The hidden economic burden of air pollution-related morbidity: evidence from the Aphekom project

Health benefits of a reduction in ambient fine particulate matter levels for post-neonatal infant survival in Taiwan

Infants' and children's health is particularly susceptible to exposure to various environmental contaminant insults as their immune systems are immature and daily activities may present differing patterns of exposure. Although some studies noted an association between long-term exposure to ambient fine particulate matter (PM2.5) and increased infant mortality frequency, few investigations examined the relationship between reduced exposure to PM2.5 and changes in infant mortality rates. Therefore, this study was conducted to determine whether diminished levels of PM2.5 in Taiwan improved post-neonatal infant health. Avoidable premature post-neonatal infant mortality was employed as an indicator of health impact. A mean value was calculated for annual PM2.5 levels across Taiwan for the years 2006, 2015, and 2023. Using these averages and following WHO methodology, differences in the number of post-neonatal infant deaths attributed to ambient PM2.5 exposure were determined. PM2.5 concentrations fell markedly throughout Taiwan over the 20-year study period. In conjunction with this decline, a lowered health burden was noted, which was represented as a fall in post-neonatal infant deaths (14.8% in 2006 to 10.3% in 2023). Reduction in annual levels of PM2.5 to 10 µg/m3 was associated with a decrease in the total burden of post-neonatal infant mortality occurrence, with a 5.58-9.31% decline in PM2.5-related deaths during that period. Evidence indicates that exposure to PM2.5 air pollution poses a significant burden to Taiwan children's health. Our findings indicate that the potential benefits to children's health need to be given importance when considering improving air quality policies.

Methodological considerations for estimating indirect costs in children and adolescents with chronic conditions: a scoping review

BACKGROUND

In children and adolescents, the prevalence of chronic diseases, e.g., obesity, asthma, and attention-deficit/hyperactivity disorder (ADHD), has increased in the last decades. These diseases have negative effects on patients and their families and pose a significant economic burden. Indirect costs related to caregivers' lost workdays or children's and adolescents' missed education are likely to be high. However, there are no guidelines for measuring and valuing indirect costs in this population. Thus, this scoping review aims to examine methods in published articles, compare these approaches, and analyze benefits and shortcomings.

METHODS

The systematic literature search was conducted in Medline, PsycINFO, Embase, NHS EED, and the HTA Database considering all articles from inception until 16 October 2024. Two researchers independently screened title, abstract, and full text. Cost-of-illness studies (COIs) reporting indirect costs for obesity, asthma, or attention-deficit/hyperactivity disorders (ADHD) in children and adolescents up to 24 years were included. Only studies published in English or German were considered. Methodological characteristics, measurement of indirect costs, cost components, data source, and costing methods were extracted.

RESULTS

The literature search revealed 45 studies. Thirty-two articles on asthma, eight on ADHD, and five on obesity were included. While all studies included absenteeism, only a few assessed and valued unpaid work (31.1%) or presenteeism (13.3%). Overall, 88.9% of the studies considered indirect costs for caregivers. Additionally, 51.1% considered productivity losses for children and adolescents, with 47.8% of these studies assigning a monetary value to these losses. The largest share of studies (53.3%) considered indirect costs by measuring and valuing caregivers' lost work time.

DISCUSSION

In conclusion, various methodologies were used to consider indirect costs for chronic diseases in children and adolescents, underlining the need for standardization. This scoping review presents methodologies for incorporating indirect costs in COIs and other types of economic evaluations, which focus on children and adolescents and adopt a societal perspective. These indirect costs include both paid and unpaid activities, as well as absenteeism and presenteeism, not only for caregivers but also for children and adolescents themselves.

Relation between air quality and asthma in high-altitude places, La Paz, Bolivia (3,600 m a.s.l.)

Introduction. Asthma is a chronic disease affecting millions of people around the world. Air quality is a major factor in triggering asthma symptoms. Objective. To analyze air quality and asthma in high-altitude residents of La Paz, Bolivia. Materials and methods. In this analytical, descriptive, and retrospective study, we collected data from patients diagnosed with asthma at the Instituto Nacional del Tórax and the Instituto Boliviano de Biología de Altura. In addition, air quality monitoring of particulate matter was carried out at the stations of the Red de Monitoreo de la Calidad del Aire. Results. Women represented 56.9% of cases at the Instituto Nacional del Tórax and the Instituto Boliviano de Biología de Altura. In both institutions, the average age was 47 years and patients were overweight or obese. Increases in PM2.5 were recorded in autumn, winter and spring from 2014, 2016 to 2019 and 2015 in all four seasons. PM10 showed increases in autumn and winter from 2014 to 2020 within the established limits. We observed a positive and significant association between PM2,5 concentration and the spirometry parameters of forced vital capacity, peak expiratory flow, and “reversibility percentage” or “bronchodilator response percentage”. The association of PM10 and forced vital capacity, forced expiratory volume in the first second, and peak expiratory flow, was also statistically significant. Conclusion. Asthma cases occur on average at 47 years of age in overweight or obese people. We observed a positive association between particles PM2,5 and PM10 with spirometric parameters, stronger with particulate matter PM2,5.

