Association between ambient air pollution and daily hospital admissions for ischemic stroke: a nationwide time-series analysis
Open accessAbstract
BACKGROUND: Evidence of the short-term effects of ambient air pollution on the risk of ischemic stroke in low- and middle-income countries is limited and inconsistent. We aimed to examine the associations between air pollution and daily hospital admissions for ischemic stroke in China. METHODS AND FINDINGS: We identified hospital admissions for ischemic stroke in 2014-2016 from the national database covering up to 0.28 billion people who received Urban Employee Basic Medical Insurance (UEBMI) in China. We examined the associations between air pollution and daily ischemic stroke admission using a two-stage method. Poisson time-series regression models were firstly fitted to estimate the effects of air pollution in each city. Random-effects meta-analyses were then conducted to combine the estimates. Meta-regression models were applied to explore potential effect modifiers. More than 2 million hospital admissions for ischemic stroke were identified in 172 cities in China. In single-pollutant models, increases of 10 μg/m3 in particulate matter with aerodynamic diameter <2.5 μm (PM2.5), sulfur dioxide (SO2), nitrogen dioxide (NO2), and ozone (O3) and 1 mg/m3 in carbon monoxide (CO) concentrations were associated with 0.34% (95% confidence interval [CI], 0.20%-0.48%), 1.37% (1.05%-1.70%), 1.82% (1.45%-2.19%), 0.01% (-0.14%-0.16%), and 3.24% (2.05%-4.43%) increases in hospital admissions for ischemic stroke on the same day, respectively. SO2 and NO2 associations remained significant in two-pollutant models, but not PM2.5 and CO associations. The effect estimates were greater in cities with lower air pollutant levels and higher air temperatures, as well as in elderly subgroups. The main limitation of the present study was the unavailability of data on individual exposure to ambient air pollution. CONCLUSIONS: As the first national study in China to systematically examine the associations between short-term exposure to ambient air pollution and ischemic stroke, our findings indicate that transient increase in air pollution levels may increase the risk of ischemic stroke, which may have significant public health implications for the reduction of ischemic stroke burden in China.
The claims and statistics of this paper haven’t been checked yet.
Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.
Integrity signals
Registry
Cites
Statistics
Claims the paper makes
The claims and statistics of this paper haven’t been checked yet.
Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
On high ozone days, there have been increased school absences, increased visits to emergency rooms, and increased hospital admissions.
“On high ozone days, there have been increased school absences, increased visits to emergency rooms, and increased hospital admissions (27–30).”
From Ozone pollution: A Major health hazard worldwide (2019) · cites this paper as [30]
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
The self-check needs the paper’s full text.
Cites
Health Effects of Fine Particulate Air Pollution: Lines that Connect
Pope, C. A., & Dockery, D. W. (2006) · Journal of the Air & Waste Management Association · doi:10.1080/10473289.2006.10464485 · Cited by 6,680 · see citing works
Brook, R. D., Rajagopalan, S., Pope, C. A., Brook, J. R., Bhatnagar, A., Diez-Roux, A. V., Holguin, F., Hong, Y., Luepker, R. V., Mittleman, M. A., et al. (2010) · Circulation · doi:10.1161/cir.0b013e3181dbece1 · Cited by 6,548 · see citing works
Interaction revisited: the difference between two estimates.
