Determining the threshold effect of ozone on daily mortality: an analysis of ozone and mortality in Seoul, Korea, 1995-1999

Relationship between short-term ozone exposure, cause-specific mortality, and high-risk populations: A nationwide, time-stratified, case-crossover study

BACKGROUND

Previous studies reported that short-term exposure to ground-level ozone is associated with mortality risk. However, due to the limited monitored areas, existing studies were limited in assessing the nationwide risk and suggesting specific vulnerable populations to the ozone-mortality risk.

METHODS

We performed a nationwide time-stratified case-crossover study to evaluate the association between short-term ozone and cause-specific mortality in South Korea (2015-2019). A machine learning-ensemble prediction model (a test R2 > 0.96) was used to assess the short-term ozone exposure. Stratification analysis was conducted to examine the high-risk populations, and the excess mortality due to non-compliance with the WHO guideline was also assessed.

RESULTS

For all-cause mortality (1,343,077 cases), the risk associated with ozone (lag0- 1) was weakly identified (odd ratio: 1.005 with 95% CI: 0.997-1.014), and the risk was prominent in mortality with circulatory system diseases. In addition, based on the point estimates, the ozone-mortality risk was higher in people aged less than 65y, and this pattern was also observed in circulatory system disease deaths and urban areas.

CONCLUSIONS

This study provides national estimates of mortality risks associated with short-term ozone. Results showed that the benefits of stricter air quality standards could be greater in vulnerable populations.

Role of oxides of nitrogen in the ozone-cardiorespiratory visit association

Ozone (O₃)-induced health effects vary in terms of severity, from deterioration of lung function and hospitalization to death. Several studies have reported a linear increase in health risks after O₃ exposure. However, current evidence suggests a non-linear U- and J-shaped concentration-response (C-R) function. The potential increasing risks with decreasing O₃ concentrations may seem counterintuitive from the traditional standpoint that decreasing exposure should lead to decreasing health risks. Tus, the question of whether the increasing risks with decreasing concentrations are truly O₃-induced or might be from other C-R mechanisms. If these potential risks were not accounted for, this may have contributed to the risks observed at the low ozone concentration range. In this study, we examined the short-term effects of photochemical oxidant (O_x, parts per billiion) on outpatient cardiorespiratory visits in 21 Japanese cities after adjusting for other air pollutant-specific C-R functions. Daily cardiorespiratory visits from January 1, 2014 to December 31, 2016 were obtained from the Japanese Medical Data Center Co. Ltd. Similar period of meteorological and air pollution variables were obtained from relevant data sources. We utilized a time-stratified case crossover design coupled with the generalized additive mixed model (TSCC-GAMM) to estimate the association between O_x and cardiorespiratory outpatient visits, after adjusting for several covariates. A total of 2,588,930 visits were recorded across the study period, with a mean of 111.87 and a standard deviation of 138.75. The results revealed that crude O_x-cardiorespiratory visits exhibited a U-shaped pattern. However, adjustment of the oxides of nitrogen, particularly nitrogen monoxide (NO), attenuated the lower risk curve and subsequently altered the shape of the C-R function, with a substantial reduction observed during winter. NO- and nitrogen dioxide (NO_2)-adjusted O_x-cardiorespiratory associations increased nearly linearly, without an apparent threshold. Current evidence suggests the importance of adjusting the oxides of nitrogen in estimating the O_x C-R risk functions.

Short-term exposure to ozone and cause-specific mortality risks and thresholds in China: Evidence from nationally representative data, 2013-2018

BACKGROUND

Ambient ozone pollution is steadily increasing and becoming a major environmental risk factor contributing to the global disease burden. Although the association between short-term ozone exposure and mortality has been widely studied, results are mostly reported on deaths from non-accidental or total cardiopulmonary disease rather than a spectrum of causes. In particular, a knowledge gap still exists for the potential thresholds in mortality risks.

METHODS

This nationwide time-series study in China included 323 counties totaling 230,266,168 residents. Daily maximum 8-hour average was calculated as the ozone exposure metric. A two-stage statistical approach was adopted to assess ozone effects on 21 cause-specific deaths for 2013-2018. The subset approach and threshold approach were utilized to explore potential thresholds, and stratification analysis was used to evaluate population susceptibility.

RESULTS

On average, the annual mean ozone concentration was 93.4 μg/m³ across 323 counties. A 10-μg/m³ increase in lag 0-1 day of ozone was associated with increases of 0.12 % in mortality risk from non-accidental disease, 0.11 % from circulatory disease, 0.09 % from respiratory disease, 0.29 % from urinary system disease, and 0.20 % from nervous system disease. There may be a "safe" threshold in the ozone-mortality association, which may be between 60 and 100 μg/m³, and vary by cause of death. Women and older adults (especially those over 75) are more affected by short-term ozone exposure. Populations in North China had a higher risk of ozone-related circulatory mortality, while populations in South China had a higher risk of ozone-related respiratory mortality.

CONCLUSIONS

National findings link short-term ozone exposure to premature death from circulatory, respiratory, neurological, and urinary diseases, and provide evidence for a potential "safe" threshold in the association of ozone and mortality. These findings have important implications for helping policymakers tighten the relevant air quality standards and developing early warning systems for public health protection in China.

Particulate matter and ozone might trigger deaths from chronic ischemic heart disease

AIMS

To study the association between short-term exposure to air pollutants and mortality of Chronic Ischemic Heart Disease (CIHD).

METHODS

Using a case-crossover design, we investigated 148,443 CIHD deaths from 2015 to 2020 in Jiangsu Province, China. Exposure to six ambient pollutants, including PM₁₀, PM_2.5, NO₂, CO, SO₂, and O_3, was assessed by extracting daily concentrations from validated 10 km × 10 km pollutant grids at each subject's residential address. A conditional logistic regression approach was used to explore the exposure-response relationship with adjustment for temperature and relative humidity. We calculated the Population Attributable Fractions (PAFs) and the attributable deaths number of CIHD.

RESULTS

An increase of 10 μg/m³ in PM₁₀ and PM_2.5 exposure was associated with a 1.16% (95% CI: 0.85-1.48%) and 1.80% (1.36-2.24%) increase in CIHD mortality, respectively. A threshold value of 123 µg/m³ was identified for the association between O₃ exposure and CIHD mortality. Controlling for PM_2.5, each increase of 10 µg/m³ in O₃ (>threshold) was statistically significantly associated with a 0.94% (0.19-1.71%) increase in CIHD mortality, however there was no association between NO₂, SO₂, CO exposure and CIHD mortality. Reducing PM_2.5, PM₁₀ and O₃ to the WHO air quality guidelines would prevent 6.16% (95% CI: 4.70-7.58%), 4.30% (3.18-5.43%) and 1.29% (0.48-4.20%) of CIHD deaths, respectively. During the warm season, mortality and PAFs of CIHD associated with PM_2.5, PM₁₀, and O₃ were significantly higher.

CONCLUSIONS

Short-term exposure to ambient PM_2.5, PM_10, and O₃ might trigger deaths from CIHD. These findings indicate that the premature deaths of CIHD patients can be alleviated by reducing exposure to polluted air.

