1. P. Otorepec, M. Gregorič IVZ RS Use of rutinely collected air pollution and health data on local level for simple evaluation of health impact

2. Health - environment data There is a large amount of health and env. data rutinely collected in most of EU countries. Most of data are used only for a limited purpose and very poorly used and almost never analysed together with different sets of data. Our attempt was to combine two sets of data with simple analytical methods, that may serve regularly for assessment of local env. and health policies that lead to improvement of env. situation and health.

3. Ljubljana - local characteristics Ljubljana metropolitan area has a population of roughly 270.000. The number of people over 65 years is 40000 (14.8%). It has a climate that is transition between continental and alpine, with prevailing weak local winds, influenced by urban heat island. It is located in basin with regular temperature inversions. The meteorological conditions are extremely unfavourable and dramatically contribute to build up of pollution. The average wind speed is below 1 m/s and average yearly daily temperature is 10,9 C.

4. Demographic characteristics

5. Sources of air pollution In the city centre road traffic is the denominating source. In some residential areas coal burning and poor oil burning is very important too. The central heating plant is using only coal. Local heating plant and individual heating systems are still responsible for 30% of PM10 and BS emissions. Transportation constitutes the main source of air pollution in Ljubljana: 70 % of the emissions of PM10. The most important vehicle category is diesel vehicles (city buses). The maximal pollution level of PM10 in winter is 139 ug/m3, and in summer 70 ug/m3. ug/m3.

6. Air pollution data PM 10 24 hours average PM 10 yearly average Ozone (8 hours maximum of daily moving average in summer) Ozone (8 hours maximum of daily moving average) Black smoke 24 hours average Sulphur dioxide 24 hours average, hourly rate NO2, NOx 24 hours average, hourly rate CO (8 hours maximum of daily moving average) Lead, cadmium - part of PM BTX - benzen, toluen, xylen (hourly values)

7. Health data Mortality data - excluding accidents and violent deaths (ICD9 800) Respiratory Mortality data - (ICD9 460-519) Cardiovascular Mortality data - (ICD9 419-414, 427, 428) Hospital admissions for respiratory diseases - (ICD9 460-519) Hospital admissions for cardiac diseases - (ICD9 419-414, 427, 428)

8. Particulate Matter – PM10 Over the past decade many epidemiological studies have shown: An association between exposure to small Short term increases in PM10 levels and increases in daily mortality and worsening symptoms of respiratory illnesses. Studies have shown an increase in death due to respiratory diseases and worsening of symptoms in people with COPD and asthma. Long term PM10 exposure caused increased incidence of respiratory disease.

9. Health Impact of PM 10 Short term exposure; Acute effects on Respiratory Mortality (RR 1.012 / 10 ug/m3) Acute effects on Cardiovascular Mortality (RR 1.008 / 10 ug/m3) Acute effects of particles on Total Mortality - excluding accidents and violent deaths (RR 1.0074 / 10 ug/m3), Hospital admissions Asthma attack Children (RR 1.051 / 10 ug/m3). Hospital admissions Asthma attacks Adults(RR 1.004 / 10 ug/m3). Long term exposure; Effects on Total Mortality (RR 1.1 / 10 ug/m3).

10. Method used Exposure data - we used regular data from air pollution monitoring network, to evaluate exposure throughout the city the levels were checked with mobile monitoring stations, and than existing results used for exposure assessment. Health data - mortality and hospital admission data were used, only reliable health data. Health effect - Exposure - Pollution - Health Effect Coefficient was used to calculate health effect of exposure. Ljubljana City specific Coefficient was obtained from analytical time series studies.

11. Exposure data The pollution indicators are monitored by Agency for Environment. The measurements from urban background stations that are geographically representative of the study area and not directly influenced by local sources of air pollution were selected: two stations for PM10. The values from the stations correlate very well with mobile stations, what means that exposure to PM10 is even throughout the city. PM 10 Monitoring cites Location Type Figovec Urban background Agency for Environment Urban background

12. Air pollution data : daily mean levels (SD) of PM10 were 35.7 µg/m3 (19.5) A.number of days where PM10 exceeded 20 µg/m3 were 287 days B.number of days where PM10 exceeded 50 µg/m3 were 67 days.

