Cathryn Tonne

A Case–Control Analysis of Exposure to Traffic and Acute Myocardial Infarction

Background Long-term exposure to particulate air pollution has been associated with an increased risk of dying from cardiopulmonary and ischemic heart disease, yet few studies have evaluated cardiovascular end points other than mortality. We investigated the relationship between long-term exposure to traffic and occurrence of acute myocardial infarction (AMI) in a case–control study. Methods A total of 5,049 confirmed cases of AMI were identified between 1995 and 2003 as part of the Worcester Heart Attack Study, a community-wide study examining changes over time in the incidence of AMI among greater Worcester, Massachusetts, residents. Population controls were selected from Massachusetts resident lists. We used cumulative traffic within 100 m of subjects’ residence and distance from major roadway as proxies for exposure to traffic-related air pollution. We estimated the relationship between exposure to traffic and occurrence of AMI using logistic regression, and we adjusted for the following potential confounders: age, sex, section of the study area, point sources emissions of particulate matter with aerodynamic diameter < 2.5 μm, area socioeconomic characteristics, and percentage of open space. Results An increase in cumulative traffic near the home was associated with a 4% increase in the odds of AMI per interquartile range [95% confidence interval (CI), 2–7%], whereas living near a major roadway was associated with a 5% increase in the odds of AMI per kilometer (95% CI, 3–6%). Conclusions hese results provide support for an association between long-term exposure to traffic and the risk of AMI.

Air pollution and mortality benefits of the London Congestion Charge: spatial and socioeconomic inequalities

Objectives: To alleviate traffic congestion in Central London, the Mayor introduced the Congestion Charging Scheme (CCS) in February 2003. We modelled the impact of the CCS on levels of traffic pollutants, life expectancy and socioeconomic inequalities. Methods: Annual average NO2 and PM10 were modelled using an emission-dispersion model. We assumed the meteorology and vehicle fleet remained constant during the pre- and post-CCS periods to isolate changes due to traffic flow. Air pollution concentrations were linked to small area socioeconomic, population and mortality data. Associated changes in life expectancy were predicted using life table analysis and exposure-response coefficients from the literature. Results: Before the introduction of the CCS, annual average NO2 was 39.9 μg/m3 and PM10 was 26.2 μg/m3 across Greater London. Concentrations were 54.7 μg/m3 for NO2 and 30.3 μg/m3 for PM10 among census wards within or adjacent to the charging zone. Absolute and relative reductions in concentrations following the introduction of the CCS were greater among charging zone wards compared to remaining wards. Predicted benefits in the charging zone wards were 183 years of life per 100 000 population compared to 18 years among the remaining wards. In London overall, 1888 years of life were gained. More deprived areas had higher air pollution concentrations; these areas also experienced greater air pollution reductions and mortality benefits compared to the least deprived areas. Conclusions: The CCS, a localised scheme targeting traffic congestion, appears to have modest benefit on air pollution levels and associated life expectancy. Greater reductions in air pollution in more deprived areas are likely to make a small contribution to reducing socioeconomic inequalities in air pollution impacts.

Long-Term Survival After Acute Myocardial Infarction Is Lower in More Deprived Neighborhoods

Background—As part of the Worcester Heart Attack Study, a community-wide study examining changes over time in the incidence and long-term case-fatality rates of greater Worcester, Mass, residents hospitalized with confirmed acute myocardial infarction (AMI), we investigated the hypothesis that census tract–level socioeconomic position is an important predictor of survival after hospital discharge for AMI, after adjusting for demographic and clinical characteristics. Methods and Results—Data were available for 3423 confirmed cases of AMI among metropolitan Worcester residents during the 4 study years of 1995, 1997, 1999, and 2001 who were followed up through the end of 2002. The mean age among patients was 69 years, and 58% were men. Using a multilevel Cox proportional hazards regression model, we estimated a 30% higher death rate after AMI for patients living in census tracts with the most residents living below the poverty line compared with patients living in the wealthiest census tracts (relative risk=1.30; 95% CI, 1.08 to 1.56). Similarly, patients living in census tracts with the highest proportion of residents with less than a high school education experienced a 47% higher death rate than patients living in census tracts with the lowest proportion of residents with less than a high school education (relative risk=1.47; 95% CI, 1.15 to 1.88). Conclusions—Within a medium-sized urban area, there are important variations in survival after hospital discharge for AMI that are associated with socioeconomic position. These associations persist after adjustment for demographic and clinical characteristics. Reasons for these differences warrant further investigation.

Energy, energy efficiency, and the built environment

Since the last decades of the 19th century, technological advances have brought substantial improvements in the efficiency with which energy can be exploited to service human needs. That trend has been accompanied by an equally notable increase in energy consumption, which strongly correlates with socioeconomic development. Nonetheless, feasible gains in the efficiency and technology of energy use in towns and cities and in homes have the potential to contribute to the mitigation of greenhouse-gas emissions, and to improve health, for example, through protection against temperature-related morbidity and mortality, and the alleviation of fuel poverty. A shift towards renewable energy production would also put increasing focus on cleaner energy carriers, especially electricity, but possibly also hydrogen, which would have benefits to urban air quality. In low-income countries, a vital priority remains the dissemination of affordable technology to alleviate the burdens of indoor air pollution and other health effects in individuals obliged to rely on biomass fuels for cooking and heating, as well as the improvement in access to electricity, which would have many benefits to health and wellbeing.

