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Do Socio-Demographic Characteristics Modify the Association Between Air Pollution and Mortality & Morbidity?

Written By

Sabit Cakmak, Sara L. Martin, Claudia Blanco Vidal, Timur Gultekin, Vladislav Brion and Maria Angelica Rubio

Submitted: October 14th, 2010 Published: August 29th, 2011

DOI: 10.5772/16737

Advanced Topics in Environmental Health and Air Pollution Case Studies IntechOpen
Advanced Topics in Environmental Health and Air Pollution Case Studies Edited by Anca Moldoveanu

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Advanced Topics in Environmental Health and Air Pollution Case Studies

Edited by Anca Maria Moldoveanu

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1. Introduction

Historical extreme air pollution events such as those experienced in London in the 1950s and 60s clearly demonstrated the potential of ambient air pollution to cause exacerbation of cardio-respiratory disease, manifested as pre-mature mortality and admission to hospital. In the intervening years, considerable efforts have been made to reduce pollution from the combustion of fossil fuels and industrial activity. Although these pollution mitigation strategies have been largely viewed as successful, evidence from population health studies in North America, Europe, South America, Mexico, Asia, Australia and New Zealand continues to identify ambient air quality as a population health concern (Table 1).

Reference Data Location Focus Outcomes Subpop.
Alberdi et al., 1998 1986-1992 Madrid, Spain TSP, SO2 NA, R, CV Sex, Age "/65
Alberdi et al., 1998b 1986-1992 Madrid, Spain TSP, SO2 NA, R, CV Sex, Age "/65
Anderson et al., 1996 1987-1992 London, England BS, SO2, NO2, O3 NA, R, CV
Bachárová et al., 1996 1987-1991 Slovak Republic TSP, SO2 A, NA, R, CV
Ballester et al., 1996 1991-1993 Valencia, Spain TSP, SO2 NA, R, CV Age "/70
Borja-Aburto et al., 1997 1990-1992 Mexico City, Mexico O3, SO2, TSP A, NA, R, CV Age
Borja-Aburto et al., 1998 1993-1995 Mexico City, Mexico PM2.5 NA, R, CV Age "/65
Boucher et al., 1996 1985-1993 Salt Lake and Utah counties, U.S. PM10 NA
Burnett et al., 1998 1980-1994 Toronto, Canada CO, NO2, SO2, TSP, PM2.5,PM10 NA, R, CV, O Age
Burnett et al., 1998b 1980-1991 11 Canadian Cities CO, NO2, SO2, O3 NA
Burnett et al., 2000 1986-1996 8 Canadian Cities PM2.5,PM10, PM10-2.5 NA
Castillejos et al., 2000 1992-1995 Mexico City, Mexico PM2.5,PM10 PM10-2.5 NA
Chock et al., 2000 1989-1991 Pittsburg, Pennsylvania, U.S. PM2.5,PM10 NA, R, CV Age
Cifuenties et al, 2000 1988-1996 Santiago, Chile PM2.5,PM10, CO, NO2, SO2, O3 NA
Dab et al., 1996 1987-1992 Paris, France BS, SO2, O3, NO2, PM13 R morbidity and mortality
Daniels et al., 2000 1987-1994 20 cities, U.S. PM10 A, CV
Díaz et al., 1999 1990-1996 Madrid, Spain TSP, SO2, NO2, NOx, O3 R, CV, Emergency hospital admission (94-96)
Dockery et al., 1992 1985-1986 St. Louis, Illinois and Missouri; Roanne county, Tennessee PM2.5, PM10,, Aerosols Mortality
