APHEIS 2Air Pollution and Health: A European Information System

A Health Impact Assessment of Air PollutionIn 26 European Cities

Emilia Maria Niciu1, Anna Paldy2, Eszter Erdei2, Michal Krzyzanowski3 Sylvia Medina4, Antonio Placencia5, on behalf of the Apheis network

1- Institutul de Sanatate Publica (Institute of Public Health), Bucharest, Romania 2- Jozsef Fodor National Center for Public Health, National Institute of Environmental

Health), Budapest, Hungary3- WHO European Centre for Environment and Health, Bonn Office, Germany

4- Institut de Veille Sanitaire, Saint-Maurice, France 5- Institut Municipal de Salut Pública (Municipal Institute of Public Health), Barcelona, Spain

ISEE CEE Chapter ,Balaton, Hungary, 4-6 October 2003

Co-funded by:

* Pollution-Related Diseases Programme of Health and Consumer Protection DG of the European Commission, contract Nos.:

• SI2.131174 [99CVF2-604]

• SI2.297300 [2000CVG2-607]

• SI2.326507 [2001CVG2-602]

* Participating institutions in 12 European countries

Who funds Apheis

Network

* Network of environmental and public-health professionals

* 16 centres16 centres totalling 26 cities26 cities in 12 European countries12 European countries

* Each centre part of a city, regional or national institution active in the field of environmental health

What methods did we use

Network

What methods did we use

APHEIS cities (26)

Steering Committee (Boston, USA)

(Tel-Aviv, Israel)

What methods did we use

Exposure assessment

(local networks, European Env. Agency; WHO collaborating centre for air quality control, Berlin; European Reference Laboratory Air Pollution, Ispra)

Health outcomes monitoring(local/national institutes of public health, EUROSTAT,

WHO)

Quantitative relationships ofexposure and health-effect

estimates

(APHEIS)

Health impact assessment (cases, population, attributable risks)

(APHEIS, WHO-ECEH)

Dissemination of information for defined target audiences(APHEIS)

Decision makers

Citizens

Air quality management/Public-health actions

Evaluation (European Commission)

E&H professionals

Network

What methods did we use

APHEIS coordination centre

Paris and Barcelona

Advisory groupsExposure assessmentEpidemiologyStatisticsPublic health Health impact assessment

Participating APHEIS Cities

Technical committeeExposure assessmentEpidemiologyStatisticsPublic HealthHealth Impact Assessment

City committeeNEHAPsLocal/national authoritiesMedical/environmental sciencesCitizens

Local/regional coordinator

Network

Created five advisory groups: public health; health-impact assessment; epidemiology; exposure assessment; statistics

Drafted guidelines for designing and implementing the surveillance system, and for developing a standardised protocol for data collection and analysis for HIA

Review of capacities for HIA in institutions of participating cities

Actions, steps and resultsduring the first year

Implement or adapt organisational models designed during first year

Collect and analyse data for health-impact assessment

Prepare different health-impact scenarios

Prepare HIA report in standardised format (HIA in 26 cities)

Actions, steps and resultsduring the second year

1. Specify exposure

* PM10, BS

* Urban background stations

Five main steps in HIA

2. Define the appropriate health outcomes

 * Acute effects* Acute effects

- Premature mortality excluding accidents and violent deaths

- Hospital admissions for respiratory diseases 65+ age group

- Hospital admissions for cardiac diseases all ages

* Chronic effects* Chronic effects

  - Premature mortality

Five main steps in HIA

3. Specify the exposure-response functions

* Short-term exposure: APHEA2

Five main steps in HIA

PM10 Black smokeHealth

indicatorRR for

10 µg/m395%CI RR for

10 µg/m395%CI

TotalmortalityAll agesICD9 <800

1.006 1.004-1.008 1.006 1.003-1.008

Respiratoryhospitaladmissions65 years+ICD9 460-519

1.009 1.006-1.013 1. 001 1.000-1.009

Cardiachospitaladmissionsall agesICD9 410-414,427,428

1.005 1.002-1.008 1.011 1.004-1.018

3. Specify the exposure-response functions

* Long-term exposure: HIA in Austria, France and Switzerland based on two American cohort studies (Künzli et al, 2000).

