- Email: [email protected]
The end of diesel-powered cars?
Correspondence
eosinophil counts, as Lipworth and colleagues suggest, then one possible explanation for the higher odds of eosinophilia at step 4 than at lower steps is that the suppressive effect of ICS on blood eosinophils is greater in mild asthma than in patients with severe disease. This finding is perhaps because additional topical corticosteroid-resistant pathways become an important cause of eosinophil recruitment in severe disease. 3 This would explain why systemic treatments that deplete circulating eosinophils independently of an effect on airway processes (ie, anti-interleukin 5) are effective treatments for severe eosinophilic airway diseases. The overall average daily ICS dose prescribed was indeed low, with a median value of 219 μg/day (nonextrafine beclomethasone equivalent) in this real-life population of patients with asthma, 54% of whom were at British Thoracic Society step 2 or lower. Higher ICS doses were prescribed to patients at step 3 (median of 329 μg/day) and step 4 (median of 740 μg/day). Our study showed that a relation between blood eosinophil count and risk was noted regardless of the level of treatment with corticosteroids. Additional adjustment for the ICS dose prescribed and for the use of maintenance oral corticosteroids
did not relevantly change the association (the coefficient changed less than 10%). Thus, increased blood eosinophil count is an independent marker of increased exacerbation risk irrespective of present asthma therapy. The authors’ competing interests remain the same as those declared in the original article.
*David B Price, Ian D Pavord, Mike Thomas, Christopher J Corrigan, Andrew M Wilson, Elizabeth V Hillyer, Marjan Kerkhof [email protected] Research in Real-Life, Cambridge, UK (DBP, EVH, MK); Academic Primary Care, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen AB25 2ZD, UK (DBP); Respiratory Medicine Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK (IDP); Primary Care and Population Sciences, and NIHR Southampton Respiratory Biomedical Research Unit, University of Southampton, Southampton, UK (MT); King’s College London, London, UK (CJC); and Norwich Medical School, University of East Anglia, Norwich, UK (AMW) 1
2
3
Price DB, Rigazio A, Campbell JD, et al. Blood eosinophil count and prospective annual asthma disease burden: a UK cohort study. Lancet Respir Med 2015; 3: 849–58. Horn BR, Robin ED, Theodore J, Van Kessel A. Total eosinophil counts in the management of bronchial asthma. N Engl J Med 1975; 292: 1152–55. Brusselle GG, Maes T, Bracke KR. Eosinophils in the spotlight: eosinophilic airway inflammation in nonallergic asthma. Nat Med 2013; 19: 977–79.
The end of dieselpowered cars?
Getty Images
Outdoor air pollution has long been known for its adverse effects on human health, being responsible for the deaths of more than 3 million people worldwide every year. 1 In large cities, emissions from vehicles represent a major contribution to air pollution. New technologies have been developed by the car industry to reduce emissions and comply with stricter environmental regulations, but the Volkswagen cheating scandal, discussed in The Lancet Respiratory Medicine by Talha K Burki (Oct 15, p 838), 2 could have implications e2
for the use of diesel fuel in cars. The potential changes might, however, be larger and more positive than expected. Outdoor air pollution is estimated to have caused 400 000 premature deaths in Europe in 2011. 3 The largest and most polluted European cities have dealt with air pollution in different ways. In London and Berlin, low emission zones have been created to restrict access for the most polluting vehicles. More recently, other cities such as Paris have followed suit by creating low emission zones. In Amsterdam, the already widespread use of bicycles, combined with higher taxes for diesel cars and much lower taxes for hybrid and electric cars, are a good example of policies for air pollution control. However, London and Paris, two of the most polluted European cities, still face frequent episodes of highly elevated levels of PM10 (particulate matter up to 10 μm in size), PM2·5 (particulate matter up to 2·5 μm in size) and particularly nitrogen dioxide. This issue has led the Mayor of Paris, Anne Hidalgo, and the Mayor of London, Boris Johnson, to consider extreme measures, including banning diesel cars from these cities until 2020.4,5 Because the main markets for diesel-powered cars are in Europe, could the Volkswagen emission cheating scandal and the proposed banning of diesel cars in two of the largest European cities suggest the end of diesel, at least for light vehicles? Curiously, within a few weeks after the Volkswagen scandal, the International Council on Clean Transportation announced that the millionth plug-in electric car was sold. This increase took only 6 years to happen, which is quite an achievement because, for many decades, a zero-emission car has been the dream of environmentalists and medical doctors. The days for use of diesel in light vehicles might be numbered. www.thelancet.com/respiratory Vol 4 January 2016
Correspondence
Although in the USA the Volkswagen scandal alone will probably restrict the sales of diesel cars, changing the habits of such a large population in Europe will probably demand government efforts and changes in the rules that favour the use of diesel. The Paris and London mayors are going in this direction and their measures will probably spread to the rest of France, the UK, and to other countries. The Volkswagen scandal might be what the world was waiting for to speed up the change to cleaner hybrids and zero-emission plug-in electric cars. Concerns still remain about how electricity is generated to fuel plug-in electric cars. However, in many countries, the use of fossil fuels has slowly given place to alternative energy sources such as wind or solar, which might turn zeroemission vehicles into the standard in coming decades. This would have a great effect on reducing air pollution and would help to save millions of lives. I declare no competing interests.
