern but less studied in Asia• OzoneOzone

• Associated with respiratory problems, asthma exacerbationAssociated with respiratory problems, asthma exacerbation• May be a concern with increased vehiclesMay be a concern with increased vehicles• Limited monitoring in Asian cities, suburban areas should be enhancedLimited monitoring in Asian cities, suburban areas should be enhanced

• Air ToxicsAir Toxics• Benzene, metals, diesel, though monitoring difficult, expensive, even in Benzene, metals, diesel, though monitoring difficult, expensive, even in

developed regions developed regions

Thank You!

Robert O’KeefeRobert O’Keefe

rokeefe@healtheffects.orgrokeefe@healtheffects.org

www.healtheffects.orgwww.healtheffects.org