A causal exposure response function with local adjustment for confounding: Estimating health effects of exposure to low levels of ambient fine particulate matter

In the last two decades, ambient levels of air pollution have declined substantially. At the same time, the Clean Air Act mandates that the National Ambient Air Quality Standards (NAAQS) must be routinely assessed to protect populations based on the latest science. Therefore, researchers should continue to address the following question: is exposure to levels of air pollution below the NAAQS harmful to human health? Furthermore, the contentious nature surrounding environmental regulations urges us to cast this question within a causal inference framework. Several parametric and semi-parametric regression approaches have been used to estimate the exposure-response (ER) curve between long-term exposure to ambient air pollution concentrations and health outcomes. However, most of the existing approaches are not formulated within a formal framework for causal inference, adjust for the same set of potential confounders across all levels of exposure, and do not account for model uncertainty regarding covariate selection and the shape of the ER. In this paper, we introduce a Bayesian framework for the estimation of a causal ER curve called LERCA (Local Exposure Response Confounding Adjustment), which a) allows for different confounders and different strength of confounding at the different exposure levels; and b) propagates model uncertainty regarding confounders' selection and the shape of the ER. Importantly, LERCA provides a principled way of assessing the observed covariates' confounding importance at different exposure levels, providing researchers with important information regarding the set of variables to measure and adjust for in regression models. Using simulation studies, we show that state of the art approaches perform poorly in estimating the ER curve in the presence of local confounding. LERCA is used to evaluate the relationship between long-term exposure to ambient PM2.5, a key regulated pollutant, and cardiovascular hospitalizations for 5,362 zip codes in the continental U.S. and located near a pollution monitoring site, while adjusting for a potentially varying set of confounders across the exposure range. Our data set includes rich health, weather, demographic, and pollution information for the years of 2011-2013. The estimated exposure-response curve is increasing indicating that higher ambient concentrations lead to higher cardiovascular hospitalization rates, and ambient PM2.5 was estimated to lead to an increase in cardiovascular hospitalization rates when focusing at the low exposure range. Our results indicate that there is no threshold for the effect of PM2.5 on cardiovascular hospitalizations.

Spatial and Temporal Dynamics in Air Pollution Exposure Assessment

Analyzing individual exposure in urban areas offers several challenges where both the individual's activities and air pollution levels demonstrate a large degree of spatial and temporal dynamics. This review article discusses the concepts, key elements, current developments in assessing personal exposure to urban air pollution (seventy-two studies reviewed) and respective advantages and disadvantages. A new conceptual structure to organize personal exposure assessment methods is proposed according to two classification criteria: (i) spatial-temporal variations of individuals' activities (point-fixed or trajectory based) and (ii) characterization of air quality (variable or uniform). This review suggests that the spatial and temporal variability of urban air pollution levels in combination with indoor exposures and individual's time-activity patterns are key elements of personal exposure assessment. In the literature review, the majority of revised studies (44 studies) indicate that the trajectory based with variable air quality approach provides a promising framework for tackling the important question of inter- and intra-variability of individual exposure. However, future quantitative comparison between the different approaches should be performed, and the selection of the most appropriate approach for exposure quantification should take into account the purpose of the health study. This review provides a structured basis for the intercomparing of different methodologies and to make their advantages and limitations more transparent in addressing specific research objectives.

Invited commentary: Assessment of air pollution and suicide risk

Suicide is a serious public health issue worldwide, with multiple risk factors, such as severe mental illness, alcohol abuse, a painful loss, exposure to violence, or social isolation. Environmental factors, particularly chemical and meteorological variables, have been examined as risk factors for suicide, but less evidence is available on whether air pollution is related to suicide. In this issue of the Journal, Bakian et al. ( publish findings from a study that found a short-term increased risk of suicide associated with increased air pollution. This study bolsters a small body of research linking air pollution exposure to suicide risk. If the association between air pollution and suicide is confirmed, it would broaden the scope of the already large disease burden associated with air pollution.

