air pollution research paper pdf

REVIEW article

Environmental and health impacts of air pollution: a review.

• 1 Delphis S.A., Kifisia, Greece
• 2 Laboratory of Hygiene and Environmental Protection, Faculty of Medicine, Democritus University of Thrace, Alexandroupolis, Greece
• 3 Centre Hospitalier Universitaire Vaudois (CHUV), Service de Médicine Interne, Lausanne, Switzerland
• 4 School of Social and Political Sciences, University of Glasgow, Glasgow, United Kingdom

One of our era's greatest scourges is air pollution, on account not only of its impact on climate change but also its impact on public and individual health due to increasing morbidity and mortality. There are many pollutants that are major factors in disease in humans. Among them, Particulate Matter (PM), particles of variable but very small diameter, penetrate the respiratory system via inhalation, causing respiratory and cardiovascular diseases, reproductive and central nervous system dysfunctions, and cancer. Despite the fact that ozone in the stratosphere plays a protective role against ultraviolet irradiation, it is harmful when in high concentration at ground level, also affecting the respiratory and cardiovascular system. Furthermore, nitrogen oxide, sulfur dioxide, Volatile Organic Compounds (VOCs), dioxins, and polycyclic aromatic hydrocarbons (PAHs) are all considered air pollutants that are harmful to humans. Carbon monoxide can even provoke direct poisoning when breathed in at high levels. Heavy metals such as lead, when absorbed into the human body, can lead to direct poisoning or chronic intoxication, depending on exposure. Diseases occurring from the aforementioned substances include principally respiratory problems such as Chronic Obstructive Pulmonary Disease (COPD), asthma, bronchiolitis, and also lung cancer, cardiovascular events, central nervous system dysfunctions, and cutaneous diseases. Last but not least, climate change resulting from environmental pollution affects the geographical distribution of many infectious diseases, as do natural disasters. The only way to tackle this problem is through public awareness coupled with a multidisciplinary approach by scientific experts; national and international organizations must address the emergence of this threat and propose sustainable solutions.

Approach to the Problem

The interactions between humans and their physical surroundings have been extensively studied, as multiple human activities influence the environment. The environment is a coupling of the biotic (living organisms and microorganisms) and the abiotic (hydrosphere, lithosphere, and atmosphere).

Pollution is defined as the introduction into the environment of substances harmful to humans and other living organisms. Pollutants are harmful solids, liquids, or gases produced in higher than usual concentrations that reduce the quality of our environment.

Human activities have an adverse effect on the environment by polluting the water we drink, the air we breathe, and the soil in which plants grow. Although the industrial revolution was a great success in terms of technology, society, and the provision of multiple services, it also introduced the production of huge quantities of pollutants emitted into the air that are harmful to human health. Without any doubt, the global environmental pollution is considered an international public health issue with multiple facets. Social, economic, and legislative concerns and lifestyle habits are related to this major problem. Clearly, urbanization and industrialization are reaching unprecedented and upsetting proportions worldwide in our era. Anthropogenic air pollution is one of the biggest public health hazards worldwide, given that it accounts for about 9 million deaths per year ( 1 ).

Without a doubt, all of the aforementioned are closely associated with climate change, and in the event of danger, the consequences can be severe for mankind ( 2 ). Climate changes and the effects of global planetary warming seriously affect multiple ecosystems, causing problems such as food safety issues, ice and iceberg melting, animal extinction, and damage to plants ( 3 , 4 ).

Air pollution has various health effects. The health of susceptible and sensitive individuals can be impacted even on low air pollution days. Short-term exposure to air pollutants is closely related to COPD (Chronic Obstructive Pulmonary Disease), cough, shortness of breath, wheezing, asthma, respiratory disease, and high rates of hospitalization (a measurement of morbidity).

The long-term effects associated with air pollution are chronic asthma, pulmonary insufficiency, cardiovascular diseases, and cardiovascular mortality. According to a Swedish cohort study, diabetes seems to be induced after long-term air pollution exposure ( 5 ). Moreover, air pollution seems to have various malign health effects in early human life, such as respiratory, cardiovascular, mental, and perinatal disorders ( 3 ), leading to infant mortality or chronic disease in adult age ( 6 ).

National reports have mentioned the increased risk of morbidity and mortality ( 1 ). These studies were conducted in many places around the world and show a correlation between daily ranges of particulate matter (PM) concentration and daily mortality. Climate shifts and global planetary warming ( 3 ) could aggravate the situation. Besides, increased hospitalization (an index of morbidity) has been registered among the elderly and susceptible individuals for specific reasons. Fine and ultrafine particulate matter seems to be associated with more serious illnesses ( 6 ), as it can invade the deepest parts of the airways and more easily reach the bloodstream.

Air pollution mainly affects those living in large urban areas, where road emissions contribute the most to the degradation of air quality. There is also a danger of industrial accidents, where the spread of a toxic fog can be fatal to the populations of the surrounding areas. The dispersion of pollutants is determined by many parameters, most notably atmospheric stability and wind ( 6 ).

In developing countries ( 7 ), the problem is more serious due to overpopulation and uncontrolled urbanization along with the development of industrialization. This leads to poor air quality, especially in countries with social disparities and a lack of information on sustainable management of the environment. The use of fuels such as wood fuel or solid fuel for domestic needs due to low incomes exposes people to bad-quality, polluted air at home. It is of note that three billion people around the world are using the above sources of energy for their daily heating and cooking needs ( 8 ). In developing countries, the women of the household seem to carry the highest risk for disease development due to their longer duration exposure to the indoor air pollution ( 8 , 9 ). Due to its fast industrial development and overpopulation, China is one of the Asian countries confronting serious air pollution problems ( 10 , 11 ). The lung cancer mortality observed in China is associated with fine particles ( 12 ). As stated already, long-term exposure is associated with deleterious effects on the cardiovascular system ( 3 , 5 ). However, it is interesting to note that cardiovascular diseases have mostly been observed in developed and high-income countries rather than in the developing low-income countries exposed highly to air pollution ( 13 ). Extreme air pollution is recorded in India, where the air quality reaches hazardous levels. New Delhi is one of the more polluted cities in India. Flights in and out of New Delhi International Airport are often canceled due to the reduced visibility associated with air pollution. Pollution is occurring both in urban and rural areas in India due to the fast industrialization, urbanization, and rise in use of motorcycle transportation. Nevertheless, biomass combustion associated with heating and cooking needs and practices is a major source of household air pollution in India and in Nepal ( 14 , 15 ). There is spatial heterogeneity in India, as areas with diverse climatological conditions and population and education levels generate different indoor air qualities, with higher PM 2.5 observed in North Indian states (557–601 μg/m 3 ) compared to the Southern States (183–214 μg/m 3 ) ( 16 , 17 ). The cold climate of the North Indian areas may be the main reason for this, as longer periods at home and more heating are necessary compared to in the tropical climate of Southern India. Household air pollution in India is associated with major health effects, especially in women and young children, who stay indoors for longer periods. Chronic obstructive respiratory disease (CORD) and lung cancer are mostly observed in women, while acute lower respiratory disease is seen in young children under 5 years of age ( 18 ).

Accumulation of air pollution, especially sulfur dioxide and smoke, reaching 1,500 mg/m3, resulted in an increase in the number of deaths (4,000 deaths) in December 1952 in London and in 1963 in New York City (400 deaths) ( 19 ). An association of pollution with mortality was reported on the basis of monitoring of outdoor pollution in six US metropolitan cities ( 20 ). In every case, it seems that mortality was closely related to the levels of fine, inhalable, and sulfate particles more than with the levels of total particulate pollution, aerosol acidity, sulfur dioxide, or nitrogen dioxide ( 20 ).

Furthermore, extremely high levels of pollution are reported in Mexico City and Rio de Janeiro, followed by Milan, Ankara, Melbourne, Tokyo, and Moscow ( 19 ).

Based on the magnitude of the public health impact, it is certain that different kinds of interventions should be taken into account. Success and effectiveness in controlling air pollution, specifically at the local level, have been reported. Adequate technological means are applied considering the source and the nature of the emission as well as its impact on health and the environment. The importance of point sources and non-point sources of air pollution control is reported by Schwela and Köth-Jahr ( 21 ). Without a doubt, a detailed emission inventory must record all sources in a given area. Beyond considering the above sources and their nature, topography and meteorology should also be considered, as stated previously. Assessment of the control policies and methods is often extrapolated from the local to the regional and then to the global scale. Air pollution may be dispersed and transported from one region to another area located far away. Air pollution management means the reduction to acceptable levels or possible elimination of air pollutants whose presence in the air affects our health or the environmental ecosystem. Private and governmental entities and authorities implement actions to ensure the air quality ( 22 ). Air quality standards and guidelines were adopted for the different pollutants by the WHO and EPA as a tool for the management of air quality ( 1 , 23 ). These standards have to be compared to the emissions inventory standards by causal analysis and dispersion modeling in order to reveal the problematic areas ( 24 ). Inventories are generally based on a combination of direct measurements and emissions modeling ( 24 ).

As an example, we state here the control measures at the source through the use of catalytic converters in cars. These are devices that turn the pollutants and toxic gases produced from combustion engines into less-toxic pollutants by catalysis through redox reactions ( 25 ). In Greece, the use of private cars was restricted by tracking their license plates in order to reduce traffic congestion during rush hour ( 25 ).

Concerning industrial emissions, collectors and closed systems can keep the air pollution to the minimal standards imposed by legislation ( 26 ).

Current strategies to improve air quality require an estimation of the economic value of the benefits gained from proposed programs. These proposed programs by public authorities, and directives are issued with guidelines to be respected.

In Europe, air quality limit values AQLVs (Air Quality Limit Values) are issued for setting off planning claims ( 27 ). In the USA, the NAAQS (National Ambient Air Quality Standards) establish the national air quality limit values ( 27 ). While both standards and directives are based on different mechanisms, significant success has been achieved in the reduction of overall emissions and associated health and environmental effects ( 27 ). The European Directive identifies geographical areas of risk exposure as monitoring/assessment zones to record the emission sources and levels of air pollution ( 27 ), whereas the USA establishes global geographical air quality criteria according to the severity of their air quality problem and records all sources of the pollutants and their precursors ( 27 ).

In this vein, funds have been financing, directly or indirectly, projects related to air quality along with the technical infrastructure to maintain good air quality. These plans focus on an inventory of databases from air quality environmental planning awareness campaigns. Moreover, pollution measures of air emissions may be taken for vehicles, machines, and industries in urban areas.

Technological innovation can only be successful if it is able to meet the needs of society. In this sense, technology must reflect the decision-making practices and procedures of those involved in risk assessment and evaluation and act as a facilitator in providing information and assessments to enable decision makers to make the best decisions possible. Summarizing the aforementioned in order to design an effective air quality control strategy, several aspects must be considered: environmental factors and ambient air quality conditions, engineering factors and air pollutant characteristics, and finally, economic operating costs for technological improvement and administrative and legal costs. Considering the economic factor, competitiveness through neoliberal concepts is offering a solution to environmental problems ( 22 ).

The development of environmental governance, along with technological progress, has initiated the deployment of a dialogue. Environmental politics has created objections and points of opposition between different political parties, scientists, media, and governmental and non-governmental organizations ( 22 ). Radical environmental activism actions and movements have been created ( 22 ). The rise of the new information and communication technologies (ICTs) are many times examined as to whether and in which way they have influenced means of communication and social movements such as activism ( 28 ). Since the 1990s, the term “digital activism” has been used increasingly and in many different disciplines ( 29 ). Nowadays, multiple digital technologies can be used to produce a digital activism outcome on environmental issues. More specifically, devices with online capabilities such as computers or mobile phones are being used as a way to pursue change in political and social affairs ( 30 ).

In the present paper, we focus on the sources of environmental pollution in relation to public health and propose some solutions and interventions that may be of interest to environmental legislators and decision makers.

Sources of Exposure

It is known that the majority of environmental pollutants are emitted through large-scale human activities such as the use of industrial machinery, power-producing stations, combustion engines, and cars. Because these activities are performed at such a large scale, they are by far the major contributors to air pollution, with cars estimated to be responsible for approximately 80% of today's pollution ( 31 ). Some other human activities are also influencing our environment to a lesser extent, such as field cultivation techniques, gas stations, fuel tanks heaters, and cleaning procedures ( 32 ), as well as several natural sources, such as volcanic and soil eruptions and forest fires.

The classification of air pollutants is based mainly on the sources producing pollution. Therefore, it is worth mentioning the four main sources, following the classification system: Major sources, Area sources, Mobile sources, and Natural sources.

Major sources include the emission of pollutants from power stations, refineries, and petrochemicals, the chemical and fertilizer industries, metallurgical and other industrial plants, and, finally, municipal incineration.

Indoor area sources include domestic cleaning activities, dry cleaners, printing shops, and petrol stations.

Mobile sources include automobiles, cars, railways, airways, and other types of vehicles.

Finally, natural sources include, as stated previously, physical disasters ( 33 ) such as forest fire, volcanic erosion, dust storms, and agricultural burning.

However, many classification systems have been proposed. Another type of classification is a grouping according to the recipient of the pollution, as follows:

Air pollution is determined as the presence of pollutants in the air in large quantities for long periods. Air pollutants are dispersed particles, hydrocarbons, CO, CO 2 , NO, NO 2 , SO 3 , etc.

Water pollution is organic and inorganic charge and biological charge ( 10 ) at high levels that affect the water quality ( 34 , 35 ).

Soil pollution occurs through the release of chemicals or the disposal of wastes, such as heavy metals, hydrocarbons, and pesticides.

Air pollution can influence the quality of soil and water bodies by polluting precipitation, falling into water and soil environments ( 34 , 36 ). Notably, the chemistry of the soil can be amended due to acid precipitation by affecting plants, cultures, and water quality ( 37 ). Moreover, movement of heavy metals is favored by soil acidity, and metals are so then moving into the watery environment. It is known that heavy metals such as aluminum are noxious to wildlife and fishes. Soil quality seems to be of importance, as soils with low calcium carbonate levels are at increased jeopardy from acid rain. Over and above rain, snow and particulate matter drip into watery ' bodies ( 36 , 38 ).

Lastly, pollution is classified following type of origin:

Radioactive and nuclear pollution , releasing radioactive and nuclear pollutants into water, air, and soil during nuclear explosions and accidents, from nuclear weapons, and through handling or disposal of radioactive sewage.

Radioactive materials can contaminate surface water bodies and, being noxious to the environment, plants, animals, and humans. It is known that several radioactive substances such as radium and uranium concentrate in the bones and can cause cancers ( 38 , 39 ).

Noise pollution is produced by machines, vehicles, traffic noises, and musical installations that are harmful to our hearing.

The World Health Organization introduced the term DALYs. The DALYs for a disease or health condition is defined as the sum of the Years of Life Lost (YLL) due to premature mortality in the population and the Years Lost due to Disability (YLD) for people living with the health condition or its consequences ( 39 ). In Europe, air pollution is the main cause of disability-adjusted life years lost (DALYs), followed by noise pollution. The potential relationships of noise and air pollution with health have been studied ( 40 ). The study found that DALYs related to noise were more important than those related to air pollution, as the effects of environmental noise on cardiovascular disease were independent of air pollution ( 40 ). Environmental noise should be counted as an independent public health risk ( 40 ).

Environmental pollution occurs when changes in the physical, chemical, or biological constituents of the environment (air masses, temperature, climate, etc.) are produced.

Pollutants harm our environment either by increasing levels above normal or by introducing harmful toxic substances. Primary pollutants are directly produced from the above sources, and secondary pollutants are emitted as by-products of the primary ones. Pollutants can be biodegradable or non-biodegradable and of natural origin or anthropogenic, as stated previously. Moreover, their origin can be a unique source (point-source) or dispersed sources.

Pollutants have differences in physical and chemical properties, explaining the discrepancy in their capacity for producing toxic effects. As an example, we state here that aerosol compounds ( 41 – 43 ) have a greater toxicity than gaseous compounds due to their tiny size (solid or liquid) in the atmosphere; they have a greater penetration capacity. Gaseous compounds are eliminated more easily by our respiratory system ( 41 ). These particles are able to damage lungs and can even enter the bloodstream ( 41 ), leading to the premature deaths of millions of people yearly. Moreover, the aerosol acidity ([H+]) seems to considerably enhance the production of secondary organic aerosols (SOA), but this last aspect is not supported by other scientific teams ( 38 ).

Climate and Pollution

Air pollution and climate change are closely related. Climate is the other side of the same coin that reduces the quality of our Earth ( 44 ). Pollutants such as black carbon, methane, tropospheric ozone, and aerosols affect the amount of incoming sunlight. As a result, the temperature of the Earth is increasing, resulting in the melting of ice, icebergs, and glaciers.

