The associations between ambient air pollution and adult respiratory mortality in 32 major Chinese cities, 2006-2010

Travel Distance Between Participants in US Telemedicine Sessions With Estimates of Emissions Savings: Observational Study

BACKGROUND

Digital health and telemedicine are potentially important strategies to decrease health care's environmental impact and contribution to climate change by reducing transportation-related air pollution and greenhouse gas emissions. However, we currently lack robust national estimates of emissions savings attributable to telemedicine.

OBJECTIVE

This study aimed to (1) determine the travel distance between participants in US telemedicine sessions and (2) estimate the net reduction in carbon dioxide (CO2) emissions attributable to telemedicine in the United States, based on national observational data describing the geographical characteristics of telemedicine session participants.

METHODS

We conducted a retrospective observational study of telemedicine sessions in the United States between January 1, 2022, and February 21, 2023, on the doxy.me platform. Using Google Distance Matrix, we determined the median travel distance between participating providers and patients for a proportional sample of sessions. Further, based on the best available public data, we estimated the total annual emissions costs and savings attributable to telemedicine in the United States.

RESULTS

The median round trip travel distance between patients and providers was 49 (IQR 21-145) miles. The median CO2 emissions savings per telemedicine session was 20 (IQR 8-59) kg CO2). Accounting for the energy costs of telemedicine and US transportation patterns, among other factors, we estimate that the use of telemedicine in the United States during the years 2021-2022 resulted in approximate annual CO2 emissions savings of 1,443,800 metric tons.

CONCLUSIONS

These estimates of travel distance and telemedicine-associated CO2 emissions costs and savings, based on national data, indicate that telemedicine may be an important strategy in reducing the health care sector's carbon footprint.

Short-term air pollution exposure and mortality in Brazil: Investigating the susceptible population groups

This is the first study to examine the association between ambient air pollution (PM2.5, O3, and NO2) and mortality (in different population groups by sex and age) based on a nationwide death record across Brazil over a 15-year period (2003-2017). We used a time-series analytic approach with a distributed lag model. Our study population includes 2,872,084 records of deaths in Brazil between 2003 and 2017. Men accounted for a higher proportion of deaths, with 58% for all-cause mortality, 54% for respiratory mortality, and 52% for circulatory mortality. Most individuals were over 65 years of age. Our results suggest an association between air pollution and mortality in Brazil. The direction, statistical significance, and effect size of these associations varied considerably by type of air pollutant, region, and population group (sex and age group). In particular, the older population group (>65 years) was most affected. The national meta-analysis for the entire data set (without stratification by sex and age) showed that for every 10 μg/m3 increase in PM2.5 concentration, the risk of death from respiratory diseases increased by 2.93% (95%CI: 1.42; 4.43). For every 10 ppb increase in O3, there is a 2.21% (95%CI: 0.59; 3.83) increase in the risk of all-cause mortality for the group of all people between 46 and 65 years old, and a 3.53% (95%CI: 0.34; 6.72) increase in the risk of circulatory mortality for the group of women, all ages. For every 10 ppb increase in NO2, the risk of respiratory mortality increases by 17.56% (95%CI: 4.44; 30.64) and the risk of all-cause mortality by 5.63% (95%CI: 1.83; 9.44). The results of our study provide epidemiological evidence that air pollution is associated with a higher risk of cardiorespiratory mortality in Brazil. Given the lack of nationwide studies on air pollution in Brazil, our research is an important contribution to the local and international literature that can provide better support to policymakers to improve air quality and public health.

The mortality and years of life lost for community-acquired pneumonia before and during COVID-19 pandemic in China

Background

Community-acquired pneumonia (CAP) is a leading cause of mortality worldwide, but disease burden of CAP is not clear so far. We aim to explore the spatial and temporal trends of mortality and years of life lost (YLL) due to CAP during 2013-2021 in mainland China, especially the mortality changes before and during COVID-19 pandemic due to COVID-19 related non-pharmaceutical interventions (NPIs).

Methods

We used data from the National Mortality Surveillance System to estimate the age-standardized rates of death and YLL of CAP at national and provincial level in China during 2013-2021. Monthly and provincial NPIs data were obtained from Oxford COVID-19 Government Response Tracker. The Average annual percentage change (AAPC) and mortality reduction were estimated by log-linear regression and interrupted time series, respectively.

Findings

In China, most CAP that caused deaths had no clear etiology, and bacterial pneumonia and viral pneumonia were the leading 2 causes among CAP deaths with determined etiology before and during COVID-19 pandemic. The age-standardized CAP mortality rate decreased from 11.18 per 100,000 in 2013 to 8.76 per 100,000 in 2019, and to 5.74 per 100,000 in 2021 (AAPC -4.51% vs -7.89%). Trends were similar in age-standardized rate of YLL. Both rates declined more for viral pneumonia, compared with bacterial pneumonia. After adjusting for NPIs at provincial level after 2020, the NPIs for COVID-19 was associated with significant reductions in CAP mortality (-0.34 per 100,000, -0.41 to -0.27; p < 0.0001), and provinces that economically developed and conducted strict regular NPIs against COVID-19 contributed the most reduction.

Interpretation

We observed a decreasing trend of age-standardized CAP mortality from 2013 to 2019, and a dramatical reduction during COVID-19 pandemic, especially for viral pneumonia. Our study provided the evidence for the effectiveness of regular NPIs on the significant reductions in CAP mortality.

Funding

This work has been supported by Beijing Municipal Science and Technology Project Z191100006619101, Chinese Academy of Medical Sciences (CAMS) Innovation Fund for Medical Sciences (CIFMS 2021-I2M-1-048), CAMS Institute of Respiratory Medicine Grant for Young Scholars (2023-ZF-8) and the New Cornerstone Science Foundation.

Analysis of severe ozone-related human health and weather influence over China in 2019 based on a high-resolution dataset

Ozone pollution in 2019 in China is particularly severe posing a tremendous threat to the health of Chinese inhabitants. In this study, we constructed a more reliable and accurate 1-km gridded dataset for 2019 with as many sites as possible using the inverse distance weight interpolation method to analyze spatiotemporal ozone pollution characteristics and health burden attributed to ozone exposure from the perspective of different diseases and weather influence. The accuracy of this new dataset is higher than other public datasets, with the coefficient of determination of 0.84 and root-mean-square error of 8.77 ppb through the validation of 300 external sites which were never used for establishing retrieval methods by the datasets mentioned-above. The averaged MDA8 (the daily maximum 8 h average) ozone concentrations over China was 43.5 ppb, and during April-July, 83.9% of total grids occurred peak-month ozone concentrations. Overall, the highest averaged exceedance days (60 days) and population-weighted ozone concentrations (55.0 ppb) both concentrated in central-eastern China including 9 provinces (only 11.4% of the national territory); meanwhile, all-cause premature deaths attributable to ozone exposure reached up to 142,000 (54.9% of national total deaths) with higher deaths for cardiovascular and respiratory, and the provincial per capita premature mortality was 0.27~0.44‰. The six most polluted weather types in the central-eastern China are in order as follows: westerly (SW and W), cyclonic, northerly, and southerly (NW, N, and S) types, which accounts for approximately 73.2% of health burden attributed to daily ozone exposure and poses the greatest public health risk with mean daily premature deaths ranging from 466 to 610. Our findings could provide an effective support for regional ozone pollution control and public health management in China.

Differential Pattern of Cell Death and ROS Production in Human Airway Epithelial Cells Exposed to Quinones Combined with Heated-PM2.5 and/or Asian Sand Dust

The combined toxicological effects of airborne particulate matter (PM), such as PM2.5, and Asian sand dust (ASD), with surrounding chemicals, particularly quinones, on human airway epithelial cells remain underexplored. In this study, we established an in vitro combination exposure model using 1,2-naphthoquinones (NQ) and 9,10-phenanthroquinones (PQ) along with heated PM (h-PM2.5 and h-ASD) to investigate their potential synergistic effects. The impacts of quinones and heated PM on tetrazolium dye (WST-1) reduction, cell death, and cytokine and reactive oxygen species (ROS) production were examined. Results revealed that exposure to 9,10-PQ with h-PM2.5 and/or h-ASD dose-dependently increased WST-1 reduction at 1 μM compared to the corresponding control while markedly decreasing it at 10 μM. Higher early apoptotic, late apoptotic, or necrotic cell numbers were detected in 9,10-PQ + h-PM2.5 exposure than in 9,10-PQ + h-ASD or 9,10-PQ + h-PM2.5 + h-ASD. Additionally, 1,2-NQ + h-PM2.5 exposure also resulted in an increase in cell death compared to 1,2-NQ + h-ASD and 1,2-NQ + h-PM2.5 + h-ASD. Quinones with or without h-PM2.5, h-ASD, or h-PM2.5 + h-ASD significantly increased ROS production, especially with h-PM2.5. Our findings suggest that quinones, at relatively low concentrations, induce cell death synergistically in the presence of h-PM2.5 rather than h-ASD and h-PM2.5 + h-ASD, partially through the induction of apoptosis with increased ROS generation.

Health Impact Assessment of Short-Term Exposure to Particulate Matter (PM10) in Northern Thailand

In northern Thailand, in recent decades, particulate pollution from the burning of biomass has become a serious issue with toxicological implications for human health, especially during the winter months of January to April. The purpose of this study was to explore short-term exposure to particulate matter (PM₁₀) in northern Thailand. The high PM₁₀ concentration in 2012 was used as a case study. We used the EPA's Benefits Mapping and Analysis Program-Community Edition (BenMAP-CE) for the health impact assessment, along with ground-based measurement data. The annual average observed PM₁₀ concentration was in the range of 43-61 μg/m³, with a maximum observed PM₁₀ concentration of 300 μg/m³ in March. We then assessed the impacts of PM₁₀ exposure in northern Thailand. When the PM₁₀ concentration was reduced to 120 μg/m³, the undesirable effects on respiratory mortality decreased by 5%-11%. When the concentration of PM₁₀ was reduced to 45 μg/m³, the deleterious effects on respiratory mortality decreased by 11-30%. In conclusion, adherence to the WHO-AQG, particularly for PM₁₀ (45 μg/m³), tends to result in considerable reductions in respiratory disease mortality in northern Thailand.

