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Gao C, Yao X, Wang X, Li Z, Wang Y, Xu X, Li L, Zhang X, Fang X. Effects of air pollutants and temperature on the number of asthma outpatient visits in Hohhot, China. INTERNATIONAL JOURNAL OF ENVIRONMENTAL HEALTH RESEARCH 2024; 34:183-190. [PMID: 36288535 DOI: 10.1080/09603123.2022.2136364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 10/11/2022] [Indexed: 06/16/2023]
Abstract
Although numerous studies have linked asthma to air temperature and pollution, few studies have examined their interactive effects on asthma outpatient visits. This study investigated how air pollutants and their interactions with temperature affect asthma outpatient visits in a city in northern Chinaduring the time period 2018 - 2020 . . As the results, 24,163 asthma outpatients were recorded, a 10-μg/m3 increase in PM10, PM2.5, SO2, and NO2 concentrations was associated with significant increases in visits of 3.47% (95% CI: 2.35%-4.60%), 0.83% (95% CI: 0.36%-1.30%), 3.17% (95% CI: 1.47%-4.90%), and 8.90% (95% CI: 6.09%-11.79%), respectively. The effect was stronger in females than males, and stronger in the elderly (≥65 years) than among the young. The interaction between low temperatures and high air pollution levels significantly increased the number of asthma outpatient visits. This study emphasizesthe importance of reducing air pollution in order to lessen the effects of cold.
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Affiliation(s)
- Chenghua Gao
- Public Health College, Inner Mongolia Medical University, Hohhot, Inner Mongolia, China
| | - Xing Yao
- Outpatient Department of Medical Department, Inner Mongolia People's Hospital, Hohhot, Inner Mongolia, China
| | - Xue Wang
- Public Health College, Inner Mongolia Medical University, Hohhot, Inner Mongolia, China
| | - Zichao Li
- Public Health College, Inner Mongolia Medical University, Hohhot, Inner Mongolia, China
| | - Yaping Wang
- Public Health College, Inner Mongolia Medical University, Hohhot, Inner Mongolia, China
| | - Xiaoqian Xu
- Public Health College, Inner Mongolia Medical University, Hohhot, Inner Mongolia, China
| | - Lehui Li
- Public Health College, Inner Mongolia Medical University, Hohhot, Inner Mongolia, China
| | - Xingguang Zhang
- Public Health College, Inner Mongolia Medical University, Hohhot, Inner Mongolia, China
| | - Xin Fang
- Public Health College, Inner Mongolia Medical University, Hohhot, Inner Mongolia, China
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Hayes L, Mejia-Arangure JM, Errington A, Bramwell L, Vega E, Nunez-Enriquez JC, Namdeo A, Entwistle J, Miquelajauregui Y, Jaimes-Palomera M, Torres N, Rascón-Pacheco RA, Duarte-Rodríguez DA, McNally R. Relationship between air quality and asthma-related emergency hospital admissions in Mexico City 2017-2019. Thorax 2023; 79:43-49. [PMID: 37940200 PMCID: PMC10803984 DOI: 10.1136/thorax-2022-219262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 09/22/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Previous studies found exposure to air pollution leads to exacerbations of asthma in paediatric and adult patients and increases asthma-related emergency hospital admissions (AREHA). METHODS AREHAs and levels of air pollutants (PM10, PM2.5 and NO2) were obtained from Mexico City for the period 2017-2019. A time-series approach was used to explore the relationship between air pollutants and AREHA. Relative risks of AREHA were estimated using a negative binomial regression in young children (less than 5 years) and adults (greater than 18 years). RESULTS There was a positive association between AREHA and PM10, PM2.5 and NO2 in adults, which remained after mutual adjustment for these pollutants. The relative risk (RR) of admission in adults increased by 3% (95% CI 1% to 4%) for a 10 µg/m3 increase in PM10, 1% (0.03% to 3%) for a 5 µg/m3 increase in PM2.5 and by 1% (0.06% to 2%) for a 5 µg/m3 increase in NO2. In contrast, in young children, AREHAs were negatively associated with PM10 after adjustment for NO2 (RR 0.97 (0.95 to 0.99) for a 10 µg/m3 and with NO2 after adjustment for PM10 and PM2.5 (RR 0.98 (0.96 to 0.99) and 0.97 (0.96 to 0.99), respectively, for a 5 µg/m3 increase in NO2). AREHAs in children were not associated with PM2.5 after adjustment for NO2. CONCLUSIONS Ambient air pollution, within the previous week, was associated with emergency hospital admissions for asthma to public hospitals in adults in Mexico City. The relationship in children was less consistent. Further work is needed to explore why differences between adults and children exist to inform appropriate interventions to benefit public health.
