lbourg, 1996.

umulation of )f the ele~lric :wch.)

: content: the :alth Effects, :hapman and

~ HEA 18191 . ited at State

m Agency;

,nal hazards. . edition , St.

for Europe, ,pp.426.

and ulinary ltions in the 5 (8), 1997,

nicals, Risk 996, pp. 45. Report pre­ssessmenl),

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Cent. Eur. J. pub\. Health 8, 2000, No.1, p. 33-39

ENVIRONMENTAL RESPIRATORY HEALTH IN CENIRAL AND EASTERN EUROPE

Jedrychowski W, Chair of Epidemiology and Preventive Medicine, College of Medicine, Jagiellonian University, Krakow, Poland

SUMMARY

The main objective of the paper was to discuss the environmental issues in the cou~trles of central and eastern Europe (GEE~ and to show their significance for respiratory health. Many epidemiologic studies carried out in the region have documented an association oetween air pollution and adverse health effect!:; in the respiratory tract. Short-term exposure to ambient air pollution has been related to an incrrease in mortality and hospital admissions for diseases of respiratory tract. Effects of long-term exposure was implicated in the rising trends of lower respiratory tract diseases, such as asthma and bronchitis, in both children and adults. Recent evidence indicates that the prevalence of allergic sensitization in the GEE countries is higher in urban than in rural areas, however, it is not clear to wlilat extent ambient air pollution has contributed to this difference. It is difficult to estimate the toll of adverse health effects caused by air pollution in the GEE countries because of insufficient data on exposure. However, it is evident that significant positive effects would occur if air pollutioll concentrations in the region were reduced along with the WHO guidelines.

Key words: environmental health, respiratory diseases, ambient air pollution

Address for correspondence: W. Jedrychowski, Chair of Epidemiology and Preventive Medicine, College of Medicine, Jagiellonian University, 7 Kopernika Street, 31-034 Krak6w, Poland

INTRODUCTION

From both the clinical and public health perspective the most common environment-relatedhealth problems in the countries in the former Eastern bloc concern exposure to excessive levels of air pollutants, possibly affecting tens of millions of inhabi­tants (1). Ambient air pollution reSUlting from the combustion of fossil fuels includes emissions from power plants (stationary sources) , from motor vehicle engines (mobile sources), and from household sources. Power plant emissions are largely responsible for atmospheric sulfur dioxide and for a complex array of respirable particulate matter. The latter includes ni­trates, acid sulfates and other sulfate salts generated secondarily in the atmosphere, metal salts and carbonaceous particles. Waste incinerators, smelters, and other industrial activities may be responsible for emissions of a variety of acidic, organic, and metallic compounds that cause local changes in air quality.

The main cause of air pollution in central and eastern Europe (CEE) is the extended use of coal-fired power and heavy industrial plants that were not fitted with efficient air treatment equipment. However, current figures reveal that a sharp de-

%

.... ... . .... .. 80

70

60

50

40

30

20

10 rnissing data

0 Western Europe CCEE ex-USSR

' I WHO air qu'ality guideline (annual mean concentration) ; 50 Ilg/m3

33

cline in industrial production following the economic difficul ­ties of transition, was accompanied by matching decrease in air pollution levels (Figs. 1,2). In some CEE countries such as Poland, efforts aiming at implementing the environmental protection programs have b.rought about very substantial re­duction in emission of classical air pollutants (Fig. 3).

The available data on communal air pollution across West­ern and Eastern Europe are related to classical air pollutants being present in the towns and big cities . Presumably, up to 30 % of the European population may experience these pollut­ants in concentrations exceeding the daily WHO air quality guidelines levels, though for most of the people the exposure is limited to less than 30 days per year. The proportion of city residents with high long-term average levels were markedly higher in the CEE than in western countries (Figs. 4, 5). The comparison of annual mean S021eveis before and after 1985, for cities with data from both periods, as well as the trends from a number of other cities indicate a decrease in the average S02 pollution levels over the decade. The highest annual average concentrations reported at the end of the 1980s were in Leipzig (200 Ilg/m3). On average, over 50 % of the population li ving in cities in the former USSR experienced days with pollution

Fig. 1. Exposure of the populations in cities. Annual mean concentrations of SPM > 50 ~g/m3 *.

