District 8 SONPM Big Sky

Perinatal and Fetal Effects from Climate Change and Air Pollution

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21 April 2022

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Rob Byron, MD, MPH

Lori Byron, MD, MS

Acknowledgment & Appreciation

• We acknowledge that we inhabit the unsurrendered lands of the  Absaalooka (Crow) people who have been stewards of their land for 1000s of years;
•  We are indebted to the Crow and Northern Cheyenne peoples for their openness and the trust they placed in us.

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Air Pollution caused 500,000 newborn deaths/year

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Air pollution accounts for 20% of newborn deaths worldwide, most related to complications of low birth weight and preterm birth

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Soot was found on the fetal side of the placenta for the first time in 20198 by the European Lung Foundation

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https://www.sciencedaily.com/releases/2018/09/180916152704.htm

Photo: https://ifpafederation-2i09v4zdrcmtpsrxer.stackpathdns.com/wp-content/uploads/2019/06/shutterstock_1281014467.jpg

State of the Air, 2020. American Lung Association. https://www.stateoftheair.org/

Air pollution emissions have dropped steadily since 1970 thanks to the Clean Air Act. Source: U.S. EPA, Air Trends: Air Quality National Summary, 2019.

Air Pollution Damages Our Health

-68,000-250,000 premature deaths/year in the US^1,2

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-~1 in 5 premature deaths globally linked to burning fossil fuels³

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1. Lancet Countdown, 2020: 2020 Lancet Countdown on Health and Climate Change Policy Brief for the United States of America. Salas RN, Lester PK, Hess JJ. Lancet Countdown U.S. Policy Brief, London, United Kingdom. )https://www.lancetcountdownus.org/wp-content/uploads/2021/01/2020-lancet-brief.pdf)

2. Shindell D, Ru M, Zhang Y, et al. Temporal and spatial distribution of health, labor, and crop benefits of climate change mitigation in the United States. Proc Natl Acad Sci. 2021;118(46). doi:10.1073/pnas.2104061118

3. Karn Vohra, Alina Vodonos, Joel Schwartz, Eloise A. Marais, Melissa P. Sulprizio, Loretta J. Mickley (2021). Global mortality from outdoor fine particle pollution generated by fossil fuel combustion: Results from GEOS-Chem. Environmental Research, 2021, 110754, ISSN 0013-9351. https://doi.org/10.1016/j.envres.2021.110754.

Mechanisms: Air Pollution and Preterm Birth

• Maternal hematologic transport of inhaled toxic chemicals

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• Increased levels of systemic inflammation

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• Changes in function of the autonomic nervous system

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1. Kannan. Exposures to airborne particulate matter and adverse perinatal outcomes: a biologically plausible mechanistic

framework.  Environ Health Perspect. 2006;114(11):1636-1642

2. Brook. Insights into the mechanisms and mediators of the effects of air pollution exposure on blood pressure and vascular

function in healthy humans. Hypertension. 2009;54(3):659-667

3. US Environmental Protection Agency. Integrated Science Assessment (ISA) of ozone and related photochemical oxidants

(final report, Feb 2013). US Environmental Protection Agency; 2013.

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Bekkar B, Pacheco S, Basu R, DeNicola N. Association of Air Pollution and Heat Exposure With Preterm Birth, Low Birth Weight, and Stillbirth in the US: A Systematic Review. JAMA Network Open. 2020;3(6):e208243

Preterm Birth

• Dehydration via prostaglandin or oxytocin release
• Altered blood viscosity
• Inefficient thermoregulation
• Preterm premature rupture of membranes during the warm season.

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1. Wolfenson. Secretion of PGF2alpha and oxytocin during hyperthermia in cyclic and pregnant heifers.   Theriogenology. 1993;39(5):1129-1141.
2. Bouchama. Heat stroke.   N Engl J Med. 2002;346(25):1978-1988. 
3. Stan. Hydration for treatment of preterm labour.   Cochrane Database Syst Rev. 2002;(2)
4. Ha. Acute associations between outdoor temperature and premature rupture of membranes.   Epidemiology. 2018;29(2):175-182. 

