title: Ambient PM2.5and Stroke: Effect Modifiers and Population Attributable Risk in Six Low- and Middle-Income Countries.
abstract: Short-term exposure to ambient fine particulate pollution (PM2.5) has been linked to increased stroke. Few studies, however, have examined the effects of long-term exposure.
  
  
  
  A total of 45 625 participants were interviewed and included in this study, the participants came from the Study on Global Ageing and Adult Health, a prospective cohort in 6 low- and middle-income countries. Ambient PM2.5levels were estimated for participants' communities using satellite data. A multilevel logistic regression model was used to examine the association between long-term PM2.5exposure and stroke. Potential effect modification by physical activity and consumption of fruit and vegetables was assessed.
  
  
  
  The odds of stroke were 1.13 (95% confidence interval, 1.04-1.22) for each 10 μg/m3increase in PM2.5. This effect remained after adjustment for confounding factors including age, sex, smoking, and indoor air pollution (adjusted odds ratio=1.12; 95% confidence interval, 1.04-1.21). Further stratified analyses suggested that participants with higher levels of physical activity had greater odds of stroke, whereas those with higher consumption of fruit and vegetables had lower odds of stroke. These effects remained robust in sensitivity analyses. We further estimated that 6.55% (95% confidence interval, 1.97%-12.01%) of the stroke cases could be attributable to ambient PM2.5in the study population.
  
  
  
