Assessing the Health Effects of Air Pollution in Asia: HEIs Public Health and Air Pollution in Asia

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Assessing the Health Effects of Air Pollution in
Asia HEIs Public Health and Air Pollution in
Asia (PAPA) Program

• Sumi Mehta, Aaron Cohen, Wei Huang, Robert
  OKeefe
• Health Effects Institute

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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 in US from
• Government (U.S. EPA)
• Industry (28 Worldwide Vehicle Manufacturers)
• Also partnerships around the world
• WHO, European Commission, California, ADB,
• Other industries (eg. oil, chemical)
• Independent Board and International Expert
  Science Committees oversee and review all
  research
• Over 220 studies completed increasingly
  international focus
• Policy relevant research but no policy positions!

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Air pollution and health

• Air pollution is a growing environmental problem
  in Asian cities due to growing urbanization,
  motorization and industrialization
• Health impacts of air pollution are considerable.
  World Health Organization estimates that about
  480,000 people die prematurely in Asia each year
  due to exposure to ambient air pollution.
• Many hundreds of thousands develop health
  problems or experience decreased health because
  of pollution. They miss work or school because of
  air pollution.
• Air pollution costs Asian cities hundreds of
  millions of dollars per year.

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While air pollution poses clear health effects,
the bulk of the evidence is from urban areas of
developed countries
6 of mortality in Austria, France, and
Switzerland attributable to outdoor air pollution
at much lower levels (Kunzli et al., 2000) What
is happening in developing countries where
average PM10 levels are much higher? What is
happening indoors in developing countries where
24-hr PM10 levels often exceed 1000-2000 µg/m3?
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Many Sources of Air Pollution in Asia

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

• Combustion
• Agricultural burning
• Brick Kilns
• Vehicles
• Trash burning
• Factories
• Power generation
• Cooking in slums
• Other area sources

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Extrapolation of developed country research to
other populations is challenging, and often
inadequate

• Pollution sources and mixes are different
• Competing risk factors are different
• Population characteristics addressed / overlooked
• Health effects addressed / overlooked
• Epidemiologic evidence base often only at low end
  of the dose-response curve

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Public Health and Air Pollution in Asia (PAPA)

• Partnership with CAI-ASIA to understand the
  health effects of air pollution in Asia, now and
  in the future
• Supported by US AID, Foundations, industry, ADB,
  others
• 4 year program to
• Assess the state of air pollution and health
  across Asian cities
• Initial review of what is known today about
  health effects in Asian cities published April
  2004
• A second comprehensive assessment in four years
• Initiate a series of epidemiological studies in
  representative Asian cities to estimate local
  impacts, inform extrapolation throughout the
  region
• Build capacity of local scientists
• Overall Goal
• Inform key Asian regulatory policy decisions

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Health Effects of Outdoor Air Pollution in
Developing Countries of Asia a Literature Review
(2004)

• Systematic identification of peer-reviewed Asian
  studies 1980-2003
• Identify knowledge gaps/research needs
• Put results in context of broader air pollution
  health science
• First regional meta analysis of studies of
  daily changes in air pollution and health
• Similar Risk Estimates Across Region
• Significant Asian health literature exists
• Studies address a wide range of health endpoints
• Some countries studied extensively (China,
  Korea), but research lacking in others (India,
  Indonesia, Vietnam)

available at www.healtheffects.org
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0.61
0.62
.

• Estimates Using Pre-GAM Results (without
  revision)
• Latin American estimates from a review by the Pan
  American Health Organization (PAHO)

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Public Health and Air Pollution in Asia
Science Access on the Net (PAPA-SAN )

• Web-based compendium of studies of the health
  effects of air pollution in Asia
• Currently includes over 250 studies on the health
  effects of air pollution in Asia
• PAPA-SAN can be accessed at
• www.healtheffects.org/international
• PAPA-SAN CDs are available at BAQ 2006!

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Epidemiologic studies of the health effects of
air pollution in Asia (19802006)
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Publications of epidemiologic studies of air
pollution in Asia, by year of publication
Note published papers collected through June 2006
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Epidemiologic Studies of Outdoor Air Pollution in
Asia (1980 - 2006)
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Epidemiologic Studies of Outdoor Air Pollution
in Asia (1980 - 2006)
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New Research PAPA Coordinated Time-Series
Studies

• Provide the most definitive epidemiologic
  evidence of the effects of short-term exposure.
• Expand current science base with studies in
  representative regional populations
• Are observed risks similar, greater, or smaller?
  
