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Wildfires and Health

Wildfires and Health. Planetary Health Series. Kari Nadeau, PhD, MD 2-20-19. Outline. Background What are we measuring in wildfire smoke? How does it enter the body? What research has been published on wildfire and health?

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Wildfires and Health

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  1. Wildfires and Health Planetary Health Series Kari Nadeau, PhD, MD 2-20-19

  2. Outline • Background • What are we measuring in wildfire smoke? • How does it enter the body? • What research has been published on wildfire and health? • What research is our lab currently doing and planning for the next wildfire season? • Conclusions

  3. Acres Burned in Wildfires 1985 - 2013 Source: National Interagency Fire Center • Source: National Interagency Fire Center • Source: National Interagency Fire Center • Source: National Interagency Fire Center • Source: National Interagency Fire Center

  4. Southern CA Wildfires – Dec. 2017

  5. In the News

  6. Is Drought in California the New Normal?

  7. Wildfire Size and Season Duration • Wildfire season in California typically ends in October when autumn rains begin • Thomas Fire near Santa Barbara in December 2017 was at that time California's largest wildfire • Mendocino Complex Fire in summer 2018 was much larger than the Thomas Fire • Camp Fire in Butte County in November 2018 became California’s deadliest and most destructive wildfire

  8. 2017 and 2018 were Bad Wildfire Years - Why? • 5 years of drought 2011-2016; many dead trees • El Nino winter of 2017 brought lots of rain, ending the drought • Increased growth of vegetation in spring • Normally dry and very hot summer weather generating lots of fuel • Lack of rain during fall

  9. Catastrophic Wildfires CA Climate Action Team, 2009 Report: “An increase in the number, size and duration of fires will add to the air pollution that already burdens California.” Risk of large wildfires: • Up to 55% increase by 2050 • Up to 128% increase by 2099, with estimated burned area increase of 59% to 169%

  10. Climate Change and Increase in Wildfires Source: Westerling and Bryant, 2006; climate change.gov

  11. Changing climatic conditions are influencing large wildfire frequency End-of-century wildfire emissions are projected to increase by 19–101% (median increase 56%) above the baseline period (1961–1990) in California for a medium-high temperature scenario, with the largest emissions increases concentrated in northern California. Hurteau, et al, Environ. Sci. Technol., 2014

  12. Cause of Wildfires • Over 90% man-made • Many are preventable Courtesy California Fire, 2017

  13. The air we breathe: composition of wildfire smoke • Wildfire smoke contains carbon dioxide, water vapor, carbon monoxide, particulate matter, complex hydrocarbons, nitrogen oxides, trace minerals, and several thousand other compounds. • Actual composition of smoke depends on the fuel type (e.g., deciduous vs. coniferous trees), the temperature of the fire, and the wind conditions. • Wood smoke contains many of the same toxic and carcinogenic substances as cigarette smoke, including benzene, benzo[a]pyrene, and dibenz[a,h]anthracene. • 3 cigarettes a day is about equivalent to an AQI of 200 Photo: Wiki commons Balmes, NEJM, Mar 8 2018

  14. The Air We Breathe: These toxins can be active at parts per billion Particulate matter (PM) is classified according to particle diameter, commonly in categories of PM2.5 (particles 2.5 μm and smaller) and PM10 (particles 10.0 μm and smaller). Over 80% of wildfire smoke is less than 2.5 uM. Figure courtesy of US EPA S.L. Steinberg and W.A. Sprigg (eds.), Extreme Weather, Health, and Communities, Extreme Weather and Society, 2016

  15. Chemistry of Wildfires • Primary air pollutants • Particulate Matter (PM) • CO • NO2 • Polycyclic aromatic hydrocarbons (PAHs) • Volatile organic compounds (VOCs) • Secondary air pollutants • Particulate Matter (PM) • Ozone • When vehicles and buildings burn: • Structural fire smoke contains other toxic air contaminants • HCN, HCl, phosgene, metals • toluene, styrene, dioxins

  16. Wildfire emissions and related health impacts Youssouf et al, 2014

  17. Particle Inhalation Based on Size (American Assoc for Respir Care, 2011)

  18. What are the effects of the PM2.5 once inside the body? • Lung inflammation • 1.6 million COPD deaths • Asthma exacerbations • Systemic inflammation • Cardiovascular system • 19% CVD deaths • 21% stroke deaths • Immune system • Allergies • Autoimmune disorders • Endocrine System • Diabetes • Brain • Alzheimer's • Lower child IQ • Autism • Cancer • 500,000 lung cancer deaths • Bladder cancer • Childhood leukemia (Wu, 2018I)

  19. PM 2.5 PM 2.5 exposure is comparable to smoking cigarettes: • A mathematical model compares smoking and tobacco-related deaths to levels of PM2.5 (Martinyand Mueller): • One cigarette per day is the rough equivalent of a PM2.5level of 22 μg/m3. • PM2.5 causes increased deaths worldwide: • PM2.5 caused 4.2 million premature deaths worldwide per year in 2016 (Schraufnagel, 2018) • Air pollution causes 9 million premature deaths (Lancet Commission on Public Health, 2018)

