Review of the Primary National Ambient Air Quality Standards for Sulfur Oxides

Federal RegisterJun 8, 2018

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ENVIRONMENTAL PROTECTION AGENCY

40 CFR Part 50

[EPA-HQ-OAR-2013-0566; FRL-9979-00-OAR]

RIN 2060-AT68

Review of the Primary National Ambient Air Quality Standards for Sulfur Oxides

AGENCY:

Environmental Protection Agency (EPA).

ACTION:

Proposed action.

SUMMARY:

Based on the Environmental Protection Agency's (EPA's) review of the air quality criteria addressing human health effects and the primary national ambient air quality standard (NAAQS) for sulfur oxides (SO

), the EPA is proposing to retain the current standard, without revision.

DATES:

Comments must be received on or before July 23, 2018.

If, by June 15, 2018, the EPA receives a request from a member of the public to speak at a public hearing concerning the proposed decision (see

SUPPLEMENTARY INFORMATION

below), we will hold a public hearing, with information about the hearing provided in a subsequent notice in the

Federal Register

ADDRESSES:

You may submit comments, identified by Docket ID No. EPA-HQ-OAR-2013-0566, to the Federal eRulemaking Portal:

http://www.regulations.gov.

Instructions:

Follow the online instructions for submitting comments. Once submitted to the Federal eRulemaking Portal, comments cannot be edited or withdrawn. The EPA may publish any comment received to its public docket. Do not submit electronically any information you consider to be Confidential Business Information (CBI) or other information whose disclosure is restricted by statute. Multimedia submissions (audio, video, etc.) must be accompanied by a written comment. The written comment is considered the official comment and should include discussion of all points you wish to make. The EPA will generally not consider comments or comment contents located outside of the primary submission (

i.e.,

on the web, the cloud, or other file sharing system). For additional submission methods, the full EPA public comment policy, information about CBI or multimedia submissions, and general guidance on making effective comments, please visit

http://www2.epa.gov/dockets/commenting-epa-dockets.

If a public hearing is to be held on this proposed action (see

SUPPLEMENTARY INFORMATION

below), in addition to publishing a

Federal Register

notice, the EPA will post information regarding it, including date and time, online at

https://www.epa.gov/so2-pollution/primary-national-ambient-air-quality-standard-naaqs-sulfur-dioxide.

Docket:

All documents in the dockets pertaining to this action are listed on the

www.regulations.gov

website. This includes documents in the docket for the proposed decision (Docket ID No. EPA-HQ-OAR-2013-0566) and a separate docket, established for the Integrated Science Assessment (ISA) for this review (Docket ID No. EPA-HQ-ORD-2013-0357) that has been incorporated by reference into the docket for this proposed decision. Although listed in the index, some information is not publicly available,

e.g.,

CBI or other information whose disclosure is restricted by statute. Certain other material, such as copyrighted material, is not placed on the internet and may be viewed, with prior arrangement, at the EPA Docket Center. Publicly available docket materials are available either electronically in

www.regulations.gov

or in hard copy at the Air and Radiation Docket Information Center, EPA/DC, WJC West Building, Room 3334, 1301 Constitution Ave. NW, Washington, DC. The Public Reading Room is open from 8:30 a.m. to 4:30 p.m., Monday through Friday, excluding legal holidays. The telephone number for the Public Reading Room is (202) 566-1744 and the telephone number for the Air and Radiation Docket Information Center is (202) 566-1742.

FOR FURTHER INFORMATION CONTACT:

Dr. Nicole Hagan, Health and Environmental Impacts Division, Office of Air Quality Planning and Standards, U.S. Environmental Protection Agency, Mail Code C504-06, Research Triangle Park, NC 27711; telephone: (919) 541-3153; fax: (919) 541-0237; email:

hagan.nicole@epa.gov.

SUPPLEMENTARY INFORMATION:

General Information

Preparing Comments for the EPA

1. Submitting CBI

Do not submit this information to the EPA through

www.regulations.gov

or email. Clearly mark the part or all of the information that you claim to be CBI. For CBI information in a disk or CD-ROM that you mail to the EPA, mark the outside of the disk or CD-ROM as CBI and then identify electronically within the disk or CD-ROM the specific information that is claimed as CBI. In addition to one complete version of the comment that includes information claimed as CBI, a copy of the comment that does not contain the information claimed as CBI must be submitted for inclusion in the public docket. Information so marked will not be disclosed except in accordance with procedures set forth in 40 Code of Federal Regulations (CFR) part 2.

2. Tips for Preparing Your Comments

When submitting comments, remember to:

• Identify the action by docket number and other identifying information (subject heading,

Federal Register

date and page number).

• Follow directions—the agency may ask you to respond to specific questions or organize comments by referencing a CFR part or section number.

• Explain why you agree or disagree, suggest alternatives, and substitute language for your requested changes.

• Describe any assumptions and provide any technical information and/or data that you used.

• Provide specific examples to illustrate your concerns, and suggest alternatives.

• Explain your views as clearly as possible, avoiding the use of profanity or personal threats.

• Make sure to submit your comments by the comment period deadline identified.

Public Hearing:

If, by June 15, 2018, the EPA receives a request from a member of the public to speak at a public hearing concerning the proposed decision, we will hold a public hearing, with information about the hearing provided in a subsequent notice in the

Federal Register

. To request a hearing, to register to speak at a hearing or to inquire if a hearing will be held, please contact Ms. Regina Chappell at (919) 541-3650 or by email at

chappell.regina@epa.gov.

If a public hearing is to be held on this proposed action, the EPA will also post information regarding it, including, date and time, online at

https://www.epa.gov/so2-pollution/primary-national-ambient-air-quality-standard-naaqs-sulfur-dioxide.

Availability of Information Related to This Action

A number of the documents that are relevant to this proposed decision are available through the EPA's website at

https://www.epa.gov/naaqs/sulfur-dioxide-so2-primary-air-quality-standards.

These documents include the Integrated Review Plan for the Primary

National Ambient Air Quality Standard for Sulfur Dioxide (U.S. EPA, 2014a), available at

https://www3.epa.gov/ttn/naaqs/standards/so2/data/20141028so2reviewplan.pdf,

the Integrated Science Assessment for Sulfur Oxides—Health Criteria (U.S. EPA, 2017a), available at

https://cfpub.epa.gov/ncea/isa/recordisplay.cfm?deid=338596,

the Risk and Exposure Assessment for the Review of the National Ambient Air Quality Standard for Sulfur Oxides (U.S. EPA, 2018a), available at

https://www.epa.gov/naaqs/sulfur-dioxide-so2-standards-risk-and-exposure-assessments-current-review

and the Policy Assessment for the Review of the Primary National Ambient Air Quality Standard for Sulfur Oxides (U.S. EPA, 2018b), available at

https://www.epa.gov/naaqs/sulfur-dioxide-so2-standards-policy-assessments-current-review.

These and other related documents are also available for inspection and copying in the EPA docket identified above.

Table of Contents

The following topics are discussed in this preamble:

Executive Summary

I. Background

A. Legislative Requirements

B. Related SO

Control Programs

C. Review of the Air Quality Criteria and Standard for Sulfur Oxides

D. Air Quality Information

1. Sources and Emissions of Sulfur Oxides

2. Ambient Concentrations

II. Rationale for Proposed Decision

A. General Approach

1. Approach in the Last Review

2. Approach for the Current Review

B. Health Effects Information

1. Nature of Effects

2. At-Risk Populations

3. Exposure Concentrations Associated With Health Effects

4. Potential Impacts on Public Health

C. Summary of Risk and Exposure Information

1. Key Design Aspects

2. Key Limitations and Uncertainties

3. Summary of Exposure and Risk Estimates

D. Proposed Conclusions on the Current Standard

1. Evidence- and Exposure and Risk-Based Considerations in the Policy Assessment

2. CASAC Advice

3. Administrator's Proposed Conclusions on the Current Standard

III. Statutory and Executive Order Reviews

A. Executive Order 12866: Regulatory Planning and Review and Executive Order 13563: Improving Regulation and Regulatory Review

B. Executive Order 13771: Reducing Regulations and Controlling Regulatory Costs

C. Paperwork Reduction Act (PRA)

D. Regulatory Flexibility Act (RFA)

E. Unfunded Mandates Reform Act (UMRA)

F. Executive Order 13132: Federalism

G. Executive Order 13175: Consultation and Coordination with Indian Tribal Governments

H. Executive Order 13045: Protection of Children From Environmental Health and Safety Risks

I. Executive Order 13211: Actions that Significantly Affect Energy Supply, Distribution or Use

J. National Technology Transfer and Advancement Act

K. Executive Order 12898: Federal Actions To Address Environmental Justice in Minority Populations and Low-Income Populations

L. Determination Under Section 307(d)

References

Executive Summary

This document presents the Administrator's proposed decision in the current review of the primary (health-based) NAAQS for SO

, a group of closely related gaseous compounds that include sulfur dioxide (SO

). Of these compounds, SO

(the indicator for the current standard) is the most prevalent in the atmosphere and the one for which there is a large body of scientific evidence on health effects. The current primary standard is set at a level of 75 ppb, as the 99th percentile of daily maximum 1-hour SO

concentrations, averaged over 3 years. This document summarizes the background and rationale for the Administrator's proposed decision to retain the current standard, without revision, and solicits comment on this proposed decision and on the array of issues associated with review of this standard, including public health and science policy judgments inherent in the proposed decision. The EPA solicits comment on the four basic elements of the current NAAQS (indicator, averaging time, level, and form), including whether there are appropriate alternative approaches for the averaging time or statistical form that provide comparable public health protection, and the rationale upon which such views are based.

This review of the primary SO

standard is required by the Clean Air Act (CAA) on a periodic basis. The schedule for completing this review is established by a consent decree, which established May 25, 2018 as the deadline for signature of a notice setting forth the proposed decision in this review and January 28, 2019 as the deadline for signature on a final decision notice.

The last review of the primary SO

NAAQS was completed in 2010 (75 FR 35520, June 22, 2010). In that review, the EPA significantly strengthened the primary standard, establishing a 1-hour standard and revoking the 24-hour and annual standards. The 1-hour standard was established to provide protection from respiratory effects associated with exposures as short as a few minutes based on evidence from health studies that documented respiratory effects in people with asthma exposed to SO

for 5 to 10 minutes while breathing at elevated rates. Revisions to the NAAQS were accompanied by revisions to the ambient air monitoring and reporting regulations, requiring the reporting of hourly maximum 5-minute SO

concentrations, in addition to the hourly concentrations.

Emissions of SO

and associated concentrations in ambient air have declined appreciably since 2010 and over the longer term. For example, emissions nationally are estimated to have declined by 82% over the period from 2000 to 2016, with a 64% decline from 2010 to 2016 (PA, Figure 2-2; 2014 NEI). Such declines in SO

emissions are likely related to the implementation of national control programs developed under the Clean Air Act Amendments of 1990, as well as changes in market conditions,

e.g.,

reduction in energy generation by coal (PA, section 2.1, Figure 2-2; U.S. EIA, 2017). One-hour concentrations of SO

in ambient air the U.S. declined more than 82% from 1980 to 2016 at locations continuously monitored over this period (PA, Figure 2-4). The decline since 2000 has been 69% at a larger number of locations continuously monitored since that time (PA, Figure 2-5). Daily maximum 5-minute concentrations have also consistently declined from 2011 to 2016 (PA, Figure 2-6).

In this review, as in past reviews of the primary NAAQS for SO

, the health effects evidence evaluated in the ISA is focused on SO

. The health effects of particulate atmospheric transformation products of SO

, such as sulfates, are addressed in the review of the NAAQS for particulate matter (PM). Additionally, the welfare effects of sulfur oxides and the ecological effects of particulate atmospheric transformation products are being considered in the review of the secondary NAAQS for oxides of nitrogen, oxides of sulfur, and PM, while the visibility, climate, and materials damage-related welfare effects of particulate sulfur compounds are being evaluated in the review of the secondary NAAQS for PM.

The proposed decision to retain the current primary NAAQS for SO

, without revision, has been informed by careful consideration of the key aspects

of the currently available health effects evidence and conclusions contained in the ISA, quantitative risk and exposure information presented in the REA, considerations of this evidence and information discussed in the Policy Assessment, advice from the Clean Air Scientific Advisory Committee (CASAC), and public input received as part of the ongoing review of the primary NAAQS for SO

The health effects evidence newly available in this review, as critically assessed in the ISA in conjunction with the full body of evidence, reaffirms the conclusions from the last review. The health effects evidence continues to support the conclusion that respiratory effects are causally related to short-term SO

exposures, including effects related to asthma exacerbation in people with asthma, particularly children with asthma. The clearest evidence for this conclusion comes from controlled human exposure studies, available at the time of the last review, that show that people with asthma experience respiratory effects following very short (

e.g.,

5-10 minute) exposures to SO

while breathing at elevated rates. Epidemiologic evidence, including studies not available in the last review, also supports this conclusion, primarily due to studies reporting positive associations between ambient air concentrations and emergency department visits and hospital admissions, specifically for children.

The quantitative analyses of population exposure and risk also inform the proposed decision. These analyses expand and improve upon the quantitative analyses available in the last review. Unlike the REA available in the last review, which analyzed single-year air quality scenarios for potential standard levels bracketing the now current level, the current REA assesses an air quality scenario for three years of air quality conditions that just meet the now-current standard, considering all of its elements, including its 3-year form. Other ways in which the current REA analyses are improved and expanded include improvements to models, model inputs and underlying databases, including the vastly expanded ambient air monitoring dataset for 5-minute concentrations, available as a result of changes in the last review to data reporting requirements.

Based on this evidence and quantitative information, as well as CASAC advice and public comment thus far in this review, the Administrator proposes to conclude that the current primary SO

standard is requisite to protect public health, with an adequate margin of safety, from effects of SO

in ambient air and should be retained, without revision. These proposed conclusions are consistent with CASAC recommendations. In its advice to the Administrator, the CASAC concurred with the preliminary conclusions in the draft PA that “the current scientific literature does not support revision of the primary NAAQS for SO

” (Cox and Diez Roux, 2018b, p. 1 of letter). The CASAC further stated that it “supports retaining the current standard, and specifically recommends that all four elements (indicator, averaging time, form, and level) should remain the same” (Cox and Diez Roux, 2018b, p. 1 of letter). The Administrator solicits comment on the proposed conclusion that the current standard is requisite to protect public health, with an adequate margin of safety, and on the proposed decision to retain the standard, without revision. The Administrator also solicits comment on the array of issues associated with review of this standard, including public health and science policy judgments inherent in the proposed decision, as discussed in detail in section II below. The EPA solicits comment on the four basic elements of the current NAAQS (indicator, averaging time, level, and form), including whether there are appropriate alternative approaches for the averaging time or statistical form that provide comparable public health protection, and the rationale upon which such views are based.

I. Background

This review focuses on the presence in ambient air of SO

, a group of closely related gaseous compounds that includes SO

and sulfur trioxide and of which SO

(the indicator for the current standard) is the most prevalent in the atmosphere and the one for which there is a large body of scientific evidence on health effects. The health effects of particulate atmospheric transformation products of SO

, such as sulfates, are addressed in the review of the NAAQS for PM (U.S. EPA 2014a, 2016a). Additionally, the ecological welfare effects of sulfur oxides and particulate atmospheric transformation products are being considered in the review of the secondary NAAQS for oxides of nitrogen, oxides of sulfur, and PM (U.S. EPA, 2014a, 2017b), while the visibility, climate, and materials damage-related welfare effects of particulate sulfur compounds are being evaluated in the review of the secondary NAAQS for PM.

