Population exposure to CO:some Italian experiences
Zauli Sajani S.1, Marchesi S. 1, Ottone M. 1, Veronesi A. 2, Percoraro V. 2, Trenti T. 2, Lauriola P. 1
1 Centre for Environment and Health, Arpae Emilia-Romagna (Italy)2 Local Health Authority of Modena (Italy)
Toronto, 9-10 November 2016
Ambient CO
The EXPOLIS project
The EXPOLIS project
Indoor /outdoor measurements in school
Air pollutants
• Nitrogen dioxide• Carbon monoxide• PM10• Benzene • Formaldehyde
Children exposure to CO: the SEARCH project
Children exposure to CO: the SEARCH project
Children exposure to CO: the SEARCH project
Indoor Outdoor Station 1 Station 2
Children exposure to CO: the SEARCH project
Indoor Outdoor Station 1 Station 2
Emilia-Romagna Region
Province of Modena
A database of COHb levels in general population
Population: 700,000 inhabitants Total area: 2,688 km2
• Provincial coverage (some 700.000 inhabitants)• About 10 millions bio-chemical assays per year• Availability of name, surname, date of birth, address of the patient for each exam• Availability of data from ABL90FLEX providing data of 17 parameters in real time (see below)
Data from ABL90FLEX
Electrolytes
Blood gas
pH
Metabolites
CO-oximetry
A database of COHb levels in general population
The database includes, for each subject, the :• age• sex• nationality• residence address• domicile address• clinical wards of the patients• fiscal code
Database offers the possibility of record linkage with other databases such as mortality data, geographical localization and the possibility of including only the first available test result for each patient in order to form a database of test results “on admission”.
A database of COHb levels in general population
The centralized laboratory executes 10 millions bio-chemical assays per year on average
- Data of both arterial blood gas (ABS) and venous blood gas (VBS)- COHb data available from October 2014- Some data come from the 9 emergency rooms (ERs) in the Province of Modena
2015 dataTotal COHb testsn°ABS= 50000, n°VBS= 40500, Total BGA n°= 90500COHb in Emergency Roomn°ER-ABS= 13200, n°ER-VBS=6600, ER-Total BGA n°=19800
A database of COHb levels in general population
Differences of COHb mean concentrations between areas and seasons
** Highly significant - Wilcoxson test
Mountain vs main city Mountain vs rural area
Winter vs summer
1.70 vs 1.43**
1.80 vs 0.87 **
1.70 vs 1.43 **
1.58 vs 1.52**
Winter vs summer (mountain area)
First results
A database of COHb levels in general population
Strengths
• Easy access to laboratory data retrieved by standardized methods and techniques
• Possibility of record linkage with mortality data, hospital admissions, emergency department visits, hyperbaric oxygen chamber data
• Possibility of comparison among high levels of COHb individuals and individuals who underwent HOBT treatment
• Possibility of geographical investigations
• Potential of prevention actions by alerting individuals with high levels of COHb but without CO poisoning diagnosis
A database of COHb levels in general population
Issues to be scrutinized• How much COHb is indicative of CO exposures?
• Is it possible to disentangle the various type of exposures causing high COHb levels?
• Is it possible to increase the value of the database by cross analyses of the various parameters? How?
• Would it be possible to identify smokers based on cross analyses?
• Would it be possible to identify endogenous and exogenous reasons for high levels of COHb?
• What’s the relative weight of indoor and outdoor sources of CO exposure?
A database of COHb levels in general population
We are finalizing a systematic review of the literature to evaluate the current evidence about the usefulness of COHb as biomarker of unintentional CO exposure
Search strategy, eligibility criteria and study selectionWe performed a systematic research using the following terms: ”carboxyhemoglobin”, “carbon monoxide” “poisoning”, “biological marker”, “blood oxygenation”, “blood oxygen saturation”, “blood gas analysis”, “population surveillance”, “public health surveillance”, “indoor air pollution”, and it was adapted to each database.The literature search identified 1183 bibliographic records
19 studies were included
Review on CO exposure and COHb levels in blood
Seven studies reported information about the air-CO concentration and COHb
Study air-CO (ppm) COHb (%) CorrelationSmokers/
total
Pollard 2014
RGa median=0.4UGb median=5.8
(p<0.01)
RG median=0.96UG median=1.56
p=0.04NA 1/104
Eppler 2013
Post-SIc mean=0.8 Pre-SIc mean=3.6
p<0.0001
Post-SI mean=1.18 CI 95% (1.12-1.25)Pre-SI mean=1.76 CI 95% (1.62-1.91)
p<0.001NA 0/35
Bono 2007
mean=2.98ppmmean=3.41mg/m3 (SD=1.38)
range=[1.65-5.70]ppm
Non-smoker group mean=0.6 (SD=0.3)Smoker group mean=2.4 (SD=1.8)
Only in non-smoker group significant relationship (p<0.05) between
Ln(air-CO mg/m3) and COHb%52/260
Keyes 2001
BCd median=2ACe median=19
p=0.005
BC median=0.3AC median=1.2
p<0.001NA 0/22
Amitai 1998
range=[17-100]mean=61 (SD=24)
range= [1-11]mean=4 (SD=3)
Pearson correlation testr= 0.39, p=0.01 14/92
Chung 1994
range= [0.6-11.5] (24h CO exposure)
mean=5.4 (SD=2.5)range=[1.2-5.0]
mean=2.2 (SD=0.8) COHb=1.34+0.18CO, R=0.55 0/30
Creswell 2015 range=[45-165]
HGf mean= 13.0 (SD=3.6)SGg mean =9.7 (SD=3.0)
p<0.001NA 1/91
a) RG= rural group, b) UG= urban group, c) SI= Stove installation, d) AC= before cooking, e) BC=after cooking, f) HG=hockey-player group, g) SG=spectator group
Review on CO exposure and COHb levels in blood
The data from Modena’s centralized laboratory for blood samplesseems promising in order to an easy and systematic access toCOHb data within a CO poisoning surveillance framework.
