Air Quality - A Guide For Directors Of Public Health - GOV.UK
Air QualityA Briefing for Directorsof Public HealthMarch 2017
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Air Quality3ContentsForeword by Dr Thérèse Coffey and Professor Paul Cosford4Introduction from Dr Andrew Furber and Councillor Izzi Seccombe61. Getting to grips with air pollution – the latest evidence and techniques82. Understanding air pollution in your area363. Engaging local decision-makers about air pollution524. Communicating with the public during air pollution episodes685. Communicating with the public on the long term impacts of air pollution786. Air Pollution: an emerging public health issue. Briefing for elected members98
4Air QualityForeword byDr Thérèse Coffeyand Professor Paul CosfordDr Thérèse CoffeyParliamentary Under Secretaryof State for the Environment andRural Life Opportunities – DefraProfessor Paul CosfordDirector for Health Protectionand Medical Director, PublicHealth EnglandAir pollution can damage liveswith harmful effects on humanhealth, the economy and theenvironment. It is the largestenvironmental risk to thepublic’s health, contributingto cardiovascular disease,lung cancer and respiratorydiseases. It increases thechances of hospital admissions,visits to EmergencyDepartments and respiratoryand cardiovascular symptomswhich interfere with everydaylife, especially for people whoare already vulnerable. Bad airquality affects everyone and ithas a disproportionate impacton the young and old, the sickand the poor.
Air QualityAir quality in the UK has improvedsignificantly over recent decades: since1970 sulphur dioxide emissions havedecreased by 95%, particulate matterby 73% and nitrogen oxides by 69%.The government is firmly committed toseeing further improvements in the UK’sair quality and cutting harmful emissions.The government has committed morethan 2billion since 2011 to increase theuptake of ultra-low emission vehicles andsupport greener transport schemes. Thegovernment has also set out how theywill improve air quality through a newprogramme of Clean Air Zones and iscommitted to doing more.The air quality impacts of drivingare already widely discussed andunderstood, but vehicles aren’t the onlysource of air pollution. All sorts of othereveryday activities, such as industrialprocesses, farming, heating homes andgenerating energy also affect air quality.These activities can’t stop. They are anessential part of our daily lives and oureconomy. But there are cost-effectivechanges that can be implemented bothlocally and nationally to secure cleanercities and a clean, green economy.That’s why the UK has signed up totougher legally binding ceilings foremissions of five major pollutants with5the goal of halving the number of deathsfrom poor air quality by 2030.Alongside national measures, localleadership is essential. Local authoritieshave a central role in achievingimprovements in air quality; their localknowledge and interaction with thecommunities that they serve mean thatthey know the issues on the ground indetail. They are best placed to decideand work with partners to implement theappropriate solutions in regards to localtransport, smoke control, planning andpublic health. Directors of Public Healthhave a crucial role to play as leadersand influencers, shaping how localapproaches can help clean up air in theirarea most effectively.
6Air QualityIntroduction byDr Andrew Furber andCouncillor Izzi SeccombeDr Andrew FurberADPH President, Directorof Public Health in Wakefield.Councillor Izzi SeccombeChair of the Local GovernmentAssociation’s CommunityWellbeing BoardTaking action to improve airquality is crucial in order toimprove population health.There is growing evidence thatair pollution is a significantcontributor to preventable illhealth and early death. Thesehealth impacts impose a coston the UK economy that hasbeen estimated to run intobillions. Although significantprogress has been made inimproving air quality overprevious decades, furtherprogress is necessary andpossible. This will require acombination of innovativenational and local approaches.Local authorities have a major roleto play. The transfer of additionalresponsibilities for public health to localgovernment in 2013 has presented amajor opportunity for Directors of PublicHealth and Councillors to take action toenhance this leadership on air quality.Progress will be seen by designing andimplementing the right policies andinterventions and raising awareness ofthe issue. They will be able to do thiseven more effectively when equippedwith the right data and tools. We look
forward to seeing this toolkit put togood use to make a difference to thequality of the air across the country.We hope that it will be helpful forenabling local authorities to adopt arobust and effective local approachthat will complement a nationalstrategy from the government.We are delighted that ADPH and theLGA have worked collaborativelywith Defra and PHE to generate thisupdated suite of tools which will helplocal authorities to take action toimprove air quality. Local authoritiesare already well positioned to improveair quality but their role and abilityneeds to be strengthened. The toolkitis designed to make it easier forlocal authorities to be as effective aspossible in improving it.