Additional information on the review of secondary NAAQS for oxides of nitrogen, oxides of sulfur, and PM with regard to ecological welfare effects is available at:

https://www.epa.gov/naaqs/nitrogen-dioxide-no2-and-sulfur-dioxide-so2-secondary-air-quality-standards.

Additional information on the review of the PM NAAQS is available at:

https://www.epa.gov/naaqs/particulate-matter-pm-air-quality-standards.

A. Legislative Requirements

Two sections of the Clean Air Act (CAA or the Act) govern the establishment and revision of the NAAQS. Section 108 (42 U.S.C. 7408) directs the Administrator to identify and list certain air pollutants and then to issue air quality criteria for those pollutants. The Administrator is to list those air pollutants that in his “judgment, cause or contribute to air pollution which may reasonably be anticipated to endanger public health or welfare;” “the presence of which in the ambient air results from numerous or diverse mobile or stationary sources;” and “for which . . . [the Administrator] plans to issue air quality criteria . . . .” Air quality criteria are intended to “accurately reflect the latest scientific knowledge useful in indicating the kind and extent of all identifiable effects on public health or welfare which may be expected from the presence of [a] pollutant in the ambient air . . . .” 42 U.S.C. 7408(b). Section 109 (42 U.S.C. 7409) directs the Administrator to propose and promulgate “primary” and “secondary” NAAQS for pollutants for which air quality criteria are issued. Section 109(b)(1) defines a primary standard as one “the attainment and maintenance of which in the judgment of the Administrator, based on such criteria and allowing an adequate margin of safety, [is] requisite to protect the public health.”

A secondary standard, as defined in section 109(b)(2), must “specify a level of air quality the attainment and maintenance of which, in the judgment of the Administrator, based on such criteria, is requisite to protect the public welfare from any known or anticipated adverse effects associated with the presence of [the] pollutant in the ambient air.”

The legislative history of section 109 indicates that a primary standard is to be set at “the maximum permissible ambient air level . . . which will protect the health of any [sensitive] group of the population,” and that for this purpose “reference should be made to a representative sample of persons comprising the sensitive group rather than to a single person in such a group.”

See

S. Rep. No. 91-1196, 91st Cong., 2d Sess. 10 (1970).

See also Lead Industries Association

EPA,

647 F.2d 1130, 1152 (D.C. Cir 1980);

American Lung Association

EPA,

134 F.3d 388, 389 (D.C. Cir. 1998) (“NAAQS must protect not only average healthy individuals, but also `sensitive citizens'—children, for example, or people with asthma, emphysema, or other conditions rendering them particularly vulnerable to air pollution.”).

As specified in section 302(h) (42 U.S.C. 7602(h)) effects on welfare include, but are not

limited to, “effects on soils, water, crops, vegetation, man-made materials, animals, wildlife, weather, visibility, and climate, damage to and deterioration of property, and hazards to transportation, as well as effects on economic values and on personal comfort and well-being.”

The requirement that primary standards provide an adequate margin of safety was intended to address uncertainties associated with inconclusive scientific and technical information available at the time of standard setting. It was also intended to provide a reasonable degree of protection against hazards that research has not yet identified.

See Lead Industries Association

EPA,

647 F.2d 1130, 1154 (D.C. Cir, 1980);

American Petroleum Institute

Costle,

665 F.2d 1176, 1186 (D.C. Cir. 1981);

American Farm Bureau Federation

EPA,

559 F.3d 512, 533 (D.C. Cir. 2009);

Association of Battery Recyclers

EPA,

604 F. 3d 613, 617-18 (D.C. Cir. 2010). Both kinds of uncertainties are components of the risk associated with pollution at levels below those at which human health effects can be said to occur with reasonable scientific certainty. Thus, in selecting primary standards that provide an adequate margin of safety, the Administrator is seeking not only to prevent pollution levels that have been demonstrated to be harmful but also to prevent lower pollutant levels that may pose an unacceptable risk of harm, even if the risk is not precisely identified as to nature or degree. However, the CAA does not require the Administrator to establish a primary NAAQS at a zero-risk level or at background concentrations,

see Lead Industries Association

EPA,

647 F.2d at 1156 n.51, but rather at a level that reduces risk sufficiently so as to protect public health with an adequate margin of safety.

In addressing the requirement for an adequate margin of safety, the EPA considers such factors as the nature and severity of the health effects involved, the size of sensitive population(s) at risk,

and the kind and degree of the uncertainties that must be addressed. The selection of any particular approach to providing an adequate margin of safety is a policy choice left specifically to the Administrator's judgment.

See Lead Industries Association

EPA,

647 F.2d at 1161-62.

As used here and similarly throughout this notice, the term population (or group) refers to persons having a quality or characteristic in common, such as a specific pre-existing illness or a specific age or lifestage. Section II.B.2 below describes the identification of sensitive groups (called at-risk groups or at-risk populations) in this review.

In setting primary and secondary standards that are “requisite” to protect public health and welfare, respectively, as provided in section 109(b), the EPA's task is to establish standards that are neither more nor less stringent than necessary for these purposes. In so doing, the EPA may not consider the costs of implementing the standards.

See generally Whitman

American Trucking Associations,

531 U.S. 457, 465-472, 475-76 (2001). Likewise, “[a]ttainability and technological feasibility are not relevant considerations in the promulgation of national ambient air quality standards.”

American Petroleum Institute

Costle,

665 F.2d at 1185.

Section 109(d)(1) requires that “not later than December 31, 1980, and at 5-year intervals thereafter, the Administrator shall complete a thorough review of the criteria published under section 108 and the national ambient air quality standards . . . and shall make such revisions in such criteria and standards and promulgate such new standards as may be appropriate. . . .” Section 109(d)(2) requires that an independent scientific review committee “shall complete a review of the criteria . . . and the national primary and secondary ambient air quality standards . . . and shall recommend to the Administrator any new . . . standards and revisions of existing criteria and standards as may be appropriate. . . .” Since the early 1980s, this independent review function has been performed by the Clean Air Scientific Advisory Committee (CASAC).

Lists of CASAC members and members of the CASAC Sulfur Oxides Review Panel are available at:

https://yosemite.epa.gov/sab/sabpeople.nsf/WebCommitteesSubcommittees/CASAC%20Sulfur%20Oxides%20Panel.

B. Related SO

Control Programs

States are primarily responsible for ensuring attainment and maintenance of ambient air quality standards once the EPA has established them. Under section 110 of the Act, 42 U.S.C. 7410, and related provisions, states are to submit, for EPA approval, state implementation plans (SIPs) that provide for the attainment and maintenance of such standards through control programs directed to sources of the pollutants involved. The states, in conjunction with the EPA, also administer the prevention of significant deterioration program that covers these pollutants.

See

42 U.S.C. 7470-7479. In addition, federal programs provide for nationwide reductions in emissions of these and other air pollutants under Title II of the Act, 42 U.S.C. 7521-7574, which involves controls for automobile, truck, bus, motorcycle, nonroad engine and equipment, and aircraft emissions; the new source performance standards under section 111 of the Act, 42 U.S.C. 7411; and the national emission standards for hazardous air pollutants under section 112 of the Act, 42 U.S.C. 7412.

C. Review of the Air Quality Criteria and Standard for Sulfur Oxides

The initial air quality criteria for SO

were issued in 1969 (34 FR 1988, February 11, 1969). Based on these criteria, the EPA, in initially promulgating NAAQS for SO

in 1971, established the indicator as SO

. The SO

are a group of closely related gaseous compounds that include sulfur dioxide and sulfur trioxide and of which sulfur dioxide (the indicator for the current standard) is the most prevalent in the atmosphere and the one for which there is a large body of scientific evidence on health effects. The two primary standards set in 1971 were 0.14 parts per million (ppm) averaged over a 24-hour period, not to be exceeded more than once per year, and 0.03 ppm, as an annual arithmetic mean (36 FR 8186, April 30, 1971).

The first review of the air quality criteria and primary standards for SO

was initiated in the early 1980s and concluded in 1996 with the decision to retain the standards without revision (61 FR 25566, May 22, 1996). In reaching this decision, the Administrator considered the evidence newly available since the standards were set that documented asthma-related respiratory effects in people with asthma exposed for very short periods, such as 5 to 10 minutes. Based on his consideration of an exposure analysis using the then-limited monitoring data and early exposure modeling methods, the Administrator judged that revisions to the standards were not needed to provide requisite public health protection from SO

in ambient air at that time (61 FR 25566, May 22, 1996). This decision was challenged and the U.S. Court of Appeals for the District of Columbia Circuit (D.C. Circuit) found that the EPA had failed to adequately explain its determination that no revision to the primary SO

standards was appropriate and remanded the determination back to the EPA for further explanation (

American Lung Association

EPA,

134 F.3d 388 [D.C. Cir. 1998]).

This remand was addressed in the most recent review, which was completed in 2010. In that review, the EPA promulgated a new 1-hour standard and also promulgated

provisions for the revocation of the then-existing 24-hour and annual primary standards.

The new 1-hour standard was set with a level of 75 parts per billion (ppb), a form of the 3-year average of the annual 99th percentile of daily maximum 1-hour SO

concentrations, and with SO

as the indicator. The Administrator judged that such a standard would provide the requisite protection for at-risk populations, such as people with asthma, against the array of adverse respiratory health effects related to short-term SO

exposures, including those as short as 5 minutes. With regard to longer-term exposures, the new standard was expected to maintain 24-hour and annual concentrations generally well below the levels of the previous standards, and the available evidence did not indicate the need for separate standards designed to protect against longer-term exposures (75 FR 35520, June 22, 2010). The EPA also revised the SO

ambient air monitoring regulations to require that monitoring agencies using continuous SO

methods report the highest 5-minute concentration for each hour of the day;

agencies may report all twelve 5-minute concentrations for each hour, including the maximum, although it is not required (75 FR 35568, June 22, 2010). This rule was challenged in court, and the D.C. Circuit denied or dismissed on jurisdictional grounds all the claims in the petitions for review.

National Environmental Development Association's Clean Air Project

EPA,

686 F.3d 803, 805 (D.C. Cir. 2012).

Timing and related requirements for the implementation of the revocation are specified in 40 CFR 50.4(e).

The rationale for this requirement was described as providing additional monitoring data for use in subsequent reviews of the primary standard, particularly for use in considering the extent of protection provided by the 1-hour standard against 5-minute peak SO

concentrations of concern (75 FR 35568, June 22, 2010). In establishing this requirement, the EPA described such data as being “of high value to inform future health studies and, subsequently, future SO

NAAQS reviews” (75 FR 35568, June 22, 2010).

In May 2013, the EPA initiated the current review by issuing a call for information in the

Federal Register

and also announcing a public workshop to inform the review (78 FR 27387, May 10, 2013). As was the case for the prior review, this review is focused on health effects associated with SO

and the public health protection afforded by the existing standard. Participants in the kickoff workshop included a wide range of external experts as well as EPA staff representing a variety of areas of expertise (

e.g.,

epidemiology, human and animal toxicology, statistics, risk/exposure analysis, atmospheric science, and biology). Workshop discussions focused on key policy-relevant issues around which the Agency would structure the review and the newly available scientific information related to these issues. Based in part on the workshop discussions, the EPA developed the draft integrated review plan (IRP) outlining the schedule, process, and key policy-relevant questions to guide this review of the SO

air quality criteria and standards (U.S. EPA, 2014b). The draft IRP was released for public comment and was reviewed by the CASAC at a public teleconference on April 22, 2014 (79 FR 14035, March 12, 2014; Frey and Diez Roux, 2014). The final IRP was developed with consideration of comments from the CASAC and the public (U.S. EPA, 2014a; 79 FR 16325, March 25, 2014; 79 FR 66721, November 10, 2014).

As an early step in development of the Integrated Science Assessment (ISA) for this review, the EPA's National Center for Environmental Assessment (NCEA) hosted a public workshop at which preliminary drafts of key ISA chapters were reviewed by subject matter experts (79 FR 33750, June 12, 2014). Comments received from this review as well as comments from the public and the CASAC on the draft IRP were considered in preparation of the first draft ISA (U.S. EPA, 2015), released in November 2015 (80 FR 73183, November 24, 2015). The first draft ISA was reviewed by the CASAC at a public meeting in January 2016 and a public teleconference in April 2016 (80 FR 79330, December 21, 2015; 80 FR 79330, December 21, 2015; Diez Roux, 2016). The EPA released the second draft ISA in December 2016 (U.S. EPA, 2016b; 81 FR 89097, December 9, 2016), which was reviewed by the CASAC at a public meeting in March 2017 and a public teleconference in June 2017 (82 FR 11449, February 23, 2017; 82 FR 23563, May 23, 2017; Diez Roux, 2017a). The final ISA was released in December 2017 (U.S. EPA, 2017a; 82 FR 58600, December 13, 2017).

In considering the need for quantitative exposure and risk analyses in this review, the EPA completed the Risk and Exposure Assessment (REA) Planning Document in February 2017 (U.S. EPA, 2017c; 82 FR 11356, February 22, 2017), and held a consultation with the CASAC at a public meeting in March 2017 (82 FR 11449, February 23, 2017; Diez Roux, 2017b). In consideration of the CASAC's comments at that consultation and public comments, the EPA developed the draft REA and draft Policy Assessment (PA), which were released on August 24, 2017 (U.S. EPA, 2017d,e; 82 FR 43756, September 19, 2017). The draft REA and draft PA were reviewed by the CASAC on September 18-19, 2017 (82 FR 37213, August 9, 2017; Cox and Diez Roux, 2018a,b). The EPA considered the advice and comments from the CASAC on the draft REA and draft PA as well as public comments, in developing the final REA and final PA, which were released in early May 2018 (U.S. EPA, 2018a,b).

The schedule for completion of this review is governed by a consent decree resolving a lawsuit filed in July 2016 by a group of plaintiffs which included a claim that the EPA had failed to complete its review of the primary SO

NAAQS within five years, as required by the CAA.

The consent decree, which was entered by the court on April 28, 2017, provides that the EPA will sign, for publication, notices setting forth proposed and final decisions concerning its review of the primary NAAQS for SO

no later than May 25, 2018 and January 28, 2019, respectively.

See

Complaint,

Center for Biological Diversity et al.

McCarthy

, No. 3:16-cv-03796-VC, (N.D. Cal., filed July 7, 2016), Doc. No. 1.

Consent Judgment at 4,

Center for Biological Diversity et al.

McCarthy,

No. 3:16-cv-03796-VC (N.D. Cal., entered April 28, 2017), Doc. No. 37.

D. Air Quality Information

This section presents information on sources and emissions of SO

and ambient concentrations, with a focus on information that is most relevant for the review of the primary SO

standard. This section is drawn from the more detailed discussion of SO

air quality in the PA and the ISA. It presents a summary of SO

sources and emissions (II.B.1) and ambient concentrations (II.B.2).

1. Sources and Emissions of Sulfur Oxides

Sulfur oxides are emitted into air from specific sources (

e.g.,

fuel combustion processes) and are also formed in the atmosphere from other atmospheric compounds (

e.g.,

as an oxidation product of reduced sulfur compounds, such as sulfides). Sulfur oxides are also transformed in the atmosphere to particulate sulfur compounds, such as sulfates.

Sulfur oxides known to occur

in the troposphere include SO

and sulfur trioxide (SO

) (ISA, section 2.3). With regard to SO

, it “is known to be present in the emissions of coal-fired power plants, factories, and refineries, but it reacts with water vapor in the stacks or immediately after release into the atmosphere to form H

” and “gas-phase H

. . . . quickly condenses onto existing atmospheric particles or participates in new particle formation” (ISA, section 2.3). Thus, as a result of rapid atmospheric chemical reactions involving SO

, the most prevalent sulfur oxide in the atmosphere is SO

(ISA, section 2.3).

