Cleaner air for safer health!

Good air quality is a requirement for preserving the exquisite balance of life on earth for humans, plants, animals and natural resources.

Real-time information on air pollution in Kosovo

Introduction

NIPH is a public health institution that has a statutory task to advise the government and population regarding public health. The functions of the NIPH include[1]:

  • The NIPH provides research on the environmental factors which harm public health and propose protection measures to prevent such harms.
  • The NIPH propose and undertake professional actions and recommends the competent institutions on how to eliminate harmful effects on public health.
  • Informs the population regarding causes of environmental pollution, which may threaten their health.
  • Elaborates the environmental health reporting system related to environmental pollution.
  • The NIPH is a reference center for health educational policies programs, supervision, evaluation, information and communication.

This analytical process requires both understanding of air pollution phenomena, and how these conditions interact with health and in particular with vulnerable people. Understanding this issue will enable sending early warnings and explain it to the general public, NGO’s and the media. The use of air quality messages/alerts/indices is in essence an exposure reduction program, which is the first priority of any government dealing with air pollution.

[1] Law no. 02/l-78 on Public Health

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What is Air Quality?

Air is a mixture of nitrogen (78%), oxygen (21%), carbon dioxide (CO2) and some inert gases. It also consists of water vapors of varying quantity.

Air quality is about how healthy the air that we breathe is. Clean air is considered to be a basic requirement of human health and well-being. However, air pollution continues to pose a significant threat to health worldwide.

Air quality refers to the condition of the air within our surrounding. Good air quality pertains to the degree which the air is clean, clear and free from pollutants such as smoke, dust and smog among other gaseous impurities in the air. Air quality is determined by assessing a variety of pollution indicators. Good air quality is a requirement for preserving the exquisite balance of life on earth for humans, plants, animals and natural resources.

Air quality depends also on the proximity to the source and altitude at which pollutants are released; meteorological conditions, including wind and heat; chemical transformations (reactions to sunlight, pollutant interactions)

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What is Air Pollution?

Clean air is a mixture of nitrogen (78%), oxygen (21%), carbon dioxide (CO2), argon, water vapor and some other inert gases.

Clean air is a mixture of nitrogen (78%), oxygen (21%), carbon dioxide (CO2), argon, water vapor and other inert gases. Air pollution refers to release of substances in the atmosphere that are harmful to humans, living organisms or plants, and cause damage to climate, materials and buildings. Air pollution consists of chemicals or particles: gases, solid particles, or liquid droplets. Primary air pollution is emitted from domestic or municipal heating systems, factories, cars, large combustion sources like power plants, agriculture or natural sources like volcanoes. Air pollution is most common in large cities where emissions from many different sources are cumulated.

The particulate matter (PM) is a common proxy indicator for air pollution. It affects more people than any other pollutant. The major components of PM are sulfates, nitrates, ammonia, sodium chloride, black carbon, soot, mineral dust and water. It consists of a complex mixture of solid and liquid particles of organic and inorganic substances suspended in the air. There is a close, quantitative relationship between exposure to high concentrations of small particulates (PM10 and PM2.5) and increased mortality or morbidity, both daily and over time. While particles with a diameter of 10 microns or less, (≤ PM10) can penetrate and lodge deep inside the lungs, the even more health-damaging particles are those with a diameter of 2.5 microns or less (≤ PM2.5). PM2.5 can penetrate the lung barrier and enter the blood system. Chronic exposure to particles contributes to the risk of accelerated aging of the lungs, with loss of lung capacity and decrease of lung function, and development of diseases like asthma, emphysema, bronchitis lung cancer, brain damage as well as IHD and stroke as leading causes of death. Symptoms like coughing, phlegm, wheezing, chest tightness, chest pain, palpitations, shortness of breath and unusual fatigue are the most common symptoms among the people affected by the air particles pollution.

Sulphur dioxide (SO2) is a colorless, poor-smelling, toxic gas formed when fuel containing sulfur, such as coal and oil, is burned. SO2 is formed in various industrial and energy combustion processes.  This gas can cause respiratory problems such as bronchitis, nose, throat and lung irritation. It may cause coughing, wheezing, phlegm and asthma attacks. The effects are worse when exercising. Sulphur dioxide is linked to cardiovascular disease.

Nitrogen dioxide (NO2) is the main source of nitrate aerosols, which form an important fraction of PM2.5 and, in the presence of ultraviolet light, of ozone. The major sources of anthropogenic emissions of NO2 are combustion processes (heating, power generation, and engines in vehicles and ships). NO2 is a toxic gas which causes significant inflammation of the airways. Epidemiological studies have shown that symptoms of bronchitis in asthmatic children increase in association with long-term exposure to NO2. Reduced lung function growth is also linked to NO2 at currently measured (or observed) concentrations in cities of Europe and North America2.

Ozone (O3) at ground level – not to be confused with the ozone layer in the upper atmosphere – is one of the major constituents of photochemical smog. It is formed by the reaction of sunlight (photochemical reaction) with pollutants such as nitrogen oxides (NOx) from vehicle and industry emissions and Volatile Organic Compounds (VOCs) emitted by vehicles, solvents and industry. As a result, the highest levels of ozone pollution occur during periods of sunny weather. Excessive ozone in the air can have a marked effect on human health. It can cause breathing problems, trigger asthma, reduce lung function and cause lung diseases[2].

Volatile Organic Compounds (VOCs) are gaseous compounds emitted by industry, road vehicles, household heating, and power generation. VOCs include a variety of chemicals that can cause eye, nose and throat irritation, shortness of breath, headaches, fatigue, nausea, dizziness and skin problems. Higher concentrations may cause irritation of the lungs, as well as damage to the liver, kidney, or central nervous system2.

[2] WHO, Health Topic Ambient (outdoor) air pollution, Fact sheets, 2 May 2018. https://www.who.int/news-room/fact-sheets/detail/ambient-(outdoor)-air-quality-and-health) (accessed October 28, 2020).

