WHO-Project Environmental Health Indicators Experiences from Germany Project coordination: Federal Environmental Agency Division of Environment and Health WHO CC Air Quality Management/Air Pollution Control J. Thelen, MPH, M.Sc. Dr. H.-G. Mücke Funded by the Ministry of Health and Social Security Ladies and gentlemen, I first want to thank WHO Bonn Office for the invitation to this conference And of course I want to thank the organiserzers for the possibility to present Some experiences here in Balatonföldvar. My Name is Jürgen Thelen, I‘m coordinating the project-work in Germany. My position is located at the WHO Collaborating Centre for Air Quality Management And Air Pollution Control at the Federal Environmental Agency in Berlin. The project is funded by the Ministry of Health and Social Security, which coordinates The German Environment and Health Action Programme together with the Ministry of Environment and the Ministry of Consumer Protection. Because the coordination between the three Ministries seems rather difficult, Things are currently moving a little slower, but we hope to solve these problems In the process of preparating the Budapest Conference.

Environmental Health Indicators Project Workplan for the Pilot Study 06/2002 Start of the Pilot Phase in Germany 06-10/2002 Indicator Definition Review/Adjustment Testing of EuroIndy (1.1 to 1.5) 10/2002-5/2003 Identification of Dataholders, Data collection Data Compliation 06-10/2003 Development of Methods for Ind.calculation Work on the Fact-sheets Quality control of EuroIndy Database 08-12/2003 Analysis and Reporting The main objectives of the German project participation where to test the proposed Environmental Health Indicator Set for Feasibility and Aplicability in Germany and To identify the relevant data holders who can provide the data that is necessary for indicator calculation. Other tasks that have been carried out were the testing of the Database EuroIndy, the work On the fact sheets and the coordination with other ongoing German Indicator projects, And similar developements in the European Union. Last but not least I‘m currently working on the national project report, including some recommendations For the further German participation. Machbarkeitsstudie in Deutschland nicht durchgeführt (keine personellen Ressourcen) Mein Eintritt in das Projekt 6/2003 Arbeitsauftrag: Sondierung des projektrelevanten Datenmaterials (u.a. aus Berichten, Datenbanken, Webseiten des Bundes und der Länder) Elektronische Erfassung, Zusammenstellung und Auswertung der Indikatordaten Mitwirkung an Projekttreffen Kooperation mit anderen Behörden Ergebnisaufgbereitung und Berichterstattung an die Bundesministerien (BMGS und BMU) sowie an die WHO Beteiligung an der Entwicklung von Auswertungs- und Darstellungsmethoden

Objectives of the Project: Test Feasibility and Applicability of the EHI Set in Germany Develop Information Tools for Stakeholders in the field of Environment and Health (Politicis, Sience, Media, Organisations): Monitoring and Evaluation of Measures and Plans concering Health Protection from environmental Risks Communication to the Public and within the Administration (horizontal und vertical) International und national Networking of the Stakeholders in the field of environment related Health Protection Establishment of national und international Reporting Structures for assesment and comparison (Benchmarking, Best-Practice Modelle) Scientific Analysis Breit gefächertes Spektrum möglicher Anwendungen: Auswahl des Adressatenkreises bestimmt wesentlich die Form der Berichterstattung Politik: Verbindung von gesundheits- und umweltinformationen kann zu einer Stärkung der Zusammenarbeit Von Gesundheits- und Umweltbehörden beitragen Medien: Bereitstellung von Informationsmaterial für Medienarbeit (APUG: BMGS, BMU, BMVEL, BZgA u.a.) Beispiel dafür: Radiobeitrag über Kinder und Asthma, anläßlich EEA Bericht (WDR 6/2003) Organisationen: Aufbereitung von Daten für nicht-Regierungsorganisationen (z.B. Deutsches Forum für Prävention, ) Ziel des Projektes: Verbesserung der Informationsgrundlage im Bereich Umwelt und Gesundheit Entwicklung einer Datenbasis für eine indikatorengestützte Umweltbezogene Gesundheitsberichterstattung (gesundheitsbezogene Umweltberichterstattung) Prinzipieller Unterschied, der die Zielrichtung des Projektes mitbestimmt: Behandlung als Thema der Gesundheitsberichterstattung: z.B. Gesundheitsbericht Deutschland 1998 : Kapitel 4 Gesundheitsverhalten und Gesundheitsgefährdungen Risikomerkmale der Umwelt Dort Behandlung der Thematik nach Umweltmedien: Unerwünschte Stoffe im Wasser (z.B. Infektionserreger, Chemikalien) Außenluft Lärm Arbeitswelt, Freizeit und Verkehr Behandlung im Bericht des Umweltbundesamtes: Daten zur Umwelt Dort findet sich in mehreren Kapiteln ein impliziter Gesundheitsbezug: z.B. Trinkwasser, Luft, Böden, Eigenes Kapitel: Belastung des Menschen mit Schadstoffen und Mikroorganismen Wirkung von Luftschadstoffen Lebensmittel: Pflanzenschutzmittel, POP,,Schwermetalle, Dioxine Behandlung von Gesundheitsrisiken in Verbindung mit bestimmten Umwelteinflüssen. Eine weiter Möglichkeit der Darstellung wäre die Behandlung der Risikofaktoren aus der Umwelt Als Determinanten für bestimmte Erkrankungen Also z.B. im Kapitel 5 GBD 1998 Krankheiten: Erläuterung des Bedeutung von Umweltschadstoffen im direkten Kontext mit Den betrachteten Erkrankungen: Outcome- orientierte Berichterstattung

