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![Page 1: 1 17 th EPIET Epidemiology Course Menorca, September / October 2011 Environmental Epidemiology (Introduction) Helen Maguire HPA London region with acknowledgement.](https://reader035.fdocuments.net/reader035/viewer/2022062619/55152a73550346a80c8b6686/html5/thumbnails/1.jpg)
1
17th EPIET Epidemiology CourseMenorca, September / October 2011
Environmental Epidemiology(Introduction)Helen Maguire HPA London region with acknowledgement of previous work of Amandine COCHETFrench institute for public health surveillance Environmental health department and colleagues at HPA CRCE London
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To provide a basic knowledge about
►Challenges and issues relating to environmental epidemiology
►Concept of low risk but large impact
►Methods of investigation
Objectives
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Restrictive definition: environment = air + water + soil
► all the physical, chemical and biological factors external to a person, and all the related behaviours (WHO)
► the sum of all external conditions affecting the life, development and survival of an organism (US-EPA)
► everything that is not me (Einstein)
► Involuntary exposure
What is the environment ?
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► Occupational environment- aromatic amines and bladder cancer- asbestos fibres and mesothelioma- cadmium and kidney diseases- benzene and leukaemia- pesticides and infertility- organic solvents and neurological disordersetc ...
► General environment …
High risks of adverse health outcome resulting from exposure
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December 1952 - London
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December 1952 - London
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1932-1968 - Minamata
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1932-1968 - Minamata
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December 1984 - Bhopal
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December 1984 - Bhopal
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1986 - Tchernobyl
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Thyroid cancer in children
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120
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Years
Inci
den
ce R
ate
per
mil
lio
n
Belarus
Ukraine
Briansk
Gomel
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2003 - Paris
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2005 - Katrina
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Buncefield Explosion
• Plume stretched • for 70 miles • across southern
England
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► Anthropogenic activities– London fog 1952, Minamata 1953, Bhopal
1984, Tchernobyl 1986, Buncefield fire England 2005,
► Natural origin– Heat waves,
– Hurricanes…
► Mixed origin– UV and melanoma
Nature of risks in general environment
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E D
The 2 most FAQ in environmental health
• What is the environment’s Health impact = Considering environmental factor E, how many cases of disease D is it expected to generate?
• What is the Burden of disease attributable to the environment = Considering disease D, what percentage is due to environmental factor E?
?
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Epidemiologicalstudies
Observational(non-intervention)
Data fromindividuals
Data from groups
Descriptive Analytic
Ecological study
Descriptive Analytic
Cross sectional study Cohort studyCase control
study
Data from groupsData fromindividuals
Experimental(intervention)
Community trialClinical trial,
individual fieldtrial
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does this space time
dsitribution = a cluster?
space
1 2 3 4 5 6
time
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..sometimes there is no doubt about a common exposure
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Some challenges in environmental epidemiology
E D?
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Characteristics of exposure in environmental epidemiology
E D
- Multiple pollutants (RF)- Multiple routes of exposure- 1 RF n D- Low levels of exposure- Long duration of exposure- Changes over time
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Characteristics of health outcomes in environmental epidemiology
E D
- Multifactorial diseases : n RF 1 D- Rare disease- Long latent periods
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Buncefiled oil depot explosion and fire East of England 2005
attendance at A&E after the fire
Fig 1: Distribution of attendances in Hemel Hempstead and Watford A&E between 11/12/05 and 14/12/05, by date and time. (N=244)
0
5
10
15
20
25
30
35
40
45
4-6
6-8
8-10
10-1
212
-14
14-1
616
-18
18-2
020
-22
22-2
4 0-2
2-4
4-6
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8-10
10-1
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-14
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-18
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-14
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-18
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8-10
10-1
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-14
14-1
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-18
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020
-22
22-2
4
38697 38698 38699 38700
Date & Time
No.
Oil depot worker
Public
Em. Services
Time of explosion
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… presenting complaints
Fig 2: Main presenting complaints as percentage for each group
0
10
20
30
40
50
60
70
80
90
Injuries Respiratory Anxiety Headache vomiting Cardiac
Presenting complaints
Pro
port
ion
of c
ompl
aint
s
Members of the public % of 40
Oil depot workers % of 17
Emergency workers % of 187
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Characteristics of environmental risks
E D
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► High RR– benzidine / bladder cancer RR =
500– tobacco (>25cig/d) / lung cancer RR =
30
► Usually severe and often specific health outcomes
► “Well defined” populations– in space, in time, sociodemographic,
High risks
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► Urban air pollution and short-term respiratory diseases– RR = 1.1 - 1.5
► Magnetic fields and children leukaemia– RR = 1.3
► …
Low risks
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Relative risk
ratio measure
Attributable risk (AR) %
100 * (Incidence in exposed – Incidence unexposed)______________________________
Incidence in exposed
• PAR% = p * ( RR -1) / [ 1+ p * ( RR - 1) ]if the relation is causal, it estimates the proportion (amount) of disease that we can attribute to the exposure
Small relative risks do not mean small health impacts
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example calculation of AR and AR%Phospheneexposure incidence genetic mutation
exposed 0.71
unexposed 0.14
RR 0.71/0.14 = 5.1
attributable risk 0.71-0.14= 0.57
AR% 0.57/0.71*100= 80%
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attributable risk for smoking and lung cancer death (Doll and Hill 1956)
exposure lung cancer death/100,000
heavy smokers 166
non smokers 7
RR 166/7= 23.7
attributable risk 166-7= 159
AR% 159/166*100= 95.7%
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Further challenges: misclassification Theoretical
baseline situation E0 E1 E2
Prevalence 80% 15% 5%
Incidence* 100 300 500
RR** ref 3.0 5.0
E0 = non exposed, E1=low exposure, E2=high exposure* Incidence : x /100.000, ** RR : true Relative Risk
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Heterogeneity in the population’s
sensitivity to the exposure E0 E1 E2
Prevalence 80% 15% 5%
Incidence (S) 100 300 500
Incidence (s) 100 200 300
Incidence (mean) 100 250 400
RR ref 2.5 4.0
50%%
50%%
* (S) : “normal” sensitivity (s) : low sensitivity35
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Non specific definition of the health outcome
E0 E1 E2
Prevalence 80% 15% 5%
Incidence (D) 100 250 400
Incidence (d) 50 50 50
150 300 450
RR ref 2.0 3.0
•(D) : disease specifically related to exposure.•(d) : disease not related to exposure 36
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Errors in the exposure classification
20% of non exposed (E0) are categorised E1 and 10% of non-exposedare categorised E2.
