The link between PM2.5 exposure and adverse health outcomes is well documented from studies across the world. However, the reported effect estimates vary across studies, locations and constituents. ...We aimed to conduct a meta-analysis on associations between short-term exposure to PM2.5 constituents and mortality using city-specific estimates, and explore factors that may explain some of the observed heterogeneity.
We systematically reviewed epidemiological studies on particle constituents and mortality using PubMed and Web of Science databases up to July 2015.We included studies that examined the association between short-term exposure to PM2.5 constituents and all-cause, cardiovascular, and respiratory mortality, in the general adult population. Each study was summarized based on pre-specified study key parameters (e.g., location, time period, population, diagnostic classification standard), and we evaluated the risk of bias using the Office of Health Assessment and Translation (OHAT) Method for each included study. We extracted city-specific mortality risk estimates for each constituent and cause of mortality. For multi-city studies, we requested the city-specific risk estimates from the authors unless reported in the article. We performed random effects meta-analyses using city-specific estimates, and examined whether the effects vary across regions and city characteristics (PM2.5 concentration levels, air temperature, elevation, vegetation, size of elderly population, population density, and baseline mortality).
We found a 0.89% (95% CI: 0.68, 1.10%) increase in all-cause, a 0.80% (95% CI: 0.41, 1.20%) increase in cardiovascular, and a 1.10% (95% CI: 0.59, 1.62%) increase in respiratory mortality per 10μg/m3 increase in PM2.5. Accounting for the downward bias induced by studies of single days, the all-cause mortality estimate increased to 1.01% (95% CI: 0.81, 1.20%). We found significant associations between mortality and several PM2.5 constituents. The most consistent and stronger associations were observed for elemental carbon (EC) and potassium (K). For most of the constituents, we observed high variability of effect estimates across cities.
Our meta-analysis suggests that (a) combustion elements such as EC and K have a stronger association with mortality, (b) single lag studies underestimate effects, and (c) estimates of PM2.5 and constituents differ across regions. Accounting for PM mass in constituent's health models may lead to more stable and comparable effect estimates across different studies.
PROSPERO: CRD42017055765.
•A meta-analysis of acute effects of PM2.5 constituents on mortality was conducted.•EC and K had the strongest and most consistent association with mortality.•Single lag studies underestimate effects.•Mortality effects of PM2.5 and constituents differ across regions.
Between March and April 2020, Cyprus and Greece health authorities enforced three escalated levels of public health interventions to control the COVID-19 pandemic. We quantified compliance of 108 ...asthmatic schoolchildren (53 from Cyprus, 55 from Greece, mean age 9.7 years) from both countries to intervention levels, using wearable sensors to continuously track personal location and physical activity. Changes in 'fraction time spent at home' and 'total steps/day' were assessed with a mixed-effects model adjusting for confounders. We observed significant mean increases in 'fraction time spent at home' in Cyprus and Greece, during each intervention level by 41.4% and 14.3% (level 1), 48.7% and 23.1% (level 2) and 45.2% and 32.0% (level 3), respectively. Physical activity in Cyprus and Greece demonstrated significant mean decreases by - 2,531 and - 1,191 (level 1), - 3,638 and - 2,337 (level 2) and - 3,644 and - 1,961 (level 3) total steps/day, respectively. Significant independent effects of weekends and age were found on 'fraction time spent at home'. Similarly, weekends, age, humidity and gender had an independent effect on physical activity. We suggest that wearable technology provides objective, continuous, real-time location and activity data making possible to inform in a timely manner public health officials on compliance to various tiers of public health interventions during a pandemic.
The health burden from exposure to air pollution has been studied in many parts of the world. However, there is limited research on the health effects of air quality in arid areas where sand dust is ...the primary particulate pollution source.
Study the risk of mortality from exposure to poor air quality days in Kuwait.
We conducted a time-series analysis using daily visibility as a measure of particulate pollution and non-accidental total mortality from January 2000 through December 2016. A generalized additive Poisson model was used adjusting for time trends, day of week, and temperature. Low visibility (yes/no), defined as visibility lower than the 25th percentile, was used as an indicator of poor air quality days. Dust storm events were also examined. Finally, we examined these associations after stratifying by gender, age group, and nationality (Kuwaitis/non-Kuwaitis).
