Relationship between air pollution and daily mortality in a tropical city: Kaohsiung, Taiwan

Climate Change Projections for Stroke Incidence in Taiwan: Impact of 2 °C and 4 °C Global Warming Level

OBJECTIVES

This study aimed to establish the exposure-lag-response effect between daily maximum temperature and stroke-related emergency department visits and to project heat-induced stroke impacts under global warming levels (GWL) of 2 °C and 4 °C.

METHODS

Stroke-related emergency department visits in Taiwan from 2001 to 2020 were identified using the National Health Insurance Research Database (NHIRD). The study population consisted of 1,100,074 initial stroke cases matched with 2,200,148 non-stroke controls. We employed Distributed Lag Nonlinear Models (DLNM) in a case-crossover study to investigate the association between temperature and stroke. Generalized Estimating Equations (GEE) models with a Poisson function were used to correlate high-temperature exposure with annual stroke incidence rates. Projections were made under two global warming scenarios, GWL 2.0 °C and 4.0 °C, using Coupled General Circulation Model (GCMs). Baseline data from 1995 to 2014 were transformed for spatial distribution at the township level. Geographic Information System (GIS) spatial analysis was performed using Quantum GIS 3.2.0 software.

RESULTS

DLNM exposure-lag-response effect revealed that daily maximum temperature exceeding 34 °C significantly increased the risk of stroke-related emergency department visits, particularly for ischemic stroke. Under the 2 °C GWL scenario, the frequency of days with temperatures surpassing 34 °C is projected to rise substantially by the median year of 2042, with a further increase to 92.6 ± 18.0 days/year by 2065 under the 4 °C GWL scenario. Ischemic stroke showed the highest increase in temperature-related incidence rates, notably rising from 7.80% under the GWL 2 °C to 36.06% under the GWL 4 °C. Specifically, the annual temperature-related incidence rate for ischemic stroke is expected to increase significantly by 2065. Regions such as Taichung, Hsinchu, Yilan, and Taitung demonstrated pronounced changes in heat-related ischemic stroke incidence under the GWL 4 °C.

CONCLUSIONS

The findings emphasize the importance of addressing temperature-related stroke risks, particularly in regions projected to experience significant temperature increases. Effective mitigation strategies are crucial to reduce the impact of rising temperatures on stroke incidence and safeguard public health.

The Correlation between Oral Health and Air Pollution: A Systematic Review

This systematic review assessed to evaluate the potential correlation between oral health and air pollution. To the best of the authors' knowledge, this is the first systematic review endeavoring to compare air pollution and oral health. A systematic search was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) statement and employed the PICO(S) approach (Patient or Population, Intervention, Control or Comparison, Outcome, and Study types). The search was limited to English-language articles, and publications within a 15-year timeframe were included in the electronic search. A comprehensive search was conducted across PubMed, Scopus, Embase, and Web of Science databases, spanning the years 2008 to 2023, resulting in a total of 4983 scientific articles. A final selection of 11 scientific papers was made based on their study type and the specific air pollutants examined. The selected papers analyzed various air pollutants associated with health-related diseases, including Ozone, Nitrogen Dioxide, Nitrogen Monoxide, Carbon Monoxide, sulfur dioxide, and particulate matter. Three out of eleven of the reviewed studies assert a strong correlation between air pollutants and oral diseases, specifically periodontitis. However, the exact biological mechanisms underlying this correlation do not seem to be fully understood, indicating the need for further comprehensive investigation in this regard. Dentists can contribute to the collective effort by educating their patients about the oral health implications of air pollution, thereby supporting initiatives aimed at promoting environmental and health sustainability.

Short-term exposure to ambient ozone and cardiovascular mortality in China: a systematic review and meta-analysis

Air pollution is a major public health concern in China. Notwithstanding this, there is limited evidence regarding the impact of short-term exposure to ambient ozone on cardiovascular mortality in the Chinese population. Therefore, we conducted this meta-analysis to address this important question. The random-effects model was applied to pool the results from individual studies. Finally, 32 effect estimates extracted from 19 studies were pooled in this meta-analysis. The pooled relative risk for cardiovascular mortality for each 10 µg/m3 increment in ozone concentration was 1.0068 (95% CI: 1.0049, 1.0086). Ths significant positive association between ozone exposure and cardiovascular mortality was also observed in different two-pollutant models. This meta-analysis revealed that exposure to ozone was associated with an increased risk of cardiovascular mortality in China, and more efforts on controlling the population from ozone are needed to improve cardiovascular health of Chinese population.

Analysis of the Interior Microclimate in Art Nouveau Heritage Buildings for the Protection of Exhibits and Human Health

Poor air quality inside museums can have a double effect; on the one hand, influencing the integrity of the exhibits and on the other hand, endangering the health of employees and visitors. Both components can be very sensitive to the influence of the internal microclimate, therefore careful monitoring of the physical parameters and pollutants is required in order to maintain them within strict limits and thus to reduce the hazards that can be induced. The current study considers the determination and analysis of 15 indicators of the internal microclimate in an Art Nouveau museum built at the beginning of the 20th century in the Municipality of Oradea, Romania. The monitoring spanned a period of seven months, between September 2021 and March 2022, targeting three rooms of the museum with different characteristics and containing exhibits with a high degree of fragility. The results show that, although there are numerous indicators that have exceeded the thresholds induced by international standards, the possible negative impact on the exhibits and/or on human health remains moderate. This is due to the fact that, most of the time, exceeding the permitted limits are small or only sporadic, the values quickly returning to the permitted limits. Thus, only 22 of the 212 days of monitoring recorded marginal conditions regarding the quality of the indoor air, the rest having acceptable and good conditions. To improve the indoor conditions, a more careful management is needed, especially regarding the values of temperature, humidity, particulate matters, natural and artificial light, volatile organic compounds (VOC) and formaldehyde (HCHO), which during the measurements recorded high values that fluctuated in a wide spectrum. The obtained results can represent the basis for the development and implementation of long-term strategies for stabilizing the microclimatic conditions in the museum in order to preserve the exhibits preventively and to ensure a clean and safe environment for people.

Systematic review and meta-analysis of studies between short-term exposure to ambient carbon monoxide and non-accidental, cardiovascular, and respiratory mortality in China

Although a growing number of original epidemiological studies imply a link between ambient pollution exposure and mortality risk, the findings associated with carbon monoxide (CO) exposure are inconsistent. Thus, we conducted a systematic review and meta-analysis of epidemiological studies to evaluate the correlations between ambient CO and non-accidental, cardiovascular, and respiratory mortality in China. Eight databases were searched from inception to 15 May 2021. A random-effect model was used to calculate the pooled relative risks (RRs) and 95% confidence intervals (CIs). Subgroup analyses as well as sensitivity analyses were performed. The I square value (I²) was used to assess heterogeneity among different studies. The assessment of publication bias on included studies was examined by funnel plot and Egger's test. The influence of a potential publication bias on findings was explored by using the trim-and-fill procedure. Ultimately, a total of 19 studies were included in our analysis. The pooled relative risk for each 1 mg/m³ increase of ambient carbon monoxide was 1.0220 (95%CI: 1.0102-1.0339) for non-accidental mortality, 1.0304 (95%CI:1.0154-1.0457) for cardiovascular mortality, and 1.0318 (95%CI:1.0132-1.0506) for respiratory mortality. None of subgroup analyses could explain the source of heterogeneity. Exclusion of any single study did not materially alter the pooled effect estimates. Although it was suggestive of publication bias, findings were generally similar with principal findings when we explored the influence of a potential publication bias using the trim-and-fill method. Our meta-analysis demonstrated that exposure to ambient CO was positive with risk of deaths from all non-accidental causes, total cardiovascular, and respiratory diseases. Based on these findings, tougher intervention policies and initiatives to reduce the health effects of CO exposure should be established.