Toxicity Risk Assessment Due to Particulate Matter Pollution from Regional Health Data: Case Study from Central Romania

Air pollution poses one of the greatest dangers to public well-being. This article outlines a study conducted in the Central Romania Region regarding the health risks associated with particulate matter (PM) of two sizes, viz., PM10 and PM2.5. The methodology used consists of the following: (i) an analysis of the effects of PM pollutants, (ii) an analysis of total mortality and cardiovascular-related mortality, and (iii) a general health risk assessment. The Central Region of Romania is situated in the Carpathian Mountains' inner arch (consisting of six counties). The total population of the region under investigation is about 2.6 million inhabitants. Health risk assessment is calculated based on the relative risk (RR) formula. During the study period, our simulations show that reducing these pollutants' concentrations below the new WHO guidelines (2021) will prevent over 172 total fatalities in Brasov alone, as an example. Furthermore, the potential benefit of reducing annual PM2.5 levels on total cardiovascular mortality is around 188 persons in Brasov. Although health benefits may also depend upon other physiological parameters, all general health indicators point towards a significant improvement in overall health by a general reduction in particulate matter, as is shown by the toxicity assessment of the particulate matter in the region of interest. The modality can be applied to other locations for similar studies.

Health benefits of reducing ambient levels of fine particulate matter: a mortality impact assessment in Taiwan

While numerous studies have found a relationship between long-term exposure to airborne fine particulate matter (PM2.5) and higher risk of death, few investigations examined the contribution that a reduction of exposure to ambient PM2.5 levels might exert on mortality rates. This study aimed to collect data on changes in annual average ambient levels of PM2.5 from 2006 to 2020 and consequent health impact in public health in 65 municipalities in Taiwan. Avoidable premature mortality was used here as an indicator of adverse health impact or health benefits. Annual PM2.5 levels were averaged for the years 2006, 2010, and 2020. In accordance with World Health Organization (WHO) methodology, differences were estimated in the number of deaths attributed to ambient PM2.5 exposure which were derived from concentration-response data from prior epidemiological studies. PM2.5 concentrations were found to have been decreased markedly throughout Taiwan over the two-decade study. As the PM2.5 concentrations fell, so was the health burden as evidenced by number of deaths concomitantly reduced from 22.4% in 2006 to 8.47% in 2020. Data demonstrated that reducing annual mean levels of PM2.5 to PM10 ug/m3 was associated with decrease in the total burden of mortality, with a 2.22-13.18% fall in estimated number of PM2.5-related deaths between 2006 and 2020. Based upon these results, these declines in ambient PM2.5 levels were correlated with significant improvement in public health (health benefits) and diminished number of deaths in Taiwan.

Valuation of health benefits of green-blue areas for the purpose of ecosystem accounting: a pilot in Flanders, Belgium

In recent years, a vast amount of scientific literature has highlighted the benefits of nearby green space for physical and mental health, but the large variation in scope, methods and indicators used in these studies hampers the assessment of these benefits in the context of natural capital accounting. To our knowledge, this paper is one of the first studies to quantify and value these benefits in the context of natural capital accounting. A method was developed and applied to the Flemish Region in Belgium for 2013 and 2016.

The physical supply and use accounts for health are based on a set of selected dose-effect relationships that quantify the impact of the availability of greenspace on seven specific indicators for physical and mental health, including mortality, cardio-vascular diseases, diabetes and depression. The indicator for green-blue areas is the percentage of green-blue areas in total land use, calculated for 0.5, 1 and 3 km radius from the residence, based on detailed land-use maps (10 m x 10 m) for Flanders, Belgium. The base-line data for mortality and illness are average data for the Flemish Region. These health impacts are weighted using Daly's (disability-adjusted life years) and aggregated. The total health benefits due to the availability of green-blue areas for the total Flemish population was estimated at almost 85,000 DALYs. This is 27% of the estimated total burden of disease in Flanders in 2016 for the seven selected diseases.

The monetary accounts are based on a detailed assessment for mortality and morbidity of three different cost components, i.e. avoided medical costs (e.g. hospitalisation) and avoided absenteeism and welfare loss due to suffering and reduced life expectancy. Productivity gains from avoided absenteeism is valued, based on statistics on absenteeism for specific diseases for and labour market data from Belgium and account for 52% of the total monetary value of green spaces. Cost of illness is valued, based on market data and illness specific studies for Belgium or Europe and account for 36% of total values. Welfare gains from increased life expectancy are valued on the basis of European studies for the VOLY (value of a life year lost), based on the simulated exchange value for the willingness-to-pay for increased life expectancy. This accounts for 12% of the total monetary value of green space. The total monetary benefits amount to 464 Euro per inhabitant per year or 3 billion Euro per year for Flanders. This corresponds to 1.3% of the GDP, which reflects the importance of these benefits.