Helotonio Carvalho [email protected] Department of Biophysics and Radiobiology, Biological Sciences Center, Federal University of Pernambuco, Recife, PE 50670-901, Brazil and Department of Immunology, Aggeu Magalhães Research Institute, Oswaldo Cruz Foundation, Recife, Brazil 1
2
3
4
5
GBD 2013 Risk Factors Collaborators, Forouzanfar MH, Alexander L, et al. Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2015; Published online Sept 11. http://dx.doi.org/10.1016/ S0140-6736(15)00129-4. Burki TK. Diesel cars and health: the Volkswagen emissions scandal. Lancet Respir Med 2015; 3: 838–39. European Environmental Agency. Air quality in Europe—2014 report. Nov 19, 2014. http://www.eea.europa.eu/publications/airquality-in-europe-2014 (accessed Oct 28, 2015). Van Eeckhout L. Comment Anne Hidalgo veut réduire la pollution à Paris. Le Monde (Paris), Jan 27, 2015. Graham G. London will follow Paris and ban diesel cars, campaigners warn. The Telegraph (London), Dec 8, 2014.
www.thelancet.com/respiratory Vol 4 January 2016
Decade of the lung—a call for action to promote lung health globally The Forum of International Respiratory Societies launched The Decade of the Lung campaign at the 2015 International Congress of the European Respiratory Society in Amsterdam. The importance of this campaign is underscored by the failure to achieve the Millennium Development Goals in 2015 in many areas of the world and the recent launch of the 2030 agenda for the Sustainable Development Goals by the UN. Lung diseases are a major burden of disease globally, and their prevention, early diagnosis, and effective management are key to attaining these new goals. COPD, asthma, tuberculosis, lung cancer, acute respiratory infections, or pneumonia, affect more than 500 million people globally. 1–3 The burden of respiratory diseases can be anticipated to grow with climate change because global warming is closely coupled with rising concentrations of air pollutants. 4 Chronic respiratory diseases also constitute a large burden of noncommunicable diseases globally, causing substantial morbidity. In low-income and middle-income countries, non-communicable respiratory diseases are increasingly recognised as a major cause of health care use, contributing to the dual burden of infectious diseases and non-communicable diseases. 3 Asthma, occurring in about 15% of children globally is the most common, non-communicable disease in children. 3 Respiratory infectious diseases have been increasingly linked to the development or worsening of respiratory non-communicable diseases, such as the association of tuberculosis with development of COPD. Importantly, increasing
evidence suggests that the origins of chronic lung disease might arise prenatally and early in childhood, with early life exposures such as tobacco smoke or acute respiratory infections, associated with asthma or COPD in adulthood.5 If effective interventions for primary prevention are to be developed, research into respiratory non-communicable diseases should be prioritised, including the study of the association between child lung health and adult disease. These facts call for concerted action. The key to addressing this burden is the need for strong political commitment, implementation of effective preventative and management strategies, and efficient surveillance and monitoring systems. Tobacco smoke and biomass exposures continue to constitute major preventable risk factors for development or worsening of respiratory disease. 1 Poverty, poor nutrition, or HIV infection, important risk factors for many of these diseases or for severe illnesses, are amenable to intervention. Strengthening of childhood immunisation programmes and development of new vaccination strategies are needed to prevent respiratory infections. Pneumonia case management guidelines with use of antibiotics can substantially reduce mortality from childhood pneumonia, yet globally, almost 40% of children with pneumonia symptoms do not access health care.6 Strengthening of health care systems, early diagnosis, and training of health care professionals in prevention and management of such respiratory diseases are essential. Greater availability of essential medicines for treatment is needed, with guidelines for management that are adapted to the local context. Universal access to effective, affordable, high-quality medicines must be a priority.1 For example, oxygen treatment is still not widely available in many lowincome and middle-income settings.
