Multi-city Studies Research Articles

Modeling the Effect of Temperature on Ozone-Related Mortality

Background: Previous studies show ozone and temperature are associated with increased mortality; however, the joint effect has not been well explored. Understanding the nature of this relationship is important for estimating the potential effects of increasing temperatures on ozone-related mortality. Aims: We propose a model to evaluate joint ozone-temperature risk in multicity studies and evaluate the impact of temperature on ozone-related mortality. Methods: We extend the ozone risk model used by the National Morbidity, Mortality, and Air Pollution Study to include ozone-temperature risk surfaces for 95 US urban centers. These surfaces are modeled using city specific polynomial basis expansion with closed form derivatives to quantify relative risk. To obtain national and regional estimates, at the second stage we use a spatial process prior for spline coefficients and introduce a monotonicity constraint in the ozone direction. This modeling approach is computationally efficient and enables informative smoothing of the risk surface while avoiding over parameterizing the first-stage models. Closed form estimates of the risk surfaces allow for easy comparison of surfaces between cities and regions at all levels of temperature and ozone. Results: Preliminary results based on cross-validation with the NMMAPS data and a simulation study show good model performance, particularly at high concentrations. At the 95th percentile of the city-specific ozone and temperature distributions a monotone model reduces the mean width of 95% posterior intervals by 5.3% while the monotone model together with spatial smoothing reduces the width by 29.6%. We will estimate the effect of rising temperature at all levels of ozone, compare regional heterogeneity, and contrast these results to those obtained using linear and additive assumptions. Conclusions: Initial analysis suggests that the ozone effect is nonlinear and that temperature confounds the ozone effect in a nonlinear manner. Disclaimer: This abstract does not necessarily reflect U.S. EPA policy.

Temperature–mortality relationship in four subtropical Chinese cities: A time-series study using a distributed lag non-linear model

BackgroundNumerous studies have reported the association between ambient temperature and mortality. However, few multicity studies have been conducted in subtropical regions in developing countries. The present study assessed the health effects of temperature on mortality in four subtropical cities of China. MethodsWe used “double threshold-natural cubic spline” distributed lag non-linear model (DLNM) to investigate the cold and hot effects on mortality at different lags in four subtropical cities. Then we conducted a meta-analysis to estimate the overall cold and hot effects on mortality at different lag days. ResultsA U-shaped relationship between temperature and mortality was found in the four cities. Cold effect was delayed and persisted for about 27days, whereas hot effect was acute and lasted for 3days. In Changsha, Kunming, Guangzhou and Zhuhai, a 1°C decrease of temperature under the low threshold was associated with a lag0–27 cumulative relative risk (RR) of 1.061 (95% confidence interval (CI): 1.023–1.099), 1.044 (95% CI: 1.033–1.056), 1.096 (95% CI: 1.075–1.117) and 1.111 (95% CI: 1.078–1.145) for total mortality, respectively. And RR for 1°C increase of temperature above the hot threshold at the lag0 was 1.020 (95% CI: 1.003–1.037), 1.017 (95% CI: 1.004–1.030), 1.029 (95% CI: 1.020–1.039) and 1.023 (95% CI: 1.004–1.042), respectively. The cold and hot effects were greater among the elderly in Changsha, Guangzhou and Zhuhai. Meta analysis showed that the hot effect decreased gradually with lag days, with the greatest effect at current day (RR=1.023, 95% CI: 1.015–1.031); while the cumulative cold effect increased gradually with lag days, with the highest effect at lag0–27 (RR=1.076, 95% CI: 1.046–1.107). ConclusionBoth low and high temperatures were associated with increased mortality in the four subtropical Chinese cities, and cold effect was more durable and pronounced than hot effect.

Acute Effect of Ambient Air Pollution on Stroke Mortality in the China Air Pollution and Health Effects Study

