Short term exposure to air pollution and stroke: systematic review and meta-analysis

Association between proximity to industrial chemical installations and cancer mortality in Spain

It is likely that pollution from chemical facilities will affect the health of any exposed population; however, the majority of scientific evidence available has focused on occupational exposure rather than environmental. Consequently, this study assessed whether there could have been an excess of cancer-related mortality associated with environmental exposure to pollution from chemical installations - for populations residing in municipalities in the vicinity of chemical industries. To this end, we designed an ecological study which assessed municipal mortality due to 32 types of cancer in the period from 1999 to 2008. The exposure to pollution was estimated using distance from the facilities to the centroid of the municipality as a proxy for exposure. In order to assess any increased cancer mortality risk in municipalities potentially exposed to chemical facilities pollution (situated at a distance of ≤5 km from a chemical installation), we employed Bayesian Hierarchical Poisson Regression Models. This included two Bayesian inference methods: Integrated Nested Laplace Approximations (INLA) and Markov Chain Monte Carlo (MCMC, for validation). The reference category consisted of municipalities beyond the 5 km limit. We found higher mortality risk (relative risk, RR; estimated by INLA, 95% credible interval, 95%CrI) for both sexes for colorectal (RR, 1.09; 95%CrI, 1.05-1.15), gallbladder (1.14; 1.03-1.27), and ovarian cancers (1.10; 1.02-1.20) associated with organic chemical installations. Notably, pleural cancer (2.27; 1.49-3.41) in both sexes was related to fertilizer facilities. Associations were found for women, specifically for ovarian (1.11; 1.01-1.22) and breast cancers (1.06; 1.00-1.13) in the proximity of explosives/pyrotechnics installations; increased breast cancer mortality risk (1.10; 1.03-1.18) was associated with proximity to inorganic chemical installations. The results suggest that environmental exposure to pollutants from some types of chemical facilities may be associated with increased mortality from several different types of cancer.

Intensive care admissions and outcomes associated with short-term exposure to ambient air pollution: a time series analysis

PURPOSE

Short-term exposure to outdoor air pollution has been positively associated with numerous measures of acute morbidity and mortality, most consistently as excess cardiorespiratory disease associated with fine particulate matter (PM_2.5), particularly in vulnerable populations. It is unknown if the critically ill, a vulnerable population with high levels of cardiorespiratory disease, is affected by air pollution.

METHODS

We performed a time series analysis of emergency cardiorespiratory, stroke and sepsis intensive care (ICU) admissions for the years 2008-2016, using data from the Australian and New Zealand Intensive Care Society Adult Patient Database (ANZICS-APD). Case-crossover analysis was conducted to assess the relationship between air pollution and the frequency and severity of ICU admissions having adjusted for temperature, humidity, public holidays and influenza activity.

RESULTS

46,965 episodes in 87 separate ICUs were analysed. We found no statistically significant associations with admission counts. However, ICU admissions ending in death within 30 days were significantly positively associated with short-term exposure to PM_2.5 [RR 1.18, 95% confidence interval (CI) 1.02-1.37, per 10 µg/m³ increase]. This association was more pronounced in those aged 65 and over (RR 1.33, 95% CI 1.11-1.58, per 10 µg/m³).

CONCLUSIONS

Increased ICU mortality was associated with higher levels of PM_2.5. Larger studies are required to determine if the frequency of ICU admissions is positively associated with short-term exposure to air pollution.

Out-of-Hospital Cardiac Arrests and Wildfire-Related Particulate Matter During 2015-2017 California Wildfires

Background

The natural cycle of large‐scale wildfires is accelerating, increasingly exposing both rural and populous urban areas to wildfire emissions. While respiratory health effects associated with wildfire smoke are well established, cardiovascular effects have been less clear.

Methods and Results

We examined the association between out‐of‐hospital cardiac arrest and wildfire smoke density (light, medium, heavy smoke) from the National Oceanic Atmospheric Association's Hazard Mapping System. Out‐of‐hospital cardiac arrest data were provided by the Cardiac Arrest Registry to Enhance Survival for 14 California counties, 2015–2017 (N=5336). We applied conditional logistic regression in a case‐crossover design using control days from 1, 2, 3, and 4 weeks before case date, at lag days 0 to 3. We stratified by pathogenesis, sex, age (19–34, 35–64, and ≥65 years), and socioeconomic status (census tract percent below poverty). Out‐of‐hospital cardiac arrest risk increased in association with heavy smoke across multiple lag days, strongest on lag day 2 (odds ratio, 1.70; 95% CI, 1.18–2.13). Risk in the lower socioeconomic status strata was elevated on medium and heavy days, although not statistically significant. Higher socioeconomic status strata had elevated odds ratios with heavy smoke but null results with light and medium smoke. Both sexes and age groups 35 years and older were impacted on days with heavy smoke.

Conclusions

Out‐of‐hospital cardiac arrests increased with wildfire smoke exposure, and lower socioeconomic status appeared to increase the risk. The future trajectory of wildfire, along with increasing vulnerability of the aging population, underscores the importance of formulating public health and clinical strategies to protect those most vulnerable.

The Impact of Ambient Fine Particulate Matter on Consumer Expenditures

Airborne particulate matter suspended from industrial facilities, power plants, and automobiles is detrimental to health. Growing concerns about the increasing level of airborne particulate matter have led many industrialized nations to advocate for the transformation of the energy market and investment in sustainable energy products. At the other end, consumers have made individual adjustments and attempted to reduce the exposure to the particulate matter. In this paper, we focus on the effect of ambient air pollution on consumer expenditures based on scanner panel data on consumers’ debit and credit card transactions. A series of empirical analyses found robust evidence that the increased level of particulate matter led to considerable disruption in total consumer expenditures with significant heterogeneity across categories. Our findings suggest that consumers alter their spending behaviors in an attempt to reduce the risk of exposures to particulate matter. Such an estimated effect of air pollution is qualitatively different from those of other macroeconomic factors and provides important guidance for policy interventions and practical decisions aimed at sustaining economic growth.

Multicenter Ozone Study in oldEr Subjects (MOSES): Part 2. Effects of Personal and Ambient Concentrations of Ozone and Other Pollutants on Cardiovascular and Pulmonary Function

INTRODUCTION

The Multicenter Ozone Study of oldEr Subjects (MOSES) was a multi-center study evaluating whether short-term controlled exposure of older, healthy individuals to low levels of ozone (O3) induced acute changes in cardiovascular biomarkers. In MOSES Part 1 (MOSES 1), controlled O3 exposure caused concentration-related reductions in lung function with evidence of airway inflammation and injury, but without convincing evidence of effects on cardiovascular function. However, subjects' prior exposures to indoor and outdoor air pollution in the few hours and days before each MOSES controlled O3 exposure may have independently affected the study biomarkers and/or modified biomarker responses to the MOSES controlled O3 exposures.

METHODS

MOSES 1 was conducted at three clinical centers (University of California San Francisco, University of North Carolina, and University of Rochester Medical Center) and included healthy volunteers 55 to 70 years of age. Consented participants who successfully completed the screening and training sessions were enrolled in the study. All three clinical centers adhered to common standard operating procedures and used common tracking and data forms. Each subject was scheduled to participate in a total of 11 visits: screening visit, training visit, and three sets of exposure visits consisting of the pre-exposure day, the exposure day, and the post-exposure day. After completing the pre-exposure day, subjects spent the night in a nearby hotel. On exposure days, the subjects were exposed for 3 hours in random order to 0 ppb O3 (clean air), 70 ppb O3, and 120 ppm O3. During the exposure period the subjects alternated between 15 minutes of moderate exercise and 15 minutes of rest. A suite of cardiovascular and pulmonary endpoints was measured on the day before, the day of, and up to 22 hours after each exposure.

In MOSES Part 2 (MOSES 2), we used a longitudinal panel study design, cardiopulmonary biomarker data from MOSES 1, passive cumulative personal exposure samples (PES) of O3 and nitrogen dioxide (NO2) in the 72 hours before the pre-exposure visit, and hourly ambient air pollution and weather measurements in the 96 hours before the pre-exposure visit. We used mixed-effects linear regression and evaluated whether PES O3 and NO2 and these ambient pollutant concentrations in the 96 hours before the pre-exposure visit confounded the MOSES 1 controlled O3 exposure effects on the pre- to post-exposure biomarker changes (Aim 1), whether they modified these pre- to post-exposure biomarker responses to the controlled O3 exposures (Aim 2), whether they were associated with changes in biomarkers measured at the pre-exposure visit or morning of the exposure session (Aim 3), and whether they were associated with differences in the pre- to post-exposure biomarker changes independently of the controlled O3 exposures (Aim 4).

RESULTS

Ambient pollutant concentrations at each site were low and were regularly below the National Ambient Air Quality Standard levels. In Aim 1, the controlled O3 exposure effects on the pre- to post-exposure biomarker differences were little changed when PES or ambient pollutant concentrations in the previous 96 hours were included in the model, suggesting these were not confounders of the controlled O3 exposure/biomarker difference associations. In Aim 2, effects of MOSES controlled O3 exposures on forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC) were modified by ambient NO2 and carbon monoxide (CO), and PES NO2, with reductions in FEV1 and FVC observed only when these concentrations were "Medium" or "High" in the 72 hours before the pre-exposure visit. There was no such effect modification of the effect of controlled O3 exposure on any other cardiopulmonary biomarker.

