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Environmentalepidemiology,RiskAssessmentandHealthImpactAssessment:what’satstake?
CarlaAnconaDepartmentofEpidemiology,LazioRegionalHealthService,RomeItaly
IEHIAofAirPolluBonandClimateChangeinMediterraneanAreasTrieste,23-27Aprile2018
ASLROMA E
SISTEMASANITARIOREGIONALE
Department ofEpidemiologyLazioRegionalHealthService-Italy
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is the exposure to an environmental factor associated with an effect, or a change in the health status of population exposed?
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We need: ü an exposure that can be
measured/estimated ü a completed pathway ü an exposed population (and an
unexposed) ü a measurable effect that is
plausibly related to the exposure
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Howcanweassessexposures?
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Biomonitoring the concentrations of biomarkers in
blood or in urine allows to assess the human
contamination to environmental pollutants through all routes of
exposure Contamination of soil, plants and animals
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exposureassessment:fromfixedmonitorstosensorsandsatellites
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Dispersionmodel
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Test simulation - hourly images
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Vertical streamlines and concentrations across Campanile di Giotto
Vertical stream & conc, campanile - movie Total elapsed time = 1 h Frames time step = 100 sec
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Streamlines and 3D concentration plumes
3D stream & conc - movie Total elapsed time = 1 h Frames time step = 100 sec
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NO2 (Media annua)
0
20
40
60
80
100
0 20 40 60 80 100
measured
com
pute
d
Valore limite per la protezione della salute:
40 µg m-3
Area Metropolitana
NO2 Concentrazioni medie annuali
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Lessonlearnedondispersionmodelsandbiomonitoring
• Dispersionmodelsusefulfor«footprint»• Spa9aldifferencesinconcentra9onscouldbeusedto
rankindividuals• Predictedabsolutevaluesdependonthequalityof
emissiondataandofthemeteomodels• Biomonitoringofsomecontaminantsreflectsrecent
exposures• Humancontamina9onismostlyduetoinges9on• Aircontamina9onisaweakdeterminantofbodyburden• Someassocia9onsemergedandindicatehuman
contamina9onrelatedtospecificsources
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GlobalBurdenofDisease
• Theburdenofdiseaseisthetotalquan9tyofillhealthcausedbyapar9culardiseaseorriskfactor.– Magnitudeofimpact
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DefiniBonHealthRiskAssessment
• Ahumanhealthriskassessmentistheprocesstoes9matethenatureandprobabilityofadversehealtheffectsinhumanswhomaybeexposedtochemicals*incontaminatedenvironmentalmedia,noworinthefuture.[USEPA]• *Stressorsorenvironmentalhazard:• Chemicals• Radia9on• Physical(dust,heat)• (Micro)biological• Nutri9onal(diet,fitness)• Socio-economic(healthcareaccess)
objecBve:toesBmatetoxicityofasubstanceToolfortranslaBngthefindingsofresearchintoscience-basedriskmanagement
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Noise, air pollution
How much risk ↑ when exposed?
YLL (Years of life lost), DALY‘s or Costs
PM10 Konzentration [µg/m≥]0 102030
0204060
80100Anzahl F‰lle
2. Exposure assessment
3. Exposure- outcome association
4. Risk characterization
Number of attributable cases = exposure x exposure-outcome association
1. Hazard identification
HealthRiskAssessment
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Riskassessment
Riskassessmentis,tothehighestextentpossible,ascien9ficprocess.Riskdependsonthefollowingfactors:• Howmuchofachemicalispresentinanenvironmentalmedium(soil,water,air)
• Howmuchcontact(exposure)apersonorecologicalreceptorhaswiththecontaminatedenvironmentalmedium
• Theinherenttoxicityofthechemical.
