Air Pollution: What you can do about it in the office and community FMF, November, 2018 Alan Abelsohn - Houses of Parliament: Sunset. Claude Monet ...
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Air Pollution: What you can do about it in the office and community
FMF, November, 2018
Alan Abelsohn
Houses of Parliament: Sunset. Claude Monet
Faculty/Presenter Disclosure • Faculty: Alan Abelsohn • Relationships with financial sponsors: – Contract with Health Canada
How many of you………………….??
Health Services Use (OP Visits)-AQHI
Ontario
Disease AQHI=3 AQHI=6 %age change
Low Risk Mod Risk
Asthma 1.8 1.97 9.3%
COPD 2.41 2.82 16.9%
Hypertension 5.83 6.41 9.8%
Angina 1.51 1.70 12.8%
Stroke 5.21 5.24 0.7%
Heart Failure 6.19 6.63 7.1%
Diabetes 10.72 11.79 9.9%
To T. BMJ Open 2015;5:e009075
Airhealth.ca AQHI Canada App
Air Health Messages
Health Quality
Risk Health
Index At Risk Population* General Population
Enjoy your usual outdoor Ideal air quality for outdoor
Low Risk 1-3
activities. activities.
Consider reducing or No need to modify your usual
Moderate rescheduling strenuous outdoor activities unless you
Risk
4-6 activities outdoors if you are experience symptoms such as
experiencing symptoms. coughing and throat irritation.
Reduce or reschedule Consider reducing or rescheduling
strenuous activities outdoors. strenuous activities outdoors if you
High Risk 7 - 10
Children and the elderly experience symptoms such as
should also take it easy. coughing and throat irritation.
Avoid strenuous activities Reduce or reschedule strenuous
Very Above outdoors. Children and the activities outdoors, especially if you
High Risk 10 elderly should also avoid experience symptoms such as
outdoor physical exertion. coughing and throat irritation.
*People with heart or breathing problems are at greater risk.
Follow your doctor's usual advice about exercising and managing your condition.
Health Canada: Airhealth.ca
Air Pollution: What you can do about it in the office and community
Learning Objectives
At the conclusion of this activity, participants will be able to
1. To identify the health effects of indoor and outdoor air pollution
on respiratory and cardiac health
2. To use the Air Quality Health Index, as a health risk communication tool
3. To counsel their patients to avoid the negative health impacts of air pollution
■ You assess 14 year-old, Maria, a high school student, in the emergency department with shortness of breath; worsening of her asthma ■ PMH: She has had difficult to control asthma; on ■ Fluticasone/ Salmeterol Combination diskus; Salbutamol prn ■ She is a track athlete, and was out running for 2 hours yesterday. She does not smoke, and no-one at home smokes ■ What are the possible triggers for the worsening of her asthma?
■ You assess 14 year-old, Maria, a high school student, in the emergency department with shortness of
breath; worsening of her asthma
■ PMH: She has had difficult to control asthma; on
■ Fluticasone/ Salmeterol Combination diskus; Salbutamol prn
■ She is a track athlete, and was training yesterday. She does not smoke, and no-one at home smokes
■ What are the possible triggers for the worsening of her asthma?
■ Could air pollution be a trigger that is exacerbating her asthma?
■ Where could she be exposed to air pollution; what exposures?
CH2OPD 2 C: Community H: Home/ Hobbies O: Occupation P: Personal D: Diet/ Drugs
CH2OPD 2
C: Community
• Ambient air; Traffic
H: Home
• Irritants
• Gases (VOCs, NO2, chemical odors, fragrances)
• Particles (Outdoor PM; SHS, dust, incense)
• Allergens (HDM, cat, cockroach, pollen, mold)
Hobbies
• Glues, paints
O: Occupation
P: Personal
D: Diet/ Drugs
Asthma Initiative of Michigan
https://getasthmahelp.org/asthma-triggers.aspx■ You assess 61 year-old male in the emergency department with atrial fibrillation x 4hrs ■ PMH: Hypertension; on Ramipril 5mg and HCT 12.5mg od; non- smoker ■ He is a runner, and was out training this morning. ■ Could air pollution be a trigger for his arrhythmia?
Air Pollution triggering Atrial Fibrillation
26% increased odds 2 hrs after exposure for each 5ug/m3 PM2.5
In patients with heart disease
Link MS. J American Coll Cardiology 2013 62(9)■ Outdoor Air pollution and health ■ Burden of Illness ■ Pollutants ■ Household Air Pollution ■ What can we do?
