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Take a look at a selection of our recent media coverage:

ESMO: Study reveals statistically significant link between breast cancer risk and air pollution

9th November 2023

Women who live and work in areas with higher levels of fine particulate air pollution are at greater risk of developing breast cancer than women who live and work in less polluted places, finds research presented at the European Society of Medical Oncology (ESMO) Congress 2023.

In a matched case-control study, researchers compared home and workplace air pollution exposure in 2,419 French women diagnosed with breast cancer against the exposure of 2,984 women without the disease from 1990 to 2011.

They found a statistically significant linear increase in breast cancer risk related to mean fine particulate matter (PM2.5) exposure, with a 28% increase in risk with an increment of 10 µg/m3 of PM2.5.

Lead author Professor Béatrice Fervers, head of prevention, cancer environment department, Léon Bérard Comprehensive Cancer Centre, France, said: ‘This contrasts with previous research which looked only at fine particle exposure where women were living, and showed small or no effects on breast cancer risk.’

In a study abstract published in the Annals of Oncology, the research term explained cases were matched to randomly selected controls based on several variables including place of residence, age and menopausal status.

All participants were drawn from the prospective E3N cohort – the French element of the European EPIC Study, coordinated by the International Agency for Research on Cancer.

Researchers using a Land Use Regression model to estimate annual mean PM2.5, coarse particulate matter (PM10) and nitrogen dioxide (NO2) and assigned them to women based on geocoded home and workplace addresses.

Mean exposure was calculated for each woman from the time they were included in the E3N cohort to their index date – the date of diagnosis of cases.

For PM10 and NO2 exposure, researchers found a numerical, but statistically non-significant, increased risk with an incremental increase of 10 µg/m3.

Hormone receptor or menopausal status did not affect any of the results, they added.

Commenting on the findings, Professor Charles Swanton, clinician scientist at the Francis Crick Institute in London, UK, said fine particulate matter can penetrate deep into the lungs, entering the blood stream and then being absorbed into breast and other tissues.

Professor Swanton, who presented research at ESMO Congress 2022 suggesting how PM2.5 particles may trigger lung cancer in non-smokers, said there was already evidence that air pollutants can change breast architecture.

‘It will be important to test if pollutants allow cells in breast tissue with pre-existing mutations to expand and drive tumour promotion possibly through inflammatory processes, similar to our observations in non-smokers with lung cancer,’ he said.

‘There is an urgent need to set up laboratory studies to investigate the effects of these small air pollutant particles on the latency, grade, aggression and progression of breast tumours.’ 

The French research comes weeks after US National Institute of Health researchers published data in the Journal of the National Cancer Institute showing living in an area with high levels of fine particulate air pollution was significantly associated with an increased risk of breast cancer incidence.

Professor Jean-Yves Blay, ESMO director of public policy, said there was strong epidemiological and biological evidence for the link between PM2.5 particle exposure and cancer, with good clinical and economic reasons for reducing pollution to prevent cancers.

In September 2023, the European Parliament adopted in plenary session its report on the ongoing revision of the EU Ambient Air Quality Directives, reflecting ESMO’s recommendations to set the annual limit value for PM2.5 at 5 µg/m³.

This adoption opens interinstitutional negotiations between the co-legislators – European Parliament, European Commission and EU Council – to agree on the final text of the directive.

Air pollution and antibiotic resistance: is there cause for concern?

20th October 2023

Air pollution contains particulate matter that can carry antibiotic resistance genes, which have been found to accelerate microbial threats to human health. Here, Rod Tucker considers the extent to which air pollution could serve as a primary vector and driving force behind the increasing levels of global antibiotic resistance.

There‘s no doubt that global antibiotic resistance represents a major health challenge and is responsible for a huge number of deaths. For example, in a systematic review looking at the global burden of bacterial antimicrobial resistance in 2019, the authors estimated there were 4.95 million associated deaths.

In addition, data published in 2018 from the European Centre for Disease Prevention and Control estimated that around 33,000 people die each year in the in the European Union and European Economic Area as a direct consequence of infections with antibiotic-resistant bacteria.

Although antibiotic resistance represents the failure of a particular drug, there are a number of underlying factors responsible. Perhaps the greatest risk comes from interconnected human, animal and environmental habitats that are likely to contribute towards the emergence, evolution and spread of antibiotic resistance. In fact, resistance emerges as a result of the local confluence that occurs when bacteria colonise different human and animal hosts, enabling the spread of antibiotic resistant genes.

In response to the global rise in antibiotic resistance, countries have introduced antimicrobial stewardship programmes. Such initiatives represent a coordinated approach to promote the appropriate use of antimicrobials and reduce both microbial resistance and the spread of infections caused by multidrug-resistant organisms. 

