1. Outdoor Air Pollution and Population Health in China Haidong Kan, M.D., Ph.D. School of Public Health, Fudan University Shanghai, China kanh@fudan.edu.cn 5th International Conference on Environmental and Occupational Medicine Apr. 9, 2010

2. Outline Ambient air pollution levels in China Air pollution epidemiologic studies in China Health burden of air pollution in China Co-benefits of GHGs reduction in China Summary

3. Air pollution levels in China Outline

4. “Pollution in China” – by LU Guang

5. Estimated PM 10 Concentration in World Cities (pop=100,000+) Source: World Bank

6. Annual PM 10 levels in 30 provincial capitals of China (μg/m 3 ， 2004)

7. Kan et al, CVD Prevention & Control, 2009 Comparison of the PM 10 /SO 2 /NO 2 levels in Chinese cities and International/National Air Quality Standards (annual average)

8. Kan et al, Env Int, 2007; Guo et al, Sci Total Environ, 2009 Comparison of the PM 2.5 levels in Shanghai, Beijing and International/National Air Quality Standards Fine particle: PM 2.5

9. Energy production and emissions of SO 2 and dust in China, 1998 - 2008 Zhang et al, Lancet, 2010

10. Air pollution epidemiologic studies in China Outline

11. A summary of air pollution epidemiologic studies in China Short-term exposure studies: Time-series/case crossover studies Single-city analysis: Beijing, Hong Kong, Shanghai, Shenyang, Taiyuan, Wuhan, etc. Multi-city analysis: PAPA, CAPES Panel study: Beijing Long-term exposure study Cross-sectional study: several Cohort study: ONE only Intervention study Beijing Olympics Hong Kong

12. Public Health and Air Pollution in Asia (PAPA) http://www.healtheffects.org/international.htm Shanghai Wuhan Hong Kong Bangkok Short-term exposure: Time-series

13. Results: comparison between PAPA cities BK had the biggest but less precise ER than the others PM 10 : Health effects Levels Wong et al, EHP, 2008

14. Traffic-originated particles has the largest health hazard! % Increase in Daily Deaths by Specific PM 2.5 Sources: Six Cities Study (1979-1988) 1 Source factor% increase95% CI Crustal (Si)-2.3-5.8, 1.2 Motor vehicles (Pb)3.41.7, 5.2 Coal (Se)1.10.3, 2.0 1 % increase in daily deaths associated with 10 ug/m 3 increase in mass concentration from source; Laden et al, EHP, 2000. Source factor% increase95% CI Crustal (Si)-2.3-5.8, 1.2 Motor vehicles (Pb)3.41.7, 5.2 Coal (Se)1.10.3, 2.0 1 % increase in daily deaths associated with 10 ug/m 3 increase in mass concentration from source; Laden et al, EHP, 2000.

15. Similar ERs across cities, but less precise in BK Wong et al, EHP, 2008; Kan et al, Env Res, 2010 SO 2 : Health effects Levels Results: comparison between PAPA cities

16. Wong et al, EHP, 2008 NO 2 : Health effects Levels Results: comparison between PAPA cities

17. Wong et al, EHP, 2008 O 3 : Health effects Levels Results: comparison between PAPA cities

18. PM 10, concentration-response curve WHO AQG China National Standard II

19. Public Health and Air Pollution in Asia (PAPA) http://www.healtheffects.org/international.htm Shanghai Wuhan Hong Kong Bangkok Short-term exposure: Time-series

20. CAPES China Air Pollution and Health Effects Study A new multi-city time-series study in Mainland China Supported by China Ministry of Environmental Protection PIs: Haidong Kan and Bingheng Chen Short-term exposure: Time-series

21. CAPES cities 上海 杭州 桂林 天津 太原 沈阳 福州 广州 西安 鞍山 乌鲁木齐

22. SO 2 NOxPM 10 PM 2.5 CO VOCs Spatial Distribution of Emissions in China, 2005

23. Panel study Wu et al, EHP, 2009 Association of Heart Rate Variability in Taxi Drivers with Marked Changes of Particulate Air Pollution in Beijing in 2008 Short-term exposure

24. Among PM 10, PM 2.5 : significant effects on daily mortality; PM 10-2.5 : NO significant health effects PM 10 : PM 2.5 vs. PM 10-2.5 Kan et al, Environ Int, 2007 Short-term exposure

25. Interaction between pollutants Chen et al, Biomed Environ Sci, 2007 Higher PM 10 significantly increased the effect of O 3 on total mortality; O 3 also increased the effect of PM 10. Short-term exposure

