Cardiovascular, respiratory, and total mortality ...

Environ Monit Assess (2016) 188:570 DOI 10.1007/s10661-016-5574-y

Cardiovascular, respiratory, and total mortality attributed to PM2.5 in Mashhad, Iran Ziaeddin Bonyadi & Mohammad Hasan Ehrampoush & Mohammad Taghi Ghaneian & Mehdi Mokhtari & Abbas Sadeghi

Received: 27 December 2015 / Accepted: 31 August 2016 # Springer International Publishing Switzerland 2016

Abstract Poor air quality is one of the most important environmental problems in many large cities of the world, which can cause a wide range of acute and chronic health effects, including partial physiological disorders and cardiac death due to respiratory and cardiovascular diseases. According to the latest edition of the national standard for air quality, maximum contamination level is 15 μg/m3 per year and 35 μg/m3 per day. The aim of this study was to evaluate cardiovascular, respiratory, and total mortality attributed to PM2.5 in the city of Mashhad during 2013. To this end, the Air Q model was used to assess health impacts of PM2.5 and human exposure to it. In this model, the attributable proportion of health outcome, annual number of excess cases of mortality for all causes, and cardiovascular and respiratory diseases were estimated. The results showed that the number of excess cases of mortality for all causes and cardiovascular and respiratory diseases attributable to PM2.5 was 32, 263, and 332 μg/m3, respectively. Moreover, the annual average of PM2.5 in Mashhad was obtained to be 37.85 μg/m3. This study demonstrated that a high percentage of mortality resulting Z. Bonyadi : M. H. Ehrampoush : M. T. Ghaneian : M. Mokhtari Department of Environmental Health Engineering, Faculty of Health, Shahid Sadoughi University of Medical Science, Yazd, Iran Z. Bonyadi : A. Sadeghi (*) Department of Environmental Health Engineering, Faculty of Health, Mashhad University of Medical Science, Mashhad, Iran e-mail: [email protected]

from this pollutant could be due to the high average concentration of PM2.5 in the city during 2013. In this case, using the particle control methods, such as optimal use of fuel, management of air quality in urban areas, technical inspection of vehicles, faster development of public transport, and use of industrial technology can be effective in reducing air pollution in cities and turning existing situations into preferred ones. Keywords PM2.5 . Cardiovascular mortality . Respiratory mortality . Total mortality

Introduction Poor air quality is one of the most important environmental problems in many large cities of the world, which can cause a wide range of acute and chronic health effects, including partial physiological disorders and cardiac death due to respiratory and cardiovascular diseases (Anonymous 1996; Richard et al. 2002; Arfaeinia et al. 2014; Education 2012 (In Persian)). Particle is one of the main air pollutants in urban areas, which is often produced from multiple sources including vehicle exhaust, industrial combustion, or secondary change of gaseous pollutants (Funasaka et al. 2000). The inhalation of pollutant particles in indoor air and the environment can cause harmful health effects and damage to humans (Chunram et al. 2007). Airborne particles have the size range of 0.001–500 μm, and their major portion is in the range of 0.1–10 μm (Griffin 2007. Almost 40 % of particles with the size between

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1 and 2 μm remain in the bronchi. Moreover, particles with the size between 0.25 and 1 μm, due to Brownian motion in the respiratory system, remain in the bronchi (Zallaghi et al. 2014 (In Persian); Tuan et al. 2015). According to the estimate by World Health Organization (WHO) in 2006, 5,000,000 people across the world prematurely die each year due to their lifetime exposure to airborne particulate matter (PM) and the rate of mortality resulting from air pollution with particles is equal to 6 % of the total mortality rate, almost half of which is caused by air pollutants emitted from cars. Size, concentration, and chemical composition are the most important features of particulate matters in the air. An airborne particulate matter adversely affects human health and ecosystems. Particulate matters with the diameter of less than 10 μm, because of entering into the lower respiratory system, are introduced as the main indicator of suspended matters in air. Particles with the diameter of less than 2.5 μm penetrate into the lungs and cause respiratory disorders (Heinsohn and Kabel 1999). According to the epidemiological evidence, heart disease is associated with air particulate matter. Results of studies show a close relationship between daily changes in the concentrations of particulate matters in the air and mortality from cardiovascular diseases, hospital admissions, and exacerbation of symptoms in patients with physiological premature reaction (Peters 2005). Environmental particles are considered an important indicator of outside air quality, and many health problems are associated with high concentrations of these particles. Studies have proven that exposure to particles in different sizes can increase the risk of heart disease and respiratory problems (Finkelstein et al. 1996; Bateson and Schwartz 2004). Elena et al. (2006) assessed the effects of exposure to particulate air pollution (PM10 and PM2.5) on health in Ukraine and estimated 46,000 death cases, 27,000 of which were related to cardiovascular, respiratory, and lung cancer diseases (Elena et al. 2006). Mate et al. (2010) investigated short-term effect of fine particulate matter (PM2.5) on daily mortality due to cardiovascular system-related diseases in Madrid (Spain) and showed that PM2.5 concentrations had a major impact on the death of cardiovascular patients (Mate et al. 2010). In another study, Geravandi (2010) examined health effects of exposure to particulate matter of less than 10 μm (PM10) in Ahvaz and found that the total number of mortality and cases of cardiovascular mortality were due to the presence of higher PM10 than the standard