Major strengths are the possibility to have surveillance data onCOHb levels for the general population and the possibility ofrecord linkage with other bio-chemical parameters and healthdatabases.
Some points needs to be scrutinized such as the relationshipbetween COHb levels and the various CO sources of exposures andpossibility to identify smoking individuals and those withpathologies leading to high COHb leves via cross analyses ofavailable parameters.
Conclusions and perspectives
A database of COHb levels in general population
Ministry of Health and Ministry of Justice funded a project to verifywhether indoor sources may induce bad air quality and health effects
In the period Sep 2015 – Aug 2016 monitoring campaigns were carriedout in 19 prisons located in different regions in Italy
Measurements included Temperature, Humidity, PM2.5, VOC and CO
Indoor air quality in prisons
Relevant Indoor sources of air pollution in prisons
One CO monitor in each prison
Instruments located in corridors, not in cells
Measurements campaigns were conducted with LANGAN T15z
Indoor air quality in prisons
In the coming weeks typical air quality conditions experienced by prisonerswithin cells will be reproduced defining a protocol based on questionnaires
0
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CO
[ppm
]
Indoor air quality in prisons
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
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200
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Num
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di o
reIndoor air quality in prisons
Num
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edan
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of75
°per
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Hyperbaric centres in Italy
34 4
31
1
61
5 1
124
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16
Hyperbaric Hoxygen Therapy
Number of patients treated for CO poisoning in each region
Region 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Lombardia 251 130 248 188 239 226 160 168 162 246
Emilia- Romagna 292 313 255 354 295 333 373 252 412 309
Veneto 173 165 201 131 185 177 168 132 173 174
Toscana 35 64 48 54 59 84 94 79 79 89
Liguria 20 61 56 42 40 28 48 51 62 55
Calabria 3 28 12 6 3 18 19 29 5 6
Lazio 35 48 29 13 28 83 50 58 31 45
Campania 22 0 7 12 11 12 11 8 9 23
Piemonte 154 174 135 167 192 211 233 114 154 131
Puglia 0 0 0 13 14 4 10 8 0 .
Trentino A.A. 45 38 38 12 45 28 44 50 29 31
Sardegna 7 10 8 1 11 15 24 12 0 25
Sicilia 12 23 7 1 5 39 31 17 19 15
Molise 0 0 16 13 4 2 7 7 2 .
Marche 9 10 14 28 12 47 0 2 57 49
Friuli 10 17 29 14 21 26 30 25 22 17
Hyperbaric Hoxygen Therapy
Hyperbaric Hoxygen Therapy
Treated patients / population (*100.000 inhab)
Regione 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Lombardia 2.672 1.372 2.598 1.950 2.453 2.300 1.613 1.732 1.654 2.467
Emilia- Romagna 7.034 7.475 6.038 8.279 6.800 7.576 8.415 5.805 9.412 6.950
Veneto 3.681 3.482 4.211 2.711 3.787 3.603 3.402 2.720 3.544 3.532
Toscana 0.973 1.768 1.319 1.469 1.591 2.252 2.507 2.154 2.139 2.373
Liguria 1.256 3.789 3.483 2.609 2.477 1.733 2.969 3.254 3.961 3.455
Calabria 0.149 1.397 0.601 0.299 0.149 0.896 0.945 1.481 0.255 0.303
Lazio 0.664 0.905 0.528 0.234 0.498 1.461 0.873 1.055 0.558 0.767
Campania 0.380 0.000 0.121 0.206 0.189 0.206 0.189 0.139 0.156 0.392
Piemonte 3.556 4.008 3.101 3.794 4.332 4.746 5.227 2.616 3.521 2.953
Puglia 0 0 0 0.319 0.343 0.098 0.244 0.198 0
Trentino A.A. 4.617 3.857 3.820 1.191 4.418 2.723 4.243 4.856 2.789 2.947
Sardegna 0.424 0.604 0.482 0.060 0.658 0.897 1.432 0.733 0 1.503
Sicilia 0.239 0.458 0.140 0.020 0.099 0.773 0.614 0.340 0.380 0.294
Molise 0 0 4.999 4.052 1.247 0.625 2.189 2.235 0.638
Marche 0.593 0.654 0.911 1.803 0.765 3.014 0 0.130 3.689 3.155
Friuli 0.830 1.407 2.392 1.146 1.706 2.107 2.428 2.053 1.801 1.383
Hyperbaric Hoxygen Therapy
Strengths
Weaknesses
• Lack of information on the severity of poisoning• Lack of informations about the cause(s) of poisoning (non-fire-
related/fire-related, unintentional/intentional)• No follow up of subjects
• Long time series of data• Good geographical distribution• Data related to residents and non-residents• Possible improvement of quality and quantity of information via
record linkage and questionnaires
Poison centers
9 Poison centers
MilanoTorino
Pavia
Firenze
Roma
Napoli
Padova
Genova
Thank you for your attention