In this vein, climatic changes will affect the incidence and prevalence of both residual and imported infections in Europe. Climate and weather affect the duration, timing, and intensity of outbreaks strongly and change the map of infectious diseases in the globe ( 45 ). Mosquito-transmitted parasitic or viral diseases are extremely climate-sensitive, as warming firstly shortens the pathogen incubation period and secondly shifts the geographic map of the vector. Similarly, water-warming following climate changes leads to a high incidence of waterborne infections. Recently, in Europe, eradicated diseases seem to be emerging due to the migration of population, for example, cholera, poliomyelitis, tick-borne encephalitis, and malaria ( 46 ).

The spread of epidemics is associated with natural climate disasters and storms, which seem to occur more frequently nowadays ( 47 ). Malnutrition and disequilibration of the immune system are also associated with the emerging infections affecting public health ( 48 ).

The Chikungunya virus “took the airplane” from the Indian Ocean to Europe, as outbreaks of the disease were registered in Italy ( 49 ) as well as autochthonous cases in France ( 50 ).

An increase in cryptosporidiosis in the United Kingdom and in the Czech Republic seems to have occurred following flooding ( 36 , 51 ).

As stated previously, aerosols compounds are tiny in size and considerably affect the climate. They are able to dissipate sunlight (the albedo phenomenon) by dispersing a quarter of the sun's rays back to space and have cooled the global temperature over the last 30 years ( 52 ).

Air Pollutants

The World Health Organization (WHO) reports on six major air pollutants, namely particle pollution, ground-level ozone, carbon monoxide, sulfur oxides, nitrogen oxides, and lead. Air pollution can have a disastrous effect on all components of the environment, including groundwater, soil, and air. Additionally, it poses a serious threat to living organisms. In this vein, our interest is mainly to focus on these pollutants, as they are related to more extensive and severe problems in human health and environmental impact. Acid rain, global warming, the greenhouse effect, and climate changes have an important ecological impact on air pollution ( 53 ).

Particulate Matter (PM) and Health

Studies have shown a relationship between particulate matter (PM) and adverse health effects, focusing on either short-term (acute) or long-term (chronic) PM exposure.

Particulate matter (PM) is usually formed in the atmosphere as a result of chemical reactions between the different pollutants. The penetration of particles is closely dependent on their size ( 53 ). Particulate Matter (PM) was defined as a term for particles by the United States Environmental Protection Agency ( 54 ). Particulate matter (PM) pollution includes particles with diameters of 10 micrometers (μm) or smaller, called PM 10 , and extremely fine particles with diameters that are generally 2.5 micrometers (μm) and smaller.

Particulate matter contains tiny liquid or solid droplets that can be inhaled and cause serious health effects ( 55 ). Particles <10 μm in diameter (PM 10 ) after inhalation can invade the lungs and even reach the bloodstream. Fine particles, PM 2.5 , pose a greater risk to health ( 6 , 56 ) ( Table 1 ).

Table 1 . Penetrability according to particle size.

Multiple epidemiological studies have been performed on the health effects of PM. A positive relation was shown between both short-term and long-term exposures of PM 2.5 and acute nasopharyngitis ( 56 ). In addition, long-term exposure to PM for years was found to be related to cardiovascular diseases and infant mortality.

Those studies depend on PM 2.5 monitors and are restricted in terms of study area or city area due to a lack of spatially resolved daily PM 2.5 concentration data and, in this way, are not representative of the entire population. Following a recent epidemiological study by the Department of Environmental Health at Harvard School of Public Health (Boston, MA) ( 57 ), it was reported that, as PM 2.5 concentrations vary spatially, an exposure error (Berkson error) seems to be produced, and the relative magnitudes of the short- and long-term effects are not yet completely elucidated. The team developed a PM 2.5 exposure model based on remote sensing data for assessing short- and long-term human exposures ( 57 ). This model permits spatial resolution in short-term effects plus the assessment of long-term effects in the whole population.

Moreover, respiratory diseases and affection of the immune system are registered as long-term chronic effects ( 58 ). It is worth noting that people with asthma, pneumonia, diabetes, and respiratory and cardiovascular diseases are especially susceptible and vulnerable to the effects of PM. PM 2.5 , followed by PM 10 , are strongly associated with diverse respiratory system diseases ( 59 ), as their size permits them to pierce interior spaces ( 60 ). The particles produce toxic effects according to their chemical and physical properties. The components of PM 10 and PM 2.5 can be organic (polycyclic aromatic hydrocarbons, dioxins, benzene, 1-3 butadiene) or inorganic (carbon, chlorides, nitrates, sulfates, metals) in nature ( 55 ).

Particulate Matter (PM) is divided into four main categories according to type and size ( 61 ) ( Table 2 ).

Table 2 . Types and sizes of particulate Matter (PM).

Gas contaminants include PM in aerial masses.

Particulate contaminants include contaminants such as smog, soot, tobacco smoke, oil smoke, fly ash, and cement dust.

Biological Contaminants are microorganisms (bacteria, viruses, fungi, mold, and bacterial spores), cat allergens, house dust and allergens, and pollen.

Types of Dust include suspended atmospheric dust, settling dust, and heavy dust.

Finally, another fact is that the half-lives of PM 10 and PM 2.5 particles in the atmosphere is extended due to their tiny dimensions; this permits their long-lasting suspension in the atmosphere and even their transfer and spread to distant destinations where people and the environment may be exposed to the same magnitude of pollution ( 53 ). They are able to change the nutrient balance in watery ecosystems, damage forests and crops, and acidify water bodies.

As stated, PM 2.5 , due to their tiny size, are causing more serious health effects. These aforementioned fine particles are the main cause of the “haze” formation in different metropolitan areas ( 12 , 13 , 61 ).

Ozone Impact in the Atmosphere

Ozone (O 3 ) is a gas formed from oxygen under high voltage electric discharge ( 62 ). It is a strong oxidant, 52% stronger than chlorine. It arises in the stratosphere, but it could also arise following chain reactions of photochemical smog in the troposphere ( 63 ).

Ozone can travel to distant areas from its initial source, moving with air masses ( 64 ). It is surprising that ozone levels over cities are low in contrast to the increased amounts occuring in urban areas, which could become harmful for cultures, forests, and vegetation ( 65 ) as it is reducing carbon assimilation ( 66 ). Ozone reduces growth and yield ( 47 , 48 ) and affects the plant microflora due to its antimicrobial capacity ( 67 , 68 ). In this regard, ozone acts upon other natural ecosystems, with microflora ( 69 , 70 ) and animal species changing their species composition ( 71 ). Ozone increases DNA damage in epidermal keratinocytes and leads to impaired cellular function ( 72 ).

Ground-level ozone (GLO) is generated through a chemical reaction between oxides of nitrogen and VOCs emitted from natural sources and/or following anthropogenic activities.

Ozone uptake usually occurs by inhalation. Ozone affects the upper layers of the skin and the tear ducts ( 73 ). A study of short-term exposure of mice to high levels of ozone showed malondialdehyde formation in the upper skin (epidermis) but also depletion in vitamins C and E. It is likely that ozone levels are not interfering with the skin barrier function and integrity to predispose to skin disease ( 74 ).

Due to the low water-solubility of ozone, inhaled ozone has the capacity to penetrate deeply into the lungs ( 75 ).

Toxic effects induced by ozone are registered in urban areas all over the world, causing biochemical, morphologic, functional, and immunological disorders ( 76 ).

The European project (APHEA2) focuses on the acute effects of ambient ozone concentrations on mortality ( 77 ). Daily ozone concentrations compared to the daily number of deaths were reported from different European cities for a 3-year period. During the warm period of the year, an observed increase in ozone concentration was associated with an increase in the daily number of deaths (0.33%), in the number of respiratory deaths (1.13%), and in the number of cardiovascular deaths (0.45%). No effect was observed during wintertime.

Carbon Monoxide (CO)

Carbon monoxide is produced by fossil fuel when combustion is incomplete. The symptoms of poisoning due to inhaling carbon monoxide include headache, dizziness, weakness, nausea, vomiting, and, finally, loss of consciousness.

The affinity of carbon monoxide to hemoglobin is much greater than that of oxygen. In this vein, serious poisoning may occur in people exposed to high levels of carbon monoxide for a long period of time. Due to the loss of oxygen as a result of the competitive binding of carbon monoxide, hypoxia, ischemia, and cardiovascular disease are observed.

Carbon monoxide affects the greenhouses gases that are tightly connected to global warming and climate. This should lead to an increase in soil and water temperatures, and extreme weather conditions or storms may occur ( 68 ).

However, in laboratory and field experiments, it has been seen to produce increased plant growth ( 78 ).

Nitrogen Oxide (NO 2 )

Nitrogen oxide is a traffic-related pollutant, as it is emitted from automobile motor engines ( 79 , 80 ). It is an irritant of the respiratory system as it penetrates deep in the lung, inducing respiratory diseases, coughing, wheezing, dyspnea, bronchospasm, and even pulmonary edema when inhaled at high levels. It seems that concentrations over 0.2 ppm produce these adverse effects in humans, while concentrations higher than 2.0 ppm affect T-lymphocytes, particularly the CD8+ cells and NK cells that produce our immune response ( 81 ).It is reported that long-term exposure to high levels of nitrogen dioxide can be responsible for chronic lung disease. Long-term exposure to NO 2 can impair the sense of smell ( 81 ).

However, systems other than respiratory ones can be involved, as symptoms such as eye, throat, and nose irritation have been registered ( 81 ).

High levels of nitrogen dioxide are deleterious to crops and vegetation, as they have been observed to reduce crop yield and plant growth efficiency. Moreover, NO 2 can reduce visibility and discolor fabrics ( 81 ).

Sulfur Dioxide (SO 2 )

Sulfur dioxide is a harmful gas that is emitted mainly from fossil fuel consumption or industrial activities. The annual standard for SO 2 is 0.03 ppm ( 82 ). It affects human, animal, and plant life. Susceptible people as those with lung disease, old people, and children, who present a higher risk of damage. The major health problems associated with sulfur dioxide emissions in industrialized areas are respiratory irritation, bronchitis, mucus production, and bronchospasm, as it is a sensory irritant and penetrates deep into the lung converted into bisulfite and interacting with sensory receptors, causing bronchoconstriction. Moreover, skin redness, damage to the eyes (lacrimation and corneal opacity) and mucous membranes, and worsening of pre-existing cardiovascular disease have been observed ( 81 ).

Environmental adverse effects, such as acidification of soil and acid rain, seem to be associated with sulfur dioxide emissions ( 83 ).

Lead is a heavy metal used in different industrial plants and emitted from some petrol motor engines, batteries, radiators, waste incinerators, and waste waters ( 84 ).

Moreover, major sources of lead pollution in the air are metals, ore, and piston-engine aircraft. Lead poisoning is a threat to public health due to its deleterious effects upon humans, animals, and the environment, especially in the developing countries.

Exposure to lead can occur through inhalation, ingestion, and dermal absorption. Trans- placental transport of lead was also reported, as lead passes through the placenta unencumbered ( 85 ). The younger the fetus is, the more harmful the toxic effects. Lead toxicity affects the fetal nervous system; edema or swelling of the brain is observed ( 86 ). Lead, when inhaled, accumulates in the blood, soft tissue, liver, lung, bones, and cardiovascular, nervous, and reproductive systems. Moreover, loss of concentration and memory, as well as muscle and joint pain, were observed in adults ( 85 , 86 ).

Children and newborns ( 87 ) are extremely susceptible even to minimal doses of lead, as it is a neurotoxicant and causes learning disabilities, impairment of memory, hyperactivity, and even mental retardation.

Elevated amounts of lead in the environment are harmful to plants and crop growth. Neurological effects are observed in vertebrates and animals in association with high lead levels ( 88 ).

Polycyclic Aromatic Hydrocarbons(PAHs)

The distribution of PAHs is ubiquitous in the environment, as the atmosphere is the most important means of their dispersal. They are found in coal and in tar sediments. Moreover, they are generated through incomplete combustion of organic matter as in the cases of forest fires, incineration, and engines ( 89 ). PAH compounds, such as benzopyrene, acenaphthylene, anthracene, and fluoranthene are recognized as toxic, mutagenic, and carcinogenic substances. They are an important risk factor for lung cancer ( 89 ).

Volatile Organic Compounds(VOCs)

Volatile organic compounds (VOCs), such as toluene, benzene, ethylbenzene, and xylene ( 90 ), have been found to be associated with cancer in humans ( 91 ). The use of new products and materials has actually resulted in increased concentrations of VOCs. VOCs pollute indoor air ( 90 ) and may have adverse effects on human health ( 91 ). Short-term and long-term adverse effects on human health are observed. VOCs are responsible for indoor air smells. Short-term exposure is found to cause irritation of eyes, nose, throat, and mucosal membranes, while those of long duration exposure include toxic reactions ( 92 ). Predictable assessment of the toxic effects of complex VOC mixtures is difficult to estimate, as these pollutants can have synergic, antagonistic, or indifferent effects ( 91 , 93 ).

Dioxins originate from industrial processes but also come from natural processes, such as forest fires and volcanic eruptions. They accumulate in foods such as meat and dairy products, fish and shellfish, and especially in the fatty tissue of animals ( 94 ).

Short-period exhibition to high dioxin concentrations may result in dark spots and lesions on the skin ( 94 ). Long-term exposure to dioxins can cause developmental problems, impairment of the immune, endocrine and nervous systems, reproductive infertility, and cancer ( 94 ).

Without any doubt, fossil fuel consumption is responsible for a sizeable part of air contamination. This contamination may be anthropogenic, as in agricultural and industrial processes or transportation, while contamination from natural sources is also possible. Interestingly, it is of note that the air quality standards established through the European Air Quality Directive are somewhat looser than the WHO guidelines, which are stricter ( 95 ).

Effect of Air Pollution on Health

The most common air pollutants are ground-level ozone and Particulates Matter (PM). Air pollution is distinguished into two main types:

Outdoor pollution is the ambient air pollution.

Indoor pollution is the pollution generated by household combustion of fuels.

People exposed to high concentrations of air pollutants experience disease symptoms and states of greater and lesser seriousness. These effects are grouped into short- and long-term effects affecting health.

Susceptible populations that need to be aware of health protection measures include old people, children, and people with diabetes and predisposing heart or lung disease, especially asthma.

As extensively stated previously, according to a recent epidemiological study from Harvard School of Public Health, the relative magnitudes of the short- and long-term effects have not been completely clarified ( 57 ) due to the different epidemiological methodologies and to the exposure errors. New models are proposed for assessing short- and long-term human exposure data more successfully ( 57 ). Thus, in the present section, we report the more common short- and long-term health effects but also general concerns for both types of effects, as these effects are often dependent on environmental conditions, dose, and individual susceptibility.

Short-term effects are temporary and range from simple discomfort, such as irritation of the eyes, nose, skin, throat, wheezing, coughing and chest tightness, and breathing difficulties, to more serious states, such as asthma, pneumonia, bronchitis, and lung and heart problems. Short-term exposure to air pollution can also cause headaches, nausea, and dizziness.

These problems can be aggravated by extended long-term exposure to the pollutants, which is harmful to the neurological, reproductive, and respiratory systems and causes cancer and even, rarely, deaths.

The long-term effects are chronic, lasting for years or the whole life and can even lead to death. Furthermore, the toxicity of several air pollutants may also induce a variety of cancers in the long term ( 96 ).

As stated already, respiratory disorders are closely associated with the inhalation of air pollutants. These pollutants will invade through the airways and will accumulate at the cells. Damage to target cells should be related to the pollutant component involved and its source and dose. Health effects are also closely dependent on country, area, season, and time. An extended exposure duration to the pollutant should incline to long-term health effects in relation also to the above factors.

Particulate Matter (PMs), dust, benzene, and O 3 cause serious damage to the respiratory system ( 97 ). Moreover, there is a supplementary risk in case of existing respiratory disease such as asthma ( 98 ). Long-term effects are more frequent in people with a predisposing disease state. When the trachea is contaminated by pollutants, voice alterations may be remarked after acute exposure. Chronic obstructive pulmonary disease (COPD) may be induced following air pollution, increasing morbidity and mortality ( 99 ). Long-term effects from traffic, industrial air pollution, and combustion of fuels are the major factors for COPD risk ( 99 ).

Multiple cardiovascular effects have been observed after exposure to air pollutants ( 100 ). Changes occurred in blood cells after long-term exposure may affect cardiac functionality. Coronary arteriosclerosis was reported following long-term exposure to traffic emissions ( 101 ), while short-term exposure is related to hypertension, stroke, myocardial infracts, and heart insufficiency. Ventricle hypertrophy is reported to occur in humans after long-time exposure to nitrogen oxide (NO 2 ) ( 102 , 103 ).