Fairley, 1990 1980-1986 Santa Clara County, California PM10 NA
Fairley, 1999 1989-1996 Santa Clara County, California PM2.5 NA, R, CV
Reference Data Location Focus Outcomes Subpop.
Goldberg et al., 2000 1995-1999 Montreal, Quebec predicted PM2.5 NA, CV, C Age
Gouveia& Fletcher, 2000 1991-1993 São Paulo, Brazil PM2.5,PM10, CO, NO2, SO2, O3 NA, R, CV Socioeco.
sex, age
Hales et al., 2000 1988-1993 Christchurch, New Zealand PM10, NOx, SO2, O3, CO NA, R, CV Age "/65
Gwynn et al., 2000 1988-1990 Buffalo, New York, U.S. H+ and SO4 2- PM R, CV and A mortality and morbidity
Hatzakis et al., 1986 1975-1982 Athens, Greece BS, SO2 Mortality
Hoek et al., 1997 1983-1991 Rotterdam, Netherlands TSP, BS, SO2, O3, CO Mortality
Hoek et al., 2000 1986-1994 The Netherlands PM10, BS NA, R, CV
Hong et al., 1999 1995-1996 Inchon, South Korea PM10, SO2,CO, O3 NA, R, CV
Ito et al., 1993 1965-1972 London, England BS, S02, Acidic Aerosols Mortality
Ito et al., 1995 1985-1990 Cook County, Illinois and Los Angeles County, California, U.S. PM10 Mortality
Ito et al., 1996 1985-1990 Cook County, Illinois, U.S. PM10 R, CV, C Age, Sex, Race
Kelsall et al., 1997 1974-1988 Philadelphia, Pennsylvania, U.S. TSP NA, R, CV Age
Kinney & Özkaynak, 1991 1970 - 1979 Los Angeles, County, California, U.S. Ox, SO4, NO2, CO NA, R, CV
Kinney et al., 1995 1985-1990 Los Angeles, County, California, U.S. PM10 NA
Klemm & Mason, 2000 1998-1999 Atlanta, Georgia, U.S. PM2.5 NA Age ("/65)
Kotesovec et al., 2000 1982-1994 Northern Bohemia, Czech Republic TSP, SO2 A, CV and C Sex, Age
Krzyzanowski & Wojtyniak 1991/92 1977-1989 Cracow, Poland SO2, PM20 NA, R, CV Sex, Age
Le Tertre et al., 1998 1987-1990 Paris, France S02 Mortality
Lee et al., 1999 1991-1995 Seoul and Ulsan, South Korea TSP, SO2, O3 NA
Lee et al., 2000 1991-1997 7 South Korean cities TSP, SO2, O3 NA
Reference Data Location Focus Outcomes Subpop.
Lipfert et al., 2000 1992-1995 Philadelphia, Pennsylvania TSP Mortality
Lippmann et al., 2000 Various Detroit, Michigan, U.S. H+ and SO4 2- PM Mortality and elderly morbidity Age
Lyon et al., 1995 1985-1992 Utah County, U.S. PM10 NA, R, CV, O Age
Machenbach et al., 1993 1979-1987 The Netherlands S02 Mortality
Mar et al., 2000 1995-1997 Phoenix, Arizona, U.S. PM2.5,PM10, PM10-2.5 NA, R, CV
Michelozzi et al., 1998 1992-1995 Rome, Italy PM10, SO2, O3, NO2, CO Mortality
Moolgavak, 2000 1987-1995 3 U.S. Counties PM10, CO, O3 NA, R, CV
Moolgavakar et al., 1995 1974–1984 Steubenville, Ohio, U.S. TSP, SO2 NA
Moolgavakar et al., 1995b 1973-1988 Philadelphia, Pennsylvania, U.S. TSP, SO2,O3 NA
Morgan et al., 1998 1989-1993 Sydney, Australia PM, NO2, O3 NA, R, CV
Ostro, 1995 1980-1986 California, U.S. PM2.5 NA, R, CV
Ostro et al., 1996 1989-1991 Santiago, Chile PM10 NA, R, CV Age "/65
Ostro et al., 1999 1989-1992 Coachella Valley, California, U.S. PM10 NA, R, CV
Ostro et al., 1999b 1992-1995 Bangkok, Thailand PM10 R, CV Age
Ostro et al., 2000 1989-1998 Coachella Valley, California, U.S. PM10 NA, R, CV