Associations of particulate air pollution and daily mortality in 16 Chinese cities: an improved effect estimate after accounting for the indoor exposure to particles of outdoor origin

People typically spend most of their time indoors. We modeled the daily indoor PM10 concentrations of outdoor origin using a set of exposure parameters, including the fraction of residences with air conditionings (AC), the fraction of time that windows are closed when cooling occurs for buildings with AC, the fractions of time that windows are open or closed for buildings with or without AC, the particle penetration factors, air change rates, and surface removal rate constant of PM10. We calculated the time-weighted average of the simulated indoor PM10 concentration of outdoor origin and the original recorded outdoor PM10 concentration. We then evaluated the acute effects of PM10 using traditional and amended exposure metrics in 16 Chinese cities. Compared with the original estimates, the new effect estimates almost doubled, with improved model fit and attenuated between-city heterogeneity. Conclusively, this proposed exposure assessment approach could improve the effect estimates of ambient particles.

Development and evaluation of alternative approaches for exposure assessment of multiple air pollutants in Atlanta, Georgia

Measurements from central site (CS) monitors are often used as estimates of exposure in air pollution epidemiological studies. As these measurements are typically limited in their spatiotemporal resolution, true exposure variability within a population is often obscured, leading to potential measurement errors. To fully examine this limitation, we developed a set of alternative daily exposure metrics for each of the 169 ZIP codes in the Atlanta, GA, metropolitan area, from 1999 to 2002, for PM(2.5) and its components (elemental carbon (EC), SO(4)), O(3), carbon monoxide (CO), and nitrogen oxides (NOx). Metrics were applied in a study investigating the respiratory health effects of these pollutants. The metrics included: (i) CS measurements (one CS per pollutant); (ii) air quality model results for regional background pollution; (iii) local-scale AERMOD air quality model results; (iv) hybrid air quality model estimates (a combination of (ii) and (iii)); and (iv) population exposure model predictions (SHEDS and APEX). Differences in estimated spatial and temporal variability were compared by exposure metric and pollutant. Comparisons showed that: (i) both hybrid and exposure model estimates exhibited high spatial variability for traffic-related pollutants (CO, NO(x), and EC), but little spatial variability among ZIP code centroids for regional pollutants (PM(2.5), SO(4), and O(3)); (ii) for all pollutants except NO(x), temporal variability was consistent across metrics; (iii) daily hybrid-to-exposure model correlations were strong (r>0.82) for all pollutants, suggesting that when temporal variability of pollutant concentrations is of main interest in an epidemiological application, the use of estimates from either model may yield similar results; (iv) exposure models incorporating infiltration parameters, time-location-activity budgets, and other exposure factors affect the magnitude and spatiotemporal distribution of exposure, especially for local pollutants. The results of this analysis can inform the development of more appropriate exposure metrics for future epidemiological studies of the short-term effects of particulate and gaseous ambient pollutant exposure in a community.

Application of alternative spatiotemporal metrics of ambient air pollution exposure in a time-series epidemiological study in Atlanta

Exposure error in studies of ambient air pollution and health that use city-wide measures of exposure may be substantial for pollutants that exhibit spatiotemporal variability. Alternative spatiotemporal metrics of exposure for traffic-related and regional pollutants were applied in a time-series study of ambient air pollution and cardiorespiratory emergency department visits in Atlanta, GA, USA. Exposure metrics included daily central site monitoring for particles and gases; daily spatially refined ambient concentrations obtained from regional background monitors, local-scale dispersion, and hybrid air quality models; and spatially refined ambient exposures from population exposure models. Health risk estimates from Poisson models using the different exposure metrics were compared. We observed stronger associations, particularly for traffic-related pollutants, when using spatially refined ambient concentrations compared with a conventional central site exposure assignment approach. For some relationships, estimates of spatially refined ambient population exposures showed slightly stronger associations than corresponding spatially refined ambient concentrations. Using spatially refined pollutant metrics, we identified socioeconomic disparities in concentration-response functions that were not observed when using central site data. In some cases, spatially refined pollutant metrics identified associations with health that were not observed using measurements from the central site. Complexity and challenges in incorporating modeled pollutant estimates in time-series studies are discussed.

