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Background: Higher greenness was associated with a lower risk of adult mortality. However, the effects of greenness on the mortality of infant and child under-5 have not been fully examined. Objectives: The association of greenness on the infant mortality rate (IMR) and child under-5 mortality rate (U5MR) in 147 Chinese cities from 2009 to 2020 was evaluated. Methods: Average and maximum annual population-weighted greenness, IMR (per 1000 live births), and U5MR (per 1000 live births) in 147 cities from 2009 to 2020 were collected, and a longitudinal panel study was conducted. Greenness exposure was evaluated using satellite-derived data at a spatial resolution of 250 m ×250 m in urban regions, and linear mixed-effect models were applied to assess the associations between greenness and IMR or U5MR in China. Results: This national study showed that long-term exposure to greenness was associated with lower IMR and U5MR, respectively. Specifically, a 0.1 increase of Normalized Difference Vegetation Index (NDVI) in greenness was statistically significant with a decrease in IMR (-1.05 ‰, 95 % CI: −1.48, −0.63 ‰) and U5MR (-1.82 ‰, 95 % CI: −2.39, −1.25 ‰) in fully-adjusted model, respectively. In the stratified analyses, greenness effects on U5MR in the western (-2.33 ‰, 95 % CI: −3.43, −1.23 ‰) and central regions (-2.06 ‰, 95 % CI: −3.01, −1.10 ‰) were stronger than that in the eastern region (-0.86 ‰, 95 % CI: −1.66, −0.07 ‰). Conclusions: This nationwide study indicated that exposure to higher greenness was associated with lower mortality rates in infant and child under-5 in China.

Non-optimal temperature is a leading risk factor for global disease burden. Most epidemiological studies assessed only outdoor temperature, with important uncertainties on personal exposure misclassification. The CKB-Air study measured personal, household (kitchen and living room), and outdoor temperatures in the summer (MAY-SEP 2017) and winter (NOV 2017-JAN 2018) in 477 participants in China. After data cleaning, ∼88,000 person-hours of data were recorded across each microenvironment. Using multivariable linear regression (MLR) and random forest (RF) models, we identified key predictors and constructed personal temperature exposure prediction models. We used generalised additive mixed effect models to examine the relationships of personal and outdoor temperatures with heart rate. The 24-hour mean (SD) personal and outdoor temperatures were 29.2 (3.8) °C and 27.6 (6.4) °C in summer, and 12.0 (4.0) °C and 7.5 (4.2) °C in winter, respectively. The temperatures across microenvironments were strongly correlated (Spearman’s ρ: 0.86–0.92) in summer. In winter, personal temperature was strongly related to household temperatures (ρ: 0.74–0.79) but poorly related to outdoor temperature (ρ: 0.30). RF algorithm identified household and outdoor temperatures and study date as top predictors of personal temperature exposure for both seasons, and heating-related factors were important in winter. The final MLR and RF models incorporating questionnaire and device data performed satisfactorily in predicting personal exposure in both seasons (R2summer: 0.92; R2winter: 0.68–0.70). We found consistent U-shaped associations between measured and predicted personal temperature exposures and heart rate (lowest at ∼ 14.5 °C), but a weak positive linear association with outdoor temperature. Personal and outdoor temperatures differ substantially winter, but prediction models incorporating household and outdoor temperatures and questionnaire data performed satisfactorily. Exposure misclassification from using outdoor temperature may produce inappropriate epidemiological findings.

Summary: Background: To assess the long-term impact of residential air pollution and green space exposure on cause-specific mortality in individuals with type 2 diabetes mellitus (T2DM). Methods: This study includes 174,063 participants newly diagnosed with T2DM from a prospective cohort in Shanghai, China, enrolled between 2011 and 2013. Residential annual levels of air pollutants, including fine (PM2.5) and coarse (PM2.5-10) particulate matter, nitrogen dioxide (NO2), along with the normalized difference vegetation index (NDVI), were derived from satellite-based exposure models. Findings: During a median follow-up of 7.9 years (equivalent to 1,333,343 person-years), this study recorded 22,205 deaths. Higher exposure to PM2.5 was significantly associated with increased risks for all mortality outcomes, whilst PM2.5-10 showed no significant impacts. The strongest associations of PM2.5 were observed for diabetes with peripheral vascular diseases [hazard ratio (HR): 2.70; per 10 μg/m3 increase] and gastrointestinal cancer (2.44). Effects of NO2 became significant at concentrations exceeding approximately 45 μg/m³, with the highest associations for lung cancer (1.20) and gastrointestinal cancer (1.19). Conversely, each interquartile range increase in NDVI (0.10) was linked to reduced mortality risks across different causes, with HRs ranging from 0.76 to 1.00. The association between greenness and mortality was partly and significantly mediated by reduced PM2.5 (23.80%) and NO2 (26.60%). There was a significant and negative interaction between NO2 and greenness, but no interaction was found between PM2.5 and greenness. Interpretation: Our findings highlight the vulnerability of individuals with T2DM to the adverse health effects of air pollution and emphasise the potential protective effects of greenness infrastructure. Funding: The 6th Three-year Action Program of Shanghai Municipality for Strengthening the Construction of Public Health System (GWVI-11.1-22), the National Key Research and Development Program (2022YFC3702701), and the National Natural Science Foundation of China (82030103, 82373532).

Summary: Background: Short-term exposure to particulate matter air pollution has been associated with the exacerbations of COPD, but its association with COPD mortality was not fully elucidated. We aimed to assess the association between short-term particulate matter exposure and the risk of COPD mortality in China using individual-level data. Methods: We derived 2.26 million COPD deaths from a national death registry database in Chinese mainland between 2013 and 2019. Exposures to fine particulate matter (PM2.5) and coarse particulate matter (PM2.5-10) were assessed by satellite-based models of a 1 × 1 km resolution and assigned to each individual based on residential address. The associations of PM2.5 and PM2.5-10 with COPD mortality were examined using a time-stratified case-crossover design and conditional logistic regressions with distributed lag models. We further conducted stratified analyses by age, sex, education level, and season. Findings: Short-term exposures to both PM2.5 and PM2.5-10 were associated with increased risks of COPD mortality. These associations appeared and peaked on the concurrent day, attenuated and became nonsignificant after 5 or 7 days, respectively. The exposure-response curves were approximately linear without discernible thresholds. An interquartile range increase in PM2.5 and PM2.5-10 concentrations was associated with 4.23% (95% CI: 3.75%, 4.72%) and 2.67% (95% CI: 2.18%, 3.16%) higher risks of COPD mortality over lag 0–7 d, respectively. The associations of PM2.5 and PM2.5-10 attenuated slightly but were still significant in the mutual-adjustment models. A larger association of PM2.5-10 was observed in the warm season. Interpretation: This individual-level, nationwide, case-crossover study suggests that short-term exposure to PM2.5 and PM2.5-10 might act as one of the environmental risk factors for COPD mortality. Funding: This study is supported by the National Key Research and Development Program of China (2023YFC3708304 and 2022YFC3702701), the National Natural Science Foundation of China (82304090 and 82030103), the 3-year Action Plan for Strengthening the Construction of the Public Health System in Shanghai (GWVI-11.2-YQ31), and the Science and Technology Commission of Shanghai Municipality (21TQ015).

