Outdoor Air Quality and Health

Care Process Model SEPTEMBER 2015

September 2015

The Air Quality and Health Team, under the guidance of Intermountain LiVe Well and the Office of the Sustainability, developed this care process model (CPM) to provide evidence-based guidelines on the health effects of air quality. It is primarily intended to help providers counsel patients about outdoor physical activity when air quality is poor. This CPM is based on guidelines from the U.S. Environmental Protection Agency, current research on air quality and health, and advice from Intermountain experts.

WHAT’S INSIDE

Why Focus on OUTDOOR AIR QUALITY? POLLUTANTS...... 2

• Everyone is affected. Air quality affects the entire population we care HEALTH EFFECTS OF POOR AIR QUALITY...... 3 for. All providers need to know how to counsel patients on how to respond. Because exposure to polluted air cannot be measured in the individual COUNSELING PATIENTS...... 4 Pregnant women...... 4 patient, it is usually not apparent as a contributor to acute and chronic health Very young children...... 4 conditions. The World Health Organization (WHO) estimates, however, that Children with asthma ...... 4 WHO 2 million premature deaths may be attributable to air pollution each year. People exercising or working outdoors ...... 4 • A high proportion of Utah’s population is at risk. People at increased Adults with asthma...... 5 risk for adverse health outcomes from exposure to poor air include children, Adults with lung disease...... 5 the elderly, and people with existing asthma, lung disease, cardiovascular Adults with cardiovascular conditions. . . 5 disease, and stroke. One‑third of Utah’s population is either 18 and under Adults with neurological conditions. . . 5 or 65 and older; about 230,000 have asthma; and nearly 500,000 have AIR QUALITY AND LOCATION. . . .6 cardiovascular disease. THE AIR QUALITY INDEX...... 7 Measurement stations in Utah. . . . . 7 • Utah’s air can be especially bad. The American Lung Association’s State of the Air 2015 report ranked the Salt Lake City-Provo-Orem area as RESOURCES...... 8 the 7th worst in the U.S. for short‑term spikes in particle pollution, a regular Patient education resources ...... 8 ALA Provider resources...... 8 occurrence during wintertime temperature inversions. Logan was ranked 8th. Other helpful resources...... 8 • Clear, objective evidence can aid healthcare providers in counseling patients. GOALS This CPM provides evidence-based recommendations, acknowledges gaps The GOALS goals of this CPM are to: in our current understanding of the health effects of air pollution, and helps clinicians better understand susceptible groups for whom a more precautionary The• Improve goals of clinicians’ this CPM knowledge are to: of the impact of air quality on health outcomes. approach may be advised. • Improve clinicians’ knowledge of the impact • ofHelp air cliniciansquality on provide health outcomes.evidence‑based recommendations to their patients. • Help clinicians provide evidence-based recommendations to their patients. OUTDOOR AIR QUALITY AND HEALTH SEPTEMBER 2015

POLLUTANTS

The table below lists “criteria pollutants,” or pollutants with national air quality standards that define allowable concentrations in ambient air. Click on each pollutant name to link to more detailed information from the U.S. Environmental Protection Agency.

Pollutant What it is Mechanisms of harm and populations at risk Particulate Particulate matter (PM) is a complex mixture of particles and liquid Particle size and composition influence the toxicity of PM. droplets of varied constituents, including acids, organic chemicals, matter PM uses gravity to settle in the metals, soil, and dust. PM is categorized by size, which in turn 10 (PM) nasal or oral cavities, pharynx, larynx, dictates health effects. and upper trachea and relies on PM10 •• PM10 — coarse particles, such as those found in the dust of mucociliary clearance for removal. roadways, agriculture, or construction sites, and are between PM2.5 deposits on the surface of PM 2.5 µm (micrometers) and 10 µm in diameter. 2.5 epithelial cells in the bronchioles and

•• PM2.5 — fine particles, such as those found in smoke and haze, alveoli, and are phagocytosed by are less than 2.5 µm in diameter. These are formed from gas and alveolar macrophages. PM1.0 condensation of high temperature vapors during combustion. PM1.0 deposition depends largely on • PM — ultrafine particles, a subset of fine particles, are less diffusion and may have unique effects • 1.0 Particle size determines than 1.0 µm in diameter. The leading source is motor vehicles, because of translocation into the level of deposition. especially those powered by diesel engines. bloodstream, with transport to other organs, including the heart and brain. Sources: Human and natural activities, including vehicle emissions,

industrial processes, agricultural operations, combustion of wood Both PM2.5 and PM1.0 have been implicated in inducing pulmonary and fossil fuels, construction activities, road dust, windblown dust, and systemic inflammation and oxidative stress, and may be wind erosion, and wildfires. associated with various cardiovascular endpoints, including vascular and endothelial dysfunction, alterations in heart rate variability, coagulation, and cardiac autonomic function. Populations at greatest risk: people with heart or lung disease, previous stroke, older adults, and children.

Ground- Ground-level ozone (O3) is an irritant gas, and a primary component When exposed to ozone, epithelial cells lining the respiratory tract level ozone of smog. (Atmospheric ozone, by contrast, is not harmful.) leak intracellular enzymes and initiate a series of events leading (O ) Ground-level ozone is created by chemical reactions between to lung inflammation and airway narrowing. Neural inhibition of 3 inhalation effort also leads to shortness of breath. nitrogen oxides (NO2) and volatile organic compounds (VOCs) in the presence of sunlight. It’s generally worse in hot, sunny weather and The degree of decreased lung function varies substantially among later in the day. In high elevations with heavy industry (such as Cache individuals exposed to the same level of ozone, due to variations in Valley and Uintah Basin) it can also be high in winter. While ozone breathing patterns and lung anatomy. is worse in urban environments, it can be transported hundreds of Populations at greatest risk: people with lung disease, children miles by wind. and older adults, and people who are active outdoors. Sources: Emissions from industrial facilities, electric utilities, motor vehicle exhaust, gasoline vapors, and chemical solvents.

Sulfur SO2 reacts with other compounds to form particulate matter. Short-term exposure is linked to adverse respiratory effects including dioxide Sources: Vehicle emissions and industrial activity. bronchoconstriction and increased asthma symptoms, especially in (SO ) asthmatics while exercising or playing. 2 Populations at greatest risk: children, asthmatics, the elderly, and people with heart or lung disease.