Five main steps in HIA

Health indicator RR for 10 µg/m3 95%CI Total mortality

30 years + ICD9 <800

1.043 1.026-1.061

4. Derive population baseline frequency measures for health outcomes

5. Calculate number of attributable cases in target population

Five main steps in HIA

HIA modelKünzli, Kaiser, Medina et al, Lancet 2000; 356: 795 - 801

PM10

Incidence/prevalence

Attributable cases

Reference level PM10

Scenarios

E-R function

Observed level: annual mean

Demographic characteristicsDemographic characteristics

* Nearly 39 million39 million inhabitants in Western and Eastern Europe ( 34 mil.34 mil. in 2121 WEWE cities 5 mil5 mil. in 5 CEE5 CEE cities)

* Proportion of people over 65 years: 15%15%,, with highest proportion in Barcelona and lowest in London

Descriptive findingsDescriptive findings

Air pollution levelsAir pollution levels

* PMPM1010 - measurements provided by 19 cities:

Bordeaux, Bucharest, Budapest, Celje, Cracow, Gothenburg, Lille, Ljubljana, London, Lyon, Madrid, Marseille, Paris, Rome, Seville, Stockholm, Strasbourg, Tel Aviv and Toulouse

* Black SmokeBlack Smoke - measurements provided by 15 cities:

Athens, Barcelona, Bilbao, Bordeaux, Celje, Cracow, Dublin, Le Havre, Lille, Ljubljana, London, Marseille, Paris, Rouen and Valencia

Descriptive findings

Distribution of Distribution of annual mean levelsannual mean levels (10th and 90th percentiles) of (10th and 90th percentiles) of PM10PM10

Descriptive findingsDescriptive findings

0

10

20

30

40

50

60

70

80

90

100

Bordea

ux

Buchar

est *

Budapes

t

Celje

Craco

w

Gothen

burg

Lille

Ljublja

na

London

Lyon

Mad

rid

Mar

seill

e

Paris

Rome

Sevill

e

Stock

holm

Strasb

ourg

Tel A

viv

Toulouse

µg/m3

2005

2010

Distribution of Distribution of annual mean levelsannual mean levels (10th and 90th percentiles) of (10th and 90th percentiles) of Black SmokeBlack Smoke

Descriptive findingsDescriptive findings

0

20

40

60

80

100

120

Athen

s

Barce

lona

Bilbao

Bordea

ux

Celje

Craco

w

Dublin

Le Hav

re

Lille

Ljublja

na

London

Mar

seill

e

Paris

Rouen

Valen

cia

µg/m3

Health indicators :Health indicators : Standardised mortality rates for all causes of Standardised mortality rates for all causes of deaths in the 26 citiesdeaths in the 26 cities

Descriptive findingsDescriptive findings

0

200

400

600

800

1000

1200

Athen

s

Barce

lona

Bilbao

Bordea

ux

Buchar

est

Budapes

t

Celje

Craco

w

Dublin

Gothen

burg

Le Hav

re

Lille

Ljublja

na

London

Lyon

Mad

rid

Mar

seill

e

Paris

Rome

Rouen

Sevill

e

Stock

holm

Strasb

ourg

Tel A

viv

Toulouse

Valen

cia

Rate / 100 000 /year

Health indicatorsHealth indicators: : Incidence rates for Incidence rates for hospital admissionshospital admissions in 22 cities in 22 cities

( 8 with ( 8 with emergency admissionsemergency admissions, 14 with , 14 with general admissionsgeneral admissions))

Descriptive findingsDescriptive findings

0

500

1000

1500

2000

2500

3000

3500

4000

Barce

lona

Bilbao

Gothen

burg

London

Mad

rid

Sevill

e

Stock

holm

Valen

cia

Bordea

ux

Buchar

est

Celje

Le Hav

re

Lille

Ljublja

na

Lyon

Mar

seill

e

Paris

Rome

Rouen

Strasb

ourg

Tel A

viv

Toulouse

incidence rate of cardiac admissions all ages

incidence rate of respiratory admissions over 65years of age

Rate / 100 000 /year

Acute effects scenarios

* Reduction of PM10/BS levels to a 24-hour value of 50 24-hour value of 50 µg/mµg/m33 (2005 and 2010 limit values for PM10) on all days on all days exceeding this valueexceeding this value

* Reduction of PM10/BS levels to a 24-hour value of 20 24-hour value of 20 µg/mµg/m33 (to allow for cities with low levels of PM10/BS) on on all days exceeding this valueall days exceeding this value

* Reduction by 5 µg/mby 5 µg/m33 of all the 24-hour daily values of all the 24-hour daily values of PM10/BS (to allow for cities with low levels of PM10/BS)

Health impact assessment findingsHealth impact assessment findings

Chronic effects scenariosChronic effects scenarios

* Reduction of the annual mean valueannual mean value of PM10 to a level of 40 40 µg/mµg/m33 (2005 limit values for PM10)

of 20 µg/m20 µg/m33 (2010 limit values for PM10)

of 10 µg/m10 µg/m33 (to allow for cities with low levels of PM10)