Altman, D. G., & Bland, J. M. (2003) · BMJ · doi:10.1136/bmj.326.7382.219 · Cited by 3,203 · see citing works
Fine Particulate Air Pollution and Hospital Admission for Cardiovascular and Respiratory Diseases
Dominici, F., Peng, R. D., Bell, M. L., Pham, L. D., McDermott, A., Zeger, S. L., & Samet, J. M. (2006) · JAMA · doi:10.1001/jama.295.10.1127 · Cited by 2,640 · see citing works
Feigin, V. L., Norrving, B., & Mensah, G. A. (2017) · Circulation Research · doi:10.1161/circresaha.116.308413 · Cited by 2,184 · see citing works
Prevalence, Incidence, and Mortality of Stroke in China
Wang, W., Jiang, B., Sun, H., Ru, X., Sun, D., Wang, L., Wang, L., Jiang, Y., Yichong, L., Wang, Y., et al. (2017) · Circulation · doi:10.1161/circulationaha.116.025250 · Cited by 1,985 · see citing works
Chen, Y., Ebenstein, A. Y., Greenstone, M., & Li, H. (2013) · Proceedings of the National Academy of Sciences · doi:10.1073/pnas.1300018110 · Cited by 1,828 · see citing works
Feigin, V. L., Roth, G. A., Naghavi, M., Parmar, P., Krishnamurthi, R., Chugh, S., Mensah, G. A., Norrving, B., Shiue, I., Ng, M., et al. (2016) · The Lancet Neurology · doi:10.1016/s1474-4422(16)30073-4 · Cited by 1,691 · see citing works
Short term exposure to air pollution and stroke: systematic review and meta-analysis
Shah, A. S. V., Lee, K. K., McAllister, D. A., Hunter, A., Nair, H., Whiteley, W., Langrish, J. P., Newby, D. E., & Mills, N. L. (2015) · BMJ · doi:10.1136/bmj.h1295 · Cited by 870 · see citing works
Fine Particulate Air Pollution and Daily Mortality. A Nationwide Analysis in 272 Chinese Cities
Chen, R., Yin, P., Meng, X., Liu, C., Wang, L., Xu, X., Ross, J. A., Tse, L. A., Zhao, Z., Kan, H., et al. (2017) · American Journal of Respiratory and Critical Care Medicine · doi:10.1164/rccm.201609-1862oc · Cited by 751 · see citing works
Self-citationEbenstein, A. Y., Fan, M., Greenstone, M., He, G., & Zhou, M. (2017) · Proceedings of the National Academy of Sciences · doi:10.1073/pnas.1616784114 · Cited by 744 · see citing works
Ambient air pollution, climate change, and population health in China
Kan, H., Chen, R., & Tong, S. (2011) · Environment International · doi:10.1016/j.envint.2011.03.003 · Cited by 729 · see citing works
Characteristics of PM 2.5 speciation in representative megacities and across China
Yang, F., Tan, J., Zhao, Q., Du, Z.-Y., He, K., Ma, Y., Duan, F., Chen, G., & Zhao, Q. (2011) · Atmospheric chemistry and physics · doi:10.5194/acp-11-5207-2011 · Cited by 600 · see citing works
Meng, Q., Fang, H., Liu, X., Yuan, B., & Xu, J. (2015) · The Lancet · doi:10.1016/s0140-6736(15)00342-6 · Cited by 555 · see citing works
Chen, R., Kan, H., Chen, B., Huang, W. Y., Bai, Z., Song, G., Pan, G., & O. B. O. T. C. C. G. (2012) · American Journal of Epidemiology · doi:10.1093/aje/kwr425 · Cited by 430 · see citing works
Peng, R. D. (2008) · JAMA · doi:10.1001/jama.299.18.2172 · Cited by 405 · see citing works
Ambient ozone pollution and daily mortality: a nationwide study in 272 Chinese cities
Yin, P., Chen, R., Wang, L., Meng, X., Liu, C., Niu, Y., Lin, Z., Liu, Y., Liu, J., Qi, J., et al. (2017) · Environmental Health Perspectives · doi:10.1289/ehp1849 · Cited by 403 · see citing works
Gao, J., Wang, K., Wang, Y., et al. (2017) · Environmental Pollution · doi:10.1016/j.envpol.2017.10.123 · Cited by 371 · see citing works
Ambient Air Pollution and the Risk of Acute Ischemic Stroke
Wellenius, G. A. (2012) · Archives of Internal Medicine · doi:10.1001/archinternmed.2011.732 · Cited by 368 · see citing works
Wellenius, G. A., Schwartz, J. D., & Mittleman, M. A. (2005) · Stroke · doi:10.1161/01.str.0000189687.78760.47 · Cited by 362 · see citing works
Spatial and temporal trends in the mortality burden of air pollution in China: 2004–2012
Liu, M., Huang, Y., Ma, Z., et al. (2016) · Environment International · doi:10.1016/j.envint.2016.10.003 · Cited by 311 · see citing works
Effects of air pollutants on acute stroke mortality.