Respiratory mortality associated with ozone in China: A systematic review and meta-analysis

This systematic review and meta-analysis was performed to obtain updated evidence regarding the short-term effect of ozone on respiratory mortality in China. We systematically searched the Embase, PubMed, Scopus, Web of Science, China National Knowledge Internet, and Wanfang databases for relevant studies. After screening based on the inclusion criteria, 12 studies with 19 estimates were selected for further meta-analysis. The results revealed that respiratory mortality significantly increased by 0.55% (95% confidence interval: 0.24%-0.85%; Q = 39.47, I² = 54.4%, P = 0.002, tau² < 10^-5) for every 10-μg/m³ increase in the maximum 8-h average concentration of ozone. Furthermore, differences in combined estimates were observed between various regions and lag structures. The combined effect of single-day lags was generally larger than that of multiday lags; the estimate of mortality for the population in the north was larger than that for the population in the south. The sensitivity analysis demonstrated that the main findings were stable; funnel plots with Egger's and Begg's tests indicated no significant publication bias in our analysis.

Association between short-term exposure to sulfur dioxide and carbon monoxide and ischemic heart disease and non-accidental death in Changsha city, China

Background

To investigate the effects of short-term exposure to sulfur dioxide (SO₂) and carbon monoxide (CO) in the central and southern China areas on ischemic heart disease (IHD) and non-accidental deaths.

Method

We investigated the associations between short-term exposure to SO₂ and CO in a city in south-central China and IHD and non-accidental death using a time-series design and generalized additive models with up to a 5-day lag adjusting for day of the week, temperature, air pressure, wind speed, and relative humidity. The relative risks of IHD and non-accidental death per 10-unit increase in SO₂ and CO were derived from zero to five days in single-pollutant models.

Results

Between 2016 and 2018, a total of 10,507 IHD and 44,070 non-accidental deaths were identified. The largest significant relative risk for IHD death was lag 02 for both SO₂ (1.080; 95% confidence interval: 1.075–1.084) and CO (5.297; 95% confidence interval: 5.177–5.418) in single-pollutants models. A significant association was shown at all lag multiple-day moving averages. Two-pollutant models identified an association between SO₂ and mortality when adjusting for CO. In stratified analyses, SO₂ exhibited a stronger association with death during the cold season, while CO exhibited a stronger association with mortality from IHD during the warm season. The risk of death was more robust in the elderly for both pollutants, but was greater in men for CO and in women for SO₂.

Conclusions

Overall, we found an association between short-term exposure to low-level SO₂ and CO and the risk of IHD and non-accidental death.

Ambient carbon monoxide and daily mortality: a global time-series study in 337 cities

BACKGROUND

Epidemiological evidence on short-term association between ambient carbon monoxide (CO) and mortality is inconclusive and limited to single cities, regions, or countries. Generalisation of results from previous studies is hindered by potential publication bias and different modelling approaches. We therefore assessed the association between short-term exposure to ambient CO and daily mortality in a multicity, multicountry setting.

METHODS

We collected daily data on air pollution, meteorology, and total mortality from 337 cities in 18 countries or regions, covering various periods from 1979 to 2016. All included cities had at least 2 years of both CO and mortality data. We estimated city-specific associations using confounder-adjusted generalised additive models with a quasi-Poisson distribution, and then pooled the estimates, accounting for their statistical uncertainty, using a random-effects multilevel meta-analytical model. We also assessed the overall shape of the exposure-response curve and evaluated the possibility of a threshold below which health is not affected.

FINDINGS

Overall, a 1 mg/m³ increase in the average CO concentration of the previous day was associated with a 0·91% (95% CI 0·32-1·50) increase in daily total mortality. The pooled exposure-response curve showed a continuously elevated mortality risk with increasing CO concentrations, suggesting no threshold. The exposure-response curve was steeper at daily CO levels lower than 1 mg/m³, indicating greater risk of mortality per increment in CO exposure, and persisted at daily concentrations as low as 0·6 mg/m³ or less. The association remained similar after adjustment for ozone but was attenuated after adjustment for particulate matter or sulphur dioxide, or even reduced to null after adjustment for nitrogen dioxide.

INTERPRETATION

This international study is by far the largest epidemiological investigation on short-term CO-related mortality. We found significant associations between ambient CO and daily mortality, even at levels well below current air quality guidelines. Further studies are warranted to disentangle its independent effect from other traffic-related pollutants.

FUNDING

EU Horizon 2020, UK Medical Research Council, and Natural Environment Research Council.

The impact of carbon monoxide on years of life lost and modified effect by individual- and city-level characteristics: Evidence from a nationwide time-series study in China

Ambient carbon monoxide (CO) has been linked with mortality and morbidity. Little evidence is available regarding the relation between CO and years of life lost (YLL). Using data from 48 major cities in China from 2013 to 2017, we applied generalized additive models and random effects meta-analyses to explore the effects of CO on YLL from various diseases. Stratified analyses and meta-regression were performed to estimate potential effect modifications of demographic factors, regions, meteorological factors, co-pollutants, urbanization rate, economic level and health service level. Additional life gains due to avoidable YLL under certain scenario were also evaluated. Results indicated that a 1-mg/m³ increase of CO concentrations (lagged over 0-3 d), was associated with 2.08% (95% confidence interval [CI], 1.35%, 2.80%), 2.35% (95% CI: 1.39%, 3.30%), 1.47% (95% CI: -0.01%, 2.93%), 2.28% (95% CI: 1.09%, 3.47%), 2.42% (95% CI: 1.31%, 3.54%), 2.09% (95% CI: 0.47%, 3.72%) increments in daily YLL from non-accidental causes, cardiovascular diseases, respiratory diseases, coronary heart disease, stroke and chronic obstructive pulmonary disease, respectively. These associations were robust to the adjustment of co-pollutants and varied substantially by geography and demographic characteristics. Associations were stronger in the elder people (≥65 years), females, population with low education attainment, and lived in south region, than younger people, males, high educated populations and those lived in north region. Moreover, the harmful impact of increasing CO concentration could be attenuated by city-level characteristics, including the growth of urbanization rate, gross domestic product (GDP), GDP per capita, number of hospital beds, doctors and hospitals. Finally, an estimated life of 0.081 (95% CI: -0.027, 0.190) years would be gained per deceased people if CO concentration could fall to 1 mg/m³. In conclusions, this nationwide analysis showed significant associations between short-term CO exposure and cause-specific YLL. The heterogeneity of both individual- and city-level characteristics should be considered for relevant intervention. These findings may have significant public health implications for the reduction of CO-attributed disease burden in China.

Short-Term Effects of Atmospheric Pollution on Daily Mortality and Their Modification by Increased Temperatures Associated with a Climatic Change Scenario in Northern Mexico

Short-term effects of air pollution on the health of residents in the Metropolitan Area of Monterrey, Mexico were assessed from 2012–2015 using a time-series approach. Guadalupe had the highest mean concentrations for SO₂, CO and O₃; whereas Santa Catarina showed the highest NO₂ concentrations. Escobedo and Garcia registered the highest levels for PM₁₀. Only PM₁₀ and O₃ exceeded the maximum permissible values established in the Mexican official standards. Most of pollutants and municipalities showed a great number of associations between an increase of 10% in their current concentrations and mortality, especially for people >60 years. Different scenarios resulting from climatic change were built (increases of 5–25% in daily mean temperature), but only the increase of 25% (5 °C) showed a significant association with air pollutant concentrations and mortality. All pollutants and municipalities showed significant increases in relative risk indexes (RRI) resulting from an increase of 5 °C when people >60 years was considered. Results were comparable to those reported by other authors around the world. The RRI were low but significant, and thus are of public concern. This study demonstrated that the elderly is strongly threatened not only by atmospheric pollution but also by climatic change scenarios in warm and semiarid places.

