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Open Access Research article

A case-control study of medium-term exposure to ambient nitrogen dioxide pollution and hospitalization for stroke

Julie YM Johnson1, Brian H Rowe2, Ryan W Allen3, Paul A Peters4 and Paul J Villeneuve15*

Author Affiliations

1 Population Studies Division, Health Canada, Ottawa, Canada

2 Department of Emergency Medicine, Faculty of Medicine and Dentistry and School of Public Health, University of Alberta, Edmonton, Canada

3 Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada

4 Health Analysis Division, Statistics Canada, Ottawa, Canada

5 Dalla Lana School of Public Health, University of Toronto, Toronto, Canada

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BMC Public Health 2013, 13:368  doi:10.1186/1471-2458-13-368

Published: 19 April 2013

Abstract

Background

There are several plausible mechanisms whereby either short or long term exposure to pollution can increase the risk of stroke. Over the last decade, several studies have reported associations between short-term (day-to-day) increases in ambient air pollution and stroke. The findings from a smaller number of studies that have looked at long-term exposure to air pollution and stroke have been mixed. Most of these epidemiological studies have assigned exposure to air pollution based on place of residence, but these assignments are typically based on relatively coarse spatial resolutions. To date, few studies have evaluated medium-term exposures (i.e, exposures over the past season or year). To address this research gap, we evaluated associations between highly spatially resolved estimates of ambient nitrogen dioxide (NO2), a marker of traffic pollution, and emergency department visits for stroke in Edmonton, Canada.

Methods

This was a case-control study with cases defined as those who presented to an Edmonton area hospital emergency department between 2007 and 2009 with an acute ischemic stroke, hemorrhagic stroke, or transient ischemic attack. Controls were patients who presented to the same emergency departments for lacerations, sprains, or strains. A land-use regression model provided estimates of NO2 that were assigned to the place of residence. Logistic regression methods were used to estimate odds ratios for stroke in relation to an increase in the interquartile range of NO2 (5 ppb), adjusted for age, sex, meteorological variables, and neighborhood effects.

Results

The study included 4,696 stroke (cases) and 37,723 injury patients (controls). For all strokes combined, there was no association with NO2. Namely, the odds ratio associated with an interquartile increase in NO2 was 1.01 (95% confidence interval {CI}: 0.94-1.08). No associations were evident for any of the stroke subtypes examined.

Conclusion

When combined with our earlier work in Edmonton, our findings suggest that day-to-day fluctuations in air pollution increase the risk of ischemic stroke during the summer season, while medium term exposures are unrelated to stroke risk. The findings for medium term exposure should be interpreted cautiously due to limited individual-level risk factor data.

Keywords:
Stroke; Air pollution; Odds ratio; Case-control study; Land use regression; NO2