The changing climate poses a growing challenge to the population health. The objective of this study was to assess the association between ambient temperature and cause-specific mortality in Suzhou. Based on the non-accidental mortality data collected during 2008–2022 in Suzhou, China, this study utilized an individual-level case-crossover design to evaluate the associations of temperature with cause-specific mortality. We applied a distributed lag nonlinear model with a maximum lag of 14 days to account for lag effects. Mortality risk due to extreme cold (97.5th percentile) was analyzed. A total of 634,530 non-accidental deaths were analyzed in this study. An inverse J-shaped exposure-response relationship was observed between ambient temperature and non-accidental mortality, with the minimum mortality temperature (MMT) at 29.1℃. The relative risk (RR) of mortality associated with extreme cold (2.5th percentile) was 1.37 [95 % confidence interval (CI): 1.30, 1.44], higher than estimate of 1.09 (95 %CI: 1.07, 1.11) for extreme heat (97.5th percentile) relative to the MMT. Heat effect lasted for 2–3 days, while cold effect could persist for almost 14 days. Higher mortality risk estimates were observed for cardiorespiratory deaths compared to total deaths, with statistically significant between-group differences. Consequently, this study provides first-hand evidence on the associations between ambient temperatures and mortality risks from various causes, which could help local government and policy-makers in designing targeted strategies and public health measures against the menace of climate change.

Summary: Background: Urban living is linked to better health outcomes due to a combination of enhanced access to healthcare, transportation, and human development opportunities. However, spatial inequalities lead to disparities, resulting in urban health advantages and penalties. Understanding the relationship between health and urban development is needed to generate empirical evidence in promoting healthy aging populations. This study provides a comparative analysis using epidemiological evidence across diverse major Chinese cities, examining how their unique urban development trajectories over time have impacted the health of their aging residents. Methods: We tracked changes in air pollution (NO2, PM2.5, O3), green space (measured by NDVI), road infrastructure (ring road areas), and nighttime lighting over 20 years in six major cities in China. We followed a longitudinal cohort of 4992 elderly participants (average age 87.8 years) over 16,824 person-years. We employed Cox proportional hazard regression to assess longevity, assessing 14 variables, including age, sex, ethnicity, marital status, residence, household income, occupation, education, smoking, alcohol consumption, exercise, and points of interest (POI) count of medicine-related facilities, sports, and leisure service-related places, and scenic spots within a 5 km-radius buffer. Findings: Geographic proximity to points of interest significantly improves survival. Elderly living in proximity of the POI-rich areas had a 34.6%–35.6% lower mortality risk compared to those in POI-poor areas, for the highest compared to the lowest quartile. However, POI-rich areas had higher air pollution levels, including PM2.5 and NO2, which was associated with a 21% and 10% increase in mortality risk for increase of 10 μg/m3, respectively. The benefits of urban living had higher effect estimates in monocentric cities, with clearly defined central areas, compared to polycentric layouts, with multiple satellite city centers. Interpretation: Spatial inequalities create urban health advantages for some and penalties for others. Proximity to public facilities and economic activities is associated with health benefits, and may counterbalance the negative health impacts of lower green space and higher air pollution. Our empirical evidence show optimal health gains for age-friendly urban environments come from a balance of infrastructure, points of interest, green spaces, and low air pollution. Funding: Natural Science Foundation of Beijing (IS23105), National Natural Science Foundation of China (82250610230, 72061137004), World Health Organization (2024/1463606-0), Research Fund Vanke School of Public Health Tsinghua University (2024JC002), Beijing TaiKang YiCai Public Welfare Foundation, National Key R&D Program of China (2018YFC2000400).

Abstract Floods have affected billions worldwide. Yet, the indirect health impacts of floods on vulnerable groups, particularly women in the developing world, remain underexplored. Here, we evaluated the risk of pregnancy loss for women exposed to floods. We analyzed 90,465 individual pregnancy loss records from 33 developing countries, cross-referencing each with spatial-temporal flood databases. We found that gestational flood exposure is associated with increased pregnancy loss with an odds ratio of 1.08 (95% confidence interval: 1.04 - 1.11). This risk is pronounced for women outside the peak reproductive age range (35) or during the mid and late-stage of pregnancy. The risk escalated for women dependent on surface water, with lower income or education levels. We estimated that, over the 2010s, gestational flood events might be responsible for approximately 107,888 (CIs: 53,944 - 148,345) excess pregnancy losses annually across 33 developing countries. Notably, there is a consistent upward trend in annual excess pregnancy losses from 2010 to 2020, and was more prominent over Central America, the Caribbean, South America, and South Asia. Our findings underscore the disparities in maternal and child health aggravated by flood events in an evolving climate.

The spatial disparity of air pollutants is one of the key influential factors for environmental inequality. We quantitatively evaluated the evolution of PM2.5 spatial disparity in China during 2013–2020, and investigated the associations between PM2.5 spatial disparity and economic indicators. Differences in PM2.5 between more- and less-polluted cities declined over time, suggesting decreased absolute disparity. However, the more polluted cities in 2013 remained so in 2017 and 2020, and vice versa, indicating persistent relative disparity. PM2.5 pollution levels increased with higher GDP per capita in less-developed areas of China, but such negative effects weakened over time, while economic development tended to promote cleaner air in developed areas of China. Therefore, policies to improve air quality and promote economic development simultaneously are needed in China to reduce the disparity of air pollution and promote all people to enjoy environmental equality.

Abstract Limited knowledge exists regarding the ramifications of climate warming on death burden from neurodegenerative diseases. Here, we conducted a nationwide, individual-level, case-crossover study between 2013 and 2019 to investigate the effects of non-optimal temperatures on various neurodegenerative diseases and to predict the potential death burden under different climate change scenarios. Our findings reveal that both low and high temperatures are linked to increased risks of neurodegenerative diseases death. We project that heat-related neurodegenerative disease deaths would increase, while cold-related deaths would decrease. This is characterized by a steeper slope in the high-emission scenario, but a less pronounced trend in the scenarios involving mitigation strategies. Furthermore, we predict that the net changes in attributable death would increase after the mid-21st century, especially under the unrestricted-emission scenario. These results highlight the urgent need for effective climate and public health policies to address the growing challenges of neurodegenerative diseases associated with global warming.

