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CEEH Scientific Report No. 7a

Description of the CEEH health effects model - Selection of concentration-response functions

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Summary (English)

This report is based on a number of up-to-date reviews of the existing literature on health effects from air pollution at the population level and conclude with recommendations for CEEH.
The pollutants in the CEEH models have been selected based on the following criteria:

  • They stem from combustion sources either directly or via chemical transformations. This may include evaporation or dust from the energy sources themselves (i.e. from wear and tear). Other pollution derived from energy production but not liberated to the air is not included (e.g. heavy metals in soil deposits). However, heavy metals, dioxins and possibly PAHs that are emitted to the air, deposit on soil or in water and end up by being ingested should ideally be covered by CEEH.
  • Be possible to model in the CEEH settings both in terms of emissions, chemical transformations and transport.
  • Be sufficiently investigated in terms of documented health effects and in terms of the costs associated with these health effects.
Combustion sources and accordingly combustion products are highly diverse and widespread. In practice, therefore, not all sources that contribute to health effects in humans can be included in the CEEH models. Other sources than combustion contribute some of the pollutants and as a result a brief discussion of the relevance and effect of such non-combustion derived air pollutants is included in this report. For a more comprehensive discussion of secondary pollutants from e.g. agricultural activities the reader is referred to CEEH report no. 3.

The EVA model was based on existing European models such as EcoSense 4.0 from ExternE and used the same air pollution products as these in the versions available in 2003-4. With time EVA has changed independently from its predecessors. A more recent version of the ExternE methods is now available (ExternE, 2005). The pollutants contained by ExternE are provided in table 1. Pollutants originally included in EVA are the following: SO2, O3, PM2.5, nitrate, sulphate, dioxin, Pb, and Hg.

Additional national and international reports that have been reviewed in the process of creating the CEEH model include US-EPA, WHO, OECD, DEFRA (UK), COMEAP (UK), APHEA, NEEDS and CAFE (EU) reports.

As there is consensus that the most important health effects (also in terms of costs) stem from particles, CEEH should include effects of particles composed of nitrates and sulphates as well as primary particles in the size fractions PM10 and PM2.5 as both size fractions are used in CRFs for a range of health effects. Effects of particulate matter include all-cause or cause-specific morbidity (as hospital admissions) and mortality for both adults and infants.

Ozone should be modelled in CEEH for use in a CRF on long-term effects on all respiratory mortality.

The gaseous pollutants SO2 and NO2 should also be modelled. In contrast to other recent reviews, but from the point of view that independent effects of SO2 do seem to exist and that they are plausible from a mechanistic point of view and despite the risk of double counting effects in CEEH we propose a short-term CRF of SO2. This is particularly warranted as we suggest a slightly conservative CRF of particles on cause-specific mortality (see the chapter on particles) which miss some of the effect of air pollution. Recent Danish evidence (Andersen Z, et al., 2010) of an effect of long-term NO2 on COPD incidence has prompted us to use NO2 rather than PM for the CRF for this disease,
The entire list of recommended CRFs are provided in table 3.

Further we propose to:

  • Use estimates for fine particulate matter (PM2.5) effects when available as the coarser fractions’ contribution cannot be separated sufficiently and would lead to double counting. If the evidence is insufficient for fine but sufficient for coarse particles estimates for the latter can be used instead.
  • Regarding mortality, only use estimates from population (prospective) studies as in other recent reviews (primarily NEEDS 2007 and COMEAP 2009).
  • In contrast to other recent reviews which use all-cause mortality we recommend the use of cause-specific estimates because these form a better basis for specific cost calculation although from a health perspective the total effect appears to be better covered by all-cause estimates.
  • Only include estimates if based on several independent sources or based on single high quality and large studies endorsed by other reviews, i.e. assuring that the evidence is solid and the risk of double counting is neglible. CRF that include 1 in the 95% CI are thus not considered even if endorsed by recent review such as COMEAP or NEEDS.
  • Recommended CEEH Concentration-Response functions (CRF)

The general approach to estimating the effects of pollutants on health uses the relative risk (RR) found in the epidemiological studies, expressed as % change in end-point per unit pollutant (concentration) (CRF). If the CRF is multiplied on the background rates of the health end-point in the target population and the population at risk the CRF can be expressed as new cases (or events) per year (or day) per unit of this population per relevant pollution increment. Results are then expressed as estimated new or ‘extra’ cases, events or days per year (or day) attributed to the pollutant.