* Reduction by 5 µg/mby 5 µg/m33 of the annual mean value of the annual mean value of PM10 (to allow for cities with low levels of PM10)

Health impact assessment findingsHealth impact assessment findings

Potential benefits of reducing daily PM10 levels by 5 µg/mPotential benefits of reducing daily PM10 levels by 5 µg/m33 - Number of deaths per 100 000 inhabitants attributable to the acute effects of PM10 (95% C.I.) - Number of deaths per 100 000 inhabitants attributable to the acute effects of PM10 (95% C.I.)

HIA findings: PM10 PM10 acute-effects scenarios

0

1

2

3

4

5

6

7

Bordea

ux

Buchar

est

Budapes

t

Celje

Craco

w

Gothen

burg

Lille

Ljublja

na

London

Lyon

Mad

rid

Mar

seill

e

Paris

Rome

Sevill

e

Stock

holm

Strasb

ourg

Tel A

viv

Toulouse

Rate/100 000/year

Potential benefits of reducing daily black smoke levels by 5 µg/mPotential benefits of reducing daily black smoke levels by 5 µg/m33- Number of deaths per 100 000 - Number of deaths per 100 000 inhabitants attributable to the acute effects of black smoke (95%C.I.) inhabitants attributable to the acute effects of black smoke (95%C.I.)

HIA findings: Black SmokeBlack Smoke acute-effects scenarios

0

1

2

3

4

5

6

Athen

s

Barce

lona

Bilbao

Bordea

ux

Celje

Craco

w

Dublin

Le Hav

re

Lille

Ljublja

na

London

Mar

seill

e

Paris

Rouen

Valen

cia

Rate /100 000 /year

Potential benefits of reducing annual mean values of PM10 by 5 µg/mPotential benefits of reducing annual mean values of PM10 by 5 µg/m33- Number of deaths per 100 000 inhabitants attributable to the - Number of deaths per 100 000 inhabitants attributable to the chronic effects of PM10 (95% C.I.)chronic effects of PM10 (95% C.I.)

HIA findings: PM10 PM10 chronic-effects scenarios

0

5

10

15

20

25

30

35

40

45

50

Bordea

ux

Buchar

est

Budapes

t

Celje

Craco

w

Gothen

burg

Lille

Ljublja

na

London

Lyon

Mad

rid

Mar

seill

e

Paris

Rome

Sevill

e

Stock

holm

Strasb

ourg

Tel A

viv

Toulouse

Rate /100 000 / year

CEE CITIESCEE CITIES

• out of a total of 32 mil in 19 cities out of a total of 32 mil in 19 cities

• HIA for long term exposure on total mortality found that HIA for long term exposure on total mortality found that

5 547 (3 368 - 7 744) premature death could be prevented annually if PM10 5 547 (3 368 - 7 744) premature death could be prevented annually if PM10 concentrations were reduced by 5 µg/mconcentrations were reduced by 5 µg/m33

HIA findings: PM10 in CEE citiesPM10 in CEE cities

CITY population 1999

mean annual

PM10 ug/m3 -1999

NUMBER OF DEATH - LONG TERM BENEFIT of reducing mean annual val. PM10 by 5 ug/m3

/100.000 NUMBER OF DEATH - SHORT TERM BENEFIT

of reducing daily val. PM10 by 5 ug/m3

/100.000

BUCHAREST 2,028,000 73 450.1 22.2 66.5 3.3BUDAPEST 1,775,587 29.5 559.6 31.5 82.7 4.7CELJE 50,121 36 12.9 25.8 1.9 3.8CRACOW 738,150 45.4 139.1 18.9 20.6 2.8LJUBLIANA 267,763 35.7 58.5 21.9 8.7 3.2TOTAL 4,859,621 43.92 1220.2 25.1 180.4 3.7

Standardised protocol for data collection and analysisStandardised protocol for data collection and analysis

Conservative approach :Conservative approach :

* Did not consider newborn or infant mortality separately

* Did not consider many other health outcomes listed by WHO

* Did not consider independent effect of ozone

* Used range of reference levels in different scenarios

Interpretation of findingsInterpretation of findings

Transferability of Exposure-Response (E-R) functions:Transferability of Exposure-Response (E-R) functions:

* Short-term exposure: Question avoided by using E-R functions developed by APHEA 2

* Long-term exposure: Open question - used U.S. E-R functions

Interpretation of findingsInterpretation of findings

ConclusionsConclusions* Our HIA provides a conservative but accurate and

detailed picture of the impact of air pollution on health in 26 European cities, and shows that air pollution continues to threaten public health in Europe.

