Global burden and strength of evidence for 88 risk factors in 204 countries and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Understanding the health consequences associated with exposure to risk factors is necessary to inform public health policy and practice. To systematically quantify the contributions of risk factor exposures to specific health outcomes, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 aims to provide comprehensive estimates of exposure levels, relative health risks, and attributable burden of disease for 88 risk factors in 204 countries and territories and 811 subnational locations, from 1990 to 2021.

METHODS

The GBD 2021 risk factor analysis used data from 54 561 total distinct sources to produce epidemiological estimates for 88 risk factors and their associated health outcomes for a total of 631 risk-outcome pairs. Pairs were included on the basis of data-driven determination of a risk-outcome association. Age-sex-location-year-specific estimates were generated at global, regional, and national levels. Our approach followed the comparative risk assessment framework predicated on a causal web of hierarchically organised, potentially combinative, modifiable risks. Relative risks (RRs) of a given outcome occurring as a function of risk factor exposure were estimated separately for each risk-outcome pair, and summary exposure values (SEVs), representing risk-weighted exposure prevalence, and theoretical minimum risk exposure levels (TMRELs) were estimated for each risk factor. These estimates were used to calculate the population attributable fraction (PAF; ie, the proportional change in health risk that would occur if exposure to a risk factor were reduced to the TMREL). The product of PAFs and disease burden associated with a given outcome, measured in disability-adjusted life-years (DALYs), yielded measures of attributable burden (ie, the proportion of total disease burden attributable to a particular risk factor or combination of risk factors). Adjustments for mediation were applied to account for relationships involving risk factors that act indirectly on outcomes via intermediate risks. Attributable burden estimates were stratified by Socio-demographic Index (SDI) quintile and presented as counts, age-standardised rates, and rankings. To complement estimates of RR and attributable burden, newly developed burden of proof risk function (BPRF) methods were applied to yield supplementary, conservative interpretations of risk-outcome associations based on the consistency of underlying evidence, accounting for unexplained heterogeneity between input data from different studies. Estimates reported represent the mean value across 500 draws from the estimate's distribution, with 95% uncertainty intervals (UIs) calculated as the 2·5th and 97·5th percentile values across the draws.

FINDINGS

Among the specific risk factors analysed for this study, particulate matter air pollution was the leading contributor to the global disease burden in 2021, contributing 8·0% (95% UI 6·7-9·4) of total DALYs, followed by high systolic blood pressure (SBP; 7·8% [6·4-9·2]), smoking (5·7% [4·7-6·8]), low birthweight and short gestation (5·6% [4·8-6·3]), and high fasting plasma glucose (FPG; 5·4% [4·8-6·0]). For younger demographics (ie, those aged 0-4 years and 5-14 years), risks such as low birthweight and short gestation and unsafe water, sanitation, and handwashing (WaSH) were among the leading risk factors, while for older age groups, metabolic risks such as high SBP, high body-mass index (BMI), high FPG, and high LDL cholesterol had a greater impact. From 2000 to 2021, there was an observable shift in global health challenges, marked by a decline in the number of all-age DALYs broadly attributable to behavioural risks (decrease of 20·7% [13·9-27·7]) and environmental and occupational risks (decrease of 22·0% [15·5-28·8]), coupled with a 49·4% (42·3-56·9) increase in DALYs attributable to metabolic risks, all reflecting ageing populations and changing lifestyles on a global scale. Age-standardised global DALY rates attributable to high BMI and high FPG rose considerably (15·7% [9·9-21·7] for high BMI and 7·9% [3·3-12·9] for high FPG) over this period, with exposure to these risks increasing annually at rates of 1·8% (1·6-1·9) for high BMI and 1·3% (1·1-1·5) for high FPG. By contrast, the global risk-attributable burden and exposure to many other risk factors declined, notably for risks such as child growth failure and unsafe water source, with age-standardised attributable DALYs decreasing by 71·5% (64·4-78·8) for child growth failure and 66·3% (60·2-72·0) for unsafe water source. We separated risk factors into three groups according to trajectory over time: those with a decreasing attributable burden, due largely to declining risk exposure (eg, diet high in trans-fat and household air pollution) but also to proportionally smaller child and youth populations (eg, child and maternal malnutrition); those for which the burden increased moderately in spite of declining risk exposure, due largely to population ageing (eg, smoking); and those for which the burden increased considerably due to both increasing risk exposure and population ageing (eg, ambient particulate matter air pollution, high BMI, high FPG, and high SBP).

INTERPRETATION

Substantial progress has been made in reducing the global disease burden attributable to a range of risk factors, particularly those related to maternal and child health, WaSH, and household air pollution. Maintaining efforts to minimise the impact of these risk factors, especially in low SDI locations, is necessary to sustain progress. Successes in moderating the smoking-related burden by reducing risk exposure highlight the need to advance policies that reduce exposure to other leading risk factors such as ambient particulate matter air pollution and high SBP. Troubling increases in high FPG, high BMI, and other risk factors related to obesity and metabolic syndrome indicate an urgent need to identify and implement interventions.

FUNDING

Bill & Melinda Gates Foundation.

Increasing Racial and Ethnic Disparities in Ambient Air Pollution-Attributable Morbidity and Mortality in the United States

BACKGROUND

Ambient nitrogen dioxide (NO 2 ) and fine particulate matter with aerodynamic diameter ≤ 2.5 μ m (PM 2.5 ) threaten public health in the US, and systemic racism has led to modern-day disparities in the distribution and associated health impacts of these pollutants.

OBJECTIVES

Many studies on environmental injustices related to ambient air pollution focus only on disparities in pollutant concentrations or provide only an assessment of pollution or health disparities at a snapshot in time. In this study, we compare injustices in NO 2 - and PM 2.5 -attributable health burdens, considering NO 2 -attributable health impacts across the entire US; document changing disparities in these health burdens over time (2010-2019); and evaluate how more stringent air quality standards would reduce disparities in health impacts associated with these pollutants.

METHODS

Through a health impact assessment, we quantified census tract-level variations in health outcomes attributable to NO 2 and PM 2.5 using health impact functions that combine demographic data from the US Census Bureau; two spatially resolved pollutant datasets, which fuse satellite data with physical and statistical models; and epidemiologically derived relative risk estimates and incidence rates from the Global Burden of Disease study.

RESULTS

Despite overall decreases in the public health damages associated with NO 2 and PM 2.5 , racial and ethnic relative disparities in NO 2 -attributable pediatric asthma and PM 2.5 -attributable premature mortality have widened in the US during the last decade. Racial relative disparities in PM 2.5 -attributable premature mortality and NO 2 -attributable pediatric asthma have increased by 16% and 19%, respectively, between 2010 and 2019. Similarly, ethnic relative disparities in PM 2.5 -attributable premature mortality have increased by 40% and NO 2 -attributable pediatric asthma by 10%.

DISCUSSION

Enacting and attaining more stringent air quality standards for both pollutants could preferentially benefit the most marginalized and minoritized communities by greatly reducing racial and ethnic relative disparities in pollution-attributable health burdens in the US. Our methods provide a semi-observational approach to track changes in disparities in air pollution and associated health burdens across the US. https://doi.org/10.1289/EHP11900.

Tracking Progress Toward Urban Nature Targets Using Landcover and Vegetation Indices: A Global Study for the 96 C40 Cities

Access to urban natural space, including blue and greenspace, is associated with improved health. In 2021, the C40 Cities Climate Leadership Group set 2030 Urban Nature Declaration (UND) targets: "Quality Total Cover" (30% green area within each city) and "Equitable Spatial Distribution" (70% of the population living close to natural space). We evaluate progress toward these targets in the 96 C40 cities using globally available, high-resolution data sets for landcover and normalized difference vegetation index (NDVI). We use the European Space Agency (ESA)'s WorldCover data set to define greenspace with discrete landcover categories and ESA's Sentinel-2A to calculate NDVI, adding the "open water" landcover category to characterize total natural space. We compare 2020 levels of urban green and natural space to the two UND targets and predict the city-specific NDVI level consistent with the UND targets using linear regressions. The 96-city mean NDVI was 0.538 (range: 0.148, 0.739). Most (80%) cities meet the Quality Total Cover target, and nearly half (47%) meet the Equitable Spatial Distribution target. Landcover-measured greenspace and total natural space were strong (mean R 2 = 0.826) and moderate (mean R 2 = 0.597) predictors of NDVI and our NDVI-based natural space proximity measure, respectively. The 96-city mean predicted NDVI value of meeting the UND targets was 0.478 (range: 0.352-0.565) for Quality Total Cover and 0.660 (range: 0.498-0.767) for Equitable Spatial Distribution. Our translation of the area- and access-based metrics common in urban natural space targets into the NDVI metric used in epidemiology allows for quantifying the health benefits of achieving such targets.

