Health Effects of Air Pollution: A Summary of Recent Findings Francesco Forastiere Carpi, 27 October 2017 f.forastiere@deplazio.it

Science 307:1857-1861, News Focus, March 2005

Osservazioni satellitari Environ Health Perspect 118:847–855 (2010).

Satellite-derived map of PM2. 5 averaged over 2001-2006 Satellite-derived map of PM2.5 averaged over 2001-2006. Credit: Dalhousie University, Aaron van Donkelaar

Stafoggia et al, Env Int, 2016 Air pollution maps, Italy, 2006-2012 Maps of PM10 in Italy at high resolution using satellite data (1 Km grid) Stafoggia et al, Env Int, 2016

From proxies to fixed monitors to sensors, satellites and data fusion

(target or limit value) WHO AQG Summary (2005) Pollutant Averaging time AQG value EU standard (target or limit value) Particulate matter PM2.5 PM10 1 year 24 hour (99th percentile) 10 µg/m3 25 µg/m3 20 µg/m3 50 µg/m3 -- 40 µg/m3 50 µg/m3*** Ozone, O3 8 hour, daily maximum 100 µg/m3 120 µg/m3*** Nitrogen dioxide, NO2 1 hour 200 µg/m3 200 µg/m3*** Sulfur dioxide, SO2 24 hour 10 minute 500 µg/m3 125 µg/m3*** 350 µg/m3*** (1 hr) WHO levels are recommended to be achieved everywhere in order to significantly reduce the adverse health effects of pollution ***Permitted exceedances each year

THE EFFECTS OF AIR POLLUTION ON HEALTH ARE OFTEN CONVENIENTLY CLASSIFIED: In short-term and long-term effects although there is probably a continuum of effects in the time scale, which are not yet fully understood.

Acute effects Temporal differences Chronic effects Spatial differences Roma PM10 ed NO2

Short-term health effects

Deaths from London Smog, December 1952

Samet et al, NEJM, 2000; 343 (24):1742 % change per 10μg/m3

APHEA RESULTS Percentage increase in the daily number of deaths associated with 10 ug/m3 increase in PM10 measurements for each city. Katsouyanni, 2001

MED-PARTICLES: the cities

Effects of PM2.5 and PM2.5-10 on mortality, EHP 2013

Long-term health effects

Long-term exposure and mortality POPE ET AL, JAMA 2002

Cause of mortality RR (95% CI) All cause 1.06 (1.02 – 1.11) Adjusted mortality relative risks (RR) associated with 10μg/m3 change in PM2.5* (Pope et al, 2002) Cause of mortality RR (95% CI) All cause 1.06 (1.02 – 1.11) Lung cancer 1.14 (1.04 – 1.23) Cardiopulmonary 1.09 (1.03 – 1.16) All other cause 1.01 (0.95 – 1.06) *Adjusted for age, sex, race, smoking, education, marital status, body mass, alcohol consumption, occupational exposure, diet.

European Studies

Air pollution in the Rome Longitudinal Study EHP 2013 Average exposure at baseline: 43.6 μg/m3 NO2 23.0 μg/m3 PM2.5

The air pollution maps in Rome

Air pollution and mortality in the Rome Longitudinal Study EHP 2013 10 ug/m3 NO2 10 ug/m3 PM2.5   Cases HR 95%CI Non accidental mortality 144,441 1.03 1.02 1.04 1.05 Cardiovascular mortality 60,318 1.06 1.08 IHD mortality 22,562 1.10 1.13 Respiratory mortality 8,825 1.00 0.97

EHP 2013 EU Limit Value EU Limit Value Using these maps, they established that NO2 was related to all-cause and cardiovascular mortality, and that this relationship was also clear at levels well below the EU Limit Value of 40 microgram/m3. Even more important, this relationship was found to be independent of the relationship between PM2.5 and mortality in this study. EHP 2013

ESCAPE study areas in EUROPE PM+NOx NOx only

The ESCAPE project

The ESCAPE project

The ESCAPE project PM10 (10 ug/m3) PM2.5 (5 ug/m3)   PM10 (10 ug/m3) PM2.5 (5 ug/m3) Non accidental mortality 1.04 (1.00–1.09) 1.07 (1.02–1.13) CV mortality 1.02 (0.92–1.14)  0,99 (0.91–1.08) Incidence of acute coronary events 1.12 (1.04-1.28) 1.13 (0.98-1.30) Incidence of stroke 1.02 (0.90-1.16) 1.19 (0.88-1.62) Lung cancer incidence 1.22 (1.03–1.45) 1.18 (0.96–1.46)

Recent statements and publications on air pollution

IARC Monographs There are other sources of particles for which the evidence base is strong. Here I am showing you a recent re-evaluation for household use of solid fuels, and in that monograph you can find the evidence for the combustion of coal – it is also categorized as Group 1. And obviously, another source of particles with very important health consequences is tobacco smoke, both for the smoker as well as for non-smokers from exposure to environmental tobacco smoke.

68th World Health Assembly May 26, 2015

Health effects of particulate air pollution Insulin Resistance Type 2 diabetes Type 1 diabetes Bone metabolism Skin Aging Stroke Neurological development Mental Health Neurodegenerative diseases Cardiovascular Disease Mortality Cardiovascular Disease Morbidity Myocardial Infarction Arrhythmia Congestive Heart Failure Changes in Heart Rate Variability ST-Segment Depression Premature Birth Decreased Birth Weight Decreased foetal growth In uterine growth retardation Decreased sperm quality Preclampsia High blood pressure Endothelial dysfunction Increased blood coagulation Systemic inflammation Deep Venous Thrombosis Respiratory Disease Mortality Respiratory Disease Morbidity Lung Cancer Pneumonia Upper and lower respiratory symptoms Airway inflammation Decreased lung function Decreased lung growth Joint ERS / ATS statement (ERJ, 2016)

The Lancet, May 2017 4.2 million deaths attributable to PM2.5 in 2015

Deaths attributable to ambient particulate matter pollution in 2015 Figure 5 Deaths attributable to ambient particulate matter pollution in 2015 Deaths attributable to ambient particulate matter pollution in 2015 ATG=Antigua and Barbuda. FSM=Federated States of Micronesia. Isl=Island. LCA=Saint Lucia. TLS=Timor-Leste. TTO=Trinidad and Tobago. VCT=Saint Vincent and the Grenadines. The Lancet DOI: (10.1016/S0140-6736(17)30505-6) Copyright © 2017 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license Terms and Conditions

October 2017 “Targets and timetables are essential, and governments at all levels need to establish short-term and long-term targets for pollution control and to support the agencies and regulations needed to attain these goals. Legally mandated regulation is an essential tool, and both the polluter-pays principle and an end to subsidies and tax breaks for polluting industries need to be integral components of pollution control programmes”.