title: Season, sex, age, and education as modifiers of the effects of outdoor air pollution on daily mortality in Shanghai, China: The Public Health and Air Pollution in Asia (PAPA) Study.
abstract: BACKGROUND
  Various factors can modify the health effects of outdoor air pollution. Prior findings about modifiers are inconsistent, and most of these studies were conducted in developed countries.
  
  
  OBJECTIVE
  We conducted a time-series analysis to examine the modifying effect of season, sex, age, and education on the association between outdoor air pollutants [particulate matter < 10 microm in aerodynamic diameter (PM(10)), sulfur dioxide, nitrogen dioxide, and ozone] and daily mortality in Shanghai, China, using 4 years of daily data (2001-2004).
  
  
  METHODS
  Using a natural spline model to analyze the data, we examined effects of air pollution for the warm season (April-September) and cool season (October-March) separately. For total mortality, we examined the association stratified by sex and age. Stratified analysis by educational attainment was conducted for total, cardiovascular, and respiratory mortality.
  
  
  RESULTS
  Outdoor air pollution was associated with mortality from all causes and from cardiorespiratory diseases in Shanghai. An increase of 10 mug/m(3) in a 2-day average concentration of PM(10), SO(2), NO(2), and O(3) corresponds to increases in all-cause mortality of 0.25% [95% confidence interval (CI), 0.14-0.37), 0.95% (95% CI, 0.62-1.28), 0.97% (95% CI, 0.66-1.27), and 0.31% (95% CI, 0.04-0.58), respectively. The effects of air pollutants were more evident in the cool season than in the warm season, and females and the elderly were more vulnerable to outdoor air pollution. Effects of air pollution were generally greater in residents with low educational attainment (illiterate or primary school) compared with those with high educational attainment (middle school or above).
  
  
  CONCLUSIONS
  Season, sex, age, and education may modify the health effects of outdoor air pollution in Shanghai. These findings provide new information about the effects of modifiers on the relationship between daily mortality and air pollution in developing countries and may have implications for local environmental and social policies.
authors.affiliation: Department of Environmental Health, School of Public Health, Fudan University, Shanghai, China. haidongkan@gmail.com
authors.forename: Haidong
authors.initials: H
authors.lastname: Kan
authors.forename: Stephanie J
authors.initials: SJ
authors.lastname: London
authors.forename: Guohai
authors.initials: G
authors.lastname: Chen
authors.forename: Yunhui
authors.initials: Y
authors.lastname: Zhang
authors.forename: Guixiang
authors.initials: G
authors.lastname: Song
authors.forename: Naiqing
authors.initials: N
authors.lastname: Zhao
authors.forename: Lili
authors.initials: L
authors.lastname: Jiang
authors.forename: Bingheng
authors.initials: B
authors.lastname: Chen
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D000368:Aged; D000397:Air Pollution; D002648:Child; D002675:Child, Preschool; D002681:China; D004522:Educational Status; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011634:Public Health; D012621:Seasons; D012737:Sex Factors
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