26. Visibility and mortality risk Huang et al, Sci Total Environ 2009 Short-term exposure

27. Modifiers of air pollution acute health effects Season: warm vs. cool Gender: male vs. female Age SES Sensitive sub- population Kan et al, EHP, 2008 Short-term exposure

28. Warm seasonCool season Total mortalityPM 10 0.21 (0.09, 0.33)0.26 (0.22, 0.30) SO 2 0.79 (0.16, 1.42)1.41 (0.98, 1.83) NO 2 0.88 (0.34, 1.42)1.61 (1.21, 1.99) * O3O3 0.22 (-0.08, 0.52)1.18 (0.52, 1.83) * Cardiovascular mortality PM 10 0.26 (0.00, 0.51)0.30 (0.20, 0.40) SO 2 0.56 (-0.44, 1.55)1.46 (0.84, 2.07) NO 2 0.76 (-0.09, 1.62)1.77 (1.19, 2.33) O3O3 0.26 (-0.22, 0.74)1.35 (0.41, 2.28) * Respiratory mortality PM 10 -0.21 (-0.82, 0.41)0.79 (0.47, 1.11) * SO 2 -0.31 (-2.06, 1.43)3.05 (2.04, 4.07) * NO 2 -1.01 (-2.50, 0.48)3.34 (2.40, 4.28) * O3O3 0.09 (-0.75, 0.92)0.39 (-1.19, 1.97) Warm (May-Oct) and cold (Nov-Apr) seasons Kan et al, EHP, 2008 Short-term exposure

29. Warm (May-Oct) and cold (Nov-Apr) seasons Cao et al, Sci Total Environ, 2009 Short-term exposure

30. Female vs. male FemaleMale PM 10 0.33 (0.18, 0.47)0.17 (0.03, 0.32)* SO 2 1.05 (0.61, 1.49)0.85 (0.43, 1.27) NO 2 1.10 (0.69, 1.50)0.88 (0.49, 1.27) O3O3 0.40 (0.03, 0.76)0.19 (-0.16, 0.54)* Kan et al, EHP, 2008 Short-term exposure

31. Young vs. old 5-4445-6465+ PM 10 0.04 (-0.52, 0.59) 0.17 (-0.11, 0.44) 0.26 (0.14, 0.38) SO 2 1.20 (-0.47, 2.87) 0.22 (-0.60, 1.03) 1.00 (0.65, 1.35) NO 2 0.52 (-1.02, 2.06) 0.64 (-0.11, 1.39) 1.01 (0.69, 1.33) O3O3 -0.08 (-1.39, 1.24) 0.47 (-0.19, 1.12) 0.32 (0.03,0.61) Short-term exposure Kan et al, EHP, 2008

32. Educational level: a measure of SES Short-term exposure Kan et al, EHP, 2008

33. Air pollution and mortality in Beijing Zhang et al, Sci Total Environ, 2000 Long-term exposure: cross-sectional

34. Air pollution and lung cancer in Guangzhou Tie et al, Atmos Environ, 2009 Long-term exposure: cross-sectional

35. CNHS Air Study China National Hypertension Survey (CNHS) Baseline survey in 1991 Follow-up visit in 1999 158,666 participants in 17 provinces of China (including both urban and rural areas) CNHS Air: a retrospective cohort analysis of outdoor air pollution and mortality in China 90,167 urban participants in 41 Chinese cities Long-term exposure: cohort study

36. Previous findings from the CNHS Gu et al, JAMA, 2006He et al, NEJM, 2005Gu et al, NEJM, 2009 Long-term exposure: cohort study

37. CNHS Air cities MeanRange TSP293135 - 489 SO 2 8313 - 209 NO X 4711 - 106 Outdoor air pollution levels ( in 1991-1993, μg/m 3 ) Long-term exposure: cohort study

38. CNHS Air Results Each 10 μg/m 3 increase in TSP was associated with increased risk of death *: 0.2% for total mortality (p=0.222) 0.8% for cardiovascular mortality (p=0.003) 0.4% for respiratory mortality (p=0.448) 1.0% for lung cancer mortality (p=0.095) Long-term exposure: cohort study * After adjustment for age, gender, smoking (smoking status, age at starting smoking, years smoked, and cigarettes per day), alcohol intake, physical activity, education, hypertension

39. Comparison with the ACS study CNHS*: 10 μg/m 3 increase of PM 2.5 was associated with - 0.6% ↑ of total mortality - 2.5% ↑ of cardiovascular mortality - 1.2% ↑ of respiratory mortality - 3.1% ↑ of lung cancer mortality *: assuming PM 2.5 /PM 10 ≈0.65 and PM 10 /TSP ≈0.5 ACS:10 μg/m 3 increase of PM 2.5 was associated with - 4% ↑ of total mortality - 6% ↑ of cardiopulmonary mortality - 8% ↑ of lung cancer mortality Pope et al, JAMA, 2002 Long-term exposure: cohort study

