title: Spatial variation in nitrogen dioxide concentrations and cardiopulmonary hospital admissions.
abstract: BACKGROUND
  Air pollution episodes are associated with increased cardiopulmonary hospital admissions. Cohort studies showed associations of spatial variation in traffic-related air pollution with respiratory and cardiovascular mortality. Much less is known in particular about associations with cardiovascular morbidity. We explored the relation between spatial variation in nitrogen dioxide (NO2) concentrations and cardiopulmonary hospital admissions.
  
  
  METHODS
  This ecological study was based on hospital admissions data (2001-2004) from the National Medical Registration and general population data for the West of the Netherlands (population 4.04 million). At the 4-digit postcode area level (n=683) associations between modeled annual average outdoor NO2concentrations and hospital admissions for respiratory and cardiovascular causes were evaluated by linear regression with the log of the postcode-specific percentage of subjects that have been admitted at least once during the study period as the dependent variable. All analyses were adjusted for differences in composition of the population of the postcode areas (age, sex, income).
  
  
  RESULTS
  At the postcode level, positive associations were found between outdoor NO2concentrations and hospital admission rates for asthma, chronic obstructive pulmonary disease (COPD), all cardiovascular causes, ischemic heart disease and stroke (e.g. adjusted relative risk (95% confidence interval) for the second to fourth quartile relative to the first quartile of exposure were 1.87 (1.46-2.40), 2.34 (1.83-3.01) and 2.81 (2.16-3.65) for asthma; 1.44 (1.19-1.74), 1.50 (1.24-1.82) and 1.60 (1.31-1.96) for COPD). Associations remained after additional (indirect) adjustment for smoking (COPD admission rate) and degree of urbanization.
  
  
  CONCLUSIONS
  Our study suggests an increased risk of hospitalization for respiratory and cardiovascular causes in areas with higher levels of NO2. Our findings add to the currently limited evidence of a long-term effect of air pollution on hospitalization. The ecological design of our study is a limitation and more studies with individual data are needed to confirm our findings.
authors.affiliation: Public Health Service (GGD) Amsterdam, Department of Environmental Health, Amsterdam, The Netherlands; Institute for Risk Assessment Sciences (IRAS), Division Environmental Epidemiology, Utrecht University, Utrecht, The Netherlands.
authors.forename: Marieke B A
authors.initials: MBA
authors.lastname: Dijkema
authors.affiliation: Public Health Service (GGD) Amsterdam, Department of Environmental Health, Amsterdam, The Netherlands.
authors.forename: Robert T
authors.initials: RT
authors.lastname: van Strien
authors.affiliation: Public Health Service (GGD) Amsterdam, Department of Environmental Health, Amsterdam, The Netherlands.
authors.forename: Saskia C
authors.initials: SC
authors.lastname: van der Zee
authors.affiliation: Public Health Service (GGD) Amsterdam, Department of Environmental Health, Amsterdam, The Netherlands.
authors.forename: Sanne F
authors.initials: SF
authors.lastname: Mallant
authors.affiliation: National Institute for Public Health and the Environment (RIVM), Centre for Environmental Health, Bilthoven, The Netherlands.
authors.forename: Paul
authors.initials: P
authors.lastname: Fischer
authors.affiliation: Institute for Risk Assessment Sciences (IRAS), Division Environmental Epidemiology, Utrecht University, Utrecht, The Netherlands.
authors.forename: Gerard
authors.initials: G
authors.lastname: Hoek
authors.affiliation: Institute for Risk Assessment Sciences (IRAS), Division Environmental Epidemiology, Utrecht University, Utrecht, The Netherlands; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: Bert
authors.initials: B
authors.lastname: Brunekreef
authors.affiliation: Institute for Risk Assessment Sciences (IRAS), Division Environmental Epidemiology, Utrecht University, Utrecht, The Netherlands. Electronic address: u.gehring@uu.nl.
authors.forename: Ulrike
authors.initials: U
authors.lastname: Gehring
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000393:Air Pollutants / Q000032:analysis* / Q000633:toxicity; D002318:Cardiovascular Diseases / Q000139:chemically induced / Q000453:epidemiology* / Q000628:therapy; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D005260:Female; D006801:Humans; D007223:Infant; D019570:Inhalation Exposure / Q000009:adverse effects / Q000032:analysis*; D008297:Male; D008875:Middle Aged; D009426:Netherlands / Q000453:epidemiology; D009585:Nitrogen Dioxide / Q000032:analysis* / Q000633:toxicity; D010343:Patient Admission / Q000706:statistics & numerical data*; D012140:Respiratory Tract Diseases / Q000139:chemically induced / Q000453:epidemiology* / Q000628:therapy; D062206:Spatial Analysis; D014507:Urbanization; D001335:Vehicle Emissions / Q000032:analysis / Q000633:toxicity; D055815:Young Adult
chemical_list: D000393:Air Pollutants; D001335:Vehicle Emissions; D009585:Nitrogen Dioxide
keywords: Air pollution; Cardiovascular; Hospital admission; Nitrogen dioxide; Respiratory