There were 73,748 deaths from natural causes in Kuwait during the study period. The rate ratio comparing the mortality rate on low visibility days to high visibility days was 1.01 (95% CI: 0.99–1.03). Similar estimates were observed for dust storms (1.02, 95% CI: 1.00–1.04). Higher and statistically significant estimates were observed among non-Kuwaiti men and non-Kuwaiti adolescents and adults.
We observed a higher risk of mortality during days with poor air quality in Kuwait from 2000 through 2016.
•The health effects of air quality in arid areas are not well studied.•Studied the acute effect of poor air quality and dust storms on mortality in Kuwait•Time-series analysis using 2000-16 daily visibility and all nonaccidental mortality•People are in higher risk of dying during days with poor air quality in Kuwait.•Non-Kuwaiti people especially men and adults are in higher risk.
There is growing concern about the accuracy of trace elemental analysis of ambient particulate matter (PM) samples. This has become important because ambient PM concentrations have decreased over the ...years, and the lower filter loadings result in difficulties in accurate analysis. The performance of energy-dispersive X-ray reflectance spectrometry was evaluated at Harvard School of Public Health using several methodologies, including intercomparison between two other laboratories. In reanalysis of standard films as unknown samples following calibration, the HSPH ED XRF measurements represented good performance: 2% errors in precision and 4% errors in accuracy. Replicate analysis of ambient air filters with low PM2.5 levels indicated that S, K, Fe, and Ca showed excellent reproducibility, most other quantifiable elements were below 15% error, and the elements with larger percent of flagged measurements had less in precision. Results from the interlaboratory comparison demonstrated that most quantifiable elements, except Na and Al, were quite comparable for the three laboratories. Na performance could be validated from the stoichiometry of Na to Cl of indoor PM2.5 filter samples.
Desert dust events in Mediterranean countries, originating mostly from the Sahara and Arabian deserts, have been linked to climate change and are associated with significant increase in mortality and ...hospital admissions from respiratory causes. The MEDEA clinical intervention study in children with asthma is funded by EU LIFE+ program to evaluate the efficacy of recommendations aiming to reduce exposure to desert dust and related health effects.
This paper describes the design, methods, and challenges of the MEDEA childhood asthma study, which is performed in two highly exposed regions of the Eastern Mediterranean: Cyprus and Greece-Crete. Eligible children are recruited using screening surveys performed at primary schools and are randomized to three parallel intervention groups: a) no intervention for desert dust events, b) interventions for outdoor exposure reduction, and c) interventions for both outdoor and indoor exposure reduction. At baseline visits, participants are enrolled on MEDena® Health-Hub, which communicates, alerts and provides exposure reduction recommendations in anticipation of desert dust events. MEDEA employs novel environmental epidemiology and telemedicine methods including wearable GPS, actigraphy, health parameters sensors as well as indoor and outdoor air pollution samplers to assess study participants' compliance to recommendations, air pollutant exposures in homes and schools, and disease related clinical outcomes.
The MEDEA study evaluates, for the first time, interventions aiming to reduce desert dust exposure and implement novel telemedicine methods in assessing clinical outcomes and personal compliance to recommendations. In Cyprus and Crete, during the first study period (February-May 2019), a total of 91 children participated in the trial while for the second study period (February-May 2020), another 120 children completed data collection. Recruitment for the third study period (February-May 2021) is underway. In this paper, we also present the unique challenges faced during the implementation of novel methodologies to reduce air pollution exposure in children. Engagement of families of asthmatic children, schools and local communities, is critical. Successful study completion will provide the knowledge for informed decision-making both at national and international level for mitigating the health effects of desert dust events in South-Eastern Europe.
ClinicalTrials.gov: NCT03503812 , April 20, 2018.
Background
This study investigated cause-specific mortality rates in 12 countries during the COVID-19 pandemic in 2020 and 2021.
Methods
We collected weekly cause-specific mortality data from ...respiratory disease, pneumonia, cardiovascular disease (CVD) and cancer from national vital statistic databases. We calculated excess mortality for respiratory disease (excluding COVID-19 codes), pneumonia, and CVD in 2020 and 2021 by comparing observed weekly against expected mortality based on historical data (2015–2019), accounting for seasonal trends. We used multilevel regression models to investigate the association between country-level pandemic-related variables and cause-specific mortality.
