1. 1 Issues in Global Health: An Investigation of Respiratory Health Effects of Air Pollution in Durban, South Africa  Thomas Robins, MD, MPH

2. 2 Issues in Global Health: An Investigation of Respiratory Health Effects of Air Pollution in Durban, South Africa  Some themes to keep in mind during the presentation:  Why are health issues in the developing world important to study?  When and how can effective studies be carried out in challenging situations with limited resources?  How can studies of respiratory morbidity associations with environmental pollution be designed to give valid & useful results?

3. 3 Overview of Presentation  Who was involved in the study and how was it funded?  What was the purpose of the study?  How was the study carried out?  What did we learn about:  Pollutant sources and levels?  Current health of the participants?  Health effects of air pollution?  What conclusions did we reach?  What recommendations do we have?

4. 4 Team Of Investigators University of Natal Faculty of Medicine: Barry Kistnasamy, MBChB, Dean Rajen Naidoo, MBChB, Head, Occupational Health Unit Umesh Lalloo, MBChB, Head, Department of Medicine Elvis Irusen, MBChB, Department of Medicine (now at University of Stellenbosch) Caron Jack, Department of Medicine Prem Ramlutchman, Department of Medicine Natasha Maistry, Office of the Dean

5. 5 Team Of Investigators Durban Institute of Technology: Joy Kistnasamy, Lecturer, Environmental Health Nitasha Baijnath, Environmental Health University of Michigan, USA: Thomas G. Robins, MD, MPH, Professor, Environmental Health Sciences Stuart Batterman, PhD, Professor and Associate Chair, Environmental Health Sciences Graciela Mentz, PhD, Department of Statistics Heinrich Amsterdam (visiting from Pentech)

6. 6 Collaborators Settlers Primary Environment Committee South Durban Community Environmental Alliance ECOSERV Ethekwini Municipality Health Department Ethekwini Municipality Water Department Dr. Barry Seetharam Prof. Prakash Jeena

7. 7 Funding Sources groundWork Ethekwini Municipality Health Department University of Natal Durban Institute of Technology Fogarty International Center, USA University of Michigan, USA Medical Research Council Engen SAPREF

8. 8 Background  A legacy of Apartheid era policies: lack of ‘zoning’ of industrial development  South Durban has two large international refineries, a paper mill, an international airport, a chemical tank farm, a number of landfill sites and various mills, processing and manufacturing industries  All in close proximity to residential and recreational areas

9. 9 Background  Long history of community groups raising concerns: South Durban Community Environmental Alliance (SDCEA); at the school, Settlers Primary Environmental Committee (SPEC)  Specific responses of governmental agencies & industries

10. 10 Background (Cont.)  SO 2 Committee (‘tripartite’)  continuous monitoring of SO 2 at the school since June 2000  continuous monitoring of oxides of nitrogen, carbon monoxide, total reduced sulfurs, and PM 10 since October 2000  No previous studies of exposure-health outcome associations  Current government request for tenders for larger study: ZAR 6 million

11. 11 What Was The Main Purpose Of The Study?  To look at whether air pollution is causing breathing problems amongst students and teachers at the School

12. Settlers Primary School

13. Settlers Primary School (Cont)

14. 14 Research Questions  How many learners and teachers at the Settlers School have chronic respiratory symptoms and conditions, including asthma?  Do air pollutants measured at the Settlers School affect respiratory symptoms and breathing function among students and teachers?  Do those with asthma or other respiratory diseases suffer more from air pollution?

15. 15 Research Questions (continued)  Which pollutants cause these health problems?  What are the sources of these pollutants?  What steps should be taken to improve the health of students & teachers? Of the larger community?

16. 16 How Was The Study Carried Out?  Exposure assessment  Levels in the air of several pollutants were measured on the school grounds during an 18-day period, 19 April – 6 May, 2001.

17. 17 Durban Metro Area, SO2 Monitoring Sites

18. Air Quality Monitoring at School

19. Inside Monitoring Van

20. 20 Monitored Air Pollutants

21. 21 How was the study carried out?  Recruitment of Participants. All teachers, all students in grades 3 and 6, and some students in grades 5 and 7, were invited to participate in the study.  More than 90% of those invited did participate; the participants included 248 students and 25 teachers.  The baseline health of the participants was looked at by using:  parent and child interviews  breathing function tests including a special test – called methacholine challenge – to look for asthma

22. 22 How was the study carried out?  Also, participants were asked to complete:  each evening at home a daily diary of symptoms  every two hours while at school:  a symptom log  blow into a handheld monitor which measures breathing function

23. 23 Bi-Hourly Symptom Activity Log

24. 24 AirWatch  Lung Function Monitoring Device 

25. 25 How was the study carried out?  The relationships between exposure to air pollutants such as sulphur dioxide (SO2), particles (PM10), and nitrogen dioxide (NO2) and symptoms and breathing function while at school were looked at.

26. 26 Monthly Trends of Sulfur Dioxide at the Settlers School What did we learn?: Exposure Assessment

27. 27 Long term Pollutant Trends – Sulfur Dioxide

28. 28 Daily Trends of SO2 During Study Period

29. 29 Diurnal Trends of SO2 During Study Period

30. 30 Comparison of Measured Pollutants to Standards & Guidelines

31. 31 Summary of Pollutant Measurements  We focused on monitoring at the Settlers School for the study period in April – May, 2001.  Pollutant levels vary by season, time-of-day, location and pollutant. Monitoring at the school provides only an approximate indication of pollutant exposure.  At the Settlers School during the study period, pollutant levels were below guideline levels  Historically, pollutants have exceeded guideline levels  Looking at the long term trends, levels appear to be decreasing for one pollutant, sulfur dioxide.  Long term data on other pollutants is not available.

32. 32 Figure 19. Distribution of asthma severity from parent baseline interview among students in grades 3 and 6. (n=147 students)     What did we learn?: Health Status of Participants

33. 33 Figure 20. Student asthma severity from the baseline parent interview by various demographic variables among students in grades 3 and 6. (Part I) (average n=143 students)

34. 34 Figure 21. Student asthma severity from the baseline parent interview by various demographic variables among students in grades 3 and 6. (Part II) (average n=162 students)

35. 35 Figure 23. Distribution of methacholine challenge test results among students in grades 3 and 6. (n=204 students).