Association between sub-daily exposure to ambient air pollution and risk of asthma exacerbations in Australian children

Short-term exposure to ambient air pollution is associated with risk of asthma attacks. We investigated the association between ultra-short-term exposure to air pollution and risk of childhood asthma exacerbations. Hourly data on emergency department visits (EDVs) for asthma in children during 2013-2015 in Brisbane, Australia, were obtained. We undertook time-stratified case-crossover analyses to examine the hourly association between exposure to air pollutants (particles with diameter ≤10 μm (PM₁₀), particles with diameter ≤2.5 μm (PM_2.5), ozone (O₃), and nitrogen dioxide (NO₂)) and risk of EDVs for asthma after controlling for temperature, relative humidity, public holidays and circulating levels of influenza and respiratory syncytial virus. Risk of EDVs for asthma increased within a few hours after exposure to O₃ (odds ratio [OR]: 1.170, 95% confidence interval (CI): 1.003-1.365) or NO₂ (OR: 1.359, 95%CI: 1.049-1.760). The association between O₃ exposure and risk of EDVs for asthma was stronger in boys (OR: 1.244, 95%CI: 1.025-1.511) than that in girls (OR: 1.055, 95%CI: 0.818-1.361). The association between NO₂ exposure and risk of EDVs for asthma was stronger in school-age children [OR ranged from 1.376 (95%CI: 1.044-1.813) to 3.607 (95%CI: 1.552-8.385) across different lags] than that in preschool-age children, whereas the association between PM₁₀ exposure and risk of EDVs for asthma was greater in preschool-age children [OR ranged from 1.873 (95%CI: 1.022-3.433) to 1.878 (95%CI: 1.028-3.431)] than that in school-age children. We observed an association of risk of EDVs for asthma with daytime air pollution exposure, but not with night-time air pollution exposure. This study suggests that risk of childhood asthma exacerbations increases within a few hours of air pollution exposure.

Causal association between ambient ozone concentration and mortality in Seoul, Korea

BACKGROUND

The linearity of concentration-response (C-R) curve between ambient ozone (O₃) concentration and mortality has been controversial. The aim of the present analysis was to examine the C-R curve between O₃ concentration and mortality with a causal framework approach.

METHODS

We extracted data of hourly meteorology, hourly O₃ concentration and daily non-accidental mortality in Seoul from 2001 to 2009. We divided the dataset into two, odd-number (training set) and even-number years (testing set). Using the training set, we constructed a prediction model from hourly O₃ concentration with support vector regression estimating the daily variations of mean O₃ concentration caused by sun irradiation, wind speed and direction, controlling temperature, barometric pressure and temporal trend. With this model we predicted variance of daily O₃ from the testing set, thus creating an instrumental variable. We analyzed the association between the instrumental variable and daily mortality. We also analyzed the association according to the quartiles of daily mean O₃ concentration to examine the linearity of the association.

RESULTS

The instrumental variable was significantly and negatively associated with daily mortality in the linear model. In the stratified analysis, the negative slope was observed in the lowest quartile and the negative slope of the association diminished as the quartile increased, and the slope became positive over the 3rd quartile (O₃ > 23.3 ppb). The interaction between quartiles and instrumental variable was significant (P = 0.0108).

CONCLUSION

We observed unequal effect of exposure to ambient O₃ concentration on mortality according to the different ranges of daily mean O₃ concentration with a causal framework approach.

Air quality co-benefits from climate mitigation for human health in South Korea

Climate change mitigation efforts to reduce greenhouse gas (GHG) emissions have associated costs, but there are also potential benefits from improved air quality, such as public health improvements and the associated cost savings. A multidisciplinary modeling approach can better assess the co-benefits from climate mitigation for human health and provide a justifiable basis for establishment of adequate climate change mitigation policies and public health actions. An integrated research framework was adopted by combining a computable general equilibrium model, an air quality model, and a health impact assessment model, to explore the long-term economic impacts of climate change mitigation in South Korea through 2050. Mitigation costs were further compared with health-related economic benefits under different socioeconomic and climate change mitigation scenarios. Achieving ambitious targets (i.e., stabilization of the radiative forcing level at 3.4 W/m²) would cost 1.3-8.5 billion USD in 2050, depending on varying carbon prices from different integrated assessment models. By contrast, achieving these same targets would reduce costs by 23 billion USD from the valuation of avoided premature mortality, 0.14 billion USD from health expenditures, and 0.38 billion USD from reduced lost work hours, demonstrating that health benefits alone noticeably offset the costs of cutting GHG emissions in South Korea.

Characterization of the concentration-response curve for ambient ozone and acute respiratory morbidity in 5 US cities

Although short-term exposure to ambient ozone (O₃) can cause poor respiratory health outcomes, the shape of the concentration-response (C-R) between O₃ and respiratory morbidity has not been widely investigated. We estimated the effect of daily O₃ on emergency department (ED) visits for selected respiratory outcomes in 5 US cities under various model assumptions and assessed model fit. Population-weighted average 8-h maximum O₃ concentrations were estimated in each city. Individual-level data on ED visits were obtained from hospitals or hospital associations. Poisson log-linear models were used to estimate city-specific associations between the daily number of respiratory ED visits and 3-day moving average O₃ levels controlling for long-term trends and meteorology. Linear, linear-threshold, quadratic, cubic, categorical, and cubic spline O₃ C-R models were considered. Using linear C-R models, O₃ was significantly and positively associated with respiratory ED visits in each city with rate ratios of 1.02-1.07 per 25 ppb. Models suggested that O₃-ED C-R shapes were linear until O₃ concentrations of roughly 60 ppb at which point risk continued to increase linearly in some cities for certain outcomes while risk flattened in others. Assessing C-R shape is necessary to identify the most appropriate form of the exposure for each given study setting.

Current State of Research on the Risk of Morbidity and Mortality Associated with Air Pollution in Korea

PURPOSE

The effects of air pollution on health can vary regionally. Our goal was to comprehensively review previous epidemiological studies on air pollution and health conducted in Korea to identify future areas of potential study.

MATERIALS AND METHODS

We systematically searched all published epidemiologic studies examining the association between air pollution and occurrence of death, diseases, or symptoms in Korea. After classifying health outcomes into mortality, morbidity, and health impact, we summarized the relationship between individual air pollutants and health outcomes.

RESULTS

We analyzed a total of 27 studies that provided 104 estimates of the quantitative association between risk of mortality and exposure to air pollutants, including particulate matter with aerodynamic diameter less than 10 μm, particulate matter with aerodynamic diameter less than 2.5 μm, sulfur dioxide, nitrogen dioxide, ozone, and carbon monoxide in Korea between January 1999 and July 2018. Regarding the association with morbidity, there were 38 studies, with 98 estimates, conducted during the same period. Most studies examined the short-term effects of air pollution using a time series or case-crossover study design; only three cohort studies that examined long-term effects were found. There were four health impact studies that calculated the attributable number of deaths or disability-adjusted life years due to air pollution.

CONCLUSION

There have been many epidemiologic studies in Korea regarding air pollution and health. However, the present review shows that additional studies, especially cohort and experimental studies, are needed to provide more robust and accurate evidence that can be used to promote evidence-based policymaking.