  This study suggests that ambient PM2.5may increase the risk of stroke and may be responsible for the astounding stroke burden in low- and middle-income countries. In addition, greater physical activity may enhance, whereas greater consumption of fruit and vegetables may mitigate the effect.
authors.affiliation: From the Guangdong Provincial Institute of Public Health, Guangzhou, China (H.L., J.X., T.L., X.L., W.Z.,W.M.); Shanghai Municipal Centre for Disease Control and Prevention, China (Y.G., Y.Z., F.W.); Harvard T.H. Chan School of Public Health, Boston, MA (Q.D.); Department of Health Statistics and Information Systems, World Health Organization, WHO SAGE, Geneva, Switzerland (P.K.); University of Newcastle Research Centre on Gender, Health and Ageing, Australia (P.K.); Saint Louis University College for Public Health and Social Justice, Missouri (S.H., Z.Q.); Department of Epidemiology and Biostatistics, IU School of Public Health-Bloomington, Indiana (E.N.).
authors.forename: Hualiang
authors.initials: H
authors.lastname: Lin
authors.affiliation: From the Guangdong Provincial Institute of Public Health, Guangzhou, China (H.L., J.X., T.L., X.L., W.Z.,W.M.); Shanghai Municipal Centre for Disease Control and Prevention, China (Y.G., Y.Z., F.W.); Harvard T.H. Chan School of Public Health, Boston, MA (Q.D.); Department of Health Statistics and Information Systems, World Health Organization, WHO SAGE, Geneva, Switzerland (P.K.); University of Newcastle Research Centre on Gender, Health and Ageing, Australia (P.K.); Saint Louis University College for Public Health and Social Justice, Missouri (S.H., Z.Q.); Department of Epidemiology and Biostatistics, IU School of Public Health-Bloomington, Indiana (E.N.).
authors.forename: Yanfei
authors.initials: Y
authors.lastname: Guo
authors.affiliation: From the Guangdong Provincial Institute of Public Health, Guangzhou, China (H.L., J.X., T.L., X.L., W.Z.,W.M.); Shanghai Municipal Centre for Disease Control and Prevention, China (Y.G., Y.Z., F.W.); Harvard T.H. Chan School of Public Health, Boston, MA (Q.D.); Department of Health Statistics and Information Systems, World Health Organization, WHO SAGE, Geneva, Switzerland (P.K.); University of Newcastle Research Centre on Gender, Health and Ageing, Australia (P.K.); Saint Louis University College for Public Health and Social Justice, Missouri (S.H., Z.Q.); Department of Epidemiology and Biostatistics, IU School of Public Health-Bloomington, Indiana (E.N.).
authors.forename: Qian
authors.initials: Q
authors.lastname: Di
authors.affiliation: From the Guangdong Provincial Institute of Public Health, Guangzhou, China (H.L., J.X., T.L., X.L., W.Z.,W.M.); Shanghai Municipal Centre for Disease Control and Prevention, China (Y.G., Y.Z., F.W.); Harvard T.H. Chan School of Public Health, Boston, MA (Q.D.); Department of Health Statistics and Information Systems, World Health Organization, WHO SAGE, Geneva, Switzerland (P.K.); University of Newcastle Research Centre on Gender, Health and Ageing, Australia (P.K.); Saint Louis University College for Public Health and Social Justice, Missouri (S.H., Z.Q.); Department of Epidemiology and Biostatistics, IU School of Public Health-Bloomington, Indiana (E.N.).
authors.forename: Yang
authors.initials: Y
authors.lastname: Zheng
authors.affiliation: From the Guangdong Provincial Institute of Public Health, Guangzhou, China (H.L., J.X., T.L., X.L., W.Z.,W.M.); Shanghai Municipal Centre for Disease Control and Prevention, China (Y.G., Y.Z., F.W.); Harvard T.H. Chan School of Public Health, Boston, MA (Q.D.); Department of Health Statistics and Information Systems, World Health Organization, WHO SAGE, Geneva, Switzerland (P.K.); University of Newcastle Research Centre on Gender, Health and Ageing, Australia (P.K.); Saint Louis University College for Public Health and Social Justice, Missouri (S.H., Z.Q.); Department of Epidemiology and Biostatistics, IU School of Public Health-Bloomington, Indiana (E.N.).
authors.forename: Paul
authors.initials: P
authors.lastname: Kowal
authors.affiliation: From the Guangdong Provincial Institute of Public Health, Guangzhou, China (H.L., J.X., T.L., X.L., W.Z.,W.M.); Shanghai Municipal Centre for Disease Control and Prevention, China (Y.G., Y.Z., F.W.); Harvard T.H. Chan School of Public Health, Boston, MA (Q.D.); Department of Health Statistics and Information Systems, World Health Organization, WHO SAGE, Geneva, Switzerland (P.K.); University of Newcastle Research Centre on Gender, Health and Ageing, Australia (P.K.); Saint Louis University College for Public Health and Social Justice, Missouri (S.H., Z.Q.); Department of Epidemiology and Biostatistics, IU School of Public Health-Bloomington, Indiana (E.N.).
authors.forename: Jianpeng
authors.initials: J
authors.lastname: Xiao
authors.affiliation: From the Guangdong Provincial Institute of Public Health, Guangzhou, China (H.L., J.X., T.L., X.L., W.Z.,W.M.); Shanghai Municipal Centre for Disease Control and Prevention, China (Y.G., Y.Z., F.W.); Harvard T.H. Chan School of Public Health, Boston, MA (Q.D.); Department of Health Statistics and Information Systems, World Health Organization, WHO SAGE, Geneva, Switzerland (P.K.); University of Newcastle Research Centre on Gender, Health and Ageing, Australia (P.K.); Saint Louis University College for Public Health and Social Justice, Missouri (S.H., Z.Q.); Department of Epidemiology and Biostatistics, IU School of Public Health-Bloomington, Indiana (E.N.).
authors.forename: Tao
authors.initials: T
authors.lastname: Liu