Improving consistency in estimating future health burdens from environmental risk factors: Case study for ambient air pollution

Future changes in exposure to risk factors should impact mortality rates and population. However, studies commonly use mortality rates and population projections developed exogenously to the health impact assessment model used to quantify future health burdens attributable to environmental risks that are therefore invariant to projected exposure levels. This impacts the robustness of many future health burden estimates for environmental risk factors. This work describes an alternative methodology that more consistently represents the interaction between risk factor exposure, population and mortality rates, using ambient particulate air pollution (PM2.5) as a case study. A demographic model is described that estimates future population based on projected births, mortality and migration. Mortality rates are disaggregated between the fraction due to PM2.5 exposure and other factors for a historic year, and projected independently. Accounting for feedbacks between future risk factor exposure and population and mortality rates can greatly affect estimated future attributable health burdens. The demographic model estimates much larger PM2.5-attributable health burdens with constant 2019 PM2.5 (∼10.8 million deaths in 2050) compared to a model using exogenous population and mortality rate projections (∼7.3 million), largely due to differences in mortality rate projection methods. Demographic model-projected PM2.5-attributable mortality can accumulate substantially over time. For example, ∼71 million more people are estimated to be alive in 2050 when WHO guidelines (5 µg m-3) are achieved compared to constant 2019 PM2.5 concentrations. Accounting for feedbacks is more important in applications with relatively high future PM2.5 concentrations, and relatively large changes in non-PM2.5 mortality rates.

Public Health Benefits From Improved Identification of Severe Air Pollution Events With Geostationary Satellite Data

Despite improvements in ambient air quality in the US in recent decades, many people still experience unhealthy levels of pollution. At present, national-level alert-day identification relies predominately on surface monitor networks and forecasters. Satellite-based estimates of surface air quality have rapidly advanced and have the capability to inform exposure-reducing actions to protect public health. At present, we lack a robust framework to quantify public health benefits of these advances in applications of satellite-based atmospheric composition data. Here, we assess possible health benefits of using geostationary satellite data, over polar orbiting satellite data, for identifying particulate air quality alert days (24hr PM2.5 > 35 μg m-3) in 2020. We find the more extensive spatiotemporal coverage of geostationary satellite data leads to a 60% increase in identification of person-alerts (alert days × population) in 2020 over polar-orbiting satellite data. We apply pre-existing estimates of PM2.5 exposure reduction by individual behavior modification and find these additional person-alerts may lead to 1,200 (800-1,500) or 54% more averted PM2.5-attributable premature deaths per year, if geostationary, instead of polar orbiting, satellite data alone are used to identify alert days. These health benefits have an associated economic value of 13 (8.8-17) billion dollars ($2019) per year. Our results highlight one of many potential applications of atmospheric composition data from geostationary satellites for improving public health. Identifying these applications has important implications for guiding use of current satellite data and planning future geostationary satellite missions.

All-Cause NO2-Attributable Mortality Burden and Associated Racial and Ethnic Disparities in the United States

Nitrogen dioxide (NO2) is a regulated pollutant that is associated with numerous health impacts. Recent advances in epidemiology indicate high confidence linking NO2 exposure with increased mortality, an association that recent studies suggest persists even at concentrations below regulatory thresholds. While large disparities in NO2 exposure among population subgroups have been reported, U.S. NO2-attributable mortality rates and their disparities remain unquantified. Here we provide the first estimate of NO2-attributable all-cause mortality across the contiguous U.S. (CONUS) at the census tract-level. We leverage fine-scale, satellite-informed, land use regression model NO2 concentrations and census tract-level baseline mortality data to characterize the associated disparities among different racial/ethnic subgroups. Across CONUS, we estimate that the NO2-attributable all-cause mortality is ∼170,850 (95% confidence interval: 43,970, 251,330) premature deaths yr-1 with large variability across census tracts and within individual cities. Additionally, we find that higher NO2 concentrations and underlying susceptibilities for predominately Black communities lead to NO2-attributable mortality rates that are ∼47% higher compared to CONUS-wide average rates. Our results highlight the substantial U.S. NO2 mortality burden, particularly in marginalized communities, and motivate adoption of more stringent standards to protect public health.

Ethnoracial Disparities in Nitrogen Dioxide Pollution in the United States: Comparing Data Sets from Satellites, Models, and Monitors

In the United States (U.S.), studies on nitrogen dioxide (NO2) trends and pollution-attributable health effects have historically used measurements from in situ monitors, which have limited geographical coverage and leave 66% of urban areas unmonitored. Novel tools, including remotely sensed NO2 measurements and estimates of NO2 estimates from land-use regression and photochemical models, can aid in assessing NO2 exposure gradients, leveraging their complete spatial coverage. Using these data sets, we find that Black, Hispanic, Asian, and multiracial populations experience NO2 levels 15-50% higher than the national average in 2019, whereas the non-Hispanic White population is consistently exposed to levels that are 5-15% lower than the national average. By contrast, the in situ monitoring network indicates more moderate ethnoracial NO2 disparities and different rankings of the least- to most-exposed ethnoracial population subgroup. Validating these spatially complete data sets against in situ observations reveals similar performance, indicating that all these data sets can be used to understand spatial variations in NO2. Integrating in situ monitoring, satellite data, statistical models, and photochemical models can provide a semiobservational record, complete geospatial coverage, and increasingly high spatial resolution, enhancing future efforts to characterize, map, and track exposure and inequality for highly spatially heterogeneous pollutants like NO2.

State-of-the-Science Data and Methods Need to Guide Place-Based Efforts to Reduce Air Pollution Inequity

BACKGROUND

Recently enacted environmental justice policies in the United States at the state and federal level emphasize addressing place-based inequities, including persistent disparities in air pollution exposure and associated health impacts. Advances in air quality measurement, models, and analytic methods have demonstrated the importance of finer-scale data and analysis in accurately quantifying the extent of inequity in intraurban pollution exposure, although the necessary degree of spatial resolution remains a complex and context-dependent question.

OBJECTIVE

The objectives of this commentary were to a) discuss ways to maximize and evaluate the effectiveness of efforts to reduce air pollution disparities, and b) argue that environmental regulators must employ improved methods to project, measure, and track the distributional impacts of new policies at finer geographic and temporal scales.

DISCUSSION

The historic federal investments from the Inflation Reduction Act, the Infrastructure Investment and Jobs Act, and the Biden Administration's commitment to Justice40 present an unprecedented opportunity to advance climate and energy policies that deliver real reductions in pollution-related health inequities. In our opinion, scientists, advocates, policymakers, and implementing agencies must work together to harness critical advances in air quality measurements, models, and analytic methods to ensure success. https://doi.org/10.1289/EHP13063.

Reversal of trends in global fine particulate matter air pollution

Ambient fine particulate matter (PM2.5) is the world's leading environmental health risk factor. Quantification is needed of regional contributions to changes in global PM2.5 exposure. Here we interpret satellite-derived PM2.5 estimates over 1998-2019 and find a reversal of previous growth in global PM2.5 air pollution, which is quantitatively attributed to contributions from 13 regions. Global population-weighted (PW) PM2.5 exposure, related to both pollution levels and population size, increased from 1998 (28.3 μg/m3) to a peak in 2011 (38.9 μg/m3) and decreased steadily afterwards (34.7 μg/m3 in 2019). Post-2011 change was related to exposure reduction in China and slowed exposure growth in other regions (especially South Asia, the Middle East and Africa). The post-2011 exposure reduction contributes to stagnation of growth in global PM2.5-attributable mortality and increasing health benefits per µg/m3 marginal reduction in exposure, implying increasing urgency and benefits of PM2.5 mitigation with aging population and cleaner air.

Unified real-time environmental-epidemiological data for multiscale modeling of the COVID-19 pandemic

An impressive number of COVID-19 data catalogs exist. However, none are fully optimized for data science applications. Inconsistent naming and data conventions, uneven quality control, and lack of alignment between disease data and potential predictors pose barriers to robust modeling and analysis. To address this gap, we generated a unified dataset that integrates and implements quality checks of the data from numerous leading sources of COVID-19 epidemiological and environmental data. We use a globally consistent hierarchy of administrative units to facilitate analysis within and across countries. The dataset applies this unified hierarchy to align COVID-19 epidemiological data with a number of other data types relevant to understanding and predicting COVID-19 risk, including hydrometeorological data, air quality, information on COVID-19 control policies, vaccine data, and key demographic characteristics.