Antimicrobial stewardship programmes are predicated on the notion that antibiotic use per se, is associated with the development of resistance. However, simply controlling usage may not be an effective means of reducing the rate at which resistance develops.

This was highlighted in a 2018 analysis of the factors driving global antimicrobial resistance. It found that reducing antibiotic consumption would be unlikely to control antimicrobial resistance because the spread of resistant strains and resistance genes seemed to be the most important contributory factor.

So, if this is case, what are the most likely vectors of resistant genes?

The role of air pollution

In 2018, Chinese researchers profiled the relative abundances of 30 antibiotic resistance genes (ARGs) in urban air carried in particulate matter. They found that urban air is being polluted by ARGs and different cities are challenged with varying health risks due to airborne ARG exposure.

Moreover, fine particulate matter, with a diameter of 2.5 μm or less (i.e. PM2·5), is easily inhaled and therefore serves to increase the intake of airborne ARGs.

But to what extent is air pollution and the carriage of ARGs actually responsible for the spread of resistance?

A more recent study by Chinese researchers tried to answer this question. Writing in the journal Lancet Planetary Health, the team provided the first global estimates of antibiotic resistance and burden of premature deaths attributable to antibiotic resistance resulting from PM2·5 pollution.

They used data from multiple sources and included a number of potential confounders, such as levels of air pollution, antibiotic use, sanitation services, climate, year, and region, from a total of 116 countries collected between 2000 and 2018.

Using raw antibiotic-resistance data on nine pathogens and 43 types of antibiotic agents, the team identified significant global correlations between PM2·5 and antibiotic resistance (R2= 0.42 – 0.76, p<0.0001). Furthermore, these correlations appeared to strengthen over time.

The researchers also estimated that antibiotic resistance derived from PM2·5 led to an estimated 0.48 million premature deaths and 18.2 million years of life lost in 2018 worldwide. In other words, with a positive and robust association between PM2·5 and antibiotic resistance, the findings implied that globally, air pollution, and in particular PM2·5, was an important driving factor.

Implications for practice

While the findings from the Lancet Planetary Health study are intriguing, this was an ecological study, which is more suited to the generation of hypotheses, and the finding of an association between air pollution and antibiotic resistance is not necessarily causal.

The authors of the paper also acknowledge some limitations. For instance, several low- and middle-income countries – the likes of which are most affected by antibiotic resistance – did not provide pathogen and antibiotic data.

In addition, the unrestricted use of antibiotics in animal farming was not examined in the study, which is a potentially important determinant of resistance in countries that also tend to have higher air pollution levels.

Finally, the authors also state that ‘some factors could be almost as important as PM2·5 in contributing to antibiotic resistance’. This is another way of stating the obvious: there are lots of other possible factors that could account for the observed association. As information on such data was unavailable, it could not be included in the statistical models.

While it is possible that air pollution is a factor linked to increased levels of antibiotic resistance, in the absence of experimental evidence to support this premise, it remains yet another factor to be considered and addressed, if possible, in the global fight to reduce the adverse outcomes associated with increased antibiotic resistance.

ERS: Air pollution shown to affect birthweight and level of childhood respiratory infections

18th September 2023

Three studies presented at the recent European Respiratory Society (ERS) International Congress in Milan, Italy, highlight the various damaging effects of air pollution in early childhood, including on birthweight and the incidence of respiratory infections.

According to a recent consensus statement from the European Respiratory Society on climate change, there is likely to be a disproportionately greater negative impact from global warming on individuals living with respiratory diseases such as asthma and chronic obstructive pulmonary disease (COPD).

One of the most important and detrimental consequences of climate change is the resulting increased levels of air pollution, which is already known to damage the lungs and have other negative consequences such as mental health issues in dementia.

Now, three related studies presented at the ERS International Congress have shed further light on the deleterious effect of air pollution. The studies reveal how pollution not only reduces the birthweight of newborns, but also increases the incidence of respiratory infections experienced by young children.

Effect on birthweight

In the first study (abstract PA311), researchers sought to investigate the association of maternal exposure to air pollution based on what they described as the level of environmental ‘greenness’ during pregnancy, and whether this affected birthweight.

They devised a measure of greenness termed the ‘normalised difference vegetation index‘ (NDVI), which was based on the density of vegetation seen on satellite images. In addition, the team modelled exposure to five known pollutants: nitrogen dioxide (NO2), ozone, black carbon (BC), and two types of particulate matter (PM2.5 and PM10). The levels of these pollutants were estimated for mothers based on their residential address during pregnancy.

The researchers analysed data on 5,434 children from 2,742 mothers. The median NDVI300m was 0.3 (interquartile range, IQR, 0.2 – 0.4). Increases in the level of greenness were positively associated with birthweight. For example, each IQR increase in NDVI300m was associated with an increase in birthweight of 29g, a 23% lower odds of a low birthweight (Odds ratio, OR = 0.77, 95% CI 0.64 – 0.94), as well as a 14% increased odds of a high birthweight (> 4000g) (OR = 1.14, 95% CI 1.02 – 1.26).