authors.affiliation: From the Guangdong Provincial Institute of Public Health, Guangzhou, China (H.L., J.X., T.L., X.L., W.Z.,W.M.); Shanghai Municipal Centre for Disease Control and Prevention, China (Y.G., Y.Z., F.W.); Harvard T.H. Chan School of Public Health, Boston, MA (Q.D.); Department of Health Statistics and Information Systems, World Health Organization, WHO SAGE, Geneva, Switzerland (P.K.); University of Newcastle Research Centre on Gender, Health and Ageing, Australia (P.K.); Saint Louis University College for Public Health and Social Justice, Missouri (S.H., Z.Q.); Department of Epidemiology and Biostatistics, IU School of Public Health-Bloomington, Indiana (E.N.).
authors.forename: Xing
authors.initials: X
authors.lastname: Li
authors.affiliation: From the Guangdong Provincial Institute of Public Health, Guangzhou, China (H.L., J.X., T.L., X.L., W.Z.,W.M.); Shanghai Municipal Centre for Disease Control and Prevention, China (Y.G., Y.Z., F.W.); Harvard T.H. Chan School of Public Health, Boston, MA (Q.D.); Department of Health Statistics and Information Systems, World Health Organization, WHO SAGE, Geneva, Switzerland (P.K.); University of Newcastle Research Centre on Gender, Health and Ageing, Australia (P.K.); Saint Louis University College for Public Health and Social Justice, Missouri (S.H., Z.Q.); Department of Epidemiology and Biostatistics, IU School of Public Health-Bloomington, Indiana (E.N.).
authors.forename: Weilin
authors.initials: W
authors.lastname: Zeng
authors.affiliation: From the Guangdong Provincial Institute of Public Health, Guangzhou, China (H.L., J.X., T.L., X.L., W.Z.,W.M.); Shanghai Municipal Centre for Disease Control and Prevention, China (Y.G., Y.Z., F.W.); Harvard T.H. Chan School of Public Health, Boston, MA (Q.D.); Department of Health Statistics and Information Systems, World Health Organization, WHO SAGE, Geneva, Switzerland (P.K.); University of Newcastle Research Centre on Gender, Health and Ageing, Australia (P.K.); Saint Louis University College for Public Health and Social Justice, Missouri (S.H., Z.Q.); Department of Epidemiology and Biostatistics, IU School of Public Health-Bloomington, Indiana (E.N.).
authors.forename: Steven W
authors.initials: SW
authors.lastname: Howard
authors.affiliation: From the Guangdong Provincial Institute of Public Health, Guangzhou, China (H.L., J.X., T.L., X.L., W.Z.,W.M.); Shanghai Municipal Centre for Disease Control and Prevention, China (Y.G., Y.Z., F.W.); Harvard T.H. Chan School of Public Health, Boston, MA (Q.D.); Department of Health Statistics and Information Systems, World Health Organization, WHO SAGE, Geneva, Switzerland (P.K.); University of Newcastle Research Centre on Gender, Health and Ageing, Australia (P.K.); Saint Louis University College for Public Health and Social Justice, Missouri (S.H., Z.Q.); Department of Epidemiology and Biostatistics, IU School of Public Health-Bloomington, Indiana (E.N.).
authors.forename: Erik J
authors.initials: EJ
authors.lastname: Nelson
authors.affiliation: From the Guangdong Provincial Institute of Public Health, Guangzhou, China (H.L., J.X., T.L., X.L., W.Z.,W.M.); Shanghai Municipal Centre for Disease Control and Prevention, China (Y.G., Y.Z., F.W.); Harvard T.H. Chan School of Public Health, Boston, MA (Q.D.); Department of Health Statistics and Information Systems, World Health Organization, WHO SAGE, Geneva, Switzerland (P.K.); University of Newcastle Research Centre on Gender, Health and Ageing, Australia (P.K.); Saint Louis University College for Public Health and Social Justice, Missouri (S.H., Z.Q.); Department of Epidemiology and Biostatistics, IU School of Public Health-Bloomington, Indiana (E.N.). zqian2@slu.edu mawj@gdiph.org.cn wufan@scdc.sh.cn.
authors.forename: Zhengmin
authors.initials: Z
authors.lastname: Qian
authors.affiliation: From the Guangdong Provincial Institute of Public Health, Guangzhou, China (H.L., J.X., T.L., X.L., W.Z.,W.M.); Shanghai Municipal Centre for Disease Control and Prevention, China (Y.G., Y.Z., F.W.); Harvard T.H. Chan School of Public Health, Boston, MA (Q.D.); Department of Health Statistics and Information Systems, World Health Organization, WHO SAGE, Geneva, Switzerland (P.K.); University of Newcastle Research Centre on Gender, Health and Ageing, Australia (P.K.); Saint Louis University College for Public Health and Social Justice, Missouri (S.H., Z.Q.); Department of Epidemiology and Biostatistics, IU School of Public Health-Bloomington, Indiana (E.N.).
authors.forename: Wenjun
authors.initials: W
authors.lastname: Ma
authors.affiliation: From the Guangdong Provincial Institute of Public Health, Guangzhou, China (H.L., J.X., T.L., X.L., W.Z.,W.M.); Shanghai Municipal Centre for Disease Control and Prevention, China (Y.G., Y.Z., F.W.); Harvard T.H. Chan School of Public Health, Boston, MA (Q.D.); Department of Health Statistics and Information Systems, World Health Organization, WHO SAGE, Geneva, Switzerland (P.K.); University of Newcastle Research Centre on Gender, Health and Ageing, Australia (P.K.); Saint Louis University College for Public Health and Social Justice, Missouri (S.H., Z.Q.); Department of Epidemiology and Biostatistics, IU School of Public Health-Bloomington, Indiana (E.N.).
authors.forename: Fan
authors.initials: F
authors.lastname: Wu
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000397:Air Pollution / Q000706:statistics & numerical data*; D002681:China / Q000453:epidemiology; D004032:Diet; D004781:Environmental Exposure / Q000706:statistics & numerical data*; D015444:Exercise / Q000502:physiology*; D005260:Female; D005638:Fruit; D005869:Ghana / Q000453:epidemiology; D006801:Humans; D007194:India / Q000453:epidemiology; D008297:Male; D008800:Mexico / Q000453:epidemiology; D008875:Middle Aged; D052638:Particulate Matter / Q000009:adverse effects*; D011446:Prospective Studies; D012426:Russia / Q000453:epidemiology; D013019:South Africa / Q000453:epidemiology; D020521:Stroke / Q000453:epidemiology* / Q000209:etiology*; D014675:Vegetables
chemical_list: D052638:Particulate Matter
keywords: air pollution; exercise; fruit; smoking; stroke