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Air Pollution in the World and in Turkey

Prof. Dr. Fatma Evyapan

Pamukkale University School of Medicine

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Main topics

• Introduction

• Historical perspective

• Effects of air pollution on cardiorespiratory morbidity and mortality

• Air polution in Turkey

• Concluding remarks

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WHO

Clean air is considered to be a

basic requirement of human health and well-being

WHO

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Agent Population at risk Clinical consequence

NO2Healthy adults

Asthmatic children

BHR ↑

symptoms ↑,pulmonary infections ↑, PFT ↓

Ozon Healthy children and adults

Asthma COPD vs

PFT↓, BHR↑

Respiratory symptoms↑

Exer cap ↓

Hospitalization ↑

CO Healthy adults

İHD patients

Exercise capacity ↓

Exercise capacity ↓, angina pectoris mortality ↑

SO2Healthy adults

COPD patients

PFT ↓

Resp mortality ↑

Hospitalization ↑ hospital admissions ↑

Acid aerosols

Healthy adults and children

Asthmatic and other pats

Mucocilliary clearance ↓ Pulmonary diseases ↑

PFT ↓, hospitalization ↑

PM10Children

Chronic cardiorespiratory dis

Asthmatic children

Respiratory symptoms ↑pulmonary disorders ↑

PFT ↓

Mortality ↑

Asthma exacerbations ↑

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History

• Throught history man has known that polluted air may be detrimental to health

• Greeks and Romans were aware of the adverse effect of polluted air in, e.g. Crowded cities and mines

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Fatal Air Pollution Episodes

• December 1-4 1930 Meuse Valley, Belgium:– İn 2 days > 60 deaths 10 fold increase

in mortality rate ↑• October 27-30 1940:Pensylvannia

Donnora:– 6 fold increase in mortality rate ↑

• December 5-9 1952 London:– 3000 excess death 3 fold increase in

mortality rate ↑– Mortality rate remained high during first

three months of 1953• Even in 1990s althought below the

national or international standardized limits air pollution still affects cardiorespiratory morbidity and mortality

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Particulate Air Pollution in the World

8http://www.wunderground.com/health/pollution.asp

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NO2 Pollution in the World

http://www.bnsc.gov.uk/6433.aspx

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Studies of Cardiorespiratory Mortality and Morbidity:

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Air Pollution and Morbidity : North America

City Results Reference

Seattle (1989-1990) PM10↑ >65y HEAasthma↑

PM10 (4) ↑ HEAasthma↑

Scwartz et al Am J Respir Dis 1993:826-831

Birmingham Alabama (1986-1989)

PM10↑ HA COPD↑

PM10↑ HB pneum↑

O3 (2) ↑ HACOPD↑

O3↑ HBpneu↑

Schwartz et al

Am J Epidemiol

1994;139:589-598

Los Angeles (1992-1995) NO2 ↑HAcardiopul↑

PM10 ↑HBcardiopull ↑

CO ↑HBcardiopul ↑

O3 ø HBcardiopul

Linn et al Environ Health Perpect 2000 108:427-434

Anchorage (1992-1995) PM10 ↑ Med adasthma ↑

░ PM10 ↑Medadasthma ↑ ↑

PM10 ↑ Med ad asthma ↑

Chodury et al Arch Environ Health 1997 52:113-117

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Air Pollution and Mortality North AmericaCity Results Reference

USA 6 cities

Harvard 6 cities study (1979-1988)

PM2,5 earth,heathing,traffic

PM2,5 traffic↑Mortality ↑↑

PM2,5heating↑Mortality↑

Laden F Environ Health Perspect 2000 108:941-947

USA 20 cities PM↑TM↑MCV↑MR↑

☼ O3↑M↑ (☼) ø

CO, SO2,NO2 øM

Samet N Eng J Med

2000 343: 1742-1749

Canada: low level pollution 8 cities

PM2,5↑Mor↑↑

SO4,Fe, Ni, Zn↑ Mortality↑

O3,NO2,CO,SO2,COH øM

Burnett et al Inhal Toxicol 2000 12 (Suppl 4):15-39

Vancouver

1994-1996

☼O3 ↑RM↑KVM↑

NO2 ↑ TM ↑

PM, SO2 CO,COH øM

Vedal et al Environ Health Perspect 2003111 (1):45-51

Mexico City (Meksica)

1994

PM↑TSM↑Mcopd↑

PM↑Melderly non-hospitalized↑↑

Eur Respir J 2000 16:391-396

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Air Pollution and Mortality: Other RegionsCity Results Reference

Shenyang (Çin)

1992

TSP↑Mkv↑

SO2↑Mcopd↑

Xu et al Arch Environ Health 2000 55:115-120

Beijing SO2 ↑ T M ↑☼

Mcopd ↑

TAP ↑ T M ↑☼

Mcopd

Chen et al Toxicology 2004; 198:: 291-300

Shangai NO2 ↑ M KR ↑

SO2 ↑ M CR ↑

O3 ↑ MCR ↑ ↑

PM10 ↑ MCR ↑ ↑M İCD ↑

Xu et al Arch Environ Health 2000 55:115-120

Brisbane (Avustralya)

