The Health Effects of Air

Pollution
Robert M. OKeefe, Vice President
Health Effects Institute

National Workshop on Improvement of

Urban Air Quality of Pakistan
Lahore
December 2004

Assessing the Health Effects of Air

Pollution
Health Effects Institute
Air Pollution and Health Effects
Public Health And Air Pollution in Asia
Program PAPA
The existing Asia science literature
New Asian studies

Conclusions

The Health Effects Institute

Founded in 1980 to provide impartial, high-quality science
on health effects of vehicle and other emissions
Joint and Equal Core Funding from
Government (U.S. EPA)
Industry (28 Worldwide Vehicle Manufacturers)
Today many partners worldwide: ADB, WHO, EU
California ARB (CARB), Oil, other Industries
Independent Expert Science Committees oversee and
peer review all research
Over 225 studies - Americas, Asia, Europe - ozone,
carbon monoxide, particulate matter, diesel exhaust,
benzene, butadiene, methanol, others

Air Pollution and Health:

What we know about the effects

Air Pollution has Many Effects

Health
Respiratory, cardiovascular morbidity
Mortality

Heritage
Nitric Sulfuric Acid erosion

Natural Resources
Acidification (lake and stream biology)
Mercury deposition (fish tissue)
Visibility

Agriculture
Ozone crop effects (~40% reduction in rice, soy yield in Pakistan
city)

*(Wahid 2003 Veranasi)

Many Sources of Air Pollution in

Asia
Combustion

Open burning
Brick Kilns
Vehicles
Trash burning
Factories
Power generation
Cooking in slums

Non-Combustion
Agricultural
cultivation
Street sweeping
Windblown sand
Unpaved roads
Paved roads
(asbestos, rubber
etc)
Construction

Vehicle Emissions and Exposure

Must consider all effects of the system:
different vehicle types 2 and 3 wheelers
cars
trucks and buses

vehicle plus fuels (and fuel components)

tailpipe emissions plus evaporative
emissions
maintenance of system

Major Vehicle/Fuel Emissions

Carbon Monoxide
Diesel Exhaust
Particulate Matter (PM)
Lead
Nitrogen Oxides (NOx)
and Hydrocarbons (HC)
Precursors to Ozone
and PM
Nitrogen Dioxide

Air Toxics
Aldehydes
formaldehyde
acetaldehyde
others

Benzene
1,3-butadiene
Methanol
Polycyclic organic
matter (e.g. PAHs)

Health Effects
Different Pollutants have Different Effects
Carbon Monoxide - circulatory system, heart
Ozone - respiratory system, lung
Lead - nervous system, brain
PM - lung, potential effects on heart
Diesel, Air Toxics - cancer, respiratory
effects
There are potential effects of the Mixture

Health Effects
Some populations more sensitive than others
Children
Elderly
people with heart and lung disease
Asthma is growing
150 million asthmatics worldwide
Increasing in most countries (2% to 5% per year)
Asthmatics much more sensitive to air pollution

Particulate Matter (PM)

Health Effects
High levels of PM (e.g. 500 /m3) known to
cause premature death
e.g. London 1952
Recent studies in US, Europe, Asia, South
America have found association of PM with
death at much lower levels (< 50ugm3)
no evidence of a threshold (safe level)
Progress made to identify a plausible
biological mechanism for these effects;
results not yet definitive

PM - The Epidemiology Studies

A Number of Epidemiology Studies

Europe Studies

Harvard 6 Cities Study

PM Health Effects - India, Thailand

% Increase in Effects

Source: Chhabra 2001, Pande 2001, Vichit-Vadakan, 2001

50
45
40
35
30
25
20
15
10
5
0

Asthma
COAD
Cardiac
Cough
Phlegm
Lung Function
Adult Resp.
Child Resp.
Nurse Resp.