Taehwa Research Forest: A receptor site for severe domestic pollution events in Korea during 2016

During the May-June 2016 International Cooperative Air Quality Field Study in Korea (KORUS-AQ), light synoptic meteorological forcing facilitated Seoul metropolitan pollution outflow to reach the remote Taehwa Research Forest (TRF) site and cause regulatory exceedances of ozone on 24 days. Two of these severe pollution events are thoroughly examined. The first, occurring on 17 May 2016, tracks transboundary pollution transport exiting eastern China and the Yellow Sea, traversing the Seoul Metropolitan Area (SMA), and then reaching TRF in the afternoon hours with severely polluted conditions. This case study indicates that although outflow from China and the Yellow Sea were elevated with respect to chemically unperturbed conditions, the regulatory exceedance at TRF was directly linked in time, space, and altitude to urban Seoul emissions. The second case studied, occurring on 09 June 2016, reveals that increased levels of biogenic emissions, in combination with amplified urban emissions, were associated with severe levels of pollutions and a regulatory exceedance at TRF. In summary, domestic emissions may be causing more pollution than by trans-boundary pathways, which have been historically believed to be the major source of air pollution in South Korea. The case studies are assessed with multiple aircraft, model (photochemical and meteorological) simulations, in-situ chemical sampling, and extensive ground-based profiling at TRF. These observations clearly identify TRF and the surrounding rural communities as receptor sites for severe pollution events associated with Seoul outflow, which will result in long-term negative effects to both human health and agriculture in the affected areas.

Concentration-response curve and cumulative effects between ozone and daily mortality: an analysis in Wallonia, Belgium

Many studies have shown an association between ozone and mortality. However, little data is available on the cumulative effects of ozone on health. A time-series analysis using a Poisson regression was used to measure the impact of ozone on non-traumatic mortality in Wallonia over the period 2000-2012. Initially, a single-lag model was tested. Then a distributed-lag non-linear model was used in order to verify the cumulative effects of ozone on mortality. Our study confirms the existence of an association between ozone and mortality. The linear model without threshold shows a higher sensitivity in persons aged 75 and over (ERR = 0.7, 95 % CI: 0.4; 1.0 %) compared to younger people (ages 25-74) (ERR = 0.2, 95 % CI: - 0.2; 0.6 %). Taking cumulative effects into account, men and women aged 25-74 have an ozone sensitivity equivalent to those over 75.

Short-term air pollution exposure aggravates Parkinson's disease in a population-based cohort

Increasing experimental evidence has suggested air pollution as new risk factor for neurological disease. Although long-term exposure is reportedly related to neurological disease, information on association with short-term exposure is scarce. We examined the association of short-term exposure to particles <2.5 μm (PM_2.5), nitrogen dioxide (NO₂), sulfur dioxide (SO₂), ozone (O₃), and carbon monoxide (CO) with PD aggravation in Seoul from the National Health Insurance Service–National Sample Cohort, Korea during 2002–2013. PD aggravation cases were defined as emergency hospital admissions for primarily diagnosed PD and analyzed with a case-crossover analysis, designed for rare acute outcomes. Pollutants concentrations on case and control days were compared and effect modifications were explored. A unit increase in 8-day moving average of concentrations was significantly associated with PD aggravation. The association was consistent for PM_2.5 (odds ratio [95% confidence interval]: 1.61 [1.14–2.29] per 10 μg/m³), NO₂ (2.35 [1.39–3.97] per 10 ppb), SO₂ (1.54 [1.11–2.14] per 1 ppb), and CO (1.46 [1.05–2.04] per 0.1 ppm). The associations were stronger in women, patients aged 65–74 years, and cold season, but not significant. In conclusion, short-term air pollution exposure increased risk of PD aggravation, and may cause neurological disease progression in humans.

Mortality and morbidity due to exposure to outdoor air pollution in Mashhad metropolis, Iran. The AirQ model approach

In the past two decades, epidemiological studies have shown that air pollution is one of the causes of morbidity and mortality. In this study the effect of PM10, PM2.5, NO2, SO2 and O3 pollutants on human health among the inhabitants of Mashhad has been evaluated. To evaluate the health effects due to air pollution, the AirQ model software 3.3.2, developed by WHO European Centre for Environment and Health, was used. The daily data related to the pollutants listed above has been used for the short term health effects (total mortality, cardiovascular and respiratory mortality, hospitalization due to cardiovascular and respiratory diseases, chronic obstructive pulmonary disease and acute myocardial infarction). PM2.5 had the most health effects on Mashhad inhabitants. With increasing in each 10μg/m3, relative risk rate of pollutant concentration for total mortality due to PM10, PM2.5, SO₂, NO₂ and O₃ was increased of 0.6%, 1.5%, 0.4%, 0.3% and 0.46% respectively and, the attributable proportion of total mortality attributed to these pollutants was respectively equal to 4.24%, 4.57%, 0.99%, 2.21%, 2.08%, and 1.61% (CI 95%) of the total mortality (correct for the non-accident) occurred in the year of study. The results of this study have a good compatibly with other studies conducted on the effects of air pollution on humans. The AirQ software model can be used in decision-makings as a useful and easy tool.

Projecting ozone-related mortality in East China

BACKGROUND

The concentrations of ozone (O3) in China are increasing, especially in East China, but its future trends and potential health impacts remain to be explored.

OBJECTIVES

The objective was to assess future trends in O3 concentrations and related premature death in East China between 2005 and 2030.

METHODS

First, a global chemical transport model (MIROC-ESM-CHEM) and regional chemical transport modelling system (including the Weather Research and Forecasting model and the Community Multiscale Air Quality model) were combined to estimate daily O3 concentrations in 2005 and 2030 in East China under the "current legislation" (CLE) and "maximum technically feasible reduction" (MFR) scenarios which were applied globally. O3 concentrations were then linked with population projections, mortality projections, and O3-mortality associations to estimate changes in O3-related mortality in East China.

RESULTS

The annual mean O3 concentration was projected to increase in East China between 2005 and 2030 under the CLE scenario, while decrease under the MFR scenario. Under the CLE scenario, O3-attributable health burden could increase by at least 40,000 premature deaths in East China, without considering the population growth. Under the MFR scenario, the health burden could decrease by up to 260,000 premature deaths as a result of the reduction in O3 concentration with a static population. However, when the population growth was considered, O3-attributable health burden could increase by up to 46,000 premature deaths in East China under the MFR scenario.

CONCLUSIONS

The results suggest that the health burden attributable to O3 may increase in East China in 2030.

Benefit-cost analysis of commercially available activated carbon filters for indoor ozone removal in single-family homes

This study involved the development of a model for evaluating the potential costs and benefits of ozone control by activated carbon filtration in single-family homes. The modeling effort included the prediction of indoor ozone with and without activated carbon filtration in the HVAC system. As one application, the model was used to predict benefit-to-cost ratios for single-family homes in 12 American cities in five different climate zones. Health benefits were evaluated using disability-adjusted life-years and included city-specific age demographics for each simulation. Costs of commercially available activated carbon filters included capital cost differences when compared to conventional HVAC filters of similar particle removal efficiency, energy penalties due to additional pressure drop, and regional utility rates. The average indoor ozone removal effectiveness ranged from 4 to 20% across the 12 target cities and was largely limited by HVAC system operation time. For the parameters selected in this study, the mean predicted benefit-to-cost ratios for 1-inch filters were >1.0 in 10 of the 12 cities. The benefits of residential activated carbon filters were greatest in cities with high seasonal ozone and HVAC usage, suggesting the importance of targeting such conditions for activated carbon filter applications.

