1. April 9, 2018 The Medical Society Consortium on Climate Health
The Cardiovascular Effects Of Air Pollution In Vulnerable Populations: Nursing Implications
April 9, 2018
The Medical Society Consortium on Climate Health

2. Presentation Purpose
Describe the cardiovascular (CV) effects of air pollution.
Recognize environmental factors that increase cardiovascular (CV) health disparities among vulnerable populations.
-- older adults, women, Latinos
Discuss nursing implications for promoting cardiovascular health and climate solutions through advocacy, research and practice.
cardiovascular effects of air pollution
Older persons are identified as a group meriting special care during disasters, especially those within that age group who have preexisting chronic conditions.
As people age, the risk of having multiple chronic conditions rises, and the risk of mortality, poor functional status, and health care complexity increases.

3. The Cardiovascular Effects of Air Pollution
Traditional CV risk factors account for the major portion of the risk for ischemic cardiac events.
Sufficient epidemiologic evidence to conclude that a causal relationship exists between: short-term & long- term exposure to PM2.5 & mortality.
Short-term exposures to elevated levels of particle pollution can worsen heart failure, trigger heart attacks, strokes & some arrhythmias.
Long-term, exposure to air pollution can have more insidious effects, such as accelerating the development of atherosclerosis, & contributing to premature death.
Traditional cardiovascular risk factors account for the major portion of the risk for ischemic cardiac events within a population.
Outdoor air pollution has long been recognized as affecting the respiratory system, but many people don’t know that air pollution also impacts cardiovascular health. Scientific research provides strong evidence of the cardiovascular effects of particle pollution and ground-level ozone. These pollutants are known for increasing risks of morbidity and mortality, from both short and long-term exposures. (EPA)
US EPA, 2009 Final Report: Integrated Science Assessment for Particulate Matter,
US EPA, 2013 Final Report: Integrated Science Assessment of Ozone and Related Photochemical Oxidants,

4. Air Pollution Deaths Comparable to Alzheimer’s, Diabetes, Flu30
740
% of Total Deaths
30.0%
25.0%
20.0%
15.0%
10.0%
5.0%
0.0%
~130,000 excess deaths attributed
to outdoor air pollution in the U.S.
585 20 10
(No. of Deaths in Thousands)
149
131 85 76 57
47 41 38 36
Cause of Death
National Vital Statistics Report

5. Mechanisms are under investigation but are likely related to effects on oxidative stress, autonomic control and inflammation
Biological pathways linking PM exposure with CVDs -- The generalized intermediary pathways and the subsequent specific biological responses that could be capable of instigating cardiovascular events are shown. MPO indicates myeloperoxidase; PAI, plasminogen activator inhibitor; PSNS, parasympathetic nervous system; SNS, sympathetic nervous system; and WBCs, white blood cells. A question mark (?) indicates a pathway/mechanism with weak or mixed evidence or a mechanism of likely yet primarily theoretical existence based on the literature.
Brook et al. 2010

6. Cardiovascular Health Disparities
Among older Latinos, CV health disparities may reflect differences in environmental factors, including issues related to neighborhood walkability and air pollution.
Latinos represent 7% of the older adult population; and expected to increase to 25% by the year 2050.
States with the largest Latino Population will increase the most in the next 15 years. These include:
Arizona, Nevada, Texas, Florida
As women age, they are at risk for chronic diseases including CVD, diabetes, COPD, and asthma.
Cardiovascular health disparities continue to exist among vulnerable populations and disproportionately affect older ethnic minorities in the United States; among older adults, those with pre-existing heart disease, and diabetes are at higher risk
Latinos are expected to drive the growth in America’s senior population.

7. Estimated Excess Mortality
Burden of Air Pollution Deaths by County
PM2.5 and O3-related Mortality by County based
on 2005 air pollution levels
< 19
20 to 159
160 to 379
380 to 799
800 to 2,799
2,800 to 5,400
US EPA’s BENMAP
h6 ttp://
Fann et al. Risk Analysis 2012 6

8. Effects of Air Pollution on the Cardiovascular Health of Latinos
Specific to lifestyle and environmental factors contributing to CVD, many older Latinos are at particular risk for exposure to hazardous pollutants
occupational factors
higher rates of traffic density in disadvantaged neighborhoods
Mobility and community engagement is affected by the design and characteristics of the environment, including the availability of walking paths.
These challenges may increase the risk of CVD as they interrupt healthy food systems and make mobility more difficult.
Specific to lifestyle and environmental factors contributing to cardiovascular disease (CVD), many older Latinos are at particular risk for exposure to hazardous pollutants due to occupational factors and higher rates of traffic density in disadvantaged neighborhoods. In addition, mobility and community engagement is affected by the design and characteristics of the environment, including the availability of walking paths. These challenges may increase the risk of CVD as they interrupt healthy food systems and make mobility more difficult