BackgroundThe regional disparity of heatwave-related mortality over a long period has not been sufficiently assessed across the globe, impeding the localisation of adaptation planning and risk management towards climate change. We quantified the global mortality burden associated with heatwaves at a spatial resolution of 0.5°×0.5° and the temporal change from 1990 to 2019.Methods and findingsWe collected data on daily deaths and temperature from 750 locations of 43 countries or regions, and 5 meta-predictors in 0.5°×0.5° resolution across the world. Heatwaves were defined as location-specific daily mean temperature ≥95th percentiles of year-round temperature range with duration ≥2 days. We first estimated the location-specific heatwave-mortality association. Secondly, a multivariate meta-regression was fitted between location-specific associations and 5 meta-predictors, which was in the third stage used with grid cell-specific meta-predictors to predict grid cell-specific association. Heatwave-related excess deaths were calculated for each grid and aggregated. During 1990 to 2019, 0.94% (95% CI: 0.68-1.19) of deaths [i.e., 153,078 cases (95% eCI: 109,950-194,227)] per warm season were estimated to be from heatwaves, accounting for 236 (95% eCI: 170-300) deaths per 10 million residents. The ratio between heatwave-related excess deaths and all premature deaths per warm season remained relatively unchanged over the 30 years, while the number of heatwave-related excess deaths per 10 million residents per warm season declined by 7.2% per decade in comparison to the 30-year average. Locations with the highest heatwave-related death ratio and rate were in Southern and Eastern Europe or areas had polar and alpine climates, and/or their residents had high incomes. The temporal change of heatwave-related mortality burden showed geographic disparities, such that locations with tropical climate or low incomes were observed with the greatest decline. The main limitation of this study was the lack of data from certain regions, e.g., Arabian Peninsula and South Asia.ConclusionsHeatwaves were associated with substantial mortality burden that varied spatiotemporally over the globe in the past 30 years. The findings indicate the potential benefit of governmental actions to enhance health sector adaptation and resilience, accounting for inequalities across communities.

Background: Ultrafine particle (UFP) has been linked with higher risks of cardiovascular diseases; however, the biological mechanisms remain to be fully elucidated. Objectives: This study aims to investigate the cardiovascular responses to short-term UFP exposure and the biological pathways involved. Methods: A longitudinal panel study was conducted among 32 healthy, non-smoking young adults in Shanghai, China, who were engaged in five rounds of follow-ups between December 2020 and November 2021. Individual exposures were calculated based on the indoor and outdoor real-time measurements. Blood pressure, arterial stiffness, targeted biomarkers, and untargeted proteomics and metabolomics were examined during each follow-up. Linear mixed-effect models were applied to analyze the exposure and health data. The differential proteins and metabolites were used for pathway enrichment analyses. Results: Short-term UFP exposure was associated with significant increases in blood pressure and arterial stiffness. For example, systolic blood pressure increased by 2.10 % (95 % confidence interval: 0.63 %, 3.59 %) corresponding to each interquartile increase in UFP concentrations at lag 0–3 h, while pulse wave velocity increased by 2.26 % (95 % confidence interval: 0.52 %, 4.04 %) at lag 7–12 h. In addition, dozens of molecular biomarkers altered significantly. These effects were generally present within 24 h after UFP exposure, and were robust to the adjustment of co-pollutants. Molecular changes detected in proteomics and metabolomics analyses were mainly involved in systemic inflammation, oxidative stress, endothelial dysfunction, coagulation, and disturbance in lipid transport and metabolism. Discussion: This study provides novel and compelling evidence on the detrimental subclinical cardiovascular effects in response to short-term UFP exposure. The multi-omics profiling further offers holistic insights into the underlying biological pathways.

Background: Temperature variability (TV) is associated with increased mortality risk. However, it is still unknown whether intra-day or inter-day TV has different effects. Objectives: We aimed to assess the association of intra-day TV and inter-day TV with all-cause, cardiovascular, and respiratory mortality. Methods: We collected data on total, cardiovascular, and respiratory mortality and meteorology from 758 locations in 47 countries or regions from 1972 to 2020. We defined inter-day TV as the standard deviation (SD) of daily mean temperatures across the lag interval, and intra-day TV as the average SD of minimum and maximum temperatures on each day. In the first stage, inter-day and intra-day TVs were modelled simultaneously in the quasi-Poisson time-series model for each location. In the second stage, a multi-level analysis was used to pool the location-specific estimates. Results: Overall, the mortality risk due to each interquartile range [IQR] increase was higher for intra-day TV than for inter-day TV. The risk increased by 0.59% (95% confidence interval [CI]: 0.53, 0.65) for all-cause mortality, 0.64% (95% CI: 0.56, 0.73) for cardiovascular mortality, and 0.65% (95% CI: 0.49, 0.80) for respiratory mortality per IQR increase in intra-day TV0–7 (0.9 °C). An IQR increase in inter-day TV0–7 (1.6 °C) was associated with 0.22% (95% CI: 0.18, 0.26) increase in all-cause mortality, 0.44% (95% CI: 0.37, 0.50) increase in cardiovascular mortality, and 0.31% (95% CI: 0.21, 0.41) increase in respiratory mortality. The proportion of all-cause deaths attributable to intra-day TV0–7 and inter-day TV0–7 was 1.45% and 0.35%, respectively. The mortality risks varied by lag interval, climate area, season, and climate type. Conclusions: Our results indicated that intra-day TV may explain the main part of the mortality risk related to TV and suggested that comprehensive evaluations should be proposed in more countries to help protect human health.

Chinese children are exposed to broad environmental risks ranging from well-known hazards, such as pesticides and heavy metals, to emerging threats including many new man-made chemicals. Although anecdotal evidence suggests that the exposure levels in Chinese children are substantially higher than those of children in developed countries, a systematic assessment is lacking. Further, while these exposures have been linked to a variety of childhood diseases, such as respiratory, endocrine, neurological, behavioral, and malignant disorders, the magnitude of the associations is often unclear. This review provides a current epidemiologic overview of commonly reported environmental contaminants and their potential impact on children’s health in China. We found that despite a large volume of studies on various topics, there is a need for more high-quality research and better-coordinated regional and national data collection. Moreover, prevention of such diseases will depend not only on training of environmental health professionals and enhanced research programs, but also on public education, legislation, and networking.

Assessing the association between temperature frequency and mortality can provide insights into human adaptation to local ambient temperatures. We collected daily time-series data on mortality and temperature from 757 locations in 47 countries/regions during 1979–2020. We used a two-stage time series design to assess the association between temperature frequency and all-cause mortality. The results were pooled at the national, regional, and global levels. We observed a consistent decrease in the risk of mortality as the normalized frequency of temperature increases across the globe. The average increase in mortality risk comparing the 10th to 100th percentile of normalized frequency was 13.03% (95% CI: 12.17–13.91), with substantial regional differences (from 4.56% in Australia and New Zealand to 33.06% in South Europe). The highest increase in mortality was observed for high-income countries (13.58%, 95% CI: 12.56–14.61), followed by lower-middle-income countries (12.34%, 95% CI: 9.27–15.51). This study observed a declining risk of mortality associated with higher temperature frequency. Our findings suggest that populations can adapt to their local climate with frequent exposure, with the adapting ability varying geographically due to differences in climatic and socioeconomic characteristics.

