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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 [email protected]@cyf-kr.edu.pl