Association between ambient air pollution and daily hospital admissions for ischemic stroke: A nationwide time-series analysis

Abstract

Background

Evidence of the short-term effects of ambient air pollution on the risk of ischemic stroke in low- and middle-income countries is limited and inconsistent. We aimed to examine the associations between air pollution and daily hospital admissions for ischemic stroke in China.

Methods and findings

We identified hospital admissions for ischemic stroke in 2014–2016 from the national database covering up to 0.28 billion people who received Urban Employee Basic Medical Insurance (UEBMI) in China. We examined the associations between air pollution and daily ischemic stroke admission using a two-stage method. Poisson time-series regression models were firstly fitted to estimate the effects of air pollution in each city. Random-effects meta-analyses were then conducted to combine the estimates. Meta-regression models were applied to explore potential effect modifiers. More than 2 million hospital admissions for ischemic stroke were identified in 172 cities in China. In single-pollutant models, increases of 10 μg/m ³ in particulate matter with aerodynamic diameter <2.5 μm (PM _2.5), sulfur dioxide (SO ₂), nitrogen dioxide (NO ₂), and ozone (O ₃) and 1 mg/m ³ in carbon monoxide (CO) concentrations were associated with 0.34% (95% confidence interval [CI], 0.20%–0.48%), 1.37% (1.05%–1.70%), 1.82% (1.45%–2.19%), 0.01% (−0.14%–0.16%), and 3.24% (2.05%–4.43%) increases in hospital admissions for ischemic stroke on the same day, respectively. SO ₂ and NO ₂ associations remained significant in two-pollutant models, but not PM _2.5 and CO associations. The effect estimates were greater in cities with lower air pollutant levels and higher air temperatures, as well as in elderly subgroups. The main limitation of the present study was the unavailability of data on individual exposure to ambient air pollution.

Conclusions

As the first national study in China to systematically examine the associations between short-term exposure to ambient air pollution and ischemic stroke, our findings indicate that transient increase in air pollution levels may increase the risk of ischemic stroke, which may have significant public health implications for the reduction of ischemic stroke burden in China.

Abstract

Yonghua Hu and colleagues, in a large-scale analysis of 172 cities in China, reveal associations between short-term air pollution exposure and increased incidences of stroke.

Author summary

Why was this study done?

• Epidemiological studies have reported associations between short-term exposure to ambient air pollution and mortality and morbidity from ischemic stroke.

• Previous studies have been primarily conducted in high-income countries, and few research data at the country level have been generated in low- and middle-income countries, despite their much higher air pollution levels.

What did the researchers do and find?

• We conducted a national time-series study using data on more than 2 million hospital admissions for ischemic stroke in 172 cities in China from 2014 to 2016.

• City-specific associations between ambient air pollution and hospital admissions for ischemic stroke were estimated with Poisson time-series regression models. Random-effects meta-analyses were used to obtain national and regional average associations.

• Our results indicated that short-term exposures to PM _2.5, SO ₂, NO ₂, and CO were associated with increased hospital admissions for ischemic stroke. The associations were stronger in the elderly.

What do these findings mean?

• To our knowledge, this is the first national study in China to systematically examine the associations between short-term exposure to ambient air pollution and ischemic stroke.

• Our findings strengthened the rationale for further limiting air pollution levels in low- and middle-income countries.