Fetal Growth Restriction

• Reducing uterine blood flow
• Altering placental-fetal exchange

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1. Stan. Hydration for treatment of preterm labour.   Cochrane Database Syst Rev. 2002;(2)
2. Prada. Biological mechanisms of environmentally induced causes of IUGR.   Eur J Clin Nutr. 1998;52
3. Browne. Uterine artery blood flow, fetal hypoxia and fetal growth.   Philos Trans R Soc Lond B Biol Sci. 2015;370(1663)

Stillbirth

• Premature labor
• Lowering amniotic fluid volume
• Damaging the placenta
• Abruption

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1. Li . Hot tub use during pregnancy and the risk of miscarriage.   Am J Epidemiol. 2003;158(10):931-937
2. He. Heat and pregnancy-related emergencies: risk of placental abruption during hot weather.   Environ Int. 2018;111:295-300

Mechanisms: Heat

Bekkar B, Pacheco S, Basu R, DeNicola N. Association of Air Pollution and Heat Exposure With Preterm Birth, Low Birth Weight, and Stillbirth in the US: A Systematic Review. JAMA Netw Open. 2020;3(6):e208243. 

Air Pollution and Preterm Birth

• Globally, in 2010, the number of PM_2.5-associated preterm births was estimated as 2.7 million, 18% of total preterm births globally

Air Pollution and

Preterm Birth

• Percentage of total preterm births which were associated with anthropogenic ambient PM_2.5 only in 2010.

Air Pollution and Preterm Birth:

3.32% of PTBs nationally attributed to PM2.5 

5.09 billion in cost of which $760 million are medical care

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Air Pollution and Preterm Birth:

Knock-Out Test: 27% Reduction in PTB

Air Pollution and Low Birthweight:

Dose Effect

• Babies of moms living within one kilometer of a hydraulic fracturing, or fracking, site in the state had a 25 percent greater chance of being born underweight 

ENVIRONMENTAL STUDIES

Hydraulic fracturing and infant health: New evidence from Pennsylvania

Janet Currie,1,2* Michael Greenstone,2,3 Katherine Meckel4

Toxic environmental exposures in maternal, fetal, and reproductive health

September 12, 2018

Nathaniel DeNicola, MD, MSHP , Marya G. Zlatnik, MD, MMS , Jeanne Conry, MD, PhD

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Fetuses :

Particulate Matter, Ozone, Heat, & PAHs

� PM first visualized in macrophages in placentas in 2018

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• IUGR (Intrauterine Growth Retardation)
• - associated w PAH’s, esp. 1^st Trimester
• Premature Birth (3% of preemies due to PM)
• - linked to heat and PM
• Some Congenital Heart Disease
• - Associated w heat
• Thyroid Disruption
• - PM associated w hypothyroidism
• Possibly post-neonatal mortality (SUIDs)
• -Links to prenatal PM and ozone, esp. 1 wk. PTD
• Stillbirths and miscarriages -
• -Links to ozone, traffic pollution exposure

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https://cms.qz.com/wp-content/uploads/2018/11/india-delhi-pollution.jpg?quality=75&strip=all&w=1400

IUGR: Ambient Air Pollution and Pregnancy Outcomes: A Review of the Literature. Sram, R. Env Health Perspective.2005

Preemies: Particulate Matter Exposure and Preterm Birth: Estimates of U.S. Attributable Burden and Economic Costs. Trasande, L. Env Health Perspectives. 2016

CHD: Projected Changes in Maternal Heat Exposure During Early Pregnancy and the Associated Congenital Heart Defect Burden in the United States. Zhang, W. JAHA. 2019.

Thyroid: Association of Exposure to Ambient Air Pollution With Thyroid Function During Pregnancy. Ghassabian, A. Jama Network Open. 2019.

SUIDs:  Air pollution and sudden infant death syndrome: a literature review. Tong, S.l Pediatric Perinatal Epidemiology. 2004.

Stillbirths - Chronic and Acute Ozone Exposure in the Week Prior to Delivery Is Associated with the Risk of Stillbirth. Mendola, P.

International Journal of Environmental Research and Public Health. July 2017.

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Adverse neurodevelopment :

• learning disabilities
• lowered IQ
• autism
• attention-deficit/hyperactivity disorder

linked to exposure to PM_2.5, polycyclic aromatic hydrocarbons, NOx, black carbon as a fetus

Payne-Sturges, D. Healthy Air, Healthy Brains: Advancing Air Pollution Policy to Protect Children’s Health. American Journal of Public Health. 2019.

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Schizophrenia, Autism

Links to prenatal and early childhood PM

Autism and Schizophrenia: Woodward, N. Traffic-related air pollution and brain development. AIMS Env Science. 2015

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Air Quality

• Monitor air index quality to guide outdoor exercise, activity
• Ask about indoor air quality, gas stoves
• Smoking cessation counseling
• Consider discussing home air filters

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1. Wolfenson. Secretion of PGF2alpha and oxytocin during hyperthermia in cyclic and pregnant heifers.   Theriogenology. 1993;39(5):1129-1141.
2. Bouchama. Heat stroke.   N Engl J Med. 2002;346(25):1978-1988. 
3. Stan. Hydration for treatment of preterm labour.   Cochrane Database Syst Rev. 2002;(2)
4. Ha. Acute associations between outdoor temperature and premature rupture of membranes.   Epidemiology. 2018;29(2):175-182. 

