Utility of controlled human exposure studies for assessing the health effects of complex mixtures and indoor air pollutants.

The study of health effects induced by exposure to mixtures of pollutants is a complex task. The purpose of this paper is to identify areas of research in which the conduct of human controlled exposure (clinical) studies may contribute to better understanding health effects of exposure to indoor air and other mixtures. The strengths and weaknesses of clinical studies in general are reviewed, as well as examples from the literature of approaches that have been used. Human chamber studies play an important role alongside epidemiologic and animal toxicologic studies in such research. Human chamber studies are limited with regard to assessing chronic effects, rare effects, or effects from long-duration exposures but are powerful in assessing acute, reversible effects from short-duration exposures in humans. The areas in which human chamber studies are most likely to contribute include identification of effects or markers of effects for exposure to a given pollutant or mix of pollutants; direct dose-response assessment of effects for individual compounds and mixtures of set composition; identification of individual compounds responsible for the effects of a mixture; study of the joint effects of a binary mixture; development of markers of acute exposure for particular compounds; development of outcome measurements to be used in the field; and identification, characterization, and testing of sensitive subpopulations.

Respiratory symptoms and pulmonary function in an elderly nonsmoking population.

OBJECTIVE: To examine risk factors for chronic airway disease (CAD) in elderly nonsmokers, as determined by pulmonary function tests (PFTs), and to correlate reported respiratory symptoms with PFT measures. DESIGN: An observational survey. SETTING: Several communities in California. MEASUREMENTS: Exposures and respiratory history were assessed by standardized questionnaire. PFTs were performed and prediction equations derived. RESULTS: Significant risk factors for obstruction on PFTs in multiple logistic regression included reported environmental tobacco smoke (ETS) exposure (relative risk [RR]=1.44), parental CAD or hay fever (RR=1.47), history of childhood respiratory illness (RR=2.15), increasing age, and male sex. The number of years of past smoking was of borderline significance (RR=1.29 for 10 years of smoking; p=0.06). The prevalence of obstruction on PFTs was 24.9% in those with definite symptomatic CAD, compared with 7.5% in those with no symptoms of CAD. The prevalence of obstruction was 36.0% among those with asthma and 70.6% among those with emphysema. Also, symptomatic CAD correlated with reduction in lung function by analysis of covariance. The mean percent predicted FEV1 adjusted for covariates was 90.6% in persons with definite symptoms of CAD, compared with 97.8% in those without it (p < 0.001). CONCLUSIONS: Age, sex, parental history, childhood respiratory illness, and reported ETS exposures were significant risk factors for obstruction on PFTs. Self-reported respiratory symptoms also correlated significantly with PFTs.

Peak flow lability: association with asthma and spirometry in an older cohort.

OBJECTIVE: To determine the success rate and correlates of ambulatory peak expiratory flow (PEF) monitoring in an epidemiologic study. DESIGN: An observational survey. SETTING: Several communities in California. PARTICIPANTS: We studied 1,223 nonsmoking men and women (mean age, 66 years) from an established cohort. OUTCOME MEASURES: A standard respiratory symptoms and diagnoses questionnaire, spirometry before and after bronchodilator, and a diary of PEF recorded four times per day for 7 days at home. RESULTS: A physician diagnosis of asthma was reported in 8.6% of the women and 9.4% of the men. Of those who agreed to complete PEF diaries at home, 87% successfully provided a valid measure of PEF lability. The mean PEF lability from those with asthma was significantly higher than the others (12.0% vs 8.9% in women and 10.2% vs 8.1% in men). Independent correlates of higher PEF lability included asthma, wheezing symptoms, airways obstruction by spirometry, older age, and male gender. CONCLUSIONS: Middle-aged and elderly persons are largely successful at providing a measure of PEF lability at home. In nonsmoking adults living in California, increased PEF lability is correlated with asthma, wheezing, airways obstruction, and older age, validating its use in epidemiology studies as an index of airways hyperreactivity.

Description of acute ozone response as a function of exposure rate and total inhaled dose.