level (Geravandi et al. 2014). Moreover, similar studies have been conducted by others to represent the relationship between PM2.5, cardiovascular diseases, and nervous system (Peters et al. 1997; Brook et al. 2002; Zanobetti et al. 2004; Urch et al. 2005). According to the latest edition of the national standard for air quality, maximum contamination level is 15 μg/m3 per year and 35 μg/m3 per day (EPA 2012). Mashhad is a metropolis in the northeast of Iran and is the capital city of Khorasan Razavi Province. The population of the city of Mashhad was 3.152 million people in 2013 (Ghaneian et al. 2014). The aim of this study was to evaluate cardiovascular, respiratory, and total mortality attributed to PM2.5 in the city of Mashhad during 2013.

Materials and methods In this study, the Air Q model was used for quantifying the cardiovascular and respiratory diseases attributed to PM2.5. This approach was adopted using the Air Quality Health Impact Assessment (AirQ 2.2.3) software developed by WHO European Centre for Environment Health, Bilthoven Division. The Air Q model was also used to estimate the impact of exposure to PM2.5 on the health of people living over a particular period of time and area. The assessment was based on attributable proportion (AP), defined as the fraction of the health outcome in a specific population attributable to exposure to a given atmospheric pollutant, assuming a proven causal relationship between exposure and health outcome and no major confounding effects in this regard. AP is calculated by the following general formula (Krzyzanowski, 1997; Naddafi et al. 2012a, b): AP ¼

∑f½RRðc−1 PðcÞg ∑½RRðcÞ PðcÞ:

where AP describes the attributable proportion of the health outcome, and RR and P(c) are the relative risk for a given health outcome and the proportion of population in “c” or considered category, respectively. If the baseline frequency of the health outcome in the studied population is known, the rate attributable to the exposure will be calculated as follows: IE ¼ I AP where IE describes the rate of health outcome attributable to the exposure, and I is the baseline frequency of


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the health outcome in the investigated population. Finally, the number of cases attributable to the exposure can be calculated as follows (Monn et al. 1997; Naddafi et al. 2012a, b):

NE ¼ IE N

where NE describes the number of cases attributed to the exposure, and N is the size of the studied population. RR describes the increase in the probability of the adverse effect associated with a given change in exposure levels and comes from time-series studies, where day-to-day changes in air pollutants over long periods are related to daily mortality, hospital admissions, and other public health indicators. The RR value used for PM2.5 was the summary of estimates obtained from the quantitative meta-analysis of peer-reviewed studies focused on European investigations (Anderson et al. 2004; Naddafi K Hassanvand M S 2012). Air concentrations of the selected PM2.5 in the city were determined by Mashhad Air Quality Control Corporation (M AQCC), Iran, using four permanent monitoring stations. Finally, the PM2.5 data from December 2012 to December 2013 were used. There were eight stations for the measurement of air pollution in Mashhad, some of which were based on WHO. Criteria for Air Quality Health Impact Assessment had invalid data for assessment. Finally, data on PM2.5 from Sadaf, Sajad, Daneshgah, and Khayyam stations that were consistently active during the period of the study were used. For PM2.5, the parameters required by the software (annual and seasonal maximum and annual 98th percentiles) were obtained, and concentrations were recorded to 10 μg/m3 categories, corresponding to equivalent exposure categories. Data were expressed as daily averages. Moreover, exposure was estimated considering the city of Mashhad as single agglomerate with the residential population of 3,152,000 people. Table 1 Summary of Annual 24 h PM2.5 concentrations (μg/ m3), (Ghaneian et al. 2014) Science

Results Table 1 shows the summary of the changes in the PM2.5 concentration in terms of microgram per cubic meter. Accordingly, the average annual, maximum annual, and annual 98th percentile of the PM2.5 concentration were 37.85, 302.96, and 97.08 μg/m3, respectively. Table 2 shows the estimate of relative risk indicators, attributable proportion, and number of excess cases for total mortality and cardiovascular and respiratory diseases. Further, Fig. 1 indicates the percentage of the days during which people were exposed to different concentrations of PM2.5. The obtained results showed that the annual average of PM2.5 in Mashhad was 3.8 times greater than the guideline values prescribed by WHO in 2005 (Organization 2005) and also 2.5 times greater than the guideline values prescribed by EPA in 2012.