1.0.0

8.0

6.0

4.0

2.0

%

(~Up to 1985 lIMiter 1985)

······77.9

D~ ____ -L ____________ -L ____________ -L------J

Western Europe CCEE ex-USSR

'I WHO air quality guideline (annual mean 'concentration) = 50 1l9/m3 Fig. 2. Exposure of the populations in cities. Annual mean concentrations of S02 > 50 ~g/m3 *.

5nu;'I=Ii~on~t~on~s __________ r-____________________ ~ ________________ --' 5

T8P ) 802 N~

4 4

3 3

2 ... ........... .. .. .............. 2

o Fig. 3. Trends in emission of TSP, S02 and o '88 '90 ; 92 ' 94 '86' 88 '90 '92 '94 '86' 88 '90 ' 92 ' 94

. ____ Target limits for 2.0.0.0 year defined by the Geneva Convention (1985)

Sour~e: Institute of Environmental Protection, Warsaw, Poland NOx in Poland over the last 10 years ( 1986-1995).

Western Europe CEE USSR

42 . .0%

No of days per year with total SPM concentrations> 120 ~g/m 3

rll'Jl1-49 UIlll50-99 1i1!I100-149.1lIlIJ150-199 [(£J>200 Dmissing Fig. 4. Percentage of city populations exposed to different number of days with total SPM

'1 WHO air quality guideline (24-hour mean concentration) = 120 ILg/rr?

%

50 42

40

30

2.0

10

o~ __ ~ ____________ ~ ________ ~~ ____ J

Western Europe

Fig. 5. Percentage of population with total SPM > 150 ~g/m3 for at least 100 days per year.

34

> 120 ~g/m3, 1986-1991.

levels exceeding the daily guideline level of 125 /-lg/m3. In the CEE and ex-USSR, the levels were higher than 200 /-lg/m3 on most of these days and levels of over 125 /-lg/m3 were more common than in western countries (1). Excess pollution was estimated for large parts of central Europe; the highest levels estimated were above 350 /-lg/m3 for up to 10 days per year, and found in the Black Triangle, an area between the former German Democratic Republic, ex-Czechoslovakia and Poland. In the northern Bohemia region of the Czech Republic, where lo,w-grade coal is used for power generation and metal smelters predominate in industry, maximum concentrations of S02 (I-hour measurements) might be as high as 2 500 /-lg/m3 during inversion periods (I50 /-lg/m3 is the maximum permissible level).

1

r

Annual mean

, 'ISP, S02 and ';1st 10 years

ons exposed SPM

~/m3. In the o J..lg/m3 on were more llution was ~hest levels YS per year, the former

~ndPoland.

blic, where tal smelters ns of S02 1m3 during ermissible

,..

Table 1. Health effects and biologie markers or response associated with air pollution

1. Excess cardiorespiratory mortality Death from heart or lung disease in excess of number expected

2. Increased health care utilization Increased hospitalizations, physician visits, emergency department visits

3. Asthma exacerbations Increased physician visits, medication use Decreased peak flow measurements

4. Increased respiratory illness Increased respiratory infections, physician visits, episodic symptoms

5. Increased chronic respiratory symptoms 6. Decreased lung function

Decreased spirometry, peak flow rates, increased airways resistance 7. Increased airways reactivity

Altered response to challenge with methacholine, carbachol, histamine, cold air

8. Lung inflammation Influx of inflammatory cells, mediators, proteins

9. Altered host defense i Altered mucocillary clearance, macrophage function, immune response

HEALTH EFFECTS OF OUTDOOR AIR POLLUTANTS

Health effects due to air pollution are manifested in various ways but mainly they pose a risk on respiratory tract. Particles, S02, and acid aerosols are a complex group of distinct pollut­ants that have common sources and usually covary in concentration and change in parallel. These air pollutants, possibly combined with other harmful agents and unhealthy life style behavior may damage general health of the popula­tion, not only respiratory tract.

The evidence linking the respiratory effects to air pollution comes from a variety of disciplines, including epidemiology. Health effect endpoints include cardiorespiratory mortality, morbidity as measured by hospital admissions or physician visits, symptom reporting, lung function testing, medication use and altered host defense (Table 1). For some observed effects, the mechanisms and specific toxicants responsible remain unclear (for example, the mechanisms and specific toxicants responsible for the excess morbidity and mortality reported to be associated with increases in PMlO). A recent hypothesis suggests that ultrafine particles may have uncon­ventional toxicological properties. These effects may be mediated through the generation of free radicals and may be independent of particle composition. For example, 20 nm diameter particles of carbon black have been shown to be capable of generating free radicals as have samples of urban PM2.5. Animal studies indicate that fine particles are associ­ated with a wide variety of organic species and that in some

locations aerosol nitrates and sulfates constitute a considerable fraction of the PM 10 (2).

