globEMED bullEtin RESPiRatoRy PRoblEMS anD …...Prepared by Sarkis M. El Zein, PhD globEMED bullEtin RESPiRatoRy PRoblEMS anD Pollution globeMed limited/MedSystems Kazandjian building

Prepared bySarkis M. El Zein, PhD

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RESPiRatoRy PRoblEMS anD

Pollution

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LEGAL DISCLAIMERGlobeMed Ltd is providing this bulletin as an information tool only, without any other purposes whatsoever. Although GlobeMed Ltd has made every effort to ensure that its contents are correct and accurate, it cannot be held liablefor any of the information contained herein.

This bulletin is not addressed to the general public. It is designed to be distributed to GlobeMed Ltd’s partners and clients (insurance companies, healthcare providers, etc.). It serves as a means of communication that opens up a dialogue and promotes a better understanding of health issues that are of interest to all parties.

Copyright GlobeMed Ltd, 2012. All rights reserved.

GM A4 Respiratory Bulletin Inside Pages AW.indd 1 8/8/12 10:49 AM

Table of ContentsIntroductionPollution’s Impact on the Respiratory SystemMethodologyFindings Chronic Obstructive Pulmonary Disease (COPD)AsthmaPneumoniaCancer of the LungsConclusionsReferences

List of Tables

Table 1 Incidence Rate of Respiratory Diseases Table 2 Incidence Rate of Respiratory Diseases by Age Group Table 3 Incidence Rate of Respiratory Diseases by Gender Table 4 Incidence Rate of Chronic Obstructive Pulmonary DiseaseTable 5 Incidence Rate of Chronic Obstructive Pulmonary Disease, MedNet Liban vs. USA Table 6 Incidence Rate of AsthmaTable 7 Incidence Rate of Asthma, MedNet Liban vs. USA Table 8 Incidence Rate of Pneumonia, MedNet Liban vs. USA Table 9 Incidence Rate of Lung Cancer

List of Graphs

Graph 1 Incidence Rate of Respiratory Diseases Graph 2 Incidence Rate of Respiratory Diseases by Age Group Graph 3 Incidence Rate of Respiratory Diseases by Gender Graph 4 Incidence Rate of Respiratory Diseases by Caza in Lebanon Graph 5 Incidence Rate of Chronic Obstructive Pulmonary Disease Graph 6 Incidence Rate of AsthmaGraph 7 Incidence Rate of Lung Cancer

04050809141719202224

09101215 1617181920

10111213161821

Statistics byRawad Daou, Actuarial Analyst

Technical Work byHanadi Mhawej, Administrative Assistant

Prepared bySarkis M. El Zein, PhDVice President, Actuarial and Reinsurance Services Division

Copyright GlobeMed Ltd, 2012. All rights reserved.

Work Experience Employer Position

2/1995 - Present GlobeMed Ltd, Lebanon Vice President, Actuarialand Reinsurance Services Division

3/2006 - Present Université Saint-Esprit de Kaslik, Lebanon Part-Time Lecturer, Actuarial Courses

1997 - 2001 Muhanna Foundation, Lebanon Lecturer, Actuarial Courses

2/1995 - 7/1995 Notre Dame University, Lebanon P/T Math Instructor

1987-1994 Auto Club of Southern California Los Angeles, CA, USA

Senior Actuary

1985-1987 Farmers Insurance GroupLos Angeles, CA, USA

Assistant Actuary

1982-1984 University of Southern California Los Angeles, CA, USA

Teaching Assistant, Math Department

1977-1979 Lebanese Republic, Lebanon Secondary Schools Math Teacher

Education Institution Degree

1985 University of Southern CaliforniaLos Angeles, CA, USA

PhD in Math Education

1978 Lebanese University, Lebanon CAPES, Math

1977 Lebanese University, Lebanon BSc, Math

Professional Actuarial Education

Member of the Society of Insurance Research, USA

Associate of the Lebanese Association of Actuaries, Lebanon

GM A4 Respiratory Bulletin Inside Pages AW.indd 2-3 8/8/12 10:49 AM

GLOBEMED BULLETIN / RESPIRATORY PROBLEMS AND POLLUTION / 2012

5

As mentioned earlier, pollution takes on various forms, the most noticeable of which is outdoorair pollution.