Urban and transport planning related exposures and mortality : a health impact assessment for cities

Background: By 2050, nearly 70% of the global population is projected to live in urban areas. Because the environments we inhabit affect our health, urban and transport designs that promote healthy living are needed. Objective: We estimated the number of premature deaths preventable under compliance with international exposure recommendations for physical activity (PA), air pollution, noise, heat, and access to green spaces. Methods: We developed and applied the Urban and TranspOrt Planning Health Impact Assessment (UTOPHIA) tool to Barcelona, Spain. Exposure estimates and mortality data were available for 1,357,361 residents. We compared recommended with current exposure levels. We quantified the associations between exposures and mortality and calculated population attributable fractions to estimate the number of premature deaths preventable. We also modeled life-expectancy and economic impacts. Results: We estimated that annually, nearly 20% of mortality could be prevented if international recommendations for performance of PA; exposure to air pollution, noise, and heat; and access to green space were followed. Estimations showed that the greatest portion of preventable deaths was attributable to increases in PA, followed by reductions of exposure to air pollution, traffic noise, and heat. Access to green spaces had smaller effects on mortality. Compliance was estimated to increase the average life expectancy by 360 (95% CI: 219, 493) days and result in economic savings of 9.3 (95% CI: 4.9, 13.2) billion EUR/year. Conclusions: PA factors and environmental exposures can be modified by changes in urban and transport planning. We emphasize the need for a) the reduction of motorized traffic through the promotion of active and public transport and b) the provision of green infrastructure, both of which are suggested to provide opportunities for PA and for mitigation of air pollution, noise, and heat. Citation: Mueller N, Rojas-Rueda D, Basagaña X, Cirach M, Cole-Hunter T, Dadvand P, Donaire-Gonzalez D, Foraster M, Gascon M, Martinez D, Tonne C, Triguero-Mas M, Valentín A, Nieuwenhuijsen M. 2017. Urban and transport planning related exposures and mortality: a health impact assessment for cities. Environ Health Perspect 125:89–96; http://dx.doi.org/10.1289/EHP220

An approach for estimating the health effects of changes over time in air pollution: an illustration using cardio-respiratory hospital admissions in London.

Objectives First, we present a general analytical approach to estimating the association between medium-term changes in air pollution and health across small areas. As a specific illustration, we then applied the approach to data on London residents from a 4-year period to test whether reductions in traffic-related air pollution were associated with reductions in cardio-respiratory hospital admissions. Methods A binomial distribution was used to model change in admissions over time in each small area, which was measured as the proportion of admissions in 2003–2004 out of admissions over all study years (2001–2004). Annual average concentrations of nitrogen oxides (NOx) were modelled using an emissions-dispersion model. The association between change in NOx and change in hospital admissions was estimated using logistic regression and an instrumental variable approach. Results For some diagnostic groups, suggestive associations between reductions in NOx and reductions in admissions were observed, for example, OR=0.97 (95% CI 0.96 to 0.99) for an IQR decrease in NOx (3 μg/m3) and all respiratory admissions. Accounting for spatial dependence attenuated several of the associations; for respiratory admissions, the OR was 1.00 (95% CI 0.98 to 1.02), leaving only that for bronchiolitis significant (OR=0.91; 95% CI 0.84 to 0.99). In this particular illustration, the instrumental variable approach did not appear to add information. Conclusions In this illustration, there was relatively limited power to detect an association between changes in air pollution and hospital admissions over time. However, the analytical approach could deliver more robust estimates of the health effects of changes in air pollution in settings with greater spatial contrast in changes in air pollution over time.

Integrated assessment of exposure to PM2.5 in South India and its relation with cardiovascular risk: Design of the CHAI observational cohort study

While there is convincing evidence that fine particulate matter causes cardiovascular mortality and morbidity, little of the evidence is based on populations outside of high income countries, leaving large uncertainties at high exposures. India is an attractive setting for investigating the cardiovascular risk of particles across a wide concentration range, including concentrations for which there is the largest uncertainty in the exposure-response relationship. CHAI is a European Research Council funded project that investigates the relationship between particulate air pollution from outdoor and household sources with markers of atherosclerosis, an important cardiovascular pathology. The project aims to (1) characterize the exposure of a cohort of adults to particulate air pollution from household and outdoor sources (2) integrate information from GPS, wearable cameras, and continuous measurements of personal exposure to particles to understand where and through which activities people are most exposed and (3) quantify the association between particles and markers of atherosclerosis. CHAI has the potential to make important methodological contributions to modeling air pollution exposure integrating outdoor and household sources as well as in the application of wearable camera data in environmental exposure assessment.