Short-term exposure
(Hours to days)
■ Exacerbation of pre-existing respiratory disease
– asthma
– COPD
■ Exacerbation of pre-existing CVS disease
– ischemia
– heart failure
– Arrhythmia
– Ischemic strokeAir pollution and asthma ■ Short term exposure – Air pollution clearly exacerbates asthma Does long term exposure contribute to: ■ New onset of asthma? (Stieb Health Place 2015,Brauer Europ Resp J 2007, Dell Env Int 2014, Zmirou J Epi Comm Health 2004)
Asthma Incidence: birth address exposure
Gehring. Lancet Respiratory Medicine. 2015FEV1 Response to Traffic Related Air Pollution (TRAP)
A cross-over study
Respiratory effects of exposure to diesel traffic on persons with asthma
McCreanor NEJM Dec 2007Long-term exposure
(Weeks, months, years)
■ Increased mortality
■ Respiratory
– Increased incidence of Ca lung
– Asthma, COPD
– Reduced lung function
■ Cardiovascular:
– Development of atherosclerosis
■ Pregnancy effects
■ Cognitive effects
■ Other effectsBiological pathways linking PM exposure with CVDs.
Brook R D et al. Circulation. 2010;121:Figure 3Air pollution and
Coronary Artery Calcium Progression (Agaston units)
Kaufman JD Lancet 2016Who’s at risk – vulnerability/ exposure ■ People with existing heart and lung disease ■ Diabetics ■ The elderly ■ Young children ■ Pregnancy/ foetus ■ People who are active outdoors (exercise; workers)
■ Outdoor Air pollution and health ■ Burden of Illness ■ Pollutants ■ Household Air Pollution ■ What can we do?
Outdoor Air Pollution Globally 3.7 million premature deaths annually 5th-ranking mortality risk factor WHO 2018
National Illness Costs of Air Pollution. CMA 2008
Canada 2008
Acute premature 2,682 (21,000)
deaths
Hospital 10,966
admissions
ED visits 92,690
Minor illnesses 22,542,500
Doctors office 623,369
visits
Costs $ 8 billionAnnual mean concentration PM2.5 (ug/m3) 2014
BreatheLife: A campaign for Clean Air
http://breathelife2030.org
WHO, CCAC, UNEP■ Outdoor Air pollution and health ■ Burden of Illness ■ Pollutants ■ Household Air Pollution ■ What can we do?
Air Pollutants
PM 2.5, Ozone, Nitrogen Dioxide
A) Toronto - August 17-23, 2003
AQHI
10
Regional Smog 100
NO2 (ppb)
9 90
8 O3 (ppb) 80
7 PM2.5 (ug/m3) 70
concentration
Pollutant
6 60
AQHI
5 50
4 40
3 30
2 20
1 10
0 0
1 11 21 31 41 51 61 71 81 91 101 111 121 131 141 151
HourCase #3
■ A 3 yr old boy in clinic in Ghana
– Fever 38.50C x 24 hours
– No vomiting; taking fluids OK; occasional cough
■ On exam:
– Hydration N
– Tachypnoea 44/min
– No chest indrawing, no nasal flaring, no grunting
– Chest auscultation: Rhonchi and creps R base
■ Diagnosis: ?
■ Management: ?
– Is air pollution a factor?
– What other history would you want to ask to understand that?
– Who else might be at-risk?Household Air Pollution
4.3 million deaths a year globally
Infectious:
■ ALRI: >50% childhood pneumonia deaths
■ TB
A major cause of NCD:
■ COPD
■ Ischemic heart disease and Stroke
■ Lung cancer
■ Cataracts
■ Adverse pregnancy outcomes
Children's Health and the Environment
WHO Training Package for the Health Sector
World Health Organization
www.who.int/cehMortality rate attributable to ambient and household air pollution
Over 7 million deaths per year: 2012Case 4 58 year old male in your office in Calgary Cough x 3 months Weight loss of 10 lbs What else do you want to know in history? Differential?
Case 3 Could environmental exposures cause Ca lung? What exposures and where? • Canada • New Delhi
Case 3
Dr Arvind Kumar; Thoracic Surgeon, New Delhi
• There are no non-smokers in Delhi
• Everyone in Delhi, from infants on, smoke equivalent of 7 cigs/ day
• Changing incidence of Ca Lung
• Smokers = non smokers
• Women catching up to men
• Age; as young as 35-40Radon and lung cancer in Canada
Radon is:
1. The second-leading cause of lung cancer, after smoking: 16 % of lung cancer
deaths, >3200 deaths per year in Canada.
