Public health impacts of city policies to reduce climate change: findings from the URGENCHE EU-China project.

BACKGROUND: Climate change is a global threat to health and wellbeing. Here we provide findings of an international research project investigating the health and wellbeing impacts of policies to reduce greenhouse gas emissions in urban environments. METHODS: Five European and two Chinese city authorities and partner academic organisations formed the project consortium. The methodology involved modelling the impact of adopted urban climate-change mitigation transport, buildings and energy policy scenarios, usually for the year 2020 and comparing them with business as usual (BAU) scenarios (where policies had not been adopted). Carbon dioxide emissions, health impacting exposures (air pollution, noise and physical activity), health (cardiovascular, respiratory, cancer and leukaemia) and wellbeing (including noise related wellbeing, overall wellbeing, economic wellbeing and inequalities) were modelled. The scenarios were developed from corresponding known levels in 2010 and pre-existing exposure response functions. Additionally there were literature reviews, three longitudinal observational studies and two cross sectional surveys. RESULTS: There are four key findings. Firstly introduction of electric cars may confer some small health benefits but it would be unwise for a city to invest in electric vehicles unless their power generation fuel mix generates fewer emissions than petrol and diesel. Second, adopting policies to reduce private car use may have benefits for carbon dioxide reduction and positive health impacts through reduced noise and increased physical activity. Third, the benefits of carbon dioxide reduction from increasing housing efficiency are likely to be minor and co-benefits for health and wellbeing are dependent on good air exchange. Fourthly, although heating dwellings by in-home biomass burning may reduce carbon dioxide emissions, consequences for health and wellbeing were negative with the technology in use in the cities studied. CONCLUSIONS: The climate-change reduction policies reduced CO2 emissions (the most common greenhouse gas) from cities but impact on global emissions of CO2 would be more limited due to some displacement of emissions. The health and wellbeing impacts varied and were often limited reflecting existing relatively high quality of life and environmental standards in most of the participating cities; the greatest potential for future health benefit occurs in less developed or developing countries.

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).

A graphical tool to evaluate temporal coverage of occupational history by exposure measurements.

INTRODUCTION: In occupational epidemiology, differences in the temporal coverage of the exposure history by available exposure measurement data may affect the uncertainty of exposure estimates. In the reporting of results of studies, greater attention should be paid to the extent to which exposure assessments require extrapolation outside the timeframe for which exposure measurements are available. We propose a simple graphical method that can be used to visualise the temporal coverage of exposure history with exposure measurements and the extent of temporal extrapolation needed. METHODS: We construct a graph that displays the accumulated work history years for which exposure had to be assessed in each calendar year. Years for which exposure measurements were available are shaded. The proportion of work history years covered by exposure measurements and the proportion of work history years accrued before the first measurements are summarised. When available, the actual number of measurements available in each calendar year is shown. RESULTS: We demonstrate the application of the graphical tool in three nested case-control studies that reported on leukaemia in relation to low-level benzene exposures in the petroleum industry. Considerable differences in temporal coverage between the studies were illustrated, which may have resulted in differences in the reliability of the retrospective exposure estimates derived for these studies. CONCLUSION: We introduce a graphical tool for visualising the temporal coverage by available exposure measurement data in epidemiological studies and encourage others to use similar graphs to derive and share better qualitative insights into the uncertainty in exposure assessment.

Health Impact Assessment of Volcanic Ash Inhalation: A Comparison With Outdoor Air Pollution Methods.