Commenting on the findings, lead author, Robin Mzati Sinsamala, a researcher in the department of global public health and primary care at the University of Bergen (UiB), Norway said: ‘The time when babies are growing in the womb is critical for lung development. We know that babies with lower birthweight are susceptible to chest infections, and this can lead on to problems like asthma and COPD later on.

‘Our results suggest that pregnant women exposed to air pollution, even at relatively low levels, give birth to smaller babies. They also suggest that living in a greener area could help counteract this effect. It could be that green areas tend to have lower traffic or that plants help to clear the air of pollution, or green areas may mean it’s easier for pregnant women to be physically active.’

Air pollution and respiratory infections

In the second study (abstract PA311), which was published in the journal Pediatric Pulmonology, a UK team from Sussex Medical School and University Hospitals Sussex NHS Foundation Trust sought to evaluate the effect of environmental factors on respiratory infections and symptoms in early childhood.

Researchers turned to data from the GO-CHILD prospective birth cohort study, which explored the role of environment and gene variation on infection and atopy-related outcomes. As part of the study, pregnant women were recruited and their children followed up for infection and respiratory symptoms and outcomes after 12 and 24 months via postal questionnaires.

Information was available for 1,344 children, and the researchers identified how several environmental factors and settings were significantly associated with respiratory infections. For example, use of daycare facilities was associated with a more than two-fold increased risk of pneumonia (odds ratio, OR = 2.39), wheeze (OR = 2.16) and a dry cough (OR = 2.01). There was also a higher risk of developing bronchiolitis (OR = 1.40).

The presence of visible damp in the home increased the risk of wheeze (OR = 1.85) and led to a two-fold increased risk of being prescribed an inhaled corticosteroid (Relative risk, RR = 2.61).

Air pollution also contributed to the risk of respiratory problems. The presence of dense traffic around the child’s home, increased the risk of bronchiolitis (OR = 1.32). However, it was found that the harmful effects of environmental pollution could be mitigated to some extent by measures such as breastfeeding. In fact, continuing to breastfeed beyond six months was associated with a significantly reduced odds of bronchiolitis (OR = 0.55).

Commenting on this study, lead author, Dr Tom Ruffles from the Sussex Medical School, said: ‘This research provides some important evidence about how we can help reduce chest infections in babies and toddlers. The benefits of breastfeeding are well-established, and we should continue to support mothers who want to breastfeed their babies. We should also be making every effort to reduce exposure to infections in daycare, keep homes free of damp and mould, reduce tobacco smoking and cut air pollution.’

Rural versus urban location

Finally, researchers in the third study (abstract PA2721), who were part of the Copenhagen Prospective Studies on Asthma in Childhood (COPSAC) based at Gentofte Hospital and the University of Copenhagen in Denmark, looked at the level of respiratory infections seen in children who had been born in either a rural or urban location.

Using the COPSAC2010 mother-child cohort, researchers followed the participants from pregnancy until three years of age and recorded whether the children were growing up in urban or rural areas and how many respiratory infections they developed. The researchers also performed an analysis of the airway immune profile in the children at age four weeks and undertook both maternal and child metabolomic profiling during week 24 of their pregnancy and two to three days after birth.

Among 663 children, the team found there was a mean of 16.3 infections, which were mainly respiratory in nature. Among children living in an urban area, there was a 15% higher risk of infections compared to those living in rural areas (adjusted incidence rate ratio = 1.15, 95% CI 1.05 – 1.26, p = 0.002).

Urbanisation resulted in a different airway immune profile and it was this change that increased the risk of infections, they concluded. Furthermore, urbanisation resulted in different maternal and child metabolomic profiles, which significantly increased the risk of infections.

Lead author for the study and COPSAC researcher and physician, Dr Nicklas Brustad, said: ‘Our findings suggest that urban living is an independent risk factor for developing infections in early life when taking account of several related factors such as exposure to air pollution and starting day care. Interestingly, changes in the blood of pregnant mothers and newborn babies, as well as changes in the newborn immune system, seem to partly explain this relationship.

‘Our results suggest that the environment children live in can have an effect on their developing immune system before they are exposed to coughs and colds. We continue to investigate why some otherwise healthy children are more prone to infections than others and what the implications are for later health.

‘We have several other studies planned that will look for risk factors and try to explain the underlying mechanisms using our large amount of data.’

Long-term exposure to higher road traffic noise linked to increased risk of hypertension

3rd April 2023

Exposure to higher road traffic noise over time is linked to a higher incidence of hypertension particularly if there is higher air pollution

In a prospective study, Chinese and UK researchers have found that long-term exposure to high levels of road traffic noise (RTN), especially when levels of air pollution are also increased, is associated with an increased risk for the development of hypertension.

