Health Report

Health Risk Assessment – Preliminary Work to
Identify Concentration-Response Functions for

Selected Ambient Air Pollutants
Report prepared for EPA Victoria
Bin Jalaludin
Christine Cowie
Respiratory and Environmental Epidemiology
Woolcock Institute of Medical Research
30 June 2012
1
Background
EPA Victoria wishes to identify health endpoints and relevant concentration-response

functions (CRFs) associated with exposure to particulate matter less than 10µg (PM10) and
2.5µg (PM2.5) in diameter, nitrogen dioxide (NO2), ozone (O3) and sulphur dioxide (SO2) in
ambient air. This preliminary work is expected to form the basis of an exposure assessment
and risk characterisation for a broader health risk assessment (HRA) project for the review of
the National Environment Protection (Ambient Air Quality) Measure.
Scope of the project
The scope of the consultancy was as follows:
1. All relevant health endpoints for PM10, PM2.5, NO2, O3 and SO2 to be identified.
2. For each health endpoint, the relevant associated CRF will be identified. In the first
instance, CRFs from Australian studies will be identified. If Australian studies are either
not available or not appropriate, then CRFs from international studies will be identified.
3. Health endpoints and associated CRFs to be identified solely from published reports,
systematic reviews and meta-analyses. The grey literature from the United Kingdom (for
example, Department of Health), United States (for example, US EPA), the European
Union, World Health Organization and Australia, and electronic databases (for example,
Medline, PubMed) will be searched for any published systematic reviews and meta-
analyses. Literature reviews, systematic reviews or meta-analyses of primary studies
will not be conducted.
4. Weight of evidence (WoE) assessments of primary studies will not be conducted. WoE
requires interpretation of findings from all epidemiological and toxicological studies (of
air pollutants in this instance) to form a considered opinion on the relevance and the
significance of the findings overall. It involves evaluating the quality of measurement
methods, size and power of study design, consistency of results across studies, and
biological plausibility of CRFs and statistical associations. Such WoE assessments are
beyond the scope of this consultancy. WoE outlined in reviews and reports identified
under point 3 above will be assessed.
5. Information on the availability of routinely collected baseline health data at the state or
national level where available will be provided.
2
Health effects of air pollution
Exposure to ambient air pollution has been linked to various health outcomes ranging from
small transient changes in the respiratory tract and impaired lung function, restricted
activity/reduced performance, emergency department visits and hospital admissions to
mortality. There is also now strong evidence that there are important effects on the
cardiovascular system. The most severe effects in terms of the overall health burden include
a significant reduction in life expectancy of the average population which is linked to long-
term exposure to high levels of particulate matter (PM). Documented health effects
associated with air pollution exposures are shown in the table below (WHO Europe 2000;
WHO Europe 2004).
Table: Health effects of ambient air pollution

Air pollutant Effects related to short-term Effects related to long-term exposure
exposure
Particulate matter  Lung inflammatory reactions  Increase in lower respiratory
symptoms
 Respiratory symptoms  Reductions in lung function in
children
 Adverse effects on the  Increase in chronic obstructive
cardiovascular system pulmonary disease
 Increased medication use  Reductions in lung function in
adults
 Increased hospitalisations  Reduction in life expectancy,
mainly due to cardiopulmonary
mortality and probably to lung
cancer
 Increased mortality
Ozone  Adverse effects on pulmonary  Reductions in lung function

function development
 Lung inflammatory reactions
 Adverse effects on the
respiratory system
 Increased medication use
 Increased hospitalisations
Nitrogen dioxide  Effects on pulmonary function,  Reduction in lung function

(an indicator of especially in asthmatics
traffic-related air
pollution)
 Increase in airway allergic  Increased probability of
inflammatory reactions respiratory symptoms
Sulphur dioxide  Effects on pulmonary function,  Probable reduction in life

especially in asthmatics expectancy
3
Brief overview of published health risk assessments and cost-benefit analyses
Health risk assessments (HRAs) are often undertaken to provide data for cost-benefit
analyses (CBAs).
The World Health Organisation has suggested that health outcomes that are potentially
relevant and should be considered in a HRA include the following (WHO Europe 2001):
Acute (short-term) outcomes

 Daily mortality
 Respiratory hospital admissions
 Cardiovascular hospital admissions
 Emergency room visits for respiratory and cardiac problems
 Primary care visits for respiratory and cardiac conditions
 Use of respiratory and cardiovascular medications
 Days of restricted activity
 Work absenteeism
 School days missed
 Self-medication
 Avoidance behaviour
 Acute symptoms
 Physiologic changes, for example, in lung function
Chronic (long-term) disease outcomes

 Mortality (in infants and adults) from cardiopulmonary disease
 Chronic respiratory disease incidence and prevalence (including asthma, chronic
obstructive pulmonary disease (COPD))
 Chronic change in physiologic function
 Lung cancer
 Chronic cardiovascular disease
Reproductive outcomes
 Pregnancy complications (including foetal death)
 Low birth weight
4
 Pre-term delivery
However, in reviewing existing guideline documents it is clear that evidence for some of
these outcomes is either inadequate or inconsistent, leading to difficulty in setting CRFs.
Where data are adequate, CRFs have been established. Often these have been location
specific with European agencies using data from European studies and the United States
Environmental Protection Agency (USEPA) using data from US studies. Occasionally, CRFs
have been chosen based on the results of one epidemiological study only. Reports of CBAs
of air pollutants provide a good source of information on CRFs and these have been
reviewed for this project.
A recent report summarised eight major CBAs (Jalaludin, Salkeld et al. 2009) from the USA
(US EPA 1999; US EPA 2004), Europe (Seethaler 1999; AEA Technology Environment
2005; DEFRA 2006), New Zealand (Fisher, Kjellstrom et al. 2005) and Australia (BTRE
2005; DEC 2005). The pollutants commonly evaluated in CBAs include PM10, PM2.5, O3, SO2,
NO2 and carbon monoxide (CO). There is good evidence and a broad epidemiological
literature to obtain CRFs for PM. While all of the eight CBAs assessed the effects of PM, four
of them (Seethaler 1999; BTRE 2005; DEC 2005; Fisher, Kjellstrom et al. 2005) used PM as
the only indicator of ambient air pollution for cost-benefit purposes. However, a concern is
that selecting only one ambient air pollutant as the main pollutant may underestimate the
magnitude of the health effects. Adding the health effect estimates of another air pollutant
not correlated with PM (for example, O3) can minimise the extent of this underestimation.
Some of the reviewed CBAs have used this approach.
However, other CBAs also quantified the health effects of other air pollutants, for example,
SO2, NO2 and CO, in addition to PM either in the main analysis or in sensitivity analyses. An
issue here is that ambient concentration of some of these air pollutants are highly correlated
making it difficult to separate out the effects of the individual pollutants. This is particularly
the case for PM and NO2, PM and SO2 (overseas) and also sometimes for NO2 and O3. It is
therefore thought that NO2 and SO2 might be markers or surrogates of the effects of PM
pollution and that they do not exert independent adverse effects on health. Therefore, simply
summing the health effects associated with each of the specific pollutants can lead to an
overestimation of the total health effects.
5
Some studies have used multi-pollutant models in their analyses in an attempt to distinguish
the independent effects of each pollutant. In general, they have found that the estimates for
the effects of PM pollution are robust and change minimally when pollutants such as NO2
and SO2 are added to the model. This implies that the majority of effects seen are likely to be
due to exposure to PM in ambient air rather than to the other pollutants. In Australian
studies, the effects of exposure to O3 have been similarly robust and independent of the
effects of other pollutants.
Therefore, in HRAs and CBAs, use is often made of a single index pollutant (or surrogate
pollutant) or alternatively two pollutants. This approach encompasses the majority of effects
of all other correlated pollutants, and avoids the issue of overestimation of effects. Currently,
the USEPA (US EPA 2011) and the European Commission (European Commission 2005)
focus only on PM and O3 in their HRAs, for these reasons. The recent CBA from the United
States (US EPA 2011) quantified and monetised health endpoints only for PM and O3 as
follows:
1. PM
a. Premature mortality (long-term exposure)
b. Chronic and acute bronchitis
c. Hospital admissions for cardiovascular disease and respiratory disease
d. Emergency department visits for asthma
e. Non-fatal heart attacks
f. Lower respiratory symptoms
g. Minor restricted activity days
h. Work loss days
i. Asthma exacerbations (asthmatic population)
j. Upper respiratory symptoms (asthmatic population)
k. Infant mortality
2. O3
a. Premature mortality (short-term exposure)
b. Hospital admissions for respiratory disease
c. Emergency department visits for asthma
d. Minor restricted activity days
e. School loss days
f. Outdoor worker productivity
6
Health effects associated with ambient air pollution are divided into two broad categories -
premature mortality and morbidity. For PM (PM10, PM2.5), there is an established association
with both long-term and short-term premature mortality. Only one CBA (DEFRA 2006)
quantified both the long-term and short-term premature mortality. The other CBAs only
quantified long-term premature mortality as any short-term mortality effects would be
captured in the long-term mortality effects. The other two key health effects quantified for PM
by all the CBAs were respiratory and cardiovascular hospital admissions.
Of the eight CBAs reviewed, four quantified the health effects associated with O3 (US EPA
1999; US EPA 2004; AEA Technology Environment 2005; DEFRA 2006). The most common
health effect quantified was respiratory hospital admissions. Two CBAs also quantified the
short-term effect of ozone on premature mortality (AEA Technology Environment 2005;
DEFRA 2006). Other health endpoints reported in at least two CBAs were emergency
department visits for asthma and minor restricted activity days, although at least for the latter
health outcome, quantification is based primarily on one study only.
Two CBAs quantified the effects of NO2 (US EPA 1999; DEFRA 2006) and SO2 (US EPA
1999; DEFRA 2006) and only one report quantified the effect of CO (US EPA 1999). For
NO2, the health effects that were quantified included respiratory and cardiovascular disease
hospital admissions and respiratory illness; for SO2 they included short-term mortality,
cardiovascular disease hospital admissions and respiratory illness; and, for CO they
included only respiratory and cardiovascular disease hospital admissions.
Brief overview of hazard assessment in Australia
In 2011, the National Environment Protection Council (NEPC) (National Environment

Protection Council 2011) recommended the following approach to hazard assessment::
 Human-based studies are preferred.
 Epidemiological studies, especially those representative of the general population

(including sensitive groups), should be used, if available. Controlled human exposure
studies should only be used for short-term health outcomes, when appropriate
epidemiological studies are not available. Toxicological studies should be used as
supporting evidence of biological plausibility and coherence of effect. When no
epidemiological human data are available, toxicological evidence can be used for
standard setting, with the appropriate application of uncertainty factors.
7
 Any clinically significant effect of air pollution should be considered adverse.
 Mortality should be considered as a critical health outcome.
 More sensitive health outcomes (for example, hospital admissions, emergency

department visits, exacerbation of asthma and other respiratory or cardiovascular
diseases and reversible decrements in lung function) should also be used where
CRFs are available. Particular attention should be paid to people with asthma, given
the high prevalence of asthma in the Australian population.
 Broader quality-of-life issues, such as work loss days and school absenteeism,
should be considered as health outcomes where data are available.
 Sensitive subpopulations within the general population should be taken into

consideration; they include children, older adults, people with existing respiratory and
cardiovascular disease, asthmatics, diabetics, and low socioeconomic groups.
 A non-threshold approach should be taken for the current criteria pollutants.
 CRFs obtained from meta-analyses or multi-city studies should be used, provided the
primary data are homogeneous. If significant heterogeneity is present, then CRFs for
single cities should be used, and risk assessed for the relevant cities for which data
are available.
 CRFs from well-conducted Australian studies are preferred. If high-quality Australian

data for a particular health outcome are not available, then CRFs from overseas
studies should be used provided the nature of the exposure and demographics of the
population are similar. If overseas data are used, then the uncertainties associated
with the use of the data need to be well documented.
When individual epidemiological studies are used to derive CRFs, the National Health and
Medical Research Council (National Health and Medical Research Council 2006)
recommends the following steps to assess the validity and usefulness of such studies:
8
 Step 1—Evaluate studies for internal validity: that is, the adequacy of study design
and the extent to which it has validly measured what it intends or purports to
measure.
 Step 2 —Evaluate studies for external validity: that is, determine whether the results
can be validly generalised, extrapolated or transferred to other settings (for example,
climatic, demographic, pollution sources and levels).
 Step 3 —Evaluate corroboration, contradiction and plausibility: that is, consider
whether the Bradford-Hill criteria may be useful here.
 Step 4 —Make a choice: that is, select the study or studies that best represent the
endpoint of most relevance for setting an air quality standard.
Methods used in this report
For this report, we have broadly followed the approach recommended by the NEPC
(National Environment Protection Council 2011). However, in view of the very short
timeframe for the completion of this report, we have adopted the following approach:
1. Only human epidemiological studies were considered. We have not considered

controlled human exposure studies and toxicological studies.
2. CRFs representative of the general population were selected where available.
3. Identification of relevant health endpoints and associated CRFs from published

reports, systematic reviews and meta-analyses from:
 United Kingdom (Committee on the Medical Effects of Air Pollutants 1998;
Committee on the Medical Effects of Air Pollutants 2007; Committee on the
Medical Effects of Air Pollutants 2009; Committee on the Medical Effects of
Air Pollutants 2010);
 United States (US EPA 2006; US EPA 2008; US EPA 2010; US EPA 2010;
US EPA 2010; US EPA 2011);
 European Commission (AEA Technology Environment 2005; European
Commission 2005);
 World Health Organization (WHO Europe 2000; WHO Europe 2003; WHO
Europe 2004); and,
 Australia (Curtin University of Technology 2009; Jalaludin, Salkeld et al.
2009).
9
4. Identification of relevant health endpoints and associated CRFs from individual
Australian studies if systematic reviews and meta-analyses of Australian studies
were not available.
5. Recommended CRFs from well-conducted Australian meta-analyses in the first

instance. If CRFs from well-conducted Australian meta-analyses are not available,
then CRFs from international reports are recommended. If CRFs from Australian
meta-analyses and international reports are not available, then CRFs from individual
Australian studies are recommended if appropriate.
For each of the air pollutants, we have tabulated the available health endpoints and
associated CRFs. We have also provided references of the source reports and original
publications from where the health endpoints and CRFs were derived. Finally, we have
recommended CRFs that could be used for HRAs in the Australian context.
There may be assumptions and uncertainties associated with each of the health endpoints
and CRFs. We therefore recommend that those who wish to use the health endpoints and
associated CRFs also seek out the original reports and publications. CRFs derived from
single studies (not meta-analyses or multi-city studies) or single locations should be used
with caution as they may not be representative of the larger population.
CRFs for the five air pollutants are presented in Tables 1-5.
Availability of health outcome data
We have reported on the availability of relevant Australian health outcome data deemed
useful for HRAs and CBAs (presented in Table 6). Relevant morbidity data will need to be
accessed via each state health agency. While the Australian Institute of Health & Welfare
does collate state data for some health outcomes, in most cases they will not be available to
external users in the format required. Mortality data are available from the Australian Bureau
of Statistics. Application to all agencies is necessary and for state agencies the timeframe for
receipt of data may vary from a few weeks to a few months.
REFERENCES
10
AEA Technology Environment (2005). Methodology for the cost-benefit analysis for CAFE: Volume
2: Health impact assessment. Oxon, UK, AEA Technology Environment.
BTRE (2005). Health impacts of transport emissions in Australia: economic costs. Working Paper 63.
Canberra, Bureau of Transport and Regional Economics, Department of Transport and
Regional Services, Commonwealth of Australia.
Committee on the Medical Effects of Air Pollutants (1998). Quantification of the effects of air
pollution on health in the United Kingdom. London, Department of Health, United Kingdom.
Committee on the Medical Effects of Air Pollutants (2007). The effects of long-term exposure to
ozone. London, Department of Health, UK.
Committee on the Medical Effects of Air Pollutants (2009). Long-term exposure to air pollution:
effect on mortality. London, Department of Health, UK.
Committee on the Medical Effects of Air Pollutants (2010). The mortality effects of long-term
exposure to pariculate air pollution in the United Kingdom. London, Department of Health,
UK.
Curtin University of Technology (2009). Review of the health effects of specific air pollutants
Canberra, Report Commissioned by the Australian Government Department of Health and
Ageing.
DEC (2005). Air Pollution Economics: Health Costs of Air Pollution in the Greater Sydney
Metropolitan Region. Sydney, Department of Environment and Conservation, NSW.
DEFRA (2006). An Economic Analysis to Inform the Air Quality Strategy Review Consultation.
London, UK, Department for Environment, Food and Rural Affair.
European Commission (2005). ExternE. Externalities of Energy: Methodology 2005 Update. P.

Bickel and R. Friedrich, Luxemburg, European Commission.
Fisher, G., T. Kjellstrom, et al. (2005). Health and Air Pollution in New Zealand: Christchurch Pilot
Study, Health Research Council, Ministry for the Environment, Ministry of Transport, New
Zealand.
Jalaludin, B., G. Salkeld, et al. (2009). A methodology for cost-benefit analysis of ambient air
pollution health impacts. Canberra, Australian Government Department of the Environment,
Water, Heritage and the Arts, Commonwealth of Australia: 314.
National Environment Protection Council (2011). Methodology for setting air quality standards in
Australia. Part A. Adelaide, Commonwealth of Australia.
National Health and Medical Research Council (2006). Ambient air quality standards setting. An
approach to health-based hazard assessment. Canberra, Australian Government.
11
Seethaler, R. (1999). Health Costs due to Road Traffic-related Air Pollution. Bern, Federal
Department of Environment, Transport, Energy and Communications; Bureau for Transport
Studies, Switzerland.
US EPA (1999). The Benefits and Costs of the Clean Air Act 1990 to 2010. Washington, DC, United
States Environmental Protection Agency.
US EPA (2004). Final Regulatory Analysis: Control of Emissions from Nonroad Diesel Engines.
Washington, DC, United States Environmental Protection Agency.
US EPA (2006). Regulatory impact analysis. National Ambient Air Quality Standards for particle
pollution, Research Triangle Park, North Carolina.
US EPA (2008). Final ozone National Ambient Air Quality Standards regulatory impact analysis,
Office of Air Quality Planning and Standards, Research Triangle Park, North Carolina: 558.
US EPA (2010). Final Regulatory Impact Analysis (RIA) for the NO2 National Ambient Air Quality
Standards (NAAQS), Office of Air Quality Planning and Standards, U.S. Environmental
Protection Agency, North Carolina, USA: 155.
US EPA (2010). Final Regulatory Impact Analysis (RIA) for the SO2 National Ambient Air Quality
Standards (NAAQS), Office of Air Quality Planning and Standards, U.S. Environmental
Protection Agency, Research Triangle Park, NC, USA: 189.
US EPA (2010). Quantitative Health Risk Assessment for Particulate Matter, Health and
Environmental Impacts Division, US Environmental Protection Agency, NC, USA: 596.
US EPA (2011). The benefits and costs of the Clean Air act from 1990 to 2020, U.S. Environmental
Protection agency, USA.
WHO Europe (2000). Air quality guidelines for Europe: second edition. Copenhagen, WHO Regional
Office for Europe.
WHO Europe (2001). Quantification of the heatlh effects of exposure to air pollution: report of a
WHO working group Bilthoven, Netherlands 20-22 November 2000. Copenhagen, WHO
Regional Office for Europe.
WHO Europe (2003). Health aspects of air pollution with particulate matter, ozone and nitrogen
dioxide: report on a WHO working group. Bonn, Germany, WHO: 98.
WHO Europe (2004). Health aspects of air pollution. Results from the WHO project "Systematic
review of health aspects of air pollution in Europe". Copenhagen, World Health Organization.
WHO Europe (2004). Meta-analysis of time-series studies and panel studies of Particulate Matter
(PM) and Ozone (O3). Report of a WHO task group. Copenhagen, World Health
Organization.
12
Table 1: PM2.5 health endpoints and associated concentration-response functions
Concentration-response function (95%CI)
Health outcomes Australian UK Europe US EPA WHO Recommended
Long-term outcomes (annual average concentration)

Mortality
All cause n/a1 1.06 (1.04-1.11) per 1.05 per 10 µg/m3 1.06 (1.04-1.08) per 1.14 (1.04-1.24) per Recommended
10 µg/m3 (95%CI not 10 µg/m3 10 µg/m3 CRF: 1.06 (1.04-
provided) (Krewski, Jerrett et (Dockery, Pope et 1.08) per 10 µg/m3
1.06 (1.00-1.15) per Pooled estimate al. 2009) al. 1993) (Krewski, Jerrett et
10 µg/m3 to be used from (Pope, Burnett (US EPA 2010) (WHO Europe 2000) al. 2009)
in a sensitivity et al. 2002) All ICD9 Age: 30+ years (US EPA 2010)
analysis. (European Age: 30+years.
(Pope, Burnett et al. Commission 2005) 1.07 (1.04-1.11) per
2002) Age: 30+years. 10 µg/m3
(Committee on the (Pope, Thun et al.
Medical Effects of 1995)
Air Pollutants 2009) (WHO Europe 2000)
Age: 30+ years. Age: 30+years.
Cardiopulmonary n/a 1.09 (1.03-1.16) n/a 1.14 (1.11-1.17 per n/a Recommended
per 10 µg/m3 10 µg/m3 CRF: 1.14 (1.11-
(Pope, Burnett et al. (Krewski, Jerrett et 1.17 per 10 µg/m3
2002) al. 2009) (Krewski, Jerrett et
(Committee on the (US EPA 2010) al. 2009)
Medical Effects of ICD9: 401-440, 460- (US EPA 2010)
Air Pollutants 2009) 519
Age: 30+ years. Age: 30+ years.
Ischaemic heart n/a n/a n/a 1.24 (1.19-1.28) per n/a Recommended
disease 10 µg/m3 CRF: 1.24 (1.19-
(Krewski, Jerrett et 1.28) per 10 µg/m3
13
al. 2009) (Krewski, Jerrett et

(US EPA 2010) al. 2009)
ICD9: 410-414 (US EPA 2010)
Age: 30+ years.
Lung cancer n/a 1.08 (1.01-1.16) n/a 1.14 (1.06-1.123) n/a Recommended
per 10 µg/m3 per 10 µg/m3 CRF: 1.14 (1.06-
(Pope, Burnett et al. (Krewski, Jerrett et 1.123) per 10 µg/m3
2002) al. 2009) (Krewski, Jerrett et
(Committee on the (US EPA 2010) al. 2009)
Medical Effects of ICD9: 162 (US EPA 2010)
Air Pollutants 2009) Age: 30+ years.
Age: 30+ years.
Infant (<12 months n/a n/a n/a 1.07 (0.93-1.24) for n/a Recommended
of age) 10 µg/m3 CRF: 1.07 (0.93-
(Woodruff, Parker et 1.24) for 10 µg/m3
al. 2006) (Woodruff, Parker et
(US EPA 2006) al. 2006)
All ICD9 (US EPA 2006)
Age: <12 months
Life expectancy lost n/a 6 months of life 6.02E-04 YOLL/ n/a n/a Recommended
(years of life lost; expectancy lost in (person/year/µg/m3) CRF: 6.02E-04
YOLL) the UK at current (Leksell and Rabl YOLL/
levels of 2001) (person/year/µg/m3)
anthropogenic PM2.5 (European (Leksell and Rabl
(~9 µg/m3) Commission 2005) 2001)
(Committee on the (European
Medical Effects of Commission 2005)
Air Pollutants 2010)
Morbidity
14
Incidence of chronic n/a n/a Chronic bronchitis: COPD: Chronic bronchitis: Recommended CRF
obstructive 1.181 (0.98-3.25) 1.81 (0.98-3.25) per 1.34 (0.94-1.99) per for COPD: 1.81
pulmonary disease per 45 µg/m3 10 µg/m3 10 µg/m3 (0.98-3.25) per 10
(COPD) or chronic OR (Abbey, Hwang et (Dockery, µg/m3
bronchitis 1.141 (0.996-1.30) al. 1995) Cunningham et al. (Abbey, Hwang et
per 10 µg/m3 (US EPA 2006) 1996) al. 1995)
(Abbey, Lebowitz et Age: >26 years (WHO Europe 2000) (US EPA 2006)
al. 1995) ?Age Age: >26 years
(European
Commission 2005) Chronic bronchitis:
Adults (27+ years) No CRF
with cough or recommended.
sputum on most
days for at least
three months of the
year for at least two
years.
Incidence of asthma Ever had wheezing: n/a n/a n/a n/a No CRF
No effect. recommended.
Ever had asthma:
No effect. No effect in
(Williams, Marks et Australian 6-cities
al. 2012) study (Williams,
Six cities – Marks et al. 2012).
Adelaide, Brisbane,
Canberra,
Melbourne, Perth,
Sydney.
Average hourly.
PM2.5 over lifetime.
Age: mean age10.0
years.
15
2,860 children.
Recent symptoms No effect for asthma n/a n/a n/a n/a Recommended CRF
(in last 12 months) exacerbation, only for rhinitis
wheeze, cough or (Williams, Marks et
shortness of breath. al. 2012).
(Bennett, Simpson
et al. 2007) No effect for other
Melbourne symptoms in
N=1,446 Australian 6-cities
Mean age: 37 study (Williams,
years. Marks et al. 2012).
12-month average.
No effect for
wheeze, wheeze
after exercise,
current asthma, use
of bronchodilators,
cough, visit to
doctor/hospital,
rhinitis and itchy
rash in single
pollutant models.
Increased risk for

rhinitis in 2-pollutant
model with O3: 1.26
(1.04-1.53) per 2.16
µg/m3
(Williams, Marks et
al. 2012)
Six cities –
Adelaide, Brisbane,
16
Canberra,
Melbourne, Perth,
Sydney.
Average hourly.
Age: mean age10.0
years.
2,860 children.
Lung function n/a n/a n/a n/a n/a No CRF

growth recommended.
Change in forced No effect n/a n/a n/a n/a No CRF

expiratory volume in (Williams, Marks et recommended.
1 second (FEV1; al. 2012)
litres) Six cities – No effect in
Adelaide, Brisbane, Australian 6-cities
Canberra, study (Williams,
Melbourne, Perth, Marks et al. 2012).
Sydney.
Average hourly.
Age: mean age10.0
years.
2,860 children.

vital capacity (FVC; (Williams, Marks et recommended.
litres) al. 2012)
Six cities – No effect in
17
Sydney.
Average hourly.
Age: mean age10.0
years.
2,860 children.
Airway inflammation No effect n/a n/a n/a n/a No CRF

(Williams, Marks et recommended.
al. 2012)
Sydney.
Average hourly.
Age: mean age10.0
years.
2,860 children.
Birth outcomes
Birth defects n/a n/a n/a n/a n/a No CRF

recommended.
Prematurity 1.09 (0.97–1.23) per n/a n/a n/a n/a No CRF

10 Mm-1 bsp in first recommended.
trimester
Inconsistent results
0.95 (0.85–1.06) per from 2 Australian
8.2 Mm-1 bsp in last studies.
90 days before birth
18
(Hansen, Neller et
al. 2006)
Preterm: <37 weeks
gestation.
Brisbane
1.426 (1.264–1.608)
per 1 µg/m3
(Jalaludin, Mannes
et al. 2007)
Sydney
Preterm: <37 weeks
gestation.
First trimester.
Winter season.
Low birth weight No effect of bsp on n/a n/a n/a n/a No CRF
birth weight or small recommended.
for gestational age
(<10th centile for Inconsistent results
age and gender) from 2 Australian
(Hansen, Neller et studies.
al. 2007)
Brisbane
1.03 (1.01-1.05) for

small for gestational
age (<2 standard
deviations for age
and gender) per 1
µg/m3
Second trimester
-4.10 grams (-6.79

19
to -1.41 grams) per

1 µg/m3
Second trimester
(Mannes, Jalaludin
et al. 2005)
Sydney
Short-term outcomes (daily average concentration)