If you would like to respond to an article published in The Lancet Respiratory Medicine, please submit your correspondence online at: http:// ees.elsevier.com/thelancetrm
e3
eosinophil counts, as Lipworth and colleagues suggest, then one possible explanation for the higher odds of eosinophilia at step 4 than at lower steps is that the suppressive effect of ICS on blood eosinophils is greater in mild asthma than in patients with severe disease. This finding is perhaps because additional topical corticosteroid-resistant pathways become an important cause of eosinophil recruitment in severe disease. 3 This would explain why systemic treatments that deplete circulating eosinophils independently of an effect on airway processes (ie, anti-interleukin 5) are effective treatments for severe eosinophilic airway diseases. The overall average daily ICS dose prescribed was indeed low, with a median value of 219 μg/day (nonextrafine beclomethasone equivalent) in this real-life population of patients with asthma, 54% of whom were at British Thoracic Society step 2 or lower. Higher ICS doses were prescribed to patients at step 3 (median of 329 μg/day) and step 4 (median of 740 μg/day). Our study showed that a relation between blood eosinophil count and risk was noted regardless of the level of treatment with corticosteroids. Additional adjustment for the ICS dose prescribed and for the use of maintenance oral corticosteroids
did not relevantly change the association (the coefficient changed less than 10%). Thus, increased blood eosinophil count is an independent marker of increased exacerbation risk irrespective of present asthma therapy. The authors’ competing interests remain the same as those declared in the original article.
*David B Price, Ian D Pavord, Mike Thomas, Christopher J Corrigan, Andrew M Wilson, Elizabeth V Hillyer, Marjan Kerkhof [email protected] Research in Real-Life, Cambridge, UK (DBP, EVH, MK); Academic Primary Care, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen AB25 2ZD, UK (DBP); Respiratory Medicine Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK (IDP); Primary Care and Population Sciences, and NIHR Southampton Respiratory Biomedical Research Unit, University of Southampton, Southampton, UK (MT); King’s College London, London, UK (CJC); and Norwich Medical School, University of East Anglia, Norwich, UK (AMW) 1
2
3
Price DB, Rigazio A, Campbell JD, et al. Blood eosinophil count and prospective annual asthma disease burden: a UK cohort study. Lancet Respir Med 2015; 3: 849–58. Horn BR, Robin ED, Theodore J, Van Kessel A. Total eosinophil counts in the management of bronchial asthma. N Engl J Med 1975; 292: 1152–55. Brusselle GG, Maes T, Bracke KR. Eosinophils in the spotlight: eosinophilic airway inflammation in nonallergic asthma. Nat Med 2013; 19: 977–79.
The end of dieselpowered cars?
Getty Images
Outdoor air pollution has long been known for its adverse effects on human health, being responsible for the deaths of more than 3 million people worldwide every year. 1 In large cities, emissions from vehicles represent a major contribution to air pollution. New technologies have been developed by the car industry to reduce emissions and comply with stricter environmental regulations, but the Volkswagen cheating scandal, discussed in The Lancet Respiratory Medicine by Talha K Burki (Oct 15, p 838), 2 could have implications e2
for the use of diesel fuel in cars. The potential changes might, however, be larger and more positive than expected. Outdoor air pollution is estimated to have caused 400 000 premature deaths in Europe in 2011. 3 The largest and most polluted European cities have dealt with air pollution in different ways. In London and Berlin, low emission zones have been created to restrict access for the most polluting vehicles. More recently, other cities such as Paris have followed suit by creating low emission zones. In Amsterdam, the already widespread use of bicycles, combined with higher taxes for diesel cars and much lower taxes for hybrid and electric cars, are a good example of policies for air pollution control. However, London and Paris, two of the most polluted European cities, still face frequent episodes of highly elevated levels of PM10 (particulate matter up to 10 μm in size), PM2·5 (particulate matter up to 2·5 μm in size) and particularly nitrogen dioxide. This issue has led the Mayor of Paris, Anne Hidalgo, and the Mayor of London, Boris Johnson, to consider extreme measures, including banning diesel cars from these cities until 2020.4,5 Because the main markets for diesel-powered cars are in Europe, could the Volkswagen emission cheating scandal and the proposed banning of diesel cars in two of the largest European cities suggest the end of diesel, at least for light vehicles? Curiously, within a few weeks after the Volkswagen scandal, the International Council on Clean Transportation announced that the millionth plug-in electric car was sold. This increase took only 6 years to happen, which is quite an achievement because, for many decades, a zero-emission car has been the dream of environmentalists and medical doctors. The days for use of diesel in light vehicles might be numbered. www.thelancet.com/respiratory Vol 4 January 2016
Correspondence
Although in the USA the Volkswagen scandal alone will probably restrict the sales of diesel cars, changing the habits of such a large population in Europe will probably demand government efforts and changes in the rules that favour the use of diesel. The Paris and London mayors are going in this direction and their measures will probably spread to the rest of France, the UK, and to other countries. The Volkswagen scandal might be what the world was waiting for to speed up the change to cleaner hybrids and zero-emission plug-in electric cars. Concerns still remain about how electricity is generated to fuel plug-in electric cars. However, in many countries, the use of fossil fuels has slowly given place to alternative energy sources such as wind or solar, which might turn zeroemission vehicles into the standard in coming decades. This would have a great effect on reducing air pollution and would help to save millions of lives. I declare no competing interests.
