1. Health Impacts of OZONE POLLUTION

2. Volume Growth The relationship between ozone pollution and pubic health Dr. Tonya McDonald M.D. Pediatrician MyChildren’s Lancaster Kiest

3. Volume Growth Overview • Describe how ozone is formed and where it is found • Identify the effects that exposure to ozone has on the general population • Identify the effects that ozone has on asthma patients • Address typical patient questions and clinical scenarios relating to asthma

4. Ozone • A gas composed of three atoms of oxygen • Can be good or bad • Ozone occurs in two layers of the atmosphere • Stratosphere- six to 30 miles above the earth • The “Ozone Layer” • “Good Ozone” • Troposphere- ground level to approximately six miles above earth • “Bad Ozone”

5. Two Layers of Ozone O3 Good O3 Bad

6. Ozone: Where Does Ozone Come From • Produced by chemical reactions between oxides of nitrogen (NOx) and volatile organic compounds (VOC) in the presence of sunlight • Acts as a respiratory irritant, is harmful to breathe, damages crops, trees and other vegetation http://www.epa.gov/air

7. How Does Ozone Form? + UV O3 NOx + VOCs

8. Ozone Concentrations Depend On… • Concentration and ratio of NOx and VOCs • Wind speed and direction • Terrain • Temperature • Stagnant conditions (depends on wind and temperature) • Time of year (“ozone season”)

9. How Are People Exposed to Ozone • Ozone exposure occurs when people breathe ambient air containing ozone • The rate of exposure for a given individual is related to the concentration of ozone in the surrounding air and the amount of air the individual is breathing per minute • Dose = Concentration x Ventilation Rate x Time • Ozone concentrations are higher outdoors than indoors • Increased physical activity increases a person's rate of ozone exposure

10. Ozone Reacts with the Respiratory Tract • The upper respiratory tract is not as effective in scrubbing ozone from inhaled air as it is for more water soluble pollutants • Consequently, the majority of inhaled ozone reaches the lower respiratory tract • Ozone reacts with chemical constituents of airway lining fluid throughout the respiratory tract, producing very reactive chemical intermediates

11. Ozone Affects Health • Health Issues: Respiratory Problems • Coughing • Congestion • Chest Pain • Throat Irritation • Worsens respiratory diseases such as asthma, bronchitis and emphysema

12. Volume Growth Human Lung • Air conducting • Trachea • Bronchi • Bronchioles • Gas exchange • Respiratory bronchioles • Alveoli

13. Volume Growth Volume Growth Ozone Irritates Airways • Symptoms • Cough • Sore or scratchy throat • Pain with deep breath • Fatigue • Rapid onset • Similar symptoms - people with and without asthma

14. Volume Growth Ozone Causes Inflammation • Ozone reacts completely in surface layer - forms reactive oxygen molecules • Influx of white blood cells • Damages cells that line the airways • Effect is greater 24 hours after exposure • Increases airway reactivity • Concern about repeated exposures

15. “Pyramid of Effects” Volume Growth • Effects seen across a wide range of health outcomes • Sensitive groups include: • Asthmatic children and other people with lung disease • All children and older adults, especially people active outdoors • Outdoor workers Adversity of Effects Proportion of Population Affected http://www.epa.gov/air

16. It’s a Public Health Concern • Estimated 60,000 children in Dallas County with Asthma • Prevalence of asthma in children is particularly high and because children are generally at higher risk due to time spent being active outdoors, • they may be disproportionately affected by ozone exposure • Ranked 8th for high ozone days out of 277 metropolitan areas • Dallas County is graded as an “F” for high ozone • Over 30 “Orange” Ozone Days a year • Poor Air Quality associated with increases in: • Hospital admissions • Doctor and emergency room visits • Medication use • Absences from work or school

17. Ozone and People with Asthma • People with asthma are likely affected by ozone in two ways: • They might be more sensitive to ozone than other people and experience lung function changes • Exposure may worsen a person's  underlying asthma, increasing the probability of an asthma attack. • Respiratory symptoms and bronchodilator use are increased, and lung function is decreased, on days when ozone concentrations are high • Numbers of emergency room visits and hospital admissions for asthma are increased on days when ozone concentrations are high

18. Asthma • Chronic inflammatory disorder of the airway • Infiltration of mast cells, eosinophils and lymphocytes • Recurrent episodes of wheezing, coughing and shortness of breath • Airway hyperesponsiveness • Reversible airflow obstruction, either spontaneously or with treatment.

19. Asthma Exacerbation • Airway inflammation produces four forms of airflow limitation: • Acute bronchoconstriction • Inflammation of the airway wall • Increased mucus formation • Cell mediator proliferation * Airway wall remodeling

20. Asthma is Different For Everyone • No two people have exactly the same asthma symptoms or outcomes Asthma’s two parts • The Quiet Part Inflammation • The Noisy Part Constriction

21. Asthma Exacerbation Sequence

22. Reduce Exposure to Reduce Risk • Reduce time spent outdoors when ozone levels are high (use AQI) • Pay attention to symptoms • People with asthma – follow asthma action plan • Coaches – rotate players frequently • People with heart disease • Check with your doctor • Don’t exercise near busy roads

24. Children’s Asthma Management Text Messaging Program • The text messaging program provides educational asthma texts to program participants and caregivers phones. • The messages/reminders are educational and include: • Taking asthma medications • Following the child’s asthma action plan • Avoiding asthma triggers • Air Quality Alerts

25. Community Collaboration • North Texas Asthma Consortium Program • Asthma-Friendly Flag Program • Multi-colored flag system reflecting outdoor air quality • Based on AQI used by EPA • Goals: • Inform school staff, students, parents and the community of the daily air quality • Provide alternative physical activities for poor ozone days • Reduce student exposure to harmful outdoor air pollutants • www.northtexasasthma.org

26. Resources Environmental websites to check ozone alerts: • http://www.enviroflash.info provides email alerts • www.airnorthtexas.org • www.cleanair.org • www.tceq.state.tx.us • http://www.tceq.texas.gov/agency/data/aq-data.html • http://greendallas.net/air-quality/ • http://www.epa.gov/o3healthtraining/tools.html

27. References • U.S. Environmental Protection Agency: Ozone and Your Patients' Health Training for Health Care Providers http://www.epa.gov/apti/ozonehealth/cme.html