Results
Significant reductions in cumulative mortality from respiratory disease and pneumonia were observed in 2020 and/or 2021, except for Georgia, Northern Ireland, Kazakhstan, and Ukraine, which exhibited excess mortality for one or both causes. Australia, Austria, Cyprus, Georgia, and Northern Ireland experienced excess cumulative CVD mortality in 2020 and/or 2021. Australia, Austria, Brazil, Cyprus, Georgia, Northern Ireland, Scotland and Slovenia, experienced increased crude cumulative cancer mortality during 2020 and/or 2021 compared to previous years. Among pandemic-related variables, reported COVID-19 incidence was negatively associated with increased cancer mortality, excess respiratory, (2020) and pneumonia (2021) mortality, and positively associated with respiratory and CVD mortality (2021). Stringency of control measures were negatively associated with excess respiratory disease, CVD, and increased cancer mortality (2021).
Conclusions
This study provides evidence of substantial excess mortality from CVD, and notable reductions in respiratory disease and pneumonia in both years across most countries investigated. Our study also highlights the beneficial impact of stringent control measures in mitigating excess mortality from most causes in 2021.
Abstract Exposure to extreme temperatures can trigger a cascade of adverse cardiovascular and respiratory events. However, in Cyprus, a hotspot of climate change in the Eastern Mediterranean region, ...little is known about the temperature-related cardiorespiratory morbidity risks. We analyzed daily counts of hospital admissions for cardiovascular and respiratory diseases from four general hospitals in three districts in Cyprus from 2000 through 2019. For each district, we fitted time-series quasi-Poisson regression with distributed lag non-linear models to analyze the associations between daily mean temperature (lag 0–21 d) and hospital admissions for cardiorespiratory, cardiovascular, and respiratory diseases. A random-effects meta-analytical model was then applied to pool the district-specific estimates and obtain the national average associations. We analyzed 20 years of cause-specific hospitalization data with a total of 179 988 cardiovascular and respiratory events. The relationships between cardiorespiratory morbidity and temperature were overall U-shaped. During extreme temperature days, 15.85% (95% empirical CI eCI: 8.24, 22.40%) excess cardiovascular hospitalizations and 9.59% (95% eCI: −0.66, 18.69%) excess respiratory hospitalizations were attributable to extreme cold days (below the 2.5th percentile). Extreme hot days (above the 97.5th percentile) accounted for 0.17% (95% eCI: 0.03, 0.29%) excess cardiovascular hospitalizations and 0.23% (95% eCI: 0.07, 0.35%) excess respiratory hospitalizations. We found evidence of increased cardiovascular morbidity risk associated with extreme temperatures in Cyprus. Our study highlights the necessity to implement public health interventions and adaptive measures to mitigate the related temperature effects in an understudied region.
Polycyclic Aromatic Hydrocarbons (PAHs) are one of the most hazardous substances in the environment. Although their occurrence and fate in the atmosphere of Eastern Mediterranean is well documented, ...there is limited information on PAH levels in the inhalable aerosol fraction. Additionally, to the best of our knowledge, there is lack of information on particulate matter with aerodynamic diameter equal or less than 2.5 and 10 μm (PM2.5/PM10)-bound PAH concentrations and sources in Cyprus. We therefore present the first study that i) determines the concentration levels of PAHs in the respirable and inhalable (PM2.5 and PM10) fraction of particulate matter; ii) identifies, quantifies, and compares PAH emission sources by applying two receptor models (Principal Components Analysis/Multiple Linear Regression Analysis, PCA/MLR; and UNMIX factorization), and iii) assesses their relative toxicity at two different coastal sites in Eastern Mediterranean (Island of Crete, Greece; and Cyprus). For this purpose, a total of 79 samples were collected in Heraklion (Island of Crete) and Limassol (Cyprus) during a 2-year sampling campaign between 2012 and 2014. Thirty five PAH members were identified and the total concentration (Σ35PAHs) levels in PM2.5 ranged between 0.15 and 9.19 ng/m3 in Heraklion; 0.12 and 3.91 ng/m3 (PM2.5), and 0.16 and 4.02 ng/m3 (PM10) in Limassol. PAH concentrations were the highest when air masses were passing over highly polluted areas, such as the eastern Balkan Peninsula/Adriatic Sea and northern Greece. The most abundant members at both sites were Benzobfluoranthene (7–16%), Benzoepyrene (8–11%), Indeno1,2,3-cdpyrene (10–18%) and Benzoghiperylene (9–21%); as well as Anthranene (5–6%) and Coronene (9–11%) in Limassol. The major PAH emission sources obtained from the application of PCA/MLRA were gasoline and diesel/coal combustion sources, accounting for almost 60% and 40% of total contribution in Heraklion, while in Limassol both sources contributed nearly equally (51% and 49%, respectively). Similar findings were obtained using the UNMIX model. The lifetime incremental cancer risk (ILCR) due to both inhalation and ingestion exposure from particulate PAHs was well below the U.S. EPA regulatory threshold in both study areas.