The methodology is incomplete as not all health indicators are covered, mainly due to a lack of dose-effect relationships. The research priority for potential users of the accounts is a better indicator for contact with green space that does differentiate between ecosystems, their quality, accessibility or their use. This requires more systematic health impact studies that take these elements into account, as well as more systematic data on the daily use of green space by citizens. In the meantime, an additional set of condition accounts on these elements can be used, especially to follow changes in quality and use of green-blue areas over time.

Improved air quality from China's clean air actions alleviates health expenditure inequality

Clean air actions aimed at improving air quality in China have brought about significant health benefits, thereby generating substantial savings in air-pollution-related healthcare spending. Yet, uneven regional air quality improvements and economic developments may alter existing inequality in health expenditures in the context of scarce healthcare resources. Here, we developed an econometric model that resolves individual characteristics at the city level to examine the disparity of public health expenditures in air quality improvements across regions differing in economic development and healthcare coverages and projected a range of future health expenditure savings under different air quality targets. We find that of the estimation on four air-pollution-related diseases (COPD, LRI, IHD, and stroke) in 98 cities over the year 2015-2017, a decline of 8.26 % in average hospitalization days and 10.21 % in hospitalization expenses was achieved, leading to a reduction of 8.09 % in total health expenditures as the implementation of clean air actions. Improved air quality has declined health expenditure inequality in low-middle cities and cities with imbalanced healthcare coverage. For example, the total expenses for the four diseases declined significantly in the low (-11.31 %) and medium (-7.34 %) per capita GDP groups, as well as a remarkable decline in the fewer medical resources. Health savings in some future scenarios are significant, showing substantial health expenditure savings under different air quality targets, but the savings will be greatly offset by an aging society. For example, In the Low-Level Improvement Pathway of air quality targets with aging (LLIPA scenario), health expenditure savings will be about 3537, 464, and 311 million CNY in the eastern, central, and western regions in 2035, respectively. Our findings thus highlight the importance of strengthening air pollution control policies and considering the equality of alleviating regional public health costs.

A novel fire smoke removal technology using electric agglomeration: The concept, experimental verification and mechanisms

Electric agglomeration technology is effective in removing particulate matter from the environment and has been widely used in the field of dust removal. For the first time, this technology is applied to the field of fire smoke removal at lab scale. By varying applied electric potential and initial concentration of smoke, the removal characteristics and mechanisms during the electric agglomeration process are systematically studied. The results show that when the applied electric potential is higher than 4 kV, the smoke transmittance increases from 4% to 90% in just 10 s, and the threshold for people safe escape can be reached in only 5 s. Three main mechanisms involved in the process of smoke removal using electric agglomeration are proposed. In addition to the conventional Coulomb agglomeration of charged particles, the turbulence-enhanced agglomeration induced by ionic wind and dipole chainization at the grounded plate are also observed. This study demonstrates the feasibility and potential of electric agglomeration technology to remove fire smoke.

Influence of the environment on the characteristics of asthma

Few studies have compared the prevalence of asthma in urban and rural settings or explored the issue of whether these two manifestations of the disease may represent different phenotypes. The aim of this study was: (a) to establish whether the prevalence of asthma differs between rural and urban settings, and b) to identify differences in the clinical presentation of asthma in these two environments. Descriptive epidemiological study involving individuals aged 18 or over from a rural (n = 516) and an urban population (n = 522). In the first phase, individuals were contacted by letter in order to organize the administration of a first validated questionnaire (Q1) designed to establish the possible prevalence of bronchial asthma. In the second phase, patients who had presented association patterns in the set of variables related to asthma in Q1 completed a second validated questionnaire (Q2), designed to identify the characteristics of asthma. According to Q1, the prevalence of asthma was 15% (n = 78) and 11% (n = 59) in rural and urban populations respectively. Sixty-five individuals with asthma from the rural population and all 59 individuals from the urban population were contacted and administered the Q2. Thirty-seven per cent of the individuals surveyed had previously been diagnosed with bronchial asthma (35% in the rural population and 40% in the urban setting). In the urban asthmatic population there was a predominance of women, a greater personal history of allergic rhinitis and a family history of allergic rhinitis and/or eczema. Asthma was diagnosed in adulthood in 74.8% of the patients, with no significant differences between the two populations. Regarding symptoms, cough (morning, daytime and night) and expectoration were more frequent in the urban population. The prevalence of asthma does not differ between urban and rural settings. The differences in exposure that characterize each environment may lead to different manifestations of the disease and may also affect its severity.

Estimated public health benefits of a low-emission zone in Malmö, Sweden

Air pollution is one of the leading causes of morbidity and mortality worldwide. Low-emission zones (LEZ) have been increasingly implemented in cities throughout Europe as a measure to reduce the adverse health effects and premature deaths associated with traffic-related air pollution. In the present study, a health impact analysis was conducted to estimate the effect of a hypothetical LEZ on mortality and morbidity in Malmö, Sweden. Baseline health statistics were gathered from health registers and applied to each resident according to individual-level data on age and/or sex. Concentration-response parameters were derived from current epidemiological literature, specifically meta-analyses. A Gaussian dispersion model (AERMOD) combined with a detailed emission database was used to calculate NO₂ emissions from traffic, which could be applied on an individual-level using data on each person's residential coordinates. The adjusted exposure scenario replaced all vehicles on municipal roads having Euro 5 or lower emission standards with Euro 6 equivalents. This LEZ would, on average, decrease NO₂ concentrations by 13.4%, preventing an estimated 9-26 deaths in Malmö each year. Additionally, 12 respiratory disease hospitalizations, 8 childhood asthma cases, and 9 cases of hypertensive disorders of pregnancy were estimated to be avoided annually. These results suggest that LEZs can effectively improve air quality, reduce greenhouse gas emissions, and safeguard public health.