Neurological effects have been observed in adults and children after extended-term exposure to air pollutants.

Psychological complications, autism, retinopathy, fetal growth, and low birth weight seem to be related to long-term air pollution ( 83 ). The etiologic agent of the neurodegenerative diseases (Alzheimer's and Parkinson's) is not yet known, although it is believed that extended exposure to air pollution seems to be a factor. Specifically, pesticides and metals are cited as etiological factors, together with diet. The mechanisms in the development of neurodegenerative disease include oxidative stress, protein aggregation, inflammation, and mitochondrial impairment in neurons ( 104 ) ( Figure 1 ).

Figure 1 . Impact of air pollutants on the brain.

Brain inflammation was observed in dogs living in a highly polluted area in Mexico for a long period ( 105 ). In human adults, markers of systemic inflammation (IL-6 and fibrinogen) were found to be increased as an immediate response to PNC on the IL-6 level, possibly leading to the production of acute-phase proteins ( 106 ). The progression of atherosclerosis and oxidative stress seem to be the mechanisms involved in the neurological disturbances caused by long-term air pollution. Inflammation comes secondary to the oxidative stress and seems to be involved in the impairment of developmental maturation, affecting multiple organs ( 105 , 107 ). Similarly, other factors seem to be involved in the developmental maturation, which define the vulnerability to long-term air pollution. These include birthweight, maternal smoking, genetic background and socioeconomic environment, as well as education level.

However, diet, starting from breast-feeding, is another determinant factor. Diet is the main source of antioxidants, which play a key role in our protection against air pollutants ( 108 ). Antioxidants are free radical scavengers and limit the interaction of free radicals in the brain ( 108 ). Similarly, genetic background may result in a differential susceptibility toward the oxidative stress pathway ( 60 ). For example, antioxidant supplementation with vitamins C and E appears to modulate the effect of ozone in asthmatic children homozygous for the GSTM1 null allele ( 61 ). Inflammatory cytokines released in the periphery (e.g., respiratory epithelia) upregulate the innate immune Toll-like receptor 2. Such activation and the subsequent events leading to neurodegeneration have recently been observed in lung lavage in mice exposed to ambient Los Angeles (CA, USA) particulate matter ( 61 ). In children, neurodevelopmental morbidities were observed after lead exposure. These children developed aggressive and delinquent behavior, reduced intelligence, learning difficulties, and hyperactivity ( 109 ). No level of lead exposure seems to be “safe,” and the scientific community has asked the Centers for Disease Control and Prevention (CDC) to reduce the current screening guideline of 10 μg/dl ( 109 ).

It is important to state that impact on the immune system, causing dysfunction and neuroinflammation ( 104 ), is related to poor air quality. Yet, increases in serum levels of immunoglobulins (IgA, IgM) and the complement component C3 are observed ( 106 ). Another issue is that antigen presentation is affected by air pollutants, as there is an upregulation of costimulatory molecules such as CD80 and CD86 on macrophages ( 110 ).

As is known, skin is our shield against ultraviolet radiation (UVR) and other pollutants, as it is the most exterior layer of our body. Traffic-related pollutants, such as PAHs, VOCs, oxides, and PM, may cause pigmented spots on our skin ( 111 ). On the one hand, as already stated, when pollutants penetrate through the skin or are inhaled, damage to the organs is observed, as some of these pollutants are mutagenic and carcinogenic, and, specifically, they affect the liver and lung. On the other hand, air pollutants (and those in the troposphere) reduce the adverse effects of ultraviolet radiation UVR in polluted urban areas ( 111 ). Air pollutants absorbed by the human skin may contribute to skin aging, psoriasis, acne, urticaria, eczema, and atopic dermatitis ( 111 ), usually caused by exposure to oxides and photochemical smoke ( 111 ). Exposure to PM and cigarette smoking act as skin-aging agents, causing spots, dyschromia, and wrinkles. Lastly, pollutants have been associated with skin cancer ( 111 ).

Higher morbidity is reported to fetuses and children when exposed to the above dangers. Impairment in fetal growth, low birth weight, and autism have been reported ( 112 ).

Another exterior organ that may be affected is the eye. Contamination usually comes from suspended pollutants and may result in asymptomatic eye outcomes, irritation ( 112 ), retinopathy, or dry eye syndrome ( 113 , 114 ).

Environmental Impact of Air Pollution

Air pollution is harming not only human health but also the environment ( 115 ) in which we live. The most important environmental effects are as follows.

Acid rain is wet (rain, fog, snow) or dry (particulates and gas) precipitation containing toxic amounts of nitric and sulfuric acids. They are able to acidify the water and soil environments, damage trees and plantations, and even damage buildings and outdoor sculptures, constructions, and statues.

Haze is produced when fine particles are dispersed in the air and reduce the transparency of the atmosphere. It is caused by gas emissions in the air coming from industrial facilities, power plants, automobiles, and trucks.

Ozone , as discussed previously, occurs both at ground level and in the upper level (stratosphere) of the Earth's atmosphere. Stratospheric ozone is protecting us from the Sun's harmful ultraviolet (UV) rays. In contrast, ground-level ozone is harmful to human health and is a pollutant. Unfortunately, stratospheric ozone is gradually damaged by ozone-depleting substances (i.e., chemicals, pesticides, and aerosols). If this protecting stratospheric ozone layer is thinned, then UV radiation can reach our Earth, with harmful effects for human life (skin cancer) ( 116 ) and crops ( 117 ). In plants, ozone penetrates through the stomata, inducing them to close, which blocks CO 2 transfer and induces a reduction in photosynthesis ( 118 ).

Global climate change is an important issue that concerns mankind. As is known, the “greenhouse effect” keeps the Earth's temperature stable. Unhappily, anthropogenic activities have destroyed this protecting temperature effect by producing large amounts of greenhouse gases, and global warming is mounting, with harmful effects on human health, animals, forests, wildlife, agriculture, and the water environment. A report states that global warming is adding to the health risks of poor people ( 119 ).

People living in poorly constructed buildings in warm-climate countries are at high risk for heat-related health problems as temperatures mount ( 119 ).

Wildlife is burdened by toxic pollutants coming from the air, soil, or the water ecosystem and, in this way, animals can develop health problems when exposed to high levels of pollutants. Reproductive failure and birth effects have been reported.

Eutrophication is occurring when elevated concentrations of nutrients (especially nitrogen) stimulate the blooming of aquatic algae, which can cause a disequilibration in the diversity of fish and their deaths.

Without a doubt, there is a critical concentration of pollution that an ecosystem can tolerate without being destroyed, which is associated with the ecosystem's capacity to neutralize acidity. The Canada Acid Rain Program established this load at 20 kg/ha/yr ( 120 ).

Hence, air pollution has deleterious effects on both soil and water ( 121 ). Concerning PM as an air pollutant, its impact on crop yield and food productivity has been reported. Its impact on watery bodies is associated with the survival of living organisms and fishes and their productivity potential ( 121 ).

An impairment in photosynthetic rhythm and metabolism is observed in plants exposed to the effects of ozone ( 121 ).

Sulfur and nitrogen oxides are involved in the formation of acid rain and are harmful to plants and marine organisms.

Last but not least, as mentioned above, the toxicity associated with lead and other metals is the main threat to our ecosystems (air, water, and soil) and living creatures ( 121 ).

In 2018, during the first WHO Global Conference on Air Pollution and Health, the WHO's General Director, Dr. Tedros Adhanom Ghebreyesus, called air pollution a “silent public health emergency” and “the new tobacco” ( 122 ).

Undoubtedly, children are particularly vulnerable to air pollution, especially during their development. Air pollution has adverse effects on our lives in many different respects.

Diseases associated with air pollution have not only an important economic impact but also a societal impact due to absences from productive work and school.

Despite the difficulty of eradicating the problem of anthropogenic environmental pollution, a successful solution could be envisaged as a tight collaboration of authorities, bodies, and doctors to regularize the situation. Governments should spread sufficient information and educate people and should involve professionals in these issues so as to control the emergence of the problem successfully.

Technologies to reduce air pollution at the source must be established and should be used in all industries and power plants. The Kyoto Protocol of 1997 set as a major target the reduction of GHG emissions to below 5% by 2012 ( 123 ). This was followed by the Copenhagen summit, 2009 ( 124 ), and then the Durban summit of 2011 ( 125 ), where it was decided to keep to the same line of action. The Kyoto protocol and the subsequent ones were ratified by many countries. Among the pioneers who adopted this important protocol for the world's environmental and climate “health” was China ( 3 ). As is known, China is a fast-developing economy and its GDP (Gross Domestic Product) is expected to be very high by 2050, which is defined as the year of dissolution of the protocol for the decrease in gas emissions.

A more recent international agreement of crucial importance for climate change is the Paris Agreement of 2015, issued by the UNFCCC (United Nations Climate Change Committee). This latest agreement was ratified by a plethora of UN (United Nations) countries as well as the countries of the European Union ( 126 ). In this vein, parties should promote actions and measures to enhance numerous aspects around the subject. Boosting education, training, public awareness, and public participation are some of the relevant actions for maximizing the opportunities to achieve the targets and goals on the crucial matter of climate change and environmental pollution ( 126 ). Without any doubt, technological improvements makes our world easier and it seems difficult to reduce the harmful impact caused by gas emissions, we could limit its use by seeking reliable approaches.

Synopsizing, a global prevention policy should be designed in order to combat anthropogenic air pollution as a complement to the correct handling of the adverse health effects associated with air pollution. Sustainable development practices should be applied, together with information coming from research in order to handle the problem effectively.

At this point, international cooperation in terms of research, development, administration policy, monitoring, and politics is vital for effective pollution control. Legislation concerning air pollution must be aligned and updated, and policy makers should propose the design of a powerful tool of environmental and health protection. As a result, the main proposal of this essay is that we should focus on fostering local structures to promote experience and practice and extrapolate these to the international level through developing effective policies for sustainable management of ecosystems.

Author Contributions

All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.

Conflict of Interest

IM is employed by the company Delphis S.A.

The remaining authors declare that the present review paper was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Keywords: air pollution, environment, health, public health, gas emission, policy

Citation: Manisalidis I, Stavropoulou E, Stavropoulos A and Bezirtzoglou E (2020) Environmental and Health Impacts of Air Pollution: A Review. Front. Public Health 8:14. doi: 10.3389/fpubh.2020.00014

Received: 17 October 2019; Accepted: 17 January 2020; Published: 20 February 2020.

Reviewed by:

Copyright © 2020 Manisalidis, Stavropoulou, Stavropoulos and Bezirtzoglou. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Ioannis Manisalidis, giannismanisal@gmail.com ; Elisavet Stavropoulou, elisabeth.stavropoulou@gmail.com

† These authors have contributed equally to this work

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• Published: 17 June 2020

Half the world’s population are exposed to increasing air pollution

• G. Shaddick   ORCID: orcid.org/0000-0002-4117-4264 1 ,
• M. L. Thomas 2 ,
• P. Mudu 3 ,
• G. Ruggeri 3 &
• S. Gumy 3  

npj Climate and Atmospheric Science volume  3 , Article number:  23 ( 2020 ) Cite this article

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Air pollution is high on the global agenda and is widely recognised as a threat to both public health and economic progress. The World Health Organization (WHO) estimates that 4.2 million deaths annually can be attributed to outdoor air pollution. Recently, there have been major advances in methods that allow the quantification of air pollution-related indicators to track progress towards the Sustainable Development Goals and that expand the evidence base of the impacts of air pollution on health. Despite efforts to reduce air pollution in many countries there are regions, notably Central and Southern Asia and Sub-Saharan Africa, in which populations continue to be exposed to increasing levels of air pollution. The majority of the world’s population continue to be exposed to levels of air pollution substantially above WHO Air Quality Guidelines and, as such, air pollution constitutes a major, and in many areas, increasing threat to public health.

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Introduction.

In 2016, the WHO estimated that 4.2 million deaths annually could be attributed to ambient (outdoor) fine particulate matter air pollution, or PM 2.5 (particles smaller than 2.5 μm in diameter) 1 . PM 2.5 comes from a wide range of sources, including energy production, households, industry, transport, waste, agriculture, desert dust and forest fires and particles can travel in the atmosphere for hundreds of kilometres and their chemical and physical characteristics may vary greatly over time and space. The WHO developed Air Quality Guidelines (AQG) to offer guidance for reducing the health impacts of air pollution. The first edition, the WHO AQG for Europe, was published in 1987 with a global update (in 2005) reflecting the increased scientific evidence of the health risks of air pollution worldwide and the growing appreciation of the global scale of the problem 2 . The current WHO AQG states that annual mean concentration should not exceed 10 μg/m 3  2 .

The adoption and implementation of policy interventions have proved to be effective in improving air quality 3 , 4 , 5 , 6 , 7 . There are at least three examples of enforcement of long-term policies that have reduced concentration of air pollutants in Europe and North America: (i) the Clean Air Act in 1963 and its subsequent amendments in the USA; (ii) the Convention on Long-range Transboundary Air Pollution (LRTAP) with protocols enforced since the beginning of the 1980s in Europe and North America 8 ; and (iii) the European emission standards passed in the European Union in the early 1990s 9 . However, between 1960 and 2009 concentrations of PM 2.5 globally increased by 38%, due in large part to increases in China and India, with deaths attributable to air pollution increasing by 124% between 1960 and 2009 10 .

The momentum behind the air pollution and climate change agendas, and the synergies between them, together with the Sustainable Development Goals (SDGs) provide an opportunity to address air pollution and the related burden of disease. Here, trends in global air quality between 2010 and 2016 are examined in the context of attempts to reduce air pollution, both through long-term policies and more recent attempts to reduce levels of air pollution. Particular focus is given to providing comprehensive coverage of estimated concentrations and obtaining (national-level) distributions of population exposures for health impact assessment. Traditionally, the primary source of information has been measurements from ground monitoring networks but, although coverage is increasing, there remain regions in which monitoring is sparse, or even non-existent (see Supplementary Information) 11 . The Data Integration Model for Air Quality (DIMAQ) was developed by the WHO Data Integration Task Force (see Acknowledgements for details) to respond to the need for improved estimates of exposures to PM 2.5 at high spatial resolution (0.1° × 0.1°) globally 11 . DIMAQ calibrates ground monitoring data with information from satellite retrievals of aerosol optical depth, chemical transport models and other sources to provide yearly air quality profiles for individual countries, regions and globally 11 . Estimates of PM 2.5 concentrations have been compared with previous studies and a good quantitative agreement in the direction and magnitude of trends has been found. This is especially valid in data rich settings (North America, Western Europe and China) where trends results are consistent with what has been found from the analysis of ground level PM 2.5 measurements.

Figure 1a shows average annual concentrations of PM 2.5 for 2016, estimated using DIMAQ,; and Fig. 1b the differences in concentrations between 2010 and 2016. Although air pollution affects high and low-income countries alike, low- and middle-income countries experience the highest burden, with the highest concentrations being seen in Central, Eastern Southern and South-Eastern Asia 12 .

a Concentrations in 2016. b Changes in concentrations between 2010 and 2016.

The high concentrations observed across parts of the Middle East, parts of Asia and Sub-Saharan regions of Africa are associated with sand and desert dust. Desert dust has received increasing attention due to the magnitude of its concentration and the capacity to be transported over very long distances in particular areas of the world 13 , 14 . The Sahara is one of the biggest global source of desert dust 15 and the increase of PM 2.5 in this region is consistent with the prediction of an increase of desert dust due to climate change 16 , 17 .

Globally, 55.3% of the world’s population were exposed to increased levels of PM 2.5 , between 2010 and 2016, however there are marked differences in the direction and magnitude of trends across the world. For example, in North America and Europe annual average population-weighted concentrations decreased from 12.4 to 9.8 μg/m 3 while in Central and Southern Asia they rose from 54.8 to 61.5 μg/m 3 . Reductions in concentrations observed in North America and Europe align with those reported by the US Environmental Protection Agency and European Environmental Agency (EEA) 18 , 19 . The lower values observed in these regions reflect substantial regulatory processes that were implemented thirty years ago that have led to substantial decreases in air pollution over previous decades 18 , 20 , 21 . In high-income countries, the extent of air pollution from widespread coal and other solid-fuel burning, together with other toxic emissions from largely unregulated industrial processes, declined markedly with Clean Air Acts and similar ‘smoke control’ legislation introduced from the mid-20th century. However, these remain important sources of air pollution in other parts of the world 22 . In North America and Europe, the rates of improvements are small reflecting the difficulties in reducing concentrations at lower levels.