Air pollution is more visible to the naked eye during hot days. Looking down on Beirut from a high point during the summer and the early months of fall, you can see a thick layer of haze hanging over the city’s sky.

The Daily Star quoted scientific experts from the University of St. Joseph as saying that “air pollution has reached alarming levels in Beirut.” The major substance contaminating the atmosphere is Nitrogen Dioxide (NO2). Nitrogen dioxides are found in vehicle exhaust, smoke and smog. “The main problem with NO2 is that, upon interaction with the sun’s rays, it generates particles in the atmosphere that can lead to serious respiratory diseases.”(3)

A joint, two-year study conducted by the American University of Beirut and the University of St. Joseph in collaboration with the National Center for Scientific Research revealed that about 93% of Beirut’s population is being exposed to high levels of air pollution.

The finding of the joint study, presented in May 2011, showed an annual concentration of NO2 that is 45% above the maximum allowable concentration set by the World Health Organization (WHO).(4)

Air pollution has been linked to pneumonia, peptic ulcer, lung and stomach cancers and rheumatic heart diseases.(5)

POLLUTION’S IMPACTON THE RESPIRATORY SYSTEM

Tobacco smoke, second hand tobacco smoke, indoor and outdoor air pollutants, allergens, occupational agents, diet and nutritionare among the major risk factors for chronic respiratory diseases.(1)

It is estimated that tobacco smoke causes 4.9 million premature deaths every year. Research has shown that, in addition to tobacco smoke, long-term exposure to air pollutants increases the risk of respiratory diseases such as asthma, allergies, Chronic Obstructive Pulmonary Disease (COPD) and lung cancer. Ozone and other airborne toxicants affect the young and the elderly at the same time.(2)

As a result of this research, more stringent air quality standards have been developed and adopted in some developed countries. In our part of the world, pollution is widespread and greatly harms the health of the residents.

INTRODUCTION

Air pollution, soil pollution, water pollution and land pollution (or “trash”) are all forms of pollution resulting from either negligence, ignorance or indifference, yet their impact on our health is very obvious.


7GLOBEMED BULLETIN / RESPIRATORY PROBLEMS AND POLLUTION / 2012

Short-term exposure to air pollutants can cause “acute” effects such as eye irritation, headaches and nausea. Those short-term effects are reversible and they usually end when exposure to pollutants ends. But “chronic” effects are long-term as a result of extended exposure to pollutants; the latter include decreased lung capacity and lung cancer.

Pollutants affect primarily the respiratory system. Particles inhaled through the nose end up on the walls of the lungs. Some of those particles are cleansed when coughing or sneezing occurs. However, small particles may reach the air sacks (alveoli) where it takes weeks or even years for the body to remove them. The process of inhaling air pollutants does not stop at the lungs since the blood stream might be affected, leading to cardiovascular impairments.

Based on the preceding brief literature review, it could be concluded that respiratory diseases are linked to pollutants of varying types. The remainder of this study sheds some light on the trends of respiratory diseases based on the claims experience of close to two million people exposed to risk from 1999 to 2010.

The main source of air pollution in Lebanon is transportation: cars, trucks and buses. “Lebanese people have a love-hate relationship with their cars, which are both a source of pride and status, but also spew out the fumes that pose a public health hazard.” The high volume of aging vehicles, frequent construction projects, and lack of extensive regulation and enforcement all contribute to poor air quality.(6)

Now Lebanon News reports that Lebanon ranks 90 out of 149 countries overall in the 2008 Environmental Performance Index (EPI).(7)

In addition to outdoor air pollution, indoor air pollution is believed to affect three billion people around the globe. Nearly two million a year die prematurely from illnesses attributable to indoor air pollution. Those exposed to the risk of indoor air pollution are people who still cook and heat their homes using solid fuels in open fires and leaky stoves. Such cooking and heating produces high levels of health-damaging pollutants, including small impure carbon particles (soot) that penetrate deep into the lungs and affect mostly women and children who spend most of their time near the “hearth” (brick fire place often used for cooking).(8)

The National Institute for Environmental Health Sciences (NIEHS) funded a six-city study (a long-term study on residents of six U.S. cities) to assess the effects of air pollutants on the risk of pulmonary and cardiovascular disease.