• Are the right health outcomes addressed?
• Asian effects can be documented relative to those
  in developed countries, enhancing possibilities
  for extrapolation
• Results can be used to inform regional air
  regulatory decisions
• Seven studies of air pollution and mortality
• First four studies Hong Kong, Mainland China
  (Shanghai, Wuhan), Thailand (Bangkok)
• India studies Chennai, Delhi, Ludhiana (data
  challenges are not an excuse for inaction!)

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Air Pollution, Poverty, and Health

• The poor may suffer more health effects from air
  pollution (global perspective)
• The poor may suffer higher exposures to air
  pollution
• Roadside exposures (occupational, commuting,
  residential)
• Small and medium scale enterprises / Cottage
  industries
• Use of solid fuels for cooking
• The poor may be more susceptible to air pollution
• Poorer nutrition / immunosuppression
• Higher incidence of diseases of poverty
• Lack of timely or comprehensive access to health
  care
• Limited evidence from the West, but a clear need
  to explore this issue in the Asian context

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New Research Air Pollution, Poverty, and Health
in Ho Chi Minh City (HCMC)

• At the request of ADB, the PAPA program has
  developed a program to explore the relation among
  air pollution, poverty and health in Ho Chi Minh
  City (HCMC).
• Overall Objectives
• Develop feasible approaches to studying air
  pollution, poverty, and health
• Methods appropriate for HCMC context
• Methods suitable for use in other cities -
  promote building an evidence base across Asian
  cities
• Develop infrastructure for future studies of the
  health effects of air pollution in HCMC
• Technical capacity (epidemiologic methods,
  exposure assessment, analysis)
• Resources (data integration, equipment)

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New Research Air Pollution, Poverty, and Health
in HCMC

• Hospital Study
• Assess the effects of short-term exposure to air
  pollution on hospital admissions from 2003 to
  2005 for acute lower respiratory infections
  (ALRI) in young children (lt5 years of age) of
  HCMC
• Assess whether there are there different effects
  in poor children vs. other children
• Household Study
• What is the correlation between ambient air
  pollution concentrations and personal exposures?
  
• Is this correlation different for the poor vs.
  the non-poor?
• Are the poors personal exposures to air
  pollution higher?
• Ambient air pollution
• traffic
• Cooking indoors with wood, kerosene and/or coal
• Environmental tobacco smoke (ETS)
• Cottage industries
• Are the mean total exposures of the poor higher?

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Summary hypotheses to be tested

• H1 the poor experience greater health impacts
  from ambient air pollution
• H2 the poor are more exposed to air pollution
  (ambient and other sources)
• H3 exposures of the poor are more correlated
  with ambient air pollution

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Strengthening the Network of Asian Environmental
Health Researchers

• Providing technical assistance and capacity
  building tailored to investigator needs
• Biostatistics
• HCMC infrastructure for personal monitoring and
  analysis
• Facilitating interaction with international
  experts and colleagues
• Guidance on study design and progress from
  International Scientific Oversight Committee
• Collaboration with other groups conducting
  similar research
• Supporting active participation at scientific
  meetings (HEI Annual Conference, ISEE, BAQ)

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PAPA International Scientific Oversight Committee

• Frank Speizer, M.D. - Chair
• Harvard Medical School
• H. Ross Anderson
• St. George's Hospital Medical School
• Michael Brauer
• University of British Columbia
• Bingheng Chen
• Fudan University
• Kenneth L. Demerjian
• State University of New York, Albany
• Jiming Hao
• Tsinghua University

• Anthony. J. Hedley
• The University of Hong Kong
• Jitendra N. Pande
• All India Institute of Medical Sciences
• C. Arden Pope, III
• Brigham Young University
• Kirk R. Smith
• University of California, Berkeley
• Mark J. Utell ex officio
• University of Rochester
• Paul Wise
• Stanford University

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PAPA Team Investigators, ISOC, and HEI Staff
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In Summary

• Exposure to air pollution has been linked with
  increased death and illness
• Most studies have been done in Europe and North
  America
• Asia faces significant air pollution problems
  today
• Some aspects of the problem will grow with
  economic expansion
• Other more traditional aspects will not go away
  on their own
• Air pollution impacts on the urban poor likely to
  be qualitatively different
• Major objectives of the PAPA program
• Contribute to a policy-relevant base of Asian
  health and air pollution science
• Develop further understanding of urban air
  pollution health effects in less developed,
  under- studied areas in Asia
• Explore the relations among air pollution,
  poverty, and health in Asia

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For further information about the PAPA
ProgramPAPA_at_healtheffects.orgwww.healtheffects.
org