EXCESS IN CARDIORESPIRATORY MORTALITY

There is evidence coming from CEE countries that a short term increase in the concentration of a pollutant in the atmos­phere, especially of particulate matter, may result in an increase in mortality in the days following the episode, and that this occurs even at moderate of relatively low pollutant levels (3). The study on short term effects of air pollution on mortality among inhabitants in Krakow over 4-year period (1992-1995) has shown that there was significant positive association be­tween mortality from all causes and from cardiovascular diseases and particulate matter measured by black smoke but not by S02 (Fig. 6). The similar analysis performed by Woj­tyniak et al. (4) in 4 major cities in Poland has shown that thef(~ was significant relationship between black smoke and mortal­ity in Lodz and Krakow, however, in other large cities (Poznan, Wroclaw) the positive association was not statistically signifi­cant.

It has been shown in a long-term monitoring study of adults in Krakow that a decrease in black smoke and S02 levels in the city was associated with the slowing down trends in age­standardized respiratory mortality rates over 20 years. Although the individual risk factors such as smoking habit or occupational hazards were not considered, the prevalence of cigarette smoking and employment in heavy industry did not change drastically over the study period (Fig. 7).

INCREASED RESPIRATORY MORBIDITY

Epidemiologic studies concerning acute effects of air pollu­tion on health have been carried out in areas fraught with a potential smog hazard in the former East Germany. Bredel and Herbarth (5) and Herbarth (6, 7) published investigations on acute effects of air pollution over a period of 6 and 8 years, respectively. A significant correlation was found between air pollution measured by S02 and specific morbidity recorded by emergency calls. The relationship between cases of illness of the respiratory tract, especially among children, and unfavor­able air pollution was particularly marked. During smog situations concentrations of sulphur dioxide of more than 4.5 mg/m3 (3D/min average) or 2.5 mg/m3 (24/h average) were observed. The findings were confirmed by an investigation carried out in another heavily polluted city (Halle), in which the same methods of analysis were applied. An increase in the number of emergency calls due to illnesses of the respiratory tract was observed in adults at 0.8 mg SOllm3 and in children

Black smoke

I All causes

35

Cardiovascular

Fig. 6. Relative risk of death (and 95% el) associ­ated with 100 Ilglm3 increase in daily concentration of air pollutants in Krakow, 1992-1995.

\' A. \ '

\ ,.1

\.

Change (percent)

60

40

20

Ischaemic heart diseases (+33%)

o Malignant neoplasm (+10%)

Diseases of digestive system (+7.5%)

-20

-40

-60

-80

Diseases of respiratory system

(-64%)

Sufpliur rfiox;jrf. (-26%)

'1!{acksmoR!- (-55%)

at 0.24 mg S02im3 (daily averages). The respiratory effects usually appeared with a time delay of 24 h.

The analysis of association between number of daily office visits to a general practitioner and air pollution (SOz, SPM, N02 and fluorides) was carried out in Krakow (8). The daily number of visits and specifically those due to respiratory diseases was significantly related to SOz concentrations. High concentrations of SPM (suspended particulate matter) were associated with greater number of visits due to cardiovascular system but only in warm days. Some association was also found between higher levels ofNOz and fluorides and number of visits.

The allergic disorders have been analyzed in 2 800 children referred to the outpatientpneumonological clinic in Szczecin over 5 years period (9). The authors found the higher frequency of visits due to allergic problems among very young children «3 years old) living in the Police region than in the rural control area. In Police, where very big chemical plant of fertilizers started to operate, the concentration of fluorides and sulfuric acid in the air was very high and exceeded manyfold hygienic standards.

INCREASED RESPIRATORY SYMPTOMS IN CHILDREN AND ADULTS

Kleine (0) from former East Germany demonstrated that there are spatial differences in the prevalence in some diseases of the respiratory tract in territories differing in air pollution. The data came from a questionnaire survey of children born in the regions of Bitterfeld and Wismar in 1982. Bronchitis, pseudocroup and chronic cough were significantly more com­mon in the children from Bitterfeld (three times more frequent than in Wismar).

