Multiple Imputation of Missing Race/Ethnicity Information in the National Assisted Reproductive Technology Surveillance System.

Background: Missing race/ethnicity data are common in many surveillance systems and registries, which may limit complete and accurate assessments of racial and ethnic disparities. Centers for Disease Control and Prevention's National Assisted Reproductive Technology (ART) Surveillance System (NASS) has a congressional mandate to collect data on all ART cycles performed by fertility clinics in the United States and provides valuable information on ART utilization and treatment outcomes. However, race/ethnicity data are missing for many ART cycles in NASS. Materials and Methods: We multiply imputed missing race/ethnicity data using variables from NASS and additional zip code-level race/ethnicity information in U.S. Census data. To evaluate imputed data quality, we generated training data by imposing missing values on known race/ethnicity under missing at random assumption, imputed, and examined the relationship between race/ethnicity and the rate of stillbirth per pregnancy. Results: The distribution of imputed race/ethnicity was comparable to the reported one with the largest difference of 0.53% for non-Hispanic Asian. Our imputation procedure was well calibrated and correctly identified that 89.91% (standard error = 0.18) of known race/ethnicity values on average in training data. Compared to complete-case analysis, using multiply imputed data reduced bias of parameter estimates (the range of bias for stillbirth per pregnancy across race/ethnicity groups is 0.02%-0.18% for imputed data analysis, versus 0.04%-0.66% for complete-case analysis) and yielded narrower confidence intervals. Conclusions: Our results underscore the importance of collecting complete race/ethnicity information for ART surveillance. However, when the missingness exists, multiply imputed race/ethnicity can improve the accuracy and precision of health outcomes estimated across racial/ethnic groups.

Resource allocation for mitigating regional air pollution-related mortality: A summertime case study for five cities in the United States.

UNLABELLED: An important issue of regional air quality management is to allocate air quality management funds to maximize environmental and human health benefits. In this study, we use an innovative approach to tackle this air quality management issue. We develop an innovative resource allocation model that allows identification of air pollutant emission control strategies that maximize mortality avoidances subject to a resource constraint. We first present the development of the resource allocation model and then a case study to show how the model can be used to identify resource allocation strategies that maximize mortality avoidances for top five Metropolitan Statistical Areas (MSAs) (i.e., New York, Los Angeles, Chicago, Dallas-Fort Worth, and Philadelphia) in the continental United States collectively. Given budget constraints in the U.S. Environmental Protection Agency's (EPA) Clean Air Act assessment, the results of the case study suggest that controls of sulfur dioxide (SO2) and primary carbon (PC) emissions from EPA Regions 2, 3, 5, 6, and 9 would have significant health benefits for the five selected cities collectively. Around 30,800 air pollution-related mortalities could be avoided during the selected 2-week summertime episode for the five cities collectively if the budget could be allocated based on the results of the resource allocation model. Although only five U.S. cities during a 2-week episode are considered in the case study, the resource allocation model can be used by decision-makers to plan air pollution mitigation strategies to achieve the most significant health benefits for other seasons and more cities over a region or the continental U.S. IMPLICATIONS: Effective allocations of air quality management resources are challenging and complicated, and it is desired to have a tool that can help decision-makers better allocate the funds to maximize health benefits of air pollution mitigation. An innovative resource allocation model developed in this study can help decision-makers identify the best resource allocation strategies for multiple cities collectively. The results of a case study suggest that controls of primary carbon and sulfur dioxides emissions would achieve the most significant health benefits for five selected cities collectively.

Optimization of multipollutant air quality management strategies: A case study for five cities in the United States.

