HEI Health Review Committee. Part 2. Association of daily mortality with ambient air pollution, and effect modification by extremely high temperature in Wuhan, China

Pennsylvania State College of Medicine, Hershey, Pennsylvania, USA.
Research report (Health Effects Institute) 11/2010; 154(154):91-217.
Source: PubMed


Fewer studies have been published on the association between daily mortality and ambient air pollution in Asia than in the United States and Europe. This study was undertaken in Wuhan, China, to investigate the acute effects of air pollution on mortality with an emphasis on particulate matter (PM*). There were three primary aims: (1) to examine the associations of daily mortality due to all natural causes and daily cause-specific mortality (cardiovascular [CVD], stroke, cardiac [CARD], respiratory [RD], cardiopulmonary [CP], and non-cardiopulmonary [non-CP] causes) with daily mean concentrations (microg/m3) of PM with an aerodynamic diameter--10 pm (PM10), sulfur dioxide (SO2), nitrogen dioxide (NO2), or ozone (O3); (2) to investigate the effect modification of extremely high temperature on the association between air pollution and daily mortality due to all natural causes and daily cause-specific mortality; and (3) to assess the uncertainty of effect estimates caused by the change in International Classification of Disease (ICD) coding of mortality data from Revision 9 (ICD-9) to Revision 10 (ICD-10) code. Wuhan is called an "oven city" in China because of its extremely hot summers (the average daily temperature in July is 37.2 degrees C and maximum daily temperature often exceeds 40 degrees C). Approximately 4.5 million residents live in the core city area of 201 km2, where air pollution levels are higher and ranges are wider than the levels in most cities studied in the published literature. We obtained daily mean levels of PM10, SO2, and NO2 concentrations from five fixed-site air monitoring stations operated by the Wuhan Environmental Monitoring Center (WEMC). O3 data were obtained from two stations, and 8-hour averages, from 10:00 to 18:00, were used. Daily mortality data were obtained from the Wuhan Centres for Disease Prevention and Control (WCDC) during the study period of July 1, 2000, to June 30, 2004. To achieve the first aim, we used a regression of the logarithm of daily counts of mortality due to all natural causes and cause-specific mortality on the daily mean concentrations of the four pollutants while controlling for weather, temporal factors, and other important covariates with generalized additive models (GAMs). We derived pollutant effect estimations for 0-day, 1-day, 2-day, 3-day, and 4-day lagged exposure levels, and the averages of 0-day and 1-day lags (lag 0-1 day) and of 0-day, 1-day, 2-day, and 3-day lags (lag 0-3 days) before the event of death. In addition, we used individual-level data (e.g., age and sex) to classify subgroups in stratified analyses. Furthermore, we explored the nonlinear shapes ("thresholds") of the exposure-response relations. To achieve the second aim, we tested the hypothesis that extremely high temperature modifies the associations between air pollution and daily mortality. We developed three corresponding weather indicators: "extremely hot," "extremely cold," and "normal temperatures." The estimates were obtained from the models for the main effects and for the pollutant-temperature interaction for each pollutant and each cause of mortality. To achieve the third aim, we conducted an additional analysis. We examined the concordance rates and kappa statistics between the ICD-9-coded mortality data and the ICD-10-coded mortality data for the year 2002. We also compared the magnitudes of the estimated effects resulting from the use of the two types of ICD-coded mortality data. In general, the largest pollutant effects were observed at lag 0-1 day. Therefore, for this report, we focused on the results obtained from the lag 0-1 models. We observed consistent associations between PM10 and mortality: every 10-microg/m3 increase in PM10 daily concentration at lag 0-1 day produced a statistically significant association with an increase in mortality due to all natural causes (0.43%; 95% confidence interval [CI], 0.24 to 0.62), CVD (0.57%; 95% CI, 0.31 to 0.84), stroke (0.57%; 95% CI, 0.25 to 0.88), CARD (0.49%; 95% CI, 0.04 to 0.94), RD (0.87%; 95% CI, 0.34 to 1.41), CP (0.52%; 95% CI, 0.27 to 0.77), and non-CP (0.30%; 95% CI, 0.05 to 0.54). In general, these effects were stronger in females than in males and were also stronger among the elderly (> or = 65 years) than among the young. The results of sensitivity testing over the range of exposures from 24.8 to 477.8 microg/m3 also suggest the appropriateness of assuming a linear relation