Association between ambient air pollution and hospitalization for ischemic and hemorrhagic stroke in China: A multicity case-crossover study.

There is growing interest in the association between ambient air pollution and stroke, but few studies have investigated the association in developing countries. The primary objective of this study was to examine the association between levels of ambient air pollutants and hospital admission for stroke in China. A time-stratified case-crossover analysis was conducted between 2014 and 2015 in 14 large Chinese cities among 200,958 ischemic stroke and 41,746 hemorrhagic stroke hospitalizations. We used conditional logistic regression to estimate the percentage changes in stroke admissions in relation to interquartile range increases in air pollutants. Air pollution was positively associated with ischemic stroke. A difference of an interquartile range of the 6-day average for particulate matter less than 10 μm in aerodynamic diameter, sulfur dioxide, nitrogen dioxide, carbon monoxide, and ozone corresponded to 0.7% (95% CI: 0%, 1.4%), 1.6% (95% CI: 1.0%, 2.3%), 2.6% (95% CI: 1.8%, 3.5%), 0.5% (95% CI: -0.2%, 1.1%), and 1.3% (95% CI: 0.3%, 2.3%) increases in ischemic stroke admissions, respectively. For hemorrhagic stroke, we observed the only significant association in relation to nitrogen dioxide on the current day (percentage change: 1.6%; 95% CI: 0.3%, 2.9%). Our findings contribute to the limited scientific literature concerning the effect of ambient air pollution on stroke in developing countries. Our findings may have significant public health implications for primary prevention of stroke in China.

[1]  Keyong Dong,et al.  Medical insurance system evolution in China , 2009 .

[2]  M. Budoff,et al.  Association between air pollution and coronary artery calcification within six metropolitan areas in the USA (the Multi-Ethnic Study of Atherosclerosis and Air Pollution): a longitudinal cohort study , 2016, The Lancet.

[3]  J. Hogg,et al.  Cytokines involved in the systemic inflammatory response induced by exposure to particulate matter air pollutants (PM(10)). , 2001, American journal of respiratory and critical care medicine.

[4]  M. Dennekamp,et al.  Hypothesis: Ill health associated with low concentrations of nitrogen dioxide—an effect of ultrafine particles? , 2003, Thorax.

[5]  Matthias Ketzel,et al.  Association between short-term exposure to ultrafine particles and hospital admissions for stroke in Copenhagen, Denmark. , 2010, European heart journal.

[6]  V. Chair,et al.  Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. , 2014, Stroke.

[7]  David E Newby,et al.  Short term exposure to air pollution and stroke: systematic review and meta-analysis , 2015, BMJ : British Medical Journal.

[8]  Joel Schwartz,et al.  Air Pollution and Hospital Admissions for Ischemic and Hemorrhagic Stroke Among Medicare Beneficiaries , 2005, Stroke.

[9]  V. Feigin,et al.  Global and regional burden of stroke during 1990–2010: findings from the Global Burden of Disease Study 2010 , 2014, The Lancet.

[10]  Mary G. George,et al.  Trends in hospitalizations and cost associated with stroke by age, United States 2003–2012 , 2016, International journal of stroke : official journal of the International Stroke Society.

[11]  Lucila Ohno-Machado,et al.  Natural language processing: an introduction , 2011, J. Am. Medical Informatics Assoc..

[12]  Richard L. Verrier,et al.  Association of Air Pollution with Increased Incidence of Ventricular Tachyarrhythmias Recorded by Implanted Cardioverter Defibrillators , 2005, Environmental health perspectives.

[13]  Gottfried Schlaug,et al.  Air Pollution and Risk of Stroke: Underestimation of Effect Due to Misclassification of Time of Event Onset , 2009, Epidemiology.

[14]  P. Villeneuve,et al.  Associations between outdoor air pollution and emergency department visits for stroke in Edmonton, Canada , 2006, European Journal of Epidemiology.

[15]  Douglas G Altman,et al.  Interaction revisited: the difference between two estimates , 2003, BMJ : British Medical Journal.

[16]  A. Gasparrini,et al.  The short-term influence of temperature on daily mortality in the temperate climate of Montreal, Canada. , 2011, Environmental research.

[17]  L. Waller,et al.  Impact of exposure measurement error in air pollution epidemiology: effect of error type in time-series studies , 2011, Environmental health : a global access science source.

[18]  H. Kan,et al.  Acute Stroke Mortality and Air Pollution: New Evidence from Shanghai, China , 2003, Journal of occupational health.

[19]  E. Talbott,et al.  Estimation of Short-Term Effects of Air Pollution on Stroke Hospital Admissions in Wuhan, China , 2013, PloS one.