Association between provincial sunshine duration and mortality rates in China: Panel data study

Background

mortality rates are usually influenced by the variations of environmental factors. However, there are few studies on the impact of sunlight duration induced mortality. In this study, we examine provincial level associations between the sunshine duration and crude mortality rates.

Methods

we use China mortality data from the National Bureau of Statistics of China combined with China census data and data from the China Meteorological Data Service Centre. Annual mortality rates for 31 provinces, autonomous regions, and municipalities in China from 2005 to 19. Data are analyzed at the provincial level by using panel regression methods. The main outcome measures are the mortality rates associated with average daily sunshine duration. Then we perform a series of sentimental analyses.

Results

the average daily sunshine duration ratio cubed is positively associated with provincial level mortality rates (β = 11.509, 95% confidence interval 1.869 to 21.148). According to this estimate, increasing 2.895 h of additional daily sunshine is associated with an estimated 1.15% increase in the crude mortality rates. A series of sensitivity analyses show a consistent pattern of associations between average daily sunshine duration ratio cubed and mortality rates.

Conclusions

more sunshine duration is associated with increased mortality rates. While the associations documented cannot be assumed to be causal, they suggest a potential association between increased sunshine duration and increased mortality rates.

Epidemiological features and trends in the mortality rates of 10 notifiable respiratory infectious diseases in China from 2004 to 2020: Based on national surveillance

Objectives

The aim of this study is to describe, visualize, and compare the trends and epidemiological features of the mortality rates of 10 notifiable respiratory infectious diseases in China from 2004 to 2020.

Setting

Data were obtained from the database of the National Infectious Disease Surveillance System (NIDSS) and reports released by the National and local Health Commissions from 2004 to 2020. Spearman correlations and Joinpoint regression models were used to quantify the temporal trends of RIDs by calculating annual percentage changes (APCs) in the rates of mortality.

Results

The overall mortality rate of RIDs was stable across China from 2004 to 2020 (R = -0.38, P = 0.13), with an APC per year of -2.2% (95% CI: -4.6 to 0.3; P = 0.1000). However, the overall mortality rate of 10 RIDs in 2020 decreased by 31.80% (P = 0.006) compared to the previous 5 years before the COVID-19 pandemic. The highest mortality occurred in northwestern, western, and northern China. Tuberculosis was the leading cause of RID mortality, and mortality from tuberculosis was relatively stable throughout the 17 years (R = -0.36, P = 0.16), with an APC of -1.9% (95% CI -4.1 to 0.4, P = 0.1000). Seasonal influenza was the only disease for which mortality significantly increased (R = 0.73, P = 0.00089), with an APC of 29.70% (95% CI 16.60-44.40%; P = 0.0000). The highest yearly case fatality ratios (CFR) belong to avian influenza A H5N1 [687.5 per 1,000 (33/48)] and epidemic cerebrospinal meningitis [90.5748 per 1,000 (1,010/11,151)]. The age-specific CFR of 10 RIDs was highest among people over 85 years old [13.6551 per 1,000 (2,353/172,316)] and was lowest among children younger than 10 years, particularly in 5-year-old children [0.0552 per 1,000 (58/1,051,178)].

Conclusions

The mortality rates of 10 RIDs were relatively stable from 2004 to 2020 with significant differences among Chinese provinces and age groups. There was an increased mortality trend for seasonal influenza and concerted efforts are needed to reduce the mortality rate of seasonal influenza in the future.

Spatial effects of air pollution on the economic burden of disease: implications of health and environment crisis in a post-COVID-19 world

Background

Air pollution has been identified as related to the diseases of susceptible population, but the spatial heterogeneity of its economic burden and its determinants are rarely investigated. The issue is of great policy significance, especially after the epidemic of COVID-19, when human are facing the joint crisis of health and environment, and some areas is prone to falling into poverty.

Methods

The geographical detector was adopted to study the spatial distribution characteristics of the incidence of catastrophic health expenditure (ICHE) for older adults in 100 rural areas in China at the prefecture-city level. The health factors, sociological factors, policy factors and environmental factors and their interactions are identified.

Results

First, most health service factors had strong explanatory power for ICHE whether it interacts with air pollution. Second, 50 single-factor high-risk areas of ICHE were found in the study, but at the same time, there were 21 areas dominated by multiple factors.

Conclusion

The different contributions and synergy among the factors constitute the complex mechanism of factors and catastrophic health expenditure. Moreover, during this process, air pollution aggravates the contribution of health service factors toward ICHE. In addition, the leading factors of ICHE are different among regions. At the end, this paper also puts forward some policy suggestions from the perspective of health and environment crisis in the post-COVID-19 world: environmental protection policies should be combined with the prevention of infectious diseases; advanced health investment is the most cost-effective policy for the inverse health sequences of air pollution and infectious diseases such as coronavirus disease 2019 (COVID-19); integrating environmental protection policy into healthy development policy, different regions take targeted measures to cope with the intertwined crisis.

Assessing the cooking oil fume exposure impacts on Chinese women health: an influential mechanism analysis

Oil fume is always considered as a major source of indoor air pollution. This article aims to examine the effects of cooking oil fume as environmental pollution on the health of Chinese women by using the data obtained from China Labor force Dynamic Survey (CLDS). In order to estimate the effect of environmental pollution on the human health, we utilize probit model approach and baseline regression method. The results showed that oil fume has a significant negative impact on the health indicators of "physical pain, health impact on work and injury." By conducting endogeneity analysis, our results show the robustness and indicate that oil fume has a robust effect on the women health. Heterogeneity analysis show that heavier oil fume has a negative impact on the subjective health of middle-aged and young women, while it has  a significant negative impact on the objective health of middle-aged women. Analysis of the impact mechanism reveal that heavier oil fumes will reduce women's sleep quality and will lead to the poorer health. Based on our study findings, this study proposes policy recommendations from the perspectives of the use of smoke extraction equipment, cooking methods, and sleep quality to reduce the negative impact of cooking fumes on women's health.

Air Pollution and Settlement Intention: Evidence from the China Migrants Dynamic Survey

This study analyses the effect of air pollution on the settlement intention of migrants in China. In recent years, the willingness of residents to migrate induced by air pollution has received a lot of attention from academics. By matching information from the China Migrants Dynamic Survey from 2015 to 2017 with the air quality index (AQI), we used the Probit model to assess the impact of air pollution on the settlement intentions of migrants with different socioeconomic statuses. First, we demonstrated that air pollution has a significant negative effect on migrants’ settlement intention. Second, we found that the effect of air pollution on settlement intention is influenced by individual socioeconomic status; that education level, as an indicator of cognitive ability, affects migrants’ motivation to migrate; and that personal income, as an indicator of economic ability, affects the feasibility of their migration. Motivation to migrate and the feasibility of moving determine together the divergence in settlement intention, and those with higher incomes and higher education levels are more likely to leave cities with serious air pollution. Third, the heterogeneous effects suggested that the negative effect of air pollution was greater for older, male, and married migrants. Our findings suggested that air pollution has a variety of effects on the heterogeneous migrants, resulting in changes in the demographic structure of cities.

Does Advanced Human Capital Structure Provide Positive Feedback on Public Health? Evidence From China

This paper explores the relationship of advanced human capital structure with public health applying the panel threshold regression model in China. The empirical results highlight that the advanced human capital structure has a non-linear single threshold effect on population health indicators. The health-promoting effect of advanced human capital structure is significantly weaker when exceeding the threshold. These asymmetric effects are strongly related to the response of China's health policies. The promotion effect of the advanced human capital structure on public health has significant heterogeneity in different regions. There is a single threshold value in the eastern and central regions, but the threshold value and facilitation effect are different. However, the western region has no threshold. The heterogeneity effects are caused by the different levels of advanced human capital structure. Governments should adopt appropriate public health policies according to the development characteristics of different regions.

Long-term exposure to PM10 above WHO guidelines exacerbates COVID-19 severity and mortality

BACKGROUND

Age, sex, race and comorbidities are insufficient to explain why some individuals remain asymptomatic after SARS-CoV-2 infection, while others die. In this sense, the increased risk caused by the long-term exposure to air pollution is being investigated to understand the high heterogeneity of the COVID-19 infection course.

OBJECTIVES

We aimed to assess the underlying effect of long-term exposure to NO2 and PM10 on the severity and mortality of COVID-19.

METHODS

A retrospective observational study was conducted with 2112 patients suffering COVID-19 infection. We built two sets of multivariate predictive models to assess the relationship between the long-term exposure to NO2 and PM10 and COVID-19 outcome. First, the probability of either death or severe COVID-19 outcome was predicted as a function of all the clinical variables together with the pollutants exposure by means of two regularized logistic regressions. Subsequently, two regularized linear regressions were constructed to predict the percentage of dead or severe patients. Finally, odds ratios and effects estimates were calculated.

RESULTS

We found that the long-term exposure to PM10 is a more important variable than some already stated comorbidities (i.e.: COPD/Asthma, diabetes, obesity) in the prediction of COVID-19 severity and mortality. PM10 showed the highest effects estimates (1.65, 95% CI 1.32-2.06) on COVID-19 severity. For mortality, the highest effect estimates corresponded to age (3.59, 95% CI 2.94-4.40), followed by PM10 (2.37, 95% CI 1.71-3.32). Finally, an increase of 1 µg/m3 in PM10 concentration causes an increase of 3.06% (95% CI 1.11%-4.25%) of patients suffering COVID-19 as a severe disease and an increase of 2.68% (95% CI 0.53%-5.58%) of deaths.

