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Rationale: The strength of the association between outdoor air pollution and hospital admissions in children has not yet been well
defined. Objectives: To estimate the impact of outdoor air pollution
on respiratory morbidity in children after controlling for the confounding effects of weather, season, and other pollutants. Methods:
The study used data on respiratory hospital admissions in children
(three age groups: 1, 14, and 514 years) for five cities in Australia
and two in New Zealand. Time series of daily numbers of hospital
admissions were analyzed using the case-crossover method; the
results from cities were combined using a random-effects metaanalysis. Measurements and Main Results: Significant increases across
the cities were observed for hospital admissions in children for
pneumonia and acute bronchitis (0, 14 years), respiratory disease
(0, 14, 514 years), and asthma (514 years). These increases were
found for particulate matter with a diameter less than 2.5 m (PM2.5)
and less than 10 m (PM10), nephelometry, NO2, and SO2. The
largest association found was a 6.0% increase in asthma admissions
(514 years) in relation to a 5.1-ppb increase in 24-hour NO2. Conclusions: This study found strong and consistent associations between
outdoor air pollution and short-term increases in childhood hospital
admissions. A number of different pollutants showed significant
associations, and these were distinct from any temperature (warm
or cool) effects.
Keywords: air pollutants; Australasia; meta-analysis; respiration disorders
Many studies have found associations between selected air pollutants and adverse health effects in children (1). These adverse
health effects include the following: childhood hospital admissions (26), school absences (7), physician visits for upper and
lower respiratory illness (8), deficits in lung function growth
rates (9), bronchitis and chronic cough (10, 11), and increased
infant mortality (1214). A recent review in Europe strongly
recommended a reduction in childrens exposure to air pollution
(15). However, the strength of the association is still not well
defined because of the small number of studies of hospital admissions (which represent a common and serious outcome in children), and the complexity of the time-series modeling. In addition, there are few studies that have been able to examine a range
of pollutants. When multiple pollutants have been examined,
(Received in original form November 25, 2004; accepted in final form March 9, 2005)
Supported by the Environment Protection and Heritage Council, and partly supported by the National Health and Medical Research Council of Australia (grant
252834).
Correspondence and requests for reprints should be addressed to Rod W. Simpson,
Ph.D., Dean and Chair in Environmental Science, Faculty of Science, Health and
Education, University of the Sunshine Coast, Maroochydore DC, QLD 4558, Australia. E-mail: rsimpson@usc.edu.au
This article has an online supplement, which is accessible from this issues table
of contents at www.atsjournals.org
Am J Respir Crit Care Med Vol 171. pp 12721278, 2005
Originally Published in Press as DOI: 10.1164/rccm.200411-1586OC on March 11, 2005
Internet address: www.atsjournals.org
METHODS
Respiratory Health Data and Air Pollutant Data
Daily hospital and pollution data were collected for the period 1998
2001 in five of the largest cities in Australia (Brisbane, Canberra,
Melbourne, Perth, and Sydney) and the two largest cities in New
Zealand (Auckland, Christchurch). In 2001, these cities comprised 53%
of the Australian population and 44% of the New Zealand population.
Health data for all respiratory admissions of children aged 14 years
or younger were collected from state government health departments
in Australia and the New Zealand Health Information Service (Ministry
of Health), and details, including International Classification of Disease
codes, are provided in the online supplement.
The air pollutants considered were particulate matter less than 2.5 m
in diameter (PM2.5; g m3) and less than 10 m in diameter (PM10;
g m3), coefficient of light-scattering by nephelometry (an indicator
of fine particles 0.12 m in diameter [bsp]; in 104 m1), nitrogen
dioxide (NO2; in ppb), carbon monoxide (CO; in ppm), sulfur dioxide
(SO2; in ppb), and ozone (O3; in ppb). Additional information on how
these pollutants were measured is provided in the online supplement.
Statistical Methods
The case-crossover method controlled for long-term trend, seasonal
changes, and respiratory epidemics by design. Matched case-crossover
1273
RESULTS
Summary statistics of hospital admissions and demographic data
for each city are given in Table 1. Summary statistics of the air
pollutant and meteorology data in each city are given in Table 2.
Pollutant exposures used were the average of the current and
previous day. Estimates of the percentage increase in morbidity
are shown for an interquartile range increase (using the mean
interquartile range across cities). This made the increases from
different pollutants more comparable because the results showed
the changes to be expected for the cities under study, and allowed
the largest impacts to be identified.