Associations between short-term exposure to ambient sulfur dioxide and increased cause-specific mortality in 272 Chinese cities

BACKGROUND

Ambient sulfur dioxide (SO₂) remains a major air pollutant in developing countries, but epidemiological evidence about its health effects was not abundant and inconsistent.

OBJECTIVES

To evaluate the associations between short-term exposure to SO₂ and cause-specific mortality in China.

METHODS

We conducted a nationwide time-series analysis in 272 major Chinese cities (2013-2015). We used the over-dispersed generalized linear model together with the Bayesian hierarchical model to analyze the data. Two-pollutant models were fitted to test the robustness of the associations. We conducted stratification analyses to examine potential effect modifications by age, sex and educational level.

RESULTS

On average, the annual-mean SO₂ concentrations was 29.8 μg/m³ in 272 cities. We observed positive and associations of SO₂ with total and cardiorespiratory mortality. A 10 μg/m³ increase in two-day average concentrations of SO₂ was associated with increments of 0.59% in mortality from total non-accidental causes, 0.70% from total cardiovascular diseases, 0.55% from total respiratory diseases, 0.64% from hypertension disease, 0.65% from coronary heart disease, 0.58% from stroke, and 0.69% from chronic obstructive pulmonary disease. In two-pollutant models, there were no significant differences between single-pollutant model and two-pollutant model estimates with fine particulate matter, carbon monoxide and ozone, but the estimates decreased substantially after adjusting for nitrogen dioxide, especially in South China. The associations were stronger in warmer cities, in older people and in less-educated subgroups.

CONCLUSIONS

This nationwide study demonstrated associations of daily SO₂ concentrations with increased total and cardiorespiratory mortality, but the associations might not be independent from NO₂.

Fine particulate air pollution associated with increased risk of hospital admissions for hypertension in a tropical city, Kaohsiung, Taiwan

The aim of this study was to assess whether a correlation exists between fine particles (PM_2.5) levels and number of hospital admissions for hypertension in Kaohsiung, Taiwan. Hospital admission frequency and ambient air pollution data were obtained for Kaohsiung for 2009-2013. A time-stratified case-crossover method was used to estimate relative risk for hospital admissions, controlling for weather, day of the week, seasonality, and long-term time trends. Odds ratios and 95% confidence intervals were calculated for a 10 µg/m³ increment of PM_2.5 for lags from days 0 to 6. Data showed no significant associations between PM_2.5 levels and number of hypertension-related hospital admissions on warm days (>25°C). However, on cool days (<25°C), a significant positive association was found with frequency of hypertension admissions in the single-pollutant model (without adjusting for other pollutants) with a 10 µg/m³ rise in PM_2.5 on day of admission (lag 0) associated with a 12% increase in number of admissions for hypertension. In the two-pollutant model, the association of PM_2.5 with rate of hypertension hospitalizations remained significant after including SO₂ or O₃ on lag day 0. Data demonstrate that an association between short-term exposure to PM_2.5 and elevated risk of hypertension-related hospital admissions may exist in Kaohsiung, Taiwan, a tropical city.

Ambient carbon monoxide and cardiovascular mortality: a nationwide time-series analysis in 272 cities in China

BACKGROUND

Evidence of the acute health effects of ambient carbon monoxide air pollution in developing countries is scarce and mixed. We aimed to evaluate short-term associations between carbon monoxide and daily cardiovascular disease mortality in China.

METHODS

We did a nationwide time-series analysis in 272 major cities in China from January, 2013, to December, 2015. We extracted daily cardiovascular disease mortality data from China's Disease Surveillance Points system. Data on daily carbon monoxide concentrations for each city were obtained from the National Urban Air Quality Real-time Publishing Platform. City-specific associations between carbon monoxide concentrations and daily mortality from cardiovascular disease, coronary heart disease, and stroke were estimated with over-dispersed generalised linear models. Bayesian hierarchical models were used to obtain national and regional average associations. Exposure-response association curves and potential effect modifiers were evaluated. Two-pollutant models were fit to evaluate the robustness of the effects of carbon monoxide on cardiovascular mortality.

FINDINGS

The average annual mean carbon monoxide concentration in these cities from 2013 to 2015 was 1·20 mg/m³, ranging from 0·43 mg/m³ to 2·45 mg/m³. For a 1 mg/m³ increase in average carbon monoxide concentrations on the present day and previous day (lag 0-1), we observed significant increments in mortality of 1·12% (95% posterior interval [PI] 0·42-1·83) from cardiovascular disease, 1·75% (0·85-2·66) from coronary heart disease, and 0·88% (0·07-1·69) from stroke. These associations did not vary substantially by city, region, and demographic characteristics (age, sex, and level of education), and the associations for cardiovascular disease and coronary heart disease were robust to the adjustment of criteria co-pollutants. We did not find a threshold below which carbon monoxide exposure had no effect on cardiovascular disease mortality.

INTERPRETATION

This analysis is, to our knowledge, the largest study done in a developing country, and provides robust evidence of the association between short-term exposure to ambient carbon monoxide and increased cardiovascular disease mortality, especially coronary heart disease mortality.

FUNDING

Public Welfare Research Program.

Systematic Review and Meta-Analysis of the Association between Ambient Nitrogen Dioxide and Respiratory Disease in China

Objective: This study aimed to assess the quantitative effects of short-term exposure of ambient nitrogen dioxide (NO₂) on respiratory disease (RD) mortality and RD hospital admission in China through systematic review and meta-analysis. Methods: A total of 29 publications were finally selected from searches in PubMed, Web of Science, CNKI and Wanfang databases. Generic inverse variance method was used to pool effect estimates. Pooled estimates were used to represent the increased risk of RD mortality and RD hospital admission per 10 μg/m³ increase in NO₂ concentration. Results: Positive correlations were found between short-term NO₂ exposure and RD in China. RD mortality and RD hospital admission respectively increased by 1.4% (95% CI: 1.1%, 1.7%) and 1.0% (95% CI: 0.5%, 1.5%) per 10 μg/m³ increase in NO₂ concentration. Differences were observed across geographic regions of China. The risk of RD mortality due to NO₂ was higher in the southern region (1.7%) than in the north (0.7%). Conclusions: Evidence was found that short-term exposure to NO₂ was associated with an increased risk of RD mortality and RD hospital admission in China and these risks were more pronounced in the southern regions of the country, due in part to a larger proportion of elderly persons with increased susceptibility to NO₂ in the population compared with the north.

Short-Term Effect of Coarse Particles on Daily Mortality Rate in A Tropical City, Kaohsiung, Taiwan

Many studies examined the short-term effects of air pollution on frequency of daily mortality over the past two decades. However, information on the relationship between exposure to levels of coarse particles (PM(2.5-10)) and daily mortality rate is relatively sparse due to limited availability of monitoring data and findings are inconsistent. This study was undertaken to determine whether an association exists between PM(2.5-10) levels and rate of daily mortality in Kaohsiung, Taiwan, a large industrial city with a tropical climate. Daily mortality rate, air pollution parameters, and weather data for Kaohsiung were obtained for the period 2006-2008. The relative risk (RR) of daily mortality occurrence was estimated using a time-stratified case-crossover approach, controlling for (1) weather variables, (2) day of the week, (3) seasonality, and (4) long-term time trends. For the single-pollutant model without adjustment for other pollutants, PM(2.5-10) exposure levels showed significant correlation with total mortality rate both on warm and cool days, with an interquartile range increase associated with a 14% (95% CI = 5-23%) and 12% (95% CI = 5-20%) rise in number of total deaths, respectively. In two-pollutant models, PM(2.5-10) exerted significant influence on total mortality frequency after inclusion of sulfur dioxide (SO(2)) on warm days. On cool days, PM(2.5-10) induced significant elevation in total mortality rate when SO(2) or ozone (O(3)) was added in the regression model. There was no apparent indication of an association between PM(2.5-10) exposure and deaths attributed to respiratory and circulatory diseases. This study provided evidence of correlation between short-term exposure to PM(2.5-10) and increased risk of death for all causes.