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Affiliation(s)
- Louise Hayes
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Juan Manuel Mejia-Arangure
- Unidad de Investigación Médica en Genética Humana, UMAE Hospital de Pediatría CMN Siglo XXI Dr Silvestre Frenk Freund Instituto Mexicano del Seguro Social, Instituto Mexicano del Seguro Social, Mexico City, Mexico
- Facultad de Medicina, National Autonomous University of Mexico (UNAM), Mexico City, Mexico
- Cancer Genomic, National Institute of Genomic Medicine, Mexico City, Mexico
| | - Adam Errington
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Lindsay Bramwell
- Department of Geography and Environmental Sciences, Northumbria University, Newcastle upon Tyne, UK
| | - Elizabeth Vega
- Instituto de Ciencias de la Atmosfera y Cambio Climatico, UNAM, Mexico City, Mexico
| | - Juan Carlos Nunez-Enriquez
- Unidad de Investigación Médica en Epidemiología Clínica, UMAE Hospital de Pediatría CMN Siglo XXI Dr Silvestre Frenk Freund Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Anil Namdeo
- Department of Geography and Environmental Sciences, Northumbria University, Newcastle upon Tyne, UK
| | - Jane Entwistle
- Department of Geography and Environmental Sciences, Northumbria University, Newcastle upon Tyne, UK
| | - Yosune Miquelajauregui
- Laboratorio Nacional de Ciencias de la Sostenibilidad, Instituto de Ecología, Universidad Nacional Autónoma de México, Ciudad de Mexico, Mexico
| | - Mónica Jaimes-Palomera
- Dirección de Monitoreo de Calidad del Aire, Secretaria del Medio Ambiente, Gobierno de la Ciudad de Mexico, Mexico City, Mexico
| | - Nancy Torres
- Coordinación de Vigilancia Epidemiológica, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - R Alberto Rascón-Pacheco
- Unidad de Educación, Investigación y Políticas de Salud, Instituto Mexicano del Seguro Social, Ciudad de Mexico, Mexico
| | - David A Duarte-Rodríguez
- Unidad de Investigación Médica en Epidemiología Clínica, UMAE Hospital de Pediatría CMN Siglo XXI Dr Silvestre Frenk Freund Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Richard McNally
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
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Zhang Y, Yin X, Zheng X. The relationship between PM2.5 and the onset and exacerbation of childhood asthma: a short communication. Front Pediatr 2023; 11:1191852. [PMID: 37593445 PMCID: PMC10429171 DOI: 10.3389/fped.2023.1191852] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 07/17/2023] [Indexed: 08/19/2023] Open
Abstract
Much is known about the link between air pollution and asthma in adults, particularly fine particulate matter (PM2.5). Studies have found that certain levels of fine PM2.5 can increase airway responsiveness and worsen asthma. PM2.5 may play a role in the onset and exacerbation of childhood asthma. However, there is little in the literature on how PM2.5 affects asthma attacks and exacerbations in children. Asthma is a common chronic disease in children, and air pollution can aggravate it. The effect of PM2.5 on childhood asthma needs further research. By evaluating, reviewing, and collating existing results in this area, this paper aims to explore the relationship between PM2.5 and asthma onset and exacerbation in children.