The respiratory function in 721 schoolchildren was exam­ined by Bistraninova and Kotesovec (1). The authors found a seasonal variation in respiratory function values. The lowest values were observed in March, and it was assumed that this was due to the high degree of pollution in the preceding winter period.

Population study comparing the prevalence of respiratory disorders in 9 - lO-year-old children has been carried out in 3 areas differing with air pollution level in the Upper Silesia. In the lower polluted area (Zawiercie) the prevalence of acute diseases of upper respiratory tract was much lower 07.3 %) than in the high polluted towns (Chorzow, Olkusz) where the

36

Fig. 7. Mortality change over 15 -year period (1980-1994)for leading causes of death and change in air pollution level in Krakow, Po­land.

rates were 55.6% and 66.0% correspondingly. There was no correlation between the degree of air pollution and spirometric testing. The annual mean SOz concentrations in the highest polluted town (Chorzow) was 174Ilg/m3, in the less polluted 11-96Ilg/m3 (Olkusz), while in the control area only 321lg/m3 (2).

Sram et al. (3) from the Czech Republic published the results of the epidemiologic study on respiratory effects of air pollution in the large sample of 2nd grade, 5th grade and 8th

grade schoolchildren in the Teplice and Prachatice districts. The data have shown that chronic exposure to high levels of classical pollutants was associated with increased prevalence of respiratory symptoms of cough and wheezing and of wheez­ing bronchitis and asthma, but not of hay fever. Maternal smoking and childhood infections before 2 years of age were also associated with wheezy bronchitis and asthma. Odds ratio estimates for respiratory symptoms were significantly higher in the high polluted district Teplice than in the reference area of Prachatice (Fig. 8). The study indicated that there is an interaction between living in a highly polluted area and mater­nal smoking and this is a potential risk factor of asthma. It is necessary to mention that many children from the study have been born during the early 1980s, when pollution levels in the district of Teplice were at maximal levels.

In adults, a number of epidemiological studies have been carried out on air pollution and respiratory diseases in the Upper Silesia. One of these studies was performed on the population of inhabitants of the urban and rural regions of the

5 Odds ratio

4

3

2

OL---c~h~rown~ic----W~h-e-eLzi~n~gaW~it~h--~-LLL~~~--oXtLtaLcAk-s--cough colds of wheezing

Respiratory symptoms

Fig. 8. Comparison between the districts ofTeplice (highly polluted region) and Prachatice (control area) in 7-16 years children.

county Toszek (1 of men and 7.5 of men and 3.0 of chronic ers living in the

lung function w study of chronic based on a rando : age 19-70 years tionnaire collecte was performed 1 80 % of the survi were invited to . spirometric testi veys. Data on am measurements p' Station. The con' black smoke and the city. Apart transformation r S032-, in total s a surogate indica

TheFEVl de the add aerosol c areas as defined presumably with sidered as a refe STR, were treat FEV 1 decline ra faster by 12 mIl highest level of ers and in non-s occupational ex

The Krakow showed the pres in the urban air with the detrim from the additio and STR could

Epidemiologi volunteers have induces asthma and inhaled all baseline airway pollutant-induc' this interaction, will be crucial regulatory strat

Shown, that exel exposure to SO as 0.25 ppm S I

inhaled ~-adrenl I

not appear to cal constrictive rei exercise-induce' though the prec

Numerous El ing prevalence prevalence of

i i l "

~arperiod death and lkow, Po-

~ was no rometric r highest iPolluted ,21lg/m3

fhed the ~ts of air i and 8th

~istricts. ~vels of ,valence lwheez­~aternal ge were lids ratio ~ higher lee area I . e IS an I mater­~a. It is ly have f in the

b been in the n the of the

county Toszek (14). Chronic bronchitis was found in 24.3 % of men and 7.5 % of women living in the city, and in 19.8 % of men and 3.0 % of women from the rural region. Symptoms of chronic bronchitis were seen more frequently in non-smok­ers living in the town than in those living in the rural region.

DECREASE IN LUNG FUNCTION

Evaluation of effects of ambient air pollution in Krakow on lung function was one of the objectives of the longitudinal study of chronic airways diseases (15-17). The study was based on a random sample of permanent residents of Krakow, age 19-70 years in 1968. Interviewers using the MRC ques­tionnaire collected data from 4 355 subjects. Similar interview was performed 13 years later (1981) in 3 082 subjects, i.e. in 80 % of the survivors from the original group. All respondents were invited to spirometric testing. For 1 824 subjects, the spirometric testing was obtained in both 1968 and 1981 sur­veys. Data on ambient air pollution were obtained in the routine measurements performed by the Sanitary-Epidemiological Station. The concentrations of particulate matter measured as black smoke and S02 were measured in seventeen locations in the city. Apart from the classical air pollutants, the sulfur transformation rate (STR), i.e., proportion of sulfate sulfur, S032-,.in total sulfur was also measured, and it may serve as a surogate indicator of acid aerosols in ambient air.