Peters et al., 2000 1982-1991 Coal districts, Czech Republic;Bavarian districts, Germany TSP, SO2, PM2.5,PM10 NA, R(Czech Republic only), CV
Pope et al., 1992 1985-1989 Utah County PM10 NA, R, CV, O
Pope et al., 1996 1985-1989 Utah County PM10 NA, R, CV, O
Pope et al., 1999 1985-1995 Wasatch Front, Utah PM10 NA, R, CV, O
Rahlenbeck & Kahl, 1996 1981-1989 East Berlin, Germany TSP, SO2 NA
Rossi et al., 1999 1980-1989 Milan, Italy TSP, SO2, NO2, PM13 NA, R, CV
Saldiva et al., 1995 1990-1991 São Paulo, Brazil PM10 NA
Samet et al., 1998 1973-1980 Philadelphia, Pennsylvania TSP, SO2 NA
Reference Data Location Focus Outcomes Subpop.
Samet et al., 2000 1987-1994 20 cities, U.S. PM10 NA, R, CV
Schwartz & Dockery, 1992 1974–1984 Steubenville, Ohio TSP, SO2 NA
Schwartz & Dockery, 1996 1973-1980 Philadelphia, Pennsylvania TSP, SO2 NA, R, CV Age
Schwartz et al., 1990 1958-1972 London, England BS, SO2 Non-traumatic
Schwartz, 1991 1973-1982 Detroit, Michigan, U.S. TSP NA
Schwartz, 1993 1985-1988 Birmingham, Alabama, U.S. PM10 NA
Schwartz, 1994 1977 - 1982 Cincinnati, Ohio, U.S. TSP A, R, CV Age "/65
Schwartz, 2000 1986-1993 10 cities, U.S. PM10 Mortality Socioeco.
Schwartz, 2000b 1986-1993 10 cities, U.S. PM10 Mortality Age "/65
Schwartz, 2000c 1979-1986 Boston, Massachusetts, U.S. PM2.5 A, R, CV
Schwartz, 2000d 1974-1988 Philadelphia, Pennsylvania TSP and SO2 NA
Simpson et al., 1997 1987-1993 Brisbane, Australia PM10, SO2, O3 NA, R, CV Age "/65
Simpson et al., 2000 1991-1996 Melbourne, Australia PM2.5,PM10 NA, R, CV Age
Smith et al., 1999 Various Alabama & Illinois, U.S. PM10 Mortality Age "/65
Spix & Wichmann, 1996 1976-1985 Köln, Germany TSP, SO2, NO2 Mortality
Spix et al., 1993 1980-1989 Erfurt, Germany TSP, SO2 Mortality
Styer et al., 1995 1985-1990 Utah, U.S. PM10 NA Age, Sex, Race
Sunyer et al., 1996 1985-1991 Barcelona, Spain BS, NO2, SO2, O3 NA, R, CV Age "/70
Szafraniec et al., 1997 1993-1996 Kraków, Poland SO2, PM10 NA, CV Sex
Tobias & Campbell, 1999 1991-1995 Barcelona, Spain BS Mortality
Touloumi et al., 1994 1984-1988 Athens, Greece BS, CO, SO2 Mortality
Touloumi et al., 1996 1987-1991 Athens, Greece BS, CO, SO2 Mortality
Touloumi et al., 1997 Various 6 European Cities NO2, O3 Mortality
Vigotti et al., 1996 1980-1989 Milan, Italy TSP, SO2 Respiratory morbidity
Reference Data Location Focus Outcomes Subpop.
Wichmann et al., 2000 1991-2002 Erfurt, Germany CO, NO2, SO2, O3,PM10 Mortality
Wietlishbach et al., 1996 1984-1989 Zurich, Basle and Geneva, Switerland TSP, CO, NO2, SO2, O3 NA, R, CV Age "/65
Wojtyniak & Piekarski, 1996 Various Cracow, Lodz, Poznan and Wroclaw, Poland SO2, BS NA, R, CV, D
Wordley et al., 1997 1992-1994 Brimingham, U.K. PM10 R,CV morbidity
X. Xu et al., 1994 1989 Dongchen and Xichen, Beijing, China TSP, SO2 NA, R, CV, C
Z. Y. Xu et al., 2000 1992 Shenyang, China TSP, SO2 NA, R, CV, C, O
Zanobetti & Schwartz, 2000 1986-1993 4 U.S. cities PM10 NA Sex, Race, Edu.
Zmirou et al., 1996 1985-1990 Lyon, France S02, NO2, O3, PM13 NA, R, CV, D