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Affiliation(s)
- Yue Zhang
- Department of Pediatrics, Xiangya Hospital, Central South University, Changsha, China
- The Center of Respiratory Medicine, Xiangya Hospital, Central South University, Changsha, China
| | - Xixi Yin
- Department of Pediatrics, Xiangya Hospital, Central South University, Changsha, China
- The Center of Respiratory Medicine, Xiangya Hospital, Central South University, Changsha, China
| | - Xiangrong Zheng
- Department of Pediatrics, Xiangya Hospital, Central South University, Changsha, China
- The Center of Respiratory Medicine, Xiangya Hospital, Central South University, Changsha, China
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Zhang J, Dong C, Xu H, Chen T, Chen F, Wang D, Shi Y, Liu Y, Su J. Use of symptom diary in primary students: association of nitrogen dioxide with prevalence of symptoms. ENVIRONMENTAL GEOCHEMISTRY AND HEALTH 2023:10.1007/s10653-023-01541-8. [PMID: 36973524 DOI: 10.1007/s10653-023-01541-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 03/12/2023] [Indexed: 06/18/2023]
Abstract
Air pollution is a global public health concern, and numerous studies have attempted to identify the health effects of air pollutants, including nitrogen dioxide (NO2). In China, there are few studies investigating the relationship between NO2 exposure and symptoms among children at an individual level. The aim of the study was to evaluate the acute effects of NO2 on prevalence of symptoms of primary students. An environmental and health questionnaire survey was administered to 4240 primary students in seven districts of Shanghai. Daily symptoms, as well as the daily air pollution and meteorological data from each community, were recorded during the corresponding period. A multivariable logistic regression model was utilized to analyze the relationship between the prevalence of symptoms and NO2 exposure in school-age children. A model with interaction items was adopted to estimate the interactive effects of NO2 and confounding factors on symptoms. The average NO2 level in central urban, industrial and rural areas were 62.07 ± 21.66, 54.86 ± 18.32 and 36.62 ± 21.23 μg m-3, respectively. Our findings demonstrate that the occurrence of symptoms was significantly affected by NO2 exposure in the short-term. The largest associations were observed for a 10 μg m-3 increase in 5-day moving average (lag04) NO2 concentration with prevalence of general symptoms (odds ratio [OR] = 1.15, 95% confidence interval [95% CI]: 1.07-1.22), throat symptoms (OR = 1.23, 95% CI: 1.13-1.35) and nasal symptoms (OR = 1.142, 95% CI: 1.02-1.27). Subgroup analysis showed that non-rural areas, boys, nearby environmental pollution source and history of present illness were all susceptible factors to the effects of NO2 exposure. Furthermore, there were interactive effects between NO2 exposure and area types on reported symptoms. NO2 can increase the risk of symptoms in primary students in the short-term, which could be significantly enhanced in central urban and industrial areas.
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Affiliation(s)
- Jianghua Zhang
- Division of Health Risk Factors Monitoring and Control, Shanghai Municipal Center for Disease Control and Prevention, Changning District, Shanghai, 200336, China
| | - Chunyang Dong
- Division of Health Risk Factors Monitoring and Control, Shanghai Municipal Center for Disease Control and Prevention, Changning District, Shanghai, 200336, China
| | - Huihui Xu
- Division of Health Risk Factors Monitoring and Control, Shanghai Municipal Center for Disease Control and Prevention, Changning District, Shanghai, 200336, China.