DISCUSSION

These results demonstrate that long-term PM10 burdens above WHO guidelines exacerbate COVID-19 health outcomes. Hence, WHO guidelines, the air quality standard established by the Directive 2008/50/EU, and that of the US-EPA should be updated accordingly to protect human health.

The effects of indoor and outdoor air pollution on the prevalence of adults' respiratory diseases in four Chinese cities: a comparison between 2017-2018 and 1993-1996

Background

Over the past decades, both ambient and household air pollution have changed in several aspects, including the emission sources and the concentrations of pollutants, in many Chinese cities. It is unknown whether these changes are associated with changes in health conditions, especially given changes in other factors due to rapid economic growth.

Methods

Two cross-sectional surveys were conducted in two periods spanning more than twenty years (1993–1996 vs. 2017–2018) in four Chinese cities of Chongqing, Wuhan, Lanzhou, and Guangzhou. Data were collected regarding adults’ respiratory disease, smoking status, education, occupation, and household characteristics. Ambient air pollution data were obtained for each study. We first used logistic regression models to construct the district-specific adjusted disease prevalences. In the second stage, first-difference regression models were employed to examine whether the change in respiratory diseases prevalences was associated with the change in outdoor air pollution and indoor air pollution surrogates.

Results

A total of 7,557 and 9,974 households were participating in Period 1 (1993–1996) and Period 2 (2017–2018), respectively. Compared to Period 1, we found substantial reductions in the ambient air pollution concentrations, and a suggestive improvement in cooking-related indoor air pollution in Period 2. We observed decreases in the district-specific covariate-adjusted prevalences of both asthma and chronic bronchitis among participants, with an average reduction of 3.6% (range: 0.0% to 24.3%). From Period 1 to Period 2, one percent decrease in the proportion of cooking with coal was associated with a 19.0% (95% CI, 0.96–37.04%) decrease in the prevalence of males’ chronic bronchitis and a 1.86% (0.69–3.04%) increase in the prevalence of females’ asthma. Little evidence was observed regarding the potential health benefits associated with the decreases in ambient air pollution levels.

Conclusions

The substantial reduction in household use of coal for cooking might be an important contributor to the decrease in adults’ respiratory disease prevalence from 1993–1996 to 2017–2019 in four Chinese cities. Changes in this indoor air pollution source, along with other risk factors for respiratory diseases, may have masked respiratory health benefits associated with reductions in outdoor air pollution levels.

The dilemma of paraxylene plants in China: Real trouble for the environment?

China's demand for paraxylene, an essential material for the chemical industry, is growing rapidly. However, the public is worried about the influence of paraxylene plants on the environment. The contradiction between supporting paraxylene and opposing it poses a considerable challenge for the Chinese government. Therefore, objective evaluation of paraxylene plants' impact on the environment is of great significance to industrial development. Using the urban panel data of 102 cities in China from 2003 to 2017, this paper applies the PSM-DID method to study the relationship between paraxylene plants and air quality. This paper shows that paraxylene plants play a significantly positive role in aggravating urban air pollution. Specifically, paraxylene plants increase not only industrial dust pollution but also increase SO₂ emissions. This influence is still valid after multiple robustness tests. Moreover, the mechanism analysis reveals that paraxylene plants' construction promotes income growth but hinders foreign direct investment. Finally, this paper provides policy suggestions on promoting paraxylene industrial development in terms of governments, enterprises, and the public.

Climatic modification effects on the association between PM1 and lung cancer incidence in China

Background

Nationwide studies that examine climatic modification effects on the association between air pollution and health outcome are limited in developing countries. Moreover, few studies focus on PM1 pollution despite its greater health effect.

Objectives

This study aims to determine the modification effects of climatic factors on the associations between PM1 and the incidence rates of lung cancer for males and females in China.

Methods

We conducted a nationwide analysis in 345 Chinese counties (districts) from 2014 to 2015. Mean air temperature and relative humidity over the study period were used as the proxies of climatic conditions. In terms of the multivariable linear regression model, we examined climatic modification effects in the stratified and combined datasets according to the three-category and binary divisions of climatic factors. Moreover, we performed three sensitivity analyses to test the robustness of climatic modification effects.

Results

We found a stronger association between PM1 and the incidence rate of male lung cancer in counties with high levels of air temperature or relative humidity. If there is a 10 μg/m³ shift in PM1, then the change in male incidence rate relative to its mean was higher by 4.39% (95% CI: 2.19, 6.58%) and 8.37% (95% CI: 5.18, 11.56%) in the middle and high temperature groups than in the low temperature group, respectively. The findings of climatic modification effects were robust in the three sensitivity analyses. No significant modification effect was discovered for female incidence rate.

Conclusions

Male residents in high temperature or humidity counties suffer from a larger effect of PM1 on the incidence rate of lung cancer in China. Future research on air pollution-related health impact assessment should consider the differential air pollution effects across different climatic conditions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10912-8.

Could Air Quality Get Better during Epidemic Prevention and Control in China? An Analysis Based on Regression Discontinuity Design

Though many scholars and practitioners are paying more attention to the health and life of the public after the COVID-19 outbreak, extant literature has so far failed to explore the variation of ambient air quality during this pandemic. The current study attempts to fill the gap by disentangling the causal effects of epidemic prevention on air quality in China, measured by the individual pollutant dimensionless index, from other confounding factors. Using the fixed effects model, this article finds that five air indicators, PM2.5, PM10, CO, NO2, and SO2, significantly improved during the shutdown period, with NO2 showing the most improvement. On the contrary, O3 shows an inverse pattern, that is, O3 gets worse unexpectedly. The positive impact of epidemic prevention on air quality, especially in terms of PM2.5, PM10, and NO2, become manifest five days after the resumption of labor, indicated by the result of a regression discontinuity design. These findings are still robust and consistent after the dataset of 2019 as a counterfactual sample is utilized. The findings of this paper make contributions to both environmental governance and pandemic prevention, with relevant guidelines regarding the health and life of the public and governmental behavioral management strategies discussed.

Developing and Testing the Validity and Reliability of the Brief Adolescent Respiratory System Health Assessment Scale-Student Version in a Chinese Sample

Objectives: To develop a Brief Adolescent Respiratory System Health Assessment Scale-Student Version (BARSHAS-SV) and test the validity and reliability of the scale. Methods: Considering common respiratory system diseases and respiratory system symptoms as a theoretical basis, researchers developed a Brief Adolescent Respiratory System Health Assessment Scale-Student Version-I (BARSHAS-SV-I). After six medical experts reviewed the BARSHAS-SV-I, and six adolescents tested the BARSHAS-SV-I, researchers developed an updated BARSHAS-SV-II. Researchers randomly selected two middle schools in Baoding, China. Thousand twenty nine valid questionnaires were recovered. Researchers evaluated the validity and reliability of the scale and obtained the final version of the scale (BARSHAS-SV). The exploratory factor analysis (EFA) and the confirmatory factor analysis (CFA) were used to evaluate the construct validity of the scale. The content validity index (CVI) was used to evaluate the content validity of the scale. The Cronbach's α coefficient and the mean inter-item correlation coefficient (MIIC) were used to assess the reliability of the scale. Results: BARSHAS-SV Cronbach's α = 0.910, content validity = 0.941, and factor cumulative variance contribution rate = 64.047% conducting EFA. Conducting CFA, Chi square value (χ2) = 233.806, degrees of freedom (df) = 106, Chi square value/degree of freedom (χ2/df) = 2.206, root-mean-square error of approximation (RMSEA) = 0.063, normed fit index (NFI) = 0.922, goodness of fit index (GFI) = 0.917, Tueker-Lewis index (TLI) = 0.942, comparative fit index (CFI) = 0.955, incremental fit index (IFI) = 0.956. BARSHAS-SV consisted of 4 dimensions and 17 items. Four factors were as follows: Factor 1, mild respiratory system diseases (Cronbach's α coefficient = 0.781); Factor 2, severe respiratory system diseases (Cronbach's α coefficient = 0.829); Factor 3, respiratory system symptoms (Cronbach's α coefficient = 0.835); Factor 4, treatment and recovery of respiratory system diseases (Cronbach's α coefficient = 0.845). Conclusions: BARSHAS-SV is a valid and reliable method that can be applied to assess adolescent respiratory system health status. BARSHAS-SV may help teachers and medical staff in schools to quickly and conveniently evaluate the adolescent respiratory system health status and identify respiratory issues.

Intensified impacts on mortality due to compound winter extremes in the Czech Republic

Although impacts of extremely cold temperatures on human health have been widely studied, adverse effects of other extreme weather phenomena have so far received much less attention. We employed a high-quality long-term mortality time series (1982-2017) to evaluate impacts of extreme winter weather in the Czech Republic. We aimed to clarify whether compound events of extreme weather cause larger impacts on mortality than do each type of extreme if evaluated individually. Using daily data from the E-OBS and ERA5 datasets, we analyzed 9 types of extreme events: extreme wind gust, precipitation, snowfall, and sudden temperature and pressure changes. Relative mortality deviations from the adjusted baseline were used to estimate the immediate effect of the selected extreme events on excess mortality. The impact was adjusted for the effect of extreme cold. Extreme events associated with sudden rise of minimum temperature and pressure drops had generally significant impact on excess mortality (3.7% and 1.4% increase). The impacts were even more pronounced if these events occurred simultaneously or were compounded with other types of extremes, such as heavy precipitation, snowfall, maximum temperature rise, and their combinations (increase as great as 14.4%). Effects of some compound events were significant even for combinations of extremes having no significant impact on mortality when evaluated separately. On the other hand, a "protective" effect of pressure increases reduced the risk for its compound events. Meteorological patterns during extreme events linked to excess mortality indicate passage of a low-pressure system northerly from the study domain. We identified extreme winter weather events other than cold temperatures with significant impact on excess mortality. Our results suggest that occurrence of compound extreme events strengthen the impacts on mortality and therefore analysis of multiple meteorological parameters is a useful approach in defining adverse weather conditions.

