The relationship of short-term air pollution and weather to ED visits for asthma in Japan

doi:10.1016/j.ajem.2008.01.013

The American Journal of Emergency Medicine

Volume 27, Issue 2, February 2009, Pages 153-159

https://doi.org/10.1016/j.ajem.2008.01.013 Get rights and content

Abstract

Introduction

The incidence of asthma exacerbation has been increasing in many countries. Environmental factors may play an important role in this trend. We aimed to investigate the relationship of weather conditions and air pollution to significant exacerbation of asthma.

Methods

The daily number of emergency department (ED) visits by ambulance for asthma was collected through records of the Tokyo Fire Department from January 1 to December 31, 2005. We also collected daily air pollution levels and meteorological data for Tokyo during the same period. Meteorological data included minimum temperature, maximum barometric pressure, maximum relative humidity, and precipitation. Measured air pollutants included sulfur dioxide, nitrogen monoxide, nitrogen oxides, suspended particulate matter, and carbon monoxide. We performed a time series analysis using multivariable-adjusted autoregressive integrated moving average model. The analysis was conducted separately among adults and among children (<15 years old).

Results

Of a total of 643 849 patients who were transported to the ED by ambulance, there were 6447 patients with exacerbation of asthma. Among adults, lower minimum temperature was significantly associated with increased transport. Among children, there were no significant associations between exacerbation of asthmas requiring emergency transport and air pollutants or meteorological factors. The highest number of transports was found on October 11, the day after the National Sports Day in Japan.

Conclusions

Cold temperature is related to an increased risk of significant exacerbation of asthma in adults. Air pollution does not seem to play a major role in significant exacerbation of asthma requiring ambulance transports to ED.

Introduction

The prevalence of bronchial asthma and the incidence of asthma exacerbation have been increasing in many countries [1], [2], [3]. Emergency department (ED) visits and hospital admission for asthma have also been increasing [4], [5]. Factors related to exacerbation of asthma include respiratory tract infections, individual idiosyncrasy, exercise, allergen exposure, emotional stress, obesity, food, smoking, and environmental factors [6], [7], [8], [9], [10], [11], [12]. Among these environmental factors, weather conditions and air pollution are suggested to play an important role in the increased trend for exacerbation of asthma [12], [13], [14], [15].

Several studies have indicated positive associations between ED visits for asthma and various weather factors, including low temperature, heavy precipitation, higher barometric pressure, and a rapid decrease from higher to lower barometric pressure [15], [16], [17]. In contrast, other studies have suggested no association between ED visits for asthma and several weather conditions [12], [18].

Several studies have also investigated the relationship between levels of air pollutants and exacerbation of asthma. One study has indicated positive associations between ED visits for asthma and levels of air pollutants, including nitrogen oxides (NO_x), carbon monoxide (CO), and particulate matter with a diameter of 10 μm or less (PM10), among children, but not among adults [13]. Other studies have identified positive associations between ED visits for asthma and levels of ozone [14] and sulfur dioxide (SO₂) [19]. In contrast, another study has suggested a negative correlation between ED visits for asthma and ozone concentrations [15].

Time series analyses have been increasingly used in epidemiological research. Since the early 1970s, time series methods, in particular autoregressive integrated moving average (ARIMA) models, which have the ability to cope with stochastic dependence of consecutive data, have become well established in the commercial and industrial fields [20], [21], [22]. Therefore, in this study, we aimed to investigate the relationship between exacerbation of asthma and weather conditions as well as air pollutants, by controlling the autocorrelations of time series data, based on ARIMA model.

For an available indicator of asthma exacerbation, we used the number of ambulance transports to the ED for exacerbation of asthma in the entire metropolitan area of Tokyo. Daily data for ambulance transports to the ED for asthma were analyzed to capture the frequency of significant exacerbation of asthma because ambulance-transported patients usually have more severe symptoms and are at higher risk of hospital admission or tracheal intubation than ambulatory patients with asthma [23], [24].