1987-1993

PM10↑M↑

O3↑ M↑

O3↑Myaş>65↑↑

Simpson et al

Arch Environ Health 1997 52 (6):441-454

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APHEA (Air Pollution and Health: a European Approach) Project

• Held in 10 european countries with different socioeconomical status and different air pollution levels

• Aims:– To show the short term effects of air pollution on

health• Daily deaths, cause specific deaths, urgent hospital

admissions– Analysis of large data profile;– Standardized approach to epidemiological time-series

analysis Katsouyanni et al Eur RespirJ 1995:1030-1038

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APHEA Project :Results(Lon,Ams,Par, Rot, Mi)

• Age groups :16-64; >65;• Pollutants

– Gas: SO2,O3,NO2,– Particulate: PM (TAP, BS)

• Other factors which may affect the results:Seasonal changes, temperature, humidity, social events (strike etc..holydays etc..)

• Hospital admissions (HA) for COPD, asthma, respiratory infections:– SO2 no relationship;– BS↑ HA ↑– NO2 ↑ HA borderline association ↑– O3 ↑HA ↑ >65 ↑ ↑

• The effect of pollutant didn’t show seasonal difference Spix C Arch Environ Health 1998 53 (1):54-64

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APHEA-2 PROJESİ(Barse, Birm,Lond,Mil, Holl, Par,Ro, Stok)

• PM10,PM13, BS, TAP Hospital Emergency Admission (HEA) – asthma (0-14y, 15-64y) – COPD + asthma (>65y) – tüm solunum yolu hastalıkları (>65 y)

• 0-14 yr :PM10↑ HAB↑• 15-64 yr: BS ↑ HEA ↑

PM 10↑ HEA ↑ PM13 ↑HEA ↑ TAP ↑HEA↑

• >65 yr: COPD +asthma BS ↑ HB ↑ TAP ↑ PM10 ↑>65 yr: PM10 ↑ all respiratory diseases ↑ Atkinson R Am J Respir Crit Care Med 2001 164:1860-1866

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Air Pollution and Mortality: European Results

City Results Ref

Milano (1980-1989) TSP↑ DM↑

SO2↑ DM↑

Vigotti et al J Epidemiol Comm Health 1996 50:(Suppl 1): s71-s75

Cracow Lodz Poznan

Wroclaw(1977-1989)

BS↑DTMLc ↑

SO2↑DTMLc ↑

BS SO2ø SM

Wojtyniak et al JEpidemiol Comm Health 1996 (Suppl 1):

S36-s42

Köln 1975-1985 TSP↑DM↑

SO2↑DM↑

NO2 øDM

PM7 øDM

Spix et al J Epidemiol Comm Health 1996 (Suppl 1): s52-s58

Barcelona (1985-1991) BS↑TM↑CVM↑RM↑

SO2↑TM↑CVM↑RM↑☼:TM↑↑

O3 NO2 øTM KVM SM

Sunyer J et al J Epidemiol Comm Health 1996 (Suppl 1): s76-s80

Paris( 1987-1990) PM13↑RM↑

BS↑TM↑

SO2,O3,NO2 øRM,

Dal et al J Epidemiol Comm Health 1996 (Suppl 1): s42-s46

Bratislava (1987-1991) SO2 ø TM

TSP ø TM

Bacharova et al 1996 50:(Suppl 1): s19-s21

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Air Pollution and Mortality: European ResultsBölge Sonuç ø↓↑ Kaynak

Hollanda(1986-1994) O3↑<65yTM↑KOAHM↑

PM10↑<65yMPnö↑

CO↑<65yMPnö↑

NO2↑<65yMPnö↑

O3↑BS↑SO2↑NO2↑CO↑>75yM↑

O3↑BS↑SO2↑NO2↑CO↑ 65-74yaşTM↑Mp↑,Mkv↑Mkoah↑

Fischer et al Eur Respir J 2003 21:suppl 40:34s-38s

Hollanda 1986-1994 BSm↑ NO2m↑ (trafik)55-59 yaşKVM↑(ana yola yakın)

Hoek et al Lacet 2002 1203-1209

Atn,Bdp,Ldz,Lnd,Mad,Pa,PrR,Stck,TA

(1990-1997)

PM10↑ (40) TM↑ Zanobetti et al Epidemiology 2002 13:87-89

Atn,Bdp,Ldz,Lnd,Mad,Pa,PrR,Stck,TA

(1990-1997)

PM10↑ (40) MS ↑MKV ↑ Zanobetti et al Environ Health Perspect 2003 1188-1193

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WHO Air Quality GuidelinePM2,5 10 g/m3 annual mean