Mortality
Non-trauma No effect. n/a n/a 0.98% (0.75 to 1.00339 (0.99150- Recommended

(Simpson, Williams 1.22%) per 10 µg/m3 1.01542) per 10 CRF: 0.9% (0.2-
et al. 2005) (Zanobetti and µg/m3 1.6%) per 3.78
Pooled CRF from 3 Schwartz 2009) (Anderson, Bremner µg/m3 (Environment
cities (Sydney, (US EPA 2010) et al. 2001) Protection and
Perth, Melbourne) ICD10: A00-R99 (WHO Europe 2004) Heritage Council
ICD9: <800; ICD10: All ages 1 study only 2005).
A-R, Z35.5, Z35.8 ICD9: <800
Age: All All ages
0.9% (0.2-1.6%) per 1.015 (1.011-1.019)

3.78 µg/m3 per 10 µg/m3
(Environment (WHO Europe 2000)
Protection and ?ICD codes
Heritage Council ?All ages
2005)
24-hour average.
Lag 01.
Age: All ages.
All year.
Low heterogeneity.
Meta-analysis of 4
20
cities - Brisbane,
Melbourne, Perth
Sydney.
ICD9: <800; ICD10:
A-R, Z35.5, Z35.8
Cardiovascular 1.0439 (1.0090- 1.4% (0.7-2.2%) per n/a 0.85% (0.46 to 1.00507 (0.98808- Recommended
1.0800) increase 10 µg/m3 1.25%) per 10 µg/m3 1.02236) per 10 CRF: 1.5% (0.7-
per 1 unit bsp (10- (Committee on the (Zanobetti and µg/m3 2.3%) per 3.78
4
.m-1) Medical Effects of Schwartz 2009) (Anderson, Bremner µg/m3 (Environment
(Simpson, Williams Air Pollutants 2006) (US EPA 2010) et al. 2001) Protection and
et al. 2005) 9 studies ICD10: I01-I59 (WHO Europe 2004) Heritage Council
Pooled CRF from 4 ICD9: 390-459 Ages: All ages. 1 study only 2005).
cities (Sydney, All ages. ICD9: 390-459
Perth, Melbourne, Age: All ages.
Brisbane)
ICD9: 390-459
ICD10: I00-I99
(excluding I67.3,
I68.0, I88, I97.8,
I97.9, I98.0), G45
(excluding G45.3),
G46, M30, M31,
R58
Age: All ages.
Lag 1 24-hour bsp.
1.5% (0.7-2.3%) per

3.78 µg/m3
(Environment
Protection and
Heritage Council
2005)
24-hour average.
21
Lag 01.
Age: All ages.
All year.
No heterogeneity.
Meta-analysis of 4
cities - Brisbane,
Melbourne, Perth
Sydney.
ICD9: 390-459
ICD10: I00-I99
(excluding I67.3,
I68.0, I88, I97.8,
I97.9, I98.0), G45
(excluding G45.3),
G46, M30, M31,
R58
Respiratory 1.0948 (1.0174- n/a n/a 1.68% (1.04 to 0.99943 No CRF

1.1781) increase 2.33%) per 10 µg/m3 ( 0.96912- 1.03069) recommended.
per 1 unit bsp (10- (Zanobetti and per 10 µg/m3
4
.m-1) Schwartz 2009) (Anderson, Bremner No effect in
(Simpson, Williams (US EPA 2010) et al. 2001) Australian 4- cities
et al. 2005) ICD10: J00-J99 (WHO Europe 2004) studies
Pooled CRF from 4 Age: All ages. 1 study only (Environment
cities (Sydney, ICD9: 460-519 Protection and
Perth, Melbourne, Age: All ages. Heritage Council
Brisbane) 2005)
ICD9: 460-519
ICD10: J00-J99 May use CRF from
(excluding J95.4 to Zanobetti et al
J95.9), R09.1, (Zanobetti and
R09.8 Schwartz 2009)
Age: All ages. In a sensitivity
Lag 1 24-hour bsp. analysis.
22
No effect
(Environment
Protection and
Heritage Council
2005)
24-hour average.
Lag 01.
Age: All ages.
All year.
No heterogeneity.
Meta-analysis of 4
cities - Brisbane,
Melbourne, Perth
Sydney.
ICD9: 460-519
ICD10: J00-J99
(excluding J95.4 to
J95.9), R09.1,
R09.8
Hospitalisation
Cardiovascular 15-64 years: No n/a n/a 0.80% (0.59-1.10%) n/a Recommended

effect per 10 µg/m3 CRF:
65+ years: 1.3% (Bell, Ebisu et al. 65+ years: 1.3%
(0.6-2.0) increase 2008) (0.6-2.0) increase
per 3.78 µg/m3 (US EPA 2010) per 3.78 µg/m3
(Environment ICD9: 426-428, 430- (Environment
Protection and 438,410-414, 429, Protection and
Heritage Council 440-449 Heritage Council
2005) Age: 65-99 years 2005).
24-hour average.
Lag 01.
23
Moderate
heterogeneity for
65+ years.
Meta-analysis of 4
cities - Brisbane,
Melbourne, Perth
Sydney.
ICD9: 390-459;
ICD10: I00–I99
(excluding I67.3,
I68.0, I88, I97.8,
I97.9, I98.0),
G45 (excluding
G45.3), G46, M30,
M31, R58
Cardiac 5.1% (3.5-6.7% per n/a n/a n/a n/a Recommended

10 µg/m3 CRF:
(Environment 65+ years: 1.9%
Protection and (1.0-2.7%) increase
Heritage Council per 3.78 µg/m3
2005) (Environment
(Simpson, Williams Protection and
et al. 2005) Heritage Council
Pooled estimate 2005).
from 3 cities -
Sydney, Melbourne, May use the CRF
Perth. from Simpson et al
lCD9: 390-429; (Simpson, Williams
ICDI0: I00-I52, et al. 2005) in a
I97.0, I97.1, I98.1 sensitivity analysis.
Age: All ages.
1-hour maximum.
24
15-64 years: No
effect
65+ years: 1.9%
(1.0-2.7%) per 3.78
µg/m3
(Environment
Protection and
Heritage Council
2005)
24-hour average.
Lag 01.
Moderate
heterogeneity for
65+ years.
Meta-analysis of 4
cities - Brisbane,
Melbourne, Perth
Sydney.
lCD9: 390-429;
ICDI0: I00-I52,
I97.0, I97.1, I98.1
Cardiac failure 15-64 years: No n/a n/a n/a n/a Recommended

effect CRF:
65+ years: 3.6% 65+ years: 3.6%
(1.8-5.4%) per 3.78 (1.8-5.4%) increase
µg/m3 per 3.78 µg/m3
24-hour average. (Environment
Lag 01. Protection and
Moderate Heritage Council
heterogeneity for 2005).
65+ years.
Meta-analysis of 4
cities - Brisbane,
25
Melbourne, Perth
Sydney.
ICD9: 428; ICD10:
I50
Cerebrovascular Stroke: n/a n/a n/a n/a No CRF

15-64 years: No recommended.
effect
65+ years: No effect No effect in
(Environment Australian 4-cities
Protection and meta-analysis
Heritage Council (Environment
2005) Protection and
24-hour average. Heritage Council
Lag 01. 2005).
Low heterogeneity.
Meta-analysis of 4
cities - Brisbane,
Melbourne, Perth
Sydney.
ICD9: 430-438;
ICD10: I60-I66, I67
(excluding I67.0,
I67.3), I68
(excluding I68.0),
I69, G45 (excluding
G45.3), G46
Ischaemic heart 15-64 years: No n/a n/a n/a n/a Recommended

disease effect CRF:
65+ years: 1.6% 65+ years: 1.6%
(0.7-2.4%) per 3.78 (0.7-2.4%) increase
(Environment (Environment
26
Protection and Protection and

Heritage Council Heritage Council
2005) 2005).
24-hour average.
Lag 01.
Low heterogeneity.
Meta-analysis of 4
cities - Brisbane,
Melbourne, Perth
Sydney.
ICD9: 410-413;
ICD10: 120-122,
124, 125.2
Arrhythmia 15-64 years: No n/a n/a n/a n/a No CRF

effect. recommended.
65+ years: No
effect. No effect in
24-hour average. Heritage Council
Lag 01. 2005).
Low heterogeneity.
Meta-analysis of 4
cities - Brisbane,
Melbourne, Perth
Sydney.
ICD9: 437; ICD10:
I46-I49
Myocardial infarction 15-64 years: No n/a n/a n/a n/a Recommended

effect. CRF:
27
65+ years: 2.7% 65+ years: 2.7%

(1.3-4.2%) per 3.78 (1.3-4.2%) increase
2005) 2005).
24-hour average.
Lag 01.
Low heterogeneity
for 65+ years.
Meta-analysis of 4
cities - Brisbane,
Melbourne, Perth
Sydney.
lCD9: 410; ICDI0:
I21, I22
Respiratory 1.0401 (1.0045- n/a n/a No effect. 0-14 years: No Recommend CRF:
1.0770) increase (Bell, Ebisu et al. effect. CRFs from
per 1 unit bsp (10- 2008) 15-64 years: Australian 4-cities
4
.m-1) (US EPA 2010) No effect. meta-analysis
(Simpson, Williams ICD9: 490-492, 463- 65+ years: (Environment
et al. 2005) 466, 480-487 No effect. Protection and
Pooled CRF from 4 Age: 65-99 years. (Anderson, Bremner Heritage Council
cities - Sydney, et al. 2001) 2005).
Perth, Melbourne, 2.07% (1.2-2.95%) (WHO Europe 2004)
Brisbane. per 10 µg/m3 1 study only
ICD9: 460-519; (Zanobetti and ICD9: 460-519.
ICD10: J00-J99 Schwartz 2009) Age: All ages.
(excluding J95.4 to (Abt Associates Inc
J95.9), R09.1, 2011)
R09.8 ICD9: 460-519
Age: 65+ years. Age: 65-99 years.
28
24-hour bsp. 2-day average

Lag 1.
0 year: 2.4% (1.0-

3.8%) increase per
3.78 µg/m3
1-4 years: 1.7%
(0.7-2.7%) increase
per 3.78 µg/m3
5-14 years: No
effect
15-64 years: 1.1%
(0.0-2.1%) increase
per 3.78 µg/m3
65+ years: 1.6%
(0.9-2.3%) increase
per 3.78 µg/m3
(Environment
Protection and
Heritage Council
2005)
24-hour average.
Lag 01.
Low heterogeneity.
Meta-analysis of 4
cities - Brisbane,
Melbourne, Perth
Sydney.
ICD9: 460-519;
ICD10: J00-J99
(excluding J95.4 to
J95.9),
R09.1, R09.8
29
Asthma 1.0893 (1.0240- n/a n/a 1.04 (1.01-1.06) per n/a Recommend CRF:
1.1587) increase 11.8 µg/m3 CRFs from
per 1 unit bsp (10- (Sheppard 2003) Australian 4-cities
4
.m-1) (Abt Associates Inc meta-analysis
(Simpson, Williams 2011) (Environment
et al. 2005) Age: 0-64 years Protection and
Pooled CRF from 4 ICD9 493 Heritage Council
cities (Sydney, 2005).
Perth, Melbourne,
Brisbane)
ICD9: 493; ICD10:
J45, J46, J44.8
Age: 15-64 years.
Lag 3 24-hour bsp.
0 year: not
calculated due to
uncertain diagnosis.
1-4 years: No effect.
5-14 years: No
effect.
15-64 years: 2.2%
(0.7-3.6%) per 3.78
µg/m3.
65+ years: No
effect.
(Environment
Protection and
Heritage Council
2005)
24-hour average.
Lag 01.
Moderate
heterogeneity for
30
15-64 years.
Meta-analysis of 4
cities - Brisbane,
Melbourne, Perth
Sydney.
ICD9: 493; ICD10:
J45, J46, J44.8
Chronic obstructive 15-64 years: No n/a n/a n/a n/a Recommend CRF:
pulmonary disease effect CRF for 65+ years
(COPD) 65+ years: 1.6% from Australian 4-
(0.6-2.7%) per 3.78 cities meta-analysis
µg/m3 (Environment
(Environment Protection and
Protection and Heritage Council
Heritage Council 2005).
2005)
24-hour average.
Lag 01.
Moderate
heterogeneity for
15-64 years.
Meta-analysis of 4
cities - Brisbane,
Melbourne, Perth
Sydney.
lCD9: 490-492, 494-
496; ICDI0: J40-
J44, J47, J67
Pneumonia and 0 years: 1.0% (0.0- n/a n/a n/a n/a Recommend CRF:
acute bronchitis 3.4%) per 3.78 CRFs from
µg/m3 Australian 4-cities
1-4 years: 2.4% meta-analysis
31
(0.1-4.7%) per 3.78 (Environment

µg/m3 Protection and
15-64 years: No Heritage Council
effect 2005).
65+ years: 2.0%
(0.8-3.2%) per 3.78
µg/m3
(Environment
Protection and
Heritage Council
2005)
24-hour average.
Lag 01.
Moderate
heterogeneity for
15-64 years.
Meta-analysis of 4
cities - Brisbane,
Melbourne, Perth
Sydney.
ICD9: 466, 480-486;
ICD10: J12-J17,
J18.0, J18.1, Jl8.8,
JI8.9, J20, J21
Emergency department visits
Asthma 1.4% (0.9-1.8%) n/a n/a 1.0045 (1.0029- n/a Recommended

increase per 9.4 1.0062) per 1 µg/m3 CRF: 1.4% (0.9-
µg/m3 (Ito, Thurston et al. 1.8%) increase per
(Jalaludin, Khalaj et 2007) 9.4 µg/m3
al. 2008) (US EPA 2010) (Jalaludin, Khalaj et
Sydney. ICD9: 493 al. 2008)
ICD9: 493. Age: All ages.
32
Age: 1-14 years. 24-hour average. May use CRF from

New York. Ito et al (Ito,
Thurston et al.
2007) in a sensitivity
analysis.
Respiratory disease n/a n/a n/a 1.00046 (0.99954- n/a No CRF

1.00136) per 1 recommended.
µg/m3
(Tolbert, Klein et al. May use CRF from
2007) Tolbert (Tolbert,
(US EPA 2010) Klein et al. 2007)
Age: All ages. in a sensitivity
24-hour average. analysis as the CRF
Atlanta. is close to being
ICD9: 491-493, statistically
786.07, 786.09, significant. Note that
496, 460-465, respiratory disease
460.0, 477, 480- ICD codes include
486, 466.1, 466.11, asthma.
466.19
Cardiovascular n/a n/a n/a 1.00046 (0.99936- n/a No CRF

disease 1.00154) per 1 recommended.
µg/m3
(Tolbert, Klein et al. May use CRF from
2007) Tolbert (Tolbert,
(US EPA 2010) Klein et al. 2007)
All ages. in a sensitivity
24-hour average. analysis as the CRF
Atlanta. is close to being
ICD9: 410-414, 427- statistically
428, 433-437, 440, significant.
443-445, 451-453
33
Incidence of myocardial infarction (heart attacks)
Non-fatal heart n/a n/a n/a 1.62 (1.13-2.34) per n/a Recommended
attacks 20 µg/m3 CRF: 1.62 (1.13-
(24-hr PM) (Peters, Dockery et 2.34) per 20 µg/m3
al. 2001) (Peters, Dockery et
(US EPA 2006) al. 2001)
Age: 18+ years
ICD9: 410
Lung function
Change in forced No effect n/a n/a n/a -1.9% (-3.1 to No CRF

expiratory volume in (Williams, Marks et -0.6%) per 10 µg/m3 recommended.
1 second (FEV1; al. 2012) (Raizenne, Neas et
litres) Six cities – al. 1996) No effect in
Adelaide, Brisbane, Children Australian 6-cities
Sydney.
Age: mean age 10.0
years.
270 children with
current asthma.
Change in peak No effect of bsp. n/a n/a n/a n/a No CRF

expiratory flow rate (Rutherford, recommended.
(PEF; litres per Simpson et al.
minute) 2000) No effect in
Brisbane and Australian 6-cities
Ipswich study (Williams,
Mixed-models Marks et al. 2012).
34
Age: All
(n=53)
History of allergy to
pollen or fungi on
skin prick testing
No effect.
(Williams, Marks et
al. 2012)
Six cities –
Adelaide, Brisbane,
Canberra,
Melbourne, Perth,
Sydney.
Age: mean age 10.0
years.
270 children with
current asthma.
Minor morbidity
Asthma n/a n/a n/a n/a n/a No CRF

exacerbation (not reported in Abt recommended.
Associates 2011
or in USEPA 2006)
Pooled estimate
from Vedal 1998
and Ostro 2001
(US EPA 2006)
Age: 6-18 years
Increased airway n/a n/a n/a n/a n/a No CRF

hyper- recommended.
35
responsiveness
Restricted activity n/a n/a 0.475% (0.417- n/a n/a Recommended

days (RAD)2 0.533%) per 1 CRF: 0.475%
μg/m3 (0.417-0.533%) per
(Ostro 1987) 1 μg/m3 PM2.5
(European (Ostro 1987)
Commission 2005) (European
Age: 15-64 years. Commission 2005)
In a sensitivity
analysis, all ages
used.
Minor restricted n/a n/a 0.74% (0.60-0.88%) 1.0769 (1.0622- n/a Recommended
activity days per 1 μg/m3 1.0918) per 10 CRF: 1.0769
(MRAD)3 (Ostro and μg/m3 (1.0622-1.0918) per
Rothschild 1989) (Ostro and 10 μg/m3
(European Rothschild 1989) (Ostro and
Commission 2005) (US EPA 2006) Rothschild 1989)
Age: 18-64 years. Age: 18-64 years. (US EPA 2006)
Work lost days n/a n/a 0.46% (0.39-0.53%) 1.0471 (1.0397- n/a Recommended
(WLD)2 per 1 μg/m3 1.0545) per 10 CRF: 1.0471
(Ostro 1987) μg/m3 (1.0397-1.0545) per
(European (Ostro 1987) 10 μg/m3
Commission 2005) (US EPA 2006) (Ostro 1987)
CAFE CBA 2005 Age: 18-64 years. (US EPA 2006)
Age: 15-64 years.
Acute bronchitis n/a n/a n/a 1.5 (0.91-2.47) per n/a Recommended
(incidence, 8-12 14.9 µg/m3 CRF: 1.5 (0.91-
years) (Dockery, 2.47) per 14.9 µg/m3
Cunningham et al. (Dockery,
36
1996) Cunningham et al.

(US EPA 2006) 1996)
Annual average. (US EPA 2006)
Lower respiratory n/a n/a n/a 1.33 (1.11-1.58) per n/a Recommended
symptoms 15 µg/m3 CRF: 1.33 (1.11-
(Schwartz and Neas 1.58) per 15 µg/m3
2000) (Schwartz and Neas
(US EPA 2006) 2000)
Age: 7-14 years. (US EPA 2006)
Acute respiratory n/a n/a n/a n/a n/a No CRF

symptoms recommended.
Wheeze No effect. n/a n/a Only for African- n/a No CRF

Rodriguez 2007 American children recommended.
Age: 0-5 years. (Ostro, Lipsett et al.
Perth. 2001) No effect in
1-hour maximum. (Abt Associates Inc Australian 6-cities
2011) study (Williams,
No effect. Marks et al. 2012).
(Williams, Marks et
al. 2012)
Six cities –
Adelaide, Brisbane,
Canberra,
Melbourne, Perth,
Sydney.
Age: mean 10.0
years.
270 children with
current asthma.
37
Cough 1.006 (1.000-1.012) n/a n/a Only for African- n/a No CRF
per ?1µg/m3 American children. recommended.
(Rodriguez, Tonkin (Ostro, Lipsett et al.
et al. 2007) 2001) No effect in
Age: 0-5 years. (Abt Associates Inc Australian 6-cities
Perth. 2011) study (Williams,
1-hour maximum. Marks et al. 2012).
No effect
(Williams, Marks et
al. 2012)
Six cities –
Adelaide, Brisbane,
Canberra,
Melbourne, Perth,
Sydney.
Age: mean 10.0
years.
270 children with
current asthma.
Shortness of breath No effect. n/a n/a Only for African- n/a No CRF
(Williams, Marks et American children. recommended.
al. 2012) (Ostro, Lipsett et al.
Six cities – 2001) No effect in
Adelaide, Brisbane, (Abt Associates Inc Australian 6-cities
Canberra, 2011) study (Williams,
Sydney.
Age: mean 10.0
years.
270 children with
current asthma.
38
Bronchodilator use No effect. n/a n/a n/a n/a No CRF

(Williams, Marks et recommended.
al. 2012)
Sydney.
Age: mean 10.0
years.
270 children with
current asthma.
Upper respiratory Runny/blocked n/a n/a Only for African- n/a No CRF
symptoms nose: No effect. American children. recommended.
(Rodriguez, Tonkin (Ostro, Lipsett et al.
et al. 2007) 2001) Only Australian
Age: 0-5 years. (Abt Associates Inc study did not show
Perth. 2011) any adverse effects.
1-hour maximum.
Increased Any day symptoms: n/a n/a n/a n/a No CRF

respiratory No effect on any recommended.
symptoms day symptoms -
cough, wheeze, No effect in
shortness of breath, Australian 6-cities
runny nose, eye study (Williams,
irritation, fever. Marks et al. 2012).
Any night
symptoms: No
effect on any night
symptoms - cough,
wheeze, shortness
39
of breath.
(Williams, Marks et
al. 2012)
Six cities –
Adelaide, Brisbane,
Canberra,
Melbourne, Perth,
Sydney.
Age: mean 10.0
years.
270 children with
current asthma.
General practitioner n/a n/a n/a n/a n/a No CRF