Nitrogen NO2 contributes to the formation of ground-level ozone and PM2.5 Short-term exposure to NO2 is linked to adverse respiratory effects oxides Sources: Emissions of motor vehicles, power plants, gas appliances, including airway inflammation in healthy people and increased (NO ) and other sources that burn fossil fuels. respiratory symptoms in people with asthma. 2 Populations at greatest risk: people with asthma, children, and older adults. Carbon CO is a toxic gas that is colorless, odorless, and tasteless. In addition CO exposure initiates pulmonary and systemic oxidative stress, monoxide to the conditions described at right, it can cause sudden illness leading to a cascade of physiological responses that can instigate or death. cardiovascular events such as congestive heart failure, cerebrovascular (CO) BRO Sources: Vehicle exhaust, fuel-burning appliances (wood stoves, gas disease, anemia, and COPD. Large quantities of CO inhibit the water heaters, gas stoves, improperly used generators in enclosed ability of hemoglobin to deliver oxygen to the body. spaces, unvented gas or kerosene heaters), cars idling in enclosed Populations at greatest risk: people with cardiovascular disease spaces, and smoking. or lung disease, pregnant women and their fetuses, and young infants.

HEALTH EFFECTS OF POOR AIR QUALITY

TABLE 1. Health effects of poor air Long-term effects of repeated Acute effects of short-term exposure or chronic exposure Heart

•• PM is associated with changes in heart rate •• PM exposure may accelerate the progression of variability, blood pressure, vascular tone, atherosclerosis. Many of these effects are mediated blood coagulability, and destabilization and through proinflammatory pathways and the ABE ABE

rupture of existing coronary artery plaque. generation of reactive oxygen species. •• CO reduces the oxygen-carrying capacity of the blood. blocked artery

ischemic area

Lungs

•• PM is associated with significant inflammatory •• PM exposure is associated with pulmonary response even in healthy controls, and inflammation, airway obstruction, and increased with increased asthma symptoms in those normal airway susceptibility to respiratory infection and sensitivity SAL DIC with asthma. to allergens, increased childhood wheeze, and MOR asthma development. It is also associated with •• Ozone is associated with decreased lung ABE function and inflamed lung tissue, leading to increased risk of lung cancer. neural shortness of breath, chest pain, cough, •• In children, repeated short-term ozone exposure throat irritation, and congestion. damages developing lungs and may lead to reduced lung function in adulthood. •• NO2 is associated with airway inflammation in people with and without asthma. •• In adults, ozone exposure may permanently scar inflamed /obstructed lung tissue and accelerate the natural decline EPA1 in lung function that occurs with age.

Brain

•• Both PM and ozone increase the number of •• PM and ozone exposure are associated with stroke events over several days following neuroinflammation, oxidative stress, and cerebral BLO exposure — especially in people with prior vascular damage. history of stroke or greater number of cardiac •• The above processes lead to increased incidence HEN risk factors. of ischemic stroke, Alzheimer’s disease, and BLO •• Systemic effects known to impact lung and Parkinson’s disease. cardiovascular disease also impinge on central plaque •• PM has been associated with insidious effects on BLO nervous system health. restricted structural brain aging, even in dementia-free and ruptured WIL stroke-free persons. blood flow plaque

Pregnancy, infant, young child

•• Researchers suspect that lung inflammation •• PM exposure is associated with premature delivery EPA2 initiates a biochemical response that may cause and low birth weight. EPA2 placental insufficiency. •• Maternal PM exposure during pregnancy may EPA2 •• High levels of PM or CO during pregnancy contribute to higher rates of infant mortality. may interfere with placental development and •• Children are at greatest risk from ozone exposure, subsequent oxygen and nutrient delivery to as their lungs are still developing and they are the fetus. more likely to be active outdoors when ozone EPA2 •• CO complicates the delivery of oxygen to the levels are high. AAP developing fetus.

COUNSELLING PATIENTS AVOIDING OR REDUCING EXPOSURE Poor quality air can affect all people, but certain populations are at increased risk. The guidelines outlined below are designed to help providers recommend reasonable The factors listed below increase health safety precautions without causing undue alarm. The handouts pictured in each section risk from poor air. Most recommended patient counselling revolves around provide guidance for patients. See page 8 for ordering instructions. these issues. Pregnant women and developing fetuses • Prolonged exertion is outdoor activity, either continued or intermittent, What we know: Prenatal exposure to high levels of polluted air can increase the risk of preterm birth, AAP over several hours that causes intrauterine growth retardation (IUGR), and low birth weight (LBW). Women exposed to high levels of ozone EPA2 a person to breathe harder than during the second and third trimesters are at particular risk for IUGR. In utero and early life exposure DON normal. Examples include working to traffic‑related pollution may increase the likelihood of clinically significant asthma later in life. in the yard for part of the day, doing What remains unclear: Existing evidence does not allow precise identification of specific

WHO LiVe Well FACT SHEET FOR PATIENTS AND FAMILIES outdoor work, or prolonged exercise. pollutants and timing of exposure that can result in birth defects. A recent study found Air Quality and Pregnancy When you’re pregnant, poor air quality may affect both you and your baby. This handout will help you know what you can do to have a healthier pregnancy.

