Environmentalepidemiology,RiskAssessmentandHealthImpactAssessment:what’satstake?

CarlaAnconaDepartmentofEpidemiology,LazioRegionalHealthService,RomeItaly

IEHIAofAirPolluBonandClimateChangeinMediterraneanAreasTrieste,23-27Aprile2018

ASLROMA E

SISTEMASANITARIOREGIONALE

Department ofEpidemiologyLazioRegionalHealthService-Italy

is the exposure to an environmental factor associated with an effect, or a change in the health status of population exposed?

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

Howcanweassessexposures?

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

exposureassessment:fromfixedmonitorstosensorsandsatellites

Dispersionmodel

Test simulation - hourly images

Vertical streamlines and concentrations across Campanile di Giotto

Vertical stream & conc, campanile - movie Total elapsed time = 1 h Frames time step = 100 sec

Streamlines and 3D concentration plumes

3D stream & conc - movie Total elapsed time = 1 h Frames time step = 100 sec

NO2 (Media annua)

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measured

com

pute

d

Valore limite per la protezione della salute:

40 µg m-3

Area Metropolitana

NO2 Concentrazioni medie annuali

Lessonlearnedondispersionmodelsandbiomonitoring

•  Dispersionmodelsusefulfor«footprint»•  Spa9aldifferencesinconcentra9onscouldbeusedto

rankindividuals•  Predictedabsolutevaluesdependonthequalityof

emissiondataandofthemeteomodels•  Biomonitoringofsomecontaminantsreflectsrecent

exposures•  Humancontamina9onismostlyduetoinges9on•  Aircontamina9onisaweakdeterminantofbodyburden•  Someassocia9onsemergedandindicatehuman

contamina9onrelatedtospecificsources

GlobalBurdenofDisease

•  Theburdenofdiseaseisthetotalquan9tyofillhealthcausedbyapar9culardiseaseorriskfactor.– Magnitudeofimpact

DefiniBonHealthRiskAssessment

• Ahumanhealthriskassessmentistheprocesstoes9matethenatureandprobabilityofadversehealtheffectsinhumanswhomaybeexposedtochemicals*incontaminatedenvironmentalmedia,noworinthefuture.[USEPA]• *Stressorsorenvironmentalhazard:•  Chemicals•  Radia9on•  Physical(dust,heat)•  (Micro)biological•  Nutri9onal(diet,fitness)•  Socio-economic(healthcareaccess)

objecBve:toesBmatetoxicityofasubstanceToolfortranslaBngthefindingsofresearchintoscience-basedriskmanagement

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

Riskassessment

Riskassessmentis,tothehighestextentpossible,ascien9ficprocess.Riskdependsonthefollowingfactors:•  Howmuchofachemicalispresentinanenvironmentalmedium(soil,water,air)

•  Howmuchcontact(exposure)apersonorecologicalreceptorhaswiththecontaminatedenvironmentalmedium

•  Theinherenttoxicityofthechemical.

the aim is to estimate the effect of exposure of interest

(the ambition would be to measure causal effects)

Exp+

cases cases

Exp-

EnvironmentalEpidemiology

§  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)

Life9mecourse

Schwartz, EHP 2002

toassessdose-responserelaBonshipsbetweenexposureandrisk

Cesaroni, 2013 EHP

Exposure-responserelaBonships

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)

PM10

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AcuteeffectsTemporaldifferences

ChroniceffectsSpaBaldifferences

Roma PM10 ed NO2

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

DefiniBonHIAAcombina9onofprocedures,methodsandtoolsbywhichapolicy,programorprojectmaybejudgedastoitspoten9aleffectsonthehealthofapopula9on,andthedistribu9onofthoseeffectswithinthepopula9on.[EuropeanCentreforHealthPolicy,WHORegionalOfficeforEurope.GothenburgConsensusPaper(1999)]

