HEI Research Report Air Pollution and Health: a European and North

R EPO R T 142 RESEA R C H R E P O R T Air Pollution and Health: A HE A L TH A Air and European Pollution and Health: AmericanNorth Approach HE A L TH EFF E CTS EFF E CTS European and North American INSTITUTE INSTITUTE Approach (APHENA) 101 Federal Street, Suite 500 Boston, MA 02110, USA Number 142 Klea Katsouyanni and Jonathan M. Samet +1-617-488-2300 October 2009 www.healtheffects.org Europe Investigators: H. Ross Anderson, Richard Atkinson, Alain Le Tertre, Sylvia Medina, PRESS Evangelia Samoli, and Giota Touloumi RESEA R CH VERSION REPO R T Canada Investigators: Richard T. Burnett, Daniel Krewski, Timothy Ramsay Number 142 United States Investigators: Francesca Dominici, October 2009 Roger D. Peng, Joel Schwartz, and Antonella Zanobetti Includes a Commentary by the Institute’s Health Review Committee October 2009 October Air Pollution and Health: A European and North American Approach (APHENA) Klea Katsouyanni, and Jonathan M. Samet Europe Investigators: H. Ross Anderson, Richard Atkinson, Alain Le Tertre, Sylvia Medina, Evangelia Samoli, and Giota Touloumi Canada Investigators: Richard T. Burnett, Daniel Krewski, Timothy Ramsay United States Investigators: Francesca Dominici, Roger D. Peng, Joel Schwartz, and Antonella Zanobetti with a Commentary by the HEI Health Review Committee Research Report 142 Health Effects Institute Boston, Massachusetts Trusted Science · Cleaner Air · Better Health Publishing history: The Web version of this document was posted at www.healtheffects.org in October 2009 and then finalized for print. Citation for whole document: Katsouyanni K, Samet J, Anderson HR, Atkinson R, Le Tertre A, Medina S, Samoli E, Touloumi G, Burnett RT, Krewski D, Ramsay T, Dominici F, Peng RD, Schwartz J, Zanobetti A. 2009. Air Pollution and Health: A European and North American Approach (APHENA). HEI Research Report 142. Health Effects Institute, Boston, MA. When specifying a section of this report, cite it as a chapter of the whole document. © 2009 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 vi HEI STATEMENT 1 INVESTIGATORS’ REPORT by Klea Katsouyanni and Jonathan M. Samet et al. 5 ABSTRACT 5 Introduction 5 Methods 5 Results 6 Conclusions 6 INTRODUCTION 6 METHOD 7 Overview 7 Description of Databases 8 First-Stage Analysis: City-Specific Time Series Data Modeling Approach 12 Second-Stage Analysis 17 Simulation Study to Compare Methods for Pooling Results Across Cities 20 RESULTS 20 Description of the Database 20 Summary Analysis of Databases 21 Effects of PM10 and O3 on Mortality 22 Effects of PM10 and O3 on Hospital Admissions for People Ն 65 Years with Cardiovascular or Respiratory Disease 41 Combined Results 47 Exploration of Effect Modification 51 Further Analyses 53 Quality Control of the City-Specific Analysis 62 DISCUSSION 71 Background 71 Methodological Issues 72 Overall Results 75 Heterogeneity and Effect Modification 76 Limitations 78 Synthesis and Future Research 78 ACKNOWLEDGMENTS 79 REFERENCES 80 APPENDIX A. Simulation Study 85 APPENDIX B. APHENA Methodology Protocol 86 Outcomes 86 Exposure 86 Research Report 142 Data Sets 86 Model Specification 86 APPENDIX C. HEI QUALITY ASSURANCE STATEMENT 87 APPENDICES AVAILABLE ON THE WEB 87 ABOUT THE AUTHORS 88 OTHER PUBLICATIONS RESULTING FROM THIS RESEARCH 90 ABBREVIATIONS AND OTHER TERMS 90 COMMENTARY by the Health Review Committee 91 INTRODUCTION 91 SCIENTIFIC BACKGROUND 91 SUMMARY OF THE STUDY 93 Specific Aims 93 Structure of the Collaboration 93 Construction of the Data Sets 94 Methods 97 Summary of Key Results 100 HEI EVALUATION OF THE STUDY 106 Methodology 106 Limitations 110 SUMMARY AND CONCLUSIONS 111 ACKNOWLEDGMENTS 112 REFERENCES 112 RELATED HEI PUBLICATIONS 117 HEI BOARD, COMMITTEES, AND STAFF 119 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 research and analyses to public and private decision makers. HEI 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 certain research programs. 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’s Web 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 142, Air Pollution and Health: A European and North American Approach (APHENA), presents a research project funded by the Health Effects Institute and conducted by Dr. Klea Katsouyanni of the Department of Hygiene and Epidemiology, University of Athens Medical School, Athens, Greece, and Dr. Jonathan M. Samet of the Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, and their 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 Drs. Katsouyanni and Samet and their 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 142 Air Pollution and Health: A European and North American Approach BACKGROUND morbidity that were the subject of lively debates at Over the past decade, scientists seeking to under- the time the project was first conceived in 1999. stand the role that air pollution might play in popu- The investigators undertook a rigorous examina- lation health effects have relied heavily on epide- tion of time-series methods used to model the rela- miologic studies known as time-series studies. Time- tionship between daily PM10 (particulate matter series studies use information on daily concentra- with an aerodynamic less than 10 micrometers) and tions of air pollutants and daily measures of health ozone concentrations and daily mortality and hos- impact (numbers of deaths or of admissions to hospital admissions. They sought to develop a stan- pitals), initially at the level of a single city. How- dardized approach to the analysis of time series ever, the wide range of methods used to assemble data at the city and regional level, to assess the con- and analyze data from individual cities has made sistency between relative rates of mortality

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