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Air Quality in Kosovo

Institutional responsibilities of KHMI and KEPA for Air Quality in Kosovo

KHMI is a national institution, scientific and professional in the field of meteorology, hydrology, climate, air, water and soil which acts within Ministry of Environment and has a duty to carry out the following activities[3]:

  • Planning, construction, equipping, maintenance and development of national systems or networks of meteorological, hydrological stations, air quality and water stations.
  • Systematic measurements and monitoring (observations) elements and phenomena of hydrological, meteorological, through the state network system of hydrological and meteorological including radar observation system, monitoring system of air, water and soil.
  • Development, establishment, and functioning of computer and telecommunications systems for collection, processing, exchanging and distribution data and information on the current situation and weather forecasting for climate and hydrology, and also data on air, water and soil quality.
  • KHMI issues notifications, alerts and warnings on natural disasters and meteorological and hydrological disasters, and cases of exceeding the air, water and soil pollution for certain locations by informing relevant institutions.

The institutional responsibilities of KEPA regarding air pollution are defined by Law on environmental protection No. 03/L-025:

  • Provides proper information for administration, Government and Kosovo Assembly for the implementation of environmental protection policies.
  • Develops and coordinates unique system of information on environmental protection regarding to system for conduction of environmental state in Kosovo as well as collecting the records for environment.
  • Supports administrative bodies on developing of new forms of policy for environmental protection and monitoring the implementation of environmental protection plans and programs.
  • Information and Alert Thresholds for Air quality. The Ministry shall ensure that timely information about actual or predicted exceedances of alert thresholds or information thresholds is provided to the public[4].

The role of NIPH regarding environmental health is described in section 8.1 of this document.

Air quality policy and law in Kosovo

Many cities in Kosovo suffer from poor air quality, with ambient concentrations of particulate matter (PM) with a diameter of 2.5 micrometers or less (PM2.5) significantly exceeding the national[5] and European Union standards and global air quality guidelines for PM2.5 established by WHO.

The law on Air Protection from Pollution 03/L-160 is the most important legal instrument for air quality management. It sets a framework for air quality managements and is a legal base document:

  • The administrative instruction on limit values of air quality Nr. 02/2011, established the Ministry of Environment and Spatial Planning as the competent authority for assessing air quality, and set the reference methods and criteria. It establishes limit values for the main pollutants, methods of air quality management (establishing zones and agglomeration, introducing Air Quality Plans) and reporting and public information rules.
  • Administrative Instruction No. 15/2010 on the Criteria for Defining of Air Quality Monitoring Points, Number and Frequency Of Measurements, Classification of Pollutants Which Are Monitored, The Methodology Of Work, Form And Timing[4] set the defining criteria for the implementation of the air quality monitoring system.
  • Administrative Instruction No. 21/2013 For Arsenic, Cadmium, Mercury, Nickel and Polycyclic Aromatic Hydrocarbons In Air[7] set target values for the concentration of arsenic, cadmium, nickel and benzo (a) pyrene, and establishes requirements for air quality assessment.
  • Administrative Instruction No. 08/2016 For the Allowed Norms Of Discharges In Air From Mobile Sources[8] set the discharge limits from mobile ground sources, roads vehicles, and measures for their implementation.

The Strategy on Air Quality in Kosovo 2013-2022 sets out an action plan for a ten-year period. The following measures are planned: implementation of the existing air legislation, emissions reduction from individual sources, mobile sources and public activities, reduce greenhouse gas emissions.[9]

The air standards of Kosovo follow European Union air quality directives.

Air quality standards in Kosovo

Kosovo’s air quality standards are based on the EU’s air quality directives (2008/50/EC Directive on Ambient Air Quality and Cleaner Air for Europe and 2004/107/EC Directive on heavy metals and polycyclic aromatic hydrocarbons in ambient air) and set pollutant concentrations thresholds that shall not be exceeded in a given period of time. The most important standards in Kosovo are summarized in Table 1. These apply over differing periods of time because the observed health impacts associated with the various pollutants occur over different exposure times.  The information regarding the allowable number of days or hours during the year with concentrations over the limit is also included.

Table 1 Kosovo’s air quality standards

Kosovo’s air quality standards based on EU Air Quality Directive
Pollutant Averaging Period Objective and concentration Other information*
PM2.5 Annual 25 µg/m3
PM10 Daily (24-hour mean) 50 µg/m3 Not to exceed more than 35 days per year
Annual 40 µg/m3
SO2 hourly 350 µg/m3 Not to be exceed more than 24 hours per year
Daily (24-hour mean) 125 µg/m3 Not to be exceed more than 3 days per year
NO2 Hourly 200 µg/m3 Not to be exceed more than 18 hours per year
Annual 40 µg/m3

 

The air pollution in the capital city of Pristina competes with the levels of large polluted cities like Beijing, Mumbai, and New Delhi. Especially in the winter, urban areas face severe smog episodes, caused by the increased demand for heat from the residential and commercial sector, which is burning solid fuels. Such levels of air pollution are unsafe for Kosovo’s population of 1.9 million and cause significant deterioration of health impacts. Recent reports indicate that the residential sector is the largest source of exposure to harmful PM2.5 associated with the burning of solid fuels in individual houses. For example, results of the first emission inventory and air quality modeling in Kosovo carried out as a part of the MCC funded project “Supply of project management, air quality information management, behavior change and communication services’’ confirm the major role of domestic heating in high air pollution. Domestic heating has the major – above 85% share in total emission of PM10 and PM2.5 in annual concentrations for most urban areas. Domestic heating contributes to PM10 and PM2.5 concentration at level of 56% and 58% in Pristina[10]. Additional sources of exposure to PM2.5 include energy, industry, agriculture, and others.