9. Latinos in America Are Far More Likely Than the Average Citizen to Breathe Polluted Air (Velez,J )
especially sensitive to neighborhood climate issues because their limited mobility and physical frailty exacerbate feelings of vulnerability to negative forces in their environments

10. Data source: Methanefacts.org
More than half of America’s population lives in communities with unhealthy levels of ozone smog, but according to a report by the The Clean Air Task Force (CATF), the League of United Latin American Citizens, and the National Hispanic Medical Association published late last year, Latinos are 51 percent more likely than non-Hispanic whites to live in counties with unsafe ozone levels.
The report also found that closer proximity to sources of air pollution and lower incomes were closely correlated.
More than 1 in 3 Latinos now live in an area that violates federal standards for ozone, a chemical that is desirable high in the atmosphere but at ground level is a pollutant linked to asthma and other health problems.
Data source: Methanefacts.org

11. Significance
Many Latino communities face an elevated risk of health disparities, including cancer, asthma, CVD, due to air toxics emissions from oil and gas development.
Nearly 1.78 million Latinos live in counties that face a cancer risk above EPA’s level of concern from toxics emitted by oil and gas facilities.
Air in many Latino communities violates air quality standards for ozone smog.
Latinos are particularly burdened with health impacts from this air pollution due to high levels of poverty and relatively low rates of health insurance coverage.
• As a result, many Latino communities face an elevated risk of cancer due to air toxics emissions from oil and gas development: Nearly 1.78 million Latinos live in counties that face a cancer risk above EPA’s level of concern from toxics emitted by oil and gas facilities.
• The air in many Latino communities violates air quality standards for ozone smog: As a result of ozone increases due to oil and gas emissions during the summer ozone season, Latino communities are burdened by 153,000 childhood asthma attacks and 112,000 lost school days each year.
• Rates of asthma are relatively high in Latino communities.
• Many Latinos are particularly burdened with health impacts from this air pollution due to high levels of poverty and relatively low rates of health insurance coverage.
Latinos are expected to drive the growth in America’s senior population.

12. Nursing Implications: Practice, Research, and Policy
Million Hearts 2022 Framework includes information on improving outcomes for priority populations.
People who have had a heart attack or stroke are advised to increase cardiac rehabilitation participation, avoid exposure to PM2.5
Advancing environmental health literacy (EHL) can improve CV health by raising public awareness of potentially harmful environmental exposures and empowering communities to avoid or reduce such exposures.
Air pollution education and messaging must reflect the linguistic & cultural needs of patients and the public.
Nurses, especially those in CV nursing, have an important role to play in supporting educational and policy initiatives as well as counseling their patients
CDC and Medicare are now gearing up to begin Million Hearts Since this workshop, the Million Hearts 2022 Framework includes information on improving outcomes for priority populations. Specifically, people who have had a heart attack or stroke are advised to increase cardiac rehabilitation participation and avoid exposure to PM2.5.
advancing environmental health literacy (EHL) can improve health by raising public awareness of potentially harmful environmental exposures and empowering communities to avoid or reduce such exposures.
address communication, specifically the potential to message about air pollution or climate change depending on audience
As multidisciplinary advocates for older adults and their families, our work and practice should keep in mind the impacts of climate change on older women. While there are significant challenges to effectively addressing climate change, there is also tremendous opportunity to lead in this area. The first step is to raise awareness internally among our peers and externally among older adults to whom we provide healthcare or social services and to the public.

13. Nursing Implications: Practice, Research, and Policy
Participatory framework: promotes engagement, community leadership.
Climate change, air pollution remains understudied & underfunded. We must engage in or support research that examines the effects, both short & long term; test interventions that may control/diminish effects on vulnerable populations.
Nurses must advocate for maintaining and building on the Clean Air Act and effort by US cities to meet the Paris Treaty targets.
“Air pollution creates more patients…prevention is the only real, effective & long-term treatment” (American Nurses Association)
Additional work remains to be done to address CV health disparities & effects of air pollution on overburdened, vulnerable communities (National Association of Hispanic Nurses).
Secondly, climate change remains understudied and underfunded. We must engage in or support research that examines the effects of climate change, in both the short and long term, as well as test interventions that may control or diminish these effects upon vulnerable populations.