Short-term population-based non-linear concentration-response associations between fine particulate matter and respiratory diseases in Taipei (Taiwan): a spatiotemporal analysis

Fine particulate matter <2.5 μm (PM2.5) has been associated with human health issues; however, findings regarding the influence of PM2.5 on respiratory disease remain inconsistent. The short-term, population-based association between the respiratory clinic visits of children and PM2.5 exposure levels were investigated by considering both the spatiotemporal distributions of ambient pollution and clinic visit data. We applied a spatiotemporal structured additive regression model to examine the concentration-response (C-R) association between children's respiratory clinic visits and PM2.5 concentrations. This analysis was separately performed on three respiratory disease categories that were selected from the Taiwanese National Health Insurance database, which includes 41 districts in the Taipei area of Taiwan from 2005 to 2007. The findings reveal a non-linear C-R pattern of PM2.5, particularly in acute respiratory infections. However, a PM2.5 increase at relatively lower levels can elevate the same-day respiratory health risks of both preschool children (<6 years old) and schoolchildren (6-14 years old). In preschool children, same-day health risks rise when concentrations increase from 0.76 to 7.44 μg/m(3), and in schoolchildren, same-day health risks rise when concentrations increase from 0.76 to 7.52 μg/m(3). Changes in PM2.5 levels generally exhibited no significant association with same-day respiratory risks, except in instances where PM2.5 levels are extremely high, and these occurrences do exhibit a significant positive influence on respiratory health that is especially notable in schoolchildren. A significant high relative rate of respiratory clinic visits are concentrated in highly populated areas. We highlight the non-linearity of the respiratory health effects of PM2.5 on children to investigate this population-based association. The C-R relationship in this study can provide a highly valuable alternative for assessing the effects of ambient air pollution on human health.

Effects of cold and hot temperature on dehydration: a mechanism of cardiovascular burden

The association between temperature (cold or heat) and cardiovascular mortality has been well documented. However, few studies have investigated the underlying mechanism of the cold or heat effect. The main goal of this study was to examine the effect of temperature on dehydration markers and to explain the pathophysiological disturbances caused by changes of temperature. We investigated the relationship between outdoor temperature and dehydration markers (blood urea nitrogen (BUN)/creatinine ratio, urine specific gravity, plasma tonicity and haematocrit) in 43,549 adults from Seoul, South Korea, during 1995-2008. We used piece-wise linear regression to find the flexion point of apparent temperature and estimate the effects below or above the apparent temperature. Levels of dehydration markers decreased linearly with an increase in the apparent temperature until a point between 22 and 27 °C, which was regarded as the flexion point of apparent temperature, and then increased with apparent temperature. Because the associations between temperature and cardiovascular mortality are known to be U-shaped, our findings suggest that temperature-related changes in hydration status underlie the increased cardiovascular mortality and morbidity during high- or low-temperature conditions.

Non-Linear Concentration-Response Relationships between Ambient Ozone and Daily Mortality

Background

Ambient ozone (O₃) concentration has been reported to be significantly associated with mortality. However, linearity of the relationships and the presence of a threshold has been controversial.

Objectives

The aim of the present study was to examine the concentration-response relationship and threshold of the association between ambient O₃ concentration and non-accidental mortality in 13 Japanese and Korean cities from 2000 to 2009.

Methods

We selected Japanese and Korean cities which have population of over 1 million. We constructed Poisson regression models adjusting daily mean temperature, daily mean PM₁₀, humidity, time trend, season, year, day of the week, holidays and yearly population. The association between O₃ concentration and mortality was examined using linear, spline and linear-threshold models. The thresholds were estimated for each city, by constructing linear-threshold models. We also examined the city-combined association using a generalized additive mixed model.

Results

The mean O₃ concentration did not differ greatly between Korea and Japan, which were 26.2 ppb and 24.2 ppb, respectively. Seven out of 13 cities showed better fits for the spline model compared with the linear model, supporting a non-linear relationships between O₃ concentration and mortality. All of the 7 cities showed J or U shaped associations suggesting the existence of thresholds. The range of city-specific thresholds was from 11 to 34 ppb. The city-combined analysis also showed a non-linear association with a threshold around 30-40 ppb.

Conclusion

We have observed non-linear concentration-response relationship with thresholds between daily mean ambient O₃ concentration and daily number of non-accidental death in Japanese and Korean cities.

Public-health impact of outdoor air pollution for 2(nd) air pollution management policy in Seoul metropolitan area, Korea

Objectives

Air pollution contributes to mortality and morbidity. We estimated the impact of outdoor air pollution on public health in Seoul metropolitan area, Korea. Attributable cases of morbidity and mortality were estimated.

Methods

Epidemiology-based exposure-response functions for a 10 μg/m3 increase in particulate matter (PM_2.5 and PM₁₀) were used to quantify the effects of air pollution. Cases attributable to air pollution were estimated for mortality (adults ≥ 30 years), respiratory and cardiovascular hospital admissions (all ages), chronic bronchitis (all ages), and acute bronchitis episodes (≤18 years). Environmental exposure (PM_2.5 and PM₁₀) was modeled for each 3 km × 3 km.

Results

In 2010, air pollution caused 15.9% of total mortality or approximately 15,346 attributable cases per year. Particulate air pollution also accounted for: 12,511 hospitalized cases of respiratory disease; 20,490 new cases of chronic bronchitis (adults); 278,346 episodes of acute bronchitis (children). After performing the 2^nd Seoul metropolitan air pollution management plan, the reducible death number associated with air pollution is 14,915 cases per year in 2024. We can reduce 57.9% of death associated with air pollution.

Conclusion

This assessment estimates the public-health impacts of current patterns of air pollution. Although individual health risks of air pollution are relatively small, the public-health consequences are remarkable. Particulate air pollution remains a key target for public-health action in the Seoul metropolitan area. Our results, which have also been used for economic valuation, should guide decisions on the assessment of environmental health-policy options.

A probabilistic spatial dengue fever risk assessment by a threshold-based-quantile regression method

Understanding the spatial characteristics of dengue fever (DF) incidences is crucial for governmental agencies to implement effective disease control strategies. We investigated the associations between environmental and socioeconomic factors and DF geographic distribution, are proposed a probabilistic risk assessment approach that uses threshold-based quantile regression to identify the significant risk factors for DF transmission and estimate the spatial distribution of DF risk regarding full probability distributions. To interpret risk, return period was also included to characterize the frequency pattern of DF geographic occurrences. The study area included old Kaohsiung City and Fongshan District, two areas in Taiwan that have been affected by severe DF infections in recent decades. Results indicated that water-related facilities, including canals and ditches, and various types of residential area, as well as the interactions between them, were significant factors that elevated DF risk. By contrast, the increase of per capita income and its associated interactions with residential areas mitigated the DF risk in the study area. Nonlinear associations between these factors and DF risk were present in various quantiles, implying that water-related factors characterized the underlying spatial patterns of DF, and high-density residential areas indicated the potential for high DF incidence (e.g., clustered infections). The spatial distributions of DF risks were assessed in terms of three distinct map presentations: expected incidence rates, incidence rates in various return periods, and return periods at distinct incidence rates. These probability-based spatial risk maps exhibited distinct DF risks associated with environmental factors, expressed as various DF magnitudes and occurrence probabilities across Kaohsiung, and can serve as a reference for local governmental agencies.

Ozone and daily mortality rate in 21 cities of East Asia: how does season modify the association?