•The most abundant PAH members in Crete-Greece and Cyprus were BbF,BeP,IP, and BghiP.•Gasoline and diesel/coal combustion were the main sources of PAHs at both sites.•PAH levels reached max when air masses were passing over highly polluted countries.•The most important contributors to cancer burden were BaP (∼50%), BbF, DBA, and IP.
In many regions of the world, the relationship between ambient temperature and mortality is well-documented, but little is known about Cyprus, a Mediterranean island country where climate change is ...progressing faster than the global average. We Examined the association between daily ambient temperature and all-cause mortality risk in Cyprus. We conducted a time-series analysis with quasipoisson distribution and distributed lag non-linear models to investigate the association between temperature and all-cause mortality from 1 January 2004 to 31 December 2019 in five districts in Cyprus. We then performed a meta-analysis to estimate the overall temperature-mortality dose-response relationship in Cyprus. Excess mortality was computed to determine the public health burden caused by extreme temperatures. We did not find evidence of heterogeneity between the five districts (p = 0.47). The pooled results show that for cold effects, comparing the 1st, 2.5th, and 5th percentiles to the optimal temperature (temperature associated with least mortality, 25 ℃), the overall relative risks of mortality were 1.55 (95% CI: 1.32, 1.82), 1.41 (95% CI: 1.21, 1.64), and 1.32 (95% CI: 1.15, 1.52), respectively. For heat effects, the overall relative risks of mortality at the 95
th
, 97.5th and 99th percentiles were 1.10 (95% CI: 1.04, 1.16), 1.17 (95% CI: 1.07, 1.29), and 1.29 (95% CI: 1.11, 1.5), respectively. The excess mortality attributable to cold days accounted for 8.0 deaths (95% empirical CI: 4.5-10.8) for every 100 deaths, while the excess mortality attributable to heat days accounted for 1.3 deaths (95% empirical CI: 0.7-1.7) for every 100 deaths. The results prompt additional research into environmental risk prevention in this under-studied hot and dry region that could experience disproportionate climate change related exposures.
Implications: The quantification of excess mortality attributable to temperature extremes shows an urgent need for targeted public health interventions and climate adaptation strategies in Cyprus and similar regions facing rapid climate change. Future steps should look into subpopulation sensitivity, coping strategies, and adaptive interventions to reduce potential future risks.
Middle Eastern desert countries like Kuwait are known for intense dust storms and enormous petrochemical industries affecting ambient air pollution. However, local health authorities have not been ...able to assess the health impacts of air pollution due to limited monitoring networks and a lack of historical exposure data.
To assess the burden of PM
on mortality in the understudied dusty environment of Kuwait.
We analyzed the acute impact of fine particulate matter (PM
) on daily mortality in Kuwait between 2001 and 2016. To do so, we used spatiotemporally resolved estimates of PM
in the region. Our analysis explored factors such as cause of death, sex, age, and nationality. We fitted quasi-Poisson time-series regression for lagged PM
adjusted for time trend, seasonality, day of the week, temperature, and relative humidity.
There was a total of 70,321 deaths during the study period of 16 years. The average urban PM
was estimated to be 46.2 ± 19.8 µg/m
. A 10 µg/m
increase in a 3-day moving average of urban PM
was associated with 1.19% (95% CI: 0.59, 1.80%) increase in all-cause mortality. For a 10 µg/m
reduction in annual PM
concentrations, a total of 52.3 (95% CI: 25.7, 79.1) deaths each year could be averted in Kuwait. That is, 28.6 (95% CI: 10.3, 47.0) Kuwaitis, 23.9 (95% CI: 6.4, 41.5) non-Kuwaitis, 9.4 (95% CI: 1.2, 17.8) children, and 20.9 (95% CI: 4.3, 37.6) elderly deaths each year.
The overwhelming prevalence of devastating dust storms and enormous petrochemical industries in the Gulf and the Middle East has intensified the urgency to address air pollution and its detrimental health effects. Alarmingly, the region's epidemiological research lags behind, hindered by a paucity of ground monitoring networks and historical exposure data. In response, we are harnessing the power of big data to generate predictive models of air pollution across time and space, providing crucial insights into the mortality burden associated with air pollution in this under-researched yet critically impacted area.
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