Syndromic surveillance data were used to estimate the direct impact of air pollution on healthcare-seeking behaviour, between 1 April 2012 and 31 December 2017. A difference-in-differences approach was used to control for spatial and temporal variations that were not due to air pollution and a meta-analysis was conducted to combine estimates from different pollution periods. Significant increases were found in general practitioner (GP) out-of-hours consultations, including a 98% increase (2–386, 95% confidence interval) in acute bronchitis and a 16% (3–30) increase in National Health Service (NHS) 111 calls for eye problems. However, the numbers involved are small; for instance, roughly one extra acute bronchitis consultation in a local authority on a day when air quality is poor. These results provide additional information for healthcare planners on the impacts of localised poor air quality. However, further work is required to identify the separate impact of different pollutants.

INTRODUCTION:Poor air quality (AQ) is a global public health issue and AQ events can span across countries. Using emergency department (ED) syndromic surveillance from England and France, we describe changes in human health indicators during periods of particularly poor AQ in London and Paris during 2014. METHODS:Using daily AQ data for 2014, we identified three periods of poor AQ affecting both London and Paris. Anonymised near real-time ED attendance syndromic surveillance data from EDs across England and France were used to monitor the health impact of poor AQ.Using the routine English syndromic surveillance detection methods, increases in selected ED syndromic indicators (asthma, difficulty breathing and myocardial ischaemia), in total and by age, were identified and compared with periods of poor AQ in each city. Retrospective Wilcoxon-Mann-Whitney tests were used to identify significant increases in ED attendance data on days with (and up to 3 days following) poor AQ. RESULTS:Almost 1.5 million ED attendances were recorded during the study period (27 February 2014 to 1 October 2014). Significant increases in ED attendances for asthma were identified around periods of poor AQ in both cities, especially in children (aged 0-14 years). Some variation was seen in Paris with a rapid increase during the first AQ period in asthma attendances among children (aged 0-14 years), whereas during the second period the increase was greater in adults. DISCUSSION:This work demonstrates the public health value of syndromic surveillance during air pollution incidents. There is potential for further cross-border harmonisation to provide Europe-wide early alerting to health impacts and improve future public health messaging to healthcare services to provide warning of increases in demand.

ObjectiveTo explore the utility of syndromic surveillance systems for detecting and monitoring the impact of air pollution incidents on health-care seeking behaviour in England between 2012 and 2017.IntroductionThe negative effect of air pollution on human health is well documented illustrating increased risk of respiratory, cardiac and other health conditions. [1] Currently, during air pollution episodes Public Health England (PHE) syndromic surveillance systems [2] provide a near real-time analysis of the health impact of poor air quality. In England, syndromic surveillance has previously been used on an ad hoc basis to monitor health impact; this has usually happened during widespread national air pollution episodes where the air pollution index has reached ‘High’ or ‘Very High’ levels on the UK Daily Air Quality Index (DAQI). [3-5]We now aim to undertake a more systematic approach to understanding the utility of syndromic surveillance for monitoring the health impact of air pollution. This would improve our understanding of the sensitivity and specificity of syndromic surveillance systems for contributing to the public health response to acute air pollution incidents; form a baseline for future interventions; assess whether syndromic surveillance systems provide a useful tool for public health alerting; enable us to explore which pollutants drive changes in health-care seeking behaviour; and add to the knowledge base.MethodsThe systematic approach will involve accessing historical data for air pollution incidents and syndromic surveillance data over the period 2012-17 across England. We will use PM10, PM2.5, ozone, NO2 , SO2 and DAQI data to define air pollution periods, and historical syndromic surveillance system data for respiratory syndromes (asthma, difficulty breathing, wheeze, cough, bronchitis, sore throat and allergic rhinitis), cardiac (all cardiovascular and myocardial infarction) and eye irritation/conjunctivitis syndromes. We will use regression modelling and cross-correlation analyses to determine the effects of air pollution, weather and pollen upon these syndromes and thus provide evidence of the sensitivity of these systems. Historical data on additional environmental variables including temperature and precipitation, humidity and thunderstorm activity, pollen and fungal spores will be accounted for in the regression models, as well as data on influenza and respiratory syncytial virus (RSV) laboratory reports. We will include sub-national geographies and age/gender analyses in the study depending on the data availability and suitability.ResultsInitial results presented will include the preliminary descriptive epidemiology with a focus on asthma and the impact of air pollution incidents on health-care seeking behaviour using data from the PHE national syndromic surveillance systems.ConclusionsWe aim to demonstrate an innovative use of syndromic surveillance data to explore the impact of air pollution incidents on health-care seeking behaviour in England, in turn improving our understanding of the sensitivity and specificity of these systems for detecting the impact of air pollution incidents and to contribute to the knowledge base. This understanding will improve the public health response to future incidents.References1. World Health Organization (WHO). Preventing disease through healthy environments. Exposure to air pollution: A major public health concern. (http://www.who.int/ipcs/features/air_pollution.pdf). Accessed 28/09/20172. Public Health England. Syndromic surveillance: systems and analyses. (https://www.gov.uk/government/collections/syndromic-surveillance-systems-and-analyses). Accessed 20/09/20173. Department for Environment Food and Rural Affairs (Defra). Daily Air Quality Index (DAQI). (https://uk-air.defra.gov.uk/air-pollution/daqi). Accessed 28/06/20174. Smith GE, et al. Using real-time syndromic surveillance systems to help explore the acute impact of the air pollution incident of March/April 2014 in England. Environ Res 2015; 136: 500-504.5. Elliot AJ, et al. Monitoring the effect of air pollution episodes on health care consultations and ambulance call-outs in England during March/April 2014: A retrospective observational analysis. Environ Pollut 2016; 214: 903-911.