Association between ambient air pollution and laryngeal neoplasms incidence in twelve major Chinese cities, 2006-2013

Epidemiological evidence has suggested that ambient air pollution is an increasingly important risk factor for respiratory diseases without assessing its influence on laryngeal neoplasms incidence in China. We constructed two-way fixed effect models and Poisson regression models to explore the effects of ambient air pollutants including nitrogen dioxide (NO₂), sulfur dioxide (SO₂), and particulate matter less than or equal to 10 μm in aerodynamic diameter (PM₁₀) on incidence of laryngeal neoplasms in twelve major cities in China over the period 2006-2013. The annual average concentration for PM₁₀, SO₂, and NO₂ was 107.22 μg/m³, 44.07 μg/m³, and 46.71 μg/m³ with standard deviations of 24.84 μg/m³, 13.68 μg/m³, and 9.19 μg/m³, respectively. We observed that ambient air pollutants were significantly positively correlated with the incidence of laryngeal neoplasms, especially for NO₂. The relative risks of overall incidence of laryngeal neoplasms in the current period were 1.20, 1.04, and 1.00 for NO₂, SO₂, and PM₁₀, with 95% confidence intervals (CIs) of 1.01-1.43, 0.93-1.16, and 0.96-1.05, respectively. Moreover, this deleterious impact was stronger in the male than in the female, likely due to genetic predisposition caused by longer exposure to more serious air pollution for men. Our findings complement the epidemiological evidence of laryngeal neoplasms due to ambient air pollution and reinforce the necessity of policy efforts to control the noxious air pollution emissions.

Acute effects of ambient air pollution on hospital outpatients with chronic pharyngitis in Xinxiang, China

We present results on a time-series study that analyzed the acute effects of six criteria air pollutants on hospital outpatient with chronic pharyngitis (CP) in Xinxiang, China. Data on the concentration of air pollutants and CP outpatient records were collected daily in Xinxiang, China, from January 1, 2015 to December 31, 2018. This study identified 62,823 outpatients with CP. The annual average concentrations of PM_2.5, PM₁₀, SO₂, NO₂, CO, and O₃ are 75.7, 132.1, 33.2, 48.4, 1377, and 59.4 μg/m³, respectively. Further, a 10 μg/m³ increment in the concentration of PM₁₀, SO₂, NO₂, and CO corresponds to an increase of 0.28% (95% confidence interval (CI): 0.03-0.53%), 1.10% (95% CI: 0.09-2.11%), 1.82% (95% CI: 0.84-2.80%), and 0.03% (95% CI: 0.01-0.06%) in daily CP hospital outpatients, respectively. Furthermore, results indicated that outpatients under the age of 15 are more susceptible to the air pollutants, excluding O₃. Meanwhile, males might be more susceptible, and effect estimates appear slightly stronger in the cool season. Therefore, we should implement effective measures to manage air pollutants and reinforce protection of the high-risk population.

Health impacts of long-term ozone exposure in China over 2013-2017

Increasing ozone concentrations are becoming a severe problem for air pollution in China and have an adverse impact on human health. Here we evaluate premature deaths attributable to long-term exposure to ambient ozone in China between 2013 and 2017 with an air quality model at 5 km resolution and the latest estimates of the relative risk to health. We use a modified inverse distance weighting method to bias-correct the key model-simulated ozone metrics. We find that on a 5-year average basis there are 186,000 (95% Confidence Interval: 129,000-237,000) respiratory deaths and 125,000 (42,000-204,000) cardiovascular deaths attributable to ozone exposure. Sichuan exhibits the largest per capita respiratory mortality (0.31‰) among all provinces. We find that there are 73,000 (51,000-93,000) premature respiratory deaths in urban areas, accounting for 39% of total deaths. Between 2013 and 2017 the population-weighted annual average maximum daily 8-h average ozone (AMDA8) and premature respiratory deaths increased by 14% and 31%, respectively, at a national level. Changes in precursor emissions explain most of these increases, with differences in meteorology accounting for 21% and 16% respectively. Interannual variations in population-weighted ozone and premature respiratory deaths at a provincial level are much larger than those at a national level, particularly in northern, central and eastern China. These findings emphasize that ozone should be an important focus of future air quality policies in China, and tighter controls of precursor emissions are urgently needed.

PM2.5-inducible long non-coding RNA (NONHSAT247851.1) is a positive regulator of inflammation through its interaction with raf-1 in HUVECs

Several studies have demonstrated that PM_2.5 inhalation is associated with an increased risk of cerebrovascular disease (CVD), in which inflammation plays an important role. The mechanisms of this disease are not fully understood to date. Long non-coding RNAs (lncRNAs) are involved in many pathophysiological processes, such as immune responses; however, their functions associated with inflammation are largely unexplored. High-throughput sequencing assay and obtained numerous lncRNAs that altered the expression in response to PM_2.5 treatment in HUVECs. NONHSAT247851.1 was also identified, which was significantly up-regulated to control the expression of immune response genes. Mechanistically, the results indicated that NONHSAT247851.1 knockdown reduced the expression of IL1β. In study, we investigated NONHSAT247851.1 as a promoter in regulating immune response genes via binding with raf-1 to regulate the phosphorylation level of p65 protein in HUVECs. The data collected suggests that NONHSAT247851.1 regulates inflammation via interaction with raf-1 to control the inflammatory expression in PM_2.5 exposure.

Real-Ambient Particulate Matter Exposure-Induced Cardiotoxicity in C57/B6 Mice

It is generally accepted that exposure to particulate matter (PM) increases the risk of cardiovascular-related morbidity and mortality, though the exact mechanism behind this has yet to be elucidated. Oxidative stress plays a potentially important role in the mechanism of toxicity, with Nrf2 serving as a major antioxidant gene. In the current study, a Nrf2 knockout mouse model was used in combination with an individual ventilated cage (IVC)-based real-ambient PM exposure system to assess the potential cardiotoxicity induced by real-ambient PM exposure and the potential role of Nrf2 and related signaling in this endpoint. After 6- or 11-weeks exposure to PM, ICP-mass spectrometry was used to assess the metal depositions in the heart tissue following PM exposure. Functional and morphological changes in the hearts were investigated with echocardiography and histopathology, and oxidative stress levels were assessed with a serum malondialdehyde content assay. In the further mechanistic study, an RNA-seq technique was utilized to assess the gene transcription status in the hearts of C57/B6 mice exposed to PM with or without Nrf2 knockout. The expression levels of genes of interest were then further investigated with quantitative real-time PCR and western blotting. The results indicated that PM exposure resulted in significant elevation of sodium, potassium, selenium, and ferrum levels in mouse heart tissue. Meanwhile, significantly altered heart function and morphology were observed. Interestingly, Nrf2 knockout led to abolishment of PM-induced effects in several functional parameters but not the morphological changes. Meanwhile, elevated malondialdehyde content was observed in Nrf2 knockout animals. RNA-seq results revealed thousands of genes altered by PM exposure and/or Nrf2 knockout, and this affected several pathways, such as MAPK, phagosome, calcium signaling, and JAK-STAT. In subsequent molecular studies, enhanced nuclear translocation of Nrf2 was also observed following PM exposure, while the MAPK signaling pathway along with related JAK-STAT and TGF-β1 pathway genes, such as p38MAPK, AKT, TAK1, JAK1, STAT3, GRB2, TGFb1, and SMAD2, were confirmed to be affected by PM exposure and/or Nrf2 knockout. The data suggested that PM may induce cardiotoxicity in C57/B6 mice in which Nrf2 plays both protective and detrimental roles involving cardiac-related pathways, such as MAPK, JAK-STAT, and TGF-β1.

Association of Ambient Air Pollution with Nasopharyngeal Carcinoma Incidence in Ten Large Chinese Cities, 2006-2013

Large cities in China are experiencing severe ambient air pollution. Although China accounts for more than 45% of new cases of nasopharyngeal carcinoma worldwide in 2018, few studies have examined the association between ambient air pollution and the high nasopharyngeal carcinoma (NPC) incidence in China. Thus, we aim to investigate whether exposure to ambient air pollution (including nitrogen dioxide, sulfur dioxide, and PM10) would significantly affect NPC incidence in large Chinese cities. We collected panel data of ten Chinese provincial cities about local NPC incidence, air pollution level, meteorology, and city profiles during 2006 to 2013 to construct a two-way fixed-effects model to explore the association between ambient air pollution and NPC incidence, as well as possible regional and gender differences behind the association. We found that NO2 had the strongest association with NPC incidence, and the relative risks were 2.2995 (95% CI, 1.2567-4.2075) for males and 1.3010 (95% CI, 0.8212-2.0620) for females, respectively. Under cumulative exposure, it was still NO2 that had the strongest association with NPC incidence, with a relative risk of 1.8836 (95% CI, 1.2416-2.8577), compared to 1.0857 (95% CI, 0.9474-1.2450) and 1.0547 (95% CI, 0.8790-1.2663) for SO2 and PM10, respectively. In addition, males were found more sensitive to ambient air pollution than females. We also found that southern Chinese cities were more sensitive to NO2 than northern cities, which might be related to a higher humidity there. Our study reveals that exposure to ambient air pollutants like SO2, PM10, and particularly NO2, is significantly positively associated with NPC incidence in China.

