Final Report: Multiple Pollutants and Risk of Emergency Department Visits for Cardiorespiratory Outcomes in Atlanta

EPA Grant Number: R829213
Title: Multiple Pollutants and Risk of Emergency Department Visits for Cardiorespiratory Outcomes in Atlanta
Investigators: Tolbert, Paige , Flanders, Dana , Klein, Mitchel , Lyles, Robert , Metzger, Kristina , Mulholland, James , Peel, Jennifer , Russell, Armistead G. , Ryan, P. Barry , Sarnat, Stefanie Ebelt , Sarnat, Jeremy , Todd, Knox , Waller, Lance
Institution: Emory University
EPA Project Officer: Chung, Serena
Project Period: January 1, 2002 through December 31, 2004 (Extended to December 31, 2006)
Project Amount: $1,238,940
RFA: Health Effects of Particulate Matter (2001) RFA Text |  Recipients Lists
Research Category: Air Quality and Air Toxics , Particulate Matter , Health Effects , Air

Objective:

In this project, roles of specific air contaminants, and inter-relationships among them, in producing acute exacerbations of certain cardiac and respiratory conditions were investigated. To do this, the study period of an ongoing epidemiologic study was doubled and multi-pollutant questions in the resulting unique and powerful database were addressed. The study is a time-series investigation of cardiac and respiratory emergency department (ED) visits in relation to daily measures of air quality, including detailed measurements of particulate matter (PM) components being conducted at the station being operated for the Aerosol Research and Inhalation Epidemiology Study (ARIES) in downtown Atlanta. The study period for the previous epidemiologic study, part of the Study of Particulates and Health in Atlanta (SOPHIA) done in conjunction with ARIES, was August 1, 1998 through August 31, 2000. Operation of the ARIES station has been extended, and under this STAR grant we extended outcome data collection for this period and conducted epidemiologic analysis of the combined data. Outcome data were obtained from the 40 hospitals in the metro-Atlanta area participating in the SOPHIA study. Using the diagnostic codes for the visits, multiple cardiac and respiratory case groups were formed. For each group, time series analysis was performed to examine the relationship of pollutant levels to daily counts of the outcome. Pollutants of a priori interest measured at the ARIES station included: the criteria gaseous pollutants, oxygenated hydrocarbons, multiple size fractions of particulate matter -- including PM10, coarse PM, PM2.5, and selected components of PM2.5: sulfates, nitrates, acidity, water-soluble metals, elemental carbon, and organic matter. Control for co-pollutants and assessment of interactions among them was performed. In addition, the impact of spatial variability on the epidemiological results was assessed. With over one million ED visits per year, this study may be the largest study of its type (i.e., single-city ED study with speciated PM data). This investigation makes advances in disentangling effects of PM from the effects of other pollutants and contributes to our understanding of the effects of exposure to PM in the presence of other pollutants. Moreover, the detailed air quality data available to the investigators allowed assessment of the role of components of PM (e.g., sulfates, water-soluble metals) and size fractions in the multi-pollutant analysis. Finally, source apportionment methods were applied and the used in epidemiologic models.

Summary/Accomplishments (Outputs/Outcomes):

  • Completion of acquisition of emergency department data for the period 2000-2002 from metro-Atlanta hospitals. We compiled data on over one million emergency department visits for each year of the extended study period (2000-02). We received data from all of the 40 hospitals that were operating in the period 2000-02, a remarkable level of cooperation by the hospitals, particularly given the impact of the HIPAA’s enactment. Data from each hospital were comprehensively reviewed and edited.
  • Descriptive analysis of new air quality data. We have published descriptive spatial and temporal analyses of the air quality data for the extended period 2000-2002 assembled from the Air Quality System (AQS), ASACA, and the ARIES monitor (Wade, et al, 2006). These analyses provide insight regarding pollutant-specific representativeness of the central monitors, and information on measurement error (both instrument error and spatial heterogeneity). In addition, we have conducted intensive work on source apportionment of the available air quality data (Marmur, et al, 2005; Marmur, et al, 2006; Marmur, et al, submitted).
  • Epidemiologic analysis of the final database. We conducted extensive epidemiologic analysis of the relationships of air quality and cardiorespiratory counts in the final database (Metzger, et al, 2004; Peel, et al, 2005; Peel, et al, 2007; Tolbert, et al, in press). The primary approach entailed time series analysis of air pollutants of a priori interest and visits for specific cardiorespiratory conditions, controlling for long-term trends and meteorology. Further analyses have assessed alternative lag structures, meteorological control, subgroups defined by age, place of residence, and comorbid conditions, the impact of measurement error, as well as a variety of other questions. Multi-pollutant models have been performed (Tolbert, et al, in press) and a case-crossover methodology has been applied as well (Tolbert, et al, manuscript in preparation). Spatial subanalyses of the health outcome data making use of the descriptive spatial analyses by Wade et al, 2006, above, have been performed (Sarnat S, et al, manuscript in preparation). In addition, output from the source apportionment performed above (Marmur, et al, 2005; Marmur, et al, 2006; Marmur, et al, submitted) has been used in epidemiologic models (Sarnat J, et al, manuscript in preparation).
  • Work on methodological issues. Our group was one of two groups to independently note and report the problem of underestimated variances associated with GAM software (Flanders, et al, 2002; Klein, et al, 2002; Flanders, et al, 2005). We have also conducted extensive work on modeling issues relating to the time series air pollution analyses. This work assists in optimizing our modeling approach used in the analysis of the study data, as well as having applications to other similar studies.