UNLABELLED: Developing regional air quality management strategies is a difficult task because formation of air pollutants is interdependent and air quality at different locations may have different responses to emissions from common sources. We developed an optimization-based model, OPtimal integrated Emission Reduction Alternatives (OPERA), which allows for identifications of least-cost control strategies for attaining multipollutant air quality targets at multiple locations simultaneously. To implement OPERA, first, sensitivities of air quality to precursor emission changes are quantified. Second, cost functions of emission reductions are estimated using a cost analysis tool that includes a pool of available control measures. The third step is to determine desired reductions in concentrations of air pollutants. The last step is to identify the optimal control strategies by minimizing costs of emission controls using the sensitivities of air pollutants to emission changes, cost functions, and constraints for feasible emission reduction ratios. A case study that investigates ozone and PM2.5 air quality in the summer of 2007 for five major cities in the eastern United States is presented in this paper. The results of the OPERA calculations show that reductions in regional NOx and VOC as well as local primary PM2.5 emissions were more cost-effective than SO2 controls for decreasing ozone and total PM2.5 concentrations in the summer of 2007. This was because reductions in SO2 emissions would only decrease PM2.5 concentrations, and reductions in primary PM2.5 emissions were more cost-effective than SO2 emission controls. IMPLICATIONS: We developed an optimization-based model, OPtimal integrated Emission Reduction Alternatives (OPERA), which allows for identification of least-cost emission control strategies for attaining multipollutant air quality targets at multiple locations simultaneously. A major strength of OPERA is its flexibility, which allows for changes in air quality regulations, involving agencies, study regions, and so on, to be readily incorporated. Overall, it has been demonstrated that OPERA is useful in developing least-cost emission control strategies for achieving multipollutant air quality targets at multiple locations simultaneously and could be useful for policymakers developing integrated air quality management plans.

Contributions of regional air pollutant emissions to ozone and fine particulate matter-related mortalities in eastern U.S. urban areas.

Ground-level ozone and fine particulate matter (PM2.5) are associated with adverse human health effects such as lung structure dysfunction, inflammation and infection, asthma, and premature deaths. This study estimated contributions of emissions of anthropogenic nitrogen oxides (NOx), volatile organic compounds (VOCs) and sulfur dioxides (SO2) from four regions to summertime (i.e., June, July, and August) ozone and PM2.5-related mortalities in seven major Metropolitan Statistical Areas (MSAs with more than 4 million people) in the eastern United States (U.S.). A photochemical transport model, Community Multi-scale Air Quality (CMAQ) with sensitivity analyses, was applied to quantify the contribution of the regional anthropogenic emissions to ambient ozone and PM2.5 concentrations in the seven MSAs. The results of the sensitivity analysis, along with estimates of concentration-response from published epidemiologic studies, were used to estimate excess deaths associated with changes in ambient daily 8-h average ozone and daily PM2.5 concentrations during the summer of 2007. The results show that secondary PM2.5 (i.e., PM2.5 formed in the atmosphere) had larger effects on mortality (95% confidence interval (C.I.) ranged from 700 to 3854) than ambient ozone did (95% C.I. was 470-1353) in the seven MSAs. Emissions of anthropogenic NOx, VOCs and SO2 from the northeastern U.S. could cause up to about 2500 ozone and PM2.5-related deaths in the urban areas examined in this study. The results also show that the contributions of emissions from electrical generating units (EGUs) and anthropogenic non-EGU sources to ozone-related mortality in the MSAs were similar. However, emissions from EGUs had a more significant impact on PM2.5-related deaths than anthropogenic emissions from non-EGUs sources did. Anthropogenic NOx and VOCs emissions from the regions where the MSAs are located had the most significant contributions to ozone-related mortalities in the eastern U.S. urban areas. On the other hand, PM2.5-related mortalities in the MSAs were more likely to be affected by precursors transported from other regions.

Development of risk-based air quality management strategies under impacts of climate change.

UNLABELLED: Climate change is forecast to adversely affect air quality through perturbations in meteorological conditions, photochemical reactions, and precursor emissions. To protect the environment and human health from air pollution, there is an increasing recognition of the necessity of developing effective air quality management strategies under the impacts of climate change. This paper presents a framework for developing risk-based air quality management strategies that can help policy makers improve their decision-making processes in response to current and future climate change about 30-50 years from now. Development of air quality management strategies under the impacts of climate change is fundamentally a risk assessment and risk management process involving four steps: (1) assessment of the impacts of climate change and associated uncertainties; (2) determination of air quality targets; (3) selections of potential air quality management options; and (4) identification of preferred air quality management strategies that minimize control costs, maximize benefits, or limit the adverse effects of climate change on air quality when considering the scarcity of resources. The main challenge relates to the level of uncertainties associated with climate change forecasts and advancements in future control measures, since they will significantly affect the risk assessment results and development of effective air quality management plans. The concept presented in this paper can help decision makers make appropriate responses to climate change, since it provides an integrated approach for climate risk assessment and management when developing air quality management strategies. IMPLICATIONS: Development of climate-responsive air quality management strategies is fundamentally a risk assessment and risk management process. The risk assessment process includes quantification of climate change impacts on air quality and associated uncertainties. Risk management for air quality under the impacts of climate change includes determination of air quality targets, selections of potential management options, and identification of effective air quality management strategies through decision-making models. The risk-based decision-making framework can also be applied to develop climate-responsive management strategies for the other environmental dimensions and assess costs and benefits of future environmental management policies.