Some sulfur compounds formed from or emitted with SO

are very short-lived (ISA, pp. 2-23 to 2-24). For example, studies in the 1970s and 1980s identified particle-phase sulfur compounds, including inorganic SO

3−2

complexed with Fe(III) in the particles emitted by a smelter near Salt Lake City, UT. Subsequent studies reported rapid oxidation of such compounds, “on the order of seconds to minutes” and “further accelerated by low pH” (ISA, p. 2-24). Thus, “[t]he highly acidic aqueous conditions that arise once smelter plume

particles equilibrate with the ambient atmosphere ensure that S(IV)-Fe(III) complexes have a small probability of persisting and becoming a matter of concern for human exposure” (ISA, 2-24).

The health effects of particulate atmospheric transformation products of SO

, such as sulfates, are addressed in the review of the NAAQS for PM (U.S. EPA 2014a, 2016a).

Fossil fuel combustion is the main anthropogenic source of SO

emissions, while volcanoes and landscape fires (wildfires as well as controlled burns) are the main natural sources (ISA, section 2.1).

Industrial chemical production, pulp and paper production, natural biological activity (plants, fungi, and prokaryotes), and volcanoes are among many sources of reduced sulfur compounds that contribute, through various oxidation reactions in the atmosphere, to the formation of SO

in the atmosphere (ISA, section 2.1). Anthropogenic SO

emissions originate primarily from point sources, including coal-fired electricity generating units (EGUs) and other industrial facilities (ISA, section 2.2.1). The largest SO

-emitting sector within the U.S. is electricity generation, and 97% of SO

from electricity generation is from coal combustion. Other anthropogenic sources of SO

emissions include industrial fuel combustion and process emissions, industrial processing, commercial marine activity, and the use of fire in landscape management and agriculture (ISA, section 2.2.1).

A modeling analysis estimated annual mean SO

concentrations for 2001 in the absence of any U.S. anthropogenic emissions of SO

(2008 ISA, section 2.5.3; ISA, section 2.5.5). Such concentrations are referred to as U.S background or USB. The 2008 ISA analysis estimated USB concentrations of SO

to be below 0.01 ppb over much of the U.S., ranging up to a maximum of 0.03 ppb (ISA, section 2.5.5).

National average SO

emissions are estimated to have declined by 82% over the period from 2000 to 2016, with a 64% decline from 2010 to 2016 (PA, Figure 2-2; 2014 NEI). Such declines in SO

emissions are likely related to the implementation of national control programs developed under the Clean Air Act Amendments of 1990, including Phase I and II of the Acid Rain Program, the Clean Air Interstate Rule, the Cross-State Air Pollution Rule, and the Mercury Air Toxic Standards,

as well as changes in market conditions,

e.g.,

reduction in energy generation by coal (PA, section 2.1, Figure 2-2; U.S. EIA, 2017).

Regulations on sulfur content of diesel fuel, both fuel for onroad vehicles and nonroad engines and equipment, may also contribute to declining trends in SO

emissions.

Declines in emissions from all sources between 1971, when SO

NAAQS were first established, and 1990, when the Amendments were adopted, were on the order of 5,000 tpy deriving primarily from reductions in emissions from the metals processing sector (ISA, Figure 2-5).

When established, the MATS Rules was estimated to reduce SO

emissions from power plants by 41% beyond the reductions expected from the Cross State Air Pollution Rule (U.S. EPA, 2011).

In 2014, the EPA promulgated Tier 3 Motor Vehicle Emission and Fuel Standards that set emissions standards for new vehicles and lowered the sulfur content of gasoline. Reductions in SO

emissions resulting from these standards are expected to be more than 14,000 tons in 2018 (U.S. EPA, 2014c).

See

https://www.epa.gov/diesel-fuel-standards/diesel-fuel-standards-and-rulemakings#nonroad-diesel.

2. Ambient Concentrations

Ambient air concentrations of SO

in the U.S. have declined substantially from 1980 to 2016, more than 82% in terms of the form of the current standard (the 99th percentile daily maximum 1-hour concentrations averaged over three years) at locations continuously monitored over this period (PA, Figure 2-4).

The decline since 2000 has been 69% at the larger number of locations continuously monitored since that time (PA, Figure 2-5).

This decline is the average of observations at 24 monitoring sites that have been continuously operating from 1980-2016.

This decline is the average of observations at 193 monitoring sites that have been continuously operating across 2000-2016.

As a result of the reporting requirements promulgated in 2010 (as summarized in section I.C above) maximum hourly five-minute concentrations of SO

in ambient air are available at SO

NAAQS compliance monitoring sites (PA, Figure 2-3; FR 75 35554, June 22, 2010).

These newly available data document reductions in peak 5-minute concentrations across the U.S. For example, over the period from 2011 to 2016, the 99th percentile 5-minute SO

concentrations declined approximately 53% (PA, Figure 2-6, Appendix B).

Such measurements were available for fewer than 10% of monitoring sites at the time of the last review. Of the monitors reporting 5-minute data in 2016, almost 40% are reporting all twelve 5-minute SO

measurements in each hour while about 60% are reporting the maximum 5-minute SO

concentration in each hour (PA, section 2.2). The expanded dataset has provided a more robust foundation for the quantitative analyses in the REA for this review.

Concentrations of SO

vary across the U.S. and tend to be higher in areas with sources having relatively higher SO

emissions (

e.g.,

locations influenced by emissions from EGUs). Consistent with the locations of larger SO

sources, higher concentrations are primarily located in the eastern half of the continental U.S., especially in the Ohio River valley, upper Midwest, and along the Atlantic coast (PA, Figure 2-7). The point source nature of SO

emissions contributes to the relatively high spatial variability of SO

concentrations compared with pollutants such as ozone (ISA, section 3.2.3). Another factor in the spatial variability is the dispersion and oxidation of SO

in the atmosphere, processes that contribute to decreasing concentrations with increasing distance from the source. Point source emissions of sulfur oxides create a plume of higher concentrations, which may or may not impact large portions of surrounding populated areas depending on meteorological conditions and terrain.

Analyses in the ISA of data for 2013-2015 in six areas indicate that 1-hour daily maximum SO

concentrations vary across seasons, with the greatest variations seen in the upper percentile concentrations (versus average or lower percentiles) for each season (ISA, section 2.5.3.2).

This seasonal variation as well as month-to-month variations are generally consistent with month-to-month emissions patterns and the expected atmospheric chemistry of SO

for a given season. Consistent with the nationwide diel patterns reported in the last review, 1-hour average and 5-minute hourly maximum SO

concentrations for 2013-2015 in all six areas evaluated were generally low during nighttime and approached maxima values during daytime hours (ISA, section 2.5.3.3, Figures 2-23 and 2-24). The timing and duration of daytime maxima in the six sites evaluated in the ISA were likely related to a combination of source emissions and meteorological parameters (ISA,

section 2.5.3.3; U.S. EPA 2008a, section 2.5.1).

The six “focus areas” evaluated in the ISA are: Cleveland, OH; Pittsburgh, PA; New York City, NY; St. Louis, MO-IL; Houston, TX; and Gila County, AZ (ISA, section 2.5.2.2). These six locations were selected based on (1) their relevance to current health studies (

i.e.,

areas with peer-reviewed, epidemiologic analysis); (2) the existence of four or more monitoring sites located within the area boundaries; and (3) the presence of several diverse SO

sources within a given focus area boundary.

II. Rationale for Proposed Decision

This section presents the rationale for the Administrator's proposed decision to retain the current primary SO

standard. This rationale is based on a thorough review of the latest scientific information generally published through August 2016,

as presented in the ISA, on human health effects associated with SO

and pertaining to the presence of SO

in ambient air. The Administrator's rationale also takes into account: (1) The PA evaluation of the policy-relevant information in the ISA and quantitative analyses of air quality, human exposure and health risks in the REA; (2) CASAC advice and recommendations, as reflected in discussions of drafts of the ISA, REA, and PA at public meetings and in the CASAC's letters to the Administrator; and (3) public comments received during the development of these documents.

In addition to the review's opening “call for information” (78 FR 27387, May 10, 2013), “the U.S. EPA routinely conducted literature searches to identify relevant peer-reviewed studies published since the previous ISA (

i.e.,

from January 2008 through August 2016)” (ISA, p. 1-3). References that are cited in the ISA, the references that were considered for inclusion but not cited, and electronic links to bibliographic information and abstracts can be found at:

https://hero.epa.gov/hero/sulfur-oxides.

In presenting the rationale for the Administrator's proposed decision and its foundations, section II.A provides background on the general approach for review of the primary SO

standard, including a summary of the approach used in the last review (section II.A.1) and the general approach for the current review (section II.A.2). Section II.B summarizes the currently available health effects evidence, focusing on consideration of key policy-relevant aspects. Section II.C summarizes the exposure and risk information for this review, drawing on the quantitative analyses for SO

, presented in the REA. Section II.D presents the Administrator's proposed conclusions on the current standard (section II.D.3), drawing on both evidence-based and exposure/risk-based considerations (section II.D.1) and advice from the CASAC (section II.D.2).

A. General Approach

The past and current approaches described below are both based, most fundamentally, on using the EPA's assessments of the current scientific evidence and associated quantitative analyses to inform the Administrator's judgment regarding a primary standard for SO

that protects public health with an adequate margin of safety. The EPA's assessments are primarily documented in the ISA, REA and PA, all of which have received CASAC review and public comment (80 FR 73183, November 24, 2015; 81 FR 89097, December 9, 2016; 82 FR 11356, February 22, 2017; 82 FR 43756, September 19, 2017). In bridging the gap between the scientific assessments of the ISA and REA and the judgments required of the Administrator in determining whether the current standard remains requisite to protect public health with an adequate margin of safety, the PA evaluates policy implications of the evaluation of the current evidence in ISA and the quantitative analyses in the REA. In evaluating the health protection afforded by the current standard, the four basic elements of the NAAQS (indicator, averaging time, level, and form) are considered collectively.

We note that in drawing conclusions with regard to the primary standard, the final decision on the adequacy of the current standard is largely a public health policy judgment to be made by the Administrator. The Administrator's final decision will draw upon scientific information and analyses about health effects, population exposure and risks, as well as judgments about how to consider the range and magnitude of uncertainties that are inherent in the scientific evidence and analyses. This approach is based on the recognition that the available health effects evidence generally reflects a continuum, consisting of levels at which scientists generally agree that health effects are likely to occur, through lower levels at which the likelihood and magnitude of the response become increasingly uncertain. This approach is consistent with the requirements of the NAAQS provisions of the Clean Air Act and with how the EPA and the courts have historically interpreted the Act. These provisions require the Administrator to establish primary standards that, in the judgment of the Administrator, are requisite to protect public health with an adequate margin of safety. In so doing, the Administrator seeks to establish standards that are neither more or less stringent than necessary for this purpose. The Act does not require that primary standards be set at a zero-risk level, but rather at a level that avoids unacceptable risks to public health, including the health of sensitive groups.

As noted in section I.A above, such protection is specified for the sensitive group of individuals and not to a single person in the sensitive group (see S. Rep. No. 91-1196, 91st Cong., 2d Sess. 10 [1970]).

1. Approach in the Last Review

The last review of the primary NAAQS for SO

was completed in 2010 (75 FR 35520, June 22, 2010). The decision in that review to substantially revise the standards (establishing a 1-hour standard and revoking the 24-hour and annual standards) was based on the extensive body of evidence of respiratory effects in people with asthma that has expanded in this area over the four decades since the first SO

standards were set in 1971 (U.S. EPA 1982, 1986, 1994, 2008a). In so doing, the 2010 decision considered the full body of evidence, as assessed in the 2008 ISA; the 2009 REA, which included the staff assessment of the policy-relevant information contained in the ISA and analyses of air quality, exposure and risk; the advice and recommendations of the CASAC; and public comment. In addition to epidemiologic evidence linking respiratory outcomes in people with asthma to short-term SO

air quality metrics, a key element of the expanded evidence base in the 2010 review was a series of controlled human exposure studies which document bronchoconstriction-related effects on lung function in people with asthma exposed while breathing at elevated rates

for periods as short as five minutes. Another key element was the air quality database, expanded since the previous review (completed in 1996), which documented the then-recent pattern of peak 5-minute SO

concentrations. The EPA used these data in the quantitative exposure and risk assessments to provide an up-to-date ambient air quality context for interpreting the health effects evidence in the 2010 review. Together these aspects of the 2010 review additionally addressed the issues raised in the court remand to the EPA of the Agency's 1996 decision not to revise the standards at that time to specifically address 5-minute exposures (75 FR 35523, June 22, 2010). In so doing, the EPA strengthened the primary NAAQS for

to provide the requisite protection of public health with an adequate margin of safety and to specifically afford increased protection for at-risk populations, such as people with asthma, against adverse respiratory health effects related to short-term SO

exposures (75 FR 35550, June 22, 2010).

The phrase “elevated ventilation” (or “moderate or greater exertion”) was used in the 2009 REA and

Federal Register

notices in the last review to refer to activity levels that in adults would be associated with ventilation rates at or above 40 liters per minute; an equivalent ventilation rate was derived in order to identify corresponding rates for the range of ages and sizes of the simulated populations (U.S. EPA, 2009, section 4.1.4.4). Accordingly, these phrases are used in the current review when referring to REA analyses from the last review. Otherwise, however, the documents for this review generally use the phrase “elevated breathing rates” to refer to the same situation.

Thus, the 2010 decision focused on the effects most pertinent to SO

in ambient air and recognized the long-standing evidence regarding the sensitivity of some people with asthma to brief SO

exposures experienced while breathing at elevated rates. The Administrator gave particular attention to the robust evidence base, comprised of findings from controlled human exposure, epidemiologic, and animal toxicological studies that collectively were judged “sufficient to infer a causal relationship” between short-term SO

exposures ranging from 5 minutes to 24 hours and respiratory morbidity (75 FR 35535, June 22, 2010). The “definitive evidence” for this conclusion came from studies of 5- to 10-minute controlled exposures that reported respiratory symptoms and decreased lung function in exercising individuals with asthma (2008 ISA, section 5.3). Supporting evidence was provided by epidemiologic studies of a broader range of respiratory outcomes, with uncertainty noted about the magnitude of the study effect estimates, quantification of the exposure concentration-response relationship, potential confounding by copollutants, and other areas (75 FR 35535-36, June 22, 2010; 2008 ISA, section 5.3).

The conclusions reached in the last review were based primarily on interpretation of the short-term health effects evidence, particularly the interpretation of the evidence from controlled human exposure studies within the context of the quantitative exposure and risk analyses. The epidemiologic evidence also provided support for various aspects of the decision. In making judgments on the public health significance of health effects related to ambient air-related SO

exposures, the Administrator considered statements from the American Thoracic Society (ATS) regarding adverse effects of air pollution,

the CASAC's written advice and recommendations,

and judgments made by the EPA in considering similar effects in previous NAAQS reviews (75 FR 35526 and 35536, June 22, 2010; ATS, 1985, 2000). Based on these considerations, the Administrator, in reaching decisions in the last review, gave weight to the findings of respiratory effects in exercising people with asthma after 5- to 10-minute exposures as low as 200 ppb. With regard to higher exposures, at or above 400 ppb, she noted their association with respiratory symptoms as indication of their clear adversity, as well as the greater number of study subjects responding with lung function decrements. Moreover, she took note of the greater severity of the response, recognizing effects associated with exposures as low as 200 ppb to be less severe (75 FR 35547, June 22, 2010).

The 1999 statement of the ATS (published in 2000) on “What Constitutes an Adverse Health Effect of Air Pollution?” is “intended to provide guidance to policy makers and others who interpret the scientific evidence on the health effects of air pollution for the purpose of risk management” and describes “principles to be used in weighing the evidence” when considering what may be adverse and nonadverse effects on health (ATS, 2000).