Table 1.

Selected references examining air quality and health outcomes around the world with information on the years in which data was collected, as well as the location, the compounds, the health outcomes and subpopulations studied. In the compound column BS indicates black smoke and TSP indicates total suspended particulates. Cause of death categories studied in each paper were coded as A (accidental), NA (Non-accidental), R (respiratory including lung and chronic obstructive pulmonary disease), CV (cardiovascular or circulatory diseases), C (cancer), D (digestive system) and O (other).

Previous work that has found increases in morbidity and mortality are associated with both ambient air pollution and low socio-economic status (Dockery & Pop, 2002; Brunekreef & Holgate, 2002; Bascom et al., 1996; Hahn et al., 1996; Carr et al., 1992, Chen et al., 2001).

However, the literature regarding the effect of age, gender, and social status is conflicting with some studies documenting increased susceptibility studies (Cifuentes et al., 1999; Wojtyniak & Wysocki, 1989; Health Effects Institute[HEI], 2000; Pope, 2000 ) and others finding little or no effect (Gouveia & Fletcher, 2000; Samet et al., 2000; Zanobetti et al., 2000). A variety of factors have been implicated in the increased susceptibility to air pollution among the socially disadvantaged including, higher pollutant levels in living or working areas, increased cigarette smoking, fewer dietary fruits and vegetables, and reduced access to medical care (O'Neill et al., 2003, Sexton et al. 1993). However, identification of subgroups which are more susceptible to the effects of air pollution is important for three reasons:

  1. developing targeted intervention programs;

  2. determining whether the air pollution-health effects found in one region can be extrapolated to other geographic regions;

  3. setting effective air pollution policies that reduce risk for the entire population.

This study investigates whether age, gender and an indicator of social status – educational attainment – modify the effect of particulate air pollution on mortality.

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2. Methods

2.1. Air pollution data

Daily air pollution data for the nine communities (communas) that make up the Conception Region (Fig. 1.), Tomé, Penco, Talcahuano, Hualpén, Concepción, San Pedro de la Paz, Chiguayante, Lota, and Coronel, were obtained from monitoring stations located within each of the centers (Fig. 2.). We obtained information for the period from 1 January 2000 to 31 December 2009, although some stations had information for only a subset of these dates. The information collected was the average concentration of particulate matter with mass median aerodynamic diameter less than 10 microns (PM10) over 24 hour periods

2.2. Mortality and sociodemographic data

The daily number of non-accidental deaths (ICD-9 <800) in the study areas were obtained from the Instituto Nacional de Estadisticas, the official source of statistical data in Chile from 1 January 2000 to 31 December 2009 for all nine areas. The daily number of hospitalizations were obtained for five of the areas under study: Tomé, Talcahuano, Concepción,, Lota, and Coronel for the period of January 1 2006 to December 31 2007. Age, gender, and individual educational attainment data were obtained from the Departamento de Estadísticas e Información en Salud (DEIS).

2.3. Statistical medhods

We used time series analyses and assumed both a Poisson distribution and that there was a linear association between ambient air pollution and mortality or morbidity on a logarithmic scale (Rupprecht et al., 1995).

Natural splines were created for air pollution concentrations on the day of study with one knot for each of 15, 30, 60, 90, 120, 180, and 365 days of observation. We then selected the model with the number of knots that either minimized the Akaike Information Criteria

Figure 1.

Map of Chile. The red area on the map has been declared a non-attainment zone because of failure to maintain daily PM10 concentrations below a standard threshold. The area includes nine communities with a population of 1 million inhabitants.

