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Special FeaturesAir Pollution and Noncommunicable Diseases: A Review by the Forum of International Respiratory Societies’ Environmental Committee, Part 2: Air Pollution and Organ Systems
Introduction
This second of a two-part report describes specific conditions associated with air pollution. The conditions are listed alphabetically. In addition to the text, Figure 1 presents associated organ systems, and Table 1 shows other effects of air pollution that are generally not associated with specific organs. It is important to note that for many of the diseases, the associations with exposures to air pollution in observational epidemiologic studies are not causal and may be subject to residual confounding due to other factors, such as smoking, lower socioeconomic status, and neighborhood factors. However, exposure dose and time relationships and animal studies corroborate and add strength to the conclusions from the epidemiologic studies.
Section snippets
Allergic Sensitization and Rhinitis
It is well established that air pollution can exacerbate allergic responses in sensitized persons.1 Clinical epidemiologic studies show that ambient air pollution may also enhance allergic sensitization in children and increase IgE levels in the very young.2
There is considerable evidence that air pollution plays a role in both the development and the exacerbation of allergic rhinitis. A study of preschool-aged children found that exposure to traffic-related air pollution prenatally and in early
Bone Diseases
Environmental factors play a role in bone density and mineralization. To evaluate the effect of air pollution on bone structure and function, an analysis of > 9 million US Medicare enrollees found that osteoporosis-related bone fractures were statistically more common in areas of higher ambient PM2.5 concentrations. The effect was greater when only low-income communities were included in a sensitivity analysis.8
The same investigators studied 692 middle-aged men with low incomes from the Boston
Cancers
Outdoor air pollution has been classified as carcinogenic to humans by the International Agency for Research on Cancer based on evidence from epidemiologic and animal studies and mechanistic data.12 Many studies have shown an association between exposure to PM2.5 and particulate matter with an aerodynamic diameter < 10 μm (PM10) and risk of lung cancer.13 In addition, NO2 and ozone (O3) levels have been experimentally linked to cellular changes related to neoplasia: altered telomere length,
Cardiovascular Diseases
Particulate air pollution has been strongly associated with an increased risk of cardiovascular disease mortality, myocardial infarction, stroke, and hospital admission for congestive heart failure25 and has been estimated to account for 19% of all cardiovascular deaths, 23% of all ischemic heart disease deaths, and 21% of all stroke deaths.26 A 10 μg/m3 increase in PM2.5 in a 2-day period was associated with an approximately 2% increase in myocardial infarctions and hospital admissions for
Cognitive Function and Neurologic Diseases
Air pollution has deleterious effects on the CNS, including impairment of cognitive function and increased risk of dementia and stroke in older adults. A Canadian study of 4.4 million people showed that the risk of dementia was correlated in a “dose-dependent” manner with distance from a major roadway. People living within 50 meters had a hazard ratio of 1.07, whereas those living 50 to 100 meters away had a hazard ratio of 1.04, and those living 101 to 200 meters away had a hazard ratio of
Diabetes, Obesity, and Endocrine Diseases
Evidence from several studies links air pollution and type 2 diabetes mellitus.51 PM2.5 and NO2 exposures are associated with prevalence of diabetes and increased glycosylated hemoglobin levels among both diabetic and nondiabetic individuals.52 There is also a higher morbidity and mortality related to ambient air pollution among patients with diabetes.53 Several studies have described increased risk for metabolic syndrome in adults exposed to high ambient PM10.54 It seems that air pollution
Eye Diseases
Tearing and ocular irritation may occur as a reaction to visible haze, and this finding is often worse for contact lens wearers. Conjunctivitis is most associated with O3 and NO2 exposure, although PM10 and SO2 are also correlated.61 Cataract formation has been described in women exposed to household air pollution in low-income countries.62 O3 levels and decreased humidity have been associated with dry eye disease.63 Air pollution, specifically PM and CO, have been associated with acute
GI Diseases
Although less investigated, air pollution has been linked to several GI conditions, including inflammatory bowel disease, enteritis, gastric ulcer, and appendicitis. A case-control study of chronic pollution exposure in the United Kingdom found that younger individuals were more likely to have Crohn's disease if they lived in areas with high NO2 or SO2 levels, although there was no overall association between exposure to air pollutants and risk of inflammatory bowel disease.65 Other studies,
Hematologic Diseases
It has been known since the 1970s that air pollution containing lead from gasoline causes anemia. Other pollutants released during fuel combustion may also contribute to hematologic disease, either by directly entering the bloodsteam following inhalation, or by activating inflammatory pathways in the lung that then result in intravascular inflammation. PM2.5 promotes an imbalanced coagulative state through platelet and endothelial activation by inflammatory cytokines.70 These increase the risk
Liver Diseases
Living near a major roadway, which is associated with increased air pollution, is linked to an increased prevalence of hepatic steatosis.77 There are several potential reasons for this link as air pollution has many damaging effects on liver cells through inflammatory mediators, genotoxicity, mitochondrial damage, and damage to other organs, which affect the liver secondarily.78 The liver is the main detoxifying organ, and a variety of substances that enter the body, including toxic components
Renal Diseases
The kidney, a highly vascular organ, is vulnerable to both large and small vessel dysfunction and is therefore likely to be susceptible to the oxidative stress and systemic inflammatory effects of air pollution exposure. Animal models have shown that breathing diesel exhaust fumes exacerbates chronic renal failure by worsening renal oxidative stress, inflammation, and DNA damage.82 Living closer to a major highway has been found to be associated with a lower estimated glomerular filtration rate
Respiratory Diseases
The respiratory tract is the main organ affected by air pollution and the most studied: there are more than 13,000 entries in PubMed for air pollution and respiratory disease. Ambient air pollution is estimated to cause the death of > 800,000 persons from COPD and 280,000 persons from lung cancer.85 Indoor air pollution is estimated to cause the death of > 750,000 persons from COPD and 300,000 persons from lung cancer,86, 87 making the toll for both forms of air pollution 1.6 million deaths for
Skin Diseases
Several biologic parameters affecting skin quality are influenced by pollution, such as change in sebum excretion rate and composition, level of carbonylated proteins in the stratum corneum, and a higher erythematous index on the face of highly exposed subjects.102 The change in sebum may be a cause for increased acne occurring with air pollution.103
Several skin diseases have been associated with air pollution. A multicenter study found that air pollution was associated with a higher frequency
The Role of the Health-Care Provider
Assessing exposure by primary care providers may be difficult because the source of air pollution varies between communities and within household situations. Studies on indoor air pollution use extensive surveys to report on smoke exposure, burning conditions, and symptoms during cooking and household work. Research on outdoor air pollution relies on monitoring of the individual pollutants by sophisticated means, including personal monitors. For primary care health-care providers, simply asking
Summary and Resolve
Air pollution is one of the most important avoidable risks to health globally. Air pollution has been termed the “silent killer” by the World Health Organization113 because its effects often go unnoticed or are not easily measured. Even when there is organ harm, it is usually attributed to an unknown or chance malfunction of that organ. Although the lungs have been the most studied organ, air pollution affects most systems. Many studies have found harmful effects of air pollution on a continuum
Acknowledgments
Financial/nonfinancial disclosures: None declared.
Other contributions: Laura Feldman, MPH, contributed content regarding maternal exposure to air pollution and adverse effects on fetal health.
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FUNDING/SUPPORT: The contribution by G. D. T. was supported in part by a National Institute of Environmental Health Sciences Center grant [Grant E500260] to the New York University School of Medicine.