[3] Law No. 06/L-035 on Hydrometeorological Activities.

[4] Administrative instruction no. 02/ 2011 on air quality assessment, appendix viii and law on air protection from pollution/ articles 24 and 25.

[5] https://gzk.rks-gov.net/ActsByCategoryInst.aspx?Index=3&InstID=1&CatID=6

[6] https://gzk.rks-gov.net/ActDetail.aspx?ActID=7900

[7] https://gzk.rks-gov.net/ActDocumentDetail.aspx?ActID=10346

[8] https://gzk.rks-gov.net/ActDetail.aspx?ActID=15113

[9] Air Quality in Kosovo: Towards European Standards, Institution of Development Policy, 2019

[10] TASK D3: Model and model outputs – Modeling Methodology and Results

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Air Quality Portal

Air Quality information is a substantial part of the health advisories process.  

Air Quality Portal (AQP) Kosovo is a public service providing near real-time and historic air quality information as well as a 3-day air quality forecast: today, tomorrow and next day. Information visualized on maps powered by Terria Map and hosted by the Kosovo Hydro Meteorological Institute (KHMI) was developed by NIRAS and ATMOTERM in consultation with stakeholders, the Kosovo Ministry of Environment and Spatial Planning (MESP), Kosovo National Institute for Health (NIPH) and the Millennium Foundation Kosovo (MFK). 

One of the main purposes of AQP is to provide answers to citizens: what is the pollution level and how to reduce impact of pollution on citizen’s health. Information about air pollution consists of two elements: current air quality based on measurements in 12 Kosovo official monitoring stations and air quality forecast based on mathematical modeling. 

Measurements presented on the main map of AQP show current air concentrations of the following pollutants: PM10, PM2.5, NO2, SO2, CO, NO, O3 and basic weather conditions in monitoring stations location. This information is calculated into an Air Quality Index (AQI) according to the European Union methodology. AQI reflects the potential impact of air quality on health, driven by the pollutant for which concentrations are highest due to associated health impacts. By clicking on monitoring stations, information on AQI, health advice and pollutant concentrations will appear. The markers are color coded to reflect the AQI level which allows the user to quickly obtain information on the air pollution level. 

Measurement, however accurate, only provides air quality information at the location of the monitoring station. Implementing mathematical air quality modeling enables the calculation of air quality over the entire area of Kosovo and also the calculation of the air quality forecast. Such forecasts are based on weather forecasting and air pollution dispersion models of the atmosphere. The AQP includes forecasts of four pollutants: PM10, PM2.5, NO2 and O3. It uses a Calpuff model for regional and urban scales and the Copernicus Atmosphere Monitoring Service (CAMS ensemble – Eulerian air quality models) for boundary conditions and ozone modeling. Weather Research and Forecasting Model (WRF – meteorological prognostic model) is used for weather forecast calculations. Forecasts can be switched on through the Menu function in the AQP. They are available at two levels: for entire Kosovo and for Pristina with more detailed modeling and higher resolution maps. Forecasts provide an estimate of what air quality will be in the coming hours and days in a selected place, and allow planning activities to reduce exposure to high pollution levels (poor AQI).

AQP functionalities are prepared additionally in the form of a mobile application which makes getting air quality information much easier. 

The smartphone application provides an easy to use solution for iOS and Android platforms to visualize air quality data in a simple graphical format. The dissemination of information by smartphone application is the most effective way to inform citizens “What is the air quality today and in two consecutive days?” and what they should do in case of high pollution levels. The application includes information like health effects for every level of pollution and recommended actions with specific advice for sensitive and vulnerable populations. It provides also values of weather parameters.

The main functionalities of the smartphone application are:

  • Visualization of current AQ Index, pollutant concentrations, values of weather parameters and health recommendations for selected points in Kosovo and for AQ monitoring stations.
  • All data are visualized in hourly resolution and for 3-days forecasts.
  • Displaying a map of Kosovo with marked monitoring stations and pop-up windows with detailed information about the selected station.
  • Storing favorite places in ‘My places’.
  • Adding to ‘My places’ by address, selecting from the monitoring station list, pointing on the map and by current location from GPS.
  • Displaying a list of all monitoring stations with station parameters and details.

 

The AQP may be also used by specialists, scientists, government institutions or universities. The data part of AQP provides reports in excel and graphs which can be very useful for more specific air quality analyses. 

For more information on air quality and the Air Quality Index in Kosovo go to http://ihmk-rks.net/?page=1,5 or visit https://www.facebook.com/ihmk.rks/

KHMI air quality measurements are used in EEA air quality website: https://airindex.eea.europa.eu/Map/AQI/Viewer/

It should be noted that some of the air quality websites available on the internet use different air quality indices (for instance based on USA EPA methodology). Therefore, the air quality index values and health recommendation may differ from those presented in the AQP (which uses European methodology).

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Air emission inventory and air emission modeling for Kosovo

The emission inventory and air quality modeling are very important parts of the air quality management process. The first national air emission inventory of such level of detail and the first national air quality model were prepared as a part of the MCC funded project “Supply of project management, air quality information management, behavior change and communication services. 

The air emission inventory was prepared for the whole of Kosovo. The work was done in cooperation with KEPA and with the use of inputs from a project by Japan International Cooperation Agency (JICA). The base year for the development of emission database data was 2018, the year for which input data (measurements data, statistical data and other) has the best availability. The emission inventory included the following pollutants: PM10, PM2.5, nitrogen oxides (NOx), sulfur dioxide (SO2), carbon monoxide (CO), total non-methane volatile organic compounds (NMVOC), arsenic, cadmium, mercury and lead.

