1. APHEIS 2 Air Pollution and Health: A European Information System A Health Impact Assessment of Air Pollution In 26 European Cities Emilia Maria Niciu 1, Anna Paldy 2, Eszter Erdei 2, Michal Krzyzanowski 3 Sylvia Medina 4, Antonio Placencia 5, on behalf of the Apheis network 1- Institutul de Sanatate Publica (Institute of Public Health), Bucharest, Romania 2- Jozsef Fodor National Center for Public Health, National Institute of Environmental Health), Budapest, Hungary 3- WHO European Centre for Environment and Health, Bonn Office, Germany 4- Institut de Veille Sanitaire, Saint-Maurice, France 5- Institut Municipal de Salut Pública (Municipal Institute of Public Health), Barcelona, Spain ISEE CEE Chapter,Balaton, Hungary, 4-6 October 2003

2. Co-funded by: * Pollution-Related Diseases Programme of Health and Consumer Protection DG of the European Commission, contract Nos.: SI2.131174 [99CVF2-604] SI2.297300 [2000CVG2-607] SI2.326507 [2001CVG2-602] * Participating institutions in 12 European countries Who funds Apheis

3. Network * Network of environmental and public-health professionals 16 centres26 cities12 European countries * 16 centres totalling 26 cities in 12 European countries * Each centre part of a city, regional or national institution active in the field of environmental health What methods did we use

4. Network What methods did we use

5. Exposure assessment (local networks, European Env. Agency; WHO collaborating  centre for air quality control, Berlin; European Reference Laboratory Air Pollution, Ispra)  Health outcomes monitoring (local/national institutes of public health, EUROSTAT, WHO) Quantitative relationships of exposure and health-effect estimates (APHEIS)  Health impact assessment (cases, population, attributable risks) (APHEIS, WHO-ECEH)  Dissemination of information for defined target audiences (APHEIS)  Decision makers  Citizens  Air quality management/Public-health actions  Evaluation (European Commission) E&H professionals Network

6. What methods did we use APHEIS coordination centre Paris and Barcelona Advisory groups Exposure assessment Epidemiology Statistics Public health Health impact assessment Participating APHEIS Cities Technical committee Exposure assessment Epidemiology Statistics Public Health Health Impact Assessment City committee NEHAPs Local/national authorities Medical/environmental sciences Citizens Local/regional coordinator Network

7. l Created five advisory groups: public health; health- impact assessment; epidemiology; exposure assessment; statistics l Drafted guidelines for designing and implementing the surveillance system, and for developing a standardised protocol for data collection and analysis for HIA l Review of capacities for HIA in institutions of participating cities Actions, steps and results during the first year

9. l Implement or adapt organisational models designed during first year l Collect and analyse data for health-impact assessment l Prepare different health-impact scenarios l Prepare HIA report in standardised format (HIA in 26 cities) Actions, steps and results during the second year

10. 1. Specify exposure * PM10, BS * Urban background stations Five main steps in HIA

11. 2. Define the appropriate health outcomes * Acute effects - Premature mortality excluding accidents and violent deaths - Hospital admissions for respiratory diseases 65+ age group - Hospital admissions for cardiac diseases all ages * Chronic effects - Premature mortality Five main steps in HIA

12. 3. Specify the exposure-response functions * Short-term exposure: APHEA2 Five main steps in HIA

13. 3. Specify the exposure-response functions * Long-term exposure: HIA in Austria, France and Switzerland based on two American cohort studies (Künzli et al, 2000). Five main steps in HIA Health indicator RR for 10 µg/m 3 95%CI Total mortality 30 years + ICD9 <800 1.043 1.026-1.061

14. 4. Derive population baseline frequency measures for health outcomes 5. Calculate number of attributable cases in target population Five main steps in HIA

15. HIA model Künzli, Kaiser, Medina et al, Lancet 2000; 356: 795 - 801 PM10 Incidence/ prevalence Attributable cases Reference level PM10 Scenarios E-R function Observed level: annual mean

16. Demographic characteristics 39 million 34 mil.21WE5 mil5 CEE * Nearly 39 million inhabitants in Western and Eastern Europe ( 34 mil. in 21 WE cities 5 mil. in 5 CEE cities) 15%, * Proportion of people over 65 years: 15%, with highest proportion in Barcelona and lowest in London Descriptive findings