The FEV I decline rate to air pollution levels was related to the acid aerosol content using the partition of Krakow into three areas as defined earlier. The area C, with low STR and thus presumably with low concentration of acid aerosols was con­sidered as a reference area, and the areas A and B, with higher STR, were treated as the exposed ones. It was found that the FEVI decline rate in the 13-year follow-up was significantly faster by 12 ml/per year in the area A with presumably the highest level of acid aerosols. This effect was similar in smok­ers and in non-smokers, and was not modified by the reported occupational exposures.

The Krakow follow-up study is the only one in Europe that showed the presumed chronic effect of higher sulfate content in the urban air on lung function was so strong as comparable with the detrimental consequences of smoking. It was evident from the additional analysis that the effect of sulfate pollutants and STR could not be confounded by occupational hazards.

EXACERBATIONS OF ASTHMA AND ATOPY

Epidemiologic and controlled exposure studies of human volunteers have shown that exposure to a variety of pollutants induces asthma exacerbations. The interaction of pollutants and inhaled allergens and the effect of pollutant exposure on baseline airway inflammation may be a key mechanism of pollutant-induced exacerbation of asthma. Further studies of this interaction, as well as interactions of multiple pollutants, will be crucial for rational development of intervention and regulatory strategies. Moreover, S02 exposure studies have shown that exercising asthmatic subjects are sensitive to brief exposure to S02. Some respond with bronchospams to as little

. as 0.25 ppm S02; the bronchospasm is rapidly reversed by inhaled ~-adrenergic antagonists. However, such exposures do not appear to cause delayed or prolonged effects. The broncho­constrictive response shares a number of features with exercise-induced bronchospasm in subjects with asthma, al­though the precise mechanism is not known.

Numerous European studies have demonstrated an increas­ing prevalence of asthma during the last three decades. The prevalence of symptoms suggesting current asthma and

37

asthma-related disorder were less common in Estonia than in other Nordic countries, although respiratory problems in gen­eral were more common. Comparing Tartu with Uppsala revealed that the prevalence of atopy was lower in Tartu and profile of antigens differed between centers. There were also some differences in risk factors for atopy and allergic respira­tory diseases (18). In Kaunas administrative district of Lithuania (21), the study on asthma in children in 1993 (81 259 children) and particulate air pollution has been carried out. There was more cases of asthma (6.5 %) than in the area with lower level of TSP (3.2 %) in children population under 15 years of age.

An association between asthma, chronic bronchitis and air pollution in residential area in the group of military conscripts has been analyzed over 3 years (1979-1982) in the whole Poland (22). The author found a clear gradient of respiratory diseases under study with S02 concentrations and almost perfect correlation of rates for chronic bronchitis and asthma with the level of air pollution in the place ofresidency. Since the diagnostic criteria were based only on symptoms, the possibly bias in overreporting the symptoms by recruits com­ing from towns makes the results less explicit.

In this study urban living was a risk factor for at least one positive skin prick test to pollen or animal dander, OR = 1.83 (95%CI: 1.26-2.67). Parental questionnaires, skin prick tests and serial peak flow measurements 'were used in the study involving about 2 600 of 1O-12-year-old children from Swe­den, Poland and Estonia. The risk of positive skin prick test was lower in the industrial center of Poland (19) and Estonia than in urban area in Sweden (18).