Air Quality
Air Quality91. Getting to grips withair pollution – the latestevidence and techniquesIntroduction10The new evidence putting air quality on the agenda13What are the main air pollutants?What is the current understanding of the health outcomes and impacts?Where air pollutants go in our bodies and what they doWhat are the sources of air pollution and where are people exposed?16192024Can local action on air pollution improve public health?27Case studies of local action30So what can I do next?32Where can I get more information?35
10Air QualityIntroductionThis briefing provides Directors ofPublic Health with the informationyou need to help you consider theappropriate public health responseto air pollution in your area. Thereis extensive evidence about thehealth impacts of air pollution,growing media and public interestand an indicator on mortalityattributed to particulate matter(PM) air pollution in the PublicHealth Outcomes Framework.This guide describes the latest evidence,outlines the role that Public Health officialscan play, highlights techniques to get abetter understanding of the local issues,and presents evidence-based principlesfor communicating with the public onair pollution. This document is part of aresource pack for Public Health teams.The resource comprises of a further“Briefing for Elected Members” as wellas four short guides to help Directorsof Public Health and their teams to takeaction.Briefing: Air Pollution: a public health issue.A Briefing for Elected MembersGuides: Understanding air pollution in your area Engaging local decision-makersabout air pollution Communicating with the public duringair pollution episodes Communicating with the public aboutair pollutionThe briefings and guides have beeninformed by research with Directors ofPublic Health and their teams about theirinformation needs, and research with thepublic to inform approaches to publiccommunication. This resource wasoriginally commissioned by Defra andits development was steered by Defra,Public Health England, the Departmentof Health, Department for Transport,Local Government Association and theHealthy Air Campaign. The work wasreviewed and updated in early 2017by Defra, Public Health England, theLocal Government Association and theAssociation of Directors of Public Health.
Air QualityKey points: Air pollution is a serious public healthissue. The Department of Health’s(DH) Committee on the MedicalEffects of Air Pollutants (COMEAP)estimated the burden of particulatematter (PM) air pollution in the UKin 2008 to be equivalent to nearly29,000 deaths and an associatedloss of population life of 340,000life years lost. Defra has made aninitial estimate that nitrogen dioxide(NO2) contributes to shortening livesby an average of around 5 months– ranging from healthy individualsexperiencing negligible effects tosusceptible individuals whose poorhealth is seriously exacerbated byNO2 pollution. This overall populationburden is estimated to be equivalent tonearly 23,500 deaths in the UK peryear. There is likely to be an overlapin the health burden associatedwith ambient concentrations ofparticulate matter (PM) and NO2, so itis not possible to reliably estimate thecombined health burden of multiplepollutants from the same sources,although it is reasonable to assumethat some individuals will be adverselyaffected by exposure to both pollutantsat the same time and that the totalburden across the population willbe increased to a certain extent.Further work is being undertaken tounderstand and quantify this overlap.123411 Tackling air pollution is a priorityfor this government and that is whywe have agreed legally binding UKtargets to reduce emissions of the fivekey primary air pollutants1 by 2020(through the UNECE Gothenburgprotocol) and 2030 (as part of theNational Emission Ceilings Directive). Legal limits are in place toprotect human health. However,it is recognised that there are noabsolutely safe levels of PM, oneof the main pollutants of concern.Evidence suggests that health effectscan still occur well below these limits.Any improvement in air quality willhave positive health consequences2and the UK has a target to reduceaverage concentrations of PM2.5 aturban background locations by2 µg/m3 (a reduction of 15% on 2010levels)” by 20203. Population exposure to particulatematter. PM2.5 has been used as thebasis of the Public Health OutcomesFramework (PHOF) Indicator 3.014. Theindicator provides a starting point but itis not hard to gain a more accurate anddetailed picture of the local situation. The local nature of pollution hotspotscreates scope for local action toreduce local concentrations andreduce people’s exposure to airpollution. Local authorities havea range of powers which can bedeployed effectively to improve airFine particulate matter, nitrogen oxides, sulphur dioxide, ammonia and non-methane volatile organic compoundsReview of evidence on Health Aspects of Air Pollution – REVIHAAP: final Technical Report, World Health OrganizationOffice for Europe, 2013 vihaap-project-final-technical-reportThis is called the National Exposure Reduction Target (NERT), and is determined on the basis of the population’saverage exposure to PM2.5 at urban background sites, the Average Exposure Indicator (AEI). Urban background sites aremeasurement sites in town and cities that are not significantly influenced by emissions from specific local major roads,industry or other pollution sources. For more information on site types see: ://www.phoutcomes.info/
12Air Qualityquality – for example on transport,smoke control areas, environmentalpermitting, and planning. Local actions to address the healthimpacts of air pollution on localpopulations can play a critical role insupporting other local priorities suchas active travel, health inequalities,integrated care, sustainability, growthand regeneration, and localism andcommunity engagement. Public Health officials have a crucial roleto play in assessing the public healthimpacts of air pollution and providingadvice and guidance on takingappropriate action to the public andtheir colleagues in local authorities.