CO2 emissions from C40 cities: citywide emission inventories and comparisons with global gridded emission datasets

Under the leadership of the C40 Cities Climate Leadership Group (C40), approximately 1100 global cities have signed to reach net-zero emissions by 2050. Accurate greenhouse gas emission calculations at the city-scale have become critical. This study forms a bridge between the two emission calculation methods: (a) the city-scale accounting used by C40 cities-the Global Protocol for Community-Scale Greenhouse Gas Emission Inventories (GPC) and (b) the global-scale gridded datasets used by the research community-the Emission Database for Global Atmospheric Research (EDGAR) and Open-Source Data Inventory for Anthropogenic CO2 (ODIAC). For the emission magnitudes of 78 C40 cities, we find good correlations between the GPC and EDGAR (R 2 = 0.80) and the GPC and ODIAC (R 2 = 0.72). Regionally, African cities show the largest variability in the three emission estimates. For the emission trends, the standard deviation of the differences is ±4.7% yr-1 for EDGAR vs. GPC and is ±3.9% yr-1 for ODIAC vs. GPC: a factor of ∼2 larger than the trends that many C40 cities pledged (net-zero by 2050 from 2010, or -2.5% yr-1). To examine the source of discrepancies in the emission datasets, we assess the impact of spatial resolutions of EDGAR (0.1°) and ODIAC (1 km) on estimating varying-sized cities' emissions. Our analysis shows that the coarser resolution of EDGAR can artificially decrease emissions by 13% for cities smaller than 1000 km2. We find that data quality of emission factors (EFs) used in GPC inventories vary regionally: the highest quality for European and North American and the lowest for African and Latin American cities. Our study indicates that the following items should be prioritized to reduce the discrepancies between the two emission calculation methods: (a) implementing local-specific/up-to-date EFs in GPC inventories, (b) keeping the global power plant database current, and (c) incorporating satellite-derived CO2 datasets (i.e. NASA OCO-3).

Inequitable Exposures to U.S. Coal Power Plant-Related PM2.5: 22 Years and Counting

BACKGROUND

Emissions from coal power plants have decreased over recent decades due to regulations and economics affecting costs of providing electricity generated by coal vis-à-vis its alternatives. These changes have improved regional air quality, but questions remain about whether benefits have accrued equitably across population groups.

OBJECTIVES

We aimed to quantify nationwide long-term changes in exposure to particulate matter (PM) with an aerodynamic diameter ≤2.5μm (PM2.5) associated with coal power plant SO2 emissions. We linked exposure reductions with three specific actions taken at individual power plants: scrubber installations, reduced operations, and retirements. We assessed how emissions changes in different locations have influenced exposure inequities, extending previous source-specific environmental justice analyses by accounting for location-specific differences in racial/ethnic population distributions.

METHODS

We developed a data set of annual PM2.5 source impacts ("coal PM2.5") associated with SO2 emissions at each of 1,237 U.S. coal-fired power plants across 1999-2020. We linked population-weighted exposure with information about each coal unit's operational and emissions-control status. We calculate changes in both relative and absolute exposure differences across demographic groups.

RESULTS

Nationwide population-weighted coal PM2.5 declined from 1.96μg/m3 in 1999 to 0.06 μg/m3 in 2020. Between 2007 and 2010, most of the exposure reduction is attributable to SO2 scrubber installations, and after 2010 most of the decrease is attributable to retirements. Black populations in the South and North Central United States and Native American populations in the western United States were inequitably exposed early in the study period. Although inequities decreased with falling emissions, facilities in states across the North Central United States continue to inequitably expose Black populations, and Native populations are inequitably exposed to emissions from facilities in the West.

DISCUSSION

We show that air quality controls, operational adjustments, and retirements since 1999 led to reduced exposure to coal power plant related PM2.5. Reduced exposure improved equity overall, but some populations continue to be inequitably exposed to PM2.5 associated with facilities in the North Central and western United States. https://doi.org/10.1289/EHP11605.

Trends in urban air pollution over the last two decades: A global perspective

Ground-level ozone (O₃), fine particles (PM_2.5), and nitrogen dioxide (NO₂) are the most harmful urban air pollutants regarding human health effects. Here, we aimed at assessing trends in concurrent exposure of global urban population to O₃, PM_2.5, and NO₂ between 2000 and 2019. PM_2.5, NO₂, and O₃ mean concentrations and summertime mean of the daily maximum 8-h values (O₃ MDA8) were analyzed (Mann-Kendall test) using data from a global reanalysis, covering 13,160 urban areas, and a ground-based monitoring network (Tropospheric Ozone Assessment Report), collating surface O₃ observations at nearly 10,000 stations worldwide. At global scale, PM_2.5 exposures declined slightly from 2000 to 2019 (on average, - 0.2 % year^-1), with 65 % of cities showing rising levels. Improvements were observed in the Eastern US, Europe, Southeast China, and Japan, while the Middle East, sub-Saharan Africa, and South Asia experienced increases. The annual NO₂ mean concentrations increased globally at 71 % of cities (on average, +0.4 % year^-1), with improvements in North America and Europe, and increases in exposures in sub-Saharan Africa, Middle East, and South Asia regions, in line with socioeconomic development. Global exposure of urban population to O₃ increased (on average, +0.8 % year^-1 at 89 % of stations), due to lower O₃ titration by NO. The summertime O₃ MDA8 rose at 74 % of cities worldwide (on average, +0.6 % year^-1), while a decline was observed in North America, Northern Europe, and Southeast China, due to the reduction in precursor emissions. The highest O₃ MDA8 increases (>3 % year^-1) occurred in Equatorial Africa, South Korea, and India. To reach air quality standards and mitigate outdoor air pollution effects, actions are urgently needed at all governance levels. More air quality monitors should be installed in cities, particularly in Africa, for improving risk and exposure assessments, concurrently with implementation of effective emission control policies that will consider regional socioeconomic imbalances.

A Source Apportionment and Emission Scenario Assessment of PM2.5- and O3-Related Health Impacts in G20 Countries

Exposure to air pollution is a leading risk factor for premature death globally; however, the complexity of its formation and the diversity of its sources can make it difficult to address. The Group of Twenty (G20) countries are a collection of the world's largest and most influential economies and are uniquely poised to take action to reduce the global health burden associated with air pollution. We present a framework capable of simultaneously identifying regional and sectoral sources of the health impacts associated with two air pollutants, fine particulate matter (PM_2.5) and ozone (O₃) in G20 countries; this framework is also used to assess the health impacts associated with emission reductions. This approach combines GEOS-Chem adjoint sensitivities, satellite-derived data, and a new framework designed to better characterize the non-linear relationship between O₃ exposures and nitrogen oxides emissions. From this approach, we estimate that a 50% reduction of land transportation emissions by 2040 would result in 251 thousand premature deaths avoided in G20 countries. These premature deaths would be attributable equally to reductions in PM_2.5 and O₃ exposure which make up 51% and 49% of the potential benefits, respectively. In our second application, we estimate that the energy generation related co-benefits associated with G20 countries staying on pace with their net-zero carbon dioxide targets would be 290 thousand premature deaths avoided in 2040; action by India (47%) would result in the most benefits of any country and a majority of these avoided deaths would be attributable to reductions in PM_2.5 exposure (68%).

Nowcasting Applications of Geostationary Satellite Hourly Surface PM2.5 Data

The mass concentration of fine particulate matter (PM2.5; diameters less than 2.5 μm) estimated from geostationary satellite aerosol optical depth (AOD) data can supplement the network of ground monitors with high temporal (hourly) resolution. Estimates of PM2.5 over the United States (US) were derived from NOAA's operational geostationary satellites Advanced Baseline Imager (ABI) AOD data using a geographically weighted regression with hourly and daily temporal resolution. Validation versus ground observations shows a mean bias of -21.4% and -15.3% for hourly and daily PM2.5 estimates, respectively, for concentrations ranging from 0 to 1000 μg/m3. Because satellites only observe AOD in the daytime, the relation between observed daytime PM2.5 and daily mean PM2.5 was evaluated using ground measurements; PM2.5 estimated from ABI AODs were also examined to study this relationship. The ground measurements show that daytime mean PM2.5 has good correlation (r > 0.8) with daily mean PM2.5 in most areas of the US, but with pronounced differences in the western US due to temporal variations caused by wildfire smoke; the relation between the daytime and daily PM2.5 estimated from the ABI AODs has a similar pattern. While daily or daytime estimated PM2.5 provides exposure information in the context of the PM2.5 standard (> 35 μg/m3), the hourly estimates of PM2.5 used in Nowcasting show promise for alerts and warnings of harmful air quality. The geostationary satellite based PM2.5 estimates inform the public of harmful air quality ten times more than standard ground observations (1.8 vs. 0.17 million people per hour).

Global trends in ozone concentration and attributable mortality for urban, peri-urban, and rural areas between 2000 and 2019: a modelling study

BACKGROUND

Data on long-term trends of ozone exposure and attributable mortality across urban-rural catchment areas worldwide are scarce, especially for low-income and middle-income countries. This study aims to estimate trends in ozone concentrations and attributable mortality for urban-rural catchment areas worldwide.

METHODS

In this modelling study, we used a health impact function to estimate ozone concentrations and ozone-attributable chronic respiratory disease mortality for urban areas worldwide, and their surrounding peri-urban, peri-rural, and rural areas. We estimated ozone-attributable respiratory health outcomes using a modified Global Burden of Diseases, Injuries, and Risk Factors 2019 Study approach. We evaluate long-term trends with linear regressions of annual ozone concentrations and ozone-attributable mortality against time in years, and examined the influence of each health impact function input parameter to temporal changes in ozone-attributable disease burden estimates for 12 946 cities worldwide by region, from 2000 to 2019.