17. Air pollution levels PM 10 * PM 10 - measurements provided by 19 cities: Bordeaux, Bucharest, Budapest, Celje, Cracow, Gothenburg, Lille, Ljubljana, London, Lyon, Madrid, Marseille, Paris, Rome, Seville, Stockholm, Strasbourg, Tel Aviv and Toulouse Black Smoke * Black Smoke - measurements provided by 15 cities: Athens, Barcelona, Bilbao, Bordeaux, Celje, Cracow, Dublin, Le Havre, Lille, Ljubljana, London, Marseille, Paris, Rouen and Valencia Descriptive findings

18. Distribution of annual mean levels (10th and 90th percentiles) of PM10 Descriptive findings 0 10 20 30 40 50 60 70 80 90 100 Bordeaux Bucharest * Budapest Celje Cracow Gothenburg Lille Ljubljana London Lyon Madrid Marseille Paris Rome Seville Stockholm Strasbourg Tel Aviv Toulouse µg/m3 2005 2010

19. Distribution of annual mean levels (10th and 90th percentiles) of Black Smoke Descriptive findings

20. Health indicators : Standardised mortality rates for all causes of deaths in the 26 cities Descriptive findings 0 200 400 600 800 1000 1200 Athens Barcelona Bilbao Bordeaux Bucharest Budapest Celje Cracow Dublin Gothenburg Le Havre Lille Ljubljana London Lyon Madrid Marseille Paris Rome Rouen Seville Stockholm Strasbourg Tel Aviv Toulouse Valencia Rate / 100 000 /year

21. Health indicators: Incidence rates for hospital admissions in 22 cities ( 8 with emergency admissions, 14 with general admissions) Descriptive findings

22. Acute effects scenarios 24-hour value of 50 µg/m 3 on all days exceeding this value * Reduction of PM10/BS levels to a 24-hour value of 50 µg/m 3 (2005 and 2010 limit values for PM10) on all days exceeding this value 24-hour value of 20 µg/m 3 on all days exceeding this value * Reduction of PM10/BS levels to a 24-hour value of 20 µg/m 3 (to allow for cities with low levels of PM10/BS) on all days exceeding this value by 5 µg/m 3 of all the 24-hour daily values * Reduction by 5 µg/m 3 of all the 24-hour daily values of PM10/BS (to allow for cities with low levels of PM10/BS) Health impact assessment findings

23. Chronic effects scenarios annual mean value 40 µg/m 3 * Reduction of the annual mean value of PM10 to a level of 40 µg/m 3 (2005 limit values for PM10) 20 µg/m 3 of 20 µg/m 3 (2010 limit values for PM10) 10 µg/m 3 of 10 µg/m 3 (to allow for cities with low levels of PM10) by 5 µg/m 3 of the annual mean value * Reduction by 5 µg/m 3 of the annual mean value of PM10 (to allow for cities with low levels of PM10) Health impact assessment findings

24. Potential benefits of reducing daily PM10 levels by 5 µg/m 3 - Number of deaths per 100 000 inhabitants attributable to the acute effects of PM10 (95% C.I.) PM10 HIA findings: PM10 acute-effects scenarios

25. Potential benefits of reducing daily black smoke levels by 5 µg/m 3 - Number of deaths per 100 000 inhabitants attributable to the acute effects of black smoke (95%C.I.) Black Smoke HIA findings: Black Smoke acute-effects scenarios

26. Potential benefits of reducing annual mean values of PM10 by 5 µg/m 3 - Number of deaths per 100 000 inhabitants attributable to the chronic effects of PM10 (95% C.I.) PM10 HIA findings: PM10 chronic-effects scenarios

27. CEE CITIES out of a total of 32 mil in 19 cities out of a total of 32 mil in 19 cities HIA for long term exposure on total mortality found that HIA for long term exposure on total mortality found that 5 547 (3 368 - 7 744) premature death could be prevented annually if PM10 concentrations were reduced by 5 µg/m 3 PM10 in CEE cities HIA findings: PM10 in CEE cities

28. Standardised protocol for data collection and analysis Conservative approach : * Did not consider newborn or infant mortality separately * Did not consider many other health outcomes listed by WHO * Did not consider independent effect of ozone * Used range of reference levels in different scenarios Interpretation of findings

29. Transferability of Exposure-Response (E-R) functions: * Short-term exposure: Question avoided by using E-R functions developed by APHEA 2 * Long-term exposure: Open question - used U.S. E-R functions Interpretation of findings