Critical windows for maternal fine particulate matter exposure and adverse birth outcomes: The Shanghai birth cohort study

BACKGROUND

Prenatal exposure to ambient levels of air pollution has been reported to adversely affect birth outcomes, yet few studies have investigated refined susceptible windows for adverse birth outcomes.

OBJECTIVES

The study aimed at estimating associations between maternal exposure to ambient fine particulate matter (PM_2.5; particles with an aerodynamic diameter ≤ 2.5 μm) and birth outcomes, including birth weight, low birth weight (LBW) and preterm birth (PTB), and identify specific susceptible windows.

METHODS

A total of 3692 singleton live births were enrolled between 2013 and 2016 in Shanghai Birth Cohort, China. Based on mothers' residential addresses, weekly mean concentrations of PM_2.5 over gestation were estimated based on an incorporated evaluating approach combining satellite-based estimates and ground-level measurements. Distributed lag non-liner models (DLNMs) were fitted by incorporating with multiple liner models and Cox proportional hazard models to evaluate weekly-as well as trimester-exposure-lag-response associations between average PM_2.5 level and birth weight, LBW and PTB, and to identify critical windows.

RESULTS

In this study, gestational exposure to PM_2.5 was associated with adverse birth outcomes in infants, and critical windows were identified as 31st-34th gestational weeks for reduced birth weight, 38th-42 nd weeks for LBW and 27th-30th weeks for PTB, respectively. Trimester-specific associations were found for all birth outcomes during the third trimester.

CONCLUSIONS

Ambient PM_2.5 exposure exhibited adverse impacts on multiple outcomes including reduced birth weight, LBW and PTB in the late pregnancy. The study provides further evidence supporting harmful effects of maternal PM_2.5 exposure on birth outcomes and identifying critical windows.

Effects of extreme meteorological factors on daily mumps cases in Hefei, China, during 2011-2016

Mumps remains one of the worldwide major health problems over the past decade. Seasonal variations of mumps indicate that meteorological factors play an important role in the development of mumps, but few studies have investigated the relationship between extreme meteorological factors and the incidence of mumps. Daily mumps cases and meteorological factors in Hefei, China, from 2011 to 2016 were obtained. A generalized additive model combined with the distributed lag nonlinear model (DLNM) was used to quantify the risk of extreme meteorological factors on mumps incidence. Nonlinear relationships were observed among all meteorological factors and mumps incidence. We found that extremely low and high temperatures increased the risk of mumps. The relative risks (RRs) of the cumulative effects along 30 lag days were 2.02 (95%CI: 1.14-3.56) and 2.42 (95%CI: 1.37-4.24), respectively. Both short and long sunshine duration had negative correlation on mumps, with cumulative RRs of 0.64 (95%CI: 0.46-0.92) and 0.57 (95%CI: 0.44-0.74), respectively. In the subgroup analysis, males were found to be more sensitive to extreme weather, especially extreme temperatures and sunshine duration. This study suggests that extreme meteorological factors, especially extreme temperatures and sunshine duration, exert a significant impact on the incidence of mumps. When formulating and implementing effective strategies to the prevention and control of mumps, authorities should take the effect caused by extreme meteorological factors into consideration and pay more attention to susceptible populations, such as male children and teenagers.

[The impact of sugarcane burning on hospitalization due to respiratory diseases]

The scope of this article is to evaluate the impact of emissions from sugarcane burning on hospital admission numbers for respiratory diseases in a sugarcane region. Hospital admission records for respiratory diseases were acquired from the database of the Hospital Information System of the Unified Health System (SIH-SUS) in the period from March 28, 2011 to December 28, 2012. Levels of PM10, NO2, O3, Temperature and Relative Humidity were recorded. Logistic regression models were created to analyze the association between the total number of hospitalizations, atmospheric pollutants and meteorological variables. A total of 1,179 hospitalization admissions were recorded, with a significant increase in cases of pneumonia in the burning period (p = 0.005). Likewise, it was observed that the cluster of PM10 and NO2 was influenced 67.9% (95% CI: 11.111-2.537) followed by cluster PM10, NO2, O3 and Temperature that influenced 91.1% (95% CI: 1.116; 3.271) in the total number of hospitalization admissions. During the sugarcane burning period there were more hospitalization admissions due to respiratory tract diseases, mainly pneumonia, where the influence of air pollutants and temperature in the process of illness in the population was detected.

Ambient air pollution and respiratory mortality in Xi'an, China: a time-series analysis

Background

Although air pollution is a known fundamental problem in China, few studies have investigated the associations between ambient air pollution and respiratory mortality in non-metropolitan cities of China. The study aimed to investigate a potential relationship between short-term exposure to ambient air pollutants and respiratory mortality in Xi’an, China.

Methods

Daily averages of PM_2.5, SO₂, O₃, temperature, relative humidity and daily counts of respiratory mortality were obtained (2014–2016). Using a single and multi-pollutant approach in time-series analysis, the generalized additive model with natural splines was used for analysis. Subgroup analysis stratified by gender and age group (≤ 64 years and ≥ 65 years) was conducted.

Results

Seven thousand nine hundred sixty-five cases of respiratory mortality were assessed, with 62.9, 28.5, and 8.6% of mortality attributed to chronic lower respiratory diseases, influenza and pneumonia, as well as other forms of respiratory diseases, respectively. Observed pollutants were significantly associated with respiratory mortality. In the single pollutant model, 10 μg/m³ increase in a two-day moving average of PM_2.5, and SO₂ concentrations were significantly associated with relative risk 1.313(1.032, 1.708) and 1.4020(0.827, 2.854) of respiratory mortality, respectively. The effects of both air pollutants remained statistically significant after adjusting for collinearity in the multi-pollutant model. Ozone was only statistically associated with respiratory mortality in females at lag 0 [RR: 0.964(0.938, 0.991)].

Conclusion

This study provided evidence that respiratory mortality in Xi’an was significantly associated with exposure to ambient air pollutants from 2014 to 2016.

Ambient carbon monoxide and increased risk of daily hospital outpatient visits for respiratory diseases in Dongguan, China

BACKGROUND

The toxicity of high-concentration carbon monoxide (CO) on human health has previously been documented. However, the epidemiological evidence on the association between acute exposure to ambient CO and respiratory diseases is relatively lacking and controversial.

OBJECTIVES

To examine the short-term association between ambient CO and hospital outpatient visits for respiratory diseases in Dongguan, China.

METHODS

The number of daily hospital outpatient visits for respiratory diseases, and air pollution and meteorological data were collected from January 2013 to August 2017. A generalized additive model with a quasi-Poisson link was used to estimate the association between ambient CO concentration and the total number of hospital outpatient visits for all respiratory diseases and those for asthma, bronchiectasis, chronic obstructive pulmonary disease (COPD) and pneumonia. We further analyzed the effect of ambient CO by gender and age.

RESULTS

Over the study period, a 24-h mean concentration of ambient CO of 0.88 mg/m³ (below the limit for CO in China) and a total of 89,484 hospital outpatient visits for respiratory diseases were recorded. Ambient CO was found to increase the risk for asthma, bronchiectasis, pneumonia and the total number of respiratory diseases. The per interquartile range (IQR) increase in ambient CO at lag₀₃ day corresponded to a 5.62% (95% confidence interval (CI): 3.24%, 8.05%), 8.86% (95% CI: 4.89%, 12.98%), 6.67% (95% CI: 0.87%, 12.81%) and 7.20% (95% CI: 2.35%, 12.29%) increased risk in outpatient visits for all respiratory diseases, asthma, bronchiectasis and pneumonia, respectively. Each association was partially weakened after adjusting for co-pollutants. The effect of ambient CO on respiratory diseases appeared to be greater for females and the elderly.

CONCLUSIONS

Short-term exposure to ambient CO was associated with increased risk of outpatient visits for respiratory diseases. Our analysis may help to understand the health effects of low-levels of CO and provide evidence for the creation of air quality standards.

Including intangible costs into the cost-of-illness approach: a method refinement illustrated based on the PM2.5 economic burden in China

The concentrations of particulate matter with aerodynamic diameters less than 2.5 µm (PM_2.5) and 10 µm (PM₁₀) is a widespread concern and has been demonstrated for 103 countries. During the past few years, the exposure-response function (ERf) has been widely used to estimate the health effects of air pollution. However, past studies are either based on the cost-of-illness or the willingness-to-pay approach, and therefore, either do not cover intangible costs or costs due to the absence of work. To address this limitation, a hybrid health effect and economic loss model is developed in this study. This novel approach is applied to a sample of environmental and cost data in China. First, the ERf is used to link PM_2.5 concentrations to health endpoints of chronic mortality, acute mortality, respiratory hospital admission, cardiovascular hospital admission, outpatient visits-internal medicine, outpatient visits-pediatrics, asthma attack, acute bronchitis, and chronic bronchitis. Second, the health effect of PM_2.5 is monetized into the economic loss. The mean economic loss due to PM_2.5 was much heavier in the North than the South of China. Furthermore, the empirical results from 76 cities in China show that the health effects and economic losses were over 4.98 million cases and 382.30 billion-yuan in 2014 and decreased dramatically compared with those in 2013.