As hypothesized for Aim 3, increased ambient O3 concentrations were associated with decreased pre-exposure heart rate variability (HRV). For example, high frequency (HF) HRV decreased in association with increased ambient O3 concentrations in the 96 hours before the pre-exposure visit (-0.460 ln[ms2]; 95% CI, -0.743 to -0.177 for each 10.35-ppb increase in O3; P = 0.002). However, in Aim 4 these increases in ambient O3 were also associated with increases in HF and low frequency (LF) HRV from pre- to post-exposure, likely reflecting a "recovery" of HRV during the MOSES O3 exposure sessions. Similar patterns across Aims 3 and 4 were observed for LF (the other primary HRV marker), and standard deviation of normal-to-normal sinus beat intervals (SDNN) and root mean square of successive differences in normal-to-normal sinus beat intervals (RMSSD) (secondary HRV markers).

Similar Aim 3 and Aim 4 patterns were observed for FEV1 and FVC in association with increases in ambient PM with an aerodynamic diameter ≤ 2.5 μm (PM2.5), CO, and NO2 in the 96 hours before the pre-exposure visit. For Aim 3, small decreases in pre-exposure FEV1 were significantly associated with interquartile range (IQR) increases in PM2.5 concentrations in the 1 hour before the pre-exposure visit (-0.022 L; 95% CI, -0.037 to -0.006; P = 0.007), CO in the 3 hours before the pre-exposure visit (-0.046 L; 95% CI, -0.076 to -0.016; P = 0.003), and NO2 in the 72 hours before the pre-exposure visit (-0.030 L; 95% CI, -0.052 to -0.008; P = 0.007). However, FEV1 was not associated with ambient O3 or sulfur dioxide (SO2), or PES O3 or NO2 (Aim 3). For Aim 4, increased FEV1 across the exposure session (post-exposure minus pre-exposure) was marginally significantly associated with each 4.1-ppb increase in PES O3 concentration (0.010 L; 95% CI, 0.004 to 0.026; P = 0.010), as well as ambient PM2.5 and CO at all lag times. FVC showed similar associations, with patterns of decreased pre-exposure FVC associated with increased PM2.5, CO, and NO2 at most lag times, and increased FVC across the exposure session also associated with increased concentrations of the same pollutants, reflecting a similar recovery. However, increased pollutant concentrations were not associated with adverse changes in pre-exposure levels or pre- to post-exposure changes in biomarkers of cardiac repolarization, ST segment, vascular function, nitrotyrosine as a measure of oxidative stress, prothrombotic state, systemic inflammation, lung injury, or sputum polymorphonuclear leukocyte (PMN) percentage as a measure of airway inflammation.

CONCLUSIONS

Our previous MOSES 1 findings of controlled O3 exposure effects on pulmonary function, but not on any cardiovascular biomarker, were not confounded by ambient or personal O3 or other pollutant exposures in the 96 and 72 hours before the pre-exposure visit. Further, these MOSES 1 O3 effects were generally not modified, blunted, or lessened by these same ambient and personal pollutant exposures. However, the reductions in markers of pulmonary function by the MOSES 1 controlled O3 exposure were modified by ambient NO2 and CO, and PES NO2, with reductions observed only when these pollutant concentrations were elevated in the few hours and days before the pre-exposure visit. Increased ambient O3 concentrations were associated with reduced HRV, with "recovery" during exposure visits. Increased ambient PM2.5, NO2, and CO were associated with reduced pulmonary function, independent of the MOSES-controlled O3 exposures. Increased pollutant concentrations were not associated with pre-exposure or pre- to post-exposure changes in other cardiopulmonary biomarkers. Future controlled exposure studies should consider the effect of ambient pollutants on pre-exposure biomarker levels and whether ambient pollutants modify any health response to a controlled pollutant exposure.

The role of cities in reducing the cardiovascular impacts of environmental pollution in low- and middle-income countries

BACKGROUND

As low- and middle-income countries urbanize and industrialize, they must also cope with pollution emitted from diverse sources.

MAIN TEXT

Strong and consistent evidence associates exposure to air pollution and lead with increased risk of cardiovascular disease occurrence and death. Further, increasing evidence, mostly from high-income countries, indicates that exposure to noise and to both high and low temperatures may also increase cardiovascular risk. There is considerably less research on the cardiovascular impacts of environmental conditions in low- and middle-income countries (LMICs), where the levels of pollution are often higher and the types and sources of pollution markedly different from those in higher-income settings. However, as such evidence gathers, actions to reduce exposures to pollution in low- and middle-income countries are warranted, not least because such exposures are very high. Cities, where pollution, populations, and other cardiovascular risk factors are most concentrated, may be best suited to reduce the cardiovascular burden in LMICs by applying environmental standards and policies to mitigate pollution and by implementing interventions that target the most vulnerable. The physical environment of cities can be improved though municipal processes, including infrastructure development, energy and transportation planning, and public health actions. Local regulations can incentivize or inhibit the polluting behaviors of industries and individuals. Environmental monitoring can be combined with public health warning systems and publicly available exposure maps to inform residents of environmental hazards and encourage the adoption of pollution-avoiding behaviors. Targeted individual or neighborhood interventions that identify and treat high-risk populations (e.g., lead mitigation, portable air cleaners, and preventative medications) can also be leveraged in the very near term. Research will play a key role in evaluating whether these approaches achieve their intended benefits, and whether these benefits reach the most vulnerable.

CONCLUSION

Cities in LMICs can play a defining role in global health and cardiovascular disease prevention in the next several decades, as they are well poised to develop innovative, multisectoral approaches to pollution mitigation, while also protecting the most vulnerable.

Association of short-term exposure to sulfur dioxide and hospitalization for ischemic and hemorrhagic stroke in Guangzhou, China

BACKGROUND

In developing countries, ambient sulfur dioxide (SO₂) is a serious air pollutant concern, but there is no enough and consistent epidemiological evidence about its health effects on stroke hospitalization.

METHODS

We collected the daily air pollution data, meteorological data and number of daily hospital admissions for ischemic and hemorrhagic stroke, in Guangzhou from January 1st 2009 to December 31st 2014. Then we applied generalized additive model with a quasi-Poisson link to assess the relationship between short-term SO₂ exposure and the total number of hospital admissions for ischemic and hemorrhagic stroke. In addition, we evaluated the effect of ambient SO₂ by age (< 65 years and ≥ 65 years).

RESULTS

During the study period, a 24-h mean concentration of ambient SO₂ of 27.82 μg/m³, a total of 58,473 ischemic stroke and 9167 hemorrhagic stroke hospital admissions hospital were recorded. Ambient SO₂ was found to increase the risk for both ischemic and hemorrhagic stroke hospital admission in single pollutant model. The maximum value of percentage changes for ischemic and hemorrhagic stroke occurred in lag 0 day and lag 1 day, per 10 μg/m³ increase in SO₂ concentrations was corresponded to a 1.27% (95% confidence interval (CI), 0.42-2.12%) and 1.55% (95%CI, 0.02-3.11%) increased risk, respectively. The association between SO₂ and ischemic stroke hospitalization was robust to two pollutant model, but for hemorrhagic stroke it's partially weakened after adjusting for co-pollutants. The effect of ambient SO₂ on ischemic stroke appeared to be greater for people < 65 years old, but null effect on hemorrhagic stroke was identified for both age groups.

CONCLUSIONS

We found short-term exposure to ambient SO₂ may significantly increase the risks of hospitalization for ischemic stroke. The findings may contribute to a better understanding of the health effects of low-levels of SO₂.

Who Could Not Avoid Exposure to High Levels of Residence-Based Pollution by Daily Mobility? Evidence of Air Pollution Exposure from the Perspective of the Neighborhood Effect Averaging Problem (NEAP)

It has been widely acknowledged that air pollution has a considerable adverse impact on people’s health. Disadvantaged groups such as low-income people are often found to experience greater negative effects of environmental pollution. Thus, improving the accuracy of air pollution exposure assessment might be essential to policy-making. Recently, the neighborhood effect averaging problem (NEAP) has been identified as a specific form of possible bias when assessing individual exposure to air pollution and its health impacts. In this paper, we assessed the real-time air pollution exposure and residential-based exposure of 106 participants in a high-pollution community in Beijing, China. The study found that: (1) there are significant differences between the two assessments; (2) most participants experienced the NEAP and could lower their exposure by their daily mobility; (3) three vulnerable groups with low daily mobility and could not avoid the high pollution in their residential neighborhoods were identified as exceptions to this: low-income people who have low levels of daily mobility and limited travel outside their residential neighborhoods, blue-collar workers who spend long hours at low-end workplaces, and elderly people who face many household constraints. Public policies thus need to focus on the hidden environmental injustice revealed by the NEAP in order to improve the well-being of these environmentally vulnerable groups.

Air pollution and cardiovascular disease: car sick

The cardiovascular effects of inhaled particle matter (PM) are responsible for a substantial morbidity and mortality attributed to air pollution. Ultrafine particles, like those in diesel exhaust emissions, are a major source of nanoparticles in urban environments, and it is these particles that have the capacity to induce the most significant health effects. Research has shown that diesel exhaust exposure can have many detrimental effects on the cardiovascular system both acutely and chronically. This review provides an overview of the cardiovascular effects on PM in air pollution, with an emphasis on ultrafine particles in vehicle exhaust. We consider the biological mechanisms underlying these cardiovascular effects of PM and postulate that cardiovascular dysfunction may be implicated in the effects of PM in other organ systems. The employment of multiple strategies to tackle air pollution, and especially ultrafine particles from vehicles, is likely to be accompanied by improvements in cardiovascular health.