What we know What we are studying Poor air quality has been linked to: Scientists are trying to learn whether poor air that higher maternal exposure to PM during pregnancy, in particular the third trimester, was quality may be related to these conditions: Autism Miscarriage Birth defects disorders 2.5 Low birth Baby born weightBaby born Baby with –– Counsel patients to reduce activity too early too small lung problems The Air Quality Index (AQI) is a number for reporting how clean or unhealthy your air is every day. You can find it on the Internet at RAZ AirNow.gov AirNow.gov. It’s also reported TV in local news sources:

associated with greater odds of having a child with autism spectrum disorder. Further study When AQI is: A pregnant woman should:

1–50 time or schedule activity early in the Enjoy usual outdoor activities GOOD

Do less outdoor exercise — 51–100 not as long, not as hard If you’re coughing or you don’t feel well, MODERATE stay indoors is needed before this association can be confirmed. Traffic pollution is harmful even when 101–150 AQI is good day when pollution is less. UNHEALTHY for sensitive If you can, groups Exercise Plan avoid indoors outdoor outdoor air activities in places 151–200 in the with a lot of UNHEALTHY morning, traffic when air for all quality is usually What to do: Counsel patients to adjust activity or stay indoors during inversions and other 201–300 better VERY UNHEALTHY for all 1 • Heavy exertion. Intense outdoor If you have asthma, be sure to take your asthma medication all through your pregnancy. You’re breathing for two! periods of high AQI, and to quit smoking. Give the patient fact sheet. activity that causes a person to breathe hard. Very young children –– Counsel patients to exercise indoors, What we know: Young children are especially vulnerable due to ongoing lung development, incomplete early in the day, or at an altitude WHO metabolic systems, immature host defenses, and activity patterns that lead to higher exposure. above the inversion. WHO Chronic exposure to air pollution may increase the risk of respiratory infections. • Increased pollution levels. •• Ambient air pollution is associated with increased upper and lower respiratory symptoms, reduced lung Ambient air pollution is generally worse WHO growth rates and lung function, aggravation of asthma, and increased cough and bronchitis. near roads with heavy traffic and during LiVe Well •• Children with underlying chronic lung diseases, particularly asthma and cystic fibrosis, FACT SHEET FOR PATIENTS AND FAMILIES Outdoor Air Quality and Early Childhood commute hours, when more vehicles are Infants and very young children are at extra risk for the harmful effects of air pollution because WHO they breathe faster and their brains, lungs, and immune systems are still developing. Air pollutants interact with allergens, viruses, diet, and other factors that affect children’s health.

Too much time in polluted air can:

are especially vulnerable later in childhood. Reduce lung growth Harm nervous system Increase risk of and function, development and death from lung worsen symptoms behavior, especially infections and of asthma and when exposed sudden infant death cystic fibrosis, to chemicals in syndrome (SIDS) in increase cough, air pollution like the youngest infants on the road. and bronchitis mercury and lead The Air Quality Index (AQI) is a number for reporting how clean or unhealthy your air is every day. You can find it on the Internet at AirNow.gov AirNow.gov. It’s also reported TV What remains unclear: Existing evidence does not show whether there is an increased risk in local news sources: When AQI is: You and your very young child should:

1–50 Enjoy usual –– Counsel patients to avoid exposure GOOD outdoor activities 51–100 MODERATE If you or your child have symptoms, of allergic sensitization in otherwise healthy children. Limit time outdoors Traffic (coughing, runny eyes) stay indoors pollution is harmful even when AQI is 101–150 good UNHEALTHY If you can, for sensitive groups avoid to outdoor air near heavy road traffic outdoor air Plan necessary in places outdoor with a lot of 151–200 activities in traffic UNHEALTHY the morning, Infants and for all when air toddlers quality is What to do: Counsel parents to keep very young children indoors during inversions and other should play usually 201–300 indoors better VERY UNHEALTHY whenever possible, and to schedule for all 1 ABE periods of high AQI. Give the patient fact sheet. outdoor activities early in the day. • Individual susceptibility. Patients Children with asthma should be taught to pay attention to What we know: The effect of poor air quality on asthma is greater in children than adults due to ongoing how they feel and learn their personal development of lungs, brain, and immune systems. sensitivity to each risk level of the Air Quality Index (see page 7). •• Short-term exposure is associated with exacerbation of existing asthma; increased severity of respiratory TO symptoms;increased use of outpatient care, emergency department visits, and hospitalizations. –– Counsel patients to pay attention ABE to places and situations that induce •• Long-term exposure is associated with development of new asthma ; possible delay of lung ABE EPA1 reactions. People who experience development ; Repeated short-term ozone damage to may lead to reduced lung function in adulthood.

LiVe Well any unusual coughing, chest What remains unclear: Existing evidence does not show which element of pollution FACT SHEET FOR PATIENTS AND FAMILIES Outdoor Air Quality and Childhood Asthma Poor air quality is unhealthy for everyone, but especially for children with asthma. Children are more at risk because they breathe faster, they play outside more, and their lungs are still developing. Poor air quality can cause asthma to develop in a child who did not have it before. In a child with asthma, it can be a trigger for an asthma attack — and it can make symptoms come on faster and stronger. Here’s how poor air quality can affect your child: discomfort, wheezing, breathing is most responsible, or whether day-by-day prevention is possible. NOW LATER Decreased lung growth in Worse asthma More severe More doctor and children, higher risk of lung symptoms respiratory infections hospital visits cancer and early death

The Air Quality Index (AQI) is a number for reporting how clean or unhealthy your air is every day. You can find it on the Internet at AirNow.gov AirNow.gov. It’s also reported TV in local news sources: difficulty, or unusual fatigue should What to do: Manage acute exacerbations triggered by air pollution clinically in the same When AQI is: A child with asthma should:

1–50 GOOD Enjoy usual outdoor activities

51–100 MODERATE Limit time If you have symptoms, reduce their activity level or move manner as those triggered by other factors. Counsel patients to follow their asthma action outdoors play indoors Traffic pollution 101–150 is harmful Keep your even when UNHEALTHY fast‑acting AQI is good for sensitive inhaler groups nearby (such Whenever possible, Play Plan outdoor as albuterol) avoid activities — and indoors outdoor air 151–200 in the contact your doctor if in places UNHEALTHY morning, when air your child with a lot plan, adhere to medications, and to avoid playing/exercising outdoors when AQI is high. for all is using of traffic inside. Persistent symptoms should quality is usually it often 201–300 better VERY UNHEALTHY 1 prompt medical attention. Give the patient fact sheet. for all People exercising or working outdoors WHAT WE DON’T KNOW What we know: During exercise, elevated ventilation rate, mouth breathing, and increased airflow velocity MAR Exposure to poor quality air varies carry pollutants deeper into the lungs and amplify the dose of pollutants. The effect may be worse in women. greatly among individuals. We don’t •• People exercising may be at particular risk of ozone exposure, due to heavier exertion in summer. know enough to be able to provide •• The benefits of exercise outweigh the risks. Individuals should change location or timing of exercise, not quit. detailed advice on safe:

What remains unclear: It is not clear how much exposure is a danger, or how long a person LiVe Well

FACT SHEET FOR PATIENTS AND FAMILIES

Air Quality and Outdoor Exercise or Work Getting plenty of exercise is one of the best things you can do for your health. But exercising outdoors when air quality is poor can be unhealthy. When you exercise you breathe harder and faster — and take in more air. • Duration of exposure needs to be exposed. Further research is needed to better understand the role of PM and athlete Children, older people, and people with asthma, heart, or lung disease, should talk to their doctor about exercising when the air quality is poor. If you are otherwise healthy, follow the guidelines below to exercise safely. For people who exercise or work actively outdoors, poor air quality can cause: CUT NOW LONG TERM Coughing, Trouble breathing, Exercising or working outdoors often in poor air can performance on respiratory and cardiovascular disease. sore throat chest pain, or tightness increase risk of heart and lung problems The Air Quality Index (AQI) is a number for reporting how clean or unhealthy your air is every day. You can find it on the Internet at • AirNow.gov. It’s also reported AirNow.gov Chronicity of exposure TV in local news sources: When AQI is: A healthy, active person should:

1–50 Enjoy usual GOOD outdoor activities

Reduce outdoor exercise — What to do: Counsel patients to adjust activity and exercise indoors when possible. not as long, not as hard 51–100 MODERATE If you have trouble breathing or you are • Intensity of activity coughing, take it easier or exercise indoors Whenever possible, 101–150 don’t UNHEALTHY exercise for sensitive outdoors in groups places with a Plan outdoor lot of traffic exercise in Give the patient fact sheet. the morning, 151–200 Moving when air even a few UNHEALTHY quality is blocks away for all usually better Exercise can help 201–300 indoors VERY UNHEALTHY for all 1

Adults with asthma KEY What we know:

ABE RECOMMENDATIONS •• Short-term exposure is associated with exacerbation of preexisting asthma; increased susceptibility to allergens ; EPA1 TO reduced lung function and airway inflammation ; and increased use of asthma-related health services. • Guidance related to air EPA1 Patients with asthma have increased sensitivity to ozone, even at low levels of exposure. pollution exposure should not ABE discourage physical activity, •• Long-term exposure is associated with development of new asthma ; acceleration of age-related decline in lung function. except for those with known LiVe Well FACT SHEET FOR PATIENTS AND FAMILIES cardiopulmonary disease. Outdoor Air Quality and Adult Asthma Poor air quality is unhealthy for everyone, but especially for people with asthma. Poor air quality can be What remains unclear: Existing evidences does not show which elements of pollution are most a trigger for your asthma — and can make symptoms come on faster and stronger. Here’s how poor air quality can affect you:

NOW LATER

Worse asthma More severe More missed More Permanent lung damage, higher symptoms respiratory infections work or school hospital visits risk of lung cancer, and early death • Counsel patients to adjust responsible, or whether day-by-day prevention is possible. The Air Quality Index (AQI) is a number for reporting how clean or unhealthy your air is every day. You can find it on the Internet at AirNow.gov AirNow.gov. It’s also reported TV in local news sources:

When AQI is: A person with asthma should:

1–50 Enjoy usual outdoor activities activity and/or exercise GOOD

What to do: Manage acute exacerbations triggered by air pollution clinically in the same manner Consider reducing outdoor exercise — 51–100 not as long, not as hard MODERATE If you have symptoms, stay indoors

Whenever 101–150 possible, Keep your avoid UNHEALTHY indoors as recommended in fast-acting outdoor air for sensitive inhaler nearby in places groups (such as with a lot Reduce Plan outdoor albuterol) of traffic as those triggered by other factors. Counsel patients to follow their asthma action plan, adhere to or avoid activities — and outdoor in the contact your Going 151–200 exercise morning, doctor if even a few when air UNHEALTHY you’re using blocks away quality is ______it often can help usually Avoid all better outdoor 201–300 exercise VERY patient handout. UNHEALTHY medications (especially when AQI is high), adjust activity, and quit smoking. Give the patient fact sheet. 1 • Give patient fact sheet at Adults with lung disease (COPD, chronic bronchitis) visit. To pre‑order color copies of fact sheets, see What we know: instructions on page 8. •• Short-term exposure is linked to exacerbation of preexisting disease; increased coughing and wheezing; increase in FAU COPD hospitalizations and COPD-related mortality. Ambient air pollution, including traffic-related fine PM and FAU SAL wood smoke, is associated with increased risk of COPD and chronic bronchitis.

FAU

•• COPD patients are especially susceptible to PM10 and NO2. LiVe Well FACT SHEET FOR PATIENTS AND FAMILIES

Outdoor Air Quality and Adult Lung Disease Poor air quality is unhealthy for everyone, but especially for adults with lung disease — such as COPD, chronic bronchitis, or emphysema. Older people are also at risk because they may have lung conditions they don’t know about. These pages will help you know where and when to exercise. For people with lung disease, poor air quality can cause: What remains unclear: Limited data exist in examining the relationship between air pollution NOW LONG TERM

Coughing, Trouble More severe More Permanent lung damage, higher risk wheezing breathing disease symptoms hospital visits of heart attack, and early death

The Air Quality Index (AQI) is a number for reporting how clean or unhealthy your air is every day. You can find it on the Internet at AirNow.gov AirNow.gov. It’s also reported TV exposure, physical activity, and resultant respiratory disease. in local news sources: OLDER ADULTS ARE When AQI is: A person with lung disease should:

1–50 Enjoy usual outdoor activities GOOD

Reduce outdoor exercise — Always Traffic not as long, not as hard take your pollution 51–100 medicines is harmful If you have symptoms, MODERATE as prescribed even when What to do: Manage acute exacerbations triggered by air pollution clinically in the same manner as stay indoors by your AQI is good doctor, If you are especially coughing, Whenever when air possible, don’t quality is ALSO AT GREATER RISK 101–150 avoid exercise unhealthy UNHEALTHY outdoor air If you are in places for sensitive with a lot groups having Plan Exercise trouble of traffic outdoor indoors breathing, activities get medical 151–200 in the help right morning, away UNHEALTHY when air and don’t those triggered by other factors.Counsel patients to adhere to medications (especially during periods of for all quality is exercise usually better 201–300 VERY UNHEALTHY inversion), to adjust activity, and to quit smoking. Give the patient fact sheet. for all 1 Older adults are considered to be particularly susceptible to short‑term risk. This may be due to Adults with existing cardiovascular conditions (CAD, CHF, unstable angina) the fact that they are more likely to What we know: have undiagnosed cardiovascular or respiratory conditions. •• Short-term exposure to poor air is linked to exacerbation of preexisting heart disease, increased hospitalization, and mortality due to cardiovascular disease, especially in persons with congestive heart failure, frequent arrhythmias, BRO,POP1 or both. •• Short-term elevated PM exposures and related inflammation may contribute to acute ischemic events by increasing POP1 the risk of plaque rupture and thrombosis. Exposure to particulate air pollution may play a role in precipitating POP2 heart failure symptoms in otherwise well-managed patients.

•• Long-term exposure to air pollutants (especially PM2.5, sulfate particles, and SO2) has been linked to death from cardiovascular disease. There also appears to be an association between cardiopulmonary mortality and BRO summertime ozone. Air pollution is associated with both ischemic and nonischemic cardiovascular events.

LiVe Well What remains unclear: Limited data exist in examining the relationship between air pollution FACT SHEET FOR PATIENTS AND FAMILIES Outdoor Air Quality and Heart Disease Poor air quality is unhealthy for everyone, but especially for people with heart disease — such as heart failure or coronary artery disease. The recommendations below relate to where and when you exercise. Follow the recommendations related to your specific health condition for how much you exercise. For people with heart disease, poor air quality can cause:

NOW LATER

Person exposure, physical activity, and new onset cardiovascular disease. in bed? Shortness of Chest pain Heart attack More hospital and Greater risk of heart attack, stroke, breath emergency visits blood clots, and early death

When AQI is: A person with heart disease should:

What to do: Manage acute exacerbations triggered by air pollution clinically in the same manner as 1–50 Enjoy usual outdoor activities GOOD

Always Traffic Take it take your pollution 51–100 easy medicines is harmful MODERATE outdoors as prescribed even when by your AQI is good doctor, Exercise If you have: especially Whenever indoors • pain or when air possible, 101–150 tightness in quality is those triggered by other factors. Counsel patients to adhere to medications (especially when AQI is high), the chest, avoid UNHEALTHY unhealthy arms, neck, outdoor air for sensitive back, or jaw in places groups with a lot Plan • palpitations of traffic outdoor • shortness activities of breath 151–200 in the • unusual UNHEALTHY morning, tiredness for all when air for all quality Call your doctor and is usually don’t 201–300 better exercise to adjust activity, and to quit smoking. Give the patient fact sheet. VERY UNHEALTHY for all 1 Adults with existing neurological conditions (stroke, TIA) What we know: •• Short-term exposure to elevated levels of particulate matter and ozone increases the number of ischemic OUD cerebrovascular events on subsequent days, especially in patients with prior history of stroke and cardiac risk HEN factors. Recent PM2.5 and ozone exposure has been associated with stroke/TIA risk even in a community with MIT relatively low pollutant levels. •• Long-term, chronic exposure to air pollution is also associated with increased risk of stroke. The association is MIT stronger for fatal than nonfatal stroke, and stronger for ischemic than hemorrhagic stroke. LiVe Well FACT SHEET FOR PATIENTS AND FAMILIES

Outdoor Air Quality and Stroke Poor air quality is unhealthy for everyone, but especially for older adults and people at risk for stroke. If you have had a stroke in the past, poor air quality can make you more likely to have another one. For people at risk for stroke, poor air quality can cause: NOW LONG TERM What remains unclear: The pathways for such an increased susceptibility are unknown.

Stroke Heart attack More hospital and Greater risk of stroke, blood clots, emergency visits heart attack, and early death

The Air Quality Index (AQI) is a number for reporting how clean or unhealthy your air is every day. You can find it on the Internet at AirNow.gov AirNow.gov. It’s also reported TV in local news sources: What to do: Manage acute exacerbations triggered by air pollution clinically in the same manner as When AQI is: A person at risk for stroke should:

1–50 Enjoy usual outdoor activities GOOD

Reduce outdoor exercise — Always Traffic not as long, not as hard take your pollution 51–100 If you have symptoms, medicines as is harmful MODERATE stay indoors prescribed even those triggered by other factors. Counsel patients to adhere to medications (especially when AQI is high), by your when AQI doctor, is good If you have especially a sudden when air Whenever problem possible, 101–150 quality is with: avoid UNHEALTHY unhealthy • Balance outdoor for sensitive • Eyes air in groups Plan Exercise • Face places outdoor indoors drooping with a lot activities • Arm of traffic 151–200 in the weakness morning, • Speech UNHEALTHY when air to adjust activity, and to quit smoking. Give the patient fact sheet. quality Get is usually emergency better help 201–300 immediately VERY UNHEALTHY 1

AIR QUALITY AND LOCATION KEY MESSAGES Air quality in Utah has been consistently recognized as some of the worst in the • Winter temperature inversions United States. This is due in part to a confluence of topographic and meteorologic increase particulate factors, and concentrated populations. matter pollution. Winter temperature inversions in Utah valleys and particulate matter • Within‑city variations in air quality vary greatly. Living near a major Utah’s topography contributes to the creation of winter temperature inversions, which roadway can have a greater in turn increase the concentration of winter air pollution. Temperature inversion is effect on health than city-wide especially problematic in the basin communities of the Wasatch Front, Cache Valley, background air pollution. and the Uintah Basin.

• Cold air flows from mountain peaks into the valleys and pushes under the warmer air rising from the valley. • Warm air acts as a “lid” trapping the cold air below. • Snow-covered valley floors reflect the heat rather than absorb it, and prevent the normal vertical mixing of air. • Pollutants build up in the trapped cold air.

