1. The Health Effects of Air Pollution Asian Science in a Global Context “PAPA Program” Robert O’Keefe, Vice President Health Effects Institute CAI-Asia China Workshop Beijing, China September, 2006

2. HEI-PAPA Program HEI: International air pollution research institute supported by government and industry HEI overseeing Public Health and Air Pollution in Asia “PAPA” Program Partnership with CAI-ASIA to understand & communicate the health effects of air pollution in Asia Published Scientific Review and Meta Analysis of what is known today about health effects in Asian cities Publish PAPA-SAN Web–based compendium of Asian studies (<120 in China) Series of epidemiological studies in 8 Asian cities (HK, Wuhan; Shanghai) Understand local pollution impact Combine to provide Asia-wide Build capacity of local scientists Publish a Comprehensive Assessment of the state of air pollution and health across Asian cities Initiate new research to understand intersection of poverty air pollution and health Overall Goal: Communicate quality science to policy makers to drive key Asian regulatory & policy decisions

3. Source: Lancet 1953 London, December 1952

4. 50+ Years of Air Pollution Research 1960 1970 1980 1990 2000 1950 London Fog Surveys Ecological studies Early time-series studies Six Cities Study Exposure Assessment Modern time-series studies Toxicology, cohort, multi-city studies; 2005

5. High Air pollution in many Asian cities (2000-2003) …..and new compliance challenges Source: CAI-Asia network (annual averages) SO2 NO2 SPM PM10 SPM Limit = 60-90 µg/m 3 (WHO, 1979) 3 PM 10 Limit = 20 µg/m 3 (WHO, 2005) SO 2 Limit = 50 µg/m 3 (WHO, 1999) NO 2 Limit = 40 µg/m 3 (WHO, 1999) NEW! USEPA adopts stringent new PM2.5 Standard 2.5 standard (35µg/m 3 ) a 40% reduction from previous standard

6. WHO Global Burden of Disease Report (Lancet October, 2002) Impact of urban outdoor air pollution in Asia 519,000 Premature Deaths Year 295,000 in China (>1,000,000 Indoor Air) >2 million years of life lost (disability adjusted)

7. PAPA Literature Review: Health Effects of Outdoor Air Pollution in Developing Countries of Asia Systematic identification of 140 peer-reviewed Asian studies 1980- 2003 (over 60 from China) Special focus on studies of daily changes in air pollution and health Conduct first ever Asian meta analysis” 28 “time series” studies evaluated in depth effects in Asia and to assess relative to West Identify knowledge gaps to guide future research Now being updated with many recent studies, made web accessible,

8. PM: Key Data on Short-Term Effects The National Morbidity, Mortality and Air Pollution Study 90 Largest Cities in the US Daily changes in PM, mortality, weather Relatively consistent increase in Mortality: 2% per 100 ug/m 3 of PM 10 Smaller results than previous U.S. analyses Remain significant Not sensitive to inclusion of other pollutants Results in different in different regions require additional analysis

9. Air Pollution and Health: Europe (APHEA), North American (NMMAPS), Asia (PAPA) ( Acute effect studies HEI the EU and Asia)

10. PAPA Review Initial Results: Asian Risk Estimates Similar to West * Estimates Using Pre-GAM Results (without revision) PAPA (Public health and Air Pollution in Asia, a CAI-ASIA Initiative)

11. New PAPA Studies in China Hong Kong SAR Time-series (1996-2002); mortality, influenza Dr. CM Wong, Hong Kong University Shanghai Time-series (2002-2005) Drs. HD Kan and Bingheng Chen, Fudan University Wuhan Time-series (7/2000-6/2004) Dr. ZM Qian, Penn State University, Wuhan Monitoring Center Combined analysis to provide cross-Asia profile Individual studies now complete and in Peer Review -Preliminary results at 2006 BAQ

12. The PAPA Studies

13. New: Ozone and Daily Deaths in Shanghai (Zhang et al EHP #8 August 2006) Assessed Ozone concentration and daily death Found increased effect of death from cardiovascular during winter season (though not in warm season) Effects seen at levels below current standard First Journal study from PAPA teams, first to report acute effect of Ozone and death in mainland China (Full HEI Studies in Review)

14. Long Term Effects: Key PM Data HEI Reanalysis (Krewski, et al, 2000) Key Cohort Studies American Cancer Society: 550,000 individuals; 150 cities, many years Detailed health, socioeconomic info on each subject 2000 HEI reanalysis: Validated results, identified robust associations of mortality with PM2.5, SO2, Sulfate Analysis recently extended as population ages, found new effect of PM2.5 on lung cancer, heart effects (Pope, et al)

15. Long-term analysis of “Concentration-Response” PM effect threshold extends below current standard, though with increasing uncertainty American Cancer Society HEI Reanalysis Results (Krewski, et al 2000)