Previous studies in East Asia have revealed that the short-term associations between tropospheric ozone and daily mortality rate were strongest in winter, which is opposite to the findings in North America and Western Europe. Therefore, we investigated the season-varying association between ozone and daily mortality rate in 21 cities of East Asia from 1979 to 2010. Time-series Poisson regression models were used to analyze the association between ozone and daily nonaccidental mortality rate in each city, testing for different temperature lags. The best-fitting model was obtained after adjustment for temperature in the previous 2 weeks. Bayesian hierarchical models were applied to pool the city-specific estimates. An interquartile-range increase of the moving average concentrations of same-day and previous-day ozone was associated with an increase of 1.44% (95% posterior interval (PI): 1.08%, 1.80%) in daily total mortality rate after adjustment for temperature in the previous 2 weeks. The corresponding increases were 0.62% (95% PI: 0.08%, 1.16%) in winter, 1.46% (95% PI: 0.89%, 2.03%) in spring, 1.60% (95% PI: 1.03%, 2.17%) in summer, and 1.12% (95% PI: 0.73%, 1.51%) in fall. We found significant associations between short-term exposure to ozone and higher mortality rate in East Asia that varied considerably from season to season with a significant trough in winter.

The impact of climate change on ozone-related mortality in Sydney

Coupled global, regional and chemical transport models are now being used with relative-risk functions to determine the impact of climate change on human health. Studies have been carried out for global and regional scales, and in our paper we examine the impact of climate change on ozone-related mortality at the local scale across an urban metropolis (Sydney, Australia). Using three coupled models, with a grid spacing of 3 km for the chemical transport model (CTM), and a mortality relative risk function of 1.0006 per 1 ppb increase in daily maximum 1-hour ozone concentration, we evaluated the change in ozone concentrations and mortality between decades 1996–2005 and 2051–2060. The global model was run with the A2 emissions scenario. As there is currently uncertainty regarding a threshold concentration below which ozone does not impact on mortality, we calculated mortality estimates for the three daily maximum 1-hr ozone concentration thresholds of 0, 25 and 40 ppb. The mortality increase for 2051–2060 ranges from 2.3% for a 0 ppb threshold to 27.3% for a 40 ppb threshold, although the numerical increases differ little. Our modeling approach is able to identify the variation in ozone-related mortality changes at a suburban scale, estimating that climate change could lead to an additional 55 to 65 deaths across Sydney in the decade 2051–2060. Interestingly, the largest increases do not correspond spatially to the largest ozone increases or the densest population centres. The distribution pattern of changes does not seem to vary with threshold value, while the magnitude only varies slightly.

Seasonal variation in the acute effects of ozone on premature mortality among elderly Japanese

We conducted a multicity time-series study using monitoring data to assess seasonal patterns of short-term ozone-mortality association among elderly aged 65 years and over in Japan. Daily exposure to ambient ozone was computed using hourly measurements of photochemical oxidants available at multiple monitoring stations in each city. Effects of ozone on daily all-cause non-accidental, cardiovascular, and respiratory mortality were estimated using distributed lag linear models, controlling for confounding by temporal, day of the week, temperature, and flu epidemics. City-level effect estimates were combined using inverse variance meta-analysis. In spring and autumn, a 10-ppbv increase of daily maximum 8-h average ozone concentration in the previous 3 days was associated with 0.69 % (95 % confidence interval (CI): 0.27-1.10), 1.07 % (0.34-1.82), and 1.77 % (0.78-2.77) increases in daily all-cause, cardiovascular, and respiratory mortality, respectively. Forward displacement of respiratory mortality was large during the cold season despite lower ozone concentration. Results were generally independent of fine particulate matter and nitrogen dioxide. Findings suggest significant mortality effects of short-term ozone exposure among the elderly during the moderate season. Those with underlying respiratory diseases were susceptible, even during winter.

Changes in the association between summer temperature and mortality in Seoul, South Korea

The health impact of climate change depends on various conditions at any given time and place, as well as on the person. Temporal variations in the relationship between high temperature and mortality need to be explored in depth to explain how changes in the level of exposure and public health interventions modify the temperature-mortality relationship. We examined changes in the relationship between human mortality and temperature in Seoul, which has the highest population in South Korea, considering the change in population structure from 1993-2009. Poisson regression models were used to estimate short-term temperature-related mortality impacts. Temperature-related risks were divided into two "time periods" of approximately equal length (1993 and 1995-2000, and 2001-2009), and were also examined according to early summer and late summer. Temperature-related mortality in summer over the past 17 years has declined. These decreasing patterns were stronger for cardiovascular disease-related mortality than for all non-accidental deaths. The novel finding is that declines in temperature-related mortality were particularly noteworthy in late summer. Our results indicate that temperature-related mortality is decreasing in Seoul, particularly during late summer and, to a lesser extent, during early summer. This information would be useful for detailed public health preparedness for hot weather.

Relationship between heat index and mortality of 6 major cities in Taiwan

Increased mortality, linked to events of extreme high temperatures, is recognized as one critical challenge to the public health sector. Therefore, this ecological study was conducted to assess whether this association is also significant in Taiwan and the characteristics of the relationship. Daily mean heat indices, from 1994 through 2008, were used as the predictor for the risk of increased mortality in populations from 6 major Taiwanese cities. Daily mortality data from 1994 through 2008 were retrieved from the Taiwan Death Registry, Department of Health, Taiwan, and meteorological data were acquired from the Central Weather Bureau. Poisson regression analyses using generalized linear models were applied to estimate the temperature-mortality relationship. Daily mean heat indices were calculated and used as the temperature metric. Overall, increased risk ratios in mortality were associated with increased daily mean heat indices. Significantly increased risk ratios of daily mortality were evident when daily mean heat indices were at and above the 95th percentile, when compared to the lowest percentile, in all cities. These risks tended to increase similarly among those aged 65 years and older; a phenomenon seen in the cities of Keelung, Taipei, Taichung, Tainan, and Kaohsiung, but not Chiayi. Being more vulnerable to heat stress is likely restricted to a short-term effect, as suggested by lag models which showed that there was dominantly an association during the period of 0 to 3 days. In Taiwan, predicting city-specific daily mean heat indices may provide a useful early warning system for increased mortality risk, especially for the elderly. Regional differences in health vulnerabilities should be further examined in relation to the differential social-ecological systems that affect them.

Concentration-response function for ozone and daily mortality: results from five urban and five rural U.K. populations

BACKGROUND

Short-term exposure to ozone has been associated with increased daily mortality. The shape of the concentration-response relationship-and, in particular, if there is a threshold-is critical for estimating public health impacts.

OBJECTIVE

We investigated the concentration-response relationship between daily ozone and mortality in five urban and five rural areas in the United Kingdom from 1993 to 2006.

METHODS

We used Poisson regression, controlling for seasonality, temperature, and influenza, to investigate associations between daily maximum 8-hr ozone and daily all-cause mortality, assuming linear, linear-threshold, and spline models for all-year and season-specific periods. We examined sensitivity to adjustment for particles (urban areas only) and alternative temperature metrics.

RESULTS

In all-year analyses, we found clear evidence for a threshold in the concentration-response relationship between ozone and all-cause mortality in London at 65 µg/m3 [95% confidence interval (CI): 58, 83] but little evidence of a threshold in other urban or rural areas. Combined linear effect estimates for all-cause mortality were comparable for urban and rural areas: 0.48% (95% CI: 0.35, 0.60) and 0.58% (95% CI: 0.36, 0.81) per 10-µg/m3 increase in ozone concentrations, respectively. Seasonal analyses suggested thresholds in both urban and rural areas for effects of ozone during summer months.

CONCLUSIONS

Our results suggest that health impacts should be estimated across the whole ambient range of ozone using both threshold and nonthreshold models, and models stratified by season. Evidence of a threshold effect in London but not in other study areas requires further investigation. The public health impacts of exposure to ozone in rural areas should not be overlooked.

