A systematic review on the association between total and cardiopulmonary mortality/morbidity or cardiovascular risk factors with long-term exposure to increased or decreased ambient temperature.

The health effects of acute exposure to temperature extremes are established; those of long-term exposure only recently received attention. We performed a systematic review to assess the associations of long-term (>3 months) exposure to higher or lower temperature on total and cardiopulmonary mortality and morbidity, screening 3455 studies and selecting 34. The studies were classified in those observing associations within a population over years with changing annual temperature indices and those comparing areas with a different climate. We also assessed the risk of bias, adapting appropriately an instrument developed by the World Health Organization for air pollution. Studies reported that annual temperature indices for extremes and variability were associated with annual increases in mortality, indicating that effects of temperature extremes cannot be attributed only to short-term mortality displacement. Studies on cardiovascular mortality indicated stronger associations with cold rather than hot temperature, whilst those on respiratory outcomes reported effects of both heat and cold but were few and used diverse health outcomes. Interactions with air pollution were not generally assessed. The few studies investigating effect modification showed stronger effects among the elderly and those socially deprived. Comparisons of health outcome prevalence between areas reported lower blood pressure and a tendency for higher obesity in populations living in warmer climates. Our review indicated interesting associations between long-term exposure to unusual temperature levels in specific areas and differences in health outcomes and cardiovascular risk factors between geographical locations with different climate, but the number of studies by design and health outcome was small. Risk of bias was identified because of the use of crude exposure assessment and inadequate adjustment for confounding. More and better designed studies, including the investigation of effect modifiers, are needed

Mixtures of long-term exposure to ambient air pollution, built environment and temperature and stroke incidence across Europe

Introduction: The complex interplay of multiple environmental factors and cardiovascular has scarcely been studied. Within the EXPANSE project, we evaluated the association between long-term exposure to multiple environmental indices and stroke incidence across Europe. Methods: Participants from three traditional adult cohorts (Germany, Netherlands and Sweden) and four administrative cohorts (Catalonia [region Spain], Rome [city-wide], Greece and Sweden [nationwide]) were followed until incident stroke, death, migration, loss of follow-up or study end. We estimated exposures at residential addresses from different exposure domains: air pollution (nitrogen dioxide (NO2), particulate matter < 2.5 μm (PM2.5), black carbon (BC), ozone), built environment (green/blue spaces, impervious surfaces) and meteorology (seasonal mean and standard deviation of temperatures). Associations between environmental exposures and stroke were estimated in single and multiple-exposure Cox proportional hazard models, and Principal Component (PC) Analyses derived prototypes for specific exposures domains. We carried out random effects meta-analyses by cohort type. Results: In over 15 million participants, increased levels of NO2 and BC were associated with increased higher stroke incidence in both cohort types. Increased Normalized Difference Vegetation Index (NDVI) was associated with a lower stroke incidence in both cohort types, whereas an increase in impervious surface was associated with an increase in stroke incidence. The first PC of the air pollution domain (PM2.5, NO2 and BC) was associated with an increase in stroke incidence. For the built environment, higher levels of NDVI and lower levels of impervious surfaces were associated with a protective effect [%change in HR per 1 unit = −2.0 (95 %CI, −5.9;2.0) and −1.1(95 %CI, −2.0; −0.3) for traditional adult and administrative cohorts, respectively]. No clear patterns were observed for distance to blue spaces or temperature parameters. Conclusions: We observed increased HRs for stroke with exposure to PM2.5, NO2 and BC, lower levels of greenness and higher impervious surface in single and combined exposure models

Disentangling associations between multiple environmental exposures and all-cause mortality: an analysis of European administrative and traditional cohorts