16. “Roadway” Effects Growing number of studies looking at exposures and effects at roadside High levels of some pollutants Substantial populations potentially affected especially in urban areas Rapid vehicle growth Exposure, Animal, and Epidemiology Studies Crude Exposure metrics Difficult to separate sources

17. Near Highway: Levels of some pollutants higher U Fine, Black Carbon, CO peak near roadways (PM 2.5 consistent) (Zhu et al 2003) PM mass Particle numbers

18. Near Highway: Diesel Effects on Childhood Illness (Brunekreef, et al Study in 24 Dutch schools)

19. Time Spent in Traffic and Heart Attack HEI Study (Peters et al 2005) -Found elevated risk of MI for those in traffic 2 hrs prior to event -Association with PM10, SO2, (not PM2.5, UF) Noise, stress could also play role

20. The “Other” Pollutants Recent Findings Nitrogen Dioxide (NO2 ) Sulfur Dioxide (SO2) CO Ozone Toxic air pollutants (i.e. benzene)

21. Nitrogen Dioxide (NO2) Known, like many “oxidants” to cause inflammation May cause serious problems at lower levels and short, high doses Also may be a “marker” for other pollutants (e.g. fine PM)

22. Childhood lung function development reduced in those exposed to higher NO2 Community-specific average growth in FEV1 among Girls and Boys for the period 1993 to 2001 plotted against average nitrogen dioxide (NO2) levels from 1994 to 2000 (Gauderman 2004)

23. Sulfur Dioxide Emitted from vehicles using high sulfur fuels and coal combustion Impairs breathing in asthmatic children and adults Has been associated, along with PM, with premature mortality (ACS Study 2000, 2002) Recent study in Hong Kong (Lancet 2002) has found benefits of reduction ACS Extended Analysis (Pope 2002) Type of Mortality Statistically Significant Effect? PM 2.5 SO 2 Sulfate All Cause ++ Cardio- pulmonary ++ Lung Cancer ++++ Other Cause -++

24. 1992199319941995 0 20 40 60 80 NO 2 SO 2 O3O3 PM 10 Micrograms per cubic metre Year Hong Kong Fuel Sulfur Ban Air Pollutant Concentrations 1988 – 95 Pre and Post Ban Fuel restriction on sulfur 50% reduction in SO 2 after the intervention No change in other pollutants

25. -6-6 -5-5 -4-4 -3-3 -2-2 -1 0 15-6465+15-6465+15-6465+ REDUCTIONS IN DEATHS AFTER SULFUR RESTRICTION All causesCardiovascularRespiratory % Reduction in annual trend -1.8% -2.8% -1.6% -2.4% -4.8% -4.2%

26. Looking Ahead

27. Tracking the Scientific Literature: The PAPA-SAN Web Accessible Data Base http://www.healtheffects.org/Asia/papasan- home.htm -New resource for scientists, policy makers -240 Studies Identified through June 2005 (Over 120 in China) - Complete listing of studies, characteristics results now available at HEI Website -New analyses of data planned

28. Epidemiologic studies of the health effects of air pollution in China (1980–2006)

30. A Special Challenge for PAPA: Air pollution, poverty, and health Some evidence (mostly from US, Europe) that the poor face worse effects from air pollution No study to date in Asia PAPA implementing new study in Ho Chi Minh City, Vietnam Support from Asian Development Bank, DFID Led by HCMC health and environment experts Are the poor exposed to higher levels of air pollution? Do the poor suffer worse effects from air pollution?

31. Conclusions 1 We know much more about air pollution effects than we did 50 years ago The epidemiology has strengthened: Short Term: Many more studies around world, higher quality Initial PAPA time series analysis finds effects in Asia similar to those in Europe US Long Term: ACS, Six Cities Studies validated and extended original results, lung cancer begins to emerge as concern Lack of an observed threshold for PM raises concerns about effects at or below current standards Agencies respond with tougher standards WHO, issued new stringent PM10 guideline (20 ugm3) New Stringent USEPA Daily PM 2.5Standard (65 to 35 ug/m3) 40% reduction

32. Conclusions 2 Levels of air pollution, mortality still high in Asia Vehicles, coal fired plants, area sources all of concern in China However interventions can be highly successful to reduce emissions, improve health, reduce costs (e.g. fuel sulfur in Hong Kong) New HEI-CAI ASIA resources (Review, China studies, PAPA-SAN) are becoming available to document science for policy makers to drive intervention measures

33. Capacity Building: Frequent Workshops on Study Design, Analysis 亚洲当地的科研能力培养：经常举办研究方案设计分 析研讨会

34. Thank You! rokeefe@healtheffects.org