ObjectiveTo assess the impact on human health observed in associationwith periods of poor air quality which extended across internationalborders, affecting both London (UK) and Paris (France).In particular to quantify increased levels of emergency department(ED) attendances for asthma and wheeze/ difficulty breathing, andhow different age groups were affected. Here, using ED syndromicsurveillance from England and France, we aimed to identify anddescribe the acute impact of periods of particularly poor air qualityduring 2014 on human health in both London and Paris.IntroductionThe impact of poor air quality (AQ) on human health is a globalissue, with periods of poor AQ known to occur in multiple locations,across different countries at, or around the same time.The Public Health England (PHE) Emergency DepartmentSyndromic Surveillance System (EDSSS) is a public health legacyof the London 2012 Olympic and Paralympic Games, monitoringanonymised daily attendance data in near real-time from a sentinelnetwork of up to 38 EDs across England and Northern Ireland during2014.The Organisation de la Surveillance COordonnée des URgences(OSCOUR®) is a similar ED system coordinated by Santé publiqueFrance and has been running in France since 2004, establishedfollowing a major heatwave in 2003 to improve real-time publichealth surveillance capabilities. This truly national network includedaround 540 EDs in 2014.MethodsPeriods of poor AQ during 2014 in both London and Paris, whichwere likely to have an acute impact on human health were identifiedfrom the daily particulate monitoring data made available by themonitoring authorities in each location.1,2Daily ED syndromic surveillance data for selected health indicators(asthma, difficulty breathing type attendances and myocardialischaemia (MI)) were gathered from EDSSS and OSCOUR®forLondon and Paris respectively.The standard method used for the daily statistical analysis ofEDSSS(RAMMIE method),3was also applied to OSCOUR®and usedto identify days where the numbers of attendances reported in boththe EDSSS and OSCOUR®systems were statistically significantlydifferent to the historical data, based on the previous 2 years.ResultsDistinct differences were identified between the impact observedon different age groups, with increased asthma ED attendances forchildren during/ following some AQ events, though a greater impactwas observed in adults around other AQ events.Increases in ED attendances for asthma were identified at severalpoints where no AQ events were reported, both short lived spikesduring the summer period in particular and a more sustained increasetowards the start of autumn.ConclusionsDespite EDSSS and OSCOUR®having been developed in differentcountries, at different times and resulting from different drivers, bothsystems use very similar syndromic indicators to identify asthma,difficulty breathing and MI attendances. Using these systems theshort term impacts of multiple AQ events which crossed internationalboundaries were successfully identified and investigated by Englishand French public health authorities.Periods of poor AQ are not the only events that can affect asthmatype attendances as identified here, thunderstorm activity and thebeginning of a new academic year also coincided with increasedattendances in both London and Paris.Harmonisation of surveillance methods across differentinternational jurisdictions is possible and there is the potential forfuture cross border surveillance and harmonisation of methodsbetween countries to improve international health surveillance andearly warning of potential public health threats affecting multiplecountries.