Association of daily asthma emergency department visits and hospital admissions with ambient air pollutants among the pediatric Medicaid population in Detroit: time-series and time-stratified case-crossover analyses with threshold effects

BACKGROUND

Asthma morbidity has been associated with ambient air pollutants in time-series and case-crossover studies. In such study designs, threshold effects of air pollutants on asthma outcomes have been relatively unexplored, which are of potential interest for exploring concentration-response relationships.

METHODS

This study analyzes daily data on the asthma morbidity experienced by the pediatric Medicaid population (ages 2-18 years) of Detroit, Michigan and concentrations of pollutants fine particles (PM2.5), CO, NO2 and SO2 for the 2004-2006 period, using both time-series and case-crossover designs. We use a simple, testable and readily implementable profile likelihood-based approach to estimate threshold parameters in both designs.

RESULTS

Evidence of significant increases in daily acute asthma events was found for SO2 and PM2.5, and a significant threshold effect was estimated for PM2.5 at 13 and 11 μg m(-3) using generalized additive models and conditional logistic regression models, respectively. Stronger effect sizes above the threshold were typically noted compared to standard linear relationship, e.g., in the time series analysis, an interquartile range increase (9.2 μg m(-3)) in PM2.5 (5-day-moving average) had a risk ratio of 1.030 (95% CI: 1.001, 1.061) in the generalized additive models, and 1.066 (95% CI: 1.031, 1.102) in the threshold generalized additive models. The corresponding estimates for the case-crossover design were 1.039 (95% CI: 1.013, 1.066) in the conditional logistic regression, and 1.054 (95% CI: 1.023, 1.086) in the threshold conditional logistic regression.

CONCLUSION

This study indicates that the associations of SO2 and PM2.5 concentrations with asthma emergency department visits and hospitalizations, as well as the estimated PM2.5 threshold were fairly consistent across time-series and case-crossover analyses, and suggests that effect estimates based on linear models (without thresholds) may underestimate the true risk.

Distributed lag effects in the relationship between temperature and mortality in three major cities in South Korea

In many cases, the effect of an environmental exposure event is not restricted to the period when it occurs. Understanding the extent to which high-temperature exposure hastens the occurrence of health outcomes is a key to interpreting public health risks correctly and developing appropriate intervention programs related to heat. We explored distributed lag effects in the relationship between high temperature and mortality in summer (June-August) in Seoul, Daegu, and Incheon, South Korea, from 1991 to 2008. A Poisson regression model adapted for time-series data was used to estimate short-term heat-related mortality impacts. To examine the distributed lag effects, we fitted a constrained distributed lag model that included lagged exposure variables as covariates, applying a function of days of lag according to B-spline bases. The effects on mortality caused by high-temperature exposure continued for about 5 days, and slight deficit effects after the initial mortality increases were observed, even if not initially apparent. Thirty days after high-temperature exposure, the cumulative effects were still high in Seoul and Incheon. This study shows a pattern of distributed lag effects of high-temperature exposure that the single-day model could not identify. Our results confirm that summer high temperature has an effect on mortality, not advancing the date of adverse events by a few days. Ultimately, it suggests that public health programs be amended to allow for differential high-temperature effects spread over multiple days.

Effect of previous-winter mortality on the association between summer temperature and mortality in South Korea

BACKGROUND

It has recently been postulated that low mortality levels in the previous winter may increase the proportion of vulnerable individuals in the pool of people at risk of heat-related death during the summer months.

OBJECTIVES

We explored the sensitivity of heat-related mortality in summer (June-August) to mortality in the previous winter (December-February) in Seoul, Daegu, and Incheon in South Korea, from 1992 through 2007, excluding the summer of 1994.

METHODS

Poisson regression models adapted for time-series data were used to estimate associations between a 1 °C increase in average summer temperature (on the same day and the previous day) above thresholds specific for city, age, and cause of death, and daily mortality counts. Effects were estimated separately for summers preceded by winters with low and high mortality, with adjustment for secular trends.

RESULTS

Temperatures above city-specific thresholds were associated with increased mortality in all three cities. Associations were stronger in summers preceded by winters with low versus high mortality levels for all nonaccidental deaths and, to a lesser extent, among persons ≥ 65 years of age. Effect modification by previous-winter mortality was not evident when we restricted deaths to cardiovascular disease outcomes in Seoul.

CONCLUSIONS

Our results suggest that low winter all-cause mortality leads to higher mortality during the next summer. Evidence of a relation between increased summer heat-related mortality and previous wintertime deaths has the potential to inform public health efforts to mitigate effects of hot weather.

Environmental health indicators and a case study of air pollution in Latin American cities

Environmental health indicators (EHIs) are applied in a variety of research and decision-making settings to gauge the health consequences of environmental hazards, to summarize complex information, or to compare policy impacts across locations or time periods. While EHIs can provide a useful means of conveying information, they also can be misused. Additional research is needed to help researchers and policy-makers understand categories of indicators and their appropriate application. In this article, we review current frameworks for environmental health indicators and discuss the advantages and limitations of various forms. A case study EHI system was developed for air pollution and health for urban Latin American centers in order to explore how underlying assumptions affect indicator results. Sixteen cities were ranked according to five indicators that considered: population exposed, children exposed, comparison to health-based guidelines, and overall PM(10) levels. Results indicate that although some overall patterns in rankings were observed, cities' relative rankings were highly dependent on the indicator used. In fact, a city that was ranked best under one indicator was ranked worst with another. The sensitivity of rankings, even when considering a simple case of a single pollutant, highlights the need for clear understanding of EHIs and how they may be affected by underlying assumptions. Careful consideration should be given to the purpose, assumptions, and limitations of EHIs used individually or in combination in order to minimize misinterpretation of their implications and enhance their usefulness.

Comparison of temperature indexes for the impact assessment of heat stress on heat-related mortality

OBJECTIVES

In order to evaluate which temperature index is the best predictor for the health impact assessment of heat stress in Korea, several indexes were compared.

METHODS

We adopted temperature, perceived temperature (PT), and apparent temperature (AT), as a heat stress index, and changes in the risk of death for Seoul and Daegu were estimated with 1℃ increases in those temperature indexes using generalized additive model (GAM) adjusted for the non-temperature related factors: time trends, seasonality, and air pollution. The estimated excess mortality and Akaike's Information Criterion (AIC) due to the increased temperature indexes for the 75th percentile in the summers from 2001 to 2008 were compared and analyzed to define the best predictor.

RESULTS

For Seoul, all-cause mortality presented the highest percent increase (2.99% [95% CI, 2.43 to 3.54%]) in maximum temperature while AIC showed the lowest value when the all-cause daily death counts were fitted with the maximum PT for the 75(th) percentile of summer. For Daegu, all-cause mortality presented the greatest percent increase (3.52% [95% CI, 2.23 to 4.80%]) in minimum temperature and AIC showed the lowest value in maximum temperature. No lag effect was found in the association between temperature and mortality for Seoul, whereas for Daegu one-day lag effect was noted.

CONCLUSIONS

There was no one temperature measure that was superior to the others in summer. To adopt an appropriate temperature index, regional meteorological characteristics and the disease status of population should be considered.

