So, welcome to air pollution and health from tailpipes and smokestacks to our patients and communities. We are, I just want to remind everybody to go ahead and remember that you can evaluate our session in the mobile app or on the online program. And so that's kind of important also I think for CME. And then the other thing I wanted to let people know is that we work together to make sure we're kind of taking people through air pollution as a topic in a way that kind of makes sense. So we're not, you know, all covering the same things. So the order of the talks in the app is unfortunately different than we think the best way to kind of understand things. I've emailed them about it several times, but here we are. So apologies if you're planning to dart in and dart out. You can still do that, but it won't maybe be the talk you were hoping to sync with. So I have the very great pleasure to introduce the people up here with me. My name is Erica Moseson. I'm from Portland, Oregon. So Dr. Jillian Gooby is our first speaker today. She is a skier who is a respirologist, which is Canadian for pulmonologist, at the University of British Columbia in Vancouver, Canada, where she cares for patients with ILD and conducts research into the environmental pathophysiology of these conditions. Her PhD work at University of Pittsburgh focused on the impacts of air pollution on clinical outcomes and the epigenome in patients with fibrotic ILD, and she's currently the co-chair of the ATS Environmental Health Policy Committee. Dr. Samuel Evans is an avid surfer and musician who is also the division chief of the pulmonary medicine of the John A. Burns School of Medicine and chief of pulmonary medicine at Hawaii Pacific Health. He has cared for patients and conducted research and worked in medical education in Hawaii for over 20 years and is the former governor of the Hawaii region of the American College of Chest Physicians. And Dr. Adelie Martinez, who's going to be our last speaker, is a dancer and mother and a second-year pulmonary and critical care fellow at the University of California, San Francisco. Her background prior to her medical training was in health policy and advocacy at the local and state level, and under the mentorship of Dr. Anita Talker at UCSF, her research focuses on addressing the impact of chronic stress and environmental exposures on asthma outcomes. So, welcome to our session, and happy Indigenous Peoples' Day. I also wanted to let people know that we're going to go through the talks, and then, because we do kind of have a kind of a comprehensive approach to it, and then do question and answer at the end. And we have tried to save time for that, because we know that's often one of the most important parts of these sessions. Thank you. Thank you so much, Dr. Mohsen. So I'm Jill Gooby, and as Dr. Mohsen said, I'm a clinical assistant professor at the University of British Columbia, and these are my disclosures. And I'd just like to acknowledge that I live, work, and play on the traditional and unceded territories of the Musqueam, Squamish, and Tsleil-Waututh Nations in Vancouver, BC. The objectives for my talk today are to understand the different components of air pollution, how they're produced, and where they deposit in the body, to understand the all-cause mortality burden of PM2.5 pollution, and to discuss air pollution impacts in patients with COPD, asthma, and fibrotic ILDs, which is my particular area of interest. So these are the Environmental Protection Agency criteria-regulated air pollutants, and we have the primary sources of air pollution, which are industry, transportation, and agriculture. And we're also seeing more and more in recent years how biomass burning from wildfires and other climate change-induced crises are also contributing significant amounts to air pollution that we're experiencing in our day-to-day lives. And so our top four pollutants that are listed here are ozone, carbon monoxide, sulfur dioxide, and nitrogen dioxide. And what is common between those is that they're all gaseous forms of pollutants. And we have particulate matter with a diameter of 10 micrometers or less, which is PM10, and PM2.5 is 2.5 micrometers or less. And then lead is also a regulated air pollutant, which kind of falls into a slightly different category. And so it's important, when we're talking about particulate matter, to know that particulate matter is an amalgamation of all sorts of different particles that exist in our airborne within our atmosphere. And depending on the size of the particulate matter, they deposit in different parts of the respiratory tract. So we have our coarse particulate matter, which is typically the PM10 range, and that tends to deposit in the nasopharynx and in the larger respiratory bronchial, larger airways. And then when we get down into the lower respiratory tract, we're dealing with primarily ultrafine particulate and fine particulate matter deposition in the alveoli and the bronchi, and you can see that primarily here. We're also getting ultrafine deposition, which are very small particles, less than 0.1 micrometers that also deposit in the nasopharynx and oropharynx, and that's where you get a lot of the sinus discomfort and nasal discharge and that sort of thing when you have high particulate matter exposure days, especially during wildfire season. So a key message to convey here is that PM2.5 pollution is a massive global health problem. So the WHO recently changed their air quality guidelines to recommend that everyone should be living in an area where annual PM2.5 average exposure is less than 5 microgram per meter cube, and pretty much nowhere is achieving that. So that means that 99% of the globe's population is living in areas that exceed WHO recommendations for PM2.5 pollution. And some estimates estimate that up to 8.9 million premature deaths per year are attributable to PM2.5 pollution. And what you can see on the plot on the left here is that as your PM2.5 level increases, your hazard ratio for all-cause mortality increases quite rapidly as well. And then on the right-hand side here, we're looking at cause-specific mortality. And so again, you can see that as the PM2.5 levels increase, the hazard ratio for cause-specific mortality from lower respiratory tract infection in black, ischemic heart disease in green, lung cancer in yellow, stroke in red, and COPD in purple all increase. So there's significant risks in both cardiovascular and respiratory disease, as well as significant risks in other systemic diseases as well. So focusing on chronic obstructive pulmonary disease. So there was a really excellent GOLD 2023 committee report that I recommend that all of you read. And they summarized a lot of the literature linking air pollution to COPD, morbidity, and mortality. And they summarized that they can attribute approximately 8% of global COPD deaths to air pollution. That's a huge number when you think about the global burden of COPD. And they've demonstrated that air pollution is associated with increased incidence of COPD, accelerated lung function decline in patients with COPD, impaired childhood