This paper critically appraises the extrapolation of concentration-response functions (CRFs) for fine and coarse particulate matter, PM2.5 and PM10, respectively, used in outdoor air pollution health impact assessment (HIA) studies to assess the extent of health impacts in communities exposed to volcanic emissions. Treating volcanic ash as PM, we (1) consider existing models for HIA for general outdoor PM, (2) identify documented health effects from exposure to ash in volcanic eruptions, (3) discuss potential issues of applying CRFs based on the composition and concentration of ash-related PM, and (4) critically review available case studies of volcanic exposure scenarios utilizing HIA for outdoor air pollution. We identify a number of small-scale studies focusing on populations exposed to volcanic ash; exposure is rarely quantified, and there is limited evidence concerning the health effects of PM from volcanic eruptions. That limited evidence is, however, consistent with the CRFs typically used for outdoor air pollution HIA. Two health assessments of exposure to volcanic emissions have been published using population- and occupational-based CRFs, though each application entails distinct assumptions and limitations. We conclude that the best available strategy, at present, is to apply outdoor air pollution risk estimates to scenarios involving volcanic ash emissions for the purposes of HIA. However, due to the knowledge gaps on, for example, the health effects from exposure to volcanic ash and differences in ash composition, there is inherent uncertainty in this application. To conclude, we suggest actions to enable better prediction and assessment of health impacts of volcanic emissions.

Meeting report: atmospheric pollution and human reproduction.

BACKGROUND: There is a growing body of epidemiologic literature reporting associations between atmospheric pollutants and reproductive outcomes, particularly birth weight and gestational duration. OBJECTIVES: The objectives of our international workshop were to discuss the current evidence, to identify the strengths and weaknesses of published epidemiologic studies, and to suggest future directions for research. DISCUSSION: Participants identified promising exposure assessment tools, including exposure models with fine spatial and temporal resolution that take into account time-activity patterns. More knowledge on factors correlated with exposure to air pollution, such as other environmental pollutants with similar temporal variations, and assessment of nutritional factors possibly influencing birth outcomes would help evaluate importance of residual confounding. Participants proposed a list of points to report in future publications on this topic to facilitate research syntheses. Nested case-control studies analyzed using two-phase statistical techniques and development of cohorts with extensive information on pregnancy behaviors and biological samples are promising study designs. Issues related to the identification of critical exposure windows and potential biological mechanisms through which air pollutants may lead to intrauterine growth restriction and premature birth were reviewed. CONCLUSIONS: To make progress, this research field needs input from toxicology, exposure assessment, and clinical research, especially to aid in the identification and exposure assessment of feto-toxic agents in ambient air, in the development of early markers of adverse reproductive outcomes, and of relevant biological pathways. In particular, additional research using animal models would help better delineate the biological mechanisms underpinning the associations reported in human studies.

Assessing the unintended health impacts of road transport policies and interventions: translating research evidence for use in policy and practice.

BACKGROUND: Transport and its links to health and health inequalities suggest that it is important to assess both the direct and unintended indirect health and related impacts of transport initiatives and policies. Health Impact Assessment (HIA) provides a framework to assess the possible health impacts of interventions such as transport. Policymakers and practitioners need access to well conducted research syntheses if research evidence is to be used to inform these assessments. The predictive validity of HIA depends heavily on the use and careful interpretation of supporting empirical evidence. Reviewing and digesting the vast volume and diversity of evidence in a field such as transport is likely to be beyond the scope of most HIAs. Collaborations between HIA practitioners and specialist reviewers to develop syntheses of best available evidence applied specifically to HIA could promote the use of evidence in practice. METHODS: Best available research evidence was synthesised using the principles of systematic review. The synthesis was developed to reflect the needs of HIA practitioners and policymakers. RESULTS: Aside from injury reduction measures, there is very little empirical data on the impact of road transport interventions. The possibility of impacts on a diverse range of outcomes and differential impacts across groups, make it difficult to assess overall benefit and harm. In addition, multiple mediating factors in the pathways between transport and hypothesised health impacts further complicate prospective assessment of impacts. Informed by the synthesis, a framework of questions was developed to help HIA practitioners identify the key questions which need to be considered in transport HIA. CONCLUSION: Principles of systematic review are valuable in producing syntheses of best available evidence for use in HIA practice. Assessment of the health impacts of transport interventions is characterised by much uncertainty, competing values, and differential or conflicting impacts for different population groups at a local or wider level. These are issues pertinent to the value of HIA generally. While uncertainty needs explicit acknowledgement in HIA, there is still scope for best available evidence to inform the development of healthy public policy.

