Katherine Yulo, MD Ruchi Gupta, MD Renu Gandhe, MD The Relationship between Residence near Sources of Petrochemical Pollution and Worsening Respiratory Outcomes in Children of the Nueces and San Patricio Counties Katherine Yulo, MD Ruchi Gupta, MD Renu Gandhe, MD

Abstract OBJECTIVE To determine an association between residence near sources of petrochemical pollution and prevalence of respiratory disease in Nueces and San Patricio counties. METHODS This is a cross-sectional study of the Driscoll Health Plan database including medicaid and CHIP patients. We identified children aged 21 years and younger enrolled in the plan between January 2007 and December 2008 with ICD-9 codes for asthma, bronchitis, allergic rhinitis, cough, dyspnea, bronchospasm, or wheezing. We excluded children with respiratory infection, cystic fibrosis, chronic lung disease, congenital heart disease, and pregnancy. GEO software was used to plot the GPS coordinates of seven local oil refineries on a map.  Surrounding the refineries, 5 mile radii were drawn and longitude and latitude of the subjects’ residences were plotted using GEO software.  A chi square test and computation of odds ratios were used to evaluate the association between location of residence and prevalence of respiratory disease in the study population. RESULTS 11, 653 subjects met the inclusion criteria.  5 mile sectors located closer to petrochemical plants had incrementally higher proportions of children with respiratory disease (chi square test, p < 0.0001) and higher odds of having respiratory disease (odds ratio 12.48; CI 11.09 – 14.04) than the sector situated >20 miles from the petrochemical plants. CONCLUSIONS Proximity of residence to petrochemical plants is positively associated with prevalence of respiratory disease in the study population.  This association appears to be most significant within 20 miles.

AIR POLLUTION The prevalence of asthma and respiratory disease is increasing over time. Air pollution can increase the risk of developing respiratory disease and it can also trigger exacerbations of respiratory disease. PM2.5 , PM10 N0X S02 03 (ozone)

PM 2.5 From Epa.gov

AMERICAN ACADEMY OF PEDIATRICS POLICY STATEMENT “… numerous studies are finding important health effects from air pollution at levels once considered safe…” “… Children and infants are among the most susceptible to many of the air pollutants…” “…recent studies have found links between air pollution and preterm birth, infant mortality, deficits in lung growth, and possibly, development of asthma…” From Ambient Air Pollution: Health Hazards to Children Pediatrics 2004;114:1699–1707

AIR POLLUTION AND RESPIRATORY MORBIDITY Respiratory admissions directly proportional to levels of ambient NO2, PM2.5, PM10 1,2 Decline in FEV1, FVC, FEF25-75 associated with exposure PM2.5, NO2, and acid vapor 3 2.5 minute exposure to SO2 induces bronchoconstriction in asthmatics 4 Children living near petrochemical plants had more asthma, respiratory symptoms, and >13% lower predicted FEV1 than those living in more distant areas (urban, semi-rural, residential) 5 1 Stieb, et al., Environmental Health, June 2009 2 Barnett, et al, American Journal of Respiratory Critical Care Medicine, March 2005 3 Gauderman, et al, New England Journal of Medicine, 2004 4 Koenig, Journal of Allergy and Clinical Immunology, July 1999 5 Wichmann, Journal of Allergy and Clinical Immunology, March 2009

STUDY OBJECTIVES PRIMARY OBJECTIVE: To evaluate the association between distance of residence to sources of petrochemical air pollution and the prevalence of respiratory disease SECONDARY OBJECTIVE: To determine the distance at which residence near sources of petrochemical air pollution becomes a risk for respiratory disease

METHODOLOGY Large retrospective cross-sectional study DRISCOLL HEALTH PLAN DATABASE January 2007- December 2008 ICD-9 codes for Respiratory Diagnoses Claims for in-patient, clinic, ER visits Inclusion criteria Age 0-21 yrs diagnoses: asthma, cough, dyspnea, wheezing, bronchospasm, bronchitis, allergic rhinitis, allergy nonspecific Exclusion Criteria Respiratory Disease due to Infection, CF, BPD, congenital heart disease, chronic lung disease, Pregnancy Demographic Data Date of birth, gender, ethnicity, date of service Longitude and latitude of residence GEO software for map plotting SAS system for statistics