Coarse Particulate Air Pollution Associated with Increased Risk of Hospital Admissions for Respiratory Diseases in a Tropical City, Kaohsiung, Taiwan

This study was undertaken to determine whether there was an association between coarse particles (PM₂.₅-₁₀) levels and frequency of hospital admissions for respiratory diseases (RD) in Kaohsiung, Taiwan. Hospital admissions for RD including chronic obstructive pulmonary disease (COPD), asthma, and pneumonia, and ambient air pollution data levels for Kaohsiung were obtained for the period from 2006 to 2010. The relative risk of hospital admissions for RD was estimated using a case-crossover approach, controlling for weather variables, day of the week, seasonality, and long-term time trends. For the single pollutant model (without adjustment for other pollutants), increased rate of admissions for RD were significantly associated with higher coarse PM levels only on cool days (<25 °C), with a 10 µg/m³ elevation in PM₂.₅-₁₀ concentrations associated with a 3% (95% CI = 1%-5%) rise in COPD admissions, 4% (95% CI = 1%-7%) increase in asthma admissions, and 3% (95% CI = 2%-4%) rise in pneumonia admissions. No significant associations were found between coarse particle levels and the number of hospital admissions for RD on warm days. In the two-pollutant models, PM₂.₅-₁₀ levels remained significantly correlated with higher rate of RD admissions even controlling for sulfur dioxide, nitrogen dioxide, carbon monoxide, or ozone on cool days. This study provides evidence that higher levels of PM₂.₅-₁₀ enhance the risk of hospital admissions for RD on cool days.

Systematic review and meta-analysis of the adverse health effects of ambient PM2.5 and PM10 pollution in the Chinese population

INTRODUCTION

As the largest developing country, China has some of the worst air quality in the world. Heavy smog in January 2013 led to unprecedented public concern about the health impact of exposure to particulate matter. Conducting health impact assessments of particulate matter has thus become an urgent task for public health practitioners. Combined estimates of the health effects of exposure to particulate matter from quantitative reviews could provide vital information for epidemiology-based health impact assessments, but estimates for the Chinese population are limited.

METHODS

On December 31, 2013, we systematically searched the PubMed, Web of Science, and China National Knowledge Infrastructure databases using as keywords names of 127 major cities in Mainland China, Hong Kong, and Taiwan. From among the 1464 articles identified, 59 studies were manually screened. Random-effects or fixed-effects models were used to combine their risk estimates, the funnel plots with Egger test were performed to evaluate the publication bias and Meta regression were run to explore the association between exposure to particulate matter with aerodynamic diameters less than 10 and 2.5 µm (PM10 and PM2.5) and the resulting health effects by the Comprehensive Meta Analysis.

RESULTS

In terms of short-term effects, the combined excess risks of total non-accidental mortality, mortality due to cardiovascular disease, and mortality due to respiratory disease were 0.36% (95% confidence interval [95%CI]: 0.26%, 0.46%), 0.36% (95%CI: 0.24%, 0.49%), and 0.42% (95%CI: 0.28%, 0.55%), for each 10 μg/m(3) increase in PM10. A 10 μg/m(3) increase in PM2.5 was associated with a 0.40% (95%CI: 0.22%, 0.59%) increase in total non-accidental mortality, a 0.63% (95%CI: 0.35%, 0.91%) increase in mortality due to cardiovascular disease, and a 0.75% (95%CI: 01.39%, 1.11%) increase in mortality due to respiratory disease. For constituent-specific mortality, increases of 0.40-3.11% were associated with an increase of 10 ng/m(3) for nickel in PM. The summary estimate ranges of hospital utilization were 0.08% ~ 0.72% and -0.58% ~ 1.32% for a 10 μg/m(3) increase in PM10 and PM2.5. In terms of long-term effects, a 10 μg/m(3) increase of PM10 corresponded to 23-67% increase in the risk of mortality.

CONCLUSION

Short exposures to PM10 and PM2.5 are associated with increases in mortality, but evidence of constituent-associated health effects, long-term effects and morbidity in China is still inadequate.

Short-term effects of fine particulate air pollution on hospital admissions for cardiovascular diseases: a case-crossover study in a tropical city

This study was undertaken to determine whether there was an association between fine particles (PM2.5) levels and hospital admissions for cardiovascular diseases (CVD) in Kaohsiung, Taiwan. Hospital admissions for CVD (including ischemic heart disease [IHD], stroke, congestive heart failure [CHF], and arrhythmias) and ambient air pollution data for Kaohsiung were obtained for the period from 2006-2010. The relative risk of hospital admissions for CVD was estimated using a case-crossover approach, controlling for weather variables, day of the week, seasonality, and long-term time trends. For the single-pollutant model (without adjustment for other pollutants), elevated number of admissions for CVD were significantly associated with higher PM2.5 levels only on cool days (<25°C), with an interquartile range rise associated with a 47% (95% CI = 39-56%), 48% (95% CI = 40-56%), 47% (95% CI = 34-61%), and 51% (95% CI = 34-70%) increase in IHD, stroke, CHF, and arrhythmias admissions, respectively. No significant associations between PM2.5 and hospital admissions for CVD were observed on warm days. In the two-pollutant models, PM2.5 levels remained significant even controlling for sulfur dioxide, nitrogen dioxide, carbon monoxide, or ozone on cool days. This study provides evidence that higher levels of PM2.5 enhance the risk of hospital admissions for CVD in Kaohsiung, Taiwan.

Short-Term Effects of Coarse Particulate Matter on Hospital Admissions for Cardiovascular Diseases: A Case-Crossover Study in a Tropical City

This study was undertaken to determine whether there was an association between coarse particles (PM2.5-10) levels and frequency of hospital admissions for cardiovascular diseases (CVD) in Kaohsiung, Taiwan. Hospital admissions for CVD, including ischemic heart disease (IHD), stroke, congestive heart failure (CHF), and arrhythmias, and ambient air pollution data levels for Kaohsiung were obtained for the period 2006-2010. The relative risk of hospital admissions for CVD was estimated using a case-crossover approach, controlling for weather variables, day of the week, seasonality, and long-term time trends. For the single-pollutant model (without adjustment for other pollutants), increased rates of admissions for CVD were significantly associated with higher coarse PM levels only on cool days (< 25°C), with a 10-μg/m(3) elevation in PM2.5-10 concentrations associated with a 3% (95% CI = 2-4%) rise in IHD admissions, 5% (95% CI = 4-6%) increase in stroke admissions, 3% (95% CI = 1-6%) elevation in CHF admissions, and 3% (95% CI = 0-6%) rise in arrhythmias admissions. No significant associations were found between coarse particle levels and number of hospital admissions for CVD on warm days. In the two-pollutant models, PM2.5-10 levels remained significantly correlated with higher rate of CVD admissions even controlling for sulfur dioxide, nitrogen dioxide, carbon monoxide, or ozone on cool days. Compared to the effect estimate associated with a 10-μg/m(3) increase in PM2.5 levels, effect estimates of frequency of CVD-related admissions associated with a 10-μg/m(3) rise in coarse PM levels were weaker. This study provides evidence that higher levels of PM2.5-10 enhance the risk of hospital admissions for CVD.