consultation for recommended.
asthma

upper respiratory
disease
1
n/a=not available
2
A restricted activity days is defined as a day when a person is forced to alter his/her normal activity. A severe restriction include days when it necessary to stay in bed. For
employed adults, restricted activity days include Work Loss Days; for children, it would include days off school (whether or not the child is confined to bed) (ExternE 1995).
3
Minor restricted activity days do not involve work loss or bed disability but do include some noticeable limitation on ‘normal’ activity (ExternE 1995).
REFERENCES
Abbey, D. E., B. L. Hwang, et al. (1995). "Estimated long-term ambient concentrations of PM10 and development of respiratory symptoms in a nonsmoking population."
Archives of Environmental Health 50(2): 139-152.
40
Abbey, D. E., M. D. Lebowitz, et al. (1995). "Long-term ambient concentrations of particulates and oxidants and development of chronic disease in a cohort of nonsmoking
California residents " Inhalation Toxicology 7: 19-34.
Abt Associates Inc (2011). BENMAP. User's manual appendices, Office of Air Quality Planning and Standards, Research Triangle Park, NC, USA. .
Abt Associates Inc. (2005). BENMAP: Technical appendices, Prepared by Abt Associates Inc. for the Office of Air Quality Planning and Standards, US EPA, Research
Triangle Park, North Carolina.
ACAM (2011). Asthma in Australia 2011 Canberra, AIHW Asthma Series no 4. Cat. No. ACM. Australian Centre for Asthma Monitoring, AIHW.
Ackermann-Liebrich, U., P. Leuenberger, et al. (1997). "Lung function and long term exposure to air pollutants in Switzerland. Study on Air Pollution and Lung Diseases in
Adults (SAPALDIA) Team." American Journal of Respiratory and Critical Care Medicine 155(1): 122-129.
AEA Technology Environment (2005). Methodology for the cost-benefit analysis for CAFE: Volume 2: Health impact assessment. Oxon, UK, AEA Technology
Environment.
Anderson, H. R., R. W. Atkinson, et al. (2004). Meta-Analysis of Time-Series Studies and Panel Studies of Particulate Matter (PM) and Ozone (O 3). Copenhagen, World
Health Organization Regional Office for Europe: 80.
Anderson, H. R., S. A. Bremner, et al. (2001). "Particulate matter and daily mortality and hospital admissions in the west midlands conurbation of the United Kingdom:
associations with fine and coarse particles, black smoke and sulphate." Occupational & Environmental Medicine 58(8): 504-510.
Anderson, H. R., C. Spix, et al. (1997). "Air pollution and daily admissions for chronic obstructive pulmonary disease in 6 European cities: results from the APHEA project
[see comments]." European Respiratory Journal 10(5): 1064-1071.
Australian Institute of Health and Welfare (2005). Chronic respiratory diseases in Australia. Their prevalence, consequences and prevention AIHW Cat. No. PHE 63.
Canberra: AIHW.
Barnett, A. G., G. M. Williams, et al. (2005). "Air pollution and child respiratory health. A case-crossover study in Australia and New Zealand." American Journal of
Respiratory and Critical Care Medicine 171(11): 1272-1278.
Bell, M. L., K. Ebisu, et al. (2008). "Seasonal and regional short-term effects of fine particles on hospital admissions in 202 US counties, 1999-2005." American Journal of
Epidemiology 168(11): 1301-1310.
41
Bennett, C. M., P. Simpson, et al. (2007). "Associations between ambient PM2.5 concentrations and respiratory symptoms in Melbourne, 1998–2005." Journal of Toxicology
and Environmental Health, Part A 70(19): 1613-1618.
BTRE (2005). Health impacts of transport emissions in Australia: economic costs. Working Paper 63. Canberra, Bureau of Transport and Regional Economics, Department of
Transport and Regional Services, Commonwealth of Australia.
Buist, A. S., W. M. McBurnie, et al. (2007). "International variation in the prevalence of COPD (The BOLD Study): a population-based prevalence study." The Lancet 370:
741-750.
Burnett, R. T., D. Stieb, et al. (2004). "Associations between short-term changes in nitrogen dioxide and mortality in Canadian cities." Archives of Environment Health 59:
228-236.
Chen, L., K. Mengersen, et al. (2007). "Spatiotemporal relationship between particle air pollution and respiratory emergency hospital admissions in Brisbane, Australia."
Science of the Total Environment 373(1): 57-67.
Committee on the Medical Effects of Air Pollutants (1998). Quantification of the effects of air pollution on health in the United Kingdom. London, Department of Health,
United Kingdom.
Committee on the Medical Effects of Air Pollutants (2002). Is there a threshold for the effect of ozone on health? 1. Is there an effect on mortality and respiratory or
circulatory admissions? London, Department of Health, United Kingdom.
Committee on the Medical Effects of Air Pollutants (2006). Cardiovascular disease and air pollution. London, Department of Health, UK.
Committee on the Medical Effects of Air Pollutants (2007). The effects of long-term exposure to ozone. London, Department of Health, UK.
Committee on the Medical Effects of Air Pollutants (2009). Long-term exposure to air pollution: effect on mortality. London, Department of Health, UK.
Committee on the Medical Effects of Air Pollutants (2010). The mortality effects of long-term exposure to pariculate air pollution in the United Kingdom. London,
Department of Health, UK.
Curtin University of Technology (2009). Review of the health effects of specific air pollutants Canberra, Report Commissioned by the Australian Government Department of
Health and Ageing.
42
DEC (2005). Air Pollution Economics: Health Costs of Air Pollution in the Greater Sydney Metropolitan Region. Sydney, Department of Environment and Conservation,
NSW.
Declerq, C. and V. Macquet (2000). "Short-term Effects of Ozone on Respiratory Health of Children in Armentieres, North of France." Rev Epidemiol Sante Publique
48(Suppl 2): S37-43.
DEFRA (2006). An Economic Analysis to Inform the Air Quality Strategy Review Consultation. London, UK, Department for Environment, Food and Rural Affair.
Delfino, R. J., R. S. Zeiger, et al. (2002). "Association of asthma symptoms with peak particulate air pollution and effect modification by anti-inflammatory medication use."
Environmental Health Perspectives 110(10): A607-A617.
Dockery, D. W., J. Cunningham, et al. (1996). "Health effects of acid aerosols on North American children: Respiratory symptoms." Environmental Health Perspectives
104(5): 500-505.
Dockery, D. W., A. C. Pope, III, et al. (1993). "An association between air pollution and mortality in six U.S. cities [see comments]." New England Journal of Medicine
329(24): 1753-1759.
Dockery, D. W. and C. A. Pope, III (1994). "Acute respiratory effects of particulate air pollution." Annual Review of Public Health 15: 107-132.
Dusseldorp, A., H. Kruize, et al. (1995). "Associations of PM10 and airborne iron with respiratory health of adults living near a steel factory." American Journal of
ECRHS (1996). "European Community Respiratory Health Survey: Variations in the prevalence of respiratory symptoms, self-reported asthma attacks, and use of asthma
medication in the European Community Respiratory Health Survey (ECRHS). ." Eur Respir J 9: 687-695.
Environment Protection and Heritage Council (2005). Expansion of the multi-city mortality and morbidity study. Final report. Volume 3. Tabulated results, Environment
Protection and Heritage Council.
Erbas, B., A.-M. Kelly, et al. (2005). "Air pollution and childhood asthma emergency hospital admissions: estimating intra-city regional variations." International Journal of
Environmental Health Research 15(1): 11-20.
European Commission (1995). Externalities of Energy "ExternE" Project, Volume 2, Methodology. Method for estimation of physical impacts and monetary valuation for
priority impact pathways. Oxfordshire, UK, Prepared by ETSU and others: 408.
43
European Commission (2005). ExternE. Externalities of Energy: Methodology 2005 Update. P. Bickel and R. Friedrich, Luxemburg, European Commission.
Fisher, G., T. Kjellstrom, et al. (2005). Health and Air Pollution in New Zealand: Christchurch Pilot Study, Health Research Council, Ministry for the Environment, Ministry
of Transport, New Zealand.
Gielen, M. H., S. C. van der Zee, et al. (1997). "Acute effects of summer air pollution on respiratory health of asthmatic children." American Journal of Respiratory and
Critical Care Medicine 155(6): 2105-2108.
Hajat, S., H. R. Anderson, et al. (2002). "Effects of air pollution on general practitioner consultations for upper respiratory diseases in London." Occupational &
Environmental Medicine 59(5): 294-299.
Hajat, S., A. Haines, et al. (2001). "Association between air pollution and daily consultations with general practitioners for allergic rhinitis in London, United Kingdom."
American Journal of Epidemiology 153(7): 704-714.
Hajat, S., A. Haines, et al. (1999). "Association of air pollution with daily GP consultations for asthma and other lower respiratory conditions in London." Thorax 54(7): 597-
605.
Hansen, C., A. Neller, et al. (2006). "Maternal exposure to low levels of ambient air pollution and preterm birth in Brisbane, Australia." BJOG: An International Journal of
Obstetrics & Gynaecology 113(8): 935-941.
Hansen, C., A. Neller, et al. (2007). "Low levels of ambient air pollution during pregnancy and fetal growth among term neonates in Brisbane, Australia." Environmental
Research 103(3): 383-389.
Hansen, C. A., A. G. Barnett, et al. (2009). "Ambient Air Pollution and Birth Defects in Brisbane, Australia." Plos One 4(4).
Hiltermann, T. J., J. Stolk, et al. (1998). "Asthma severity and susceptibility to air pollution." European Respiratory Journal 11(3): 686-693.
Hinwood, A., N. De Klerk, et al. (2006). "The relationship between changes in daily air pollution and hospitalizations in Perth, Australia 1992 - 1998: A case-crossover
study." International Journal of Environmental Health Research 16(1): 27-46.
Hoek, G. and B. Brunekreef (1995). "Effect of photochemical air pollution on acute respiratory symptoms in children." American Journal of Respiratory and Critical Care
Medicine 151(1): 27-32.
44
Hu, W., K. Mengersen, et al. (2008). "Temperature, air pollution and total mortality during summers in Sydney, 1994–2004." International Journal of Biometeorology 52(7):
689-696.
Hurley, F., A. Hunt, et al. (2005). Methodology Paper (Volume 2) for Service Contract for Carrying out Cost-Benefit Analysis of Air Quality Related Issues, In Particular in
the Clean Air for Europe (CAFE) Programme. Oxon, UK, AEA Technology Environment.
Ito, K., G. Thurston, et al. (2007). "Characterization of PM2.5 gaseous pollutants and meteorological interactions in the context of time-series health effects models." Journal
of Exposure Science and Environmental Epidemiology 17(S2): S45-S60.
Jalaludin, B., T. Chey, et al. (2000). "Acute effects of low levels of ambient ozone on peak expiratory flow rate in a cohort of Australian children." International Journal of
Epidemiology 29(3): 549-557.
Jalaludin, B., B. Khalaj, et al. (2008). "Acute effects of ambient air pollutants on ED visits for asthma in children, Sydney, Australia: a case-crossover analysis." International
Archives of Occupational & Environmental Health 81(8): 967-974.
Jalaludin, B., B. Khalaj, et al. (2008). "Air pollution and ED visits for asthma in Australian children: a case-crossover analysis." International Archives of Occupational and
Environmental Health 81(8): 967-974.
Jalaludin, B., T. Mannes, et al. (2007). "Impact of ambient air pollution on gestational age is modified by season in Sydney, Australia." Environmental Health 6.
Jalaludin, B., T. Mannes, et al. (2007). "Impact of ambient air pollution on gestational age is modified by season in Sydney, Australia." Environmental Health 6: 16.
Jalaludin, B., B. O'Toole, et al. (2004). "Acute effects of urban ambient air pollution on respiratory symptoms, asthma medication use, and doctor visits for asthma in a cohort
of Australian children." Environmental Research 95(1): 32-42.
Jalaludin, B., G. Salkeld, et al. (2009). A methodology for cost-benefit analysis of ambient air pollution health impacts. Canberra, Australian Government Department of the
Environment, Water, Heritage and the Arts, Commonwealth of Australia: 314.
Jalaludin, B., M. Smith, et al. (2000). "Acute effects of bushfires on peak expiratory flow rates in children with wheeze: a time series analysis." Australian & New Zealand
Journal of Public Health 24(2): 174-177.
Jalaludin, B. B., B. I. O'Toole, et al. (2004). "Acute effects of bushfires on respiratory symptoms and medication use in children with wheeze in Sydney, Australia."
45
Jerrett, M., R. T. Burnett, et al. (2009). "Long-term ozone exposure and mortality." New England Journal of Medicine 360(11): 1085-1095.
Just, J., C. Segala, et al. (2002). "Short-term health effects of particulate and photochemical air pollution in asthmatic children." European Respiratory Journal 20(4): 899-906.
Krewski, D., M. Jerrett, et al. (2009). Extended follow-up and spatial analysis of the American Cancer Society study linking particulate air pollution and mortality Boston,
MA, HEI Research Report 140: Health Effects Institute.
Krupnick, A., W. Harrington, et al. (1990). "Ambient Ozone and Acute Health Effects: Evidence from Daily Data." Journal of Environmental Economics and Management
18(1): 1-18.
Lebowitz, M. D. (1996). "Epidemiological studies of the respiratory effects of air pollution." The European Respiratory Journal 9: 1029-1054.
Leksell, I. and A. Rabl (2001). "Air Pollution and Mortality: Quantification and Valuation of Years of Life Lost." Risk Analysis 21(5): 843-857.
Lewis, P. R., M. J. Hensley, et al. (1998). "Outdoor air pollution and children's respiratory symptoms in the steel cities of New South Wales [see comments]." Medical Journal
of Australia 169(9): 459-463.
Linn, W. S., Y. Szlachcic, et al. (2000). "Air pollution and daily hospital admissions in metropolitan Los Angeles." Environmental Health Perspectives 108(5): 427-434.
Mannes, T., B. Jalaludin, et al. (2005). "Impact of ambient air pollution on birth weight in Sydney, Australia." Occup Environ Med 62: 524-530.
Mannes, T., B. Jalaludin, et al. (2005). "Impact of ambient air pollution on birth weight in Sydney, Australia." Occupational and Environmental Medicine 62(8): 524-530.
McDonnell, W. F., D. E. Abbey, et al. (1999). "Long-term ambient ozone concentration and the incidence of asthma in nonsmoking adults: the AHSMOG Study."
Environmental Research 80(Section A): 110-121.
Moolgavkar, S. H. (2003). Air pollution and daily deaths and hospital admissions in Los Angeles and Cook counties. Revised analyses of time-series studies of air pollution
and health. Special report. Boston, MA, Health Effects Institute: 183-198.
Morgan, G., S. Corbett, et al. (1998). "Air pollution and hospital admissions in Sydney, Australia, 1990 to 1994." American Journal of Public Health 88(12): 1761-1766.
Morgan, G., V. Sheppeard, et al. (2010). "Effects of bushfire smoke on daily mortality and hospital admissions in Sydney, Australia." Epidemiology 21(1): 47-55.
46
Mortimer, K. M., L. M. Neas, et al. (2002). "The effect of air pollution on inner-city children with asthma." European Respiratory Journal 19(4): 699-705.
National Environment Protection Council (2011). Methodology for setting air quality standards in Australia. Part A. Adelaide, Commonwealth of Australia.
National Health and Medical Research Council (2006). Ambient air quality standards setting. An approach to health-based hazard assessment. Canberra, Australian
Government.
NYDOH (2006). A study of ambient air contaminants and asthma in New York City, New
York State Department of Health Center for Environmental Health.
O'Connor, G. T., L. Neas, et al. (2008). "Acute respiratory health effects of air pollution on children with asthma in US inner cities." Journal of Allergy & Clinical
Immunology 121(5): 1133-1139.
Ostro, B., M. Lipsett, et al. (2001). "Air pollution and exacerbation of asthma in African-American children in Los Angeles." Epidemiology 12(2): 200-208.
Ostro, B. D. (1987). "Air pollution and morbidity revisited: A specification test." Journal of Environmental Economics and Management 14(1): 87-98.
Ostro, B. D. and S. Rothschild (1989). "Air pollution and acute respiratory morbidity: an observational study of multiple pollutants." Environmental Research 50(2): 238-247.
Peel, J. L., P. E. Tolbert, et al. (2005). "Ambient air pollution and respiratory emergency department visits." Epidemiology 16(2): 164-174.
Pereira, G., A. Cook, et al. (2010). "A case-crossover analysis of traffic-related air pollution and emergency department presentations for asthma in Perth, Western Australia."
Medical Journal of Australia 193(9): 511-514.
Peters, A., D. W. Dockery, et al. (2001). "Increased particulate air pollution and the triggering of myocardial infarction." Circulation 103(23): 2810-2815.
Petroeschevsky, A., R. W. Simpson, et al. (2001). "Associations between outdoor air pollution and hospital admissions in Brisbane, Australia." Archives of Environmental
Health 56(1): 37-52.
Pope, C. A., III, R. T. Burnett, et al. (2002). "Lung cancer, cardiopulmonary mortality, and long-term exposure to fine particulate air pollution." JAMA 287(9): 1132-1141.
47
Pope, C. A., III, D. W. Dockery, et al. (1991). "Respiratory health and PM10 pollution. A daily time series analysis." American Review of Respiratory Disease 144(3 Pt 1):
668-674.
Pope, C. A., III, M. J. Thun, et al. (1995). "Particulate air pollution as a predictor of mortality in a prospective study of US adults." American Journal of Respiratory and
Raizenne, M., L. M. Neas, et al. (1996). "Health effects of acid aerosols on North American children: Pulmonary function." Environmental Health Perspectives 104(5): 506-
514.
Rodriguez, C., R. Tonkin, et al. (2007). "The relationship between outdoor air quality and respiratory symptoms in young children." International Journal of Environmental
Health Research 17(5): 351-360.
Roemer, W., G. Hoek, et al. (1993). "Effect of ambient winter air pollution on respiratory health of children with chronic respiratory symptoms." American Review of
Respiratory Disease 147(1): 118-124.
Rutherford, S., R. Simpson, et al. (2000). "Relationships between environmental factors and lung function of asthmatic subjects in south east Queensland, Australia." Journal
of Occupational & Environmental Medicine 42(9): 882-891.
Schildcrout, J. S., L. Sheppard, et al. (2006). "Ambient air pollution and asthma exacerbations in children: an eight-city analysis." American Journal of Epidemiology 164(6):
505-517.
Schwartz, J. (1993). "Air pollution and daily mortality in Birmingham, Alabama." American Journal of Epidemiology 137(10): 1136-1147.
Schwartz, J., D. W. Dockery, et al. (1994). "Acute effects of summer air pollution on respiratory symptom reporting in children." American Journal of Respiratory and
Schwartz, J. and L. M. Neas (2000). "Fine particles are more strongly associated than coarse particles with acute respiratory health effects in schoolchildren." Epidemiology
11(1): 6-10.
Schwartz, J., D. Slater, et al. (1993). "Particulate air pollution and hospital emergency room visits for asthma in Seattle." American Review of Respiratory Disease 147(4):
826-831.
48
Seethaler, R. (1999). Health Costs due to Road Traffic-related Air Pollution. Bern, Federal Department of Environment, Transport, Energy and Communications; Bureau for
Transport Studies, Switzerland.
Sheppard, L. (2003). Ambient air pollution and nonelderly asthma hospital admissions in Seattle, Washington, 1987-1994. Revised analyses of time-series studies of air
pollution and health. Special report. Boston, MA, Health Effects Institute: 227-230.
Simpson, R., G. Williams, et al. (2005). "The short-term effects of air pollution on daily mortality in four Australian cities." Australian & New Zealand Journal of Public
Health 29(3): 205-212.
Simpson, R., G. Williams, et al. (2005). "The short-term effects of air pollution on hospital admissions in four Australian cities " Australian & New Zealand Journal of Public
Health 29(3): 213-221.
Spix, C., H. R. Anderson, et al. (1998). "Short-term effects of air pollution on hospital admissions of respiratory diseases in Europe: a quantitative summary of APHEA study
results. Air Pollution and Health: a European Approach." Archives of Environmental Health 53(1): 54-64.
Streeton, J. (1997). A review of existing health data on six pollutants. National environment protection (ambient air quality) measure. Adelaide, National Environment
Protection Council: 278.
Sunyer, J., J. Castellsague, et al. (1996). "Air pollution and mortality in Barcelona." Journal of Epidemiology & Community Health 50(Suppl 1): s76-s80.
Sunyer, J., M. Saez, et al. (1993). "Air pollution and emergency room admissions for chronic obstructive pulmonary disease: a 5-year study." American Journal of
Sunyer, J., C. Spix, et al. (1997). "Urban air pollution and emergency admissions for asthma in four European cities: the APHEA Project." Thorax 52(9): 760-765.
Toelle, B. (2012). Airflow obstruction, respiratory symptoms and respiratory illnesses in Australians aged 40 years and older: the Burden of Obstructive Lung Disease
(BOLD) study in Australia (personal communication; manuscript currently under review with the Medical Journal of Australia).
Tolbert, P. E., M. Klein, et al. (2007). "Multipollutant modeling issues in a study of ambient air quality and emergency department visits in Atlanta." Journal of Exposure
Science and Environmental Epidemiology 17(S2): S29-S35.
Touloumi, G., K. Katsouyanni, et al. (1997). "Short-term effects of ambient oxidant exposure on mortality: a combined analysis within the APHEA project. Air Pollution and
Health: a European Approach." American Journal of Epidemiology 146(2): 177-185.
49
US EPA (1999). The Benefits and Costs of the Clean Air Act 1990 to 2010. Washington, DC, United States Environmental Protection Agency.
US EPA (2004). Final Regulatory Analysis: Control of Emissions from Nonroad Diesel Engines. Washington, DC, United States Environmental Protection Agency.
US EPA (2006). Regulatory impact analysis. National Ambient Air Quality Standards for particle pollution, Research Triangle Park, North Carolina.
US EPA (2008). Final ozone National Ambient Air Quality Standards regulatory impact analysis, Office of Air Quality Planning and Standards, Research Triangle Park,
North Carolina: 558.
US EPA (2008). Integrated science assessment for oxides of nitrogen-health criteria, EPA/600/R-08/071. US Enviromental Protection Agency.
US EPA (2008). Integrated science assessment for sulfur oxides-health criteria, ISA: EPA/600/R-08/047F US Environmental Protection Agency
US EPA (2010). Final Regulatory Impact Analysis (RIA) for the NO2 National Ambient Air Quality Standards (NAAQS), Office of Air Quality Planning and Standards, U.S.
Environmental Protection Agency, North Carolina, USA: 155.
US EPA (2010). Final Regulatory Impact Analysis (RIA) for the SO2 National Ambient Air Quality Standards (NAAQS), Office of Air Quality Planning and Standards, U.S.
Environmental Protection Agency, Research Triangle Park, NC, USA: 189.
US EPA (2010). Quantitative Health Risk Assessment for Particulate Matter, Health and Environmental Impacts Division, US Environmental Protection Agency, NC, USA:
596.
US EPA (2011). The benefits and costs of the Clean Air act from 1990 to 2020, U.S. Environmental Protection agency, USA.
Vedal, S., J. Petkau, et al. (1998). "Acute effects of ambient inhalable particles in asthmatic and nonasthmatic children." American Journal of Respiratory and Critical Care
Medicine 157(4): 1034-1043.
Ward, D. J. and J. G. Ayres (2004). "Particulate air pollution and panel studies in children: a systematic review." Occupational & Environmental Medicine 61(4): e13.
Whittemore, A. S. and E. L. Korn (1980). "Asthma and air pollution in the Los Angeles area." American Journal of Public Health 70(7): 687-696.
WHO (2006). "WHO Air Quality Guidelines for Particulate Matter, Ozone, Nitrogen Dioxide and Sulfur Dioxide. Global Update 2005. Summary of Risk Asessment.".
50
WHO (2006). WHO Air quality guidelines for particulate matter, ozone, nitrogen dioxide and sulfur dioxide. Global Update 2005. Summary of risk assessment. Geneva,
World Health Organization.
WHO Europe (2000). Air quality guidelines for Europe: second edition. Copenhagen, WHO Regional Office for Europe.
WHO Europe (2001). Quantification of the heatlh effects of exposure to air pollution: report of a WHO working group Bilthoven, Netherlands 20-22 November 2000.
Copenhagen, WHO Regional Office for Europe.
WHO Europe (2003). Health aspects of air pollution with particulate matter, ozone and nitrogen dioxide: report on a WHO working group. Bonn, Germany, WHO: 98.
WHO Europe (2004). Health aspects of air pollution. Results from the WHO project "Systematic review of health aspects of air pollution in Europe". Copenhagen, World
Health Organization.
WHO Europe (2004). Meta-analysis of time-series studies and panel studies of Particulate Matter (PM) and Ozone (O3). Report of a WHO task group. Copenhagen, World
Williams, G., G. Marks, et al. (2012). Australian Child Health and Air Pollution Study (ACHAPS). Final report. Environment Protection and Heritage Council (in press).
Wilson, A. M., C. P. Wake, et al. (2005). "Air pollution, weather, and respiratory emergency room visits in two northern New England cities: an ecological time-series
study." Environmental Research 97(3): 312-321.
Wong, C. M., R. W. Atkinson, et al. (2002). "A tale of two cities: effects of air pollution on hospital admissions in Hong Kong and London compared." Environmental Health
Perspectives 110(1): 67-77.
Woodruff, T. J., J. Grillo, et al. (1997). "The relationship between selected causes of postneonatal infant mortality and particulate air pollution in the United States."
Environmental Health Perspectives 105(6): 608-612.
Woodruff, T. J., J. D. Parker, et al. (2006). "Fine particle matter (PM2.5) air pollution and selected causes of postneonatal infant mortality in California." Environmental
Health Perspectives 114(5): 786-790.
Yu, O., L. Sheppard, et al. (2000). "Effects of ambient air pollution on symptoms of asthma in Seattle-area children enrolled in the CAMP study." Environmental Health
Perspectives 108(12): 1209-1214.
51
Zanobetti, A. and J. Schwartz (2009). "The effect of fine and coarse particulate air pollution on mortality: A National Analysis." Environmental Health Perspectives 117(6):
898-903.
Zmirou, D., J. Schwartz, et al. (1998). "Time-series analysis of air pollution and cause-specific mortality." Epidemiology 9(5): 495-503.
52
Table 2: PM10 health endpoints and concentration-response functions

Mortality
All cause n/a1* n/a 0.386% (0.295- n/a 1.10 (1.03-1.18) per Recommended
0.477%) per 1 10 µg/m3 CRF: 0.386%
µg/m3 (Dockery, Pope et (0.295-0.477%) per
(Pope, Thun et al. al. 1993) 1 µg/m3
1995) (WHO Europe 2000) (Pope, Thun et al.
(European ?ICD codes 1995).
Commission 1995) ?Age
ICD9: All
Age: 30+ years
Cardiopulmonary n/a n/a n/a n/a n/a No CRF

recommended.
Ischaemic heart n/a n/a n/a n/a n/a No CRF

disease recommended.
Lung cancer n/a n/a n/a n/a n/a No CRF

recommended.
Infant all cause (<12 n/a n/a 4% (2-7%) per 10 n/a n/a Recommended
months age) µg/m3 CRF: 4% (2-7%) per
(Woodruff, Grillo et 10 µg/m3
al. 1997) (Woodruff, Grillo et
(European al. 1997).
Commission 2005)
ICD9: All
53
Age: <12 months
Life expectancy n/a 2-6 months per 2.69E-04 YOLL / n/a n/a Recommended
(Years of life lost; death brought (person/yr/µg/m3) CRF: 2.69E-04
YOLL) forward. (European YOLL /
(DEFRA 2006) Commission 2005) (person/yr/µg/m3)
Applies CRF from (European
Pope 1995 to whole Commission 2005).
population.
Morbidity
Incidence of chronic n/a n/a Chronic bronchitis: n/a Chronic bronchitis: No CRF
obstructive 1.15 (0.99-1.33) per 1.29 (0.96-1.83) per recommended for
pulmonary disease 20 µg/m3 10 µg/m3 chronic bronchitis.
(COPD) or chronic (Abbey, Hwang et (Dockery,
bronchitis al. 1995) Cunningham et al. Both the reported
(European 1996) CRFs are
Commission 2005) (WHO Europe 2000) statistically non-
(AEA Technology ?Age significant. May be
Environment 2005) used in a sensitivity
Adults (27+ years) analysis.
with cough or
sputum on most
days for at least
three months of the
year for at least two
years.
No effect recommended.
Ever had asthma:
54
No effect No effect in
(Williams, Marks et Australian 6-cities
Six cities – Marks et al. 2012).
Adelaide, Brisbane,
Canberra,
Melbourne, Perth,
Sydney.
Average hourly
PM10 over lifetime.
Age: mean age10.0
years.
2,860 children.
Recent symptoms Nigh cough: 1.34 n/a n/a n/a n/a No CRF
(in last 12 months) (1.19-1.53) per 10 recommended.
µg/m3
Chest colds: 1.43 No effect in
(1.12-1.82) per 10 Australian 6-cities
µg/m3 study (Williams,
(Lewis, Hensley et Marks et al. 2012).
al. 1998)
Children in school May use the CRFs
years 3-5. from the study by
Illawarra/Hunter. Lewis et al (Lewis,
Annual mean PM10. Hensley et al. 1998)
in a sensitivity
No effect or analysis.
protective effects for
wheeze, wheeze
after exercise,
current asthma, use
of bronchodilators,
cough, visit to
55
doctor/hospital,
rhinitis and itchy
rash in various
single pollutant and
2-pollutant models.
(Williams, Marks et
al. 2012)
Six cities –
Adelaide, Brisbane,
Canberra,
Melbourne, Perth,
Sydney.
Average hourly
PM10 over lifetime.
Age: mean age10.0
years.
2,860 children.

growth recommended.

Sydney.
Average hourly
PM10 over lifetime.
Age: mean age10.0
years.
2,860 children.
56

litres) al. 2012)
Sydney.
Average hourly
PM10 over lifetime.
Age: mean age10.0
years.
2,860 children.
Airway inflammation 1.04 (1.01-1.06) per n/a n/a n/a n/a Recommended
1 µg/m3 in single CRF: 1.04 (1.01-
pollutant model. 1.06) per 1 µg/m3
Estimates are (Williams, Marks et
similar in 2-pollutant al. 2012).
models with PM2.5,
NO2, SO2 and CO
(Williams, Marks et
al. 2012)
Six cities –
Adelaide, Brisbane,
Canberra,
Melbourne, Perth,
Sydney.
Average hourly
PM10 over lifetime.
Age: mean age10.0
years.
2,860 children.
57
Birth outcomes
Birth defects Mixed results from n/a n/a n/a n/a No CRF
only Australian recommended.
study
(Hansen, Barnett et Only 1 Australian
al. 2009) study.
Brisbane
Prematurity 1.462 (1.267-1.688) n/a n/a n/a n/a No CRF
per 1 µg/m3 recommended.
Autumn
First trimester Few Australian
studies.
1.343 (1.190-1.516)
per 1 µg/m3
Winter
First Trimester
(Jalaludin, Mannes
et al. 2007)
Preterm: <37 weeks
gestation.
Sydney
1.15 (1.06–1.25) per

4.5 µg/m3
First trimester
(Hansen, Neller et
al. 2006)
Preterm: <37 weeks
gestation.
Brisbane
58
Low birth weight 1.01 (1.00-1.04) per n/a n/a n/a n/a No CRF
1 µg/m3 for small for recommended.
gestational age (<2
standard deviations Few Australian
for age and gender). studies.
Second trimester
-2.05 (-3.36 to
-0.74) grams per 1
µg/m3 for small for
gestational age (<2
standard deviations
for age and gender).
Second trimester
(Mannes, Jalaludin
et al. 2005)
Sydney
No effect on birth
weight or small for
gestational age
(<10thcentile for age
and gender).
(Hansen, Neller et
al. 2007)
Brisbane

Mortality
Non-trauma All ages: No effect 0.074% (0.062- 1.0105 (1.0025- n/a 1.0074 (1.0062- No CRF
(Simpson, Williams 0.086%) per 1 1.0186) per 10 1.0086) per 10 recommended.
59
et al. 2005) µg/m3 µg/m3 µg/m3

Pooled CRF from 3 (Committee on the (Schwartz 1993) (WHO Europe 2000) No effect in 2
cities - Brisbane, Medical Effects of (European ?ICD Australian meta-
Sydney, Melbourne. Air Pollutants 1998) Commission 1995) ?Age analyses
ICD9: <800 CRF is a WHO ?ICD (Environment
ICD10: A-R, Z35.5, summary finding ?Age 1.006 (1.004-1.008) Protection and
Z35.8 based on 17 per 10 µg/m3 Heritage Council
international studies (WHO Europe 2004) 2005; Simpson,
1.3% (0.4-2.3%) per ICD: All 33 studies Williams et al.
10 µg/m3 Age: All ages. ICD9: <800 2005).
(Morgan, Age: All ages.
Sheppeard et al. CRF from Morgan
2010) et al (Morgan,
Sydney Sheppeard et al.
Age: All ages. 2010) or WHO
24-hour average (WHO Europe
ICD9: <800; ICD10: 2004) may be used
A-R, Z35.5, Z35.8 in a sensitivity
analysis.
All ages: No effect
(Environment
Protection and
Heritage Council
2005)
24-hour average
Lag 01
All year
High heterogeneity.
Meta-analysis of 4
cities - Brisbane,
Melbourne, Perth
Sydney.
ICD9: <800; ICD10:
A-R, Z35.5, Z35.8
60
Cardiovascular 1.4 (0.0-2.9%) per 0.9% (0.7-1.2%) per n/a n/a 1.009 (1.005-1.013) Recommended
10 µg/m3 10 µg/m3 per 10 µg/m3 CRF: 1.8% (0.6-
(Morgan, (Committee on the (WHO Europe 2004) 3.0%) per 7.53
Sheppeard et al. Medical Effects of 17 studies µg/m3 (Environment
2010) Air Pollutants 2006) ICD9: 390-459 Protection and
Sydney CRF not intended Ages: All ages. Heritage Council
Age: All for health risk 2005).
24-hour average assessment
ICD9: 390-459; purposes.
ICD10: I00-I99 40 studies
(excluding I67.3, ICD9: 390-459
I68.0, I88, I97.8, Age: All ages.
I97.9, I98.0), G45
(excluding G45.3),
G46, M30, M31,
R58
1.8% (0.6-3.0%) per