2. The primary cause of lung cancer in non-smokers in Canada.
3. Exposure to radon and cigarette smoke is synergistic:
Radon Level Lifetime Risk Lifetime Risk
(Bq/m3) Non-Smoker Smoker
Background 1% 12%
200 2% 17%
400 3% 22%
800 5% 30%What is radon? ■ Radon is a colourless, odourless radioactive gas produced naturally by the breakdown of uranium in the ground. ■ Inhaled radon gas releases alpha radiation which is carcinogenic to bronchial epithelial cells. ■ There is no known threshold below which there is no risk. ■ All homes have some level of radon- the question is how much and the only way to know is to test
Where is radon? ■ No areas of the country that are 'radon free’. Manitoba, New Brunswick, Saskatchewan, and the Yukon had the highest percentages homes above the radon guideline ■ 7 percent of Canadians are living in homes with elevated levels of radon. ■ Radon levels vary significantly across the country.
HOW RADON ENTERS A HOUSE
• Any cracks, openings or gaps in
foundation walls or floors provide
route(s) of entry into home
• Once inside the home, radon can
build up to dangerous levels
Image: Courtesy of the Department of Natural Resources Canada
39HOW CAN YOU TEST FOR RADON
■ The ONLY way to know if you have a problem is to TEST
1. Hire a certified radon measurement professional
2. Purchase a do-it-yourself test kit
• Use a long-term test device for a minimum of 3 months.
www.TakeActiononRadon.ca/testHOW TO REDUCE RADON LEVELS
• If the radon level is found to be
high, it can be fixed at a
reasonable cost
• Hire a certified radon mitigation
professional
• Canadian – National Radon
Proficiency Program (C-NRPP)
To find a certified mitigation professional go to:
www.TakeActiononRadon.ca/reduce
www.c-nrpp.caCase 4 AQHI 10 +: Where/what is this?
AQHI Forest Fires
B) Kelowna - August 18-21, 2003
Forest Fires
20 300
18
NO2=7, O3=55, PM2.5=75, AQHI=7
250
16
14
concentration
200
Pollutant
12
AQHI
10 150
NO2=22, O3=13, PM2.5=100, AQHI=7
8
100
6
4
50
2
0 0
1 11 21 31 41 51 61 71 81 91
HourWildfire Smoke •Local plume •Distant spread •Health effects Protecting your health •Limit outdoor activity and strenuous physical activities as much as possible. •If you have difficulty breathing, reduce your activities or stop altogether. •At home: stay indoors with the windows closed. •Turn off your furnace and air conditioner as it may draw smoke indoors. •In a vehicle: keep the windows closed and set the ventilation system to recirculate. •Watch out for others in your care who may be more vulnerable to smoke. •Leave the area: If you are able to, move to a location with cleaner air
■ Outdoor Air pollution and health ■ Burden of Illness ■ Pollutants ■ Household Air Pollution ■ What can we do? Interventions
What can health professionals do?
In the office or clinic
• Guidelines
• Disease control
• asthma control
• heart failure control
• Reduce exposure
• AQHI education
• Exercise
• Traffic*
• Personal protection
• Masks
• Air Purifiers
• Anti-oxidants
• Indoor Air
In the community
• Reduce emissions
• Industry
• Transport
• WoodstovesTraffic Related Air Pollution (TRAP) Beckerman et al. (2008) Atmos Enviro. 42:275-290; Hudda N. Environ Sci Technol. Sept 2013
Face Masks
• Even the best performing masks did not always reduce exposure consistently
across a range of activities.
• Do they fit?
• cost US$2 per mask
Benefit
Mask wearing is associated with positive impacts
• short-term reductions in blood pressure
• increases in heart rate variability
John W Cherrie et al. Occup Environ Med 2018;75:446-452
©2018 by BMJ Publishing Group LtdAir Purifiers
(Winter, Prince George)
■ Average 33% (5.8 to 3.9 μg/m3) reduction of indoor PM2.5
Barn P J Exp Science and Env Epi 2008
“clear, but modest, cardiopulmonary benefits of using an indoor air purifier in China”
Kan H. J Am Coll Cardiol. 2015Counselling asthmatic and cardiac patients? 1. Tune in to the AQHI 2. Determine risk group 3. Know your number 4. Reduce or Reschedule strenuous activities 5. Avoid traffic 6. Watch out for heat
What can health professionals do?
In the office or clinic
• Disease control
• asthma control
• heart failure control
• Reduce exposure
• AQHI education
• Exercise
• Traffic
• Personal protection
• Masks
• Air Purifiers
• Anti-oxidants
In the community
• Reduce emissions
• Industry
• Transport
• WoodstovesHow is air pollution related to climate change?
Warming climate increases air pollution:
• More ozone
• More forest fires
Co-benefits of reducing CO2 emissions
• Energy: less Air Pollution
• Transport: Less air pollution and Active transportation
• Agriculture
Short lived climate pollutants (SLCP)
• Black carbonCanadian AQHI Train the Trainer Program Outreach activities 2016-17
Thank you Alan.abelsohn@utoronto.ca
Patient Handouts
Contact Michele.charrier@hc-sc.gc.ca
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