There have been no multicity studies on the acute effects of air pollution on stroke mortality in China. This study was undertaken to examine the associations between daily stroke mortality and outdoor air pollution (particulate matter <10 μm in aerodynamic diameter, sulfur dioxide, and nitrogen dioxide) in 8 Chinese cities. We used Poisson regression models with natural spline-smoothing functions to adjust for long-term and seasonal trends, as well as other time-varying covariates. We applied 2-stage Bayesian hierarchical statistical models to estimate city-specific and national average associations of air pollution with daily stroke mortality. Air pollution was associated with daily stroke mortality in 8 Chinese cities. In the combined analysis, an increase of 10 μg/m(3) of 2-day moving average concentrations of particulate matter <10 μm in aerodynamic diameter, sulfur dioxide, and nitrogen dioxide corresponded to 0.54% (95% posterior intervals, 0.28-0.81), 0.88% (95% posterior intervals, 0.54-1.22), and 1.47% (95% posterior intervals, 0.88-2.06) increase of stroke mortality, respectively. The concentration-response curves indicated linear nonthreshold associations between air pollution and risk of stroke mortality. To our knowledge, this is the first multicity study in China, or even in other developing countries, to report the acute effect of air pollution on stroke mortality. Our results contribute to very limited data on the effect of air pollution on stroke for high-exposure settings typical in developing countries.

Impact of Covariate Models on the Assessment of the Air Pollution-Mortality Association in a Single- and Multipollutant Context

With the advent of multicity studies, uniform statistical approaches have been developed to examine air pollution-mortality associations across cities. To assess the sensitivity of the air pollution-mortality association to different model specifications in a single and multipollutant context, the authors applied various regression models developed in previous multicity time-series studies of air pollution and mortality to data from Philadelphia, Pennsylvania (May 1992-September 1995). Single-pollutant analyses used daily cardiovascular mortality, fine particulate matter (particles with an aerodynamic diameter ≤2.5 µm; PM(2.5)), speciated PM(2.5), and gaseous pollutant data, while multipollutant analyses used source factors identified through principal component analysis. In single-pollutant analyses, risk estimates were relatively consistent across models for most PM(2.5) components and gaseous pollutants. However, risk estimates were inconsistent for ozone in all-year and warm-season analyses. Principal component analysis yielded factors with species associated with traffic, crustal material, residual oil, and coal. Risk estimates for these factors exhibited less sensitivity to alternative regression models compared with single-pollutant models. Factors associated with traffic and crustal material showed consistently positive associations in the warm season, while the coal combustion factor showed consistently positive associations in the cold season. Overall, mortality risk estimates examined using a source-oriented approach yielded more stable and precise risk estimates, compared with single-pollutant analyses.

Short-term exposure to sulfur dioxide and daily mortality in 17 Chinese cities: The China air pollution and health effects study (CAPES)

Sulfur dioxide (SO2) is a major air pollutant and has significant impacts upon human health. Few multi-city studies in Asia have examined the acute health effects of SO2. As part of the China Air Pollution and Health Effects Study (CAPES), this study aimed at investigating the short-term association between SO2 and daily mortality in 17 Chinese cities. We applied two-stage Bayesian hierarchical models to obtain city-specific and national average estimates for SO2. In each city, we used Poisson regression models incorporating natural spline smoothing functions to adjust for long-term and seasonal trend of mortality, as well as other time-varying covariates. We examined the associations by age, gender and education status. As a result, the combined analysis showed that an increase of 10μg/m3 of two-day moving averaged SO2 was associated with 0.75% [95% posterior interval (PI), 0.47 to 1.02], 0.83% (0.95% PI, 0.47 to 1.19) and 1.25% (95% PI, 0.78 to 1.73) increase of total, cardiovascular and respiratory mortality, respectively. The effects of SO2 appeared more evident among the elderly. These associations were generally independent of particles with aerodynamic diameter <10μm (PM10) but did not persist after adjustment for nitrogen dioxide (NO2). In conclusions, this largest epidemiologic study of air pollution in China to date suggests that short-term exposure to SO2 is associated with increased mortality risk; however, these associations may be attributable to SO2 serving as a surrogate of other substances. Further studies are needed to tackle the independent health effect of SO2.

Associations between short-term exposure to nitrogen dioxide and mortality in 17 Chinese cities: The China Air Pollution and Health Effects Study (CAPES)