(AIC), a measure of model prediction, or maximized the evidence that the model residuals did not display any type of structure, including serial correlation, using Bartlett’s test (Lindstrom & Bates, 1990; Priestly, 2002). We plotted model residuals against time and found neither a pattern nor a significant correlation between air pollution and time. Once we had selected the optimal model for time, we assessed the value of including terms for the twenty-four hour means of temperature, humidity, and barometric pressure. The best meteorological predictors of death were temperature and humidity while humidex (Meterorological Service of Canada, 2000), a composite measure of temperature and humidity, was the best meteorological predictor of morbidity. We considered temperature and humidex readings on the day of death and the day prior to death and accounted for non-linear associations with death by using natural spline functions. Indicator functions for the day-of-the-week were also included. The association between air pollutants and death was tested at lags of zero to seven days and results were presented for the lags which maximized the effect size. Results from each urban center were pooled using a random effects model.

Figure 2.

Detailed Map of Chile. The locations of ten metropolitan areas highlighted in circles

Here we present the increase in relative risk (RR) of mortality or morbidity with 95% confidence intervals for an increase in PM10 concentration equal to the interquartile range of the pollutant’s concentration over the period of study. The interquartile range includes the middle fifty-percent of the exposure data and provides a realistic estimate of the day-to-day changes in the pollutant’s concentration. The interquartile range is a nonparametric measure of the data’s spread and, as such, is not influenced by skewed data, extreme values or outliers which are unstable and infrequently seen. A random effects model was used to pool the estimates of relative risk following a DerSimonian- Laird test for homogeneity among estimates.

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3. Results

Regional population sizes varied by over fourfold from 49,923 in Penco to 224,212 in Conception (Table 2). The number of daily deaths varied by four to fivefold between Conception and Penco. In the population of about one million people, there was an average of 15 deaths per day. The twenty-four hour mean concentrations of particulate matter varied by about 50% - 60% between regions with Chiguayante and San Pedro de la Paz reaching the greatest concentrations of PM10 (Table 2).

Risk of mortality from cardiac disease appeared to be particularly sensitive to increases in air pollution with an estimated increase of 26% (7% to 49%). The point estimate for mortality relative risk was somewhat greater in the oldest compared to the youngest age group, however, the effect was not significantly greater for those at least eighty-five years old compared to less than sixty-five (p > 0.05). The point estimates for mortality risk from PM10 were similar for males and females (p > 0.05) indicating a lack of effect modification by sex. The effect of PM10 on mortality was greatest among those with the lower level of educational attainment. An interquartile increase in pollutants among those who did not complete a college or university degree was associated with a 16.8% (3% to 33%) increase in mortality whereas among college and university graduates there was 13% (-1% to 28%) increase, which was not statistically significant. The risk of death associated with air pollution was particularly high among the elderly with low educational attainment with an increase of 19% (3% to 35%).

Population 100,000s Total Mortality Cardiac Mortality Respiratory Mortality PM10
(µg/m3)		 Total Hospitaliza tion Temperature
Tomé 5.47 0.935
(0.964)		 0.081
(0.288)		 0.285
(0.539)		 47.613
(45.975)		 12.441 12.592
(4.388)
Penco 4.99 0.681
(0.819)		 0.067
(0.262)		 0.175
(0.423)		 56.118
(49.525)		 NA 12.592
(4.388)
Talcahuano 17.13 3.010
(1.832)		 0.264
(0.526)		 0.791
(0.921)		 50.030
(28.060)		 61.760 13.355
(5.871)
Hualpén 8.8 1.272
(1.131)		 0.113
(0.343)		 0.346
(0.578)		 34.645
(19.025)		 NA 13.355
(5.871)
Concepción 22.42 3.487
(1.939)		 0.321
(0.570)		 1.006
(1.002)		 41.734
(23.350)		 101.414 13.355
(5.871)
San Pedro 8.92 0.975
(1.006)		 0.070
(0.265)		 0.269
(0.524)		 56.118
(49.525)		 NA 13.355
(5.871)
Chiguayante 9.98 1.042
(1.022)		 0.091
(0.298)		 0.302
(0.544)		 56.118
(49.525)		 NA 12.852
(3.101)
Lota 4.89 1.126
(1.077)		 0.100
(0.320)		 0.293
(0.544)		 49.778
(31.325)		 15.047 12.852
(3.101)
Coronel 10.31 1.344
(1.173)		 0.129
(0.365)		 0.358
(0.610)		 52.148
(29.500)		 22.280 12.852
(3.101)

Table 2.