The magnitude of respiratory responses to short-term ozone exposure is known to be a function of the exposure variables concentration (C), duration of exposure (T), and minute ventilation (VE) during exposure. The purpose of this study was to identify a mathematical model that described ozone-induced mean decrements in forced expiratory volume in 1 s (FEV1) as a function of exposure rate (C x VE) and total inhaled dose (C x VE x T). Three hundred seventy-four young male nonsmokers participated in 504 exposures to several concentrations of ozone for 2 or 6.6 h. Mean percent change in FEV1 was calculated for each hour of exposure and was fit to the exposure variables by use of nonlinear models. We identified a general sigmoid-shaped model that well described the observed mean response in terms of exposure rate and total inhaled dose over a wide range of C and T. By fixing the value of a single parameter, this model reduces to a simpler form, which was adequate for description of responses over narrower ranges of exposure conditions. We concluded that the observed mean responses to short-term ozone exposure were adequately described by the nonlinear models identified in this study and that models of this form may be useful for description of responses over a wide range of C and T.

Role of the parasympathetic nervous system in acute lung response to ozone.

We conducted an ozone (O3) exposure study using atropine, a muscarinic receptor blocker, to determine the role of the parasympathetic nervous system in the acute response to O3. Eight normal subjects with predetermined O3 responsiveness were randomly assigned an order for four experimental exposures. For each exposure a subject inhaled either buffered saline or atropine aerosol followed by exposure either to clean air or 0.4 ppm O3. Measurements of lung mechanics, ventilatory response to exercise, and symptoms were obtained before and after exposure. O3 exposure alone resulted in significant changes in specific airway resistance, forced vital capacity (FVC), forced expiratory flow rates, tidal volume (VT), and respiratory rate (f). Atropine pretreatment prevented the significant increase in airway resistance with O3 exposure and partially blocked the decrease in forced expiratory flow rates but did not prevent a significant fall in FVC, changes in f and VT, or the frequency of reported respiratory symptoms after O3. These results suggest that the increase in pulmonary resistance during O3 exposure is mediated by a parasympathetic mechanism and that changes in other measured variables are mediated, at least partially, by mechanisms not dependent on muscarinic cholinergic receptors of the parasympathetic nervous system.

Spirometric reference equations for older adults.

The objective of this study was to develop spirometric reference equations for healthy, never-smoking, older adults. It was designed as a cross-sectional observational study consisting of 1510 Seventh Day Adventists, ages 43-79 years enrolled in a study of health effects of air pollutants. Individuals were excluded from the reference group (n = 565) for a history of current respiratory illness, smoking, or chronic respiratory disease, and for a number of 'non-respiratory' conditions which were observed in these data to be related to lower values of FEV1. Gender-specific reference equations were developed for the entire reference group and for a subset above 65 years of age (n = 312). Controlling for height and age, lung function was found to be positively related to the difference between armspan and height, and in males was found to be quadratically related to age. The predicted values for this population generally fell within the range of those of other population groups containing large numbers of adults over the age of 65 years. Individuals with lung function below the 5th percentile in this sample, however, could not be reliably identified by using the lower limits of normal predictions commonly used in North America and Europe.

Relationships of mortality with the fine and coarse fractions of long-term ambient PM10 concentrations in nonsmokers.

In a cohort of 6338 California Seventh-day Adventists, we previously observed for males associations between long-term concentrations of particulate matter (PM) with an aerodynamic diameter less than 10 microm (PM10) and 15-year mortality due to all natural causes (ANC) and lung cancer (LC) listed as underlying causes of death and due to nonmalignant respiratory disease listed as either the underlying or a contributing (CRC) cause of death. The purpose of this analysis was to determine whether these outcomes were more strongly associated with the fine (PM2.5) or the coarse (PM2.5-10) fractions of PM10. For participants who lived near an airport (n=3769), daily PM2.5 concentrations were estimated from airport visibility, and on a monthly basis, PM2.5-10 concentrations were calculated as the differences between PM10 and PM2.5. Associations between ANC, CRC, and LC mortality (1977-1992) and mean PM10, PM2.5, and PM2.5-10 concentrations at study baseline (1973-1977) were assessed using Cox proportional hazards models. Magnitudes of the PM10 associations for the males of this subgroup were similar to those for the males in the entire cohort although not statistically significant due to the smaller numbers. In single-pollutant models, for an interquartile range (IQR) increase in PM10 (29.5 microg/m3), the rate ratios (RRs) and 95% confidence intervals (CI) were 1.15 (0.94, 1.41) for ANC, 1.48 (0.93, 2.34) for CRC, and 1.84 (0.59, 5.67) for LC. For an IQR increase in PM2.5 (24.3 microg/m3), corresponding RRs (95% CI) were 1.22 (0.95, 1.58), 1.64 (0.93, 2.90), and 2.23 (0.56, 8.94), and for an IQR increase in PM2.5-10 (9.7 microg/m3), corresponding RRs (95% CI) were 1.05 (0.92, 1.20), 1.19 (0.88, 1.62), and 1.25 (0.63, 2.49), respectively. When both PM25 and PM2.5-10 were entered into the same model, the PM2.5 estimates remained stable while those of PM2.5-10 decreased. We concluded that previously observed associations of long-term ambient PM10 concentration with mortality for males were best explained by a relationship of mortality with the fine fraction of PM10 rather than with the coarse fraction of PM10.