40. Kan et al, Biomed Environ Sci, 2005

41. Strengths and limitations of CNHS Air Strengths Large sample size Detailed individual information on potential confounders Limitations TSP only Air pollution exposure on the aggregated city level, rather than individual level Long-term exposure: cohort study

42. Health benefits gained from environmental intervention Hong Kong Dublin Atlanta Beijing Olympics Intervention study

43. 1992199319941995 0 20 40 60 80 NO 2 SO 2 O3O3 PM 10 Micrograms per cubic metre Year HALF YEARLY MEAN LEVELS Fuel restriction on sulphur 50% reduction in SO 2 after the intervention No change in other pollutants Hedley et al 2002 Hong Kong: air pollutants 1988 – 95

44. -6 -5 -4 -3 -2 0 15-6465+15-6465+15-6465+ Reductions In Deaths After Sulfur Restriction All causesCardiovascularRespiratory % Reduction in annual trend -1.8% -2.8% -1.6% -2.4% -4.8% -4.2%

45. Typical air pollution in Beijing Good air quality during the Beijing Olympics

46. 2008 Beijing Olympic Games

48. Intervention study Li et al, Sci Total Environ, 2010

49. Health burden of air pollution in China Outline

50. Smith et al., 2005. Derived from WHO data 4.9 million deaths/y Global burden of disease from top 10 risk factors plus selected other risk factors Outdoor air pollution

51. Smith et al., 2005. Derived from WHO data Chinese burden of disease from top 10 risk factors plus selected other risk factors Outdoor air pollution

52. Economic analysis: national 3.8% of GDP 1.2% of GDP

53. Estimation of the economic cost of health impacts due to PM 10 exposure in Shanghai in 2000 Health outcomesmean (95% CI) Premature death 787.8 Chronic bronchitis 91.9 Respiratory Hospital admission 2.9 Cardiovascular Hospital admission 2.9 Outpatient visits (internal medicine) 4.0 Outpatient visits (pediatrics) 0.4 Acute bronchitis 3.7 Asthma attack(<15) 0.3 Total893.8* * Accounting for 1.62% of Shanghai GDP in 2000 Kan and Chen, Sci Total Environ, 2004

54. Smith et al., 2005. Derived from WHO data Chinese burden of disease from top 10 risk factors plus selected other risk factors Climate change

55. Total yearly worldwide, US, Chinese, and western European CO 2 emissions (left) and per-head yearly CO 2 emissions (right) Zhang et al, Lancet, 2010

56. Modifiers of the temperature- mortality association in Shanghai Ma et al, submitted Kan et al, Env Res, 2007

57. Huang et al, Sci Total Environ, 2010

58. Diurnal temperature range (DTR) Easterling DR et al, Science, 1997, 277: 364-367

60. Ancillary benefits of low-carbon policy Low carbon policy Acting Locally While Thinking Globally Greenhouse Gases Emission (global effect) Air Pollutants Emission Air Quality Changes (local effect) Population Exposure Health Outcomes

61. Solar hot water heater in China Solar powered Christmas tree Low carbon life

62. EndpointsEEGASWINDSO 2 bSO 2 c Premature death 987022210231002728027340 Chronic bronchitis 2070046330481605677056890 Respiratory Hospital admission 505712030125601515015190 Cardiovascular Hospital admission 25376075634776727691 Outpatient visits (internal medicine) 34860084420088270010720001074000 Outpatient visits (pediatrics) 362108762091620111200111500 Acute bronchitis 6597001478000153700018120001816000 Asthma attack 1358029590307003586035930

63. Summary Strong evidence that ambient air pollution is associated with adverse health effects in Chinese populations Current air quality standard in China can not fully protect population health Low-carbon policy will play an active role in the reduction of air pollutant emission, improvement of air quality and the promotion of public health Kan et al, EHP, 2009

64. Acknowledgement Fudan Univ.: Bingheng Chen, Weimin Song US NIH/NIEHS: Stephanie J. London Shanghai CDC: Guixiang Song, Lili Jiang Shanghai Environmental Monitoring Center: Guohai Chen Peking Univ. : Wei Huang Graduate Students: Renjie Chen, Wenjuan Ma, Chunxue Yang

65. THANK YOU FOR YOUR ATTENTION hdkan@shmu.edu.cn