Section snippets

Study population

We conducted the study in Tokyo, the capital prefecture of Japan, with a population of approximately 12 million in 2005, a land area of 2187 km², and a temperate climate. As a prefectural institution, the Tokyo Fire Department organizes a 1-tiered system covering the whole prefecture, with basic life support ambulances based at 80 fire stations throughout the prefecture. Although emergency care services are somewhat fragmented between private and public hospitals in the competition for patients

Results

Of a total of 643 849 patients who were transported to hospitals by ambulances in Tokyo during the 1-year study period, there were 6447 patients with exacerbation of asthma (1.0% of all patients). The mean (SD) age of patients with asthma was 49.8 (25.2) years. Of these, 47.2% were women and 52.8% were men; 5666 (87.9%) were adults and 781 (12.1%) were children. There were 2940 (45.6%) patients who were admitted to hospital wards. The mean number of daily ambulance transports to ED for asthma in

Discussion

Based on our time series analysis using large, population-based, and daily data for ambulance transports in one of the mega-cities of the world, lower minimum temperature is a significant factor associated with exacerbation of asthma among adults, as suggested in a previous study [26], [28]. However, other meteorological factors and air pollution levels do not seem related to exacerbation of asthma among adults. No associations between these environmental factors and ambulance transports were

Acknowledgments

The authors thank all emergency technicians, attending physicians, and residents of EDs in Tokyo, Japan. We also thank all staffs in the Tokyo Fire Department, the Japan Meteorological Agency, and the Ministry of the Environment, Government of Japan, for supporting our work.

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Mounting studies have associated asthma with environmental and climatic factors, but their interaction during pregnancy on childhood asthma are unclear. This study aims to investigate the interaction of in utero air pollution and environmental temperature exposure on childhood asthma, to identify key timing windows for exposure. A retrospective cohort study with 2,598 pre-schoolers was conducted during 2011–2012 in Changsha, China. Maternal exposure to three critical ambient air pollutants (PM₁₀, SO₂ and NO₂, as proxies of industrial and vehicular air pollution) and temperature (T), was assessed for the 40 gestational weeks, three trimesters of gestation, and entire pregnancy by an inverse distance weighted (IDW) method. Logistic regression analysis was used to examine the association of childhood asthma with air pollution and temperature exposure. Our results showed that pre-schooler's asthma was significantly associated with SO₂ and NO₂ exposure in utero, ORs = 1.46 (95% CI: 1.12–1.89) and 1.67 (95% CI: 1.24–2.26) by inter quartile range (IQR) increase of their exposure respectively. Significant risk was observed for exposure of SO₂ and NO₂ particularly during the 1st and 2nd trimesters and their specific gestational weeks. Pre-schooler's asthma was related with high temperature exposure during 1st trimester, OR = 2.33 (95% CI: 1.11–4.90) by IQR increase of T exposure. Low T and high T respectively increased the asthma risk of NO₂ exposure in the 1st and 3rd trimester. Boys were more susceptible to the temperature-pollution interaction on asthma development. Our study indicates that low and high temperature respectively during early and late pregnancy significantly increased the impact of air pollution exposure in utero on pre-schooler's asthma.
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A study in Shanghai found lower temperature was associated with higher risk of asthma hospital admission (Zhang et al., 2014). In addition, Birrer el al., has linked exposure to low temperature with emergency-room visit for asthma in Tokyo, Japan (Abe et al., 2009). However, these studies used hospital visit for asthma as the outcome of interest, which may mostly consist of severe exacerbation cases and thus may have limited ability to capture mild and subclinical exacerbation.
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The number of accident and emergency visits and hospitalisations for exacerbation of asthma is associated with higher levels of NO₂ and with lower temperatures.

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Original ContributionThe relationship of short-term air pollution and weather to ED visits for asthma in Japan

Abstract

Introduction

Methods

Results

Conclusions

Introduction

Section snippets

Study population

Results

Discussion

Acknowledgments

J Emerg Med

Aust N Z J Public Health

J Allergy Clin Immunol

Am J Emerg Med

Ann Allergy Asthma Immunol

Chest

Lancet

Ann Allergy Asthma Immunol

Continued increase in the prevalence of asthma and atopy

Arch Dis Child

Epidemiology of asthma: the year in review

Curr Opin Pulm Med

Evidence for the increase in asthma worldwide

Ciba Found Symp

Respiratory syncytial virus bronchiolitis in infancy is an important risk factor for asthma and allergy at age 7

Am J Respir Crit Care Med

Obesity and its relationship with asthma prevalence and severity in adolescents from southern Brazil

J Asthma

Fast foods—are they a risk factor for asthma?

Allergy

Outdoor air pollution and asthma

Pediatr Pulmonol Suppl

Evaluation of asthmatic patients referred to Jahrom hospital and clinic

Iran J Allergy Asthma Immunol

Analysis of the relationships between environmental factors (aeroallergens, air pollution, and weather) and asthma emergency admissions to a hospital in Mexico City

Allergy

Visits to the emergency room for asthma attacks and short-term variations in air pollution. A case-crossover study

Respiration

Influence of climate factors on emergency visits for childhood asthma attack

Pediatr Int

Enhancement of exercise-induced asthma by cold air

N Engl J Med

Original Contribution
The relationship of short-term air pollution and weather to ED visits for asthma in Japan