Ischaemic heart disease and stroke mortality by specific coal type among non-smoking women with substantial indoor air pollution exposure in China

BACKGROUND

Lifetime use of bituminous ('smoky') coal is associated with nearly a 100-fold higher risk of lung cancer mortality compared with anthracite ('smokeless') coal use in rural Xuanwei, China, among women. Risk of mortality from ischaemic heart disease (IHD) and stroke for these coal types has not been evaluated.

METHODS

A cohort of 16 323 non-smoking women in Xuanwei, who were lifetime users of either smoky or smokeless coal, were followed up from 1976 to 2011. We estimated hazard ratios (HRs) and 95% confidence intervals (CI) to evaluate lifetime use of coal types and stoves in the home in relation to risk of IHD and stroke mortality.

RESULTS

Among lifetime users of smokeless coal, higher average exposure intensity (≥4 tons/year vs <2.5 tons/year, HR = 7.9, 95% CI = 3.5-17.8; Ptrend =<0.0001) and cumulative exposure (>64 ton-years vs ≤28 ton-years, HR = 6.5, 95% CI = 1.5-28.3; Ptrend =0.003) during follow-up and over their lifetime was associated with increased IHD mortality, and ventilated stove use dramatically reduced this risk (HR = 0.2, 95% CI 0.1-0.5). Higher cumulative exposure to smoky coal during follow-up showed positive associations with IHD mortality, but the evidence for other metrics was less consistent compared with associations with smokeless coal use.

CONCLUSIONS

Higher use of smokeless coal, which is burned throughout China and is generally regarded to be a cleaner fuel type, is associated with IHD mortality. Use of cleaner fuels or stove interventions may be effective in reducing the increasing burden of IHD in developing regions that currently rely on smokeless coal for cooking and heating.

Improving air quality needs to be a policy priority for governments globally

In this Perspective, Aziz Sheikh discusses the importance of research to understand the impact of air pollution on human health, commenting on a study by Yaohua Tian and colleagues that examined associations between ambient air quality and risk of hospitalization for pneumonia in adults in China.

Association between air pollution exposure and diabetic retinopathy among diabetics

BACKGROUND

Exposure to air pollution has been linked to adverse effects on vascular diseases. However, the effects of air pollution exposure on diabetic retinopathy (DR), a vascular disease, have not been studied.

OBJECTIVE

To determine the association of ambient air pollution exposure with DR risk.

METHODS

Patients newly diagnosed as having diabetes mellitus (DM) during 2003-2012 from Longitudinal Health Insurance Database 2005), a subset of National Health Insurance Research Database, were included as the study cohort. Newly diagnosed DR patients one year or later after DM diagnosis were identified as cases. Kriging was used to interpolate yearly concentrations of air pollutants at township levels and linked with every individual's residence in each year; average concentrations during the follow-up period were then calculated as personal exposure. Conditional logistic regressions with adjustments for age at DM diagnosis and comorbidities were applied.

RESULTS

Of newly diagnosed DM cases during 2003-2012, 579 were newly diagnosed as having DR over a mean follow-up period of 5.6 years. The Odds ratio (95% confidence interval) of DR occurrence for every 10-μg/m³ increase in particulate matter with ≤2.5 and 2.5-10-μm diameter was 1.29 (1.11-1.50) and 1.37 (1.17-1.61), respectively.

CONCLUSION

In patients with DM, the higher particulate matter exposure, the higher is the DR risk.

Impact of Air Pollution and Seasonal Haze on Neurological Conditions: A Review

Introduction: Air pollution is a global problem and seasonal haze from forest clearing and peat land burning in Indonesia is an annual phenomenon in Southeast Asia. As neurological disorders comprise 6.3% of the burden of disease globally, we reviewed evidence of the association between common neurological conditions and air pollution exposure, and summarised existing data on the impact of the haze phenomenon in Southeast Asia. Materials and Methods: A PubMed search for relevant studies on air pollution, Alzheimer’s disease (AD), dementia, epilepsy, haze, headache, migraine, stroke, Parkinson’s disease (PD) and neuromuscular conditions was performed. There were 52 articles which were relevant and were reviewed. Results: There were associations between short-term air pollution exposure with AD, epilepsy, ischaemic stroke and migraine. Long-term air pollution exposure was associated with AD, amyotrophic lateral sclerosis, dementia and ischaemic stroke. Evidence on the link between air pollution and PD was inconsistent. Currently, there is no specific data on the effects haze has on neurological conditions in Southeast Asia. Conclusion: Air pollution is associated with increased risk of certain common neurological disorders. More specific studies are needed to investigate the impact of seasonal haze on neurological conditions in Southeast Asia. Key words: Alzheimer’s disease, Epilepsy, Migraine, Parkinson’s disease, Stroke

Pollution, Particles, and Dementia: A Hypothetical Causative Pathway

Epidemiological studies of air pollution have shown associations between exposure to particles and dementia. The mechanism of this is unclear. As these seem unlikely in terms of the very small dose likely to reach the brain in usual Western urban circumstances, we extend our 1995 hypothetical explanation of the association of air pollution with cardiac deaths as a plausible alternative explanation of its associations with dementia. Since our original proposal, it has become apparent that inflammation may be carried by blood from organ to organ by biologic microparticles derived from cell membranes. These transmit inflammatory messages to endothelial cells throughout the body as part of a general defensive response to assumed bacterial infection; particulate air pollution has recently been shown to be associated with their release into the blood. We propose that episodic release of biologic microparticles from pollution-induced lung inflammation causes secondary inflammation in the blood-brain barrier and cerebral microbleeds, culminating over time in cognitive impairment. Ultimately, by incomplete repair and accumulation of amyloid, this increases the risk of Alzheimer’s disease. Importantly, this mechanism may also explain the relationships of other inflammatory conditions and environmental factors with cognitive decline, and point to new opportunities to understand and prevent dementia.

Association between short-term exposure to air pollution and ischemic stroke onset: a time-stratified case-crossover analysis using a distributed lag nonlinear model in Shenzhen, China

BACKGROUND

Stroke, especially ischemic stroke (IS), has been a severe public health problem around the world. However, the association between air pollution and ischemic stroke remains ambiguous.

METHODS

A total of 63, 997 IS cases aged 18 years or above in Shenzhen were collected from 2008 to 2014. We used the time-stratified case-crossover design combining with distributed lag nonlinear model (DLNM) to estimate the association between air pollution and IS onset. Furthermore, this study explored the variability across gender and age groups.

RESULTS

The cumulative exposure-response curves were J-shaped for SO₂, NO₂ and PM₁₀, and V-shaped for O₃, and crossed over the relative risk (RR) of one. The 99th, 50th (median) and 1st percentiles of concentration (μg/m³) respectively were 37.86, 10.06, 3.71 for SO₂, 116.26, 41.29, 18.51 for NO₂, 145.94, 48.29, 16.14 for PM₁₀, and 111.57, 49.82, 16.00 for O₃. Extreme high-SO₂, high-NO₂, high-PM₁₀, high-O₃, and low-O₃ concentration increased the risk of IS, with the maximum RR values and 95% CIs: 1.50(1.22, 1.84) (99th vs median) at 0-12 lag days, 1.37(1.13, 1.67) (99th vs median) at 0-10 lag days, 1.26(1.04, 1.53) (99th vs median) at 0-12 lag days, 1.25(1.04, 1.49) (99th vs median) at 0-14 lag days, and 1.29(1.03, 1.61) (1st vs median) at 0-14 lag days, respectively. The statistically significant minimal RR value and 95% CI was 0.79(0.66,0.94) at 0-10 lag days for extreme low-PM₁₀. The elderly aged over 65 years were susceptible to extreme pollution conditions. Difference from the vulnerability of males to extreme high-SO₂, high-NO₂ and low-O₃, females were vulnerable to extreme high-PM₁₀ and high-O₃. Comparing with the elderly, adults aged 18-64 year were immune to extreme low-NO₂ and low-PM₁₀. However, no association between CO and IS onset was found.

CONCLUSIONS

SO₂, NO₂, PM₁₀ and O₃ exerted non-linear and delayed influence on IS, and such influence varied with gender and age. These findings may have significant public health implications for the prevention of IS.

Effects of short-term exposure to particulate matters on heart rate variability: A systematic review and meta-analysis based on controlled animal studies

BACKGROUND

Exposure to particulate matters (PM) is recognized as an important risk factor for cardiovascular disease. A change in cardiac autonomic function is one postulated mechanism leading to PM related cardiovascular events. This study therefore evaluated the associations of short-term exposure to PM and heart rate variability (HRV) parameters, which can reflect the cardiac autonomic function.

METHODS

Four electronic databases were searched for controlled studies of rodents published prior to December 2018. A systematic review and meta-analysis was conducted. Effect sizes were calculated for five main HRV parameters, including standard deviation of normal-to-normal intervals (SDNN), square root of mean squared differences between successive normal-to-normal intervals (rMSSD), low frequency (LF), high frequency (HF), and the ratio of LF and HF (LF/HF).

RESULTS

The review included 23 studies with 401 animals. Short-term exposure to PM by instillation yielded statistically significant effects on SDNN (Standardized Mean Difference [SMD] = -1.11, 95% Confidence Intervals [CI] = -2.22 to -0.01, P = 0.05), LF (SMD = -1.19, 95% CI = -1.99 to -0.40, P = 0.003) and LF/HF (SMD = -1.05, 95% CI = -2.03 to -0.07, P = 0.04). Short-term exposure to PM by inhalation only yielded statistically significant effect on LF/HF (SMD = -0.83, 95% CI = -1.39 to -0.27, P = 0.004). There was no evidence that animal model and exposure frequency influenced the relationship of PM and HRV.