7.53 µg/m3
(Environment
Protection and
Heritage Council
2005)
24-hour average
Lag 01
Age: All ages.
All year.
No heterogeneity
Meta-analysis of 4
cities - Brisbane,
Melbourne, Perth
Sydney.
ICD9: 390-459;
61
ICD10: I00-I99
(excluding I67.3,
I68.0, I88, I97.8,
I97.9, I98.0), G45
(excluding G45.3),
G46, M30, M31,
R58
Respiratory No effect n/a n/a n/a 1.013 (1.005-1.020) No CRF

(Morgan, per 10 µg/m3 recommended.
Sheppeard et al. (WHO Europe 2004)
2010) 18 studies No effect in
Sydney ICD9: 460-519 Australian 4-cities
Age: All ages. Age: All ages. meta-analysis
24-hour average (Environment
ICD9: 460-519; Protection and
ICD10: J00-J99 Heritage Council
(excluding J95.4 to 2005) and in study
J95.9), R09.1, by Morgan et al
R09.8 (Morgan,
Sheppeard et al.
All ages: No effect 2010).
(Environment
Protection and CRF from WHO
Heritage Council (WHO Europe
2005) 2004) may be used
24-hour average. in a sensitivity
Lag 01 analysis.
Age: All ages.
All year
High heterogeneity
Meta-analysis of 4
cities - Brisbane,
Melbourne, Perth
62
Sydney.
ICD9: 460-519;
ICD10: J00-J99
(excluding J95.4 to
J95.9), R09.1,
R09.8
Hospitalisation
Cardiovascular 15-64 years: No 0.8 per 10 µg/m3 (no 0.6% (0.3-0.9%) per n/a n/a No CRF
effect 95%CI provided) 10 µg/m3 recommended.
65+ years: No effect (DEFRA 2006) (AEA Technology
(Environment (based on COMEAP Environment 2005) No effect in
Protection and 1998) ICD9: 390-429 Australian 4-cities
Heritage Council Age: All ages. meta-analysis
2005) No effect (Environment
24-hour average (Committee on the Protection and
Lag 01 Medical Effects of Heritage Council
Low heterogeneity Air Pollutants 2006) 2005).
Meta-analysis of 4 CRF not intended
cities - Brisbane, for health risk CRF from the study
Melbourne, Perth assessment by Morgan et al
Sydney. purposes. (Morgan,
ICD9: 390-459; 6 studies Sheppeard et al.
ICD10: I00–I99 ICD9: 390-459 2010) may be used
(excluding I67.3, Age: All ages. in a sensitivity
I68.0, I88, I97.8, analysis.
I97.9, I98.0),
G45 (excluding
G45.3), G46, M30,
M31, R58
1.22% (0.41 to
2.03%) per 10
63
µg/m3
(Morgan,
Sheppeard et al.
2010)
Sydney
Age: All ages.
24-hour average
ICD9: 390-459;
ICD10: I00-I99
(excluding I67.3,
I68.0, I88, I97.8,
I97.9, I98.0), G45
(excluding
G45.3), G46, M30,
M31, R58
Cardiac 2.4% (1.5-3.4%) per n/a n/a n/a n/a Recommended

10 µg/m3 CRF:
(Simpson, Williams 65+ years: 1.4%
et al. 2005) (0.5-2.2%) per 7.53
Pooled estimate µg/m3 (Environment
from 3 cities Protection and
(Sydney, Heritage Council
Melbourne, 2005). This is a
Brisbane) more recent study
lCD9: 390-429; compared to the
ICDI0: I00-I52, Simpson et al study
I97.0, I97.1, I98.1 (Simpson, Williams
Age: All ages. et al. 2005).
1-hour maximum.
15-64 years: No Use CRF from

effect Simpson et al
65+ years: 1.4% (Simpson, Williams
64
(0.5-2.2%) per 7.53 et al. 2005) in a

µg/m3 sensitivity analysis.
(Environment Note that this study
Protection and is for all ages and
Heritage Council has a larger CRF.
2005)
24-hour average.
Lag 01.
Low heterogeneity.
Meta-analysis of 4
cities - Brisbane,
Melbourne, Perth
Sydney.
lCD9: 390-429;
ICDI0: I00-I52,
I97.0, I97.1, I98.1
Cardiac failure 15-64 years: No n/a n/a n/a n/a Recommended

effect CRF:
65+ years: 3.6% 65+ years: 3.6%
(2.0-5.2%) per 7.53 (2.0-5.2%) per 7.53
µg/m3 µg/m3 (Environment
2005)
24-hour average.
Lag 01.
Moderate
heterogeneity for
65+ years.
Meta-analysis of 4
cities - Brisbane,
Melbourne, Perth
65
Sydney.
ICD9: 428; ICD10:
I50
Cerebrovascular Stroke: No CRF

effect
65+ years: No effect No effect in
24-hour average Heritage Council
Lag 01. 2005).
Low heterogeneity.
Meta-analysis of 4
cities - Brisbane,
Melbourne, Perth
Sydney.
ICD9: 430-438;
ICD10: I60-I66, I67
(excluding I67.0,
I67.3), I68
(excluding I68.0),
I69, G45 (excluding
G45.3), G46
Ischaemic heart 15-64 years: No n/a n/a n/a n/a No CRF

disease effect recommended.
65+ years: No effect
(Environment No effect in
Protection and Australian 4-cities
Heritage Council meta-analysis
2005) (Environment
66
24-hour average Protection and

Lag 01 Heritage Council
Low heterogeneity 2005).
Meta-analysis of 4
cities - Brisbane,
Melbourne, Perth
Sydney.
ICD9: 410-413;
ICD10: 120-122,
124, 125.2

effect recommended.
2005) (Environment
24-hour average. Protection and
Lag 01. Heritage Council
Low heterogeneity. 2005).
Meta-analysis of 4
cities - Brisbane,
Melbourne, Perth
Sydney.
ICD9: 437; ICD10:
I46-I49
Myocardial infarction 15-64 years: No n/a n/a n/a n/a No CRF

effect recommended.
67
2005) (Environment
Meta-analysis of 4
cities - Brisbane,
Melbourne, Perth
Sydney.
lCD9: 410; ICDI0:
I21, I22
Respiratory 0 year: 2.3% (0.2- 0.080% (0.048- 1.14% (0.62-1.67%) n/a 1.0080 (1.0048- Recommended
4.3%) increase per 0.112%) per 1µg/m3 per 10µg/m3 1.0112) per 10 CRF:
7.53 µg/m3 (Committee on the (AEA Technology µg/m3 CRFs from the
1-4 years: 2.3% Medical Effects of Environment 2005) (WHO Europe 2000) Australian 4-cities
(0.9-3.8%) increase Air Pollutants 1998) Age: All ages. ?ICD meta-analysis
per 7.53 µg/m3 CRF is a WHO ICD9: 460-519 ?Age (Environment
5-14 years: 2.3% summary finding Protection and
(0.2-4.4%) increase based on 6 cities 0-14 years: 1.010 Heritage Council
per 7.53 µg/m3 All respiratory (0.998-1.021) per 10 2005).
15-64 years: No causes µg/m3
effect Age: All ages. 3 studies May use CRF from
65+ years: No effect 14-64years: 1.008 the study by Morgan
(Environment (1.001-1.015) per 10 et al (Morgan,
Protection and µg/m3 Sheppeard et al.
Heritage Council 3 studies 2010) in a sensitivity
2005) 65+ years: 1.007 analysis. This CRF
24-hour average. (1.002-1.013) per 10 is for all ages but
Lag 01. µg/m3 from one location
Low heterogeneity. 8 studies only.
Meta-analysis of 4 (WHO Europe 2004)
cities - Brisbane, ICD9: 460-519
Melbourne, Perth Age: All ages.
Sydney.
68
ICD9: 460-519;
ICD10: J00-J99
(excluding J95.4 to
J95.9),
R09.1, R09.8
2.7% (1.0-5.9%) per

10 µg/m3 in 2-
pollutant model with
O3
(Chen, Mengersen
et al. 2007)
Brisbane
24-hour average
Age: All ages
ICD9: 460-519
(excluding 487);
ICD10: Joo-J99
(excluding J11)
1.04% (0.02-
2.07%) per 10
µg/m3
(Morgan,
Sheppeard et al.
2010)
Sydney
Age: All ages.
24-hour average.
ICD9: 460-519;
ICD10: J00-J99
(excluding J95.4 to
J95.9), R09.1,
R09.8
69
Asthma 0 year: not n/a n/a n/a n/a No CRF

calculated due to recommended.
uncertain diagnosis
1-4 years: No effect No effect in
5-14 years: No Australian studies
effect including the
15-64 years: No Australian 4-cities
effect meta-analysis
65+ years: No effect (Environment
2005) .
24-hour average
Lag 01
Low to moderate
heterogeneity
Meta-analysis of 4
cities - Brisbane,
Melbourne, Perth.
Sydney.
ICD9: 493; ICD10:
J45, J46, J44.8
1-14 years: No
effect
15-64 years: No
effect
(Morgan,
Sheppeard et al.
2010)
Sydney.
ICD9: 493; ICD10:
70
J45, J46, J44.8

24-hour average
Chronic obstructive 15-64 years: No n/a n/a n/a n/a No CRF

pulmonary disease effect recommended.
(COPD) 65+ years: No effect
2005) (Environment
Meta-analysis of 4
cities - Brisbane,
Melbourne, Perth
Sydney.
lCD9: 490-492, 494-
496; ICDI0: J40-
J44, J47, J67
Pneumonia and 0 years: No effect n/a n/a n/a n/a Recommended

acute bronchitis 1-4 years: No effect CRF:
15-64 years: No 65+ years: 1.0%
effect (0.2-3.8%) per 7.53
65+ years: 1.0% µg/m3 per 7.53
(0.2-3.8%) per 7.53 µg/m3 (Environment
µg/m3 Protection and
(Environment Heritage Council
Protection and 2005).
Heritage Council
2005)
24-hour average
Lag 01
71
Low heterogeneity
for 65+4 years
Meta-analysis of 4
cities - Brisbane,
Melbourne, Perth
Sydney.
ICD9: 466, 480-486;
ICD10: J12-J17,
J18.0, J18.1, Jl8.8,
JI8.9, J20, J21

Asthma Inner Melbourne: n/a 1.0374 (1.0121- n/a n/a Recommended
1.17 (1.05-1.31) per 1.0633) per 10 CRF: 1.4% (0.8-
34.3 µg/m3 µg/m3 2.0%) per 7.6 µg/m3
Eastern Melbourne: (Schwartz, Slater et (Jalaludin, Khalaj et
1.09 (1.01-1.18) per al. 1993) al. 2008).
34.3 µg/m3 (European
(Erbas, Kelly et al. Commission 1995) There are few
2005) Age: All ages. Australian studies.
Melbourne The study by Erbas
ICD10: J45, J46 et al (Erbas, Kelly et
Age: 1-15 years al. 2005) used
Modelled air modelled air
pollution data using pollution data.
TAPM
1-hour maximum
1.4% (0.8-2.0%) per

7.6 µg/m3
(Jalaludin, Khalaj et
al. 2008)
Sydney
72
Age: 1-14 years

ICD9: 439
Respiratory disease n/a n/a COPD: 5.7% (4.56- n/a n/a No CRF
6.84%) per 25 recommended.
µg/m3
(Sunyer, Saez et al. The CRF from
1993) Sunyer et al
(European (Sunyer, Saez et al.
Commission 1995) 1993) may be used
Age: All ages. in a sensitivity
analysis.
Cardiovascular n/a n/a n/a n/a n/a No CRF
Non-fatal heart n/a n/a n/a n/a n/a No CRF

attacks recommended.
Lung function
Change in forced No effect in single n/a n/a n/a -1.2% (-2.3 to - Recommended
expiratory volume in pollutant models, 0.1%) per 10 µg/m3 CRF: -0.0043
1 second (FEV1; but significant (Raizenne, Neas et (-0.0078 to -0.0008)
litres) effects in 2-pollutant al. 1996) per 1 µg/m3
models with 1-hour (WHO Europe 2000) (Williams, Marks et
SO2 and 24-hour Children al. 2012).
SO2 ?Age
With 1-hour SO2: -1.0% (95%CI not

-0.0041 (-0.0076 to available) per 10
-0.0006) per 1 µg/m3
73
µg/m3 (Ackermann-
24-hour average Liebrich,
Lag 2 Leuenberger et al.
With 24-hour SO2: 1997)
-0.0043 (-0.0078 to (WHO Europe 2000)
-0.0008) per 1 Adults
µg/m3 ?Age
24-hour average
Lag 2
(Williams, Marks et
al. 2012)
Six cities –
Adelaide, Brisbane,
Canberra,
Melbourne, Perth,
Sydney.
Age: mean age 10.0
years.
270 children with
current asthma.
Change in peak No effect n/a n/a n/a -0.13% (-0.17 to Recommended

expiratory flow rate (Jalaludin, Chey et -0.09%) per 10 CRF: -0.8187
(PEF; litres per al. 2000) µg/m3 (-1.3325 to -0.3048)
minute) Sydney (WHO Europe 2000) per 1 µg/m3
125 children with a ?Age (Williams, Marks et
history of wheezing Change in peak al. 2012).
in previous 12 expiratory flow
months. relative to mean. Note
Age: mean age inconsistencies in
about 9.6 years. CRFs from
Australian single
No effect site studies.
(Jalaludin, Smith et
74
al. 2000)
Sydney
32 children (mean
age about 9.2
years) with a history
of wheezing in
previous 12 months.
-0.0036 (-0.0067 to
-0.0005) per 1
µg/m3
(Rutherford,
Simpson et al.
2000)
Brisbane and
Ipswich
Mixed-models
4-day lag
Age: All ages.
53 people with
history of allergy to
pollen or fungi on
skin prick testing.
No effect in single
pollutant models,
but significant
effects in 2-pollutant
models with 1-hour
ozone, 1-hour SO2
and 24-hour SO2
With 1-hour ozone:
-0.3674 (-0.7291 to
-0.0057)
75
24-hour average
Lag 2
With 1-hour SO2:
-0.7972 (-1.33148 to
-0.2796) per 1
µg/m3
24-hour average
Lag 2
With 24-hour SO2:
-0.8187 (-1.3325 to
-0.3048) per 1
µg/m3
24-hour average
Lag 2
(Williams, Marks et
al. 2012)
Six cities –
Adelaide, Brisbane,
Canberra,
Melbourne, Perth,
Sydney
Age: mean age 10.0
years
270 children with
current asthma
Minor morbidity
Asthma n/a n/a n/a 1.05 (0.95-1.16) per n/a No CRF

exacerbation 10 µg/m3 recommended.
(Yu, Sheppard et al.
2000) CRF from Yu et al
(US EPA 2006) (Yu, Sheppard et al.
2000) was not
76
(Abt Associates Inc. statistically

2005) significant.
Asthmatic children
Age: 5-13 years
At least one asthma
symptom: wheeze,
cough, chest
tightness, shortness
of breath.
Restricted activity n/a n/a n/a n/a n/a No CRF

days (RAD)2 recommended.
Minor restricted n/a n/a n/a n/a n/a No CRF

activity days recommended.
(MRAD)3
Work lost days n/a n/a n/a n/a n/a No CRF

(WLD)2 recommended.
Acute bronchitis n/a n/a n/a n/a n/a No CRF

(incidence) recommended.
Lower respiratory No effect on 0-15 years: 0.330% 5-14 years: 1.004 n/a 1.0324 (1.0185- Recommended
symptoms wheezing. (0.134-0.526%) per (1.002-1.006) per 1.0464) per 10 CRFs:
(Jalaludin, O'Toole 1 µg/m3 10 µg/m3 µg/m3 5-14 years: 1.004
et al. 2004) 15+ years: No (Ward and Ayres (WHO Europe 2000) (1.002-1.006) per
148 children (mean effect. 2004) ?Age 10 µg/m3 (Ward and
age about 9.6 (Roemer, Hoek et (European Ayres 2004) from a
years) with a history al. 1993) Commission 2005) meta-analysis.
of wheezing in (Dusseldorp, Kruize (AEA Technology
previous 12 months. et al. 1995) Environment 2005) 20+ years: 1.017
Sydney. (Committee on the CRF from meta- (1.002-1.032) per
77
Medical Effects of analysis. 10 µg/m3 (European

Wheezing: 3.149 Air Pollutants 1998) All children. Commission 2005)
(1.495-6.631) per CRFs for those with Lower respiratory from a meta-
10 µg/m3 asthma. symptoms include analysis.
(Jalaludin, O'Toole NOT included in wheeze, chest
et al. 2004) impact assessment tightness, shortness Australian studies
32 children (mean in the UK because of breath, cough. are single site
age about 9.2 of doubts about the studies CRFs are
years) with a history transferability of the 20+ years: 1.017 for individual
of wheezing in data and lack of UK (1.002-1.032) per symptoms.
previous 12 months. studies. 10 µg/m3
Sydney. (European
Commission 2005)
(AEA Technology
Environment 2005)
CRF from meta-
analysis of five
panel studies.
Symptomatic adults
only: wheeze, chest
tightness, phlegm,
shortness of breath,
cough.
Acute respiratory n/a n/a 1.0049 (0.9999- n/a n/a No CRF

symptoms 1.0098) per 1 µg/m3 recommended.
(Krupnick,
Harrington et al. CRF from Krupnick
1990) et al (Krupnick,
(European Harrington et al.
Commission 1995) 1990) may be used
All ages in a sensitivity
Whole population. analysis. Note that
Only for sensitivity CRF is statistically
78
analysis marginally non-

Presence of any significant.
one of 19
respiratory-related
symptoms including:
head cold, chest
cold, sinus trouble,
croup, cough with
phlegm, sore,
throat, asthma, hay
fever, wheeze, ear
infection, bronchitis,
bronchiolitis,
pneumonia,
influenza.
Wheeze Day wheeze: n/a n/a n/a n/a Recommended

1.0288 (1.0049- CRF: Use CRF from
1.0534) per 1 μg/m3 Australian 6-cities
in 2-pollutant model study (Williams,
with 1-hour NO2 Marks et al. 2012).
24-hour average
Lag 1
Night wheeze:
1.0453 (1.0143-
1.0774) per 1 μg/m3
in 2-pollutant model
with 8-hour CO
24-hour average
Lag 2
(Williams, Marks et
al. 2012)
Six cities –
Adelaide, Brisbane,
79
Canberra,
Melbourne, Perth,
Sydney.
Age: mean 10.0
years.
270 children with
current asthma.
Cough No effect. 0-15 years: 0.508% 5-14 years: 1.004 8% (0-16%) per 10 1.0356 (1.0197- Recommended
(Jalaludin, O'Toole (0.226-0.790%) per (1.002-1.006) per μg/m3 1.0518) per 10 CRF: Use CRF from
et al. 2004) 1 µg/m3 10 µg/m3 (Vedal, Petkau et al. µg/m3 Australian 6-cities
148 children (mean 15+ years: No effect (Ward and Ayres 1998) (WHO Europe 2000) study (Williams,
age about 9.6 (Dockery and Pope 2004) (US EPA 2006) ?Age Marks et al. 2012).
years) with a history 1994) (European (Abt Associates Inc.
of wheezing in (Dusseldorp, Kruize Commission 2005) 2005) 5-15 years: 0.999
previous 12 months. et al. 1995) (AEA Technology Asthmatic children. (0.987-1.011) per 10 May use CRFs from
Sydney. (Committee on the Environment 2005) Age: 6-13 years. µg/m3 Ward et al (Ward
Medical Effects of All children 34 studies. and Ayres 2004) in
Day cough: 1.0229 Air Pollutants 1998) Symptomatic a sensitivity
(1.0006-1.0456) per CRFs for those with 20+ years: 1.043 children. analysis. CRFs from
1 μg/m3 in 2- asthma. (1.005-1.084) per a meta-analysis.
pollutant model with NOT included in 10 µg/m3 16-70 years: 1.043
8-hour CO impact assessment (Ward and Ayres (1.005-1.084) per 10
24-hour average in the UK because 2004) µg/m3
Lag 1 of doubts about the (European 3 studies.
Night cough: 1.0277 transferability of the Commission 2005) Symptomatic adults.
(1.0003-1.0559) per data and lack of UK (AEA Technology (WHO Europe 2004)
1 μg/m3 in 2- studies. Environment 2005)
pollutant model with CRF from meta-
24-hour SO2 analysis.
24-hour average Symptomatic adults
Lag 2 only: cough,
(Williams, Marks et nocturnal cough,
al. 2012) cough+phlegm
80
Six cities –
Adelaide, Brisbane,
Canberra,
Melbourne, Perth,
Sydney.
Age: mean 10.0
years.
270 children with
current asthma.
Shortness of breath Day SOB: No effect n/a n/a n/a n/a Recommended
Night SOB: 1.0417 CRF: 1.0417
(1.0031-1.0819) per (1.0031-1.0819) per
1 μg/m3 in 2- 1 μg/m3 (Williams,
pollutant model with Marks et al. 2012).
CO 8-hour average
24-hour average
Lag 2
(Williams, Marks et
al. 2012)
Six cities –
Adelaide, Brisbane,
Canberra,
Melbourne, Perth,
Sydney.
Age: mean 10.0
years.
270 children with
current asthma.
Bronchodilator use No effect. 0-15 years: 0.230% 5-14 years : No n/a 1.0305 (1.0201- No CRF
(people with (Jalaludin, O'Toole (0.073-0.3876%) effect 1.0410) per 10 recommended.
asthma) et al. 2004) per 1µg/m3 20+ years: No effect µg/m3
148 children (mean (WHO Europe (WHO Europe 2000) No effect in
81
age about 9.6 15+ years: 0.180% 2004) ?Age Australian 6-cities
years) with a history (0.004-0.357%) per (European study (Williams,
of wheezing in 1µg/m3 Commission 2005) 5-15 years: No Marks et al. 2012).
previous 12 months. (Roemer, Hoek et (AEA Technology effect
Sydney. al. 1993) Environment 2005) 31 studies Inconsistent CRFs
(Dusseldorp, Kruize People with asthma. Symptomatic reported. There is
No effect et al. 1995) children. generally a lack of
(Williams, Marks et (Committee on the 16-70 years: No an effect.
al. 2012) Medical Effects of effect
Six cities – Air Pollutants 1998) 3 studies
Adelaide, Brisbane, CRFs for those with Symptomatic adults.
Canberra, asthma. (WHO Europe 2004)
Melbourne, Perth, NOT included in
Sydney impact assessment
Age: mean 10.0 in the UK because
years of doubts about the
270 children with transferability of the
current asthma data and lack of UK
studies.
Upper respiratory n/a n/a n/a 1.0367 (1.0066- n/a No CRF

symptoms 1.0676) per 10 recommended.
µg/m3
(Pope, Dockery et The CRF from Pope
al. 1991) et al (Pope, Dockery
(US EPA 2006) et al. 1991) may be
Asthmatics 9-11 used in a sensitivity
years. analysis.
At least one of the
following symptoms:
runny/stuffy nose,
wet cough, burning,
aching or red eyes.
82
Increased Any day symptoms: Recommended

respiratory With 1-hour SO2: CRF: Use CRFs
symptoms 1.0257 (1.00189- from Australian 6-
1.0502) per 1 μg/m3 cities study
(Any cough, (Williams, Marks et
wheeze, shortness al. 2012).
of breath, runny
nose, eye irritation,
fever)
24-hour average
Lag 1
With 24-hour SO2:

1.0253 (1.0015-
1.0496) per 1 μg/m3
(Any cough,
wheeze, shortness
of breath, runny
fever)
24-hour average
Lag 1
Any night
symptoms: 1.0163
(1.0029-1.0298) per
1 μg/m3 (any
cough, wheeze,
shortness of breath)
24-hour average
Lag 2
(Williams, Marks et
al. 2012)
Six cities –
83
Adelaide, Brisbane,
Canberra,
Melbourne, Perth,
Sydney.
Age: mean 10.0
years.
270 children with
current asthma.
General practitioner 1.11 (1.04-1.19) per n/a 0-14 years: 2.5% n/a n/a No recommended
consultation for 12 µg/m3 (0.0-5.2%) per 10 CRF.
asthma (Jalaludin, O'Toole µg/m3
et al. 2004) 15-64 years: 3.1% CRFs from Jalaludin
125 children (mean (1.2-5.0%) per 10 et al (Jalaludin,
age about 9.6 µg/m3 O'Toole et al. 2004)
years) with a history 65+ years: 6.3% and Hajat et al
of wheezing in (2.1-11.2%) per 10 (Hajat, Haines et al.
previous 12 months. µg/m3 1999) may be used
Sydney. (Hajat, Haines et al. in may be used in
1999) sensitivity analyses.
(European
Commission 2005)
(AEA Technology
Environment 2005)
CRFs for warm
season only.
CRFs only used for
sensitivity analysis
General practitioner n/a n/a 0-14 years: No n/a n/a No recommended
consultation for effect CRF.
upper respiratory 15-64 years: 1.8%
disease (0.9-2.8%) per 10 CRFs from Hajat et
µg/m3 al (Hajat, Anderson
65+ years: 3.3% et al. 2002) may be
84
(1.7-5.0%) per 10 used in may be