Emergency
Visits(Pande)

Chronic
Effects
(Chhabra)

Bangkok

Ozone Health Effects

Known to cause inflammation in respiratory tract
Effects have been demonstrated for short term, long
term effects are less certain
some people appear to develop tolerance
Reduces ability to breathe (lung function) for some
people
Increases hospitalization for asthma, other lung
diseases
New US study finds Ozone mortality effects*
(Domenchi et. al 2004)

Ozone Health Effects

Some humans have been shown to have reduced lung
function (measured as FEV1) after exposure to ozone
Figure 1. Individual Response to
Ozone Exposure (after Kulle, et al,
Am. Rev.)
-5

% Reduction in FEV1

0
5
10
15
20
25
0.1
30

0.15

0.2

Ozone Concentration (ppm)

0.25

Diesel Health Effects

Diesel Engines have substantial advantages:
higher fuel efficiency
lower CO and CO2 emissions
However, they also emit high levels of :
particulate matter, NOx, and chemicals attached
to the particles (e.g. PAHs)
Two major types of health effects :
acute effects (e.g. exacerbating asthma)
cancer effects

Diesel Effects on Childhood Illness

(Brunekreef, et al Study in 24 Dutch schools)
Increased Symptoms comparing High Truck Traffic
(>10,000) to Low Truck Traffic

2.2
2

asthma
hayfever

1.8
phlegm
1.6
1.4
1.2
1

HD allergy
pet allergy
wheeze last year

Assessing Diesel Cancer Risk

In general, some 30 studies of effects on
workers have provided best data
Consistent small (20-40%) increase in
lung cancer associated with exposure
Some questions about each study
Leading International Agencies (WHO,
IARC, US NIEHS, US EPA) have
concluded diesel is a probable human
carcinogen

Sulfur Dioxide
Emitted from fossil fuel combustion
especially from coal burning facilities, high sulfur fuels

Can impair breathing in asthmatic children

and adults
Has been associated, along with PM, with
increased aggravation of heart and lung disease
premature mortality

Recent study in Hong Kong (Lancet 2002)

has found:
substantial reductions in SO2 emissions can result in
measurable improvements in mortality and illness

60

Fuel restriction on sulphur

PM10

NO2

50% reduction in SO2

after the intervention

40

SO2

20

O3

No change in
other pollutants
0

Micrograms per cubic metre

80

AIR POLLUTANT CONCENTRATIONS 1988 - 95 IN HONG KONG

HALF YEARLY MEAN LEVELS

1988

1989

1990

1991

1992
Year

1993

1994

1995

-1.6%

-1.8%

-2.4%
-2.8%

-4.2%
-4.8%

-6

% Reduction in annual trend

-5
-4
-3
-2
-1

REDUCTIONS IN DEATHS AFTER SULPHUR RESTRICTION

15-64

65+

All causes

15-64

65+

Cardiovascular

15-64

65+

Respiratory

Air Toxics Health Effects

Benzene
a known human
carcinogen
studies in U.S. and
Chinese workers have
shown link between
exposure and
increased leukemia

Metals
Range of effects,
heart, reproductive,
cancers

1,3 Butadiene
a probable or
known human
carcinogen
studies in laboratory
animals and US and
Czech workers have
shown effects

Aldehydes, PAHs
Cancers, Irritants

Air Pollution and Health in Asia:

The Public health and Air Pollution Program
(PAPA)

The Problem: Air Pollution in Asia:

High Levels in Many Cities (2000-2001)
400
SPM Limit = 90 g/m3 (WHO, 1979)

350

PM10 Limit = 50 g/m3 (USEPA, 1997)

SO2 Limit = 50 g/m3 (WHO, 1999)

concentration in g/m

300

NO2 Limit = 40 g/m3 (WHO, 1999)

250

200

150

100

50

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

SO2

NO2

SPM

PM10

Lancet
October,
2002

Environmental Burdens
Premature Deaths
source: WHO Global Burdon of Disease

Environmental Global
Asian Estimate Asia as a
Risks
Estimate (SEAR+WPR)
percent of
Global
Unsafe Water 1,730,000 730,000
42%
Urban Outdoor 799,000
487,000
61%
Air
Indoor Air
1,619,000 1,025,000
63%
Lead
234,000
88,000
37%

