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CLEAN AIR IN EUROPE Life after WHO 2021 AQG - What does science tell us? •••••• ::: ::: ••• •••

ERS

24* May, 2023

Zorana Jovanovic Andersen, Chair of the European Respiratory Society (ERS) Environment and Health Committee; Professor in Environmental Epidemiology, Department of Public Health, University of Copenhagen, Denmark

WHO 2021AQG - main messages and beyond

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WHO AIR QtlALITY GUIDELINES -----r NO2

2005: 40 pg/m^ annual

2021: 10 pgAn^iHHinual

2005: 10 pg/m’, annual PM2.S

1021: 5 pg/m’.lnnual

1. Everyone is exposed - no lower threshold

# ERS

1. Everyone in Europe is exposed to harmful levels of air pollution (97.5% European population) 2. No lower threshold below which air pollution is safe 2.2-

325367 people 6 EU countries .OCH , ELAPSE DNC

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1,0

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0

5

10

15

20

25

30

PM2.5 (Mg/m3) Source; file:///C:/Users/vlq961/Downloads/ETC%20HE%20report%202022-3_status_eionet_mix_2021_2022-03-31_FINAL-2.pdf

2. Air pollution burden is huge, increasing & underestimated

EPS

EEA WHO 2005 AQG (Hoek et al. 2013): 6.2%*

2019:307,000 deaths attributed to PM 2.5

WHO 2021 AQG (Chen & Hoek 2020): 8.0% “

Global >

2020:412,000 deaths attributed to PM 2.5

238,000 deaths > 5 (ig/m^ PM 2.5

1. ELAPSE (after WHO 2021 AQG): 11.8% Author and year

HR [95% Cl] per 10 pg/m’

Area

EU

2. Stronger effects at low levels?

Chen & Hoek 2020 (WHO Systematic review)

1.030 [1.060,1.090)

ELAPSE pooled estimates (Figure 1)

1.118 [1.060,1.179)

Other European Studies published after Chen & Hoek 2020

2.2'I

20-

New WHO AQG

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~ cn 1.6-

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Netherlands

1.172 [1.138,1.195)

Hvidtfeldt 2019

Copenhagen B Aarhus, Denmark

1.277 [1.103,1.464)

Nieuwenhuijsen 2018

Barcelona, Spain

1.061 [0.930,1.124]

Raachou-Nielsen 2020

Denmark

1.080 [1.040,1.130]

So 2020

Denmark

1.142 [1.023, 1.242]

So 2022

Denmark

1.232 [1.180,1.270]

Sommar 2021

UmeS, Sweden

1.082 [0.372,3.168]

Sommar 2021

Stockholm, Sweden

1.638 [1.000, 2.690]

OtiORA

Sommar 2021

Gothenburg, Sweden

0.656 [0.336, 1.300]

O'VHH&PP

Sommar 2021

Gothenburg, Sweden

1.613 ]1.1B8, 2,220]

Wang 2022

United Kingdom

1.270 ]1.050,1.550]

6 EU countries HLAPSE ÖNC

EU Limit Value

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: :

Fischer 2020

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15

20

25

30

PM2.5 (pgZm3) interpretation: 6.2 % increase in mortality risk for each 10 pg/m^ increase in PM 2,5

Figure 3. Total mortality and long-term PM2.5from other European studies published since the WHO

systematic review by Chen & Hoek (2020).* *Red line indicates the summary estimate from the systematic review by Chen & Hoek (2020). Range of mean PM2.S exposure ^^ji^f^^^/^'(j{i{i^^fgf^f^oi<l(^y>l^^fff^uDloads/2022/04/Statement-HIA-bv-ERS ISEE final-002.Ddf • https://iournals.lww.eom/environepidem/Fulltext/2022/10000/Benefits of future clean air policies in Europe .S.aspx

3. Air pollution and climate change inseparable issues

REDUCING AIR POLLUTION AND MITIGATING CLIMATE CHANGE, TOGETHER HELP TO PROTECT OUR HEALTH

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EXHAUSTION

WE BREATHE CLIMATE CHANGE More people will die oF lung diseases in our cities when high temperatures are combined with high levels oF air pollution. This is especially true For those of us who are 65 and older.

The good news Policies that make us less exposed to heat and air pollution will be beneficial for our health and wellbeing.

Change in number of deaths from lung diseases in European cities [%) in association with high temperatures, by different levels of air pollution [PM2.5] OVERALL ESTIMATE META-ANALY5I5 DF WB EUROPEAN CITIES

%

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Change in n" of deaths from lung diseases when we are exposed to moderate temperatures compared to:

40-

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low 2

medium 6

high

low

15

S

Rome i medium 15

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high

23

low 7

medium 12

WHO Air Quality Guidelines set goals to protect millions of lives from air pollution.