Background disease rates

Health impacts

Population

Source

Policy/intervention

Hazard 2 Hazard n

Hazard

Exposure

Dose-response Risk

Health impact assessment

Benefits

MajorstepsinHIA1.  SpecifypurposeandframeworkoftheHIA2. Decidewhichexposure-effectpathwayswillbe

quan9fied3.  Iden9fyandcharacterisepopula9onatrisk4.  Selectordevelopasuitablesetofexposure-response

func9ons(ERFs)5. Derivepopula9onexposuredistribu9on6. Es9matebackgrounddiseaserates7. Calculateburdenofdiseaseinpopula9on8. Valuatetheburdenofdisease9. Assessandquan9fyuncertaintyoftheHIA

ImpactpathwayPolicy

Emissions

Concentrations

Exposures

Impacts

Health effects Background disease rates

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

KeyfeaturesinIEHIA

•  Specificallydesignedtodealwithcomplexissues,usuallybeyondthescopeofhealthriskorimpactassessment

•  Bothposi9veandnega9veeffectsonhealth–theenvironmentasahazardandsourceofbeneficialresources(environmentalservicesandcapital);

•  Moreagen9onfordefiningtheproblem•  Providesasynop9candbalancedmeasureofimpacts,by

weigh9ngandsummingthevarioushealtheffects;•  Designedtobepar9cipatory–involveallkey

stakeholderswithinterestsintheissue.

Issueframing

•  Specifyingtheques9on•  Iden9fyingandengagingkeystakeholders•  Agreeinganoverallapproachtotheassessment(scoping)

•  Selec9ngandconstruc9ngthescenariosfortheassessment(diagnos9c,summa9veorprognos9c)

•  Definingtheindicatorsthatwillbeusedtodescribetheimpacts.

Protocol•  Studyareasandpopula9ons•  Scenarios•  Timescales(exposureperiods,impactperiods)•  Causalfactors,exposurepathwaysandhealthoutcomes•  Healtheffectsandassociatedimpacts•  Outcomeindicatorsusedtorepresenttheresults;•  Datasourcesandmodels•  Mainsourcesofuncertainty

Appraisal

•  Tobringtogether,communicateandinterprettheresultsoftheassessment.Thisinvolvestwokeysteps:– Repor9ngtheassessmentresults-i.e.deliveringthemtotheend-usersinasynthesisedandunderstandableform;

– Comparingandrankingoutcomes-i.e.iden9fyingandinterpre9ngthemessagesthattheresultsimply.

Environment and Health studies

ü MulBplesourcesü  Differentpathwaysü  VariableBmeofcontaminaBon

ü  PopulaBonsize(andsizeoftheexposedgroups)ü  Socioeconomicstatus(environmentaljusBce)

ü OccupaBonalexposure

ü OutcomesdefiniBonanddatacollecBonü  Enviromentalworriesandmediapressure

•  EnvironmentalScience•  Toxicology•  Laboratory&biomonitoring•  StaBsBcs•  Epidemiology•  OccupaBonalMedicine•  IndustrialHygiene•  Medicine•  PublicHealth•  ComunicaBon•  Journalism•  Law

Multidisciplinary context

thedisciplinerequireswell-trainedexperts!

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.

https://reteambientesalute.epiprev.it

Inconclusion,aclosecollabora9onofresearchers(thenetwork)isa“must”Suchcollabora9oncansupportthedevelopmentofpublichealthandhavealong-termposi9veimpactonpopula9onhealth

No CoI

Environmentalepidemiology,RiskAssessmentandHealthImpactAssessment:what’satstake?

CarlaAnconaDepartmentofEpidemiology,LazioRegionalHealthService,RomeItaly

ASLROMA E

SISTEMASANITARIOREGIONALE

Department ofEpidemiologyLazioRegionalHealthService-Italy

•  Long-termeffects– Ecologicalstudies(municipali9es,smallareasta9s9cs)

– Cross-sec9onal(biomonitoring)– Cohortstudies– Case-controls

Studydesign

DALYs=disability-adjusted life-years.

Global DALYs attributable to Level 2 risk factors for (A) men in 2015

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).

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.

•  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.