The Challenge: Expanding current science

base to inform Asian air regulatory decisions
Air pollution poses clear health effects
Western research is relevant to Asian populations,
however extrapolation poses challenges
Population characteristics
Pollution sources and mixes
Are observed risks similar?, greater?, smaller?
A clear need for representative air pollution & health
studies of local Asian populations

PAPA Program
Partnership with CAI-ASIA to understand the health effects of air
pollution in Asia, now and in the future
Active effort underway:
Published Scientific Review and Meta Analysis of what is known
today about health effects in Asian cities
Conducting series of epidemiological studies in representative
Asian cities
Understand local impact
Combine to provide Asia-wide understanding

Publish a Comprehensive Assessment of the state of air pollution

and health across Asian cities
Build capacity of local scientists

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

Health Effects of Outdoor Air Pollution

in Developing Countries of Asia: A
Literature Review
Systematic identification of 140
peer-reviewed Asian studies
1980-2003
Special focus on studies of daily
changes in air pollution and
health
Conduct first ever Asian meta
analysis quantifying risks,
finding initial similarities with
West
Identify knowledge gaps to
guide future research
Active communication to policy
makers

Studies of Air Pollution and Health in Asia 19802003

Many Health Effects Studied

12

Number of Studies

10
TSP
PM10
PM2.5
SO2
NO2
CO
O3

8
6
4
2
0
All-Cause
Mortality

Respiratory
Mortality

Cardiovascular
Mortality

Respiratory
Hospital
Admissions

Outcome Diagnosis

Cardiovascular
Hospital
Admissions

Daily Mortality: Initial Results:

Asian Risk Estimates Similar to West
Percent Increase in Mortality per 10 micrograms of
Exposure
0.7
0.6
0.5
Percent 0.4
Increase 0.3
0.2
0.1
0

0.62
0.46

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

* Estimates Using Pre-GAM Results (without revision)

0.49

Asia (4 Cities)

New Research in Asian Cities

To strengthen base of Asian Health Science:
Eight new studies of air pollution and health now
underway in Asian cities
Acute (short term) effects studies in
Bangkok, Hong Kong, Shanghai, Wuhan
Strong teams, quality data

Long Term (chronic) effects

Guangzhou, China pilot study in elderly cohort

New!
Study teams now identified in India: Chennai; Delhi;
Ludhiana

PAPA: Looking Ahead

A Special Challenge: Understanding the interaction
among air pollution, poverty, and health
In Asia high levels of air pollution, dense population,
extensive poverty are prevalent
Some initial evidence (mostly from West) that the poor
face worse effects from air pollution
Could be due to:
Different exposures (roadside, indoor, occupational)
Poorer SES\health status (nutrition, medical care) leading to
higher susceptibility
Other factors

Potential Public health implications could be significant

New study under design in Ho Chi Minh City to

understand poverty effects

Conclusions
Air Pollution from many sources, including vehicles,
fuels have been shown to have effects on mortality,
morbidity
Problem will grow with economic expansion
WHO estimates place air pollution mortality in hundreds
of thousands across South Asia, Eastern Mediterranean
region (including Pakistan)
While studies are extrapolated from developed world,
initial PAPA Review and analysis tend to confirm results
in Asian populations, though many limitations exist
The PAPA program is building a better base of Asian
health and air pollution science
New studies across Asia, with capacity building as a priority
Role of poverty in air pollution to be assessed

Conclusions
Better air monitoring needed over long term
To determine current status, monitor ongoing
progress and assess health, communicate to
public

However, Pakistan urban conditions also

warrant near term action

Visible emissions wide-spread

Dense population level, clear exposure
Acute effects commonplace
Provided basis of action in many countries (UK,
HK, others) before comprehensive monitoring

Thank You!
Bob OKeefe
rokeefe @healtheffects.org

www.healtheffects.org