Hong, Y., Lee, J.-T., Kim, H., Ha, E., Schwartz, J. D., & Christiani, D. C. (2002) · Environmental Health Perspectives · doi:10.1289/ehp.02110187 · Cited by 305 · see citing works
Winter Heating or Clean Air? Unintended Impacts of China's Huai River Policy
Almond, D. V., Chen, Y., Greenstone, M., & Li, H. (2009) · American Economic Review · doi:10.1257/aer.99.2.184 · Cited by 302 · see citing works
Barnett, A. G., Williams, G. M., Schwartz, J. D., Best, T. L., Roiko, A. H., Petroeschevsky, A. L., & Simpson, R. W. (2006) · Environmental Health Perspectives · doi:10.1289/ehp.8674 · Cited by 294 · see citing works
Liu, C., Yin, P., Chen, R., Meng, X., Wang, L., Niu, Y., Lin, Z., Liu, Y., Liu, J., Qi, J., et al. (2018) · The Lancet Planetary Health · doi:10.1016/s2542-5196(17)30181-x · Cited by 206 · see citing works
Goldman, G. T., Mulholland, J. A., Russell, A. G., et al. (2011) · Environmental Health · doi:10.1186/1476-069x-10-61 · Cited by 197 · see citing works
Chen, Y., Ebenstein, A. Y., Greenstone, M. A., et al. (2013) · SSRN Electronic Journal · doi:10.2139/ssrn.2291154 · Cited by 192 · see citing works
Chen, R., Samoli, E., Wong, C.-M., Huang, W., Wang, Z., Chen, B., & Kan, H. (2012) · Environment International · doi:10.1016/j.envint.2012.04.008 · Cited by 178 · see citing works
Qian, Z. M., He, Q., Lin, H.-M., Kong, L., Bentley, C. M., Liu, W., & Zhou, D. (2008) · Environmental Health Perspectives · doi:10.1289/ehp.10847 · Cited by 168 · see citing works
Ambient air pollution and risk for ischemic stroke and transient ischemic attack
Lisabeth, L. D., Escobar, J. D., Dvonch, J. T., Sánchez, B. N., Majersik, J. J., Brown, D. L., Smith, M. A., & Morgenstern, L. B. (2008) · Annals of Neurology · doi:10.1002/ana.21403 · Cited by 166 · see citing works
Associations Between Ambient Nitrogen Dioxide and Daily Cause-specific Mortality
Chen, R., Yin, P., Meng, X., Wang, L., Liu, C., Niu, Y., Lin, Z., Liu, Y., Liu, J., Qi, J., et al. (2018) · Epidemiology · doi:10.1097/ede.0000000000000829 · Cited by 159 · see citing works
Wang, L., Liu, C., Meng, X., Niu, Y., Lin, Z., Liu, Y., Liu, J., Qi, J., You, J., Tse, L. A., et al. (2018) · Environment International · doi:10.1016/j.envint.2018.04.019 · Cited by 148 · see citing works
Particulate air pollution and mortality in 38 of China’s largest cities: time series analysis
Yin, P., He, G., Fan, M., Chiu, K. Y., Fan, M., Liu, C., Xue, A., Liu, T., Pan, Y., Mu, Q., et al. (2017) · BMJ · doi:10.1136/bmj.j667 · Cited by 140 · see citing works
Urban air pollution and emergency admissions for cerebrovascular diseases in Taipei, Taiwan
Chan, C., Chuang, K.-J., Chien, L.-C., Chen, W., & Chang, W. (2006) · European Heart Journal · doi:10.1093/eurheartj/ehi835 · Cited by 137 · see citing works
Costa, A. F., Hoek, G., Brunekreef, B., & de León, A. P. (2016) · Environmental Health Perspectives · doi:10.1289/ehp98 · Cited by 113 · see citing works