FINDINGS

Ozone-attributable mortality worldwide increased by 46% from 2000 (290 400 deaths [95% CI 151 800-457 600]) to 2019 (423 100 deaths [95% CI 223 200-659 400]). The fraction of global ozone-attributable mortality occurring in peri-urban areas remained unchanged from 2000 to 2019 (56%), whereas urban areas gained in their share of global ozone-attributable burden (from 35% to 37%; 54 000 more deaths). Across all cities studied, average population-weighted mean ozone concentration increased by 11% (46 parts per billion [ppb] to 51 ppb). The number of cities with concentrations above the WHO peak season ozone standard (60 μg/m³) increased from 11 568 (89%) of 12 946 cities in 2000 to 12 433 (96%) cities in 2019. Percent change in ozone-attributable mortality averaged across 11 032 cities within each region from 2000 to 2019 ranged from -62% in eastern Europe to 350% in tropical Latin America. The contribution of ozone concentrations, population size, and baseline chronic respiratory disease rates to the change in ozone-attributable mortality differed regionally.

INTERPRETATION

Ozone exposure is increasing worldwide, contributing to disproportionate ozone mortality in peri-urban areas and increasing ozone exposure and attributable mortality in urban areas worldwide. Reducing ozone precursor emissions in areas affecting urban and peri-urban exposure can yield substantial public health benefits.

FUNDING

NASA Health and Air Quality Applied Sciences Team, the National Institute for Occupational Safety and Health, and the NOAA Co-operative Agreement with the Cooperative Institute for Research in Environmental Sciences.

Disparities in Air Pollutants Across Racial, Ethnic, and Poverty Groups at US Public Schools

We investigate socioeconomic disparities in air quality at public schools in the contiguous US using high resolution estimates of fine particulate matter (PM_2.5) and nitrogen dioxide (NO₂) concentrations. We find that schools with higher proportions of people of color (POC) and students eligible for the federal free or reduced lunch program, a proxy for poverty level, are associated with higher pollutant concentrations. For example, we find that the median annual NO₂ concentration for White students, nationally, was 7.7 ppbv, compared to 9.2 ppbv for Black and African American students. Statewide and regional disparities in pollutant concentrations across racial, ethnic, and poverty groups are consistent with nationwide results, where elevated NO₂ concentrations were associated with schools with higher proportions of POC and higher levels of poverty. Similar, though smaller, differences were found in PM_2.5 across racial and ethnic groups in most states. Racial, ethnic, and economic segregation across the rural-urban divide is likely an important factor in pollution disparities at US public schools. We identify distinct regional patterns of disparities, highlighting differences between California, New York, and Florida. Finally, we highlight that disparities exist not only across urban and non-urban lines but also within urban environments.

Sources of ambient PM2.5 exposure in 96 global cities

To improve air quality, knowledge of the sources and locations of air pollutant emissions is critical. However, for many global cities, no previous estimates exist of how much exposure to fine particulate matter (PM_2.5), the largest environmental cause of mortality, is caused by emissions within the city vs. outside its boundaries. We use the Intervention Model for Air Pollution (InMAP) global-through-urban reduced complexity air quality model with a high-resolution, global inventory of pollutant emissions to quantify the contribution of emissions by source type and location for 96 global cities. Among these cities, we find that the fraction of PM_2.5 exposure caused by within-city emissions varies widely (μ = 37%; σ = 22%) and is not well-explained by surrounding population density. The list of most-important sources also varies by city. Compared to a more mechanistically detailed model, InMAP predicts urban measured concentrations with lower bias and error but also lower correlation. Predictive accuracy in urban areas is not particularly high with either model, suggesting an opportunity for improving global urban air emission inventories. We expect the results herein can be useful as a screening tool for policy options and, in the absence of available resources for further analysis, to inform policy action to improve public health.

Health and Clinical Impacts of Air Pollution and Linkages with Climate Change

Air Pollution Impacts and Climate Change LinksAs part of the NEJM Group series on climate change, Keswani and colleagues review the linkages between climate change and air pollution and suggest strategies that clinicians may use to mitigate the adverse health impacts of air pollution.

Global urban temporal trends in fine particulate matter (PM2·5) and attributable health burdens: estimates from global datasets

BACKGROUND

With much of the world's population residing in urban areas, an understanding of air pollution exposures at the city level can inform mitigation approaches. Previous studies of global urban air pollution have not considered trends in air pollutant concentrations nor corresponding attributable mortality burdens. We aimed to estimate trends in fine particulate matter (PM_2·5) concentrations and associated mortality for cities globally.

METHODS

We use high-resolution annual average PM_2·5 concentrations, epidemiologically derived concentration response functions, and country-level baseline disease rates to estimate population-weighted PM_2·5 concentrations and attributable cause-specific mortality in 13 160 urban centres between the years 2000 and 2019.

FINDINGS

Although regional averages of urban PM_2·5 concentrations decreased between the years 2000 and 2019, we found considerable heterogeneity in trends of PM_2·5 concentrations between urban areas. Approximately 86% (2·5 billion inhabitants) of urban inhabitants lived in urban areas that exceeded WHO's 2005 guideline annual average PM_2·5 (10 μg/m³), resulting in an excess of 1·8 million (95% CI 1·34 million-2·3 million) deaths in 2019. Regional averages of PM_2·5-attributable deaths increased in all regions except for Europe and the Americas, driven by changes in population numbers, age structures, and disease rates. In some cities, PM_2·5-attributable mortality increased despite decreases in PM_2·5 concentrations, resulting from shifting age distributions and rates of non-communicable disease.

INTERPRETATION

Our study showed that, between the years 2000 and 2019, most of the world's urban population lived in areas with unhealthy levels of PM_2·5, leading to substantial contributions to non-communicable disease burdens. Our results highlight that avoiding the large public health burden from urban PM_2·5 will require strategies that reduce exposure through emissions mitigation, as well as strategies that reduce vulnerability to PM_2·5 by improving overall public health.

FUNDING

NASA, Wellcome Trust.

Long-term trends in urban NO2 concentrations and associated paediatric asthma incidence: estimates from global datasets

BACKGROUND

Combustion-related nitrogen dioxide (NO₂) air pollution is associated with paediatric asthma incidence. We aimed to estimate global surface NO₂ concentrations consistent with the Global Burden of Disease study for 1990-2019 at a 1 km resolution, and the concentrations and attributable paediatric asthma incidence trends in 13 189 cities from 2000 to 2019.

METHODS

We scaled an existing annual average NO₂ concentration dataset for 2010-12 from a land use regression model (based on 5220 NO₂ monitors in 58 countries and land use variables) to other years using NO₂ column densities from satellite and reanalysis datasets. We applied these concentrations in an epidemiologically derived concentration-response function with population and baseline asthma rates to estimate NO₂-attributable paediatric asthma incidence.

FINDINGS

We estimated that 1·85 million (95% uncertainty interval [UI] 0·93-2·80 million) new paediatric asthma cases were attributable to NO₂ globally in 2019, two thirds of which occurred in urban areas (1·22 million cases; 95% UI 0·60-1·8 million). The proportion of paediatric asthma incidence that is attributable to NO₂ in urban areas declined from 19·8% (1·22 million attributable cases of 6·14 million total cases) in 2000 to 16·0% (1·24 million attributable cases of 7·73 million total cases) in 2019. Urban attributable fractions dropped in high-income countries (-41%), Latin America and the Caribbean (-16%), central Europe, eastern Europe, and central Asia (-13%), and southeast Asia, east Asia, and Oceania (-6%), and rose in south Asia (+23%), sub-Saharan Africa (+11%), and north Africa and the Middle East (+5%). The contribution of NO₂ concentrations, paediatric population size, and asthma incidence rates to the change in NO₂-attributable paediatric asthma incidence differed regionally.

INTERPRETATION

Despite improvements in some regions, combustion-related NO₂ pollution continues to be an important contributor to paediatric asthma incidence globally, particularly in cities. Mitigating air pollution should be a crucial element of public health strategies for children.

FUNDING

Health Effects Institute, NASA.

