Air pollution and cardiovascular admissions association in Spain: results within the EMECAS project

Environmental and societal influences acting on cardiovascular risk factors and disease at a population level: a review

It has long been known that cardiovascular disease (CVD) rates vary considerably among populations, across space and through time. It is now apparent that most of the attributable risk for myocardial infarction 'within' populations from across the world can be ascribed to the varying levels of a limited number of risk factors among individuals in a population. Individual risk factors (e.g. blood pressure) can be modified with resulting health gains. Yet, the persistence of large international variations in cardiovascular risk factors and resulting CVD incidence and mortality indicates that there are additional factors that apply to 'populations' that are important to understand as part of a comprehensive approach to CVD control. This article reviews the evidence on why certain populations are more at risk than others.

Seasonal and regional short-term effects of fine particles on hospital admissions in 202 US counties, 1999-2005

The authors investigated whether short-term effects of fine particulate matter with an aerodynamic diameter < or =2.5 microm (PM(2.5)) on risk of cardiovascular and respiratory hospitalizations among the elderly varied by region and season in 202 US counties for 1999-2005. They fit 3 types of time-series models to provide evidence for 1) consistent particulate matter effects across the year, 2) different particulate matter effects by season, and 3) smoothly varying particulate matter effects throughout the year. The authors found statistically significant evidence of seasonal and regional variation in estimates of particulate matter effect. Respiratory disease effect estimates were highest in winter, with a 1.05% (95% posterior interval: 0.29, 1.82) increase in hospitalizations per 10-microg/m(3) increase in same-day PM(2.5). Cardiovascular diseases estimates were also highest in winter, with a 1.49% (95% confidence interval: 1.09, 1.89) increase in hospitalizations per 10-microg/m(3) increase in same-day PM(2.5), with associations also observed in other seasons. The strongest evidence of a relation between PM(2.5) and hospitalizations was in the Northeast for both respiratory and cardiovascular diseases. Heterogeneity of PM(2.5) effects on hospitalizations may reflect seasonal and regional differences in emissions and in particles' chemical constituents. Results can help guide development of hypotheses and further epidemiologic studies on potential heterogeneity in the toxicity of constituents of the particulate matter mixture.

A 10-year time-series analysis of respiratory and cardiovascular morbidity in Nicosia, Cyprus: the effect of short-term changes in air pollution and dust storms

BACKGROUND

To date, a substantial body of research has shown adverse health effects of short-term changes in levels of air pollution. Such associations have not been investigated in smaller size cities in the Eastern Mediterranean. A particular feature in the region is dust blown from the Sahara a few times a year resulting in extreme PM10 concentrations. It is not entirely clear whether such natural phenomena pose the same risks.

METHODS

The effect of changes in daily levels of particulate matter (PM10) and ozone (O3) on hospitalization for all, cardiovascular and respiratory causes in the two hospitals in Nicosia during 1 January 1995 and 30 December 2004 was investigated using generalized additive Poisson models after controlling for long- and short-term patterns as well as for the effect of weather. Meteorological records were reviewed to identify dust-storm days and analyses were repeated to quantify their effect on cardio-respiratory morbidity.

RESULTS

For every 10 microg/m3 increase in daily average PM10 concentrations, there was a 0.9% (95%CI: 0.6%, 1.2%) increase in all-cause and 1.2% (95%CI: -0.0%, 2.4%) increase in cardiovascular admissions. With respect to respiratory causes, an effect was observed only in the warm months. No lagged effects with levels of PM10 were observed. In contrast, positive associations with levels of ozone were only observed the two days prior to admission. These appeared stronger for cardiovascular causes and independent of the effect of PM. All-cause and cardiovascular admissions were 4.8% (95%CI: 0.7%, 9.0%) and 10.4% (95%CI: -4.7%, 27.9%) higher on dust storm days respectively. In both cases the magnitude of effect was comparable to that seen on the quartile of non-storm days with the highest levels of PM10.

CONCLUSION

We observed an increased risk of hospitalization at elevated levels of particulate matter and ozone generally consistent with the magnitude seen across several European cities. We also observed an increased risk of hospitalization on dust storm days, particularly for cardiovascular causes. While inference from these associations is limited due to the small number of dust storm days in the study period, it would appear imperative to issue health warnings for these natural events, particularly directed towards vulnerable population groups.

Cardiovascular disease and air pollutants: evaluating and improving epidemiological data implicating traffic exposure

Evidence suggests that traffic-related pollutants play a role in the observed associations between air pollution and adverse cardiovascular health effects. The contribution of traffic to individual exposures is difficult to quantify in traditional epidemiological studies, however, and researchers have employed various approaches in attempt to isolate its effects. Many investigators have employed ambient measurements such as nitrogen oxides, carbon monoxide, or black carbon as surrogates for traffic in studying associations with health outcomes. Source-apportionment techniques also have been used in a few studies to identify associations with the mixture of pollutants from specific origins, including traffic. In other studies, estimates of traffic near a person's home have predicted cardiovascular endpoints, and local traffic levels have modified the effect of regional air pollution. More recently, studies have linked changes in cardiovascular health to time spent in traffic. In this article, we review the epidemiological evidence regarding the impact of traffic-related pollution on cardiovascular diseases and examine the different techniques used to examine this important research question. We conclude with a discussion of the future directions being used in ongoing epidemiological studies to identify the cardiovascular health impacts of traffic.

