A 10-year time-series analysis of respiratory and cardiovascular morbidity in Nicosia, Cyprus: the effect of short-term changes in air pollution and dust storms

Nicos Middleton, Panayiotis Yiallouros, Savvas Kleanthous, Ourania Kolokotroni, Joel Schwartz, Douglas W Dockery, Phil Demokritou, Petros Koutrakis, Nicos Middleton, Panayiotis Yiallouros, Savvas Kleanthous, Ourania Kolokotroni, Joel Schwartz, Douglas W Dockery, Phil Demokritou, Petros Koutrakis

Abstract

Background: To date, a substantial body of research has shown adverse health effects of short-term changes in levels of air pollution. Such associations have not been investigated in smaller size cities in the Eastern Mediterranean. A particular feature in the region is dust blown from the Sahara a few times a year resulting in extreme PM10 concentrations. It is not entirely clear whether such natural phenomena pose the same risks.

Methods: The effect of changes in daily levels of particulate matter (PM10) and ozone (O3) on hospitalization for all, cardiovascular and respiratory causes in the two hospitals in Nicosia during 1 January 1995 and 30 December 2004 was investigated using generalized additive Poisson models after controlling for long- and short-term patterns as well as for the effect of weather. Meteorological records were reviewed to identify dust-storm days and analyses were repeated to quantify their effect on cardio-respiratory morbidity.

Results: For every 10 microg/m3 increase in daily average PM10 concentrations, there was a 0.9% (95%CI: 0.6%, 1.2%) increase in all-cause and 1.2% (95%CI: -0.0%, 2.4%) increase in cardiovascular admissions. With respect to respiratory causes, an effect was observed only in the warm months. No lagged effects with levels of PM10 were observed. In contrast, positive associations with levels of ozone were only observed the two days prior to admission. These appeared stronger for cardiovascular causes and independent of the effect of PM. All-cause and cardiovascular admissions were 4.8% (95%CI: 0.7%, 9.0%) and 10.4% (95%CI: -4.7%, 27.9%) higher on dust storm days respectively. In both cases the magnitude of effect was comparable to that seen on the quartile of non-storm days with the highest levels of PM10.

Conclusion: We observed an increased risk of hospitalization at elevated levels of particulate matter and ozone generally consistent with the magnitude seen across several European cities. We also observed an increased risk of hospitalization on dust storm days, particularly for cardiovascular causes. While inference from these associations is limited due to the small number of dust storm days in the study period, it would appear imperative to issue health warnings for these natural events, particularly directed towards vulnerable population groups.

Figures

Figure 1
Figure 1
The effect of short-term changes in ozone concentrations on hospital admissions. Percentage increase (and 95% CI) in all, cardiovascular and respiratory admissions per 10 ppb increase in the daily maximum 8-hour moving average levels of O3 in Nicosia Central the same (lag 0) and two previous days (lags 1 and 2) before (solid squares) and after (empty squares) controlling for levels of PM10 as estimated in models adjusting for long- and short-term patterns as well as the effect of weather.
Figure 2
Figure 2
Seasonal effects of short-term changes in concentrations of air pollutants on hospital admissions. Percentage increase (and 95% CI) in all-cause, cardiovascular and respiratory admissions per 10 μg/m3increase in PM10 or 10 ppb increase in O3 (after adjusting for levels of PM10) by A) cold and warm months as indexed by monthly average temperature and B) cold and warm days as indexed by mean daily temperature lower or higher than 20 or 30° (shown only for PM).
Figure 3
Figure 3
Typical levels of PM10 concentrations during a dust storm. Hourly levels of PM10 concentrations as recorded at Nicosia Central and Ayia Marina stations during A) a suspected dust storm, not confirmed by Meteorological Services records, between 4–6 April 2000, B) a dust storm confirmed by Meteorological Services records between 3–6 April 2003 and C) a confirmed dust storm with the highest recorded levels of PM10 (log-scale) between 29–30 May 2003.
Figure 4
Figure 4
Identification of the likely source of dust storm events. Backwards wind trajectories ending in Nicosia on the day and about the time of the first elevated PM10 concentrations of the four suspected dust storm events.
Figure 5
Figure 5
Hospital admissions on dust storm days as compared to non-storm days. Percentage increase (and 95% CI) in all, cardiovascular and respiratory admissions across quartiles of days with increasing levels of particulate matter (PM10), compared to the quarter of days with the lowest levels, after adjusting for seasonality and the confounding effect of weather. Shown separately, the estimated percentage increase in admissions on dust-storm days (n = 63 all candidate days, 56 confirmed dates irrespective of levels of PM and 45 confirmed dates with the highest levels of PM). Note: scales are not comparable across graphs.

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