Air Pollution and Adverse Pregnancy Outcomes in Wuhan, China

1. Air Pollution and Adverse Pregnancy Outcomes in Wuhan, China Zhengmin (Min) Qian, MD, PhD Edwin Trevathan, MD, MPH Saint Louis University School of Public Health, Saint Louis, MO, USA Lyon, France November 13, 2012

2. Picture of Wuhan

3. Picture of Wuhan

4. ▲ Map of China

5. Background Multiple research projects have been conducted by Chinese and U.S. investigators in Wuhan, China for over 25 years. The major funding sources are listed below: • Health Effects Institute (HEI) • U.S. Environmental Protection Agency (EPA) • Chinese government • Pennsylvania State University • Saint Louis University

6. Study Objectives The Primary Objective To extend our HEI-sponsored Public Health and Air Pollution in Asia (PAPA) program of Ambient Particle Air Pollution and Daily Mortality in Wuhan to population-based investigations of associations between air pollution and adverse pregnancy outcomes Specifically, to evaluate whether high pollution levels of PM2.5 and PM10, SO2, NO2, O3, and CO are related to increased occurrence of preterm birth, LBW, and intrauterine growth retardation in a population based cohort of about 100,000 neonates born in Wuhan, China during a two year period 2011 to 2013

7. Specific Aims To test the following hypotheses: Specific Aim 1: Are elevated ambient concentrations of PM10, PM2.5, SO2, NO2, O3, and CO during vulnerable pregnancy periods associated with increased adverse pregnancy outcomes, adjusted for major risk factors? Specific Aim 2: Are the associations confounded by co-pollutants? Specific Aim 3: How much does residual confounding affect the associations? Specific Aim 4: Are the associations between pollutants’ concentrations and adverse pregnancy outcomes modified by socio-economic status and indoor pollution sources, including parental cigarette smoking?

8. Study Design - 1 The proposed research is being conducted in two phases: ● Population-based cohort study ● Nested case-control study

9. Unique Parts of the Study Design ● One of the largest studies in China assessing air pollution effects on adverse pregnancy outcomes ● Both high quality maternal/infant data and pollution data have been collected systematically ● A population-based cohort study in which nested case-control samples are selected ● This study design, less likely to suffer selection bias, is an efficient and cost-effective strategy to study adverse pregnancy outcomes ● With the detailed additional covariate information, this study possesses an enhanced ability to assess residual confounding and effect modification

10. Resources Needed The successful completion of the project requires four distinct resources: ● The existing close collaborations among the key investigators ● The existing comprehensive infrastructure and outstanding maternal/infant data collection system ● The availability of complete and high quality data ● The ability to collect additional data on potential confounders/effect modifiers and to assess the extent to which residual confounding may affect the observed associations

11. Methods of Outcome Data Collection ● Wuhan Medical and Health Center for Women and Children (MHCWC) electronically archives all prenatal care visits, birth delivery information and postnatal care visit information. ● MHCWC established a comprehensive perinatal health care system two decades ago. This system consists of health care centers at levels of city, district, and community. ● All pregnant women are required to register at their district maternal health care center within three months of becoming pregnant. Each pregnant woman: ► receives a manual with instructions for prenatal and postnatal care ► obtains forms for obstetricians to record data on maternal age, height, weight, education, occupation, medical history, infant weight, etc. ► has complete physical examinations done

12. Data Collection For phase I, the population cohort study of 100,000 women and infants ► Multiple prenatal care visits ► Delivery ► Postnatal care visits ► Physical examination ► Immunization ► Blood Samples for a subgroup For phase II, the nested case-control study of 3,500 cases and 3,500 controls ► Survey data, in addition to the above data ► Risk factor data

13. Data Collection Methods for Childhood Cancer Option 1 MHCWC’s capacity to collect childhood cancer data from the hospital system and then link the cancer incidence data with their maternal and children health data (prenatal care visit data, delivery data, and postnatal care visit data) Option 2 Combining the maternal and child health data in the MHCWC with the Wuhan Cancer Registry (WCR) in the Wuhan Center of Disease Control (Wuhan CDC)

14. Wuhan CDC ● Another important, long-term collaborator of ours in Wuhan. We have maintained an active agenda with the Wuhan CDC since 2003. ● Dr. Qian used to work with the researchers in Wuhan CDC on a daily basis in the Wuhan mortality time-series study during 2004-2007. ● We have published five papers together using the Wuhan mortality data, including cancer mortality data. ●During the meetings in Wuhan in June, 2012, both Dr. Edwin Trevathan, Dean of School of Public Health, Saint Louis University and Dr. Dunjin Zhou, Director of Wuhan CDC are interested in continuing our collaborated studies on chronic disease epidemiology by using the Wuhan Cancer Registry data.

15. Wuhan Cancer Registry within Wuhan CDC ● The WCR was established in 1980 and the data have been computerized since 1992. ● By the regulation, this registry collects cancer incidence data on a daily basis, known as “real time” monitoring. ● All hospitals (more than 110 units) in Wuhan must notify all newly diagnosed cancer cases to the registry according to the standardized procedures. ● Each hospital has a special department to collect and send the cancer incidence data to the registry on time. ● The Registry audits the hospitals and undertakes training regularly.

16. Acknowledgements The investigators acknowledge comments/advice made by members from the Health Effects Institute’s (HEI) International Scientific Oversight Committee. This study is being conducted under contract with HEI and Chinese government, and was made possible, in part, through support provided by Saint Louis University, Wuhan Medical and Health Center for Women and Children, and Wuhan Center of Environmental Monitoring. We thank the following key investigators for their contributions: Bin Zhang, Shengwen Liang, Louise Flick, Bernard D. Goldstein, Evelyn Talbott, Walter F. Stewart, Shaoping Yang, Rong Yang, Ronghua Hu, Jing Wang, Jianming Wang, and Ke Hu

17. Thank You!