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Health Effects Institute Research Report 171: Multicity Study of Air Pollution and Mortality in Latin America (The ESCALA Study)

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Health Effects Institute Research Report 171: Multicity Study of Air Pollution and Mortality in Latin America (The ESCALA Study) RESEARCH REPORT HEA L TH HEA L TH Multicity Study of Air Pollution and EFFE CTS EFFE CTS Mortality in Latin America INSTITUTE INSTITUTE (the ESCALA Study) 101 Federal Street, Suite 500 Boston, MA 02110, USA Number 171 Isabelle Romieu, Nelson Gouveia, and Luis A. Cifuentes +1-617-488-2300 October 2012 www.healtheffects.org Brazil Investigators: Antonio Ponce de Leon, Washington Junger RESEARCH Chile Investigators: Jeanette Vera, Valentina Strappa REPORT México Investigators: Magali Hurtado-Díaz, Number 171 Victor Miranda-Soberanis, Leonora Rojas-Bracho, October 2012 Luz Carbajal-Arroyo, and Guadalupe Tzintzun-Cervantes Includes a Commentary by the Institute’s Health Review Committee Multicity Study of Air Pollution and Mortality in Latin America (the ESCALA Study) Isabelle Romieu, Nelson Gouveia, and Luis A. Cifuentes Brazil Investigators: Antonio Ponce de Leon, Washington Junger Chile Investigators: Jeanette Vera, Valentina Strappa México Investigators: Magali Hurtado-Díaz, Victor Miranda-Soberanis, Leonora Rojas-Bracho, Luz Carbajal-Arroyo, and Guadalupe Tzintzun-Cervantes with a Commentary by the HEI Health Review Committee Research Report 171 Health Effects Institute Boston, Massachusetts Trusted Science · Cleaner Air · Better Health Publishing history: This document was posted at www.healtheffects.org in October 2012. Citation for whole document: Romieu I, Gouveia N, Cifuentes LA, Ponce de Leon A, Junger W, Hurtado-Díaz M, Miranda-Soberanis V, Vera J, Strappa V, Rojas-Bracho L, Carbajal-Arroyo L, Tzintzun-Cervantes G. 2012. Multicity Study of Air Pollution and Mortality in Latin America (the ESCALA Study). Research Report 171. Health Effects Institute, Boston, MA. © 2012 Health Effects Institute, Boston, Mass., U.S.A. Cameographics, Belfast, Me., Compositor. Printed by Recycled Paper Printing, Boston, Mass. Library of Congress Catalog Number for the HEI Report Series: WA 754 R432. Cover paper: made with at least 55% recycled content, of which at least 30% is post-consumer waste; free of acid and elemental chlorine.Text paper: made with at l00% post-consumer waste recycled content; acid free; no chlorine used in processing. The book is printed with soy-based inks and is of permanent archival quality. CONTENTS About HEI v About This Report vii HEI STATEMENT 1 INVESTIGATORS’ REPORT by Romieu et al. 5 ABSTRACT 5 Introduction 5 Methods 5 Results 6 Conclusions 7 INTRODUCTION 7 SPECIFIC AIMS 8 METHODS 8 Study Design and Area 8 Databases 8 Workshops 16 Statistical Analyses 16 RESULTS 21 Description of Databases 21 Time-Series Analyses 21 Results Stratified by SES 36 Meta-Analyses and Meta-Regression Analyses 41 DISCUSSION 62 Summary of Results 63 Methodologic Issues 64 Heterogeneity 66 Limitations 66 Summary and Future Research 68 ACKNOWLEDGMENTS 69 REFERENCES 69 APPENDIX A. HEI Quality Assurance Statement 72 APPENDIX B. QA/QC Mortality Data Protocol 72 APPENDIX C. QA/QC Air Pollution Data Protocol 73 APPENDIX D. Monitor Specification Protocol 74 APPENDIX E. Time-Series Analysis Protocol 78 APPENDIX F. SES Index Protocol 80 APPENDICES AVAILABLE ON THE WEB 83 ABOUT THE AUTHORS 83 Research Report 171 OTHER PUBLICATIONS RESULTING FROM THIS RESEARCH 85 ABBREVIATIONS AND OTHER TERMS 85 COMMENTARY by the Health Review Committee 87 INTRODUCTION 87 SCIENTIFIC BACKGROUND 88 STUDY SUMMARY 89 Objectives 89 Methods 90 SUMMARY OF MAJOR RESULTS 92 City-Level Analyses 92 Meta-Analyses and Meta-Regression Analyses 93 HEI EVALUATION OF THE STUDY 93 Mortality and Air Pollution Data 96 Statistical Analyses 96 Results and Interpretation 99 Summary and Conclusions 101 ACKNOWLEDGMENTS 102 REFERENCES 102 Related HEI Publications 105 HEI Board, Committees, and Staff 107 ABOUT HEI The Health Effects Institute is a nonprofit corporation chartered in 1980 as an independent research organization to provide high-quality, impartial, and relevant science on the effects of air pollution on health.To accomplish its mission, the institute • Identifies the highest-priority areas for health effects research; • Competitively funds and oversees research projects; • Provides intensive independent review of HEI-supported studies and related research; • Integrates HEI’s research results with those of other institutions into broader evaluations; and • Communicates the results of HEI’s research and analyses to public and private decision makers. HEI typically receives half of its core funds from the U.S. Environmental Protection Agency and half from the worldwide motor vehicle industry. Frequently, other public and private organizations in the United States and around the world also support major projects