CONCLUSIONS

Short-term exposure to PM can decrease HRV of rodents, affecting cardiac autonomic function. Exposure methods can influence the relationships of PM and HRV parameters. Further studies should focus on the effects of long-term PM exposure, on human beings, and potential influential factors of PM-HRV associations.

Polyaromatic hydrocarbons in pollution: a heart-breaking matter

Air pollution is associated with detrimental effects on human health, including decreased cardiovascular function. However, the causative mechanisms behind these effects have yet to be fully elucidated. Here we review the current epidemiological, clinical and experimental evidence linking pollution with cardiovascular dysfunction. Our focus is on particulate matter (PM) and the associated low molecular weight polycyclic aromatic hydrocarbons (PAHs) as key mediators of cardiotoxicity. We begin by reviewing the growing epidemiological evidence linking air pollution to cardiovascular dysfunction in humans. We next address the pollution-based cardiotoxic mechanisms first identified in fish following the release of large quantities of PAHs into the marine environment from point oil spills (e.g. Deepwater Horizon). We finish by discussing the current state of mechanistic knowledge linking PM and PAH exposure to mammalian cardiovascular patho-physiologies such as atherosclerosis, cardiac hypertrophy, arrhythmias, contractile dysfunction and the underlying alterations in gene regulation. Our aim is to show conservation of toxicant pathways and cellular targets across vertebrate hearts to allow a broad framework of the global problem of cardiotoxic pollution to be established. AhR; Aryl hydrocarbon receptor. Dark lines indicate topics discussed in this review. Grey lines indicate topics reviewed elsewhere.

Is air pollution affecting the disease activity in patients with systemic lupus erythematosus? State of the art and a systematic literature review

OBJECTIVE

It has been documented that several major components of air pollution, including trace elements and polycyclic aromatic hydrocarbons, are associated with the prevalence of systemic lupus erythematosus (SLE). However, the impact of air pollution on the SLE disease activity is still elusive. In this paper, we review the current evidence investigating the link between air pollution, especially when measured as PM2.5, and SLE severity and activity.

METHODS

A detailed literature search was applied a priori to the Ovid MEDLINE In-Process and Other Non-Indexed Citation 1986 to present. Presented abstracts from the European League Against Rheumatism and American College of Rheumatology (ACR)/Association for Rheumatology Health Professionals (ARHP) Annual Meetings (2011-2018) were also screened.

RESULTS

Out of a total of 1354 papers retrieved from search and references list for detailed evaluation, data from 652 patients with SLE from three studies were analyzed. Two studies had an observational longitudinal design, counting for 348 patients with a follow-up of 24 months and 79 months. Retrieved studies differed for disease activity assessment and air pollution quantifications.

CONCLUSION

Current evidence suggests that variations in air pollution may influence the disease activity in patients with SLE. However, the sample size, methodological biases, and differences across the studies make further research mandatory. Understanding the increased burden of SLE and its complications, not only from a medical, but also from a socio-demographic perspective, including an exposure to pollutants, should have implications for resource allocation and access to subspecialty care.

Effect of air pollution on hospitalization for acute exacerbation of chronic obstructive pulmonary disease, stroke, and myocardial infarction

This study aims to analyze the acute effects of PM_2.5, PM₁₀, SO₂, NO₂, and O₃ on hospitalizations for acute exacerbation of chronic obstructive pulmonary disease (AECOPD), stroke, and myocardial infarction (MI) from 2014 to 2017 in Shenyang, China. Hospitalization records for AECOPD (17,655), stroke (276,736) and MI (26,235) and air pollutions concentration data (PM_2.5, PM₁₀, SO₂, NO₂, and O₃) were collected. A generalized additive model (GAM) was utilized to determine the impact of air pollutants on the relative risk (RR) of hospitalization for AECOPD, stroke, and MI. Stratified analysis for AECOPD was based on gender and age. It was based on gender, age, hypertension, and diabetes for stroke, and for MI it was based on gender, age, and coronary atherosclerosis. The lag effect for AECOPD in terms of gender analysis occurred at lag3-lag5. The hospitalization risk for stroke with hypertension due to SO₂ and NO₂ was greater than that of stroke without hypertension. The risk of hospitalization for stroke with hypertension as a comorbidity due to O₃ was lower than without hypertension. The risk of hospitalization for MI combined with coronary atherosclerosis due to PM_2.5, PM₁₀, or NO₂ was higher than that of hospitalizations for MI without coronary atherosclerosis. Air pollution increased the rate of hospitalization for AECOPD. SO₂ and O₃ appeared protective for stroke patients with coronary atherosclerosis. PM_2.5, PM₁₀, and NO₂ had no influence on total hospitalization for myocardial infarction.

Long term exposure to ambient fine particulate matter and incidence of stroke: prospective cohort study from the China-PAR project

OBJECTIVE

To study the effect of long term exposure to ambient fine particulate matter of diameter ≤2.5 μm (PM2.5) on the incidence of total, ischemic, and hemorrhagic stroke among Chinese adults.

DESIGN

Population based prospective cohort study.

SETTING

Prediction for Atherosclerotic Cardiovascular Disease Risk in China (China-PAR) project carried out in 15 provinces across China.

PARTICIPANTS

117 575 Chinese men and women without stroke at baseline in the China-PAR project.

MAIN OUTCOME MEASURES

Incidence of total, ischemic, and hemorrhagic stroke.

RESULTS

The long term average PM2.5 level from 2000 to 2015 at participants' residential addresses was 64.9 μg/m3, ranging from 31.2 μg/m3 to 97.0 μg/m3. During 900 214 person years of follow-up, 3540 cases of incident stroke were identified, of which 63.0% (n=2230) were ischemic and 27.5% (n=973) were hemorrhagic. Compared with the first quarter of exposure to PM2.5 (<54.5 μg/m3), participants in the highest quarter (>78.2 μg/m3) had an increased risk of incident stroke (hazard ratio 1.53, 95% confidence interval 1.34 to 1.74), ischemic stroke (1.82, 1.55 to 2.14), and hemorrhagic stroke (1.50, 1.16 to 1.93). For each increase of 10 μg/m3 in PM2.5 concentration, the increased risks of incident stroke, ischemic stroke, and hemorrhagic stroke were 13% (1.13, 1.09 to 1.17), 20% (1.20, 1.15 to 1.25), and 12% (1.12, 1.05 to 1.20), respectively. Almost linear exposure-response relations between long term exposure to PM2.5 and incident stroke, overall and by its subtypes, were observed.

CONCLUSIONS

This study provides evidence from China that long term exposure to ambient PM2.5 at relatively high concentrations is positively associated with incident stroke and its major subtypes. These findings are meaningful for both environmental and health policy development related to air pollution and stroke prevention, not only in China, but also in other low and middle income countries.

Atrial fibrillation hospitalization is associated with exposure to fine particulate air pollutants

BACKGROUND

Although air pollutants have been associated with cardiopulmonary mortality, their effects on the occurrence of atrial fibrillation (Afib) remain unclear. This study examined the association between ambient air pollutants and Afib occurrence.

METHODS

Using a representative sample from the National Health Insurance Database of Taiwan, we applied a case-crossover study design to explore the associations between air pollutants and patients hospitalized with Afib from 2006 to 2011. The event day was when a patient was hospitalized with Afib, and the control days were the same days of the following weeks of the same month. The association between Afib occurrence and levels of ambient air pollutants (including particulate matter [PM] 2.5 PM₁₀, NO₂, SO₂, and O₃) was examined after adjusting for temperature and relative humidity. A two-pollutant model was used to examine the effect of the second pollutant when the first pollutant was determined to be significantly related to Afib.

RESULTS

During 2006-2011, 670 patients hospitalized with the first onset of Afib were identified. The occurrence of Afib was associated with PM_2.5, in which a 22% (95% confidence interval = 3-44%) increase was related to an interquartile range increase (26.2 μg/m3) on the same day and a 19% (95% confidence interval = 0-40%) increase on the second day. A two-pollutant model was applied, and the results indicated that the effect of PM_2.5 was significantly associated with the occurrence of Afib. Patients aged over 65 years with DM and with hyperlipidemia were more susceptible to the effect of PM_2.5.

CONCLUSIONS

In conclusion, the occurrence of Afib was associated with short-term exposure to fine particulate air pollutants in the general population.

Association between ambient fine particulate pollution and hospital admissions for cause specific cardiovascular disease: time series study in 184 major Chinese cities

OBJECTIVE

To estimate the risks of daily hospital admissions for cause specific major cardiovascular diseases associated with short term exposure to ambient fine particulate matter (aerodynamic diameter ≤2.5 μm; PM_2.5) pollution in China.

DESIGN

National time series study.

SETTING

184 major cities in China.

POPULATION

8 834 533 hospital admissions for cardiovascular causes in 184 Chinese cities recorded by the national database of Urban Employee Basic Medical Insurance from 1 January 2014 to 31 December 2017.

MAIN OUTCOME MEASURES

Daily counts of city specific hospital admissions for primary diagnoses of ischaemic heart disease, heart failure, heart rhythm disturbances, ischaemic stroke, and haemorrhagic stroke among different demographic groups were used to estimate the associations between PM_2.5 and morbidity. An overdispersed generalised additive model was used to estimate city specific associations between PM_2.5 and cardiovascular admissions, and random effects meta-analysis used to combine the city specific estimates.