| | - Tian Chen
- Division of Public Health Service and Safety Assessment, Shanghai Municipal Center for Disease Control and Prevention, Shanghai, 200336, China
| | - Feier Chen
- Division of Health Risk Factors Monitoring and Control, Shanghai Municipal Center for Disease Control and Prevention, Changning District, Shanghai, 200336, China
| | - Duo Wang
- Division of Health Risk Factors Monitoring and Control, Shanghai Municipal Center for Disease Control and Prevention, Changning District, Shanghai, 200336, China
| | - Yewen Shi
- Division of Health Risk Factors Monitoring and Control, Shanghai Municipal Center for Disease Control and Prevention, Changning District, Shanghai, 200336, China
| | - Yongping Liu
- School of Public Health, Fudan University, Shanghai, 200032, China
| | - Jin Su
- Division of Health Risk Factors Monitoring and Control, Shanghai Municipal Center for Disease Control and Prevention, Changning District, Shanghai, 200336, China.
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Dąbrowiecki P, Chciałowski A, Dąbrowiecka A, Badyda A. Ambient Air Pollution and Risk of Admission Due to Asthma in the Three Largest Urban Agglomerations in Poland: A Time-Stratified, Case-Crossover Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19105988. [PMID: 35627528 PMCID: PMC9140383 DOI: 10.3390/ijerph19105988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 05/04/2022] [Accepted: 05/11/2022] [Indexed: 11/16/2022]
Abstract
Ambient air pollution in urban areas may trigger asthma exacerbations. We carried out a time-series analysis of the association between the concentrations of various air pollutants and the risk of hospital admission due to asthma over 7 days from exposure. We used distributed lag nonlinear models to analyze data gathered between 2010 and 2018 in the three largest urban agglomerations in Poland. Overall, there were 31,919 asthma hospitalizations. Over 7 days since exposure, the rate ratio (95%CI) for admission per 10 µg/m3 was 1.013 (1.002–1.024) for PM10; 1.014 (1.000–1.028) for PM2.5; 1.054 (1.031–1.078) for NO2; and 1.044 for SO2 (95%CI: 0.986–1.104). For all pollutants, the risk of admission was the greatest on the day of exposure (day 0), decreased below baseline on days 1 and 2, and then increased gradually up to day 6. The proportions (95%CI) of hospitalizations attributable to air pollution were 4.52% (0.80%–8.14%) for PM10; 3.74% (0.29%–7.11%) for PM2.5; 16.4% (10.0%–21.8%) for NO2; and 2.50% (−0.75%–5.36%) for SO2. In conclusion, PM2.5, PM10, NO2, and SO2 pollution was associated with an increased risk of hospital admission due to asthma in the three largest urban agglomerations in Poland over nine years.
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Affiliation(s)
- Piotr Dąbrowiecki
- Department of Allergology and Infectious Diseases, Military Institute of Medicine, 04-141 Warsaw, Poland; (P.D.); (A.C.)
- Polish Federation of Asthma Allergy and COPD Patients Associations, 01-604 Warsaw, Poland
| | - Andrzej Chciałowski
- Department of Allergology and Infectious Diseases, Military Institute of Medicine, 04-141 Warsaw, Poland; (P.D.); (A.C.)