Air Quality13The new evidence puttingair quality on the agendaIn 2010 COMEAP undertook a studyto quantify the effects of long termexposure to PM. In doing so, COMEAPestimated the burden of PM air pollutionin the UK in 2008 to be equivalent tonearly 29,000 deaths and an associatedloss of population life of 340,000 lifeyears lost5. In comparison, a study in2006 found that reducing PM by 10µg/m3 would extend lifespan in theUK by five times more than eliminatingcasualties on the roads, or three timesmore than eliminating passive smoking6.The main outcomes of PM air pollutionare cardiovascular (CVD) and respiratorydiseases. There are no safe levels of PMand impacts are observed below levelspermitted by current legal limits.Since 2005 when the most recent waveof EU air pollution policy was launchedwith the Thematic Strategy on AirPollution, scientific understanding of thehealth effects of everyday air pollutionhas changed dramatically due to severalthousand epidemiological panel, time5678series and cohorts studies, backed upby laboratory and toxicological studies.In 2011, the Department of Health (DH)included an indicator based on annualaverage PM2.5 concentrations in thenew PHOF. In 2012, the InternationalAgency for Research on Cancer listeddiesel exhaust pollution as a Class 1carcinogen7 and extended this to allambient air pollution in 20138. In 2013,the World Health Organization (WHO)published a review2 of 2,200 studiesconcluding that: Annual PM2.5 concentrations areassociated with all-cause mortality toa high level of confidence, and withmuch greater certainty than in 2005 “There is no evidence of a safe levelof exposure to PM or a thresholdbelow which no adverse health effectsoccur”. Negative health impacts havebeen found well below current EU &UK limitsThe mortality effects of long-term exposure to particulate air pollution in the UK, Committee on the Medical Effects of AirPollution, Dept of Health, 2010 ds/attachment data/file/304641/COMEAP mortality effects of long term exposure.pdfB Miller & F Hurley, Comparing estimated risks for air pollution with risks for other health effects, Institute of OccupationalMedicine, Report TM/06/01, 2006 http://www.iom-world.org/pubs/IOM TM0601.pdfIARC: Diesel engine exhaust carcinogenic, WHO International Agency for Research on Cancer, Press release No 213,June 12, 2012. 213 E.pdfIARC: Outdoor air pollution a leading environmental cause of cancer deaths, WHO International Agency for Research onCancer, Press release No 221, October 17, 2013. 221 E.pdf
14Air Quality Nitrogen dioxide (NO2) was associatedwith “adverse health effects atconcentrations that were at or belowthe current EU limit values”The report considered detailedepidemiological, toxicological andlaboratory evidence answering a seriesof policy and health questions. A furtherWHO report9 made recommendationsfor Health Impact Assessments of airpollution for policy purposes.In 2015, the Royal College of Physiciansand the Royal College of Paediatricsand Child Health published a reporton the lifelong impact of air pollution.It considered the effects of chronicand persistent pollution exposurefrom conception to old age, takinginto account both outdoor and indoorpollution exposure sources. It alsoviewed air pollution as a stressor thatinteracts with many other stressors suchas diet, socio-economic deprivationand climatic conditions to createadverse health impacts and increasedsusceptibility to disease10.9The result is that the population effectsof air pollution are now increasinglyquantifiable for some of the key pollutants.This has allowed the resulting burden ofdisease to be assessed for public healthpolicy purposes and has driven thedevelopment and implementation of newinternational and European commitmentsto reduce air pollution.In November 2016 the EuropeanParliament voted to support the revisedNational Emission Ceilings Directive. TheCouncil of the European Union adoptedthe revised Directive on 8 December andit entered into force on 31 December2016; the UK has supported the revisionof this legislation. The revised NationalEmission Ceilings Directive has stricternational emission ceilings for the 5main air pollutants: sulphur dioxide,nitrogen oxides, non-methane volatileorganic compounds, ammonia and fineparticulate matter. Implementing theseceilings will save lives. The governmentis committed to ensuring that the UK isready to meet these ceilings during thisParliament, including publishing an AirPollution Emissions Reduction Plan forthe UK by March 2019.Health Risk Assessment of Air Pollution http://www.euro.who.int/ data/assets/pdf on-General-principles-en.pdf?ua 110 Royal College of Physicians. Every breath we take: the lifelong impact of air pollution. Report of a working party. London:RCP, 2016.