Conclusions:

Using our a priori modeling approach in single-pollutant models, emergency visits for all cardiovascular diseases combined were associated with: NO2, CO, PM2.5 elemental carbon, PM2.5 organic carbon. Cardiovascular subgroups, such as congestive heart failure and peripheral and cerebrovascular disease, were also associated with several of these pollutant measures. All respiratory disease visits were associated with: ozone, NO2, CO, and PM10. Upper respiratory infection visits were also associated with PM2.5 sulfate, and COPD with PM2.5 organic carbon. Associations with cardiovascular ED visits were generally stronger in the cold months, while associations with respiratory ED visits, especially asthma, were generally stronger in the warm months. Asthma visits were associated with the following pollutants in the warm months: ozone, NO2, coarse particles, PM2.5, PM2.5 metals, PM2.5 sulfate, PM2.5 organic carbon, PM2.5 elemental carbon. Distributed lag models indicated pollution had a more immediate effect on the cardiovascular disease outcomes than the respiratory outcomes with lag 0 and lag 1 being optimal for CVDs while the lag for asthma lasted over one week. Multipollutant models suggested robust associations of respiratory outcomes with ozone and CVD outcomes with CO, which may be operating as a surrogate for vehicular emissions. Results of the analysis of comorbid conditions suggest that people with atherosclerosis, COPD, hypertension and diabetes may be more susceptible to cardiovascular health effects of air pollution. Source apportionment models (zero-day lag) support an association of the CVD outcomes with PM2.5 mobile sources, as expected from the species-specific results, as well as with biomass burning; respiratory outcomes were associated with secondary sulfate. A large number of additional secondary analyses provide further insight regarding these findings.

Under this EPA STAR grant, we have conducted a powerful assessment of the relationship of particulate and gaseous air pollution constituents with emergency visits for specific cardiac and respiratory illnesses. These types of studies are critical to our understanding of the public health impacts of ambient pollution and provide the foundation on which federal air quality standards are based. This particular study complements the body of literature to date by providing an intensive assessment of components and characteristics of ambient urban pollution, and the size of the study allows examination of specific health outcomes rather than heterogeneous groupings.