Hypertension is the leading cause of cardiovascular disease and premature death worldwide with one estimate suggesting that 349 million in high-income countries are affected by the condition. While modification of lifestyle factors such as a reduced intake of sodium, stopping smoking and increased physical activity are an integral part of the overall management strategy for the disease, it has become recognised that road traffic noise exposure is associated with increased risk of premature arteriosclerosis, coronary artery disease, and stroke. Moreover, the World Health Organisation (WHO) has suggested that there is high quality evidence linking road traffic road and ischaemic heart disease. However, while the WHO has found evidence linking noise from air, road, or rail traffic with hypertension, they considered the quality of the supportive evidence to be ‘very low’. Although some data indicates that exposure to RTN increases both systolic and diastolic blood pressure, it remains uncertain if exposure might actually cause hypertension.

In the current study, researchers examined information held in the UK Biobank to evaluate the association between long-term RTN exposure with incident primary hypertension. The RTN level was estimated with common noise assessment methods and the development of hypertension through linkage with medical records.

Road traffic noise and incident hypertension

A total of 246,447 individuals with mean age of 55 years (54.6%) were included in the analysis. Over a median follow-up period of 8.1 years, there were 21,140 cases of incident primary hypertension recorded.

In fully adjusted models for continuous exposure to RTN, there was 7% increase in newly diagnosed hypertension per 10 dB [A] increment in the mean weighted average 24-hour road traffic noise level (hazard ratio, HR = 1.07, 95% CI 1.02 – 1.13). Interestingly, exposure to the highest level of RTN (> 65 db[A]), and the highest levels of air pollution, based on both fine particles and nitrogen dioxide, posed the greatest risk for incident hypertension (HR = 1.22 for fine particles, HR = 1.18 for nitrogen dioxide).

The authors concluded that long-term exposure to road traffic noise was associated with an increased incidence of primary hypertension and that this effect was stronger in presence of higher air pollution.

Huang J et al. Road Traffic Noise and Incidence of Primary Hypertension: A Prospective Analysis in UK Biobank. JACC Adv 2023

Higher ozone levels linked to increased risk of hospital admission for cardiovascular diseases

30th March 2023

Increased ozone pollution has been associated with an increased risk of hospital admission for a range of cardiovascular diseases

Higher atmospheric ozone levels have been linked to a greater risk of a hospital admission for a range of adverse cardiovascular events according to the findings of a time-series analysis by Chinese researchers.

Although there are a number of clearly recognised risk factors for cardiovascular disease, recent studies generally support positive associations of exposure to chemical environmental stressors such as air pollution, with an increased risk for cardiovascular mortality and morbidity. Moreover, some evidence points to adverse effects associated with exposure to ozone and which appears to affect several pathways associated with cardiovascular disease. In addition, other work found a statistically significant association between short-term changes in ozone and mortality for 95 large US urban communities. However, while these data link ozone with mortality, much less is known about the association between the gas and cardiovascular morbidity and for which, hospital admissions, could serve as a useful proxy.

In the current study, Chinese researchers undertook a multi-city, time-series study to explore the associations of exposure to ambient ozone with daily hospital admissions for cardiovascular diseases over a two-year period. The city-specific daily concentrations of 8-hour maximum average ozone (O3) and 24-hour average of O3 were obtained, together with data on both fine particles (PM2.5), inhaled particles (PM10), and other gases such as sulphur and nitrogen dioxide and carbon monoxide.

Ozone pollution levels and risk of hospital admissions for cardiovascular disease

During the two-year period, there were 6,444,441 hospital admissions for adverse cardiovascular events in the 70 cities included in the study.

The results showed that a 10 μg/m3 increment in the two-day average daily, 8-hour maximum ozone concentrations, was associated with an increased risk for admission of 0.46% for coronary heart disease, 0.45% for angina pectoris, 0.75% for acute myocardial infarction and 0.41% for ischaemic stroke.

In fact, the researchers also calculated the excess risk attributable to higher ozone levels and different adverse cardiovascular events. For example, that there was a 6.52% excess risk of an acute myocardial infarction (AMI) for a high O3 concentrations (≥100 μg/m3) compared to lower levels of < 70 μg/m3, which is considered to be naturally occurring level that is not due to human activity. Furthermore, the AMI risks were also elevated by 3.28% when ozone levels were ≥ 70 μg/m3 and 2.35% for levels between 70 and 99 μg/m3.

The authors concluded that ambient ozone was associated with increased risk of hospital admission for cardiovascular events and which was higher as levels of the gas increased. They added that these data should prompt the need for greater control of high ozone pollution.

Jiang Y et al. Ozone pollution and hospital admissions for cardiovascular events. Eur Heart J 2023