Health impact assessment of air pollution in Lisbon, Portugal

BACKGROUND

Lisbon has about 500,000 inhabitants and it's the capital and the main economic hub of Portugal. Studies have demonstrated that exposure to Particulate Matter with an aerodynamic diameter<2.5 μm (PM_2.5) have strong association with health effects. Researchers continue to identify new harmful air pollutants effects in our health even in low levels.

OBJECTIVES

This study evaluates air pollution scenarios considering a Health Impact Assessment approach in Lisbon, Portugal.

METHODS

We have studied abatement scenarios of PM_2.5 concentrations and the health effects in the period from 2015 to 2017 using the APHEKOM tool and the associated health costs were assessed by Value of Life Year.

RESULTS

The mean concentration of PM_2.5 in Lisbon was 23 μg/m³ ± 10 μg/m³ (±Standard Deviation). If we consider that World Health Organization (WHO) standards of PM_2.5 (10 μg/m³) were reached, Lisbon would avoid more than 423 premature deaths (equivalent to 9,172 life years' gain) and save more than US$45 million annually. If Lisbon city could even diminish the mean of PM_2.5 by 5 μg/m³, nearly 165 deaths would be avoided, resulting in a gain of US$17 million annually.

CONCLUSION

According to our findings, if considered the worst pollution scenario, levels of PM2.5 could improve the life's quality and save a significant amount of economic resources.Implications: The manuscript addresses the health effects and costs of air pollution and constitutes an important target for improving public policies on air pollutants in Portugal. Although Portugal has low levels of air pollution, there are significant health and economic effects that, for the most part, are underreported. The health impact assessment approach associated with costs had not yet been addressed in Portugal, which makes this study more relevant in the analysis of policies aimed to drive stricter control on pollutants' emissions. Health costs are a fundamental element to support decision-making process and to orientate the trade-offs in investments for improving public policies so that to diminish health effects, which can impact the management of the local health services and the population's quality of life, especially after the pandemic period when resources are scarce.

A randomized crossover trial of HEPA air filtration to reduce cardiovascular risk for near highway residents: Methods and approach

BACKGROUND

Near highway residents are exposed to elevated levels of traffic-related air pollution (TRAP), including ultrafine particles, which are associated with adverse health effects. The efficacy of using in-home air filtration units that reduce exposure and potentially yield health benefits has not been tested in a randomized controlled trial.

METHODS

We will conduct a randomized double-blind crossover trial of portable air filtration units for 200 adults 30 years and older who live in near-highway homes in Somerville, MA, USA. We will recruit participants from 172 households. The intervention periods will be one month of true or sham filtration, followed by a one-month wash out period and then a month of the alternate intervention. The primary health outcome will be systolic blood pressure (BP); secondary outcome measures will include diastolic and central BP, C-Reactive Protein (CRP) and D-dimer. Reasons for success or failure of the intervention will be evaluated in a subset of homes using indoor/outdoor monitoring for particulate pollution, personal monitoring, size and composition of particulate pollution, tracking of time spent in the room with the filter, and interviews for qualitative feedback.

RESULTS

This trial has begun recruitment and is expected to take 2-3 years to be completed. Recruitment has been particularly challenging because of additional precautions required by the COVID-19 pandemic.

DISCUSSION

This study has the potential to shed light on the value of using portable air filtration in homes close to highways to reduce exposure to TRAP and whether doing so has benefits for cardiovascular health.

Air Pollution Health Risk Assessment (AP-HRA), Principles and Applications

Air pollution is a major public health problem. A significant number of epidemiological studies have found a correlation between air quality and a wide variety of adverse health impacts emphasizing a considerable role of air pollution in the disease burden in the general population ranging from subclinical effects to premature death. Health risk assessment of air quality can play a key role at individual and global health promotion and disease prevention levels. The Air Pollution Health Risk Assessment (AP-HRA) forecasts the expected health effect of policies impacting air quality under the various policy, environmental and socio-economic circumstances, making it a key tool for guiding public policy decisions. This paper presents the concept of AP-HRA and offers an outline for the proper conducting of AP-HRA for different scenarios, explaining in broad terms how the health hazards of air emissions and their origins are measured and how air pollution-related impacts are quantified. In this paper, seven widely used AP-HRA tools will be deeply explored, taking into account their spatial resolution, technological factors, pollutants addressed, geographical scale, quantified health effects, method of classification, and operational characteristics. Finally, a comparative analysis of the proposed tools will be conducted, using the SWOT (strengths, weaknesses, opportunities, and threats) method.