Assessing the health impacts of air pollution requires detailed information of the levels to which specific populations are exposed. Specifically, it is important to identify whether areas where there are high concentrations are co-located with high populations within a country or region. Population-weighted concentrations, often referred to as population-weighted exposures, are calculated by spatially aligning concentrations of PM 2.5 with population estimates (see Supplementary Information).

Figure 2 shows global trends in estimated concentrations and population-weighted concentrations of PM 2.5 for 2010–2016, together with trends for SDG regions (see Supplementary Fig. 1.1 ). Where population-weighted exposures are higher than concentrations, as seen in Central Asia and Southern Asia, this indicates that higher levels of air pollution coincide with highly populated areas. Globally, whilst concentrations have reduced slightly (from 12.8 μg/m 3 in 2010 to 11.7 in 2016), population-weighted concentrations have increased slightly (33.5 μg/m 3 in 2010, 34.6 μg/m 3 in 2016). In North America and Europe both concentrations and population-weighted concentrations have decreased (6.1–4.9 and 12.4–9.8 μg/m 3 , respectively). The association between concentrations and population can be clearly seen for Central Asia and Southern Asia where concentrations increased from 29.6 to 31.7 μg/m 3 (a 7% increase) while population-weighted concentrations were higher both in magnitude and in percentage of increase, increasing from 54.8 to 61.5 μg/m 3 (a 12% increase).

a Concentrations. b Population-weighted concentrations.

For the Eastern Asia and South Eastern Asia concentrations increase from 2010 to 2013 and then decrease from 2013 to 2016, a result of the implementation of the ‘Air Pollution Prevention and Control Action Plan’ 21 and the transition to cleaner energy mix due to increased urbanization in China 23 , 24 , 25 . Population-weighted concentrations for urban areas in this region are strongly influenced by China, which comprises 62.6% of the population in the region. Population-weighted concentrations are higher than the concentrations and the decrease is more marked (in the population-weighted concentrations), indicating that the implementation of policies has been successful in terms of the number of people affected. The opposite effect of population-weighting is observed in areas within Western Asia and Northern Africa where an increasing trend in population-weighted concentrations (from 42.0 to 43.1. μg/m 3 ) contains lower values than for concentrations (from 50.7 to 52.6 μg/m 3 ). In this region, concentrations are inversely correlated with population, reflecting the high concentrations associated with desert dust in areas of lower population density.

Long-term policies to reduce air pollution have been shown to be effective and have been implemented in many countries, notably in Europe and the United States. However, even in countries with the cleanest air there are large numbers of people exposed to harmful levels of air pollution. Although precise quantification of the outcomes of specific policies is difficult, coupling the evidence for effective interventions with global, regional and local trends in air pollution can provide essential information for the evidence base that is key in informing and monitoring future policies. There have been major advances in methods that expand the knowledge base about impacts of air pollution on health, from evidence on the health effects 26 , modelling levels of air pollution 1 , 11 and quantification of health impacts that can be used to monitor and report on progress towards the air pollution-related indicators of the Sustainable Development Goals: SDG 3.9.1 (mortality rate attributed to household and ambient air pollution); SDG 7.1.2 (proportion of population with primary reliance on clean fuels and technology); and SDG 11.6.2 (annual mean levels of fine particulate matter (e.g., PM 2.5 and PM 10 ) in cities (population weighted)) 1 . There is a continuing need for further research, collaboration and sharing of good practice between scientists and international organisations, for example the WHO and the World Meteorological Organization, to improve modelling of global air pollution and the assessment of its impact on health. This will include developing models that address specific questions, including for example the effects of transboundary air pollution and desert dust, and to produce tools that provide policy makers with the ability to assess the effects of interventions and to accurately predict the potential effects of proposed policies.

Globally, the population exposed to PM 2.5 levels above the current WHO AQG (annual average of 10 μg/m 3 ) has fallen from 94.2% in 2010 to 90.0% in 2016, driven largely by decreases in North America and Europe (from 71.0% in 2010 to 48.6% in 2016). However, no such improvements are seen in other regions where the proportion has remained virtually constant and extremely high (e.g., greater than 99% in Central, Southern, Eastern and South-Eastern Asia Sustainable Development Goal (SDG) regions. See Supplementary Information for more details).

The problem, and the need for solutions, is not confined to cities: across much of the world the vast majority of people living in rural areas are also exposed to levels above the guidelines. Although there are differences when considering urban and rural areas in North America and Europe, in the vast majority of the world populations living in both urban and rural areas are exposed to levels that are above the AQGs. However, in other regions the story is very different (see Supplementary Information Fig. 7.1 and Supplementary Information Sections 7 and 8), for example population-weighted concentrations in rural areas in the Central and Southern Asia (55.5 μg/m 3 ), Sub-Saharan Africa (39.1 μg/m 3 ), Western Asia and Northern Africa (42.7 μg/m 3 ) and Eastern Asia and South-Eastern Asia (34.3 μg/m 3 ) regions (in 2016) were all considerably above the AQG. From 2010 to 2016 population-weighted concentrations in rural areas in the Central and Southern Asia region rose by approximately 11% (from 49.8 to 55.5 μg/m 3 ; see Supplementary Information Fig. 7.1 and Supplementary Information Sections 7 and 8). This is largely driven by large rural populations in India where 67.2% of the population live in rural areas 27 . Addressing air pollution in both rural and urban settings should therefore be a key priority in effectively reducing the burden of disease associated with air pollution.

Attempts to mitigate the effects of air pollution have varied according to its source and local conditions, but in all cases cooperation across sectors and at different levels, urban, regional, national and international, is crucial 28 . Policies and investments supporting affordable and sustainable access to clean energy, cleaner transport and power generation, as well as energy-efficient housing and municipal waste management can reduce key sources of outdoor air pollution. Interventions would not only improve health but also reduce climate pollutants and serve as a catalyst for local economic development and the promotion of healthy lifestyles.

Assessment of trends in global air pollution requires comprehensive information on concentrations over time for every country. This information is primarily based on ground monitoring (GM) from 9690 monitoring locations around the world from the WHO cities database for 2010–2016. However, there are regions in this may be limited if not completely unavailable, particularly for earlier years (see Supplementary Information). Even in countries where GM networks are well established, there will still be gaps in spatial coverage and missing data over time. The Data Integration Model for Air Quality (DIMAQ) supplements GM with information from other sources including estimates of PM2.5 from satellite retrievals and chemical transport models, population estimates and topography (e.g., elevation). Specifically, satellite-based estimates that combine aerosol optical depth retrievals with information from the GEOS-Chem chemical transport model 29 were used, together with estimates of sulfate, nitrate, ammonium, organic carbon and mineral dust 30 .

The most recent release of the WHO ambient air quality database, for the first time, contains data from GM for multiple years, where available The version of DIMAQ used here builds on the original version 11 , 30 by allowing data from multiple years to be modelled simultaneously, with the relationship between GMs and satellite-based estimates allowed to vary (smoothly) over time. The result is a comprehensive set of high-resolution (10 km × 10 km) estimates of PM2.5 for each year (2010–2016) for every country.

In order to produce population-weighted concentrations, a comprehensive set of population data on a high-resolution grid (Gridded Population of the World (GPW v4) database 31 ) was combined with estimates from DIMAQ. In addition, the Global Human Settlement Layer 32 was used to define areas as either urban, sub-urban or rural (based on land-use, derived from satellite images, and population estimates). A further dichotomous classification of whether grid-cells within a particular country were urban or rural (allocating sub-urban as either urban or rural) was based on providing the best alignment (at the country-level) to the estimates of urban-rural populations produced by the United Nations 27 .

It is noted that the estimates from DIMAQ used in this article may differ slightly from those used in the WHO estimates of the global burden of disease associated with ambient air pollution 1 , and the associated estimates of air pollution related SDG indicators, due to recent updates in the database and further quality assurance procedures.

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Acknowledgements

The authors would like to thank the WHO Data Integration Task Force, a multi-disciplinary group of experts established as part of the recommendations from the first meeting of the WHO Global Platform for Air Quality, Geneva, January 2014. The Task Force developed the Data Integration Model for Air Quality and consists of the first author, Michael Brauer, Aaron van Donkelaar, Rick Burnett, Howard H. Chang, Aaron Cohen, Rita Van Dingenen, Yang Liu, Randall Martin, Lance A. Waller, Jason West, James V. Zidek and Annette Pruss-Ustun. The authors would like to give particular thanks to Michael Brauer who provided specialist expertise, together with data on ground measurements, and Aaron van Donkelaar and the Atmospheric Composition Analysis Group at Dalhousie University for providing estimates from satellite remote sensing. The authors would also like to thank Dan Simpson for technical expertise on implementing extensions to DIMAQ. Matthew L Thomas is supported by a scholarship from the EPSRC Centre for Doctoral Training in Statistical Applied Mathematics at Bath (SAMBa), under the project EP/L015684/1. The views expressed in this article are those of the authors and they do not necessarily represent the views, decisions or policies to institutions with which they are affiliated.

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Shaddick, G., Thomas, M.L., Mudu, P. et al. Half the world’s population are exposed to increasing air pollution. npj Clim Atmos Sci 3 , 23 (2020). https://doi.org/10.1038/s41612-020-0124-2

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Research Article

Exposure to outdoor air pollution and its human health outcomes: A scoping review

Contributed equally to this work with: Zhuanlan Sun, Demi Zhu

Roles Writing – original draft

Affiliation Department of Management Science and Engineering, School of Economics and Management, Tongji University, Shanghai, China

Roles Writing – review & editing

* E-mail: [email protected]

Affiliation Department of Comparative Politics, School of International and Public Affairs, Shanghai Jiaotong University, Shanghai, China

• Zhuanlan Sun, 

• Published: May 16, 2019
• https://doi.org/10.1371/journal.pone.0216550
• Reader Comments

Despite considerable air pollution prevention and control measures that have been put into practice in recent years, outdoor air pollution remains one of the most important risk factors for health outcomes. To identify the potential research gaps, we conducted a scoping review focused on health outcomes affected by outdoor air pollution across the broad research area. Of the 5759 potentially relevant studies, 799 were included in the final analysis. The included studies showed an increasing publication trend from 1992 to 2008, and most of the studies were conducted in Asia, Europe, and North America. Among the eight categorized health outcomes, asthma (category: respiratory diseases) and mortality (category: health records) were the most common ones. Adverse health outcomes involving respiratory diseases among children accounted for the largest group. Out of the total included studies, 95.2% reported at least one statistically positive result, and only 0.4% showed ambiguous results. Based on our study, we suggest that the time frame of the included studies, their disease definitions, and the measurement of personal exposure to outdoor air pollution should be taken into consideration in any future research. The main limitation of this study is its potential language bias, since only English publications were included. In conclusion, this scoping review provides researchers and policy decision makers with evidence taken from multiple disciplines to show the increasing prevalence of outdoor air pollution and its adverse effects on health outcomes.

Citation: Sun Z, Zhu D (2019) Exposure to outdoor air pollution and its human health outcomes: A scoping review. PLoS ONE 14(5): e0216550. https://doi.org/10.1371/journal.pone.0216550

Editor: Mathilde Body-Malapel, University of Lille, FRANCE

Received: December 15, 2018; Accepted: April 10, 2019; Published: May 16, 2019

Copyright: © 2019 Sun, Zhu. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting Information files.

Funding: This work received support from Major projects of the National Social Science Fund of China, Award Number: 13&ZD176, Grant recipient: Demi Zhu.

Competing interests: The authors have declared that no competing interests exist.

Introduction

In recent years, despite considerable improvements in air pollution prevention and control, outdoor air pollution has remained a major environmental health hazard to human beings. In some developing countries, the concentrations of air quality far exceed the upper limit announced in the World Health Organization guidelines [ 1 ]. Moreover, it is widely acknowledged that outdoor air pollution increases the incidence rates of multiple diseases, such as cardiovascular disease, lung cancer, respiratory symptoms, asthma, negatively affected pregnancy, and poor birth outcomes [ 2 – 6 ].

The influence of outdoor air pollution exposure and its mechanisms continue to be hotly debated [ 7 – 11 ]. Some causal inference studies have been conducted to examine these situations [ 12 ]; these have indicated that an increase in outdoor air exposure affects people’s health outcomes both directly and indirectly [ 13 ]. However, few studies in the existing literature have examined the extent, range, and nature of the influence of outdoor air pollution with regard to human health outcomes. Thus, such research gaps need to be identified, and related fields of study need to be mapped.

Systematic reviews and meta-analyses, the most commonly used traditional approach to synthesize knowledge, use quantified data from relevant published studies in order to aggregate findings on a specific topic [ 14 ]; furthermore, they formally assesses the quality of these studies to generate precise conclusions related to the focused research question [ 15 ]. In comparison, scoping review is a more narrative type of knowledge synthesis, and it focuses on a broader area [ 16 ] of the evidence pertaining to a given topic. It is often used to systematically summarize the evidence available (main sources, types, and research characteristics), and it tends to be more comprehensive and helpful to policymakers at all levels.

Scoping reviews have already been used to examine a variety of health related issues [ 17 ]. As an evidence synthesis approach that is still in the midst of development, the methodology framework for scoping reviews faces some controversy with regard to its conceptual clarification and definition [ 18 , 19 ], the necessity of quality assessment [ 20 – 22 ], and the time required for completion [ 19 , 21 , 23 ]. Comparing this approach with other knowledge synthesis methods, such as evidence gap map and rapid review, the scoping review has become increasingly influential for efficient evidence-based decision-making because it offers a very broad topic scope [ 15 ].

To our knowledge, few studies have systematically reviewed the literature in the broad field of outdoor air pollution exposure research, especially with regard to related health outcomes. To fill this gap, we conducted a comprehensive scoping review of the literature with a focus on health outcomes affected by outdoor air pollution. The purposes of this study were as follows: 1) provide a systematic overview of relevant studies; 2) identify the different types of outdoor air pollution and related health outcomes; and 3) summarize the publication characteristics and explore related research gaps.

Materials and methods

The methodology framework used in this study was initially outlined by Arksey and O’Malley [ 23 ] and further advanced by Levac et al. [ 20 ], Daudt et al. [ 21 ], and the Joanna Briggs Institute [ 24 ]. The framework was divided into six stages: identifying the research question; identifying relevant studies; study selection; charting the data; collating, summarizing and reporting the results; and consulting exercise.

Stage one: Research question identification

As recommended, we combined broader research questions with a clearly articulated scope of inquiry [ 20 ]; this included defining the concept, target population, and outcomes of interest in order to disseminate an effective search strategy. Thus, an adaptation of the “PCC” (participants, concept, context) strategy was used to guide the construction of research questions and inclusion criteria [ 24 ].

Types of participants.

There were no strict restrictions on ages, genders, ethnicity, or regions of participants. Everyone, including newborns, children, adults, pregnant women, and the elderly, suffer from health outcomes related to exposure to outdoor air pollution; hence, all groups were included in the study to ensure that the inquiry was sufficiently comprehensive.

The core concept was clearly articulated in order to guide the scope and breadth of the inquiry [ 24 ]. A list of outdoor air pollution and health outcome related terms were compiled by reviewing potential text words in the titles or abstracts of the most pertinent articles [ 25 – 33 ]; we also read the most cited literature reviews on air pollution related health outcomes. To classify the types of air pollution and health outcomes, we consulted researchers from different air pollution related disciplines. The classified results are shown in Table 1 .

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https://doi.org/10.1371/journal.pone.0216550.t001

Our scoping review included studies from peer-reviewed journals. There were no restrictions in terms of the research field, time period, and geographical coverage. The intended audiences of our scoping review were researchers, physicians, and public policymakers.

Stage two: Relevant studies identification

We followed Joanna Briggs Institute’s instructions [ 24 ] to launch three-step search strategies to identify all relevant published and unpublished studies (grey literature) across the multi-disciplinary topic in an iterative way. The first step included a limited search of the entire database using keywords relevant to the topic and conducting an abstract and indexing categorizations analysis. The second step was a further search of all included databases based on the newly identified keywords and index terms. The final step was to search the reference list of the identified reports and literatures.

Electronic databases.

We conducted comprehensive literature searches by consulting with an information specialist. We searched the following three electronic databases from their inception until now: PubMed, Web of Science, and Scopus. The language of the studies included in our sample was restricted to English.

Search terms.

The search terms we used were broad enough to uncover any related literature and prevent chances of relevant information being overlooked. This process was conducted iteratively with different search item combinations to ensure that all relevant literature was captured ( S1 Table ).