CLEAN AIR FOR HEALTH

High temperatures and medium air pollution

21

/Oi World Health V?»/ Organization

#AirPollution

Paris, February 2021

High temperatures and low air pollution

Fine

ES

Confidence interval: the estimate lies in this interval, with very high probability Moderate temperature level: in the stuc^ period 75% of the days in the city have a temperature below this level ['’Ó

Oslo 15.3

Rome 25.7

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1,..

3

Beriin 20.2

High temperature level; in the study period. 1% of the days in the city have a temperature above this level [°C)

Berlin

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High temperatures and high air pollution

Overall estimate 20.2

Low. medium and high levels of air pollutnn (fine particles PM2S pgZrtrO Overall estimate I low medium h^ 4 10 21

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50-

40

40-

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70-

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ROME

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REDUCE AIR POLLUTION

REDUCE CLIMATE CHANGE

www.exhaustion.eu

Overall esUnnate 254

Oslo 217

Rome

29B

Berlin 271

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1111

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SAHARAN ÜU&T-MOVES iN'rnniHfle.f

Health burden of air pollution Premature deaths + millions of new cases of disease, symptoms, worsened quality of life, doctor visits, ER visits, hospital admissions, sick days (school & work), medication use....

Pregnancy and birth outcomes ?■'

■"I

Offspring • Intrauterine growth restriction

- Decreased birthweight FIGURE 1

• Cancer morbidity and mortality - Lung cancer - Breast cancer - Kidney cancer - Bladder cancer ~ Liver cancer - Stomach cancer

Adults

- Brain tumors - Leukemia - Lymphomas

• All-cause mortality • Respiratory disease mortality • Respiratory disease morbidity - Asthma -COPD

• Type 2 diabetes mortality • Type 2 diabetes morbidity

- Pneumonia • Cardiovascular disease mortality

• Cardiovascular disease morbidity

!?f

- Myocardial infarction - Stroke

- Heart failure

E

• Hypertensive disorders in pregnancy ...

- Preeclampsia - Gestational hypertension • Gestational diabetes

Children outcomes

- Reduced fetal growth • Preterm birth • Congential anomalies • Spontaneous abortion • Stillbirth • Infant death

• Childhood Cancers

- Leukemia - Lymphomas

- Central nervous system cancers

V • Neurodegenrative disease morbidity - Dementia and Alzheimer’s Disease - Parkinson's disease - Multiple sclerosis

• Respiratory disease mortality

• Psychiatric diseases morbidity

- Lower respiratory infections

- Depression - Suicide

- Atrial fibrilation

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COVID-19

Mother

1

■i, • Tumors originating in embryonic tissue

• Respiratory disease morbidity

- Neuroblastoma

- Asthma and asthma related outcomes

- Retinoblastoma - Nephroblastoma .• Neurodevelopment

• Metabolic disease

- Autism

- Type 1 diabetes

-ADHD

Air Pollution and Lung (Erik)

COPD

• Long-term (years, lifetime) exposure to air pollution can lead to impaired lung function and development of new lung disease in healthy individuals and increased risk of dying from those diseases:

40®^

k Lowerrespiratory infections

https://www.stateof globalair.org/

303?

asthma, COPD, pneumonia, COVID-19, lung cancer I

• Short-term (hours, days) exposure to air pollution can exacerbate existing lung disease in lung patients and trigger:

wheezing, cough, shortness of breath, need for medication, ER visits, hospitalizations, and death

# ERS

GBDMortality specific­ causes, 'fraction attributable' to air pollution

Ella Adoo-Kissi-Debrah: Air pollution a factor in girl's death, inquest finds

1

16% asthma cases in children due to air pollution*

■1

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*Khreis H, et al.. Environ. Int. 2017 li.A iS-aWi-Ki’.L fïi-Tii-xhiSfïfrt

Ella Kissi-Debrah - 9 year old girl suffered fatal asthma attack triggered by air pollution, London, February 2013

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Ischemic heart

Bronchioles/Alveoli

3. BLOOD

PM and/or constituents transmitted into blood

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Lung receptors (TRP-A) ANS reflex arcs • CNS transport

Lung oxidative stress & inflammation

Circulating PM constituents UFP, soluble metals Organic compounds

2. SYSTEMIC INFLAMMATION “SPILL-OVER” Lung cell derived cytokines Activated cells (Toll-like, NLR)

Cells: Activated WBCs Cytokine: IL-1/6, TNF gp et-1, LT, AT-2

Circulating mediators of oxidative stress & inflammation

I

Activated-inflamed tissue niches Vascular/fat

Hypothalamus

t (adipo)cytokines tcytokines/ROS -Oxidative stress HPAA activation (NADPH oxidase) -TLR-4 activation - Rho Kinase activation - WBC homing (Ml phenotype)