Data availability for Germany (national level) (29.03.2003) (Number of Variables in the field of ...) %

Data: Collection, Analysis Testing and Trail Operation of EuroIndy (1.1-1.5) Spatial Breakdown to NUTS 1-3 and large Cities Data availability: NUTS1: good NUTS2: limited NUTS3: no data Large Cities: Data from NUTS 2 and 3 is difficult to obtain Problems: Action Indicators are Subject to Bias (subjective Assessment) Database EuroIndy needs further Development No Common Strategy for Health Impact Assessment Air Quality Data is collected in a central Database; no common strategy for HIA with our database

Remarks on the thematic fields Most relevant for Germany: Reports: Air Quality yes Noise yes Traffic Accidents yes Drinking and Bathing Water Quality yes Relevant; further Developement needed Chemical Safety (Emergencies) yes Food Safety partly Radiation yes Sector: Air Quality Relevant for Germany Share of urban population in large Cities 31% Evidence for Impact on Human Health Relevant Data for Exposure Assessment available Proposed Methodology for Air_Ex was modified to calculate a more understandable Indicator (even though not self-expanatory) Indicators will be revised in the EU-Context Noise Share of annoyed Population 16% (Road Traffic Noise) Relevant Data for Daytime Annoyance available Due to sample size not applicable to Federal State Level Traffic accidents Relevant for Germany; International Comparison revealed different Methods of Surveillance Water/ Sanitation High Standard for Drinking Water and Water Supply in D, Data on Water Quality (chem./microbiological) is reported to the EC (Different limit values) Water Quality Data is not reffering to the selected Health Outcomes that should be reported Housing relevant: Indicators are not applicable/useful for Germany

Remarks on the thematic fields Relevant; Health Impact uncertain Reports: Waste and Contaminated Land yes Relevant; Comprehensive Reporting by the National Agency Workplace Radiation: relevant, Indikatorenauswahl zu unspezifisch fehlende Gesundheitsdaten (Krebsregister), Berichterstattung durch BfS Food Safety: relevant, Berichterstattung durch BfR/RKI Chemical Safety: relevant, Berichterstattung durch UBA Workplace: relevant, Berichterstattung durch BMWA und BAuA Waste and Contaminated Land: relevant (Indikatoren nicht ausreichend) Most of the issues are allready reported in Publications of the Federal Health Office (Robert-Koch Institut) or the Federal Environmental Agency and by the Corresponding Agencys in the Federal States

Air Quality: Results from Germany Air_D1 Passenger Traffic Demand (by mode of transportation) Policies to Reduce Exposure to ETS (Air_A1) (not shown) Air_P1 Emissions of Air Pollutants State (no Indicator) Air_Ex1 Exposure of urban Population to Air Pollutants Health Impact: (Air_E1, E2 and E3 not evaluated) To be considered as an own Indicator, or as part of the Assessment within Air_Ex1 ?

Air_D1: Passenger transport demand per inhabitant (Germany 1996-2001) Darstellung des Anteils der Verkehrsträger am Verkehrsaufkommen in Deutschland Anteil des motorisierten Individualverkehrs ca. 78% Zeigt das Potential der Verlagerung von motorisiertem Individualverkehr für eine Verlagerung Auf andere Träger Stagnation des motoris. Indiv.verkehr seit 1996 mit einem leichten Abwärtstrend seit 1999 Wahrscheinlich eine Folge der im Zuge der Ökosteuer gestiegenen Benzinpreise. Die Steuer zeigt innerhalb kurzer Zeit eine Einfluss auf das Nutzerverhalten der Auto- (Motorrad-) fahrer Betrachtung der Gesamtdeutschen Zahlen liefert nur wenig verwertbare Informationen für Eine kleinräumige Verkehrsplanung (Anteile des Verkehrs in Großstädten anders) Source: BMVBW, DIW (2003) Traffic in Figures