Relationship between ambient ozone concentrations and daily hospital admissions for childhood asthma/atopic dermatitis in two cities of Korea during 2004-2005

The objective of this study was to estimate the association between ambient ozone levels and hospitalization for asthma/atopic dermatitis among children younger than 15 years old living in Seoul and Ulsan, Korea, in the years 2004-2005. Estimated relative risks of hospital admissions associated with an interquartile range (IQR) increase in ozone concentration were calculated using a generalized additive Poisson model. For childhood asthma, the effect of an ozone increase on the relative risks in Ulsan [1.21 (95% CI, 1.10-1.34)] was higher than that in Seoul [1.05 (95% CI, 0.99-1.11)]. The relative risks for childhood atopic dermatitis were also found to be higher in Ulsan [1.38 (95% CI, 0.80-2.36)] than in Seoul [1.28 (95% CI, 1.04-1.58)]. These results support previously reported findings and also indicate that ozone concentrations at levels below the standards in the Republic of Korea can be correlated with asthma hospital admissions in children.

Evaluation of the waste Tire Resources Recovery Program and environmental health policy in Taiwan

This paper examines the effectiveness of Taiwanese environmental health policies, whose aim is to improve environmental quality by reducing tire waste via the Tire Resource Recovery Program. The results confirm that implemented environmental health policies improve the overall health of the population (i.e. a decrease in death caused by bronchitis and other respiratory diseases). Current policy expenditures are far below the optimal level, as it is estimated that a ten percent increase in the subsidy would decrease the number of deaths caused by bronchitis and other respiratory diseases by 0.58% per county/city per year on average.

Surface ozone and meteorological condition in a single year at an urban site in central-eastern China

Surface ozone and some meteorological parameters were continuously measured from June 2003 to May 2004 at urban Jinan, China. The levels and variations of surface ozone were studied and the influences of meteorological parameters on ozone were analyzed. Annual and diurnal ozone variation patterns in Jinan both show a typical pattern for polluted urban areas. Daytime ozone concentrations in summer were the highest in the four seasons. However, during nighttime from 2100 to 0600 hours ozone concentrations in spring was higher than that in summer. Daily averaged ozone showed negative correlation with pressure and relative humidity and positive correlation with temperature, total solar radiation, sunshine duration and wind speed during the study period. Further studies show that, solar radiation is a primary influence factor for the daytime variations of ozone concentrations at this site; transport of pollutants by wind could enhance the pollution at this site; precipitation has a significant influence on decreasing surface ozone. A multi-day ozone episode from 16 to 21 June 2003 was observed at this site. Surface meteorological data analysis and backward trajectory computation show that the episode is associated with the influence of typhoon Soudelor, attributing to both local photochemical processes and transport of air pollutants from southeastern coastal region, especially Yangtze River Delta region.

Relationship between winter temperature and mortality in Seoul, South Korea, from 1994 to 2006

In South Korea, the mortality increases with temperature above a certain threshold during the warm season. In contrast, despite the common burden of cold weather, little is known about the effects of low temperatures on mortality. We evaluated the relationship between low temperatures and mortality in winter (December-February) in Seoul, South Korea, from 1994 to 2006. Data were obtained from government agencies. After adjusting for trends in time, day of the week, holidays, and relative humidity, we explored the associations between mortality and various cold indicators of winter in Seoul, South Korea. First, we fitted nonparametric smoothing regression models to check the shape of associations and then fitted threshold models (including two different slopes in a model) to estimate the thresholds and the effects of low temperatures using the Akaike Information Criterion (AIC). The graphical associations between cardiorespiratory, cardiovascular, and all causes of mortality and the cold wave index (CWI=T(min, previous day)-T(min, current day)) were observed. We confirmed the threshold according to a lag structure and after that, estimated the effects of CWI below the threshold, respectively. The effects of the daytime CWI lagged by 0-2 days were the strongest among those of the daytime CWI lagged by 0-6 days. The most significant mortality outcomes were cardiovascular-related. Although we could not consider respiratory-related mortality, the effect of CWI on cardiovascular-related mortality below a certain threshold was greater than cardiorespiratory-related or all cause-related mortality. In addition, the association between mortality and CWI was more immediate and vulnerable in an elderly subgroup (> or =65 years old) than in a younger subgroup (0-64 years old). Our results suggest that public health programs should be considered to alleviate not only the effect of sudden change in winter temperature on mortality.

A distributed lag approach to fitting non-linear dose-response models in particulate matter air pollution time series investigations

The majority of studies that have investigated the relationship between particulate matter (PM) air pollution and mortality have assumed a linear dose-response relationship and have used either a single-day's PM or a 2- or 3-day moving average of PM as the measure of PM exposure. Both of these modeling choices have come under scrutiny in the literature, the linear assumption because it does not allow for non-linearities in the dose-response relationship, and the use of the single- or multi-day moving average PM measure because it does not allow for differential PM-mortality effects spread over time. These two problems have been dealt with on a piecemeal basis with non-linear dose-response models used in some studies and distributed lag models (DLMs) used in others. In this paper, we propose a method for investigating the shape of the PM-mortality dose-response relationship that combines a non-linear dose-response model with a DLM. This combined model will be shown to produce satisfactory estimates of the PM-mortality dose-response relationship in situations where non-linear dose response models and DLMs alone do not; that is, the combined model did not systemically underestimate or overestimate the effect of PM on mortality. The combined model is applied to ten cities in the US and a pooled dose-response model formed. When fitted with a change-point value of 60 microg/m(3), the pooled model provides evidence for a positive association between PM and mortality. The combined model produced larger estimates for the effect of PM on mortality than when using a non-linear dose-response model or a DLM in isolation. For the combined model, the estimated percentage increase in mortality for PM concentrations of 25 and 75 microg/m(3) were 3.3% and 5.4%, respectively. In contrast, the corresponding values from a DLM used in isolation were 1.2% and 3.5%, respectively.

Air pollution, socioeconomic position, and emergency hospital visits for asthma in Seoul, Korea

OBJECTIVE

Some epidemiological literature has observed that air pollution effects on health differed across regional or individual socioeconomic position. This study evaluated whether regional and individual socioeconomic position, as indicated by health insurance premiums, modified the effect of air pollution on hospital visits for asthma.

METHODS

Effects of ambient air pollutants (particulate matter, carbon monoxide, sulfur dioxide, nitrogen dioxide, and ozone) on 92,535 emergency out-patient hospital visits for asthma in Seoul, Korea during 2002 were estimated using case-crossover analysis, adjusting for time trend, weather conditions, and seasonality. Next, interactions between air pollutants and Korean National Health Insurance premium (1) for the individual patient and (2) averaged across the patient's residence district, were entered, first singly then jointly, in the models.

RESULTS

Relative risks of emergency outpatient hospital visits were all positively and significantly associated with interquartile increases for selected lags for all air pollutants. In the regression model with interaction terms for both individual premium and regional-average premium, associations with all five-air pollutants ranged from 1.03 to 1.09 times higher among the lowest premium districts compared to the highest premium districts. Of all the pollutants, nitrogen dioxide showed the strongest associations in lower premium districts compared to the higher premium districts. Individual socioeconomic position did not modify the associations in either the single or joint interaction models.

CONCLUSION

In Seoul, community but not individual socioeconomic conditions modified risk of asthma hospital visits on high air pollution days.