The emission inventory includes the following emission sources:

  • Small combustion – most of emission in the small combustion sector comes from domestic heating. Transport – traffic emission, considering national, regional, county and municipal roads, emissions from vehicle tires and brake wear, road surface wear, and PM resuspension are also included.
  • Industry (point and area sources) – it includes emission from IPPC installations (with integrated environmental permits or applying for IPPC), landfills and quarries.
  • Agriculture (crops and breeding) – emissions from agriculture, areas under cultivation, livestock husbandry and the use of fertilizers and agricultural machinery.

In relation to total emission from all sources (small combustion, transport, industry, agriculture) – small combustion accounts for 69% (PM10) and 84% (PM2.5) of total PM emission, transport (roads) for 12% and 7%, industry (industry and quarries) for 17% and 8% and agriculture for 3% and 1% respectively. Shares of emission from various sectors are different in the case of NO2: small combustion – 5%, transport (roads) – 32%, industry – 56% and agriculture – 9%. 

Sectors contributions to emission of NO2 and PM2.5 are presented in the pie charts below.

Figure 1 Share of individual sectors in PM2.5 and NO2 emissions 

Emission data bases were prepared in Excel files. The structure of the database is presented in Figure 2.

Figure 2  Emission database structure

The air emission inventory is one of the most important input sources for the air quality modeling and air quality forecast presented in the AQP.

The air quality modeling provides information on spatial distribution of air pollution (where the air pollution is the worst or the best), indicates the area with air quality standard exceedances and gives information which emission sources are responsible for high pollution levels.  Air quality modeling for 2018 supports the air quality monitoring system with the spatial distribution of pollution in the area of the country (not only at measurements points). The modeling results confirmed that the greatest problem is particulate matter (PM10 and PM2.5) in urban areas.

According to the modeling results, there are many areas of PM10 and PM2.5 in Kosovo where PM concentrations are above limit values (see Figure 2). Generally, areas of high PM10 and PM2.5 concentrations overlap with location of the main emission sources such as large cities and main roads. The regions with very high PM pollution (exceeding national standards): Pristina region, Prizren region, Mitrovice, Gjilan, Gjakova and Ferizaj region. Exceedances are predicted also in smaller cities. 

Small combustion (domestic heating) has the largest contribution to PM10 and PM2.5 annual concentrations in most of the urban areas. The average share of the small combustion sector in PM10 concentration is about 50% (PM10) and 57% (PM2.5). Domestic heating contributes to PM10 and PM2.5 concentrations at level of 56% and 58% in Pristina.

Exceedances of NO2 annual concentrations are small and concentrated in a few cities like: Pristina, Fushe Kosovo, Obiliq, Ferizaj, Gjilan, Prizren and others. The exceedances are also observed along main roads especially highways and the regional road from Ferizaj via Pristina to Mitrovica. There are no predicted exceedances of NO2 hourly concentrations in the territory of Kosovo. 

In the case of NO2, transport has the largest contribution to the annual concentration for most of the urban areas. The average contribution the of transport sector to NO2 concentrations is about 57% nationally and 61% in Pristina.

There are no predicted exceedances of hourly and daily limits for SO2

Figure 2 present spatial distribution of PM10, PM2.5 and NO2 in Kosovo based on modeling for 2018 year (red colors mean concentrations above limit values).

 

Figure 2  36th the highest daily concentration of PM10 and annual concentration of PM2.5 and NO2 in Kosovo in 2018

 

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Air Quality Index AQI

-The Air Quality Index allows users to understand more about air quality where they live, work or travel. Displaying up-to-date information for Kosovo, users can gain insights into the air quality in regions and cities.

The Index is based on concentration values for up to five key pollutants, including:

  • particulate matter (PM10),
  • fine particulate matter (PM2.5),
  • ozone (O3),
  • nitrogen dioxide (NO2),
  • sulphur dioxide (SO2).

It reflects the potential impact of air quality on health, driven by the pollutant for which concentrations are poorest due to associated health impacts. Concentrations values for up to five key pollutants (PM10, PM2.5, SO2, NO2 and ozone) determine the index level that reflects air quality at each monitoring station. The index corresponds to the poorest level for any of five pollutants, according to the table shown below. For forecast 4 pollutants are used: ozone, nitrogen dioxide, and particulate matter (PM10 and PM2.5).

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AP Health effects

Air pollution has significant health, environmental and economic impacts. The negative impact is especially evident in the health of citizens, especially those living in urban areas and areas near intensive traffic and industrial areas.

Air pollution is recognized as one of the leading contributors to the global environmental burden of diseases. Every year thousands of people are admitted to hospital suffering from the effects of air pollution and some of them die prematurely.

Air pollution affects people on a daily basis but long-term exposure to lower doses poses a greater threat to human health. Depending on the length of time you are exposed, your health status, and the concentration of pollutants, air pollution can have a negative effect on our health.

When microscopic air pollutants enter the body, penetrating deep into the respiratory and circulatory system, they can have effects on various different organs and systems, not just the respiratory system.Microscopic air pollutants interfere negatively in maturation of brain and mental development of children.

Long-term exposure to polluted air could cause serious and permanent health effects such as:

  • Accelerated aging of the lungs;
  • Loss of lung capacity and decreased lung function;
  • Development of diseases such as asthma, bronchitis, emphysema, and possibly lung cancer.
  • Ischemic heart disease and stroke which cause 80 % of premature deaths due to air pollution.

Beware of the symptoms like

  • cough, phlegm, chest tightness, wheezing, shortness of breath
  • chest tightness, chest pain (angina pectoris), palpitations, shortness of breath, unusual fatigue, coronary artery disease, abdominal rhythms, congestive heart failure, stroke

Finally and always important – Visit your family doctor or health clinic if you feel unwell experiencing any adverse effects from air pollution.

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AP Sensitive Groups

Vulnerability exists because of a more than average risk of health effects after exposure (health vulnerability) or because of a more than average risk of relevant information not being received or appreciated (information vulnerability).

Vulnerability exists because of a more than average risk of health effects after exposure (health vulnerability) or because of a more than average risk of relevant information not being received or appreciated (information vulnerability).