This study was among one of the first studies to establish a link between air pollutants and respiratory health. People living in polluted cities had a higher riskof hospitalization and early death from lung cancer than those living in the less polluted cities.

Scientists at the University of Southern California found that children who live in highly polluted communities are five times more likely to have low lung functions, less than 80% of the lung function normal for their age.(10)

Another five-year study conducted by the University of Southern California found that children who were active in outdoor sports in areas with high ozone concentration were more than three times as likely to develop asthma as thosewho did not engage in outdoor sports.(11)

Each year, millions of people die as a result of tobacco use and of being exposed to air pollutants.(12) Exposure to air pollution has numerous health effects. The Environmental Protection Agency (EPA) cited pulmonary, cardiac and neurological impairments as being some of the effects of pollution in human health.(13) Although air pollution affects all the population, the elderly, infants, pregnant women and those who suffer from chronic heart and lung diseases are “high-risk” groups. Children are at greater risk because they are more active outdoors and their lungs are still developing.

Of those who die from exposure to indoor air pollution, 44% die from pneumonia, 54% from Chronic Obstructive Pulmonary Disease (COPD) and 2% from lung cancer.(9)



The overall incidence rate (rate per 1,000 exposed to risk persons) of the identified respiratory diseases increased from around 3 per thousandin 1999 to around 25 per thousand in 2010.

In other words, the risk of respiratory diseases increased at an average rate of 21% per year. Over the same period of time, the cost impact of respiratory diseases increased more than five folds, adding to the price of private health insurance policies (See Table 1 and Graph 1).

Table 1: Incidence Rate of Respiratory Diseases 1999-2010

FINDINGS

Calendar Year Rate per 1,000 Exposures

1999 2.62

2000 2.20

2001 9.58

2002 14.17

2003 14.33

2004 12.80

2005 15.61

2006 15.98

2007 15.25

2008 19.25

2009 22.86

2010 25.04

Total 15.55

A brief literature review coupled with close consultations with a senior medical officer at MedNet Liban helped identify the diseases to be reviewed. The following impairments have been reviewed:• Chronic Obstructive Pulmonary Disease (COPD)• Cancer of the Lungs and Bronchus• Asthma• Pneumonia

Where people live and/or work was also considered an important indicatorof exposure to the risk of respiratory diseases.

Based on the above, incidence rates have been calculated (for each of the identified diseases) by year of occurrence, age and gender of patients. Wherever possible, data by geographical location of patients’ residence was extracted and reviewed. Trends of incidence rates over time have also been calculated. The results are presented in the findings section.

METHODOLOGY

The literature review also indicated that respiratory diseases affect the young and the elderly more than they do other age groups.



Graph 2: Incidence Rate of Respiratory Diseases by Age Group 1999-2010

Males have exhibited higher incidence rates than females throughout the study period. The difference in incidence rates between males and females started to increase from calendar year 2007 onwards (Table 3, Graph 3). Each male exposed to respiratory diseases is contributing 3% more to the cost of an insurance policy than a female counterpart.

Graph 1: Incidence Rate of Respiratory Diseases 1999-2010

The following table shows that infants (less than 2 years) and the elderly(over 65 years) have higher incidence rates than other age groups. This result is consistent throughout the study period.

More importantly, the incidence rate of infants increased more than twenty folds over the 12-year period from around 8 per thousand in 1999 to 162 per thousand in 2010. This could be related to the increased rate of smoking parents: Greater awareness of children’s vulnerability to pollution’s hazards is needed. Example: Avoid smoking narguileh near a child, and avoid using chemicals.

The incidence rate of the elderly also increased over this time span but not in the same proportion (less than five folds).

