Short term effects of air pollution on hospitalizations for cardiovascular diseases in eight French cities: The PSAS program
Introduction
Many epidemiological studies, mainly time-series studies, offer reliable results relating air pollution to both total and cardio-respiratory mortality. However, morbidity data stored in the medical information systems existing in many countries thus offer an interesting possibility to study a part of these non-lethal effects.
Hospitalizations for respiratory diseases have been widely used as an outcome in time-series studies because of the direct effect of air pollutants on epithelial cells of the respiratory tract, and numerous studies showed significant relationships with air pollutants levels (Pope et al., 1991). However, during acute air pollution episodes in London (1952) and Germany (1985), a significant part of the observed mortality excess was due to cardiovascular diseases (Wichmann et al., 1989). Results from toxicological studies have indeed produced indications concerning the pathways linking exposure to air pollutants with effects on the cardiovascular system which seem to involve oxidative stress, inflammation responses and cardiac autonomic function (Brook et al., 2004).
Time-series studies using hospitalizations for cardiovascular diseases as an outcome have produced results consistent with these observations. A large number of these studies found significant positive relationships between air pollutants levels and relative risks of hospitalizations for all cardiovascular diseases (Zanobetti et al., 2000, Wong et al., 2002, von Klot et al., 2005, Sunyer et al., 2003, Prescott et al., 1998, Morris, 2001, Ballester et al., 2006, Atkinson et al., 1999), and for more specific causes such as heart diseases (Ballester et al., 2006), congestive heart failure (Atkinson et al., 1999, Wellenius et al., 2006, Burnett et al., 1997), myocardial infarction (D'Ippoliti et al., 2003, Zanobetti and Schwartz, 2005) or stroke (Tsai et al., 2003). The relationships between air pollution and admissions for cardiovascular diseases seem to be higher among elderly than in general population (Sunyer et al., 2003, Prescott et al., 1998, D'Ippoliti et al., 2003, Morgan et al., 1998). These links have been observed for both particulate matter (Morgan et al., 1998, Morris et al., 1995) and gaseous air pollutants (NO2 (Atkinson et al., 1999, Morgan et al., 1998, Morris et al., 1995, Hinwood et al., 2006, Koken et al., 2003), O3 (Koken et al., 2003), and SO2 (Sunyer et al., 2003)). However, concerning ozone, some studies did not found any significant link with cardiovascular hospitalizations (Atkinson et al., 1999, Morris et al., 1995, Linn et al., 2000, Burnett et al., 1999, Barnett et al., 2006), or even found a negative relationship (Prescott et al., 1998).
The French national program on air pollution health effects (PSAS), has been studying the short term links between air pollution levels and both mortality and morbidity in 9 French cities since 1997. In a first study, significant relationships were found with mortality (Le Tertre et al., 2002a) and hospitalizations for respiratory diseases in children (Eilstein et al., 2004). The present study aims to analyze the associations between ambient air pollution and hospitalizations for cardiovascular diseases in eight cities participating to this program.
Section snippets
Study population and period
This study was conducted in eight French urban areas, representative of the diversity of geographical situations in France and large enough to generate daily numbers of hospitalizations suitable for the statistical analysis: Bordeaux, Le Havre, Lille, Lyon, Marseille, Paris, Rouen and Toulouse. For each city, a study area including the central city and bordering cities where urbanization and background air pollutants levels were similar was defined. Local air quality expert's advices were taken
Results
In the 8 French cities considered in this study, the daily mean number of hospitalizations for cardiovascular diseases ranged from 4 in Le Havre, the smallest city to 92 in Paris, the biggest city (Table 2).
The daily number of hospitalizations varied according to the size of the city but also to the proportion of people 65 years and over, which represented more than half of the hospitalizations in every city whereas they represented between 12 and 19% of their population.
Mean levels of air
Discussion
Although relationships between air pollution and cardiovascular hospitalizations have been largely explored over the past decade, this study is one of the few multicentric programs performed in this view. It was conducted in eight cities representative of the geographic and climatic diversity of France, and of its various air pollution levels and sources. Hospitalizations and air pollution data were obtained using standardized procedures. The results showed that the daily number of
Acknowledgments
The authors acknowledge the contributions of the local air quality monitoring networks in the 8 cities, and the departments of medical information of the hospitals that agreed to take part in this study.
What this paper adds
This study adds knowledge in the field of short term relationship between air pollution and cardiovascular morbidity. It is one of the few multicentric programs performed in this view, and it was conducted in eight cities representative from the geographic and climatic
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