A statistical model for FEV1 response to arbitrary dynamic ozone exposure conditions.

Lung function response to inhaled ozone at ambient air pollution levels is known to be a function of ozone concentration, exposure duration, and minute ventilation. Most data-driven exposure-response models address exposures under static condition (i.e., with a constant ozone concentration and exercise pattern). Such models are simplifications, as both ambient ozone concentrations and normal human activity patterns change with time. The purpose of this study was to develop a dynamic model of response with the advantages of a statistical model (a relatively simple structure with few parameters). A previously proposed mechanistic model for changes in specific airways resistance was adapted to describe the percent change in forced expiratory volume in one second (FEV1). This model was then reduced using the fit to three existing exposure-response data sets as criterion. The resulting model consists of a single linear differential equation together with an algebraic logistic equation. Under restricted static conditions the model reduces to a logistic model presented earlier by the authors.

Individual variability in human lung function responses to ozone exposure.

Ozone is a common photochemical air pollutant which is present in the ambient air of many urban areas at concentrations sufficient to produce acute respiratory effects in humans. Because individuals vary considerably in the magnitude of their responses to ozone exposure, it is difficult to estimate the number of individuals in a given population who are experiencing adverse effects. Consequently risk and benefits analysis for various regulatory scenarios cannot be carried out with precision. As an aid to risk assessment this paper presents a method of predicting the proportion of individuals in the population who experience a particular health effect. Risk equations predicting the proportion of individuals experiencing lung function decrements as a function of ozone concentration, duration of exposure, and age are presented.

Effects of age, socioeconomic status, and menstrual cycle on pulmonary response to ozone.

The purpose of this study was to investigate the effects of age, socioeconomic status, and menstrual cycle phase on the pulmonary response to ozone exposure. Three hundred seventy-two healthy white and black young adults, between the ages of 18 and 35 y, were exposed only once to 0.0, 0.12, 0.18, 0.24, 0.30, or 0.40 ppm ozone for 2.3 h. Prior to and after exposure, pulmonary function tests were obtained. Prior to exposure, each subject completed a personal and family-history questionnaire. The responses to this questionnaire were used to investigate age, socioeconomic status, and menstrual cycle phase effects on pulmonary responsiveness to ozone. We concluded that the ages of subjects, within the age range studied, had an effect on responsiveness (i.e., decrements in forced expiratory volume in 1 s decreased as the subjects' ages decreased). Socioeconomic status, as reflected by education of fathers, also appeared to affect forced expiratory volume in 1-s responsiveness to ozone, with the middle socioeconomic group being the most responsive. The phase of menstrual cycle did not have an impact on individual responsiveness to ozone.

Relationship between acute ozone responsiveness and chronic loss of lung function in residents of a high-ozone community.

We hypothesized that acute respiratory responsiveness to ozone predicts chronic lung injury from repeated exposure to ozone-containing air pollution. We tested this hypothesis in 164 middle-aged nonsmoking residents of an ozone-polluted community who underwent lung-function measurements during 1986 and 1987 (i.e., time 3). The time-3 study was a follow up of more comprehensive studies conducted in 1977-1978 (time 1) and in 1982-1983 (time 2). In contrast to the apparent rapid (i.e., approximately 60 ml/y) decline in lung-function measurements between times 1 and 2, our subjects showed little change in forced vital capacity (FVC) or forced expired volume in 1 s (FEV1.0) between times 2 and 3, and they experienced a normal decline between times 1 and 3. A subgroup (n = 45) underwent 2-h laboratory ozone exposures to 0.4 ppm ozone, accompanied by intermittent exercise, and they experienced mild acute reductions in FEV1.0 and FVC, but there was little change in bronchial responsiveness to methacholine. Individual acute responses to laboratory ozone were not correlated with individual long-term changes between times 1 and 3. In summary, the results did not support our initial hypothesis, and they did not confirm rapid function decline in nonsmokers chronically exposed to ozone-containing air pollution.

Respiratory response of humans exposed to low levels of ozone for 6.6 hours.