Table 2: Incidence Rate of Respiratory Diseases by Age Group 1999-2010

Source: MedNet Liban


Age Group

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

0Y-1Y 8.06 5.04 43.10 81.28 71.98 62.84 81.44 83.01 84.16 95.45 124.75 162.02

2Y-6Y 2.34 1.30 20.99 30.82 30.44 23.36 30.06 26.49 25.47 28.18 32.49 33.96

7Y-12Y 0.95 0.49 5.81 9.27 5.61 6.06 8.55 10.94 6.78 7.85 10.77 10.73

13Y-16Y 0.60 0.12 3.78 6.59 6.06 5.00 6.17 7.93 5.70 5.29 10.20 9.45

17Y-64Y 2.09 2.08 5.82 8.71 9.25 8.51 9.71 9.84 9.59 12.01 13.91 15.13

65 or OLDER

11.65 9.02 27.46 29.84 37.99 33.38 40.65 44.04 44.59 58.20 64.53 63.91



Graph 4: Incidence Rate of Respiratory Diseases by Caza in Lebanon

00.00

25.99

19.35

30.67

53.69

13.34

27.85

34.24

19.92

30.72

56.13

13.39

28.52

36.26

23.32

30.87

59.71

16.82

29.18

43.60

24.55

31.50

18.99

29.63

44.78

25.88

31.54

Sawfar

Minieh

Byblos

Koura

Jezzine

Hermel

Batroun

Baalbeck

Kesrouane

Tyre

Saida

Marjayoun

Zahle

West Bekaa

Aley

Chouf

Hasbaya

Bcharre

Akkar

Rachaya

Bent Jbeil

Tripoli

Metn

Zgharta

Beirut

Baabda

Nabatieh

Table 3: Incidence Rate of Respiratory Diseases by Gender 1999-2010

Graph 3: Incidence Rate of Respiratory Diseases by Gender 1999-2010

Having identified the geographical residence of each patient with a respiratory disease incidence, Graph 4 (following) shows that the most congested urban areas have the highest incidence rate of respiratory diseases. The Beirut metropolitan area, Baabda, Dahya, and Saida are some areas where the rate per 1,000 exposedto risk persons is high.


Year Female Male

1999 2.18 3.02

2000 1.62 2.80

2001 7.64 11.58

2002 12.08 16.32

2003 12.96 15.74

2004 11.01 14.69

2005 13.53 17.80

2006 14.70 17.36

2007 12.72 18.00

2008 16.61 21.77

2009 19.76 25.81

2010 22.22 27.73



How can you reduce the risk of getting bronchitis?

• Don't smoke.• Don't allow others to smoke in your home. • Stay away from or reduce your time around things that irritate your nose, throat and lungs, such as dust or pets. • If you catch a cold, get plenty of rest. • Take your medicine exactly the way your doctor instructs you.• Eat a healthy diet.• Wash your hands often.• Do not share food, cups, glasses, or eating utensils.

Table 4: Incidence Rate of Chronic Obstructive Pulmonary Disease 1999-2010

The incidence rates of COPD increased from less than 2 per 1,000 lives in 1999 to over 4 per 1,000 lives in 2010. This almost represents an average 8% yearly increase. Compared to U.S. data, our incidence rates are 102% higher(14) (for the year 2009; latest available U.S. data).

Year Rate per 1,000 ERP

1999 1.78

2000 1.37

2001 1.87

2002 2.10

2003 1.71

2004 1.72

2005 1.97

2006 2.26

2007 2.17

2008 3.69

2009 4.11

2010 4.48

Average Annual Change 7.99%

Chronic Obstructive Pulmonary Disease (COPD) is one of the most common lung diseases. There are two main types of COPD: • Chronic bronchitis, which involves a long-term cough with mucus.• Emphysema, which involves a destruction of the lungs over time. Smoking is the leading cause of COPD. However, some people smoke for years and never get COPD. Non-smokers could, in rare cases, develop emphysema due to a lack of alpha-1 protein. Other risk factors for COPD include exposure to gases or fumes in the workplace, exposure to heavy amounts of second hand smoke and pollution and frequent use of cooking fire without proper ventilation. COPD is a major cause of disability and it is the third leading cause of deaths in the United States.(12)

Chronic bronchitis may be caused by one or several factors. Repeated attacks of acute bronchitis may be a cause of chronic bronchitis. Industrial pollution is another culprit. Chronic bronchitis is found in higher-than-normal rates among coal miners, grain handlers, metal molders, and other people who are continually exposed to dust. But the primary cause is heavy, long-term cigarette smoking, which irritates the bronchial tubes and causes them to produce excess mucus. The symptoms of chronic bronchitis are also worsened by high concentrations of sulfur dioxide and other pollutants in the atmosphere.