* Even very small and achievable reductions in air pollution levels have an impact on public health

* This impact justifies taking preventive measures even in cities with low levels of air pollution

Interpretation of findings

Apheis 2002-2003

To keep our HIA as accurate and up-to-date as possible:

- Produce new exposure-response functions on short-term effects of AP

- Calculate years of life lost or reduction in life expectancy, in addition to the attributable number of deaths based on long-term effects

Actions, steps and resultsduring the third year (2002-03)

To fulfill our mission of making our learnings available to the broadest possible audiences, and to evaluate the usefulness of our work on HIA among those who need to know:

- Explore and understand how best to meet the information needs of policy makers concerned with the impact of air pollution on public health

and

- Understand how to meet those needs in terms of content and form

Actions, steps and resultsduring the third year

Apheis is a multiyear, multiphase proactive public-health programme

Each phase builds on learnings of previous phase

First broad-based European HIA of air pollution on both the city and European levels simultaneously

Consistent with other HIAs on air pollution worldwide

Translates epidemiological findings into decision-making tool

One more brick in the wall of evidence that air pollution continues to threaten public health

The broad view

The future

Epheis Environmental Pollution and Health: A European

Information System

Background Call for proposals DGSANCO 2003-2008

ENHIS Environment and Health Information System (WHO- ECEH Bonn)

Six modules:1. Identification of relevant policies/corresponding needs2. Development of Indicators3. Methods for data retrieval/processing 4. Creation of NCC, networking5. Integrate HIA (Epheis)6. Database development and maintenance

Coordination WHO-BonnSteering CommitteeLength first year :1 Feb 2004-30 Jan 2005

ObjectiveComparative risk assessment (CRA) of different environmental risk factors in Europe

o Selected environmental risk factors

o Method based on HIA and CRA

For further information please visit:

www.apheis.org

1. University of Athens, Athens, Greece 2. Institut Municipal de Salut Pública (Municipal Institute of Public Health),

Barcelona, Spain3. Departamento de Sanidad, Gobierno Vasco, Vitoria-Gasteiz, Spain4. Institutul de Sanatate Publica (Institute of Public Health), Bucharest, Romania 5. Jozsef Fodor National Center for Public Health, National Institute of

Environmental Health), Budapest, Hungary6. National Institute of Hygiene, Warsaw, Poland7. Saint James Hospital, Dublin, Ireland8. Institut de Veille Sanitaire, Saint-Maurice, France9. Inštitut za Varovanje Zdravja RS, (Institute of Public Health), Ljubljana,

Republic of Slovenia

Who are our partners

10. Saint George’s Hospital Medical School, London, UK

11. Dirección General de Salud Pública, Consejeria de Sanidad,

Comunidad de Madrid (Department of Public Health, Regional

Ministry of Health, Madrid Regional Government), Madrid, Spain

12. ASL RM/E Local Health Authority Roma E, Rome, Italy

13. Escuela Andaluza de Salud Pública (Andalusia School of Public

Health), Granada, Spain

14. Umeå University, Department of Public Health and Clinical

Medicine, Umeå, Sweden

15. Tel Aviv University, Tel Aviv, Israel

16. Escuela Valenciana de Estudios para la Salud (Valencia School

of Health Studies), Valencia, Spain

Who are our partners

Steering CommitteeSteering CommitteeRoss Anderson, Saint George’s Hospital Medical School, London, UKEmile De Saeger, Joint Research Centre, Institute for Environment and

Sustainability, Ispra, ItalyKlea Katsouyanni, Department of Hygiene and Epidemiology, University

of Athens, Athens, Greece Michal Krzyzanowski, WHO European Centre for Environment and Health,

Bonn Office, GermanyHans-Guido Mücke, Umweltbundesamt - Federal Environmental Agency,

WHO Collaborating Centre, Berlin, Germany Joel Schwartz, Harvard School of Public Health, Boston, USARoel Van Aalst, European Environmental Agency, Copenhagen, Denmark

Who are our partners

CoordinatorsCoordinators Sylvia Medina, Institut de Veille Sanitaire (Institute of Public

Health), Saint-Maurice, France Antoni Plasència, Institut Municipal de Salut Pública (Municipal

Institute of Public Health), Barcelona, Spain

  

Programme AssistantProgramme Assistant Claire Sourceau, Institut de Veille Sanitaire, Saint-Maurice, France

Who are our partners