Estimating Intra-Urban Inequities in PM2.5-Attributable Health Impacts: A Case Study for Washington, DC

Air pollution levels are uneven within cities, contributing to persistent health disparities between neighborhoods and population sub-groups. Highly spatially resolved information on pollution levels and disease rates is necessary to characterize inequities in air pollution exposure and related health risks. We leverage recent advances in deriving surface pollution levels from satellite remote sensing and granular data in disease rates for one city, Washington, DC, to assess intra-urban heterogeneity in fine particulate matter (PM2.5)- attributable mortality and morbidity. We estimate PM2.5-attributable cases of all-cause mortality, chronic obstructive pulmonary disease, ischemic heart disease, lung cancer, stroke, and asthma emergency department (ED) visits using epidemiologically derived health impact functions. Data inputs include satellite-derived annual mean surface PM2.5 concentrations; age-resolved population estimates; and statistical neighborhood-, zip code- and ward-scale disease counts. We find that PM2.5 concentrations and associated health burdens have decreased in DC between 2000 and 2018, from approximately 240 to 120 cause-specific deaths and from 40 to 30 asthma ED visits per year (between 2014 and 2018). However, remaining PM2.5-attributable health risks are unevenly and inequitably distributed across the District. Higher PM2.5-attributable disease burdens were found in neighborhoods with larger proportions of people of color, lower household income, and lower educational attainment. Our study adds to the growing body of literature documenting the inequity in air pollution exposure levels and pollution health risks between population sub-groups, and highlights the need for both high-resolution disease rates and concentration estimates for understanding intra-urban disparities in air pollution-related health risks.

COVID-19 pandemic reveals persistent disparities in nitrogen dioxide pollution

The unequal spatial distribution of ambient nitrogen dioxide ([Formula: see text]), an air pollutant related to traffic, leads to higher exposure for minority and low socioeconomic status communities. We exploit the unprecedented drop in urban activity during the COVID-19 pandemic and use high-resolution, remotely sensed [Formula: see text] observations to investigate disparities in [Formula: see text] levels across different demographic subgroups in the United States. We show that, prior to the pandemic, satellite-observed [Formula: see text] levels in the least White census tracts of the United States were nearly triple the [Formula: see text] levels in the most White tracts. During the pandemic, the largest lockdown-related [Formula: see text] reductions occurred in urban neighborhoods that have 2.0 times more non-White residents and 2.1 times more Hispanic residents than neighborhoods with the smallest reductions. [Formula: see text] reductions were likely driven by the greater density of highways and interstates in these racially and ethnically diverse areas. Although the largest reductions occurred in marginalized areas, the effect of lockdowns on racial, ethnic, and socioeconomic [Formula: see text] disparities was mixed and, for many cities, nonsignificant. For example, the least White tracts still experienced ∼1.5 times higher [Formula: see text] levels during the lockdowns than the most White tracts experienced prior to the pandemic. Future policies aimed at eliminating pollution disparities will need to look beyond reducing emissions from only passenger traffic and also consider other collocated sources of emissions such as heavy-duty vehicles.

Shaping the Future of Science: COVID-19 Highlighting the Importance of GeoHealth

From the heated debates over the airborne transmission of the novel coronavirus to the abrupt Earth system changes caused by the sudden lockdowns, the dire circumstances resulting from the coronavirus disease 2019 (COVID-19) pandemic have brought the field of GeoHealth to the forefront of visibility in science and policy. The pandemic has inadvertently provided an opportunity to study how human response has impacted the Earth system, how the Earth system may impact the pandemic, and the capacity of GeoHealth to inform real-time policy. The lessons learned throughout our responses to the COVID-19 pandemic are shaping the future of GeoHealth.

TROPOMI NO2 in the United States: A Detailed Look at the Annual Averages, Weekly Cycles, Effects of Temperature, and Correlation With Surface NO2 Concentrations

Observing the spatial heterogeneities of NO2 air pollution is an important first step in quantifying NOX emissions and exposures. This study investigates the capabilities of the Tropospheric Monitoring Instrument (TROPOMI) in observing the spatial and temporal patterns of NO2 pollution in the continental United States. The unprecedented sensitivity of the sensor can differentiate the fine-scale spatial heterogeneities in urban areas, such as emissions related to airport/shipping operations and high traffic, and the relatively small emission sources in rural areas, such as power plants and mining operations. We then examine NO2 columns by day-of-the-week and find that Saturday and Sunday concentrations are 16% and 24% lower respectively, than during weekdays. We also analyze the correlation of daily maximum 2-m temperatures and NO2 column amounts and find that NO2 is larger on the hottest days (>32°C) as compared to warm days (26°C-32°C), which is in contrast to a general decrease in NO2 with increasing temperature at moderate temperatures. Finally, we demonstrate that a linear regression fit of 2019 annual TROPOMI NO2 data to annual surface-level concentrations yields relatively strong correlation (R 2 = 0.66). These new developments make TROPOMI NO2 satellite data advantageous for policymakers and public health officials, who request information at high spatial resolution and short timescales, in order to assess, devise, and evaluate regulations.

Assessing the Distribution of Air Pollution Health Risks within Cities: A Neighborhood-Scale Analysis Leveraging High-Resolution Data Sets in the Bay Area, California

BACKGROUND

Air pollution-attributable disease burdens reported at global, country, state, or county levels mask potential smaller-scale geographic heterogeneity driven by variation in pollution levels and disease rates. Capturing within-city variation in air pollution health impacts is now possible with high-resolution pollutant concentrations.

OBJECTIVES

We quantified neighborhood-level variation in air pollution health risks, comparing results from highly spatially resolved pollutant and disease rate data sets available for the Bay Area, California.

METHODS

We estimated mortality and morbidity attributable to nitrogen dioxide (NO2), black carbon (BC), and fine particulate matter [PM ≤2.5μm in aerodynamic diameter (PM2.5)] using epidemiologically derived health impact functions. We compared geographic distributions of pollution-attributable risk estimates using concentrations from a) mobile monitoring of NO2 and BC; and b) models predicting annual NO2, BC and PM2.5 concentrations from land-use variables and satellite observations. We also compared results using county vs. census block group (CBG) disease rates.

RESULTS

Estimated pollution-attributable deaths per 100,000 people at the 100-m grid-cell level ranged across the Bay Area by a factor of 38, 4, and 5 for NO2 [mean=30 (95% CI: 9, 50)], BC [mean=2 (95% CI: 1, 2)], and PM2.5, [mean=49 (95% CI: 33, 64)]. Applying concentrations from mobile monitoring and land-use regression (LUR) models in Oakland neighborhoods yielded similar spatial patterns of estimated grid-cell-level NO2-attributable mortality rates. Mobile monitoring concentrations captured more heterogeneity [mobile monitoring mean=64 (95% CI: 19, 107) deaths per 100,000 people; LUR mean=101 (95% CI: 30, 167)]. Using CBG-level disease rates instead of county-level disease rates resulted in 15% larger attributable mortality rates for both NO2 and PM2.5, with more spatial heterogeneity at the grid-cell-level [NO2 CBG mean=41 deaths per 100,000 people (95% CI: 12, 68); NO2 county mean=38 (95% CI: 11, 64); PM2.5 CBG mean=59 (95% CI: 40, 77); and PM2.5 county mean=55 (95% CI: 37, 71)].

DISCUSSION

Air pollutant-attributable health burdens varied substantially between neighborhoods, driven by spatial variation in pollutant concentrations and disease rates. https://doi.org/10.1289/EHP7679.

Synergistic health effects of air pollution, temperature, and pollen exposure: a systematic review of epidemiological evidence

BACKGROUND

Exposure to heat, air pollution, and pollen are associated with health outcomes, including cardiovascular and respiratory disease. Studies assessing the health impacts of climate change have considered increased exposure to these risk factors separately, though they may be increasing simultaneously for some populations and may act synergistically on health. Our objective is to systematically review epidemiological evidence for interactive effects of multiple exposures to heat, air pollution, and pollen on human health.

METHODS

We systematically searched electronic literature databases (last search, April 29, 2019) for studies reporting quantitative measurements of associations between at least two of the exposures and mortality from any cause and cardiovascular and respiratory morbidity and mortality specifically. Following the Navigation Guide systematic review methodology, we evaluated the risk of bias of individual studies and the overall quality and strength of evidence.

RESULTS

We found 56 studies that met the inclusion criteria. Of these, six measured air pollution, heat, and pollen; 39 measured air pollution and heat; 10 measured air pollution and pollen; and one measured heat and pollen. Nearly all studies were at risk of bias from exposure assessment error. However, consistent exposure-response across studies led us to conclude that there is overall moderate quality and sufficient evidence for synergistic effects of heat and air pollution. We concluded that there is overall low quality and limited evidence for synergistic effects from simultaneous exposure to (1) air pollution, pollen, and heat; and (2) air pollution and pollen. With only one study, we were unable to assess the evidence for synergistic effects of heat and pollen.

CONCLUSIONS

If synergistic effects between heat and air pollution are confirmed with additional research, the health impacts from climate change-driven increases in air pollution and heat exposure may be larger than previously estimated in studies that consider these risk factors individually.