DISEASE SPECIFIC RESULTS

CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)


17

Asthma is a chronic lung disease that inflames and narrows the airways. Asthma causes recurring wheezing (breathing accompanied with whistling sound), chest tightness, shortness of breath and coughing.

Asthma affects people of all ages, but most often it starts at childhood. It is estimated that three out of every eleven asthma cases are children-related. Some people develop what is known as “occupational” asthma because of contact with certain chemical irritants or industrial dusts in the work place.(15)

A Norwegian study revealed that asthma is linked to the “belly fat” syndrome. Researchers followed around 23,200 adults for eleven years. They found that obese and “centrally” obese adults were 1.8 times more likely to develop asthma.(16)

Another Danish study conducted on about 43,000 children showed that 19% of children whose mothers were occupationally exposed to certain substances and chemicals (while in their jobs) during pregnancy had asthma.(17)

The results obtained from MedNet Liban’s database showed that the incidence rate of asthma increased at an average annual rate of 8.2% from 2001 to 2010. The incidence rate of asthma is highest among children seven years old or younger. However, the incidence rate of asthma has fluctuated over the most recent years. And the trend calls for an increase over time.

Table 6: Incidence Rate of Asthma 2001-2010

ASTHMA


2001 0.72

2002 1.17

2003 0.91

2004 1.13

2005 1.46

2006 1.54

2007 1.46

2008 1.62

2009 1.48

2010 1.59



GLOBEMED LTD BULLETIN / RESPIRATORY PROBLEMS AND POLLUTION / 2012

Graph 5: Incidence Rate of Chronic Obstructive Pulmonary Disease 1999-2010

Table 5: Incidence Rate of Chronic Obstructive Pulmonary Disease, MedNet Liban vs. USA 2007-2009


Year MedNet Liban U.S.

2007 2.17 1.58

2008 3.69 2.01

2009 4.11 2.03



Year MedNet Liban U.S.

2007 4.07 3.52

2008 5.51 3.91

2009 7.03 3.74

Pneumonia is a lung infection that can cause mild to severe illness in people of all ages, especially those over the age of 64 years and in children younger than 5 years of age.

People who smoke or have asthma are at an increased risk of getting pneumonia. There are two types of pneumonia: Hospital-Acquired Pneumonia (HAP) and Community-Acquired Pneumonia (CAP).

Community-Acquired Pneumonia (CAP) is a condition in people who have not recently been in the hospital. This is less serious than Hospital-Acquired Pneumonia (HAP) since hospitalized persons are often unable to fight off germs that are usually present in hospitals.

A study by Canadian researchers revealed that exposure to nitrogen oxide and particulate matter more than doubles the risk of CAP. The study published in the American Journal of Respiratory and Critical Care Medicine (December 2009) highlighted the important health impact that long-term exposure to ambient air pollution can have on respiratory infections.(18) The World Health Organization (WHO) reports that about 50% of deaths from pneumonia among children under 5 are due to particulate matter inhaled from indoor air pollution.(19)

Based on MedNet Liban’s data, (reported) pneumonia cases are on the rise at an average annual rate of about 12% (See Table 8). The mortality rate is 1.1% despite the availability of highly effective antibiotics.(20)

Unknown and/or unreported pneumonia cases could make the incidence rates in Table 8 even higher. According to the statistics published by the Centersfor Disease Control (CDC), the incidence rates of pneumonia increased from 3.52per thousand in 2007 to 3.74 per thousand in 2009. The incidence rates derived from our data were 4.07 and 7.03 respectively.

Table 8: Incidence Rate of Pneumonia, MedNet Liban vs. USA 2007-2009

PNEUMONIAGraph 6: Incidence Rate of Asthma 2001-2010

Compared to U.S. data, asthma rates are pretty close (less than 2 casesper 1,000 lives).