Association between air quality and quality of life

Air quality-or its converse, air pollution-is a significant risk factor for human health. Recent studies have reported association between air pollution and human health. There are numerous diseases that may be caused by air pollution such as respiratory infection, lung cancer, cardiovascular disease, chronic obstructive pulmonary disease, and asthma. In this study, the relationship between air quality and quality of life was examined by using canonical correlation analysis. Data of this study was collected from 27 countries. WHO statistics were used as the main source of quality of life data set (Y variables set). European Environment Agency statistics and (for outdoor air-PM10) WHO statistics were used as the main source of air quality data set (X variables set). It is found that there are significant positive correlation between air quality and quality of life.

Short-term effect of fine particulate air pollution on daily mortality: a case-crossover study in a tropical city, Kaohsiung, Taiwan

Many studies have examined the short-term effects of air pollution on frequency of daily mortality over the past two decades. However, information on the relationship between levels of fine particles (PM(2.5)) and daily mortality is relatively sparse due to limited availability of monitoring data. Further the results are inconsistent. This study was undertaken to determine whether there was an association between PM(2.5) levels and daily mortality rate in Kaohsiung, Taiwan, a large industrial city with a tropical climate. Daily mortality rate, air pollution parameters, and weather data for Kaohsiung were obtained for the period from 2006 through 2008. The relative risk of daily mortality occurrence was estimated using a time-stratified case-crossover approach, controlling for (1) weather variables, (2) day of the week, (3) seasonality, and (4) long-term time trends. For the single-pollutant model (without adjustment for other pollutants), no significant effects were found between PM(2.5) and frequency of daily mortality on warm days (≥25°C). On cool days, PM(2.5) showed significant correlation with increased risk of mortality rate for all causes and circulatory diseases in single-pollutant model. There was no indication of an association between PM(2.5) and deaths due to respiratory diseases. The relationship appeared to be stronger on cool days. This study provided evidence of associations between short-term exposure to PM(2.5) and elevated risk of death for all cause and circulatory diseases.

Short-term effects of fine particulate air pollution on hospital admissions for respiratory diseases: a case-crossover study in a tropical city

This study was undertaken to determine whether there was a correlation between fine particles (PM2.5) levels and hospital admissions for respiratory diseases in Kaohsiung, Taiwan. Hospital admissions for respiratory diseases including pneumonia, asthma, and chronic obstructive pulmonary disease (COPD) and ambient air pollution data for Kaohsiung were obtained for the period 2006-2010. The relative risk (RR) of hospital admissions for respiratory diseases was estimated using a case-crossover approach, controlling for weather variables, day of the week, seasonality, and chronic time trends. For the single-pollutant model (without adjustment for other pollutants), increased number of admissions for respiratory diseases were significantly associated with higher PM2.5 levels only on cool days (<25°C), with an interquartile range rise associated with a 50 (95% CI% = 45-55%), 40% (95% CI = 25-58%), and 46% (95% CI = 36-57%) elevation in frequency of admissions for pneumonia, asthma, and COPD, respectively. In the two-pollutant models, PM2.5 levels remained significant even controlling for sulfur dioxide, nitrogen dioxide, carbon monoxide, or ozone on cool days. This study provides evidence that higher levels of PM2.5 increase the risk of hospital admissions for respiratory diseases in Taiwan.

Meta-analysis of the Chinese studies of the association between ambient ozone and mortality

To investigate short-term effects of ambient ozone exposure on mortality in Chinese cities, we conducted a meta-analysis of 10 effect estimates of 5 short-term studies, which reported associations between ambient ozone and mortality in Chinese mainland cities. And we estimated pooled effects by non-accidental mortality, cardiovascular mortality, and respiratory mortality. Combined estimates and their 95%CI were tested by RevMan 5, and Funnel plots were used for the bias analysis. For a 10 μg m(-3) increase of maximum 8-h average concentration of ozone, the percent change for non-accidental mortality, cardiovascular mortality, and respiratory mortality were 0.42 (95%CI, 0.32-0.52%), 0.44% (95%CI, 0.17-0.70%) and 0.50% (95%CI, 0.22-0.77%), respectively. Compared with pooled estimates from other meta-analyses on ambient ozone-associated mortality, our pooled estimate for non-accidental mortality was slightly higher than previous ones and pooled estimate for cardiovascular mortality was consistent with others. However, we observed significantly positive association between ambient ozone and respiratory mortality, which were generally nonsignificant in earlier studies. By combining estimates from published evidence, a small but substantial association between ambient ozone level and mortality was observed in Mainland China.

Meta-analysis of adverse health effects due to air pollution in Chinese populations

Background

Pooled estimates of air pollution health effects are important drivers of environmental risk communications and political willingness. In China, there is a lack of review studies to provide such estimates for health impact assessments.

Methods

We systematically searched the MEDLINE database using keywords of 80 major Chinese cities in Mainland China, Hong Kong and Taiwan on 30 June 2012, yielding 350 abstracts with 48 non-duplicated reports either in English or Chinese after screening. We pooled the relative risks (RR) per 10 μg/m³ of particulate matter (PM₁₀), nitrogen dioxide (NO₂), sulphur dioxide (SO₂) and ozone (O₃).

Results

For short-term effects, the pooled RR (p < 0.05) ranges were: 1.0031 (PM₁₀) to 1.0140 (NO₂) for all-cause mortality, 1.0034 (cardiopulmonary, PM₁₀) to 1.0235 (influenza and pneumonia, SO₂) for 9 specific-causes mortality, 1.0021 (cardiovascular, PM₁₀) to 1.0162 (asthma, O₃) for 5 specific-causes hospital admissions. For birth outcomes, the RR (p < 0.05) ranged from 1.0051 (stillbirth, O₃) to 1.1189 (preterm-birth, SO₂) and for long-term effect on mortality from 1.0150 (respiratory, SO₂) to 1.0297 (respiratory, NO₂). Publication bias was absent (Egger test: p = 0.326 to 0.624). Annual PM₁₀ and NO₂ concentrations were inversely associated with RR of mortality (p = 0.017-0.028).

Conclusions

Evidence on short-term effects of air pollution is consistent and sufficient for health impact assessment but that on long-term effects is still insufficient.

PM₁₀ exposure and non-accidental mortality in Asian populations: a meta-analysis of time-series and case-crossover studies

Objectives

We investigated the association between particulate matter less than 10 µm in aerodynamic diameter (PM₁₀) exposure and non-accidental mortality in Asian populations by meta-analysis, using both time-series and case-crossover analysis.

Methods

Among the 819 published studies searched from PubMed and EMBASE using key words related to PM₁₀ exposure and non-accidental mortality in Asian countries, 8 time-series and 4 case-crossover studies were selected for meta-analysis after exclusion by selection criteria. We obtained the relative risk (RR) and 95% confidence intervals (CI) of non-accidental mortality per 10 µg/m³ increase of daily PM₁₀ from each study. We used Q statistics to test the heterogeneity of the results among the different studies and evaluated for publication bias using Begg funnel plot and Egger test.

Results

Testing for heterogeneity showed significance (p<0.001); thus, we applied a random-effects model. RR (95% CI) per 10 µg/m³ increase of daily PM₁₀ for both the time-series and case-crossover studies combined, time-series studies relative risk only, and case-crossover studies only, were 1.0047 (1.0033 to 1.0062), 1.0057 (1.0029 to 1.0086), and 1.0027 (1.0010 to 1.0043), respectively. The non-significant Egger test suggested that this analysis was not likely to have a publication bias.

Conclusions

We found a significant positive association between PM₁₀ exposure and non-accidental mortality among Asian populations. Continued investigations are encouraged to contribute to the health impact assessment and public health management of air pollution in Asian countries.

Case-crossover analysis of air pollution health effects: a systematic review of methodology and application

BACKGROUND

Case-crossover is one of the most used designs for analyzing the health-related effects of air pollution. Nevertheless, no one has reviewed its application and methodology in this context.

OBJECTIVE

We conducted a systematic review of case-crossover (CCO) designs used to study the relationship between air pollution and morbidity and mortality, from the standpoint of methodology and application.