RESULTS

Over the study period, a mean of 47 hospital admissions per day (standard deviation 74) occurred for cardiovascular disease, 26 (53) for ischaemic heart disease, one (five) for heart failure, two (four) for heart rhythm disturbances, 14 (28) for ischaemic stroke, and two (four) for haemorrhagic stroke. At the national average level, an increase of 10 μg/m³ in PM_2.5 was associated with a 0.26% (95% confidence interval 0.17% to 0.35%) increase in hospital admissions on the same day for cardiovascular disease, 0.31% (0.22% to 0.40%) for ischaemic heart disease, 0.27% (0.04% to 0.51%) for heart failure, 0.29% (0.12% to 0.46%) for heart rhythm disturbances, and 0.29% (0.18% to 0.40%) for ischaemic stroke, but not with haemorrhagic stroke (-0.02% (-0.23% to 0.19%)). The national average association of PM_2.5 with cardiovascular disease was slightly non-linear, with a sharp slope at PM_2.5 levels below 50 μg/m³, a moderate slope at 50-250 μg/m³, and a plateau at concentrations higher than 250 μg/m³. Compared with days with PM_2.5 up to 15 μg/m³, days with PM_2.5 of 15-25, 25-35, 35-75, and 75 μg/m³ or more were significantly associated with increases in cardiovascular admissions of 1.1% (0 to 2.2%), 1.9% (0.6% to 3.2%), 2.6% (1.3% to 3.9%), and 3.8% (2.1% to 5.5%), respectively.According to projections, achieving the Chinese grade 2 (35 μg/m³), Chinese grade 1 (15 μg/m³), and World Health Organization (10 μg/m³) regulatory limits for annual mean PM_2.5 concentrations would reduce the annual number of admissions for cardiovascular disease in China. Assuming causality, which should be done with caution, this reduction would translate into an estimated 36 448 (95% confidence interval 24 441 to 48 471), 85 270 (57 129 to 113 494), and 97 516 (65 320 to 129 820), respectively.

CONCLUSIONS

These data suggest that in China, short term exposure to PM_2.5 is associated with increased hospital admissions for all major cardiovascular diseases except for haemorrhagic stroke, even for exposure levels not exceeding the current regulatory limits.

Association between in vitro fertilization success rate and ambient air pollution: a possible explanation of within-year variation of in vitro fertilization success rate

Objective

To evaluate patterns in air pollution concentrations and in vitro fertilization (IVF) success rates using data from a large, long-term clinical database.

Methods

We conducted a retrospective cohort study investigating South Korean women who pursued IVF and embryo transfer (IVF-ET) between 2011 and 2017. Hourly concentrations of air pollutants measured at 318 air quality monitoring sites in South Korea between 2011 and 2017 were obtained from the National Institute of Environmental Research. Monthly trends in pregnancy rates and concentrations of air pollutants were assessed.

Results

A total of 34,427 IVF-ET cycles in 18,478 patients were analyzed. The mean age of women at the time of IVF-ET was 36.6 years. The clinical pregnancy rate in the IVF-ET cycle was 30%. Analysis of pregnancy failure rates by month showed that IVF-ET failure rates tended to be higher in March and April and lower in July and August. Concentrations of air pollutants including particulate matter (PM) less than 10 μm in diameter, PM less than 2.5 μm in diameter, sulfur dioxide, nitrogen dioxide, and carbon monoxide were highest in March and April and lowest between July and September.

Conclusion

Within-year variations were similar between IVF-ET failure rates and air pollution concentrations based on analysis of a large, long-term database. Specifically, IVF-ET success rates were highest when PM concentrations were lowest. Further studies are warranted to examine the mechanisms accounting for the association between IVF success and air pollutant exposure.

Air Pollution and Health - A Science-Policy Initiative

Air pollution is a major, preventable and manageable threat to people's health, well-being and the fulfillment of sustainable development. Air pollution is estimated to contribute to at least 5 million premature deaths each year across the world. No one remains unaffected by dirty air, but the adverse impacts of air pollution fall most heavily upon vulnerable populations, such as children, women, and people living in poverty - groups to whom States have special obligations under international human rights law. The National Academies of Sciences and Medicine of South Africa, Brazil, Germany and the United States of America are calling upon government leaders, business and citizens to take urgent action on reducing air pollution throughout the world - to the benefit of human health and well-being, to the benefit of the environment and as a condition towards sustainable development. Air pollution is a cross-cutting aspect of many UN Sustainable Development Goals.

Weather effects on hand, foot, and mouth disease at individual level: a case-crossover study

BACKGROUND

Hand, foot, and mouth disease (HFMD) raises an urgent public health issue in the Asia-Pacific region, especially in China. The associations between weather factors and HFMD have been widely studied but with inconsistent results. Moreover, previous studies utilizing ecological design could not rule out the bias of exposure misclassification and unobserved confounders.

METHODS

We used case-crossover analysis to assess the associations of weather factors on HFMD. Individual HFMD cases from 2009 to 2012 in Guangdong were collected and cases located within 10 km of the meteorological monitoring sites were included. Lag effects were examined through the previous 7 days. In addition, we explored the variability by changing the distance within 20 km and 30 km.

RESULTS

We observed associations between HFMD and weather factors, including temperature and relative humidity. An approximately U-shaped relationship was observed for the associations of temperature on HFMD across the same day and the previous 7 days, while an approximately exponential-shaped was seen for relative humidity. Statistically significant increases in rates of HFMD were associated with each 10-unit increases in temperature [Excess rate (ER): 7.7%; 95% Confidence Interval (CI): 3.9, 11.7%] and relative humidity (ER: 1.9%; 95% CI: 0.7, 3.0%) on lag days 0-6, when assessing within 10 km of the monitoring sites. Potential thresholds for temperature (30.0 °C) and relative humidity (70.3%) detected showed associations with HFMD. The associations remained robust for 20 km and 30 km.

CONCLUSIONS

Our study found that temperature and relative humidity are significantly associated with the increased rates of HFMD. Thresholds and lag effects were observed between weather factors and HFMD. Our findings are useful for planning on targeted prevention and control of HFMD.

Short-term exposure to ambient ozone and inflammatory biomarkers in cross-sectional studies of children and adolescents: Results of the GINIplus and LISA birth cohorts

BACKGROUND

While exposure to ambient particulate matter (PM) and nitrogen dioxide (NO₂) is thought to be associated with diseases via inflammatory response, the association between exposure to ozone, an oxidative pollutant, and inflammation has been less investigated.

AIM

We analyzed associations between short-term exposure to ozone and three inflammatory biomarkers among children and adolescents.

METHODS

These cross-sectional analyses were based on two follow-ups of the GINIplus and LISA German birth cohorts. We included 1330 10-year-old and 1591 15-year-old participants. Fractional exhaled nitric oxide (FeNO) and high-sensitivity C-reactive protein (hs-CRP) were available for both age groups while interleukin (IL)-6 was measured at 10 years only. Maximum 8-h averages of ozone and daily average concentrations of NO₂ and PM with an aerodynamic diameter <10 μm (PM₁₀) were adopted from two background monitoring stations 0 (same day), 1, 2, 3, 5, 7, 10 and 14 days prior to the FeNO measurement or blood sampling. To assess associations, we utilized linear regression models for FeNO, and logistic regressions for IL-6 and hs-CRP, adjusting for potential covariates and co-pollutants NO₂ and PM₁₀.

RESULTS

We found that short-term ozone exposure was robustly associated with higher FeNO in adolescents at age 15, but not at age 10. No consistent associations were observed between ozone and IL-6 in children aged 10 years. The relationship between hs-CRP levels and ozone was J-shaped. Relatively low ozone concentrations (e.g., <120 μg/m³) were associated with reduced hs-CRP levels, while high concentrations (e.g., ≥120 μg/m³) tended to be associated with elevated levels for both 10- and 15-year-old participants.

CONCLUSIONS

Our study demonstrates significant associations between short-term ozone exposure and FeNO at 15 years of age and a J-shaped relationship between ozone and hs-CRP. The finding indicates that high ozone exposure may favor inflammatory responses in adolescents, especially regarding airway inflammation.

Short-term effects of ambient particulate matter on blood pressure among children and adolescents:A cross-sectional study in a city of Yangtze River delta, China

Several studies have demonstrated associations between short-term exposure to particulate matter (PM) and blood pressure (BP) among various adults groups, but evidence in children and adolescents is still rare. In 2016, a cross-sectional survey was conducted among 194 104 participants aged 6-17 years in Suzhou, China. Daily concentrations of particulate matters with an aerodynamic diameter of ≤10 μg/m³ (PM₁₀) and aerodynamic diameter ≤2.5 μg/m³ (PM_2.5) on 0-6 days preceding BP examination were collected from nearby air monitoring stations. Using generalized linear mixed-effects models, short-term effects of PM on personal BP were estimated. A 10 μg/m³ increment in the 0-6 day mean of PM_2.5 was significantly associated with elevation of 0.20 mmHg [95% confidence interval (95% CI) 0.16-0.23] in systolic BP (SBP), 0.49 mmHg (95% CI 0.45-0.53) in diastolic BP (DBP), respectively. Similarly, 0.14 mmHg (95% CI 0.12-0.16) higher SBP and 0.32 mmHg (95% CI 0.30-0.34) higher DBP were found for each 10 μg/m³ increase in 0-6 day mean of PM₁₀. More apparent associations were observed in females than in males. Odds ratio (95%CI) of for PM_2.5 exposure at 0-6 d mean was 1.06 (1.03-1.08) in females, while it was 1.01 (0.99-1.03) in males. Participants with young ages, underweight and obesity were also associated with increased susceptibility to PM-induced BP effects. Short-term exposure in PM was significantly associated with elevated BP in children, indicating a need to control PM levels and protect children from PM exposure in China.