Because the majority of Utah’s population lives in a relatively small area along the Wasatch Front, the effects of human activity — especially vehicle exhaust — are concentrated. Encourage patients to listen to news sources for air quality updates. Regional industrial and agricultural processes and other pollutants Industrial and agricultural processes also contribute to Utah’s poor air. • Cache Valley experiences ozone pollution year round due to oil and gas production. • Eastern Utah and the Uintah Basin experience increased ozone pollution year round due to oil and gas production. • Rural communities experience increased coarse particulate matter from blowing dust and increased nitrogen dioxide from agricultural processes. Air quality variations within a city An individual’s exposure to air pollution may vary as much within a single city as BRO across different cities. Near freeways and busy highways air quality may never be acceptable and are a risk factor for mortality due to air pollution. One large study found exposure to traffic-related air pollutants was more highly related to mortality than were city‑wide background levels. Patients at high risk may benefit from moving to a less-polluted area if possible.

THE AIR QUALITY INDEX (AQI) MEASUREMENT STATIONS The AQI is a measurement used by the Environmental Protection Agency (EPA) IN UTAH and local air quality officials to let the public know when major air pollutant Utah has 23 air quality measurement levels become unhealthy. Currently, the EPA measures particle pollution (PM), stations. Three measure only ground‑level ozone (O ), sulfur dioxide (SO ), nitrogen dioxide (NO ), and wind, and 20 measure a variety of 3 2 2 pollutants, as outlined below: carbon monoxide (CO). In cities with more than 350,000 inhabitants, state and local agencies are required to report the AQI to the public daily. • Box Elder County, 140 W. Fishburn Dr, Brigham City: PM2.5, O3 What does the AQI mean? • Cache County –– 125 W. Center St, Logan: O , PM , Each pollutant “safe level” (based on EPA standards for public health) is expressed 3 10 PM , NO , SO as 100. If there is an unsafe level of a single pollutant, the AQI number will be over 2.5 2 2 –– 675 W. 220 N.,Smithfield: 100. If more than one pollutant is above the safe level, the AQI number used will be PM10, PM2.5 the highest recorded of the pollutants measured. For example, if the AQI on a given • Carbon County, 351 S. 2500 E.,

day is 130 for ozone and 101 for particulate matter, the report would announce the Price: O3, NO2, NOx AQI as “130 for ozone, and particulate matter is also high.” When AQI is above • Davis County, 171 W. 1370 N.,

100, the report must also include which groups may be sensitive to the pollutant. Bountiful: NO2, O3, SO2, PM2.5, PM10, CO Where is the AQI reported? • Duchesne County –– 6200 S. 45000 W., Fruitland: O , 1. On the web: Visit airnow gov. for daily AQI conditions and forecasts for over 300 3 NO , NO U.S. cities as well as links to local sited. 2 x –– 290 S. 1000 W., Roosevelt: O3, 2. In the media: Many local radio, television, and newspapers provide daily reports as NO2, NOx part of the weather forecast. • Uintah County, 600 N. 1650 E.,

3. On smartphone apps: Including UtahAir and AirNow. Vernal: O3, PM2.5, NO2, NOx • Utah County 4. Via email: Sign up for free emails and advice on safety measures from the EPA –– 50 N. Main St, Lindon: PM , PM at enviroflash .info. 2.5 10 –– 1355 N. 200 W., Provo: CO, NO2,

O3, PM2.5, PM10 –– Airport, Spanish Fork: O , PM When AQI is: 3 2.5 • Salt Lake County –– 1675 S. 600 E., SLC: PM , PM , 1–50 2.5 10 CO, O , NO GOOD 3 2

–– 1400 W. Goodwin Ave, SLC: PM2.5 –– 8449 S. Monroe St, Midvale: O , NO 51–100 Unusually 3 2 MODERATE sensitive –– 14058 Mirabella Dr, Herriman: people O3, NO2 Whenever should consider possible, –– 1200 S. 8560 W., Magna: SO2, don’t reducing 101–150 Sensitive Pb, PM10 exercise prolonged UNHEALTHY groups outdoors in or heavy • should avoid Tooele County: O3, PM2.5 for sensitive places with a outdoor groups exertion prolonged • Washington County: 147 N. lot of traffic or heavy Everyone Plan outdoor outdoor 870 W., Hurricane: O3, PM2.5, NO2, NOx Moving should avoid 151–200 exercise in exertion even a few prolonged • Weber County morning, UNHEALTHY blocks away or heavy when air –– 425 W. 2550 N., Harrisville: O , for all can help outdoor 3 quality is exertion PM10, PM2.5 usually better 201–300 –– 228 E. 32nd St, Ogden: NO2, NOx,

VERY PM10, PM2.5 UNHEALTHY for all

RESOURCES Patient education resources Order preprinted Intermountain fact sheets for distribution to patients:

• Use iPrintStore org. , Intermountain’s online library and print center. Print from your desktop (this option only recommended if you can print in color; key information is lost in black and white): • Log in to Intermountain net. Patient Education Library (PEL) page. Click on the Intermountain Patient Education box and search for the title or item number. • Or, click on the links provided within this document.

These fact sheets are not currently available in the iCentra workflow. Provider resources Intermountain fact sheets: LiVe Well LiVe Well

FACT SHEET FOR PATIENTS AND FAMILIES FACT SHEET FOR PATIENTS AND FAMILIES

Air Quality and Pregnancy Outdoor Air Quality and Stroke When you’re pregnant, poor air quality may affect both you and your baby. Poor air quality is unhealthy for everyone, but especially for older adults and people at risk for stroke. This handout will help you know what you can do to have a healthier pregnancy. If you have had a stroke in the past, poor air quality can make you more likely to have another one. • For people at risk for stroke, poor air quality can cause: Air Quality and Pregnancy (FSLW065) What we know What we are studying Poor air quality has been linked to: Scientists are trying to learn whether poor air NOW LONG TERM quality may be related to these conditions:

Autism LiVe Well Miscarriage Birth defects disorders Low birth Baby born weightBaby born Baby with LiVe Well too early too FACTsmall SHEETlung FOR problems PATIENTS AND FAMILIES Stroke Heart attack More hospital and Greater risk of stroke, blood clots, emergency visits heart attack, and early death FACT SHEET FOR PATIENTS AND FAMILIES The Air Quality Index (AQI) is a number for reporting how clean or unhealthy your air is every day. The Air Quality Index (AQI) is a number for reporting how clean or unhealthy your air is every day. You can find it on the Internet at Outdoor AirAirNow.gov Quality and Early Childhood You can find it on the Internet at AirNow.gov. It’s also reported TV AirNow.gov AirNow.gov. It’s also reported TV in local news sources:Infants and very young children are at extra risk for the harmful effects of air pollution because • in local news sources: Outdoor Air Quality and Early Childhood (FSLW058) they breathe faster and their brains, lungs, and immune systems are still developing. Outdoor Air Quality and Heart Disease When AQI is: Air pollutantsA pregnant interact withwoman allergens, viruses, should: diet, and other factors that affect children’s health. Poor air quality is unhealthy for everyone, but especially for people with heart disease — such as heart failure or coronary Too much time in polluted air can: When AQI is: Aartery person disease. The at recommendations risk for belowstroke relate to should: where and when you exercise. Follow the recommendations related to your specific health condition for how much you exercise. For people with heart disease, poor air quality can cause: Reduce lung growth Harm nervous system Increase risk of 1–50 Enjoy usual outdoor activities GOOD and function, development and death from lung 1–50 Enjoy usual NOW LATER worsen symptoms behavior, especially infections and outdoor activities of asthma and when exposed sudden infant death GOOD Person cystic fibrosis, to chemicals in syndrome (SIDS) in in bed? increase cough,Do less outdoor exerciseair — pollution like the youngest infants and bronchitisnot as long, not as hardmercury and lead 51–100 LiVe Well Reduce outdoor exercise — Always Traffic If you’re coughing or you don’t feel well, not as long,Shortness not as of hard Chest pain Heart attack More hospital and Greater risk of heart attack, stroke, MODERATE take your pollution stay indoors 51–100 breath medicines as emergencyis harmful visits blood clots, and early death FACT SHEETis a number FOR forPATIENTS reporting how AND clean FAMILIES or unhealthy your air is every day. If you have symptoms, The Air Quality Index (AQI) Traffic MODERATE prescribed even pollution is stay indoors • You can find it on the Internet at by your when AQI The Air Quality Index (AQI) is a number for reporting how clean or unhealthy your air is every day. Outdoor Air Quality and Childhood Asthma (FSLW059) AirNow.gov harmful LiVe Well doctor, is good AirNow.gov. It’s also reported even when TV If you have You can find it on the Internet especiallyat 101–150 in local news sources: AQI is good a sudden AirNow.gov AirNow.gov. It’s also FACTreported whenSHEET air FOR PATIENTSWhenever AND FAMILIESTV UNHEALTHY problem possible, Outdoor Air Quality and Childhood Asthma 101–150 in local news sources:quality is with: avoid for sensitive If you can, UNHEALTHY unhealthy groups When AQI is: YouPoor and air quality your is unhealthy very for young everyone, but child especially should: for children with asthma. Children are more at risk • Balance outdoor Exercise Plan avoid for sensitive indoors becauseoutdoor they breathe faster, theyoutdoor play outside air more, and their lungs are still developing. Poor air quality can cause • Eyes air in groups Plan Exercise asthmaactivities to develop in a child who indid places not have it before. In a child with asthma, it can be a trigger for an asthma When AQI is: • Face A person with heartplaces disease should: outdoor indoors drooping with a lot 151–200 attackin — the and it can make symptomswith come a lot onof faster and stronger. Here’s how poor air quality can affect your child: Air Quality and Outdoor Exercise or Work 1–50 Enjoy usual activities • Arm of traffic morning, traffic Getting plenty of exercise is one of the best things you can do for your health. But exercising outdoors when UNHEALTHY GOOD outdoor activities 151–200 in the weakness when air air Enjoyquality usual is poor can be unhealthy. When you exercise you breathe harder and faster — and take in more air. for all quality is morning, 1–50 • Speech NOW LATER UNHEALTHY when air outdoor activities usually Children, older people, and people with asthma, heart, or lung disease, should talk to their doctor about exercising quality GOOD Get better when the air quality is poor. If you are otherwise healthy, follow the guidelines below to exercise safely. 201–300 is usually emergency better help For people who exercise or work actively outdoors, poor air quality can cause: • VERY 51–100 immediately Always Traffic Outdoor Air Quality and Adult Asthma (FSLW060) Decreased lung growth in 201–300 UNHEALTHY Take it take your pollution MODERATE Worse asthma MoreIf you severe or your child haveMore symptoms, doctor and VERY NOW LONG TERM Limit time outdoors Traffic children, higher risk of lung 51–100 easy medicines is harmful for all symptoms respiratory(coughing, infections runny eyes) stayhospital indoors visits UNHEALTHY LiVe Wellpollution is cancer and early death outdoors as prescribed even when 1 harmful even MODERATE 1 by your AQI is good If you have asthma, be sure to take your asthma medication all through your pregnancy. You’re breathing for two! when AQI is The Air Quality Index (AQI)FACT is aSHEET number FORfor reporting PATIENTS how clean AND or unhealthyFAMILIES your air is every day. doctor, good Exercise If you have: 101–150 You can find it on the Internet at especially Whenever AirNow.gov indooCoughing,rs • Troublepain or breathing, Exercising or working outdoors often in poor air can UNHEALTHY AirNow.gov. It’s also reported when air possible, If you can, TV sore throat chesttightness pain, in or tightness increase risk of heart and lung problems in local news sources: 101–150 quality is avoid for sensitive avoid the chest, groups UNHEALTHY unhealthy outdoor air Plan outdoor air arms, neck, in places for sensitive The Air Quality Indexback, or (AQI) jaw is a number for reportingin howplaces clean or unhealthy your air is every day. necessary Outdoor Air Quality and Adult Asthma groups LiVe Wellwith a lot When AQI is: outdoorA child withwith asthma a lot of should: Plan You can find• palpitations it on the Internet at 151–200 Poor air quality is unhealthytraffic