lung development, which predisposes to COPD, and increased cardiovascular mortality that preferentially affects people with COPD. And they found that there's also increased susceptibility to air pollution's adverse effects in patients with COPD who are current smokers, females, and individuals who have dyssynapsis or small airway abnormalities. And they anticipate that climate change is expected to increase air pollution fatalities by 100% to 300% over the next 30 years, which is why it's imperative for us to act and be advocates as pulmonary physicians and allied health professionals that this is our lane. And I think it's really important for us to be aware of these impacts. This is a systematic review and meta-analysis of emergency department visits, hospital admissions, and mortality in patients with COPD. And this is particularly looking at hospitalizations. When they look at PM2.5, nitrogen dioxide, and sulfur dioxide, per 10 microgram per meter cubed increase, you see a 3% increased risk of hospitalizations from COPD for PM2.5, 4% for nitrogen dioxide, and 2% for sulfur dioxide. So really, all of those are affecting COPD hospitalization risk quite significantly. Air pollution impacts and asthma is a huge topic. And I'm not going to do it justice here. There's many experts that focus on this area, and I recommend you diving into that literature. This is a good review from Lancet 2014 that links gaseous pollutants to various outcomes in asthmatic adults, including bronchoconstriction, decreased FEV1 and FVC, increased airway hyper-responsiveness, airway inflammation, and enhanced responses to inhaled allergens. So I recommend having a look at that. And there's significant data linking traffic-related air pollution to childhood asthma development, such that various components of TRAP, or traffic-related air pollution, are associated with the development of asthma in children. PM2.5 is associated with a 7% increased odds of developing childhood asthma per one microgram per meter cube increase in PM2.5. Nitrogen dioxide is also significant, and then benzene as well, which is a significant contributor to, as well as airways disease, but also lung cancer risk and other malignancy risks. So this is my area of interest, is primarily fibrotic interstitial lung diseases. And there has been a growing body of literature linking air pollution to adverse effects in this population. So this was the first paper really showing that increased levels of ozone and nitrogen dioxide are associated with increased risk of acute exacerbations in IPF, and this was by Kerry Johansson et al. in 2014. This is a chest manuscript from Winterbottom et al. in 2018 demonstrating that increased PM10 exposure was associated with accelerated decline in FBC in patients with IPF. And there's been some really interesting work recently that's talking about gene and environment interactions in patients with ILD, and particularly looking at IPF incidents, where they found that the risk of incident IPF was compounded by genetic risk factors and exposure to ambient air pollution for nitrogen dioxide, nitrogen oxides, PM2.5, and PM10. So recommend looking at all of those bodies, excellent bodies of work. This was our recent published work in JAMA Internal Medicine looking at diverse cohort of patients with fibrotic ILD from across North America. So we had the Simmons Center for ILD at the University of Pittsburgh in yellow, 40 sites of the Pulmonary Fibrosis Foundation in blue across the U.S., and then eight sites in the Canadian Registry for Pulmonary Fibrosis across Canada in red. And this represented over 6,600 patients from North America. And this is projected on a PM2.5 map over North America for the year 2005. And what you can see is that there is higher levels of PM2.5 in the western, or sorry, eastern, northeastern U.S., as well as quite a bit in California, particularly around Los Angeles region. And then another thing to highlight here is these stars that are in kind of remote rural parts of North America in Quebec and Alaska. And those are actually reflective of wildfires that occurred this year, in that year. So you can see that those high exposures of particulate pollution can drag up an annual average, just giving you an idea of just how high those PM2.5 levels can get during these wildfire events. And what we found in our study was that increased PM2.5 exposure was associated with increased mortality risk in patients with fibrotic ILD, such that our hazard ratio of 1.09 can be interpreted as for each one microgram per meter cube increase in PM2.5, there was a 9% risk of increased death in these patients. So a pretty significant effect. And there appears to be a threshold somewhere in the 8 to 10 microgram per meter cube range. We also found that human-derived constituents of PM2.5, so sulfate, which is primarily due to kind of steel and coal, other industrial production, ammonium, which is also industrial production, but also agriculture, and then black carbon is combustion-related, really seem to be driving a lot of that mortality effect. We also have some recent work looking at ultrafine particulate impacts in these patients. And this is just looking at how ultrafine particulates are spread throughout the country. And what we find is that as ultrafine particulate levels increase, that the risk of death, at least in our Pittsburgh cohort of patients, increased by about 8% for 1,000 particles. And this is some unpublished data that we're hoping to have published very soon. This is just a systematic review looking at air pollution effects in patients with ILD, but basically to show that there's strong evidence in both interstitial lung abnormalities as well as clinical outcomes for lung function, baseline decline, and acute exacerbations and mortality for all of these being impacted in ILD patients. So we think of ILD patients as a sentinel group that really is vulnerable to the effects of air pollution. And our future work is looking at the mechanisms through which PM2.5 exerts its harmful effects. So this is some of the area that we're working on currently. And I'll finish up there. And hopefully we can have some time for questions afterwards. Thank you so much. So my name is Erica Moseson. I'm a pulmonary critical care physician in Portland, Oregon. And I host the Air Health, Our Health podcast. And my talk is going to be on wildfire smoke exposure and risk to the pulmonary health of our patients. So here are our lesson objectives. So first, we're going to be kind of reviewing the composition of wildland fire smoke exposure now that you've gotten a really good education on PM2.5. We'll talk about the respiratory impact of that exposure, and talk about options for patient protection, like what you can do and talk to your patients about. So as Dr. Gooby talked about, a lot of what we're starting to learn is it kind of depends what's burning in terms of what is made into the wildfire smoke. However, there are kind of the host of the usual products of combustion, right? So particulate matter, carbon monoxide, oxides of nitrogen, volatile organic compounds. And you get these other