MAP PLOTTING 2. ASSIGNMENT OF 5 MILE SECTORS 1. REFINERY ROW 3. GPS COORDINATES OF STUDY POPULATION

DCHP TOTAL CLAIMS FOR RESPIRATORY DIAGNOSES 28, 332 TOTAL VISITS FOR RESPIRATORY DISEASE 25, 931 Office Visits 1, 936 ER visits 465 Hospitalizations TOTAL CLAIMS for 2 year period = 32, 376 15, 947 DRISCOLL HEALTH PLAN ENROLLEES 0-21yrs 2007-2008 11, 653 Enrollees with Respiratory Diagnoses 4,294 Other diagnoses 57.05% 19.81% 19.39% 2.66% 1.06%

SUMMARY OF DEMOGRAPHICS COUNT PERCENTAGE (%) COUNTY Nueces 9,392 19 San Patricio 2,261 81 GENDER M 6,172 53 F 5,481 47 AGE <1yr 1,145 5 1-6yr 15,290 32 6-12yr 10,535 44 12-21yrs 5,401 ETHNICITY Hispanic 9,022 77.44 Caucasian 1,705 14.63 African Am. 513 4.4 Others 411 3.52

LOCATION OF RESIDENCE AND PROPORTIONS OF RESPIRATORY DISEASE TOTAL MEDICAID AND CHIP ENROLLEES: 15, 947 ENROLLEES SECTOR ENROLLEES RESP DSE PROPORTION OF RESP DSE 0-5mi 4,538 4,084 90% 5-10mi 3,221 2,686 83% 10-15mi 2,683 2,042 76% 15-20mi 1,952 1,353 69% >20mi 3,553 1,488 42% TOTAL 15,947 11,653 73% CHI SQUARE p <0.0001

LOCATION OF RESIDENCE AND PROPORTIONS OF ASTHMA ENROLLEES TOTAL MEDICAID AND CHIP ENROLLEES: 15, 947 SECTOR ENROLLEES ASTHMA ASTHMA PROPORTION 0-5mi 4,538 3,541 78% 5-10mi 3,221 1,998 62% 10-15mi 2,683 1,172 44% 15-20mi 1,952 768 39% >20mi 3,553 1,365 38% TOTAL 15,947 8,844 55% CHI SQUARE p <0.0001

LOCATION OF RESIDENCE AND ODDS OF RESPIRATORY DISEASE and ASTHMA SECTOR COMPARISON ODDS RATIO 95% C.I. <5mi vs 5-10mi 1.79 1.57-2.05 5-10mi vs 10-15mi 1.58 1.39-1.79 10-15mi vs 15-20mi 1.41 1.24-1.60 15-20mi vs >20mi 3.13 2.79-3.52 <5mi vs >20mi 12.48 11.10-14.64 SECTOR COMPARISON ODDS RATIO 95% C.I. <5mi vs 5-10mi 2.17 1.97-2.40 5-10mi vs 10-15mi 2.11 1.89-2.34 10-15mi vs 15-20mi 1.19 1.06-1.35 15-20mi vs >20mi 1.04 0.92-1.16 <5mi vs >20mi 5.69 5.16-6.28 ASTHMA

STRENGTHS and LIMITATIONS First in the U.S. to evaluate the correlation between location of residence in proximity to petrochemical plants and respiratory disease Large study population Data set identified of all types of visits Diagnoses made by a relatively homogenous group of clinicians in a geographic area Uniform socioeconomic status Results highly statistically significant Nature of data source Confounding variables Degree of variance in physician diagnoses Length of residence Lack of Pharmacy claims

CONCLUSIONS and IMPLICATIONS The proximity of residence to petrochemical plants is positively associated with prevalence of respiratory disease and asthma in children 21yrs and younger in the MEDICAID/CHIP population It appears that the association is most significant within 15-20 miles As healthcare providers, we must promote increased respiratory health surveillance of children who reside close to petrochemical plants Advocate that petrochemical plants should not be built within 20miles of residential areas