µg/m3 used in sensitivity
(Hajat, Anderson et analyses.
al. 2002)
(European
Commission 2005)
(AEA Technology
Environment 2005)
ICD9: 460-3, 465,
470-5, 478.
CRFs only used for
sensitivity analysis
1
Not available
2
employed adults, restricted activity days include Work Loss Days; for children, it would include days off school (whether or not the child is confined to bed). (ExternE 1995)
3
REFERENCES
Abbey, D. E., B. L. Hwang, et al. (1995). "Estimated long-term ambient concentrations of PM10 and development of respiratory symptoms in a nonsmoking population."
Archives of Environmental Health 50(2): 139-152.
Abt Associates Inc. (2005). BENMAP: Technical appendices, Prepared by Abt Associates Inc. for the Office of Air Quality Planning and Standards, US EPA, Research
Triangle Park, North Carolina.
Ackermann-Liebrich, U., P. Leuenberger, et al. (1997). "Lung function and long term exposure to air pollutants in Switzerland. Study on Air Pollution and Lung Diseases in
Adults (SAPALDIA) Team." American Journal of Respiratory and Critical Care Medicine 155(1): 122-129.
Environment.
Chen, L., K. Mengersen, et al. (2007). "Spatiotemporal relationship between particle air pollution and respiratory emergency hospital admissions in Brisbane, Australia."
Science of the Total Environment 373(1): 57-67.
United Kingdom.
85
Dockery, D. W., J. Cunningham, et al. (1996). "Health effects of acid aerosols on North American children: Respiratory symptoms." Environmental Health Perspectives
104(5): 500-505.
Dockery, D. W., A. C. Pope, III, et al. (1993). "An association between air pollution and mortality in six U.S. cities [see comments]." New England Journal of Medicine
329(24): 1753-1759.
Dockery, D. W. and C. A. Pope, III (1994). "Acute respiratory effects of particulate air pollution." Annual Review of Public Health 15: 107-132.
Dusseldorp, A., H. Kruize, et al. (1995). "Associations of PM10 and airborne iron with respiratory health of adults living near a steel factory." American Journal of
Hajat, S., H. R. Anderson, et al. (2002). "Effects of air pollution on general practitioner consultations for upper respiratory diseases in London." Occupational &
Environmental Medicine 59(5): 294-299.
Hajat, S., A. Haines, et al. (1999). "Association of air pollution with daily GP consultations for asthma and other lower respiratory conditions in London." Thorax 54(7): 597-
605.
Research 103(3): 383-389.
Jalaludin, B., T. Mannes, et al. (2007). "Impact of ambient air pollution on gestational age is modified by season in Sydney, Australia." Environmental Health 6.
Jalaludin, B., M. Smith, et al. (2000). "Acute effects of bushfires on peak expiratory flow rates in children with wheeze: a time series analysis." Australian & New Zealand
Journal of Public Health 24(2): 174-177.
Jalaludin, B. B., B. I. O'Toole, et al. (2004). "Acute effects of bushfires on respiratory symptoms and medication use in children with wheeze in Sydney, Australia."
18(1): 1-18.
86
of Australia 169(9): 459-463.
Morgan, G., V. Sheppeard, et al. (2010). "Effects of bushfire smoke on daily mortality and hospital admissions in Sydney, Australia." Epidemiology 21(1): 47-55.
Pope, C. A., III, D. W. Dockery, et al. (1991). "Respiratory health and PM10 pollution. A daily time series analysis." American Review of Respiratory Disease 144(3 Pt 1):
668-674.
Pope, C. A., III, M. J. Thun, et al. (1995). "Particulate air pollution as a predictor of mortality in a prospective study of US adults." American Journal of Respiratory and
Raizenne, M., L. M. Neas, et al. (1996). "Health effects of acid aerosols on North American children: Pulmonary function." Environmental Health Perspectives 104(5): 506-
514.
Roemer, W., G. Hoek, et al. (1993). "Effect of ambient winter air pollution on respiratory health of children with chronic respiratory symptoms." American Review of
Respiratory Disease 147(1): 118-124.
Schwartz, J. (1993). "Air pollution and daily mortality in Birmingham, Alabama." American Journal of Epidemiology 137(10): 1136-1147.
Schwartz, J., D. Slater, et al. (1993). "Particulate air pollution and hospital emergency room visits for asthma in Seattle." American Review of Respiratory Disease 147(4):
826-831.
Health 29(3): 205-212.
Health 29(3): 213-221.
Sunyer, J., M. Saez, et al. (1993). "Air pollution and emergency room admissions for chronic obstructive pulmonary disease: a 5-year study." American Journal of
Vedal, S., J. Petkau, et al. (1998). "Acute effects of ambient inhalable particles in asthmatic and nonasthmatic children." American Journal of Respiratory and Critical Care
Medicine 157(4): 1034-1043.
Ward, D. J. and J. G. Ayres (2004). "Particulate air pollution and panel studies in children: a systematic review." Occupational & Environmental Medicine 61(4): e13.
WHO Europe (2004). Meta-analysis of time-series studies and panel studies of Particulate Matter (PM) and Ozone (O3). Report of a WHO task group. Copenhagen, World
Woodruff, T. J., J. Grillo, et al. (1997). "The relationship between selected causes of postneonatal infant mortality and particulate air pollution in the United States."
Environmental Health Perspectives 105(6): 608-612.
Yu, O., L. Sheppard, et al. (2000). "Effects of ambient air pollution on symptoms of asthma in Seattle-area children enrolled in the CAMP study." Environmental Health
Perspectives 108(12): 1209-1214.
87
Table 3: O3 health endpoints and associated concentration-response functions
Long-term outcomes(annual average concentration)

Mortality
All cause n/a1 n/a n/a No effect n/a No CRF
(Jerrett, Burnett et recommended.
al. 2009)
(Abt Associates Inc
2011)
Age: 30-99 years.
Annual 1-hour
average.
Cardiopulmonary n/a n/a n/a Cardiovascular n/a No CRF

disease: No effect recommended.
(Jerrett, Burnett et
al. 2009)
(Abt Associates Inc
2011)
Age: 30-99 years.
Annual 1-hour
average.
Ischaemic heart n/a n/a n/a n/a n/a No CRF

Lung cancer n/a n/a n/a n/a n/a No CRF

recommended.
88
Respiratory n/a n/a n/a 1.040 (1.013-1.067) n/a No CRF

per 10 ppb recommended.
(Jerrett, Burnett et
al. 2009) Insufficient evidence
(Abt Associates Inc - only 1 study.
2011)
ICD9: 460-519
Age: 30-99 years.
Annual 1-hour
average.
Adjusted for PM2.5.
Infant (<12 months n/a n/a n/a n/a n/a No CRF

age) recommended.
Life expectancy lost n/a n/a n/a n/a n/a No CRF

(years of life lost) recommended.
Morbidity
Incidence of chronic n/a n/a n/a n/a n/a No CRF

obstructive recommended.
pulmonary disease
(COPD) or chronic
bronchitis
Incidence of asthma Ever had wheezing: n/a n/a 2.8% (0.1-5.6%) per n/a No CRF
Protective effect in 1 ppb recommended.
single and 2- (McDonnell, Abbey
pollutant models et al. 1999) No effect in
with PM, NO2, SO2 (US EPA 1999) Australian 6-cities
and CO. Age: Non-asthmatic study (Williams,
males 27+ years. Marks et al. 2012).
89
Ever had asthma: Annual average 8-

Protective effect in hour ozone. Study by McDonnell
single and 2- et al (McDonnell,
pollutant models Abbey et al. 1999)
with PM, NO2, SO2 may be used in a
and CO. sensitivity analysis.
(Williams, Marks et
al. 2012)
Six cities –
Adelaide, Brisbane,
Canberra,
Melbourne, Perth,
Sydney.
Average hourly O3
over lifetime.
Age: mean age10.0
years.
2,860 children.
Recent symptoms Cough: n/a n/a n/a n/a Recommended

(in last 12 months) 1.14 ( 1.01-1.29) CRF:
per 3.12 ppb in Cough: 1.26 (1.06-
single pollutant 1.50) per 3.12 ppb
model. in 2-pollutant model
1.26 (1.06-1.50) per with CO (Williams,
3.12 ppb in 2- Marks et al. 2012).
CO.
(Williams, Marks et
al. 2012)
Six cities –
Adelaide, Brisbane,
Canberra,
Melbourne, Perth,
90
Sydney.
Average hourly O3
over lifetime.
Age: mean age10.0
years.
2,860 children.

growth recommended.
Change in forced No effect. n/a n/a n/a n/a. No CRF

Sydney.
Average hourly O3
over lifetime.
Age: mean age10.0
years.
2,860 children.
Change in forced No effect. n/a n/a n/a n/a. No CRF

litres) al. 2012)]
Sydney.
Average hourly O3
91
over lifetime.
Age: mean age10.0
years.
2,860 children.
Airway inflammation Protective effect in n/a n/a n/a n/a. No CRF

single and 2- recommended.
pollutant models
with PM, NO2, SO2 No effect in
and CO Australian 6-cities
(Williams, Marks et study (Williams,
al. 2012) Marks et al. 2012).
Six cities –
Adelaide, Brisbane,
Canberra,
Melbourne, Perth,
Sydney.
Average hourly O3
over lifetime.
Age: mean age10.0
years.
2,860 children.
Birth outcomes
Birth defects Pulmonary artery & n/a n/a n/a n/a No CRF
valves: 2.96% recommended.
(1.34- 7.52%) per 5
ppb Only 1 Australian
(Hansen, Barnett et study.
al. 2009)
Brisbane.
Birth addresses
92
<6km of air
monitoring station.
Prematurity 1.26 (1.10-1.45) per n/a n/a n/a n/a No CRF

7.1 ppb recommended.
(Hansen, Neller et
al. 2006) Only 2 Australian
CRF not linear. studies are available
Brisbane. and evidence is
Preterm: <37 weeks conflicting regarding
1st trimester CRF.
exposure.
1.604 (1.268-2.030)
per 1 ppb
1st month gestation
for women living
<5km of air quality
monitor.
No effect for all
Sydney.
Preterm: <37
weeks.
1.014 (1.005-1.022)
per 1 ppb
Sydney wide
Preterm: <37 weeks
gestation
1st trimester
exposure.
93
0.807 (0.668-0.976)
per 1 ppb
for women living <5
km of air quality
monitor.
Preterm: <37 weeks
gestation.
1st trimester
exposure.
Sydney.
(Jalaludin, Mannes
et al. 2007)
Low birth weight No effect. n/a n/a n/a n/a No CRF

Brisbane. recommended.
(Hansen, Neller et
studies available.
Small for gestational
age: 1.00 (1.00-
1.01) per 1 ppb
1-hour maximum
Sydney
Small for gestational
age >2 standard
deviations below the
mean birth weight
by sex and
gestational age.
Exposure in 1st, 2nd
or 3rd trimesters.
Birth weight: grams

(-0.12 to -0.09
94
grams) per 1 ppb

2nd trimester
exposure.
Sydney.
(Mannes, Jalaludin
et al. 2005)
Head circumference No effect on either n/a n/a n/a n/a No CRF

head circumference recommended.
Crown-heel length or crown-heel
length. Only 1 Australian
(Hansen, Neller et study available.
al. 2007)
Brisbane.
Short-term outcomes(daily average concentration)

Mortality
Non-trauma 1.0004 (0.9999- 0.059% per 1 µg/m3 0.3% (0.1-0.43%) 0.5-1% increase per 0.3% (0.1-0.43%) Recommended
1.0010) per 1 ppb (Sunyer, per 10 µg/m3 30 ppb increase per 10 CRF: 1.4% (0.3-
4-hour maximum Castellsague et al. (Anderson, (US EPA 2006) µg/m3 2.4%) per 9.83 ppb
Lag 0 1996) Atkinson et al. 2004) 8-hour maximum (Anderson, Atkinson (Environment
(European (European average. et al. 2004) (AEA Protection and
1.0004 (0.9999- Commission 2005) Commission 2005) Technology Heritage Council
1.0008) per 1 ppb Age: All ages. WHO meta- n/a Environment 2005) 2005).
1-hour maximum analysis. (Abt Associates Inc WHO meta-
Lag 0 1.027 (1.013-1.039) Daily maximum 8- 2011) analysis.
(Simpson, Williams per 50 µg/m3 hour average O3. Meta-analysis of 6 Daily maximum 8-
et al. 2005) (Committee on the Assuming linearity studies. hour average.
Pooled CRF from 4 Medical Effects of without threshold. All ages.
cities - Sydney, Air Pollutants 1998)
Perth, Melbourne, 8-hour average. 0.3% (0.1-0.4%) 1.003 (1.001-1.004)
95
Brisbane. Age: All ages. change per 10 per 10 µg/m3

ICD9: <800 All non-trauma µg/m3 (8-hour average).
ICD10: A-R, Z35.5, deaths. (AEA Technology Estimate revised for
Z35.8 Meta-analysis of 5 Environment 2005) possible publication
Age: All ages. European cities. bias 1.002 (1.000-
1.003).
1.4% (0.3-2.4%) per (Anderson, Atkinson
9.83 ppb et al. 2004)
(Environment
Protection and 0.3-0.5% increase
Heritage Council in daily mortality per
2005) 10 µg/m3
1-hour maximum. 8-hour average O3
Lag 01. above 70 µg/m3.
Age: All ages. (WHO 2006)
All year.
No heterogeneity.
Meta-analysis of 4
cities - Brisbane,
Melbourne, Perth
Sydney.
ICD9: <800; ICD10:
A-R, Z35.5, Z35.8
Cardiovascular 1.0008 (0.9999- 0.4% (0.3-0.5%) n/a n/a 1.004 (1.003, 1.005) Recommended
1.0016) per 1 ppb change per 10 per 10 µg/m3 CRF: 2.1% (1.1-
(4-hour maximum) µg/m3 3.1%) per 9.83 ppb
(lag0) (Committee on the Estimate revised for (Environment
Medical Effects of possible publication Protection and
1.0006 (0.9999- Air Pollutants 2006) bias 1.004 (1.003- Heritage Council
1.0013) per 1 ppb 8-hour average 1.005). 2005).
1-hour maximum No evidence of (Anderson, Atkinson
Lag 0 publication bias. et al. 2004) Note that CRFs
Pooled CRF from 4 CRF not intended 8-hour average. from Simpson et al
96
cities - Sydney, for health risk (Simpson, Williams

Perth, Melbourne, assessment et al. 2005) are very
Brisbane. purposes. close to being
ICD9: 390-459; statistically
ICD10: I00-I99 significant.
(excluding I67.3,
I68.0, I88, I97.8,
I97.9, I98.0), G45
(excluding G45.3),
G46, M30, M31,
R58
Age: All ages.
(Simpson, Williams
et al. 2005)
2.1% (1.1-3.1%) per

9.83 ppb
(Environment
Protection and
Heritage Council
2005)
1-hour maximum.
Lag 01.
Age: All ages.
All year.
No heterogeneity.
Meta-analysis of 4
cities - Brisbane,
Melbourne, Perth
Sydney.
ICD9: 390-459;
ICD10: I00-I99
(excluding I67.3,
I68.0, I88, I97.8,
97
I97.9, I98.0), G45

(excluding G45.3),
G46, M30, M31,
R58
Respiratory 1.0023 (1.0005- n/a n/a n/a 1.000 (0.996-1.005) Recommended

1.0042) per 1 ppb per 10 µg/m3 CRF: 2.4% (0.1-
4-hour maximum. Estimate revised for 4.7%) per 9.83 ppb
Lag 0. possible publication (Environment
bias to 0.999 Protection and
1.0020 (1.0003- (0.995-1.004). Heritage Council
1.0036) per 1 ppb (Anderson, Atkinson 2005).
(Simpson, Williams et al. 2004)
et al. 2005) 8-hour average. The EPHC study
1-hour maximum. (Environment
Lag 0. Protection and
Pooled CRF from 4 Heritage Council
cities - Sydney, 2005) used as it is
Perth, Melbourne, the more recent
Brisbane. than the study by
ICD9: 460-519; Simpson et al
ICD10: J00-J99 (Simpson, Williams
(excluding J95.4 to et al. 2005).
J95.9), R09.1,
R09.8
Age: All ages.
2.4% (0.1-4.7%) per

9.83 ppb
(Environment
Protection and
Heritage Council
2005)
1-hour maximum
98
Lag 01
Age: All ages.
All year.
No heterogeneity.
Meta-analysis of 4
cities - Brisbane,
Melbourne, Perth
Sydney.
ICD9: 460-519;
ICD10: J00-J99
(excluding J95.4 to
J95.9), R09.1,
R09.8
Hospitalisation
Cardiovascular 15-64 years: No No effect. No strong evidence n/a n/a No CRF

effect (Committee on the of association Insufficient studies recommended.
65+ years: No effect Medical Effects of between daily O3 for meta-analysis
(Environment Air Pollutants 2006) and cardiovascular (Anderson, Atkinson No effect in
Protection and 8-hour average. disease admissions. et al. 2004) Australian meta-
Heritage Council No evidence of (European analysis
2005) publication bias. Commission 2005) (Environment
1-hour maximum. CRF not intended Protection and
Lag 01. for health risk Heritage Council
Meta-analysis of 4 assessment 2005) and in
cities - Brisbane, purposes. COMEAP study
Melbourne, Perth (Committee on the
Sydney. Medical Effects of
ICD9: 390-459 Air Pollutants 2006).
ICD10: I00-I99
(excluding I67.3,
I68.0, I88, I97.8,
I97.9, I98.0), G45
99
(excluding G45.3),
G46, M30, M31,
R58
Cardiac All ages: No effect. n/a n/a n/a n/a No CRF

15-64 years: 1.0009 recommended.
(1.0001-1.0017) per
1 ppb. No effect in more
4-hour average. recent Australian
Lag 3. meta-analysis
Pooled estimate (Environment
from 4 cities - Protection and
Sydney, Brisbane, Heritage Council
Melbourne, Perth. 2005).
lCD9: 390-429
ICDI0: I00-I52, CRF for 15-64 years
I97.0, I97.1, I98.1 from Simpson et al
(Simpson, Williams (Simpson, Williams
et al. 2005) et al. 2005) may be
used in a sensitivity
15-64 years: No analysis.
effect.
65+ years: No
effect.
(Environment
Protection and
Heritage Council
2005)
1-hour maximum.
Lag 01.
Meta-analysis of 4
cities - Brisbane,
Melbourne, Perth,
Sydney.
100
Low heterogeneity.
lCD9: 390-429;
ICDI0: I00-I52,
I97.0, I97.1, I98.1
Cardiac failure 15-64 years: No n/a n/a n/a n/a No CRF

65+ years: No
effect. No effect in the
(Environment EPHC study
Protection and (Environment
Heritage Council Protection and
2005) Heritage Council
1-hour maximum. 2005).
Lag 01.
Meta-analysis of 4
cities - Brisbane,
Canberra,
Melbourne, Perth
Sydney.
Moderate
heterogeneity in 15-
64 years.
ICD9: 428; ICD10:
I50
Cerebrovascular Stroke: n/a n/a n/a n/a No CRF

disease 15-64 years: No recommended.
effect.
65+ years: No No effect in the
effect. EPHC study
101
2005) 2005).
1-hour maximum.
Lag 01.
Meta-analysis of 4
cities - Brisbane,
Canberra,
Melbourne, Perth
Sydney.
Low heterogeneity.
ICD9: 430-438
ICD10: I60-I66, I67
(excluding I67.0,
I67.3), I68
(excluding I68.0),
I69, G45 (excluding
G45.3), G46
Ischaemic heart 15-64 years: No -0.1% (-0.7 to 0.4%) n/a n/a n/a No CRF
disease effect. per 10 µg/m3 recommended.
65+years: No effect. (Committee on the
(Environment Medical Effects of No effect in the
Protection and Air Pollutants 2006) EPHC study
Heritage Council 8-hour average (Environment
2005) No evidence of Protection and
Meta-analysis of 4 publication bias. Heritage Council
cities - Brisbane, CRF not intended 2005), Simpson
Melbourne, Perth, for health risk study (Simpson,
Sydney assessment Williams et al. 2005)
Low heterogeneity purposes. and in COMEAP
ICD9: 410-413 study (Committee
ICD10: 120-122, on the Medical
124, 125.2 Effects of Air
Pollutants 2006).
No effect.
102
(Simpson, Williams
et al. 2005)
Pooled estimate
from 4 cities -
Sydney, Brisbane,
Melbourne, Perth.
All ages and 65+
years.

65+ years: No
Lag 01.
Meta-analysis of 4
cities - Brisbane,
Melbourne, Perth
Sydney.
Low heterogeneity.
ICD9: 437; ICD10:
I46-I49
Myocardial 15-64 years: No n/a n/a n/a n/a No CRF

infarction effect. recommended.
65+ years: No
103

Lag 01.
Meta-analysis of 4
cities - Brisbane,
Melbourne, Perth
Sydney.
High heterogeneity.
in 65+ years
lCD9: 410; ICDI0:
I21, I22
Respiratory 65+ years: No All ages: 3.5% per Various age groups n/a n/a No CRF
effect. 50 µg/m3 analysed: effect Pooled analysis of a All ages: 5% recommended.
(Simpson, Williams 15-64 years: 1.031 close to significant number of studies – increase per 25
et al. 2005) (1.013-1.049) per 50 for 65+ years only. unable to locate µg/m3 Results are
1-hour maximum. µg/m3 CRF. (8-hour average) inconsistent.
lCD9: 460-519 (Committee on the 65+ years: No (Abt Associates Inc and 30 µg/m3
ICD10: J00-J99 Medical Effects of effect. 2011) 1-hour average The Brisbane CRFs
(excluding J95.4- Air Pollutants 1998) (Anderson, Atkinson (WHO Europe (Petroeschevsky,
J95.9), R09.1, Whole population. et al. 2004). 2000) Simpson et al.
R09.8. 8-hour average. (European 2001) and the 4-
Pooled analysis Meta-analysis of 4 Commission 2005) 0-14 years: cities meta-analysis
from 4 cities - European cities. 8-hour average. Insufficient numbers (Environment
Brisbane, Sydney, ICD9: 460-519 Meta-analysis of 5 for meta-analysis Protection and
Melbourne, Perth. European cities. 15-64 years: 1.001 Heritage Council
(0.991-1.012) per 2005) may be used
All ages: 1.023 10 µg/m3 in a sensitivity
(1.003-1.043) per 1 65+ years: 1.005 analysis.
pphm (0.998-1.012) per
0-4 years: 10 µg/m3
Protective effect. (Anderson, Atkinson
1-hour maximum et al. 2004)
Lag 0 8-hour average.
104
5-14 years: No
effect.
1-hour maximum
Lag 0
15-64 years: 1.045
(1.013-1.079) per 1
pphm
8-hour average
Lag 2
65+ years: 1.054
(1.016-1.094) per 1
pphm
8-hour average
Lag 3
(Petroeschevsky,
Simpson et al.
2001)
Brisbane
ICD9: 460-519
All ages: No effect

0-14 years: No
effect.
65+ years: No
effect.
Perth.
(Hinwood, De Klerk
et al. 2006)
0 year: No effect.
1-4 years: 1.9%
(0.5-3.4%) per 9.83
ppb
1-hour maximum.
105
Lag 01.
All year.
No heterogeneity.
5-14 years: No
effect.
15-64 years: No
effect.
65+ years: No
effect.
(Environment
Protection and
Heritage Council
2005)
Meta-analysis of 4
cities - Brisbane,
Melbourne, Perth
Sydney.
ICD9: 460-519
ICD10: J00-J99
(excluding J95.4 to
J95.9), R09.1,
R09.8
Asthma No effect on three n/a n/a n/a n/a No CRF

age groups: all recommended.
ages; <15 years;
65+ years. Australian results
Perth. are inconsistent.
(Hinwood, De Klerk
et al. 2006) The Brisbane CRFs
(Petroeschevsky,
1-14 years No Simpson et al.
effect. 2001) and the 4-
15-64 years: No cities meta-analysis
106
effect. (Environment
(Morgan, Corbett et Protection and
al. 1998) Heritage Council
Sydney. 2005) may be used
in a sensitivity
All ages: 1.090 analysis.
(1.042-1.141) per 1
pphm
Lag 5 average
0-14 years: 1.064
(1.015-1.115) per 1
pphm
Lag 1
15-64 years 1.084
(1.037-1.133)
per 1 pphm
Lag 2
(Petroeschevsky,
Simpson et al.
2001)
8-hour average.
Brisbane.
No effect.
(Simpson, Williams
et al. 2005)
Age: 15-64 years
lCD9: 493,
ICD10: J45, J46,
J44.8
Pooled analysis
from 4 cities -
Brisbane, Sydney,
Melbourne, Perth.
107
Age: 1-4 years

0.5% (0.3-0.7%) per
1 ppb
1-hour maximum.
Lag 01.
Warm season:
November-April.
No heterogeneity.
(Environment
Protection and
Heritage Council
2005)
Meta-analysis of 4
cities - Brisbane,
Melbourne, Perth
Sydney.
ICD9: 493; ICD10:
45, J46, J44.8
Chronic obstructive All ages: No effect. 65+ years: 1.038 n/a n/a n/a No CRF
pulmonary disease <15 years: No (1.018-1.058) per 50 recommended.
(COPD) effect. µg/m3
65+ years: No (Committee on the Inconsistent results
effect. Medical Effects of from the two
(Hinwood, De Klerk Air Pollutants 2002) Australian multi-city
et al. 2006) 8-hour average studies.
Perth. Meta-analysis of 4
European cities. CRF from Simpson
65+ years: No effect et al (Simpson,
(Morgan, Corbett et Williams et al. 2005)
al. 1998) may be used in a
Sydney. sensitivity analysis.
Asthma+COPD:
108
65+ years: 1.0013

(1.0001-1.0026) per
1 ppb
(Simpson, Williams
et al. 2005)
4-hour average.
Lag 0.
Asthma:
lCD9: 493; ICD10:
J45, J46, J44.8
COPD:
lCD9: 490-492, 494-
496; ICD10: J40-
J44, J47, J67
Pooled analysis
from 4 cities -
Brisbane, Sydney,
Melbourne, Perth.
15-64 years: No
effect
(Environment
Protection and
Heritage Council
2005)
1-hour maximum
Lag 01
Moderate to high
heterogeneity
Meta-analysis of 4
cities - Brisbane,
Melbourne, Perth
Sydney
109
lCD9: 490-492, 494-

496
ICDI0: J40-J44,
J47, J67
Pneumonia and All ages: No effect n/a n/a n/a n/a No CRF
acute bronchitis <15 years: No effect recommended.
(Hinwood, De Klerk No effect shown in
et al. 2006) Australian studies.
Perth
No effect.
(Simpson, Williams
et al. 2005)
65+ years.
ICD9: 466, 480-486
ICD10: J12-J17,
J18.0, J18.1, Jl8.8,
JI8.9, J20, J21
Pooled analysis
from 4 cities -
Brisbane, Sydney,
Melbourne, Perth.
0 years: No effect
1-4 years: No effect
15-64 years: No
effect
(Environment
Protection and
Heritage Council
2005)
110
High heterogeneity
for 15-64 years
only.
Meta-analysis of 4
cities - Brisbane,
Melbourne, Perth
Sydney.
ICD9: 466, 480-486
ICD10: J12-J17,
J18.0, J18.1, Jl8.8,
JI8.9, J20, J21
Asthma 1-4 years: 2.3% n/a n/a 1.022 (0.996-1.049) n/a Recommended
(1.4-3.2%) per 13.6 per 25 ppb CRF: 1-14 years:
ppb (Peel, Tolbert et al. 1.8% (1.1-2.5%) per
5-9 years: 2.1% 2005) 13.6 ppb
(0.7-3.5%) per 13.6 (Wilson, Wake et al. (Jalaludin, Khalaj et
ppb 2005) al. 2008).
10-14 years: No (Abt Associates Inc
effect. 2011)
1-14 years: 1.8% Pooled results from
(1.1-2.5%) per 13.6 3 cities and 2
ppb studies.
(Jalaludin, Khalaj et 8-hour maximum.
al. 2008) Age: 0-99 years.
1-hour maximum.
Lag 01.
Greater significant
effects in warm
months but not cool
months.
ICD9: 493
111
Children
Sydney
1-15 years
Non-linear
significant response
for Western &
South/South
Eastern regions (No
CRFs available). No
effect of O3 for Inner
Melbourne or
Eastern Melbourne
regions.
(Erbas, Kelly et al.
2005)
ICD10: J45, J46
Melbourne.
Respiratory disease n/a n/a n/a n/a n/a No CRF

recommended.


Lung function
Change in forced No effect of 1-hour n/a n/a n/a n/a No CRF
112
expiratory volume in maximum, 4-hour Lung function recommended.

