Greenhouse gas emissions associated with suboptimal asthma care in the UK: the SABINA healthCARe-Based envirONmental cost of treatment (CARBON) study.

BACKGROUND: Poorly controlled asthma is associated with increased morbidity and healthcare resource utilisation (HCRU). Therefore, to quantify the environmental impact of asthma care, this retrospective, cohort, healthCARe-Based envirONmental cost of treatment (CARBON) study estimated greenhouse gas (GHG) emissions in the UK associated with the management of well-controlled versus poorly controlled asthma. METHODS: Patients with current asthma (aged ≥12 years) registered with the Clinical Practice Research Datalink (2008‒2019) were included. GHG emissions, measured as carbon dioxide equivalent (CO2e), were estimated for asthma-related medication use, HCRU and exacerbations during follow-up of patients with asthma classified at baseline as well-controlled (<3 short-acting ß2-agonist (SABA) canisters/year and no exacerbations) or poorly controlled (≥3 SABA canisters/year or ≥1 exacerbation). Excess GHG emissions due to suboptimal asthma control included ≥3 SABA canister prescriptions/year, exacerbations and any general practitioner and outpatient visits within 10 days of hospitalisation or an emergency department visit. RESULTS: Of the 236 506 patients analysed, 47.3% had poorly controlled asthma at baseline. Scaled to the national level, the overall carbon footprint of asthma care in the UK was 750 540 tonnes CO2e/year, with poorly controlled asthma contributing excess GHG emissions of 303 874 tonnes CO2e/year, which is equivalent to emissions from >124 000 houses in the UK. Poorly controlled versus well-controlled asthma generated 3.1-fold higher overall and 8.1-fold higher excess per capita carbon footprint, largely SABA-induced, with smaller contributions from HCRU. CONCLUSIONS: These findings suggest that addressing the high burden of poorly controlled asthma, including curbing high SABA use and its associated risk of exacerbations, may significantly alleviate asthma care-related carbon emissions.

Greenhouse Gas Emissions from Respiratory Treatments: Results from the SABA CARBON International Study.

INTRODUCTION: Healthcare systems are looking to reduce their carbon impact. Short-acting ß2-agonist (SABA) overuse (≥ 3 canisters/year) is common in asthma and linked to poor outcomes; however, its environmental impact remains unknown. As part of the CARBON programme, this study retrospectively quantified the carbon footprint of SABA and controller inhalers across all respiratory indications and SABA overuse in asthma in lower-middle-income countries (LMICs), upper-middle-income countries and high-income countries across Africa, Asia Pacific, Latin America and the Middle East. METHODS: Two data sources were utilised to evaluate the carbon contribution of inhalers to respiratory care. To quantify greenhouse gas (GHG) emissions associated with total inhaler use across all respiratory indications, inhaler sales data were obtained from IQVIA MIDAS® (Q4/2018-Q3/2019) and compared by dose to prevent confounding from differences in canister actuation counts. GHG emissions associated with SABA overuse in asthma were evaluated using prescription and self-reported over-the-counter purchase data from the SABA use IN Asthma (SABINA) III study (2019-2020). Inhaler-related GHG emissions were quantified using published data and product life cycle assessments. RESULTS: SABA accounted for > 50% of total inhaler use and inhaler-related emissions in most countries analysed. The total SABA-related emissions were estimated at 2.7 million tonnes carbon dioxide equivalents, accounting for 70% of total inhaler-related emissions. Among the countries, regions and economies analysed, per capita SABA use and associated emissions were higher in Australia, the Middle East and high-income countries. Most SABA prescriptions for asthma (> 90%) were given to patients already overusing SABA. CONCLUSIONS: Globally, SABA use/overuse is widespread and is the greatest contributor to the carbon footprint of respiratory treatment, regardless of the economic status of countries. Implementing evidence-based treatment recommendations, personalising treatment and reducing healthcare inequities, especially in LMICs, may improve disease control and patient outcomes, thereby reducing SABA overuse and associated carbon emissions beyond SABA use alone.