BACKGROUND: We evaluated the independent and joint effects of air pollution, land/built environment characteristics, and ambient temperature on all-cause mortality as part of the EXPANSE project. METHODS: We collected data from six administrative cohorts covering Catalonia, Greece, the Netherlands, Rome, Sweden, and Switzerland and three traditional cohorts in Sweden, the Netherlands, and Germany. Participants were linked to spatial exposure estimates derived from hybrid land use regression models and satellite data for: air pollution [fine particulate matter (PM 2.5), nitrogen dioxide (NO₂), black carbon (BC), warm season ozone (O 3)], land/built environment [normalized difference vegetation index (NDVI), distance to water, impervious surfaces], and ambient temperature (the mean and standard deviation of warm and cool season temperature). We applied Cox proportional hazard models accounting for several cohort-specific individual and area-level variables. We evaluated the associations through single and multiexposure models, and interactions between exposures. The joint effects were estimated using the cumulative risk index (CRI). Cohort-specific hazard ratios (HR) were combined using random-effects meta-analyses. RESULTS: We observed over 3.1 million deaths out of approximately 204 million person-years. In administrative cohorts, increased exposure to PM 2.5, NO 2, and BC was significantly associated with all-cause mortality (pooled HRs: 1.054, 1.033, and 1.032, respectively). We observed an adverse effect of increased impervious surface and mean season-specific temperature, and a protective effect of increased O 3, NDVI, distance to water, and temperature variation on all-cause mortality. The effects of PM 2.5 were higher in areas with lower (10th percentile) compared to higher (90th percentile) NDVI levels [pooled HRs: 1.054 (95% confidence interval (CI) 1.030-1.079) vs. 1.038 (95% CI 0.964-1.118)]. A similar pattern was observed for NO 2. The CRI of air pollutants (PM 2.5 or NO 2) plus NDVI and mean warm season temperature resulted in a stronger effect compared to single-exposure HRs: [PM 2.5 pooled HR: 1.061 (95% CI 1.021-1.102); NO 2 pooled HR: 1.041 (95% CI 1.025-1.057)]. Non-significant effects of similar patterns were observed in traditional cohorts. DISCUSSION: The findings of our study not only support the independent effects of long-term exposure to air pollution and greenness, but also highlight the increased effect when interplaying with other environmental exposures

Air pollution and lung cancer incidence in 17 European cohorts: prospective analyses from the European Study of Cohorts for Air Pollution Effects (ESCAPE)

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Long-term exposure to elemental constituents of particulate matter and cardiovascular mortality in 19 European cohorts: Results from the ESCAPE and TRANSPHORM projects

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Investigation of the association between long-term exposure to traffic-related air pollution and nonmalignant respiratory mortality in 16 cohorts, using Cox proportional hazard models and Geographical Information Systems (GIS), within the ESCAPE Project