between daily mortality and PM10. Among the gaseous pollutants, we also observed statistically significant associations of mortality with NO, and SO2, and that the estimated effects of these two pollutants were stronger than the PM10 effects. The patterns of NO2 and SO2 associations were similar to those of PM10 in terms of sex, age, and linearity. O3 was not associated with mortality. In the analysis of the effect modification of extremely high temperature on the association between air pollution and daily mortality, only the interaction of PM10 with temperature was statistically significant. Specifically, the interaction terms were statistically significant for mortality due to all natural (P = 0.014), CVD (P = 0.007), and CP (P = 0.014) causes. Across the three temperature groups, the strongest PM10 effects occurred mainly on days with extremely high temperatures for mortality due to all natural (2.20%; 95% CI, 0.74 to 3.68), CVD (3.28%; 95% CI, 1.24 to 5.37), and CP (3.02%; 95% CI, 1.03 to 5.04) causes. The weakest effects occurred at normal temperature days, with the effects on days with low temperatures in the middle. To assess the uncertainty of the effect estimates caused by the change from ICD-9-coded mortality data to ICD-10-coded mortality data, we compared the two sets of data and found high concordance rates (> 99.3%) and kappa statistics close to 1.0 (> 0.98). All effect estimates showed very little change. All statistically significant levels of the estimated effects remained unchanged. In conclusion, the findings for the aims from the current study are consistent with those in most previous studies of air pollution and mortality. The small differences between mortality effects for deaths coded using ICD-9 and ICD-10 show that the change in coding had a minimal impact on our study. Few published papers have reported synergistic effects of extremely high temperatures and air pollution on mortality, and further studies are needed. Establishing causal links between heat, PM10, and mortality will require further toxicologic and cohort studies.

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    • "Our study, demonstrating sub clinical associations of pollution and weather with changes in BAD, gives us insight into potential mechanisms for the clinical effects of more extreme exposures on popu lations potentially at risk of particle-and temperature-related health effects. Evidence from multiple epidemiological studies suggests that people with diabetes may be more susceptible to the joint and separate effects of temperature and air pollution on cardio vascular morbidity and mortality (Medina-Ramón et al. 2006; Qian et al. 2010; Schifano et al. 2009; Schwartz 2005; Zanobetti and Schwartz 2001; Zanobetti et al. 2009). "
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    ABSTRACT: Extreme weather and air pollution are associated with increased cardiovascular risk in people with diabetes. In a population with diabetes we conducted a novel assessment of vascular brachial artery responses both to ambient pollution and to weather [temperature and water vapor pressure, a measure of humidity]. Sixty-four 49- to 85-year old Boston residents with type 2 diabetes completed up to 5 study visits (279 repeated measures). Brachial artery diameter (BAD) was measured by ultrasound before and after brachial artery occlusion (i.e., flow-mediated dilation, FMD), and before and after nitroglycerin-mediated dilation (NMD). Ambient fine particulate mass (PM2.5), black carbon (BC), particle number (PN), sulfate (SO4), elemental carbon (EC) and organic carbon (OC) were measured at our monitoring site; ambient O3, CO, NO2 data were obtained from state monitors. Particle exposure in the home and during each trip to the clinic (home/trip exposure) was measured continuously and as a 5-day integrated sample. We used linear models with fixed effects for subjects, and adjusting for date, season, temperature, and water vapor pressure on the day of each visit, to estimate associations between our outcomes and interquartile range (IQR) increases in exposure. Baseline BAD was negatively associated with particle pollution, including home/trip integrated BC (-0.02 mm; 95% CI: -0.04, -0.003, for a 0.28 µg/m(3) increase in BC), OC (-0.08 mm; 95% CI: -0.14, -0.03, for a 1.61 µg/m(3) increase) and PM2.5; and 5-day average ambient PM2.5 and BC. BAD was positively associated with ambient temperature and water vapor pressure. However, exposures were not consistently associated with FMD or NMD. Brachial artery diameter, a predictor of cardiovascular risk, decreased in association with particle pollution and increased in association with ambient temperature in our study population of adults with type 2 diabetes.