Maternal fine particulate matter (PM2.5) exposure and adverse birth outcomes: an updated systematic review based on cohort studies

Exposure to ambient air pollutants during pregnancy may be associated with numerous side health effects and adverse birth outcomes. Growing numbers of studies have explored a possible linkage between prenatal exposure to PM_2.5 (particulate matter with aerodynamic diameter ≤ 2.5 μm) and impacts on fetal development. We aimed to conduct a systematic review based on published cohort studies to summarize evidence regarding the association between maternal PM_2.5 exposure and birth outcomes, including birth weight, low birth weight (LBW), preterm birth (PTB), and small for gestational age (SGA). Eligible studies meeting the following criterion were selected: PM_2.5 exposure during pregnancy and live birth singletons, certain presentation of sample sizes, and quantitative evaluation of the associations between exposure and outcomes. Among the 42 selected studies, 23 evaluated the impact of prenatal PM_2.5 exposure on birth weight of infants while 12 of them provided a significantly negative association for exposure and birth weight. Twenty-one studies aimed to identify the possible relationship between maternal exposure and LBW and 8 studies proved significant associations. Among 18 studies that explored the correlation between prenatal exposure and PTB, 9 reached a consistent conclusion that gestational exposure would add to the risk of PTB. Nine studies assessed the impact of PM_2.5 on SGA and 5 of them demonstrated a significant effect. So far, linkages between maternal PM_2.5 exposure during varied gestational stages and multiple adverse birth outcomes have been observed in many studies. A summary of them will be meaningful for further research on maternal exposure and adverse birth outcomes.

The macroeconomic burden of noncommunicable diseases associated with air pollution in China

BACKGROUND

While a few studies have tried to estimate the economic burden of noncommunicable diseases (NCDs) associated with air pollution, most previous studies have methodological limitations. For example, neither the cost of illness approach nor the value of a statistical life approach accounts for economic adjustment mechanisms (i.e., they do not include substitution of labor lost due to an illness with capital or other workers), and neither approach considers disease impact on physical and human capital. Furthermore, since new evidence shows that air pollution is also linked to diabetes, previous studies did not estimate the economic costs of diabetes associated with air pollution. The total economic costs of NCDs associated with air pollution under a comprehensive framework therefore remained unexplored.

OBJECTIVES

This study uses a human capital-augmented production function framework to analyze and estimate the macroeconomic impact of NCDs associated with air pollution in China in 1990-2030 and in 2015-2030. It makes several contributions-beyond those of the extant literature-to understanding the economic burden of NCDs associated with air pollution. It does this by accounting for economic adjustment mechanisms and by incorporating human capital into the model.

METHODS

In our framework, aggregate output is produced according to a human capital-augmented production function that accounts for the effects of projected disease prevalence. NCDs associated with air pollution affect the aggregate output through three pathways: 1) Mortality effect-when working-age individuals die from a disease, aggregate output decreases because physical capital is an imperfect substitute for the loss of human capital in the production process. 2) Morbidity effect-when working-age individuals suffer from a disease but do not die from it, their contribution to overall output also decreases depending on disease severity; for example, they might work fewer hours or with lower productivity, or they might retire earlier. We also incorporate age-specific human capital to account for education-related productivity differences between members of different cohorts who are differentially affected by NCDs. 3) Treatment cost effect-when households in which members suffer from a disease use part of their savings to cover the out-of-pocket share of their treatment costs, physical capital accumulation diminishes. Our estimates are based on the recently updated Global Burden of Disease epidemiology data, which identify four pathways through which air pollution affects health: cardiovascular diseases, respiratory diseases, cancer, and diabetes.

RESULTS

Total losses from NCDs associated with air pollution in China in 1990-2030 are estimated to be $1,137 billion (constant 2010 USD) and in 2015-2030 are estimated to be $499 billion (constant 2010 USD). Cardiovascular diseases account for the highest burden, followed by chronic respiratory diseases, diabetes, and cancer. Treatment costs account for nearly 30% of the total economic burden of NCDs associated with air pollution. We also find that the share of economic burden associated with treatment costs is highest for diabetes. This is mainly driven by the fact that, on a per case basis, diabetes has a lower health burden than other diseases associated with air pollution.

DISCUSSION

The NCDs associated with air pollution impose a large economic burden on China.

Study of the Effects of Air Pollutants on Human Health Based on Baidu Indices of Disease Symptoms and Air Quality Monitoring Data in Beijing, China

There is an increasing body of evidence showing the impact of air pollutants on human health such as on the respiratory, and cardio- and cerebrovascular systems. In China, as people begin to pay more attention to air quality, recent research focused on the quantitative assessment of the effects of air pollutants on human health. To assess the health effects of air pollutants and to construct an indicator placing emphasis on health impact, a generalized additive model was selected to assess the health burden caused by air pollution. We obtained Baidu indices (an evaluation indicator launched by Baidu Corporation to reflect the search popularity of keywords from its search engine) to assess daily query frequencies of 25 keywords considered associated with air pollution-related diseases. Moreover, we also calculated the daily concentrations of major air pollutants (including PM10, PM2.5, SO₂, O₃, NO₂, and CO) and the daily air quality index (AQI) values, and three meteorological factors: daily mean wind level, daily mean air temperature, and daily mean relative humidity. These data cover the area of Beijing from 1 March 2015 to 30 April 2017. Through the analysis, we produced the relative risks (RRs) of the six main air pollutants for respiratory, and cardio- and cerebrovascular diseases. The results showed that O₃ and NO₂ have the highest health impact, followed by PM10 and PM2.5. The effects of any pollutant on cardiovascular diseases was consistently higher than on respiratory diseases. Furthermore, we evaluated the currently used AQI in China and proposed an RR-based index (health AQI, HAQI) that is intended for better indicating the effects of air pollutants on respiratory, and cardio- and cerebrovascular diseases than AQI. A higher Pearson correlation coefficient between HAQI and RRTotal than that between AQI and RRTotal endorsed our efforts.

Incidence and mortality for respiratory cancer and traffic-related air pollution in São Paulo, Brazil

BACKGROUND

Multiple lines of evidence have associated exposure to ambient air pollution with an increased risk of respiratory malignancies. However, there is a dearth of evidence from low-middle income countries, including those within South America, where the social inequalities are more marked.

OBJECTIVES

To quantify the association between exposures to traffic related air pollution and respiratory cancer incidence and mortality within São Paulo, Brazil. Further, we aim to investigate the role of socioeconomic status (SES) upon these outcomes.

METHODS

Cancer incidence between 2002 and 2011 was derived from the population-based cancer registry. Mortality data (between 2002 and 2013) was derived from the Municipal Health Department. A traffic density database and an annual nitrogen dioxide (NO₂) land use regression model were used as markers of exposure. Age-adjusted Binomial Negative Regression models were developed, stratifying by SES and gender.

RESULTS

We observed an increased rate of respiratory cancer incidence and mortality in association with increased traffic density and NO₂ concentrations, which was higher among those regions with the lowest SES. For cancer mortality and traffic exposure, those in the most deprived region, had an incidence rate ratio (IRR) of 2.19 (95% CI: 1.70, 2.82) when comparing the highest exposure centile (top 90%) to the lowest (lowest 25%). By contrast, in the least deprived area, the IRR for the same exposure contrast was.1.07 (95% CI: 0.95, 1.20). For NO₂ in the most deprived regions, the IRR for cancer mortality in the highest exposed group was 1.44 (95% CI: 1.10, 1.88) while in the least deprived area, the IRR for the highest exposed group was 1.11 (95% CI: 1.01, 1.23).

CONCLUSIONS

Traffic density and NO₂ were associated with an increased rate of respiratory cancer incidence and mortality in São Paulo. Residents from poor regions may suffer more from the impact of traffic air pollution.

Air pollution and healthcare expenditure: Implication for the benefit of air pollution control in China

Quantitating the health effects of air pollution is important for understanding the benefits of environmental regulations. Using the China Urban Household Survey (UHS) Database, this paper estimated the effect of air pollution exposure on household healthcare expenditure. To address potential endogeneity concerns, we performed household healthcare expenditure regressions using an instrumental variables (IV) strategy based on spatial air pollution spillovers. Our research revealed that a 1% increase in yearly exposure to fine particulate matter (PM_2.5) corresponds to a 2.942% (95% confidence interval: 1.084%, 4.799%) increase in household healthcare expenditure. The estimates suggest that the 13th Five-Year Plan for Ecological and Environmental Protection (the 13th FYP) would reduce annual national healthcare expenditure by 47.36 Billion Dollar (95% confidence interval: 17.45 Billion Dollar, 77.25 Billion Dollar), which accounts for 0.64% (95% confidence interval: 0.24%, 1.04%) of China's gross domestic product (GDP).

The burden of overall and cause-specific respiratory morbidity due to ambient air pollution in Sichuan Basin, China: A multi-city time-series analysis

Few studies have investigated the respiratory morbidity burden due to ambient air pollution in China, especially in a multi-city setting. This study aimed to estimate the short-term effects of ambient air pollutants (PM₁₀, PM_2.5, NO₂ and SO₂) on hospital admissions (HAs) for overall and cause-specific respiratory diseases, as well as the associated burden in 17 cities of Sichuan Basin, China during 2015-2016. Firstly, city-specific effect estimates for each pollutant on respiratory HAs were obtained using generalized additive model with quasi-Poisson link, and then random- or fixed-effects meta-analysis was applied to pool the effect estimates at the regional level. Subgroup analyses by sex, age, season and region were also performed. A total of 757,712 respiratory HAs were collected from all the tertiary and secondary hospitals located in the 17 cities. Risks of HAs for overall and cause-specific respiratory diseases were elevated following increased PM₁₀, PM_2.5, NO₂ and SO₂ exposure. An increase of 10 μg/m³ in PM₁₀ at lag01, PM_2.5 at lag01, NO₂ at lag0 and SO₂ at lag02 was associated with a 0.43% (95% CI: 0.33%, 0.53%), 0.53% (95% CI: 0.39%, 0.68%), 2.36% (95% CI: 1.75%, 2.98%) and 2.54% (95% CI: 1.51%, 3.59%) increases in total respiratory HAs, respectively. Children (≤ 14 years) and elderly (≥ 65 years) appeared to be more vulnerable to the effects of ambient air pollutants. Comparing to the WHO's air quality guidelines, we estimated that 1.84% (95%CI: 1.42%, 2.25%), 1.73% (95%CI: 1.27%, 2.19%) and 0.34% (95%CI: 0.21%, 0.48%) of respiratory HAs were due to PM₁₀, PM_2.5 and SO₂ exposure, respectively. This study suggests that air pollution might be an important trigger of respiratory admissions, and result in substantial burden of HAs for respiratory diseases in Sichuan Basin.

