Original Article | Published:

Short-term exposure to ambient ozone and stroke hospital admission: A case-crossover analysis

Journal of Exposure Science and Environmental Epidemiology volume 26, pages 162166 (2016) | Download Citation

Abstract

We evaluated the association between short-term exposure to ambient ozone air pollution and stroke hospital admissions among adult residents of South Carolina (SC). Data on all incident stroke hospitalizations from 2002 to 2006 were obtained from the SC Office of Research and Statistics. Ozone exposure data were obtained from the US Environmental Protection Agency’s Hierarchical Bayesian Model. A semi-symmetric bidirectional case-crossover design was used to examine the association between ozone exposure on lag days 0–2 (0 to 2 days before admission) and stroke hospitalization. Conditional logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs). No significant associations were observed between short-term ozone exposure and hospitalization for all stroke (e.g., lag day 0: OR=0.98; 95% CI=0.96, 1.00) or ischemic stroke (lag day 0: OR=0.98; 95% CI=0.96, 1.01). Risk of hospitalization for hemorrhagic stroke appeared to be higher among African Americans than European Americans; however, the majority of these associations did not reach statistical significance. Among adults in SC from 2002 to 2006, there was no evidence of an association between ozone exposure and risk of hospitalization for all stroke or ischemic stroke; however, African Americans may have an increased risk of hemorrhagic stroke.

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References

  1. 1.

    , , , , , et al. Heart disease and stroke statistics—2014 update: a report from the American Heart Association. Circulation 2014; 129: e28–e292.

  2. 2.

    , , , , , . Association between short-term exposure to ultrafine particles and hospital admissions for stroke in Copenhagen, Denmark. Eur Heart J 2010; 31: 2034–2040.

  3. 3.

    , , , , . Short-term effects of ambient particulates and gaseous pollutants on the incidence of transient ischaemic attack and minor stroke: a case-crossover study. Environ Health 2012; 11: 77.

  4. 4.

    , , , , , et al. Ambient air pollution and the risk of acute ischemic stroke. Arch Intern Med 2012; 172: 229–234.

  5. 5.

    , . Ambient air pollution and stroke. Stroke 2014; 45: 3734–3741.

  6. 6.

    WHO. Burden of disease from ambient air pollution for 2012: World Health Organization; 2014. Available at (cited 12 May 2014).

  7. 7.

    , , , , , et al. Long term exposure to ambient air pollution and incidence of acute coronary events: prospective cohort study and meta-analysis in 11 European cohorts from the ESCAPE Project. BMJ 2014; 348: f7412.

  8. 8.

    , , , . Fine particulate air pollution and hospital admissions for myocardial infarction in a subtropical city: Taipei, Taiwan. J Toxicol Environ Health A 2013; 76: 440–448.

  9. 9.

    , , , , , . Long-term exposure to PM2.5 and incidence of acute myocardial infarction. Environ Health Perspect 2013; 121: 192–196.

  10. 10.

    , , , , , et al. Airborne pollutants and lacunar stroke: a case cross-over analysis on stroke unit admissions. Neurol Int 2012; 4: e11.

  11. 11.

    , , , , . Estimation of short-term effects of air pollution on stroke hospital admissions in southern Sweden. Neuroepidemiology 2010; 34: 131–142.

  12. 12.

    , , , . Evidence for an association between air pollution and daily stroke admissions in Kaohsiung, Taiwan. Stroke 2003; 34: 2612–2616.

  13. 13.

    , , , , . Association between ozone exposure and onset of stroke in Allegheny County, Pennsylvania, USA, 1994-2000. Neuroepidemiology 2013; 41: 2–6.

  14. 14.

    , , , , , . Effects of ozone and particulate matter on cardiac mechanics: role of the atrial natriuretic peptide gene. Toxicol Sci 2013; 131: 95–107.

  15. 15.

    , , , , , et al. Vascular and cardiac impairments in rats inhaling ozone and diesel exhaust particles. Environ Health Perspect 2011; 119: 312–318.

  16. 16.

    , , , , , . Inhalation of fine particulate air pollution and ozone causes acute arterial vasoconstriction in healthy adults. Circulation 2002; 105: 1534–1536.

  17. 17.

    , , , , , et al. Air pollution and cardiovascular disease: a statement for healthcare professionals from the Expert Panel on Population and Prevention Science of the American Heart Association. Circulation 2004; 109: 2655–2671.

  18. 18.

    , , , , , et al. Factors influencing the decline in stroke mortality: a statement from the American Heart Association/American Stroke Association. Stroke 2014; 45: 315–353.

  19. 19.

    , , , . Short-term effects of ozone air pollution on ischaemic stroke occurrence: a case-crossover analysis from a 10-year population-based study in Dijon, France. Occup Environ Med 2007; 64: 439–445.

  20. 20.

    , , , , , et al. Lack of association between air pollutant exposure and short-term risk of ischaemic stroke in Lyon, France. Int J Stroke 2012; 7: 669–674.

  21. 21.