Development of the Low Emissions Analysis Platform - Integrated Benefits Calculator (LEAP-IBC) tool to assess air quality and climate co-benefits: Application for Bangladesh

Low- and middle-income countries have the largest health burdens associated with air pollution exposure, and are particularly vulnerable to climate change impacts. Substantial opportunities have been identified to simultaneously improve air quality and mitigate climate change due to overlapping sources of greenhouse gas and air pollutant emissions and because a subset of pollutants, short-lived climate pollutants (SLCPs), directly contribute to both impacts. However, planners in low- and middle-income countries often lack practical tools to quantify the air pollution and climate change impacts of different policies and measures. This paper presents a modelling framework implemented in the Low Emissions Analysis Platform - Integrated Benefits Calculator (LEAP-IBC) tool to develop integrated strategies to improve air quality, human health and mitigate climate change. The framework estimates emissions of greenhouse gases, SLCPs and air pollutants for historical years, and future projections for baseline and mitigation scenarios. These emissions are then used to quantify i) population-weighted annual average ambient PM_2.5 concentrations across the target country, ii) household PM_2.5 exposure of different population groups living in households cooking using different fuels/technologies and iii) radiative forcing from all emissions. Health impacts (premature mortality) attributable to ambient and household PM_2.5 exposure and changes in global average temperature change are then estimated. This framework is applied in Bangladesh to evaluate the air quality and climate change benefits from implementation of Bangladesh's Nationally Determined Contribution (NDC) and National Action Plan to reduce SLCPs. Results show that the measures included to reduce GHGs in Bangladesh's NDC also have substantial benefits for air quality and human health. Full implementation of Bangladesh's NDC, and National SLCP Plan would reduce carbon dioxide, methane, black carbon and primary PM_2.5 emissions by 25%, 34%, 46% and 45%, respectively in 2030 compared to a baseline scenario. These emission reductions could reduce population-weighted ambient PM_2.5 concentrations in Bangladesh by 18% in 2030, and avoid approximately 12,000 and 100,000 premature deaths attributable to ambient and household PM_2.5 exposures, respectively, in 2030. As countries are simultaneously planning to achieve the climate goals in the Paris Agreement, improve air quality to reduce health impacts and achieve the Sustainable Development Goals, the LEAP-IBC tool provides a practical framework by which planners can develop integrated strategies, achieving multiple air quality and climate benefits.

Guidelines for Modeling and Reporting Health Effects of Climate Change Mitigation Actions

BACKGROUND

Modeling suggests that climate change mitigation actions can have substantial human health benefits that accrue quickly and locally. Documenting the benefits can help drive more ambitious and health-protective climate change mitigation actions; however, documenting the adverse health effects can help to avoid them. Estimating the health effects of mitigation (HEM) actions can help policy makers prioritize investments based not only on mitigation potential but also on expected health benefits. To date, however, the wide range of incompatible approaches taken to developing and reporting HEM estimates has limited their comparability and usefulness to policymakers.

OBJECTIVE

The objective of this effort was to generate guidance for modeling studies on scoping, estimating, and reporting population health effects from climate change mitigation actions.

METHODS

An expert panel of HEM researchers was recruited to participate in developing guidance for conducting HEM studies. The primary literature and a synthesis of HEM studies were provided to the panel. Panel members then participated in a modified Delphi exercise to identify areas of consensus regarding HEM estimation. Finally, the panel met to review and discuss consensus findings, resolve remaining differences, and generate guidance regarding conducting HEM studies.

RESULTS

The panel generated a checklist of recommendations regarding stakeholder engagement: HEM modeling, including model structure, scope and scale, demographics, time horizons, counterfactuals, health response functions, and metrics; parameterization and reporting; approaches to uncertainty and sensitivity analysis; accounting for policy uptake; and discounting.

DISCUSSION

This checklist provides guidance for conducting and reporting HEM estimates to make them more comparable and useful for policymakers. Harmonization of HEM estimates has the potential to lead to advances in and improved synthesis of policy-relevant research that can inform evidence-based decision making and practice. https://doi.org/10.1289/EHP6745.

Disentangling the Impact of the COVID-19 Lockdowns on Urban NO2 From Natural Variability

TROPOMI satellite data show substantial drops in nitrogen dioxide (NO₂) during COVID-19 physical distancing. To attribute NO₂ changes to NO _x emissions changes over short timescales, one must account for meteorology. We find that meteorological patterns were especially favorable for low NO₂ in much of the United States in spring 2020, complicating comparisons with spring 2019. Meteorological variations between years can cause column NO₂ differences of ~15% over monthly timescales. After accounting for solar angle and meteorological considerations, we calculate that NO₂ drops ranged between 9.2% and 43.4% among 20 cities in North America, with a median of 21.6%. Of the studied cities, largest NO₂ drops (>30%) were in San Jose, Los Angeles, and Toronto, and smallest drops (<12%) were in Miami, Minneapolis, and Dallas. These normalized NO₂ changes can be used to highlight locations with greater activity changes and better understand the sources contributing to adverse air quality in each city.

Using Satellites to Track Indicators of Global Air Pollution and Climate Change Impacts: Lessons Learned From a NASA-Supported Science-Stakeholder Collaborative

The 2018 NASA Health and Air Quality Applied Science Team (HAQAST) "Indicators" Tiger Team collaboration between NASA-supported scientists and civil society stakeholders aimed to develop satellite-derived global air pollution and climate indicators. This Commentary shares our experience and lessons learned. Together, the team developed methods to track wildfires, dust storms, pollen counts, urban green space, nitrogen dioxide concentrations and asthma burdens, tropospheric ozone concentrations, and urban particulate matter mortality. Participatory knowledge production can lead to more actionable information but requires time, flexibility, and continuous engagement. Ground measurements are still needed for ground truthing, and sustained collaboration over time remains a challenge.

Improving and Expanding Estimates of the Global Burden of Disease Due to Environmental Health Risk Factors

BACKGROUND

The Global Burden of Disease (GBD) study, coordinated by the Institute for Health Metrics and Evaluation (IHME), produces influential, data-driven estimates of the burden of disease and premature death due to major risk factors. Expanded quantification of disease due to environmental health (EH) risk factors, including climate change, will enhance accuracy of GBD estimates, which will contribute to developing cost-effective policies that promote prevention and achieving Sustainable Development Goals.

OBJECTIVES

We review key aspects of the GBD for the EH community and introduce the Global Burden of Disease-Pollution and Health Initiative (GBD-PHI), which aims to work with IHME and the GBD study to improve estimates of disease burden attributable to EH risk factors and to develop an innovative approach to estimating climate-related disease burden-both current and projected.

METHODS

We discuss strategies for improving GBD quantification of specific EH risk factors, including air pollution, lead, and climate change. We highlight key methodological challenges, including new EH risk factors, notably evidence rating and global exposure assessment.

DISCUSSION

A number of issues present challenges to the scope and accuracy of current GBD estimates for EH risk factors. For air pollution, minimal data exist on the exposure-risk relationships associated with high levels of pollution; epidemiological studies in high pollution regions should be a research priority. For lead, the GBD's current methods do not fully account for lead's impact on neurodevelopment; innovative methods to account for subclinical effects are needed. Decisions on inclusion of additional EH risk-outcome pairs need to be guided by findings of systematic reviews, the size of exposed populations, feasibility of global exposure estimates, and predicted trends in exposures and diseases. Neurotoxicants, endocrine-disrupting chemicals, and climate-related factors should be high priorities for incorporation into upcoming iterations of the GBD study. Enhancing the scope and methods will improve the GBD's estimates and better guide prevention policy. https://doi.org/10.1289/EHP5496.

Extreme Weather, Chemical Facilities, and Vulnerable Communities in the U.S. Gulf Coast: A Disastrous Combination

Many chemical facilities are located in low-lying coastal areas and vulnerable to damage from hurricanes, flooding, and erosion, which are increasing with climate change. Extreme weather can trigger industrial disasters, including explosions, fires, and major chemical releases, as well as chronic chemical leakage into air, water, and soil. We identified 872 highly hazardous chemical facilities within 50 miles of the hurricane-prone U.S. Gulf Coast. Approximately 4,374,000 people, 1,717 schools, and 98 medical facilities were within 1.5 miles of these facilities. Public health risks from colocated extreme weather, chemical facilities, and vulnerable populations are potentially disastrous and growing under climate change.

Global, national, and urban burdens of paediatric asthma incidence attributable to ambient NO2 pollution: estimates from global datasets

BACKGROUND

Paediatric asthma incidence is associated with exposure to traffic-related air pollution (TRAP), but the TRAP-attributable burden remains poorly quantified. Nitrogen dioxide (NO₂) is a major component and common proxy of TRAP. In this study, we estimated the annual global number of new paediatric asthma cases attributable to NO₂ exposure at a resolution sufficient to resolve intra-urban exposure gradients.

METHODS

We obtained 2015 country-specific and age-group-specific asthma incidence rates from the Institute for Health Metrics and Evaluation for 194 countries and 2015 population counts at a spatial resolution of 250 × 250 m from the Global Human Settlement population grid. We used 2010-12 annual average surface NO₂ concentrations derived from land-use regression at a resolution of 100 × 100 m, and we derived concentration-response functions from relative risk estimates reported in a multinational meta-analysis. We then estimated the NO₂-attributable burden of asthma incidence in children aged 1-18 years in 194 countries and 125 major cities at a resolution of 250 × 250 m.