    Full-text · Article · Jan 2014 · Environmental Health Perspectives
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    • "For example, a study in Delhi reported that daily PM 10 was associated with increased the rate of non-accidental mortality [6]. Qian et al [38] examining the association of daily mortality with ambient air pollution in China, observed that a 10 µg m −3 increase in daily PM 10 was associated with a 0.43% (95% CI, 0.24–0.62%) increase in mortality due to all natural causes. "
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    ABSTRACT: Most studies of short-term particulate matter (PM) exposure use 24 h averages. However, other pollutants have stronger effects in shorter timeframes, which has influenced policy (e.g., ozone 8 h maximum). The selection of appropriate exposure timeframes is important for effective regulation. The US EPA identified health effects for sub-daily PM exposures as a critical research need. Unlike most areas, Seoul, Korea has hourly measurements of PM10, although not PM2.5. We investigated PM10 and mortality (total, cardiovascular, respiratory) in Seoul (1999–2009) considering sub-daily exposures: 24 h, daytime (7 am–8 pm), morning (7–10 am), nighttime (8 pm–7 am), and 1 h daily maximum. We applied Poisson generalized linear modeling adjusting for temporal trends and meteorology. All PM10 metrics were significantly associated with total mortality. Compared to other exposure timeframes, morning exposure had the most certain effect on total mortality (based on statistical significance). Increases of 10 μg m−3 in 24 h, daytime, morning, nighttime, and 1 h maximum PM10 were associated with 0.15% (95% confidence interval 0.02–0.28%), 0.14% (0.01–0.27%), 0.10% (0.03–0.18%), 0.12% (0.03–0.22%), and 0.10% (0.00–0.21%) increases in total mortality, respectively. PM10 was significantly associated with cardiovascular mortality for 24 h, morning, and nighttime exposures. We did not identify significant associations with respiratory mortality. The results support use of a 24 h averaging time as an appropriate metric for health studies and regulation, particularly for PM10 and mortality.
    Full-text · Article · Jan 2013 · Environmental Research Letters
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    • "It is possible that GCC will also contribute to changes in population vulnerability to harmful air pollutants. For example, added cardiovascular stress from high summer temperatures may increase sensitivity to the cardiovascular effects of PM2.5 and ozone 44, 67, 68. Conversely, warmer winter temperatures may both reduce cardiovascular stress and lower emissions of combustion products because of reduced heating needs. "
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    ABSTRACT: Global climate change (GCC) is likely to alter the degree of human exposure to pollutants and the response of human populations to these exposures, meaning that risks of pollutants could change in the future. The present study, therefore, explores how GCC might affect the different steps in the pathway from a chemical source in the environment through to impacts on human health and evaluates the implications for existing risk-assessment and management practices. In certain parts of the world, GCC is predicted to increase the level of exposure of many environmental pollutants due to direct and indirect effects on the use patterns and transport and fate of chemicals. Changes in human behavior will also affect how humans come into contact with contaminated air, water, and food. Dietary changes, psychosocial stress, and coexposure to stressors such as high temperatures are likely to increase the vulnerability of humans to chemicals. These changes are likely to have significant implications for current practices for chemical assessment. Assumptions used in current exposure-assessment models may no longer apply, and existing monitoring methods may not be robust enough to detect adverse episodic changes in exposures. Organizations responsible for the assessment and management of health risks of chemicals therefore need to be more proactive and consider the implications of GCC for their procedures and processes. Environ. Toxicol. Chem. © 2012 SETAC.
    Full-text · Article · Jan 2013 · Environmental Toxicology and Chemistry
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