kind of downstream formation of other pollutants. But I would say that PM2.5 is the primary hazard in air pollution related to wildfire smoke exposure. And so we've heard a lot about how devastating PM2.5 in general can be for our patients for both asthma, COPD, and fibrotic ILD. And so trying to understand, well, what's the contribution from wildfire events here? And so this is a study looking at kind of trying to estimate what is the annual contribution from the wildfires to the PM2.5 burden in an area. And I would say when this is looking at if you're considering a protective standard of 12 for annual or 35 for a 24-hour period. But I do just have to note, as a member of the ATS Environmental Health Policy Committee, that the ATS strongly recommends that we limit that to eight for an annual average. And I think Dr. Gooby's data about that massive inflection point that occurs there, and the WHO recommends a level of five. So we really do have wildfire events, though they are sporadic, contributing significantly to the total particulate matter burden around the country. So what is the respiratory impact of this in particular? So I try to emphasize to people, because I think sometimes clinicians especially, who suffer from imposter syndrome or worrying that they're not an expert in something, come into a room like this and look at all those different chemical compounds on things and think that they can't really be an expert in that. And you are, because if you can talk about smoking, you can talk about particulate matter exposure, and you can just kind of think it through when you're talking to your patients. So if you're not familiar with Air Quality and the Air Now app or other measurements of that, download it on your phone, tell your patients to do that, and help them try to understand when you pull things up and there's this Air Quality Index, and it kind of has this little scale over here, what do you want to do with that? So who are sensitive groups? Well, I think we just learned from Dr. Gooby that all your patients are sensitive groups, so don't worry about it too much. You can just tell them they're a sensitive group. You'll probably be right. But the way to think through who's a sensitive group is to think about life stage, because that can be really helpful, because really, air pollution is something that is dosed. I think we're all familiar with that, with the addition of secondhand smokers, thirdhand smoke, that sort of thing. So life stage is really important. So kids breathe a lot more, and they run around, and they're active in the smoke. And they also inhale more air pollution for their pound of body weight. Pregnant women also have increased ventilation. We think there's likely an increased risk of premature delivery and lower birth weight, like we'll see with other effects from PM2.5. Older adults often have a higher burden of preexisting comorbidities. Obviously, we've got studies with asthma and COPD, leading to this increased risk of lung function worsening, hospitalization, death. Patients who are at a lower socioeconomic status are often included in this, both because there's an increased risk of underdiagnosed or undertreated illness, and also because people may be living in substandard housing, or may just suffer a chronic daily burden of air pollution that kind of puts them closer to a threshold of having a bad effect from one of these big wildfire events. The other really vulnerable group are people that we may think of as pretty healthy, often are outdoor workers, because they are working at prolonged exposure at very high levels, and they're exerting. If you're working as a wildland firefighter, or a worker in agriculture, or in construction, you're exerting really hard in the outdoor area, in heat and high air pollution exposure, you're actually inhaling a really high dose of that air pollution. There's a lot of studies. This is one that just kind of highlights the idea of the sensitive groups. This was a study following wildfires in Southern California, which basically looked at children in the state Medicaid program. What you had is after you had kind of a wildfire event where the average PM 2.5 level was 89, so we're blowing 12, and 25, and 35 out of the water, you had these ER visits increasing for all age groups, but it was kind of 34% for all comers. For the zero to four-year-olds, it was 70%, and it was like 240% for kids less than one. The younger you are, the more vulnerable you are breathing this higher level of pollution. I think a lot of people struggle with where do we break things down with the air quality index. Well, when the air quality index was unhealthy for sensitive groups, again, your patients, you had a 73% increase in ER visits following that. And again, similar to other studies of PM 2.5, you just had this kind of, as the PM 2.5 level went up, you had increased rates of ER visits for asthma. So then getting a little bit to what Dr. Gooby was talking about, does it matter what's burning? Is wildfire, maybe because it's like trees and shrubs, it's safer to breathe than coal exhaust? A lot of those things are still being teased out. I'm going to give you two studies that look at it two different ways. This is one from Southern California, which was looking at trying to separate out PM 2.5 from wildfire events carried on the Santa Ana winds from just the ambient chronic toll of PM 2.5 that afflicts Southern California. They looked at zip code-specific PM 2.5 and hospitalization for respiratory diseases and really tried to differentiate the toll from general PM 2.5 to wildfire-specific PM 2.5. And here's their models, their PM 2.5 levels, and their computational analysis. They looked at it in a couple of different ways. And basically what they found is, like everything else, like as the PM 2.5 level went up, the percentage of people being hospitalized from all causes went up by 2 3rds or 3 quarters of a percent. But what they found is when they were imputing it to wildfires, they actually had higher rates of hospitalizations compared to background air pollution. And there's a whole host of confounders. If you're going to the hospital for an asthma exacerbation and your house burned down, like they're not going to send you home. Or we know that a lot of things are afflicted by stress. So if you're fleeing a catastrophic fire and you're having all the climate anxiety that goes with that, and that's related to wildfire pollution, maybe there's kind of these additive factors that are leading to that. A little bit on the flip side was this study that just came out recently over the summer after the smoke from the Canadian wildfires sent a lot of asthma folks to the ER in New York City. And what this group did is they compared the PM 2.5 again to the background PM 2.5. They tried to remove the background PM 2.5. And they found a risk ratio that was fairly similar to other forms of PM 2.5. But the interesting thing is they also evaluated for the presence of oxidative stress inducing metals like copper and sulfur, kind of what Dr. Gooby was talking about. And so this is what they had. So they had, as you can