FINDINGS

Globally, we estimated that 4·0 million (95% uncertainty interval [UI] 1·8-5·2) new paediatric asthma cases could be attributable to NO₂ pollution annually; 64% of these occur in urban centres. This burden accounts for 13% (6-16) of global incidence. Regionally, the greatest burdens of new asthma cases associated with NO₂ exposure per 100 000 children were estimated for Andean Latin America (340 cases per year, 95% UI 150-440), high-income North America (310, 140-400), and high-income Asia Pacific (300, 140-370). Within cities, the greatest burdens of new asthma cases associated with NO₂ exposure per 100 000 children were estimated for Lima, Peru (690 cases per year, 95% UI 330-870); Shanghai, China (650, 340-770); and Bogota, Colombia (580, 270-730). Among 125 major cities, the percentage of new asthma cases attributable to NO₂ pollution ranged from 5·6% (95% UI 2·4-7·4) in Orlu, Nigeria, to 48% (25-57) in Shanghai, China. This contribution exceeded 20% of new asthma cases in 92 cities. We estimated that about 92% of paediatric asthma incidence attributable to NO₂ exposure occurred in areas with annual average NO₂ concentrations lower than the WHO guideline of 21 parts per billion.

INTERPRETATION

Efforts to reduce NO₂ exposure could help prevent a substantial portion of new paediatric asthma cases in both developed and developing countries, and especially in urban areas. Traffic emissions should be a target for exposure-mitigation strategies. The adequacy of the WHO guideline for ambient NO₂ concentrations might need to be revisited.

FUNDING

George Washington University.

Effects of Increasing Aridity on Ambient Dust and Public Health in the U.S. Southwest Under Climate Change

The U.S. Southwest is projected to experience increasing aridity due to climate change. We quantify the resulting impacts on ambient dust levels and public health using methods consistent with the Environmental Protection Agency's Climate Change Impacts and Risk Analysis framework. We first demonstrate that U.S. Southwest fine (PM2.5) and coarse (PM2.5-10) dust levels are strongly sensitive to variability in the 2-month Standardized Precipitation-Evapotranspiration Index across southwestern North America. We then estimate potential changes in dust levels through 2099 by applying the observed sensitivities to downscaled meteorological output projected by six climate models following an intermediate (Representative Concentration Pathway 4.5, RCP4.5) and a high (RCP8.5) greenhouse gas concentration scenario. By 2080-2099 under RCP8.5 relative to 1986-2005 in the U.S. Southwest: (1) Fine dust levels could increase by 57%, and fine dust-attributable all-cause mortality and hospitalizations could increase by 230% and 360%, respectively; (2) coarse dust levels could increase by 38%, and coarse dust-attributable cardiovascular mortality and asthma emergency department visits could increase by 210% and 88%, respectively; (3) climate-driven changes in dust concentrations can account for 34-47% of these health impacts, with the rest due to increases in population and baseline incidence rates; and (4) economic damages of the health impacts could total $47 billion per year additional to the 1986-2005 value of $13 billion per year. Compared to national-scale climate impacts projected for other U.S. sectors using the Climate Change Impacts and Risk Analysis framework, dust-related mortality ranks fourth behind extreme temperature-related mortality, labor productivity decline, and coastal property loss.

Estimates of Present and Future Asthma Emergency Department Visits Associated With Exposure to Oak, Birch, and Grass Pollen in the United States

Pollen is an important environmental cause of allergic asthma episodes. Prior work has established a proof of concept for assessing projected climate change impacts on future oak pollen exposure and associated health impacts. This paper uses additional monitor data and epidemiologic functions to extend prior analyses, reporting new estimates of the current and projected future health burden of oak, birch, and grass pollen across the contiguous United States. Our results suggest that tree pollen in the spring currently accounts for between 25,000 and 50,000 pollen-related asthma emergency department (ED) visits annually (95% confidence interval: 14,000 to 100,000), roughly two thirds of which occur among people under age 18. Grass pollen in the summer season currently accounts for less than 10,000 cases annually (95% confidence interval: 4,000 to 16,000). Compared to a baseline with 21st century population growth but constant pollen, future temperature and precipitation show an increase in ED visits of 14% in 2090 for a higher greenhouse gas emissions scenario, but only 8% for a moderate emissions scenario, reflecting projected increases in pollen season length. Grass pollen, which is more sensitive to changes in climatic conditions, is a primary contributor to future ED visits, with the largest effects in the Northeast, Midwest, and Southern Great Plains regions. More complete assessment of the current and future health burden of pollen is limited by the availability of data on pollen types (e.g., ragweed), other health effects (e.g., other respiratory disease), and economic consequences (e.g., medication costs).

Estimates of the Global Burden of Ambient [Formula: see text], Ozone, and [Formula: see text] on Asthma Incidence and Emergency Room Visits

BACKGROUND

Asthma is the most prevalent chronic respiratory disease worldwide, affecting 358 million people in 2015. Ambient air pollution exacerbates asthma among populations around the world and may also contribute to new-onset asthma.

OBJECTIVES

We aimed to estimate the number of asthma emergency room visits and new onset asthma cases globally attributable to fine particulate matter ([Formula: see text]), ozone, and nitrogen dioxide ([Formula: see text]) concentrations.

METHODS

We used epidemiological health impact functions combined with data describing population, baseline asthma incidence and prevalence, and pollutant concentrations. We constructed a new dataset of national and regional emergency room visit rates among people with asthma using published survey data.

RESULTS

We estimated that 9–23 million and 5–10 million annual asthma emergency room visits globally in 2015 could be attributable to ozone and [Formula: see text], respectively, representing 8–20% and 4–9% of the annual number of global visits, respectively. The range reflects the application of central risk estimates from different epidemiological meta-analyses. Anthropogenic emissions were responsible for [Formula: see text] and 73% of ozone and [Formula: see text] impacts, respectively. Remaining impacts were attributable to naturally occurring ozone precursor emissions (e.g., from vegetation, lightning) and [Formula: see text] (e.g., dust, sea salt), though several of these sources are also influenced by humans. The largest impacts were estimated in China and India.

CONCLUSIONS

These findings estimate the magnitude of the global asthma burden that could be avoided by reducing ambient air pollution. We also identified key uncertainties and data limitations to be addressed to enable refined estimation. https://doi.org/10.1289/EHP3766.

Updated Global Estimates of Respiratory Mortality in Adults ≥30Years of Age Attributable to Long-Term Ozone Exposure

BACKGROUND

Relative risk estimates for long-term ozone (O₃) exposure and respiratory mortality from the American Cancer Society Cancer Prevention Study II (ACS CPS-II) cohort have been used to estimate global O₃-attributable mortality in adults. Updated relative risk estimates are now available for the same cohort based on an expanded study population with longer follow-up.

OBJECTIVES

We estimated the global burden and spatial distribution of respiratory mortality attributable to long-term O₃ exposure in adults ≥30y of age using updated effect estimates from the ACS CPS-II cohort.

METHODS

We used GEOS-Chem simulations (2×2.5º grid resolution) to estimate annual O₃ exposures, and estimated total respiratory deaths in 2010 that were attributable to long-term annual O₃ exposure based on the updated relative risk estimates and minimum risk thresholds set at the minimum or fifth percentile of O₃ exposure in the most recent CPS-II analysis. These estimates were compared with attributable mortality based on the earlier CPS-II analysis, using 6-mo average exposures and risk thresholds corresponding to the minimum or fifth percentile of O₃ exposure in the earlier study population.

RESULTS

We estimated 1.04-1.23 million respiratory deaths in adults attributable to O₃ exposures using the updated relative risk estimate and exposure parameters, compared with 0.40-0.55 million respiratory deaths attributable to O₃ exposures based on the earlier CPS-II risk estimate and parameters. Increases in estimated attributable mortality were larger in northern India, southeast China, and Pakistan than in Europe, eastern United States, and northeast China.

CONCLUSIONS

These findings suggest that the potential magnitude of health benefits of air quality policies targeting O₃, health co-benefits of climate mitigation policies, and health implications of climate change-driven changes in O₃ concentrations, are larger than previously thought. https://doi.org/10.1289/EHP1390.

Impacts of oak pollen on allergic asthma in the United States and potential influence of future climate change

Future climate change is expected to lengthen and intensify pollen seasons in the U.S., potentially increasing incidence of allergic asthma. We developed a proof-of-concept approach for estimating asthma emergency department (ED) visits in the U.S. associated with present-day and climate-induced changes in oak pollen. We estimated oak pollen season length for moderate (Representative Concentration Pathway (RCP) 4.5) and severe climate change scenarios (RCP8.5) through 2090 using five climate models and published relationships between temperature, precipitation, and oak pollen season length. We calculated asthma ED visit counts associated with 1994-2010 average oak pollen concentrations and simulated future oak pollen season length changes using the Environmental Benefits Mapping and Analysis Program, driven by epidemiologically derived concentration-response relationships. Oak pollen was associated with 21,200 (95% confidence interval, 10,000-35,200) asthma ED visits in the Northeast, Southeast, and Midwest U.S. in 2010, with damages valued at $10.4 million. Nearly 70% of these occurred among children age <18 years. Severe climate change could increase oak pollen season length and associated asthma ED visits by 5% and 10% on average in 2050 and 2090, with a marginal net present value through 2090 of $10.4 million (additional to the baseline value of $346.2 million). Moderate versus severe climate change could avoid >50% of the additional oak pollen-related asthma ED visits in 2090. Despite several key uncertainties and limitations, these results suggest that aeroallergens pose a substantial U.S. public health burden, that climate change could increase U.S. allergic disease incidence, and that mitigating climate change may have benefits from avoided pollen-related health impacts.