Estimating short-term mortality and economic benefit attributable to PM10 exposure in China based on BenMAP

With the rapidly booming economy, China has been suffering from serious particulate matter (PM) pollution in recent years. In order to improve the air quality, Chinese government issued a new China National Ambient Air Quality Standard (No. GB3095-2012) in 2012. In this study, PM₁₀ exposure level was simulated based on the data of 912 newly constructed monitoring sites and Voronoi Neighborhood Averaging (VNA) interpolation method. It is widely accepted that PM₁₀ can cause short-term health effects. We calculated the short-term health benefit due to decreasing PM₁₀ concentration to the levels of China National Ambient Air Quality Standard based on Environmental Benefits Mapping and Analysis Program (BenMAP). Our results indicated that if the daily average concentration of PM₁₀ reduced to the daily Grade II standard (150 μg/m³), the avoided deaths for all cause, cardiovascular disease, and respiratory disease would be 82,000 (95%CI: 49,000-120,000), 56,000 (95%CI: 34,000-78,000), and 16,000 (95%CI: 10,000-22,000) in 2014, respectively. The economic benefits of avoiding deaths due to all cause for rolling back the concentration of PM₁₀ to the level of 50 μg/m³ were estimated to be 240 billion CNY and 16 billion CNY using willingness to pay (WTP) and human capital (HC) methods, respectively, which accounted for 0.38% (95%CI: 0.11-0.64%) and 0.03% (95%CI: 0.02-0.03%) of the total annual gross domestic product (GDP) of China in 2014.

Individual-level modifiers of the acute effects of air pollution on mortality in Wuhan, China

Background

Ambient air pollution has posed negative effects on human health. Individual-level factors may modify this effect, but previous studies have controversial conclusions, and evidence is lacking especially in developing countries. This study aims to examine the modifying effects of sex, age, and education level of individuals on the associated between daily mortality and air pollutants, including particulate matter < 10 μm in aerodynamic diameter (PM₁₀), sulfur dioxide (SO₂), and nitrogen dioxide (NO₂).

Methods

Time-series analysis was conducted to investigate the acute effects of the air pollution on daily mortality from January 2002 to December 2010 in Wuhan, China. Generalized Additive Models (GAM) were used to examine the association stratified by sex for non-accidental, cardiovascular, and respiratory mortality. For non-accidental mortality, stratified analysis was also conducted by age and educational level.

Results

Outdoor air pollution was associated with daily non-accidental and cardiovascular mortality. An increase of 10 μg/m³ in a 2-day average concentration of PM₁₀, SO₂, and NO₂ was corresponding to the increase in non-accidental mortality of 0.29% (95%CI: 0.06–0.53%), 1.22% (95%CI: 0.77–1.67%) and 1.60% (95%CI: 1.00–2.19%), respectively. The effects of air pollution were faster in females than males. The magnitude of the estimates was higher for females with low education, aged 65–75 years for PM₁₀ and < 65 years for SO₂. To be more specific, we observed that per 10 μg/m³ increase in SO₂ was association with increases in non-accidental mortality of 2.03% (95%CI: 1.38–2.67) for all females and 3.10% (95%CI: 2.05–4.16) for females with low education.

Conclusion

Females and people with low-education are more susceptible to the effect of air pollution, which would provide a sound scientific basis for determination of air pollution standards.

Brief adult respiratory system health status scale-community version (BARSHSS-CV): developing and evaluating the reliability and validity

Background

The evaluation of respiratory system health status in hospitalized patients is usually based on many laboratory examinations and imaging examinations. Medical examinations require a lot of manpower, material resources, financial resources, and may cause a certain degree of mechanical damage and radiation damage. It is not easily used widely and economically to assess the respiratory health status of community adults. Therefore, researchers developed a brief adult respiratory system health status scale-community version (BARSHSS-CV) and tested its reliability and validity.

Methods

Using clinical characteristics and pathogenic factors of respiratory system diseases as a theoretical basis and through reference to relevant literature, researchers developed an initial scale. A randomized cluster sampling strategy was used to recruit adults in the communities of Baoding City, Shijiazhuang City, Cangzhou city and Chifeng City in China. Researchers randomly selected 1 district from each city. Subsequently, 4 communities were respectively randomly selected from 4 districts. Then, researchers conducted the questionnaire survey in 4 communities. Finally, researchers investigated 615 community adults. 584 valid questionnaires were recovered. By applying exploratory factor analysis, confirmatory factor analysis, content validity index, Cronbach’s α coefficient, mean inter-item correlation coefficient and test-retest reliability, researchers tested the reliability and validity of scale and created the final BARSHSS-CV.

Results

BARSHSS-CV Cronbach’s α=0.951, content validity = 0.933, test-retest reliability = 0.963 and factor cumulative contribution rate = 67.168% by exploratory factor analysis. By confirmatory factor analysis, Chi square value (χ2) was 442.117, degrees of freedom (df) was 161, Chi square value/degrees of freedom (χ2 /df) was 2.746, root-mean-square error of approximation (RMSEA) was 0.065, goodness of fit index (GFI) was 0.902, incremental fit index (IFI) was 0.955, comparative fit index (CFI) was 0.955, normed fit index (NFI) was 0.931, Tueker-Lewis index (TLI) was 0.947. BARSHSS-CV consisted of 20 items and 3 dimensions.

Conclusions

BARSHSS-CV with good test-retest reliability and content/construct validity is a brief and economical tool for assessing the state of respiratory system amongst adult communities. BARSHSS-CV may help medical staff in community primary medical institutions quickly, conveniently and economically assess the status of respiratory system and the main problems of respiratory system in community adults.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3505-z) contains supplementary material, which is available to authorized users.

Short-term effects of ambient benzene and TEX (toluene, ethylbenzene, and xylene combined) on cardiorespiratory mortality in Hong Kong

BACKGROUND

Numerous epidemiological and experimental studies have demonstrated the detrimental effects of the criteria air pollutants on population health, including particulate matters, ozone, and nitrogen dioxide. However, evidence on health effects of benzene, toluene, ethylbenzene, and xylene (BTEX in short) is insufficient.

OBJECTIVES

The present study aimed to assess the exposure-lag-response relations of ambient BTEX components with cardiorespiratory mortality in Hong Kong population.

METHODS

Daily BTEX concentrations from April 2011 to December 2014 were collected from the Hong Kong Environmental Protection Department. Cause-specific mortality records were obtained from the Census and Statistics Department of Hong Kong. Generalized additive model (GAM) integrated with a distributed lag model (DLM) was used to estimate the excess risks of cardiorespiratory mortality associated with the cumulative exposure to benzene and TEX (toluene, ethylbenzene and xylene combined) over 0-9 lag days, while adjusting for time trend, seasonality, weather conditions and calendar effects.

RESULTS

We observed the delayed and distributed lag effects of BTEX components on circulatory mortality. The cumulative exposures over 0-9 lag days for IQR increments of benzene (1.4 μg/m³) and TEX (7.9 μg/m³) were associated with 5.8% (95%CI: 1.0% to 10.8%) and 3.5% (95%CI: 1.0% to 6.1%) increases in circulatory mortality, respectively. The effect estimates of benzene and TEX were more delayed than that of PM_2.5. We didn't observe any significant association of BTEX exposure on total and respiratory deaths.

CONCLUSIONS

Short-term elevations in ambient BTEX concentrations may trigger circulatory mortality in Hong Kong population.

The characteristics of pollution in the big industrial cities of Kazakhstan by the example of Almaty

BACKGROUND

Environmental pollution is a problem in the most industrial cities, including Almaty. These cities are frequently overpopulated and hazardous industrial facilities often have a negative impact on public health. The purpose of this study was to determine the characteristics of pollution in Almaty city and assess possible impact on a human by comparing obtained results with sanitary and hygienic standards. (Hygienic standards (HS) 2.1.7.2042-06. AAC of chemical substances in soil Russia). We used both local standards, such as ST RK 2011-2010 "Water, Food, Stern and Tobacco Products. Determination of Chlororganic Pesticides" and International Standards (Customs Union) Sanitary Regulations and Norms number 4630-88.

METHODS

The study was conducted by sampling air, water, and soil and subsequently analyzing them via laboratory and instrumental methods.

RESULTS

Heavy metals were detected via a high-precision method of atomic absorption spectroscopy. Noise was measured on location. Geographic regions with characteristic types of pollution were discovered. It was found that the main polluting factors were as follows: air pollution - carbon monoxide, suspended solids in the form of dust, lead, and noise; water - ammonium compounds, organic substances (assessed based on the chemical oxygen demand (COD) parameter), polychlorinated biphenyl (PCB); soil - lead and PCB. The amount of suspended solids in the air exceeded standard levels by as much as 13.6 times.

CONCLUSIONS

We visualized obtained data (using StatSoft Statistica v6.0 Rus and Exhibit 3.0 (MIT Simile Project) Softwares) for three districts of Almaty, which allowed us to compare the results efficiently. The results show the need for a detailed study on the optimization of the state of the environment and public health. Plans for further studies include development of a system that would enable reducing the negative impact of industrial facilities on public health and the environment in general.