Benefit Analysis of the 1st Spanish Air Pollution Control Programme on Health Impacts and Associated Externalities

This paper aims to provide scientific support for decision-making in the field of improving air quality by evaluating pollution reduction measures included in the current Spanish policy framework of the 1st National Air Pollution Control Programme (NAPCP). First, the health impacts of air quality are estimated by using the concentrations estimated by multiscale air quality modeling and the recommended concentration–response functions (CRF), specifically as a result of exposure to particulate matter (PM), nitrogen dioxide (NO2), and ozone (O3). Second, the associated external costs are calculated by monetization techniques. Two scenarios are analyzed: a package including existing measures (WM2030) and a package with additional measures (WAM2030). Compared with the baseline scenario, an improvement was found in the health effects of NO2, PM10, and PM2.5, while for O3 there was a slight worsening, mainly due to the increase in the O3 metric used (SOMO35), which increases over some urban areas. Despite this, the monetary valuation of the total effects on health as a whole shows external benefits due to the adoption of measures (WM2030), compared with the reference scenario (no measures) of more than € 17.5 billion and, when considering the additional measures (WAM2030), benefits of about € 58.1 billion.

Cancer incidence in the vicinity of a waste incineration plant in the Nice area between 2005 and 2014

INTRODUCTION

Few studies on cancer incidence have been conducted since the adoption of the EU 2000/76/EC waste incineration directive which aimed to limit dioxin emission levels to less than 0.1 ng TEQ/m³ before December 31, 2005.

OBJECTIVE

To measure cancer incidence among the population exposed to atmospheric emissions from the waste incineration plant near the town of Nice (South-Eastern France), compared to the unexposed population of the Alpes-Maritimes department (A-M).

METHODS

All primary invasive cancers and haematological malignancies diagnosed among AM residents between 2005 and 2014 were recorded. The exposed surface was modeled on an average dioxin deposition model ≥4.25 ng/m²/year. Each case was geolocated and assigned to one of 36 predefined geographic units of exposed area, or one of 462 units in the unexposed area. The adjusted incidence rate, the standardized incidence ratio and the Comparative Morbidity Figure were calculated for two periods: 2005-2009/2010-2014.

RESULTS

We recorded 80,865 new cancers in the A-M population. Between 2005 and 2009, we observed a higher incidence among exposed women of acute myeloid leukaemia, myelodysplastic syndromes and myeloma and, among exposed men, of soft tissue sarcomas, myeloma and lung cancer. Between 2010 and 2014, there was no excess incidence among women, while among men incidence of myeloma and lung cancer remained higher.

CONCLUSION

Only among men, the incidence of myeloma and lung cancer remained higher in the exposed area during the second period. The EU directive resulting in the limitation of atmospheric emissions from incinerators could explain the decrease in incidence of cancers with protracted latency. Consideration of other risk factors and further data collection will be necessary to validate this hypothesis.

Adolescent Haze-Related Knowledge Level Study: A Cross-Sectional Survey With Sensitivity Analysis

Objective: This study aimed to investigate the level of haze-related knowledge adolescents have and to explore relevant influencing factors. Methods: From June 2015 to January 2016, researchers randomly selected 2 districts from the 20 districts of Baoding, China. Then, researchers randomly selected two middle schools from two districts. By conducting a stratified cluster sampling and considering one class as a unit, researchers randomly selected, from the other middle school, five first-grade classes, five second-grade classes, five third-grade classes from the one middle school, and three first-grade classes, two second-grade classes, and two third-grade classes. Finally, 1,100 adolescents were investigated by using the demographic questionnaire and the Adolescent Haze-Related Knowledge Awareness Assessment Scale (AHRKAAS). Multiple linear regressions were conducted to explore factors affecting the adolescent haze-related knowledge. Sensitivity analysis was used to confirm associations between influencing factors and AHRKAAS scores. Results: The AHRKAAS score rate was 69.9%. The dimension of human factors of haze formation was the highest (score rate = 85.6%). The dimension of haze harms on the human body was the lowest (score rate = 57.1%). Compared with the group (monthly expenses <300 yuan), the group (monthly expenses ≥ 600 yuan) had a higher AHRKAAS score (β = 4.882, 95% CI: 0.979, 8.784). Compared with the group (Do not live with parents), the group (Live with parents) had a higher AHRKAAS score (β = 14.675, 95% CI: 9.494, 19.855). Compared with the group (Never undergo a physical examination), the group (Once a year) (β = 7.444, 95% CI: 2.922, 11.966) and the group (A few times a year) (β = 7.643, 95% CI: 2.367, 12.919) had a higher AHRKAAS score. Compared with the group (Know nothing), the group (Know most) (β = 9.623, 95% CI: 2.929, 16.316) and the group (Know very well) (β = 15.367, 95% CI: 7.220, 23.515) had a higher AHRKAAS score. These associations were still reliable and consistent in different sensitivity analysis models. Conclusion: The level of adolescent haze-related knowledge is low and is affected by monthly expenses, living condition, physical examination frequency, and knowledge of respiratory system diseases. Government bodies, schools, and research institutions should strengthen cooperation of health publicity and health education to improve adolescent haze-related knowledge.