1 second (FEV1; average and 8-hour deficits seen in
litres) average on PEF exercising children No effect in
either in all year exposed to daily Australian 6-cities
analysis or in warm maximum 8-hour study (Williams,
season only average of 160 Marks et al. 2012).
analysis µg/m3.
(Williams, Marks et (WHO 2006)
al. 2012)
Six cities – 10% change in
Adelaide, Brisbane, FEV1 at 160µg/m3
Canberra, (8-hour average)
Melbourne, Perth, and 350µg/m3 (1-
Sydney hour average).
Age: mean 10.0
years (n=270) 5% change in FEV1
270 children with at 120µg/m3 (8-hour
current asthma average) and
250µg/m3 (1-hour
average)
(WHO Europe
2000)
Controlled exposure
studies.
Change in peak Average change in n/a n/a n/a n/a No CRF

expiratory flow rate PEF: -0.8823 l/min recommended.
(PEF; litres per ( -0.0542 to -1.7104
minute) l/min) per 1 pphm No effect in
(Jalaludin, Chey et Australian 6-cities
Mean daytime Marks et al. 2012).
ozone.
148 children with
113
history of wheezing
in last 12 months.
Mean age: 9.6
years.
Sydney.
15-54 years:
-0.2047 l/min
(-0.2760 to -0.03342
l/min) per 1 pphm
8-hour average
3-day average
Spring
55+ years:
-0.1568 l/min
(-0.2864 to -0.0272
l/min) per 1 pphm
8-hour average
Lag 2
Winter
(Rutherford,
Simpson et al.
2000)
Brisbane
Asthmatics allergic
to at least one
pollen or fungal
allergen.
No effect of 1-hour
maximum, 4-hour
average and 8-hour
average on PEF
either in all year
114
analysis or in warm
season only
analysis.
(Williams, Marks et
al. 2012)
Six cities –
Adelaide, Brisbane,
Canberra,
Melbourne, Perth,
Sydney.
Age: mean 10.0
years.
270 children with
current asthma.
Minor morbidity
Asthma n/a n/a n/a 1.0018 (1.0004- n/a Recommended

exacerbation 1.0032) per 1 ppb CRF: 1.0018
(asthmatics) However, CRF from (Whittemore and (1.0004-1.0032) per
Whittemore and Korn 1980) 1 ppb (Whittemore
Korn 1980 used in (US EPA 1999) and Korn 1980)
health risk Asthmatics of all (US EPA 1999)
assessment ages
1-hour maximum
Asthma/ respiratory n/a n/a No effect. n/a n/a No CRF

exacerbations (Hoek and 25% increased recommended.
(whole population) Brunekreef 1995; symptoms in adults
Declerq and or asthmatics per CRF from European
Macquet 2000)) 100 µg/m3 (8-hour Commission
(European average) and 200 (European
Commission 2005) µg/m3 (1-hour Commission 2005)
115
Whole population of average). is not statistically

children aged 5-14 (WHO Europe significant and
years 2000) CRFs from WHO
France. (WHO Europe 2000)
8-hour daily do not have
maximum . associated
confidence limits.

hyper- recommended.
responsiveness

Minor restricted n/a 1.48% (0.57- 1.48% (0.57-2.38%) 1.0022 (1.0009- n/a Recommended
activity days 2.38%) per 10 per 10 µg/m3 1.0035) per 1 ppb CRF: 1.0022
(MRAD)3 µg/m3 8-hour average (Ostro and (1.0009-1.0035) per
8-hour average 0.11% (0.043- Rothschild 1989) 1 ppb
0.11% (0.043- 0.179%) per 1 (US EPA 1999) (Ostro and
0.179%) per 1 µg/m3 (Abt Associates Inc Rothschild 1989)
µg/m3 1-hour maximum 2011) (US EPA 1999)
(Ostro and (Ostro and 1-hour maximum. (Abt Associates Inc
Rothschild 1989) in Rothschild 1989). Age: 18-65 years. 2011)
(European (European O3 adjusted for
Commission 1995) Commission 2005) PM2.5 in study.
(AEA Technology Age: 18+ years.
Environment 2005) Whole population.
Age: Adults. O3 adjusted for
1-hour maximum PM2.5 in study.
O3 adjusted for
PM2.5 in study.
116

(WLD)2 Pooled estimate recommended.
from 2 studies –
unable to locate
CRF.
(Abt Associates Inc
2011)

recommended.
Upper respiratory n/a n/a n/a n/a n/a No CRF

illness recommended.
Lower respiratory n/a n/a n/a n/a n/a No CRF

Acute respiratory No effect on cough, n/a Presence of any 19 Presence of any 19 n/a No CRF
symptoms wheeze, acute respiratory acute respiratory recommended.
runny/blocked nose. symptoms: symptoms:
(Rodriguez et al, 1.0055 (1.0002- 1.0001 (1.0000- CRF by Krupnick et
2007) 1.0109) per 10 ppb 1.0003) per 1 ppb al (Krupnick,
Perth. (Krupnick, (Krupnick, Harrington et al.
Harrington et al. Harrington et al. 1990) may be used
1990) 1990) in a sensitivity
(European (US EPA 1999) analysis.
Commission 1995). Age: 18-65 years.
(AEA Technology Whole population. This endpoint not
Environment 2005) 1-hour maximum. used by US EPA in
its most recent cost-
benefit analysis
(US EPA 2011).
117
Wheeze No effect. n/a n/a n/a n/a No CRF

(Rodriguez et al, recommended.
2007)
Perth. No effects have
been shown in
Evening wheeze: Australian studies
No effect including the 6-cities
(Jalaludin, O'Toole study (Williams,
et al. 2004) Marks et al. 2012).
148 children.
Mean age 9.6
years.
Sydney.
Day wheeze: No
effect of 1-hour
maximum, 4-hour
average or 8-hour
average in either all
year analysis or
warm season only
analysis except for
protective effect for
8-hour average in
all year analysis.
Night symptoms:
Protective effects
for 1-hour
maximum, 4-hour
average and 8-hour
average in both all
year analysis and
warm season only
118
analysis
(Williams, Marks et
al. 2012)
Six cities –
Adelaide, Brisbane,
Canberra,
Melbourne, Perth,
Sydney
Age: mean 10.0
years
270 children with
current asthma
Cough No effect. n/a Incidence night n/a n/a No CRF

(Rodriguez et al, cough: recommended.
2007) No effect
Perth (Just et al. 2002) No effects have
(European been shown in
Evening dry/wet Commission 2005) Australian studies
cough: No effect. Based on 1 study including the 6-cities
(Jalaludin, O'Toole (82 children aged 7- study (Williams,
et al. 2004) 15 years with doctor Marks et al. 2012).
148 children. diagnosed asthma
Mean age 9.6 taking daily asthma
years. medications).
Sydney. 8-hour daily
average.
Day cough: No
effect of 1-hour Prevalence cough:
maximum, 4-hour No effect.
average and 8-hour (Declerq and
average in either all Macquet 2000)
year analysis or in (European
warm season only Commission 2005)
119
analysis. Whole population of

children aged 5-14
Night cough: No years.
effect of 1-hour France.
maximum, 4-hour
average and 8-hour
year analysis or in
warm season only
analysis.
(Williams, Marks et
al. 2012)
Six cities –
Adelaide, Brisbane,
Canberra,
Melbourne, Perth,
Sydney.
Age: mean 10.0
years.
270 children with
current asthma.
Shortness of breath Day SOB: No effect n/a n/a n/a n/a No CRF
of 1-hour maximum, recommended.
4-hour average and
8-hour average in No effects shown in
either all year Australian 6-cities
analysis or in warm study (Williams,
season only Marks et al. 2012).
analysis.
Night SOB: No
effect of 1-hour
maximum, 4-hour
120
average and 8-hour

year analysis or in
warm season only
analysis
(Williams, Marks et
al. 2012)
Six cities –
Adelaide, Brisbane,
Canberra,
Melbourne, Perth,
Sydney.
Age: mean 10.0
years.
270 children with
current asthma.
Bronchodilator use No effect n/a Days of n/a n/a No CRF

(Jalaludin, O'Toole supplementary recommended.
et al. 2004) bronchodilator use.
148 children 5-14 years: 1.41 No effects shown in
Mean age 9.6 years (1.05-1.89) per 10 Australian 6-cities
Sydney µg/m3 study (Williams,
(Gielen, van der Zee Marks et al. 2012).
Day use: No effect et al. 1997; Just,
of 1-hour maximum, Segala et al. 2002)
4-hour average and Recommended
8-hour average in using as upper limit
either all year for sensitivity
analysis or in warm analyses only, as
season only based on 1 study
analysis (82 children aged 7-
15 years with doctor
Night use: No effect diagnosed asthma
121
of 1-hour maximum, taking daily asthma

4-hour average and medications) only
8-hour average in with high odds
either all year ratios. Odds ratios
analysis or in warm based on days
season only when children not
analysis taking
(Williams, Marks et corticosteroids.
al. 2012) (European
Six cities – Commission 2005)
Adelaide, Brisbane,
Canberra, Adults 20+ years:
Melbourne, Perth, No effect.
Sydney. (ECRHS 1996;
Age: mean 10.0 Hiltermann, Stolk et
years. al. 1998).
270 children with (European
current asthma. Commission 2005)
Adults with well-
established asthma.
8-hour maximum
moving average.

Increased Day symptoms: No n/a n/a n/a n/a No CRF

respiratory effect of 1-hour recommended.
symptoms maximum, 4-hour
average or 8-hour No effects shown in
average on any day Australian 6-cities
symptoms (cough, study (Williams,
wheeze, shortness Marks et al. 2012).
of breath, runny
122

fever) in either all
year analysis or
warm season only
analysis except for
protective effect for
8-hour average in
all year analysis.
Night symptoms: No
effect of 1-hour
maximum, 4-hour
average or 8-hour
average on any
night symptoms
(cough, wheeze,
shortness of breath)
in either all year
analysis or warm
season only
analysis
(Williams, Marks et
al. 2012)
Six cities –
Adelaide, Brisbane,
Canberra,
Melbourne, Perth,
Sydney
Age: mean 10.0
years
270 children with
current asthma
General practitioner No effect n/a n/a n/a n/a No CRF

123
consultation for (Jalaludin, O'Toole recommended.

asthma et al. 2004)
148 children
Mean age 9.6 years
Sydney
General practitioner n/a n/a Consultations for n/a n/a No CRF

consultation for allergic rhinitis: recommended.
upper respiratory 0-14 years: 8.2%
disease (5.1-11.6%) per 10 May use CRFs from
µg/m3 paper by Hajat et al
15-64 years: 5.5% (Hajat, Haines et al.
(4.2-7.0%) 10 µg/m3 2001) in a sensitivity
(Hajat, Haines et al. analysis.
2001) in (Hurley,
Hunt et al. 2005)
(European
Commission 2005)
London
(ICD9: 477)
Lag 0-3
8-hour daily
maximum
Recommended
using only for
sensitivity analyses
as based on 1 study
only.
1
n/a=not available
2
3
124
REFERENCES
Environment.
Anderson, H. R., R. W. Atkinson, et al. (2004). Meta-Analysis of Time-Series Studies and Panel Studies of Particulate Matter (PM) and Ozone (O 3). Copenhagen, World
Health Organization Regional Office for Europe: 80.
United Kingdom.
Committee on the Medical Effects of Air Pollutants (2002). Is there a threshold for the effect of ozone on health? 1. Is there an effect on mortality and respiratory or
circulatory admissions? London, Department of Health, United Kingdom.
Declerq, C. and V. Macquet (2000). "Short-term Effects of Ozone on Respiratory Health of Children in Armentieres, North of France." Rev Epidemiol Sante Publique
48(Suppl 2): S37-43.
ECRHS (1996). "European Community Respiratory Health Survey: Variations in the prevalence of respiratory symptoms, self-reported asthma attacks, and use of asthma
medication in the European Community Respiratory Health Survey (ECRHS). ." Eur Respir J 9: 687-695.
Gielen, M. H., S. C. van der Zee, et al. (1997). "Acute effects of summer air pollution on respiratory health of asthmatic children." American Journal of Respiratory and
Hajat, S., A. Haines, et al. (2001). "Association between air pollution and daily consultations with general practitioners for allergic rhinitis in London, United Kingdom."
American Journal of Epidemiology 153(7): 704-714.
Research 103(3): 383-389.
Hiltermann, T. J., J. Stolk, et al. (1998). "Asthma severity and susceptibility to air pollution." European Respiratory Journal 11(3): 686-693.
Hinwood, A., N. De Klerk, et al. (2006). "The relationship between changes in daily air pollution and hospitalizations in Perth, Australia 1992 - 1998: A case-crossover
study." International Journal of Environmental Health Research 16(1): 27-46.
125
Hoek, G. and B. Brunekreef (1995). "Effect of photochemical air pollution on acute respiratory symptoms in children." American Journal of Respiratory and Critical Care
Medicine 151(1): 27-32.
Hurley, F., A. Hunt, et al. (2005). Methodology Paper (Volume 2) for Service Contract for Carrying out Cost-Benefit Analysis of Air Quality Related Issues, In Particular in
the Clean Air for Europe (CAFE) Programme. Oxon, UK, AEA Technology Environment.
Jerrett, M., R. T. Burnett, et al. (2009). "Long-term ozone exposure and mortality." New England Journal of Medicine 360(11): 1085-1095.
Just, J., C. Segala, et al. (2002). "Short-term health effects of particulate and photochemical air pollution in asthmatic children." European Respiratory Journal 20(4): 899-906.
18(1): 1-18.
McDonnell, W. F., D. E. Abbey, et al. (1999). "Long-term ambient ozone concentration and the incidence of asthma in nonsmoking adults: the AHSMOG Study."
Environmental Research 80(Section A): 110-121.
Ostro, B. D. and S. Rothschild (1989). "Air pollution and acute respiratory morbidity: an observational study of multiple pollutants." Environmental Research 50(2): 238-247.
Health 56(1): 37-52.
Health 29(3): 205-212.
Health 29(3): 213-221.
Sunyer, J., J. Castellsague, et al. (1996). "Air pollution and mortality in Barcelona." Journal of Epidemiology & Community Health 50(Suppl 1): s76-s80.
US EPA (2011). The benefits and costs of the Clean Air act from 1990 to 2020, U.S. Environmental Protection agency, USA.
Whittemore, A. S. and E. L. Korn (1980). "Asthma and air pollution in the Los Angeles area." American Journal of Public Health 70(7): 687-696.
WHO (2006). "WHO Air Quality Guidelines for Particulate Matter, Ozone, Nitrogen Dioxide and Sulfur Dioxide. Global Update 2005. Summary of Risk Asessment.".
126
Wilson, A. M., C. P. Wake, et al. (2005). "Air pollution, weather, and respiratory emergency room visits in two northern New England cities: an ecological time-series
study." Environmental Research 97(3): 312-321.
127
Table 4: NO2 health endpoints and associated concentration–response functions
Mortality
All cause n/a1 n/a n/a n/a n/a No CRF
Results recommended.
inconsistent.
(US EPA 2008)

age) recommended.

(years of life lost; recommended.
YOLL)
Morbidity

pulmonary disease
(COPD) or chronic
bronchitis
Incidence of asthma Ever had wheezing: n/a n/a n/a n/a Recommended CRF
No effect in single Results for asthma
pollutant model. inconsistent. incidence: 1.27
Largest effect in 2- (US EPA 2008) (1.04-1.56) per 4.31
128
pollutant model with ppb (in 2-pollutant

PM2.5: 1.15 (1.01- model with CO)
1.31) per 4.31 ppb (Williams, Marks et
al. 2012).
Ever had asthma:
No effect in single
pollutant model.
Largest effect in 2-
CO: 1.27 (1.04-
1.56) per 4.31 ppb
(Williams, Marks et
al. 2012)
Six cities –
Adelaide, Brisbane,
Canberra,
Melbourne, Perth,
Sydney.
Average hourly NO2
over lifetime.
Age: mean age10.0
years.
2,860 children.
Recent symptoms Wheeze: 1.25 n/a n/a n/a n/a Recommended

(in last 12 months) (1.07-1.46) per 4.31 CRFs:
ppb in 2-pollutant Wheeze: 1.25
model with PM2.5 (1.07-1.46) per 4.31
ppb in 2-pollutant
Wheeze after model with PM2.5
exercise: 1.43
(1.05-1.96) per 4.31 Wheeze after
ppb in 2-pollutant exercise: 1.43
model with CO (1.05-1.96) per 4.31
129
ppb in 2-pollutant
Current asthma: model with CO
1.51
(1.08-2.12) per 4.31 Current asthma:
ppb in 2-pollutant 1.51
ppb in 2-pollutant
Visit to model with CO
doctor/hospital: 1.51
(1.04-2.19) per 4.31 Visit to
ppb in 2-pollutant doctor/hospital: 1.51
model with O3 (1.04-2.19) per 4.31
ppb in 2-pollutant
Use of model with O3
bronchodilators:
1.35 Use of
(1.05-1.76) per 4.31 bronchodilators:
ppb in 2-pollutant 1.35
(Williams, Marks et ppb in 2-pollutant
al. 2012) model with CO
Six cities – (Williams, Marks et
Adelaide, Brisbane, al. 2012).
Canberra,
Melbourne, Perth,
Sydney.
Average hourly NO2
over lifetime .
Age: mean age10.0
years.
2,860 children.

growth recommended.
130
Change in forced -26.2 mls (-42.2 to n/a n/a n/a n/a Recommended
expiratory volume in -10.1 mls) per 4.31 CRF: -45.4 mls
1 second (FEV1; ppb in single (-74.3 to -16.5 mls)
litres) pollutant model per 4.31 ppb (in 2-
Minimal change in CO) (Williams,
estimates in 2- Marks et al. 2012).
pollutant models
with PM2.5, PM10, O3.
Effect increased in
2-pollutant model
with CO: -45.4 mls
(-74.3 to -16.5 mls)
per 4.31 ppb
(Williams, Marks et
al. 2012)
Six cities –
Adelaide, Brisbane,
Canberra,
Melbourne, Perth,
Sydney.
Average hourly NO2
over lifetime.
Age: mean age10.0
years.
2,860 children.
Change in forced -25.3 mls (-40.6 to Recommended

vital capacity (FVC; -10.0 mls) per 4.31 CRF: -43.1 mls
litres) ppb in single (-72.2 to -14.1 mls)
pollutant model. per 4.31 ppb (in 2-
131
Minimal change in O3) (Williams, Marks

estimates in 2- et al. 2012).
pollutant models
with PM2.5, PM10, O3.
Effect increased in
2-pollutant model
with O3: -43.1 mls (-
72.2 to -14.1 mls)
per 4.31 ppb
(Williams, Marks et
al. 2012)
Six cities –
Adelaide, Brisbane,
Canberra,
Melbourne, Perth,
Sydney.
Average hourly NO2
over lifetime.
Age: mean age10.0
years.
2,860 children.
Airway inflammation 1.03 (1.01-1.05) per n/a n/a n/a n/a Recommended
1 ppb in single CRF: 1.03 (1.01-
pollutant model. 1.05) per 1 ppb
Remains significant (Williams, Marks et
in 2-pollutant al. 2012).
models with PM2.5,
PM10, O3 and SO2
and CO.
(Williams, Marks et
al. 2012)
Six cities –
132
Adelaide, Brisbane,
Canberra,
Melbourne, Perth,
Sydney.
Average hourly NO2
over lifetime.
Age: mean age10.0
years.
2,860 children.
Birth outcomes
Birth defects No significant n/a n/a n/a n/a No CRF

associations for cleft recommended.
lip and/or palate and
cardiac defects. Only 1 Australian
(Hansen, Barnett et study.
al. 2009)
Brisbane
Prematurity 1.03 (0.86–1.23) n/a n/a n/a n/a No CRF

per 4.5 ppb recommended.
(Hansen, Neller et
Brisbane studies - no effect
24-hour average shown.
Exposure period 3
months preceding
birth.
1.006 (0.993-1.019)
per 1 ppb
(Jalaludin, Mannes
133
et al. 2007)
Sydney
1-hour maximum
Exposure period 3
months preceding
birth.
Low birth weight 1.01 (1.00-1.02) per n/a n/a n/a n/a No CRF
1 ppb for small for recommended.
gestation age
Only a few
-1.48 (-2.70 to Australian studies.
-0.26) grams per 1
ppb
(Mannes, Jalaludin
et al. 2005)
Sydney
1-hour maximum
Exposure period
third trimester for
both metrics.
Small for gestation
age <2 standard
deviations from
mean for sex and
gestational age.
Short-term outcomes(daily average concentration)

Mortality
Non-trauma 1.0012 (1.0006- 3.5% (1.6-5.4%) per n/a n/a n/a Recommended
1.0018) per 1 ppb 100 ug/m3 (US EPA 2008) CRF: 1.7% (0.3-
134
(Simpson, Williams (Touloumi, Suggestive but not 3.2%) per 8.98 ppb
et al. 2005) Katsouyanni et al. sufficient to infer a (Environment
Pooled CRF from 4 1997) causal relationship Protection and
cities (Committee on the as it is difficult to Heritage Council
ICD9: <800; ICD10: Medical Effects of attribute effects to 2005).
A-R, Z35.5, Z35.8 Air Pollutants 1998) NO2 alone.
Age: All Pooled CRF from 6 However, estimates
cities. were robust to
1.7% (0.3-3.2%) per adjustment for co-
8.98 ppb pollutants.
(Environment
Protection and
Heritage Council
2005)
1-hour maximum
Lag 01
Age: All
All year.
Moderate
heterogeneity.
Meta-analysis of 5
cities-Brisbane,
Canberra,
Melbourne, Perth,
Sydney.
ICD9: <800; ICD10:
A-R, Z35.5, Z35.8
Cardiovascular 1.0018 (1.0008- 1.0% (0.8-1.3%) per n/a n/a n/a Recommended
1.0027) per 1 ppb 10 ug/m3 Suggestive but not CRF: 1.6% (0.4-
(Simpson, Williams (Committee on the sufficient to infer a 2.8%) per 8.98 ppb
et al. 2005) Medical Effects of causal relationship (Environment
Pooled CRF from 4 Air Pollutants 2006) as it is difficult to Protection and
cities. Moderate evidence attribute effects to Heritage Council
135
ICD9: 390-459; of publication bias. NO2 alone. 2005).

ICD10: I00-I99 CRF not intended However, estimates
(excluding I67.3, for health risk were robust to
I68.0, I88, I97.8, assessment adjustment for co-
I97.9, I98.0), G45 purposes. pollutants.
(excluding G45.3), (US EPA 2008)
G46, M30, M31,
R58
Age: All
1.6% (0.4-2.8%) per

8.98 ppb
(Environment
Protection and
Heritage Council
2005)
1-hour maximum
Lag 01
Age: All ages
All year
No heterogeneity.
Meta-analysis of 5
cities-Brisbane,
Canberra,
Melbourne, Perth,
Sydney.
ICD9: 390-459
ICD10: I00-I99
(excluding I67.3,
I68.0, I88, I97.8,
I97.9, I98.0), G45
(excluding G45.3),
G46, M30, M31,
R58
136
Respiratory 1.0038 (1.0017- No effect. n/a n/a n/a Recommended

1.0058) per 1 ppb (Zmirou, Schwartz CRF: 3.9% (0.6-
(Simpson, Williams et al. 1998) 7.4%) per 8.98 ppb
et al. 2005) (Committee on the (Environment
Pooled CRF from 4 Medical Effects of Protection and
cities. Air Pollutants 1998) Heritage Council
ICD9: 460-519 2005).
ICD10: J00-J99
(excluding J95.4 to
J95.9), R09.1,
R09.8
Age: All
3.9% (0.6-7.4%) per

8.98 ppb
(Environment
Protection and
Heritage Council
2005)
1-hour maximum
Lag 01
Age: All ages
All year
No heterogeneity
Meta-analysis of 5
cities-Brisbane,
Canberra,
Melbourne, Perth,
Sydney.
ICD9: 460-519
ICD10: J00-J99
(excluding J95.4 to
J95.9), R09.1,
137
R09.8
Hospitalisation
Cardiovascular n/a for all n/a n/a n/a n/a Recommended

cardiovascular CRF: 1.3% (0.3-
disease 2.3%) per 8.98 ppb
Four cities study. in 15-64 years;
(Simpson, Williams 2.6% (1.8-3.3%)
et al. 2005) per 8.98 ppb in 65+
years (Environment
No effect Protection and
(Petroeschevsky, Heritage Council
Simpson et al. 2005).
2001)
Brisbane
ICD9: 390-459
Age: All
Heart disease:
7.52% (5.21-9.88%)
per 17 ppb
(Morgan, Corbett et
al. 1998)
Sydney
Age: All
ICD9: 410, 413,
427, 428
24-hour average
15-64 years: 1.3%

(0.3-2.3%) per 8.98
ppb
65+ years: 2.6%
138
(1.8-3.3%) per 8.98

ppb
(Environment
Protection and
Heritage Council
2005)
1-hour maximum
Lag 01
(Barnett, Williams et
al. 2005)
Meta-analysis of 5
cities - Brisbane,
Canberra,
Melbourne, Perth,
Sydney
Low heterogeneity
ICD9: 390-459;
ICD10: I00-I99
(excluding I67.3,
I68.0, I88, I97.8,
I97.9, I98.0), G45
(excluding G45.3),
G46, M30, M31,
R58
Cardiac 1.0022 (1.0016- 1.3% (1.0-1.7%) per n/a n/a n/a Recommended
1.0028) per 1 ppb 10 ug/m3 Inadequate CRF:
(Simpson, Williams (Committee on the evidence for causal 15-64 years: 1.2%
et al. 2005) Medical Effects of relationship, but (0.0-2.4%) per 8.98
Pooled estimate Air Pollutants 2006) generally positive ppb in 15-64 years;
from 4 cities No evidence of associations seen 3.3% (2.4-4.3%) per
(Sydney, Perth, publication bias. with cardiovascular 8.98 ppb in 15-64
Melbourne, CRF not intended disease years (Environment
Brisbane) for health risk hospitalisations or Protection and
139
lCD9: 390-429 assessment emergency Heritage Council

ICDI0: I00-I52, purposes. department 2005). Chosen as it
I97.0, I97.1, I98.1 presentations. is a more recent
Age: All (US EPA 2008) study.
1-hour maximum
In a sensitivity
15-64 years: 1.2% analysis use the
(0.0-2.4%) per 8.98 following CRFs:
ppb 1.0022 (1.0016-
65+ years: 3.3% 1.0028) per 1 ppb
(2.4-4.3%) per 8.98 (Simpson, Williams
ppb et al. 2005).
(Environment This study applies to
Protection and all ages.
Heritage Council
2005)
1-hour maximum
Lag 01
Meta-analysis of 5
cities - Brisbane,
Canberra,
Melbourne, Perth,
Sydney
Low heterogeneity
lCD9: 390-429;
ICDI0: I00-I52,
I97.0, I97.1, I98.1
Cardiac failure 15-64 years: No 1.3% (0.4-2.3%) n/a n/a n/a Recommended
effect change per 10 CRF: 7.5% (5.3-
65+ years: 7.5% ug/m3 9.7%) per 8.98 ppb
(5.3-9.7%) per 8.98 (Committee on the in 65+ years
ppb Medical Effects of (Environment
(Environment Air Pollutants 2006) Protection and
140
Protection and Weak evidence of Heritage Council

Heritage Council publication bias. 2005).
2005) CRF not intended
1-hour maximum for health risk
Lag 01 assessment
Meta-analysis of 5 purposes.
cities - Brisbane,
Canberra,
Melbourne, Perth,
Sydney
Low heterogeneity
ICD9: 428; ICD10:
I50
Cerebrovascular Stroke: 0.4% (0.0-0.8%) per n/a n/a n/a No CRF

15-64 years: No 10 ug/m3 recommended.
effect (Committee on the
65+ years: No effect Medical Effects of This CRF may be
(Environment Air Pollutants 2006) used in a sensitivity
Protection and No evidence of analysis: 0.4% (0.0-
Heritage Council publication bias. 0.8%) per 10 ug/m3
2005) CRF not intended (Committee on the
1-hour maximum for health risk Medical Effects of
Lag 01 assessment Air Pollutants 2006).
Meta-analysis of 5 purposes. However note that
cities - Brisbane, CRF not intended
Canberra, for health risk
Melbourne, Perth, assessment
Sydney. purposes.
Low heterogeneity.
ICD9: 430-438;
ICD10: I60-I66, I67
(excluding I67.0,
I67.3), I68
141
(excluding I68.0),
I69, G45 (excluding
G45.3), G46
Ischaemic heart 1.0017 (1.0007- 0.6% (-0.1 to 1.4%) n/a n/a n/a Recommended
disease 1.0027) per 1 ppb per 10 ug/m3 CRF: 1.0017
(Simpson, Williams (Committee on the (1.0007-1.0027) per
et al. 2005) Medical Effects of 1ppb (Simpson,
Pooled estimate Air Pollutants 2006) Williams et al.
from 4 cities No evidence of 2005).
(Sydney, Perth, publication bias.
Melbourne, CRF not intended The following CRF
Brisbane) for health risk may be used in a
lCD9: 410-413; assessment sensitivity analysis:
ICDI0: I20-I22, I24, purposes. 2.7% (1.5-4.0%) per
I25.2 8.98 ppb in 65+
Age: All years (Environment
1-hour maximum Protection and
Heritage Council
15-64 years: No 2005). Note the
effect restricted agegroup.
65+ years: 2.7%
(1.5-4.0%) per 8.98
ppb
(Environment
Protection and
Heritage Council
2005)
1-hour maximum
Lag 01
Meta-analysis of 5
cities - Brisbane,
Canberra,
Melbourne, Perth,
142
Sydney.
Low heterogeneity.
lCD9: 410-413;
ICDI0: I20-I22, I24,
I25.2
Arrhythmia 15-64 years: 3.4% n/a n/a n/a n/a Recommended