Resurgence of scarlet fever in China: a 13-year population-based surveillance study

Background

A re-emergence of scarlet fever has been noted in Hong Kong, South Korea, and England, UK, since 2008. China also had a sudden increase in the incidence of the disease in 2011. In this study, we aimed to assess the epidemiological changes before and after the upsurge. We also aimed to explore the reasons for the upsurge in disease in 2011, the epidemiological factors that contributed to it, and assess how these could be managed to prevent future epidemics.

Methods

In this observational study, we extracted the epidemiological data for all cases of scarlet fever between 2004 and 2016 in China from the Chinese Public Health Science Data Center, the official website of National Health Commission of the People's Republic of China, and the National Notifiable Infectious Disease Surveillance System. These data had been collected from 31 provinces and regions in China and included geographical, seasonal, and patient demographic information. We used descriptive statistical methods and joinpoint regression to examine the spatiotemporal patterns and annual percentage change in incidence of the upsurge of disease across China.

Findings

Between Jan 1, 2004, and Dec 31, 2016, 502 723 cases of scarlet fever, with ten fatalities, were reported in China, resulting in an annualised average incidence of 2·8807 per 100 000 people. The annual average incidence increased from 1·457 per 100 000 people in 2004 to 4·7638 per 100 000 people in 2011 (incidence rate ratio [IRR] 3·27, 95% CI 3·22–3·32; p<0·0001), peaking in 2015 (5·0092 per 100 000 people). The annual incidence after the 2011 upsurge of scarlet fever, between 2011 and 2016, was twice the average annual incidence reported between 2004 and 2010 (4·0125 vs 1·9105 per 100 000 people; IRR 2·07, 95% CI 2·06–2·09; p<0·0001). Most cases were distributed in the north, northeast, and northwest of the country. Semi-annual patterns were observed in May–June and November–December. The median age at onset of disease was 6 years, with the annual highest incidence observed in children aged 6 years (49·4675 per 100 000 people). The incidence among boys and men was 1·54 greater than that among girls and women before the upsurge, and 1·51 times greater after the upsurge (p<0·0001 for both). The median time from disease onset to reporting of the disease was shorter after the upsurge in disease than before (3 days vs 4 days; p=0·001).

Interpretation

To our knowledge, this is the largest epidemiological study of scarlet fever worldwide. The patterns of infection across the country were similar before and after the 2011 upsurge, but the incidence of disease was substantially higher after 2011. Prevention and control strategies being implemented in response to this threat include improving disease surveillance and emergency response systems. In particular, the school absenteeism and symptom monitoring and early-warning system will contribute to the early diagnosis and report of the scarlet fever. This approach will help combat scarlet fever and other childhood infectious diseases in China.

Funding

National Key R&D Plan of China Science and key epidemiological disciplines of Zhejiang Provincial Health of China.

Effects of ambient air pollution from municipal solid waste landfill on children's non-specific immunity and respiratory health

This cross-sectional study investigated the association between air pollutant (AP) and respiratory health of 951 children residing near a municipal solid waste (MSW) landfill in Northern China. Results showed that students in non-exposure areas had significantly higher levels of lysozyme, secretory immunoglobulin A (SIgA), and better lung capacity than students in exposure areas (p < .05). Multiple regression model analysis indicated that lysozyme levels exhibited a consistent negative association with methane (CH₄: β = -76.3, 95% CI -105 to -47.7) and sulfuretted hydrogen (H₂S: β = -11.7, 95% CI -20.2 to -3.19). In addition, SIgA levels were negatively associated with H₂S (β = -68.9, 95% CI -97.9 to -39.9) and ammonia (NH₃: β = -30.3, 95% CI -51.7 to -8.96). Among all AP, H₂S and sulfur dioxide (SO₂) were the most robustly related with reduced lung function. H₂S exposure was negatively associated with six lung function indices, 1-s forced expiratory volume (FEV1%), mean forced expiratory flow between 25% and 75% (MMF), maximum voluntary ventilation (MVV), and forced expiratory flow at 25%, 50%, and 75% of the pulmonary volume (FEF25, FEF50, FEF75); and SO₂ was negatively associated with FEV1%, MVV, FEF25, FEF50 and FEF75. Our results suggested that AP exposure was negatively associated with more lung function parameters in boys than in girls. In conclusion, our findings suggested that children living adjacent to landfill sites were more likely to have deficient non-specific immunity and impaired lung function.

A Multicity Analysis of the Short-Term Effects of Air Pollution on the Chronic Obstructive Pulmonary Disease Hospital Admissions in Shandong, China

Although there is growing evidence linking chronic obstructive pulmonary disease (COPD) hospital admissions to the exposure to ambient air pollution, the effect can vary depending on the local geography, pollution type, and pollution level. The number of large-scale multicity studies remains limited in China. This study aims to assess the short-term effects of ambient air pollution (PM_2.5, PM₁₀, SO₂, NO₂) on chronic obstructive pulmonary disease hospital admissions from 2015 to 2016, with a total of 216,159 records collected from 207 hospitals in 17 cities all over the Shandong province, east China. Generalized additive models and penalized splines were applied to study the data whilst controlling for confounding meteorological factors and long-term trends. The air pollution was analyzed with 0–6 day lag effects and the percentage change of hospital admissions was assessed for a 10-μg/m³ increase in the air pollution levels. We also examined the percentage changes for different age groups and gender, respectively. The results showed that air pollution was significantly associated with adverse health outcomes and stronger effects were observed for females. The air pollution health effects were also impacted by geographical factors such that the air pollution had weaker health effects in coastal cities.

Acute effects of air pollution on respiratory disease mortalities and outpatients in Southeastern China

The objective of this study was to investigate the potential association between air pollutants and respiratory diseases (RDs). Generalized additive models were used to analyze the effect of air pollutants on mortalities or outpatient visits. The average concentrations of air pollutants in Hangzhou (HZ) were 1.6–2.8 times higher than those in Zhoushan (ZS), except for O₃. In a single pollutant model, the increased concentrations of PM_2.5, NO₂, and SO₂ were strongly associated with deaths caused by RD in HZ, while PM_2.5 and O₃ were associated with deaths caused by RD in ZS. All air pollutants (PM_2.5, NO₂, SO₂, and O₃) were strongly associated with outpatient visits for RD in both HZ and ZS. In multiple pollutant models, a significant association was only observed between PM_2.5 and the mortality rate of RD patients in both HZ and in ZS. Moreover, strong associations between SO₂, NO₂, and outpatient visits for RD were observed in HZ and ZS. This study has provided evidence that both the mortality rates and outpatient visits for RD were significantly associated with air pollutants. Furthermore, the results showed that different air pollutant levels lead to regional differences between mortality rates and outpatient visits.

Using local knowledge and sustainable transport to promote a greener city: The case of Bucharest, Romania

Cities undergoing climate change and rapid urbanization are faced with significant transformational processes that affect the environment and society, challenging them to become more sustainable and resilient. The promotion of nature-based solutions represents an efficient approach to meet sustainability targets in cities and improve the quality of life of citizens. The association of large components of green infrastructure, such as urban parks, with physical activity can counteract the sedentary lifestyle endemic to cities and improve the overall health and well-being of individuals (Carrus et al., 2013; Scopelliti et al., 2016). By promoting a sustainable means of transport and connecting green spaces within a highly urbanized city, bicycle lanes represent an effective tool for associating physical activity with nature in cities allowing bicycle users to benefit from the positive health effects of nature-based solutions. Our study focuses on the potential of bicycle lanes to improve functional connectivity among green spaces. We administered 820 questionnaires in 34 green spaces (i.e., urban parks) in Bucharest, Romania, to identify the factors influencing the use of bicycle lanes connecting urban parks and to understand which planning criteria for bicycle lanes are considered as the most important by park visitors. We applied binary and ordinal logistic regressions and found that the factors affecting bicycle lane use are illegally parked cars and lack of accessibility to urban parks. The criteria preferred by park visitors for bicycle lane planning are determined by experience level and frequency of bicycle use. To develop a functional and integrated bicycle lane network that can make cities healthier and more sustainable, policy makers are advised to engage in a public participatory process and focus on the needs of bicycle users.

Pregnancy and Lifetime Exposure to Fine Particulate Matter and Infant Mortality in Massachusetts, 2001-2007

Many studies have found associations between particulate matter having an aerodynamic diameter of ≤2.5 μm (PM2.5) and adult mortality. Comparatively few studies evaluated particles and infant mortality, although infants and children are particularly vulnerable to pollution. Moreover, existing studies mostly focused on short-term exposure to larger particles. We investigated PM2.5 exposure during pregnancy and lifetime and postneonatal infant mortality. The study included 465,682 births with 385 deaths in Massachusetts (2001-2007). Exposures were estimated from PM2.5-prediction models based on satellite imagery. We applied extended Cox proportional hazards modeling with time-dependent covariates to total, respiratory, and sudden infant death syndrome mortality. Exposure was calculated from birth to death (or end of eligibility for outcome, at age 1 year) and pregnancy (gestation and each trimester). Models adjusted for sex, birth weight, gestational length, season of birth, temperature, relative humidity, and maternal characteristics. Hazard ratios for total, respiratory, and sudden infant death syndrome mortality per-interquartile-range increase (1.3 μg/m3) in lifetime PM2.5 exposure were 2.66 (95% confidence interval (CI): 2.11, 3.36), 3.14 (95% CI: 2.39, 4.13), and 2.50 (95% CI: 1.56, 4.00), respectively. We did not observe a statistically significant relationship between gestational exposure and mortality. Our findings provide supportive evidence that lifetime exposure to PM2.5 increases risk of infant mortality.