Respiratory Health Effects of Climate Change Meredith C. McCormack, MD MHS April 8, 2018

Projected Changes in Global Average Temperature Source: USGCRP (2009) https://www.epa.gov/climate-change-science/future-climate-change#Temperature

Death toll exceeded 70,000 in Europe during the summer of 20031 Excess Mortality Compared 2003 to 1998-2002 Highest death rates in France, Portugal, Italy, Spain, Luxenborg No evidence of a harvesting effects in fall months that followed June 1 Sept 30 Estimated excess of 70,000 deaths in summer 2003 compared to 1998-2002

People most affected by extreme temperature Extremes of age- children and elderly Those with underlying chronic disease Living in a temperate climate Lack of air conditioning Mental illness, living alone Studies in US regions- including NY, California, etc They have shown that individuals, especially those with chronic disease are susceptible to the detrimental effects of heat Braga et al. Environ Health Persp 2002; Basu Environ Mealth 2009 Kovats Annu Rev Public Health 2008; Semenza et al. Am J Prev Med 1999

12.5 million Medicare beneficiaries Respiratory hospitalizations increased 4.3% or every 10 ͦF increase in summer temperature Risk was higher (1.4% higher) in areas with cooler average summer temperatures. Effect was independent of pollution and strongest on same day Anderson et al. AJRCCM 2013

Individual Exposure to Heat and Health Effects in COPD McCormack MC et al. Annals of Am Thor Soc 2016

LONDON SMOG 1952 During this period and in the 2 weeks following, there was a sharp increase in deaths- with an 80% increase in mortality rates compared to December of the previous year. It is estimated that there were an excess of 12,000 deaths These were primarily respiratory deaths – related to infection, including pneumonia, influenza, tuberculosis, exacerbations of asthma and obstructive lung disease- and there were also increases in cardiac deaths. Martin AE. Mortality and morbidity statistics and air pollution. Proc R Soc Med 1964;57:969-75.

Particulate Matter Current standards are 24 hour 35 and annual 12 Studies of severe episodes of air pollution RESEARCH Studies of air pollution in urban areas Focus on susceptible populations | 1940 | 1950 | 1960 | 1970 | 1980 | 1990 | 2000 | 2010 | POLICY Clean Air Act 1970 PM10 standard 1987 PM2.5 standard 1997 PM2.5 standards tightened 2006, 2012

Clean Air Act: Top 6 Major Air Pollutants* Particulate Matter Ozone Sulfur dioxide Carbon Monoxide Nitrogen dioxide Lead *Regulated based on health effects in sensitive populations The clean air act identified criteria air pollutants that are regulated to protect human health. The standards are based evidence of health effects related to exposure in the general population and also in sensitive populations. Sensitive populations include children, the elderly, those with asthma and other chronic diseases

Epidemiologic evidence of association between PM and mortality All cause mortality Cardiopulmonary Cardiovascular cohort studies have established that exposure to pollution over time is associated with increased risk of mortality These estimates come from the Harvard 6 Cities Study, the American Cancer Survey and others. Findings reflect increases in average exposure over time that are associated with increases in mortality on the order of 5-15 percent per 10 ug/m3 increase in PM2.5 * Risk estimates per 10 µg/m3 increase in PM2.5 or PM10 Brook et al. Circulation 2010;121:2331-2378

Air pollution during warm season and childhood asthma emergency visits In addition to patients with underlying risk factors or history of heart and lung disease, children are a population that are sensitive to health effects of particulate pollution. Particulate pollution has been shown to exacerbate childhood asthma and has been linked to increases in symptoms, exacerbations and decreases in lung function. In a study of children evaluated in emergency departments in Atlanta hospitals, investigators- Stirckland and colleagues- demonstrated that increases in PM2.5 were associated with increased risk of emergency visits for asthma. Children ages 5-17 years Atlanta hospitals 1993-2004 Emergency visits for asthma or wheeze Strickland et al. 2010 AJRCCM; 182:307-16.

Health Effects of Air Pollution Overall Mortality Hospitalizations Emergency Department Visits Cardiac and Respiratory exacerbations Myocardial Infarction Heart Failure COPD Asthma Respiratory Infections Mention the fact that there is active investigation related the fact that pollution may be obesogenic

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Reduction in air pollution has resulted in measurable health benefits Samet JM, Burke TA, Goldstein BD. NEJM 2017

Take Home Message The impact of climate change on air quality has significant respiratory health consequences Scientific evidence has informed policy that has led to pollution reduction Improved air quality has proven health benefits Reduction of motor vehicle emissions and industrial emissions through regulation and adoption of low emission vehicles and clean power sources are needed to protect our air