  20. PM2.5 is shortening lives around the world ScienceNews, 29 set. 2018. v. 194, n. 6, p. 32. 

  21. What wildfire/health studies have been done? • Observational <40 • Studies of firefighters <10 • Reviews or Commentaries <20 • Animals in the field <5 • Basic Science (Human or mouse models) <20 • Studies looking at air filter or mask effectiveness during wildfires (1 observational, no RCTs)

  22. Observational Study • Large fire burned for 2 months with poor air quality (high PM10) • CDC investigators documented increased health care utilization for lower respiratory illness • Recollection of public service announcements was associated with a reduced odds of reporting adverse respiratory health effects • Increased duration of the use of HEPA air cleaners was associated with a reduced odds of reporting adverse respiratory health effects • No protective effects were observed for use of masks or duration of evacuation Mott, et al, 2002

  23. Wildfire and Health: Respiratory Effects • Wildfire PM2.5assoc with inflammation-related respiratory effects • Asthma: Increased ER and hospital admissions • Peat forest fires in NC (Rappold, 2011) • Bush fires in Australia (Morgan, 2010) • Forest fires in British Columbia (Henderson, 2011) • Increase of 70 ug/m3 assoc with 34% increase in asthma admissions in CA (Delfino, 2009) • COPD: Increased ER and hospital admissions • Increase 3.8% of admission assoc with 10 ug/m3 increase of PM10 (Morgan, 2010) • Increase 6.9% admission assoc with 10 ug/m3increase PM2.5(Delfino, 2009) • Acute bronchitis and pneumonia admissions increased • Every 10 ug/m3 increase in PM2.5 with 9.6 % increase AB admissions and 6.4% increase pneumonia admissions (Delfino, 2009)

  24. Wildfires in California increased asthma exacerbations Asthma Monitoring Map Before During After Pneumonia Relative Risk [PM2.5] Reid, et al, Environ Health Persp, 2016 N=12.7 million; 112, 000 hospital visits Reid, Merritt, Tager, Mann, Balmes Environmental Research 2016

  25. Wildfire and Health: Cardiovascular Effects • Wildfire PM2.5assoc with inflammation-related CVD effects, but fewer studies and some conflicting findings. • Increased cardiovascular (ischemic heart disease, dysrhtmia, heart failure, PE) and cerebrovascular (stroke) ER visits in CA in 2015, • esp > 65 yrs old (Wettstein, 2018) • Mechanism: Increased systemic inflammation, oxidative stress and coagulation through PM2.5 mediated changes in ANS (Reid, 2016) • 10 ug/m3 increase PM2.5 assoc with 8% to 18%increase in mortality (Pope, 2003)

  26. Cardiovascular and Cerebrovascular Emergency Department Visits Associated With Wildfire Smoke Exposure in California in 2015 • Wildfire smoke exposure was associated with increased rates of emergency department visits for numerous cardiovascular disease outcomes, including ischemic heart disease, dysrhythmia, heart failure, pulmonary embolism, and stroke. • The observed risk was greatest among adults aged>65 years. With a an increase in the risk of heart attacks similar to the increase in risk of a heart attack if you smoke 2 cigarettes per day for a year. • This analysis used data from nearly the entire wildfire season across a large area of California, which is one of the most extensive studies of wildfire health impacts in California to date. Wettstein, et al. J Am Heart Assoc. 2018 Apr

  27. Cardiovascular and Cerebrovascular Emergency Department Visits Associated With Wildfire Smoke Exposurein California in 2015 Total number of days with any smoke plumes by county from May 1 through September 30, 2015. California air basins in the study region are labeled and outlined in black, those excluded in gray. o NortheastPlateau o SacramentoValley Redding Eureka Wettstein, et al. J Am Heart Assoc. 2018 Apr o MountainCounties o LakeTahoe North Coast o Chico Lake County o Sacramento SantaRosa o Great BasinValleys SanFrancisco SanJose Monterey Fresno o San JoaquinValley Bakersfield 60 50 40 30 20 10 LosAngeles SanDiego Figure 1. Total number of days with any smoke plumes by county from May 1 through September 30, 2015.Californiaairbasinsinthestudyregionarelabeledandoutlinedinblack,thoseexcludedingray. Figure 1. Total number of days with any smoke plumes by county from May 1 through September 30, 2015.Californiaairbasinsinthestudyregionarelabeledandoutlinedinblack,thoseexcludedingray. Figure 1. Total number of days with any smoke plumes by county from May 1 through September 30, 2015.Californiaairbasinsinthestudyregionarelabeledandoutlinedinblack,thoseexcludedingray.