(0.7-6.3%) per 8.98 CRF: 3.4% (0.7-
ppb 6.3%) per 8.98 ppb
65+ years: No effect in 15-64 years
2005) 2005).
1-hour maximum
Lag 01
Meta-analysis of 5
cities - Brisbane,
Canberra,
Melbourne, Perth,
Sydney.
Low heterogeneity.
ICD9: 437; ICD10:
I46-I49
Myocardial 15-64 years: No n/a n/a n/a n/a Recommended

infarction effect CRF: 4.8% (2.3-
65+ years: 4.8% 7.4%) per 8.98 ppb
(2.3-7.4%) per 8.98 in 65+ years
ppb (Environment
2005)
143
1-hour maximum
Lag 01
Meta-analysis of 5
cities - Brisbane,
Canberra,
Melbourne, Perth,
Sydney.
Low heterogeneity.
lCD9: 410; ICDI0:
I21, I22
Respiratory 65+ years: 1.0016 No effect n/a n/a n/a Recommended

(1.0006-1.0026) per (Spix, Anderson et Consistent evidence CRF:
1 ppb al. 1998) of positive 1-4 years: 3.6%
Pooled estimate (Committee on the associations. (1.5-5.7%) per 9.0
from 4 cities - Medical Effects of (US EPA 2008) ppb; 5-14 years:
Sydney, Perth, Air Pollutants 1998), 4.0% (1.1-7.1%) per
Melbourne, Pooled CRF from 5 9.0 ppb; 15-64
Brisbane. cities. years: 1.6% (0.5-
lCD9: 460-519 2.8%) per 9.0 ppb
ICDI0: J00-J99 2.5% (95%CI not (Environment
(excluding J95.4- available) per 10 Protection and
J95.9), R09.1, ug/m3 Heritage Council
R09.8 (DEFRA 2006) 2005).
1-hour maximum (Committee on the
Medical Effects of 65+ years: 1.0016
1-4 years: 3.6% Air Pollutants 1998) (1.0006-1.0026) per
(1.5-5.7%) per 9.0 ICD9: 460-519 1 ppb (Simpson,
ppb Williams et al. 2005)
5-14 years: 4.0%
(1.1-7.1%) per 9.0
ppb
15-64 years: 1.6%
(0.5-2.8%) per 9.0
144
ppb
65+ years: No
effect.
(Environment
Protection and
Heritage Council
2005)
Meta-analysis of 5
cities - Brisbane,
Canberra,
Melbourne, Perth,
Sydney.
Low heterogeneity.
lCD9: 460-519;
ICDI0: J00-J99
(excluding J95.4-
J95.9), R09.1,
R09.8
1-hour maximum
Asthma 1-14 years: 5.29% 2.6% (0.6-4.9%) per n/a n/a n/a No CRF
(1.07-9.68%) per 29 50 ug/m3 Consistent evidence recommended.
ppb (Sunyer, Spix et al. of positive
(Morgan, Corbett et 1997) associations, 2 Australian multi-
al. 1998) (Committee on the particularly for cities studies have
Sydney Medical Effects of asthma. shown no effects.
ICD9: 493 Air Pollutants 1998) (US EPA 2008)
1-hour maximum Pooled CRF from 4 May use either
cities. 0-29 years: 1.0243 Morgan et al
No effect 24-hour average (1.0084-1.0405) per (Morgan, Corbett et
(Simpson, Williams ?Age 10 ppb al. 1998) CRF in a
et al. 2005) 30-99 years: 1.0141 sensitivity analysis.
Pooled CRF from 4 (1.0042-1.0241) per Note the restricted
cities (Sydney, 10 ppb age group.
145
Perth, Melbourne, (Linn, Szlachcic et

Brisbane) al. 2000)
lCD9: 493; ICDI0: (US EPA 2010)
J45, J46, J44.8 (Abt Associates Inc
1-hour maximum 2011)
ICD9: 493
1-4 years: No effect All ages
5-14 years: No
effect
15-64 years: No
effect
(Environment
Protection and
Heritage Council
2005)
Meta-analysis of 5
cities - Brisbane,
Canberra,
Melbourne, Perth,
Sydney.
Moderate
heterogeneity
Brisbane, Canberra,
Melbourne, Perth,
Sydney.
lCD9: 493; ICDI0:
J45, J46, J44.8
1-hour maximum
Chronic obstructive 65+ years: 1.0019 1.9% (0.2-4.7%) per n/a Pooled CRF from 2 n/a No CRF
pulmonary disease (1.0005-1.0033) per 50 ug/m3 analyses shown recommended.
(COPD) 1 ppb (Anderson, Spix et below (pooled CRF
(Simpson, Williams al. 1997) not available) No effect in the 5-
146
et al. 2005) (Committee on the cities meta-analysis

Pooled estimate Medical Effects of LA County: 1.0182 (Environment
from 4 cities - Air Pollutants 1998) (1.0144-1.0219) per Protection and
Sydney, Perth, Pooled CRF from 6 10 ppb Heritage Council
Melbourne, cities Cook County: 2005).
Brisbane. 1.0243 (1.0083-
lCD9: 490-496; 1.0405) per 10 ppb May use the CRF
ICDI0: J40-47, J67 (Moolgavkar 2003) (65+ years: 1.0019
1-hour maximum (US EPA 2010) (1.0005-1.0033) per
Asthma+COPD (Abt Associates Inc 1 ppb) from
2011) Simpson et al
15-64 years: No ICD9: 490-496 (Simpson, Williams
effect Age: > 65 years et al. 2005) in a
65+ years: No effect sensitivity analysis.
(Environment
Protection and
Heritage Council
2005)
Moderate
heterogeneity for
65+ years.
Meta-analysis of 5
cities - Brisbane,
Canberra,
Melbourne, Perth,
Sydney.
lCD9: 490-492, 494-
496; ICDI0: J40-
J44, J47, J67
1-hour maximum
Pneumonia and 65+ years: 1.0018 n/a n/a n/a n/a No CRF
acute bronchitis (1.0002-1.0033) per recommended.
1 ppb
147
(Simpson, Williams No effect in the 5-

et al. 2005) cities meta-analysis
Pooled estimate (Environment
from 4 cities - Protection and
Sydney, Perth, Heritage Council
Melbourne, 2005).
Brisbane.
ICD9: 466, 480-486; May use the CRF
ICD10: J12-J17, (65+ years: 1.0018
J18.0, J18.1, Jl8.8, (1.0002-1.0033) per
JI8.9, J20, J21 1 ppb) from
Simpson et al
(Simpson, Williams
0 years: No effect et al. 2005) in a
1-4 years: No effect sensitivity analysis.
15-64 years: No
effect
(Environment
Protection and
Heritage Council
2005)
Moderate
heterogeneity.
Meta-analysis of 5
cities - Brisbane,
Canberra,
Melbourne, Perth,
Sydney.
ICD9: 466, 480-486;
ICD10: J12-J17,
J18.0, J18.1, Jl8.8,
JI8.9, J20, J21
148
Asthma Western Melbourne: n/a n/a No CRF n/a Recommended

1.15 (1.03-1.27) per Consistent evidence CRF: Two pollutant
28.9 ppb of positive model with PM2.5:
(Erbas, Kelly et al. associations. 1.1% (0.6-1.6%) per
2005) (US EPA 2008) 9.5 ppb (Jalaludin,
Melbourne Khalaj et al. 2008).
ICD10: J45, J46 Pooled CRF from 3
Age: 1-15 years studies (pooled US EPA (Abt
Modelled air CRF unavailable). Associates Inc
pollution data using 1.14 (1.09-1.19) per 2011) pooled CRF,
TAPM. 24 ppb if available, would
Lag 2 daily 1-hour (Ito, Thurston et al. be more suitable as
maximum. 2007) it applies to all ages.
1.08 (1.00-1.17)
Single pollutant per 34 ppb
model: 2.3% (1.4, (NYDOH 2006)
3.2%) per 9.5 ppb 1.047 (1.011-1.085)
Two pollutant model per 20 ppb
with PM2.5: 1.1% (Peel, Tolbert et al.
(0.6-1.6%) per 9.5 2005)
ppb 1-hour maximum
(Jalaludin, Khalaj et (US EPA 2010)
al. 2008) (Abt Associates Inc
Sydney 2011)
Age: 1-14 years ICD9: 493
1-hour maximum Age: All
1.21 (1.03–1.43) per

1ppb
(Pereira, Cook et al.
2010)
Perth
149
Age: 0-4 years

24-hour average

Respiratory disease n/a n/a n/a No CRF n/a No CRF

Consistent evidence recommended.
of positive
associations.
(US EPA 2008)

(24-hour PM)
Lung function
Change in forced Morning FEV1: n/a n/a n/a n/a Recommended

expiratory volume in -0.0025 (-0.0047 to Inconsistent CRF:
1 second (FEV1; -0.0002) per 1 ppb evidence. Morning FEV1:
litres) (Williams, Marks et (US EPA 2008) -0.0025 (-0.0047 to
al. 2012) -0.0002) per 1 ppb
1-hour maximum (Williams, Marks et
Lag 2 al. 2012)..
Two-pollutant model
with O3
Six cities –
Adelaide, Brisbane,
Canberra,
Melbourne, Perth,
150
Sydney.
Age: mean 10.0
years.
270 children with
current asthma.
Change in peak No effect. n/a n/a n/a n/a Recommended

expiratory flow rate (Jalaludin, Chey et CRF:
(PEF; litres per al. 2000) Morning PEF:
minute) Sydney -0.4042 (-0.7318 to
125 children with a -0.0767) per 1 ppb
history of wheezing (Williams, Marks et
in previous 12 al. 2012).
months
Age: mean age
about 9.6 years
No effect.
(Rutherford,
Simpson et al.
2000)
Brisbane and
Ipswich
Mixed-models
Age: All
(n=53)
History of allergy to
pollen or fungi on
skin prick testing
Morning PEF:
-0.4042 (-0.7318 to
-0.0767) per 1 ppb
(Williams, Marks et
151
al. 2012)
1-hour maximum
Lag 2
Two-pollutant model
with O3
Six cities –
Adelaide, Brisbane,
Canberra,
Melbourne, Perth,
Sydney.
Age: mean 10.0
years.
270 children with
current asthma.
Minor morbidity n/a n/a n/a n/a n/a No CRF

recommended.
Asthma n/a n/a n/a Pooled CRF from 3 n/a No CRF

exacerbation studies (pooled recommended.
CRF unavailable).
Not clear from the Uunable to locate
reports how asthma pooled CRF used by
symptoms were US EPA.
combined.
(O'Connor, Neas et
al. 2008)
Slow play, missed
school days,
Night-time asthma.
(Ostro, Lipsett et al.

2001)
152
Cough, cough (new

cases), shortness of
breath, shortness of
breath (new cases),
wheeze, wheeze
(new cases).
(Schildcrout,
Sheppard et al.
2006)
One or more
symptoms.
(US EPA 2010)
(Abt Associates Inc
2011)
Age: 4–12 years
No effect
(Delfino, Zeiger et
al. 2002)
(US EPA 2010)
(Abt Associates Inc
2011)
Asthmatic children
Age: 13–18 years
One or more
symptoms
8-hour maximum

hyper- Increases observed (WHO 2006) recommended.
responsiveness in healthy adults Chamber studies of
with 1.5-2.0ppm (3- bronchial
hour) and in responsiveness in
153
asthmatics with asthmatics-effects

0.3ppm (30 seen > 200 µg/m3
minutes) or 0.1ppm (1-hour average).
(60 minutes).
(US EPA 2008)

Minor restricted n/a n/a n/a n/a n/a No CRF

(MRAD)3
(WLD)2 recommended.

(incidence, 8-12 recommended.
years)

Wheeze No effect. n/a n/a n/a n/a Recommended CRF

(Rodriguez, Tonkin in sensitivity
et al. 2007) analysis:
Age: 0-5 years 24-hour average
Perth Day wheeze:
24-hour average 1.0722 (1.0130-
1.1348) per 1 ppb in
No effect. 2-pollutant model
(Jalaludin, O'Toole with O3 (Williams,
154
et al. 2004) Marks et al. 2012).

148 children (mean
age about 9.6 Note inconsistency
years) with a history of results between
of wheezing in single and 2-
previous 12 months pollutant models.
Sydney.
Also note that two
1-hour maximum other Australian
Day wheeze: studies have not
1.0356 (1.0130- shown any effects.
1.0586) per 1 ppb
Lag 0
Day wheeze: No
effect in 2-pollutant
model with O3
Night wheeze: No
effect
24-hour average
Day wheeze:
1.0722 (1.0130-
2-pollutant model
with O3
Lag 0
Night wheeze:
1.0640 (1.0186-
1.1114) per 1 ppb
Night wheeze: No
model with O3
(Williams, Marks et
al. 2012)
155
Six cities –
Adelaide, Brisbane,
Canberra,
Melbourne, Perth,
Sydney.
Age: mean 10.0
years.
270 children with
current asthma.
Cough 1.028 (1.002-1.055) n/a n/a 1.17 (0.94-1.46) for n/a Recommended CRF
per ?1 ppm a 10 ppb in sensitivity
(Rodriguez, Tonkin (Schwartz, Dockery analysis:
et al. 2007) et al. 1994) 24-hour average
Age: 0-5 years (US EPA 2010) Night cough: 1.0447
Perth (Abt Associates Inc (1.0015-1.0898) per
24-hour mean 2011) 1 ppb in 2-pollutant
Not clear from the Age: 7-14 years model with O3
paper the metric for Lag 0-4 days (Williams, Marks et
NO2 concentration al. 2012).
used in the
calculation of CRF. Note inconsistency
of results between
Wet cough: 1.05 single and 2-
(1.00-1.10) per 8.2 pollutant models.
ppb
Dry cough: No
effect.
(Jalaludin, O'Toole
et al. 2004)
148 children (mean
age about 9.6
of wheezing in
156
previous 12 months.
Sydney.
1-hour maximum
Day cough:
1.0186 (1.0013-
1.0362) per 1 ppb
Lag 2
Day cough: No
model with O3
Night cough: 1.0282
(1.0096-1.0473) per
1 ppb
Lag 2
Night cough: No
model with O3
24-hour average
Day cough:
1.0535 (1.0219-
1.0861) per 1 ppb
Lag 0
Day cough: No
model with O3
Night cough: 1.0447
(1.0015-1.0898) per
1 ppb in 2-pollutant
model with O3
Lag 3
(Williams, Marks et
al. 2012)
157
Six cities –
Adelaide, Brisbane,
Canberra,
Melbourne, Perth,
Sydney
Age: mean 10.0
years
270 children with
current asthma
Shortness of breath 1-hour maximum n/a n/a n/a n/a No CRF

(SOB) Day SOB: No effect recommended as no
Night SOB: No effect in 2-pollutant
effect models in ACHAPS
(Williams, Marks et
24-hour average al. 2012).
Day SOB:
1.0594 (1.0134-
1.1075) per 1 ppb
Lag 0
Day SOB: No effect
in 2-pollutant model
with O3
Night SOB: 1.0771
(1.01835-1.1392)
Lag 3
Night SOB: No
model with O3
(Williams, Marks et
al. 2012)
Six cities –
Adelaide, Brisbane,
Canberra,
158
Melbourne, Perth,
Sydney.
Age: mean 10.0
years.
270 children with
current asthma.
Bronchodilator use No effect n/a n/a n/a n/a No CRF

(Jalaludin, O'Toole recommended.
et al. 2004)
148 children (mean
age about 9.6
of wheezing in
previous 12 months.
Sydney.
No effect of either 1-
hour maximum or
24-hour average
(Williams, Marks et
al. 2012)
Six cities –
Adelaide, Brisbane,
Canberra,
Melbourne, Perth,
Sydney.
Age: mean 10.0
years.
270 children with
current asthma.
Upper respiratory Runny/blocked n/a n/a n/a n/a No CRF

symptoms nose: No effect. recommended.
159
(Rodriguez, Tonkin
et al. 2007)
Age: 0-5 years
Perth
24-hour mean
Increased No effect on any n/a n/a n/a. n/a No CRF

respiratory day symptoms Increased recommended.
symptoms (cough, wheeze, symptoms &
shortness of breath, medication use in
runny nose, eye asthmatic children
irritation, fever) in 2- seen for median
pollutant models ranges of 18-26 ppb
with O3. (24-hour average)
(Schildcrout,
No effect on any Sheppard et al.
night symptoms 2006) and mean
(cough, wheeze, NO2 of 32 ppb (4-
shortness of breath) hour average)
in 2-pollutant (Mortimer, Neas et
models with O3. al. 2002)
(Williams, Marks et (US EPA 2008)
al. 2012)
Six cities – 2.8% (0.2-5.5%) per
Adelaide, Brisbane, 1ppb
Canberra, (US EPA 1999)
Melbourne, Perth,
Sydney.
Age: mean 10.0
years.
270 children with
current asthma.
General practitioner No effect. n/a n/a n/a n/a No CRF

160
consultation for (Jalaludin, O'Toole recommended.

asthma et al. 2004)
148 children (mean
age about 9.6
of wheezing in
previous 12 months.
Sydney.

upper respiratory
disease
1
n/a=not available
2
3
REFERENCES
Anderson, H. R., C. Spix, et al. (1997). "Air pollution and daily admissions for chronic obstructive pulmonary disease in 6 European cities: results from the APHEA project
[see comments]." European Respiratory Journal 10(5): 1064-1071.
Barnett, A. G., G. M. Williams, et al. (2005). "Air pollution and child respiratory health. A case-crossover study in Australia and New Zealand." American Journal of
United Kingdom.
Delfino, R. J., R. S. Zeiger, et al. (2002). "Association of asthma symptoms with peak particulate air pollution and effect modification by anti-inflammatory medication use."
Environmental Health Perspectives 110(10): A607-A617.
161
Ito, K., G. Thurston, et al. (2007). "Characterization of PM2.5 gaseous pollutants and meteorological interactions in the context of time-series health effects models." Journal
of Exposure Science and Environmental Epidemiology 17(S2): S45-S60.
Jalaludin, B., B. Khalaj, et al. (2008). "Air pollution and ED visits for asthma in Australian children: a case-crossover analysis." International Archives of Occupational and
Linn, W. S., Y. Szlachcic, et al. (2000). "Air pollution and daily hospital admissions in metropolitan Los Angeles." Environmental Health Perspectives 108(5): 427-434.
Moolgavkar, S. H. (2003). Air pollution and daily deaths and hospital admissions in Los Angeles and Cook counties. Revised analyses of time-series studies of air pollution
and health. Special report. Boston, MA, Health Effects Institute: 183-198.
Mortimer, K. M., L. M. Neas, et al. (2002). "The effect of air pollution on inner-city children with asthma." European Respiratory Journal 19(4): 699-705.
NYDOH (2006). A study of ambient air contaminants and asthma in New York City, New
York State Department of Health Center for Environmental Health.
O'Connor, G. T., L. Neas, et al. (2008). "Acute respiratory health effects of air pollution on children with asthma in US inner cities." Journal of Allergy & Clinical
Immunology 121(5): 1133-1139.
Ostro, B., M. Lipsett, et al. (2001). "Air pollution and exacerbation of asthma in African-American children in Los Angeles." Epidemiology 12(2): 200-208.
Health 56(1): 37-52.
Rodriguez, C., R. Tonkin, et al. (2007). "The relationship between outdoor air quality and respiratory symptoms in young children." International Journal of Environmental
Health Research 17(5): 351-360.
Schildcrout, J. S., L. Sheppard, et al. (2006). "Ambient air pollution and asthma exacerbations in children: an eight-city analysis." American Journal of Epidemiology 164(6):
505-517.
162
Schwartz, J., D. W. Dockery, et al. (1994). "Acute effects of summer air pollution on respiratory symptom reporting in children." American Journal of Respiratory and
Health 29(3): 205-212.
Health 29(3): 213-221.
Spix, C., H. R. Anderson, et al. (1998). "Short-term effects of air pollution on hospital admissions of respiratory diseases in Europe: a quantitative summary of APHEA study
results. Air Pollution and Health: a European Approach." Archives of Environmental Health 53(1): 54-64.
Sunyer, J., C. Spix, et al. (1997). "Urban air pollution and emergency admissions for asthma in four European cities: the APHEA Project." Thorax 52(9): 760-765.
Touloumi, G., K. Katsouyanni, et al. (1997). "Short-term effects of ambient oxidant exposure on mortality: a combined analysis within the APHEA project. Air Pollution and
Health: a European Approach." American Journal of Epidemiology 146(2): 177-185.
US EPA (2008). Integrated science assessment for oxides of nitrogen-health criteria, EPA/600/R-08/071. US Enviromental Protection Agency.
US EPA (2010). Final Regulatory Impact Analysis (RIA) for the NO2 National Ambient Air Quality Standards (NAAQS), Office of Air Quality Planning and Standards, U.S.
Environmental Protection Agency, North Carolina, USA: 155.
Zmirou, D., J. Schwartz, et al. (1998). "Time-series analysis of air pollution and cause-specific mortality." Epidemiology 9(5): 495-503.
163
Table 5: SO2 health endpoints and associated concentration-response functions
Health outcomes Australian UK Europe USEPA WHO Recommended
Mortality
All cause n/a1 n/a n/a n/a n/a No CRF
Evidence is recommended.
inadequate to
confer causal
relationship.
(US EPA 2008)

of age) recommended.

(years of life lost; recommended.
YOLL)
Morbidity

pulmonary disease
(COPD) or chronic
bronchitis
No effect in single recommended.
pollutant model and
164
protective effects in No effects in

2-pollutant models Australian 6-cities
with CO. study (Williams,
Marks et al. 2012).
Ever had asthma:
No effect in single
pollutant model and
protective effects in
2-pollutant models
with NO2 and CO.
(Williams, Marks et
al. 2012)
Six cities –
Adelaide, Brisbane,
Canberra,
Melbourne, Perth,
Sydney
Average hourly SO2
over lifetime
Age: mean age10.0
years
2,860 children
Recent symptoms Wheeze, night n/a n/a n/a n/a No CRF

(in last 12 months) cough or chest cold: recommended.
No effect.
(Lewis, Hensley et No effects in
al. 1998) Australian 6-cities
Hunter and Illawarra study (Williams,
regions. Marks et al. 2012).
Primary school
children.
No effect or
165
protective effects for

wheeze, wheeze
after exercise,
current asthma, use
of bronchodilators,
cough, visit to
doctor/hospital,
rhinitis and itchy
rash in various
single and 2-
pollutant models.
(Williams, Marks et
al. 2012)
Six cities –
Adelaide, Brisbane,
Canberra,
Melbourne, Perth,
Sydney.
Average hourly SO2
over lifetime
Age: mean age10.0
years.
2,860 children.

growth recommended.
Change in forced No effect in single n/a n/a n/a n/a Recommended

expiratory volume in pollutant model. CRF: -6.62 mls
1 second (FEV1; (-12.3 to -0.96 mls)
litres) -6.62 mls (-12.3 to per 0.74 ppb in 2-
-0.96 mls) per 0.74 pollutant model with
ppb in 2-pollutant NO2 (Williams,
model with NO2 Marks et al. 2012).
166
(Williams, Marks et
al. 2012)
Six cities –
Adelaide, Brisbane,
Canberra,
Melbourne, Perth,
Sydney
Average hourly SO2
over lifetime
Age: mean age10.0
years
2,860 children
Change in forced No effect in single n/a n/a n/a n/a Recommended

vital capacity (FVC; pollutant model CRF: -8.92 mls
litres) (-16.0 to -1.84 mls)
-8.92 mls (-16.0 to per 0.74 ppb in 2-
-1.84 mls) per 0.74 pollutant model with
ppb in 2-pollutant NO2 (Williams,
model with NO2 Marks et al. 2012).
(Williams, Marks et
al. 2012)
Six cities –
Adelaide, Brisbane,
Canberra,
Melbourne, Perth,
Sydney
Average hourly SO2
over lifetime
Age: mean age10.0
years
2,860 children
Airway inflammation Protective effect in n/a n/a n/a n/a No CRF

167
single and 2- recommended.

pollutant models
with PM, NO2, O3 No effect in
and CO Australian 6-cities
(Williams, Marks et study (Williams,
al. 2012) Marks et al. 2012).
Six cities –
Adelaide, Brisbane,
Canberra,
Melbourne, Perth,
Sydney
Average hourly SO2
over lifetime
Age: mean age10.0
years
2,860 children
Birth outcomes
Birth defects Cleft lip±cleft palate: n/a n/a n/a n/a No CRF
1.27 (1.01, 1.62) per Evidence is recommended.
0.6ppb inconsistent.
All births (US EPA 2008) Only 1 Australian
Aortic artery and study.
valve: 10.76 (1.50,
179.83) per 0.6ppb
Births within 6km of
air monitoring
station
(Hansen, Barnett et
al. 2009)
Brisbane
168
Prematurity First trimester, n/a n/a n/a n/a No CRF

autumn: 6.489 recommended.
(4.365–9.648) per
1ppb. Only 1 Australian
study.
First trimester,
winter: 1.323
(1.027–1.704) per
1ppb
3 months preceding
birth: 2.330 (1.344–
4.040) per 1 ppb.
Births within 5km of
air monitoring
station
(Jalaludin, Mannes
et al. 2007)
Sydney
1-hour maximum
Low birth weight Not assessed n/a n/a n/a n/a No CRF
(Mannes, Jalaludin recommended.
et al. 2005)
Sydney
Not assessed
(Hansen, Neller et
al. 2007)
Brisbane
169
Mortality
Non-trauma Not assessed in 4 1.029 (1.035-1.023) n/a Non-trauma n/a No CRF

cities study per 50 ug/m3 mortality: range 0.4- Various studies recommended.
(Simpson, Williams (Committee on the 2% per 10 ppb showed increased
et al. 2005) Medical Effects of (US EPA 2008) mortality with levels No effect in
Brisbane, Air Pollutants 1998) 24-hour average. between 5-10 ug/m3 Australian 2-cities
Melbourne, Perth, 24-hour average. Effects reduced 24-hour average. study (Environment
Sydney APHEA estimates when co-pollutants (Burnett, Stieb et al. Protection and
for 7 western added to model. 2004) Heritage Council
No effect. European cities. (WHO 2006) 2005).
(Environment
Protection and May use CRF from
Heritage Council COMEAP
2005) (Committee on the
1-hour maximum. Medical Effects of
Lag 01 Air Pollutants 1998)
Age: All ages. or Hu et al (Hu,
All year. Mengersen et al.
Moderate 2008) in a sensitivity
heterogeneity. analysis.
Meta-analysis of 2
cities – Brisbane,
Sydney.
ICD9: <800; ICD10:
A-R, Z35.5, Z35.8
22.3% (6.4-40.5%)
per 1 pphm in multi-
pollutant models
(Hu, Mengersen et
al. 2008)
Sydney
24-hour average.
170
Age: All ages.