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the aim is to estimate the effect of exposure of interest
(the ambition would be to measure causal effects)
Exp+
cases cases
Exp-
EnvironmentalEpidemiology
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§ Insulin Resistance § Type 2 diabetes § Type 1 diabetes § Bone metabolism
§ Skin Aging
§ Stroke § Neurological development § Mental Health § Neurodegenerative diseases
§ Cardiovascular Disease Mortality § Cardiovascular Disease Morbidity § Myocardial Infarction § Arrhythmia § Congestive Heart Failure § Changes in Heart Rate Variability § ST-Segment Depression
§ Premature Birth § Decreased Birth Weight § Decreased foetal growth § In uterine growth retardation § Decreased sperm quality § Preclampsia
§ High blood pressure § Endothelial dysfunction § Increased blood coagulation § Systemic inflammation § Deep Venous Thrombosis
§ Respiratory Disease Mortality § Respiratory Disease Morbidity § Lung Cancer § Pneumonia § Upper and lower respiratory symptoms § Airway inflammation § Decreased lung function § Decreased lung growth
Joint ERS / ATS statement (ERJ, i2017)
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Life9mecourse
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Schwartz, EHP 2002
toassessdose-responserelaBonshipsbetweenexposureandrisk
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Cesaroni, 2013 EHP
Exposure-responserelaBonships
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effects of air pollution short-term and long-term effects Short-term increase in mortality Short- term increase in morbidity (cardiovascular and respiratory conditions) Decreased survival Increased lung cancer risk (although there is probably a continuum of
effects in the time scale, which are not yet fully understood)
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PM10
0
10
20
30
40
50
60
70
80
90
100
apr-01
lug-01
ott-01
gen-02
apr-02
lug-02
ott-02
gen-03
apr-03
lug-03
ott-03
gen-04
apr-04
lug-04
ott-04
gen-05
apr-05
lug-05
ott-05
AcuteeffectsTemporaldifferences
ChroniceffectsSpaBaldifferences
Roma PM10 ed NO2
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Epidemiology is one of the essential disciplines of public health, its major aim is to contribute to fulfilment of the definition of public health as “a science and art to promote health and prevent disease by organized effort of society”.
However, to improve the health status of the
population, the knowledge produced by epidemiology needs to be used and translated into intervention
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DefiniBonHIAAcombina9onofprocedures,methodsandtoolsbywhichapolicy,programorprojectmaybejudgedastoitspoten9aleffectsonthehealthofapopula9on,andthedistribu9onofthoseeffectswithinthepopula9on.[EuropeanCentreforHealthPolicy,WHORegionalOfficeforEurope.GothenburgConsensusPaper(1999)]
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Background disease rates
Health impacts
Population
Source
Policy/intervention
Hazard 2 Hazard n
Hazard
Exposure
Dose-response Risk
Health impact assessment
Benefits
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MajorstepsinHIA1. SpecifypurposeandframeworkoftheHIA2. Decidewhichexposure-effectpathwayswillbe
quan9fied3. Iden9fyandcharacterisepopula9onatrisk4. Selectordevelopasuitablesetofexposure-response
func9ons(ERFs)5. Derivepopula9onexposuredistribu9on6. Es9matebackgrounddiseaserates7. Calculateburdenofdiseaseinpopula9on8. Valuatetheburdenofdisease9. Assessandquan9fyuncertaintyoftheHIA
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ImpactpathwayPolicy
Emissions
Concentrations
Exposures
Impacts
Health effects Background disease rates
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DefiniBonIEHIAAmeansofassessinghealth-relatedproblemsderivingfromtheenvironment,andhealth-relatedimpactsofpoliciesandotherinterven9onsthataffecttheenvironment,inwaysthattakeaccountofthecomplexi9es,interdependenciesanduncertain9esoftherealworld.Websites:
hgp://www.integrated-assessment.euhgp://en.opasnet.org/w/IEHIAS
EUfundedprojects:INTARESEandHEIMTSAKeyreferences:
Briggs2008.DOI:10.1186/1476-069X-7-61
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KeyfeaturesinIEHIA
• Specificallydesignedtodealwithcomplexissues,usuallybeyondthescopeofhealthriskorimpactassessment
• Bothposi9veandnega9veeffectsonhealth–theenvironmentasahazardandsourceofbeneficialresources(environmentalservicesandcapital);
• Moreagen9onfordefiningtheproblem• Providesasynop9candbalancedmeasureofimpacts,by
weigh9ngandsummingthevarioushealtheffects;• Designedtobepar9cipatory–involveallkey
stakeholderswithinterestsintheissue.
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Issueframing
• Specifyingtheques9on• Iden9fyingandengagingkeystakeholders• Agreeinganoverallapproachtotheassessment(scoping)
• Selec9ngandconstruc9ngthescenariosfortheassessment(diagnos9c,summa9veorprognos9c)
• Definingtheindicatorsthatwillbeusedtodescribetheimpacts.