The search used combinations of the following terms: 1) outdoor air pollution (ozone, sulfur dioxide, carbon monoxide, nitrogen dioxide, PM 2.5 , PM 10 , total suspended particle, suspended particulate matter, toxic air pollutant, volatile organic pollutant, nitrogen oxide) and 2) health outcomes (asthma, lung cancer, respiratory infection, respiratory disorder, diabetes, chronic respiratory disease, chronic obstructive pulmonary disease, hypertension, heart rate variability, heart attack, cardiopulmonary disease, ischemic heart disease, blood coagulation, deep vein thrombosis, stroke, morbidity, hospital admission, outpatient visit, emergency room visit, mortality, DNA methylation change, neurobehavioral function, inflammatory disease, skin disease, abortion, Alzheimer’s disease, disability, cognitive function, Parkinson’s disease).

Additional studies search.

Key, important, and top journals were read manually, reference lists and citation tracing were used to collect studies and related materials, and suggestions from specialists were considered to guarantee that the research was as comprehensive as possible.

Bibliographies Management Software (Mendeley) was used to remove duplicated literatures and manage thousands of bibliographic references that needed to be appraised to check whether they should be included in the final study selection.

Our literature retrieval generated a total of 5759 references; the majority of these (3567) were found on the Scopus electronic database, which emphasized the importance of collecting the findings on this broad topic.

Stage three: Studies selection

Our study identification picked up a large number of irrelevant studies; we needed a mechanism to include only the studies that best fit the research question. The study selection stage should be an iterative process of searching the literature, refining the search strategy, and reviewing articles for inclusion. Study inclusion and exclusion criteria were discussed by the team members at the beginning of the process, then two inter-professional researchers applied the criteria to independently review the titles and abstracts of all studies [ 21 ]. If there were any ambiguities, the full article was read to make decision about whether it should be chosen for inclusion. When disagreements on study inclusion occurred, a third specialist reviewer made the final decision. This process should be iterative to guarantee the inclusion of all relevant studies.

Inclusion and exclusion criteria.

The inclusion criteria used in our scoping study ensured that the articles were considered only if they were: 1) long-term and short-term exposure, perspective or prospective studies; 2) epidemiological time series studies; 3) meta-analysis and systematic review articles rather than the primary studies that contained the main parameters we were concerned with; 4) economic research studies using causality inference with observational data; and 5) etiology research studies on respiratory disease, cancer, and cardiovascular disease.

Articles were removed if they 1) focused exclusively on indoor air pollution exposure and 2) did not belong to peer-reviewed journals or conference papers (such as policy documents, proposals, and editorials).

Stage four: Data charting

The data extracted from the final articles were entered into a “data charting form” using the database, programmed Excel, so that the following relevant data could be recorded and charted according to the variables of interest ( Table 2 ).

https://doi.org/10.1371/journal.pone.0216550.t002

Stage five: Results collection, summarization, and report

The extracted data were categorized into topics such as people’s health types and regions of diseases caused by outdoor air exposure. Each reported topic should be provided with a clear explanation to enable future research. Finally, the scoping review results were tabulated in order to find research gaps to either enable meaningful research or obtain good pointers for policymaking.

Stage six: Consultation exercise

Our scoping review took into account the consultation phase of sharing preliminary findings with experts, all of whom are members of the Committee on Public Health and Urban Environment Management in China. This enabled us to identify additional emerging issues related to health outcomes.

The original search was conducted in May of 2018; the Web of Science, PubMed, and Scopus databases were searched, resulting in a total of 5759 potentially relevant studies. After a de-duplication of 1451 studies and the application of the inclusion criteria, 3027 studies were assessed as being irrelevant and excluded based on readings of the titles and the abstracts. In the end, 1281 studies were assessed for in-depth full-text screening. To prevent overlooking potentially relevant papers, we manually screened the top five impact factor periodicals in the database we were searching. We traced the reference lists and the cited literatures of the included studies, and then we reviewed the newly collected literatures to generate more relevant studies. Further, after preliminary consultation with experts, we included studies on two additional health outcome categories, pregnancy and children and mental disorders. Hence, 214 more potential studies were included during this process. Besides, 379 original studies of the inclusive meta-analysis and systematic review studies were removed for duplication. In total, 1116 studies were included for in-depth full-text screening analysis and 799 eligible studies were included in the end. The detailed articles selection process was shown in Fig 1 .

https://doi.org/10.1371/journal.pone.0216550.g001

The included air pollution related health outcome studies increased between 1992 and 2018, as shown in Fig 2 . Most studies were published in the last decade and more than 75% of studies (614/76.9%) were published after 2011.

The included studies increased during this period, more than 75% of studies were published after 2011.

https://doi.org/10.1371/journal.pone.0216550.g002

The general characteristics summary of all included studies are shown in Table 3 . Most studies were carried out in Asia, Europe and North America (280/35.0%, 261/32.7% and 219/27.4%, respectively). According to the category system of journal citation reports (JCR) in the Web of Science, 323/40.4% of all studies on health outcomes came from environmental science, 213/26.7% came from the field of medicine, and 24/3.0% were from economics. The top three research designs of the included studies were cohort studies, systematic reviews and meta-analyses, and time series studies (116/14.5%, 107/13.4% and 76/9.5%, respectively). Almost all included studies were published in journals (794/99.4%). The lengths of the included studies ranged from four pages [ 34 ] to over thirty-nine pages [ 35 ].

https://doi.org/10.1371/journal.pone.0216550.t003

Regions of studies

Table 4 outlines the locations in which health outcomes were affected by outdoor air pollution. The continents of Asia (277/34.7%), Europe (219/27.4%), and North America (168/21.0%) account for most of these studies. As the word cloud in Fig 3 illustrates, most of the included studies had been mainly conducted in the United States and China. About 62.8% of the studies (502) had been especially conducted in developed countries.

https://doi.org/10.1371/journal.pone.0216550.t004

Word cloud representing the country of included studies, the size of each term is in proportion to its frequency.

https://doi.org/10.1371/journal.pone.0216550.g003

Most authors (573/799) evaluated the air pollution health outcomes of their own continent, at a proportion of 71.7%.

Types of air pollution and related health outcomes

We categorized the health outcomes, by consulting with experts, into respiratory diseases, chronic diseases, cardiovascular diseases, health records, cancer, mental disorders, pregnancy and children, and other diseases ( Table 5 ). We also divided the outdoor air pollution into general air pollution gas, fine particulate matter, other hazardous substances, and a mixture of them.

https://doi.org/10.1371/journal.pone.0216550.t005

Most of the health records showed that mortality (163/286; 57.0%) was the most common health outcome related to outdoor air pollution, as is visually represented in Fig 4 . Respiratory diseases (e.g., asthma and respiratory symptoms) and cardiovascular diseases (e.g., heart disease) that resulted from exposure to outdoor air pollution were also common (69/199, 63/199 and 23/90; or 34.7%, 31.7% and 25.6%; respectively).

Word cloud representing the health outcomes of included studies, the size of each term is in proportion to its frequency.

https://doi.org/10.1371/journal.pone.0216550.g004

Types of affected groups

The population of included studies was categorized into seven subgroups: birth and infant, children, women and pregnancy, adults, elderly, all ages and not specified ( Table 6 ). The largest air pollution proportion fell under the groups of all ages and children (261/799; 32.7% and 165/799; 20.7%), health outcomes of respiratory diseases in children account for the largest groups (114/199; 57.3%).

https://doi.org/10.1371/journal.pone.0216550.t006

There were 121 research studies in the “Not Specified” group. As shown in Table 6 , the “Birth & Infant,” “Women & Pregnancy,” “Children,” and “elderly” groups occupied the subject areas of more than half of the total included studies, which means that air pollution affected these population groups more acutely. Moreover, age is a confounding factor for the prevalence of cancer and cardiovascular diseases. However, there were only 2 studies (2/38, 5.3%) on cancer and 14 studies (14/90, 15.6%) on cardiovascular diseases in the elderly group.

Summary of results

Of all included studies, 95.2% reported at least one statistically positive result, 4.4% were convincingly negative, and only 0.4% showed ambiguous results ( Table 7 ).

https://doi.org/10.1371/journal.pone.0216550.t007

There were 27 primary studies that showed no association between air pollution and disease, including cancer (n = 1), chronic diseases (n = 1), cardiovascular diseases (n = 6), health records (n = 7), pregnancy and children (n = 2), respiratory diseases (n = 6), mental disorders (n = 1), and other diseases (n = 3). Moreover, eight meta-analyses showed no evidence for any association between air pollution and disease prevalence (childhood asthma, chronic bronchitis, asthma, cardio-respiratory mortality, acute respiratory distress syndrome and acute lung injury, mental disorder, cardiovascular disease, and daily respiratory death). Three meta-analyses showed ambiguous results for mental health, venous thromboembolism, and hypertension.

Our scoping review provided an overview on the subject of outdoor air pollution and health outcomes. We adhered to the methodology outlined for publishing guidelines and used the six steps outlined by the scoping review protocol. The guiding principle ensured that our methods were transparent and free from potential bias. The strengths of the included studies are that they tend to focus on large sample sizes and broad geographical coverage. This research helped us to identify research gaps and disseminate research findings [ 23 ] to policymakers, practitioners, and consumers for further missing or potentially valuable investigations.

Principal findings

Among the included studies, we identified various health outcomes of outdoor air pollution, including respiratory diseases, chronic diseases, cardiovascular diseases, health records, cancer, mental disorders, pregnancy and children, and other diseases. Among them, asthma in respiratory diseases and mortality in health records were the most common ones. The study designs contained cohort, meta-analysis, time series, crossover, cross-sectional, and other qualitative methods. In addition, we included economically relevant studies [ 12 , 36 , 37 ] to investigate the causal inference of outdoor air pollution on health outcomes. Further, pregnancy and children, mental disorders, and other diseases are health outcomes that might have uncertain or inconsistent effects. For example, Kirrane et al. [ 38 ] reported that PM 2.5 had positive associations with Parkinson’s disease; however, some studies report that there is no statistically significant overall association between PM exposure and such diseases [ 39 ]. Overall, the majority of these studies suggested a potential positive association between outdoor air pollution and health outcomes, although several recent studies revealed no significant correlations [ 40 – 42 ].

Time frame of included studies

The time frame of included studies is one of the most important characteristics of air pollution research. Even in the same country or region, industrialization and modernization caused by air pollution is distinguished between different time periods [ 43 , 44 ]. In addition, the more the public understands environment science, the more people will take preventative measures to protect themselves. This is also influenced by time. Although air pollution should not be seen as an inevitable side effect of economic growth, time period should be considered in future studies. The publication trends with regard to air pollution related health outcome research increased sharply after 2010. In recent times, published studies have begun to pay more attention to controlling confounding factors such as socioeconomic factors and human behavior.

Population and country

More than 50% of the studies on the relationship between air pollution and health outcomes originated from high income countries. There was less research (<25%) from developing countries and poor countries [ 45 – 48 ], which may result from inadequate environmental monitoring systems and public health surveillance systems. Less cohesive policies and inadequate scientific research may be another reason. In this regard, stratified analysis by regional income will be helpful for exploring the real estimates. It is reported that the stroke incidence is largely associated with low and middle income countries rather than with high income countries [ 49 ]. More studies are urgently needed in highly populated regions, such as Eastern Asia and North and Central Africa.

It is worth noting that rural and urban differences in air pollution research have been neglected. There are only eight studies focused on the difference of spatial variability of air pollution [ 50 – 57 ]. Variation is common even across relatively small areas due to geographical, topographical, and meteorological factors. For example, an increase in PM 2.5 in Northern China was predominantly from abundant coal combustion used for heating in the winter months [ 58 ]. These differences should be considered with caution by urbanization and by region. Data analysis adjustment for spatial autocorrelation will provide a more accurate estimate of the differences in air. What’s more, in some countries such as China, migrants are not able to access healthcare within the cities; this has resulted in misleading conclusions about a “healthier” population and null based bias was introduced [ 59 ].

Other studies (including systematic reviews and economic studies) on outdoor air pollution

Our scoping review included a large number of systematic reviews and meta-analyses. Of the included 107 systematic review and meta-analyses, the most discussed topics were respiratory diseases influenced by mixed outdoor air pollution [ 60 – 62 ]. Little systematic review research focused on chronic diseases, cancer, and mental disorders, which are current research gaps and potential research directions. A large overlap remains between the primary studies included in the systematic reviews. However, some systematic reviews that focused on the same topic have conflicting results, which were mainly caused by different inclusion criteria and subgroup analyses [ 63 , 64 ]. To solve this problem, it is critical that reporting of systematic reviews should retrieve all related published systematic reviews and meta-analyses.

As for the 24 included economic studies, two kinds of health outcomes—morbidity [ 65 ] and economic cost [ 66 ]—were discussed separately using regression approaches. The economic methods were different from those used in the epidemiology; the study focused on causal inference and provided a new perspective for examining the relevant environmental health problems. Furthermore, meta-regression methodology, an economic synthesis approach, proved to be very effective for evaluating the outcomes in a comprehensive way [ 67 ].

Diagnostic criteria for diseases

The diagnostic criteria for diseases forms an important aspect of health-related outcomes. The diagnostic criteria for stroke and mental disorders might be less reliable than those for cancer, mobility, and cardiovascular diseases [ 68 ]. Few studies provided detailed disease diagnostic information on how the disease was measured. Thus, the overall effect estimation of outdoor air pollution might be overestimated. It is recommended that ICD-10 or ICD-11 classification should be adopted as the health outcome classification criterion to ensure consistency among studies in different disciplines considered in future research [ 69 ].

In spite of these broad disease definitions, studies in healthy people or individuals with chronic diseases were not conducted separately. People with chronic diseases were more susceptible to air pollution [ 70 ]. It is obvious that air pollution related population mobility might be underestimated. However, the obvious association of long-term exposure to air pollution with chronic disease related mortality has been reported by prospective cohort studies [ 71 ]. It should be translated to other diverse air pollution related effect research. The population with pre-existing diseases should be analyzed as subgroups.

Except for the overall population, subgroups of people with outdoor occupations and athletes [ 72 , 73 ], sensitive groups such as infants and children, older adults [ 74 , 75 ], and people with respiratory or cardiovascular diseases, should be analyzed separately.

Measurement of personal exposure

The measurement of personal exposure to air pollutants (e.g., measurement of errors associated with the monitoring instruments, heterogeneity in the amount of time spent outdoors, and geographic variation) was lacking in terms of accurate determination. There is a need for clear reporting of these measurements. The key criterion to determine if there is causal relationship between air pollution and negative health outcomes was that at least one aspect of these could be measured in an unbiased manner.

Pollutant dispersion factor

It is well known that the association between air pollution and stroke, and respiratory and cardiovascular disease subtype might be caused by many other factors such as temperature, humidity, season, barometric pressure, and even wind speed and rain [ 76 – 78 ]. These confounding factors related to aspects of energy, transportation, and socioeconomic status, may explain the varying effect size of the association between air pollution and diseases.

While the associations reported in epidemiological studies were significant, proving a causal relationship between the different air pollutants affected by any other factors and adverse effects has been more challenging. To avoid bias, these modifier effects should be compared with previous localized studies. In fact, how the confounding variables account for the heterogeneity should be explored by case-controlled study design or other causal interference research designs.

Study limitations

The following limitations should not be overlooked. First, scoping reviews are based on a knowledge synthesis approach that allows for the mapping of gaps in the existing literature; however, they lack quality assessment for the included studies, which may be an obstacle for precise interpretation. Some improvements have been made by adding a quality assessment [ 15 , 22 , 79 ] to increase the reliability of the findings, and other included studies control for quality by including only peer-reviewed publications [ 80 ]; however, this is not a requirement for scoping reviews. While our paper aimed to comprehensively present a broader range of global-level current published literatures related to outdoor air pollution health outcomes, we did not assess the quality of the analyzed literature. The conclusions of this scoping review were based on the existence of the selected studies rather than their intrinsic qualities.

Second, bias is an inevitable problem from the perspectives of languages, disciplines, and literatures in knowledge synthesis. We included literatures from electronic databases, key journals, and reference lists to avoid “selection bias” and then included unpublished literature to avoid “publication bias”; further, we also conscientiously sampled among the studies to ensure that there was a safeguard against “researcher bias.” We only took English language articles into account because of the cost and time involved in translating the material, which might have led to a potential language bias [ 23 ]. However, in scoping reviews, language restriction does not have the importance that it does in meta-analysis [ 81 ].

Conclusions

In all, the topic of outdoor air pollution exposure related health outcomes is discussed across multiple-disciplines. The various characteristics and contexts of different disciplines suggest different underlying mechanisms worth of the attention of researchers and policymakers. The presentation of the diversity of health outcomes and its relationship to outdoor exposure air pollution is the purpose of this scoping review for new findings in future investigations.