The Gender and Social Inclusion Policy of the MCC funded AQ project defines two main sensitive groups among Kosovo population. They include:

Sensitive groups (more sensitive to health effects of air pollution): children, pregnant women, older people, people with existing health problems (primarily existing respiratory and cardiovascular disease).

Sensitive (disadvantaged) groups with a risk of information vulnerability: low income groups experiencing or at risk of experiencing poverty, people living with a disability, women, minority groups: Serbs, Bosnians, Roma, Ashkali and Egyptians.

Regarding health vulnerabilities, there is a strong body of evidence confirming the sensitivity of certain population groups to air pollution exposure:

  • People with, lung disease (COPD, asthma, lung cancer) or heart disease (heart attack, congestive heart failure, coronary artery disease) and diabetes are more sensitive to air pollution.
  • Older people are at higher risk because of weakening of the heart and lungs and an increased likelihood of health problems such as heart attacks, heart failure and stroke, asthma attacks and lung cancer, but also dementia and diabetes.
  • Children are also more vulnerable to air pollution because they have a less-developed respiratory systems. Because of their size, children inhale more air per kilogram of body weight than adults. There is an increasing body of evidence that links air pollution to brain development and learning outcomes among children like psychological and behavioral problems later in childhood including symptoms of attention deficit hyperactivity disorder (ADHD), anxiety, and depression; and a four-point drop in IQ by the age of 5 among a sample of children exposed in utero to toxic air pollution.[13] Furthermore, PM5 exposure during the fifth and sixth years of life affects working memory, with boys showing much higher vulnerability including reduction in conflict network performance, reduction in the working memory and an increase in the conflict attentional network.[14]
  • Pregnant women – exposure to air pollution during pregnancy can increase the risk of miscarriage, premature birth and low birthweight[15]. Premature birth is birth that happens before 37 weeks of pregnancy.
  • People participating in strenuous sports or work outdoors breathe more deeply and rapidly, allowing more air pollution to enter their lungs. They may experience symptoms like eye, nose or throat irritation, coughing or difficulty breathing when air pollution levels are high.
  • Low income socioeconomic groups – are much more affected from air pollution than the wealthier citizens. Main reasons are low standard of heating, housing, indoor pollution and education (poorer families are more dependent on burning wood, coal and kerosene for cooking and heating).
  • Communities in areas of higher pollution, such as close to busy roads or industrial zones are significantly more exposed to the pollutants emitted from various types vehicles on the road.

[13] UNICEF. Danger in the Air. How air pollution may be affecting the brain development of young children around the world. 2017.

[14] Project BREATH 2011/16; Rivas et al., Association between early life exposure to air pollution and working memory and attention. Environmental Health Perspectives. 2019. doi: https://doi.org/10.1289/EHP3169 (accessed October 28, 2020).

[15] UNICEF, Clear the Air for children: The impact of air pollution on children, October 2016. https://www.unicef.org/publications/files/UNICEF_Clear_the_Air_for_Children_30_Oct_2016.pdf (accessed October 28, 2020).

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AP Health Advisories

Health Advisories are defined as public health information to government, health professionals and different population groups regarding health effects of Air Pollution and actions advised to be taken to protect human health as well to reduce air pollution.  Having this in mind the Health Advisories cover the four categories of the air pollution process like emission, concentration, exposure and health effects.

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Health Advisory for Government

Besides running policies and sets of various actions for proper air quality management, the government is the main organization with a responsibility to inform the public on air quality and health effects, and explain the way air pollutants are emitted and the consequences of these actions. The way of informing the public needs to be transparent and open for involvement of civil society, NGOs, media and the public.

Table 2 describes the public health advisories directed at the government of Kosovo (either national or municipal) which must be continuously implemented during the whole year.

Table 2 Health Advisories for Government.

Policies

Improving air quality is not an economic loss, it can rather go hand in hand with economic growth

  1. In the hierarchy of interventions, the priority is preventing, reducing or replacing polluting activities to reduce emissions.
  2. Actions to reduce the concentration of air pollution once it has occurred is the second priority.
  3. Individual avoidance of exposure is the third priority. 

As action is taken some groups may need particular support. Some evidence-based actions may disproportionally affect some groups of people. For example, those whose livelihoods depend on driving services but who do not have access to or the resources for cleaner vehicles, may need particular support because some of the most effective interventions target road vehicle emissions. Without such support, action on air quality may have the adverse impact of increasing inequalities.

There are many policies that the government can apply at the national level. 

A special budget should be allocated for the issue of air pollution at both municipal and government levels, since current budget is insufficient to deal with air pollution. Example of effective measures include:

  • Ban on burning poor quality coal or wood with moisture content above 30%. Introducing fines for breaking the rules.
  • Implementation of local low-stack emission reduction programs such as subsidies for replacement of heating devices based on solid fuels.
  • Inventory of stoves, boilers and fireplaces prior to starting a program for replacing solid fuel heating devices.
  • Replacement of heating systems based on solid fuel by connection to the municipal heating system, gas, electric heating, oil heating, heat pump.
  • Expansion and modernization of municipal heating networks and gas distribution networks to connect new users.
  • Thermo-modernization of buildings and support of energy efficient buildings in housing and public utilities.
  • Subsidies for the energy bills of low income residents who incur increased heating costs after replacement of solid fuel burning stoves.
  • Reduction of emissions from transport (ban on import of old second hand cars, tax on diesel, bypass roads of cities, improved public transportation, bicycle lanes etc.).
  • Environmental education and changing behavior campaign for residents: public service announcements on TV or radio, public events, leaflets, posters, play-based behavior change campaigns targeting school age children.
  • Distribution of trees and plants along the city streets.
  • Require predictive health impact assessments of policies, plans and programs with the potential to generate health effects, including those which may affect air quality.
  • Establish continuous assessment of the effectiveness of public health interventions.
  • Better inform the public.