For example, the CASAC letter on the first draft SO

REA to the Administrator stated: “CASAC believes strongly that the weight of clinical and epidemiology evidence indicates there are detectable clinically relevant health effects in sensitive subpopulations down to a level at least as low as 0.2 ppm SO

” (Henderson, 2008).

In reaching her conclusion on the adequacy of the then-existing primary standards, the Administrator gave particular attention to the exposure and risk estimates from the 2009 REA for air quality conditions just meeting the then-existing (24-hour and annual) standards. In so doing, the Administrator also noted epidemiologic study findings of associations with respiratory outcomes in studies of locations where maximum 24-hour average SO

concentrations were below the level of the then existing 24-hour standard. The 2009 REA estimated that substantial percentages of children with asthma might be expected to experience at least once annually, exposures that had been associated with moderate or greater lung function decrements

in the controlled human exposure studies (75 FR 35536, June 22, 2010). The Administrator judged that such exposures can result in adverse health effects in people with asthma and found that the estimated population frequencies for such exposures (24% of at-risk population with at least one occurrence per year at or above 400 ppb and 73% with at least one occurrence per year at or above 200 ppb) were significant from a public health perspective and that the then-existing primary standards did not adequately protect public health (75 FR 35536, June 22, 2010).

In assessments for NAAQS reviews, the magnitude of lung function responses described as indicative of a moderate response include increases in specific airway resistance (sRaw) of at least 100% (

e.g.,

2008 ISA; U.S. EPA, 1994, Table 8; U.S. EPA, 1996, Table 8-3). The moderate category has also generally included reductions in forced expiratory volume in 1 second (FEV

) of 10 to 20% (

e.g.,

U.S. EPA, 1996, Table 8). For the 2008 ISA, the midpoint of that range (15%) was used to indicate a moderate response. A focus on 15% reduction in FEV

was also consistent with the relationship observed between sRaw and FEV

responses in the Linn et al. studies (1987, 1990) for which “a 100% increase in sRaw roughly corresponds to a 12 to 15% decrease in FEV

” (U.S. EPA, 1994, p. 20). Thus, in the 2008 review, moderate or greater SO

-related bronchoconstriction or decrements in lung function referred to the occurrence of at least a doubling in sRaw or at least a 15% reduction in FEV

(2008 ISA, p. 3-5).

Based on consideration of the entire body of evidence and information available in the review, as well as the advice from the CASAC and public comments, the Administrator concluded that the appropriate approach to revising the standards was to replace the then-existing 24-hour standard with a new, short-term standard set to provide requisite protection with an adequate margin of safety to people with asthma and afford protection from the adverse health effects of 5-minute to 24-hour SO

exposures (75 FR 35536, June 22, 2010). Accordingly, the available information was then considered in reaching conclusions on the four elements of such a new standard: indicator, averaging time, form, and level. Further, upon reviewing the evidence with regard to the potential for effects from long-term exposures, the Administrator revoked the annual standard. In so doing, she recognized the lack of sufficient health evidence to support a long-term standard and that the new short-term standard would have the effect of generally maintaining the annual SO

concentrations well below the level of the revoked annual standard (75 FR 35550, June 22, 2010).

With regard to the indicator for the new short-term standard, the EPA continued to focus on SO

as the most appropriate indicator for SO

because the available scientific information regarding health effects was overwhelmingly indexed by SO

. Furthermore, although the presence of SO

species other than SO

in ambient air had been recognized, no alternative to SO

had been advanced as a more appropriate surrogate for SO

(75 FR 35536, June 22, 2010). Controlled human exposure studies and animal toxicological studies provided specific evidence for health effects following exposures to SO

, and epidemiologic studies typically analyzed associations of health outcomes with concentrations of SO

. Based on the information available in the last review and consistent with the views of the CASAC that “for indicator, SO

is clearly the preferred choice” (Samet, 2009, p. 14), the Administrator concluded it was appropriate to continue to use SO

the indicator for a standard that was intended to address effects associated with exposure to SO

, alone or in combination with other SO

(75 FR 35536, June 22, 2010). In so doing, the EPA recognized that measures leading to reductions in population exposures to SO

will also likely reduce exposures to other SO

(75 FR 35536, June 22, 2010).

With regard to the averaging time for the new standard, the Administrator judged that the requisite protection from 5- to 10-minute exposure events could be provided without having a standard with a 5-minute averaging time (75 FR 35539, June 22, 2010). She further judged that a standard with a 5-minute averaging time would result in significant and unnecessary instability in public health protection (75 FR 35539, June 22, 2010).

Accordingly, she considered longer averaging times.

Such instability could reduce public health protection by disrupting an area's ongoing implementation plans and associated control programs (75 FR 35537, June 22, 2010).

Results of air quality analyses in the REA suggested that a standard based on 24-hour average SO

concentrations would not likely be an effective or efficient approach for addressing 5-minute peak SO

concentrations, likely over-controlling in some areas while under-controlling in others (2009 REA, section 10.5.2.2). In contrast, these same analyses suggested that a 1-hour averaging time would be more efficient and would be effective at limiting 5-minute peaks of SO

(2009 REA, section 10.5.2.2.). Drawing on this information, the Administrator concluded that a 1-hour standard, with the appropriate form and level, would be likely to substantially reduce 5- to 10-minute peaks of SO

that had been shown in controlled human exposure studies to result in increased prevalence of respiratory symptoms and/or decrements in lung function in exercising people with asthma (75 FR 35539, June 22, 2010). Further, she found that a 1-hour standard could substantially reduce the upper end of the distribution of SO

concentrations in ambient air that were more likely to be associated with respiratory outcomes (75 FR 35539, June 22, 2010).

The Administrator additionally took note of advice from the CASAC. The CASAC stated that the REA had presented a “convincing rationale” for a 1-hour standard and that “a one-hour standard is the preferred averaging time” (Samet, 2009, pp. 15, 16). The CASAC further stated that it was “in agreement with having a short-term standard” and found that “the REA supports a one-hour standard as protective of public health” (Samet, 2009, p. 1). Thus, in consideration of the available information summarized here and the CASAC's advice, the Administrator concluded that a 1-hour standard (given the appropriate level and form) was an appropriate means of controlling short-term exposures to SO

ranging from 5 minutes to 24 hours (75 FR 35539, June 22, 2010).

With regard to the statistical form for the new 1-hour standard, the Administrator judged that the form of the standard should reflect the health effects evidence presented in the ISA that indicated that the percentage of people with asthma affected and the severity of the response increased with increasing SO

concentrations (75 FR 35541, June 22, 2010). She additionally found it reasonable to consider stability (

e.g.,

to avoid disruption of programs implementing the standard and the related public health protections from those programs) as part of her consideration of the form for the standard (75 FR 35541, June 22, 2010). In so doing, she noted that a concentration-based form averaged over three years would likely be appreciably more stable than a no-exceedance based form, which had been the form of the then-existing 24-hour standard (75 FR 35541, June 22, 2010). The CASAC additionally stated that “[t]here is adequate information to justify the use of a concentration-based form averaged over 3 years” (Samet, 2009, p. 16). In consideration of this information, the Administrator judged a concentration-based form averaged over three years to be most appropriate (75 FR 35541, June 22, 2010).

In selecting a specific concentration-based form, the Administrator considered health evidence from the ISA as well as air quality, exposure, and risk information from the REA. In so doing, the Administrator concluded that the form of a new 1-hour standard should be especially focused on limiting the upper end of the distribution of ambient SO

concentrations (

i.e.,

above 90th percentile SO

concentrations) in order to provide protection with an adequate margin of safety against effects observed in controlled human exposure studies and associated with ambient air SO

concentrations in epidemiologic studies (75 FR 35541, June 22, 2010). The Administrator further noted that, based on results of air quality and exposure analyses in the REA, a 99th percentile form was likely to be appreciably more effective at achieving the desired control of 5-minute peak exposures than a 98th percentile form (75 FR 35541, June 22, 2010). Thus, the Administrator selected a 99th percentile form averaged over three years (75 FR 35541, June 22, 2010).

Lastly, based on the body of scientific evidence and information available, as well as CASAC recommendations and public comment, the Administrator decided on a standard level that, in combination with the specified choice of indicator, averaging time and form, would be requisite to protect public health, including the health of at-risk populations, with an adequate margin of safety. In reaching the decision on a level for the new 1-hour standard, the Administrator gave primary emphasis to the body of health effects evidence assessed in the ISA. In so doing, she noted that the controlled human exposure studies provided the most direct evidence of respiratory effects from exposure to SO

(75 FR 35546, June 22, 2010). The Administrator drew on evidence from these studies in reaching judgments on the magnitude of adverse respiratory effects and associated potential public health significance for the air quality exposure and risk analysis results of air quality scenarios for conditions just meeting alternative levels for a new 1-hour standard (described in the 2009 REA).

In light of judgments regarding the health effects evidence, the Administrator considered what the findings of the 2009 REA exposure analyses indicated with regard to varying degrees of protection that different 1-hour standard levels might be expected to provide against 5-minute exposures to concentrations of 200 ppb and 400 ppb, given the specified choice of indicator, averaging time, and form.

For example, the single-year exposure assessment for St. Louis

estimated that a 1-hour standard at 100 ppb would likely protect more than 99% of children with asthma in that city from

experiencing any days in a year with at least one 5-minute exposure at or above 400 ppb while at moderate or greater exertion, and approximately 97% of those children with asthma from experiencing any days in a year with at least one exposure at or above 200 ppb while at moderate or greater exertion (75 FR 35546-47, June 22, 2010). Results for the air quality scenario for a 1-hour standard level of 50 ppb suggested that such a standard would further limit exposures, such that more than 99%

of children at moderate or greater exertion would likely be protected from experiencing any days in a year with a 5-minute exposure at or above the 200 ppb benchmark concentration (75 FR 35542, June 22, 2010). In considering the implications of these estimates, and the substantial reduction in 5-minute exposures at or above 200 ppb, the Administrator did not judge that a standard level as low as 50 ppb

was warranted (75 FR 35547, June 22, 2010). Before reaching her conclusion with regard to level for the 1-hour standard, the Administrator additionally considered the epidemiologic evidence, placing relatively more weight on the U.S. epidemiologic studies (some conducted in multiple locations) reporting mostly positive and sometimes statistically significant associations between ambient SO

concentrations and emergency department visits or hospital admissions related to asthma or other respiratory symptoms, and noting a cluster of three studies for which 99th percentile 1-hour daily maximum concentrations were estimated to be between 78-150 ppb and for which the SO

effect estimate remained positive and statistically significant in copollutant models with PM (75 FR 35547-48, June 22, 2010).

The Administrator additionally noted the results of the analysis of the limited available air quality data for 5-minute SO

concentrations with regard to prevalence of higher 5-minute concentrations at monitor sites when data were adjusted to just meet a standard level of 100 ppb. This 40-county analysis indicated for a 1-hour standard level of 100 ppb a maximum annual average of two days per year with 5-minute concentrations above 400 ppb and 13 days with 5-minute concentrations above 200 ppb (75 FR 35546, June 22, 2010).

With regard to the results for the two study areas assessed in the 2009 REA, the EPA considered the St. Louis results to be more informative to consideration of the adequacy of protection associated with the then-current and alternative standards (75 FR 35528, June 22, 2010; 74 FR 64840, December 8, 2009). The St. Louis study area included several counties and had population size and magnitudes of emissions density (on a spatial scale) similar to other urban areas in the U.S., while the second study area (Greene County, Missouri) was a rural county with much lower population and emissions density.

The 2009 REA indicated this percentage to be 99.9% (2009 REA, Appendix B, p. B-62).

In the 2009 REA results for the St. Louis single year scenario with a level of 50 ppb (the only level below 100 ppb that was analyzed), 99.9% of children with asthma would be expected to be protected from a day with a 5-minute exposure at or above 200 ppb, and 100% from a day with a 5-minute exposure at or above 400 ppb (2009 REA).

Regarding the monitor concentrations in these studies, the EPA noted that although they may be a reasonable approximation of concentrations occurring in the areas, the monitored concentrations were likely somewhat lower than the absolute highest 99th percentile 1-hour daily maximum SO

concentrations occurring across these areas (75 FR 35547, June 22, 2010).

Given the above considerations and the comments received on the proposal, the Administrator judged, based on the entire body of evidence and information available in that review (concluded in 2010), and the related uncertainties,

that a standard level of 75 ppb was appropriate. She concluded that such a standard, with a 1-hour averaging time and 99th percentile form, would provide a significant increase in public health protection compared to the then-existing standards and would be expected to provide protection, with an adequate margin of safety, against the respiratory effects elicited by SO

exposures in controlled human exposure studies and associated with ambient air concentrations in epidemiologic studies (75 FR 35548, June 22, 2010). The Administrator found that “a 1-hour standard at a level of 75 ppb is expected to substantially limit asthmatics' exposure to 5-10 minute SO

concentrations ≥200 ppb, thereby substantially limiting the adverse health effects associated with such exposures” (75 FR 35548, June 22, 2010). Such a standard was also considered likely “to maintain SO

concentrations below those in locations where key U.S. epidemiologic studies have reported that ambient SO

is associated with clearly adverse respiratory health effects, as indicated by increased hospital admissions and emergency department visits” (75 FR 35548, June 22, 2010). Lastly, the Administrator noted “that a standard level of 75 ppb is consistent with the consensus recommendation of CASAC” (75 FR 35548, June 22, 2010). The Administrator also considered the likelihood of public health benefits at lower standard levels, and judged a 1-hour standard at 75 ppb to be sufficient to protect public health with an adequate margin of safety (75 FR 35547-35548, June 22, 2010).

Such uncertainties included both those with regard to the epidemiologic evidence, including potential confounding and exposure error, and also those with regard to the information from controlled human exposure studies for at-risk groups, including the extent to which the results would be expected to be similar for individuals with more severe asthma than that in study subjects (75 FR 35546, June 22, 2010).

2. Approach for the Current Review

To evaluate whether it is appropriate to consider retaining the now current primary SO

standard, or whether consideration of revision is appropriate, the EPA has adopted an approach in this review that builds upon the general approach used in the last review and reflects the body of evidence and information now available. Accordingly, the approach in this review takes into consideration the approach used in the last review, addressing key policy-relevant questions in light of currently available scientific and technical information. As summarized above, the Administrator's decisions in the prior review were based on an integration of SO

health effects information with judgments on the adversity and public health significance of key health effects, policy judgments as to when the standard is requisite to protect against public health with an adequate margin of safety, consideration of CASAC advice, and consideration of public comments.

Similarly, in this review, we draw on the current evidence and quantitative assessments of exposure pertaining to the public health risk of SO

in ambient air. In considering the scientific and technical information here, we consider both the information available at the time of the last review and information newly available since the last review, including that which has been critically analyzed and characterized in the current ISA. The quantitative exposure and risk analyses provide a context for interpreting the evidence of lung function decrements in people with asthma breathing at elevated rates and the potential public health significance of exposures associated with air quality conditions that just meet the current standard.

B. Health Effects Information

The information summarized here is based on our scientific assessment of the health effects evidence available in this review; this assessment is documented in the ISA and its policy implications are further discussed in the PA. More than 400 studies are newly available and considered in the ISA, including more than 200 health studies. They are consistent with the evidence that was available in the last review. As in the last review, the key evidence comes from the body of controlled human exposure studies that document effects in people with asthma. Policy implications of the currently available evidence are discussed in the PA (as summarized in section II.D.1 below). The subsections below briefly summarize the following aspects of the evidence: The nature of SO

-related health effects (section II.B.1), the populations at risk (section II.B.2), exposure concentrations associated with health effects (section II.B.3), and potential public health implications (section II.B.4).