DATA SOURCES AND EXTRACTION

A search was made of the MEDLINE and EMBASE databases.Reports were classified as methodologic or applied. From the latter, the following information was extracted: author, study location, year, type of population (general or patients), dependent variable(s), independent variable(s), type of CCO design, and whether effect modification was analyzed for variables at the individual level.

DATA SYNTHESIS

The review covered 105 reports that fulfilled the inclusion criteria. Of these, 24 addressed methodological aspects, and the remainder involved the design's application. In the methodological reports, the designs that yielded the best results in simulation were symmetric bidirectional CCO and time-stratified CCO. Furthermore, we observed an increase across time in the use of certain CCO designs, mainly symmetric bidirectional and time-stratified CCO. The dependent variables most frequently analyzed were those relating to hospital morbidity; the pollutants most often studied were those linked to particulate matter. Among the CCO-application reports, 13.6% studied effect modification for variables at the individual level.

CONCLUSIONS

The use of CCO designs has undergone considerable growth; the most widely used designs were those that yielded better results in simulation studies: symmetric bidirectional and time-stratified CCO. However, the advantages of CCO as a method of analysis of variables at the individual level are put to little use.

Temperature-dependent association between mortality rate and carbon monoxide level in a subtropical city: Kaohsiung, Taiwan

The objective of this study was to explore the combined effect of temperature and air pollutant levels on daily non-accidental deaths and cardiovascular causes of mortality. In this study, associations were assessed by means of time-series analyses over the period 1995-1999 for Kaohsiung, Taiwan's largest industrial city, which has a subtropical climate. Ambient exposures to various air pollutants, including carbon monoxide (CO), sulfur dioxide (SO(2)), ozone (O(3)), nitrogen dioxide (NO(2)), and particulate matter (PM(10)), were estimated from the arithmetic means of all daily measurements taken by an air quality monitoring station nearest to the residential district. Generalized additive models with non-parametric spline were used to identify associations between daily mortality and air pollutants as well as the air pollutant-temperature interaction correlation. Our findings indicate that CO is associated with increased risks of non-accidental and cardiovascular mortality. For a 0.2 ppm increase in CO, the increased relative daily risk of non-accidental death is at least 4% on the same day, when the mean temperature is above 24.8 degrees C, while the increased relative risk of mortality due to cardiovascular diseases is 7% two days later at 19.7 degrees C. The study also suggests a statistically significant interaction between CO concentration and daily mean temperature, with non-accidental mortality increasing with a warm outdoor temperature and the effect of CO on cardiovascular mortality being modified by a cold climate. Further reduction of CO pollution is thus deemed crucial for the benefit of public health.

Air pollution and hospital admissions for myocardial infarction in a tropical city: Kaohsiung, Taiwan

This study was undertaken to determine whether there was an association between air pollutant levels and increased hospital admissions for myocardial infarction (MI) in Kaohsiung, Taiwan. Hospital admissions for MI and ambient air pollution data for Kaohsiung were obtained for the period 1996-2006. The relative risk of hospital admissions was estimated using a case-crossover approach, controlling for weather variables, day of the week, seasonality, and long-term time trends. In the single-pollutant models, on warm days (>25 degrees C), statistically significant positive associations were found in all pollutants except particulate matter (PM(10)) and sulfur dioxide (SO(2)). On cool days (<25 degrees C), all pollutants were significantly associated with MI admissions except for ozone (O(3)). For the two-pollutant model, O(3) and carbon monoxide (CO) were significant in combination with each of the other four pollutants on warm days. On cool days, nitrogen dioxide (NO(2)) remained statistically significant in all the two-pollutant models. This study provides evidence that higher levels of ambient air pollutants increase the risk of higher frequency of hospital admissions for MI.

Air Pollution and Hospital Admissions for Congestive Heart Failure in a Tropical City: Kaohsiung, Taiwan

This study was undertaken to determine whether there was an association between air pollutant levels and hospital admissions for congestive heart failure (CHF) in Kaohsiung, Taiwan. Hospital admissions for CHF and ambient air pollution data for Kaohsiung were obtained for the period 1996-2004. The relative risk of hospital admission was estimated using a case-crossover approach, controlling for weather variables, day of the week, seasonality, and long-term time trends. In the single-pollutant models, on warm days (> 25 degrees C) statistically significant positive associations were found in all pollutants except sulfur dioxide (SO(2)). On cool days (< 25 degrees C), all pollutants were significantly associated with CHF admissions. For the two-pollutant model, CO and O(3) were significant in combination with each of the other four pollutants on warm days. On cool days, NO(2) remained statistically significant in all the two-pollutant models. This study provides evidence that higher levels of ambient air pollutants increase the risk of hospital admissions for CHF and that the effects of air pollutants on hospital admissions for CHF were temperature dependent.

Effects of nitrogen dioxide on human health: systematic review of experimental and epidemiological studies conducted between 2002 and 2006

In order to assess health effects in humans caused by environmental nitrogen dioxide (NO(2)) a systematic review of studies in humans was conducted. MEDLINE database was searched for epidemiological studies and experiments on adverse effects of NO(2) published between 2002 and 2006. The evidence with regard to NO(2) exposure limits was assessed using the Scottish Intercollegiate Guidelines Network (SIGN) grading system and the modified three star system. Of the 214 articles retrieved 112 fulfilled the inclusion criteria. There was limited evidence that short-term exposure to a 1-h mean value below 200 microg NO(2)/m(3) is associated with adverse health effects provided by only one study on mortality in patients with severe asthma (*2+). The effect remained after adjusting for other air pollutants. There was moderate evidence that short-term exposure below a 24-h mean value of 50 microg NO(2)/m(3) at monitor stations increases hospital admissions and mortality (**2+). Evidence was also moderate when the search was restricted to susceptible populations (children, adolescents, elderly, and asthmatics). There was moderate evidence that long-term exposure to an annual mean below 40 microg NO(2)/m(3) was associated with adverse health effects (respiratory symptoms/diseases, hospital admissions, mortality, and otitis media) provided by generally consistent findings in five well-conducted cohort and case-control studies with some shortcomings in the study quality (**2+). Evidence was also moderate when the search was restricted to studies in susceptible populations (children and adolescents) and for the combination with other air pollutants. The most frequent reasons for decreased study quality were potential misclassification of exposure and selection bias. None of the high-quality observational studies evaluated was informative for the key questions due to the choice of the dose parameter (e.g., 1-week mean) and exposure levels above the limit values. Inclusion of study designs unlisted in the SIGN grading system did not bring additional evidence regarding exposures below the current air quality limit values for NO(2). As several recent studies reported adverse health effects below the current exposure limits for NO(2) particularly among susceptible populations regarding long-term exposure further research is needed. Apart from high-quality epidemiological studies on causality and the interaction of NO(2) with other air pollutants there is a need for double-blinded randomized cross-over studies among susceptible populations for further evaluation of the short-term exposure limits.

Valuing the health benefits of improving indoor air quality in residences

Unlike commercial premises, the indoor air quality of residences is more dynamic, uncontrolled, and prone to human behavioral changes. In consequence, measuring the health benefit gains derived from improving indoor air quality in residences is more complicated. To overcome this, a human thermal comfort model was first integrated with indoor microenvironment models, and subsequently linked with appropriate concentration-response and economic data for estimating the economic benefit gains derived from improving indoor air quality in residences for an adult and an elderly person. In this study, the development of the model is illustrated by using a typical residential apartment locating at the worst air quality neighborhood in Hong Kong and the daily weather profiles between 2002 and 2006. Three types of personal intervention measures were examined in the study: (i) using air cleaner in residence, (ii) changing time spent in residence, and (iii) relocating to a better air quality neighborhood. Our results revealed that employing air cleaners with windows closed in residence throughout the entire year was the most beneficial measure as it could provide the greatest annual health benefit gains. It would give a maximum of HK$2072 in 5-year cumulative benefit gain for an adult and HK$1700 for an elderly person. Employing air cleaners with windows closed in only cool season (October through March) could give the highest marginal return per dollar spent. The benefit gains would become smaller when windows were opened to a greater extent. By contrast, relocating to a better air quality neighborhood and changing the time spent in residence did not appeal to be beneficial intervention measures.