Air_P1: Emissions of Air Pollutants NOx PM10 Ozone Precursors SO2 The message from these figures is unambigious. Eventhough these emissions are rather calculated but Measured they are used in the national emission reports that have to be submitted to the UNECE and To the EU. For Germany the question raises if we need to discribe the trends in the emissions of pollutants separately Or if we should use the original data and comment on them. Especially in the field of air pollution it becomes obvious that the concideration of the environmental health Context is reapeated in the fact sheets air_p and air_ex and air_e (even though not included here).

Air_Ex1: Exposure to Air Pollutants (urban population) Methodology: Large Cities >100.000 Inhabitants: Annual average Population Measuring Data from Urban Background Stations (yearly mean) Assumption: Background Level represents long term Exposure More than one Station  Mean of background Stations Limitation: only exposure to Ambient Air Calculation of Exposure classes for urban Population in Germany Background Station 1 City Population (Annual Mean) City xy Background Station 2 Urban Air Quality: (Annual Mean Station n)/n Stations for PM10 and NO2 For Ozone: Number of days > 120µg/m3 Background Station 3

Air_Ex1: Exposure to Air Pollutants (urban population) PM10 Description: For 2001: In 2001 less than 5% of the German urban population (cities over 100.000 inhab.) were Exposed to ambient air PM10 concentrations above 40 µg/m3. The calculations contains the data of 74 cities over 100.000 inhab. With nearly 22,5 mil. People altogether Regarding the time trend we can see that the PM10 concentratins and thus the exposure of humans Continouosly decreased during the past 5 years. The reason why I choosed the exposure classes approach were the following: If only the proportion of inhabitants exposed to 40+ µg/m3 PM10 would have been regarded, the Situation looks much more simple but might also provoce some problematic conclusions. A situation where all the inhabitants are dexposed to pm10 levels under 40µg/m3 could be Considered as „healthy“ because the graph suggests that only the proportion of people exposed To PM10 values over 40µg/m3 are facing a health risk. To indicate that health effects must be expectet even below the limit value of 40 is must be underpinned That so far no threshold for the dose response relationship of PM10 and it`s health effects has been determined. This shows the necessity to show the complete picture. It then becomes obvious, that nearly all urban inhabitants are exposed to ambient air concentrations above 20µg/m3. This reflects the current background levels of PM10 in Germany and gives rise to the assumtion that the Limit value for the protection of human health for the European Union that was foreseen for 2010 (namely 20 µg/m3) Can not be reached in Germany. The main Problem concerning the construction of this indicator is, that air quality data must (1999/30/EU): Annual Mean: 40 µg/m3 Daily Mean: 50 µg/m3

Air_Ex1: Exposure to Air Pollutants (urban population) NO2 1999/30/EG Annual Mean: 40 µg/m3 1h-Mean : 200 µg/m3

Air_Ex1: Exposure to Air Pollutants (urban population) : Ozone Number of Days over > 120 µg/m3 (8h average)

Health Impact (Air_E1; Air_E2 not evaluated) Reduction of Statistical Life Expectancy by Exposure to PM2.5 Calculation of statistical Life Expectancy (Life table) RR = 1.06 (95% CI: 1.02-1.11) For all cause mortality Pope et al., 2002 ACS Cohort Study 500.000 US-Americans > 30 J. PM2.5 Country Mean (Model) 1990: 33.7 2010 (CLE): 15.7 2010 (MFR): 12.3 CLE: Current Legislation MFR: Maximum Feasible Reduction Szenario 2010 Health Impact Assessment using the data currently defined for the Indicators

Reduction of Statistical Life Expectancy by Exposure to PM2 Reduction of Statistical Life Expectancy by Exposure to PM2.5 for 1990 und 2010 (CLE/MFR) International Comparison

[Range of different Models] Prevention of Mortality: Estimated Effect of Particle Filters for Diesel Vehicles Mortality Prevention potential (Excess Risk) [95% CI] Cases Preventable Cases [Range of different Models] All cause 1,8 % [1,2-3,3] 800.000 14.400 [9.600-19.200] Cardio-pulmonary 2,7 % [0,9-4,8] 460.000 12.420 [8.280-16.560] Lung cancer 4,2 % [1,2-6,9] 40.000 1680 [1.120-2.240] Wichmann 2003