The statistically significant increases in hospital admissions
for all cities are shown in Table 3, together with the estimated
differences (heterogeneity) between cities and the leave-onecity-out sensitivity analyses (see online Tables E1E3 for a com-
The I-squared statistic represents the proportion of total variation in the estimated increase that is caused by heterogeneity
between cities and was used to identify any differences between
cities. This measure allowed the estimation of the average effect
of an air pollutant on hospital admissions using all the data, and
to identify if this effect is the same across all cities (positive or
negative) or whether the results for some cities are different
from others. In this way, we can conclude whether any identified
impact is the same for all cities or whether there are different
results arising from factors not identified in the analyses. The
I-squared statistic was generally very low, except for NO2 (Table
3), where all seven cities were available for analysis. The contrasting increases between cities are apparent in Figure 1, which
shows three of the significant meta-analysis increases for respiratory admissions (age groups: 0, 14, and 514 years).
To look for differences between countries, separate metaanalyses were run for the Australian and New Zealand cities.
The differences in the associations with NO2 between the five
TABLE 1. SUMMARY STATISTICS FOR DEMOGRAPHIC DATA AND HOSPITAL ADMISSION RATES
PER MILLION POPULATION (19982001)
Auckland
Demographic data
Total population
Median weekly individual income, $*
Population 15 yr, %
Population 65 yr, %
Daily hospital admissions, mean (range)
Respiratory
0 yr
14 yr
514 yr
Asthma
14 yr
514 yr
Pneumonia acute bronchitis
0 yr
14 yr
* Australian dollars.
Brisbane
316,224
300399
19.3
13.7
Perth
Sydney
4.6
(029)
4.7
(019)
2.1
(011)
2.1
(09)
4.2
(012)
2.1
(09)
1.9
(023)
4.8
(023)
3.9
(032)
4.7
(029)
7.9
(035)
3.2
(022)
1.4
(06)
3.1
(09)
1.6
(07)
2.4
(016)
4.7
(013)
2.2
(010)
2.2
(010)
4.5
(113)
2.1
(09)
1.6
(08)
1.0
(07)
1.7
(07)
1.3
(07)
1.3
(013)
1.0
(016)
2.2
(019)
1.3
(013)
1.3
(06)
0.9
(07)
1.9
(08)
1.3
(07)
1.9
(010)
1.2
(08)
3.6
(025)
1.9
(013)
1.4
(07)
1.0
(05)
1.3
(019)
1.3
(016)
2.8
(029)
1.6
(016)
0.9
(06)
0.6
(03)
1.3
(014)
0.9
(07)
1.2
(08)
1.0
(05)
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TABLE 2. SUMMARY STATISTICS FOR DAILY AIR POLLUTANT AND WEATHER DATA (19982001)
Auckland
Daily pollutant levels, mean (range)
24-h PM2.5, g m3
No. monitors
24-h PM10, g m3
No. monitors
24-h bsp, 104 m1
No. monitors
1-h NO2, ppb
24-h NO2, ppb
No. monitors
8-h CO, ppb
No. monitors
1-h SO2, ppb
24-h SO2, ppb
No. monitors
1-h O3, ppb
4-h O3, ppb
8-h O3, ppb
No. monitors
Weather, mean (range)
Temperature, C
Relative humidity, %
Brisbane
11.0*
9.7
(2.137.6) (3.2122.8)
1
1
18.8*
16.5
(3.2101.4) (3.850.2)
6
4
0.2
(01.7)
0
4
19.1
17.3
(4.286.3)
(444.1)
10.2
7.6
(1.728.9) (1.419.1)
2
7
2.1
1.7
(0.27.9)
(07)
3
1
7.6
(046.5)
4.3
1.8
(024.3)
(08.2)
1
2
23.9
31.5
(8.844.2)
(792.3)
22.9
28.9
(8.242.7) (5.475.2)
21.6
25.5
(7.440.1) (3.758.4)
2
7
0
20.6
(1.3156.3)
2
0
0.3
(02.1)
1
17.9
(053.7)
7.0
(022.5)
1
0.9
(05.8)
1
0
23.7
(075.3)
22.1
(062.8)
19.5
(057.7)
1
15.7
20.0
13.7
(6.324.1) (9.530.4)
(128)
79.1
72.4
69.9
(52.1100) (29.396.3) (24.197)
Perth
Sydney
8.1
9.4
(1.729.3) (2.482.1)
2
3
16.5
16.6
(4.468.9) (3.7104.7)
1
11
0.2
0.3
(0.11.6)
(03.4)
5
9
21.3
22.6
(4.448)
(5.251.4)
9.0
11.5
(223.3)
(2.524.5)
5
13
1.0
0.8
(0.14)
(04.5)
3
4
3.7
(0.120.2)
0.9
(03.9)
0
0
6
23.8
33.6
31.7
(1.785.4)
(1385)
(3.2126.7)
21.8
31.3
28.9
(1.373.1) (10.672.8) (2.2105.1)
19.0
28.5
24.9
(0.863)
(864)
(1.486.8)
8
3
12
11.6
(027.2)
75.9
(3199)
15.3
18.2
17.8
(5.931.8) (8.232.3) (8.530.1)
68.7
67.8
70.6
(25.195.5) (2898.5) (26.397.1)
0
15.7
(1.254.6)
7.1
(0.224.5)
1
0.5
(05.4)
2
10.1
(0.142.1)
2.8
(011.9)
2
8.9
(2.843.3)
2
16.6
(3.171.1)
4
0.3
(03.6)
7
23.2
(4.462.5)
11.7
(229.5)
8
1.0
(0.18)
3
Definition of abbreviation: bsp an indicator of fine particles 0.12 m in diameter; PM2.5 particle matter less than 2.5 m
in diameter; PM10 particle matter less than 10 m in diameter.