imagine, you're going along your different age groups here, you know, going along with your, you know, regular New York asthma visits, PM 2.5, there's a pollen spike here, people went to the hospital. And then here, you know, your PM 2.5 level spikes up, sure enough, whoop, up, you know, up you go. People are still getting hospitalized, but it didn't look in their scenario like it was any particularly worse than your regular PM 2.5. And so this kind of gets to the idea of looking at a little bit of the chemical composition, right? So this is what they found. So on average in New York, a lot of your PM 2.5 is from fossil fuels, right? You have high levels of copper, sulfur, and versus the wildfire smoke was kind of burning much more of the biomass, right? So I really think this is kind of intuitive and it matters what's burning, right? So if you're having like structural fires where you have like houses and cars on fire, that might be, you know, changing the composition of what people are inhaling with these pretty severe toxins, right? If a whole town goes up in flames, that's a lot that's burning. That's not just trees. And that's happened sadly. I mean, it's happened tragically here in Hawaii and Lahaina. It happened in my home state of Oregon, Phoenix and Talent, you know, were wiped off the map almost in one, you know, catastrophic fire. We saw it in Paradise, California. We're seeing these sort of events increasingly. The hard part is what do you do about this, right? Your air quality monitor is not telling you, oh, don't worry about this wildfire patients. Like it's not burning enough structures. It's just the regular severe risk to your health, not an extra severe risk to your health. So I don't really know that we need to pay attention to that yet from a clinical standpoint, but it is something to kind of think about going forward. So what do we do with having these events in the long term, right? Like what happens if you're just kind of living through these chronic smoke events? And this is something trying to separate out just living through these episodic events versus the chronic toll of air pollution is kind of challenging. This is one study that tried to do it. So in the Sealy Lake region in Montana suffered this very like prolonged, like a month long period of very high levels of PM 2.5, averaging over 200 for almost a month. And University of Montana went out and kind of did spirometry for these folks. And they found that while they were checking in the following years, they found that they initially, not much change as you would expect, but when they went back in 2018 and 2019, what they found was that the FEV1 to FEC ratio was actually lower in the years following this event. They had planned to go back in 2020, but unfortunately COVID derailed them. The other thing is they actually looked at the flu season in the following winter. And this was something that Dr. Gooby was talking about, about the increased risk of infection. In fact, that's one of the biggest increased mortality risks of infection is the way that this smoke exposure and PM 2.5 can actually change the immune system in our lungs, right? So what they did is they found changes in lung immunology a year following the fire exposure and people had more severe flu seasons in areas that had been highly afflicted by wildfire. And if we think about it, going back to smoking, we know that like ARDS, for example, is more common in smokers, right? If you smoke cigarettes and you go like get in a car accident and end up in the trauma unit, you're more likely to get ARDS just from we know that that kind of toll of smoke inhalation is not good for us. And we also know that 17% of North American COVID-19 mortality we think was actually likely related to this intersection with PM 2.5. So what do we tell our patients, right? Like, so what do you do about this, right? You can't tell them like solve all climate change and fix wildfires. So the kind of the advice for patients is if they have access to clean air, so if they can stay indoors or find a clean air shelter, you want them to do that and probably use HEPA filters. And I'll touch briefly on why I think that's worth advising to either make a clean air refuge or get to one. You don't wanna generate extra indoor air pollution, right? So don't smoke. It's always good to tell your patients quit smoking, but don't make more. It's actually a good time to not cook, right? Don't be toasting things or putting more pollution into the air. And then also just think about reducing that dose of air pollution, right? This is a time to tell people not to go for a run in the middle of this heavy air pollution. I know it's really hard for us as doctors to tell people not to exercise, but really to try to, if they're gonna do it, to try to find clean air and just really try to recognize that have people really understand what can go on here. Recommend not vacuuming, making sure you don't have like, you know, room vented appliances and everything, you know, not using flashlights to light your home. And then I just wanna touch a little bit on HEPA filters because I do think we've just entered a time in the world, especially those of us who take care of lung patients, that we all gotta start to be familiar with portable indoor air cleaning devices and know how to give rational recommendations to our patients. So there's tons of studies in pediatric asthma that can show that HEPA filters can reduce particulate matter exposure and everything. And their performance during wildfire events, I think really depends on how leaky your home is, how, you know, if they've correctly sized the HEPA filter, there's a lot of user error potential in this. And so that's why you have these ranges from all over the place from 12 to 92% reduction. So it's important to just remember that that sizing issue is key. So one study that I think is helpful for thinking through this was this study called the Clean Air Study, and it was a randomized controlled trial that basically gave people the same device, it's just one of them actually had a HEPA filter and carbon filter in it, and the other one didn't, but people plugged them in and ran them. And what you found, and these were in patients with COPD, and the average PM2.5 was at least over 10, right? So still safe, according to the EPA, until that changes, hopefully. But they monitored the use with an electric sensor, so they monitored the adherence, and they assessed them clinically at one week, three months, and six months. And they monitored PM2.5 and oxides of nitrogen in the home, and what they found is, you know, the filter worked, right? So you ran the thing, and your PM2.5 went down, your nitrogen oxide went down, and then what they found is that if you had a active filter, you actually needed less rescue medication, and you had fewer moderate exacerbations. I don't think with that many patients they were powered for severe exacerbations. But this is the point I really wanna make, is that using it matters, right? So the more you used it, so this was all participants, this is people using it 80% of the time, and these are