The healthcare sector is a large emitter of greenhouse gases (GHGs); therefore, healthcare systems will need to reduce their carbon footprint to meet their carbon reduction targets. In respiratory care, the environmental impact of controller inhalers has received considerable attention due to the global warming potential of the propellants used in metered-dose inhalers. In contrast, little is known about the contribution made by short-acting ß₂-agonist (SABA) relievers globally, which are often the only inhaled medication used by many patients with milder asthma. The SABA use IN Asthma (SABINA) programme reported that SABA overuse (3 or more SABA canisters/year) is common and associated with an increased risk of asthma attacks. Since all inhalers have a carbon footprint, SABA overuse may result in an avoidable excess carbon footprint. Therefore, to provide a complete picture of the carbon footprint of respiratory care, we examined the contribution of SABA relievers and their potential overuse. The total SABA-related GHG emissions accounted for 70% of total inhaler-related GHG emissions, and > 90% of prescriptions for SABA relievers for asthma were given to patients who were already overusing their SABA. Overall, SABA use/overuse is commonly observed worldwide and is likely a significant contributor to the carbon footprint of respiratory treatment. Therefore, there is an urgent need for healthcare providers to follow the latest international treatment guidelines to reduce high SABA use in respiratory care and improve patient outcomes. This, in turn, will enable healthcare systems to reduce their carbon footprint from both treatment and patient interactions.

Environmental Sustainability in Respiratory Care: An Overview of the healthCARe-Based envirONmental Cost of Treatment (CARBON) Programme.

INTRODUCTION: Faced with the challenges of climate change, countries are seeking to decarbonise their economies. A greater understanding of what comprises the carbon footprint of care in healthcare systems will identify potential strategies for reduction of greenhouse gas (GHG) emissions. In respiratory care, the focus has been on preventer inhalers, thereby omitting contributions from other aspects such as healthcare resource utilisation (HCRU) and reliever inhaler use. The healthCARe-Based envirONmental cost of treatment (CARBON) programme aims to provide a broader understanding of the carbon footprint associated with respiratory care. METHODS: CARBON will quantify the carbon footprint of medications and HCRU among approximately 2.5 million patients with respiratory diseases from seven ongoing studies spanning more than 40 countries. Across studies, to obtain the carbon footprint of all inhaled, oral, and injectable medications, SimaPro life cycle assessment software modelling resource and energy consumption data, in addition to Ecoinvent® data sets and certified published studies, will be used. The carbon footprint of HCRU in the United Kingdom will be estimated by applying the methodology and data obtained from the Sustainable Healthcare Coalition Care Pathway Guidance. PLANNED OUTCOMES: In asthma, CARBON studies will quantify GHG emissions associated with well-controlled versus not well-controlled asthma, the contribution of short-acting ß2-agonist (SABA) reliever inhalers (and their potential overuse) to the carbon footprint of care, and how implementation of treatment guidelines can drive improved outcomes and footprint reduction. In chronic obstructive pulmonary disease (COPD), CARBON studies will assess the impact of exacerbation history on GHG emissions associated with HCRU and SABA use in subsequent years and estimate the carbon footprint associated with all aspects of COPD care. CONCLUSION: CARBON aims to show that the principle of evidence-led care focused on improvement of clinical outcomes has the potential to benefit patients and the environment.

Comprehensive review of several surfactants in marine environments: Fate and ecotoxicity.

Surfactants are a commercially important group of chemicals widely used on a global scale. Despite high removal efficiencies during wastewater treatment, their high consumption volumes mean that a certain fraction will always enter aquatic ecosystems, with marine environments being the ultimate sites of deposition. Consequently, surfactants have been detected within marine waters and sediments. However, aquatic environmental studies have mostly focused on the freshwater environment, and marine studies are considerably underrepresented by comparison. The present review aims to provide a summary of current marine environmental fate (monitoring, biodegradation, and bioconcentration) and effects data of 5 key surfactant groups: linear alkylbenzene sulfonates, alcohol ethoxysulfates, alkyl sulfates, alcohol ethoxylates, and ditallow dimethyl ammonium chloride. Monitoring data are currently limited, especially for alcohol ethoxysulfates and alkyl sulfates. Biodegradation was shown to be considerably slower under marine conditions, whereas ecotoxicity studies suggest that marine species are approximately equally as sensitive to these surfactants as freshwater species. Marine bioconcentration studies are almost nonexistent. Current gaps within the literature are presented, thereby highlighting research areas where additional marine studies should focus.