16Air QualityWhat are the mainair pollutants?Air pollution is a mixture of particles andgases that can have adverse effectson human health. The most importantprimary air pollutants are particulatematter (PM) and nitrogen dioxide (NO2).Particulate matter (PM)PM comprises micron sized particles(a micron is 1000th of a millimetre) andis studied in three main size fractions;PM10, PM2.5 and PM0.1. PM10 includes allparticles smaller than 10 microns11 (i.e.including PM2.5 and PM0.1) and PM2.5comprises all particles smaller than 2.5microns (including PM0.1).PM2.5 has the highest epidemiologicallink to health outcomes4 and is used forthe Public Health Outcomes Frameworkindicator 3.01. At this size the particlescan be inhaled deep into the lungs.The very smallest particles,ultrafine PM 0.1 (the smallest fractionof PM2.5) are nano-particles smallerthan 0.1 microns and are thought, onceinhaled, to be able to pass directlyinto the bloodstream. See diagramson pages 16 and 23.PM can be composed of particles fromcombustion products, products fromabrasion of engine components, brakesand tyres on road surfaces, generatedduring construction and agriculturalprocesses, as well as componentsgenerated by chemical reactions in theair. Much of the PM in urban pollutionhotspots, particularly those close toroads, can come from traffic sources andcomprises soot, part burnt diesel andpetrol compounds that form benzenebased carcinogens, heavy metals, silica,bitumen, rubber and organic and otherwaste matter from road surfaces.The proportions of each componentvary strongly depending on location. Incities and along roads where highestconcentrations tend to occur, trafficgenerated compounds make up alarge or dominant portion of the overallcomposition. In the countryside,agriculture and upwind industry make abigger contribution. However, nationallyUK emissions only contribute around50-55% of total annual average PM2.5concentrations in the UK, with therest coming from transboundarycontinental sources12.In national emission terms (asopposed to urban pollution hotspots)approximately 38% of particulate matter(PM2.5) is produced by UK householdersburning wood, coal and other solid fuelsin open fires and stoves. If they have anopen fire householders can reduce PMemissions by using seasoned wood orsmokeless fuel. Householders can alsoswitch from open fires to stoves andmake sure they burn the right type of fuelfor the appliance they use and the areathey live in.The Clean Air Act of 1956, establishingSmoke Control Areas, cleaned up thesmogs of the 1950s and saw a shiftaway from domestic combustion ofcoal. However, the latest evidence11 A micron is 1 millionth of a metre, or 1000 th of a millimetre.12 Mitigation of UK PM2.5 Concentrations ort id 827
Air Qualityshows a shift back towards domesticcombustion of solid fuel such as woodand coal. 15% of wintertime PM2.5 inLondon is attributed to wood smokeand domestic wood burning has madea significant contribution to recent highpollution episodes in London. SmokeControl Areas can be declared by localauthorities. In such areas people are onlyallowed to burn wood or house coal inan authorised appliance such as a stoveand if using an open fire they are onlyallowed to burn authorised fuels such assmokeless coal.Nitrogen dioxide (NO2)Nitrogen dioxide is a gas that isproduced with nitric oxide (NO) bycombustion processes and together theyare often referred to as oxides of nitrogen(NOx). On average around 80% of oxideof nitrogen (NOx) emissions in areaswhere the UK is exceeding NO2 limitvalues are due to transport, althoughurban and regional background, nontransport sources are still considerable13.The largest source is emissions fromdiesel light duty vehicles (cars and vans)and there has been significant growth inthese vehicle numbers over the last tenyears in the UK.13 Defra (2015). Improving air quality in the UK: Tacklingnitrogen dioxide in our towns and cities. UK, Availableat: ds/attachment 17