Particulate matter (PM(2.5), PM(10-2.5), and PM(10)) and children's hospital admissions for asthma and respiratory diseases: a bidirectional case-crossover study

Epidemiological studies reported adverse effects of air pollution on the prevalence of respiratory diseases in children. The purpose of this study was to examine the association between air pollution and admissions for asthma and other respiratory diseases among children who were younger than 15 yr of age. The study used data on respiratory hospital admissions and air pollutant concentrations, including thoracic particulate matter (PM(10)), fine (PM(2.5)), and coarse (PM(10-2.5)) particulate matter in Zonguldak, Turkey. A bidirectional case-crossover design was used to calculate odds ratios for the admissions adjusted for daily meteorological parameters. Significant increases were observed for hospital admissions in children for asthma, allergic rhinitis (AR), and upper (UPRD) and lower (LWRD) respiratory diseases. All fraction of PM in children showed significant positive associations with asthma admissions. The highest association noted was 18% rise in asthma admissions correlated with a 10-microg/m(3) increase in PM(10-2.5) on the same day of admissions. The adjusted odds ratios for exposure to PM(2.5) with an increment of 10 microg/m(3) were 1.15 and 1.21 for asthma and allergic rhinitis with asthma, respectively. PM(10) exerted significant effects on hospital admissions for all outcomes, including asthma, AR, UPRD, and LWRD. Our study suggested a greater effect of fine and coarse PM on asthma hospital admissions compared with PM(10) in children.

Air pollution and hospital admissions for pneumonia in a tropical city: Kaohsiung, Taiwan

This study was undertaken to determine whether there was an association between air pollutant levels and hospital admissions for pneumonia in Kaohsiung, Taiwan. Hospital admissions for pneumonia and ambient air pollution data for Kaohsiung were obtained for the period of 1996-2004. The relative risk of hospital admission was estimated using a case-crossover approach, controlling for weather variables, day of the week, seasonality, and long-term time trends. In the single-pollutant models, on warm days (= 25 degrees C) statistically significant positive associations were found for all pollutants. On cool days (< 25 degrees C), all pollutants were also significantly associated with number of pneumonia admissions. For the two-pollutant model, O3 and CO were significant in combination with each of the other four pollutants on warm days. On cool days, PM10 and NO2 remained statistically significant in all the two-pollutant models. This study provides evidence that higher levels of ambient air pollutants increase the risk of hospital admissions for pneumonia. The effects of air pollutants on hospital admissions for pneumonia were temperature dependent.

Air pollution and hospital admissions for asthma in a tropical city: Kaohsiung, Taiwan

This study was undertaken to determine whether there is an association between air pollutants levels and hospital admissions for asthma in Kaohsiung, Taiwan. Hospital admissions for asthma and ambient air pollution data for Kaohsiung were obtained for the period from 1996 through 2003. The relative risk of hospital admission was estimated using a case-crossover approach, controlling for weather variables, day of the week, seasonality, and long-term time trends. In the single-pollutant models, on warm days (> or = 25 degrees C) statistically significant positive associations were found in all pollutants except sulfur dioxide (SO2). On cool days (< or = 25 degrees C) all pollutants were significantly associated with asthma admissions For the two pollutant models, CO and O3 were significant in combination with each of the other four pollutants on warm days. On cool days NO2 remained statistically significant in all the two-pollutant models. This study provides evidence that higher levels of ambient pollutants increase the risk of hospital admissions for asthma.

Air pollution and hospital admissions for chronic obstructive pulmonary disease in a subtropical city: Taipei, Taiwan

This study was undertaken to determine whether there was an association between air pollutant levels and hospital admissions for chronic obstructive pulmonary disease (COPD) in Taipei, Taiwan. Hospital admissions for COPD and ambient air pollution data for Taipei were obtained for the period 1996-2003. The relative risk of hospital admission was estimated using a case-crossover approach, controlling for weather variables, day of the week, seasonality, and long-term time trends. In the single-pollutant model, on warm days (> or = 20 degrees C) statistically significant positive associations were found in all pollutants except sulphur dioxide (SO2). However, statistically significant effects for COPD admissions on cool days (< 20 degrees C) were observed only for SO2 levels. For the two-pollutant model, NO2 and O3 were significant in combination with each of the other four pollutants on warm days. This study provides evidence that higher levels of ambient air pollutants increases the risk of hospital admissions for COPD in Taiwan.

Air pollution and postneonatal mortality in a tropical city: Kaohsiung, Taiwan

With growing evidence of the association between daily mortality and air pollution in adults, it is important to investigate whether infants are also susceptible to the adverse health effects of ambient air pollutants. The purpose of this study is to examine the relationship between air pollution and postneonatal mortality in Kaohsiung, Taiwan, a large industrial city with a tropical climate, during the period 1994-2000, using a case-crossover analysis. Case-crossover analysis provides an alternative to Poisson time-series regression for studying the short-term adverse health effects of air pollution. The air pollutants examined included particulate matter (PM(10)), sulfur dioxide (SO(2)), ozone (O(3)), nitrogen dioxide (NO(2)), and carbon monoxide (CO). The risk of postneonatal deaths was estimated to increase by 4.0% per 67 microg/m(3) (the interquartile range in daily ambient concentration of PM(10)) for PM(10), 1.8% per 17.84 ppb for NO(2), 5.1% per 0.31 ppm for CO, and 4.6% per 19.20 ppb for O(3). Although positive, none of these associations achieved statistical significance. The established link between air pollution levels and infant mortality may not be as strong in cities with tropical climates, although other factors such as differences in pollutant mix or the underlying health of the postneonates may explain the lack of a strong association in this study. Further studies of this type in cities with varying climates and cultures are needed.

Air pollution and hospital admissions for chronic obstructive pulmonary disease in a tropical city: Kaohsiung, Taiwan

This study was undertaken to determine whether there is an association between air pollutants levels and hospital admissions for chronic obstructive pulmonary disease (COPD) in Kaohsiung, Taiwan. Hospital admissions for COPD and ambient air pollution data for Kaohsiung were obtained for the period from 1996 to 2003. The odds ratio of hospital admission was estimated using a case-crossover approach, controlling for weather variables, day of the week, seasonality, and long-term time trends. In the single-pollutant models, on warm days (> or =25 degrees C) statistically significant positive associations were found in all pollutants except sulphur dioxide (SO2). On cool days (< 25 degrees C), all pollutants were significantly associated with COPD admissions. For the two-pollutant models, CO and O3 were significant in combination with each of the other four pollutants on warm days. On cool days, NO2 remained statistically significant in all the two-pollutant models. This study provides evidence that higher levels of ambient pollutants increase the risk of hospital admissions for COPD.

Evaluation of health benefits for improving indoor air quality in workplace

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

Air pollution and hospital admissions for asthma in a subtropical city: Taipei, Taiwan

This study was undertaken to determine whether there is an association between exposure to air pollutants levels and number of hospital admissions for asthma in Taipei, Taiwan. Hospital admissions for asthma and ambient air pollution data for Taipei were obtained for the period from 1996 through 2003. The relative risk of hospital admission for asthma was estimated using a case-crossover approach, controlling for weather variables, day of the week, seasonality, and long-term time trends. In the single-air-pollutant model, on warm days (> or = 25 degrees C) statistically significant positive associations were found for SO2, NO2, and CO levels with an increase in asthmatic admissions. On cool days (< 25 degrees C), all air pollutants were significantly associated with elevated asthma admissions except SO2. For the two-air-pollutant model, CO significantly increases hospital admissions for asthma in combination with each of the other four pollutants on warm days. On cool days, NO2 and O3 significantly elevated asthma rates in all the two-air-pollutant models. This study provides evidence that higher levels of ambient air pollutant concentrations increase the risk of hospital admissions for asthma.