A Systematic Review of the Routes and Forms of Exposure to Engineered Nanomaterials.

Background: Establishing the routes of exposure is a fundamental component of the risk assessment process for every dangerous substance. The present study systematically reviews the available literature to assess the relevance of the different routes and forms of exposure that are of concern for the protection of workers during the manufacture, handling, or end-use of engineered nanomaterials (ENMs). Methods: A systematic review of the peer-reviewed literature published between 2000 and 2015 was completed. Only studies including measurements of inhalation or dermal exposure were selected and used to identify the exposure situations for which the measurements were collected. The identified exposure situations were grouped based on the type of ENM (i.e. carbon nanotubes and fibres, silicon-based, titanium dioxide, other metal oxides, pure elemental metals, and other ENMs) and activity involved. The grouped exposure situations were assessed to provide a conclusion regarding the likelihood, form, and route of exposure. Assessment of the likelihood of exposure was based on well-defined criteria using a previously established decision logic for inhalation exposure and the outputs from measurements and/or conceptual models for dermal/ingestion exposure. For each combination of nano-activity and type of ENM, the aggregated likelihood across all relevant individual assessments was used to draw conclusions about the relevance of both the inhalation and dermal/ingestion routes. Based on the quality of the data, the strength of the evidence was also evaluated. Results: One hundred and seven studies were identified during the review process, reporting 424 individual exposure assessments. Measurement data were limited for dermal/ingestion exposure and for inhalation exposure for downstream use and end-of-life. However, the data provided high-quality evidence that in occupational settings all three routes can be of relevance for exposure to ENMs. In general, whenever inhalation exposure occurs then dermal and inadvertent ingestion exposure may occur due to surface deposition and transfer due to the ENMs release. However, for some forms of exposure (e.g. suspension/liquids), dermal exposure can occur even when inhalation exposure is unlikely. An increased likelihood of exposure was observed for manual activities such as cleaning and maintenance, collection/harvesting, spraying, and finishing as well as those involving feeding into a process and handling of powders outside enclosures. The likelihood of exposure was affected by the presence of risk management measures and the scale of the production involved. Conclusion: This literature review provides evidence that for ENMs, as found for other materials, the likelihood of the exposure depends largely on the physical form of the substance as well as the applied process and operational conditions. These results can be used to provide first indications of the likelihood of exposure and guidance for exposure controls in workplaces. However, there is a clear lack of high-quality exposure data, in particular for downstream use and end-of-life scenarios and in low- and medium-income countries.

Improving policy responses to the risk of air pollution.

This paper offers a brief review of the need for cost-benefit analysis (CBA) and the available policy instruments for air pollution. To prioritize different possible actions, one needs to know which source of pollution causes how much damage. This requires an impact pathway analysis, that is, an analysis of the chain emission --> dispersion --> dose-response function --> monetary valuation. The methodology for this is described and illustrated with the results of the ExternE (External Costs of Energy) project series of the European Commission. Two examples of an application to CBA are shown: one where a proposed reduction of emission limits is justified, and one where it is not. It is advisable to subject any proposed regulation to a CBA, including an analysis of the uncertainties. Even if the uncertainties are large and a policy decision may have to take other considerations into account, a well-documented CBA clarifies the issues and provides a basis for rational discussion. One of the main sources of uncertainty lies in the monetary valuation of premature mortality, the dominant contribution to the damage cost of air pollution. As an alternative, an innovative policy tool is described, the Life Quality Index (LQI), a compound indicator comprising societal wealth and life expectancy. It is applied to the Canada-wide standards for particulate matter and ozone. Regardless of monetary valuation, a 50% reduction of PM10 concentrations in Europe and North America has been shown to yield a population-average life expectancy increase on the order of 4 to 5 mo.

Covert observation in practice: lessons from the evaluation of the prohibition of smoking in public places in Scotland.