Recent evidence suggests that prolonged exposures of exercising men to 0.08 ppm ozone (O3) result in significant decrements in lung function, induction of respiratory symptoms, and increases in nonspecific airway reactivity. The purpose of this study was to confirm or refute these findings by exposing 38 healthy young men to 0.08 ppm O3 for 6.6 h. During exposure, subjects performed exercise for a total of 5 h, which required a minute ventilation of 40 l/min. Significant O3-induced decrements were observed for forced vital capacity (FVC, -0.25 l), forced expiratory volume in 1 s (FEV1.0, -0.35 l), and mean expiratory flow rate between 25% and 75% of FVC (FEF25-75, -0.57 l/s), and significant increases were observed in airway reactivity (35%), specific airway resistance (0.77 cm H2O/s), and respiratory symptoms. These results essentially confirm previous findings. A large range in individual responses was noted (e.g., percentage change in FEV1.0; 4% increase to 38% decrease). Responses also appeared to be nonlinear in time under these experimental conditions.

Relationships between lung function and physical characteristics in young adult black and white males and females.

The relationships of lung function to physical characteristics in young adults have not been adequately described for different gender-race groups in the United States. As part of a study of the effects of ozone exposure upon Black and White men and women, we measured lung volumes, expiratory flow rates, and airways resistance on a sample of 314 healthy 18-35 yr old nonsmokers. Regression analysis indicated that lung function was adequately described as a linear function of either height or sitting height in each of the four groups, and that while not always significant, gender and race differences in the height and sitting height coefficients were consistently present with those of males and Whites larger than those of females and Blacks, respectively. Lung volumes were frequently observed to be associated with body mass index as measured by Quetelet Index (weight.height.2). The best fitting gender-race specific multiple regression models including these terms and occasional age terms are presented. Two additional models are presented, one of which simultaneously adjusts for both gender and race, and the other of which adjusts for gender for a given race. Comparison of predicted values from our study to those of other studies suggests that the population samples from this study may be similar to those of other American populations reported upon by others.

The relationship between delivered ozone dose and functional responses in humans.

The relationship between delivered ozone dose and variability of pulmonary function response to ozone was investigated in 20 young, healthy, nonsmoking male volunteers. The subjects were exposed to 0.4 ppm ozone for 1 hr during which time they walked on a treadmill at a speed and inclination sufficient to induce a minute ventilation (VE) of 20 liter/min/m2 body surface area. Prior to and immediately following exposure spirometric and plethysmographic measurements of lung function were made. In addition, 5 min after the beginning of exposure and 5 min before the end of exposure the uptake efficiency of ozone in the upper and lower respiratory tract, spontaneous tidal volume (Vt), and breathing frequency (f) were measured. During exposure subjects wore a noseclip in order to constrain breathing to the oral pathway. Uptake efficiencies in the upper (FURT) and lower (FLRT) respiratory tracts were determined by continuously drawing air from the posterior pharynx into a rapidly responding chemiluminescent ozone analyzer. Linear regression models were constructed to examine the relationships between pulmonary function and breathing pattern responses, and the instantaneous and average values of FLRT and VE. Initial VE and average VE (VE) were found to be significant predictors of FEV1 decrement (p = 0.011 and p = 0.006, respectively). In addition the cross-product term FLRT x VE was a significant predictor of Vt decrement (p = 0.02). These results suggest that delivered dose, as determined primarily by VE, is responsible for some of the intersubject variability of ozone response. The failure of FLRT to play a significant role may be due to the fact that it primarily reflects ozone uptake in the lung periphery distal to anatomical sites where the ozone response may be mediated.

Tolerance to methacholine inhalation challenge in nonasthmatic subjects.

Airway responses to inhalation challenge with methacholine in healthy nonasthmatic subjects were examined to determine whether attenuation of response occurred upon repeated challenge. In one experiment, progressively increasing tolerance to multiple-dose challenges was seen with 4 challenges at 4-h intervals. In another study, a smaller degree of tolerance was also seen when a single-dose challenge was conducted 3 times at 24-h intervals. In these studies, the doses of methacholine used to obtain responses in nonasthmatic subjects were higher than are required under conditions of clinical methacholine challenge as a diagnostic test for asthma. Consequently, these findings may be relevant only to investigations or epidemiologic studies in which serial methacholine challenges are performed at intervals of 24 h or less in nonasthmatic subjects requiring higher cumulative doses of methacholine than do asthmatics.

U.S. Environmental Protection Agency's Ozone Epidemiology Research Program: a strategy for assessing the effects of ambient ozone exposure upon morbidity in exposed populations.