Few multi-city studies in Asian developing countries have examined the acute health effects of ambient nitrogen dioxide (NO2). In the China Air Pollution and Health Effects Study (CAPES), we investigated the short-term association between NO2 and mortality in 17 Chinese cities. We applied two-stage Bayesian hierarchical models to obtain city-specific and national average estimates for NO2. In each city, we used Poisson regression models incorporating natural spline smoothing functions to adjust for long-term and seasonal trend of mortality, as well as other time-varying covariates. We examined the associations by age, gender and education status. We combined the individual-city estimates of the concentration–response curves to get an overall NO2–mortality association in China. The averaged daily concentrations of NO2 in the 17 Chinese cities ranged from 26μg/m3 to 67μg/m3. In the combined analysis, a 10-μg/m3 increase in two-day moving averaged NO2 was associated with a 1.63% [95% posterior interval (PI), 1.09 to 2.17], 1.80% (95% PI, 1.00 to 2.59) and 2.52% (95% PI, 1.44 to 3.59) increase of total, cardiovascular, and respiratory mortality, respectively. These associations remained significant after adjustment for ambient particles or sulfur dioxide (SO2). Older people appeared to be more vulnerable to NO2 exposure. The combined concentration–response curves indicated a linear association. Conclusively, this largest epidemiologic study of NO2 in Asian developing countries to date suggests that short-term exposure to NO2 is associated with increased mortality risk.

MULTIPOLLUTANT ASSESSMENT OF SHORT-TERM MORTALITY EFFECTS OF FINE PARTICULATE MATTER, ITS CHEMICAL CONSTITUENTS AND GASEOUS POLLUTANTS IN U.S. CITIES.

Background and Aims: U.S., European, and Canadian multi-city studies have shown relatively consistent short-term mortality effects of particulate matter (PM) and ozone. However, there is less infor...

PARTICULATE AIR POLLUTION, MYOCARDIAL INFARCTION AND NEIGHBORHOOD, DEPRIVATION — A CASE-CROSSOVER ANALYSIS

Background: Large multi-city studies conducted in the United States and in Europe have demonstrated that short-term exposure to airborne particulate matter is associated with an increase in daily m...

Heat Effects Are Unique: Mortality Risk Depends on Heat Wave, Community Characteristics

Vol. 119, No. 2 NewsOpen AccessHeat Effects Are Unique: Mortality Risk Depends on Heat Wave, Community Characteristics Tanya Tillett Tanya Tillett Search for more papers by this author Published:1 February 2011https://doi.org/10.1289/ehp.119-a81Cited by:1AboutSectionsPDF ToolsDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InReddit During heat waves, higher-than-normal temperatures can present a deadly threat, with mortality occasionally doubling. Recent studies have demonstrated that heat-related mortality risk is influenced by the characteristics of the individual heat wave (such as heat intensity, duration, and timing in season). Researchers explored this relationship more fully in one of the largest multicity studies to date of heat wave impacts in the United States [EHP119(2):210–218; Anderson and Bell].The authors identified heat waves in 43 U.S. communities during the years 1987–2005. A heat wave was defined as 2 or more days in which temperatures exceeded the 95th percentile of warm season (May–September) temperatures for that community during the 19-year period. Each heat wave was characterized according to heat intensity (average mean temperature), duration in days, and the point in the season when the heat wave occurred.The investigators estimated a 3.74% increase in average daily risk of nonaccidental death during the heat waves compared with non–heat wave days. Although longer and more intense heat waves were more common in the South, estimated effects of heat waves on mortality were greater in the Midwest and greatest of all in the Northeast. The authors attribute this phenomenon to Southern residents being perhaps more physiologically and behaviorally adapted to extreme temperatures. Nationwide, heat waves that occurred earlier in the warm season appeared to have a greater effect on mortality than heat waves occurring later (an average 5.04% increase compared with an average 2.65% increase), as did hotter or longer heat waves.Considering that heat waves are expected to become more common and intense in some areas as the Earth’s climate changes, it is important to understand the factors that make individual communities vulnerable to heat-wave effects and that make individual heat waves more likely to cause excess deaths. The authors conclude it is important for officials to develop local response plans on the basis of heat-wave mortality trends in their own communities; when it comes to planning for health effects of heat waves, one size does not fit all.This Queens, New York, resident was photographed in the middle of a summer 2006 heat wave that ultimately would cause an 8% increase in nonaccidental deaths, including 40 heat-stroke deaths.FiguresReferencesRelatedDetailsCited by Cao Z, Wu Z, Li S, Guo G, Song S, Deng Y, Ma W, Sun H and Guan W (2020) Explicit Spatializing Heat-Exposure Risk and Local Associated Factors by coupling social media data and automatic meteorological station data, Environmental Research, 10.1016/j.envres.2020.109813, 188, (109813), Online publication date: 1-Sep-2020. Vol. 119, No. 2 February 2011Metrics About Article Metrics Publication History Originally published1 February 2011Published in print1 February 2011 Financial disclosuresPDF download License information EHP is an open-access journal published with support from the National Institute of Environmental Health Sciences, National Institutes of Health. All content is public domain unless otherwise noted. Note to readers with disabilities EHP strives to ensure that all journal content is accessible to all readers. However, some figures and Supplemental Material published in EHP articles may not conform to 508 standards due to the complexity of the information being presented. If you need assistance accessing journal content, please contact [email protected]. Our staff will work with you to assess and meet your accessibility needs within 3 working days.