Abstract Background The high under-five mortality rate (U5MR) in Africa is a significant public health concern. Previous studies have found that satellite retrieved light at night (LAN) data with long-term and global coverage can be used as a proxy for socio-economic development and urbanization. Currently, few studies on the effects of LAN on child mortality have been conducted in Africa, a region with varying levels of urbanization between countries. Objective To quantify the correlation between risk of child mortality and LAN as an indicator of urbanization and economic development in Africa. Methods Using data from the Demographic and Health Survey (DHS) database conducted in 15 African countries out of 46 countries from 2005 to 2013, this study estimated LAN levels for children based on their year of birth and residential addresses. This study used Cox proportional hazards models to assess the association between LAN and the risk of child mortality in Africa. Results The mean U5MR was 95 per 1,000 livebirths among the 15 African countries during 2005–2013. After adjusting for covariates, each 10-unit increment in LAN was associated with a 5.3% reduction in the risk of U5MR. The effect estimates were more pronounced in areas with lower LAN. Conclusion In Africa, the risk of U5MR decreased with increasing LAN, especially in areas with lower LAN. The results suggest that the development of urbanization and socio-economic conditions may be beneficial to child health, especially in regions with low LAN. The use of LAN as a proxy may offer an intriguing approach for identifying areas requiring targeted development in urbanization and socio-economic conditions.

Ambient particles severely threaten human health worldwide. Compared to larger particles, ultrafine particles (UFPs) are highly concentrated in ambient environments, have a larger specific surface area, and are retained for a longer time in the lung. Recent studies have found that they can be transported into various extra-pulmonary organs by crossing the air-blood barrier (ABB). Therefore, to understand the adverse effects of UFPs, it is crucial to thoroughly investigate their bio-distribution and clearance pathways in vivo after inhalation, as well as their toxicological mechanisms. This review highlights emerging evidence on the bio-distribution of UFPs in pulmonary and extra-pulmonary organs. It explores how UFPs penetrate the ABB, the blood-brain barrier (BBB), and the placental barrier (PB) and subsequently undergo clearance by the liver, kidney, or intestine. In addition, the potential underlying toxicological mechanisms of UFPs are summarized, providing fundamental insights into how UFPs induce adverse health effects.

Background: Increased attention has been paid to humid-heat extremes as they are projected to increase in both frequency and intensity. However, it remains unclear how compound extremes of heat and humidity affects morbidity when the climate is projected to continue warming in the future, in particular for a megacity with a large population. Methods: We chose the Wet-Bulb Globe Temperature (WBGT) index as the metric to characterize the humid-heat exposure. The historical associations between daily outpatient visits and daily mean WBGT was established using a Distributed Lag Non-linear Model (DLNM) during the warm season (June to September) from 2013 to 2015 in Shanghai, a prominent megacity of China. Future morbidity burden related to the combined effect of high temperature and humidity were projected under four greenhouse gases (GHGs) emission scenarios (SSP126, SSP245, SSP370 and SSP585). Results: The humid-heat weather was significantly associated with a higher risk of outpatient visits in Shanghai than the high-temperature conditions. Relative to the baseline period (2010–2019), the morbidity burden due to humid-heat weather was projected to increase 4.4 % (95 % confidence interval (CI): 1.1 %–10.1 %) even under the strict emission control scenario (SSP126) by 2100. Under the high-GHGs emission scenario (SSP585), this burden was projected to be 25.4 % (95 % CI: 15.8 %–38.4 %), which is 10.1 % (95 % CI: 6.5 %–15.8 %) more than that due to high-temperature weather. Our results also indicate that humid-hot nights could cause large morbidity risks under high-GHGs emission scenarios particularly in heat-sensible diseases such as the respiratory and cardiovascular disease by the end of this century. Conclusions: Humid heat exposures significantly increased the all-cause morbidity risk in the megacity Shanghai, especially in humid-hot nights. Our findings suggest that the combined effect of elevated temperature and humidity is projected to have more substantial impact on health compared to high temperature alone in a warming climate.

Summary: Background: It remains unknown how ambient temperature impact pneumonia of various infectious causes. Methods: Based on the national death registry covering all counties in Chinese mainland, we conducted an individual-level case-crossover study in China from 2013 to 2019. Exposures were assigned at residential addresses for each decedent. Conditional logistic regression model combined with distributed lag non-linear models were used to estimate the exposure-response associations. The attributable fractions due to non-optimum temperature were calculated after accounting for spatial and temporal patterns for the excess risks. Findings: The exposure-response curves were inversely J-shaped with both low and high temperature increasing the risks, and the effect of low temperature was stronger. Extremely low temperature was associated with higher magnitude of influenza-related pneumonia [relative risk (RR): 2.46, 95% confidence interval (CI): 1.62–3.74], than viral pneumonia (RR: 1.89, 95% CI: 1.55–2.30) and bacterial pneumonia (RR: 1.81, 95% CI: 1.56–2.09). The magnitudes of RRs associated with extremely high temperature were similar among the three categories of pneumonia. The mortality attributable fraction for influenza-related pneumonia (29.78%) was the highest. The effects were stronger in people of low education level or residence in the north. Interpretation: This nationwide study presents findings on the varied risk and burden of pneumonia mortality of various infectious causes, and highlights the susceptibility of influenza-related pneumonia to ambient low temperature. Funding: This study is supported by the National Key Research and Development Program (2022YFC3702701), the Shanghai Municipal Science and Technology Commission (21TQ015) and Shanghai International Science and Technology Partnership Project (21230780200).

Accumulating studies suggest that, as the subway is one of the important means of transport in cities, airborne microorganisms in its system have potential effects on human health, but previous studies have mainly focused on some foreign cities. We reviewed the spatio-temporal distribution characteristics of airborne microorganisms in subway stations in different cities, including diurnal, weekly, and seasonal variations, and the distribution of microorganisms in different regions of the world. The factors affecting airborne microorganisms, such as human activities, temperature and humidity, ventilation, and particulate matter, were presented. The potential health effects were described. Although there was no significant risk of infection from using subway, many pathogens do exist in the air. The influence of microorganisms in subway air on health has become a public health problem that cannot be ignored.

Abstract Few studies have examined the link between short-term exposure to air pollutants and atrial fibrillation (AF) episodes. This study aims to examine the association of hourly criteria air pollutants with AF episodes. We employ a smart device-based photoplethysmography technology to screen AF from 2018 to 2021. Hourly concentrations of six criteria air pollutants are matched to the onset hour of AF for each participant. We adopt a time-stratified case-crossover design to capture the acute effects of air pollutants on AF episodes, using conditional logistic regression models. Subgroup analyses are conducted by age, gender, and season. A total of 11,906 episodes of AF are identified in 2976 participants from 288 Chinese cities. Generally, the strongest associations of air pollutants are present at lag 18–24 h, with positive and linear exposure-response relationships. For an interquartile range increase in inhalable particles, fine particles, nitrogen dioxide, and carbon monoxide, the odds ratio (OR) of AF is 1.19 [95% confidential interval (CI): 1.03, 1.37], 1.38 (95%CI: 1.14, 1.67), 1.60 (95%CI: 1.16, 2.20) and 1.48 (95%CI: 1.19, 1.84), respectively. The estimates are robust to the adjustment of co-pollutants, and they are larger in females, older people, and in cold seasons. There are insignificant associations for sulfur dioxide and ozone. This nationwide case-crossover study demonstrates robust evidence of significant associations between hourly exposure to air pollutants and the onset of AF episodes, which underscores the importance of ongoing efforts to further improve air quality as an effective target for AF prevention.