13. Participating cities

14. Annual mean levels of the distribution of PM10, Required annual levels in EU in year 2005 (40 ug/m3) and in year 2010 (20 ug/m3)

15. Number of days per year when PM10 exceeded 24 - hour values of(50 ug/m3) and (20 g/m3)

16. Health indicators - Ljubljana National Institute of Public Health provides mortality data coded (ICD 10). For 1999 : - daily mean for total mortality (ICD9<800) was 7,7 and SD:1,62 - standardised mortality rate using European population was 803,5 per 100 000 inhabitants. Incidence rate of cardiac admissions - all ages was: 6,6/1000 Incidence rate of respiratory admissions all ages was: 9,5/1000 Incidence rates of respiratory admissions 65+ years was: 17/1000

17. Standardised mortality rates for all cause of deaths

18. Acute effect scenario - PM10 reduction of PM10 levels to a 24 hour value of 50 ug/m3 (2005, 2010 limit values for PM10) on all days exceeding this value reduction of PM10 levels to a 24 hour value of 20 ug/m3 (to allow for cities with low levels of PM10) on all days exceeding this value

19. Benefits of reducing daily PM10 levels in the city of Ljubljana to 20 µg/m 3 and to 50 µg/m 3. Short-term mortality (excess cases per 100 000 inhabitants) Number of days exceeding 20 µg/m 3 - 287 Number of days exceeding 50 µg/m 3 - 67 Excess cases per 100 000 Attributable cases Short-term mortality 20 µg/m 3 11.0 50 µg/m 3 2,0

20. Potential benefits of reducing PM10 levels to a 24- hour value of (20 ug/m3) on all days exceeding this value - Number of deaths per 100000 inhabitants attributable to acute effects of PM10

21. Chronic effect scenario - PM10 reduction of the annual mean value of PM10 to a level of 10 ug/m3 reduction of the annual mean value of PM10 to a level of 20 ug/m3 (2010 limit values for PM10)

22. Table 3. Benefits of reducing PM10 annual mean value to a level of 20 and 10 µg/m3. Long term mortality (excess cases per 100 000 inhabitants) Attributable cases Excess cases per 100 000 Long term mortality 20 µg/m 3 66,7 10 µg/m 3 106,8

23. Potential benefits of reducing annual mean values of PM10 to a level of 20 ug/m3 (2010 limit values for PM10) - Number of deaths per 100000 inhabitants attributable to acute and chronic effects of PM10

24. Table 2. Benefits of reducing daily PM10 levels to 20 µg/m3and to 50 µg/m3. Hospital admissions (excess cases per 100000 inhabitants) Hospital admissions for cardiovascular diseases (all ages) 20 µg/m316,1 50 µg/m33,0 Hospital admissions for respiratory diseases (+65) 20 µg/m312,1 50 µg/m32,2

25. Comments Both urban background stations for PM10 were used to estimate the exposure for Ljubljana in the study. The levels of PM10 are of concern. The annual daily mean level of PM10 is not decreasing and was 35,7 µg/m3 in 1999. The main source of PM10 pollution is traffic. All public transport is with diesel buses, diesel buses and trucks are very common, and part of the vehicle fleet is not kept in a good condition. The centre of the city is missing traffic free zones and pedestrian zones are scarce.

26. There are at least 40 deaths and almost 100 hospital admissions for cardiovascular diseases and respiratory diseases per year, that can be attributed only to exceed of EU level (20 µg/m3 that will be enforced in 2010). On a long run more than 300 lives per year could be spared, providing that long term PM10 average annual value would not exceed 10 µg/m3. City transport policy needs to recognise that it cannot only focus on the demand for roads but must make walking, cycling and public transport real and accessible choices. Public Health and Health Promotion is going to play a major role in developing these strategies and in their cross-sectoral implementation through Green Transport Plans, local Transport Plans and through improving access to public transport.

27. Health Impact Assessment - HIA HIA can play a role in evaluating different policy scenarios for reducing air - pollution levels. HIA provides number of health events attributable to air pollution in the target population. WHO guidelines were used for assessing and using epidemiological evidence for environmental - health risk assessment and own HIA guidelines developed.