Heat

• Monitor heat index and times of rapid temperature shift
• Tailor hydration counseling
• Factor ambient temperature into L&D triage monitoring
• Consider discussing home air conditioning

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1. Stan. Hydration for treatment of preterm labour.   Cochrane Database Syst Rev. 2002;(2)
2. Prada. Biological mechanisms of environmentally induced causes of IUGR.   Eur J Clin Nutr. 1998;52
3. Browne. Uterine artery blood flow, fetal hypoxia and fetal growth.   Philos Trans R Soc Lond B Biol Sci. 2015;370(1663)
4. Li . Hot tub use during pregnancy and the risk of miscarriage.   Am J Epidemiol. 2003;158(10):931-937
5. He. Heat and pregnancy-related emergencies: risk of placental abruption during hot weather.   Environ Int. 2018;111:295-300

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Clinical Counseling: Air Quality and Heat

Biomass Fuels (Wood Fuel) Is Associated with Preterm Birth in Central East India

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Wylie et al. Environmental Health 2014, 13:1 http://www.ehjournal.net/content/13/1/1

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N= 25.9 million people

California hospital admissions 1999-2005 May 1 – Sept 30

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Significantly increased risk of hospitalization with a 10°F increase in same-day apparent temperature.

• cardiovascular disease Dehydration
• ischemic heart disease Heat Stroke
• ischemic stroke Diabetes
• respiratory disease Acute Renal Failure

Ownership and usage of ACs significantly reduced the effects of temperature on these health outcomes, after controlling for family income and other socioeconomic factors

Health Providers as Climate Advocates

• “Trusted Messengers”

(2^nd to nurses!)

• “Captive Audiences”
• People care about the health message

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Human Health has replaced the polar bear and has become the new face of climate change.

https://thumbs.dreamstime.com/z/happy-kids-painted-hands-smiling-posing-white-background-funny-children-international-children-s-day-indian-asian-72977489.jpg

https://animals.sandiegozoo.org/sites/default/files/inline-images/polar_bear_cub_1.jpg

Everything done to lower emissions and decrease air pollution improves human health!

• Sustainable agriculture/farmers markets – healthier for people and the planet
• Transition to renewable energy
• Improvement in public /shared transportation, increased walkability and bikeability
• Planting trees – removes air pollution, stores carbon, improves our mental and physical health.

https://pricetags.ca/wp-content/uploads/2019/02/healthy-communities.jpg

Council on Environmental Health and Climate Change (COEHCC)

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Chapter Climate Advocates

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• 59 Chapters
• Operate Independently
• In all 50 states
• Plus DC and PR

Before and After Data (24 m.)

• Resolutions: 1
• Committees: 1

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• Resolutions: 20, several in process
• *Committees: 20, several in process
• Website Presence: 14
• E-newsletters: many
• EH/CC in annual meeting: 4
• Legislative Blueprints contain energy/climate concerns:10

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Education Sub-Committee

• Research on what parent’s want
• Patient-facing materials
• Physician-facing materials
• Medical School Curriculum
• Board Inclusion

Clinician for Climate Action Groups

https://www.climatereadymissoula.org/wildfire-smoke-ready-week-events.html

Clean air centers

and cooling centers

https://wtop.com/wp-content/uploads/2017/06/cooling-centers.jpeg

 Used in 60 countries,

43 U.S. States and

100’s of practices

• Evidence-based
• Saves money
• requires adding ONLY FIVE MINUTES of Green Team business to each of your regular practice or clinic planning meetings
• Everything is scripted and provided
• All free tools–brochures, handouts, posters, and other tips

Register at:

https://mygreendoctor.org

Desflourane, a common anesthesia gas, is 2500 x as potent as CO2, very expensive, and can be recycled

17,000 Hospitals are part of HCWH

The U.S. Healthcare System contributes 10% of our carbon emissions

One doctor in Portland OR saved his hospital $1M the first year they focused on sustainability

SCL Health recently signed on to Practice GreenHealth

(St James-Butte, SCL Health-Billings, Holy Rosary-Miles City)

Doing something makes us feel better!

Robert Byron, MD, MPH, FACP

rgbyron@gmail.com

406-679-0584

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Lori Byron, MD, MS, FAAP

lori.byron@gmail.com

406-671-5824

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Montanahphc.org

Please sign on with us!