Summary: Background: High-level exposure to indoor air pollutants (IAPs) and their corresponding adverse health effects have become a public concern in China in the past 10 years. However, neither national nor provincial level burden of disease attributable to multiple IAPs has been reported for China. This is the first study to estimate and rank the annual burden of disease and the financial costs attributable to targeted residential IAPs at the national and provincial level in China from 2000 to 2017. Methods: We first did a systematic review and meta-analysis of 117 articles from 37 231 articles identified in major databases, and obtained exposure–response relationships for the candidate IAPs. The exposure levels to these IAPs were then collected by another systematic review of 1864 articles selected from 52 351 articles. After the systematic review, ten IAPs with significant and robust exposure–response relationships and sufficient exposure data were finally targeted: PM2·5, nitrogen dioxide, sulphur dioxide, ozone, carbon monoxide, radon, formaldehyde, benzene, toluene, and p-dichlorobenzene. The annual exposure levels in residences were then evaluated in all 31 provinces in mainland China continuously from 2000 to 2017, using the spatiotemporal Gaussian process regression model to analyse indoor originating IAPs, and the infiltration factor method to analyse outdoor originating IAPs. The disability-adjusted life-years (DALYs) attributable to the targeted IAPs were estimated at both national and provincial levels in China, using the population attributable fraction method. Financial costs were estimated by an adapted human capital approach. Findings: From 2000 to 2017, annual DALYs attributable to the ten IAPs in mainland China decreased from 4620 (95% CI 4070–5040) to 3700 (3210–4090) per 100 000. Nevertheless, in 2017, IAPs still ranked third among all risk factors, and their DALYs and financial costs accounted for 14·1% (95% CI 12·3–15·6) of total DALYs and 3·45% (3·01–3·82) of the gross domestic product. Specifically, the rank of ten targeted IAPs in order of their contribution to DALYs in 2017 was PM2·5, carbon monoxide, radon, benzene, nitrogen dioxide, ozone, sulphur dioxide, formaldehyde, toluene, and p-dichlorobenzene. The DALYs attributable to IAPs were 9·50% higher than those attributable to outdoor air pollution in 2017. For the leading IAP, PM2·5, the DALYs attributable to indoor origins are 18·3% higher than those of outdoor origins. Interpretation: DALYs attributed to IAPs in China have decreased by 20·0% over the past two decades. Even so, they are still much higher than those in the USA and European countries. This study can provide a basis for determining which IAPs to target in various indoor air quality standards and for estimating the health and economic benefits of various indoor air quality control approaches, which will help to reduce the adverse health effects of IAPs in China. Funding: The National Key Research and Development Program of China and the National Natural Science Foundation of China.

Background: The epidemiological evidence on the interaction between heat and ambient air pollution on mortality is still inconsistent. Objectives: To investigate the interaction between heat and ambient air pollution on daily mortality in a large dataset of 620 cities from 36 countries. Methods: We used daily data on all-cause mortality, air temperature, particulate matter ≤ 10 μm (PM10), PM ≤ 2.5 μm (PM2.5), nitrogen dioxide (NO2), and ozone (O3) from 620 cities in 36 countries in the period 1995–2020. We restricted the analysis to the six consecutive warmest months in each city. City-specific data were analysed with over-dispersed Poisson regression models, followed by a multilevel random-effects meta-analysis. The joint association between air temperature and air pollutants was modelled with product terms between non-linear functions for air temperature and linear functions for air pollutants. Results: We analyzed 22,630,598 deaths. An increase in mean temperature from the 75th to the 99th percentile of city-specific distributions was associated with an average 8.9 % (95 % confidence interval: 7.1 %, 10.7 %) mortality increment, ranging between 5.3 % (3.8 %, 6.9 %) and 12.8 % (8.7 %, 17.0 %), when daily PM10 was equal to 10 or 90 μg/m3, respectively. Corresponding estimates when daily O3 concentrations were 40 or 160 μg/m3 were 2.9 % (1.1 %, 4.7 %) and 12.5 % (6.9 %, 18.5 %), respectively. Similarly, a 10 μg/m3 increment in PM10 was associated with a 0.54 % (0.10 %, 0.98 %) and 1.21 % (0.69 %, 1.72 %) increase in mortality when daily air temperature was set to the 1st and 99th city-specific percentiles, respectively. Corresponding mortality estimate for O3 across these temperature percentiles were 0.00 % (-0.44 %, 0.44 %) and 0.53 % (0.38 %, 0.68 %). Similar effect modification results, although slightly weaker, were found for PM2.5 and NO2. Conclusions: Suggestive evidence of effect modification between air temperature and air pollutants on mortality during the warm period was found in a global dataset of 620 cities.

Background: Future warming is projected to increase the heat-related mortality burden, especially for vulnerable populations. However, most previous studies focused on non-accidental morbidity or mortality, with far less research on heat-related accidental events. Methods: We collected individual accidental death records among all residents in Chinese mainland from June to August during 2013–2019. Accidental deaths were further divided into several subtypes by different causes. We used an individual-level, time-stratified, case-crossover study design to estimate the association between daily mean temperature and accidental deaths, and estimate its variation in seven geo-climatic zones, age (5–64, 65–74, ≥75), and sex (male, female). We then estimated the temperature-related excess accidental deaths under global warming scenarios of 1.5, 2, and 3℃. Findings: A total of 711,929 accidental death records were included in our study. We found that higher temperatures were associated with increased risks of deaths from the total accidental events and four main subtypes, including traffic, falls, drowning, and unintentional injuries. We also found that younger individuals (ages 5–64) and males faced a higher risk of heat-related mortality due to total accidents, traffic incidents, and drowning. For future climate scenarios, even under the 1.5℃ climate change scenario, 6,939 (95% eCI (empirical Confidence Interval): 6,818–7,067) excess accidental deaths per year are attributed to higher summertime daily temperature over mainland China, and the number of accidental deaths would increase by 16.71% and 33.59% under the 2℃ and 3℃ climate change scenarios, respectively. For residents living in southern coastal and northwest inland regions, the projected increase in accidental death is higher. Conclusions: This nationwide study confirms that higher summer temperatures are linked to an increased risk of accidental deaths. Younger age groups and males face a higher risk. This indicates that current estimates of the health effects of climate change might be underestimated, particularly for younger populations.

Few national studies have systemically examined the effects of criteria air pollutants on cardiovascular morbidity. This study aimed to investigate the associations between all criteria air pollutants and hospitalization of cause-specific cardiovascular diseases (CVD) in China. We obtained data on CVD hospitalization events of four major categories and 12 specific diseases from 153 hospitals distributed in 20 provincial-level regions from 2013 to 2020. We adopted a time-stratified case-crossover study design using individual cases to capture the effect of short-term exposure to six criteria air pollutants on CVD hospitalizations, using conditional logistic regression models. More than 1.1 million CVD hospitalization events were included. The lag pattern exploration demonstrated the largest effect for six air pollutants on lag 0–1 day. PM2.5, PM10, NO2, and CO were significantly associated with increased hospitalization from ischemic heart diseases, cerebrovascular diseases, other heart diseases, and five specific causes of CVD. The effect estimates of NO2 were the most robust when adjusting for co-pollutants. The concentration-response curves were positive and linear for most pollutant–endpoint pairs (except for O3), and these positive associations remained even below the 24-h levels recommended by WHO Air Quality Guidelines and China Air Quality Standards. This nationwide case-crossover study in China demonstrated that short-term exposure to multiple ambient air pollutants may significantly increase the risk of cause-specific CVD hospitalizations even under the most stringent air quality regulations, striking an alert for potential CVD patients against these environmental risk factors.