people who just plugged it in and left it plugged in for the six months. That's what you wanna tell your patients to do. Just plug it in, like, and run it. They tend to not use a ton of power. This may, obviously, for our patients who are very sensitive to electric costs, this might be a concern. But you had more bang for your buck the more you used it, right? If your patient goes and buys the box, and they haven't taken the filters out of the plastic and plugged the thing in, it doesn't help. It's like ARDS, if you don't twiddle the dials and actually get them on six cc's per kilo, you're not saving any lives. Just because you mean to do it, it doesn't mean it will save any lives. So, and then before and after wildfire events, between is really the important time to talk about this. So, having patients get to know about Air Now, telling them that they might be a member of a vulnerable group, encouraging them to make plans for clean air spaces, making sure they get vaccinated, and just kind of talking to them about these issues. And obviously, it's always a good time to quit smoking or vaping. So in conclusion, obviously, I think these events are very catastrophic, they're very scary, but they also have a potential to cause sickness, both in the short and long term for our patients. We need to kind of do anticipatory guidance about making plans. Science and research on this is constantly evolving, so I would just commit to adding this to a thing that you follow in your practice and stay updated on. I have a podcast called Air Health, Our Health, where I try to stay updated on these things and share it, and that's a place that I can be reached, and if you have any other questions. All right, and then I think we're. Thank you. And we're going to be saving questions for the end as well. Aloha and good morning. I'm Sam Evans. I'm from Honolulu. It's my pleasure to give you a talk about something a little different in terms of air pollution. I'm going to speak about vog, which is the smoke that comes from our volcanoes and the gases. And it affects our air quality throughout the islands, but mostly the Big Island. I am giving this talk on the shoulders of my former mentor, Dr. Elizabeth Tam, who studied school children on the Big Island and the effects of vog on them. Dr. Tam passed away two years ago, but much of this talk is using her data and what she found. So what I hope to do is teach you about what is vog and what makes up vog, how vog can affect the respiratory system in our patients and even regular persons. I will describe people who are at most risk for effects from vog, and then we'll spend a couple slides on some mitigation strategies. So Kilauea is a very active volcano on the Big Island. It's been erupting continuously since 1983, and it has released a ton, more than a ton, of sulfur dioxide into the atmosphere. Dr. Tam tried to educate me about what it really meant that these levels, 1,800 to 10,000 metric tons of sulfur dioxide. She told me there was a factory in Ohio maybe 10 years ago that let out 1,000 metric tons of sulfur dioxide, and the EPA shut them down. So this is way more than that. So even when it's not erupting, there's still a lot of sulfur dioxide emission, and it's certainly a problem. It's hard to predict. It just comes and goes. We had a pretty big eruption last month, and it was beautiful, but it did emit quite a bit of gas into the air and the environment in particular matter. There are other volcanoes in the world that do this, that create vog in Africa, Nicaragua, Costa Rica, and Japan. Not all volcanoes are the same. They emit different types of gas. So what is vog? It's a visible haze of aerosolized tiny particles, acid droplets, sulfur dioxide being a major component. And this is what happens when it all combines together with sunlight and moisture, water, and dust. And it's prone to winds and elevation levels. We have two huge mountains, Mauna Loa and Mauna Kea. They're about almost 14,000 feet. So they also influence the weather patterns and the inversion layer of where the vog can hang out. So I mentioned in the presence of water vapor, oxygen, sunlight, the SO2 turns into vog. There may be a little bit of other toxic elements such as mercury and lead in there. The half-life is about six hours. So once it's emitted, it hangs out in the air for at least six hours. And it will vary during the time of day. At nighttime, it can come down, it can go out to the ocean, and in daytime, the land mass heats up, the vog can come back onto land and affect people. So it tends to hang out at this elevation of between 300 and 6,000 feet. So the winds are important in terms of where the vog gets pushed to. Mostly we have prevailing trade winds that are northeasterly. And so the vog usually gets pushed over Kona. And so the people there are most affected by it. But sometimes our winds turn southerly, and the wind will push the vog throughout the island chain. So we'll actually see it here in Honolulu, and it will affect our patients here. So this is Mauna Loa and this is Mauna Kea. These two vents, Hale Mauma and Pu'u O'o, are what emit most of the vog. Pu'u O'o is one of the main emitters recently. And so Dr. Tam's team was looking at where the schools were located and what wind direction and time of day were doing in terms of exposure to the vog. And so they're just depicting time of day, what happens at night, where does it go, what happens when the wind change, and which parts of the island are most affected. So mostly it's the Kona side, but when the winds turn southerly, the Hilo side of the island will get affected. And the better part of the island is the northern area around Hawi that gets spared from a lot of the vog. So when it's really bad, the patients are told, take a trip up to Hawi and hang out there for a while. So there's a lot of health effects and hazards to vog. Sulfur dioxide itself is an irritant, it irritates the skin, it gets in the mucous membranes, cause your eyes to water, can get into your throat, cause sore throat, and definitely can get into the airways and cause issues that I'll talk about. The worst being asthma. So even if you're not an asthmatic, if you have a pretty bad exposure to vog, you may express asthma symptoms. Other things people complain about are headache, flu-like symptoms, fatigue, lethargy. But it's individuals that already have underlying lung disease that are at most risk from a bad vog day. These quote sensitive groups are usually asthmatics or COPD patients, and we'll even see it here on Oahu, when there's a lot of vog coming from the Big Island. Our asthmatics and our COPD patients will call the office, they'll want to be seen right away or they'll end up in the ER. Happens a lot. Other folks, cardiovascular disease, older and younger, especially infants, are affected by the vog as well, and new and expected mothers can be affected by the vog. The worst affected are those with underlying asthma. Even short-term exposure to the sulfur dioxide can cause serious bronchoconstriction, wheezing and shortness of breath, and end up in an ER visit. And of course, if you're short of