APHEISAir Pollution and Health: A European Information System

Bertil Forsberg, Sylvia Medina, Antoni Plasència, Ross Anderson, Lucia Artazcoz, Klea Katsouyanni,

Michal Krzyzanowski, Hans-Guido Mücke, Emile de Saegerand Joel Schwartz

On behalf of the APHEIS group

APHEIS is co-funded by the Pollution Related Diseases Programme of DG SANCOof the European Commission (contract No. SI2.131174 [99CVF2-604] -SI2.297300[2000CVG2-

607]-SI2.326507[2001CVG2-602]) and by the participating APHEIS institutions

APHEIS cities (26)

Steering Committee (Boston, USA)

(Tel-Aviv, Israel)

An epidemiological surveillance system

Aims to provide up-to-date and easy-to-use information on health impact assessment (HIA) of air pollution

For decision makers, environmental and health professionals, media and general public

Enables better-informed decisions about political, professional, personal issues

What is Apheis

How Apheis works

APHEIS coordination centre

Paris and Barcelona

Advisory groupsExposure assessmentEpidemiologyStatisticsPublic health Health impact assessment

Participating APHEIS Cities

Technical committeeExposure assessmentEpidemiologyStatisticsPublic HealthHealth Impact Assessment

City committeeNEHAPsLocal/national authoritiesMedical/environmental sciencesCitizens

Local/regional coordinator

Created five advisory groups: public health; health-impact assessment; epidemiology; exposure assessment; statistics

Drafted guidelines for designing and implementing the surveillance system, and for developing a standardised protocol for data collection and analysis for HIA

Review of capacities for HIA in institutions of participating cities

Actions, steps and resultsduring the first year

Implement or adapt organisational models designed during first year

Collect and analyse data for health-impact assessment

Prepare different health-impact scenarios

Prepare HIA report in standardised format (HIA in 26 cities)

Actions, steps and resultsduring the second year

1. Specify exposure

* PM10, BS

* Urban background stations

Five main steps in HIA

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

  - Mortality (all natural causes)

Five main steps in HIA

3. Specify the exposure-response functions

* Short-term exposure: APHEA2

Five main steps in HIA

Health indicator RR for 10 µg/m3 95%CI

Total mortality All ages

ICD9 <800 (Katsouyanni et al, 2001)

1.006 1.003 - 1.008

Respiratory hospital admissions 65 years +

ICD9 460-519 (Atkinson et al, 2001)

1. 001 1.00 - 1.009

Cardiac hospital admissions all ages

ICD9 410- 414.427.428 (Le Tertre et al, 2002)

1.011 1.004 - 1.018

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/m3 95%CI Total mortality

30 years + ICD9 <800

1.043 1.026-1.061

4. Derive population baseline frequency measures for health outcomes

5. Calculate number of attributable cases in target population (based on attributable proportion)

Five main steps in HIA

Demographic characteristics

* Nearly 39 million inhabitants in Western and Eastern Europe

* Proportion of people over 65 years: 15%, with highest proportion in Barcelona and lowest in London

Descriptive findings

Air pollution levels

* Black smoke measurements provided by 15 cities: Athens, Barcelona, Bilbao, Bordeaux, Celje, Cracow, Dublin, Le Havre, Lille, Ljubljana, London, Marseille, Paris, Rouen and Valencia

* PM10 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

Descriptive findings

Annual mean levels and 10th and 90th percentiles of the distribution of PM10

Descriptive findings

0

10

20

30

40

50

60

70

80

90

100

Borde

aux

Bucha

rest

*

Budap

est

Celje

Craco

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Gothe

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Ljublj

ana

Lond

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Mad

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Mar

seille

Paris

Rome

Seville

Stock

holm

Strasb

ourg

Tel A

viv

Toulo

use

µg/m3

2005

2010

Annual mean levels and 10th and 90th percentiles of the distribution of black smoke

Descriptive findings

0

20

40

60

80

100

120 µg/m3

Acute effects scenarios

* Reduction of PM10/BS levels to a 24-hour value of 50 µg/m3 (2005 and 2010 limit values for PM10) on all days exceeding this value

* Reduction of PM10/BS levels to a 24-hour value of 20 µg/m3 (to allow for cities with low levels of PM10/BS) on all days exceeding this value

* Reduction by 5 µg/m3 of all the 24-hour daily values of PM10/BS (to allow for cities with low levels of PM10/BS)

Health impact assessment findings

Chronic effects scenarios

* Reduction of the annual mean value of PM10 to a level of 40 µg/m3 (2005 limit values for PM10)

* Reduction of the annual mean value of PM10 to a level of 20 µg/m3 (2010 limit values for PM10)

* Reduction of the annual mean value of PM10 to a level of 10 µg/m3 (to allow for cities with low levels of PM10)

* Reduction by 5 µg/m3 of the annual mean value of PM10 (to allow for cities with low levels of PM10)

Health impact assessment findings

Potential benefits of reducing daily PM10 levels by 5 µg/m3 - Number of deaths per 100 000 inhabitants (95% confidence limits) attributable to the acute effects of PM10

HIA findings: PM10 acute-effects scenarios

0

1

2

3

4

5

6

7 Rate/100 000/year

Potential benefits of reducing annual mean values of PM10 by 5 µg/m3- Number of deaths per 100 000 inhabitants (95% confidence limits) attributable to the chronic effects of PM10

HIA findings: PM10 chronic-effects scenarios

0

5

10

15

20

25

30

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40

45

50 Rate /100 000 / year

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

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

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

The Apheis second-year report also provides an individual picture for each of the 26 cities that describes:

* Local characteristics

* Air pollution sources

* Exposure data

* Health outcomes

* HIA

* Specific comments

City by city reports

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 resultsduring the third year

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 government decision and 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 resultsduring the third year

Calculate costs to society of health effects of AP

Involve Apheis more closely in municipal, regional, national and European programmes (NEHAPS, AIRNET,CAFE, EUROHEIS).

Actions and steps to beundertaken in future years

The Apheis programme

* Multiyear, multiphase, proactive

* Answers key questions on air pollution and public health in Europe for a broad range of audiences

* Translates epidemiological findings into decision-making tool

* Bridges the gap between data and action

The broad view

The Apheis programme

* First broad-based European HIA of air pollution

* Consistent with other HIAs on air pollution worldwide

* Provides information on both local and European levels simultaneously with two main benefits:

- Local data can be used for local decision making (e.g. urban and transport planning; devising of steps to reduce air pollution)

- European authorities gain a global view on air pollution and public health

The broad view

The Apheis programme

* One more brick in the wall of evidence that air pollution continues to threaten public health

* Each phase builds on learnings of previous phase

* Needs ongoing commitment and funding by European Commission and EC member states

* For further information visit www.apheis.org

The broad view