Abstract Background There is a discourse on whether air pollution mixture or air pollutant components are causally linked to increased mortality. In particular, there is uncertainty on whether the association of NO2 with mortality is independent of fine particulate matter (PM2.5). Furthermore, effect modification by temperature on air pollution-related mortality also needs more evidence. Methods We used the Chinese Longitudinal Healthy Longevity Study (CLHLS), a prospective cohort with geographical and socio-economic diversity in China. The participants were enrolled in 2008 or 2009 and followed up in 2011-2012, 2014, and 2017-2018. We used remote sensing and ground monitors to measure nitrogen dioxide (NO2), fine particulate matter (PM2.5) , and temperature. We used the Cox-proportional hazards model to examine the association between component and composite air pollution and all-cause mortality, adjusted for demographic characteristics, lifestyle, geographical attributes, and temperature. We used the restricted cubic spline to visualize the concentration–response curve. Results Our study included 11 835 individuals with an average age of 86.9 (SD: 11.4) at baseline. Over 55 606 person-years of follow-up, we observed 8 216 mortality events. The average NO2 exposure was 19.1 μg/m3 (SD: 14.1); the average PM2.5 exposure was 52.8 μg/m3 (SD: 15.9). In the single pollutant models, the mortality HRs (95% CI) for 10 μg/m3 increase in annual average NO2 or PM2.5 was 1.114 (1.085, 1.143) and 1.244 (1.221, 1.268), respectively. In the multi-pollutant model co-adjusting for NO2 and PM2.5, the HR for NO2 turned insignificant: 0.978 (0.950, 1.008), but HR for PM2.5 was not altered: 1.252 (1.227, 1.279). PM2.5 and higher mortality association was robust, regardless of NO2. When acccounting for particulate matter, NO2 exposure appeared to be harmful in places of colder climates and higher seasonal temperature variation. Conclusions We see a robust relationship of PM2.5 exposure and premature mortality in advance aged individuals, however, NO2 exposure and mortality was only harmful in places of colder climate such as northeast China, indicating evidence of effect modification by temperature. Analysis of NO2 without accounting for its collinearity with PM2.5, may lead to overestimation.

Abstract Background: Dietary fish-oil supplementation might attenuate the associations between fine particulate matter (PM2.5) and subclinical biomarkers. However, the molecular mechanisms remain to be elucidated. This study aimed to explore the molecular mechanisms of fish-oil supplementation against the PM2.5-induced health effects. Methods: We conducted a randomized, double-blinded, and placebo-controlled trial among healthy college students in Shanghai, China, from September 2017 to January 2018. A total of 70 participants from the Fenglin campus of Fudan University were included. We randomly assigned participants to either supplementation of 2.5-gram fish oil (n = 35) or sunflower-seed oil (placebo) (n = 35) per day and conducted four rounds of health measurements in the last two months of the trial. As a post hoc exploratory study, the present untargeted metabolomics analysis used remaining blood samples collected in the previous trial and applied a Metabolome-Wide Association Study framework to compare the effects of PM2.5 on the metabolic profile between the sunflower-seed oil and fish oil groups. Results: A total of 65 participants completed the trial (34 of the fish oil group and 31 of the sunflower-seed oil group). On average, ambient PM2.5 concentration on the day of health measurements was 34.9 µg/m3 in the sunflower-seed oil group and 34.5 µg/m3 in the fish oil group, respectively. A total of 3833 metabolites were significantly associated with PM2.5 in the sunflower-seed oil group and 1757 in the fish oil group. Of these, 1752 metabolites showed significant between-group differences. The identified differential metabolites included arachidonic acid derivatives, omega-3 fatty acids, omega-6 fatty acids, and omega-9 fatty acids that were related to unsaturated fatty acid metabolism, which plays a role in the inflammatory responses. Conclusion: This trial suggests fish-oil supplementation could mitigate the PM2.5-induced inflammatory responses via modulating fatty acid metabolism, providing biological plausibility for the health benefits of fish-oil supplementation against PM2.5 exposure. Trial registration: This study is registered at ClinicalTrails.gov (NCT03255187).

Abstract Background Ambient air pollution is related to the onset and progression of ocular disease. However, the effect of air pollutants on the acute glaucoma remains unclear. Objective To investigate the effect of air pollutants on the incidence of acute glaucoma (acute angle closure glaucoma and glaucomatocyclitic crisis) among adults. Methods We conducted a time-stratified case-crossover study based on the data of glaucoma outpatients from January, 2015 to Dec, 2021 in Shanghai, China. A conditional logistic regression model combined with a polynomial distributed lag model was applied for the statistical analysis. Each case serves as its own referent by comparing exposures on the day of the outpatient visit to the exposures on the other 3–4 control days on the same week, month and year. To fully capture the delayed effect of air pollution, we used a maximum lag of 7 days in main model. Results A total of 14,385 acute glaucoma outpatients were included in this study. We found exposure to PM2.5, PM10, nitrogen dioxide (NO2) and carbon monoxide (CO) significantly increased the odds of outpatient visit for acute glaucoma. Wherein the odds of acute glaucoma related to PM2.5 and NO2 were higher and more sustained, with OR of 1.07 (95%CI: 1.03–1.11) and 1.12 (95% CI: 1.08–1.17) for an IQR increase over lag 0–3 days, than PM10 and CO over lag 0–1 days (OR:1.03; 95% CI: 1.01–1.05; OR: 1.04; 95% CI: 1.01–1.07). Conclusions This case-crossover study provided first-hand evidence that air pollutants, especially PM2.5 and NO2, significantly increased risk of acute glaucoma.

Background: Future climate change is likely to alter cold spell-related disease burden. Few projection studies have considered the potential impact of the aging population with changing population size on cold spell-related disease burdens. Methods: We derived the association between cold spells and daily mortality for 272 main cities in mainland China. We combined these associations with modeled daily temperatures from three different climate models under two climate change scenarios and three population scenarios to project excess deaths related to cold spells. Furthermore, we used the factor separation method to calculate the independent contribution of future population size, age structure, and climate change on projected deaths attributable to cold spells. Findings: Compared to the baseline period, future excess deaths related to cold spells are expected to increase over most of the decades under RCP 2.6 (81.5% in 2050 s and 37% in 2090 s) and RCP 4.5 (55.5% in 2050 s and −19% in 2090 s). The factor analysis indicated that the rise of the aged population (≥65) substantially would amplify the excess deaths related to cold spells (increase by 101.1% in the 2050 s and 146.2% in the 2090 s). For the near future (2021–2040), population aging could fully offset the influence of decreased cold-spell days. In the middle of this century (2051–2070), the total excess deaths will exhibit significant variation across three scenarios. By the end of 21 century (2081–2100), the population shrinking would reduce the total excess deaths. Interpretation: Excess deaths related to cold spells may still increase in a warming climate and future demographic shifts would produce considerable influences in this increase for different periods.