Spatiotemporal model or time series model for assessing city-wide temperature effects on mortality?

Most studies examining the temperature-mortality association in a city used temperatures from one site or the average from a network of sites. This may cause measurement error as temperature varies across a city due to effects such as urban heat islands. We examined whether spatiotemporal models using spatially resolved temperatures produced different associations between temperature and mortality compared with time series models that used non-spatial temperatures. We obtained daily mortality data in 163 areas across Brisbane city, Australia from 2000 to 2004. We used ordinary kriging to interpolate spatial temperature variation across the city based on 19 monitoring sites. We used a spatiotemporal model to examine the impact of spatially resolved temperatures on mortality. Also, we used a time series model to examine non-spatial temperatures using a single site and the average temperature from three sites. We used squared Pearson scaled residuals to compare model fit. We found that kriged temperatures were consistent with observed temperatures. Spatiotemporal models using kriged temperature data yielded slightly better model fit than time series models using a single site or the average of three sites' data. Despite this better fit, spatiotemporal and time series models produced similar associations between temperature and mortality. In conclusion, time series models using non-spatial temperatures were equally good at estimating the city-wide association between temperature and mortality as spatiotemporal models.

Time series analysis of personal exposure to ambient air pollution and mortality using an exposure simulator

This paper describes a modeling framework for estimating the acute effects of personal exposure to ambient air pollution in a time series design. First, a spatial hierarchical model is used to relate Census tract-level daily ambient concentrations and simulated exposures for a subset of the study period. The complete exposure time series is then imputed for risk estimation. Modeling exposure via a statistical model reduces the computational burden associated with simulating personal exposures considerably. This allows us to consider personal exposures at a finer spatial resolution to improve exposure assessment and for a longer study period. The proposed approach is applied to an analysis of fine particulate matter of <2.5 μm in aerodynamic diameter (PM(2.5)) and daily mortality in the New York City metropolitan area during the period 2001-2005. Personal PM(2.5) exposures were simulated from the Stochastic Human Exposure and Dose Simulation. Accounting for exposure uncertainty, the authors estimated a 2.32% (95% posterior interval: 0.68, 3.94) increase in mortality per a 10 μg/m(3) increase in personal exposure to PM(2.5) from outdoor sources on the previous day. The corresponding estimates per a 10 μg/m(3) increase in PM(2.5) ambient concentration was 1.13% (95% confidence interval: 0.27, 2.00). The risks of mortality associated with PM(2.5) were also higher during the summer months.

Cardiovascular disease and air pollution in Scotland: no association or insufficient data and study design?

Background

Coronary heart disease and stroke are leading causes of mortality and ill health in Scotland, and clear associations have been found in previous studies between air pollution and cardiovascular disease. This study aimed to use routinely available data to examine whether there is any evidence of an association between short-term exposure to particulate matter (measured as PM₁₀, particles less than 10 micrograms per cubic metre) and hospital admissions due to cardiovascular disease, in the two largest cities in Scotland during the years 2000 to 2006.

Methods

The study utilised an ecological time series design, and the analysis was based on overdispersed Poisson log-linear models.

Results

No consistent associations were found between PM₁₀ concentrations and cardiovascular hospital admissions in either of the cities studied, as all of the estimated relative risks were close to one, and all but one of the associated 95% confidence intervals contained the null risk of one.

Conclusions

This study suggests that in small cities, where air quality is relatively good, then either PM₁₀ concentrations have no effect on cardiovascular ill health, or that the routinely available data and the corresponding study design are not sufficient to detect an association.