Thompson, S. G., Kaptoge, S., White, I. R., Wood, A., Perry, P., & Danesh, J. (2010) · International Journal of Epidemiology · doi:10.1093/ije/dyq063 · Cited by 110 · see citing works
Liu, H., Tian, Y., Xu, Y., Huang, Z., Huang, C., Hu, Y., & Zhang, J. (2017) · Environmental Pollution · doi:10.1016/j.envpol.2017.06.057 · Cited by 106 · see citing works
Self-citationLarrieu, S., Jusot, J., Blanchard, M., Prouvost, H., Declercq, C., Fabre, P., Pascal, L., Tertre, A. L., Wagner, V., & Rivière, S. (2007) · The Science of The Total Environment · doi:10.1016/j.scitotenv.2007.07.025 · Cited by 100 · see citing works
Seaton, A. (2003) · Thorax · doi:10.1136/thorax.58.12.1012 · Cited by 92 · see citing works
Huang, F., Luo, Y., Guo, Y., Tao, L., Xu, Q., Wang, C., Wang, A., Li, X., Guo, J. C., Yan, A., et al. (2016) · Journal of the American Heart Association · doi:10.1161/jaha.116.003437 · Cited by 91 · see citing works
Regel, S. J., & Achermann, P. (2011) · Environmental Health · doi:10.1186/1476-069x-10-10 · Cited by 87 · see citing works
Lanzinger, S., Schneider, A. E., Breitner, S., et al. (2016) · American Journal of Respiratory and Critical Care Medicine · doi:10.1164/rccm.201510-2042oc · Cited by 77 · see citing works
Fine Particulate Air Pollution and First Hospital Admissions for Ischemic Stroke in Beijing, China
Tian, Y., Xiang, X., Wu, Y., Cao, Y., Song, J., Sun, K., Liu, H., & Hu, Y. (2017) · Scientific Reports · doi:10.1038/s41598-017-04312-5 · Cited by 74 · see citing works
Self-citationEstimation of Short-Term Effects of Air Pollution on Stroke Hospital Admissions in Wuhan, China
Xiang, H., Mertz, K. J., Arena, V. C., Brink, L. L., Xu, X., Bi, Y., & Talbott, E. O. (2013) · PLoS ONE · doi:10.1371/journal.pone.0061168 · Cited by 69 · see citing works
Air Pollution Is Associated With Ischemic Stroke via Cardiogenic Embolism
Chung, J., Bang, O. Y., Ahn, K., Park, S.-S., Park, T. H., Kim, J. G., Ko, Y., Lee, S. J., Lee, K. B., Lee, J., et al. (2016) · Stroke · doi:10.1161/strokeaha.116.015428 · Cited by 67 · see citing works
Ambient Particulate Matter Concentrations and Hospitalization for Stroke in 26 Chinese Cities
Liu, H., Tian, Y., Xu, Y., & Zhang, J. (2017) · Stroke · doi:10.1161/strokeaha.116.016482 · Cited by 65 · see citing works
Self-citationEvolution and comparative assessment of ambient air quality standards in China
Zhao, B., Su, Y., He, S., et al. (2016) · Journal of Integrative Environmental Sciences · doi:10.1080/1943815x.2016.1150301 · Cited by 61 · see citing works
Liu, H., Tian, Y., Xiang, X., Juan, J., Song, J., Cao, Y., Huang, C., Li, M., & Hu, Y. (2018) · Epidemiology · doi:10.1097/ede.0000000000000869 · Cited by 60 · see citing works
Self-citationTian, L., Qiu, H., Pun, V. C., Ho, K., Chan, C. S., & Yu, I. T.-S. (2015) · International Journal of Cardiology · doi:10.1016/j.ijcard.2015.07.099 · Cited by 48 · see citing works
Gaseous Air Pollution and the Risk for Stroke Admissions: A Case-Crossover Study in Beijing, China
Huang, F., Luo, Y., Tan, P., Xu, Q., Tao, L., Guo, J., Zhang, F., Xie, X., & Guo, X. (2017) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph14020189 · Cited by 45 · see citing works