Background: A large gap exists between the latest Global Air Quality Guidelines (AQG 2021) and Chinese air quality standards for NO2. Assessing whether and to what extent air quality standards for NO2 should be tightened in China requires a comprehensive understanding of the spatiotemporal characteristics of population exposure to ambient NO2 and related health risks, which have not been studied to date. Objective: We predicted ground NO2 concentrations with high resolution in mainland China, explored exposure characteristics to NO2 pollution, and assessed the mortality burden attributable to NO2 exposure. Methods: Daily NO2 concentrations in 2019 were predicted at 1-km spatial resolution in mainland China using random forest models incorporating multiple predictors. From these high-resolution predictions, we explored the spatiotemporal distribution of NO2, population and area percentages with NO2 exposure exceeding criterion levels, and premature deaths attributable to long- and short-term NO2 exposure in China. Results: The cross-validation R2 and root mean squared error of the NO2 predicting model were 0.80 and 7.78 μg/m3, respectively, at the daily level in 2019. The percentage of people (population number) with annual NO2 exposure over 40 μg/m3 in mainland China in 2019 was 10.40 % (145,605,200), and it reached 99.68 % (1,395,569,840) with the AQG guideline value of 10 μg/m3. NO2 levels and population exposure risk were elevated in urban areas than in rural. Long- and short-term exposures to NO2 were associated with 285,036 and 121,263 non-accidental deaths, respectively, in China in 2019. Tightening standards in steps gradually would increase the potential health benefit. Conclusion: In China, NO2 pollution is associated with significant mortality burden. Spatial disparities exist in NO2 pollution and exposure risks. China’s current air quality standards may no longer objectively reflect the severity of NO2 pollution and exposure risk. Tightening the national standards for NO2 is needed and will lead to significant health benefits.

Maternal exposure to ambient fine particulate matter (PM2.5) during pregnancy has been associated with impaired neurobehavioral development in children. However, the specific mechanism remains unclear. Brain derived neurotrophic factor (BDNF) is an important growth factor in the nervous system. We evaluated the associations of maternal PM2.5 exposures with fetal BDNF in the umbilical cord blood in a prospective cohort study. A total of 711 eligible mother-infant pairs from the Shanghai Birth Cohort were included in the current study. Daily maternal exposures to ambient PM2.5 were assessed with a gap-filling approach at 1 * 1 km2 resolution based on self-reported home addresses. The concentrations of BDNF in the cord blood were measured by ELISA. A linear regression model was applied to evaluate the association of maternal ambient PM2.5 exposure with fetal BDNF level at birth. The median concentration of BDNF was 13,403 pg/ml. Vaginal deliveries and female infants had higher BDNF levels than cesarean deliveries and male infants. One natural log (ln) unit increase in maternal PM2.5 exposure during the second trimester was significantly associated with − 0.20 (95% CI: −0.36, −0.05) ln-unit decrease in BDNF level in all births. These effects were stronger and more significant in vaginal deliveries and in male infants. Our study suggests that BDNF in the cord blood may serve as a potential biomarker in assessing the neurodevelopmental effects of maternal PM2.5 exposure.

New study investigates heat-induced labor loss in 231 Chinese cities, finding that lower-paid sectors could be disproportionately affected in coming decades, although adaptation measures may mitigate inequality related impacts.

A composite Air Health Index (AHI) is helpful for separately emphasizing the health risks of multiple stimuli and communicating the overall risks of an adverse atmospheric environment to the public. We aimed to establish a new AHI by integrating daily mortality risks due to air pollution with those due to non-optimum temperature in China. Based on the exposure-response (E-R) coefficients obtained from time-series models, the new AHI was constructed as the sum of excess mortality risk associated with air pollutants and non-optimum temperature in 272 Chinese cities from 2013 to 2015. We examined the association between the “total AHI” (based on total mortality) and total mortality, and further compared the ability of the “total AHI” to predict specific cardiopulmonary mortality with that of “specific AHIs” (based on specific mortalities). On average, air pollution and non-optimum temperature were associated with 28.23% of daily excess mortality, of which 23.47% was associated with non-optimum temperature while the remainder was associated with fine particulate matter (PM2.5) (1.12%), NO2 (2.29%,), and O3 (2.29%). The new AHI uses a 10-point scale and shows an average across all 272 cities of 6 points. The E-R curve for AHI and mortality is approximately linear, without any thresholds. Each one unit increase in “total AHI” is associated with a 0.84% increase in all-cause mortality and 1.01%, 0.98%, 1.02%, 1.66%, and 1.71% increases in cardiovascular disease, coronary heart disease, stroke, respiratory diseases, and chronic obstructive pulmonary disease mortality, respectively. Cause-specific mortality risk estimates using the “total AHI” are similar to those predicted by “specific AHIs.” In conclusion, the “total AHI” proposed herein could be a promising tool for communicating health risks related to exposure to the ambient environment to the public.

Objective and design: An experimental rat allergic rhinitis(AR) model was made to explore the effect of different concentrations of ozone exposure and evaluate the roles of nuclear factor erythroid 2-related factor 2(Nrf2) and oxidative stress in ozone exposure. Method: Sprague-Dawley rats were sensitized with ovalbumin (OVA). Three groups of AR rats were exposed respectively to different concentrations of ozone for 2 h on 6 weeks. Nasal symptoms and OVA- specific Ig E in the serum were evaluated. The pathological changes in the nasal mucosa were examined. Malondialdehyde (MDA) level and activity of superoxide dismutase(SOD) and glutathione peroxidase (GSH-Px,GPX) in the nasal mucosa tissue were measured through a spectrophotometry-based method. Nrf2、Kelch-1ike ECH- associated protein-l (Keap1) proteins was measured by western blotting. GPX1、GPX2 mRNA were detected by quantitative real time-PCR(qRT-PCR). Results: Our results showed that ozone exposure induced a significant increase of the number of sneezes, nasal rubs, amount of nasal secretion and OVA-sIgE in the serum of AR model. Ozone effected oxidative stress in different concentration. The content of MDA in AREH group was significantly higher than AR groups. The activities of SOD and GSH-Px in nasal mucosa showed different trends in different concentration groups. The activities of SOD and GSH-Px in AREL and AREM groups were higher than AR group, but decreased at AREH group. The nucleoprotein level of Nrf2 in AREL and AREM groups was higher than AR groups. However, in AREH group, it was significantly decreased, compared with AREL and AREM groups. GPX1 and GPX2 mRNA levels in nasal mucosa showed the same trend in different exposure groups. Conclusions: Different concentrations of ozone inhalation causes changes of the expression of Nrf2 nuclear protein and its target genes in nasal mucosa of AR. High concentration ozone breaks the redox balance and aggravates oxidative damage in AR. This study suggests that inhibiting oxidative stress might be a solution for ozone-elicited detrimental effects on AR.