30. Conclusions * Our HIA provides a conservative but accurate and detailed picture of the impact of air pollution on health in 26 European cities, and shows that air pollution continues to threaten public health in Europe. * Even very small and achievable reductions in air pollution levels have an impact on public health * This impact justifies taking preventive measures even in cities with low levels of air pollution Interpretation of findings

31. Apheis 2002-2003

32. To keep our HIA as accurate and up-to-date as possible: - Produce new exposure-response functions on short-term effects of AP - Calculate years of life lost or reduction in life expectancy, in addition to the attributable number of deaths based on long- term effects Actions, steps and results during the third year (2002-03)

33. l To fulfill our mission of making our learnings available to the broadest possible audiences, and to evaluate the usefulness of our work on HIA among those who need to know: - Explore and understand how best to meet the information needs of policy makers concerned with the impact of air pollution on public health and - Understand how to meet those needs in terms of content and form Actions, steps and results during the third year

34. l Apheis is a multiyear, multiphase proactive public-health programme l Each phase builds on learnings of previous phase l First broad-based European HIA of air pollution on both the city and European levels simultaneously l Consistent with other HIAs on air pollution worldwide l Translates epidemiological findings into decision-making tool l One more brick in the wall of evidence that air pollution continues to threaten public health The broad view

35. The future

36. Epheis Environmental Pollution and Health: A European Information System

37. Background  Call for proposals DGSANCO 2003-2008  ENHIS Environment and Health Information System (WHO- ECEH Bonn) Six modules: 1.Identification of relevant policies/corresponding needs 2.Development of Indicators 3.Methods for data retrieval/processing 4.Creation of NCC, networking 5.Integrate HIA (Epheis) 6.Database development and maintenance Coordination WHO-Bonn Steering Committee Length first year :1 Feb 2004-30 Jan 2005

38. Objective Comparative risk assessment (CRA) of different environmental risk factors in Europe o Selected environmental risk factors o Method based on HIA and CRA

39. For further information please visit: www.apheis.org

40. 1. University of Athens, Athens, Greece 2. Institut Municipal de Salut Pública (Municipal Institute of Public Health), Barcelona, Spain 3. Departamento de Sanidad, Gobierno Vasco, Vitoria-Gasteiz, Spain 4. Institutul de Sanatate Publica (Institute of Public Health), Bucharest, Romania 5. Jozsef Fodor National Center for Public Health, National Institute of Environmental Health), Budapest, Hungary 6. National Institute of Hygiene, Warsaw, Poland 7. Saint James Hospital, Dublin, Ireland 8. Institut de Veille Sanitaire, Saint-Maurice, France 9. Inštitut za Varovanje Zdravja RS, (Institute of Public Health), Ljubljana, Republic of Slovenia Who are our partners

41. 10. Saint George’s Hospital Medical School, London, UK 11. Dirección General de Salud Pública, Consejeria de Sanidad, Comunidad de Madrid (Department of Public Health, Regional Ministry of Health, Madrid Regional Government), Madrid, Spain 12. ASL RM/E Local Health Authority Roma E, Rome, Italy 13. Escuela Andaluza de Salud Pública (Andalusia School of Public Health), Granada, Spain 14. Umeå University, Department of Public Health and Clinical Medicine, Umeå, Sweden 15. Tel Aviv University, Tel Aviv, Israel 16. Escuela Valenciana de Estudios para la Salud (Valencia School of Health Studies), Valencia, Spain Who are our partners

42. Steering Committee Ross Anderson, Saint George’s Hospital Medical School, London, UK Emile De Saeger, Joint Research Centre, Institute for Environment and Sustainability, Ispra, Italy Klea Katsouyanni, Department of Hygiene and Epidemiology, University of Athens, Athens, Greece Michal Krzyzanowski, WHO European Centre for Environment and Health, Bonn Office, Germany Hans-Guido Mücke, Umweltbundesamt - Federal Environmental Agency, WHO Collaborating Centre, Berlin, Germany Joel Schwartz, Harvard School of Public Health, Boston, USA Roel Van Aalst, European Environmental Agency, Copenhagen, Denmark Who are our partners

43. Coordinators l Sylvia Medina, Institut de Veille Sanitaire (Institute of Public Health), Saint-Maurice, France l Antoni Plasència, Institut Municipal de Salut Pública (Municipal Institute of Public Health), Barcelona, Spain Programme Assistant l Claire Sourceau, Institut de Veille Sanitaire, Saint-Maurice, France Who are our partners