Health impacts related to urban and transport planning: A burden of disease assessment

INTRODUCTION Until now, estimates of the Global Burden of Disease (GBD) have mainly been produced on national or regional levels. These general estimates, however, are less useful for city governments who have to take decisions on local scales. To address this gap, we focused on the city-level burden of disease (BD) due to exposures affected by urban and transport planning. We conducted a BD assessment using the Urban and Transport Planning Health Impact Assessment (UTOPHIA) tool to estimate annual preventable morbidity and disability-adjusted life-years (DALYs) under compliance with international exposure recommendations for physical activity (PA), exposure to air pollution, noise, heat, and access to green spaces in Barcelona, Spain. METHODS Exposure estimates and morbidity data were available for 1,357,361 Barcelona residents ≥20years (2012). We compared recommended with current exposure levels to estimate the associated BD. We quantified associations between exposures and morbidities and calculated population attributable fractions to estimate the number of attributable cases. We calculated DALYs using GBD Study 2015 background DALY estimates for Spain, which were scaled to Barcelona considering differences in population size, age and sex structures. We also estimated annual health costs that could be avoided under compliance with exposure recommendations. RESULTS Not complying with recommended levels for PA, air pollution, noise, heat and access to green spaces was estimated to generate a large morbidity burden and resulted in 52,001 DALYs (95% CI: 42,866-61,136) in Barcelona each year (13% of all annual DALYs). From this BD 36% (i.e. 18,951 DALYs) was due to traffic noise with sleep disturbance and annoyance contributing largely (i.e. 10,548 DALYs). Non-compliance was estimated to result in direct health costs of 20.10 million € (95% CI: 15.36-24.83) annually. CONCLUSIONS Non-compliance of international exposure recommendations was estimated to result in a considerable BD and in substantial economic expenditure each year in Barcelona. Our findings suggest that (1) the reduction of motor traffic together with the promotion of active transport and (2) the provision of green infrastructure would result in a considerable BD avoided and substantial savings to the public health care system, as these measures can provide mitigation of noise, air pollution and heat as well as opportunities for PA promotion.

Associations of night-time road traffic noise with carotid intima-media thickness and blood pressure: The Whitehall II and SABRE study cohorts

BACKGROUND Road traffic noise has been linked to increased risk of stroke, for which hypertension and carotid intima-media thickness (cIMT) are risk factors. A link between traffic noise and hypertension has been established, but there are few studies on blood pressure and no studies on cIMT. OBJECTIVES To examine cross-sectional associations for long-term exposure to night-time noise with cIMT, systolic blood pressure (SBP), diastolic blood pressure (DBP) and hypertension. METHODS The study population consisted of 2592 adults from the Whitehall II and SABRE cohort studies living within Greater London who had cIMT, SBP and DBP measured. Exposure to night-time road traffic noise (A-weighted dB, referred to as dBA) was estimated at each participants residential postcode centroid. RESULTS Mean night-time road noise levels were 52dBA (SD=4). In the pooled analysis adjusted for cohort, sex, age, ethnicity, marital status, smoking, area-level deprivation and NOx there was a 9.1μm (95% CI: -7.1, 25.2) increase in cIMT in association with 10dBA increase in night-time noise. Analyses by noise categories of 55-60dBA (16.2μm, 95% CI: -8.7, 41.2), and >60dBA (21.2μm, 95% CI: -2.5, 44.9) vs. <55dBA were also positive but non-significant, expect among those not using antihypertensive medication and exposed to >60dBA vs. <55dBA (32.6μm, 95% CI: 6.2, 59.0). Associations for SBP, DPB and hypertension were close to null. CONCLUSIONS After adjustments, including for air pollution, the association between night-time road traffic noise and cIMT was only observed among non-medication users but associations with blood pressure and hypertension were largely null.

New frontiers for environmental epidemiology in a changing world

BACKGROUND In the next 25years, transformative changes, in particular the rapid pace of technological development and data availability, will require environmental epidemiologists to prioritize what should (rather than could) be done to most effectively improve population health. OBJECTIVES In this essay, we map out key driving forces that will shape environmental epidemiology in the next 25years. We also identify how the field should adapt to best take advantage of coming opportunities and prepare for challenges. DISCUSSION Future environmental epidemiologists will face a world shaped by longer lifespans but also larger burdens of chronic health conditions; shifting populations by region and into urban areas; and global environmental change. Rapidly evolving technologies, particularly in sensors and OMICs, will present opportunities for the field. How should it respond? We argue, the field best adapts to a changing world by focusing on healthy aging; evidence gaps, especially in susceptible populations and low-income countries; and by developing approaches to better handle complexity and more formalized analysis. CONCLUSIONS Environmental epidemiology informing disease prevention will continue to be valuable. However, the field must adapt to remain relevant. In particular, the field must ensure that public health importance drives research questions, while seizing the opportunities presented by new technologies. Environmental epidemiologists of the future will require different, refined skills to work effectively across disciplines, ask the right questions, and implement appropriate study designs in a data-rich world.