breath, you're breathing even more, your respiratory rate goes up, and so you're taking in more of this, and it can lead to pretty severe exacerbation. The EPA and the Hawaii Department of Health will monitor the levels, and they will get out advisory warnings to patients and the population when the levels are too high and unsafe. Nobody really knows what the long-term effects of exposure to vog are. So, as I mentioned, the Department of Health and the EPA have established certain levels of the particulate matter and the sulfur dioxide that people may not be paying attention to the numbers so much, but when they reach these unhealthy levels, they'll put out warnings to tell people to stay inside. Another factor of the vog is when that sulfur dioxide combines with water, it can make sulfuric acid. A lot of the people on the Big Island use water catchment devices for their own water to water their property, their farms, their animals, and so if that gets into the metal or the containers or anything that can combust like that, it'll leach the material. It'll leach the material into the water, and so not only does it damage the equipment, but it's not good for us to be drinking lead and things like that. It also can affect the plants. So there's a lot of farms on the Big Island, and the vog can, the particulate matter can get on top of the plants and kill them, or you can consume it if you don't wash it well and get sick from it. How do we mitigate vog? Well, hopefully people keep an eye on the websites and the radio and heed the warnings when they occur. With any, perhaps, disaster like in hurricane season, you tell your patients, you need to have enough of your medications on hand in case you can't go to the store or the roads are blocked or the power is out. We tell patients to stay indoors, close their windows, some will put wet towels at the gaps in the door entrances. We want the air to be as clean as possible, so if they have a HEPA air purifier, we recommend they use it, put the AC on, put it on recirculate so that the air isn't coming from the outside. If you have to go outside for some reason, we recommend you wear a mask, although a mask may not be all that effective for vog and eyewear to protect your eyes. Some say putting baking soda water in the mask may help a little bit for the particulate matter. Of course, staying hydrated is an easy thing to do. We tell people also if they're in their car and they're driving to close up the windows, put the AC on, recirculate, and if conditions are getting really, really bad, consider going up to the northern part of Hawaii Island like Kaui. Of course, decreasing their own air pollution in their home by not smoking and vaping is advisable, and we warn them about the effects of the sulfuric acid if they're using a rain catchment system, and to disconnect it if there's a heavy vog period, and we warn them about the effects on the plants. There's some wonderful resources out there. They have a hub, a vog dashboard with many, many sites that include what the current levels are, what the warning levels are, and also the Department of Health is continuously monitoring this, so is the EPA, so there's lots of resources for people to look at. There's even a Facebook group of people that live on the Big Island, and it's like a community, and they all discuss what's the vog doing in their neighborhood, and so they communicate that way, and it's a wonderful thing. This is a picture of last month's eruption. This is what it looked like. I think this was September 10th. It's not erupting with lava right now, but I hope you get a chance to visit the Big Island and go see it. It's quite beautiful. Thank you for your attention, and please don't forget to evaluate this. Thank you. Hi, everyone. My name is Adelie Martinez. I am a fellow in pulmonary and critical care at UCSF, and today I'll be talking about a community-based participatory approach to environmental justice research policy and advocacy. I have no disclosures because I'm still a fellow. So I'll start by describing the historical context that has shaped the physical and social environment in which we live in this country and how marginalized communities have been systematically placed at higher risk of exposure to air pollution and other health hazards. And in the second half of my talk, I'll go through a discussion on how community partnerships play an integral part in environmental justice research. So a little bit of history. Environmental justice, the movement at its core is a civil rights movement that was started by individuals, particularly people of color, who sought to address the inequities in the environmental protection in their communities. So starting in the civil rights movement in 1968, we have the Memphis sanitation strike where they protested unfair treatment and health concerns related to environmental exposures for sanitation workers in Memphis, Tennessee. Then in 1979, we have in Houston, Texas, African-American homeowners fought to keep the Whispering Pines sanitary landfill from being placed just 1,500 feet from a local public school. They formed the Northeast Community Action Group, and this led to a lawsuit, Bean v. Southwest Waste Management Corporation, which is the first of its kind in the U.S. to charge a waste facility with environmental discrimination. Then in 1982, we have the Warren County protests, which are thought to be the true catalyst for the environmental justice movement, which involved the protests of a PCB landfill in Warren County in which over 500 environmentalists and civil rights activists were arrested. And we fast forward today, we see time and time again that air pollution, climate change, water contamination continues to have the largest impacts on vulnerable communities and communities of color. And so environmental inequities are deeply rooted in structural racism. So discriminatory policies such as redlining, urban renewal, eminent domain, zoning laws have shaped the environment in which we live, placing marginalized communities at higher risk of exposure to substandard housing, indoor and outdoor pollutants, which in turn leads to racial disparities in several health outcomes, including asthma. A brief note about redlining, just to make sure we're all on the same page. In the 1930s, to support the financial recovery for families in the Great Depression, the federal government started to allocate housing loans. And in order to assess which neighborhoods were worth investing in, the Home Owners Loan Corporation created maps of 240 cities with a grading system where hazardous neighborhoods were graded as D and outlined in red, and those that were worth investing in were graded A and in blue. And unsurprisingly, the neighborhoods that were red were mostly African American and immigrant communities. And redlining was essentially a way to codify discriminatory policies and segregation, and it was used to allocate resources and wealth and incentivize further segregation. And we see later on that these same redline neighborhoods were then subjected to discriminatory policies such as urban renewal and eminent domain. And