Sensitivity of air pollution-induced premature mortality to precursor emissions under the influence of climate change.

The relative contributions of PM(2.5) and ozone precursor emissions to air pollution-related premature mortality modulated by climate change are estimated for the U.S. using sensitivities of air pollutants to precursor emissions and health outcomes for 2001 and 2050. Result suggests that states with high emission rates and significant premature mortality increases induced by PM(2.5) will substantially benefit in the future from SO(2), anthropogenic NO(X) and NH(3) emissions reductions while states with premature mortality increases induced by O(3) will benefit mainly from anthropogenic NO(X) emissions reduction. Much of the increase in premature mortality expected from climate change-induced pollutant increases can be offset by targeting a specific precursor emission in most states based on the modeling approach followed here.

Cost analysis of impacts of climate change on regional air quality.

Climate change has been predicted to adversely impact regional air quality with resulting health effects. Here a regional air quality model and a technology analysis tool are used to assess the additional emission reductions required and associated costs to offset impacts of climate change on air quality. Analysis is done for six regions and five major cities in the continental United States. Future climate is taken from a global climate model simulation for 2049-2051 using the Intergovernmental Panel on Climate Change (IPCC) A1B emission scenario, and emission inventories are the same as current ones to assess impacts of climate change alone on air quality and control expenses. On the basis of the IPCC A1B emission scenario and current control technologies, least-cost sets of emission reductions for simultaneously offsetting impacts of climate change on regionally averaged 4th highest daily maximum 8-hr average ozone and yearly averaged PM2.5 (particulate matter [PM] with an aerodynamic diameter less than 2.5 microm) for the six regions examined are predicted to range from $36 million (1999$) yr(-1) in the Southeast to $5.5 billion yr(-1) in the Northeast. However, control costs to offset climate-related pollutant increases in urban areas can be greater than the regional costs because of the locally exacerbated ozone levels. An annual cost of $4.1 billion is required for offsetting climate-induced air quality impairment in 2049-2051 in the five cities alone. Overall, an annual cost of $9.3 billion is estimated for offsetting climate change impacts on air quality for the six regions and five cities examined. Much of the additional expense is to reduce increased levels of ozone. Additional control costs for offsetting the impacts everywhere in the United States could be larger than the estimates in this study. This study shows that additional emission controls and associated costs for offsetting climate impacts could significantly increase currently estimated control requirements and should be considered in developing control strategies for achieving air quality targets in the future.

Potential impact of climate change on air pollution-related human health effects.

The potential health impact of ambient ozone and PM2.5 concentrations modulated by climate change over the United States is investigated using combined atmospheric and health modeling. Regional air quality modeling for 2001 and 2050 was conducted using CMAQ Modeling System with meteorology from the GISS Global Climate Model, downscaled regionally using MM5,keeping boundary conditions of air pollutants, emission sources, population, activity levels, and pollution controls constant. BenMap was employed to estimate the air pollution health outcomes at the county, state, and national level for 2050 caused by the effect of meteorology on future ozone and PM2.5 concentrations. The changes in calculated annual mean PM2.5 concentrations show a relatively modest change with positive and negative responses (increasing PM2.5 levels across the northeastern U.S.) although average ozone levels slightly decrease across the northern sections of the U.S., and increase across the southern tier. Results suggest that climate change driven air quality-related health effects will be adversely affected in more then 2/3 of the continental U.S. Changes in health effects induced by PM2.5 dominate compared to those caused by ozone. PM2.5-induced premature mortality is about 15 times higher then that due to ozone. Nationally the analysis suggests approximately 4000 additional annual premature deaths due to climate change impacts on PM2.5 vs 300 due to climate change-induced ozone changes. However, the impacts vary spatially. Increased premature mortality due to elevated ozone concentrations will be offset by lower mortality from reductions in PM2.5 in 11 states. Uncertainties related to different emissions projections used to simulate future climate, and the uncertainties forecasting the meteorology, are large although there are potentially important unaddressed uncertainties (e.g., downscaling, speciation, interaction, exposure, and concentration-response function of the human health studies).

Development of North American emission inventories for air quality modeling under climate change.