Liver

Bone marrow

tcellular inflammation tacute phase t Unfolding A EPCs protein response

I

Stroke L

ACUTE PATHWAYS

26W

Oxidized: LDL, HDL HPAA: A metabolome Skeletal muscle Insulin resistance

SUB-ACUTE & CHRONIC PATHWAYS

Insulin resistance 0 Glucose (Diabetes) Obesity

ANS imbalance t SNSiPSNS t HPAA

Fat lipolysis Insulin resist

f

Vasoconstriction ‘I'BP + heart rate

/ascular dysfunction Blood pressure GBD - Mortality specific Atherosclerosis (plaque instability) Traction attributablef 4-^ https://www.stateofglobalair.org/

I

★ * *

Air pollution and cancer (Michelle)

European Commission

I •JD CANCER

★ * ★

SELAND GA; 3AND SOMB

ENGINE IRENES S^UME 105

/

EU Health Union: Europe’s Beating Cancer Plan

Strengthening Europe in the fight against cancer

fi^EUCancerPlan 3 FEBRUARY 2021

IARC SCIEIVTIFIC •uaUCAnONNO. 161

ItTtheT^uation CARCINeGENIG RISKS TO HUMANS

«IS

"in 2020, while we were all fighting against the COVlD-19 pandemic, many of as were fighting a silent battle. The battle against cancer, in 2020, we lost 1.3 million Europeans to this disease. And sadly, the number of cases is on the rise. This is why we present Europe's Beating Cancer Plan today. The fight of

Cancer causes 1 in 4 deaths in the EU (1.3 million cancer deaths in 2020)

Air pollution is carcinogenic,* causes lung cancer and possibly other (breast, liver, blood, stomach, colon) cancers

I

Lung cancer

19%3

BECA - the EU Green Deal is a key tool to limit people's exposure to (air) pollution and prevent cancer, GBD - Traction attributable' to air pollution https://www.stateofglobalair.org/

*

International Agency for Research on Cancer (lARC) 'Air Pollution and Cancer' 2013

Cutting pollution through the EU's Zero Pollution Action Plan and the Chemical Strategy for Sustainability as well as strong implementation of other existing EU policies would go a long way to reduce cancer cases and deaths. This would be an effective investment in our citizen's well-being. Hans Bruyninckx, EEA Executive Director

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•

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NEWS

•

Exposure to pollution causes 10% of all cancer cases in Europe Exposure to air poiiution, second-hand smoke, radon, ultraviolet radiation, asbestos, certain chemicals and other pollutants causes over 10% of ail cancer cases in Europe, according to a European Environment Agency (EEA) report published today. The good news is that these risks are preventable.

I

Emerging issues: air pollution and the brain (Barbara)

ERS IS

•

Impaired neurocognitive development in children (learning difficulties, loss of IQ, ADHD, autism)

•

Accelerated cognitive decline (dementia) elderly

•

Mental health (suicide, depression, anxiety)

I

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OLFACTORY NERVE Inhaled particles travel through Ulis nerve into the brain, bypassing die lungs

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Cognitive function MCI

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Adulthood

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Everyone is exposed - some are more vulnerable Children

f

PMij VS GDP per capita quintiles

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PM;.! Population weighted average pg/m^ (20191 Most polluted 20%

Pregnant women

SWËDEN

FINLAND GDP per capita, Euro latest year available GDP per capita

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Very low (0-20%)

Helsinki

)slo

■ Low 120-40%)

Stockholm

Saint Petersburg

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Elderly

High (60-00%) Very high (top20%|

B»a«

Copenhagen

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ïublin

Chronic diseases patients

London

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Befiil

Amsterdam

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Kyiv

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UK R A I

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Conclusion

New AAQD, fully aligned with WHO 2021 AQG, is a major public and planetary health opportunity, that would: 1. 2. 3. 4.

prevent a substantial number of new cases of major NCDs make EU citizens more resilient to seasonal influenza epidemics and COVID-19-like new pandemics improve life of lung, heart, and other chronic disease patients Indirect benefit for health - help mitigate unprecedented climate change impact on our health and our planet

Clean air as a basic civil right - no one should get sick or die from breathing

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I *** ***

European Parliament

Thank You zorana.andersen@sund.ku.dk

@zoranajova ELF Award 2022 - Rosamund Adoo-Kissi-Debrah o YouTube ■ Th© European Lung Foundation • 01 Sept 2022

•••••• ::: ::: ••• •••

ERS

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Rosamund Adoo Kissi Debrah:'We need to ensure parents know the impact air pollution has on their children'

j ELF Award 2D22- Rosamund Adoo-Kissi-Debrah

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