in San Diego, for example, so this is my hometown, in 1964, eminent domain led to the construction of Interstate 5 through a neighborhood called Logan Heights, and that displaced hundreds of families and isolated a subset in a neighborhood now called Barrio Logan. It was not just the interstate, there's also a bridge that connects the freeway over Barrio Logan to the Coronado Island. So if you've ever been to the convention center in San Diego, this is about a mile south along the harbor. And so because of that, this neighborhood of Barrio Logan is now surrounded by an interstate, there is a bridge completely going over the neighborhood, and then on the other side you have a lot of industrial buildings and you have the naval shipyards. And by the way, I grew up across the street from this park right here. And unsurprisingly, Barrio Logan has the highest rates of asthma hospitalizations in San Diego County. In the last three years, we've seen more literature and evidence linking historical policies such as redlining with higher exposure of air pollution and poorer health outcomes. In this first study, Lane and colleagues geo-referenced redlining maps and cross-referenced with present-day census blocks, and they explored the association between population weight-based, weight mean concentrations of NO2 and PM2.5, and the study found substantially higher NO2 and PM2.5 levels between the grade A and grade D neighborhoods. And in the second study, Nardone and colleagues similarly geographed redlining maps with census blocks and studied the rates of asthma-related health utilization. And unsurprisingly, there was an association where you can see visually the association, the same areas that are red are the same areas with the higher asthma rates, and they saw quantitatively a 2.4 higher rates of asthma-related ED visits in these neighborhoods. And so why are community partnerships important in environmental research? Well, I hope I've made it clear up to this point that there is no talking about environmental justice without addressing structural inequities impacting marginalized communities. And to be clear, not all research needs to be community-based. You could do an epi or clinical trial that doesn't necessarily need to have community partners, but when you are implementing a strategy when you're doing any sort of intervention, it's really pivotal that you involve the folks that are actually directly impacted by these issues. So just to go through the charts, so some of the important key factors of community partnerships is that you have experts. So you have people who hold historical and current knowledge of the community. There's a deep experimental knowledge and there's trust building. It also really helps in prioritizing what would be important and there's really, they have a nuanced understanding of community needs and it creates, it helps prioritize interventions that are more accessible and they're more feasible. And then with action, really help understand the intervention targets and help co-develop interventions and implementation strategies. And it's also more sustainable because when you have voices of the community at the forefront, it's more likely to have sustainability and keep going. There's also improved uptake. And because we discussed structural racism, it's really important that I also provide you with a framework so that you can, when you're developing your study or assessing a study, you can see if the design is actually addressing issues of structural racism. And it starts first and foremost by naming racism as an issue and the mechanism in which racism operates. And in designing a study, we really have to be conscious in involving the target population and thinking about how is this going to be sustainable? And I will say the word reparations because this is really important in actually shifting the resources and the power back to community. So we can't just come in, do a study and then leave, publish our paper, get our credentials and go away. Like you actually need to establish a program that's going to be sustainable and keep going in that same community. So I'll highlight some examples here. So this is one study out of Philadelphia that really exemplified how community partnerships can be extremely effective. So Brian Stevens and colleagues developed the Community Asthma Prevention Program, or CAPP, in partnership with two organizations, the Rebuilding Together Philadelphia and also Habitat for Humanity Philadelphia. And their intervention was led primarily by community health workers. So they're the ones that are part of the community, members of the communities that were trained and compensated. And they identified families in need and they served really as liaison with the families to help prioritize necessary repairs in their homes that had direct impacts on asthma triggers, mitigations, both indoor, mitigating indoor and outdoor pollutants and allergens. And the study was very successful. They saw the post-repair questionnaire revealed a 50 percent reduction in nighttime asthma symptoms, a 40 percent reduction in the use of rescue medication, a 60 percent reduction in missed school days. And when we talk about the financial impact and why this is important, ED and hospital visits decreased by 90 percent. In the last few minutes, I'll talk you through what we're doing at UCSF and what my mentor Anita Talker has been doing with the UCSF CLEAR Lab, which has engaged youth in the community in participatory research in Richmond, California. So Richmond, California, it's located in the East Bay, east of San Francisco Bay. And it's home predominantly right now of a Latina community, but it's also home to the Chevron Refinery that you could see pictured here. Richmond was originally a predominantly black community in the 1930s, when the majority of the residents were shipbuilding, in the shipbuilding industry. In the 1960s, the Chevron Refinery became the major employers. And over the 90s and early 2000s, because of immigration patterns, it became predominantly Mexican and Central American, a Mexican and Central American community. And again, unsurprisingly, Richmond has the highest rates of asthma-related ED visits in the county of Contra Costa. And the Richmond Environmental Asthma Community Health Study, the goals were to form an academic community partnership, demonstrate feasibility of community recruitment, and engage local community members. And we're really trying to answer the questions of, what are the pollution sources? What are the place-based social stressors? And how is this associated with asthma symptoms? Going back to this framework here, we have experts prioritizing action and sustainability. So who are the experts? These are the experts. So these are young people. They're teenagers that are recruited. They're interviewed, recruited, and compensated. They're taught how to do quantitative and qualitative research. And they're the ones that think about the questions. They go in, they survey their community, and they come up with their interventions. They're really a great group of students. So the YPAR students