Table 7: Incidence Rate of Asthma, MedNet Liban vs. USA 2007-2009

(1) MedNet Liban Data(2) Centers for Disease Control, 2007-2009


Year MedNet Liban(1) U.S.(2)

2007 1.46 1.58

2008 1.62 1.49

2009 1.48 1.57



Graph 7: Incidence Rate of Lung Cancer 1999-2010

Although most lung cancer cases are caused by cigarette smoking, most research papers have shown that pollution increases the risk of lung cancer. The evidence derives from studies of lung cancer trends, occupational groups, and a comparison of urban and rural population. An increase of 30 to 50% in lung cancer rates was observed and associated with exposure to respirable particles.(22)

Lebanese Cancer Society Facts and Figures

1- Smoking association: It is never too late: “Smokers who quit before age 50 halve their risk of dying in the next 15 years in comparison with those who continue smoking. Smoking is the single most preventable cause of disease, responsible for 87% of all lung cancer cases and 30% of all cancer deaths. It also places the family at risk of lung diseases.”

2- Narguileh: It is very popular in Lebanon and considered a less dangerous form of smoking due to its filtration by water, which is not true.


Cancerous Mass

CANCER OF THE LUNGS


1999 0.52

2000 0.61

2001 1.25

2002 0.63

2003 0.71

2004 0.59

2005 0.80

2006 0.79

2007 0.58

2008 0.77

2009 0.77

2010 0.79


Lung cancer is one of the most common cancers and is a leading cause of cancer deaths in men and women.

Most lung cancers are caused by cigarette smoking. High levels of pollution, radiation and asbestos exposure may also increase the risk of lung cancer.

Cancers of the lung account for almost one in fifteen cancers of the male population.(21) From 1999 to 2010, the incidence rate of lung cancer increased at an average annual rate of 3.5% (Table 9 and Graph 7).

Table 9: Incidence Rate of Lung Cancer 1999-2010




We make choices everyday that can affect the way we live.Why not make choices that can help improve our health?

Let’s start by taking small steps such as: • Conserving energy (most of us are forced to do so when power supply is limited due to higher costs of high levels of supply.)• Recycling• Well maintaining woodstoves and fireplaces• Buying green electricity, produced by low pollution facilities• Not smoking at home, especially in the presence of children• Buying rechargeable batteries for frequently used devices• Driving wisely• Removing indoor asthma triggers from homes• Avoiding outdoor triggers of asthma

Citizens could make those simple choices if circumstances were helpful. Favorable circumstances are created by governments through the enactment and enforcement of proper laws.

CONCLUSIONS

The preceding sections indicate an upward trend in the incidence rates of respiratory diseases. Research studies at the international level link most respiratory diseases to “man-made” pollutants such as a widespread use of tobacco smoke, indoor as well as outdoor air pollutants and to other environmental factors.

In Lebanon, few studies have reviewed the problem of pollution, especially in urban areas. Unfortunately, no attempts were made to date to study the health effects of pollution. On the other hand, a 12-year, ad-hoc study of a large sample of risks, whose health status had been recorded by MedNet Liban, reveals alarming increases in the incidence of respiratory diseases. The missing link is yet to be addressed.

I am, as a simple Lebanese citizen, pretty confident that such a link couldbe established. Yet, there is no doubt that Lebanese residents are feelingthe burden of pollution. Some are active in creating awareness about pollution problems, while others might need to be educated about this issue in order to help create a cleaner environment.

Governments around the world have enacted special laws and regulations to protect the environment. Citizens of every country, residents of every city, town or village should join hands to reduce the damaging effects of pollution on their health, their economy and their living places.

Some efforts have to be made to link the increased levels of pollution to the levels of respiratory diseases.