or research programs.The ESCALA study was supported with primary funding from the William and Flora Hewlett Foundation. HEI has funded more than 280 research projects in North America, Europe, Asia, and Latin America, the results of which have informed decisions regarding carbon monoxide, air toxics, nitrogen oxides, diesel exhaust, ozone, particulate matter, and other pollutants.These results have appeared in the peer-reviewed literature and in more than 200 comprehensive reports published by HEI. HEI’s independent Board of Directors consists of leaders in science and policy who are committed to fostering the public–private partnership that is central to the organization.The Health Research Committee solicits input from HEI sponsors and other stakeholders and works with scientific staff to develop a Five-Year Strategic Plan, select research projects for funding, and oversee their conduct.The Health Review Committee, which has no role in selecting or overseeing studies, works with staff to evaluate and interpret the results of funded studies and related research. All project results and accompanying comments by the Health Review Committee are widely disseminated through HEI’sWeb site (www.healtheffects.org), printed reports, newsletters and other publications, annual conferences, and presentations to legislative bodies and public agencies. v ABOUT THIS REPORT Research Report 171, Multicity Study of Air Pollution and Mortality in Latin America (the ESCALA Study), presents a research project funded by the Health Effects Institute and conducted by Dr. Isabelle Romieu, formerly of the Instituto Nacional de Salud Pública, Cuernavaca, Morelos, México, and her colleagues.This report contains three main sections. The HEI Statement, prepared by staff at HEI, is a brief, nontechnical summary of the study and its findings; it also briefly describes the Health Review Committee’s comments on the study. The Investigators’ Report, prepared by Romieu and colleagues, describes the scientific background, aims, methods, results, and conclusions of the study. The Commentary is prepared by members of the Health Review Committee with the assistance of HEI staff; it places the study in a broader scientific context, points out its strengths and limitations, and discusses remaining uncertainties and implications of the study’s findings for public health and future research. This report has gone through HEI’s rigorous review process. When an HEI-funded study is completed, the investigators submit a draft final report presenting the background and results of the study.This draft report is first examined by outside technical reviewers and a biostatistician. The report and the reviewers’ comments are then evaluated by members of the Health Review Committee, an independent panel of distinguished scientists who have no involvement in selecting or overseeing HEI studies. During the review process, the investigators have an opportunity to exchange comments with the Review Committee and, as necessary, to revise their report.The Commentary reflects the information provided in the final version of the report. vii HEI STATEMENT Synopsis of Research Report 171 Multicity Study of Air Pollution and Mortality in Latin America (the ESCALA Study) BACKGROUND APPROACH For nearly two decades, scientists seeking to The primary objective of the ESCALA study was understand the role that air pollution might play in to estimate the effect of daily exposures to PM10 population health effects have relied heavily on (particulate matter Յ 10 µm in aerodynamic diam- epidemiologic studies known as time-series eter) and to ozone on daily mortality from several studies. Time-series studies use information on causes (all natural causes, cardiopulmonary dis- daily changes in air pollutant concentrations and ease, respiratory disease, cardiovascular disease, daily counts of mortality and morbidity. Although cerebrovascular–stroke, and chronic obstructive initially conducted at the individual city level, pulmonary disease) and for several age groups (all- coordinated analyses across many cities have age, Ն 65 years, < 1 year, 1–4 years, 1–14 years) in recently emerged as the tool of choice for devel- nine Latin American cities, and for the region as a oping more reliable and comparable estimates of whole, using a common analytic framework. The the short-term effects of air pollution on health in nine cities were Monterrey, Toluca, and Mexico regions around the world. HEI has a long-standing City in México; Rio de Janeiro, São Paulo, and Porto interest in these coordinated analyses; it has funded Alegre in Brazil; and Santiago, Concepción, and studies such as the National Morbidity, Mortality, Temuco in Chile. Of these, three cities (Porto and Air Pollution Study; Air Pollution and Health: Alegre, Concepción, and Temuco) were excluded A European and North American Approach; and from the ozone analyses because of the lack of
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