Supporting information

S1 table. literature search strategies..

https://doi.org/10.1371/journal.pone.0216550.s001

S2 Table. PRISMA-ScR checklist.

https://doi.org/10.1371/journal.pone.0216550.s002

Acknowledgments

The authors would like to thank Miaomiao Liu, an assistant professor in School of the Environment of Nanjing University, for her valuable advice with regard to this article.

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• Published: 06 November 2008

Health effects of ambient air pollution – recent research development and contemporary methodological challenges

• Cizao Ren 1 , 2 &
• Shilu Tong 1  

Environmental Health volume  7 , Article number:  56 ( 2008 ) Cite this article

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Exposure to high levels of air pollution can cause a variety of adverse health outcomes. Air quality in developed countries has been generally improved over the last three decades. However, many recent epidemiological studies have consistently shown positive associations between low-level exposure to air pollution and health outcomes. Thus, adverse health effects of air pollution, even at relatively low levels, remain a public concern. This paper aims to provide an overview of recent research development and contemporary methodological challenges in this field and to identify future research directions for air pollution epidemiological studies.

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Introduction

It is well known that exposure to high levels of air pollution can adversely affect human health. A number of air pollution catastrophes occurred in industrial countries between 1950s and 1970s, such as the London smog of 1952 [ 1 ]. Air quality in western countries has significantly improved since the 1970s. However, adverse health effects of exposure to relatively low level of air pollution remain a public concern, motivated largely by a number of recent epidemiological studies that have shown the positive associations between air pollution and health outcomes using sophisticated time-series and other designs [ 2 ].

This review highlights the key findings from major epidemiological study designs (including time-series, case-crossover, panel, cohort, and birth outcome studies) in estimating the associations of exposure to ambient air pollution with health outcomes over the last two decades, and identifies future research opportunities. We do not intend for this to be a formal systematic literature review or meta-analysis, but to discuss issues we feel are vitally important based on the recent literature and our own experience. This paper is divided into two parts: firstly to summarize recent findings from major epidemiological studies, and secondly to discuss key methodological challenges in this field and to identify research opportunities for future air pollution epidemiological studies.

Health effects of ambient air pollution

Time-series studies.

There are a large number of time-series studies on the short-term health effects of air pollution, with the emphasis on mortality and hospital admissions by means of fitting Poisson regression models at a community level or ecological level. This type of time-series design is a major approach to estimating short-term health effects of air pollution in epidemiological studies for the last two decades. Many studies have found associations between daily changes in ambient particulate air pollution and increased cardiorespiratory hospital admissions [ 3 – 6 ], along with cardiorespiratory mortality [ 7 – 9 ] and all cause mortality [ 10 ]. Because numerous air pollution time-series studies show that exposure to air pollution is associated with different kinds of human health outcomes, it is impossible to list results from all studies. Table 1 only selects major time-series studies on short-term health effects of particulate matter (PM) and ozone from different countries around the world published over the last two decades because these two air pollutants are important toxic agents and widely explored by the majority of air pollution epidemiological studies. Early findings have been systematically and thoroughly reviewed by other authors [ 11 , 12 ].

Single-site time-series studies have been criticized because of exposure measurement errors, substantial variation of the air pollution effects and the heterogeneity of the statistical approaches used in different studies [ 13 ]. Recently, several multi-site time-series studies have been conducted in Europe and the United States. Two large collaborative air pollution projects in Europe and U.S. are summarised below.

In Europe, the APHEA (Air Pollution and Health: a European Approach) studies have provided many new insights. Initial studies were based on older data (APHEA-1) [ 14 ] and a new series of studies (APHEA-2) used data of the PM 10 fraction since the late 1990s [ 15 ]. The APHEA-2 mortality studies covered over 43 million people and 29 European cities, which were all studied for more than 5 years in the 1990s. The combined effect estimate showed that all-cause daily mortality increased by 0.6% (95% CI: 0.4%, 0.8%) for each 10 μg/m 3 increase in PM 10 from data involving 21 cities. It was found that there was heterogeneity between cities with different levels of NO 2 . The estimated increase in daily mortality for an increase of 10 μg/m 3 in PM 10 were 0.2% (95% CI: 0.0%, 0.4%), and 0.8% (95% CI: 0.7%, 0.9%) in cities with low and high average NO 2 , respectively [ 16 ]. The APHEA-2 hospital admission study involved 38 million people living in eight European cities. Hospital admissions for asthma and chronic obstructive pulmonary disease (COPD) increased by 1.0% (95% CI: 0.4%, 1.5%) per 10 μg/m 3 PM 10 increment among people older than 65 years [ 15 ].

In the United States, the National Morbidity, Mortality and Air Pollution Studies (NMMAPS) focused on the 20 largest metropolitan areas in the USA, involving 50 million inhabitants, during 1987–94 [ 2 ]. All-cause mortality was increased by 0.5% (95% CI: 0.1%, 0.9%) for each increase of 10 μg/m 3 in PM 10 . The estimated increase in the relative rate of death from cardiovascular and respiratory disease was 0.7% (95% CI: 0.2%, 1.2%). Effects on hospital admissions were studied in ten cities with a combined population of 1 843 000 individuals older than 65 years [ 17 ]. The model used considered simultaneously the effects of PM 10 up to the lag of 5 days and effects of PM 10 on chronic obstructive pulmonary disease admissions to be 2.5% (95% CI: 1.8%, 3.3%) and on cardiovascular disease admissions to be 1.3% (95% CI: 1.0%, 1.5%) for an increase of 10 μg/m 3 in PM 10 . Bell et al. [ 18 ] analysed 95 NMMAPS community data to examine the association between ozone concentration and mortality, showing that a 10-ppb increase in the previous week's ozone was associated with a 0.5% (95% posterior interval (PI), 0.3%, 0.8%) increase in daily mortality and a 0.64% (95% PI, 0.31%, 0.98%) increase in cardiovascular and respiratory mortality. The effect estimates of the exposure over the previous week were larger than those considering only a single day's exposure. Recently, Dominici et al. [ 13 ] examined the short-term association between fine particulate air pollution and hospital admissions and found that exposure to PM 2.5 was associated with different health outcomes. The largest association was observed for heart failure, and a 10 μg/m 3 increase in PM 2.5 was found to be associated with a 1.3% (95% PI: 0.8%, 1.8%) increase in hospital admissions from heart failure on the same day.

Although time-series studies have shown that day-to-day variations in air pollutant concentrations are associated with daily deaths and hospital admissions, it is still unclear how many days, weeks or months of air pollution have brought such events forward. Harvesting or mortality/morbidity displacement means that some cases are occurring only in those to whom it would have happened in a few days anyway [ 19 ]. If so, the increase in cases immediately after exposure would be offset by a deficit in daily deaths a few days later [ 19 , 20 ]. If air pollution has harvesting effects, normal time-series models are unable to estimate the effects due to the issues of collinearity and statistical power. The polynomial distributed lag (PDL) model [ 21 ] and the time-scale model [ 19 ] have been adopted to explore whether air pollution has harvesting or displacement effects on daily deaths or hospital admissions. A few studies suggested potential harvesting effects of ambient air pollution while other studies have shown that there is no evidence for harvesting effects [ 19 , 22 , 23 ]. Although one study shows that potential bias might occur in PDL model [ 24 ], the estimated effects of ambient air pollutants seem to increase when longer lags of air pollution are included [ 19 , 20 ].

Case-crossover studies

Case-crossover study design is an alternative approach to estimating short-term health effects of air pollution in epidemiological studies. In the last two decades, the case-crossover design has been applied in a large number of studies of air pollution and health [ 25 – 28 ]. For example, Neas et al. [ 27 ] used a case-crossover study design to estimate the association between air pollution and mortality in Philadelphia and found a 100 μg/m 3 increment in the 48 hours mean level of TSP was associated with increased all-cause mortality (odds ratio (OR) = 1.06; 95% CI: 1.03, 1.09). A similar association was observed for deaths in individuals over 65 years of age (OR: 1.07; 95% CI: 1.04, 1.11). Levy et al. [ 28 ] estimated the effect of short-term changes in exposure to particulate matter on the rate of sudden cardiac arrest. The cases were obtained from a previously conducted population-based case-control study and were combined with ambient air monitoring data. The results did not show any evidence of a short-term effect of particulate air pollution on the risk of sudden cardiac arrest in people without previously recognised heart disease. Schwartz [ 26 ] conducted a case-crossover study to examine the sensitivity of the association between ozone and mortality when adjusted for temperature and found that 10-ppb increase of maximum hourly ozone was associated with 0.23% (95% CI: 0.01% ~0.44%) increase in daily deaths after adjusting for temperature in 14 US cities. Barnett et al. [ 25 ] examined the association between air pollution and cardio-respiratory hospital admissions in Australia and New Zealand cities. The results show that air pollution arising from common emission sources was significantly associated with cardiovascular health outcomes in the elderly. For example, for a 0.9-ppm increase in CO, there were significant increases in elderly hospital admissions for 2.2% (95% CI: 0.9%, 3.4%) increase of total cardiovascular disease and 2.8% (95% CI: 1.3%, 4.4%) increase of all cardiac disease.

Panel studies

Many air pollution panel studies have been conducted, including several large longitudinal studies of air pollution and health effects such as the Southern California Children's Health Study [ 29 , 30 ], in which children from grades 4, 7, and 10 residing in twelve communities near Los Angeles were followed annually. The results indicated that exposure to ambient particles, NO 2 , and inorganic acid vapour was associated with reduced lung function in children. Another large panel study, the Pollution Effects on Asthmatic Children in Europe (PEACE), was designed to examine the relationship between short-term changes in air pollution and lung function, respiratory symptoms and medication use [ 31 ]. This project was conducted in 14 centres using a common protocol in the winter of 1993–1994. Each PEACE centre involved an urban and a rural panel of symptomatic children and followed at least seventy-five 6–12 year old children [ 31 ]. The pooled estimates of two literature reviews which were separately conducted about the PEACE study and showed that no clear relation could be established for changes in PM 10 , black smoke, SO 2 and NO 2 and changes in respiratory health. The non-significant effects were thought to be possibly due to the short observation period. Ward and Ayres [ 32 ] reviewed 22 panel studies published in the 1990s to estimate the overall effects of ambient particles on children. Results show that the majority of identified panel studies indicated an adverse effect of particulate air pollution. Several recent panel studies also show that particulate air pollution is associated with human health [ 33 – 37 ].

Cohort studies

Compared to time-series and case-crossover studies, there are only a few large cohort studies. About a dozen cohort studies have been conducted in the United States [ 38 – 44 ], Europe [ 45 – 48 ] and Australia [ 49 ]. A cohort study conducted by Dockery et al. [ 39 ] in six U.S. cities shows that there was a statistically significant and robust association between air pollution and mortality. The adjusted mortality rate ratio for the most polluted city was 1.26 (95% CI: 1.08–1.47) compared with the least polluted city. Air pollution was also associated with deaths from lung cancer and cardiopulmonary diseases. Abbey et al. [ 38 ] conducted a cohort study during 1973–1992 to estimate effect of exposure to long-term ambient concentrations of PM 10 and other air pollutants, and show that PM 10 was strongly associated with mortality from respiratory disease for both sexes adjusting for a wide range of potentially confounding factors. The relative risk (RR) for an interquartile range (IQR) difference of PM 10 was 1.18 (95% CI: 1.42, 3.97). Ozone was strongly associated with lung cancer mortality for males for the IQR difference (RR: 4.19; 95% CI: 1.81, 9.69). Sulphur dioxide was also strongly associated with lung cancer mortality for both sexes. Pope et al. [ 44 ] conducted one cohort study in the US to examine the long-term effect of exposure to fine particulate air pollution. They found that fine particulate and sulphur oxide-related pollution were associated with all-cause, lung cancer and cardiopulmonary mortality. A 10 μg/m 3 increase in fine particulate air pollution was associated with an increase of 4%, 6%, and 8% for all-cause, cardiopulmonary, and lung cancer mortality, respectively. Hoek et al. [ 48 ] investigated a random sample of 5000 people and 489 of 4492 (11%) died during 1986–1994 in the Netherlands fining that cardiopulmonary mortality was associated with living near a major road with relative risk of 1.95 (95% CI: 1.09–3.52). A cohort study conducted by Filleul et al. [ 46 ] in France found that urban air pollution to be associated with increased mortality over 25 years in France. Frostad et al. [ 47 ], in a 30-year follow-up cohort study in Norway, found that respiratory symptoms were a significant predictor of mortality from all causes. In Australia, Jalaludin et al.[ 49 ] enrolled a cohort of primary school children with a history of wheeze (n = 148) in an 11-month longitudinal study to examine the association between ambient air pollution and respiratory morbidity. They found that PM 10 and NO 2 , but not ozone, were significantly associated with doctor visits for asthma.

Birth outcome studies

Even though effects of exposure to ambient air pollution on mortality and hospital admissions have been increasingly demonstrated over the past 30 years, exploring its adverse impact on pregnant outcomes has only begun since the last decade [ 50 ]. Because pregnancy is a period of human development particularly susceptible to the influence of many environmental factors due to high cell proliferation, organ develop and the changes of capabilities of fetal metabolism, the relative short-term period provides a unique opportunity to study the adverse effects of ambient toxins on human health [ 51 ]. The majority of birth outcome studies are based on large datasets routinely collected from air pollution monitoring systems and birth registration processes, and therefore, in general, the statistical power is strong [ 52 – 59 ]. Logistic regression models or linear regression models at the individual level are usually adopted to assess the effects of ambient air pollution on adverse birth outcomes adjusting for potential confounders including maternal age, maternal race, parity, fetal gender, season, gestational period, etc. Birth outcomes usually include low birth weight, preterm delivery and other biomarkers such as birth defect and ultrasound measures of head circumference. Personal exposures are often estimated at different terms, including the full gestation, trimesters, month after the pregnancy or before the time of delivery, etc.

Many studies have shown that there are significant associations between exposure to ambient air pollutants and adverse birth outcomes [ 52 – 60 ]. For example, Liu et al. [ 53 ] found that 5-ppb increase of sulfur dioxide was associated with an 11% (95% CI: 1%, 22%) increase of low birth weight (< 2500 grams) during the first month gestation and with a 9% increase of preterm delivery in Vancouver, Canada. A 1.0 ppm increase of carbon monoxide during the last month of pregnancy was associated with an 8% increase of preterm delivery. Parker et al. [ 60 ] selected population within 5 miles of over 40 air pollution monitoring sites across 28 California counties to estimate the adverse effects of air pollution and found that per 10 μg/m 3 PM increase was associated with 13 g (95% CI: 7.6 g, 18.3 g) decrease of birth weight. Similarly, Ritz et al. [ 59 ] conducted a population-nested case-control study to examine associations between air pollution and birth outcomes in Los Angeles and found that air pollution exposure was associated with preterm birth. Hansen et al. [ 58 ] examined the associations of exposure to ambient air pollution during early pregnancy with fetal ultrasonic measurements during mid-pregnancy in Australia. They found that a reduction in fetal abdominal circumference was associated with exposure to O 3 during the days 31–60 of pregnancy (-1.42 mm, 95% CI: -2.74, -0.09), SO2 during the days 61–90 (-1.67 mm, 95% CI: -2.94, -0.40), and PM 10 during the days 90–120 (-0.78 mm, 95% CI: -1.49, -0.08).

Implications of weak health effects

Even though the association of air pollution with health outcomes is weak, it still has strong public health implications. One reason is that air pollution is ubiquitous and affects the whole population in most metropolitan cities. Another reason is that residents are continuously and permanently exposed to air pollution, which may have both short- and long-term effects on health outcomes. Some intervention studies have shown that the reduction in air pollution has resulted in an improvement in population health [ 55 , 61 ]. For example, Hedley et al. [ 61 ] reported that cardiovascular, respiratory and all cause mortality reduced by 2.0% (p < 0.05), 3.9% (p < 0.05) and 2.1% (p < 0.05) respectively in the first 12 months after an introduction of the restrictions on sulphur content of fuel in Hong Kong.

Contemporary methodological challenges

Air pollution epidemiologic research is challenged by the complexity of human exposure to environmental agents and by the difficulty of accurately measuring exposure. Residents are usually ubiquitously exposed to air pollution. In order to detect small effects of air pollution, both high statistical power and sophisticated study design are required. In addition, the characteristics of air pollutants vary and their concentrations change both spatially and temporally. Although everyone is susceptible to high concentration of pollution, its concentrations are not evenly distributed across populations. Due to such complexities, there are still many research questions to be addressed by future air pollution epidemiological studies. The following section discusses these issues.