Pedestrian exposure to size-resolved particles in Milan

Measurement campaigns for airborne particles along a pedestrian route in the city center of Milan were performed by means of a portable instrument consisting of an optical particle counter and a global positioning system (GPS) signal receiver. Based on the size-resolved particle number concentration data and on proper density factors experimentally determined for Milan urban area, the mass concentrations were calculated in terms of particulate matter with aerodynamic diameters < or =10 microm (PM10), < or =2.5 pm (PM2.5), and < or =1 microm (PM1). Besides directly measuring the personal exposure to PM throughout the route, the measurement campaigns pointed out small spatial and temporal variations of the concentration ranges in the different urban microenvironments visited along the route as well as very peculiar features of the particles levels in the underground subway. These findings suggested that the personal exposure of pedestrians in the city center could be estimated by simply taking into account the exposure at the open air and in the subway. The comparison between measured and calculated exposures according to the microenvironment-based estimation results in reasonable accordance, even though the estimations tend to slightly underestimate (12%) the actual measured exposure.

On the use of a PM(2.5) exposure simulator to explain birthweight

In relating pollution to birth outcomes, maternal exposure has usually been described using monitoring data. Such characterization provides a misrepresentation of exposure as it (i) does not take into account the spatial misalignment between an individual's residence and monitoring sites, and (ii) it ignores the fact that individuals spend most of their time indoors and typically in more than one location. In this paper, we break with previous studies by using a stochastic simulator to describe personal exposure (to particulate matter) and then relate simulated exposures at the individual level to the health outcome (birthweight) rather than aggregating to a selected spatial unit.We propose a hierarchical model that, at the first stage, specifies a linear relationship between birthweight and personal exposure, adjusting for individual risk factors and introduces random spatial effects for the census tract of maternal residence. At the second stage, our hierarchical model specifies the distribution of each individual's personal exposure using the empirical distribution yielded by the stochastic simulator as well as a model for the spatial random effects.We have applied our framework to analyze birthweight data from 14 counties in North Carolina in years 2001 and 2002. We investigate whether there are certain aspects and time windows of exposure that are more detrimental to birthweight by building different exposure metrics which we incorporate, one by one, in our hierarchical model. To assess the difference in relating ambient exposure to birthweight versus personal exposure to birthweight, we compare estimates of the effect of air pollution obtained from hierarchical models that linearly relate ambient exposure and birthweight versus those obtained from our modeling framework.Our analysis does not show a significant effect of PM(2.5) on birthweight for reasons which we discuss. However, our modeling framework serves as a template for analyzing the relationship between personal exposure and longer term health endpoints.

Using a chemistry transport model to account for the spatial variability of exposure concentrations in epidemiologic air pollution studies

Environmental epidemiology and more specifically time-series analysis have traditionally used area-averaged pollutant concentrations measured at central monitors as exposure surrogates to associate health outcomes with air pollution. However, spatial aggregation has been shown to contribute to the overall bias in the estimation of the exposure-response functions. This paper presents the benefit of adding features of the spatial variability of exposure by using concentration fields modeled with a chemistry transport model instead of monitor data and accounting for human activity patterns. On the basis of county-level census data for the city of Paris, France, and a Monte Carlo simulation, a simple activity model was developed accounting for the temporal variability between working and evening hours as well as during transit. By combining activity data with modeled concentrations, the downtown, suburban, and rural spatial patterns in exposure to nitrogen dioxide, ozone, and PM2.5 (particulate matter [PM] < or = 10 microm in aerodynamic diameter) were captured and parametrized. Exposures predicted with this model were used in a time-series study of the short-term effect of air pollution on total nonaccidental mortality for the 4-yr period from 2001 to 2004. It was shown that the time series of the exposure surrogates developed here are less correlated across co-pollutants than in the case of the area-averaged monitor data. This led to less biased exposure-response functions when all three co-pollutants were inserted simultaneously in the same regression model. This finding yields insight into pollutant-specific health effects that are otherwise masked by the high correlation among co-pollutants.