Effects of ambient ozone concentrations with different averaging times on asthma exacerbations: A meta-analysis

BACKGROUND

Mounting evidence suggests that short-term exposure to ozone increases the risk of asthma exacerbations. However, ozone exposures have been assessed using ambient ozone concentrations averaged over different time periods in different studies.

OBJECTIVE

To evaluate the risks for asthma exacerbations related to ambient ozone measured as 1-hour or 8-hour daily maximum and 24-hour average concentrations.

METHODS

Based on a literature search in PubMed, EMBASE and Web of Science, we identified all time-series studies as of December 4th, 2018 and included 47 eligible studies in our analyses. Asthma exacerbation is defined as the risk for emergency room visits or hospital admissions. Pooled relative risks (RRs) and 95% confidence intervals (95%CIs) for a 10 μg/m3 increase in daily ozone concentration were estimated using random effect models. Subgroup analyses and sensitivity analyses were also performed to examine the risks for different seasons, regions and age groups and for the robustness of our main findings.

RESULTS

Significant and similar associations were found for O3-1 h max (RR,1.012; 95%CI, 1.005-1.019) and O3-8 h max (RR, 1.011; 95%CI, 1.007-1.014), while marginal effect was identified for O3-24 h average (RR, 1.005; 95%CI, 0.996-1.014). No significant publication bias but high heterogeneities were observed. During the warm season, ozone was significantly associated with asthma exacerbation. O3-1 h max had the highest RR of 1.014 (95%CI, 1.005-1.024), followed by O3-8 h max (RR, 1.012; 95%CI, 1.009-1.016), while marginal association was identified for O3-24 h avg (RR, 1.008; 95%CI, 0.998-1.017). During the cold season, null associations were identified for all the three averaging times. Variations were also observed in region and age.

CONCLUSION

Ozone exposure measured as 1-hour or 8-hour daily max were more consistently associated with asthma exacerbations than 24-hour average exposure during the warm season.

Short-term exposure to air pollution and incidence of stroke in the Women's Health Initiative

BACKGROUND

Evidence of the association between daily variation in air pollution and risk of stroke is inconsistent, potentially due to the heterogeneity in stroke etiology.

OBJECTIVES

To estimate the associations between daily variation in ambient air pollution and risk of stroke and its subtypes among participants of the Women's Health Initiative, a large prospective cohort study in the United States.

METHODS

We used national-scale, log-normal ordinary kriging models to estimate daily concentrations of fine particulate matter (PM2.5), respirable particulate matter (PM10), nitrogen dioxide (NO2), nitrogen oxides (NOx), sulphur dioxide, and ozone at participant addresses. Stroke was adjudicated by trained neurologists and classified as ischemic or hemorrhagic. Ischemic strokes were further classified according to the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) classification. We used a time-stratified case-crossover approach to estimate the odds ratio (OR) of the risk of stroke associated with an interquartile range (IQR) increase in concentrations of each air pollutant. We performed stratified analysis to examine whether associations varied across subgroups defined by age at stroke onset, US census region, smoking status, body mass index, and prior history of diabetes mellitus, hypertension, heart or circulation problems, or arterial fibrillation at enrollment.

RESULTS

Among 5417 confirmed strokes between 1993 and 2012, 4300 (79.4%) were classified as ischemic and 924 (17.1%) as hemorrhagic. No association was observed between day-to-day variation in any pollutant and risk of total stroke, ischemic stroke, or specific etiologies of ischemic stroke. We observed a positive association between risk of hemorrhagic stroke and NO2 and NOx in the 3 days prior to stroke with OR of 1.24 (95% CI: 1.01, 1.52) and 1.18 (95% CI: 1.03, 1.34) per IQR increase, respectively. The observed associations with hemorrhagic stroke were more pronounced among non-obese participants.

CONCLUSIONS

In this large cohort of post-menopausal US women, daily NO2 and NOx were associated with higher risk of hemorrhagic stroke, but ambient levels of four other air pollutants were not associated with higher risk of total stroke, ischemic stroke, or ischemic stroke subtypes.

Deciphering the stroke-built environment nexus in transitional cities: Conceptual framework, empirical evidence, and implications for proactive planning intervention

Adverse lifestyle-associated health outcomes, and stroke in particular, have been aggravated in transitional countries under high-speed urbanisation. Against this backdrop, deciphering the nexus between built environments (BEs) and lifestyle-associated health outcomes is of importance for crafting proactive interventions. The existing literature on this topic, however, fails to sufficiently capture the multiplicity of health-related BEs and, in turn, the complexity of such a nexus, largely challenging the applicability of established frameworks and the reliability of relevant findings. Looking at the case of stroke in Wuhan, China, this research aims to flesh out the understanding of the nexus between multidimensional BEs and lifestyle-associated health outcomes in transitional cities, with regards to conceptual framework and empirical evidence. To this end, we clarified stroke-related BE elements and integrated them into one conceptual framework. We then visualised stroke risk and examined its BE determinants using the Bayesian conditional autoregressive model. The visualisation results showed that stroke risks exhibited significant clustering in the high-density urban core. The statistical analysis found that, after the data were controlled for sociodemographic characteristics, net population density and building density were positively associated with stroke risk. In contrast, an abundance of public parks and institutional land use and access to medical care facilities have presented negative correlations with stroke risk, regardless of urban density. Our research reveals that compact urban developments might not be a silver bullet for health promotion in transitional cities, calling for an urgent need to scrutinise their applicability. To offset the adverse effects of increasingly dense urban environments, more efforts should also be made to provide better access to the identified salubrious resources. Furthermore, we argue that the establishment of comprehensive conceptual frameworks that connect BEs and lifestyle-associated health outcomes deserves to be highlighted in further research, planning intervention schemes, and health impact assessment projects.

Short-term exposure to air pollution and conjunctivitis outpatient visits: A multi-city study in China

BACKGROUND

Conjunctivitis has hazardous effects on patients' quality of life through influencing school performance, work productivity, and daily activities such as driving. However, limited evidence is available on the contributory role of air pollution on conjunctivitis, particularly in China.

METHODS

We obtained data of 81,351 conjunctivitis outpatients from the largest comprehensive hospitals of four cities, China, between Jan 1, 2013 and Dec 31, 2014. Data on air pollutants, including particulate matter ≤2.5 μm in diameter (PM_2.5), particulate matter ≤10 μm in diameter (PM₁₀), nitrogen dioxide (NO₂), ozone (O₃) and sulphur dioxide (SO₂) were collected from China National Environmental Monitoring Centre. Conjunctivitis outpatient visits were linked with air pollution concentrations by the visiting dates. A time-stratified case-crossover design with conditional logistic regression model was used to examine the effect of short-term exposure to air pollution on conjunctivitis outpatient visits.

RESULTS

We found that the associations between air pollutants (per 10 μg/m³ increase) and hospital outpatient visits for asthma were [odds ratios (ORs) and 95% confidence intervals]: 1.004(1.002-1.007) for PM_2.5, 1.004 (1.002-1.005) for PM₁₀, 1.012(1.005-1.020) for NO₂, 1.006 (1.001-1.011) for SO₂, and 1.007 (1.003-1.010) for O₃, respectively at lag0 day. Outpatients aged 35-64 years showed significant associations with exposure to PM_2.5 (1.005, 1.001-1.010), PM₁₀ (1.005, 1.002-1.008), NO₂ (1.014, 1.003-1.026), and O₃ (1.005, 1.000-1.011), while those aged 15-34 years showed significant associations with exposure to O₃ (1.010, 1.004-1.017).

CONCLUSIONS

Short-term exposure to air pollution has impacts on outpatient visits for conjunctivitis in China. This study suggests that improving air quality could protect eye health.

Fine particle environmental pollution and cardiovascular diseases

Air pollution affects 90% of the world's population and has caused 9 million deaths in 2015, becoming the most important cause of premature deaths in the world. Exposure to fine particulate matter, a major component of urban air pollution, has been associated with an increase in cardiovascular risk and associated mortality. Impact of fine particles on the cardiovascular system includes inflammation, activation of prothrombotic pathways, oxidative stress, vascular dysfunction and remodeling, and neurological dysfunction. Genetic and epigenetic factors might also increase the susceptibility to air pollution. Consequently, epidemiologic studies have identified correlations between air particulate matter concentrations and acute coronary events, ischemic cardiomyopathy, acute heart failure, and stroke. Interestingly, these effects are present even for fine particulate matter concentrations below current US and EU regulatory standards, and seems to be more harmful in the most fragile population such as low-income or elderly subjects, or patients with previous cardiovascular disease. This review aims to summarize recent data on the pathophysiology and epidemiology of cardiovascular disease after particulate matter exposure. It will also discuss potential strategies to reduce the impact of air pollution on current and future populations' health.

Novel evidence for a greater burden of ambient air pollution on cardiovascular disease

Ambient and household air pollution is a major health problem worldwide, contributing annually to approximately seven million of all-cause avoidable deaths, shorter life expectancy, and significant direct and indirect costs for the community. Air pollution is a complex mixture of gaseous and particulate materials that vary depending on their source and physicochemical features. Each material has detrimental effects on human health, but a number of experimental and clinical studies have shown a strong impact for fine particulate matter (PM_2.5). In particular, there is more and more evidence that PM_2.5 exerts adverse effects particularly on the cardiovascular system, contributing substantially (mainly through mechanisms of atherosclerosis, thrombosis and inflammation) to coronary artery and cerebrovascular disease, but also to heart failure, hypertension, diabetes and cardiac arrhythmias. In this review, we summarize knowledge on the mechanisms and magnitude of the cardiovascular adverse effects of short-and long-term exposure to ambient air pollution, particularly for the PM_2.5 size fraction. We also emphasize that very recent data indicate that the global mortality and morbidity burden of cardiovascular disease associated with this air pollutant is dramatically greater than what has been thought up to now.