* Tapered Element Oscillating Microbalance (TEOM) data were not available for Auckland in the study period. PM data in
Auckland were recorded once every 6 days (Hi-Vol); this was not suitable for the case-crossover analysis.
Australian cities and the two New Zealand cities are shown in
Table 5. The increases are quite different, but clearly not all of
the heterogeneity between the increases for all the cities is caused
by the difference in countries.
Multiple pollutant models showed that the results for NO2
were often independent of the effects of other pollutants, although some impacts caused by particles and SO2 could not be
separated from those found for NO2.
Differences by Season
Effect Modification
DISCUSSION
This study has shown statistically significant relationships between outdoor air pollution and child health in Australia and
1275
Cities
Pollutant (units)
Increase %*
(95% CI)
I-squared
(% )
Range in
Increases (% )
1.7
2.1
2.4
6.9
(0.0,
(0.3,
(0.1,
(2.3,
3.4)
3.9)
4.7)
11.7)
0
0
16.3
0
1.1
1.8
0.9
5.6
P, S
P, S
2.4
2.5
3.2
1.7
1.7
2.2
2.8
2.7
1.9
4.7
5.8
(1.0,
(1.1,
(0.3,
(0.7,
(0.5,
(1.2,
(0.7,
(0.6,
(0.1,
(1.6,
(1.7,
3.8)
4.0)
6.3)
2.7)
2.9)
3.2)
4.9)
4.8)
3.8)
7.9)
10.1)
0
0
0
0
0
0
46.9
0
0
52.0
54.0
2.0
2.2
3.0
1.3
1.4
1.9
2.1
1.9
1.4
3.8
4.5
P, S
61.9
P, S
Definition of abbreviations: A Auckland; B Brisbane; bsp an indicator of fine particles 0.12 m in diameter; Ca
Canberra; Ch Christchurch; CI confidence interval; M Melbourne; P Perth; PM2.5 particle matter less than 2.5 m
in diameter; PM10 particle matter less than 10 m in diameter; S Sydney.
* Percentage increase in admissions for an interquartile range increase in pollutant using the average over the current and
previous day.
I-squared is the percentage of total variation in the estimated increase that is due to heterogeneity between cities.
Minimum and maximum increases using a leave-one-city-out sensitivity analysis; the city in parentheses was the city left out.
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TABLE 4. MULTIPOLLUTANT MODELS: STATISTICALLY SIGNIFICANT INCREASES IN HOSPITAL
ADMISSIONS IN CHILDREN AND INCREASES AFTER MATCHING FOR OTHER EXPOSURES
(INCREASE IN EVENTS AND 95% CONFIDENCE INTERVALS)
Outcome
Pneumonia and bronchitis, 14 yr
Respiratory
0 yr
14 yr
514 yr
Single
Pollutant
Increase %*
(95% CI)
Matched
Exposure
24-h PM2.5
1-h SO2
1-h SO2
Temperature
24-h PM2.5
Temperature
24-h PM2.5
1-h SO2
24-h PM2.5
24-h PM10
1-h SO2
1-h NO2
24-h PM10
24-h NO2
1-h SO2
Temperature
24-h PM2.5
Temperature
24-h PM10
1-h SO2
1-h NO2
Temperature
24-h PM2.5
1-h SO2
1-h NO2
Temperature
24-h PM2.5
24-h PM10
1-h NO2
Temperature
24-h PM2.5
24-h PM10
1-h SO2
Temperature
24-h NO2
Temperature
24-h PM10
Temperature
Increase %*
(95% CI)
1.9
2.3
4.7
7.1
(1.7, 5.6)
(0.4, 5.1)
(1.4, 11.1)
(2.1, 12.5)
Cities Included in
Match
B,
B,
B,
B,
S
M, P, S
S
Ch, S
B, S
B, M, P, S
B, S
B, Ch, S
B, M, P, S
B, S
B, M, P, S
B, M, P, S
B, M, P, S
B, Ch, S
B, Ch, M, P,
B, Ch, M, P,
B, S
B, Ch, S
B, Ch, S
B, Ch, S
B, M, P, S
B, Ch, M, P,
B, Ch, S
All
B, Ch, M, P,
B, Ch, M, P,
B, Ch, M, P,
B, Ch, M, P,
S
S
S
S
S
S
the number of cities involved for this pollutant was always larger
than the others). Figure 1 shows that the four largest Australian
cities (Brisbane, Melbourne, Perth, and Sydney) usually showed
different results to the New Zealand cities and Canberra (the
coldest Australian city). The only significant effect modification
found was that cities with higher average temperatures had
greater increases in hospital respiratory admissions in the 1- to
4-year age group for increases in 1-hour NO2. The average tem-
Figure 1. Selected statistically significant increases and 95% confidence intervals for hospital respiratory admissions in children, with city-specific
and meta-analysis estimates by age group. (A ) Age group 12 months: 24-hour average PM2.5 (average lag, 01); (B ) age group 14 years:
1-hour maximum NO2 (average lag, 01); and (C ) age group 514 years: 1-hour maximum NO2 (average lag, 01).