The Effects of Fine and Coarse Particles on Daily Mortality in Seoul, Korea

PP-31-031 Background/Aims: Many multicity studies have demonstrated an association between acute exposure to ambient particles and both mortality and morbidity. Less is known about the health risks associated with short-term exposure to fine particles (those with an aerodynamic diameter of ≤2.5 μm; PM2.5). Methods: We conducted a time-series study to investigate the acute effects of PM2.5 and PM10 on daily mortality in Seoul, Korea from January 2005 to December 2008. We performed the time-series analysis using the generalized additive model to analyze the mortality, air pollution, and covariate data. Results: We found that PM2.5 and PM10 were significantly associated with the mortality from all causes and from specific causes. A 10 μg/m3 increase of concentration of PM2.5 corresponded to 0.95% (95% confidence interval [CI]: 0.57%–1.34%), 1.64% (95% CI: 0.89%–2.37%), and 2.16% (95% CI: 0.57%–3.77%) increase of all, cardiovascular, and respiratory mortality. A 10 μg/m3 increase of concentration of PM10 corresponded to 0.44% (95% CI: 0.25%–0.63%), 0.76% (95% CI: 0.40%–1.12%), 1.13% (95% CI: 0.35%–1.90%) increase of all, cardiovascular and respiratory mortality. Conclusion: Our analyses show an increased risk of mortality for all and specific causes associated with PM2.5, and the risks are higher than PM10, and suggest the rationale for the establishment of national ambient air quality standard of PM2.5 in Korea.

A Meta-analysis of Association Between Short-term Ambient Ozone Exposure and Respiratory Hospital Admissions

PP-29-054 Background/Aims: Tropospheric ozone is an air pollutant common in urban areas, associated with many adverse human health impacts, including increased risk of respiratory symptoms. Many studies have found significant positive associations between ozone and risk of respiratory hospitalizations; however, other studies found contradictory results. We conducted a meta-analysis of ozone and respiratory hospital admissions, which combines results from multiple studies accounting for their statistical uncertainty. Methods: A systematic review of the literature based on our protocol identified 136 estimates from 96 time-series and case-crossover studies. We stratified main estimates extracted from previous literature according disease categories (eg, total respiratory disease, chronic obstructive pulmonary disease), hospitalization types (eg, emergency hospital admission, emergency room visit), and age groups (eg, all-ages, children). We investigated how the concentration-response relationship was affected the ozone metric used (eg, 1-hour maximum), age of study population, season, and region of study. Results were compared with those from multicity studies. In addition, we examined publication bias and calculated a summary effect adjusted for publication bias. Results: Results indicate significant associations between ozone exposure and hospital admissions for various disease categories. The estimates were elevated by publication bias, but some associations remain statistically significant after adjustment of this bias. For instance, results indicate that risk of emergency hospital admissions for total respiratory disease increased 4.47% (95% interval 2.48%, 6.50%) per 10 ppb increment of 24 hours average ozone among the elderly. After adjusting for publication bias, the estimate becomes 2.97% (1.05%, 4.94%). Results reveal that different ratios to convert among ozone metrics did not greatly change results. The relationship between ozone and hospital admissions was affected by different study characteristics (eg, lag selection, age group). Conclusion: This meta-analysis can provide a better understanding of ozone exposure's influence on human health and guide future studies. Findings can also provide quantitative evidence for environmental policy decision making.

The influence of sampling protocol on nonmethane hydrocarbon mixing ratios

The effect of sampling protocol on ambient air hydrocarbon mixing ratios was examined on eight sampling days in Los Angeles during 2007 and 2008. Four protocols, which were based on previously published multi-city urban hydrocarbon studies in the United States, were compared and differences were quantified. Whole air canister samples were collected and analyzed for nonmethane hydrocarbons (NMHCs). Differing sampling protocols resulted in large differences in mixing ratios, up to an order of magnitude, for certain NMHCs on the same sampling day. However, the magnitude of the variability between NMHC levels obtained by the four protocols was not consistent throughout the eight sampling days. It was found that sampling time, followed by sampling location, had the greatest influence on the magnitude of the mixing ratio. Ratios between hydrocarbons, often used in urban studies to gain information on emission sources, also varied depending on the protocol used. Comparison of absolute NMHC mixing ratios collected in urban environments using differing sampling protocols should be made with care.