E0 E1 E2
Prevalence 50% 35% 15%
Incidence 150 214.3 250
RR ref 1.43 1.67
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Inaccuracy in the exposure categories
E0 E1
Prevalence 50% 50%
Incidence 150 225
RR Ref 1.5
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• Heterogeneity of the population
• Non specific definition of health outcome
• Errors in exposure classification
• Inaccuracy in exposure categories
E0 E1
Prevalence 50% 50%
Incidence 150 225
RR Ref 1.5
E0 E1 E2
Prevalence 80% 15% 5%
Incidence* 100 300 500
RR** ref 3.0 5.0
** RR : true Relative Risk
RR : estimated Relative Risk
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methods to improve epidemiological study where there are low risks
• Improve data quality• confounders, diagnosis
• Improve statistical power• meta analysis, large studies, pool data
• Take careful account of
• critical periods of exposure
• individual history of exposure
• behaviour, space-time activities …
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Biomonitoring
assessment of human exposure to chemicals by measuring the chemicals or their metabolites in human specimens (blood, urine, hair,…)
biomarkers of exposure and
outcome
improving assessment of exposure: biomarkers of exposure and outcome
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Ecologic studiesEcologic studies
Unit of observation is group, not individual
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Ecological studies: objectives
To generate or to test etiologic hypotheses
To evaluate the impact of intervention programs or policies
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Ecological studies: methods
• Aggregated data
• Statistical unit = « group » (time/space)– Group exposure
• Mean exposure, environmental proxy– Group effect
• Frequency of disease in the statistical unit
• Research of an association between:
– Variations of exposure levels
– Variation of health indicators44
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Limits of geographical studies
• Classification biasagregated data insufficient quality of exposure and disease indicators errors of classifications (generally non differential)
• Surveillance biasif ascertainment of disease or exposure or both differs from one place to another(can be differential)
• « Ecological fallacy »
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Ecological Fallacy
population B
population C
population A
Level of exposure
Incidence rate
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Ecological Fallacy
Incidence rate
Level of exposure
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The Ecological Fallacy is the inability to generalize information gathered at the group level to specific individuals.
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Time seriesTime series
• A type of ecological study• Looks at the (short-term) temporal association
between health events and pollution
• Less subject to confounding than many study designs
• Time-varying confounders: temperature, humidity, influenza, day of the week, public holidays
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Time series mortality and mean temperature in
Paris
1999-2002 versus 2003
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Epidemiologicalstudies
Observational(non-intervention)
Data fromindividuals
Data from groups
Descriptive Analytic
Ecological study
Descriptive Analytic
Cross sectional study Cohort studyCase control
study
Data from groupsData fromindividuals
Experimental(intervention)
Community trialClinical trial,
individual fieldtrial
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Conclusion
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• Critical aspects and challenges in environmental epidemiology
• Difficulties in exposure measurements, outcomes assessments
• Low risk can have large / important public health impact
• Question of causality is crucial
• Epidemiology is one of the tools
• Risk assessment,
• Cluster investigation, …
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H. Morgenstern, Uses of ecologic analysis in epidemiologic research. American Journal of Public Health, Vol. 72, Issue 12 1336-1344, 1982.
Talbott E. An Introduction to Environmental Epidemiology CRC Press, 1995
Bertollini R. Environmental epidemiology. Exposure and disease CRC Press, 1996
Aldrich T.E. Environmental epidemiology forwardchemosphere 41 (2000) 59-67
Morgenstern H. Principles of study design in environmental epidemiology EHP 101 (suppl 4) (1993) 23-38
Hatch M. Measurement issues in environmental epidemiologyEHP 101 (suppl 4) (1993) 49-57
Hemon D. Recherche épidémiologique sur l’environnement et la santé : quelques aspects méthodologiquesRev Epidém. et Santé Publ. 43 (1995) 395-411
References
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Thankyou
ps …I look forward to meeting you all
properly during the next 2 weeks
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