Ozone Pollution: A Major Health Hazard Worldwide

Oxides of nitrogen (NO_x) and volatile organic compounds (VOCs) released into the atmosphere can react in the presence of solar irradiation, leading to ozone formation in the troposphere. Historically, before clean air regulations were implemented to control NO_x and VOCs, ozone concentrations were high enough to exert acute effects such as eye and nose irritation, respiratory disease emergencies, and lung function impairment. At or above current regulatory standards, day-to-day variations in ozone concentrations have been positively associated with asthma incidence and daily non-accidental mortality rate. Emerging evidence has shown that both short-term and long-term exposures to ozone, at concentrations below the current regulatory standards, were associated with increased mortality due to respiratory and cardiovascular diseases. The pathophysiology to support the epidemiologic associations between mortality and morbidity and ozone centers at the chemical and toxicological property of ozone as a strong oxidant, being able to induce oxidative damages to cells and the lining fluids of the airways, and immune-inflammatory responses within and beyond the lung. These new findings add substantially to the existing challenges in controlling ozone pollution. For example, in the United States in 2016, 90% of non-compliance to the national ambient air quality standards was due to ozone whereas only 10% was due to particulate matter and other regulated pollutants. Climate change, through creating atmospheric conditions favoring ozone formation, has been and will continue to increase ozone concentrations in many parts of world. Worldwide, ozone is responsible for several hundreds of thousands of premature deaths and tens of millions of asthma-related emergency room visits annually. To combat ozone pollution globally, more aggressive reductions in fossil fuel consumption are needed to cut NO_x and VOCs as well as greenhouse gas emissions. Meanwhile, preventive and therapeutic strategies are needed to alleviate the detrimental effects of ozone especially in more susceptible individuals. Interventional trials in humans are needed to evaluate the efficacy of antioxidants and ozone-scavenging compounds that have shown promising results in animal studies.

Risk of Stroke Among Survivors of the September 11, 2001, World Trade Center Disaster

OBJECTIVE

The aim of this study was to investigate the association between 9/11-related posttraumatic stress disorder (PTSD), dust cloud exposure, and subsequent development of stroke among 42,527 enrollees in the World Trade Center (WTC) Health Registry.

METHODS

Using four waves of longitudinal data from the WTC Health Registry surveys, we employed Cox proportional hazards regression models to assess the associations.

RESULTS

Incidence of stroke was higher among those with PTSD or intense dust cloud exposure than those without, and it was even higher for those who had experienced both. In fully adjusted models, participants with PTSD had an increased risk of developing stroke [adjusted hazards ratio (AHR) 1.69, 95% confidence interval (95% CI) 1.42 to 2.02], as did those with intense dust exposure (AHR 1.29, 95% CI 1.09 to 1.53).

CONCLUSION

We found that individuals with 9/11-related PTSD and/or intense dust exposure may have an increased risk of developing stroke.

Common risk factors for major noncommunicable disease, a systematic overview of reviews and commentary: the implied potential for targeted risk reduction

Noncommunicable disease now contributes to the World Health Organization top 10 causes of death in low-, middle- and high-income countries. Particular examples include stroke, coronary heart disease, dementia and certain cancers. Research linking clinical and lifestyle risk factors to increased risk of noncommunicable disease is now well established with examples of confirmed risk factors, including smoking, physical inactivity, obesity and hypertension. However, despite a need to target our resources to achieve risk reduction, relatively little work has examined the overlap between the risk factors for these main noncommunicable diseases. Our high-level review draws together the evidence in this area. Using a systematic overview of reviews, we demonstrate the likely commonality of established risk factors having an impact on multiple noncommunicable disease outcomes. For example, systematic reviews of the evidence on physical inactivity and poor diet found each to be associated with increased risk of cancers, coronary heart disease, stroke, diabetes mellitus and dementia. We highlight the potential for targeted risk reduction to simultaneously impact multiple noncommunicable disease areas. These relationships now need to be further quantified to allow the most effective development of public health interventions in this area.

Ischaemic stroke

Stroke is the second highest cause of death globally and a leading cause of disability, with an increasing incidence in developing countries. Ischaemic stroke caused by arterial occlusion is responsible for the majority of strokes. Management focuses on rapid reperfusion with intravenous thrombolysis and endovascular thrombectomy, which both reduce disability but are time-critical. Accordingly, improving the system of care to reduce treatment delays is key to maximizing the benefits of reperfusion therapies. Intravenous thrombolysis reduces disability when administered within 4.5 h of the onset of stroke. Thrombolysis also benefits selected patients with evidence from perfusion imaging of salvageable brain tissue for up to 9 h and in patients who awake with stroke symptoms. Endovascular thrombectomy reduces disability in a broad group of patients with large vessel occlusion when performed within 6 h of stroke onset and in patients selected by perfusion imaging up to 24 h following stroke onset. Secondary prevention of ischaemic stroke shares many common elements with cardiovascular risk management in other fields, including blood pressure control, cholesterol management and antithrombotic medications. Other preventative interventions are tailored to the mechanism of stroke, such as anticoagulation for atrial fibrillation and carotid endarterectomy for severe symptomatic carotid artery stenosis.

Quantification of the Cost and Potential Environmental Effects of Unused Pharmaceutical Products in Cataract Surgery

Importance

Pharmaceutical products, including unused portions, may contribute to financial and environmental costs in the United States. Because cataract surgery is performed millions of times each year in the United States and throughout the rest of the world, understanding these financial and environmental costs associated with cataract surgery is warranted.

Objective

To investigate the financial and environmental costs of unused pharmaceutical products after phacoemulsification surgery.

Design, Setting, and Participants

This descriptive qualitative study included 4 surgical sites in the northeastern United States (a private ambulatory care center, private tertiary care center, private outpatient center, and federally run medical center for veterans). Prices and data for use of services and pharmaceuticals were obtained for the tertiary care and outpatient centers from January 1 through April 30, 2016; for the ambulatory care center from June 1, 2017, through March 31, 2018; and the federal medical center from November 1, 2017, through February 28, 2018. Data were collected from routine phacoemulsification surgical procedures without vitreous loss or other complications. Volume or weight of medications remaining after surgery was measured. Total and mean costs of medications per case and month were calculated. Environmental effects were estimated using economic input-output life cycle assessment methods. Data were analyzed from December 1, 2017, through June 30, 2018.

Main Outcomes and Measures

Cost of unused pharmaceutical products (in US dollars) and kilogram equivalents of carbon emissions (carbon dioxide [CO2-e]), air pollution (fine particulate matter emissions of ≤10 μm in diameter [PM10-e]), and eutrophication potential (nitrogen [N-e]).

Results

A total of 116 unique drugs were surveyed among the 4 centers. Assuming unmeasured medications had no materials left unused, a cumulative mean 83 070 of 183 304 mL per month (45.3%) of pharmaceuticals were unused by weight or volume across all sites. Annual unused product cost estimates reached approximately $195 200 per site. A larger percentage of eyedrops (65.7% by volume) were unused compared with injections (24.8%) or systemic medications (59.9%). Monthly unused quantities at the ambulatory care center (65.9% by volume [54 971 of 83 440 mL]), tertiary care center (21.3% [17 143 of 80 344 mL]), federal medical center (38.5% [265 of 689 mL]), and outpatient center (56.8% [10 691 of 18 832 mL]) resulted in unnecessary potential emissions at each center of 2135, 2498, 418, and 711 kg CO2-e/mo, respectively. Unnecessary potential air pollution between sites varied from 0.8 to 4.5 kg PM10-e/mo, and unnecessary eutrophication potential between sites varied from 0.07 to 0.42 kg N-e/mo.

Conclusions and Relevance

This study suggests that unused pharmaceutical products during phacoemulsification result in relatively high financial and environmental costs. If these findings can be substantiated and shown to be generalizable in the United States or elsewhere, reducing these costs may be of value.

Global burden of atherosclerotic cardiovascular disease in people with hepatitis C virus infection: a systematic review, meta-analysis, and modelling study

BACKGROUND

More than 70 million people worldwide are estimated to have hepatitis C virus (HCV) infection. Emerging evidence indicates an association between HCV and atherosclerotic cardiovascular disease. We aimed to determine the association between HCV and cardiovascular disease, and estimate the national, regional, and global burden of cardiovascular disease attributable to HCV.

METHODS

For this systematic review and meta-analysis, we searched MEDLINE, Embase, Ovid Global Health, and Web of Science databases from inception to May 9, 2018, without language restrictions, for longitudinal studies that evaluated the risk ratio (RR) of cardiovascular disease in people with HCV compared with those without HCV. Two investigators independently reviewed and extracted data from published reports. The main outcome was cardiovascular disease, defined as hospital admission with, or mortality from, acute myocardial infarction or stroke. We calculated the pooled RR of cardiovascular disease associated with HCV using a random-effects model. Additionally, we calculated the population attributable fraction and disability-adjusted life-years (DALYs) from HCV-associated cardiovascular disease at the national, regional, and global level. We also used age-stratified and sex-stratified HCV prevalence estimates and cardiovascular DALYs for 100 countries to estimate country-level burden associated with HCV. This study is registered with PROSPERO, number CRD42018091857.