Shape of exposure response curve

The shape of the exposure and response curve is very important. A key research question to be addressed is whether a threshold exists below which a certain air pollutant has no effect on population health. If such a threshold could be identified, public health benefits would be expected from bringing the pollutant below this level. Both theoretical and empirical works have been done to shed light on this issue [ 62 , 63 ]. In the analysis of NMMAPS data, no threshold evidence was found for the relationship between PM 10 and daily all-cause and cardiorespiratory mortality [ 63 ]. By contrast, a threshold of about 50 μg/m 3 was indicated for non-cardiorespiratory causes of death – viz, below this point, PM 10 had little influence on non-cardiorespiratory mortality. These issues remain to be clarified.

Model uncertainty and bias

The process of model selection includes how to select covariates (eg, meteorological variables and co-pollutants), lag structure for air pollutants and the number of degrees of freedom for smoothing functions to adjust for long-term trend, short fluctuation, seasonality, other covariates and the determination of referent in case-crossover design. Studies have shown that the model choice will impact on estimates of relative risk [ 64 ]. As a result, many authors attempted to estimate the effects using the best single lag or combination of lags for meteorological factors and/or air pollutants and to identify the best degree of freedom for smoothing to adjust for different potential confounders. Some types of data can use several different models. Some authors do not clearly state why they select models and how they conduct data analyses. For example, when we estimate associations between exposure to air pollution and recurrent asthma episodes, based on different assumptions, at least five survival Cox models could be applied to estimate the associations between exposure to air pollution and asthma episodes [ 65 ]. Different assumptions or models may result in different estimates, and sometimes the difference is considerable. The choice of software options may cause this kind of uncertainty as well [ 65 ].

Results presented by the "best" final models are likely to cause publication bias because stronger and positive estimates tend to be published but negative results are usually difficult to be published. Multi-site time series design in which all data are analysed using the same model is one way to solve this problem. However, model uncertainty still exists in a multi-site study to some extent due to the model choice. Some studies have used Bayesian Model Averaging (BMA) to take into account uncertainties in model choice when making an inference [ 64 ]. BMA uses hierarchical models. The predictions and inferences are based on multiple models rather than a single model. Predictions are obtained by forming weighted averages of predictions over the different models where weights depend on the degree to which the data support each model.

Measurement errors of exposure to air pollution and potential confounders usually exist in air pollution epidemiological studies and it is impossible to be solved in most air pollution studies [ 66 ]. Due to spatial and temporal variations, data obtained in air pollution central monitors are not well representative of individual exposures. Some models are used to assess individual exposure to air pollution [ 66 , 67 ], but they could not efficiently adjust for measurement errors. Therefore, potential misclassification bias of exposure is one of the main concerns in air pollution studies.

There are both spatial and temporal variations for exposure and outcomes in air pollution studies [ 68 ]. Both times-series and case-crossover designs at a community level can efficiently adjust for some measured and unmeasured time-invariant characteristics of the subjects (such as gender, age, smoking status and spatial characteristics) via matching, and therefore, the potential confounding from these measured and unmeasured characteristics is minimised [ 69 , 70 ]. The key concern for these designs is how to control for temporal confounding and meteorological variables, such as seasonality, short-term variations and weather conditions (eg, temperature and humidity). In a prospective cohort study design, a major issue is how to identify a cohort with a sufficient variation in cumulative exposures, particularly when data recorded in central monitoring stations are used to measure ambient air pollution levels [ 44 ]. However, in maximizing the geographical variability of exposure the relative risk estimates from cohort studies are likely to be confounded by area-specific characteristics [ 68 ]. Due to collection of relatively detailed individual characters and sufficient adjustment for potential individual social and economic status, such confounding might be efficiently adjusted for.

Birth outcome studies are mainly based on routinely collected data, including exposure, outcome and potential confounders [ 52 – 60 ]. Most studies use pollution data obtained from the different monitors and the closest residential monitoring data are used as exposure proxies [ 58 , 60 , 71 , 72 ]. In general, information related to birth outcomes is well recorded in birth registration systems. However, the data may not include complete and accurate information on other potential confounders, such as maternal social and economic status and life styles. Birth outcome data analyses are usually conducted at an individual level. Therefore, this design is inherently vulnerable to some potential biases, including both temporal and spatial misclassification bias. Ritz and Wilhelm [ 73 ] has discussed the methodological issues of birth outcome designs in detail, and this review would not repeat these issues but rather than focus on potential bias in relation to spatial variation, which was ignored in their review, in the following section.

In birth outcome studies, both exposure and outcome data include temporal and spatial variations to some extent. The majority of birth outcome studies have adjusted for temporal and other confounders which are related to delivery information, including season, maternal age and race, fetal gender, parity, and maternal education attainment [ 52 – 60 , 71 , 72 ]. However, so far, few studies have paid much attention to the potential spatial confounding. Unlike time-series or case-crossover studies, most birth outcome studies lack the ability for automatic adjustment for measured and unmeasured time-invariant spatial variations. Unlike cohort studies, birth outcome study designs also lack the ability to efficiently adjust for personal life styles and social and economic status due to the lack of the detailed information available in routinely collected data. Because both exposure to air pollution and birth outcomes are influenced by some geographic characteristics, such as land use, forest, public infrastructure, and residential social and economic status, etc, the previous birth outcome studies might introduce bias to some extent due to the failure to consider spatial variation. In general, these spatial-related factors are favourable to links between air pollution exposure and birth outcomes. Therefore, we presume that the stronger associations reported in the previous birth outcome studies might partially attribute to this kind of bias. The simple way to adjust for the spatial variation is to add a categorical variable for individual residential areas to fit a fixed effect model or to include the residential areas to fit a mixed model or a random effect model.

Interaction of temperature and air pollution

In many locations, patterns of air pollution are driven by weather. Therefore, concentrations of air pollutants may be associated with temperature. Therefore, it may be possible that temperature and air pollution interact to affect health outcomes. Although effect modification has important public health implications [ 74 ], this issue has so far received limited attention, probably because of methodological complexity and the difficulty in data interpretation. Several studies examined whether or not ambient air pollution and temperature interact to affect human health outcomes, but they produced conflicting results [ 75 – 78 ]). For example, Samet et al. [ 78 ] investigated the sensitivity of the particulate air pollution mortality effect estimate to alternative methods of controlling weather and did not find any evidence that weather conditions modified the associations of particulate air pollution and sulphur dioxide with mortality, regardless of approaches of synoptic weather conditions. Katsouyanni et al. [ 75 ] used a multiple linear regression to investigate the interaction between air pollution and high temperature during a heat wave in Athens in July 1987. They found that while the main effects of air pollution index were not statistically significant, there was statistically significant synergistic effect between high levels of sulphur dioxide and high temperature (P < 0.05). Roberts [ 77 ] found evidence that the effect of particulate air pollution on mortality might depend on temperature but the synergistic effect was sensitive to the number of degrees of freedom used in confounder adjustments. Recently, we found that temperature and particulate matter symmetrically enhanced the effect [ 76 ]. Since then, several multiple-site studies have found evidence that temperature and air pollutants interacted to impact human health but the nature and magnitude of such an interaction varied with geographic area [ 79 – 82 ]. Thus, further research is needed to examine the interactive effects between air pollutants and temperature on mortality and morbidity, especially in different spatial settings.

Many time-series, case-crossover and panel studies have shown that there are consistent short-term effects of air pollution on health outcomes (hospital admissions or deaths). Some cohort studies have also shown long-term health effects of air pollution. In spite of the weak associations of air pollution with human morbidity or mortality, its public health implications are strong because exposure to air pollution is ubiquitous and widespread. However, there are several key methodological challenges in the estimation of the health effects of low-level exposure to air pollution, such as the shape of the exposure response curve, threshold of air pollution, interactive effects of air pollution and weather conditions, and model uncertainty and potential bias. Future research efforts should focus on these important issues.

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Acknowledgements

We thank Prof. Gail Williams, School of Population Health, University of Queensland for the comments on the earlier version of the manuscript. We also thank two reviewers for their insightful and constructive comments.

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Ren, C., Tong, S. Health effects of ambient air pollution – recent research development and contemporary methodological challenges. Environ Health 7 , 56 (2008). https://doi.org/10.1186/1476-069X-7-56

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A New Textiles Economy: Redesigning fashion’s future

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Fashion is a vibrant industry that employs hundreds of millions, generates significant revenues, and touches almost everyone, everywhere.

Since the 20th century, clothing has increasingly been considered as disposable, and the industry has become highly globalised, with garments often designed in one country, manufactured in another, and sold worldwide at an ever-increasing pace. This trend has been further accentuated over the past 15 years by rising demand from a growing middle class across the globe with higher disposable income, and the emergence of the ‘fast fashion’ phenomenon, leading to a doubling in production over the same period.

Beyond laudable ongoing efforts, a new system for the textiles economy is needed and this report proposes a vision aligned with circular economy principles. In such a model, clothes, fabric, and fibres re-enter the economy after use and never end up as waste. Achieving a new textiles economy will demand unprecedented levels of alignment. A system-level change approach is required and one which will capture the opportunities missed by the current linear textiles system.

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Assessment of Onshore Renewable Energy Power Supply for Ship’s Emissions Reduction in Port Said West Port

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• Merna Makram 1 ,
• Ameen M. Bassam 1 ,
• Adel A. Tawfik 1 &
• Waleed Yehia 1  

Air pollution from shipping is becoming a critical issue, particularly in dense hub port cities. One proposed solution to minimize ship-based emissions at ports is the implementation of an Onshore Power Supply (OPS) system. OPS allows ships to shut off their auxiliary engines and instead connect to the port grid. While there have been numerous studies conducted on ports in Europe and the United States, little research has been done on Egyptian ports. Therefore, this paper aims to investigate the feasibility of implementing OPS at Port Said West Port in Egypt, aligning with Egypt Vision 2030’s goals for addressing climate change. The research primarily focuses on analyzing data collected from calling ships to generate socio-economic and cost-effectiveness analyses of OPS. To further enhance the environmental benefits of OPS, the paper proposes the use of solar energy as the OPS electricity source. The findings of the study revealed that by relying on the national grid, emissions can be reduced by 28%. Moreover, it is predicted that this reduction could reach 100% if electricity generation is solely based on solar energy. Additionally, the economic analysis demonstrates promising profitability, with a payback period of approximately two years.

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Acciaro M, Vanelslander T, Sys C, Ferrari C, Roumboutsos A, Giuliano G, Kapros S (2014) Environmental sustainability in seaports: a framework for successful innovation. Maritime Policy & Management, 41(5): 480–500. https://doi.org/10.1080/03088839.2014.932926

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Acknowledgement

The authors greatly acknowledge the support of Port Said West Port Authority in the Port Said branch towards the availability of the research data.

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• Implementing Onshore Power Supply (OPS) at Port Said West Port reduces shipping emissions by 28%.

• Emissions reduction can reach near or 100% if solar energy is the primary OPS electricity source.

• OPS adoption at the targeted Egyptian port shows promising profitability.

• The barriers facing OPS-wide implementation in Egypt are outlined.

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Makram, M., Bassam, A.M., Tawfik, A.A. et al. Assessment of Onshore Renewable Energy Power Supply for Ship’s Emissions Reduction in Port Said West Port. J. Marine. Sci. Appl. 23 , 506–524 (2024). https://doi.org/10.1007/s11804-024-00423-4

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• Maritime and shipping
• MGN 632 (M+F) Amendment 2: The merchant shipping (prevention of pollution by garbage from ships) regulations 2020
• Maritime & Coastguard Agency

MGN 632 (M+F) Amendment 2: The Merchant Shipping (Prevention of Pollution by Garbage from Ships) Regulations 2020

Published 23 May 2024

© Crown copyright 2024

This publication is licensed under the terms of the Open Government Licence v3.0 except where otherwise stated. To view this licence, visit nationalarchives.gov.uk/doc/open-government-licence/version/3 or write to the Information Policy Team, The National Archives, Kew, London TW9 4DU, or email: [email protected] .

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This publication is available at https://www.gov.uk/government/publications/mgn-632-mf-amendment-2-the-merchant-shipping-prevention-of-pollution-by-garbage-from-ships-regulations-2020/mgn-632-mf-amendment-2-the-merchant-shipping-prevention-of-pollution-by-garbage-from-ships-regulations-2020

The purpose of this MGN is to provide guidance and clarification with respect to certain aspects of MARPOL Annex V (referred to as “Annex V”), the Polar Code and the Merchant Shipping (Prevention of Pollution by Garbage from Ships) Regulations 2020 (S.I. 2020/621) (referred to as “the UK Regulations”). Future amendments to the international requirements in Annex V and the Polar Code will be incorporated into UK law by way of ambulatory reference, where appropriate.

Amendment 2 includes the extension to the requirement to provide a Garbage Record Book from ships of 400 gross tonnage (“GT”) and above to ships of 100 GT and above.

1. Introduction/background

1.1 The UK Regulations implement Annex V of MARPOL, including all the amendments to that Annex to date.

1.2 The purpose of the UK Regulations is to, by reference, incorporate the text of Annex V in its most up to date form into UK domestic law. The references in the UK Regulations to Annex V are ambulatory; this means that they will incorporate future technical amendments to Annex V (as agreed in the International Maritime Organization (“IMO”)) into UK law at the point they come into force internationally, without the need for further UK legislation. Proposed changes to Annex V will continue to be scrutinised in the IMO, and the impact of these changes will continue to be assessed well before any amendment is due to come into force. The Secretary of State at all stages retains the power to prepare additional secondary legislation in order to prevent an amendment becoming part of United Kingdom law by way of ambulatory reference. An amendment will be publicised in advance of the date that it comes into force by means of a Parliamentary Statement to both Houses of Parliament and by way of a Marine Guidance Note.

1.3 The above approach refers the reader of the UK Regulations directly to the international text, avoiding the need to transpose detailed technical obligations into the UK Regulations. This MGN supplements that approach by amplifying any aspects of the international text which are thought to lack clarity or need additional detail. The amount of documentation to be read is therefore kept to a minimum.

2. Application

2.1 The UK Regulations apply to United Kingdom ships wherever they may be (regulation 4). They also apply to non-UK ships, when they are in UK waters and controlled waters (i.e., the UK’s Exclusive Economic Zone) (regulation 4).

2.2 The Regulations do not apply to any warship, naval auxiliary or other ship owned or operated by a State and used, for the time being, only on Government, non-commercial service (regulation 4).

2.3 Shippers of solid bulk cargo on a ship to which the UK Regulations apply must make a declaration to the owner, master or forwarder as to whether the solid bulk cargo is harmful to the marine environment (regulation 9). Where such a declaration is made to a forwarder, he must provide it to the owner or master (regulation 9).

2.4 All ships of 12 metres or more in overall length and fixed or floating platforms are required to display placards which notify the crew and any passengers of the requirements for the disposal of garbage (regulation 10).

2.5 The requirement for a ship to complete a Garbage Management Plan applies to all ships of 100 GT or above, every ship which carries 15 or more persons and fixed or floating platforms (regulation 11).

2.6 The requirement for a ship to carry and fill in a Garbage Record Book applies to all ships of 100 GT or above, every ship which carries 15 or more persons and is engaged on voyages to ports or offshore terminals under the jurisdiction of a Party to the Convention other than its flag State, and fixed or floating platforms (regulation 12).

2.7 Regulation 14 provides the Secretary of State with the power to grant an exemption from the requirements for a Garbage Record Book. The exemption can be granted to fixed or floating platforms and any ship engaged on voyages of one hour or less in duration which carry 15 or more persons.

2.8 Ships which are not required to have a Garbage Record Book must nonetheless record certain discharges or accidental losses of garbage in their log-books (regulation 15).

3. Definitions

3.1 Regulation 1 and regulation 13 of Annex V provide clear definitions of terms used in the Annex. Section 5.1 of chapter 5 of part II-A of the Polar Code provides further definitions relevant to the discharge of garbage in polar waters.

3.2 To ensure that there is no ambiguity as to what is controlled, Annex V defines both ‘garbage’ and each individual garbage type. For the former, Annex V provides that:

“ Garbage means all kinds of food wastes, domestic wastes and operational wastes, all plastics, cargo residues, incinerator ashes, cooking oil, fishing gear, and animal carcasses generated during the normal operation of the ship and liable to be disposed of continuously or periodically except those substances which are defined or listed in other Annexes to the present Convention. Garbage does not include fresh fish and parts thereof generated as a result of fishing activities undertaken during the voyage, or as a result of aquaculture activities which involve the transport of fish including shellfish for placement in the aquaculture facility and the transport of harvested fish including shellfish from such facilities to shore for processing.”