Correlation between air pollution and postneonatal mortality in a subtropical city: Taipei, Taiwan

With growing evidence of the association between daily mortality and air pollution exposure in adults, it is important to investigate whether infants are also susceptible. The purpose of this study was to examine the relationship between air pollution exposure and postneonatal, defined as infant of more than 27 d and less than 1 yr old, mortality in Taipei, Taiwan's largest city, which has a subtropical climate, for the period 1994-2000, using a case-crossover analysis. This design is an alternative to Poisson time-series regression for studying the short-term adverse health effects of air pollution. The air pollutants examined included particulate matter (PM10), sulfur dioxide (SO2), ozone (O3), nitrogen dioxide (NO2), and carbon monoxide (CO). The risk of postneonatal deaths was estimated to increase by 3.1% for PM10, 4.1% for SO2, 1.7% for NO2, 3.8% for CO, and 0.1% for O3 for each interquartile range change, respectively. However, the associations were without statistical significance. The established link between air pollution levels and infant mortality may not be as strong in cities with subtropical climates, although other factors such as differences in pollutant component composition or the underlying health of the postneonates may explain the lack of a strong association in this study. Further studies of this type in cities with varying climates and cultures are needed.

Relationship between radical generation by urban ambient particulate matter and pulmonary function of school children

The mechanisms by which particulate matter (PM) produces adverse effects on the respiratory system, such as pulmonary dysfunction in children, are largely unknown. However, oxidative stress is thought to play an important role. Various chemical compounds in ambient particulate matter, including transition metals and aromatic organic compounds, may contribute to adverse effects through intrinsic generation of reactive oxygen species (ROS). It was hypothesized that ROS generation by PM, as determined through electron spin resonance (ESR) spectroscopy, may be negatively associated with pulmonary function in school children. PM(2.5), PM(10), and total suspended particulates (TSP) were sampled at the playgrounds of six elementary schools in the city of Maastricht, the Netherlands. All children (8-13 yr) from the six schools were asked to undergo spirometry. Multivariate linear regression models were constructed to evaluate associations between oxygen radical formation by PM and lung function. The radical-generating capacity per microgram PM correlated negatively to forced expiratory volume in 1 s (FEV(1)) and forced expiratory flow at 50% (FEF(50%)) of forced vital capacity (FVC). The data indicate that chemical features that contribute to intrinsic generation of ROS may be relevant for PM risk assessment.

Case???Crossover Analyses of Air Pollution Exposure Data

The case-crossover design has been widely used to study the association between short-term air pollution exposure and the risk of an acute adverse health event. The design uses cases only; for each individual case, exposure just before the event is compared with exposure at other control (or "referent") times. Time-invariant confounders are controlled by making within-subject comparisons. Even more important in the air pollution setting is that time-varying confounders can also be controlled by design by matching referents to the index time. The referent selection strategy is important for reasons in addition to control of confounding. The case-crossover design makes the implicit assumption that there is no trend in exposure across the referent times. In addition, the statistical method that is used-conditional logistic regression-is unbiased only with certain referent strategies. We review here the case-crossover literature in the air pollution context, focusing on key issues regarding referent selection. We conclude with a set of recommendations for choosing a referent strategy with air pollution exposure data. Specifically, we advocate the time-stratified approach to referent selection because it ensures unbiased conditional logistic regression estimates, avoids bias resulting from time trend in the exposure series, and can be tailored to match on specific time-varying confounders.

A call for reporting the relevant exposure term in air pollution case-crossover studies

The exposure term in the case-crossover design consists in the difference between the ambient concentration on the event day and the concentration(s) on some control day(s). So far, all air pollution case-crossover studies presented the distribution of the daily ambient pollutant concentrations but do not publish the distributional properties of the relevant exposure term--that is, the concentration difference. This article shows that this difference can be very small for a large fraction of event days, therefore, seriously limiting the statistical power to refute the null hypothesis. Publishing the distribution of the relevant differences will improve the interpretation and discussion of findings from case-crossover studies, particularly in cases with statistically non-significant associations.

Air pollution and hospital admissions for cardiovascular disease in Taipei, Taiwan

This study was undertaken to determine whether there is an association between air pollutants levels and hospital admissions for cardiovascular diseases (CVD) in Taipei, Taiwan. Hospital admissions for CVD and ambient air pollution data for Taipei were obtained for the period 1997-2001. The relative risk of hospital admission was estimated using a case-crossover approach, controlling for weather variables, day of the week, seasonality, and long-term time trends. For the one-pollutant models, on warm days (>or=20 degrees C) statistically significant positive associations were found between levels of particulate matter <10-microm aerodynamic diameter (PM10), nitrogen dioxide (NO2), carbon monoxide (CO), and ozone (O3). On cool days (<20 degrees C), all pollutants except O3 and SO2 were significantly associated with CVD admissions. For the two-pollutant models, CO, NO2, and O3 were significant in combination with each of the other four pollutants on warm days. On cool days, PM10 remained statistically significant in all the two-pollutant models. This study provides evidence that higher levels of ambient pollutants increase the risk of hospital admissions for CVD.

Relationship between air pollution and daily mortality in a subtropical city: Taipei, Taiwan

Air pollution has been associated with daily mortality in numerous studies over the past decade. However most of these studies were conducted in the United States and Europe with relatively few done in Asia. In the current study, the association between ambient air pollution and daily mortality in Taipei, Taiwan's largest city which has a subtropical climate was undertaken, for the period 1994-1998 using a case-crossover analysis. This design is an alternative to Poisson time series regression for studying the short-term adverse health effects of air pollution. The air pollutants examined included particulate matter (PM(10)), sulfur dioxide (SO(2)), ozone (O(3)), nitrogen dioxide (NO(2)), and carbon monoxide (CO). The largest observed effect, which was without statistical significance, was seen for NO(2) and CO levels on deaths due to respiratory diseases (ORs=1.013 and 1.014, respectively). The well established link between air pollution levels and daily mortality may not be as strong in cities in subtropical areas, although other factors such as differences in pollutant mix or the underlying health of the population may explain the lack of a strong association in this study. Further studies of this type in cities with varying climates and cultures are needed.

Relationship between ambient air pollution and hospital admissions for cardiovascular diseases in kaohsiung, taiwan

This study was undertaken to determine whether there is an association between air pollutants levels and increased number of hospital admissions for cardiovascular diseases (CVD) in Kaohsiung, Taiwan. Hospital admissions records for CVD and ambient air contaminant data collected from monitoring station in Kaohsiung were obtained for the period 1997-2000. The relative risk of hospital admission for CVD was estimated using a case-crossover approach, controlling for weather variables, day of the week, seasonality, and long-term time trends. In the single-pollutant model, on warm days (> or =25 degrees C) statistically significant positive associations were found between levels of particular matter of < 10 microm aerodynamic diameter (PM10), nitrogen dioxide (NO2), carbon monoxide (CO), and ozone (O3). On cool days (< 25 degrees C), all pollutants except O3 were significantly associated with increased CVD admissions. For the two-pollutant model, CO and O3 were both significant in combination with each of the other four contaminants on warm days. PM10 and NO2 remained significantly associated with elevated CVD admissions on warm days. On cool days, CO and NO2 remained statistically significant in all the two-pollutant models. This study provides evidence that higher levels of ambient contaminants, particularly CO, increase the risk of increased hospital admissions for CVD.