Population size, mean daily total mortality, 24-hour mean daily air pollution levels and 24-hour mean weather for nine urban centers in Chile from January 2000 to December 2009. Mean daily total mortality rates and 24 hour mean weather variables are accompanied by their standard deviation, while the interquartile range is reported for the concentration of PM10.

When regions were pooled, an interquartile increase in concentration of PM10 was associated with a 5.5% (0.3% to 11%) increased risk of death from all causes (Table 3).

Relative Risk
Mortality All Causes 1.055 (1.003, 1.109)
Cardiac 1.260 (1.065, 1.490)
Respiratory 1.041 (1.024, 1.076)
Sex Male 1.043 (1.020, 1.085)
Female 1.061 (1.024, 1.099)
Age < 64 1.053 (1.013, 1.096)
65 - 74 1.048 (1.007, 1.089)
85 + 1.061 (1.016, 1.107)
Education < College 1.168 (1.029, 1.325)
"/ College 1.130 (0.998, 1.280)
Ages "/ 85
& lowest educational strata		 1.190 (1.031, 1.349)

Table 3.

Increase in relative risk of mortality by age group, sex, educational attainment, associated with an interquartile increase in PM10 adjusted for long-term trends, day-of-the-week, and temperature and humidity for nine urban centers in Chile from January 2000 to December 2009.

The risk of hospitalization from all causes and from respiratory disease showed no evidence of effect modification by age or sex with an increase in air pollution (Table 4). However, risk of hospitalization from cardiac disease was greatest among those 85 years old and greater, with an increase of 23% (6% to 44%) among the elderly versus 3% (-3% to 10%) among those less than 64 years of age; but, similar to risk of hospitalization from all cause and respiratory disease, cardiac disease showed no effect modification by sex.

All Cause RR Cardiac RR Respiratory RR
Age All 1.032 (1.011 to 1.053) 1.029 (0.983 to 1.077) 1.056 (1.005 to 1.111)
< 64 1.037 (1.017 to 1.059) 1.033 (0.974 to 1.097) 1.067 (1.014 to 1.123)
65 to 74 1.034 (0.996 to 1.074) 1.089 (1.006 to 1.178) 1.071 (0.945 to 1.214)
75 to 84 1.036 (0.991 to 1.084) 1.050 (0.969 to 1.137) 1.119 (1.003 to 1.249)
"/ 85 1.048 (0.977 to 1.124) 1.232 (1.058 to 1.435) 1.081 (0.946 to 1.235)
Sex All 1.032 (1.011 to 1.053) 1.029 (0.983 to 1.077) 1.056 (1.005 to 1.111)
Females 1.031(1.010 to 1.054) 0.998 (0.940 to 1.059) 1.046 (0.986 to 1.109)
Males 1.034 (1.007 to 1.062) 1.055 (0.998 to 1.116) 1.073 (1.006 to 1.144)

Table 4.

Relative Risk (RR) of hospitalization (morbidity) associated with an interquartile increase in concentrations of PM10 adjusted for long-term trends, day-of-the-week, and humidex for the five urban centers in Conception from January 1 2006 to December 31 2007.

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4. Discussion

Although progress has been made steadily over time at reducing ambient concentrations of particulate matter (PM10) (Fig.3), the results of this work suggests that there remains a risk to human health from exposure to this pollutant.The burden of mortality and morbidity due to increases particulate matter (PM10) in the short-terms has the greatest influence on the health of those who are elderly with low educational attainment and those with cardiac disease. In general, effect modification was observed by age and by education but not by sex and effect modification was less pronounced for morbidity data than for mortality data. Air quality guidelines that seek to protect the entire population, including high risk subgroups, should consider the greater sensitivity of those who are elderly, have lower educational attainment or suffer from cardiac disease.

4.1. Effect modification by age and educational attainment

Age significantly modified the effect of cardiac morbidity for the five Chilean communities studied here. Modification by age was less pronounced for all cause mortality, all cause morbidity and respiratory morbidity. Similarly, we observed little modification by educational attainment for total mortality. However, we did find that the combination of old age and low educational attainment resulted in elevated risk from air borne particulate matter.