Helotonio Carvalho [email protected] Department of Biophysics and Radiobiology, Biological Sciences Center, Federal University of Pernambuco, Recife, PE 50670-901, Brazil and Department of Immunology, Aggeu Magalhães Research Institute, Oswaldo Cruz Foundation, Recife, Brazil 1
2
3
4
5
GBD 2013 Risk Factors Collaborators, Forouzanfar MH, Alexander L, et al. Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2015; Published online Sept 11. http://dx.doi.org/10.1016/ S0140-6736(15)00129-4. Burki TK. Diesel cars and health: the Volkswagen emissions scandal. Lancet Respir Med 2015; 3: 838–39. European Environmental Agency. Air quality in Europe—2014 report. Nov 19, 2014. http://www.eea.europa.eu/publications/airquality-in-europe-2014 (accessed Oct 28, 2015). Van Eeckhout L. Comment Anne Hidalgo veut réduire la pollution à Paris. Le Monde (Paris), Jan 27, 2015. Graham G. London will follow Paris and ban diesel cars, campaigners warn. The Telegraph (London), Dec 8, 2014.
www.thelancet.com/respiratory Vol 4 January 2016
Decade of the lung—a call for action to promote lung health globally The Forum of International Respiratory Societies launched The Decade of the Lung campaign at the 2015 International Congress of the European Respiratory Society in Amsterdam. The importance of this campaign is underscored by the failure to achieve the Millennium Development Goals in 2015 in many areas of the world and the recent launch of the 2030 agenda for the Sustainable Development Goals by the UN. Lung diseases are a major burden of disease globally, and their prevention, early diagnosis, and effective management are key to attaining these new goals. COPD, asthma, tuberculosis, lung cancer, acute respiratory infections, or pneumonia, affect more than 500 million people globally. 1–3 The burden of respiratory diseases can be anticipated to grow with climate change because global warming is closely coupled with rising concentrations of air pollutants. 4 Chronic respiratory diseases also constitute a large burden of noncommunicable diseases globally, causing substantial morbidity. In low-income and middle-income countries, non-communicable respiratory diseases are increasingly recognised as a major cause of health care use, contributing to the dual burden of infectious diseases and non-communicable diseases. 3 Asthma, occurring in about 15% of children globally is the most common, non-communicable disease in children. 3 Respiratory infectious diseases have been increasingly linked to the development or worsening of respiratory non-communicable diseases, such as the association of tuberculosis with development of COPD. Importantly, increasing
evidence suggests that the origins of chronic lung disease might arise prenatally and early in childhood, with early life exposures such as tobacco smoke or acute respiratory infections, associated with asthma or COPD in adulthood.5 If effective interventions for primary prevention are to be developed, research into respiratory non-communicable diseases should be prioritised, including the study of the association between child lung health and adult disease. These facts call for concerted action. The key to addressing this burden is the need for strong political commitment, implementation of effective preventative and management strategies, and efficient surveillance and monitoring systems. Tobacco smoke and biomass exposures continue to constitute major preventable risk factors for development or worsening of respiratory disease. 1 Poverty, poor nutrition, or HIV infection, important risk factors for many of these diseases or for severe illnesses, are amenable to intervention. Strengthening of childhood immunisation programmes and development of new vaccination strategies are needed to prevent respiratory infections. Pneumonia case management guidelines with use of antibiotics can substantially reduce mortality from childhood pneumonia, yet globally, almost 40% of children with pneumonia symptoms do not access health care.6 Strengthening of health care systems, early diagnosis, and training of health care professionals in prevention and management of such respiratory diseases are essential. Greater availability of essential medicines for treatment is needed, with guidelines for management that are adapted to the local context. Universal access to effective, affordable, high-quality medicines must be a priority.1 For example, oxygen treatment is still not widely available in many lowincome and middle-income settings.
If you would like to respond to an article published in The Lancet Respiratory Medicine, please submit your correspondence online at: http:// ees.elsevier.com/thelancetrm
e3