Health and economic consequences of applying the United States' PM2.5 automobile emission standards to other nations: a case study of France and Italy

OBJECTIVES

The US has among the world's strictest automobile emission standards, but it is now loosening them. It is unclear where a nation should draw the line between the associated cost burden imposed by regulations and the broader societal benefits associated with having cleaner air. Our study examines the health benefits and cost-effectiveness of introducing stricter vehicle emission standards in France and Italy.

STUDY DESIGN

Quasi-experimental study.

METHODS

We used cost-effectiveness modeling to measure the incremental quality-adjusted life years (QALYs) and cost (Euros) of adopting more stringent US vehicle emission standards for PM2.5 in France and Italy.

RESULTS

Adopting Obama era US vehicle emission standards would likely save money and lives for both the French and Italian populations. In France, adopting US emission standards would save €1000 and increase QALYs by 0.04 per capita. In Italy, the stricter standards would save €3000 and increase QALYs by 0.31. The results remain robust in both the sensitivity analysis and probabilistic Monte Carlo simulation model.

CONCLUSIONS

Adopting more stringent emission standards in France and Italy would save money and lives.

Developing and Testing the Reliability and Validity of the Brief Haze Weather Health Protection Behavior Assessment Scale-Adolescent Version (BHWHPBAS-AV)

Objectives: To develop a Brief Haze Weather Health Protection Behavior Assessment Scale-Adolescent Version (BHWHPBAS-AV). Methods: Considering primary prevention, secondary prevention and tertiary prevention as a theoretical basis, researchers developed a Brief Haze Weather Health Protection Behavior Assessment Scale-Adolescent Version-I(BHWHPBAS-AV-I). After performing 6 reviews by related experts, and after conducting six adolescent tests for BHWHPBAS-AV-I, researchers developed an updated BHWHPBAS-AV-II. Out of the 20 districts in Baoding, two districts were randomly selected; moreover, two middle schools from these two districts were also randomly selected. Considering one class as a unit, researchers subsequently randomly selected 22 classes by using stratified sampling. In the end, 1,025 valid questionnaires were used as part of the study. At which point, researchers investigated the validity and reliability of the scale and obtained the final scale (BHWHPBAS-AV). Results: BHWHPBAS-AV Cronbach's α = 0.878, content validity = 0.948, and factor cumulative contribution rate = 54.058% using exploratory factor analysis. By confirmatory factor analysis, Chi square value (χ²) = 271.791, degrees of freedom (df) = 94, Chi square value/degrees of freedom (χ²/df) = 2.891, root-mean-square error of approximation (RMSEA) = 0.051, normed fit index (NFI) = 0.930, incremental fit index (IFI) = 0.953, goodness of fit index (GFI) = 0.955, Tueker-Lewis index (TLI) = 0.940, comparative fit index (CFI) = 0.953. BHWHPBAS-AV was composed of 16 items as well as 3 dimensions. Conclusions: A BHWHPBAS-AV scale that has an acceptable reliability and validity can be applied to assess adolescent haze weather health protection behavior, and can also help school teachers, as well as medical staff working in community health care institutions, to perform targeted behavioral interventions and deliver health education programs to adolescents.

Diesel exhausts particles: Their role in increasing the incidence of asthma. Reviewing the evidence of a causal link

Exposure to air pollutants has been correlated with an increase in the severity of asthma and in the exacerbation of pre-existing asthma. However, whether or not environmental pollution can cause asthma remains a controversial issue. The present review analyzes the current scientific evidence of the possible causal link between diesel exhaust particles (DEP), the solid fraction of the complex mixture of diesel exhaust, and asthma. The mechanisms that influence the expression and development of asthma are complex. In children prolonged exposure to pollutants such as DEPs may increase asthma prevalence. In adults, this causal relation is less clear, probably because of the heterogeneity of the studies carried out. There is also evidence of physiological mechanisms by which DEPs can cause asthma. The most frequently described interactions between cellular responses and DEP are the induction of pulmonary oxidative stress and inflammation and the activation of receptors of the bronchial epithelium such as toll-like receptors or increases in Th2 and Th17 cytokines, which generally orchestrate the asthmatic response. Others support indirect mechanisms through epigenetic changes, pulmonary microbiome modifications, or the interaction of DEP with environmental antigens to enhance their activity. However, in spite of this evidence, more studies are needed to assess the harmful effects of pollution - not only in the short term in the form of increases in the rate of exacerbations, but in the medium and long term as well, as a possible trigger of the disease.