Concentration-response functions used in EVA (Andersen MS, 2000)

Health effects (Response)





Congestive heart failure 3,09E-05 3,09E-05 1,85E-05
Restricted activity days 4,20E-02 4,20E-02 2,50E-02
Bronchodilator usage (adults) 2,72E-01 2,72E-01 1,63E-01
Cough (adults) 2,80E-01 2,80E-01 1,33E-01
Lower resp. symptoms (adults) 1,72E-01 1,29E-01 6,10E-02
Bronchodilator usage (children) 1,29E-01 1,29E-01 7,80E-02
Cough (children) 4,45E-01 4,45E-01 2,66E-01
Lower resp. symptoms (children) 1,72E-01 1,29E-01 1,03E-01
Respiratory hospital admission 3,46E-06 3,46E-06 2,07E-06 2,04E-06 episodes/
Cerebrovascular hospital admission 8,42E-06 8,42E-06 5,04E-06
Chronic mortality - years of life lost 7,68E-04 4,60E-04 7,68E-04
Chronic bronchitis - adults 7,80E-05 7,80E-05 4,90E-05
Chronic cough - children 3,46E-03 3,46E-03

Lung cancer 0,008 0,008 0,0048
change death rate/
ug.m-3 (cases)
Acute mortality (deaths)
0,07% change death rate/
ug.m-3 (cases)
YOLL=Years of Lost Life. The concentration-response functions are expressed as number of new occurrences in the relevant age group per µg/m3/year.
Nitrates are treated as PM2.5/1.67 and sulphates equal to PM2.5.

Concentration response functions used in the CEEH HIA model

Pollutant Effect Age CRF (RR) Notes
Ozone Mortality of any respiratory All ages 1.04 (1.013-1.067) per 10 ppm in summer months mean of 1-hr max No threshold. Only April – September.
PM2.5 Cardiopulmonary mortality 30+ 1.09 (1.03-1.16)  
PM2.5 Lung cancer mortality 30+ 1.14 (1.04-1.23)  
PM2.5 Respiratory hospital admissions all ages 1.0114 (1.0062-1.0167)  
PM10 Ischemic heart disease hospital admissions all ages 1.008 (1.005-1.01)  
PM10 Dysrhythmia hospital admissions all ages 1.008 (1.001-1.014)  
PM10 Heart Failure hospital admissions all ages 1.014 (1.005-1.024)  
PM10 Infant mortality 0-1 1.04 (1.02-1.07)  
PM10 Lower respiratory symptoms symptomatic adults 1.3 days/yr/person*  
PM10 Lower respiratory symptoms 5-14 1.86 days/yr /person*  
PM2.5 Restricted activity days 15-64 0.902 days/yr /person*  
PM2.5 Work Loss days 15-64 0.207 days/yr /person*  
NO2 COPD incidence adult 0.483% (0.068-0.8979)  
SO2 All-cause mortality Adult 1.012 (1.007-1.016) per 10 μg/m3 24h previous day mean
PM10 New cases of chronic bronchitis 27+ 1.098* sensitivity analysis
PM2.5 All-cause mortality 30+ 1.06 (1.02-1.11) sensitivity analysis
PM10 Cardiac hospital admissions all ages 1.009 (1.007-1.01) sensitivity analysis
PM2.5 Incidence of fatal cardiovascular disease adult females 100% males 50%* sensitivity analysis
Recommended CRF (for yearly means of a 10 μg/m3 if not specified otherwise) in CEEH to be used as described in the text. 95% CI in parentheses. * no CI because they are derived from reports or calculations from more than one study without sufficient details for CI calculation.

Proposed use in CEEH of changes in incidences of health effects associated with air pollution, i.e. concentration-response functions (CRF) for incidences.

Recommended CEEH Concentration-Response functions (CRF) for the HIA



Age & gender







K35.0 + K35.1 + K35.9

5.43% per 10 ppb increase in the moving 5-day mean

Only during June-August


Asthma incidence

Males 25+


39.3% per 10 ppb annual mean



Incidence of non-fatal cardiovascular events

Females50-79 years

I21-I25 + I61-I69

24% per 10 μg/m3 annual mean



Lung cancer mortality



1.14 (1.04-1.23) per 10 μg/m3 annual mean

Only as sensitivity analysis


Respiratory hospital admissions used as incidence

all ages


1.0114 (1.006-1.017) per 10 μg/m3 annual mean

Only other than asthma among 2-8 yrs old and males 25+ yrs and COPD and lung cancer


