Air pollution and its impact on health: Comparing findings in China with findings in Europe and the USA Kristin Aunan, CICERO CCICED, October 29, 2007, Beijing 16 of the 20 most polluted cities in the world are Chinese What are the health benefits of abating air pollution? Delhi Mexico City Rio de Janeiro NO2 Los Angeles SO2 New York TSP Tokyo Shanghai Lanzhou Taiyuan Guangzhou Beijing 0 100 200 300 400 mg/m Policy option Emission Exposure 500 600 700 800 3 Exposure response Physical benefit Valuation Monetary benefit 2 Deaths from diseases associated with air pollution exposure are frequent in China (2002) Annual deaths per 100,000 people. Source: WHO, 2004 3 Why should there be differences between d-r coefficients across countries? • Differences in composition of air pollution • Demographic factors, e.g. age distribution • Health status and socioeconomic conditions • Access to health services 4 .. differences may (misleadingly) be due to • Confounding factors (e.g. exposure to indoor air pollution) • Conversion factors between different PM fractions (e.g. TSP to PM10) • Classification of disease (ICD 9, ICD 10) 5 Dose-response for acute all-cause mortality (time-series studies): Very good agreement across regions Percent change in health outcome per 1 mg/m3 USA USA (NMMAPS) Harvard 6 cities Reanalysis Reanalysis 0.04-0.06 0.02-0.03 0.07 0.03-0.06 No evidence Not included End-point China (meta-analysis) Europe (APHEA II) (air pollutant) Aunan & Pan, 2004 Reanalysis All-cause deaths 0.03 (PM10) (HEI, 2004: 0.04-0.05) All-cause deaths 0.04 (SO2) (HEI, 2004: 0.04-0.05) (Eastern Europe: 0.01-0.04 Western Europe: 0.03-0.06) 6 Dose-response for other end-points (time-series and cross-sectional studies): Less agreement End-point (air pollutant) Hosp. admissions (CVD) P10 Hosp. admissions (CVD) SO2 Hosp.admissions (resp.) PM10 Hosp.admissions (resp.) SO2 Chronic Resp. illness Adults PM10 Chronic Resp. illness Children PM10 Chronic bronchitis Adults PM10 Chronic bronchitis Children PM10 China (meta-analysis) Aunan & Pan, 2004 Europe (APHEA II) 0.07 0.04-0.05 0.19 0.07 0.12 (HEI, 2004: 0.07-0.16) 0.15 0.09 Europe (Kunzli metaanalysis) USA 0.13 0.10 0.13 0.10-0.40 NMMAPS (US-EPA, 2003) NMMAPS (US-EPA, 2003) 0.05 0.31 0.44 Portnay Mullahy, 1990; 0.48 0.91-1.27 Schwartz, 1993; Abbey et al., 1993 0.34 2.5 Ware et al., 1996; Dockery et al., 1989 Meta-analysis (Eastern Europe, Infant mortality 0.39 USA, S.Korea, Mexico) (Aunan and Pan, 2004) 7 Generally: Large variations across studies for most end-points Dose-Response (% change in response per mg/m3) 1.25 Meta analysis 4.8 95% CI )low) 95% CI (high) 1.00 a b c 0.75 d e f Western 0.50 0.25 0.00 8 How to deal with long-term effects on mortality in China? • Shortterm time-series studies do not capture the long-term cumulative effects of pollution exposure • No long-term cohort studies in China (or similar countries) • Cohort studies from USA (Pope et al., 1995, 2002) yield implausibly high risks in China • World Bank 2007: Use Pope et al. (low pollution areas) and cross-sectional Chinese studies (high pollution areas -Shenyang and Benxi) and adjust a logarithmic function 9 A compromise solution (gives around 400,000 premature deaths in urban China in 2003) 10 Avoided deaths mean life years gained Life years gained per person in cohort, estimated for a 10 mg/m3 reduction in PM10 exposure (Chinese life table for 2003 and Pope et al. Dose-response coefficient). Dlife expectancy at birth:~0.3 year 0.16 0.12 0.10 0.08 0.06 0.04 0.02 Years of age 90 - 59 10 -1 4 15 -1 9 20 -2 4 25 -2 9 30 -3 4 35 -3 9 40 -4 4 45 -4 9 50 -5 4 55 -5 9 60 -6 4 65 -6 9 70 -7 4 75 -7 9 80 -8 4 85 -8 9 14 0.00 01 Potential life years gained 0.14 (From Aunan et al., 2004) 11 USA Six cities study (Dockery et al. 1993): Dlife expectancy at birth: ~ 0.8 year per 10 mg/m3 PM10 Figure taken from J. Schwartz, testimony, 2007 12 COPD: An important health endpoint for which knowledge is scarce What is the incidence rate and prevalence rate in China? Regional differences? Global Health Statistics, Murray and Lopez, 1996 Incidence rate 1990 Prevalence rate 1990 Average duration 345 Per 100,000 2499 Per 100,000 7.8 years 750 Per 100,000 Ministry of Health, 2004 1/2 year prevalence (huan bin lu) Estimated average duration 12.8 (?) years 13 Conclusions • Acute effect om premature mortality: – High degree of certainty and coherence across regions (d-r and baseline rates) – But no studies on infant mortality • Better to transfer d-r for chronic mortality effects than to omit – Long-term cohort studies in China needed! • Chronic respiratory diseases (e.g. COPD): – Large uncertainties remain (d-r and baseline rates) • Data on present frequencies of health outcomes and exposure levels are insufficient, especially in rural areas 14