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Posted: February 15th, 2020

Urban Population and Respiratory Diseases

# Urban Population and Respiratory Diseases

The rapid growth of urbanization and industrialization has brought many benefits to human society, but also many challenges. One of the most serious problems is the impact of air pollution on respiratory health. Air pollution is a complex mixture of gases, particles, and chemicals that can affect the lungs and other organs of the body. Exposure to air pollution can cause or worsen chronic respiratory diseases (CRDs), such as asthma, chronic obstructive pulmonary disease (COPD), interstitial lung disease, and pneumoconiosis. CRDs are leading causes of morbidity and mortality worldwide, especially in low- and middle-income countries.

In this blog post, we will review the current evidence on the trends, risk factors, and effects of air pollution on respiratory diseases in urban areas. We will also discuss some possible solutions and recommendations to reduce the burden of CRDs and improve urban health.

## Trends in prevalence and incidence of CRDs

According to the Global Burden of Diseases, Injuries, and Risk Factors Study 2017 (GBD 2017), the total number of CRD cases increased by 39.5% from 1990 to 2017, reaching 545 million cases globally . However, the age-standardized prevalence rate (ASPR) and age-standardized incidence rate (ASIR) showed decreasing trends, indicating some improvement in prevention and treatment of CRDs. The ASPR of CRDs decreased from 8.6% in 1990 to 7% in 2017, while the ASIR decreased from 1.2% to 0.9% in the same period .

The trends of different types of CRDs varied across regions, sexes, and age groups. COPD and asthma were the most common and burdensome CRDs, accounting for 74% and 18% of the total CRD cases, respectively . The ASIRs of COPD, pneumoconiosis, and asthma decreased from 1990 to 2017, whereas the ASIR of interstitial lung disease and pulmonary sarcoidosis increased . Males had higher incidence rates of pneumoconiosis and COPD than females, while females had higher incidence rates of interstitial lung disease and pulmonary sarcoidosis than males . Elderly people (aged 70 years or older) had the highest incidence rates of all types of CRDs, except for asthma, which was more prevalent among children and young adults .

The regional variation in the incidence rates of CRDs was also remarkable. For COPD, the ASIR decreased from low-sociodemographic index (SDI) regions to high-SDI regions, reflecting the differences in exposure to risk factors such as tobacco use and indoor air pollution . The ASIR of interstitial lung disease and pulmonary sarcoidosis was highest in high-SDI regions and increased mostly from 1990 to 2017, suggesting a possible role of urbanization and industrialization in these diseases . The ASIRs for pneumoconiosis and asthma were inversely related to the human development index (HDI), indicating that these diseases were more prevalent in less developed countries with poor environmental and occupational conditions .

## Risk factors for CRDs in urban areas

Air pollution is one of the major risk factors for CRDs in urban areas. Air pollution can be classified into outdoor (ambient) air pollution and indoor (household) air pollution. Outdoor air pollution is mainly caused by emissions from vehicles, industries, power plants, waste incineration, biomass burning, and other sources. Indoor air pollution is mainly caused by combustion of solid fuels (such as wood, coal, charcoal, dung, crop residues) for cooking, heating, and lighting. Both outdoor and indoor air pollution contain harmful substances such as particulate matter (PM), nitrogen dioxide (NO2), sulfur dioxide (SO2), carbon monoxide (CO), ozone (O3), volatile organic compounds (VOCs), polycyclic aromatic hydrocarbons (PAHs), heavy metals, and allergens.

Exposure to air pollution can cause inflammation, oxidative stress, epithelial damage, mucus hypersecretion, bronchoconstriction, airway remodeling, fibrosis, and carcinogenesis in the respiratory system . These mechanisms can lead to acute or chronic effects on respiratory health, such as exacerbation of symptoms (cough, wheeze,
phlegm), reduction of lung function (volumes and flows), increase of hospitalizations and mortality for respiratory diseases.