Short-term effects of air pollution on cardiovascular diseases: outcomes and mechanisms

The effects of air pollution on health have been intensively studied in recent years. Acute exposure to environmental pollutants such as particulate and gaseous matters (carbon monoxide, nitrogen oxides, sulphur dioxide and ozone) was associated with an increased rate of events and mortality because of cardiovascular diseases. These effects were investigated in short-term studies, which related day-to-day variations in air pollution to disease, and in long-term studies, which have followed cohorts of exposed individuals over time. The evidence from the literature on the short-term cardiovascular effects of air pollutants is discussed from clinical and mechanistic points of view.

Air pollution effects on the respiratory health of the resident adult population in Turin, Italy

A case-control study was employed to investigate the relationship between atmospheric pollution and emergency hospital attendance for respiratory causes among adult and elderly patients resident in Turin in the period 1997 - 1999. Based on the primary diagnosis, adult (15 - 64 years) and elderly (>64 years) patients resident in Turin and admitted for respiratory causes were defined as Cases (n1 = 4.645); adult and elderly patients admitted for causes other than respiratory diseases or heart diseases were defined as Controls (n2 = 152.954). Sulfur dioxide (SO2 in microg/m3), total suspended particulate (TSP in microg/m3) and carbon monoxide (CO in mg/m3) were taken as indicators of urban air pollution; principal confounding factors were patient sex, age and education level; season, temperature, humidity, solar radiation; day of hospital admission. Statistical analysis was performed using logistic regression models. In accordance with Odds Ratio (OR) values and relative 95% Confidence Intervals (OR_95% CI) estimated by the models, associations are expressed as percent increase in risk (Increase%)1 and relative 95% Confidence Interval (95% CI) per 10 microg/m3 in SO2 and TSP, and per 1 mg/m3 in CO exposure. After adjusting for confounding factors, there was a mean increase in emergency hospital attendance of 2.20% (95% CI 1.70 - 2.60) and 2.55% (95% CI 1.79 - 3.32) per 10 microg/m3 increase in exposure to SO2 and TSP, respectively, and a mean increase of 5.30% (95% CI 3.00 - 7.70) per 1 mg/m3 increase in exposure to CO. A significant association was separately confirmed for SO2 and TSP in adult (15 - 64 years) and elderly (>64 years) patients, but for CO only among elderly patients. A significant association was found between the increase in emergency hospital attendance for respiratory causes and exposure to sulfur dioxide, total suspended particulate and carbon monoxide in Turin during the study period. This easy to use and manage case-control study produced results in line with those reported for other Italian and European cities.

Adhesive interaction measured between AFM probe and lung epithelial type II cells

The toxicity of inhaled nanoparticles entering the body through the lung is thought to be initially defined by the electrostatic and adhesive interaction of the particles with lung's wall. Here, we investigated the first step of the interaction of nanoparticles with lung epithelial cells using atomic force microscope (AFM) as a force apparatus. Nanoparticles were modeled by the apex of the AFM tip and the forces of interaction between the tip and the cell analyzed over time. The adhesive force and work of adhesion strongly increased for the first 100s of contact and then leveled out. During this time, the tip was penetrating deeply into the cell. It first crossed a stiff region of the cell and then entered a much more compliant cell region. The work of adhesion and its progression over time were not dependent on the load with which the tip was brought into contact with the cell. We conclude that the initial thermodynamic aspects and the time course of the uptake of nanoparticles by lung epithelial cells can be studied using our experimental approach. It is discussed how the potential health threat posed by nanoparticles of different size and surface characteristics can be evaluated using the method presented.

Evaluation of health benefits for improving indoor air quality in workplace

In contrast to a majority of reported damage-cost literature being focused on outdoor pollution, this paper describes the development of a protocol that links population exposure data with reported epidemiological concentration-response coefficients. A change in indoor particulate level is expressed as a change in total exposure levels, which is then linked with a corresponding change in ambient particulate concentrations before evaluating the associated health benefits. In this study, the development of protocol is illustrated by using a typical office building environment and daily time activity patterns of office occupants in Hong Kong. Our results indicate that some benefit gains for the owners-employers and the society would be anticipated if certain filter set configurations had been adopted. However, the amount of benefit gains for the owners-employers is shown to be increased with the average salary level of employees and the duration of their stay in offices.

Airborne particulate matter and premature deaths in urban Europe: the new WHO guidelines and the challenge ahead as illustrated by Spain

Twenty first century epidemiological publications on urban air pollution are confirming that inhalation of fine, airborne particulate matter (PM) has serious chronic human health effects and is a major cause of premature death worldwide. Recently updated recommendations by WHO identify three "Interim Targets" for the stepped reduction in PM levels within world cities in the quest to achieve an annual mean Air Quality Guideline (AQG) concentration of 20 mug/m(3) for particles less than 10 microns in size (PM(10)). In this paper we offer a perspective from Spain, a country with the longest record of reporting pollution data from large numbers of urban traffic sites to a central European database (AIRBASE). We can demonstrate that average annual PM concentrations at urban traffic monitoring stations in many European cities continue to be 50-100% above the WHO AQG, a situation exacerbated by high urban PM(2.5/10) ratios which indicate a dominance of finer, more deeply inhalable particles potentially more detrimental to health. Given that WHO has estimated in 2000 there were well over 250,000 premature deaths in Europe attributable to PM inhalation, such continuing high urban pollution levels are placing a huge burden on European medical resources.