over the last two summers have worked to identify and prioritize interventions by first assessing the community perspectives on the stressors that impact their daily life. And this was done through a photovoice project. This is a qualitative research method. And you see some of the photos that they took there of their community, and they displayed them for community members to come by and share. And then they did a quantitative research method where they developed a survey and collected data and analyzed that data. They themselves went out and surveyed 250 community members in both English and Spanish and came up with their data and results. And then it's just not data collection. They actually put together a presentation and shared these recommendations to stakeholders, including community organization leaders, researchers, city officials, and also their own family members got to join the call and see what they've been working on. And now the project has EPA funding to further understand the barriers and facilitators to these interventions and to test these strategies in a pilot. And there's several other community-based research hubs throughout the county. I just want to highlight this one, the Hercules Exome Research Center. This is based off of Emory and Georgia Tech, where they provide community, they provide grants and monies for community proposals and community partnerships. So the main takeaways to my talk is that disparities in air pollution exposure are rooted in structural racism and oppression. And community partnerships are super important when we do these interventions and environmental justice research as they provide expertise, a nuanced understanding of community needs, barriers, and levers to improve the uptake of the interventions. Thank you. Thank you so much. I'm inspired by all of you who are up here. Does anyone have any questions or comments? Hey, thank you so much for, I guess, inspiring us and empower us to kind of talk to our patients about diseases in the present. It's not the future anymore. My name is Maria Castro. I'm an pediatric respirologist in Alberta, Canada. For the ones who don't know, this province is just on top of Montana. And this year we had an unprecedented early wild season in the north of the province in May, June, followed by all the smoke from another unprecedented wild and fire season in British Columbia. And we finished that up end of August, September with another crazy wild season in the Northwest Territories with wildfire, forest, and tundra burned for weeks. And all that led us with more than 20 days of air quality in this out of 10 out of 11, if not 11. So really these recommendations of protecting the indoor space became super important for us. And I wouldn't deny some level of frustration of what else we could do for our patients. So here are my two questions for you. One, can you speak out a little bit of the maintenance of the HEPA filters? Like what is the size room for each device? How often we need to change the filters and the economic cost of that part for our patients? And my second question is, if this is the time for advocacy with the health insurances to actually cover the HEPA filters as a medical therapy or preventive medical therapy for our patients? Yeah. So I mean, personally, I think we do have enough data to do that. So if you look at the St. George Respiratory Questionnaire impact of the Clean Air Study, it was the same as it was better than Spiriva in Torch. It actually surpassed certain inhalers. And that's like one device that you can kind of plug in and change. You do have to size it. So that's the thing that's a little challenging is it is kind of device specific. So you actually have to teach patients that they need to go look at the square footage that's going to be cleaned and everything. But I don't know if you want to add another fellow wildfire country. I actually went to U of A in undergrad, so I'm very familiar. So I think that HEPA air quality filters actually have different grades in terms of the percentage of particulates that they're able to remove from the air as well as the size of the particulates. And acknowledging that there's various levels of quality and that's a quality of the HEPA air filters increases. So does the cost. And that's something that I think that we need to be aware of when we're imparting that recommendation on our patients. If that's something that they're paying out of pocket, especially for patients that are maybe coming from lower income or historically minoritized communities, I think that there is less access to those filters and we need to be cognizant of that. In Canada, I am not entirely sure about the funding opportunities for that. I don't think that we have any. In the US, they are currently proposing a bill for health spending accounts to be subsidized for the purchase of HEPA filters. So that would certainly be beneficial, but I think that those interventions can also tend to benefit more high income people. And so we also need to be cognizant of ensuring that those benefits are really going to the people that need them most. Yeah, and I would say it's also the wild west in terms of what's allowed to be sold and marketed as an air cleaner. I mean, you can actually have ozone generators. So you go into the big box store and there's this line of air cleaners and you can have things that are actually harmful to human health that are sold and marketed as an air cleaner. It's a space ripe for physician advocacy. So I'm hoping everyone in this room takes that on a little bit. So a little bit of education can go a long way. We participated with the ATS Environmental Health Policy Committee in advocating that the government considered these as part of wildfire response. The other thing from a cost effective standpoint is a box fan and a MERV 13 filter can actually do a lot to reduce particulate matter in an area. And that's actually a place where it's hard to mess it up. You don't quite have to do as much maintenance and everything. Just on that point too, with our local pulmonary fibrosis advocacy group in British Columbia, we did a session on building your own air filters. I didn't lead it, but one of the Simon Fraser University professors that works on air quality and community engagement led that. So that's something that you can engage in your communities as well if you have experts in that area that can help to bring that to communities. And really, I think it helps patients to be able to do it with their own hands too. I actually submitted a session for CHESS this year that was about indoor air cleaning technology and how to talk to your patients about it. It was a whole hour because I'm a nerd. But if you write in your app, evaluating the session in the app, gosh, we would love a session on how to use air filters and air cleaners. Then next year, we can get you that. So another reason to evaluate the session in the app.

air pollution

health

global health problem

PM2.5 pollution

respiratory health

wildfire smoke exposure

COPD

asthma

environmental justice

community partnerships

Chronic Obstructive Pulmonary Disease