1. Nature of Effects

In this review, as in past reviews, the health effects evidence evaluated in the ISA for SO

is focused on SO

(ISA, p. 5-1). As summarized in section I.D.1 above, atmospheric chemistry as well as emissions contribute to SO

being the most prevalent sulfur oxide in the atmosphere. As concluded in the ISA, “[o]f the sulfur oxides, SO

is the most

abundant in the atmosphere, the most important in atmospheric chemistry, and the one most clearly linked to human health effects” (ISA, p. 2-1). Accordingly, the ISA states that “only SO

is present at concentrations in the gas phase that are relevant for chemistry in the atmospheric boundary layer and troposphere, and for human exposures” (ISA, p. 2-18). Thus, the current health effects evidence and the Agency's review of the evidence, including the evidence newly available in this review, continues to focus on SO

Sulfur dioxide is a highly reactive and water-soluble gas that once inhaled is absorbed almost entirely in the upper respiratory tract

(ISA, sections 4.2 and 4.3). Short exposures to SO

can elicit respiratory effects, particularly in individuals with asthma (ISA, p. 1-17). Under conditions of elevated breathing rates (

e.g.,

while exercising), SO

penetrates into the tracheobronchial region,

where, in sufficient concentration, it results in responses linked to asthma exacerbation in individuals with asthma (ISA, sections 4.2, 4.3, and 5.2). More specifically, bronchoconstriction,

which is characteristic of an asthma attack, is the most sensitive indicator of SO

-induced lung function effects (ISA, p. 5-8). Associated with this bronchoconstriction response is an increase in airway resistance which is an index of airway hyperresponsiveness (AHR).

Exercising individuals without asthma have also been found to exhibit such responses, but at much higher SO

exposure concentrations (ISA, section 5.2.1.7). For example, the ISA finds that “healthy adults are relatively insensitive to the respiratory effects of SO

below 1 ppm” (ISA, p. 5-9).

The term “upper respiratory tract” refers to the portion of the respiratory tract, including the nose, mouth and larynx, that precedes the tracheobronchial region (ISA, sections 4.2 and 4.3).

The term “tracheobronchial region” refers to the region of the respiratory tract subsequent to the larynx and preceding the deep lung (or alveoli). This region includes the trachea and bronchii.

The term bronchoconstriction refers to constriction or narrowing of the airways in the respiratory tract.

Airway hyperresponsiveness, which is an increased propensity of the airways to narrow in response to bronchoconstrictive stimuli, is a characteristic feature of people with asthma (ISA, section 5.2.1.2).

Based on assessment of the currently available evidence, as in the last review, the ISA concludes that there is a causal relationship between short-term SO

exposures (as short as a few minutes) and respiratory effects (ISA, section 5.2.1). The clearest evidence for this causal relationship comes from the long-standing evidence base of controlled human exposure studies (U.S. EPA, 1994; 2008 ISA). These studies demonstrate asthma exacerbation-related lung function decrements

and respiratory symptoms (

e.g.,

cough, chest tightness and wheeze) in people with asthma exposed to SO

for 5 to 10 minutes at elevated breathing rates (ISA, section 5.2.1). Bronchoconstriction, evidenced by decrements in lung function, that are sometimes accompanied by respiratory symptoms (

e.g.,

cough, wheeze, chest tightening and shortness of breath), is observed to occur in these studies at SO

concentrations as low as 200 ppb in some people with asthma exposed while breathing at elevated rates, such as during exercise (ISA, section 5.2.1.2).

In contrast, respiratory effects are not generally observed in other people with asthma (nonresponders) and healthy adults exposed, while exercising, to SO

concentrations below 1000 ppb (ISA, sections 5.2.1.2 and 5.2.1.7). Across studies, bronchoconstriction in response to SO

exposure is mainly seen during conditions of elevated breathing rates, such as exercise or with mouthpiece exposures that involve laboratory-facilitated rapid, deep breathing.

With these conditions, breathing shifts from nasal breathing to oral/nasal breathing, which increases the concentrations of SO

reaching the tracheobronchial region of lower airways, where, depending on dose and the exposed individual's susceptibility, it may cause bronchoconstriction (ISA, sections 4.1.2.2, 4.2.2, and 5.2.1.2).

The specific responses reported in the evidence base that are described in the ISA as lung function decrements are increased specific airway resistance (sRaw) and reduced forced expiratory volume in 1 second (FEV

) (ISA, section 5.2.1.2).

The data from controlled human exposure studies of people with asthma indicate that there are two subpopulations that differ in their airway responsiveness to SO

, with the second subpopulation being insensitive to SO

bronchoconstrictive effects at concentrations as high as 1000 ppb (ISA, pp. 5-14 to 5-21; Johns

et al.,

2010).

Laboratory-facilitated rapid deep breathing involves rapid, deep breathing through a mouthpiece that provides a mixture of oxygen with enough carbon dioxide to prevent an imbalance of gases in the blood usually resulting from hyperventilation. Breathing in the laboratory with this technique is referred to as eucapnic hypernea.

The evidence base of controlled human exposure studies for people with asthma

is the same in this review as in the last review. Such studies reporting asthma exacerbation-related effects for individuals with asthma are summarized in Tables 5-1 and 5-2, as well as section 5.2.1.2 of the ISA. The main responses observed include increases in specific airway resistance (sRaw) and reductions in forced expiratory volume in one second (FEV

) after 5- to 10-minute exposures. As recognized in the last review, the results of these studies indicate that among individuals with asthma, some individuals have a greater response to SO

than others or a measurable response at lower exposure concentrations (ISA, p. 5-14). The SO

-induced bronchoconstriction in these studies occurs rapidly, in as little as two minutes from exposure start, and is transient, with recovery occurring upon cessation of exposure (ISA, p. 5-14; Table 5-2).

The subjects in these studies have primarily been adults. The exception has been a few studies conducted in adolescents aged 12 to 18 years of age (ISA, pp. 5-22 to 5-23; PA, sections 3.2.1.3 and 3.2.1.4).

The epidemiologic evidence, some of which is newly available since the time of the last review, includes studies reporting positive associations for asthma-related hospital admissions of children or emergency department visits by children with short-term SO

exposures (ISA, section 5.2.1). These findings provide evidence supportive of the EPA's conclusion of a causal relationship between short-term SO

exposures and respiratory effects, for which the controlled human exposure studies are the primary basis (ISA, section 5.2.1.9). With regard to newly available epidemiologic studies, there are a limited number of such studies that have investigated SO

effects related to asthma exacerbation, with the most supportive evidence coming from studies on asthma-related emergency department visits by children and hospital admissions of children (ISA, section 5.2.1.2). As in the last review, areas of uncertainty in the epidemiologic evidence relate to the characterization of exposure through the use of fixed site monitor concentrations as surrogates for population exposure (often over a substantially sized area and for durations greater than an hour) and the potential for confounding by PM

or other copollutants (ISA, section 5.2.1). In general, the pattern of associations across the newly available studies is consistent with the studies available in the last review (ISA, p. 5-75).

The potential for confounding by PM is of particular interest given that SO

is a precursor to PM (ISA, p. 1-7).

The evidence base for long-term

exposure and respiratory effects is somewhat augmented since the last review such that the ISA in the current review concludes it to be suggestive of,

but not sufficient to infer, a causal relationship (ISA, section 5.2.2). The support for this conclusion comes mainly from the limited epidemiologic study findings of associations between long-term SO

concentrations and increases in asthma incidence combined with findings of laboratory animal studies involving newborn rodents that indicate a potential for SO

exposure to contribute to the development of asthma, especially allergic asthma, in children (ISA, section 1.6.1.2). The evidence showing increases in asthma incidence is coherent with results of animal toxicological studies that provide a pathophysiologic basis for the development of asthma. The overall body of evidence, however, lacks consistency (ISA, section 1.6.1.2). Further, there are uncertainties that apply to the epidemiologic evidence, including newly available evidence, across the respiratory effects examined for long-term exposure (ISA, section 5.2.2.7).

In evaluating the health effects studies in the ISA, the EPA has generally categorized exposures of durations longer than a month as “long-term” (ISA, p. 1-2).

For effects other than respiratory effects, the current evidence is generally similar to the evidence available in the last review, and leads to similar conclusions. With regard to a relationship between short-term SO

exposure and total mortality, the ISA reaches the same conclusion as the previous review that the evidence is suggestive of, but not sufficient to infer, a causal relationship (ISA, section 5.5.1). This conclusion is based on the evidence of previously and newly available multicity epidemiologic studies that provide consistent evidence of positive associations coupled with uncertainty regarding the potential for SO

to have an independent effect on mortality. While recent studies have analyzed some key uncertainties and data gaps from the previous review, uncertainties still exist, given the limited number of studies that examined copollutant confounding, the evidence for a decrease in the size of SO

-mortality associations in copollutant models with nitrogen dioxide and particulate matter with mass median aerodynamic diameter below 10 microns, and the lack of a potential biological mechanism for mortality following short-term SO

exposures (ISA, section 1.6.2.4).

For other categories of health effects,

the currently available evidence is inadequate to infer the presence or absence of a causal relationship, mainly due to inconsistent evidence across specific outcomes and uncertainties regarding exposure measurement error, copollutant confounding, and potential modes of action (ISA, sections 5.3.1, 5.3.2, 5.4, 5.5.2, 5.6). These conclusions are consistent with those made in the previous review (ISA, p. xlviii).

The other categories evaluated in the ISA include cardiovascular effects with short- or long-term exposures; reproductive and developmental effects; and cancer and total mortality with long-term exposures (ISA, section 1.6.2 and Table 1-1).

Thus, the current health effects evidence supports the primary conclusion that short-term exposure to SO

in ambient air causes respiratory effects, in particular, asthma exacerbation in individuals with asthma; this evidence and these conclusions are also consistent with that available in the last review. The focus in this review, as in prior reviews, is on such effects.

2. At-Risk Populations

In this document, we use the term “at-risk populations”

to recognize populations that have a greater likelihood of experiencing SO

-related health effects,

i.e.

groups with characteristics that contribute to an increased risk of SO

-related health effects. In identifying factors that increase risk of SO

-related health effects, we have considered evidence regarding factors contributing to increased susceptibility, which generally include intrinsic factors, such as physiological factors that may influence the internal dose or toxicity of a pollutant, or extrinsic factors, such as sociodemographic or behavioral factors (ISA, p. 6-1).

As noted in section I above, we use the term “at-risk populations” to refer to persons having a quality or characteristic in common, such as a specific pre-existing illness or a specific age or lifestage for which there is an increased risk of SO

-related health effects.

The information newly available in this review has not substantially altered our previous understanding of at-risk populations for SO

in ambient air. As in the last review, people with asthma are at increased risk for SO

-related health effects, specifically for respiratory effects, and specifically asthma exacerbation elicited by short-term exposures while breathing at elevated rates (ISA, sections 5.2.1.2 and 6.3.1). This conclusion of the at-risk status of people with asthma is based on the well-established and well-characterized evidence from controlled human exposure studies, supported by the evidence on mode of action for SO

with additional support from epidemiologic studies (ISA, sections 5.2.1.2 and 6.3.1). Somewhat similar to the conclusion in the last review that children and older adults are potentially susceptible populations, the ISA (relying on a framework for evaluating the evidence for risk factors that has been developed since the last review)

indicates the evidence to be suggestive of increased risk for these groups, with some limitations and inconsistencies (ISA, sections 6.5.1.1 and 6.5.1.2).

Since the 2010 review of the primary SO

NAAQS, the EPA has developed a formal framework to transparently characterize the strength of the evidence that can inform the identification of populations and lifestages at increased risk of a health effect related to exposure to a pollutant. This framework is part of the systematic approach taken in the ISA for this review (ISA, section 6.2).

The current evidence for risk to older adults relative to other lifestages comes from epidemiologic studies, for which findings are somewhat inconsistent, and studies with which there are uncertainties in the association with the health outcome (ISA, section 6.5.1.2).

Children with asthma, however, may be particularly at risk compared to adults with asthma (ISA, section 6.3.1). This conclusion reflects several characteristics of children as compared to adults, which include their greater responsiveness to methacholine,

a chemical that can elicit bronchoconstriction in people with asthma, as well as their greater use of oral breathing, particularly by boys (ISA, sections 5.2.1.2 and 4.1.2). Oral breathing (vs. nasal breathing) and increased breathing rate are factors that allow for greater SO

penetration into the tracheobronchial region of the lower airways, and reflect conditions of individuals with asthma in which bronchoconstriction-related responses have been observed in the controlled exposure studies (ISA, sections 4.2.2, 5.2.1.2, and 6.3.1). Although the epidemiological evidence includes a number of studies focused on health outcomes in children that are supportive of the qualitative conclusions of causality (ISA, section 5.2.1.2), there are few controlled human exposure studies to inform our

understanding of exposure concentrations associated with effects in this population group. Those studies have not included subjects younger than 12 years (ISA, p. 5-22). Some characteristics particular to school-age children younger than 12 years, such as increased propensity for mouth breathing (ISA, p. 4-5), however, suggest that this age group of children with asthma might be expected to experience larger lung function decrements than adults with asthma (ISA, p. 5-25).

The ISA concluded that potential differences in airway responsiveness of children to SO

relative to adolescents and adults may be inferred by differences in responses to methacholine (ISA, section 5.2.1.2). Methacholine is a chemical that can elicit bronchoconstriction through its action on airway smooth muscle receptors. It is commonly used to identify people with asthma and accordingly has been used to screen subjects for studies of SO

effects. However, results of studies of the extent to which airway response to methacholine is predictive of SO

responsiveness have varied somewhat. For example, an analysis of the extent to which airway responsiveness to methacholine, a history of respiratory symptoms, and atopy were significant predictors of airway responsiveness to SO

, found that about 20 to 25% of subjects ranging in age from 20 to 44 years that were hyperresponsive to methacholine were also hyperresponsive to SO

(ISA, section 5.2.1.2; Nowak et al., 1997). Another study focused on individuals with airway responsiveness to methacholine found only a weak correlation between airway responsiveness to SO

and methacholine (ISA, section 5.2.1.2; Horstman et al., 1986).

The ISA does not find the evidence to be adequate to conclude differential risk status for subgroups of children with asthma (ISA, Chapter 6). In consideration of the limited information regarding factors related to breathing habit, however, and recognizing the lack of evidence from controlled human exposure studies of SO

-induced lung function decrements in children, approximately 5 to 11 years of age, with asthma, the ISA suggests that this age group of children and “particularly boys and perhaps obese children, might be expected to experience greater responsiveness (

i.e.,

larger decrements in lung function) following exposure to SO

than normal-weight adolescents and adults” (ISA, p. 4-7 and 5-36).

Additionally, some individuals with asthma have a greater response to SO

than others with similar disease status (ISA, section 5.2.1.2; Horstman

et al.,

1986; Johns

et al.,

2010). This occurrence is quantitatively analyzed in a study newly available in this review. This study examined differences in lung function response using individual subject data available from five studies of individuals with asthma exposed to multiple concentrations of SO

for 5 to 10 minutes while breathing at elevated rates (Johns

et al.,

2010). As noted in the ISA, “these data demonstrate a bimodal distribution of airway responsiveness to SO

in individuals with asthma, with one subpopulation that is insensitive to the bronchoconstrictive effects of SO

even at concentrations as high as 1.0 ppm, and another subpopulation that has an increased risk for bronchoconstriction at low concentrations of SO

” (ISA, p. 5-20). While such information provides documentation that some individuals have a greater response to SO

than others with the same disease status, the factors contributing to this greater susceptibility are not yet known (ISA, pp. 5-14 to 5-21).