4. General Prohibition

4.1 A significant change to the approach taken by the Annex since the UK Regulations in 2008 [footnote 1] is the reversal of the historical presumption that garbage may be discharged into the sea based on the nature of the garbage, defined distances from shore and treatment. Instead, regulation 3.1 of Annex V now prohibits the discharge of all garbage into the sea, with limited exceptions. This requirement is implemented in the UK Regulations in regulation 5.

5. Plastics and Cooking oil

5.1 Plastic has been prohibited from discharge into the sea since Annex V entered into force over 30 years ago. To ensure there is no confusion on discharge requirements for plastic or cooking oil, regulations 3.2 and 3.3 were added to Annex V. The intention of these regulations is to clearly show that discharge of plastic or cooking oil is only permitted in the circumstances set out in regulation 7 in Annex V (Exceptions). However, this does not mean that other garbage types that have not been specifically identified in regulation 3.1 can be discharged; this is not the case. Please refer to regulations 4, 5, 6 and 7 of Annex V, as well as chapter 5 of part II-A of the Polar Code to see the limited categories of garbage which can legally be discharged, and the conditions with which these discharges must comply. Further information about these is set out below.

6. Limited Discharges

6.1 Annex V does permit limited discharges [footnote 2] of garbage into the sea subject to conditions set out in regulations 4 (Discharge of garbage outside special areas), 5 (Special requirements for discharge of garbage from fixed or floating platforms), 6 (Discharge of garbage within special areas) and 7 (Exceptions) of Annex V. There are additional conditions for the discharge of garbage in polar waters pursuant to chapter 5 of part II-A of the Polar Code. The IMO have developed comprehensive Guidelines to assist in the implementation of, and compliance with, Annex V; the “2017 Guidelines on the Implementation of MARPOL Annex V” (“the 2017 Guidelines”) is a published document and can be purchased (ISBN 9789280115642). [footnote 3]

6.2 Ordinarily there are only four garbage categories that are permitted to be discharged into the sea, and only then in certain circumstances. These are food waste, solid bulk cargo residues which are not harmful to the marine environment (HME), animal carcasses and cleaning agents or additives which are not HME.

7. Food Waste

7.1 Food waste is the more widely acceptable garbage category that can be discharged into the sea. Its discharge is governed by:

• Outside special areas (excluding polar waters): regulations 4.1.1 and 4.1.2 of Annex V;
• From fixed or floating platforms: regulation 5.2 of Annex V;
• Inside special areas (excluding polar waters): regulation 6.1.1 of Annex V;
• In polar waters: regulation 4.1.1 and 4.1.2 or 6.1.1 of Annex V and chapter 5 of part II-A of the Polar Code.

7.2 Regulation 6.1.1 of Annex V provides that within in the Antarctic area the discharge of avian products is further restricted. The term ‘avian products’ includes all bird related products such as poultry and poultry parts. Food waste comprising of avian products needs to be sterilized to destroy microorganisms in or on the product. This can be done by cooking the product at a high temperature e.g. microwaving, boiling etc.

8. Residues of Solid Bulk Cargoes

8.1 The conditions for when cargo residues can be discharged are governed by:

• Outside special areas (excluding polar waters): regulation 4.1.3 of Annex V;
• Inside special areas (excluding polar waters): regulation 6.1.2 of Annex V;
• In polar waters: regulation 4.1.3 or 6.1.2 of Annex V and chapter 5 of Part II-A of the Polar Code.

8.2 One of these conditions is that only those cargo residues which cannot be recovered using ‘commonly available methods for unloading’ can be discharged. Variable methods are used to load and unload ships which carry solid bulk cargoes, depending on the design of the ship, size, cargo and logistics of the port infrastructure. Commonly available methods of unloading cargo from a ship may be a broom, brush, grabbers, conveyor belts, etc. Only where these commonly available methods cannot recover cargo residues can the remaining cargo residue be discharged into the sea.

8.3 Solid bulk cargoes require classification to determine whether they are HME; the criteria for classification are set out in Appendix I to Annex V. The shipper will need to undertake such classification and provide the shipowner or master with a declaration as to whether they are HME. All shippers of solid bulk cargoes will be required to provide a declaration in the form required in section 4.2.3 of the IMSBC Code (regulation 9 of the UK Regulations).

8.4 Further information can be found in the 2017 Guidelines which provide a dedicated section on solid bulk cargoes.

9. Animal carcasses

9.1 Animal carcasses may only be discharged outside of special areas, except that they cannot be discharged in Arctic waters (see regulation 4.1.4 of Annex V and paragraph 5.2.1.4 of chapter 5 of part II-A of the Polar Code and UK regulation 5(1)). Annex V applies to mortalities which may gradually accrue over the voyage of the ship due to illness, refusal to feed, exhaustion etc.; as such it covers mortalities which are generated during the normal operation of the ship. Animals which die or are euthanized onboard during the voyage due to these factors are considered to be garbage and will need to be recorded in the Garbage Record Book when they are discharged or incinerated. Carcasses of animals resulting from mortalities in excess of those generated during the normal operation of the ship will need to be treated as spoilt cargo. [footnote 4] The 2017 Guidelines provides a dedicated section on animal carcasses.

10. Cleaning agents or additives

10.1 The conditions for when cleaning agents or additives can be discharged into the sea, if they are not HME, are governed by:

• Outside special areas (excluding polar waters): regulation 4.2 of Annex V;
• Inside special areas (excluding polar waters): regulation 6.2;
• In polar waters: regulation 4.2 or 6.2 or Annex V and chapter 5 of part II-A of the Polar Code.

10.2 The HME criteria for cleaning agents or additives are different to that of solid bulk cargoes, as the criteria does not include two of the criteria in Appendix 1 of Annex V, namely:

• Specific Target Organ Toxicity Repeated Exposure Category 1 combined with not being rapidly degradable and having high bioaccumulation;
• Solid Bulk Cargoes containing or consisting of synthetic polymers, rubber, plastics, or plastic feedstock pellets (this includes materials that are shredded, milled, chopped or macerated or in similar materials) of the solid bulk cargoes criteria.

10.3 Regulation 5(2) of the UK Regulations sets out when a cleaning agent or additive will be considered to be HME.

10.4 The 2017 Guidelines provides details of the criteria and the evidence required to show that the products used are complying with the requirement not to be HME.

10.5 Cleaning agents and additives used under Annex V do not require to be assessed through the Joint Group of Experts on the Scientific Aspects of Marine Environmental Protection (GESAMP) advisory body.

11. Mixed or contaminated Garbage

11.1 Regulations 4.4 and 6.4 of Annex V cover the eventuality that garbage that can be discharged might be mixed with or contaminated by a prohibited garbage category (e.g. plastic) or a substance covered by another Annex of MARPOL. [footnote 5] Where this happens the most stringent discharge requirements apply to the mixture. For example:

• if plastic is mixed with food waste then the mixture must be treated as if it were all plastic;
• if cooking oil is mixed with oil and stored in oil sludge tank then the mixture must be treated as if were all cooking oil.

11.2 This principle applies to substances from across the MARPOL Annexes. The same requirements for mixed or contaminated garbage apply to discharges outside and within special areas and from fixed or floating platforms. This requirement is given effect in the UK Regulations in regulation 6.

12. Exceptions

12.1 Regulation 7 of Annex V (UK regulation 8) provides exceptions to the prohibition on the discharge of garbage in emergency situations. Under these provisions all garbage categories can be discharged for the purposes of securing the safety of the ship and those onboard or saving life at sea. This regulation also provides an exception for the accidental loss of garbage as a result of damage to a ship or its equipment provided that all reasonable precautions have been taken before and after the loss to prevent or minimize the loss. It also provides exceptions for the accidental loss of fishing gear provided that all reasonable precautions have been taken to prevent the accidental loss and for the discharge of fishing gear for the protection of the marine environment (see paragraphs 15.1 - 15.4 below on reporting such loss or discharge). The provisions on mixed or contaminated garbage do not apply to garbage discharged or lost under an exception.

13. Garbage Management Plans

13.1 Regulation 10.2 of Annex V (UK regulation 11) requires every ship of 100 GT and over, every ship carrying 15 or more persons and fixed or floating platforms to carry a Garbage Management Plan.

13.2 This document must set out procedures for minimizing, collecting, storing, processing and disposing of garbage, including the use of any garbage-related equipment on board. It must also designate the person or persons in charge of carrying out the Plan. The Garbage Management Plan must be set out in accordance with the IMO’s 2012 Guidelines for the Development of Garbage Management Plans. [footnote 6] The crew should be trained in garbage management and be aware of the contents of the Plan, and the Master of the ship is responsible for ensuring that this Plan is followed and implemented. The 2017 Guidelines provide further comprehensive guidance to assist crews minimize waste and on how to handle waste. The 2017 Guidelines cover collection, processing, storage and discharge and also provide details on shipboard equipment such as compaction, grinding and incineration equipment.

14. Garbage Record Books/Electronic Record Book

14.1 Regulation 10.3 of Annex V (UK regulation 12) requires every ship of 100 GT and above, every ship carrying 15 or more persons engaged in voyages to ports or offshore terminals under the jurisdiction of another Party to the Convention, and fixed or floating platforms to maintain a Garbage Record Book whether as a part of the ship’s official log-book, a separate document or an Electronic Record Book.

14.2 Regulation 10.3 was amended by IMO Resolution MEPC.314(74) [footnote 7] to allow for the use of Electronic Record Books (ERB) from 1 October 2020. This amendment to Annex V was incorporated into UK law at the same time that the amendment came into force internationally (1 October 2020) by way of the ambulatory reference provision in the UK Regulations (regulation 3). If you choose to use an ERB, it must be approved in line with the ‘Guidelines for the Use of Electronic Record Books’ Under MARPOL. [footnote 8] Companies wishing to develop and market an ERB for use on a UK ship will be able to obtain approval of their electronic system against the Guidelines from one of the UK’s delegated Recognised Organisations.

15. Reporting of accidental loss or discharge of fishing gear

15.1 The amount of marine debris resulting from the fishing industry is significant, hence specific regulations have been introduced into Annex V to control this category of garbage. Regulation 10.3.6 of Annex V (UK regulations 13(2) and 15) requires ships (including fishing vessels) to record any discharge or accidental loss referred to in regulation 7 of Annex V, which includes the accidental loss and certain other discharges of fishing gear, in the Garbage Record Book or, in the case of a ship of less than 100 GT [footnote 9] , the ship’s logbook.

15.2 Regulation 10.6 of Annex V (UK regulation 8(3)) requires ships (including fishing vessels) to report the accidental loss or discharge of fishing gear which poses a significant threat to the marine environment or navigation. The 2017 Guidelines have a dedicated section on fishing gear, which provides factors to consider when assessing whether lost or abandoned fishing gear could be considered to pose a significant threat to the marine environment or navigation. Whole or nearly whole large fishing gear or other large portions of gear is likely to constitute such a threat.

15.3 Reports of fishing gear which poses a significant threat to the marine environment or navigation need to be made to the flag State, and where appropriate to the coastal State in whose jurisdiction the loss of the fishing gear occurred. For the purposes of the UK, details of such losses or discharges need to be sent to [email protected]

15.4 The details required to be submitted will be the same as required in the Garbage Record Book, i.e., the ship’s name, distinctive number or letters, IMO No., etc. The details should include the amount and nature of the gear lost or discharged, the position of the ship (longitude/latitude) and the conditions of the marine environment where it was lost or discharged.

16. Garbage Record Books: Exemptions/Equivalence

16.1 Regulation 10.4 of Annex V (UK regulation 14) allows the Administration (in the UK the Maritime and Coastguard Agency (MCA), acting on behalf of the Secretary of State) to waive the requirements in relation to Garbage Record Books. The following may be exempted:

a) Ships engaged on a voyage of one hour or less which are certified to carry 15 or more persons. It should be noted that the MCA policy is that a Garbage Record Book will still need to be held on board the ship, but those in charge of the ship can apply for an exemption from making entries in the Book. Applications for the exemption should be made to your local MCA Marine Office. The applicant will need to declare that over the period of time the exemption is being applied for, the ship will only undertake voyages of one hour or less in duration. If an exemption is granted, it will need to be attached to the Garbage Record Book and the exemption will not have effect at any time when the ship engages in a voyage of over one hour in duration. In these situations, entries will need to be make in the Garbage Record Book as set out in Annex V.

b) Fixed or floating platforms – Fixed or floating offshore installations engaged in exploration and exploitation of the seabed must have a Garbage Record Book or equivalent. The equivalent accepted by the MCA are the waste manifest records, special waste pre-notification consignment notes (for special wastes) and duty of care transfer notes (for non-special wastes) which are already maintained and held by fixed or floating platforms. This also applies to unmanned installations. Where unmanned installations do not have a premise to maintain records then the required records must be held at the operator’s premises onshore.

17. The International Code for Ships Operating in Polar Waters (Polar Code)

17.1 Antarctic and Arctic waters are defined in Annex V in regulation 1.14.7 and regulation 13.2 respectively. Annex V applies to ships in Antarctic and Arctic waters (polar waters). However, the Polar Code sets additional requirements in relation to discharges into the sea in polar waters.

17.2 The UK Regulations apply to discharges into polar waters from United Kingdom ships which are operating, or which intend to operate, in polar waters, and non-United Kingdom ships which begin or end a voyage from or in a United Kingdom port and during that voyage operate, or intend to operate, in polar waters. The effect of regulation 5(1)(d) is that the discharge of garbage from a United Kingdom ship into the sea in polar waters is prohibited except as provided in section 5.2 of Chapter 5 of part II-A of the Polar Code. Section 5.2 only allows the discharge of garbage where the discharge meets the requirements of regulation 4 of Annex V (in the case of Arctic waters) or regulation 6 of Annex V (in the case of Antarctic waters). It then sets out additional requirements which must also be met.

17.3 As the Antarctic is a special area under Annex V regulation 6.1, the amendments for the Antarctic in the Polar Code set out appropriate geographical changes such as stipulating the distances that discharges must be from ice-shelves, fast ice and ice concentration exceeding 1/10. In addition, a United Kingdom ship must not enter the Antarctic area unless it has sufficient capacity for the retention on board of all garbage while operating in that area and has concluded arrangements for the discharge of that retained garbage at a reception facility outside of the Antarctic area (UK regulation 7). In the UK, reception facilities, and ships’ obligations in respect of the delivery of garbage to them, are governed by the Merchant Shipping and Fishing Vessels (Port Waste Reception Facilities) Regulations 2003 (S.I. 2003/1809) as amended and MGN 563 (M+F) Amendment 1.

17.4 As Arctic waters fall outside special area waters under Annex V, the Polar Code sets out more stringent provisions in addition to those in regulation 4 of Annex V. This brings Arctic waters more in line with the Antarctic standard, as well as setting out appropriate geographical changes to the discharge requirements.

More information

Clean Ship Operations Team Maritime and Coastguard Agency Bay 2/23 Spring Place 105 Commercial Road Southampton SO15 1EG

Telephone: +44 (0)203 8172448

Email: [email protected]

Website: www.gov.uk/mca

Please note that all addresses and telephone numbers are correct at time of publishing.

The Merchant Shipping (Prevention of Pollution by Sewage and Garbage from Ships) Regulations 2008, S.I. 2008/3257.  ↩

https://wwwcdn.imo.org/localresources/en/OurWork/Environment/Documents/Simplified%20overview%20of%20the%20discharge%20provisions%20of%20the%20revised%20MARPOL%20Annex%20V.pdf   ↩

The Guidelines were published in IMO Resolution MEPC.295(71).  ↩

See the IMO ‘Revised Guidance on the Management of Spoilt Cargoes’ contained in LC-LP.1/Circ.58 dated 3 July 2013: https://wwwcdn.imo.org/localresources/en/OurWork/Environment/Documents/58.pdf   ↩

Other Annexes to MARPOL regulate: oil (Annex I); noxious liquid substances in bulk (Annex II); harmful substances carried by sea in packaged form (Annex III); sewage (Annex IV); and air pollution (Annex VI).  ↩

The Guidelines were published in IMO Resolution MEPC.220(63).  ↩

IMO Resolution MEPC.314(74) is available from the IMO and also from the MCA upon request. It will also be available on the Foreign and Commonwealth Treaties Database (https://treaties.fco.gov.uk/responsive/app/consolidatedSearch/) but this may not be available at the time of the publication of this Notice.  ↩

The Guidelines were published in IMO Resolution MEPC.321(74).  ↩

Regulation 10.3.6 of Annex V was amended by IMO Resolution 360(79) to replace “400 GT” with “100GT” and this was given effect in the UK by regulation 13(2) of the Merchant Shipping (Prevention of Pollution by Garbage from Ships) Regulations 2020.  ↩

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