Estimated health benefits of exhaust free transport in the city of Malmö, Southern Sweden

Air pollution is responsible for one in eight premature deaths worldwide, and thereby a major threat to human health. Health impact assessments of hypothetic changes in air pollution concentrations can be used as a mean of assessing the health impacts of policy, plans and projects, and support decision-makers in choices to prevent disease. The aim of this study was to estimate health impacts attributable to a hypothetical decrease in air pollution concentrations in the city of Malmö in Southern Sweden corresponding to a policy on-road transportations without tail-pipe emissions in the municipality. We used air pollution data modelled for each of the 326,092 inhabitants in Malmö by a Gaussian dispersion model combined with an emission database with >40,000 sources. The dispersion model calculates Nitrogen Oxides (NO_x) (later transformed into Nitrogen Dioxide (NO₂)) and particulate matter with an aerodynamic diameter < 2.5 μg/m³ (PM_2.5) with high spatial and temporal resolution (85 m and 1 h, respectively). The average individual reduction was 5.1 (ranging from 0.6 to 11.8) μg/m³ in NO_2, which would prevent 55 (2% of all deaths) to 93 (4%) deaths annually, depending on dose-response function used. Furthermore, we estimate that the NO₂ reduction would result in 21 (6%) fewer cases of incident asthma in children, 95 (10%) fewer children with bronchitis every year, 30 (1%) fewer hospital admissions for respiratory disease, 87(4%) fewer dementia cases, and 11(11%) fewer cases of preeclampsia every year. The average reduction in PM_2.5 of 0.6 (ranging from 0.1 till 1.7) μg/m³ would mean that 2729 (0.3%) work days would not be lost due to sick-days and that there would be 16,472 fewer restricted activity days (0.3%) that year had all on-road transportations been without tail-pipe emissions. Even though the estimates are sensitive to the dose-response functions used and to exposure misclassification errors, even the most conservative estimate of the number of prevented deaths is 7 times larger than the annual traffic fatalities in Malmö, indicating a substantial possibility to reduce the health burden attributed to tail-pipe emissions in the study area.

Development and testing of the reliability and validity of the adolescent haze related knowledge awareness assessment scale (AHRKAAS)

Background

Haze leads to many direct serious public health impacts. Understanding haze related knowledge can not only help adolescents organize health protection awareness to prevent the harmful effects that haze has on the body, but also promote their normal growth and development.

Methods

By considering, as the theoretical basis, the reasons behind the formation of haze and the underlying mechanisms of the diseases that it causes, in addition to also investigating extensive literature references, our research team developed the Adolescent Haze Related Knowledge Awareness Assessment Scale (AHRKAAS-I). After 6 experts reviewed AHRKAAS-I, and 6 adolescents tested the scale, the research team further revised and improved AHRKAAS-I to form AHRKAAS-II. After which, researchers randomly selected 2 districts from the 20 districts of Baoding, and subsequently randomly selected 2 middle schools from these 2 districts. Conducting a stratified cluster sampling method, considering class as a unit, the research team randomly selected 22 classes. Finally, a total of 1100 adolescents were investigated and 1034 valid questionnaires were recovered. By analyzing the data of 1034 valid questionnaires, the researchers tested the reliability and validity of the scale and obtained the final scale (AHRKAAS).

Results

AHRKAAS Cronbach’s α=0.923, content validity = 0.940, criterion validity = 0.444, and factor cumulative contribution rate = 66.178% by exploratory factor analysis. Using confirmatory factor analysis, Chi square value = 662.780, degrees of freedom = 242, Chi square value/degrees of freedom = 2.739, root-mean-square error of approximation = 0.049, goodness of fit index = 0.929, adjusted goodness of fit index = 0.905, comparative fit index = 0.964, normed fit index = 0.944, and Tueker-Lewis index = 0.955. AHRKAAS consisted of 25 items and 4 dimensions.

Conclusion

AHRKAAS with a good reliability and validity can be used to assess the cognition level of haze related knowledge among the adolescents, help medical workers and coordinators in schools when conducting targeted behavior interventions. Furthermore, it can be used for health guidance for adolescents relating to the health prevention of haze.

Calculation of the disease burden associated with environmental chemical exposures: application of toxicological information in health economic estimation

Calculation of costs and the Burden of Disease (BoD) is useful in developing resource allocation and prioritization strategies in public and environmental health. While useful, the Disability-Adjusted Life Year (DALY) metric disregards subclinical dysfunctions, adheres to stringent causal criteria, and is hampered by gaps in environmental exposure data, especially from industrializing countries. For these reasons, a recently calculated environmental BoD of 5.18% of the total DALYs is likely underestimated. We combined and extended cost calculations for exposures to environmental chemicals, including neurotoxicants, air pollution, and endocrine disrupting chemicals, where sufficient data were available to determine dose-dependent adverse effects. Environmental exposure information allowed cost estimates for the U.S. and the EU, for OECD countries, though less comprehensive for industrializing countries. As a complement to these health economic estimations, we used attributable risk valuations from expert elicitations to as a third approach to assessing the environmental BoD. For comparison of the different estimates, we used country-specific monetary values of each DALY. The main limitation of DALY calculations is that they are available for few environmental chemicals and primarily based on mortality and impact and duration of clinical morbidity, while less serious conditions are mostly disregarded. Our economic estimates based on available exposure information and dose-response data on environmental risk factors need to be seen in conjunction with other assessments of the total cost for these environmental risk factors, as our estimate overlaps only slightly with the previously estimated environmental DALY costs and crude calculations relying on attributable risks for environmental risk factors. The three approaches complement one another and suggest that environmental chemical exposures contribute costs that may exceed 10% of the global domestic product and that current DALY calculations substantially underestimate the economic costs associated with preventable environmental risk factors. By including toxicological and epidemiological information and data on exposure distributions, more representative results can be obtained from utilizing health economic analyses of the adverse effects associated with environmental chemicals.