There is an increasing body of evidence illustrating the negative health effects of air pollution including increased risk of respiratory, cardiac and other morbid conditions. During March and April 2014 there were two air pollution episodes in England that occurred in close succession. We used national real-time syndromic surveillance systems, including general practitioner (GP) consultations, emergency department attendances, telehealth calls and ambulance dispatch calls to further understand the impact of these short term acute air pollution periods on the health seeking behaviour of the general public. Each air pollution period was comparable with respect to particulate matter concentrations (PM10 and PM2.5), however, the second period was longer in duration (6 days vs 3 days) and meteorologically driven 'Sahara dust' contributed to the pollution. Health surveillance data revealed a greater impact during the second period, with GP consultations, emergency department attendances and telehealth (NHS 111) calls increasing for asthma, wheeze and difficulty breathing indicators, particularly in patients aged 15-64 years. Across regions of England there was good agreement between air quality levels and health care seeking behaviour. The results further demonstrate the acute impact of short term air pollution episodes on public health and also illustrate the potential role of mass media reporting in escalating health care seeking behaviour. Crown Copyright (C) 2016 Published by Elsevier Ltd. This is an open access article under the Open Government License (OGL).

Environmental public health scientists and health protection practitioners are constantly challenged to respond to new or poorly understood hazards. Practitioners might also be required to address well-characterized hazards that have either increased in magnitude or re-emerged in different situations. Developing technological advances and new and emerging industrial processes (such as fracking, nanotechnology, shale gas, waste fires) can raise difficult questions for the public health practitioner, especially where research and health-related evidence is lacking. In these cases, public health science has a key role in undertaking and communicating risks and in providing the most accurate available scientific evidence and public health advice. The field of environmental public health is crowded with complex problems demanding our attention. It is impossible to devote sufficient clinical, research, and advocacy energies to all of these problems at once. Clinicians, public health professionals, and environmental public health scientists have to choose which health issues take priority.

During March and early April 2014 there was widespread poor air quality across the United Kingdom. Public Health England used existing syndromic surveillance systems to monitor community health during the period. Short lived statistically significant rises in a variety of respiratory conditions, including asthma and wheeze, were detected. This incident has demonstrated the value of real-time syndromic surveillance systems, during an air pollution episode, for helping to explore the impact of poor air quality on community health in real-time.

The introductory chapter outlines some of the central topics covered in this book, which are further expanded and built upon in subsequent chapters. It sets out the role of environmental public health science in the context of public health and highlights the importance of environmental chemistry, environmental toxicology, and epidemiology in supporting investigations into environmental public health issues. It explains why the quality of the environment plays an important role in health and wellbeing, and why environmental hazards are a significant contributor to the total burden of disease worldwide. The introduction provides a synopsis of each subsequent chapter, highlighting some of the key learning objectives contained in the book, and points the reader to practical case studies presented to illustrate and emphasize particular public health issues that reinforce the subject knowledge.

Good practices in emergency preparedness and response for chemical incidents include practices specific to the different functions of exposure assessment (e.g., within the monitoring function, the use of mobile monitoring equipment; within the modelling function, the use of rapid dispersion models with integrated mapping software) and generic practices to engage incident response stakeholders to maximise exposure assessment capabilities (e.g., sharing protocols and pre-prepared information and multi-agency training and exercising). Such practices can optimise cross-border collaboration. A wide range of practices have been implemented across MSs during chemical incident response, particularly during incidents that have cross-border and trans-boundary impacts. This paper proposes a self-assessment methodology to enable MSs, or organisations within MSs, to examine exposure assessment capabilities and communication pathways between exposure assessors and public health risk assessors. Where gaps exist, this methodology provides links to good practices that could improve response, communication and collaboration across local, regional and national borders. A fragmented approach to emergency preparedness for chemical incidents is a major obstacle to improving cross-border exposure assessment. There is no one existing body or structure responsible for all aspects of chemical incident preparedness and response in the European Union. Due to the range of different organisations and networks involved in chemical incident response, emergency preparedness needs to be drawn together. A number of recommendations are proposed, including the use of networks of experts which link public health risk assessors with experts in exposure assessment, in order to coordinate and improve chemical incident emergency preparedness. The EU's recent Decision on serious cross-border threats to health aims to facilitate MSs' compliance with the International Health Regulations, which require reporting and communication regarding significant chemical incidents. This provides a potential route to build on in order to improve chemical incident preparedness and response across Europe.

Chemical incidents do not respect national borders, and can affect communities a significant distance from the incident site. An accurate and timely assessment of risks to human health is a cornerstone of an effective response strategy . The Cross-border Exposure Characterisation for Risk Assessment in Chemical Incidents (CERACI) project aims to strengthen the public health assessment for the acute phase of a chemical incident by assessing the response to chemical incidents in European (EU) Member States, focusing in particular on the interoperability of exposure assessment guidelines, tools and practices .