The current evidence for factors evaluated in the ISA other than asthma status and lifestage is inadequate to determine whether they (

e.g.,

sex and SES) might have an influence on risk of SO

-related effects (ISA, section 6.6).

3. Exposure Concentrations Associated With Health Effects

Our understanding of exposure duration and concentrations associated with SO

-related health effects is largely based, as it was in the last review, on the longstanding evidence base of controlled human exposure studies. These studies demonstrate a dose-response relationship between 5- and 10-minute SO

exposure concentrations and decrements in lung function (

e.g.,

increased sRaw and reduced FEV

) and occurrence of respiratory symptoms in individuals with asthma exposed while breathing at elevated rates (ISA, section 1.6.1.1). Clear and consistent increases in these effects occur with increasing SO

exposure (ISA, Table 5-2 and pp. 5-35, 5-39). Further, the SO

-induced bronchoconstriction occurs rapidly; exposures as short as 5 minutes have been found to elicit a similar bronchoconstrictive response as somewhat longer exposures. For example, during exposure to SO

over a 30-minute period with continuous exercise, the response to SO

has been found to develop rapidly and is maintained throughout the 30-minute exposure (ISA, p. 5-14). In a study involving short exercise periods within a 6-hour exposure period, the effects observed following exercise were documented to return to baseline levels within one hour after the cessation of exercise, even with continued exposure (ISA, p. 5-14; Linn et al., 1984). Thus, the controlled human exposure evidence base demonstrates the occurrence of SO

-related effects as a result of peak exposures on the order of minutes.

As the air quality metrics in the epidemiologic studies are for time periods longer than the 5- to 10-minute exposures eliciting effects in the controlled human exposure studies, these studies may not adequately capture the spatial and temporal variation in SO

concentrations and cannot address whether observed associations of asthma-related emergency room visits or hospital admissions with 1-hour to 24-hour ambient air concentration metrics are indicative of a potential response to exposure on the order of hours or much shorter-term exposure to peaks in SO

concentration (ISA, pp. 5-49, 5-59, 5-25).

The controlled human exposure study findings

demonstrate that SO

concentrations as low as 200 to 300 ppb for 5 to 10 minutes elicited moderate or greater lung function decrements, measured as a decrease in FEV

of at least 15% or an increase in sRaw of at least 100%, in the study subjects (ISA, sections 1.6.1.1 and 5.2.1). The percent of individuals affected, the severity of response, and the accompanying occurrence of respiratory symptoms increased with increasing SO

exposure concentrations (ISA, section 5.2.1). At concentrations ranging from 200 to 300 ppb, the lowest levels for which the ISA describes SO

-related lung function decrements (in terms of 15% reductions in FEV

or doubling or tripling of sRaw), as many as 33% of exercising study subjects with asthma experienced moderate or greater decrements in lung function (ISA, section 5.2.1, Table 5-2). Analyses focused on subjects with asthma in multiple studies that are responsive to SO

at exposure concentrations below 1000 ppb found there to be statistically significant increases in lung function decrements occurring at 300 ppb (ISA, p. 153; Johns et al., 2010). At concentrations at or above 400 ppb, moderate or greater decrements in lung function occurred in 20 to 60% of exercising individuals with asthma and a larger percentage of individuals with asthma experienced more severe decrements in lung function (

i.e.,

an increase in sRaw of at least 200%, and/or a 20% or more decrease in FEV

), compared to exposures at 200 to 300 ppb (ISA, section 5.2.1.2, p. 5-9 and Table 5-2). Additionally, at concentrations at or above 400 ppb, moderate or greater decrements in lung function were frequently accompanied by respiratory symptoms, such as cough, wheeze, chest tightness, or shortness of breath, with some of these findings reaching statistical significance at the study group level (ISA, Table 5-2 and section 5.2.1).

The findings summarized in Table 5-2 of the ISA and in Table 3-1 of the PA are based on results that have been adjusted for effects of exercise in clean air so that they have separated out any effect of exercise in causing bronchoconstriction and reflect only the SO

-specific effect.

The lowest exposure concentration for which individual study subject data are available in terms of the sRaw and FEV

from studies that have assessed the SO

effect

versus

the effect of exercise in clean air is 200 ppb (ISA, Table 5-2 and Figure 5-1). In nearly all of these studies (and all of the studies for concentrations below 500 ppb), study subjects breathed freely (

e.g.,

without using a mouthpiece).

In studies that tested 200 ppb, a portion of the exercising study subjects with asthma (approximately 8 to 9%) responded with at least a doubling in sRaw or an increase in FEV

of at least 15% (ISA, Table 5-2 and Figure 5-2; PA, Table 3-1; Linn et al., 1983a; Linn et al., 1987).

Studies of free-breathing subjects generally make use of small rooms in which the atmosphere is experimentally controlled such that study subjects are exposed by freely breathing the surrounding air (

e.g.,

Linn et al., 1987).

With regard to exposure concentrations below 200 ppb, the very limited available evidence is for

exposure as low as 100 ppb. Some differences in methodology and the reporting of results complicate comparisons of the studies of 100 ppb exposure with studies of higher concentrations. In the studies testing this concentration, subjects were exposed by mouthpiece rather than freely breathing in an exposure chamber (Sheppard et al., 1981; Sheppard et al., 1984; Koenig et al., 1989; Koenig et al., 1990; Trenga et al., 2001; ISA, section 5.2.1.2; PA, section 3.2.1.3). Additionally, only a few of these studies included an exposure to clean air while exercising that would have allowed for determining the effect of SO

versus

the effect of exercise in causing bronchoconstriction (Sheppard et al., 1981, 1984; Koenig et al., 1989). In those cases, a limited number of adult and adolescent study subjects were reported to experience small changes in sRaw, with the magnitudes of change appearing to be smaller than responses reported from studies at exposure concentrations of 200 ppb or more.

52 53

Thus, the set of studies for the 100 ppb exposure concentration, while limited and complicated by differences from studies of higher concentrations with regard to reporting of results and exposure method, does not indicate this exposure concentration to result in as much as a doubling in sRaw, based on the extremely few adults and adolescents tested (Sheppard et al., 1981, 1984; Koenig et al., 1989).

For example, the increase in sRaw reported for two young adult subjects exposed to 100 ppb in the study by Sheppard et al. (1981) was slightly less than half the response of these subjects at 250 ppb, and the results for the study by Sheppard et al. (1984) indicate that none of the eight study subjects experienced as much as a doubling in sRaw in response to the mouthpiece exposure to 125 ppb while exercising. In the study of adolescents (aged 12 to 18 years), among the three individual study subjects for which respiratory resistance appears to have increased with SO

exposure, the magnitude of any increase after consideration of the response to exercise appears to be less than 100% in each subject (Koenig et al., 1989).

In a mouthpiece exposure system, the inhaled breath completely bypasses the nasal passages where SO

is efficiently removed, thus allowing more of the inhaled SO

to penetrate into the tracheobronchial airways (2008 ISA, p. 3-4; ISA, section 4.1.2.2). This allowance of greater penetration of SO

into the tracheobronchial airways, as well as limited evidence comparing responses by mouthpiece and chamber exposures, leads to the expectation that SO

-responsive people with asthma breathing SO

using a mouthpiece, particularly while breathing at elevated rates, would experience greater lung function responses than if exposed to the same test concentration while freely breathing in an exposure chamber (ISA, p. 5-23; Linn et al., 1983b).

Specific exposure concentrations that may be eliciting respiratory responses are not available from the epidemiological studies that find associations with outcomes such as asthma-related emergency department visits and hospitalizations. For example, in noting limitations of epidemiologic studies with regard to uncertainties in SO

exposure estimates, the ISA recognized that “[it] is unclear whether SO

concentrations at the available fixed site monitors adequately represent variation in personal exposures especially if peak exposures are as important as indicated by the controlled human exposure studies” (ISA, p. 5-37). This extends the observation of the 2008 ISA that “it is possible that these epidemiologic associations are determined in large part by peak exposures within a 24-h[our] period” (2008 ISA, p. 5-5). Given the important role of SO

as a precursor to PM in ambient air, however, a key uncertainty in the epidemiologic evidence available in this review, as in the last review, is potential confounding by copollutants, particularly PM (ISA, p. 5-5). Among the U.S. epidemiologic studies reporting mostly positive and sometimes statistically significant associations between ambient SO

concentrations and emergency department visits or hospital admissions (some conducted in multiple locations), few studies have attempted to address this uncertainty,

e.g.,

through the use of copollutant models. For example, as in the last review, there are three U.S. studies for which the SO

effect estimate remained positive and statistically significant in copollutant models with PM.

No additional such studies have been newly identified in this review that might inform this issue. Thus, such uncertainties regarding copollutant confounding, as well as exposure measurement error, remain in the currently available epidemiologic evidence base (ISA, p. 5-6).

Based on data available for specific time periods at some monitors in the areas of these studies, the 99th percentile 1-hour daily maximum concentrations were estimated in the last review to be between 78-150 ppb (Thompson and Stewart, 2009; PA, Appendix D).

4. Potential Impacts on Public Health

In general, the magnitude and implications of potential impacts on public health are dependent upon the type and severity of the effect, as well as the size and other features of the population affected (ISA, section 1.7.4; PA, 3.2.1.5). With regard to SO

concentrations in ambient air, the public health implications and potential public health impacts relate to the effects causally related to SO

exposures of interest in this review. These are respiratory effects of short-term exposures, and particularly those effects associated with asthma exacerbation in people with asthma. As summarized above in section II.B.1, the most strongly demonstrated effects are bronchoconstriction-related effects resulting in decrements in lung function elicited by short term exposures during periods of elevated breathing rate; asthma-related health outcomes such as emergency department visits and hospital admissions have also been statistically associated with ambient air SO

concentration metrics in epidemiologic studies (ISA, section 5.2.1.9).

As summarized in section II.B.2 above, people with asthma are the population at risk for SO

-related effects and children with asthma are considered to be at relatively greater risk than other age groups within this at-risk population (ISA, section 6.3.1). The evidence supporting this conclusion comes primarily from studies of individuals with mild to moderate asthma,

with very little evidence available for individuals with severe asthma. The evidence base of controlled human exposure studies of exercising people with asthma provides very limited information indicating that there are similar responses (in terms of relative decrements in lung function in response to SO

exposures) of individuals with differences in severity of their asthma.

However, the two available studies “suggest that adults with moderate/severe asthma may have more limited reserve to deal with an insult compared with individuals with mild asthma” (ISA, p. 5-22; Linn et al., 1987; Trenga et al., 1999). Consideration

of such baseline differences among members of at-risk populations and of the relative transience or persistence of these responses (

e.g.,

as noted in section II.B.3 above), as well as other factors, is important to characterizing implications for public health, as recognized by the ATS in their recent statement on evaluating adverse health effects of air pollution (Thurston et al., 2017).

These studies categorized asthma severity based mainly on the individual's use of medication to control asthma, such that individuals not regularly using medication were classified as minimal/mild, and those regularly using medication as moderate/severe (Linn et al., 1987). The ISA indicates that the moderate/severe grouping would likely be classified as moderate by today's asthma classification standards due to the level to which their asthma was controlled and their ability to engage in moderate to heavy levels of exercise (ISA, p. 5-22; Johns et al., 2010; Reddel, 2009).

The ISA identifies two studies that have investigated the influence of asthma severity on responsiveness to SO

, with one finding that a larger change in lung function observed in the moderate/severe asthma group was attributable to the exercise component of the study protocol while the other did not assess the role of exercise in differences across individuals with asthma of differing severity (Linn et al., 1987; Trenga et al., 1999). The ISA states, “[h]owever, both studies suggest that adults with moderate/severe asthma may have more limited reserve to deal with an insult compared with individuals with mild asthma” (ISA, p. 5-22). Based on the criteria used in the study by Linn et al (1987) for placing individuals in the “moderate/severe” group, the ISA concluded that the asthma of these individuals “would likely be classified as moderate by today's classification standards” (ISA, p. 5-22; Johns et al., 2010; Reddel, 2009).

The Administrator's judgment is informed by statements by the ATS on what constitutes an adverse health effect of air pollution. Building on the earlier statement by the ATS that was considered in the last review (ATS, 2000), the recent policy statement by the ATS on what constitutes an adverse health effect of air pollution provides a general framework for interpreting evidence that proposes a “set of considerations that can be applied in forming judgments” for this context (Thurston et al., 2017). The earlier ATS statement, in addition to emphasizing clinically relevant effects (

e.g.,

the adversity of small transient changes in lung function metrics in combination with respiratory symptoms), also emphasized both the need to consider changes in “the risk profile of the exposed population” and effects on the portion of the population that may have a diminished reserve that could put its members at potentially increased risk of effects from another agent (ATS, 2000). The consideration of effects on individuals with preexisting diminished lung function continues to be recognized as important in the more recent ATS statement (Thurston et al., 2017). For example, in adding emphasis in this area, this statement conveys the view that “small lung function changes” in individuals with compromised function, such as that resulting from asthma, should be considered adverse, even without accompanying respiratory symptoms (Thurston et al., 2017). All of these concepts, including the consideration of the magnitude of effects occurring in just a subset of study subjects, are recognized as important in the more recent ATS statement (Thurston et al., 2017) and continue to be relevant to consideration of the evidence base for SO

Such concepts are routinely considered by the Agency in weighing public health implications for decisions on primary NAAQS, as summarized in section I.A above. For example, in deliberations on a standard that provides the requisite public health protection under the Act, the EPA traditionally recognizes the nature and severity of the health effects involved, recognizing the greater public health significance of more severe health effects, including, for example, effects that have been documented to be accompanied by symptoms, and of the risk of repeated occurrences of effects (76 FR 54308, August 31, 2011; 80 FR 65292, October 26, 2015). Another area of consideration is characterization of the population at risk, including its size and, as pertinent, the exposure/risk estimates in this regard. Such factors related to public health significance, and the kind and degree of associated uncertainties, are considered by the EPA in addressing the CAA requirement that the primary NAAQS are requisite to protect public health, including a margin of safety, as summarized in section I.A above.

Ambient air concentrations of SO

vary considerably in areas near sources, but concentrations in the vast majority of the U.S. are well below the current standard (PA, Figure 2-7). Thus, while the population counts discussed below may convey information and context regarding the size of populations living near sizeable sources in some areas, the concentrations in most areas of the U.S. are well below the conditions assessed in the REA.

With regard to the size of the U.S. population at risk of SO

-related effects, the National Center for Health Statistics data from the 2015 National Health Interview Survey (NHIS)

indicate that approximately 8% of the U.S. population has asthma (PA, Table 3-2; CDC, 2017). Among all U.S. adults, the prevalence is estimated to be 7.6%, with women having a higher estimate (9.7%) than men (5.4%). The estimated prevalence is greater in children (8.4% for children less than 18 years of age) than adults (7.6%) (PA, Table 3-2; CDC, 2017). Asthma was the leading chronic illness affecting children in 2012, the most recent year for which such an evaluation is available (Bloom et al., 2013). As noted in the PA, there are more than 24 million people with asthma currently in the U.S., including more than 6 million children (PA, sections 3.2.2.4 and 3.2.4).