Survey of Ambient Air Pollution Health Risk Assessment Tools

Designing air quality policies that improve public health can benefit from information about air pollution health risks and impacts, which include respiratory and cardiovascular diseases and premature death. Several computer-based tools help automate air pollution health impact assessments and are being used for a variety of contexts. Expanding information gathered for a May 2014 World Health Organization expert meeting, we survey 12 multinational air pollution health impact assessment tools, categorize them according to key technical and operational characteristics, and identify limitations and challenges. Key characteristics include spatial resolution, pollutants and health effect outcomes evaluated, and method for characterizing population exposure, as well as tool format, accessibility, complexity, and degree of peer review and application in policy contexts. While many of the tools use common data sources for concentration-response associations, population, and baseline mortality rates, they vary in the exposure information source, format, and degree of technical complexity. We find that there is an important tradeoff between technical refinement and accessibility for a broad range of applications. Analysts should apply tools that provide the appropriate geographic scope, resolution, and maximum degree of technical rigor for the intended assessment, within resources constraints. A systematic intercomparison of the tools' inputs, assumptions, calculations, and results would be helpful to determine the appropriateness of each for different types of assessment. Future work would benefit from accounting for multiple uncertainty sources and integrating ambient air pollution health impact assessment tools with those addressing other related health risks (e.g., smoking, indoor pollution, climate change, vehicle accidents, physical activity).

Cleaner cooking solutions to achieve health, climate, and economic cobenefits

Nearly half the world's population must rely on solid fuels such as biomass (wood, charcoal, agricultural residues, and animal dung) and coal for household energy, burning them in inefficient open fires and stoves with inadequate ventilation. Household solid fuel combustion is associated with four million premature deaths annually; contributes to forest degradation, loss of habitat and biodiversity, and climate change; and hinders social and economic progress as women and children spend hours every day collecting fuel. Several recent studies, as well as key emerging national and international efforts, are making progress toward enabling wide-scale household adoption of cleaner and more efficient stoves and fuels. While significant challenges remain, these efforts offer considerable promise to save lives, improve forest sustainability, slow climate change, and empower women around the world.

Global air quality and health co-benefits of mitigating near-term climate change through methane and black carbon emission controls

BACKGROUND

Tropospheric ozone and black carbon (BC), a component of fine particulate matter (PM ≤ 2.5 µm in aerodynamic diameter; PM(2.5)), are associated with premature mortality and they disrupt global and regional climate.

OBJECTIVES

We examined the air quality and health benefits of 14 specific emission control measures targeting BC and methane, an ozone precursor, that were selected because of their potential to reduce the rate of climate change over the next 20-40 years.

METHODS

We simulated the impacts of mitigation measures on outdoor concentrations of PM(2.5) and ozone using two composition-climate models, and calculated associated changes in premature PM(2.5)- and ozone-related deaths using epidemiologically derived concentration-response functions.

RESULTS

We estimated that, for PM(2.5) and ozone, respectively, fully implementing these measures could reduce global population-weighted average surface concentrations by 23-34% and 7-17% and avoid 0.6-4.4 and 0.04-0.52 million annual premature deaths globally in 2030. More than 80% of the health benefits are estimated to occur in Asia. We estimated that BC mitigation measures would achieve approximately 98% of the deaths that would be avoided if all BC and methane mitigation measures were implemented, due to reduced BC and associated reductions of nonmethane ozone precursor and organic carbon emissions as well as stronger mortality relationships for PM(2.5) relative to ozone. Although subject to large uncertainty, these estimates and conclusions are not strongly dependent on assumptions for the concentration-response function.

CONCLUSIONS

In addition to climate benefits, our findings indicate that the methane and BC emission control measures would have substantial co-benefits for air quality and public health worldwide, potentially reversing trends of increasing air pollution concentrations and mortality in Africa and South, West, and Central Asia. These projected benefits are independent of carbon dioxide mitigation measures. Benefits of BC measures are underestimated because we did not account for benefits from reduced indoor exposures and because outdoor exposure estimates were limited by model spatial resolution.

Simultaneously mitigating near-term climate change and improving human health and food security

Tropospheric ozone and black carbon (BC) contribute to both degraded air quality and global warming. We considered ~400 emission control measures to reduce these pollutants by using current technology and experience. We identified 14 measures targeting methane and BC emissions that reduce projected global mean warming ~0.5°C by 2050. This strategy avoids 0.7 to 4.7 million annual premature deaths from outdoor air pollution and increases annual crop yields by 30 to 135 million metric tons due to ozone reductions in 2030 and beyond. Benefits of methane emissions reductions are valued at $700 to $5000 per metric ton, which is well above typical marginal abatement costs (less than $250). The selected controls target different sources and influence climate on shorter time scales than those of carbon dioxide-reduction measures. Implementing both substantially reduces the risks of crossing the 2°C threshold.

Estimating the national public health burden associated with exposure to ambient PM2.5 and ozone

Ground-level ozone (O(3)) and fine particulate matter (PM(2.5)) are associated with increased risk of mortality. We quantify the burden of modeled 2005 concentrations of O(3) and PM(2.5) on health in the United States. We use the photochemical Community Multiscale Air Quality (CMAQ) model in conjunction with ambient monitored data to create fused surfaces of summer season average 8-hour ozone and annual mean PM(2.5) levels at a 12 km grid resolution across the continental United States. Employing spatially resolved demographic and concentration data, we assess the spatial and age distribution of air-pollution-related mortality and morbidity. For both PM(2.5) and O(3) we also estimate: the percentage of total deaths due to each pollutant; the reduction in life years and life expectancy; and the deaths avoided according to hypothetical air quality improvements. Using PM(2.5) and O(3) mortality risk coefficients drawn from the long-term American Cancer Society (ACS) cohort study and National Mortality and Morbidity Air Pollution Study (NMMAPS), respectively, we estimate 130,000 PM(2.5) -related deaths and 4,700 ozone-related deaths to result from 2005 air quality levels. Among populations aged 65-99, we estimate nearly 1.1 million life years lost from PM(2.5) exposure and approximately 36,000 life years lost from ozone exposure. Among the 10 most populous counties, the percentage of deaths attributable to PM(2.5) and ozone ranges from 3.5% in San Jose to 10% in Los Angeles. These results show that despite significant improvements in air quality in recent decades, recent levels of PM(2.5) and ozone still pose a nontrivial risk to public health.

An estimate of the global burden of anthropogenic ozone and fine particulate matter on premature human mortality using atmospheric modeling

BACKGROUND

Ground-level concentrations of ozone (O3) and fine particulate matter [< or = 2.5 microm in aerodynamic diameter (PM2.5)] have increased since preindustrial times in urban and rural regions and are associated with cardiovascular and respiratory mortality.

OBJECTIVES

We estimated the global burden of mortality due to O3 and PM2.5 from anthropogenic emissions using global atmospheric chemical transport model simulations of preindustrial and present-day (2000) concentrations to derive exposure estimates.

METHODS

Attributable mortalities were estimated using health impact functions based on long-term relative risk estimates for O3 and PM2.5 from the epidemiology literature. Using simulated concentrations rather than previous methods based on measurements allows the inclusion of rural areas where measurements are often unavailable and avoids making assumptions for background air pollution.

RESULTS

Anthropogenic O3 was associated with an estimated 0.7 +/- 0.3 million respiratory mortalities (6.3 +/- 3.0 million years of life lost) annually. Anthropogenic PM2.5 was associated with 3.5 +/- 0.9 million cardiopulmonary and 220,000 +/- 80,000 lung cancer mortalities (30 +/- 7.6 million years of life lost) annually. Mortality estimates were reduced approximately 30% when we assumed low-concentration thresholds of 33.3 ppb for O3 and 5.8 microg/m3 for PM2.5. These estimates were sensitive to concentration thresholds and concentration-mortality relationships, often by > 50%.

CONCLUSIONS

Anthropogenic O3 and PM2.5 contribute substantially to global premature mortality. PM2.5 mortality estimates are about 50% higher than previous measurement-based estimates based on common assumptions, mainly because of methodologic differences. Specifically, we included rural populations, suggesting higher estimates; however, the coarse resolution of the global atmospheric model may underestimate urban PM(2.5) exposures.