| | | | - Artur Badyda
- Polish Federation of Asthma Allergy and COPD Patients Associations, 01-604 Warsaw, Poland
- Faculty of Building Services, Hydro and Environmental Engineering, Warsaw University of Technology, 00-653 Warsaw, Poland
- Correspondence:
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Peng W, Li H, Peng L, Wang Y, Wang W. Effects of particulate matter on hospital admissions for respiratory diseases: an ecological study based on 12.5 years of time series data in Shanghai. Environ Health 2022; 21:12. [PMID: 35027064 PMCID: PMC8756174 DOI: 10.1186/s12940-021-00828-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 12/27/2021] [Indexed: 05/08/2023]
Abstract
BACKGROUND Previous epidemiological studies on the association between short-term exposure to particulate matter (PM) with hospital admission in major cities in China were limited to shorter study periods or a single hospital. The aim of this ecological study based on a 12.5-year time series was to investigate the association of short-term exposure to PM with aerodynamic diameter ≤ 2.5 μm (PM2.5) and aerodynamic diameter ≤ 10 μm (PM10) with hospital admissions for respiratory diseases. METHODS Daily hospital admissions data were from the Shanghai Medical Insurance System for the period January 1, 2008 to July 31, 2020. We estimated the percentage change with its 95% confidence interval (CI) for each 10 μg/m3 increase in the level of PM2.5 and PM10 after adjustment for calendar time, day of the week, public holidays, and meteorological factors applying a generalized additive model with a quasi-Poisson distribution. RESULTS There were 1,960,361 hospital admissions for respiratory diseases in Shanghai during the study period. A 10 μg/m3 increase in the level of each class of PM was associated with increased total respiratory diseases when the lag time was 0 day (PM2.5: 0.755%; 95% CI: 0.422, 1.089%; PM10: 0.250%; 95% CI: 0.042, 0.459%). The PM2.5 and PM10 levels also had positive associations with admissions for COPD, asthma, and pneumonia. Stratified analyses demonstrated stronger effects in patients more than 45 years old and during the cold season. Total respiratory diseases increased linearly with PM concentration from 0 to 100 μg/m3, and increased more slowly at higher PM concentrations. CONCLUSIONS This time-series study suggests that short-term exposure to PM increased the risk for hospital admission for respiratory diseases, even at low concentrations. These findings suggest that reducing atmospheric PM concentrations may reduce hospital admissions for respiratory diseases.
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Affiliation(s)
- Wenjia Peng
- Department of Epidemiology, School of Public Health, Fudan University, Shanghai, 200032, China
| | - Hao Li
- Department of Epidemiology, School of Public Health, Fudan University, Shanghai, 200032, China
| | - Li Peng
- Department of Epidemiology, Shanghai Key Laboratory of Meteorology and Health, Shanghai, 200032, China
| | - Ying Wang
- Key Laboratory of Health Technology Assessment, National Health and Family Planning Commission of the People's Republic of China, Fudan University, Shanghai, China.
- IRDR-ICoE on Risk Interconnectivity and Governance on Weather/Climate Extremes Impact and Public Health, Fudan University, Shanghai, 200032, China.
| | - Weibing Wang
- Department of Epidemiology, School of Public Health, Fudan University, Shanghai, 200032, China.
- Department of Epidemiology, Shanghai Key Laboratory of Meteorology and Health, Shanghai, 200032, China.
- Department of Social Medicine, School of Public Health, Fudan University, Shanghai, 200032, China.
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Saygin H, Mercan Y, Yorulmaz F. The association between air pollution parameters and emergency department visits and hospitalizations due to cardiovascular and respiratory diseases: a time-series analysis. Int Arch Occup Environ Health 2021; 95:599-606. [PMID: 34617165 DOI: 10.1007/s00420-021-01769-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 09/27/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVE In this study, the association between cardiovascular and respiratory Emergency Department (ED) visits and hospitalizations and Sulfur Dioxide (SO2) and particulate matter with an aerodynamic diameter ≤ 10 µm (PM10) was determined. METHODS The records of a total of 632,223 people diagnosed with cardiovascular diseases (ICD-10 code I00-I99) and respiratory diseases (ICD-10 code J00-J99) at and over the age of 18 between 2012 and 2018 in three hospitals in Karaman in Turkey were examined in the present study. The daily 24-h averages for SO2 and PM10 concentrations were acquired in National Air Quality Monitoring. A time-series analysis with Poisson Generalized Linear Model was used. RESULTS Among the air pollution parameters, the mean ± standard deviation of SO2 and PM10 were 16.2 ± 22.1 and 75.8 ± 48.2 μg/m3, respectively. An increase of 10 μg/m3 in SO2 was associated with a 3% [Relative Risk (RR), 95% Confidence Interval (CI): 2-4)] increase in cardiovascular ED visit and 2% (RR, 95% CI 2-3) increase in respiratory ED visit, and 1% (RR, 95% CI 1-3) increase in respiratory hospitalizations. An increase of 10 μg/m3 in PM10 was associated with a 1% (RR, 95% CI 1-2) increase in cardiovascular hospitalizations. CONCLUSIONS Increases in SO2 are a risk factor for cardiovascular and respiratory ED visits, and respiratory hospitalizations. Increases in PM10 are a risk factor for cardiovascular hospitalizations.
