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Short-term effects of ozone on out-of-hospital coronary

deaths: a case-crossover analysis in Tuscany

D. Nuvolone1, D. Balzi1,2, M. Chini3, D. Scala3, F. Giovannini3, A. Barchielli1,2

1. Epidemiology Unit, Regional Agency for Public Health of Tuscany (ARS), Italy.2. Epidemiology Unit, Local Health Unit 10 – Florence, Italy. 3. CRTQA, Regional Agency for Environmental Protection of Tuscany (ARPAT), Italy

EuroEpi2010 - Epidemiology and Public Health in Evolving Europe - Daniela Nuvolone November 8th, 2010

Air Quality Data

Meteorological Data

Objectives

Analyse the short-term effects of ozone on out-of-hospital coronary deaths in Tuscany (Italy), 2002-2005

RMR - Regional Mortality Registry ICD-9 410-414Hospital discharge DB

SIRA - Regional Environmental Information SystemDaily values: O3 - PM10 – NO2 – CO

Monitoring sites managed by ARPAT and SIAN (National Agricultural Information System) Daily values : Temperature – Relative humidity

Health Data


Air quality data: identification of six homogeneous urban areas (2002-2005)

1. Selection of monitoring sites: “urban background” and “traffic” sites with annual mean value ofCO<0,8 mg/m3

2. Correlation analysis between sites to define areas with plausible homogeneous air quality levels (Pearson’s coefficients>0.5)

5 sites: PratoPrato municipality

2 sites: PistoiaPistoia municipality

7 sites: Pisa-Cascina-Pontedera-Livorno-Viareggio

Pisa-Livorno area

3 sites: Lucca – Capannori-Montecatini Terme

Lucca area

7 sites: Firenze-Calenzano-Scandicci-Signa

Florence metropolitan area

3 sites: ArezzoArezzo municipality

Definition of a UNIQUE DAILY VALUE

for each AREA

HealthHealth DataData

Selection of cases based on residence municipality(42% of total residents in Tuscany region)


Statistical analyses

1. Case-crossover study design: selection of controls according to time-stratified method

2. OR estimates by means of conditional logistic regression models

Time-dependent confounding variables

3. Area-specific analyses of the associations between out-of-hospital events and ozone levels, at different lag(lag0, 0-1, 0-2, 0-3, 0-4, 0-5, 3-5)

4. Area-specific stratified analyses by gender, age, chronic conditions(susceptibility analysis using hospital admissions in the previous 3 years)

5. Area-specific analyses of bipollutant models

6. Meta-analyses (random effect) of area-specific results

population decrease during summer holidaysinfluenza epidemicsholidaysapparent temperature (piecewise linear spline)


Air Quality Data

0.69

0.61

0.51

1.02

0.57

0.61

SD

0.99

0.86

1.04

1.28

0.91

1.10

Mean

CO mg/m3

18.8439.7222.8633.9326.8794.90Prato

15.5432.8926.2935.9626.50106.21Pistoia

12.5933.5417.5040.6819.1397.42Pisa-Livorno

14.2128.5218.7436.27--Lucca

16.9538.2719.5738.4724.8397.20Firenze

10.3339.3011.5628.1523.9893.58Arezzo

SDMeanSDMeanSDMean

NO2 μg/m3PM10 μg/m3O3 μg/m3 *Areas

* April-September


1002,1831,530Total

8,819385Prato

8,1177181Pistoia

31,7692407Pisa-Livorno

11,5252182Lucca

35,7779580Florence metropolitan

4,19095Arezzo

%No

Events*Inhabitants(thousands)

Area

* April-September

Health Data


1,950Peripheral artery diseases

3,479Stroke

11,3262Cardiac diseases hospitalizations

2,258Chronic renal failure

7,2168Chronic heart failure

4,9114Arrhythmias

9,0204AMI

8,5203Ischemic heart diseases

2,049COPD

5,0122Hypertension

3,683Diabetes

Specific chronic conditions

77,31700≥75

22,7483<75

Age (y)

49,31070Females

50,71113Males

Sex

%N

Distribution of events by gender, age, and chronic conditions


LAG

OR

0,850

0,900

0,950

1,000

1,050

1,100

1,150

0 1 2 3 4 5 0-2 0-5 3-5

Pooled resultsAssociations between ozone and out-of-hospital coronary deaths at different lag patterns: OR and 95% confidence intervals, relative to a 10μg/m3 O3 increase Years 2002– 2005.


Ischemic heart diseases

OR

Stratified Analyses Results (lag 0-5)Associations between ozone and out-of-hospital coronary deaths: OR and 95% confidence intervals, relative to a 10μg/m3 O3 increase Years 2002– 2005

0,800

0,900

1,000

1,100

1,200

1,300

1,400

1,500

<75 >=75 Males Females Yes

GenderAge group


Bipollutant Models Results (lag 0-5)

0,850

0,900

0,950

1,000

1,050

1,100

1,150

1,200

1,250

Base model Model with CO lag0-5 Model with NO2 lag0-5 Model with PM10 lag0-5

OR


Conclusions

Our study adds further evidence to the acute adverse health effects of ozone.

Our results suggest the presence of more susceptible groups of populations, mainly females and subjects with previous hospital admissions for ischemic heartdiseases.

Ozone risk estimates do not vary after adjusting for the effects of other pollutantsand temperature.

As observed in other studies, the adverse CV effects are found at pollutants levels lower than EU current standards


Thank you

for

your attention

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