Costs of coronary heart disease and mortality associated with near-roadway air pollution

BACKGROUND

Emerging evidence indicates that the near-roadway air pollution (NRAP) mixture contributes to CHD, yet few studies have evaluated the associated costs.

OBJECTIVE

We integrated an assessment of NRAP-attributable CHD in Southern California with new methods to value the associated mortality and hospitalizations.

METHODS

Based on population-weighted residential exposure to NRAP (traffic density, proximity to a major roadway and elemental carbon), we estimated the inflation-adjusted value of NRAP-attributable mortality and costs of hospitalizations that occurred in 2008. We also estimated anticipated costs in 2035 based on projected changes in population and in NRAP exposure associated with California's plans to reduce greenhouse gas emissions. For comparison, we estimated the value of CHD mortality attributable to PM less than 2.5μm in diameter (PM2.5) in both 2008 and 2035.

RESULTS

The value of CHD mortality attributable to NRAP in 2008 was between $3.8 and $11.5 billion, 23% (major roadway proximity) to 68% (traffic density) of the $16.8 billion attributable to regulated regional PM2.5. NRAP-attributable costs were projected to increase to $10.6 to $22 billion in 2035, depending on the NRAP metric. Cost of NRAP-attributable hospitalizations for CHD in 2008 was $48.6 million and was projected to increase to $51.4 million in 2035.

CONCLUSIONS

We developed an economic framework that can be used to estimate the benefits of regulations to improve air quality. CHD attributable to NRAP has a large economic impact that is expected to increase by 2035, largely due to an aging population. PM2.5-attributable costs may underestimate total value of air pollution-attributable CHD.

Short-Term Fluctuations in Air Pollution and Asthma in Scania, Sweden. Is the Association Modified by Long-Term Concentrations?

Background and aims

Asthma is one of the most common respiratory diseases in the world. Research has shown that temporal increases in air pollution concentrations can aggravate asthma symptoms. The aim of this study was to assess whether individuals living in areas with higher air pollution concentrations responded differently to short-term temporal exposure to air pollution than those living in lower air pollution areas.

Method

The study was designed as a case-crossover study in Scania, Sweden. Outcome data was visits to primary health care clinics with asthma as the main complaint during the years 2007 to 2010. Nitrogen dioxide levels were obtained from 21 different air pollution monitoring stations. Short-term exposure was defined as the average concentration four days prior to the visit. Data was pooled for areas above and below a two-year average NO2 concentration of 10 μg/m3, dispersion modelled with an emission database.

Results

The short-term association between NO2 and asthma visits seemed stronger in areas with NO2 levels below 10 μg/m3, with an odds ratio (OR) of 1.15 (95% confidence interval (CI): 1.08–1.23) associated with a 10 μg/m3 increase in NO₂ compared to areas above 10 μg/m3 NO2 levels, where corresponding OR of 1.09 (95% CI: 1.02–1.17). However, this difference was not statistically significant. (p = 0.13)

Conclusions

The study provided some evidence, although not statistically significant, that short-term associations between air pollution and asthma may depend on background air pollution levels. However, we cannot rule out that the association is due to other spatially dependent factors in Scania. The study should be reproduced in other study areas.

Health Impact Assessment of Air Pollution in São Paulo, Brazil

Epidemiological research suggests that air pollution may cause chronic diseases, as well as exacerbation of related pathologies such as cardiovascular and respiratory morbidity and mortality. This study evaluates air pollution scenarios considering a Health Impact Assessment approach in São Paulo, Brazil. We have analyzed abatement scenarios of Particulate Matter (PM) with an aerodynamic diameter <10 μm (PM₁₀), <2.5 μm (PM_2.5) and ozone concentrations and the health effects on respiratory and cardiovascular morbidity and mortality in the period from 2009 to 2011 through the APHEKOM tool, as well as the associated health costs. Considering World Health Organization (WHO) standards of PM_2.5 (10 μg/m³), São Paulo would avoid more than 5012 premature deaths (equivalent to 266,486 life years’ gain) and save US$15.1 billion annually. If São Paulo could even diminish the mean of PM_2.5 by 5 μg/m³, nearly 1724 deaths would be avoided, resulting in a gain of US$ 4.96 billion annually. Reduced levels of PM₁₀, PM_2.5 and ozone could save lives and an impressive amount of money in a country where economic resources are scarce. Moreover, the reduced levels of air pollution would also lower the demand for hospital care, since hospitalizations would diminish. In this sense, Brazil should urgently adopt WHO air pollution standards in order to improve the quality of life of its population.