Recently, an interesting study has been published by Nowak et aI. (23) on the West-Eastern European differences in the prevalence of respiratory symptoms, bronchial hyperrespon­siveness and atopy in the random sample of adults (20-44 years of age) in West and East Germany (Hamburg vs Erfurt). Within the time period from 1985 to 1989, annual mean concentrations of S02 and SPM were 31 and 53 Ilg/m3 respectively in Ham­burg, as compared to 264 and 137 Ilg/m3 for S02 and SPM respectively in Erfurt. A short respiratory questionnaire study has been carried out in 3 156 subjects (80% response rate) in Erfurt. In addition, a subset of responders completed a long questionnaire, spirometry, methacholine or bronchodilator test, skin test, and total and specific immunoglobulin E (IgE), with a total number of 1 159 participants in Hamburg and 731 in Erfurt. There was more respiratory symptoms (wheezing, breathlessness, attacks of shortness of breath, attacks of asthma, nasal allergies) in Hamburg than in Erfurt and in Hamburg the mean forced expiratory volume in one second (% of predicted) was lower (105 %) than in Erfurt (107 %). The study has shown that bronchial hyperresponsiveness (HR) was observed significantly more often (25 %) than in Erfurt (19 %). Atopic sensitization was more prevalent in Hamburg than in Erfurt (against grass pollen 24 % vs 19 %, birch pollen 19 % vs 8 %, cat 10 % vs 2 % and Dermatophagoides pteronyssinus 14 % vs 10 %). This was reflected by the prevalence of positive specific IgE values, which were higher in Hamburg than in Erfurt. In Hamburg, compared to Erfurt, there was a lower mean number of siblings, higher degree of childhood and current exposure to environmental tobacco smoke, and higher frequency of fitted carpets and reported moulds inside the house. These data may support the hypothesis that childhood factors and exposure to indoor allergens and irritants may have been more relevant for the development of asthma and atopy than the potential long-term exposure to high concentrations of classic urban pollutants.

I I

In another very recent study in Krakow respiratory reactions to outdoor air quality in allergic and non-allergic children has been evaluated (24). The purpose of the study was to check the hypothesis whether the domestic air quality together with level of residential air pollution increases the risk of allergy and whether allergy determines the occurrence of respiratory symptoms. The additional purpose of the study was to assess to what extent allergy may be related to communal outdoor air pollutants after correction for indoor air quality (environmental tobacco smoke, or mold houses). The survey targeted 1 129 schoolchildren in the age of nine years who attended schools in Krakow located in the areas differing in outdoor air pollution level. Based on measurements obtained from the air pollution monitoring stations and data from parents on sources of local emission of air pollutants, four categories of air pollution areas have been defined in the city.

The results obtained document that the prevalence of allergy in children depended on parental allergy (OR = 2.02, 95%CI: 1.52-2.69) and molds in house (OR = 1 :71, 95%CI: 1.08-2.70). In addition to that there was statistically significant trend with outdoor air pollution score.

LUNG CANCER

In the highly industrialized Silesian region of Poland, severe environmental pollution is encountered that has been associ­ated with increased risk of cancer. Polycyclic aromatic hydrocarbons produced by industrial and domestic combustion of coal are among the most prevalent carcinogenic and mu­tagenic air pollutants in Silesia. Yearly average of BaP concentrations at many measuring points in Silesia exceed by factor of 3-5 the concentrations of BaP found in a room of 36 m3 with a single air change per hour after smoking 40 ciga­rettes during an 8 h day (25). Atmospheric concentrations of benzo[a]pyrene (BaP) in the town of Gliwice, for example, were 57 ng/m3 in winter and 15 ng/m3 in summer, the differ­ence resulting from the considerable use of coal for heating. Accordingly, Perera et al. conducting a study in Silesia (Gli­wice) and in the control area (Biala Podlaska) has found out that BaP-DNA adducts in both exposed group and control group were higher in winter than in summer. They were also significantly higher in exposed winter samples than in control winter samples, as were some markers of genetic damage.

In a case-control study of lung cancer deaths occurring over a 6-year period (1980-1985) in Cracow Poland (26), it was

disclosed that urban air pollution may increase lung cancer risk, acting multiplicatively with known factors such as smok­ing and industrial exposure. Information on occupation, . smoking habits, and residence was collected from next-of-kin. i Classification of exposure to community the high air pollution " category (more than 120 llg/m3 TSP and S02) was based on measured levels of total suspended particulate matter and sulfur dioxide. Lung cancer depended strongly on total ciga­rette consumption, on age at starting to smoke, and on time since stopping smoking. Relative risk estimates for occupa­tional exposure in iron and steel foundries and in other industries were significantly increased in males. The relative risk in men exposed to the highest air pollution level was 1.48 (95% confidence interval 1.08-2.01), while in women the increase was not significant.