The NHIS is conducted annually by the U.S. Centers for Disease Control and Prevention. The NHIS collects health information from a nationally representative sample of the noninstitutionalized U.S. civilian population through personal interviews. Participants (or parents of participants if the survey participant is a child) who have ever been told by a doctor or other health professional that the participant had asthma and reported that they still have asthma were considered to have current asthma. Data are weighted to produce nationally representative estimates using sample weights; estimates with a relative standard error greater than or equal to 30% are generally not reported (Mazurek and Syamlal, 2018). The NHIS estimates described here are drawn from the 2015 NHIS, Table 4-1 (

https://www.cdc.gov/asthma/nhis/2015/table4-1.htm

Relatively greater population-level SO

impacts (

i.e.,

greater numbers of individuals affected) might be expected in population groups with relatively greater asthma prevalence (

i.e.,

groups with relatively higher percentages of individuals that have asthma). Among all U.S. children, the asthma prevalence estimate is greater for boys than girls (CDC, 2017). Asthma prevalence estimates from the 2015 NHIS vary for children of different races or ethnicities and household income, among other factors (CDC, 2017). Among populations of different races or ethnicities, black non-Hispanic and Puerto Rican Hispanic children are estimated to have the highest prevalences, at 13.4% and 13.9%, respectively. Asthma prevalence is also increased among populations in poverty, with the prevalence estimated to be 11.1% among people living in households below the poverty level compared to 7.2% of those living above it.

The information on which to base estimates of asthma prevalence in other subgroups of children is much more limited (

e.g.,

as discussed in the REA, section 4.1.2). For example, the more limited information from the NHIS for 2011-2015 indicates there to be a greater prevalence of asthma in children that are obese

compared to those that are not (REA, section 4.1.2, Figure 4-2).

Although the CDC does not report NHIS estimates for the percent of obese adults or children that have asthma, they do report that that more adults with asthma are obese than adults without asthma. As discussed in the REA, the NHIS sample size for children with asthma identified as obese is very limited (REA, section 4.1.2).

In consideration of the limited information regarding factors related to breathing habit (whether one is breathing through their nose or mouth) and recognizing the lack of evidence from controlled human exposure studies of SO

i.e.,

larger decrements in lung function) following exposure to SO

than normal-weight adolescents and adults” (ISA, pp. 4-7 and 5-36). However, the ISA does not find the evidence to be adequate to conclude differential risk status for subgroups of children with asthma (ISA, Chapter 6).

With regard to the potential for exposure of the populations at risk from exposures to SO

in ambient air, the PA recognizes that while SO

concentrations have generally declined across the U.S. since 2010 when the current standard was set (PA, Figures 2-5 and 2-6), there are numerous areas where SO

concentrations still contribute to air quality that is near or above the standard. For example, the

most recently available design values for the primary SO

standard (those based on monitoring data for the 2014-2016 period) indicate there to be 15 core-based statistical areas

with design values above the existing standard level of 75 ppb, of which a number have sizeable populations.

In addition to this evidence of elevated ambient air SO

concentrations, there are limitations in the monitoring network with regard to the extent that it might be expected to capture all areas with the potential to exceed the standard (

e.g.,

75 FR 35551; June 22, 2010).

In recognition of these limitations, the PA also examined the proximity of populations to sizeable SO

point sources using the most recently available emissions inventory information (2014), which is also characterized in the ISA (ISA, section 2.2.2).

This information indicates that there are more than 300,000 and 60,000 children living within 1 km of facilities emitting at least 1,000 and 2,000 tpy of SO

, respectively. Within 5 km of such sources, the numbers are approximately 1.4 million and 700,000, respectively (PA, Table 3-5). While information on SO

concentrations in locations of maximum impact of such sources is not available for all these areas, and SO

concentrations vary appreciably near sources, simply considering the 2015 national estimate of asthma prevalence of approximately 8% (noted above), this information would suggest there may be as many as 24,000 to more than 100,000 children with asthma that live in areas near substantially sized sources of SO

emissions to ambient air (PA, section 3.2.1.5; Table 3-5).

Core-based statistical area (CBSA) is a geographic area defined by the U.S. Office of Management and Budget to consist of an urban area of at least 10,000 people in combination with its surrounding or adjacent counties (or equivalents) with which there are socioeconomic ties through commuting (

https://www.census.gov/geo/reference/gtc/gtc_cbsa.html

). Populations in the 15 CBSAs referred to in the body of the text range from approximately 30,000 to more than a million (based on 2016 U.S. Census Bureau estimates).

Table 5c. Monitoring Site Listing for Sulfur Dioxide 1-Hour NAAQS in the Excel file labeled So2_designvalues_20142016_final_07_19_16.xlsx downloaded from

https://www.epa.gov/air-trends/air-quality-design-values

on January 26, 2018.

As state and local air agencies have the flexibility to characterize air quality using either modeling of actual source emissions or using appropriately sited ambient air monitors for designation purposes, both types of information have been used to support designations of areas not meeting the standard. To date, 42 areas have been designated as nonattainment areas, although air quality improvements in two of these 42 areas has led to the areas meeting the standard and being redesignated. The population residing in the remaining 40 nonattainment areas is approximately 3.3 million people (see

https://www3.epa.gov/airquality/greenbook/tnsum.html

). Detailed information about source types in these areas can be found in the technical support documents for individual nonattainment areas, available via

https://www.epa.gov/sulfur-dioxide-designations/sulfur-dioxide-designations-regulatory-actions.

These areas generally had significant SO

point sources, with the majority of these point sources being electric generating units.

Although source characteristics and meteorological conditions—in addition to magnitude of emissions—influence the distribution of concentrations in ambient air, these estimates are based on proximity to large sources, rather than ambient concentrations, due to limitations in the available information with regard to spatial (and temporal) patterns of SO

concentrations in the proximity of such sources in urban areas (ISA, section 2.5.2.2).

The information discussed in this section indicates the potential for exposures to SO

in ambient air to be of public health importance. Such considerations contributed to the basis for the 2010 decision to appreciably strengthen the primary SO

NAAQS and to establish a 1-hour standard to provide the requisite public health protection for at-risk populations from short-term exposures of concern.

C. Summary of Risk and Exposure Information

Our consideration of the scientific evidence available in the current review (summarized in section II.B above), as at the time of the last review, is informed by results from a quantitative analysis of estimated population exposure and associated risk of bronchoconstriction-related effects that the evidence indicates to be elicited in some portion of exercising people with asthma by short exposures to elevated SO

concentrations,

e.g.,

such exposures lasting 5 or 10 minutes. This analysis, for the air quality scenario of just meeting the current standard, estimates two types of risk metrics in terms of percentages of the simulated at-risk populations of adults with asthma and children with asthma (REA, section 4.6). The first of the two risk metrics is based on comparison of the estimated 5-minute exposure concentrations for individuals breathing at elevated rates to 5-minute exposure concentrations of potential concern (benchmark concentrations), and the second utilizes exposure-response (E-R) information from studies in which subjects experienced moderate or greater lung function decrements (specifically a doubling or more in sRaw) to estimate the portion of the simulated at-risk population likely to experience one or more days with an SO

-related increase in sRaw of at least 100% (REA, sections 4.6.1 and 4.6.2). Both of these metrics are used in the REA to characterize health risk associated with 5-minute peak SO

exposures among simulated at-risk populations during periods of elevated breathing rates. These risk metrics were also derived in the REA for the last review and the associated estimates informed the Administrator's 2010 decision to establish the current standard (75 FR 35546-35547, June 22, 2010).

The following subsections summarize key aspects of the design and methods of the quantitative assessment (section II.C.1) and the important uncertainties associated with these analyses (section II.C.2). The results of the analyses are summarized in section II.C.3.

1. Key Design Aspects

In this section, we provide an overview of key aspects of the quantitative exposure and risk assessment conducted for this review, including the study areas, air quality adjustment approach, modeling tools, at-risk populations simulated, and benchmark concentrations assessed. The assessment is described in detail in the REA and summarized in section 3.2.2 of the PA.

Given the primary overarching consideration in this review of whether the currently available information calls into question the adequacy of protection provided by the current standard, the air quality scenario analyzed in the REA focuses on air quality conditions that just meet the current standard. With this focus, the analyses estimate exposure and risk for at-risk populations in three urban study areas in: (1) Fall River, MA; (2) Indianapolis, IN; and (3) Tulsa, OK. The three study areas present a variety of circumstances related to population exposure to short-term peak concentrations of SO

in ambient air. These study areas range in total population size from approximately 180,000 to 540,000 and reflect different mixtures of SO

emissions sources, including electric utilities using fossil fuels, as well as sources such as petroleum refineries and secondary lead smelting (REA, section 3.1). The three study areas—in Massachusetts, Indiana and Oklahoma—are in three different climate regions of the U.S.: The Northeast, Ohio River Valley (Central), and South (Karl and Koss, 1984). The latter two regions comprising the part of the U.S. with generally the greatest prevalence of elevated SO

concentrations and large emissions sources (PA, Figure 2-7 and Appendix F).

Accordingly, the three study areas illustrate three different patterns of exposure to SO

concentrations in a populated area in the U.S. (REA, section 5.1). While the same air quality scenario

is simulated in all three study areas (conditions that just meet the current standard), study-area-specific source and population characteristics contribute to variation in the estimated magnitude of exposure and associated risk across study areas.

Additionally, continuous 5-minute ambient air monitoring data (

i.e.,

all 5-minute values for each hour) are available in all three study areas (REA, section 3.2).

As indicated by this case study approach to assessing exposure and risk, the analyses in the REA are intended to provide assessments of an air quality scenario just meeting the current standard for a small, diverse set of study areas and associated exposed at-risk populations that will be informative to the EPA's consideration of potential exposures and risks that may be associated with the air quality conditions occurring under the current SO

standard. The REA analyses are not designed to provide a comprehensive national assessment of such conditions (REA, section 2.2). The objective of the REA is not to present an exhaustive analysis of exposure and risk in areas of the U.S. that currently just meet the standard and/or of exposure and risk associated with air quality adjusted to just meet the standard in areas that currently do not meet the standard.

Rather, the purpose is to assess, based on current tools and information, the potential for exposures and risks beyond those indicated by the information available at the time the current standard was established. Accordingly, capturing an appropriate diversity in study areas and air quality conditions (that reflect the current standard scenario) is important to the role of the REA in informing the EPA's conclusions on the public health protection afforded by the current standard (PA, section 3.2.2.2).

Nor is the objective of the REA to provide a comprehensive assessment of current air quality across the U.S.

A broad variety of spatial and temporal patterns of SO

concentrations can exist when ambient air concentrations just meet the current standard. These patterns will vary due to many factors including the types of emissions sources in a study area and several characteristics of those sources, such as magnitude of emissions and facility age, use of various control technologies, patterns of operation, and local factors, as well as local meteorology. Estimates derived by the particular analytical approaches and methodologies used to describe the study area-specific air quality provide an indication of this variability in the spatial and temporal patterns of SO

concentrations associated with air quality conditions just meeting the current standard, while recognizing the associated uncertainty in these concentration estimates.

In this regard, the REA presents results from two different approaches to adjusting air quality. The first approach uses the highest design value across all modeled air quality receptors to adjust the air quality concentrations in each area to just meet the standard (REA, section 3.4). This is done by estimating the amount of SO

concentration reduction needed for concentrations at this highest receptor to be adjusted to just meet the current standard. Based on this amount, all other receptors impacted by the highest source(s) are adjusted proportionately. The second approach is included in the REA as a sensitivity analysis in recognition of the potential uncertainty associated with the estimated concentrations across the modeling domain, particularly the very highest concentrations. Accordingly, the second approach uses the air quality receptor having the 99th percentile of the distribution of design values (instead of the receptor having the maximum design value) to estimate the SO

concentration reductions needed to adjust the air quality to just meet the standard (REA, section 6.2.2.2).

Consistent with the health effects evidence summarized in section II.B above, the focus of the REA is on short-term (5-minute) exposures of individuals in the population with asthma during times when they are breathing at an elevated rate. Five-minute concentrations in ambient air were estimated for the current standard scenario using a combination of 1-hour concentrations from the EPA's preferred near-field dispersion model, the American Meteorological Society/EPA regulatory model (AERMOD), with adjustment such that they just meet the current standard, and relationships between 1-hour and 5-minute concentrations occurring in the local ambient air monitoring data. Air quality modeling with AERMOD is used to capture the spatial variation in ambient SO

concentrations across an urban area, which can be relatively high in areas affected by large point sources, and which the limited number of monitoring locations in each area is unlikely to capture. This provides 1-hour concentrations at model receptor sites across the modeling domain across the 3-year modeling period (consistent with the 3-year form of the standard). These concentrations were adjusted such that the air quality modeling receptor location with the highest concentrations just met the current standard.

Relationships between 1-hour and 5-minute concentrations at local monitors were then used to estimate 5-minute concentrations associated with the adjusted 1-hour concentrations across the 3-year period at all model receptor locations in each of the three study areas (REA, section 3.5). In this way, available continuous 5-minute ambient air monitoring data (datasets with all twelve 5-minute concentrations in each hour) were used to reflect the fine-scale temporal variation in SO

concentrations documented by these data and for which air quality modeling is limited,

e.g.,

by limitations in the time steps of currently available model input data such as for emissions estimates.

The air quality adjustments were implemented with a focus on reducing emissions from the source(s) contributing most to the standard exceedances until the areas just met the standard. This approach focuses on the concentrations associated with the primary contributing source(s), identifying the amount by which they need to be adjusted in order for the highest design value across all air quality receptors to just meet the current standard (REA, section 3.4). Based on this amount, all other receptors impacted by the highest source(s) are adjusted accordingly. In recognition of the potential uncertainty associated with this approach, particularly for the highest estimated concentrations, a second approach was also evaluated that bases the adjustments on the air quality receptor having the 99th percentile of the distribution of design values instead of the receptor having the maximum design value (REA, section 6.2.2.1).

The estimated 5-minute concentrations in ambient air across each study area were then used together with the Air Pollutants Exposure (APEX) model, a probabilistic human exposure model that simulates the activity of individuals in the population, including their exertion levels and movement through time and space, to estimate concentrations of 5-minute exposure events of the individuals in indoor, outdoor, and in-vehicle microenvironments. The use of APEX for estimating exposures allows for consideration of factors that affect exposures that are not addressed by consideration of ambient air concentrations alone. These factors include: (1) Attenuation in SO

concentrations expected to occur in some indoor microenvironments; (2) the influence of human activity patterns on the time series of exposure concentrations; and (3) accounting for human physiology and the occurrence of elevated breathing rates concurrent with SO

exposures. These factors are all key to appropriately characterizing health risk for SO

The APEX model has a history of application, evaluation, and progressive model development in estimating human exposure and dose for review of

NAAQS for gaseous pollutants (see,

e.g.,

U.S. EPA, 2008b; 2010; 2014d). This general exposure modeling approach was also used in the 2009 REA for the last review of the primary standard for SO

, although a number of updates have been made to the model and various datasets used with it (2009 REA; REA Planning Document, section 3.4). For example, exposure modeling in the current REA includes reliance on updates to several key inputs of the model, including: (1) A significantly expanded Consolidated Human Activity Database (CHAD), that now has over 55,000 diaries, with over 25,000 school-aged children; (2) updated National Health and Nutrition Examination Survey (NHANES) data (2009-2014), which are the basis for the age- and sex-specific body weight distributions that APEX samples to specify the individuals in the modeled populations; (3) the algorithms used to estimate age- and sex-specific resting metabolic rate, a key input to estimating a simulated individual's activity-specific ventilation (or breathing) rate; and (4) the ventilation rate algorithm itself. Further, the current model uses updated population demographic data based on the most recent Census.

As used in the current assessment, the APEX model probabilistically generates a sample of hypothetical individuals based on sampling from an actual population database, and simulates each individual's movements through time and space (

e.g.,

indoors at home, inside vehicles) to estimate his or her exposure to a pollutant. Population characteristics are taken into account to represent the demographic profile of the population in each study area. Age and gender demographics for the simulated at-risk population (adults and children with asthma) were drawn from the prevalence estimates provided by the 2011-2015 NHIS.

The APEX model generates each simulated person or profile by probabilistically selecting values for a set of profile variables, including demographic variables, status and physical attributes (

e.g.,

residence with air conditioning, height, weight, body surface area) and ventilation rate.