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Affiliation(s)
- Hasan Saygin
- Department of Public Health, Kirklareli University Institute of Health Sciences, Kirklareli, Turkey.,Karaman Provincial Health Directorate Health Services Unit, 70110, Karaman, Turkey
| | - Yeliz Mercan
- Department of Public Health, Kirklareli University Institute of Health Sciences, Kirklareli, Turkey. .,Faculty of Health Science, Department of Health Management, Kirklareli University, 39000, Kirklareli, Turkey.
| | - Faruk Yorulmaz
- Faculty of Medicine, Department of Public Health, Trakya University, Edirne, Turkey
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Mercan Y, Babaoglu UT, Erturk A. Short-term effect of particular matter and sulfur dioxide exposure on asthma and/or chronic obstructive pulmonary disease hospital admissions in Center of Anatolia. ENVIRONMENTAL MONITORING AND ASSESSMENT 2020; 192:646. [PMID: 32939661 DOI: 10.1007/s10661-020-08605-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 09/10/2020] [Indexed: 06/11/2023]
Abstract
We investigated the associations between the daily variations of coarse particulate matter (PM10) and/or sulfur dioxide (SO2) and hospital admissions for asthma and/or chronic obstructive pulmonary disease (COPD) diseases in Kirsehir, Center of Anatolia of Turkey. We analyzed the poison generalized linear model (GLM) to analyze the association between ambient air pollutants such as PM10 and SO2 and asthma and/or COPD admissions. We investigated single-lag days and multi-lag days for the risk increase in asthma, COPD, asthma, and/or COPD hospital admissions PM10, SO2, and PM10 with SO2 per 10 μg/m3. In single-lag day model a 10 μg/m3 increase in the current day (lag 0) concentrations of PM10 and SO2 corresponded to increase of 1.027 (95% CI:1.022-1.033) and 1.069 (95% CI:1.062, 1.077) for asthma. A 10 μg/m3 increase in the current day (lag 0) concentrations of PM10 and SO2 corresponded to increase of 1.029 (95% CI:1.022-1.035) and 1.065 (95% CI:1.056, 1.075) for COPD. A 10 μg/m3 increase in the current day (lag 0) concentrations of PM10 and SO2 corresponded to increase of 1.028 (95% CI:1.024-1.032) and 1.068 (95% CI:1.062, 1.074) for asthma and/or COPD. It was found that some lag structures were related with PM10 and SO2. Significant lags were detected in some lag structures from the previous first day until the previous eighth day (lag 1 to lag 7) in the asthma, COPD, and asthma and/or COPD hospital admissions in the model created with PM10 with SO2 both in the single-lag day model and in the multi-lag day model. Our study that used GLM in time series analysis showed that PM10 and/or SO2 short-term exposure in single-lag day and multi-lag day models was related with increased asthma, COPD, and asthma and/or COPD hospital admissions in the city between 2016 and 2019 until the previous-eighth day.
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Affiliation(s)
- Yeliz Mercan
- Kirklareli University Health Sciences Institute Department of Public Health, 39000, Kirklareli, Turkey.
- Kirklareli University School of Health Department of Health Management, 39000, Kirklareli, Turkey.
| | - Ulken Tunga Babaoglu
- Kirsehir Ahi Evran University Faculty of Medicine Department of Public Health, 40100, Kirsehir, Turkey
| | - Arzu Erturk
- Kirsehir Ahi Evran University Faculty of Medicine Department of Chest Diseases, Kirsehir, 40100, Turkey
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