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Protocol• Studyareasandpopula9ons• Scenarios• Timescales(exposureperiods,impactperiods)• Causalfactors,exposurepathwaysandhealthoutcomes• Healtheffectsandassociatedimpacts• Outcomeindicatorsusedtorepresenttheresults;• Datasourcesandmodels• Mainsourcesofuncertainty
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Appraisal
• Tobringtogether,communicateandinterprettheresultsoftheassessment.Thisinvolvestwokeysteps:– Repor9ngtheassessmentresults-i.e.deliveringthemtotheend-usersinasynthesisedandunderstandableform;
– Comparingandrankingoutcomes-i.e.iden9fyingandinterpre9ngthemessagesthattheresultsimply.
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Environment and Health studies
ü MulBplesourcesü Differentpathwaysü VariableBmeofcontaminaBon
ü PopulaBonsize(andsizeoftheexposedgroups)ü Socioeconomicstatus(environmentaljusBce)
ü OccupaBonalexposure
ü OutcomesdefiniBonanddatacollecBonü Enviromentalworriesandmediapressure
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• EnvironmentalScience• Toxicology• Laboratory&biomonitoring• StaBsBcs• Epidemiology• OccupaBonalMedicine• IndustrialHygiene• Medicine• PublicHealth• ComunicaBon• Journalism• Law
Multidisciplinary context
thedisciplinerequireswell-trainedexperts!
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Integra9on
• Without the participation of epidemiologists in risk assessments, the fields of risk assessment and epidemiology are likely to become unnecessarily and artificially segregated.
• On the other hand, the epidemiologist who moves from the research to the risk assessment arena needs to be prepared for the shift from hypothesis-testing to application.
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https://reteambientesalute.epiprev.it
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Inconclusion,aclosecollabora9onofresearchers(thenetwork)isa“must”Suchcollabora9oncansupportthedevelopmentofpublichealthandhavealong-termposi9veimpactonpopula9onhealth
No CoI
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Environmentalepidemiology,RiskAssessmentandHealthImpactAssessment:what’satstake?
CarlaAnconaDepartmentofEpidemiology,LazioRegionalHealthService,RomeItaly
ASLROMA E
SISTEMASANITARIOREGIONALE
Department ofEpidemiologyLazioRegionalHealthService-Italy
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• Long-termeffects– Ecologicalstudies(municipali9es,smallareasta9s9cs)
– Cross-sec9onal(biomonitoring)– Cohortstudies– Case-controls
Studydesign
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DALYs=disability-adjusted life-years.
Global DALYs attributable to Level 2 risk factors for (A) men in 2015
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Samet et al, 1998 n The 1983 National Research Council report: risk
assessment as a tool for translating the findings of research into science-based risk management strategies.
n Risk assessment evaluates and incorporates the findings of all relevant lines of investigation, from the molecular to the population levels, through the application of a systematic process
n four elements of risk assessment : hazard identification, dose-response assessment, exposure assessment,and risk characterization (table 1).
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Some epidemiologists may not accept a distinction between "risk assessment" as defined above and the practice of epidemiology, since a primary objective of epidemiologic research is to measure or assess the risk of disease in a group of individuals. Epidemiologic research also describes exposures to populations and assesses dose-response relationships between exposure and risk, two components of risk assessment. Hazard identification seems indistinguishable from assessing causality, which is fundamental to interpreting epidemiologic evidence. Risk characterization is similar to extending findings from one population to others—i.e., assessing the generalizability of a study's results and perhaps to estimating the attributable risk.
Thus, on first look, the formalism of risk assessment may seem a somewhat confusing and arbitrary redefinition of common epidemiologic practice.
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• Education for epidemiologists should begin to incorporate training in risk assessment and other approaches for the translation of epidemiologic evidence into policy. Epidemiologic curricula in academic institutions have focused on research methods, leaving the uses of research findings for policy purposes to be illustrated by anecdote.
• This void should be filled with offerings on the use of epidemiologic evidence in policy-making generally and on risk assessment specifically.
• We need to educate epidemiologists who can enter policy-making arenas and work there comfortably and effectively.