Asia: Changing Times and Changing Problems

Asia: Changing Times and Changing Problems

Acute Effects of Ambient Particulate Matter on Mortality in Europe and North America: Results from the APHENA Study

BackgroundThe APHENA (Air Pollution and Health: A Combined European and North American Approach) study is a collaborative analysis of multicity time-series data on the effect of air pollution on population health, bringing together data from the European APHEA (Air Pollution and Health: A European Approach) and U.S. NMMAPS (National Morbidity, Mortality and Air Pollution Study) projects, along with Canadian data.ObjectivesThe main objective of APHENA was to assess the coherence of the findings of the multicity studies carried out in Europe and North America, when analyzed with a common protocol, and to explore sources of possible heterogeneity. We present APHENA results on the effects of particulate matter (PM) ≤ 10 μm in aerodynamic diameter (PM10) on the daily number of deaths for all ages and for those < 75 and ≥ 75 years of age. We explored the impact of potential environmental and socioeconomic factors that may modify this association.MethodsIn the first stage of a two-stage analysis, we used Poisson regression models, with natural and penalized splines, to adjust for seasonality, with various degrees of freedom. In the second stage, we used meta-regression approaches to combine time-series results across cites and to assess effect modification by selected ecologic covariates.ResultsAir pollution risk estimates were relatively robust to different modeling approaches. Risk estimates from Europe and United States were similar, but those from Canada were substantially higher. The combined effect of PM10 on all-cause mortality across all ages for cities with daily air pollution data ranged from 0.2% to 0.6% for a 10-μg/m3 increase in ambient PM10 concentration. Effect modification by other pollutants and climatic variables differed in Europe and the United States. In both of these regions, a higher proportion of older people and higher unemployment were associated with increased air pollution risk.ConclusionsEstimates of the increased mortality associated with PM air pollution based on the APHENA study were generally comparable with results of previous reports. Overall, risk estimates were similar in Europe and in the United States but higher in Canada. However, PM10 effect modification patterns were somewhat different in Europe and the United States.

Validating National Kriging Exposure Estimation

In their article Liao et al. (2006) argued that it is feasible to use national scale daily kriging to estimate ambient air pollution exposure, even in locations where monitoring data are limited. In addition, they argued that national scale kriging is preferable to regional kriging and that automated variogram estimation is preferable to manual. The advocated methodology seems appealing when compared with the more standard approach of estimating ambient exposure separately in individual metropolitan cities (Dockery et al. 1993; Jerrett et al. 2005; Miller et al. 2007; Pope et al. 1995) because it simplifies exposure assessment for multicity studies and allows inclusion of subjects far from monitoring sites. Liao et al. (2006) also suggested estimating daily variograms without accounting for day-today relationships and variations in data availability. This is a convenient simplification if it produces reliable results, but the evidence is not convincing.

The Effect of Fine Particulate Air Matter on Emergency Admissions For Copd and Pneumonia: a Multi-City Case-Crossover Analysis

P-078 Introduction: While many studies have examined the effects of air pollution on mortality, fewer studies have examined hospital admissions for pneumonia and COPD, and generally in smaller multi-city or single city studies. In addition, PM2.5 data has only recently been available. Method: We conducted a multi-city case-crossover study of the acute effect of PM2.5 on the increased risk of being admitted to the hospital among the elderly in thirty-nine US cities with 451,000 admissions for pneumonia and 234,000 admissions for chronic obstructive pulmonary disease (COPD). We examined the association between daily fine particulate air matter (PM2.5) and Medicare data (age ge 65) on hospital admissions from the emergency room with a primary diagnosis of COPD (ICD-9: 490–496, except 493) and pneumonia (ICD-9: 480–487), in those cities for the years 1999–2003. In the first stage of the analysis, we applied a case-crossover design in each city with referent exposure days chosen using the time-stratified approach, with control days matched on year, month, and temperature to control possible residual confounding by weather. In the second stage of the analysis we combined the city-specific estimates using a random effect approach. Results: For COPD we found the higher effect at lag 1 with an increase of 1.17% (95% CI: 0.3%, 2.0%) for a 10 μg/m3 increase in PM2.5. We found a 1.51% increase (95% CI: 0.5%, 2.6%) in risk of admissions for pneumonia and PM2.5 two days before. Matching on every third day yielded similar results. Discussion and Conclusion: We conclude that our analysis showed an increased risk of hospitalization for COPD and pneumonia associated with PM2.5 among the elderly. More studies are needed to understand the biological mechanism and to examine effect modification.