Environmental Health Indicators Many Wishes – Little Resources Current Indicator Projects in Germany (including E&H Indicators) Some Examples: WHO-Environmental Health Indicators WHO/EU ECOEHIS Project National Core Indicators for Sustainable Development Indicators for the Health Reporting of the Federal States Core Indicators for Sustainable Development of the Federal States Are there too many Indicator Initiatives? Indicators (including Indicators for Environment and Health are currently developed in several different processes in Germany Die Weiterverarbeitung und Eingabe der Rohdaten in die Datenbank erfordert personelle Ressourcen, die derzeit weder vom UBA noch vom RKI oder Zur Verfügung gestellt werden Still unclear: Which Data Flow will be implemented If EU Indicators require other data than WHO-EHI Indicators only one database can be supplied

Health Impact Assessment EHI for the EU European Union: Public Health Action Programme (1786/2002/EC): EH Indicators for the European Union WHO-Project ECOENHIS/ENHIS First Meeting in May 2003: Discussion of the WHO Indicator Set: Modifications needed for the use in the European Union Environment & Health Strategy (COM(2003)338 final) Working group on Environment and Health Indicators Health Impact Assessment Data should be useful for Health Impact Assessment As we‘ve heard before the European Union is currently developing a health reporting system. Environmental Health Indicators will be part of this information system, but how will they be defined. A first working group meeting in may 2003 showed that many of the WHO-EH Indicators are Also Useful for the EC but that most of the Indicator definitions must be adapted to the Relevant limit values or legal regulations prescribed in the respective directives. This task must be connected to the recently announced Strategy on Environment and Health HIA: Quantifizierung der gesundheitlichen Auswirkungen von Umweltfaktoren Kann in verschiedenen Stufen erfolgen: Darstellung des Ist-Zustandes (einfach beim Thema Verkehrsunfälle: Anzahl der Toten und Verletzten) Schwieriger bei z.B. Luftverunreinigungen: Darstellung als : Verlorene Lebensjahre (Years of Life lost YLL) Attributable Fälle die auf die Luftverunreinigungen Zurückzuführen sind Verminderung der Lebenserwartung (Wieviele Tage verkürzt die Exposition gegenüber Luftscchadstoffen Die statistische Lebenserwartung (später dazu ein Beispiel im Zusammenhang mit dem Thema PM Größte Hindernisse bei der Verfolgung dieses Ansatzes sind: Meist unspezifische gesundheitliche Auswirkungen von Umwelteinflüssen (z.B. können Luftverunreinigungen wie PM mit Verschiedenen Mortalitätsziffern in Zusammenhang gebracht werden Respiratorisch, cardiovaskulär, gesamtsterblichkeit) Probleme bei der Expositionsschätzung: Im Bereich Außenluftschadstoffe: Die gemessenen Konzentrationen spiegeln nur einen Teil der tatsächlichen Exposition wieder, Eine Betrachtung von Innenraumluft und Außenluft zur realitätsgetreuen Expositionsabschätzung kann Mit statistischen Verfahren wie z.B. der Probabilistik erfolgen In mehreren Bereichen fehlen Erhebungen, die die Quantifizierung der Gesundheitlichen Auswirkungen bestimmter Umwelteinflüsse ermöglichen würden. z.B. Water-borne diseases, Wenn spezifischen Gesundheitlichen Zielgrößen nicht erfasst werden, bietet die Anwendung Gesicherter epidemiologischer Erkenntnisse einen Lösungsweg: Wie bei der Berechnung von YLL können epidemiologische Kennziffern zur Schätzung der gesundheitlichen Auswirkungen herangezogen werden (z.B: 2-6% der Hep-A Hepatitiden sind durch den Kontakt mit Badewasser verursacht. Ca. 6% der viralen Gastroenteritiden bei Badenden sind auf die Exposition mit dem Badewasser Zurückzuführen. Gesicherte Erkenntnisse fehlen aber leider noch in vielen Bereichen oder sind Gegenstand der Forschung, Demzufolge gibt es keine Maßzahlen, die von einem breiten wissenschaftlichen Konsens getragen werden.

Further Work (Dec. 2003) Finalisation of selected Fact Sheets Revision of the Methodology for Air Quality Indicators National Project Report Collaboration at the international Report (H.-G. Mücke) WHO Workshop (16./17. Oct. 2003) Specification of Report Structure Discussion of Fact Sheets for the International Report

Thank you for your attention For further information please contact: juergen.thelen@uba.de Federal Environmental Agency: www.umweltbundesamt.de WHO CC Air Quality Management/Air Pollution Control: www.umweltbundesamt.de/whocc/title/title21.htm