Data for these years were obtained from the NHIS, available at

https://www.cdc.gov/nchs/nhis/data-questionnaires-documentation.htm.

Based on minute-by-minute activity levels and physiological characteristics of the simulated person, APEX estimates an equivalent ventilation rate (EVR) based on normalizing the simulated individuals' activity-specific ventilation rate to their body surface area; the EVR is used to identify exposure periods during which an individual is at or above a specified ventilation level (REA, section 4.1). The level specified is based on the ventilation rates of subjects in the controlled human exposure studies of exercising people with asthma (ISA, Table 5-2). The APEX simulations performed for this review have focused on exposures to SO

emitted into ambient air that occurs in microenvironments

without additional contribution from indoor SO

emissions sources.

Five microenvironments (MEs) are modeled in the REA as representative of a larger number of MEs. The 2009 REA results indicated that the majority of peak SO

exposures occurred while individuals were within outdoor MEs (2009 REA, Figure 8-21). Based on that finding and the objective (

i.e.,

understanding how often and where short-term peak SO

exposures occur), some MEs that were used in the 2009 REA were aggregated to address exposures of ambient origin that occur within a core group of indoor, outdoor, and vehicle MEs (REA, section 4.2).

Indoor sources of SO

are generally minor in comparison to SO

from ambient air (ISA, p. 3-6; REA, section 2.1.1 and 2.1.2).

The at-risk populations for which exposure and risk are estimated (people with asthma) comprise 8.0 to 8.7% of the populations in the exposure modeling domains for the three study areas (REA, section 5.1). The percent of children with asthma in the simulated populations ranges from 9.7 to 11.2% across the three study areas (REA, section 5.1). Within each study area the percent varies with age, sex and whether family income is above or below the poverty level (REA, section 4.1.2, Appendix E).

This variation is greatest in the Fall River study area, with census block level, age-specific asthma prevalence estimates ranging from 7.9 to 18.6% for girls and from 10.7 to 21.5% for boys (REA, Table 4-1).

As described in section 4.1.2 and Appendix E of the REA, asthma prevalence in the exposure modeling domain is estimated based on national prevalence information and study area demographic information related to age, sex and poverty status.

As in the last review, the REA for this review uses the APEX model estimates of 5-minute exposure concentrations for simulated individuals with asthma while breathing at elevated rates to characterize health risk in two ways (REA, section 4.5). The first is the percentage of the simulated at-risk populations expected to experience days with 5-minute exposures, while breathing at elevated rates, that are at or above a range of benchmark levels. The second is the percentage of these populations expected to experience days with an occurrence of a doubling or tripling of sRaw. The benchmark concentrations were identified based on consideration of the evidence discussed in section II.B above.

For the benchmark metric, the REA uses benchmark concentrations of 400 ppb, 300 ppb, 200 ppb based on concentrations included in the well-documented controlled human exposure studies summarized in section II.B above, and also 100 ppb in consideration of uncertainties with regard to lower concentrations and population groups with more limited data, as discussed in section II.B above (REA, section 4.5.1). At the upper end of this range, 400 ppb represents the lowest concentration in free-breathing controlled human exposure studies of exercising people with asthma where moderate or greater lung function decrements occurred that were often statistically significant at the group mean level and were frequently accompanied by respiratory symptoms, with some increases in these symptoms also being statistically significant at the group level (ISA, Section 5.2.1.2 and Table 5-2). At 300 ppb, statistically significant increases in lung function decrements (specifically reduced FEV

) have been documented in analyses of the subset of controlled human exposure study subjects with asthma that are responsive to SO

at concentrations below 600 or 1000 ppb (ISA, pp. 5-85 and 5-153 and Table 5-21; Johns et al., 2010). The 200 ppb benchmark concentration represents the lowest level for which individual study subject data are available in terms of the sRaw and FEV

from studies that have assessed the SO

effect

versus

the effect of exercise in clean air; moderate or greater lung function decrements were documented in some of these study subjects (ISA, Table 5-2 and Figure 5-1; PA, Table 3-1; REA, section 4.6.1). For exposure concentrations below 200 ppb, limited data are available for exposures at 100 ppb that, while not directly comparable to the data at higher concentrations because of differences in methodology and metrics reported,

do not indicate that study subjects experienced responses of a magnitude as high as a doubling in sRaw. However, in consideration of some study subjects with asthma experiencing moderate or greater decrements in lung function at the 200 ppb exposure concentration (approximately 8 to 9% of the study group) and of the paucity or lack of any specific study data for some groups of individuals with asthma, such as primary-school-age children and those

with more severe asthma,

a benchmark concentration of 100 ppb (one half the lowest exposure concentration tested in free breathing exposure studies that assessed the SO

effect

versus

the effect of exercise in clean air) is also included.

As explained in section II.B.3 above, these studies involved exposures via mouthpiece, and only a few of these studies included an exposure to clean air while exercising that would have allowed for determining the effect of SO

versus

that of exercise in causing bronchoconstriction (ISA, section 5.2.1.2; PA, section 3.2.1.3).

As summarized in section II.B.3 above, recognizing that even the study subjects described as “moderate/severe” group (had well-controlled asthma, were generally able to withhold medication, were not dependent on corticosteroids, and were able to engage in moderate to heavy levels of exercise) would likely be classified as moderate by today's classification standards (ISA, p. 5-22; Johns et al., 2010; Reddel, 2009), we have considered the evidence with regard to the response of individuals with severe asthma that are not generally represented in the full set of controlled human exposure studies. There is no evidence to indicate such individuals would experience moderate or greater SO

-related lung function decrements at lower SO

exposure concentrations than individuals with moderate asthma. With regard to the severity of response, the limited data that are available indicate a similar magnitude of relative lung function decrements in response to SO

as that for individuals with less severe asthma, although the individuals with more severe asthma are indicated to have a larger absolute response and a greater response to exercise prior to SO

exposure, indicating uncertainty in the role of exercise

versus

and that those individuals “may have more limited reserve to deal with an insult compared with individuals with mild asthma” (ISA, p. 5-22). As noted previously, evidence from controlled human exposure studies are not available for children younger than 12 years old, and the ISA indicates that the information regarding breathing habit and methacholine responsiveness for the subset of this age group that is of primary school age (

e.g.,

5-12 years) indicates a potential for greater response (ISA, pp. 5-22 to 5.25).

The E-R function for estimating risk of lung function decrements was developed from the individual subject results for sRaw from the controlled exposure studies of exercising freely breathing people with asthma exposed to SO

concentrations from 1000 ppb down to as low as 200 ppb (REA, Table 4-11). Beyond the assessment of these studies and their results in past reviews, there has been extensive evaluation of the individual subject results, including a data quality review in the last primary SO

NAAQS review (Johns and Simmons, 2009), and detailed analysis in two subsequent publications (Johns et al., 2010; Johns and Linn, 2011). The sRaw responses reported in the controlled exposure studies have been summarized in the ISA in terms of percent of study subjects experiencing responses of a magnitude equal to a doubling or tripling or more (

e.g.,

ISA, Table 5-2; Long and Brown, 2018). Across the exposure range from 200 to 1000 ppb, the percentage of exercising study subjects with asthma having at least a doubling of sRaw increases from about 8-9% (at exposures of 200 ppb) up to approximately 50-60% (at exposures of 1000 ppb) (REA, Table 4-11). The E-R function was derived from these data using a probit function (REA, section 4.6.2).

2. Key Limitations and Uncertainties

While the general approach and methodology for the exposure-based assessment in this review is similar to that used in the last review, there are a number of ways in which the current analyses differ and incorporate improvements. For example, in addition to an expansion in the number and type of study areas assessed, input data and modeling approaches have improved in a number of ways, including the availability of continuous 5-minute air monitoring data at monitors within the three study areas. The REA for the current review extends the time period of simulation to a 3-year simulation period, consistent with the form established for the now-current standard. Further, the years simulated reflect more recent emissions and circumstances subsequent to the 2010 decision.

In characterizing uncertainty associated with the risk and exposure estimates in this review, the REA used an approach intended to identify and compare the relative impact that important sources of uncertainty may have (REA, section 6.2). This approach is a qualitative uncertainty characterization approach adapted from the World Health Organization (WHO) approach for characterizing uncertainty in exposure assessment (WHO, 2008) accompanied by quantitative sensitivity analyses of key aspects of the assessment approach (REA, chapter 6).

73 74

The REA considers the limitations and uncertainties underlying the analysis inputs and approaches and the extent of their influence on the resultant exposure/risk estimates. Consistent with the WHO (2008) guidance, the overall impact of the uncertainty is scaled by considering the extent or magnitude of the impact of the uncertainty as implied by the relationship between the source of the uncertainty and the exposure/risk output. The REA also evaluated the direction of influence, indicating how the source of uncertainty was judged to affect the exposure and risk estimates (

e.g.,

likely to produce over- or under-estimates).

The approach used has been applied in REAs for past NAAQS review for nitrogen oxides, carbon monoxide, ozone (U.S. EPA, 2008b; 2010; 2014d), and SO

(U.S. EPA, 2009).

The approach used varies from that of WHO (2008) in that the REA approach placed a greater focus on evaluating the direction and the magnitude of the uncertainty (

i.e.,

qualitatively rating how the source of uncertainty, in the presence of alternative information, may affect the estimated exposures and health risk results).

Several areas of uncertainty are identified as particularly important, with some similarities to those in the last review. Generally, these areas of uncertainty include estimation of the spatial distribution of SO

concentrations across each study area under air quality conditions just meeting the current standard, including the fine-scale temporal pattern of 5-minute concentrations. Among other areas, there is also uncertainty with regard to population groups and exposure concentrations for which the health effects evidence base is limited or lacking (PA, section 3.2.2.3).

With regard to the spatial distribution of SO

concentrations, there is some uncertainty associated with the ambient air concentration estimates in the air quality scenarios assessed. A more detailed characterization of contributors to this uncertainty is presented in the REA (REA, section 6.2), with a general summary provided here. Assessment approach-related aspects contributing to this uncertainty include the model estimates of 1-hour concentrations and the approach employed to adjust the air quality surface to concentrations just meeting the current standard,

as well as the estimation of 1-hour ambient air concentrations resulting from emissions sources not explicitly modeled, all of which influence the temporal and spatial pattern of concentrations and associated exposure circumstances represented in the study areas (REA, sections 6.2.1 and 6.2.2). There is also uncertainty in the estimates of 5-minute concentrations in ambient air across the modeling receptors in each study area. The ambient air monitoring dataset available to inform the 5-minute estimates, much expanded in this review over the dataset available in the last review, is used to draw on relationships occurring at one location and over one range of concentrations to estimate the fine-scale temporal pattern in concentrations at the other locations. While this is an important area of uncertainty in the REA results because the ambient air 5-minute concentrations

are integral to the 5-minute estimates of exposure, the approach used to represent fine-scale temporal variability in the three study areas is strongly based in the available information and has been evaluated in the REA (REA, Table 6-3; sections 3.5.2 and 3.5.3).

In study areas in which estimated SO

concentrations at a very small number of receptors are substantially higher than those at all other air quality receptors, the two different adjustment approaches investigated in the REA (described in section II.C.1 above) can result in very different concentrations across the area. In areas with this characteristic, the first approach (which involves determining adjustments based on concentrations at the very highest receptor locations) generally results in appreciably lower concentrations than those associated with the second approach at receptor locations beyond the small group with the very highest concentrations in the area. This is discussed in greater detail in the REA, section 6.2.2.2.

Another important area of uncertainty, particular to interpretation of the lung function risk estimates, concerns estimates derived for exposure concentrations below those represented in the evidence base (REA, Table 6-3). The E-R function on which the risk estimates are based generates non-zero predictions of the percentage of the at-risk population expected to experience a day with at least a doubling of sRaw for all exposures experienced while breathing at an elevated rate. The uncertainty in the response estimates increases substantially with decreasing exposure concentrations below those well represented in the data from the controlled human exposure studies (

i.e.,

below 200 ppb).

Additionally, the assessment focuses on the daily maximum 5-minute exposure during a period of elevated breathing rate, summarizing results in terms of the days on which the magnitude of such exposure exceeds a benchmark or contributes to a doubling or tripling of sRaw. Although there is some uncertainty associated with the potential for additional, uncounted events in the same day, the health effects evidence indicates a lack of a cumulative effect of multiple exposures over several hours or a day (ISA, section 5.2.1.2) and a reduced response to repeated exercising exposure events over an hour (Kehrl et al., 1987). Further, information is somewhat limited with regard to the length of time after recovery from one exposure by which a repeat exposure would elicit a similar effect as that of the initial exposure event (REA, Table 6-3). Another area of uncertainty concerns the potential influence of co-occurring pollutants on the relationship between short-term SO

exposures and respiratory effects. For example, there is some limited evidence regarding the potential for an increased response to SO

exposures occurring in the presence of other common pollutants such as PM (potentially including particulate sulfur compounds), nitrogen dioxide and ozone, although the studies are limited (

e.g.,

with regard to their relevance to ambient exposures) and/or provide inconsistent results (ISA, pp. 5-23 to 5-26, pp. 5-143 to 5-144; 2008 ISA, section 3.1.4.7).

For example, “studies of mixtures of particles and sulfur oxides indicate some enhanced effects on lung function parameters, airway responsiveness, and host defense,” however, “some of these studies lack appropriate controls and others involve [sulfur-containing species] that may not be representative of ambient exposures” (ISA, p. 5-144). These toxicological studies in laboratory animals, which were newly available in the last review, were discussed in greater detail in the 2008 ISA. That ISA stated that “[r]espiratory responses observed in these experiments were in some cases attributed to the formation of particular sulfur-containing species” yet, “the relevance of these animal toxicological studies has been called into question because concentrations of both PM (1 mg/m

and higher) and SO

(1 ppm and higher) utilized in these studies are much higher than ambient levels” (2008 ISA, p. 3-30).

Another area of uncertainty, which remains from the last review and is important to our consideration of the REA results, concerns the extent to which the quantitative results represent the populations at greatest risk of effects associated with exposures to SO

in ambient air. As recognized in section II.B, the controlled human exposure study evidence base does not include studies of children younger than 12 years old and is limited with regard to studies of people with more severe asthma.

The limited evidence that informs our understanding of potential risk to these groups indicates the potential for them to experience greater impacts than other population groups with asthma under similar exposure circumstances or, in the case of people with severe asthma, to have a more limited reserve for addressing this risk (ISA, section 5.2.1.2). Further, we note the lack of information on the factors contributing to increased susceptibility to SO

-induced bronchoconstriction among some people with asthma compared to others (ISA, pp. 5-19 to 5-21). These data limitations contribute uncertainty to the exposure/risk estimates with regard to the extent to which they represent the populations at greatest risk of SO

-related respiratory effects.

We additionally recognize that limitations in the activity pattern information for children younger than five years old precluded their inclusion in the populations of children simulated in the REA (REA, section 4.1.2).

In summary, among the multiple uncertainties and limitations in data and tools that affect the quantitative estimates of exposure and risk and their interpretation in the context of considering the current standard, several are particularly important. These include uncertainties related to estimation of 5-minute concentrations in ambient air; the lack of information from controlled human exposure studies for the lower, more prevalent, concentrations of SO

and limited information regarding multiple exposure episodes within a day; the prevalence of different exposure circumstance represented by the three study areas; and characterization of particular subgroups of people with asthma that may be at greater risk.

3. Summary of Exposure and Risk Estimates

The REA provides estimates for two simulated at-risk populations: Adults with asthma and school-aged children

with asthma (REA, section 2.2). Focusing on the at-risk population of children with asthma, summarized here are two sets of exposure and risk estimates for the

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