18Air QualityOther important air pollutantsinclude:Sulphur dioxide (SO2)SO2 is a respiratory irritant that can causeconstriction of the airways. People withasthma are considered to be particularlysensitive. Health effects can occur veryrapidly, making short-term exposure topeak concentrations important.Sulphur dioxide also contributes toacidification of terrestrial and aquaticecosystems, damaging habitats andleading to biodiversity loss. 46% of totalsulphur dioxide emissions come from thepower generation sector. The principalmitigation measures are changes in fueluse (such as switching from coal to gas),reducing fuel use, changes to industrialprocesses, pollutant capture and fluegas desulphurisation.Non-Methane Volatile OrganicCompounds (NMVOCs)NMVOCs are ozone precursorpollutants. In the vicinity of their releasemany VOCs react with other air pollutantsto produce ground level ozone (seebelow). Industry, both large and small, isresponsible for 71% of VOC emissions.The principal mitigation measures includeremoving and reducing solvents frompaints and coatings, as well as switchingaway from coal and oil for domesticenergy generation.Ammonia (NH3)Ammonia reacts in the atmosphere toproduce secondary particulate matter(PM) (pollutants that are transformed intoparticles by photo-chemical reactionsin the atmosphere). Ammonia canalso cause damage to terrestrial andaquatic ecosystems by contributingto acidification and eutrophication.Farming, specifically the use and storageof slurries, manures, digestate fromAnaerobic Digestion and fertilisers, is thebiggest source of ammonia emissions(81%). Improvements to fertiliser useand storage are the principal means ofreducing ammonia emissions.Ozone (O3)Ozone (O3) comes from a combinationof natural and human processes. Ozoneis a secondary air pollutant. Secondaryair pollutants are not emitted directly tothe environment; they are synthesizedin the environment by chemicalreactions involving chemicals and otherair pollutants. During some weatherconditions that lead to acute air pollutionepisodes, nitrogen dioxide, ozone andother pollutants react and condenseinto PM, adding to that which has beendirectly emitted.Unlike the five primary pollutants above,ozone cannot be managed locally, butforecasting services can help alertvulnerable individuals.
Air Quality19What is the currentunderstanding of the healthoutcomes and impacts?Air pollution damages lives with harmfuleffects on human health, the economyand the environment. It is the largestenvironmental risk to the public’shealth, contributing to cardiovasculardisease, lung cancer and respiratorydiseases. It increases the chances ofhospital admissions, visits to EmergencyDepartments and respiratory andcardiovascular symptoms which interferewith everyday life. In the most severecases it increases the risk of death,especially for people who are alreadyvulnerable. Poor air quality affectseveryone. It can have long term impactson all and immediate effects on vulnerablepeople, with a disproportionate impact onthe young and old, the sick and the poor.There is now an extensive body ofevidence that long-term exposure toeveryday air pollutants over severalyears contributes to the development ofcardiovascular disease (CVD), lung cancer,and respiratory disease. PM is inhaled intothe lungs and ultrafine PM0.1 is thought topass into the blood causing many adverseoutcomes including systemic inflammation.Air pollution is strongly associated withall-cause mortality statistics. The allcause mortality statistic captured in PHOFindicator 3.01 ranks air pollution in the top5-7 causes of mortality in polluted areas,ahead of many other PHOF preventablemortality indicators like road deaths,excess winter deaths or communicablediseases14. New evidence also points toother damaging effects.14 231223/http://www.dh.gov.uk/prod consum lasset/dh 132373.pdf
20Air QualityWhere air pollutants go inour bodies and what they doA few hours of PM2.5 over35 µg/m3 or NO2 over 200µg/m3 irritates the eyes,nose and throat.Heart and blood vesseldiseases like strokesand hardening of thearteries are one ofthe main effects of airpollution. These can becaused by a few yearsexposure to even lowlevels of PM2.5.Exposure for a fewhours to high levelsof PM2.5 can bringon existing illnessor strokes andheart attacksin ill people.PM has beenfound in thereproductiveorgans and inunborn children.PM can cause strokes.Ultrafine PM has beenfound in samplesof brain and centralnervous system tissue.Poor air qualityaffects everyone. Itcan have long termimpacts on all andimmediate effects onvulnerable people,with a disproportionateimpact on the youngand old, the sick andthe poor.Ultrafine PMcan get intothe blood thenthroughout thebody. Ultrafineparticles havebeen found inbody organs.
