Effect of Air Pollution in the Haifa Bay Area on Cardiovascular Morbidity and Mortality
Effect of Air Pollution in the Haifa Bay Area on Cardiovascular Morbidity and Mortality
The association between exposure to ambient air pollution and pulmonary disease has been well
 established.To date no study has assessed the burden of cardiovascular disease in Israel and
 its relation to ambient air pollution.

 The Haifa Bay Area has a long history of industrialization including possessing the nation's
 largest oil refineries, oil-fired power plant, agrochemical and cement producers, industrial
 incinerators and the Eastern Mediterranean's busiest port. The presence of industrial and
 mobile sources, combined with a basin effect has contributed to air pollution in the Haifa
 Bay Area and has raised concerns about potential health effects.

 Research Objectives

 -  Determine if the increased rate of cardiovascular mortality in Haifa is associated with
 PM 2.5 concentrations.

 -  Assess effect modification in diverse sub-populations.

 -  If an association does exist, assess the economic burden of PM 2.5 associated
 cardiovascular morbidity and mortality.

 -  Design prediction models of daily cardiovascular emergency department visits based on
 daily and seasonal variation of air pollution.
The association between exposure to ambient air pollution and pulmonary disease has been well
 established. Recent studies have attempted to investigate the effect of air pollution,
 specifically exposure to PM 2.5, on cardiovascular outcomes. Acute exposure to PM 2.5 is
 associated with increased heart rate, decreased heart rate variability, and increased
 incidence of cardiac arrhythmia. Population based research from the United States and Europe
 has demonstrated increased rates of emergency room visits, hospitalization and cardiovascular
 morbidity in association with increased daily concentrations of fine particulates.

 To date no study has looked at the burden of cardiovascular disease in Israel and its
 relation to ambient air pollution. Standardized mortality ratios due to cardiovascular
 disease are significantly elevated in the Haifa Bay Area in comparison to the rest of the
 country; mortality due to MI is 13% above national average while total ischemic heart disease
 mortality is 29% above national average. The Haifa Bay Area has a long history of
 industrialization including possessing the nation's largest oil refineries, oil-fired power
 plant, agrochemical and cement producers, industrial incinerators and the Eastern
 Mediterranean's busiest port. The presence of industrial and mobile sources, combined with a
 basin effect has contributed to air pollution in the Haifa Bay Area and has raised concerns
 about potential health effects.

 Research Hypothesis- Fine particulate variation in the Haifa Bay Area is positively
 associated with emergency room visit,hospitalization rates and mortality rates secondary to
 cardiovascular disease.

 Study Methodology- Critical to any environmental epidemiology research is coordination
 between experts in exposure assessment and health outcomes. This study will be a two year
 collaborative effort between the School of Public Health at the University of Haifa and the
 Faculty of Civil and Environmental Engineering at the Technion. Exposure measures will come
 from the Haifa District Municipal Association for the Environment's (HDMAE) network of 15
 monitoring stations in the region. HDMAE also monitors a number of meteorological covariates
 (ie. maximum and minimum temperatures, mean humidity, and mean barometric pressure) which
 will be incorporated into exposure modeling.

 Primary outcomes of interest will be daily mortality rates and daily rates of cardiovascular
 related emergency room visits and hospitalizations at the Rambam Medical Center in Haifa
 Israel. Electronic medical record databases will be queried for ICD-9 codes of related
 cardiac (acute coronary syndrome, heart failure, dysrhythmia/conduction disturbance)
 diagnoses. A time-series analysis will be utilized to assess change in mortality and
 emergency room visit rates in relation to incremental change in PM2.5. Covariates in the
 model will include seasonal trends in disease incidence, daily concentration of
 co-pollutants, meteorological variables such as temperature and humidity. Calculation of
 relative risk will incorporate a 1 through 7 day lag into the model into to determine latency
 of effect.

 Contribution to Environmental Health in Israel- This research hopes to evaluate the
 contribution of ambient air pollution on the increased rate of cardiovascular morbidity in
 the Haifa Bay Area. In assessing effect modification in sub-groups we will contribute to the
 understanding of how environmental pollution impacts Israel's diverse population. In
 calculating the economic impact of associated morbidity and mortality we hope to contribute
 to the cost-benefit analysis of environmental regulation in Israel. Finally, by creating
 prediction models of daily cardiovascular emergency department visits based on air pollution
 and meteorlogical variation, we can potentially inform local medical facilities and public
 health agencies on how to predict and prepare for changes in disease incidence.
Inclusion Criteria:

 -  All Patients visiting the ER between Jan 2009 and Dec 2010 at the Rambam Medical
 Center in Haifa Israel.

 Exclusion Criteria:

 -  There are no exclusion criteria