1277
Pollutant
All Cities
Increase %*
(95% CI)
1-h NO2
1-h NO2
24-h NO2
24-h NO2
Australian Cities
Increase %*
(95% CI)
I-squared
(% )
Increase %*
(95% CI)
I-squared
(% )
42.2
46.2
32.6
0.0
68.3
46.1
62.9
0.0
I-squared is the percentage of total variation in the estimated increase that is due to heterogeneity between cities.
14
514
Asthma admissions
514
Pollutant (units)
24-h PM2.5 (g m3)
24-h bsp (104 m1)
24-h PM2.5 (g m3)
1-h SO2 (ppb)
24-h PM2.5 (g m3)
24-h bsp (104 m1)
1-h SO2 (ppb)
24-h PM2.5 (g m3)
24-h PM10 (g m3)
24-h bsp (104 m1)
1-h NO2 (ppb)
1-h SO2 (ppb)
1-h O3 (ppb)*
24-h PM10 (g m3)
1-h NO2 (ppb)
24-h NO2 (ppb)
24-h NO2 (ppb)
(0.7,
(0.1,
(0.4,
(0.6,
Warm
I-squared
3.0)
3.7)
4.5)
10.8)
0
0
7.1
0
0
14.0
0
0
0
0
0
0
55.2
0
73.7
66.0
66.8
(0.9, 6.7)
(3.0, 4.5)
(2.8, 8.2)
(0.8, 5.2)
(0.2, 6.0)
(0.5, 3.7)
(1.6, 8.6)
(4.4, 10.6)
(1.8, 5.2)
(2.4, 6.4)
(4.0, 13.3)
(3.3, 16.3)
I-squared
0
0
58.4
0
0
0
0
0
27.5
0
68.3
72.4
9.7
51.1
39.8
37.6
49.2
Definition of abbreviations: bsp an indicator of fine particles 0.12 m in diameter; CI confidence interval; PM2.5 particle
matter less than 2.5 m in diameter; PM10 particle matter less than 10 m in diameter.
* Result not significant for overall (whole season) effect.
Percentage increase in admissions for an interquartile range increase in pollutant using the average over the current and
previous day.
I-squared is the percentage of total variation in the estimated increase that is due to heterogeneity between cities.
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AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL 171 2005
This reduced the power for some comparisons, and means that
comparisons across pollutants are also (to a varying degree)
comparisons across cities.
Conclusions
References
1. Schwartz J. Air pollution and childrens health. Pediatrics 2004;113:1037
1043.
2. Pope CA III. Respiratory hospital admissions associated with PM10 pollution in Utah, Salt Lake, and Cache Valleys. Arch Environ Health 1991;
46:9097.
3. Pope CA III. Respiratory disease associated with community air pollution
and a steel mill, Utah Valley. Am J Public Health 1989;79:623628.
4. Braga A, Conceicao G, Pereira L, Kishi H, Pereira J, Andrade M,
Goncalves F, Saldiva P, Latorre M. Air pollution and pediatric respiratory hospital admissions in Sao Paulo, Brazil. J Environ Med 1999;1:95
102.
5. Chew F, Goh D, Ooi B, Saharom R, Hui J, Lee B. Association of ambient
air-pollution levels with acute asthma exacerbation among children in
Singapore. Allergy 1999;54:320329.
6. Atkinson R, Anderson H, Sunyer J, Ayres J, Baccini M, Vonk J,
Boumghar A, Forastiere F, Forsberg B, Touloumi G, et al. Acute
effects of particulate air pollution on respiratory admissions: results
from APHEA 2 project. Am J Respir Crit Care Med 2001;164:1860
1866.
7. Ransom M, Pope CA III. Elementary school absences and PM10 pollution
in Utah Valley. Environ Res 1992;58:204219.
8. Ostro B, Eskeland G, Sanchez J, Feyzioglu T. Air pollution and health