The Clean Air Act Amendments of 1990 mandate a future reduction of ambient ozone levels in many areas of the country, the cost of which will be great. In order to assess the current public health burden of ambient ozone exposure and to provide information for assessment of potential health benefits of improved air quality, the Health Effects Research Laboratory of the U.S. EPA has undertaken an Ozone Epidemiology Research Program. The research strategy which will guide this scientific program is described in this paper. Criteria for selection of important research questions as well as issues which cut across all questions and study designs are discussed. In particular, this program emphasizes the study of effects which reflect morbidity in the population. The three questions identified as being of most immediate importance involve the relationship of short-term ambient ozone exposure to acute respiratory illness, the relationship of recurrent exposure to chronic respiratory disease, and the relationship of recurrent exposure to development of acute respiratory illness. Specific research approaches and initial projects to address these three questions are described.

Apolipoprotein A-II content of human plasma high density lipoproteins measured by radioimmunoassay.

A double antibody radioimmunoassay for human ApoA-II is reported. ApoA-II isolated from human plasma high density lipoprotein (HDL) by column chromatography migrated as a single band on polyacrylamide disc gel electrophoresis, had the appropriate amino acid composition, and provoked the production of monospecific antisera. (125)I-ApoA-II (iodinated by lactoperoxidase, purified by Sephadex G-75 chromatography) migrated with "cold" ApoA-II as a single band on disc gel electrophoresis in SDS. Its specific radioactivity was 5-12 mCi/ micro g. In assays, (0.05 M barbital buffer, 0.01% Triton X-100, pH 8.6) over 90% of (125)I-ApoA-II was bound by excess first antibody and over 95% was displaced by excess "cold" ApoA-II. Low density lipoprotein, very low density lipoprotein, ApoA-I, ApoC-II, and ApoC-III displaced no counts. Intraassay and interassay coefficients of variation for lipoprotein or plasma samples were 7 +/- 4 and 11 +/- 6%, respectively. As little as 1.0 ng of ApoA-II was detectable with a precision of 10%. ApoA-II made up 20-25% of the proteins of HDL (d 1.083-1.19), HDL(2) (d 1.083-1.124), and HDL(3) (d 1.124-1.19) on column chromatography. The ApoA-II contents of these HDL fractions were also 20-25% by radioimmunoassay. Similar results were obtained whether assays were carried out on intact or delipidated HDL samples. Thus, in contrast with ApoA-I (only 10% of which is detectable), all of the ApoA-II contents of intact HDL are detected with accuracy by this assay. Plasma levels of ApoA-II in young normolipemic subjects were approximately 40 mg/dl (n = 29). In these subjects, over 98% of ApoA-II was found in the d 1.063-1.21 density fractions.

Predictors of individual differences in acute response to ozone exposure.

The purpose of this study was to identify personal characteristics that predict individual differences in acute FEV1 response to ozone exposure. Response and predictor data were collected on 290 white male volunteers 18 to 32 yr of age who were each exposed to one of six concentrations of ozone between 0.0 and 0.40 part per million. The sample was divided into an exploratory sample of 96 and a confirmatory sample of 194 subjects. Exploratory analysis indicated that ozone, age, and several other variables explained a significant proportion of the variance in response. In the confirmatory sample, only age and ozone concentration predicted FEV1 decrement. For the combined sample ozone explained 31% of the variance, with age accounting for an additional 4%. The model predicted a decreasing response with increasing age for all nonzero ozone concentrations. For exposure to 0.40 ppm, the model predicts decrements in FEV1 of 1.07 and 0.47 L for 18- and 30-yr-old subjects, respectively. We concluded that for white male subjects age was a significant predictor of response, with older subjects being less responsive to ozone. Furthermore, we demonstrated that exploratory analysis without control of type I statistical error rates may result in apparent findings that cannot be replicated.

An air quality data analysis system for interrelating effects, standards, and needed source reductions: Part 11. A lognormal model relating human lung function decrease to O3 exposure.

Forced expiratory volume in 1 second (FEV1) was measured in 21 men exercising while exposed to four O3 concentrations (0.0, 0.08, 0.10, and 0.12 ppm). A lognormal multiple linear regression model was fitted to their mean FEV1 measurements to predict FEV1 percent decrease as a function of O3 concentration and exposure duration. The exercise level used was probably comparable to heavy manual labor. The longest O3 exposure studied was 6 h. Extrapolating cautiously to an 8-h workday of heavy manual labor, the model predicts that O3 concentrations of 0.08, 0.10, and 0.12 ppm would decrease FEV1 by 9, 15, and 20 percent, respectively.