Emissions

Main areas for potential actions and interventions to reduce the impact of air pollution are:

  • Domestic heating 
  • Vehicles and fuels 
  • Spatial planning – more green surfaces in the cities Industry (energy power etc.)
  • Agriculture 
  • Promote behavioral change and healthy lifestyle approach – walking, using bicycles, ban on smoking inside restaurants and on the street.

Concentration

  • Maintain AQ monitoring system.
  • Inform the public through AQ portals hosted by  KHMI.

Exposure

  • Avoid planning and building kindergartens, schools, play-grounds, prenatal and postnatal care facilities, hospitals, elderly care facilities, etc. in heavily polluted zones, using the outputs of air quality modelling to inform land-use planning.
  • Inform and advise the public.
  • Maintain an unique environment and health information system (database) which will include basic environmental, health (e.g. conditions, hospital admissions) and mortality data, enabling the assessment of the air pollution health risks to the population.

Effects

  • Educate, prepare and support the Healthcare system.
  • Support Health Impact Assessment studies.
  • Inform and advise the public regarding the assessed health risks and the measures to be taken in order to prevent or minimize them.
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Health Advisory for General Population

Although the general population is not considered as a sensitive group, they will suffer from health effects related to the exposure to air pollution when the exposure is over a long time (many years) or when the exposure levels are high. In the end, the general population will suffer as well although not so severely as vulnerable people.

Advisories issued to the population could be a mixture of health and behavior change actions and measures (HA) (Table 3 and Annex 1).

Table 3 Health Advisory for General Population.

Emission (BC)

  • Public transport to be used more regularly, and the private cars only when is necessary.
  • Prefer eco-traveling. Eco-friendly vehicle is a road motor vehicle that produces less harmful impacts to the environment than comparable conventional internal combustion engine vehicles running on gasoline or diesel, or one that uses certain alternative fuels.
  • Lower temperatures in houses and reduce solid fuel use for cooking to reduce emissions.
  • Do not burn waste, dispose of through regulated waste collection services or at official disposal sites
  • Try not to smoke indoors especially close to the children, pregnant women and older people to avoid indoor pollution health effects.

Concentration (BC)

  • Be aware where and when the AQI is poor, very poor or extremely poor

Exposure (BC)

  • Manage indoor air quality* 
  • Check the daily AQI in your area on niph-rks.org and https://airqualitykosova.rks-gov.net/en/ or visit Facebook/IKSHPK.
  • Avoid intensive activities at locations in spaces with high level of air pollution- find alternatives as physical activity is important for your health. 
  • Avoid busy roads and highways where PM levels may be higher due to emissions from cars and trucks.
  • Stay at home when PM concentration outside is very poor or extremely poor.
  • Spend time outside when and where air quality is good.

Effects (HA)

  • Improve & maintain good health.
  • Strengthen immune system.
  • Maintain a healthy diet with a lot of fruit and vegetables.
  • Consult your doctor or NIPH for use of supplements (Vitamin E, C, A and B).
  • Visit your family doctor or health clinic if you feel unwell or are experiencing any adverse effects from air pollution.

* Do not let people smoke indoors; avoid using anything that burns, such as coal, wood burning stoves, kerosene, etc..; use fuel efficient stoves and vent exhaust outdoors if must use solid fuels for heating or cooking; keep all areas clean and dry. Clean up any mold and remove excess moisture. Always ventilate when using products that can release pollutants into the air; if products must be stored following use, make sure to close them tightly. Inspect fuel-burning appliances regularly for leaks, and make repairs when necessary; consider installing a carbon monoxide alarm.[16]

Masks or particulate respirators may help in special circumstances if you have to be outside whilst pollution levels are high although scientific evidence is limited on their effectiveness against air pollution. Masks need to be of a special type and require special fitting. Masks should be disposable, regularly changed and have a rating of at least N-95 meaning that the mask is adequate for filtering out 95% of PM2.5 particles. Masks should provide a tight seal around the wearer’s mouth and nose. This may be particularly difficult for children. Paper or cloth “comfort” or “dust” masks offer little protection from fine particles[17].

[16] EPA, Care for your air: A Guide to indoor air quality, September, 2008.  (PDF). https://www.epa.gov/sites/production/files/2014-08/documents/careforyourair.pdf (accessed October 28, 2020).

[17]  WHO International South East-Asia Region, Health Topics Air Pollution, 11 November, 2019. https://www.who.int/docs/default-source/searo/wsh-och-searo/preventing-the-harmful-effects-of-air-pollution2019.pdf?sfvrsn=79c97dcd_2 (accessed October 28, 2020).

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Health Advisory for Children and Pregnant Women

Children are likely to experience increased risk for several reasons. Their lungs are still developing, they spend more time at high activity levels, and they are more likely to have asthma or acute respiratory diseases, which can be aggravated when PM levels are high.

Exposure to air pollution during pregnancy can increase the risk of miscarriage, premature birth and low birthweight. Premature birth is birth that happens before 37 weeks of pregnancy.

Table 4 Health Advisory for Children and Pregnant women 

Emission

  • See advice for General Population

Concentrations

  • See advice for General Population

Exposure

  • Select route to and from school to avoid high levels of pollution.
  • Tell parents to protect ‘us’ from exposure to air pollution.
  • If you must go out when the AQI is poor or worse, it is recommended that a suitable mask is worn if available.
  • See advice for General Population

Effects

  • See advice for General Population
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Health Advisory for Elderly People

As people age, their bodies are less able to compensate the effects of Air Pollution. Elderly people are expected to have an immune system with a lower protective status. They need to avoid exposure and ensure optimal health conditions (food and supplements, vaccination, etc.). Older adults are at increased risks from air pollution probably because they may have undiagnosed heart or lung disease or diabetes. Many studies show that when particle levels are high, older adults are more likely to be hospitalized. They are best kept away from emissions and stay at home in cleaner air (Table 5).