Ozone sensitivity of currant tomato (Lycopersicon pimpinellifolium), a potential bioindicator species

The wild tomato species Lycopersicon pimpinellifolium (currant tomato) was exposed to different O3 concentration, both in controlled environment fumigation facilities and in open-top chambers, to assess its sensitivity and to verify its potential as a bioindicator plant. Plants appeared particularly sensitive to O3 at an early stage of growth, responding with typical chlorotic spots within 24 h after exposure to a single pulse of 50 ppb for 3 h, and differentiating peculiar symptoms, such as reddish necrotic stipples, bronzing and extensive necrosis, depending on O3 concentration. Histo-cytochemical investigations with 3,3'-diaminobenzidine, to localize H2O2, and Evans blue, to detect dead cells, suggested that currant tomato sensitivity to O3 could be due to a deficiency in the anti-oxidant pools. The combination of these stainings proved to be useful, either to predict visible symptoms, early before their appearance, and to validate leaf ozone injury.

The exposure-response curve for ozone and risk of mortality and the adequacy of current ozone regulations

Time-series analyses have shown that ozone is associated with increased risk of premature mortality, but little is known about how O3 affects health at low concentrations. A critical scientific and policy question is whether a threshold level exists below which O3 does not adversely affect mortality. We developed and applied several statistical models to data on air pollution, weather, and mortality for 98 U.S. urban communities for the period 1987-2000 to estimate the exposure-response curve for tropospheric O3 and risk of mortality and to evaluate whether a "safe" threshold level exists. Methods included a linear approach and subset, threshold, and spline models. All results indicate that any threshold would exist at very low concentrations, far below current U.S. and international regulations and nearing background levels. For example, under a scenario in which the U.S. Environmental Protection Agency's 8-hr regulation is met every day in each community, there was still a 0.30% increase in mortality per 10-ppb increase in the average of the same and previous days' O3 levels (95% posterior interval, 0.15-0.45%). Our findings indicate that even low levels of tropospheric O3 are associated with increased risk of premature mortality. Interventions to further reduce O3 pollution would benefit public health, even in regions that meet current regulatory standards and guidelines.

Global health benefits of mitigating ozone pollution with methane emission controls

Methane (CH(4)) contributes to the growing global background concentration of tropospheric ozone (O(3)), an air pollutant associated with premature mortality. Methane and ozone are also important greenhouse gases. Reducing methane emissions therefore decreases surface ozone everywhere while slowing climate warming, but although methane mitigation has been considered to address climate change, it has not for air quality. Here we show that global decreases in surface ozone concentrations, due to methane mitigation, result in substantial and widespread decreases in premature human mortality. Reducing global anthropogenic methane emissions by 20% beginning in 2010 would decrease the average daily maximum 8-h surface ozone by approximately 1 part per billion by volume globally. By using epidemiologic ozone-mortality relationships, this ozone reduction is estimated to prevent approximately 30,000 premature all-cause mortalities globally in 2030, and approximately 370,000 between 2010 and 2030. If only cardiovascular and respiratory mortalities are considered, approximately 17,000 global mortalities can be avoided in 2030. The marginal cost-effectiveness of this 20% methane reduction is estimated to be approximately 420,000 US dollars per avoided mortality. If avoided mortalities are valued at 1 US dollars million each, the benefit is approximately 240 US dollars per tone of CH(4) ( approximately 12 US dollars per tone of CO(2) equivalent), which exceeds the marginal cost of the methane reduction. These estimated air pollution ancillary benefits of climate-motivated methane emission reductions are comparable with those estimated previously for CO(2). Methane mitigation offers a unique opportunity to improve air quality globally and can be a cost-effective component of international ozone management, bringing multiple benefits for air quality, public health, agriculture, climate, and energy.

A Meta-Analysis of Time-Series Studies of Ozone and Mortality With Comparison to the National Morbidity, Mortality, and Air Pollution Study

BACKGROUND

Although many time-series studies of ozone and mortality have identified positive associations, others have yielded null or inconclusive results, making the results of these studies difficult to interpret.

METHODS

We performed a meta-analysis of 144 effect estimates from 39 time-series studies, and estimated pooled effects by lags, age groups, cause-specific mortality, and concentration metrics. We compared results with pooled estimates from the National Morbidity, Mortality, and Air Pollution Study (NMMAPS), a time-series study of 95 large U.S. urban centers from 1987 to 2000.

RESULTS

Both meta-analysis and NMMAPS results provided strong evidence of a short-term association between ozone and mortality, with larger effects for cardiovascular and respiratory mortality, the elderly, and current-day ozone exposure. In both analyses, results were insensitive to adjustment for particulate matter and model specifications. In the meta-analysis, a 10-ppb increase in daily ozone at single-day or 2-day average of lags 0, 1, or 2 days was associated with an 0.87% increase in total mortality (95% posterior interval = 0.55% to 1.18%), whereas the lag 0 NMMAPS estimate is 0.25% (0.12% to 0.39%). Several findings indicate possible publication bias: meta-analysis results were consistently larger than those from NMMAPS; meta-analysis pooled estimates at lags 0 or 1 were larger when only a single lag was reported than when estimates for multiple lags were reported; and heterogeneity of city-specific estimates in the meta-analysis were larger than with NMMAPS.

CONCLUSIONS

This study provides evidence of short-term associations between ozone and mortality as well as evidence of publication bias.

Assessing ozone-related health impacts under a changing climate

Climate change may increase the frequency and intensity of ozone episodes in future summers in the United States. However, only recently have models become available that can assess the impact of climate change on O3 concentrations and health effects at regional and local scales that are relevant to adaptive planning. We developed and applied an integrated modeling framework to assess potential O3-related health impacts in future decades under a changing climate. The National Aeronautics and Space Administration-Goddard Institute for Space Studies global climate model at 4 degrees x 5 degrees resolution was linked to the Penn State/National Center for Atmospheric Research Mesoscale Model 5 and the Community Multiscale Air Quality atmospheric chemistry model at 36 km horizontal grid resolution to simulate hourly regional meteorology and O3 in five summers of the 2050s decade across the 31-county New York metropolitan region. We assessed changes in O3-related impacts on summer mortality resulting from climate change alone and with climate change superimposed on changes in O3 precursor emissions and population growth. Considering climate change alone, there was a median 4.5% increase in O3-related acute mortality across the 31 counties. Incorporating O3 precursor emission increases along with climate change yielded similar results. When population growth was factored into the projections, absolute impacts increased substantially. Counties with the highest percent increases in projected O3 mortality spread beyond the urban core into less densely populated suburban counties. This modeling framework provides a potentially useful new tool for assessing the health risks of climate change.

Molecular cloning of the monodehydroascorbate reductase gene from Brassica campestris and analysis of its mRNA level in response to oxidative stress

In a majority of living organisms, a fundamental protection mechanism from reactive oxygen species is by the ascorbate-glutathione cycle in which an important antioxidant, ascorbate (vitamin C), is utilized to convert harmful H2O2 to H2O. Monodehydroascorbate reductase (MDHAR) maintains reduced pools of ascorbate by recycling the oxidized form of ascorbate. By screening a Brassica campestris cDNA library, we identified a B. campestris MDHAR cDNA (BcMdhar) which encodes a polypeptide of 434 amino acids possessing domains characteristic of FAD- and NAD(P)H-binding proteins. The predicted amino acid sequence of the open reading frame (ORF) shows a high level of identity to the cytosolic MDHAR of rice, pea and tomato, and does not possess N-terminal leader sequence suggesting that it encodes a cytosolic form of MDHAR. Genomic Southern blot analysis indicated that a single nuclear gene encodes this enzyme. Northern hybridization analysis detected BcMdhar transcripts in all plant tissues examined. The level of BcMdhar mRNA increased in response to oxidative stress invoked by hydrogen peroxide, salicylic acid, paraquat, and ozone.