Cardiac hospital admissions

all ages


1.009 (1.007-1.01) per 10 μg/m3 annual mean

Only as sensitivity analysis or for remaining CVD


Ischemic heart disease hospital admissions used as incidence

all ages


1.008 (1.005-1.01) per 10 μg/m3 annual mean

Only other than females 50-79


Dysrhythmia hospital admissions used as incidence

all ages


1.008 (1.001-1.014) per 10 μg/m3 annual mean



Heart Failure hospital admissions used as incidence

all ages


1.014 (1.005-1.024) per 10 μg/m3 annual mean






0.326% per μg/m3 moving 2-day mean



Incidence of fatal cardiovascular disease


I21-I25 + I61-I69

females 100%

males 50%*

Only as sensitivity analysis


New cases of chronic bronchitis


J41-J44 + J47

1.098* per 10 μg/m3 annual mean

Only as sensitivity analysis


Asthma incidence

children 2-8


87.5% per 10 μg/m3 annual mean



Lung cancer incidence



1.08 (1.02–1.15) per 10 μg/m3 annual mean



Croup incidence

children 0-5


4.67% per 10 μg/m3 daily mean



COPD incidence



0.483% (0.068-0.8979) per 10 μg/m3 annual mean



Otitis media incidence

children 0-2


0.61% per μg/m3 of annual mean



Table 1. The listed CRF includes some for specific diseases, age groups and gender and some that cover broad categories of diseases including the specific ones as well as some only suggested for sensitivity analyses, i.e. to test whether effects fall within the ranges predicted by previously used CRF. When using the CRF for broad categories, the diseases and age groups already covered by use of specific diseases’ CRF should be subtracted.


Serial title: Centre for Energy,Environment and Health Report Series

Title: CEEH Scientific Report No. 7a - Description of the CEEH health effect model

Author: Jakob H. Bønløkke1

Other contributors: Torben Sigsgaard1, Jørgen Brandt2, Lise M. Frohn2, Esben M. Flachs3, Henrik Brønnum-Hansen3, Marie-Louise Siggaard-Andersen4

1Aarhus University, Department of of Public Health, Bartholins Allé 2, Building 1260, 8000 Århus C, Denmark . 2Aarhus University, National Environmental Research Institute, Department of Atmospheric Environment, Frederiksborgvej 399, 4000 Roskilde, Denmark. 3National Institute of Public Health, University of Southern Denmark. 4University of Copenhagen, Niels Bohr Institute, Juliane Maries Vej 30, 2100 København Ø, Denmark

Responsible institution:  Aarhus University

Language: English

Keywords: Air pollution, concentration-response functions, health effect model, Energy system analysis, integrated modeling, optimization, energy, environment, atmospheric pollution, meteorology, climate, health, externality, CEEH, Denmark, energy scenario, Balmorel, DEHM, Enviro-HIRLAM.


ISSN: ISSN 1904-7495

Version: November 2011


Copyright:  Any use of the content of this report should be cited as: Bønløkke, J.H. (2011) CEEH scientific report No 7a, Centre for Energy, Environment and Health (CEEH) report series.

Cover image: Clouds with CRF showing two typical concentration-response functions created only for illustrative purposes by Torben Sigsgaard and Jakob Bønløkke.

The CEEH Scientific Reports

The Centre for Energy, Environment and Health report series constitutes documentation, validation and scientific results from CEEH. The report series consists of following reports:

CEEH report (working) titles and release dates

No. CEEH Scientific Report (Working title) Release Date
  first version
Description of the CEEH integrated ‘Energy-Environment-Health-Cost’ modelling framework system Jan 2011
( Document comparing the importance of different emissions scenarios (EDGAR, IPCC, and EMEP) )
Oct 2012
Assessment of Health-Cost Externalities of Air Pollution at the National Level  using the EVA Model System
Mar 2011
( Demonstration of full CEEH chain – the EVA line )
Oct 2012
Description of the HIA line in the CEEH integrated modelling chain
Sep 2012
( Demonstration of full CEEH chain – the HIA line ) Combined with CEEH report no 5

Description of the CEEH health effects model - selection of concentration-response functions
Nov 2011
Laboratory tests of toxicity of combustion particles
Oct 2012
( Final report containing all results )
Oct 2012
Extended abstracts from International conference on Energy, Environment and Health – Held by CEEH, REBECa and CEESA
July 2011
CEEH's beregninger af helbredsomkostninger fra luftforurening i Klimakommissionens scenarier (in danish)
Nov 2011

Dato: 20-Sep-2012