Dr Amy Stebbings The Chest and Internal Medicine Clinic, Singapore

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Dr Amy Stebbings The Chest and Internal Medicine Clinic, Singapore The Effect of Forest Fires in 2015 on Asthma and Comparison with a Control Group in 2016

Background Singapore experienced increased air pollution (Haze) for 2 months in 2015 arising from regional forest fires. Aim: to investigate the effect of this on respiratory disease, particularly asthma Previous studies (Respirology 2000 Jun: 5(2): 175-182) demonstrated minimal effect, with no increase in hospitalisation

Aim To describe the effect of air pollution induced by regional forest fires on respiratory disease, with special attention to asthma, in 2015 and to compare it with a similar period in 2016

Average Hourly PSI (Aug-Nov) 2015 (Haze) vs 2016 (No haze)

Average Hourly PSI p-value <0.0001, statistically significant

Calculation of the PSI Sub-indices as defined by the breakpoints Equation used for calculation

Method -Prospective study -All patients who visited a respiratory clinic in Singapore -Over a 2-month period: September-October 2015 (Haze). -Data collected: Asthma exacerbations/hospitalisations, Asthma Control Test (ACT) scores of asthmatic patients, spirometry, adjustments in medications. -Comparison was made retrospectively with a control group in September-October 2016 (No Haze)

Table 1: Demographics and Spirometry: Case (Haze 2015) vs Control (no haze 2016) Categories Case (haze 2015) Control ( no haze 2016) p-value NS (not significant) Mean age (years) 46.08 47.34 0.665 NS Age range (years) 16-93 5-94 NA Sex (% male) 33.33 33.82 Mean FEV1 asthmatics(%) 91.9 91.8 0.974 Mean FVC asthmatics (%) 102.6 99.9 0.404 Mean FEV1 ratio asthmatics (%) 76.3 79.1 0.0979

Ethnicity of patients Chinese 18 41 0.102 NS 8 0.233 Indian 11 0.319 5 All patients (n=74) 2015 (Haze) All patients (n=125) 2016 (No Haze) p-value Significance (p<0.01) Asthmatics (n=51) 2015 (Haze) Asthmatics (n=64) 2016 (No Haze) Chinese 18 41 0.102 NS 8 0.233 Indian 11 0.319 5 7 0.371 Malay 2 3 0.448 0.295 Others 6 0.171 0.0655 Caucasian 40 64 0.348 31 34 0.0162

Other diagnoses (Non-asthmatics) Diagnosis Number of non-asthmatics (2015) Number of non-asthmatics (2016) p-value Significance Hypercholesterolaemia 3 0.0901 NS Tuberculosis 1 5 0.145 Pneumonia 2 0.316 Pulmonary Embolism 0.444 COPD Bronchitis 4 9 0.309 Bronchiectasis 7 Hypertension 6 0.0281 DM Sinusitis 0.492 Others 11 26 0.149

A closer look: the asthmatics during the haze 2015 Total number of asthmatics: 51 47% experienced asthma exacerbation 5.4% vs 0.8% required hospitalisation (significant) 6.8% required an increase in Prednisolone (not significant, NS) Mean ACT score 15.8 (range 7-25, SD 5.08) (NS) Mean change in ACT from baseline was 7.1 (range 0-18, SD 4.75) (NS)

Table 2: Comparison of Asthma Exacerbations, Hospitalisations and Treatment, Case vs Control % of total Case (haze 2015) Control ( no haze 2016) p-value Significance N 74 125 Asthma patients 51 (68.9%) 64 (51%) 0.007 p<0.01 Hospitalisation 4 (5.4%) 1 (0.8%) 0.022 p<0.05 Asthma exacerbation 21 (28.4%) 19 (15.2%) 0.013 Nebulisation 4 (5.41%) 5 (4%) 0.323 NS Oral steroids 5 (6.8%) 8 (6.4%) 0.460 ACT change 7.1 (0-18) 6.7 (0-15) 0.825

Limitations of this study Cohort based in a respiratory clinic at tertiary level, not community based Assumption is that the patients were well controlled before the haze Assumption the control group were well controlled Larger numbers needed Any confounding factors?

Conclusion Forest fires significantly impacted the health of patients with respiratory disease, particularly asthmatics, as demonstrated by increase in hospitalisations and asthma exacerbations

References Meteorological conditions, climate change, new emerging factors, and asthma and related allergic disorders. A statement of the World Allergy Organization. D’Amato et al, World Allergy organ J 2015 jul 14;8 (1):25 Asthma Control in the Asia-Pacific region : the Asthma Insights and reality in Asia-Pacific Study. Lai CK et al, J Allergy Clin Immunol 2003 Feb;111(2):263-8 An Evaluation of the British Columba Asthma Monitoring System (MCAMS) and PM2.5 Exposure Metrics during the 2014 Forest Fire Season. McLean KE et al, Int J Environ Res Public Health 2015 Jun 12;12(6):6710-24 Asthma Control in Adults in Asia Pacific. Zainuddin BM, et al, Respirology 2005 Nov 10950:579-86 Impact to lung health of haze from forest fires: the Singapore experience. Emmanuel SC. Respirology. 2000 Jun;5(2):175-82.