25g/m3 24 hours mean

PM10 20mg/m3 annual mean

50 mg/m3 24 hours mean

O3 100g/m3 8 hours mean

NO2 40g/m3 annual mean

200g/m3 one hour mean

SO2 20 g/m3 24 hours mean

500g/m3 10 minutes mean

WHO air quality guideline 2005

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Air Pollution in Turkey

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Historical Perspective

• Air pollution first occured in Ankara in 1970s;• In 1980 it became a widespread problem in many

cities especially in winter• Since 1984 Ministery of Health has been assessing

main pollutants (BS and SO2) in majority of the cities• In the first half of 1990s air pollution has increased to

the health threatening levels in many cities • Since 1991 those results has been published by

State Statistics Institute.• Since 2006 PM10 measurements have been

performed by Minister of Environment

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DİE 2002 yıllığı

<50g/m3 50-100g/m 3 > > 100g/m3 2008

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The Most Polluted Cities in 2008

SO2 g/m3 PM10 g/m3

Kars 87 Van 147

Bitlis 83 K. Maraş 136

Çanakkale 69 Iğdır 129

Siirt 68 Mardin 117

Aydın 65 Kütahya 114

Isparta 64 Karabük 111

Kütahya 49 Isparta 110

Van 48 Düzce 108

Zonguldak 48 Konya 107

Nevşehir 47 Karaman 107

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Effects Of Air Pollution on Respiratory System: Turkey Data

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City Aim Results Ref

İstanbul Effect or air pollution in 0-2 yr children on HA for respiratory diseases

Pollution HABronchitis SinusitisPneumonia

Olgun Ç Uzmanlık tezi İstanbul 1996

İstanbul Effect of air pollution on HA for acute respiratory diseases

PM HA Dağlı E, Erk M., Karakoç F. Toraks Derneği yıllık kongresi 1996

İstanbul Effect of winter air pollution on hospitalization in children

Air pollution in winterHospitalization

Bebek Ö. Aile Hk Uzmanlık tezi 1996

İstanbul Air pollution and rhinits prev (1994 ve 1996)

High air pollution levels rhinitis prevalence

Keles et al Arch Eviron Health 1999

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City Aim Results Ref

İstanbul Air pollution and allergic rhinits symptoms

Pollution Symptoms

Keles et al Am J Rhinol 1999

İzmir Effects Various climatologic pollution levels on nasal resistance

PM SO2 NR

Özüer MZ et al KBB ve Baş Boyun Cerr Der 1999

Eskişehir Air pollution and respiratory emergency admmissions

SO2 UAILAICOPDCor pulmonale

Ünsal et al Tüberküloz ve Toraks 1999

Ankara SO2 ve PM kons. İle astım acil başvuruları

Son bir haftanın SO2 ve PM kons ile kor. Bağıl nem ile pozitif, ısı ve rüzgar hızı ile neg kor

Berktaş et al Tüberküloz ve Toraks Dergisi 2003

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City Aim Results Ref

İzmit Asthma admissions and meteorological parameters

PM Relative humidity Asthma admissions

TÜSAD XXV: Ulusal Kongresi Bildiri kitabı 1999

İstanbul TAP and mortality TAP last 3-5 days

Mortalite

Şahin Ü. Doktora tezi İstanbul 2000

İzmir Hava kirliliği ile KOAH hast yatışları ve ex ilişkileri

Hava kirliliği yatış sayılarında ex ile ilişki görülm

Çelikten E.Toraks Derneği 2. Kongresi Özet kitabı 1998

Gaziantep Air pollution and health quality of moderate asthmatics

Pollution rescue med nocturnal symptoms

Bozkurt Aİ Toraks Derneği 2. Kongresi Özet kitabı 1998

Denizli Air pollution paramters and COPD emergency admissions

SO2 ↑ COPD HEA ↑

BS ↑ COPD HEA ↑Evyapan F Eur Respir J (Suppl 30) 1999

Denizli Air pollution and asthma emergency admissions

SO2 (5)↑ asthma emergency admission ↑

Evyapan F Eur Respir J Vol 16 (Suppl 2) 2000

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SO2 (g/m3) PM (g/m3)

Annual Mean 60 60

Winter Season Mean (October-March)

120 120

Maximum 24 hours mean

150 150

Maximum 1 hour 450 -

Ministery of Environment and Forestry:Guidline for the Protection of Air Quality

TC Çevre orman bakanlığı (www.cevreorman.gov.tr)

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Concluding Remarks

• Air pollutants even in low levels have impact on the health

• Particular pollutants have greater impact on cardiorespiratory mortality and morbidity, the effect is more prominent at lower diameter (i.e.PM2,5)

• The accumulated scientific evidence has forced the WHA to review air quality guideline values for air pollutants

• It should be kept in mind that guidline values can not fully protect human health

• In Turkey air pollution is the second leading cause of environmental pollution. Limit values of national air quality guideline is much higher than the WHO limits

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Global Warning!

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Thank You