The evidence on the association between air pollution exposure and respiratory diseases is abundant and consistent. A systematic review of studies conducted in Italy found that increased concentrations of all atmospheric pollutants, in particular of PM, were associated with cough and phlegm (70% of the studies), asthma symptoms (35%), reduction of lung function (30%), and increase of hospital stay days for respiratory diseases (30%) . Another systematic review of studies conducted in China found that exposure to PM2.5 (fine particles with a diameter of 2.5 micrometers or less) was associated with increased risk of COPD (odds ratio [OR] = 1.29, 95% confidence interval [CI] = 1.18–1.41), asthma (OR = 1.40, 95% CI = 1.25–1.57), and lung cancer (OR = 1.18, 95% CI = 1.10–1.27) . A meta-analysis of studies conducted worldwide found that exposure to NO2 was associated with increased risk of asthma incidence in children (relative risk [RR] = 1.14, 95% CI = 1.07–1.21) and adults (RR = 1.06, 95% CI = 1.02–1.11) .

The effects of air pollution on respiratory health may vary depending on the type, level, duration, and frequency of exposure, as well as the susceptibility and vulnerability of the exposed population. Some groups are more likely to be exposed or affected by air pollution, such as children, elderly, pregnant women, people with pre-existing respiratory diseases, people with low socioeconomic status, and people living or working in highly polluted areas . For example, children are more vulnerable to air pollution because their lungs are still developing, their breathing rate is higher, their airways are narrower, and they spend more time outdoors . Elderly people are more susceptible to air pollution because they have reduced lung function, impaired immune system, and higher prevalence of chronic diseases .

Air pollution is not the only risk factor for CRDs in urban areas. Other factors such as tobacco use, occupational exposure, climate change, lifestyle factors, and genetic factors can also contribute to the development or exacerbation of CRDs . Moreover, these factors can interact with each other and with air pollution to produce synergistic or antagonistic effects on respiratory health. For example, tobacco use can increase the susceptibility to air pollution by impairing the mucociliary clearance and the antioxidant defense system . Occupational exposure can enhance the effects of air pollution by increasing the total dose of inhaled pollutants or by causing specific respiratory diseases such as pneumoconiosis or occupational asthma . Climate change can worsen the effects of air pollution by increasing the frequency and intensity of heat waves, wildfires, dust storms, and pollen seasons .

## Solutions and recommendations for reducing CRDs in urban areas

The prevention and control of CRDs in urban areas requires a comprehensive and multisectoral approach that addresses the root causes and the modifiable risk factors of these diseases. Some possible solutions and recommendations are:

– Implementing and enforcing policies and regulations to reduce emissions from vehicles, industries, power plants, waste incineration, biomass burning, and other sources. Examples include setting emission standards, promoting fuel switching, adopting clean technologies, improving public transportation systems, encouraging active mobility (walking and cycling), and expanding green spaces.
– Improving access to clean energy sources and technologies for cooking, heating, and lighting in households. Examples include promoting liquefied petroleum gas (LPG), biogas,
electricity, solar energy, improved cookstoves, chimneys, ventilation systems, and behavior change interventions.
– Monitoring and reporting air quality data and health impacts in urban areas. Examples include establishing air quality monitoring stations, developing air quality index (AQI) systems, issuing health advisories and alerts, conducting epidemiological studies and surveillance systems.
– Raising awareness and educating the public about the health effects of air pollution and the preventive measures they can take to reduce their exposure and risk. Examples include disseminating information through mass media, social media, schools, workplaces,
healthcare facilities; providing personal protective equipment such as masks or filters; advising vulnerable groups to avoid outdoor activities during high pollution episodes; encouraging smoking cessation.
– Strengthening the health system capacity to prevent, diagnose,
treat, and manage CRDs in urban areas. Examples include developing guidelines and protocols for CRD care; training healthcare workers on CRD prevention and management; providing essential medicines and equipment for CRD treatment; implementing integrated chronic care models for CRD patients; enhancing referral systems and telemedicine services for CRD cases.

## Conclusion

In conclusion, CRDs are major public health problems in urban areas that are largely attributable to air pollution exposure. Air pollution can cause or worsen various types of


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