Air QualityLong term exposure (over several years)to elevated concentrations of PM2.5 atlevels typically experienced in urbanareas reduces life expectancy by severalmonths to a few years9. It is likely thatair pollution acts as a contributoryfactor - along with many others - inaffecting mortality with the major effecton deaths from CVD. It contributes tothe development of atherosclerosis(thickening of arterial intima media areapparent after as little as six months’exposure9), increased incidence ofcoronary events16, lung cancer 7,17 andother respiratory diseases7.Short-term exposure to PM2.5 episodesover a period of a few hours to weekscan cause respiratory effects such aswheezing, coughing and exacerbationsof asthma and chronic bronchitis. Itcan trigger CVD-related mortality andnon-fatal events including myocardialischemia and myocardial infarctions (MI),acute decompensated MI, arrhythmiasand strokes13.NO2, particularly at high concentrationsover a short time (hours), is a respiratoryirritant that can cause inflammation of theairways leading to, for example, coughing,production of mucus and shortness ofbreath. Studies have shown associationsof NO2 in outdoor air with reduced lung21development (lung function growth) andrespiratory infections in early childhoodand effects on lung function in adulthood.A number of studies have reportedassociations with long-term exposureto NO2 and adverse effects on health,including reduced life expectancy. It hasbeen unclear whether these effects arecaused by NO2 itself or by other pollutantsemitted by the same sources (such asroad traffic). Evidence associating NO2with health effects has strengthenedsubstantially in recent years and it is nowthought that, on the balance of probabilities,NO2 itself is responsible for some of thehealth impacts found to be associated withit in epidemiological studies18. COMEAP iscurrently finalising a report on the mortalityeffects associated with long-term averageconcentrations of NO2.Respiratory health effects and effects onmortality are associated with short-termexposure to O3. The effects from longterm exposure to O3 are uncertain.7,19The health effects of air pollutionare distributed unequally across thepopulation, with the heaviest burdenborne by those with greatest vulnerabilityand/or exposure. The elderly, childrenand those with cardiovascular and/orrespiratory disease are at greater risk15 231223/http://www.dh.gov.uk/prod consum lasset/dh 132373.pdf16 Long term exposure to ambient air pollution and incidence of acute coronary events: prospective cohort study and metaanalysis in 11 European cohorts from the ESCAPE Project, BMJ, January 22, 2014 http://www.bmj.com/content/348/bmj.f741217 Air pollution and lung cancer incidence in 17 European cohorts: prospective analyses from the European Study ofCohorts for Air Pollution Effects (ESCAPE), Lancet Oncology, July 13, 2013 IIS1470-2045(13)70279-1/abstract18 COMEAP (2015). Statement on the evidence for the effects of nitrogen dioxide on health, 2015. Available at: ds/attachment data/file/411756/COMEAP The evidence for the effects ofnitrogen dioxide.pdf19 COMEAP 2015 Quantification of mortality and hospital admissions associated with ground-level ozone eports
22Air Qualityfrom the health effects of air pollution.Those who spend more time in highlypolluted locations will be affected more.Since air pollution levels are typically ashigh within vehicles as just outside, thisis likely to include not only those who liveand work near busy roads, but also thosewho drive for a living.Deprived communities are more likelyto be situated near polluted busy roads,and are more likely to experience adversehealth impacts. Analysis of environmentalquality and soci
3. Engaging local decision-makers about air pollution 52 4. Communicating with the public during air pollution episodes 68 5. Communicating with the public on the long term impacts of air pollution 78 6. Air Pollution: an emerging public health issue. Briefing for elected members 98
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