EuroTB

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APHEIS 2
Air Pollution and Health A European Information
System A Health Impact Assessment of Air
Pollution In 26 European Cities Emilia Maria
Niciu1, Anna Paldy2, Eszter Erdei2, Michal
Krzyzanowski3 Sylvia Medina4, Antonio Placencia5,
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
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Who funds Apheis

• 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

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What methods did we use

• Network
• Network of environmental and public-health
  professionals
• 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

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What methods did we use

• Network

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What methods did we use
Network



Health outcomes monitoring (local/national
institutes of public health, EUROSTAT, WHO)
Exposure assessment
Quantitative relationships of exposure and
health-effect estimates
(local networks, European Env. Agency WHO
collaborating ? centre for air quality
control, Berlin European Reference Laboratory
Air Pollution, Ispra)

?
(APHEIS)


?


Health impact assessment (cases, population,
attributable risks)
(APHEIS, WHO-ECEH)
?


Dissemination of information for defined target
audiences (APHEIS)

?
?
?
EH professionals
Decision makers
Citizens
?

Air quality management/Public-health actions
?
Evaluation (European Commission)
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What methods did we use
Network
Participating APHEIS Cities
APHEIS coordination centre Paris and Barcelona
Local/regional coordinator
Technical committee Exposure assessment Epidemiolo
gy Statistics Public Health Health Impact
Assessment
Advisory groups Exposure assessment Epidemiology S
tatistics Public health Health impact assessment
City committee NEHAPs Local/national
authorities Medical/environmental
sciences Citizens
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Actions, steps and results during the first year

• 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

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Actions, steps and results during the second 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)

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Five main steps in HIA

• 1. Specify exposure
• PM10, BS
• Urban background stations

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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
•   - Premature mortality

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Five main steps in HIA

• 3. Specify the exposure-response functions
• Short-term exposure APHEA2

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Five main steps in HIA

• 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).

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Health indicator

RR for 10 µg/m

95CI

Total mortality

30 years

1.043

1.026
-
1.061

ICD9 lt800


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Five main steps in HIA

• 4. Derive population baseline frequency measures
  for health outcomes
• 5. Calculate number of attributable cases in
  target population

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HIA modelKünzli, Kaiser, Medina et al, Lancet
2000 356 795 - 801
Incidence/ prevalence
E-R function
Attributable cases
Scenarios
Observed level annual mean
PM10
Reference level PM10
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Descriptive findings

• Demographic characteristics
• Nearly 39 million inhabitants in Western and
  Eastern Europe ( 34 mil. in 21 WE cities 5 mil.
  in 5 CEE cities)
• Proportion of people over 65 years 15, with
  highest proportion in Barcelona and lowest in
  London

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Descriptive findings

• Air pollution levels
• 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
• Black Smoke - measurements provided by 15
  cities
• Athens, Barcelona, Bilbao, Bordeaux, Celje,
  Cracow, Dublin, Le Havre, Lille, Ljubljana,
  London, Marseille, Paris, Rouen and Valencia

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Descriptive findings

• Distribution of annual mean levels (10th and 90th
  percentiles) of PM10

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Descriptive findings

• Distribution of annual mean levels (10th and 90th
  percentiles) of Black Smoke

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Descriptive findings

• Health indicators Standardised mortality rates
  for all causes of deaths in the 26 cities

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Descriptive findings

• Health indicators Incidence rates for hospital
  admissions in 22 cities
• ( 8 with emergency admissions, 14 with general
  admissions)

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Health impact assessment findings

• 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)

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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)
• of 20 µg/m3 (2010 limit values for PM10)
• 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)

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HIA findings PM10 acute-effects scenarios

• Potential benefits of reducing daily PM10 levels
  by 5 µg/m3 - Number of deaths per 100 000
  inhabitants attributable to the acute effects of
  PM10 (95 C.I.)

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HIA findings Black Smoke acute-effects scenarios

• Potential benefits of reducing daily black smoke
  levels by 5 µg/m3- Number of deaths per 100 000
  inhabitants attributable to the acute effects of
  black smoke (95C.I.)

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HIA findings PM10 chronic-effects scenarios

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

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HIA findings PM10 in CEE cities

• CEE CITIES
• out of a total of 32 mil in 19 cities
• 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/m3

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Interpretation of findings

• 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

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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

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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

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Apheis 2002-2003
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Actions, steps and results during the third year
(2002-03)

• 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

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Actions, steps and results during 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 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

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The broad view

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

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The future
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Epheis
Environmental Pollution and Health A European
Information System
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Background

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

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Objective

• Comparative risk assessment (CRA) of different
  environmental risk factors in Europe
• Selected environmental risk factors
• Method based on HIA and CRA

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For further information please visit
www.apheis.org
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Who are our partners

• 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

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Who are our partners

• 10. Saint Georges 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

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Who are our partners

• Steering Committee
• Ross Anderson, Saint Georges 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

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Who are our partners

• Coordinators
• Sylvia Medina, Institut de Veille Sanitaire
  (Institute of Public Health), Saint-Maurice,
  France
• Antoni Plasència, Institut Municipal de Salut
  Pública (Municipal Institute of Public Health),
  Barcelona, Spain
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• Programme Assistant
• Claire Sourceau, Institut de Veille Sanitaire,
  Saint-Maurice, France