Figure 3.

Air pollution levels over time for all nine centres combined.

Previous work has reported modification of the effect of air pollutants by age (Bell et al., 2005; Pope, 2000; Pope et al., 2002; Spix et al., 1998; Zanobetti et al., 2000). For example, previous work indicated that compared to those under sixty-five years of age, Chileans eighty five years and older were observed to be more than twice as likely to die from acute increases in PM10, and over 50% more likely to die from increases in ozone and SO2 (Cakmak et al., 2009).

Similarly, Bell et al. (2008) reported increased mortality effects in the elderly from ozone in The National Morbidity Mortality and Air Pollution Study of 98 U.S cities

(Bell & Dominici, 2008) and Filleul et al. (2004) reported a greater effect of air pollution mortality in those over sixty-five years old in France, though these effects were not statistical significant (Filleul et al., 2004).

Previous work has also reported effect modification by educational attainment and other indicators of social status (Bell et al., 2008; Forastiere et al., 2009; Dales, 2002; O’Neil et al., 2003; Ou et al., 2008; Prescott & Vestbo, 1999; Zanobetti et al., 2000). For example, in the Harvard Six-Cities and American Cancer Society cohort studies, there was an increased risk of mortality from long-term exposure to particulate matter among those with lower educational attainment (Health Effects Institute, 2000; Pope et al., 2002; Villeneuve et al., 2002). Similarly, in Hamilton, Canada, the non-accidental mortality risk estimates associated with sulphur dioxide and coefficient of haze were greater in areas of the city with lower educational attainment as well as greater employment in manufacturing (Jerrett et al. 2004). However, this finding is far from consistent: no relation to level of education was found in a study of mortality risk estimates from gaseous and particulate air pollution in Hong Kong (Ou et al., 2008); no effect modification by education was found among urban Americans from 98 communities for ozone levels (Bell & Dominici, 2008); and neither a time-series study of 20 U.S (Samet et al., 2000) cities nor one focusing on Vancouver, Canada found social status modified the effect of air pollution on mortality (Villeneuve et al., 2003). Furthermore, a study of São Paulo, Brazil the authors reported that a monotonically increasing effects of air pollution with increasing education (Gouvenia & Fletcher, 2000). This type of conflicting results lead the authors of a systematic review of the Medline database up to May 2006 to state that because of inconsistent findings in both long-term and short-term exposure studies “Current evidence does not yet justify a definitive conclusion that socioeconomic characteristics modify the effects of air pollution on mortality” (Laurent et al., 2009). Nevertheless, here we report that in combination with old age, risk increases with lower educational attainment.

4.2. The influence of social status

There are many possible reasons why one might expect lower socioeconomic position to increase susceptibility to the deleterious effects of air pollution including: increased exposure to the air pollutants of interest, increased exposure to co-pollutants from occupational dusts and fumes and cigarette smoke, fewer dietary fruits and vegetables, and reduced access to medical care and medicines (O’Neill et al., 2003; Sexton et al., 1993; Spix et al., 1998). Unfortunately, information on these variables was not available. However, because the overall effect size is based on the association between daily changes in air pollution and daily changes in mortality or morbidity, these other variables would only confound the overall pollution-illness association if they change day-to-day which is unlikely (Bell et al., 2005). It is possible that these variables differ between the educational groups and may partly account for the between-group estimates of effect found here.

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5. Conclusion

We found that the burden of all cause mortality and cardiac morbidity due to increased particulate air pollution is disproportionately experienced by the elderly who have low educational attainment. These findings suggest that the determination of air quality guidelines designed to protect the general population may be insufficient to protect this vulnerable subgroup.

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Acknowledgments

The authors would like to thank Dra. Danuta Rajs Grzebien of the Departamento de Estadísticas e Información de Salud, Ministerio de Salud for providing morbidity data, and Roberto Martínez González and Joyce Vera Bascour from the Secretaría Regional Ministerial del Medio Ambiente Region Metropolitana for providing data and comments.

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Sabit Cakmak, Sara L. Martin, Claudia Blanco Vidal, Timur Gultekin, Vladislav Brion and Maria Angelica Rubio

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