[20]  R. Brook,et al.  Air pollution as an emerging global risk factor for stroke. , 2011, JAMA.

[21]  Xiaohui Xu,et al.  Acute Effect of Ambient Air Pollution on Stroke Mortality in the China Air Pollution and Health Effects Study , 2013, Stroke.

[22]  Xin Tong,et al.  Abstract 183: Trends in Hospitalizations and Cost Associated with Acute Ischemic Stroke by Age, United States 2003-2012 , 2016 .

[23]  Peter Achermann,et al.  Cognitive Performance Measures in Bioelectromagnetic Research - Critical Evaluation and Recommendations , 2011, Environmental health : a global access science source.

[24]  S. Yusuf,et al.  Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study , 2010, The Lancet.

[25]  Tze Wai Wong,et al.  Temporal relationship between air pollutants and hospital admissions for chronic obstructive pulmonary disease in Hong Kong , 2007, Thorax.

[26]  Mit Critical Data Secondary Analysis of Electronic Health Records , 2016 .

[27]  Haidong Kan,et al.  Public Health and Air Pollution in Asia (PAPA): A Multicity Study of Short-Term Effects of Air Pollution on Mortality , 2008, Environmental health perspectives.

[28]  V. Fuster,et al.  Long-term air pollution exposure and acceleration of atherosclerosis and vascular inflammation in an animal model. , 2005, JAMA.

[29]  B. Li,et al.  Air pollution and unscheduled hospital outpatient and emergency room visits. , 1995, Environmental health perspectives.

[30]  Alan D. Lopez,et al.  A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010 , 2012, The Lancet.

[31]  A. Tobías,et al.  Case-Crossover Analysis of Air Pollution Health Effects: A Systematic Review of Methodology and Application , 2010, Environmental health perspectives.

[32]  David E Newby,et al.  Diesel exhaust inhalation increases thrombus formation in man. , 2008, European heart journal.

[33]  S L Zeger,et al.  Exposure measurement error in time-series studies of air pollution: concepts and consequences. , 2000, Environmental health perspectives.

[34]  T. Wong,et al.  Effects of air pollution on asthma hospitalization rates in different age groups in Hong Kong , 2007, Clinical and experimental allergy : journal of the British Society for Allergy and Clinical Immunology.

[35]  Nobhojit Roy,et al.  Global, regional, and national disability-adjusted life years (DALYs) for 306 diseases and injuries and healthy life expectancy (HALE) for 188 countries, 1990–2013: quantifying the epidemiological transition , 2015, The Lancet.

[36]  Yuming Guo,et al.  Particulate Matter and Hospital Admissions for Stroke in Beijing, China: Modification Effects by Ambient Temperature , 2016, Journal of the American Heart Association.

[37]  Bernadette A. Thomas,et al.  Global, regional, and national age–sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013 , 2015, The Lancet.

[38]  Thomas Sandström,et al.  Persistent endothelial dysfunction in humans after diesel exhaust inhalation. , 2007, American journal of respiratory and critical care medicine.

[39]  Atte Meretoja,et al.  Update on the Global Burden of Ischemic and Hemorrhagic Stroke in 1990-2013: The GBD 2013 Study , 2015, Neuroepidemiology.

[40]  D. Christiani,et al.  Effects of air pollutants on acute stroke mortality. , 2002, Environmental health perspectives.

[41]  Shilu Tong,et al.  Ambient air pollution, climate change, and population health in China. , 2012, Environment international.

[42]  Liping Liu,et al.  Stroke and stroke care in China: huge burden, significant workload, and a national priority. , 2011, Stroke.

[43]  Dong Zhao,et al.  Relationship between fine particulate air pollution and ischaemic heart disease morbidity and mortality , 2014, Heart.

[44]  Joel Schwartz,et al.  Ambient air pollution and the risk of acute ischemic stroke. , 2012, Archives of internal medicine.

[45]  Fei Wang,et al.  Control Costs, Enhance Quality, and Increase Revenue in Three Top General Public Hospitals in Beijing, China , 2013, PloS one.

[46]  Yong Jiang,et al.  Prevalence, Incidence, and Mortality of Stroke in China: Results from a Nationwide Population-Based Survey of 480 687 Adults , 2017, Circulation.

[47]  Massimo Franchini,et al.  Thrombogenicity and cardiovascular effects of ambient air pollution. , 2011, Blood.

[48]  Xiping Xu,et al.  Efficacy of folic acid supplementation in stroke prevention: a meta-analysis , 2007, The Lancet.

[49]  S. Rozelle,et al.  New evidence on the impact of China’s New Rural Cooperative Medical Scheme and its implications for rural primary healthcare: multivariate difference-in-difference analysis , 2010, BMJ : British Medical Journal.