Liu, T., & He, G. (2017) · Cited by 9 · see citing works
Hahn, S., Williamson, P. R., Hutton, J. L., Garner, P., & Flynn, E. V. (2000) · Statistics in Medicine · doi:10.1002/1097-0258(20001230)19:24
Flagged first, then by citations
Cited by
Sorted by citations
Ozone pollution: A Major health hazard worldwide
Zhang, J. (., Wei, Y., & Fang, Z. (2019) · Frontiers in Immunology · doi:10.3389/fimmu.2019.02518 · Cited by 828 · see citing works
Gu, J., Shi, Y., Zhu, Y., Chen, N., Wang, H., Zhang, Z., & Chen, T. (2020) · PLOS Medicine · doi:10.1371/journal.pmed.1003188 · Cited by 184 · see citing works
Impact of long-term exposure to air pollution on cognitive decline in older adults without dementia
Park, S. Y., Han, J., Kim, S. H., Suk, H. W., Park, J. E., & Lee, D. Y. (2022) · Journal of Alzheimer's Disease · doi:10.3233/jad-215120 · Cited by 30 · see citing works
- Authors
- Tian, Y., Liu, H., Zhao, Z., Xiang, X., Li, M., Juan, J., Song, J., Cao, Y., Wang, X., Chen, L., Wei, C., Hu, Y., & Gao, P.
- Affiliations
- Peking University (CN)
- Corresponding author
- Hu, Yonghua
- Gao, Pei
- ORCID
- Venue
- PLoS Medicine
- Publisher
- Public Library of Science (PLoS)
- Published
- 2018-10-04
- Volume
- 15
- Issue
- 10
- Pages
- e1002668
- ISSN
- 1549-1277 (ISSN-L)
- 1549-1676
- PMC
- PMC6171821
- OpenAlex
- W2894986390
- Cited by
- 234
- References
- 52
- Citations by year
- 2026: 7 · 2025: 24 · 2024: 35 · 2023: 39 · 2022: 45 · 2021: 40 · 2020: 34 · 2019: 10
- FWCI
- 10.38
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- PLoS Medicine (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- RePEc: Research Papers in Economics (submittedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Figshare (submittedVersion, cc-by)
- Funders
- National Natural Science Foundation of China (91546120, 81473043, 71402003, 81230006)
- National Thousand Talents Program for Distinguished Young Scholars (QNQR201501)
- Topics
- Physical Sciences › Environmental Science › Health, Toxicology and Mutagenesis › Air Quality and Health Impacts
- Physical Sciences › Environmental Science › Health, Toxicology and Mutagenesis › Climate Change and Health Impacts
- Physical Sciences › Environmental Science › Health, Toxicology and Mutagenesis › Indoor Air Quality and Microbial Exposure
- Keywords
- ambient air pollution, ischemic stroke, hospitalization, short-term exposure, particulate matter PM2.5, sulfur dioxide, nitrogen dioxide, ozone, carbon monoxide, air temperature, older adults, China
- MeSH terms
- Adolescent, Adult, Aged, Air Pollutants, Air Pollution, Carbon Monoxide, Brain Ischemia, China, Cities, Female, Humans, Male, Middle Aged, Nitrogen Dioxide, Particle Size, Patient Admission, Sulfur Dioxide, Temperature, Time Factors, Databases, Factual, Stroke, Particulate Matter, Young Adult
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
Are you an author, or do you see a problem with this page? Request a review