Table 5 Health Advisory for Older People

Emission

  • See advice for General Population

Concentration

  • See advice for General Population

Exposure

  • See advice for General Population
  • If you must go out when the AQI is poor, it is recommended that a suitable mask is used.

Effects

  • See advice for General Population.
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Health Advisory for people with chronic diseases

Air pollution can aggravate heart disease and cause stroke, lung diseases such as chronic obstructive pulmonary disease or asthma, and diabetes. This leads to increased medication use, more visits to health care providers, admissions to emergency rooms and hospitals, and even death.

People with a compromised health status would be affected more than general population by exposure to air pollution and should protect themselves and be assisted in doing that by proper food and additives, and possible vaccination against flu.

Medical studies show that air pollution can trigger heart attacks, stroke, and irregular heart rhythms—especially in people who are already at risk of these conditions. Also, for people with heart conditions, air pollution can further reduce the ability of the heart to properly pump blood. Very small particles are the pollutants are of the greatest concern for triggering these effects. 

When ozone and particle pollution are in the air, adults and children with asthma are more likely to have poor health symptoms. Two key air pollutants which can affect asthma are particle pollution (found in haze, smoke, and dust), and ozone (found in smog). Air pollution can make it harder to breathe. It can also cause other symptoms, like coughing, wheezing, chest discomfort, and a burning feeling in the lungs. People with diabetes may also be at increased risks, possibly because they are more likely to have underlying cardiovascular disease (Table 6).

Table 6 Health Advisory for people with chronic disease 

Emission

  • See advice for general population

Concentration

  • See advice for general population

Exposure

  • See advice for general population
  • Check the daily AQI in your area on niph-rks.org and https://airqualitykosova.rks-gov.net/en/ or visit Facebook/IKSHPK levels.
  • Know when and where particle pollution may be unhealthy and plan your activities accordingly.
  • Avoid (intensive) activities at locations in spaces with high levels of air pollution – find alternatives (physical activity is important for your health). 
  • Choose easier outdoor activities (like walking instead of running) so you don’t breathe as deeply.
  • Stay at home when AQI is poor, very poor or extremely poor.
  • Spend time outside when and when AQI is good. 
  • If you must go out when the AQI is poor, it is recommended that a suitable mask is used.

Effects

  • See advice for general population.
  • Get to know how sensitive you are to air pollution – consult your physician.
  • Know the warning signs of asthma, heart attack and stroke – consult your health care provider.
  • People with asthma may find that they need to use their inhaler more often.
  • Keep your quick relief medicine on hand when you are active outdoors.
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Health Advisory for Health Professionals

Public health and health care professionals have a vital role in supporting communities, families, and individuals to act against the health impacts of poor air quality. Many of the individuals suffering from air pollution have existing health conditions, which can be exacerbated by poor air quality. Therefore, it is important that health care professionals are equipped to provide support and advice to reduce exposure and offer measures to be taken to reduce any avoidable risks (Table 7). Other public health teams can also influence the general population by providing whole system approaches. This is crucial to reduce the health impacts associated with air pollution to help people live longer and healthier lives.

An easy way physicians and other health professionals can help reduce risk from exposure is through patient education. The simple steps of advising patients to check the air quality daily, and informing them of ways to minimize exposure to particle pollution, can help reduce overall risk of particle pollution-related health effects, particularly in individuals with heart and lung disease. Note that this patient education is consistent with the recommendations of public health and health experts (consult with NIPH).

Table 7 Health Advisories for Health Professionals

Exposure

  • Patient education – let patients know when it’s a good idea to switch up outdoor activities to reduce the amount of pollution exposure.

Effects

Improve your knowledge in order to give relevant medical advice to:

  • Explain what air pollutants/size particles are, what the greatest health concern are, and where and when they are a problem.
  • Identify how particle pollution exposure affects the cardiovascular and respiratory systems.
  • Identify how particle pollution exposure can affect the general population.
  • Recognize population (patients) at risk from air pollution (children, pregnant women, elderly, children and adult asthma, COPD, heart disease and stroke, diabetes).
  • Explain the purpose and use of the AQI for advising patients on how to protect their health.
  • Discuss methods to reduce exposure during poor, very poor and extremely poor level of AQI and advise what they should do, how to react and stay calm
  • Address typical patient questions and clinical scenarios relating to particle pollution exposure.
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NIPH work in AQ and health impact assessment in Kosovo

Air pollution in Kosovo and in particular in Pristina forms a stressor for public health in particular for vulnerable groups. The Kosovo National Institute of Public Health (NIPH) is responsible for informing and advising the general public on health issues in particular who and how to protect themselves and the ones they are responsible for against the harmful health effects associated with exposure to air pollutants.

A recent report by the World Bank for Kosovo, estimates that about 760 people die prematurely every year in Kosovo because of exposure to Outdoor Air Pollution. Of the total number of deaths attributable to air pollution, 90 percent are from Ischemic heart diseases (IHD) and stroke combined. About 53 percent of IHD and 63 percent of strokes occur in people of productive age before attaining the age of 70. Population age groups between 50 and 69 years old carry the largest share (about 45 percent) of the total health burden associated with exposure to AAP, followed by people over 70 years of age[18].

The results of the study conducted by NIPH  scientists in the period 2010-2012, showed a consistent positive association between particulate air pollution and hospital admissions for respiratory and cardiovascular diseases across all ages and diagnosis in Kosovo. The relative risk for hospitalization in both genders was 8.2 times higher after 55 years of age. From a total number of cases 54.6% were diagnosed with IHD. Incidence of cardiovascular hospital admission was higher in males than in females. Similarly, the hospital admission during the air pollution episodes was increased for the children patients in the Pristina Pediatric Clinic[19]

 

[18] World Bank (2019) Western Balkans – Air Quality Management in Kosovo.