Ambient Particulate Matter and Health Effects

Time-series studies have shown short-term temporal associations between low levels of ambient particulate air pollution and adverse health effects. It is not known whether or to what extent this literature is affected by publication bias. We obtained effect estimates from time-series studies published up to January 2002. These were summarized and examined for funnel plot asymmetry. We compared summary estimates between single-city and prospective multicity studies. Using 1 multicity study, we examined the sensitivity of summary estimates to alternative lag selection policies. We found evidence for publication bias among single-city studies of daily mortality, hospital admissions for chronic obstructive lung disease (COPD), and incidence of cough symptom, but not for studies of lung function. Statistical correction for this bias reduced summary relative risk estimates for a 10 microg/m increment of particulate matter less than 10 microm aerodynamic diameter (PM10) as follows: daily mortality from 1.006 to 1.005 and admissions for COPD from 1.013 to 1.011; and odds ratio for cough from 1.025 to 1.015. Analysis of results from a large multicity study suggested that selection of positive estimates from a range of lags could increase summary estimates for PM10 and daily mortality by up to 130% above those based on nondirectional approaches. We conclude that publication bias is present in single-city time-series studies of ambient particles. However, after correcting for publication bias statistically, associations between particles and adverse health effects remained positive and precisely estimated. Differential selection of positive lags may also inflate estimates.

New director for the international harm reduction association

New director for the international harm reduction association

The HOPE VI Program: What about the residents?

During the 1990s, the federal government dramatically changed its policy on housing the poor. Under the HOPE VI (Housing Opportunities for People Everywhere) Program, the U.S. Department of Housing and Urban Development intended to address the concentration of troubled low‐income households in public housing by moving away from its reliance on project‐based assistance and promoting instead the construction of mixed‐income housing and the use of housing subsidies. This article presents important evidence from two systematic, multicity studies on how the original residents of HOPE VI developments have been affected by this radical new approach to public housing. While many residents have clearly benefited, the findings raise critical questions about whether the transformation of public housing will achieve its potential as a powerful force for improving the lives of low‐income families.

Air Pollution: The Pathobiologic Issues

In defining the adverse effects of ambient levels of ozone on the human lung, research has tended to emphasize direct cause and effect responses. However, disease is generally multicausative and the lung has relatively few ways to respond to injury. Moreover, all adult lungs have some disease. Thus, pathogenesis is more appropriately addressed by asking "What role does the agent in question play in the causation, promotion, facilitation, and/or exacerbation of disease that is present?" Our recent studies of the lungs of 107 ostensibly healthy youths between 14 and 25 years of age (violent death cases in Los Angeles County) add suggestive evidence to epidemiologic and experimental data indicating that air pollution is adversely affecting the human lung. We found 80% of the youths with some degree of presumably subclinical Centriacinar Region disease and, in 27%, the Centriacinar Region disease was severe and extensive. Centriacinar Region disease has been linked to infectious organisms, cigarette smoke, ozone, mineral dusts, and other noxious agents. Recently, a mild form of Centriacinar Region disease has been produced in primates exposed to a level of ozone (0.15 ppm) that is frequently exceeded in Los Angeles. Since there is suggestive evidence that air pollution in Los Angeles increases the rate of decline of lung function, we suspect that there has also been an increase in the rate of structural decline, manifest in part by accentuated Centriacinar Region disease. The health significance of Centriacinar Region disease is just beginning to be appreciated. At the very least, reserve depletion reflected in the Centriacinar Region disease implies some reduction in lung performance and some increase in susceptibility to disease in general. At worst, the unexpected severity of the Centriacinar Region disease may be a bellwether for an impending rise in clinically manifested lung disease for the general population. An urgent research need is the monitoring of health through inventories of the functional and structural units of the human lung, with special emphasis on subpopulations of cell societies of the lung. The feasibility of applying image analysis for large volume objective quantitations has been demonstrated and should be implemented. Multicity studies, in cooperation with Offices of the Medical Examiner-Coroner and autopsy services in general, can help meet the critical need for increased sensitivity in the monitoring of the public health in a changing environment.