  28. Heart, Brain, and Lung affected by Wildfires in Short term Emergency Department Visits Associated With Wildfire Smoke Exposure in California in 2015 L M H L M H L M H Risk of heart problems Increased by 42% Due to wildfires! Smoke Density Wettstein, et al. J Am Heart Assoc. 2018 Apr

  29. Wildfire and Health: At Risk Populations • Wildfire PM2.5 impact worse for the following populations: • Young Children: Age 0 to 4 had 8.3 % increase in asthma admissions per 10 ug/m3increase in PM2.5 (Delfino, 2009) • Elderly: Age >65 % had 10.1% increase in asthma admissions per 10 ug/m3increase in PM2.5 (Delfino, 2009). Looking at smoke wave (2 days PM2.5 >20 ug/m3), 7.2 % increase respiratory admissions in elderly if PM2.5> 37 ug/m3 (Liu, 2017) • Pre-existing Respiratory and CVD Disorders at increased risk. • PM2.5 increases risk of MI, but high NO2 and O3 may magnify the effect (via increasing oxidative potential; Weichenthal, 2016)

  30. Wildfires in California increased asthma as determined by ED visits in vulnerable populations Gender Age SES Relative Risk Results: • Females • Older (64 y+) • Lower SES L M H <20 >64 M F Reid, Merritt, Tager, Mann, Balmes Environmental Research 2016

  31. Wildfire and Health: Firefighters • Respiratory function is impacted • Firefighters have decreased FEV1 after a full season of firefighter and returns to baseline months later (Betchley, 1997; Gaughan, 2008). • If look pre-shift to post-shift FEV1, no change (Swiston, 2008): not acute, but assoc with longer smoke exposures vs FUMEXP 2008 to 2010 (n=38) acute and long term respiratory effects (Ferreira, 2011). • Biomarker data • Increased Il-6, Il-8 and sputum neutrophils (Swiston, 2008) • Increase in urinary markers of oxidative stress (Gaughan, 2014) • * Other studies looked at heat-restriction, fatigue, etc… but not in relation to wildfire smoke.

  32. Wildfire and Health: Animal Studies • Indonesia’s endangered orangutans exposed to wildfire 2015 to 2016 and had increased rest, decreased travel and ketones post-wildfire that suggested an altered energy expediture related to the immune system (Erb, 2018). • Rhesus Monkeys exposed to 2008 CA wildfires as babies showed immune dysregulation and decreased lung function 3 years later (Black, 2016). • Mice were exposed to course or fine wildfire particulate collected during the wildfire smoke of 2008 : neutrophilic inflammation and decreased macrophages in bronchial lavage, fine PM more toxic (Wegesser, 2010).

  33. Our research in Fresno, Ca for past 9 years…. • Focus on impact of air pollution on allergies/ immune system • Increased asthma • Immune dysfunction • Epigenetic changes • Blood Pressure in children

  34. Why study Fresno? 2018 GRADE MAPS Particle Day Grades Ozone Day Grades Annual Particle Pollution Grades

  35. What wildfire research is our SNP Center currently conducting? • Prescribed Burns vs Wildfires(Prunicki et al, submitted) WawonaBurn 2 phase 2/26 to 3/30 Blood draws from 5/18 to 7/23 3 months 2015 Prescribed Burn Tenaya Wildfire 9/7 to 9/21 Blood draws from 11/10/15 to 1/7/16 2 to 3 1/2 months 2015 Wildfire

  36. What wildfire research is our SNP Center currently conducting? • Prescribed Burns vs Wildfires (Prunicki et al, submitted) p<.0001 for each pollutant

  37. What wildfire research is our SNP Center currently conducting? • Prescribed Burns vs Wildfires(Prunicki et al, submitted) • Health Findings: • Decreased Th1 cells in wildfire group • Increased methylation in wildfire group • Increased wheezing and asthma exacerbations • Trend rise in pulse pressure in wildfire group Th1 Cell percentage of CD 4+ cells for children 90 days after being exposed to a prescribed fire, wildfire or no exposure (1-way ANOVA, p<.0001).

  38. What wildfire research is our SNP Center currently planning? N=80 families Initial visit: Blood, Urine, Buccal, PFTs, BP, Questionnaires Given personal pollution monitors Wildfire Air Purifier Group (N= 40 families) Placebo Air Purifier (N= 40 families) Repeat Blood, Urine, Buccal, PFTs, BP, Questionnaires up to 1 year post wildfire

  39. Summary: There is no safe distance from a wildfire • Closing windows or using HEPA filters still does not help. • N95 mask is somewhat effective providing protection from inhalation of fine particles but not hazardous gases (such as carbon monoxide, formaldehyde, and acrolein).* • Masks run out very quickly from stores and are not made to fit children. *Balmes, NEJM, Mar 8 2018

  40. Summary • Wildfire chemical makeup and toxicity levels depends on materials, Temp, O2, ventilation. • PM2.5 caused 4.2 million premature deaths worldwide in 2016 • Wildfire PM2.5associated with inflammation-related respiratory and cardiovascular effects • Need better understanding of chronic and acute effects on personal and public health. • How well does intervention of air filter inside or wearing N95 mask outside help? • Vulnerable populations are at risk, growth of populations to the edge of forests • Due to climate change, wildfires emissions are expected to increase 19-101% in CA through 2100 (Hurteau, 2014). • The need for adaption and prevention is critical

  41. With Appreciation to Planetary Health Speaker Series, USFS, Patients andFamilies, Researchers and Collaborators

  42. ThankYou!

  43. Additional Slides

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