An assessment of how future climate change will impact regional air quality requires projecting emissions many decades into the future in a consistent manner. An approach that integrates the impact of both the current regulations and the longer-term national and global trends is developed to construct an emissions inventory (EI) for North America for the mid-century in support of a regional modeling study of ozone and particulate matter (PM) less than or equal to 2.5 microm (PM2.5). Because the time horizon of such a distant projection is beyond that of EIs used in typical modeling studies, it is necessary to identify a practical approach that allows the emission projections to account for emission controls and climatic and energy-use changes. However, a technical challenge arises because this requires integration of various different types of information with which emissions from human activities are associated. Often, emission information in global models has less detail and uses coarser spatiotemporal resolution. The method developed here is based on data availability, spatiotemporal coverage and resolution, and future-scenario consistency (i.e., Intergovernmental Panel on Climate Change Special Report on Emissions Scenarios [IPCC SRES] A1B), and consists of two major steps: (1) near-future EI projection (to the year 2020), and (2) longer-term EI projection (to mid-century). The first step is based closely on the U.S. Environmental Protection Agency Clean Air Interstate Rule EI, the Environment Canada EI, as well estimates of Mexico's EI; whereas the second step follows approaches proposed by the EI from the Integrated Model to Assess the Global Environment (IMAGE), developed by Netherlands's National Institute for Public Health and the Environment (RIVM). For the United States, the year-2050 emissions for nitrogen oxides (NOx), sulfur dioxide (SO2), PM2.5, anthropogenic volatile organic compounds (VOCs), and ammonia are projected to change by -55, -55, -30, -40, and +20%, respectively, compared with 2001. NOx and SO2 emission changes are very similar in total amount but different in sectoral contribution. The projected emission trends for Canada and Mexico differ considerably. After taking into account the modeled climate changes, biogenic VOC emission increases from three countries overwhelm the decreases in anthropogenic VOC emissions, leading to a net small increase (approximately 2%) in overall VOC emissions.

Current and future linked responses of ozone and PM2.5 to emission controls.

Responses of ozone and PM2.5 to emission changes are coupled because of interactions between their precursors. Here we show the interdependencies of ozone and PM2.5 responses to emission changes in 2001 and 2050, with the future case accounting for both currently planned emission controls and climate change. Current responses of ozone and PM2.5 to emissions are quantified and linked on a daily basis for five cities in the continental United States: Atlanta, Chicago, Houston, Los Angeles, and NewYork. Reductions in anthropogenic NO(x) emissions decrease 24-h average PM2.5 levels but may either increase or decrease daily maximum 8-h average ozone levels. Regional ozone maxima for all the cities are more sensitive to NO(x) reductions than at the city center, particularly in New York and Chicago. Planned controls of anthropogenic NO(x) emissions lead to more positive responses to NO(x) reductions in the future. Sensitivities of ozone and PM2.5 to anthropogenic VOC emissions are predicted to decrease between 2001 and 2050. Ammonium nitrate formation is predicted to be less ammonia-sensitive in 2050 than 2001 while the opposite is true for ammonium sulfate. Sensitivity of PM2.5 to SO2 and NO(x) emissions changes little between 2001 and 2050. Both ammonium sulfate and ammonium nitrate are predicted to decrease in sensitivity to SO2 and NO(x) emissions between 2001 and 2050. The complexities, linkages, and daily changes in the pollutant responses to emission changes suggest that strategies developed to meet specific air quality standards should consider other air quality impacts as well.

Sensitivities of ozone and fine particulate matter formation to emissions under the impact of potential future climate change.

Impact of climate change alone and in combination with currently planned emission control strategies are investigated to quantify effectiveness in decreasing regional ozone and PM2.5 over the continental U.S. using MM5, SMOKE, and CMAQ with DDM-3D. Sensitivities of ozone and PM2.5 formation to precursor emissions are found to change only slightly in response to climate change. In many cases, mass per ton sensitivities to NO(x) and SO2 controls are predicted to be greater in the future due to both the lower emissions as well as climate, suggesting that current control strategies based on reducing such emissions will continue to be effective in decreasing ground-level ozone and PM2.5 concentrations. SO2 emission controls are predicted to be most beneficial for decreasing summertime PM2.5 levels, whereas controls of NO(x) emissions are effective in winter. Spatial distributions of sensitivities are also found to be only slightly affected assuming no changes in land-use. Contributions of biogenic VOC emissions to PM2.5 formation are simulated to be more important in the future because of higher temperatures, higher biogenic emissions, and lower anthropogenic NO(x) and SO2 emissions.