FINDINGS

Our search identified 16 639 records, of which 36 studies were included for analysis, including 341 739 people with HCV. The pooled RR for cardiovascular disease was 1·28 (95% CI 1·18-1·39). Globally, 1·5 million (95% CI 0·9-2·1) DALYs per year were lost due to HCV-associated cardiovascular disease. Low-income and middle-income countries had the highest disease burden with south Asian, eastern European, north African, and Middle Eastern regions accounting for two-thirds of all HCV-associated cardiovascular DALYs.

INTERPRETATION

HCV infection is associated with an increased risk of cardiovascular disease. The global burden of cardiovascular disease associated with HCV infection was responsible for 1·5 million DALYs, with the highest burden in low-income and middle-income countries.

FUNDING

British Heart Foundation and Wellcome Trust.

Long-term exposure to PM2.5 and stroke: A systematic review and meta-analysis of cohort studies

BACKGROUND

Stroke is one of the world's leading causes of death. Many studies have checked the relationship between short-term exposure to particulate matter (PM) and stroke, but few have focused on the effect of long-term exposure to PM_2.5 (particulate matters with an aerodynamic diameter of ≤2.5 μm). This study aimed to quantitatively examine the relationship of long-term exposure to PM_2.5 with stroke incidence and mortality.

METHODS

We identified relevant studies by searching the PubMed, EMBASE and MEDLINE. After the systematical review of pertinent studies, random-effect meta-analysis was conducted to investigate the association between long-term exposure to PM_2.5 and stroke.

RESULTS

Our meta-analysis included 16 cohort studies with more than 2.2 million people and above 49 149 endpoint events (incident stroke and death from stroke). The pooled hazard ratio (HR) for each 5 μg/m³ increment in PM_2.5 was 1.11 (95% CI: 1.05, 1.17) (CI for confidence interval) for incidence of stroke and 1.11 (95% CI:1.05, 1.17) for mortality of stroke. In the region-specific analysis, significant association between PM_2.5 and incidence of stroke was found in North America (HR=1.09, 95% CI:1.05, 1.14) and Europe (HR=1.07, 95% CI:1.05, 1.10), while the pooled result of Asia showed no significance (HR=2.31, 95% CI:0.49, 10.95).

CONCLUSIONS

Long-term exposure to PM_2.5 is an important risk factor for stroke. Since air quality is intimately related to everyone, policies aimed at reducing particulate matters will benefit public health a lot.

Ozone effects on blood biomarkers of systemic inflammation, oxidative stress, endothelial function, and thrombosis: The Multicenter Ozone Study in oldEr Subjects (MOSES)

The evidence that exposure to ozone air pollution causes acute cardiovascular effects is mixed. We postulated that exposure to ambient levels of ozone would increase blood markers of systemic inflammation, prothrombotic state, oxidative stress, and vascular dysfunction in healthy older subjects, and that absence of the glutathione S-transferase Mu 1 (GSTM1) gene would confer increased susceptibility. This double-blind, randomized, crossover study of 87 healthy volunteers 55-70 years of age was conducted at three sites using a common protocol. Subjects were exposed for 3 h in random order to 0 parts per billion (ppb) (filtered air), 70 ppb, and 120 ppb ozone, alternating 15 min of moderate exercise and rest. Blood was obtained the day before, approximately 4 h after, and approximately 22 h after each exposure. Linear mixed effect and logistic regression models evaluated the impact of exposure to ozone on pre-specified primary and secondary outcomes. The definition of statistical significance was p<0.01. There were no effects of ozone on the three primary markers of systemic inflammation and a prothrombotic state: C-reactive protein, monocyte-platelet conjugates, and microparticle-associated tissue factor activity. However, among the secondary endpoints, endothelin-1, a potent vasoconstrictor, increased from pre- to post-exposure with ozone concentration (120 vs 0 ppb: 0.07 pg/mL, 95% confidence interval [CI] 0.01, 0.14; 70 vs 0 ppb: -0.03 pg/mL, CI -0.09, 0.04; p = 0.008). Nitrotyrosine, a marker of oxidative and nitrosative stress, decreased with increasing ozone concentrations, with marginal significance (120 vs 0 ppb: -41.5, CI -70.1, -12.8; 70 vs 0 ppb: -14.2, CI -42.7, 14.2; p = 0.017). GSTM1 status did not modify the effect of ozone exposure on any of the outcomes. These findings from healthy older adults fail to identify any mechanistic basis for the epidemiologically described cardiovascular effects of exposure to ozone. The findings, however, may not be applicable to adults with cardiovascular disease.

Air Pollution and Cardiovascular Disease: JACC State-of-the-Art Review

Fine particulate matter <2.5 μm (PM_2.5) air pollution is the most important environmental risk factor contributing to global cardiovascular (CV) mortality and disability. Short-term elevations in PM_2.5 increase the relative risk of acute CV events by 1% to 3% within a few days. Longer-term exposures over several years increase this risk by a larger magnitude (∼10%), which is partially attributable to the development of cardiometabolic conditions (e.g., hypertension and diabetes mellitus). As such, ambient PM_2.5 poses a major threat to global public health. In this review, the authors provide an overview of air pollution and health, including assessment of exposure, impact on CV outcomes, mechanistic underpinnings, and impact of air pollution reduction strategies to mitigate CV risk. The review concludes with future challenges, including the inextricable link between air pollution and climate change, and calls for large-scale trials to allow the promulgation of formal evidence-based recommendations to lower air pollution-induced health risks.

Acute effect of daily fine particulate matter pollution on cerebrovascular mortality in Shanghai, China: a population-based time series study

Numerous studies have investigated the impacts of ambient fine particulate matter (PM_2.5) on human health. In this study, we examined the association of daily PM_2.5 concentrations with the number of deaths for the cerebrovascular disease on the same day, using the generalized additive model (GAM) controlling for temporal trend and meteorological variables. We used the data between 2012 and 2014 from Shanghai, China, where the adverse health effects of PM_2.5 have been of particular concern. Three different approaches (principal component analysis, shrinkage smoothers, and the least absolute shrinkage and selection operator regularization) were used in GAM to handle multicollinear meteorological variables. Our results indicate that the average daily concentration of PM_2.5 in Shanghai was high, 55 μg/m³, with an average daily death for cerebrovascular disease (CVD) of 62. There was 1.7% raised cerebrovascular disease deaths per 10 μg/m³ increase in PM_2.5 concentration in the unadjusted model. However, PM_2.5 concentration was no longer associated with CVD deaths after controlling for meteorological variables. The results were consistent in the three modelling techniques that we used. As a large number of people are exposed to air pollution, further investigation with longer time period including individual-level information is needed to examine the association.

The probability of diabetes and hypertension by levels of neighborhood walkability and traffic-related air pollution across 15 municipalities in Southern Ontario, Canada: A dataset derived from 2,496,458 community dwelling-adults

Individuals’ risk for cardiovascular disease is shaped by lifestyle factors such as participation in physical activity. Some studies have suggested that rates of physical activity may be higher in walkable neighborhoods that are more supportive of engaging in physical activity in daily life. However, walkable neighborhoods may also contain increased levels of traffic-related air pollution (TRAP). Traffic-related air pollution, often measured through a surrogate marker (e.g. NO₂), has been associated cardiovascular disease risk and risk factors [1], [2], [3], [4]. The higher levels of TRAP in walkable neighborhoods may in turn increase the likelihood of developing conditions like hypertension and diabetes. Our recent work assessed how walkability and TRAP jointly affect the odds of diabetes and hypertension in a sample of community-dwelling adults from Southern Ontario, Canada [5]. This article contains additional data on the probability and odds of hypertension and diabetes according to their walkability and TRAP exposures. Data on cardiovascular risk factors were collected using health administrative databases and environmental exposures were assessed using national land use regression models predicting ground level concentrations of NO₂ and validated walkability indices. The included data were generated using logistic regression accounting for exposures, covariates, and neighborhood clustering. These data may be used as primary data in future health risk assessments and systematic reviews, or to aid in the design of studies examining interactions between built environment and TRAP exposures (e.g. sample size calculations).

Economic fluctuations and cardiovascular diseases: A multiple-input time series analysis

Objectives

Little is known about the gender and age differences associated with the effects of economic fluctuations on hospitalization for cardiovascular diseases. This paper investigates the impact of economic fluctuations on hospitalization for ischemic heart disease (IHD), stroke, and hypertension by age and gender between January 1996 and December 2012 in Taiwan.

Methods

We adopted a multiple-input time series analysis to examine the strength of the immediate and latent effects of the 17-year quarterly unemployment rates (UR), air pollution exposure (APE), gross domestic product (GDP), per capita consumption expenditure in cigarette and alcohol (ECA), and per capita healthcare expenditure (HE) on the adjusted quarterly incidence rate of hospitalization. The data used in this paper were retrieved from the National Health Insurance Research Database and the website of the Directorate-General of Budget, Accounting and Statistics (DGBAS), Executive Yuan.

Results

Our findings indicate that higher UR increased IHD hospitalization in young men and women and middle-aged women but reduced stroke hospitalization in young men. Higher APE increased IHD hospitalization in young men but reduced it for young women, increased stroke hospitalization in old men and middle-aged women but reduced it for young men, and increased hypertension hospitalization in middle-aged men and young women. Higher ECA reduced IHD hospitalization in middle-aged men, increased stoke hospitalization in middle-aged and old men and middle-aged women. Higher HE reduced IHD hospitalization in old men, young and old women, reduced stroke hospitalization in old women, and reduced hypertension hospitalization in young and middle-aged women.

Conclusions

Overall, we found that the economic fluctuations caused increased harmful effects in certain population subgroups but also brought some soothing effects to some groups.