Journal Articles on this Report : 29 Displayed | Download in RIS Format

Other project views: All 107 publications 31 publications in selected types All 29 journal articles
Type Citation Project Document Sources
Journal Article Alhanti BA, Chang HH, Winquist A, Mulholland JA, Darrow LA, Sarnat SE. Ambient air pollution and emergency department visits for asthma: a multi-city assessment of effect modification by age. Journal of Exposure Science & Environmental Epidemiology 2016;26(2):180-188. R829213 (Final)
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  • Journal Article Chen T, Sarnat SE, Grundstein AJ, Winquist A, Chang HH. Time-series analysis of heat waves and emergency department visits in Atlanta, 1993 to 2012. Environmental Health Perspectives 2017;125(5):057009 (9 pp.). R829213 (Final)
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  • Journal Article Darrow LA, Klein M, Sarnat JA, Mulholland JA, Strickland MJ, Sarnat SE, Russell AG, Tolbert PE. The use of alternative pollutant metrics in time-series studies of ambient air pollution and respiratory emergency department visits. Journal of Exposure Science & Environmental Epidemiology 2011;21(1):10-19. R829213 (Final)
    R833626 (Final)
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  • Journal Article Flanders WD, Klein M, Tolbert P. A new variance estimator for parameters of semiparametric generalized additive models. Journal of Agricultural, Biological, and Environmental Statistics 2005;10(2):246-257. R829213 (2002)
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  • Journal Article Goldman GT, Mulholland JA, Russell AG, Strickland MJ, Klein M, Waller LA, Tolbert PE. Impact of exposure measurement error in air pollution epidemiology: effect of error type in time-series studies. Environmental Health 2011;10:61 (11 pp.). R829213 (Final)
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  • Journal Article Goldman GT, Mulholland JA, Russell AG, Gass K, Strickland MJ, Tolbert PE. Characterization of ambient air pollution measurement error in a time-series health study using a geostatistical simulation approach. Atmospheric Environment 2012;57:101-108. R829213 (Final)
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  • Journal Article Grundstein A, Sarnat SE, Klein M, Shepherd M, Naeher L, Mote T, Tolbert P. Thunderstorm associated asthma in Atlanta, Georgia. Thorax 2008;63(7):659-660. R829213 (Final)
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  • Journal Article Heidari L, Winquist A, Klein M, O’Lenick CR, Grundstein A, Sarnat SE. Susceptibility to heat-related fluid and electrolyte imbalance emergency department visits in Atlanta, Georgia, USA. International Journal of Environmental Research and Public Health 2016;13(10):982 (17 pp.). R829213 (Final)
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  • Journal Article Kim JY, Burnett RT, Neas L, Thurston GD, Schwartz J, Tolbert PE, Brunekreef B, Goldberg MS, Romieu I. Panel discussion review: session two--interpretation of observed associations between multiple ambient air pollutants and health effects in epidemiologic analyses. Journal of Exposure Science and Environmental Epidemiology 2007;17(Suppl 2):S83-S89. R829213 (Final)
    R833293 (2008)
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  • Journal Article Krall JR, Mulholland JA, Russell AG, Balachandran S, Winquist A, Tolbert PE, Waller LA, Sarnat SE. Associations between source-specific fine particulate matter and emergency department visits for respiratory disease in four U.S. cities. Environmental Health Perspectives 2017;125(1):97-103. R829213 (Final)
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  • Journal Article Marmur A, Unal A, Mulholland JA, Russell AG. Optimization-based source apportionment of PM2.5 incorporating gas-to-particle ratios. Environmental Science & Technology 2005;39(9):3245-3254. R829213 (2006)
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  • Journal Article Marmur A, Park S-K, Mulholland JA, Tolbert PE, Russell AG. Source apportionment of PM2.5 in the southeastern United States using receptor and emissions-based models:conceptual differences and implications for time-series health studies. Atmospheric Environment 2006;40(14):2533-2551. R829213 (Final)
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  • Journal Article Marmur A, Mulholland JA, Russell AG. Optimized variable source-profile approach for source apportionment. Atmospheric Environment 2007;41(3):493-505. R829213 (Final)
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  • Journal Article Metzger KB, Tolbert PE, Klein M, Peel JL, Flanders WD, Todd K, Mulholland JA, Ryan PB, Frumkin H. Ambient air pollution and cardiovascular emergency department visits. Epidemiology 2004;15(1):46-56. R829213 (2003)
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  • Journal Article O'Lenick CR, Winquist A, Mulholland JA, Friberg MD, Chang HH, Kramer MR, Darrow LA, Sarnat SE. Assessment of neighbourhood-level socioeconomic status as a modifier of air pollution-asthma associations among children in Atlanta. Journal of Epidemiology and Community Health 2017;71(2):129-136. R829213 (Final)
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  • Journal Article O’Lenick CR, Chang HH, Kramer MR, Winquist A, Mulholland JA, Friberg MD, Sarnat SE. Ozone and childhood respiratory disease in three US cities: evaluation of effect measure modification by neighborhood socioeconomic status using a Bayesian hierarchical approach. Environmental Health 2017;16(1):36 (15 pp.). R829213 (Final)
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  • Journal Article Peel JL, Tolbert PE, Klein M, Metzger KB, Flanders WD, Todd K, Mulholland JA, Ryan PB, Frumkin H. Ambient air pollution and respiratory emergency department visits. Epidemiology 2005;16(2):164-174. R829213 (2003)
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  • Journal Article Peel JL, Metzger KB, Klein M, Flanders WD, Mulholland JA, Tolbert PE. Ambient air pollution and cardiovascular emergency department visits in potentially sensitive groups. American Journal of Epidemiology 2007;165(6):625-633. R829213 (Final)
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  • Journal Article Sarnat JA, Marmur A, Klein M, Kim E, Russell AG, Sarnat SE, Mulholland JA, Hopke PK, Tolbert PE. Fine particle sources and cardiorespiratory morbidity: an application of chemical mass balance and factor analytical source-apportionment methods. Environmental Health Perspectives 2008;116(4):459-466. R829213 (Final)
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  • Journal Article Sarnat SE, Klein M, Sarnat JA, Flanders WD, Waller LA, Mulholland JA, Russell AG, Tolbert PE. An examination of exposure measurement error from air pollutant spatial variability in time-series studies. Journal of Exposure Science and Environmental Epidemiology 2010;20(2):135-146. R829213 (Final)
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  • Journal Article Strickland MJ, Darrow LA, Klein M, Flanders WD, Sarnat JA, Waller LA, Sarnat SE, Mulholland JA, Tolbert PE. Short-term associations between ambient air pollutants and pediatric asthma emergency department visits. American Journal of Respiratory and Critical Care Medicine 2010;182(3):307-316. R829213 (Final)
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  • Journal Article Strickland MJ, Darrow LA, Mulholland JA, Klein M, Flanders WD, Winquist A, Tolbert PE. Implications of different approaches for characterizing ambient air pollutant concentrations within the urban airshed for time-series studies and health benefits analyses. Environmental Health 2011;10:36 (9 pp.). R829213 (Final)
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  • Journal Article Tinker SC, Moe CL, Klein M, Flanders WD, Uber J, Amirtharajah A, Singer P, Tolbert PE. Drinking water turbidity and emergency department visits for gastrointestinal illness in Atlanta, 1993-2004. Journal of Exposure Science & Environmental Epidemiology 2010;20(1):19-28. R829213 (Final)
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  • Journal Article Tolbert PE, Klein M, Peel JL, Sarnat SE, Sarnat JA. Multipollutant modeling issues in a study of ambient air quality and emergency department visits in Atlanta. Journal of Exposure Science & Environmental Epidemiology 2007;17(Suppl 2):S29-S35. R829213 (Final)
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  • Journal Article Tolbert PE. Invited commentary: Heterogeneity of particulate matter health risks. American Journal of Epidemiology 2007;166(8):889-891. R829213 (Final)
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  • Journal Article Wade KS, Mulholland JA, Marmur A, Russell AG, Hartsell B, Edgerton E, Klein M, Waller L, Peel JL, Tolbert PE. Effects of instrument precision and spatial variability on the assessment of the temporal variation of ambient air pollution in Atlanta, Georgia. Journal of the Air & Waste Management Association 2006;56(6):876-888. R829213 (2006)
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  • Journal Article Wannemuehler KA, Lyles RH, Waller LA, Hoekstra RM, Klein M, Tolbert P. A conditional expectation approach for associating ambient air pollutant exposures with health outcomes. Environmetrics 2009;20(7):877-894. R829213 (Final)
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  • Journal Article Winquist A, Grundstein A, Chang HH, Hess J, Sarnat SE. Warm season temperatures and emergency department visits in Atlanta, Georgia. Environmental Research 2016;147:314-323. R829213 (Final)
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  • Journal Article Ye D, Klein M, Mulholland JA, Russell AG, Weber R, Edgerton ES, Chang HH, Sarnat JA, Tolbert PE, Sarnat SE. Estimating acute cardiovascular effects of ambient PM2.5 metals. Environmental Health Perspectives 2018;126:027007 (10 pp.). R829213 (Final)
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  • Supplemental Keywords:

    ambient air, exposure, risk, health effects, human health, population, sensitive populations, children, elderly, dose-response, chemicals, particulates, VOC, metals, nitrogen oxides, sulfates, organics, public policy, socioeconomic, epidemiology, modeling, Georgia, GA, RFA, Health, Scientific Discipline, PHYSICAL ASPECTS, Air, Geographic Area, particulate matter, air toxics, Health Risk Assessment, Epidemiology, State, Risk Assessments, Susceptibility/Sensitive Population/Genetic Susceptibility, Southeast, Disease & Cumulative Effects, Environmental Monitoring, Physical Processes, genetic susceptability, tropospheric ozone, ambient air quality, asthma, elderly adults, health effects, particulates, PM10, risk, sensitive populations, Nitrogen Oxides, air pollutants, effects assessment, health risks, PM 2.5, stratospheric ozone, multiple acute exposure, exposure and effects, acute cardiovascular effects, airway disease, ambient air, ambient measurement methods, exposure, pulmonary disease, VOCs, Georgia (GA), Atlanta, Georgia, COPD, air pollution, children, modeling, cardiopulmonary response, human exposure, inhalation, public health, pulmonary, clinical studies, Acute health effects, ecological risk, elderly, inhaled, sensitive subgroups, ambient particulates, Aerosol Research and Inhalation Epidemiology Study (ARIES), aerosol, cardiopulmonary, cardiotoxicity, inhaled particles, nitrogen oxides (Nox), Volatile Organic Compounds (VOCs), human health, measurement methods , Study of Particulates and Health in Atlanta (SOPHIA), human health risk, metals, cardiopulmonery responses, toxics, environmental hazard exposures

    Progress and Final Reports:

    Original Abstract
  • 2002 Progress Report
  • 2003 Progress Report
  • 2004
  • 2005 Progress Report