[19] Dervisaj A. Acute effects of air pollution with particulate matters on respiratory and cardiovascular hospital admissions in Pristina – Doctoral thesis – University “Ss Cyril and Methodius” Skopje, July, 2015

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Acronyms

  • AAP- Ambient Air Pollution
  • AP- Air Pollution
  • AQ- Air Quality
  • AQI- Air Quality Index
  • AQHI- Air Quality Health Index
  • AQP- Air Quality Portal
  • BC- Behavior Change
  • CAMS- Copernicus Atmosphere Monitoring Service (European air quality models)
  • CO- Carbon monoxide
  • CSOs- Civil Society Organizations
  • COPD- Chronic Obstructive Pulmonary Disease
  • EH- Environment and Health
  • EHE- Environment and Health Expert
  • GSI- Gender and Social Inclusion
  • HA- Health Advisories
  • HIA- Health Impact Assessment
  • IHD- Ischemic Heart Diseases
  • KHMI- Kosovo Hydro Meteorological Institute
  • MCC- Millennium Challenge Corporation
  • MESP- Kosovo Ministry of Environment and Spatial Planning
  • MFK- Millennium Foundation Kosovo
  • NGOs- Non-Governmental Organizations
  • O3- Ozone
  • NIPH- National Institute of Public Health
  • NO2- Nitrogen dioxide
  • O&BC- Outreach & Behavior Change
  • PM- Particulate Matter
  • SO2- Sulphur dioxide
  • VOCs- Volatile Organic Compounds
  • WHO- World Health Organization
  • WRF- Weather Research and Forecasting Model (meteorological prognostic model)

Good air quality is a requirement for preserving
the exquisite balance of life on earth for humans,
plants, animals and natural resources.

AQI and Health Advisory – Summary Table

Summary table for the Health Advisories to the general population and sensitive groups linked with the Air Quality Index information*

Air Quality Index General population Sensitive populations**

Good

 

The air quality is good. Enjoy your usual outdoor activities.

 

The air quality is good. Enjoy your usual outdoor activities.
Fair Enjoy your usual outdoor activities. Enjoy your usual outdoor activities.
Moderate No need to modify your usual outdoor activities unless you experience symptoms such as coughing and throat irritation Stay at home if you do not need to go out. Adults and children with lung problems, and adults with heart problems, who experience symptoms, should consider reducing strenuous physical activity, particularly outdoors. If you have to go out wear masks with proven efficiency***. Strengthen immune system. Have healthy food with a lot of fruit and vegetables. Consult your physician. Visit your family doctor or health clinic if you feel unwell or are experiencing any adverse effects from air pollution.
Poor Anyone experiencing discomfort such as sore eyes, cough or sore throat should consider reducing activity, particularly outdoors. Strengthen immune system. Have healthy food with a lot of fruit and vegetables. Visit your family doctor or health clinic if you feel unwell experiencing any adverse effects from air pollution. Stay at home if you do not need to go out. Adults and children with lung problems, and adults with heart problems, should reduce strenuous physical activity, particularly outdoors, and particularly if they experience symptoms. Pregnant women should stay indoors. People with asthma may find they need to use their inhaler more often. Older people should also reduce physical exertion. If you have to go out wear masks with proven efficiency***. Strengthen immune system. Have healthy food with a lot of fruit and vegetables. Consult your physician. Visit your family doctor or health clinic if you feel unwell or are experiencing any adverse effects from air pollution.
Very poor Stay at home or reduce physical exertion, particularly outdoors, especially if you experience symptoms such as cough or sore throat. Strengthen immune system. Have healthy food with a lot of fruit and vegetables. Visit your family doctor or health clinic if you feel unwell experiencing any adverse effects from air pollution.

 

Stay at home if you do not need to go out. Adults and children with lung problems, adults with heart problems, and older people, should avoid strenuous physical activity. Pregnant women should stay indoors.  People with asthma may find they need to use their inhaler more often. If you have to go out wear masks with proven efficiency***. Strengthen immune system. Have healthy food with a lot of fruit and vegetables. Consult your physician. Visit your family doctor or health clinic if you feel unwell or are experiencing any adverse effects from air pollution.
Extremely poor Stay at home or reduce physical exertion, particularly outdoors, especially if you experience symptoms such as cough or sore throat. Strengthen immune system. Have healthy food with a lot of fruit and vegetables. Visit your family doctor or health clinic if you feel unwell experiencing any adverse effects from air pollution. Stay at home if you do not need to go out. Adults and children with lung problems, adults with heart problems, and older people, should avoid strenuous physical activity. Pregnant women should stay at home. People with asthma may find they need to use their inhaler more often. If you have to go out wear masks with proven efficiency***. Strengthen immune system. Have healthy food with a lot of fruit and vegetables Consult your physician. Visit your family doctor or health clinic if you feel unwell or are experiencing any adverse effects from air pollution. .

*    For more information, go to Health Advisories (https://www.niph.org)

** Adults and children with respiratory problems, adults with heart conditions, pregnant women, elderly and other sensitive groups (see details on Health Advisories on ajri.niph-rks.org or facebook/IKSHP.

*** Masks or particulate respirators may help in special circumstances if you have to be outside whilst pollution levels are high although scientific evidence is limited on their effectiveness against air pollution. Masks need to be of a special type and require special fitting. Masks should be disposable, regularly changed and have a rating of at least N-95 meaning that the mask is adequate for filtering out 95% of PM2.5 particles. Masks should provide a tight seal around the wearer’s mouth and nose. This may be particularly difficult for children. Paper or cloth “comfort” or “dust” masks offer little protection from fine particles17.

 

Publications

Animated video-1

Poster

Fact sheet for pregnant women

Fact sheet for people with chronic diseases and the elderly

Fact sheet for children

Brochure

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