All causes (ICD
codes not stated).
Cardiovascular Not assessed in 4 0.8% (0.6-1.0%) per n/a n/a n/a No CRF
cities study 10 ug/m3 recommended.
(Simpson, Williams (Committee on the
et al. 2005) Medical Effects of No effect in
Brisbane, Air Pollutants 2006) Australian 2-cities
Melbourne, Perth, Random effects meta-analysis
Sydney. estimate. (Environment
24-hour average. Protection and
No effect. Moderate-strong Heritage Council
(Environment evidence of 2005).
Protection and publication bias.
Heritage Council CRF not intended May use the CRF
2005) for health risk from COMEAP
1-hour maximum assessment. (Committee on the
Lag 01 Medical Effects of
Age: All ages. 1.04 (1.01-1.06) per Air Pollutants 1998)
All year. 50 ug/m3 in a sensitivity
Moderate (Committee on the analysis.
heterogeneity. Medical Effects of
Meta-analysis of 2 Air Pollutants 1998)
cities – Brisbane, 24-hour average.
Sydney. APHEA estimates
ICD9: 390-459; for 5 western
ICD10: I00-I99 European cities.
(excluding I67.3,
I68.0, I88, I97.8,
I97.9, I98.0), G45
(excluding G45.3),
G46, M30, M31,
171
R58
Respiratory Not assessed in 4 1.05 (1.03-1.07) per n/a n/a n/a No CRF
Brisbane, Air Pollutants 1998) Australian 2-cities
Melbourne, Perth, 24-hour average. meta-analysis
Sydney. APHEA estimates (Environment
for 5 western Protection and
No effect. European cities. Heritage Council
(Environment 2005).
Protection and
Heritage Council May use the CRF
2005) from COMEAP
1-hour maximum. (Committee on the
Lag 01. Medical Effects of
Age: All ages. Air Pollutants 1998)
All year. in a sensitivity
Moderate analysis.
heterogeneity.
Meta-analysis of 2
cities – Brisbane,
Sydney
ICD9: 460-519;
ICD10: J00-J99
(excluding J95.4 to
J95.9), R09.1,
R09.8.
Hospitalisation
Cardiovascular Not assessed in 4 0.6% ( 0.1-1.2%) n/a n/a n/a No CRF
172
cities study per 10 ug/m3 Some evidence However, cited recommended.

(Simpson, Williams (Committee on the from Hong Kong study
et al. 2005) Medical Effects of epidemiological which showed no No effect in
Air Pollutants 2006) studies but evidence of Australian 2-cities
15-64 years: No Random effects inconsistent threshold for effect meta-analysis
effect estimate. toxicological at 5-40ug/m3 (Environment
65+ years: No effect 24-hour average. studies, and effect 24-hour average. Protection and
(Environment Weak evidence of estimate not robust (Wong, Atkinson et Heritage Council
Protection and publication bias. to co-pollutant al. 2002) 2005).
Heritage Council CRF not intended adjustment. (WHO 2006)
2005) for health risk (US EPA 2008) May use the CRF
1-hour maximum assessment. from COMEAP
Lag 01 (Committee on the
Meta-analysis of 2 Medical Effects of
cities - Brisbane, Air Pollutants 2006)
Sydney. in a sensitivity
Low heterogeneity. analysis.
ICD9: 390-459;
ICD10: I00-I99
(excluding I67.3,
I68.0, I88, I97.8,
I97.9, I98.0), G45
(excluding G45.3),
G46, M30, M31,
R58
Cardiac Not assessed in 4 2.4% (1.6-3.3%) per n/a n/a n/a No CRF
Air Pollutants 2006) Australian 2-cities
15-64 years: No Random effects meta-analysis
effect estimate. (Environment
65+ years: No effect 24-hour average. Protection and
173
(Environment No evidence of Heritage Council

Protection and publication bias. 2005).
Heritage Council CRF not intended
2005) for health risk May use the CRF
1-hour maximum. assessment. from COMEAP
Lag 01. (Committee on the
High heterogeneity. analysis.
for 65+ years
lCD9: 390-429;
ICDI0: I00-I52,
I97.0, I97.1, I98.1
Ischaemic heart Not assessed in 4 1.2% (0.5-1.9%) per n/a n/a n/a No CRF
disease cities study 10 ug/m3 recommended.
Air Pollutants 2006) Australian 2-cities
15-64 years: No Random effects meta-analysis
effect estimate. (Environment
65+ years: No effect 24-hour average. Protection and
(Environment No evidence of Heritage Council
Protection and publication bias. 2005).
Heritage Council CRF not intended
2005) for health risk May use the CRF
1-hour maximum. assessment. from COMEAP
Lag 01. (Committee on the
Low to moderate analysis.
heterogeneity.
174
lCD9: 410-413;
ICDI0: I20-I22, I24,
I25.2
Cardiac failure 15-64 years: No No effect n/a n/a n/a No CRF

effect (Committee on the recommended.
65+ years: No effect Medical Effects of
(Environment Air Pollutants 2006) No effect in
Protection and Random effects Australian 2-cities
Heritage Council estimate. meta-analysis
2005) 24-hour average. (Environment
1-hour maximum. No evidence of Protection and
Lag 01. publication bias. Heritage Council
Meta-analysis of 2 CRF not intended 2005).
cities - Brisbane, for health risk
Sydney. assessment.
Low to moderate
heterogeneity.
ICD9: 428; ICD10:
I50
Cerebrovascular Not assessed in 4 No effect n/a n/a n/a No CRF

cities study (Committee on the recommended.
(Simpson, Williams Medical Effects of
et al. 2005) Air Pollutants 2006) No effect in
Random effects. Australian 2-cities
Stroke: estimate meta-analysis
15-64 years: No 24-hour average. (Environment
effect No evidence of Protection and
65+ years: No effect publication bias. Heritage Council
(Environment CRF not intended 2005).
Protection and for health risk
Heritage Council assessment.
2005)
175
1-hour maximum.
Lag 01.
Meta-analysis of 2
cities - Brisbane,
Sydney.
Low heterogeneity.
ICD9: 430-438;
ICD10: I60-I66, I67
(excluding I67.0,
I67.3), I68
(excluding I68.0),
I69, G45 (excluding
G45.3), G46

effect recommended.
2005) (Environment
1-hour maximum. Protection and
Meta-analysis of 2 2005).
cities - Brisbane,
Sydney.
Low heterogeneity.
ICD9: 437; ICD10:
I46-I49
Myocardial 15-64 years: No n/a n/a n/a n/a No CRF

infarction effect. recommended.
65+ years: No
effect. No effect in
176

1-hour maximum. Heritage Council
Lag 01. 2005).
Meta-analysis of 2
cities - Brisbane,
Sydney.
Moderate to high
heterogeneity.
lCD9: 410; ICDI0:
I21, I22
Respiratory Not assessed in 4 65+ years: 0.5% per 10 ug/m3 n/a n/a Recommended
cities study 1.020 (1.005-1.046) (AEA Technology Effect ranges from CRF: For 65+ years
(Simpson, Williams per 50 ug/m3 Environment 2005) -5 to +20% risk per age-group, 2.8%
et al. 2005) 15-64 years: No 10 ppb increase in (1.0-4.7%) per 5.4
effect. SO2 (24-hour ppb from Australian
0 years: No effect (Committee on the average), with study (Environment
1-4 years: No effect Medical Effects of effects observed at Protection and
5-14 years: No Air Pollutants 1998) levels of 4 ppb, but Heritage Council
effect Based on APHEA marked increases in 2005).
15-64 years: No estimates for 5 effect at only higher
effect western European SO2 (>90th No CRF
65+ years: 2.8% cities. percentile values). recommended for all
(1.0-4.7%) per 5.4 (US EPA 2008) other age-groups as
ppb there were no
(Environment 0.4% (0-1.02%) per effects in the
Protection and 1 ppb Australian 2-cities
Heritage Council (US EPA 1999) meta-analysis
2005) (Environment
177
cities - Brisbane,
Sydney.
High heterogeneity
in 5-14 years only.
lCD9: 460-519;
ICDI0: J00-J99
(excluding J95.4-
J95.9), R09.1,
R09.8
Asthma 1-4 years: No effect n/a n/a n/a n/a No CRF

effect
15-64 years: No No effect in
effect Australian 2-cities
65+ years: No effect meta-analysis
2005) 2005).
1-hour maximum.
Lag 01.
Meta-analysis of 2
cities - Brisbane,
Sydney.
High heterogeneity.
in 5-14 years only
lCD9: 493; ICDI0:
J45, J46, J44.8
Age: 0-14 years
Chronic obstructive 15-64 years: No n/a n/a n/a n/a No CRF

pulmonary disease effect recommended.
178
(COPD) 64+ years: No effect

2005) (Environment
cities - Brisbane,
Sydney.
Moderate to high
heterogeneity
lCD9: 490-492, 494-
496; ICDI0: J40-
J44, J47, J67
Pneumonia and 0 years: No effect. n/a n/a n/a n/a No CRF

acute bronchitis 1-4 years: 8.5% recommended.
(3.0-14.3%) per 5.4
ppb. No effect in
1-4 years, two Australian 2-cities
pollutant model with meta-analysis
PM2.5: No effect. (Environment
15-64 years: No Protection and
effect. Heritage Council
65+ years: No effect 2005).
(Environment
Protection and
Heritage Council
2005)
1-hour maximum
Lag 01
Meta-analysis of 2
cities - Brisbane,
179
Sydney
Moderate to high
heterogeneity
ICD9: 466, 480-486;
ICD10: J12-J17,
J18.0, J18.1, J18.8,
J18.9,
J20, J21
Asthma Not assessed. n/a n/a n/a n/a Recommended

(Erbas, Kelly et al. CRF: 1.6% (0.7-
2005) 2.4%) per 0.8 ppb
Melbourne (Jalaludin, Khalaj et
al. 2008).
1.6% (0.7- 2.4%)
per 0.8 ppb.
(Jalaludin, Khalaj et
al. 2008)
Sydney
ICD9: 493
Age: 1-14 years.
24-hour average.
Not assessed.
(Pereira, Cook et al.
2010)
Perth
180
(24-hr PM)
Lung function
Change in forced No effect of 1-hour n/a n/a n/a. n/a No CRF

expiratory volume in maximum or 24- 3-8% decrements Toxicological However, cited recommended.
1 second (FEV1; hour average. in FEV1 in children studies: Reduction chamber studies
litres) (Williams, Marks et are associated with in FEV1 (≥15%) and that showed No effect in
al. 2012) ambient annual SO2 increased airway changes in lung Australian 6-cities
Six cities – and SO4 resistance (≥100%) function at levels study (Williams,
Adelaide, Brisbane, concentrations >100 in 5-30% of >500 ug/m3 after 10 Marks et al. 2012).
Canberra, ug/m3. exercising minutes leading to
Melbourne, Perth, (Lebowitz 1996) asthmatics at 0.2- air quality guidelines
Sydney. (Committee on the 0.3 ppm and 20- of 500 ug/m3 (10-
Age: mean 10.0 Medical Effects of 60% at 0.4-1.0 ppm minute average).
years. Air Pollutants 1998) (5-10 minutes (WHO 2006)
270 children with exposure).
current asthma. Epidemiological No CRF, but set
studies: inconsistent guideline of 125
for lung function ug/m3 (0.04 ppm)
effects in children (24-hour average)
and adults. and 50 ug/m3
(US EPA 2008) (annual average).
(WHO Europe
2000)
Change in peak 1-hour maximum n/a n/a n/a n/a No CRF

expiratory flow rate No effect. recommended.
(PEF; litres per
minute) 24-hour average SO2 shows a
Morning PEF: positive effect on
1.2686 (0.0857- lung function in
181
2.4514) per 1 ppb. Australian 6-cities

Lag 2 study (Williams,
Morning PEF: No Marks et al. 2012).
effect in model with
PM10.
Evening PEF:
1.6946 (0.1918-
model with PM10.
Lag 0
(Williams, Marks et
al. 2012)
Six cities –
Adelaide, Brisbane,
Canberra,
Melbourne, Perth,
Sydney.
Age: mean 10.0
years.
270 children with
current asthma.
Minor morbidity
Asthma n/a n/a n/a n/a n/a No CRF

exacerbation However, based on No CRF reported, Toxicological Recommended that recommended.
evidence but judgement is studies: increase in 500 ug/m3 (0.175
recommends that that 60-140 ug/m3 severity and ppm) not be
SO2 not exceed and 140-200 ug/m3 incidence of exceeded (10
0.175 ppm (500 SO2 (annual mean symptoms in minute exposure).
ug/m3) (10 minute of 24-hour mean) asthmatic adults Based on clinical
average). associated with with increasing SO2 studies of exercising
(Streeton 1997) increased between 0.2-0.6 asthmatics.
respiratory ppm for 5-10 (WHO Europe
182
symptoms in adults minutes. 2000)

and children Epidemiological
respectively. No studies: increased
threshold level symptoms in
evident. children (especially
UK Department of those with asthma
Health Advisory or chronic
Group, cited in respiratory) at
COMEAP, 1998 median range of 17-
(Committee on the 37 ppb (3-hour
Medical Effects of average) and for
Air Pollutants 1998) 2.2-7.4 ppb (24-
hour average).
Epidemiological
evidence for adults
is inconsistent for
short-term SO2
concentrations.
(US EPA 2008)
0.6% (0.1-1.1%) per

1 ppb
(US EPA 1999)

hyper- Limited evidence of recommended.
responsiveness an effect of airway
hyper-
responsiveness in
atopic individuals.
(US EPA 2008)

183
Minimal restricted n/a n/a n/a n/a n/a No CRF

(MRAD)3

(WLD) days2 recommended.

(incidence, 8-12 recommended.
years)

Wheeze Day wheeze: n/a n/a n/a n/a No CRF

Protective effects of recommended.
1-hour maximum
and 24-hour No effect in
average in 2- Australian 6-cities
pollutant models study (Williams,
with PM10. Marks et al. 2012).
Night wheeze: No
effect of 1-hour
maximum or 24-
hour average in 2-
pollutant models
with PM10.
(Williams, Marks et
al. 2012)
Six cities –
184
Adelaide, Brisbane,
Canberra,
Melbourne, Perth,
Sydney.
Age: mean 10.0
years.
270 children with
current asthma.
Cough Day cough: No n/a n/a n/a n/a No CRF

effect of 1-hour recommended.
maximum or 24-
hour average in 2- No effect in
pollutant models Australian 6-cities
with PM10. study (Williams,
Night cough: No Marks et al. 2012).
effect of 1-hour
maximum or 24-
hour average in 2-
pollutant models
with PM10.
(Williams, Marks et
al. 2012)
Six cities –
Adelaide, Brisbane,
Canberra,
Melbourne, Perth,
Sydney.
Age: mean 10.0
years.
270 children with
current asthma.
Shortness of breath 1-hour maximum n/a n/a n/a n/a No CRF

185
Day SOB: No effect recommended.

in 2-pollutant.
models with PM10 No effect in
Night SOB: No Australian 6-cities
effect in 2-pollutant study (Williams,
models with PM10. Marks et al. 2012).
24-hour average
Day SOB: No effect
in 2-pollutant
models with PM10.
Night SOB:
Protective effect in
2-pollutant models
with PM10.
Lag 3
(Williams, Marks et
al. 2012)
Six cities –
Adelaide, Brisbane,
Canberra,
Melbourne, Perth,
Sydney.
Age: mean 10.0
years.
270 children with
current asthma.
Bronchodilator use 1-hour maximum n/a n/a n/a n/a Recommended CRF
Night use: 1.0247 for night
(1.0021-1.0478) per bronchodilator use:
1 ppb in 2-pollutant 1.0247 (1.0021-
models with PM10 1.0478) per 1 ppb in
24-hour average 2-pollutant models
No effect with PM10 from
186
(Williams, Marks et Marks et al

al. 2012) (Williams, Marks et
Six cities – al. 2012).
Adelaide, Brisbane,
Canberra,
Melbourne, Perth,
Sydney.
Age: mean 10.0
years.
270 children with
current asthma.

Increased No effect on any No CRF

respiratory night symptoms recommended.
symptoms (cough, wheeze,
shortness of breath) No effect in
in 2-pollutant Australian 6-cities
models with PM10 study (Williams,
No effect on any Marks et al. 2012).
day symptoms
(cough, wheeze,
shortness of breath,
runny nose, eye
irritation, fever) in 2-
pollutant models
with PM10
(Williams, Marks et
al. 2012)
Six cities –
Adelaide, Brisbane,
Canberra,
187
Melbourne, Perth,
Sydney.
Age: mean 10.0
years.
270 children with
current asthma.

asthma

upper respiratory
disease
1
n/a=not available
2
3
REFERENCES
Environment.
Burnett, R. T., D. Stieb, et al. (2004). "Associations between short-term changes in nitrogen dioxide and mortality in Canadian cities." Archives of Environment Health 59:
228-236.
United Kingdom.
188
Research 103(3): 383-389.
Hu, W., K. Mengersen, et al. (2008). "Temperature, air pollution and total mortality during summers in Sydney, 1994–2004." International Journal of Biometeorology 52(7):
689-696.
Lebowitz, M. D. (1996). "Epidemiological studies of the respiratory effects of air pollution." The European Respiratory Journal 9: 1029-1054.
of Australia 169(9): 459-463.
Health 29(3): 205-212.
Health 29(3): 213-221.
Streeton, J. (1997). A review of existing health data on six pollutants. National environment protection (ambient air quality) measure. Adelaide, National Environment
Protection Council: 278.
US EPA (2008). Integrated science assessment for sulfur oxides-health criteria, ISA: EPA/600/R-08/047F US Environmental Protection Agency
Wong, C. M., R. W. Atkinson, et al. (2002). "A tale of two cities: effects of air pollution on hospital admissions in Hong Kong and London compared." Environmental Health
Perspectives 110(1): 67-77.
189
Table 6: Sources of health data
Type of Data custodian Years of available data Variables in dataset Process for accessing Time frame for
health data data accessing data
Mortality ABS (aggregate and coded ABS: 2002-2012 (last 10 Variables include : age or National Information Up to 1 month.
data available to SLA level years). Some data back to DOB, gender, underlying Referral Service (NIRS)
(lowest geographic 1968 but would incorporate cause of death (ABS), 1300 135 070 or complete
idenitifier)).* ICD8, ICD9 and ICD10 multiple causes of death Inquiry form located at
coding. (ABS), SLA (geographic http://www4.abs.gov.au/
Individual State Registrars identifier), ICD codes. web/survey.nsf/inquiryform/
of Births, Deaths and
Marriages (unit record data Specify requirements and
available but not coded). work is quoted. Minimum
charge of $650 for 3 hrs.
State level data available

free of charge at:
http://www.abs.gov.au/
AUSSTATS
/[email protected]/DetailsPage/
3302.02010?
OpenDocument
Hospitalisation National Hospital Morbidity Data by State; annual AIHW, Head, Hospitals
Database (NHMD) frequency of reporting Data Unit, 02 6244 1157;
administered by AIHW. (Australian Institute of [email protected]
Health and Welfare).
State health agencies, eg. NSW Admitted Patient Apply in writing to NSW 2 weeks to a few
NSW Ministry of Health. Data - 1988/89-current Data to SLA & postcode Chief Health Officer months, depending
(June 2011) levels. Other geographic whereupon data needs will on nature of
level may be available on be assessed. request.
request.
Data Custodian:
Variables include: age, Director
190
DOB, gender, postcode, Demand & Performance

primary diagnosis, Evaluation Branch, NSW
additional diagnoses, Ministry of Health
readmission within 28 Tel: 02 9391 9590.
days, date of admission
and date of separation,
length of stay, ICD codes,
other demographic &
hospital data.
Emergency State health agencies, for For example, NSW Data to SLA & postcode Apply in writing to NSW 2 weeks to a few
department example, NSW Ministry of Emergency Department levels. Other geographic Chief Health Officer months, depending
(ED) visits Health. Database; July 1996-year level may be available on whereupon data needs will on nature of
to date (2012). request. be assessed. request.
ED visit data for asthma
available for NSW, Victoria Age, DOB, gender, Data Custodian:
& WA, but method of data postcode, arrival date and Director
collection differs (ACAM time, triage date and time, Demand & Performance
2011). diagnosis- ICD9 and ICD Evaluation Branch, NSW
10, type of visit, mode of Ministry of Health
separation, other Tel: 02 9391 9590
demographic data.
Perinatal State health agencies, for For example, Perinatal Data to SLA & postcode Apply in writing to NSW 2 weeks to a few
example, NSW Ministry of Data Collection (PDC), levels of mother’s Chief Health Officer months, depending
Health. encompasses all live births residence. Other whereupon data needs will on nature of
>20 weeks gestation or geographic level may be be assessed request.
≥400 grams birth weight. available on request.
1987-1988; 1989 (missing); Data Custodian:
1990-current (2009). Variables include: mother’s Manager,
demographic details, Surveillance Methods
baby’s DOB, gender; date Centre for Epidemiology &
of last menstrual period, Research, NSW Ministry of
birth order, gestational age, Health
191
birth weight, APGAR Tel: 02 9391 9223

scores (1 & 5 minutes),
mother’s smoking status,
diabetes status. Other
details related to
pregnancy.
Chronic No geographic based data

obstructive for COPD incidence. Data
pulmonary available for hospital
disease separations for COPD.
(COPD) Data on COPD mortality
incidence and hospitalisations-
national estimates
(Australian Institute of
Health and Welfare 2005).
Prevalence of COPD in
2007-08 National Health
Survey estimated at 5.3%,
but is likely to be an under-
estimation (ACAM 2011).
COPD (Stage 2)
prevalence from BOLD
study (Sydney) 9.4%
(Buist, McBurnie et al.
2007).
Prevalence in Australia
BOLD study (Stage 2 or
higher) 7.5% in 40 years+
and 29.2% in 75 years+
(Toelle 2012).
192
Incidence data will have to

be obtained from published
studies and reports.
Asthma Asthma prevalence

prevalence estimated at 9.8% in 16+
years; 17.8% in 0-15 years.
Prevalence of “current
asthma” in adults 9.8%
(9.2-10.4%) and in children
10.4% (9.1-11.7%) (ACAM
2011).
Asthma Cumulative incidence of

incidence diagnosed “ever asthma or
illness with wheezing” 24.4
(23.5-25.3) per 100 person
years (infant cohort at 4-5
years); and 22.0 (21.0-
23.0) per 100 person years
(Kindergarten cohort aged
8-9 years).
Source: Longitudinal Study
of Australian Children,
Australia, 2004-2008, in
(ACAM 2011).
Asthma No standardised routine

exacerbation data collection. Asthma
exacerbation will have to
be obtained from published
studies and reports.
193
Lung function No standardised data

collection. Data available
will have to be obtained
from published studies and
reports.
GP encounters In 2009-2010: 8.6

for asthma encounters per 100 adults;
16.9 encounters per 100
children (ACAM 2011).
Mortality 1.6 deaths per 100,000

attributed to population (0.29% of all
asthma deaths) for 2009. Rate fell
45% between 1997 and
2009 (ACAM 2011).
Activity 8.2% of people with

restriction & asthma reported to have
disability (time some level of disability
off work or associated with asthma
school) (2003 Survey of Disability,
Ageing and Carers in
(Australian Institute of
Health and Welfare 2005)).
National Health Survey,

2007-2008, reports on
days away from work,
school or study in last 12
months: 5+ years: with
asthma 24.2% (22.2-
26.2%): without asthma
8.8% (8.2-9.4%) (ACAM,
194
2011, from National Health

Survey, 2007-2008).
ABS Australian Bureau of Statistics
SLA Statistical Local Area (geographic identifier). The following information is sourced directly from the ABS website:
http://www.abs.gov.au/websitedbs/D3110124.NSF/24e5997b9bf2ef35ca2567fb00299c59/53bbe9630b24d6f4ca256c3a000475b8!OpenDocument#Statistical%20Local
%20Area%20(SLA) The Statistical Local Area (SLA) is an Australian Standard Geographical Classification (ASGC) defined area which consists of one or more Collection
Districts (CDs). SLAs are Local Government Areas (LGAs), or parts thereof. Where there is no incorporated body of local government, SLAs are defined to cover the
unincorporated areas. SLAs cover, in aggregate, the whole of Australia without gaps or overlaps. CDs are the smallest geographic area defined in the ASGC. They are
designed for use in the Census of Population and Housing as the smallest unit for collection, processing and output of data. A CD is represented by a unique seven digit
code. For the 2001 Census there is an average of about 225 dwellings in each CD. In rural areas the number of dwellings per CD declines as population densities decrease.
CDs are defined for each census and are current only at census time. For the 2001 Census, there are about 37,000 CDs throughout Australia.
*A project is underway to pilot the process for release of national coded unit record data.
REFERENCES
ACAM (2011). Asthma in Australia 2011 Canberra, AIHW Asthma Series no 4. Cat. No. ACM. Australian Centre for Asthma Monitoring, AIHW.
Australian Institute of Health and Welfare (2005). Chronic respiratory diseases in Australia. Their prevalence, consequences and prevention AIHW Cat. No. PHE 63.
Canberra: AIHW.
Buist, A. S., W. M. McBurnie, et al. (2007). "International variation in the prevalence of COPD (The BOLD Study): a population-based prevalence study." The Lancet 370:
741-750.
Toelle, B. (2012). Airflow obstruction, respiratory symptoms and respiratory illnesses in Australians aged 40 years and older: the Burden of Obstructive Lung Disease
(BOLD) study in Australia (personal communication; manuscript currently under review with the Medical Journal of Australia).
195

Health Report

Uploaded by

Copyright:

Available Formats

Health Report

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Health Report

Uploaded by

Copyright:

Available Formats

Health Risk Assessment – Preliminary Work to

Identify Concentration-Response Functions for

Report prepared for EPA Victoria

Respiratory and Environmental Epidemiology

Woolcock Institute of Medical Research

EPA Victoria wishes to identify health endpoints and relevant concentration-response

Scope of the project

The scope of the consultancy was as follows:

Table: Health effects of ambient air pollution

Ozone  Adverse effects on pulmonary  Reductions in lung function

Nitrogen dioxide  Effects on pulmonary function,  Reduction in lung function

Sulphur dioxide  Effects on pulmonary function,  Probable reduction in life

Brief overview of published health risk assessments and cost-benefit analyses

Acute (short-term) outcomes

Chronic (long-term) disease outcomes

Brief overview of hazard assessment in Australia

In 2011, the National Environment Protection Council (NEPC) (National Environment

 Epidemiological studies, especially those representative of the general population

 Mortality should be considered as a critical health outcome.

 More sensitive health outcomes (for example, hospital admissions, emergency

 Sensitive subpopulations within the general population should be taken into

 A non-threshold approach should be taken for the current criteria pollutants.

 CRFs from well-conducted Australian studies are preferred. If high-quality Australian

Methods used in this report

1. Only human epidemiological studies were considered. We have not considered

2. CRFs representative of the general population were selected where available.

3. Identification of relevant health endpoints and associated CRFs from published

5. Recommended CRFs from well-conducted Australian meta-analyses in the first

Availability of health outcome data

European Commission (2005). ExternE. Externalities of Energy: Methodology 2005 Update. P.

Health outcomes Australian UK Europe US EPA WHO Recommended

Long-term outcomes (annual average concentration)

Health outcomes Australian UK Europe US EPA WHO Recommended

al. 2009) (Krewski, Jerrett et

Health outcomes Australian UK Europe US EPA WHO Recommended

Health outcomes Australian UK Europe US EPA WHO Recommended

Increased risk for

Health outcomes Australian UK Europe US EPA WHO Recommended

Lung function n/a n/a n/a n/a n/a No CRF

Change in forced No effect n/a n/a n/a n/a No CRF

Change in forced No effect n/a n/a n/a n/a No CRF

Health outcomes Australian UK Europe US EPA WHO Recommended

Airway inflammation No effect n/a n/a n/a n/a No CRF

Birth defects n/a n/a n/a n/a n/a No CRF

Prematurity 1.09 (0.97–1.23) per n/a n/a n/a n/a No CRF

Health outcomes Australian UK Europe US EPA WHO Recommended

1.03 (1.01-1.05) for

-4.10 grams (-6.79

Health outcomes Australian UK Europe US EPA WHO Recommended

to -1.41 grams) per

Short-term outcomes (daily average concentration)

Non-trauma No effect. n/a n/a 0.98% (0.75 to 1.00339 (0.99150- Recommended

0.9% (0.2-1.6%) per 1.015 (1.011-1.019)

Health outcomes Australian UK Europe US EPA WHO Recommended

1.5% (0.7-2.3%) per

Health outcomes Australian UK Europe US EPA WHO Recommended

Respiratory 1.0948 (1.0174- n/a n/a 1.68% (1.04 to 0.99943 No CRF

Health outcomes Australian UK Europe US EPA WHO Recommended

Cardiovascular 15-64 years: No n/a n/a 0.80% (0.59-1.10%) n/a Recommended