Discussion This paper was a case study that used WHO approach to assess the impact of atmospheric pollution on the health of people living in the city of Mashhad. According to the results, the impacts of atmospheric pollution on human health included total mortality along with cardiovascular and respiratory diseases. The results showed that the average PM2.5 concentration within a period of 208 days in Mashhad was higher than the guideline values prescribed by WHO and European Union. In other words, the PM2.5 concentration was higher than the standard in more than half of the days during the year (almost 57 %). The results of a study conducted by Naddafi et al. showed that, in some cases, the average concentration of particulate matter exceeded the standard (Naddafi et al. 2008). In another study, Mirhoseini et al. (2013) demonstrated that the PM2.5 concentration was higher in densely populated areas, but yet lower than the standard (Mirhoseini et al. 2013). The results also showed that the maximum concentration of particles in cold seasons (autumn and winter) was higher than that in warm seasons (spring and summer),

Average warm season

Max warm season

Average cold season

Max cold season

Max annual

Percentile 98

Average annual

31.07

118.55

42.79

302.96

302.96

97.08

37.85

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Table 2 Estimated RR and AP for cardiovascular and respiratory mortality in case of PM2.5(Anderson et al., 2004; Naddafi K Hassanvand M S 2012) Mortality

Incidencea

RRb( 95 % CI) per 10 μg/m3

AP (%)

Estimated number of excess cases (persons)

Total

543

1.01 (1.008–1.013)

1.93

332

Cardiovascular

231

1.019 (1.005–1.032)

1.019

263

Respiratory

48.4

1.011 (1–1.21)

2.12

32

et al. 1997). High rate of mortality resulting from this pollutant could be attributed to the high average concentration of PM2.5 in 2013. It has been shown that using the particle control methods, such as optimal use of fuel, management of air quality in urban areas, development of green space and prevention from its destruction, technical inspection of vehicles, CNG and fuel injection, faster development of public transport, and utilization of industrial technology can be effective in reducing air pollution in cities and changing existing conditions to suitable ones (Golbaz and Jafari J 2008). This study has several limitations. One of the limitations is that the health effects attributed to air pollution may have been caused by interactions between various atmospheric contaminants and other natural components which could not be accuracy determined by the approach used in the study. These interactions are not monitored in evaluating the health effects, and this requires knowledge of the mechanisms of toxicity for different components of the atmosphere which is unfortunately rarely available. A further limitation related to the exposure assessment is that the PM2.5 values measured at the monitoring stations were assumed to be 35

32.39

30

29.96

25 20 15

18.62

17.41

0

0 60-69

40-49

0

30-39

5 1.62

50-59

10

20-29

which was probably due to the increasing activity of educational centers that can cause traffic volume to be increased in the city, especially in the city center. In a similar vein, Mohammad et al. (2007) in their study found that the concentration of particles in cold seasons (autumn and winter) was higher than that in the warm seasons. By considering the intermediate level of relative risk and incidence of 543.5 per 105 people each year, the results of Table 2 showed that the number of excess cases of total mortality was estimated as 332 people per year. Moreover, the results obtained in this study revealed air pollution in the city of Mashhad to have a very significant contribution to the mortality of people (except for accidents) from December 2012 to December 2013 (12 months). Accordingly, the authorities must take measures based on comprehensive scientific research as well as sustainable, stable, and effective approaches for the control of air pollution crisis in Mashhad. Fattore et al. (2011) estimated total mortality from PM10 and PM2.5 in the industrial areas of northern Italy with the population of 24,000 people in 2011 as about 177 people per year. Given the intermediate level of relative risk and the mortality rate of 231 per 105 people caused by cardiovascular diseases, the results in Table 2 showed the cumulative frequency of mortality cases to be 263. Furthermore, studies have demonstrated that the concentration of carbon particles with the size of less than 2.5 μm emitted from motor vehicles could lead to plaque deposition in the arteries and ultimately, to heart attacks and other cardiovascular problems (Pope et al. 2002). The results (Table 2) have also demonstrated that the cumulative frequency of death cases was 32 people, which was lower than the intermediate level of relative risk and base incidence of 48.45 per 105 people each year (Monn

10-19

Daily average

0-9

Crude rate per 100,000 inhabitants

b

% Person-days

a

Concentraon for PM2.5 (μg/m3)

Fig. 1 Percentage of days on which people in Mashhad are exposed to different concentrations of PM2.5


representative of the people’s average exposures to PM2.5 in Mashhad. Finally, another limitation of this study is RR estimates that have been obtained from studies conducted in Europe. If there is no persuasive document in which the evidentiary population and the target population differ in response to the air pollution, the transferability of the mortality effect estimates from the evidentiary population (e.g., the US cohort) to the target population is possible (Fattore et al. 2011; Naddafi et al. 2012a, b).

Conclusion In this study, PM2.5 was observed to have a significant impact on people’s health. In the model, the impact of PM2.5 on the health of people living in a certain area (Mashhad) was quantified using the AirQ software. The results were in line with those of other investigations, and despite the limitations in common with similar studies, it was shown that this method could offer an effective and easy tool which is helpful in decisionmaking. It is also suggested that using the particle control methods, such as optimal use of fuel, management of air quality in urban areas, development of green space and prevention from its destruction, technical inspection of vehicles, CNG and fuel injection, faster development of public transport, and utilization of industrial technology can be effective in reducing air pollution in cities and turning existing situations into preferred ones.

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