title: Short-term effects of air pollution on total and cardiovascular mortality: the confounding effect of influenza epidemics.
abstract: BACKGROUND
  Air pollution is associated with total mortality. This association may be confounded by uncontrolled time-varying risk factors such as influenza epidemics.
  
  
  METHODS
  We analyzed independent data on influenza epidemics from 7 European cities that also had data on mortality associated with particulates (PM10). We used 10 methods to control for epidemics (5 derived from influenza data and 5 from respiratory mortality series) and compared those results with analyses that did not control for these epidemics.
  
  
  RESULTS
  Adjustment for influenza epidemics increased the PM10 effect estimate in most cases (% change in the pooled regression coefficient: -1.9 to 38.9 for total mortality and 1.3 to 25.5 for cardiovascular mortality). A 10-microg/m increase in PM10 concentrations (lag 0-1) was associated with a 0.48% (95% confidence interval=0.27-0.70%) increase in daily mortality unadjusted for influenza epidemics, whereas under the various methods to control for epidemics the increase ranged from 0.45% (0.26-0.69%) to 0.67% (0.46-0.89%). The corresponding figures for cardiovascular mortality were 0.85% (0.53-1.18%) with no adjustment and from 0.86% (0.53-1.19%) to 1.06% (0.74-1.39%) with the methods of control.
  
  
  CONCLUSIONS
  The association between air pollution and mortality is not weakened by control for influenza epidemic irrespective of the method used. To adjust for influenza epidemics, one can use methods based on respiratory mortality counts instead of counts of influenza cases if the latter are not available. However, adjustment for influenza by any method tested did not markedly alter the air pollution effect estimate.
authors.affiliation: Department of Hygiene and Epidemiology, University of Athens Medical School, Athens, Greece. gtouloum@med.uoa.gr
authors.forename: Giota
authors.initials: G
authors.lastname: Touloumi
authors.forename: Evangelia
authors.initials: E
authors.lastname: Samoli
authors.forename: Philippe
authors.initials: P
authors.lastname: Quenel
authors.forename: Anna
authors.initials: A
authors.lastname: Paldy
authors.forename: Ross H
authors.initials: RH
authors.lastname: Anderson
authors.forename: Dennis
authors.initials: D
authors.lastname: Zmirou
authors.forename: Igancio
authors.initials: I
authors.lastname: Galan
authors.forename: Bertil
authors.initials: B
authors.lastname: Forsberg
authors.forename: Christian
authors.initials: C
authors.lastname: Schindler
authors.forename: Joel
authors.initials: J
authors.lastname: Schwartz
authors.forename: Klea
authors.initials: K
authors.lastname: Katsouyanni
mesh_terms: D000397:Air Pollution / Q000009:adverse effects*; D002318:Cardiovascular Diseases / Q000209:etiology / Q000401:mortality*; D004196:Disease Outbreaks; D004784:Environmental Monitoring; D062665:Epidemiological Monitoring; D005060:Europe / Q000453:epidemiology; D006801:Humans; D007251:Influenza, Human / Q000150:complications* / Q000453:epidemiology; D013997:Time Factors