BACKGROUND: A ban on smoking in wholly or substantially enclosed public places has been in place in Scotland since 26th March 2006. The impact of this legislation is currently being evaluated in seven studies, three of which involve direct observation of smoking in bars and other enclosed public places. While the ethical issues around covert observation have been widely discussed there is little practical guidance on the conduct of such research. A workshop was therefore convened to identify practical lessons learned so far from the Scottish evaluation. METHODS: We convened a workshop involving researchers from the three studies which used direct observation. In addition, one of the fieldwork managers collected written feedback on the fieldwork, identifying problems that arose in the field and some solutions. RESULTS: There were four main themes identified: (i) the difficulty of achieving and maintaining concealment; (ii) the experience of being an observer; (iii) the risk of bias in the observations and (iv) issues around training and recruitment. These are discussed. CONCLUSION: Collecting covert observational data poses unique practical challenges, in particular in relation to the health and safety of the researcher. The findings and solutions presented in this paper will be of value to researchers designing similar studies.

Quantifying the health impacts of ambient air pollutants: recommendations of a WHO/Europe project.

OBJECTIVE: Quantitative estimates of air pollution health impacts have become an increasingly critical input to policy decisions. The WHO project "Health risks of air pollution in Europe--HRAPIE" was implemented to provide the evidence-based concentration-response functions for quantifying air pollution health impacts to support the 2013 revision of the air quality policy for the European Union (EU). METHODS: A group of experts convened by WHO Regional Office for Europe reviewed the accumulated primary research evidence together with some commissioned reviews and recommended concentration-response functions for air pollutant-health outcome pairs for which there was sufficient evidence for a causal association. RESULTS: The concentration-response functions link several indicators of mortality and morbidity with short- and long-term exposure to particulate matter, ozone and nitrogen dioxide. The project also provides guidance on the use of these functions and associated baseline health information in the cost-benefit analysis. CONCLUSIONS: The project results provide the scientific basis for formulating policy actions to improve air quality and thereby reduce the burden of disease associated with air pollution in Europe.

Quantitative health impact assessment: taking stock and moving forward.

Over the past years, application of health impact assessment has increased substantially, and there has been a strong growth of tools that allow quantification of health impacts for a range of health relevant policies. We review these developments, and conclude that further tool development is no longer a main priority, although several aspects need to be further developed, such as methods to assess impacts on health inequalities and to assess uncertainties. The main new challenges are, first, to conduct a comparative evaluation of different tools, and, second, to ensure the maintenance and continued availability of the toolkits including their data contents.

Apheis: Health impact assessment of long-term exposure to PM(2.5) in 23 European cities.

INTRODUCTION: Apheis aims to provide European decision makers, environmental-health professionals and the general public with up-to-date and easy-to-use information on air pollution (AP) and public health (PH). In the Apheis-3 phase we quantified the PH impact of long-term exposure to PM(2.5) (particulate matter < 2.5 microm) in terms of attributable number of deaths and the potential gain in life expectancy in 23 European cities. METHODS: We followed the World Health Organization (WHO) methodology for Health Impact Assessment (HIA) and the Apheis guidelines for data collection and analysis. We used the programme created by PSAS-9 for attributable-cases calculations and the WHO software AirQ to estimate the potential gain in life expectancy. For most cities, PM(2.5) levels were calculated from PM10 measurements using a local or European conversion factor. RESULTS: The HIA estimated that 16,926 premature deaths from all causes, including 11,612 cardiopulmonary deaths and 1901 lung-cancer deaths, could be prevented annually if long-term exposure to PM(2.5 )levels were reduced to 15 microg/m3 in each city. Equivalently, this reduction would increase life expectancy at age 30 by a range between one month and more than two years in the Apheis cities. CONCLUSIONS: In addition to the number of attributable cases, our HIA has estimated the potential gain in life expectancy for long-term exposure to fine particles, contributing to a better quantification of the impact of AP on PH in Europe.