In fact, the results of the above mentioned study find a sup­port in observations made later by R. Whyatt et al. (27) in the molecular epidemiologic study in Cracow among infants. The study showed a dose-response association between urban air pollution level in Krakow and cord blood WBC PAH-DNA adduct levels. There was no clear dose-response in cord blood WBC PAH-DNA adduct levels when the total Krakow cohort of infants was trichomized into low, medium and high based on PMIO levels at their place of residence. However, among infants of Krakow women not employed away from the home during pregnancy, adduct levels in infant cord WBC were significantly increased among infants residing in the middle (9.59 ± 3.50 per 108 nuc1eotides) and high (6.53 ± 1.98 per 108 nucleotides) compared to low pollution group (1.72 ± 0.49 per 108 nucleotides). This was similar to results seen with maternal adduct levels. After controlling for smoking status, coal use, diet and home/occupational exposure, WBe PAH-DNA ad­duct levels remained significantly higher in infants residing in the high compared to the low pollution group (Fig. 9). Simi­larly, a dose-related increase in placental CYP1A1 mRNA with ambient exposure was suggested.

Recent study was published by Zemlianaya et al. (28) on lung cancer related to air pollution. Risk factors for lung cancer were studied by case-control approach among females and exposure to air pollution was based on measured S02, N02, CO and TSP in the area of the residence for the period 1971-1975. Risk oflung cancer was elevated in persons living in areas with heavy air pollution (OR = 2.42, 95%CI: 1.2-4.8). It was shown significantly higher risk oflung cancer in women whose husbands smoked cigarettes (OR = 1.66) and there was no effect of occupation.

1.2r---------------------------~~~~ Difference between "High' and 'Low Pollution' group In Student's t test P=O.06

0.8 ....... , .................................................................. .

0.6

0.4

0.2

0'----­Low (23.4-64.8) Medium (66.4-90.7) High (91.3-154.2)

Source: A.M. Whyan, S.J. Garte, G. Cosma, .A. Bell, W. Jedrychowskl, J Warhendort el al.; Cancer Epidemiology, Biomarkers, and Prevention, 1995,4,147·153.

38

Fig. 9. Placental CYP fA] mRNA by level ofPM/(Jpollution the month prior to delivery for 66 mother/newborn pairs from Krakow, Poland.

In t forpu term

one numb expos sure a

Fu, possi torin rathe PM1 spon quali regia

In quest ficult deriv fect parti com effec

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5. l' ,

b;: ~f-kin. flution Fed on :r and

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lative !; 1.48 n the

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use, . ad­~g in ~mi­~A

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el y

CONCLUDING REMARKS

In the review, the published papers or manuscripts prepared for publication dealing with air pollution and short- and long­term health effects on several health outcomes have been considered. There was a good evidence for an association between health effects and air pollutants, however, there is still unclear what are the main causes of poor health effects: sulfur dioxide, particulate matter, strong acidity aerosols or sulfates.

An important limitation of the study data is the great diver­sity in methods of air pollution exposure assessment used in the studies. Exposure is a function of ambient pollution, of indoor sources, and of the movements of the individuals from one micro-enyironment to another. Often only a limited number of outdoor monitoring sites provided estimates of exposure. Representatively location of the stations for expo­sure of the population was also often poorly described.

Further, the methods of air pollution monitoring restricted possibilities for the comparison of studies using routine moni­toring· data. Particulate matter was measured and monitored rather as black smoke or total suspended particles than as PM 10, or PM2.S. Outdoor air pollution concentrations corre­spond to personal exposure to a limited extent and indoor air quality and differences in smoking habits also contribute to regional differences in pollution exposure.

In the review of the studies we could not address specific questions related to the dose-response relationship. These dif. ficulties resulted from limitations in combining the results derived in regionally and otherwise different populations, ef· fect of pollutant mixtures and diversity in definitions of particular health points. Even though there is evidence that the compounds can interact in a synergistic way to produce health effects, it was not easy to document this from the studies under review.

Because air pollution in the region affects several countries, it is recommended to carry out rather regional studies than small ones within one-country. These studies should aim at: 1. identifying the principal sources of health threatening air pol­lutants in the region and then to identify a range of specific actions to reduce risks to the population from those pollutants, 2. demonstrating how risk considerations can be used to guide decisions about environmental priorities, policies, and invest~ ments, 3. helping to build technical capabilities for conducting air quality management programs. It should be clear that risk assessment (hazard identification, dose-response assessment, exposure assessment, and risk characterization) will play a critical role, 4. introducing standardized methodologies for environmental monitoring and for epidemiological studies in­cluding population exposure and risk assessment management.

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Received May 4, 1999

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