for everyone, but especially for people with asthma. Poor air quality can be AirNow.gov. It’s also reported AirNow.govof traffic activities in outdoor • shortnessFACT SHEET FOR PATIENTS AND FAMILIESTV UNHEALTHY the morning, a trigger for your asthma — and can make symptoms come on faster and stronger. activities inof local breath news sources: Infants and 151–200 in the for all when air Here’s how poor air quality can affect you: • unusual • toddlers1–50 quality is morning, Outdoor Air Quality and Adult Lung Disease (FSLW061) UNHEALTHY When AQI is: tiredness A healthy, active person should: shouldGOOD play usually Enjoy usual outdoor activities for all when air indoors better NOW LATER for all quality Call your 201–300 doctor and is usually don’t Outdoor Air Quality in Summer VERY better 1–50 Enjoy usual UNHEALTHY 201–300 exercise GOOD In summer,outdoor the biggest activit causeies of poor air quality is ozone. Ozone is a gas that can be helpful when it’s high above for all 51–100 1 VERY the earth. But ozone at ground level is harmful. Here’s how ground-level ozone can affect your health: LiVe Well UNHEALTHY Worse asthma More severe More missed More Permanent lung damage, MODERATE Limit time If you have symptoms, higher 1 outdoorssymptoms playrespiratory indoors infections work or school hospital visits risk of lung cancer, and early death for all FACT SHEET FOR PATIENTS AND FAMILIES Reduce outdoor exerciseNOW — LATER Repeated or ongoing Traffic 51–100 not as long, not as hard exposure can lead to: pollution Chest Pain or - Asthma The Air Quality Index (AQI) is a number for reportingis harmful how clean or unhealthy your air is every day. MODERATE If you have trouble breathing orCoughing, you are Worse 101–150 tightness,coughing, take it easierburning or exercise irritated indoors allergy - Reduced lung You can find it on the InternetKeep your at even when shortness with deep function UNHEALTHY AirNow.govAQI is good throat symptoms AirNow.gov. It’s also fast‑actingreported TV of breath breath Whenever - Permanent for sensitive in local newsOutdoor sources:inhaler Air Quality and Adult Lung Disease possible, lung damage • groups nearby (such Whenever Outdoor Air Quality and Stroke (FSLW062) Poor air quality is unhealthypossible, for everyone, but especially for adults with lung disease — such as COPD, chronic 101–150 don’t Play Plan outdoor as albuterol) avoid exercise activities bronchitis,— and or emphysema. Older people are also at risk because they may have lung conditions they don’t know about. UNHEALTHY The Air Quality Index (AQI) is a number for reporting how clean or unhealthy your air is every day. indoorsWhen AQI is: A personoutdoor with air asthma should: in the contactThese pagesyour will help you know where and when to exercise. For people with lung disease, poor air quality can cause: for sensitive outdoors in 151–200 in places morning, doctor if groups You can find it on the Internet at AirNow.gov places with a UNHEALTHY with a lot Plan outdoor AirNow.gov when air your child It’s also reported in local news sources: lot of traffic TV for all 1–50quality is is using Enjoy usualof traffic NOW LONG TERM exercise in usually it oftenoutdoor activities 151–200 the morning, Moving GOOD better when air even a few UNHEALTHY 201–300 When AQI is: quality isPeople sensitiveblocks away to ozone should: VERY for all usually better(These include children,can helpolder adults, people with asthma or UNHEALTHY Consider reducing outdoor exercise — Exercise other lung diseases, and people working or exercising outdoors) Coughing, Trouble More1 severe More Permanent lung damage, higher risk indoors for all 51–100 wheezingnot as long, notbreathing as hard disease symptoms hospital visits of heart attack, and early death 201–300 MODERATE If you have symptoms, stay indoors VERY 1–50 Enjoy usual The Air Quality Index (AQI) is a number for reporting how clean or unhealthy your air is every day. UNHEALTHY outdoor activities • GOOD Outdoor Air Quality and Heart Disease (FSLW063) You can find it on the Internet at for all 1 AirNow.gov AirNow.gov. It’s also reported Whenever TV 101–150 in local news sources: possible, Keep your avoid UNHEALTHY Consider reducing outdoor exercise — fast-acting outdoor air not as long, not as hard, not in afternoon for sensitive inhaler nearby in places 51–100 groups When AQI is: A (suchperson as withwith alung lot disease should: MODERATE Reduce Plan outdoor albuterol) of traffic or avoid activities — and Traffic outdoor in the contact your Going pollution 151–200 exercise morning, doctor Enjoyif usual even a few is harmful 1–50 when air UNHEALTHY you’reoutdoor using activitiesblocks away 101–150 even when GOODquality is ______it often can help AQI is good usually UNHEALTHY Plan outdoor Avoid all better for sensitive activities and exercise in Whenever outdoor Reduce outdoor exercise — Always Traffic groups 201–300 the morning, possible, • exercise not as long, not as hard take your pollution Reduce Air Quality and Outdoor Exercise or Work (FSLW064) VERY 51–100 medicines is harmful or avoid when ozone don’t UNHEALTHY If you have symptoms, levels are exercise MODERATE as prescribed even when 151–200 outdoor stay indoors 1 by your AQI is good exercise usually lower outdoors in doctor, UNHEALTHY places with a If you are especially Whenever for all ______lot of traffic coughing, when air don’t possible, 101–150 quality is avoid Avoid all exercise unhealthy UNHEALTHY outdoor air 201–300 outdoor If you are in places exercise for sensitive VERY having with a lot UNHEALTHY groups Plan Exercise trouble of traffic 1 outdoor indoors breathing, for all activities get medical 151–200 in the help right morning, away UNHEALTHY when air and don’t • quality is exercise for all Outdoor Air Quality in Summer (FSLW066) usually better 201–300 VERY UNHEALTHY for all 1

To find this CPM and its reference list, go to either IntermountainPhysician org/clincalprograms. or Intermountain .net/clinicalprograms and click on Clinical Topics A–Z to see the Air Quality topic page. Printed copies can be ordered from iPrintstore org. .

Other helpful resources • Utah Division of Air Quality, airquality utah. .gov • Utah Clear Air, UCAIR .org • Materials from the Environmental Protection Agency, available at epa .gov/airquality –– AQI: A Guide to Air Quality and Your Health –– Air Pollution and Pregnancy

©2015 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED. This CPM is based on best evidence at the time of publication. It is not meant to be a prescription for every patient. Clinical judgment based on each patient’s unique situation remains vital. Patient and Provider Publications 801-442-2963 CPM085 - 09/15