GLOBEMED BULLETIN / RESPIRATORY PROBLEMS AND POLLUTION / 2012

REFERENCES

(1) World Health Organization

(2) Air Pollution and Respiratory Disease, National Institute of Environmental Health Sciences, National Institute of Health, November 2011

(3) The Daily Star, July 22, 2005

(4) Office of Communication, American University of Beirut, May 7, 2011 www.mediaaub.edu.lb (5) www.nowlebanon.com, September 22, 2008


(8) World Health Organization (WHO), Fact Sheet No. 292, September 2011 www.who.int/mediacenter/factsheets/fs292/en/ (9) Ibid, 2004 Data

(10) Air Pollution & Respiratory Disease, NIEHS, November 14, 2011 www.niehs.nih.gov/health/impacts/respiratory/index.cfm(11) Air Pollution & Respiratory Disease, NIEHS, November 14, 2011 www.niehs.nih.gov/health/impacts/respiratory/index.cfm(12) Risk Factors For Chronic Respiratory Diseases, World Health Organization, 2007 www.who.int/gard/publications/GARD/(13) Effects of Air pollutants – Health Effects, 2010 www.epa.gov/course422/ap7a.html(14) Rate of Discharges, Centers for Disease Control (CDC), 2009

(15) What is Asthma? National Heart, Lung and Blood Institute, National Institute of Health, U.S. Department of Health and Human Services, February 2011

(16) Belly Fat May up Asthma Risk, Top News, September 26, 2011 www.topnews.in/healthdiseases/asthma(17) Occupational Hazards in Pregnancy Can Cause Asthma in Kids, Top News, September 26, 2011 www.topnews.in/healthdiseases/asthma(18) Neupane B, et al “Long-term Exposure to Ambient Air Pollution Risk of Hospitalization with Community-Acquired Pneumonia in Older Adults” Am J Respir Crit Care Med, 2009

(19) World Health Organization, Fact Sheet No. 292, September 2011

(20) MedNet Liban Data, Outcomes Management Bulletin

(21) MedNet Liban Data, Published January 2012

(22) AJ Cohen and CA Pope, 3rd, Lung Cancer and Air Pollution, Environmental Health Prospect, November 1995, 103 (Supp 8): 219-224

REFERENCES

(1) World Health Organization

(2) Air Pollution and Respiratory Disease, National Institute of Environmental Health Sciences, National Institute of Health, November 2011




(7) World Health Organization (WHO), Fact Sheet No. 292, September 2011 www.who.int/mediacenter/factsheets/fs292/en/ (8) Ibid, 2004 Data

(9) Air Pollution & Respiratory Disease, NIEHS, November 14, 2011 www.niehs.nih.gov/health/impacts/respiratory/index.cfm(10) Risk Factors For Chronic Respiratory Diseases, World Health Organization, 2007 www.who.int/gard/publications/GARD/(11) Effects of Air pollutants – Health Effects, 2010 www.epa.gov/course422/ap7a.html(12) What Is COPD? National Heart, Lung and Blood Institute, National Institute of Health, U.S. Department of Health and Human Services, June 2010

(13) Rate of Discharges, Centers for Disease Control (CDC), 2009

(14) What is Asthma? National Heart, Lung and Blood Institute, National Institute of Health, U.S. Department of Health and Human Services, February 2011

(15) Belly Fat May up Asthma Risk, Top News, September 26, 2011 www.topnews.in/healthdiseases/asthma(16) Occupational Hazards in Pregnancy Can Cause Asthma in Kids, Top News, September 26, 2011 www.topnews.in/healthdiseases/asthma(17) Neupane B, et al “Long-term Exposure to Ambient Air Pollution Risk of Hospitalization with Community-Acquired Pneumonia in Older Adults” Am J Respir Crit Care Med, 2009

(18) World Health Organization, Fact Sheet No. 292, September 2011

(19) MedNet Liban Data, Outcomes Management Bulletin

(20) MedNet Liban Data, Published January 2012

(21) AJ Cohen and CA Pope, 3rd, Lung Cancer and Air Pollution, Environmental Health Prospect, November 1995, 103 (Supp 8): 219-224

GM A4 Respiratory Bulletin Inside Pages AW.indd 24 8/8/12 10:49 AM

Prepared bySarkis M. El Zein, PhD

globEMED bullEtin

RESPiRatoRy PRoblEMS anD

Pollution

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t +961 1 489189F +961 1 485010

[email protected] www.globemedltd.com

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