Prospective cohort studies, especially from the United States and a few single-countrystudies in Europe, have provided sufficient evidence that chronic exposure to traffic-related air pollution, as reflected in particulate matter and nitrogen oxides concentrations, is associated with all cause and cardiovascular mortality. However, the evidence for long-term exposure effects on nonmalignant respiratory mortality is less studied, and the results reported are less consistent. We have investigated the relationship of long-term exposure to air pollution and nonmalignant respiratory mortality in 16 cohorts with individual level data within the multicenter European Study of Cohorts for Air Pollution Effects (ESCAPE). Data from 16 ongoing cohort studies from Europe were used. The total number of subjects was 307,553. There were 1,559 respiratory deaths during follow-up. Within the ESCAPE project it was possible to develop land use regression models that explained a large fraction of the spatial variance in measured annual average nitrogen oxides (NO2 and NOx) and particulate matter (PM2.5, PM2.5 absorbance, PM10 and PMcoarse) concentrations. Air pollution exposure was estimated by land use regression models at the baseline residential addresses of study participants and traffic-proximity variables were derived from geographical databases following a standardized procedure. Cohort-specific hazard ratios obtained by Cox proportional hazard models from standardized individual cohort analyses were combined using metaanalyses. We found no significant associations between air pollution exposure and nonmalignant respiratory mortality. Most hazard ratios were slightly below unity, with the exception of the traffic-proximity indicators. This is the largest European study bringing together data from 16 European cohorts. Exposure assessment and the analysis were conducted by standardized and state-of-the-art methods. In the middle of inadequate and inconsistent evidence, this powerful and well conducted study points to a non significant association between air pollution exposure and nonmalignant respiratory mortality.Πρόσφατες επιδημιολογικές μελέτες έχουν εκτιμήσει τις επιδράσεις της μακροχρόνιας έκθεσης σε ατμοσφαιρική ρύπανση στην ολική και ανά αιτία θνησιμότητα. Ως δείκτες έκθεσης χρησιμοποίησαν τις συγκεντρώσεις των αιωρούμενων σωματιδίων (ΡΜ, με διάμετρο 10 και 2,5 μικρόμετρα), του μαύρου καπνού και των οξειδίων του αζώτου (ΝΟx) που προέρχονται από την κυκλοφορία οχημάτων. Οι επιδημιολογικές μελέτες που διερευνούν τις μακροχρόνιες επιδράσεις της ατμοσφαιρικής ρύπανσης στη θνησιμότητα από αναπνευστικά αίτια είναι λίγες. Γενικά τα ευρήματα παρουσίαζαν ετερογένεια, με αποτελέσματα συχνά στατιστικά μη σημαντικά. Σκοπός της παρούσας διατριβής είναι η αποτίμηση της επίδρασης της εξατομικευμένης έκθεσης σε ατμοσφαιρικούς ρύπους που συνδέονται με τον φόρτο κυκλοφορίας οχημάτων, στη θνησιμότητα από αναπνευστικά αίτια, σε 16 προοπτικές επιδημιολογικές έρευνες, με χρήση μοντέλων αναλογικών κινδύνων του Cox και γεωγραφικών συστημάτων πληροφοριών, στο πλαίσιο του ευρωπαϊκού πολυκεντρικού ερευνητικού προγράμματος με τίτλο "European Study of Cohorts for Air Pollution Effects" (ESCAPE). Ο συνολικός υπό μελέτη πληθυσμός, ήταν 307,553 άτομα και σημειώθηκαν 1,559 περιστατικά θανάτου από αναπνευστικά αίτια (εκτός του καρκίνου του πνεύμονα). Η εκτίμηση της εξατομικευμένης έκθεσης στις συγκεντρώσεις του NO2 και NOx και των PM2.5, PM2.5 absorbance, PM10 και PM2.5-10, έγινε από τα μοντέλα χρήσης γης που αναπτύχθηκαν υπό κοινό πρωτόκολλο και αφορούσε τη διεύθυνση κατοικίας των ατόμων που συμμετέχουν. Η ανάλυση των μακροχρόνιων επιδράσεων της έκθεσης σε ατμοσφαιρική ρύπανση στη θνησιμότητα από αναπνευστικά αίτια, πραγματοποιήθηκε σε κάθε επιδημιολογική προοπτική μελέτη χωριστά. Έγινε ανάλυση επιβίωσης με την εφαρμογή μοντέλων αναλογικών κινδύνων του Cox, λαμβάνοντας υπόψη και συγχυτικούς παράγοντες. Τα αποτελέσματα της κάθε περιοχής μελέτης στάλθηκαν στο Πανεπιστήμιο Αθηνών που ήταν υπεύθυνο για την αντίστοιχη ανάλυση. Για την συγκριτική αξιολόγηση των αποτελεσμάτων πραγματοποιήθηκε μετα-ανάλυση των επιμέρους εκτιμήσεων. Δεν διαπιστώθηκε στατιστικά σημαντική σχέση ανάμεσα στα επίπεδα των οξειδίων του αζώτου και των αιωρούμενων σωματιδίων στη θνησιμότητα από αναπνευστικά αίτια. Επιβαρυντική επίδραση στη θνησιμότητα από αναπνευστικά αίτια είχε η έκθεση σε αυξημένο φόρτο κυκλοφορίας οχημάτων, αλλά το αποτέλεσμα δεν είναι στατιστικά σημαντικό. Η παρούσα διατριβή αποτελεί τη μεγαλύτερη Ευρωπαϊκή μελέτη. Ο σχεδιασμός της μελέτης υπερβαίνει τους περιορισμούς των προηγούμενων μελετών, εξαιτίας του μεγάλου μεγέθους δείγματος ατόμων, της κάλυψης σε μεγάλη γεωγραφική κλίμακα και εξαιτίας της προσαρμογής για πλήθος πιθανών συγχυτικών παραγόντων