    , , , , . Ozone air pollution and ischaemic stroke occurrence: a case-crossover study in Nice, France. BMJ 2013; 3: e004060.

  22. 22.

    , . Relation between residence in the southeast region of the United States and stroke incidence. The NHANES I Epidemiologic Followup Study. Am J Epidemiol 1996; 144: 665–673.

  23. 23.

    , , , , , . The geographic variation in stroke incidence in two areas of the southeastern stroke belt: the Anderson and Pee Dee Stroke Study. Stroke 1998; 29: 2061–2068.

  24. 24.

    EPA. Green book downloads: nonattainment areas: Environmental Protection Agency; 2014. Available at (cited 15 August 2014).

  25. 25.

    , . Coding of stroke and stroke risk factors using international classification of diseases, revisions 9 and 10. Stroke 2005; 36: 1776–1781.

  26. 26.

    , , . Hierarchical Bayesian Model (HBM)-derived Estimates of Air Quality for 2001: Annual Report. US Environmental Protection Agency: : Durham, NC. 2010.

  27. 27.

    EPA. Technology Transfer Network Air Quality System (AQS): Environmental Protection Agency; 2013. Available at (cited 31 March 2013).

  28. 28.

    , . Risk set sampling for case-crossover designs. Epidemiology 2002; 13: 100–105.

  29. 29.

    , , , , . Potential for bias in case-crossover studies with shared exposures analyzed using SAS. Am J Epidemiol 2011; 174: 118–124.

  30. 30.

    Summary File 3, Summary File 4. US Census, Bureau, Washington, DC, 2000.

  31. 31.

    RHRC. Zip Code RUCA Approximation: University of Washington Rural Health Research Center 2005. Available at (cited 1 May 2012).

  32. 32.

    , , , , , et al. MERRA: NASA’s Modern-Era Retrospective Analysis for Research and Applications. J Climate 2011; 24: 3624–3648.

  33. 33.

    , , , . Environmental pollutants and stroke-related hospital admissions. Cad Saude Publica 2012; 28: 1319–1324.

  34. 34.

    . Epidemiology of stroke. Lancet 1998; 352 Suppl 3: Siii1–Siii4.

  35. 35.

    , , . Air pollution and hospital admissions for ischemic and hemorrhagic stroke among medicare beneficiaries. Stroke 2005; 36: 2549–2553.

  36. 36.

    , , , , , et al. Ambient air pollution and risk for ischemic stroke and transient ischemic attack. Ann Neurol 2008; 64: 53–59.

  37. 37.

    , , , , . An evidence-based appraisal of global association between air pollution and risk of stroke. Int J Cardiol 2014; 175: 307–313.

  38. 38.

    , , . Sex differences in stroke epidemiology: a systematic review. Stroke 2009; 40: 1082–1090.

  39. 39.

    , , , , . The incidence of deep and lobar intracerebral hemorrhage in whites, blacks, and Hispanics. Neurology 2005; 65: 518–522.

  40. 40.

    , , . Relationship between hemorrhagic stroke hospitalization and exposure to fine particulate air pollution in Taipei, Taiwan. J Toxicol Environ Health A 2014; 77: 1154–1163.

  41. 41.

    , , , , , . Outdoor air pollution and incidence of ischemic and hemorrhagic stroke: a small-area level ecological study. Stroke 2012; 43: 22–27.

  42. 42.

    , , , , , et al. Air pollution and risk of stroke: underestimation of effect due to misclassification of time of event onset. Epidemiology 2009; 20: 137–142.

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Acknowledgements

We acknowledge the SC Office of Research and Statistics, now under the SC Revenue and Fiscal Affairs Office, for providing data on stroke hospitalizations. Work by Dr. Mittleman was supported by the US Environmental Protection Agency grant RD 83479801.

Author information

Affiliations

  1. Department of Epidemiology and Biostatistics, Maryland Institute of Applied Environmental Health, University of Maryland School of Public Health, College Park, Maryland, USA

    • Jessica A Montresor-López
    • , Amir Sapkota
    •  & Robin C Puett
  2. Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA

    • Jeff D Yanosky
  3. Cardiovascular Epidemiology Research Unit, Beth Israel Deaconess Medical Center, Department of Epidemiology, Harvard University School of Public Health, Boston, Massachusetts, USA

    • Murray A Mittleman
  4. Department of Epidemiology and Biostatistics, University of Maryland School of Public Health, College Park, Maryland, USA

    • Xin He
  5. Center for Research and Nutrition and Health Disparities, University of South Carolina School of Public Health, Columbia, South Carolina, USA

    • James D Hibbert
  6. Cancer Prevention and Control Program, Department of Epidemiology and Biostatistics, University of South Carolina School of Public Health, Columbia, South Carolina, USA

    • Michael D Wirth

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Competing interests

The authors declare no conflict of interest.

Corresponding author

Correspondence to Jessica A Montresor-López.

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DOI

https://doi.org/10.1038/jes.2015.48

Supplementary Information accompanies the paper on the Journal of Exposure Science and Environmental Epidemiology website (http://www.nature.com/jes)

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