Outdoor Air Pollution and Health in the Developing Special Report 18 November 2010 Countries of Asia: a Comprehensive Review
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SPECIAL REPO SPECIAL R E P O R T 18 R T 18 HE A L TH HE A L TH Outdoor Air Pollution and Health EFF E CTS EFF E CTS INSTITUTE Countries of Asia: Review A Comprehensive Outdoor Air and in Pollution Health the Developing INSTITUTE in the Developing Countries of Asia: 101 Federal Street, Suite 500 November 2010 A Comprehensive Review Boston, MA 02110, USA +1-617-488-2300 www.healtheffects.org HEI International Scientific Oversight Committee SPECIAL REPO rT 1 8 November 2010 November 2010 Outdoor Air Pollution and Health in the Developing Countries of Asia: A Comprehensive Review HEI International Scientific Oversight Committee Special Report 18 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 November 2010. Citation for document: HEI International Scientific Oversight Committee. 2010. Outdoor Air Pollution and Health in the Developing Countries of Asia: A Comprehensive Review. Special Report 18. Health Effects Institute, Boston, MA. When specifying a section of this report, cite it as a chapter of the whole document. © 2010 Health Effects Institute, Boston, Mass., U.S.A. Cameographics, Belfast, Me., Compositor. Printed by Recycled Paper Printing, Boston, Mass. Library of Congress 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 100% 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. 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 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. The Public Health and Air Pollution in Asia (PAPA) Program was initiated by the Health Effects Institute in part to support the Clean Air Initiative for Asian Cities (CAI-Asia), a partnership of the Asian Development Bank and the World Bank to inform regional decisions about improving air quality in Asia. Additional funding was obtained from the U.S. Agency for International Development and 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’s Web site (www.healtheffects.org), printed reports, newsletters and other publications, annual conferences, and presentations to legislative bodies and public agencies. iii CONTENTS About HEI iii Contributors ix Executive Summary 1 SECTION I. INTRODUCTION 17 SECTION II. DEVELOPMENT, AIR POLLUTION EXPOSURE, AND POPULATION HEALTH 21 Trends in Development 21 Broad Trends in Development 21 Changes in Population Age Structures 24 Status of and Trends in Disease Burden 24 Trends in Environmental Risks 26 Urbanization 28 Air Pollution, Poverty, and Health 31 Sources 31 Common Sources of Air Pollution 37 Trends in Energy Use and Projected Growth in Major Point Sources and Emissions 38 Pollutant Concentrations 50 Monitoring Data 50 Modeled Estimated Pollutant Concentrations and Projected Trends in Emissions 57 Current Source-Apportionment Studies in Asia 60 Overview of Exposure Issues 69 Intake Fraction and the Role of Human Activity 69 Limitations of Ambient Pollutant Concentra- tions as a Metric of Exposure 71 Policy Issues in Air Quality Management 71 Actions Taken to Reduce Air Pollution 71 Continuing Challenges 78 New and Emerging Challenges 79 Future Directions 80 Summary 80 The Size of the Vulnerable and Potentially Exposed Population Is Increasing. 80 Asia Is Highly Dynamic and Heterogeneous, and Exposure to Air Pollution Is Becoming Increasingly Varied and Complex As Development Progresses. 81 Dramatic Increases in the Activities of Sources Are Occurring. 81 Regional Air Quality and Climate Change Are Key Emerging Issues. 81 SECTION III. SUMMARY OF CURRENT EVIDENCE ON HEALTH EFFECTS OF AIR POLLUTION: IMPLICATIONS FOR ASIA 83 Studies of Variability in Exposure 83 Short-Term Temporal Variability 83 Long-Term Spatial Variability 85 Long-Term Temporal Variability 87 Special Report 18 Air Pollution, Adverse Reproductive Outcomes, and Child Health 89 Contribution of Copollutants 90 Gaps and Limitations of Current Knowledge 90 SECTION IV. UPDATED REVIEW OF THE ASIAN LITERATURE ON AIR POLLUTION AND HEALTH 91 Literature Review 91 Search Methods 91 Search Results 93 SECTION V. QUANTITATIVE ASSESSMENT OF DAILY TIME-SERIES STUDIES 97 Introduction 97 Systematic Ascertainment of Relevant Time-Series Studies for APED 97 Literature Search 97 Data Abstraction 98 Selection of Lag Times 98 Multi-City Studies 99 Meta-Analytic Methods 99 Multiple Studies of a Single City 99 Computation of Summary Estimates 99 Investigation of Publication Bias 99 Results 100 Study Characteristics 100 Geographic Distribution of the Studies 100 Health Outcomes 100 Pollutants 100 Effect Estimates 100 Summary Estimates 123 Investigation of Sources of Heterogeneity 125 Discussion 126 Review of Findings 126 Comparison with Results from the PAPA Studies in Four Asian Cities 127 Comparison with Results from India 129 Comparison with Results from Other Parts of the World 129 Limitations of This Review 129 Heterogeneity and Effect Modification 129 Multi-Pollutant Models 130 Studies of Pollution Episodes 130 SECTION VI. STUDIES OF SELECTED EFFECTS OF LONG-TERM EXPOSURE TO AMBIENT AIR POLLUTION 131 Methods 131 Study Selection 131 Quantification of Results 131 Chronic Respiratory Disease 132 Chronic Phlegm 132 Pulmonary Function 141 Asthma and Wheeze 148 Lung Cancer 162 Studies 162 Discussion 165 Special Report 18 Adverse Pregnancy Outcomes 165 Preterm Delivery 165 Low Birth Weight 168 Discussion 173 Summary and Conclusions 173 SECTION VII. SUMMARY AND CONCLUSIONS 175 The PAPA Studies 176 Systematic and Critical Review of Studies of Chronic Effects of Long-Term Exposure to Air Pollution 177 Implications for Assessment of Health Impacts 177 Enhanced Evidence of Effects of Air Pollution in Asia 178 Knowledge Gaps and Research Needs 179 How Does the Nature of the Air Pollution Mixture Affect Air Quality, Exposure, and Health Effects? 179 What Are the Effects of Long-Term Exposure to Air Pollution? 179 What Do Results of Current Time-Series Studies in a Subset of Asian Cities Tell Us About Health Effects of Air Pollution Exposure in Other, As Yet Unstudied, Asian Locales? 179 What Role Does Indoor Air Pollution Play in the Health Effects of Outdoor Air Pollution? 180 What Role Does Poverty Play in the Health Effects of Air Pollution? 180 What Are the Health Consequences of Changes in Air Pollution Resulting from Climate Changes and Efforts to Reduce Emissions of Climate-Forcing Agents? 180 REFERENCES 181 APPENDICES 211 Appendix A. Additional Analyses of Daily Time-Series Studies 211 Appendix B. Additional Analyses of Effects of Long-Term Exposure 255 ABBREVIATIONS AND OTHER TERMS 259 CITIES, PROVINCES, AND COUNTRIES 261 GLOSSARY 263 Related HEI Publications 265 HEI Board, Committees, and Staff 267 CONTRIBUTORS This HEI Special Report was prepared on behalf of the International Scientific Oversight Committee (ISOC) of the Public Health and Air Pollution in Asia (PAPA) program, which oversaw its planning and production and reviewed its content and conclusions. The ISOC thanks the contributing authors who drafted the report and the eight peer reviewers who commented on several drafts. The ISOC also thanks Davida Schiff (HEI 2006–2008 Research Assistant, currently a Boston University Medical School student) for her early involvement in searching databases. HEI International Scientific Oversight Committee Frank Speizer, Chair Harvard Medical School, Harvard Kenneth L. Demerjian State University