There are limited studies on the associations between prenatal exposure to constituents of fine particulate matter (PM2.5) and children’s intelligence quotient (IQ). Our study aimed to explore the associations between prenatal PM2.5 and its six constituents and the IQ levels of 6-year-old children. We included 512 mother-child pairs. We used a satellite-based modelling framework to estimate prenatal PM2.5 and its six constituents (ammonium, sulfate, nitrate, organic carbon, soil dust, and black carbon). We assessed the children’s IQ using the short form of the Wechsler Intelligence Scale. Perceptual Reasoning Index (PRI), Verbal Comprehension Index (VCI), and Full Scale IQ (FSIQ) scores were computed. The multiple informant model (MIM) was applied to explore the trimester specific effects of PM2.5 and its six constituents’ exposure on children’s PRI, VCI, and FSIQ. To examine whether the duration of breastfeeding and physical activity (PA) could modify the effects of PM2.5 on children’s IQ, we stratified the analyses according to the duration of breastfeeding (≤6 and >6 months) and time of outdoor activities after school (≤2 and >2 h/week). The first trimester PM2.5 and its five constituents’ exposures were inversely associated with FSIQ [β = −1.34, 95 % confidence interval [CI] (−2.71, 0.04) for PM2.5] and PRI [β = −2.18, 95 %CI (−3.80, −0.57) for PM2.5] in children. The associations were magnified among boys and those with less outdoor activities or shorter breastfeeding duration. Our results indicate that prenatal PM2.5 and several of its main constituents’ exposure may disrupt cognitive development in children aged 6 years. More PA and longer breastfeeding duration may alleviate the detrimental effects of prenatal PM2.5 exposure on children’s cognitive function.

Background: Evidence on the potential interactive effects of heat and ambient air pollution on cause-specific mortality is inconclusive and limited to selected locations. Objectives: We investigated the effects of heat on cardiovascular and respiratory mortality and its modification by air pollution during summer months (six consecutive hottest months) in 482 locations across 24 countries. Methods: Location-specific daily death counts and exposure data (e.g., particulate matter with diameters ≤ 2.5 µm [PM2.5]) were obtained from 2000 to 2018. We used location-specific confounder-adjusted Quasi-Poisson regression with a tensor product between air temperature and the air pollutant. We extracted heat effects at low, medium, and high levels of pollutants, defined as the 5th, 50th, and 95th percentile of the location-specific pollutant concentrations. Country-specific and overall estimates were derived using a random-effects multilevel meta-analytical model. Results: Heat was associated with increased cardiorespiratory mortality. Moreover, the heat effects were modified by elevated levels of all air pollutants in most locations, with stronger effects for respiratory than cardiovascular mortality. For example, the percent increase in respiratory mortality per increase in the 2-day average summer temperature from the 75th to the 99th percentile was 7.7% (95% Confidence Interval [CI] 7.6–7.7), 11.3% (95%CI 11.2–11.3), and 14.3% (95% CI 14.1–14.5) at low, medium, and high levels of PM2.5, respectively. Similarly, cardiovascular mortality increased by 1.6 (95%CI 1.5–1.6), 5.1 (95%CI 5.1–5.2), and 8.7 (95%CI 8.7–8.8) at low, medium, and high levels of O3, respectively. Discussion: We observed considerable modification of the heat effects on cardiovascular and respiratory mortality by elevated levels of air pollutants. Therefore, mitigation measures following the new WHO Air Quality Guidelines are crucial to enhance better health and promote sustainable development.

Background: Epidemiological evidence regarding the relation of exposure to ambient particulate matter (PM) with gallstone disease (GSD) risk remains lacking. We tested the hypothesis that long-term exposure to PM is related to the development of GSD and that dyslipidemia can mediate the effect of PM-associated GSD formation. Methods: We extracted related information on the basis of the baseline survey of the China Multi-Ethnic Cohort Study. The exposure levels of PM (PM1, PM2.5, and PM10) were assessed by validated spatiotemporal models. The relation of exposure to ambient PM with GSD risks was analyzed by non-conditional logistic regression models. Additionally, mediation analysis was conducted to assess whether dyslipidemia was related to the relation of PM exposure with GSD risks. Results: A total of 72,893 participants were included. Increased ambient PM exposure was positively associated with a higher GSD risk, with ORs (and 95% CI) of 1.17 (1.06, 1.28), 1.10 (1.05, 1.15), and 1.07 (1.04, 1.10) for every 10 μg/m3 increment in PM1, PM2.5, and PM10, separately. The association was more remarkable in males, drinkers, and central obesity participants. Dyslipidemia significantly mediated the association between PM and GSD, with mediating proportions of 5.37%, 9.13%, and 7.66% in PM1, PM2.5, and PM10, respectively. Conclusion: Exposure to PM may relate to the increased risk of GSD in Chinese adults, especially among males, drinkers, and central obesity participants. Dyslipidemia may partially mediate the effect of PM-associated GSD development. Our results might provide epidemiological evidence for the progression of GSD related to PM and give new insights into GSD prevention and screening priorities.

Abstract Background We hypothesize higher air pollution and fewer greenness exposures jointly contribute to metabolic syndrome (MetS), as mechanisms on cardiometabolic mortality. Methods We studied the samples in the Chinese Longitudinal Healthy Longevity Survey. We included 1755 participants in 2012, among which 1073 were followed up in 2014 and 561 in 2017. We used cross-sectional analysis for baseline data and the generalized estimating equations (GEE) model in a longitudinal analysis. We examined the independent and interactive effects of fine particulate matter (PM2.5) and Normalized Difference Vegetation Index (NDVI) on MetS. Adjustment covariates included biomarker measurement year, baseline age, sex, ethnicity, education, marriage, residence, exercise, smoking, alcohol drinking, and GDP per capita. Results At baseline, the average age of participants was 85.6 (SD: 12.2; range: 65–112). Greenness was slightly higher in rural areas than urban areas (NDVI mean: 0.496 vs. 0.444; range: 0.151–0.698 vs. 0.133–0.644). Ambient air pollution was similar between rural and urban areas (PM2.5 mean: 49.0 vs. 49.1; range: 16.2–65.3 vs. 18.3–64.2). Both the cross-sectional and longitudinal analysis showed positive associations of PM2.5 with prevalent abdominal obesity (AO) and MetS, and a negative association of NDVI with prevalent AO. In the longitudinal data, the odds ratio (OR, 95% confidence interval-CI) of PM2.5 (per 10 μg/m3 increase) were 1.19 (1.12, 1.27), 1.16 (1.08, 1.24), and 1.14 (1.07, 1.21) for AO, MetS and reduced high-density lipoprotein cholesterol (HDL-C), respectively. NDVI (per 0.1 unit increase) was associated with lower AO prevalence [OR (95% CI): 0.79 (0.71, 0.88)], but not significantly associated with MetS [OR (95% CI): 0.93 (0.84, 1.04)]. PM2.5 and NDVI had a statistically significant interaction on AO prevalence (p interaction: 0.025). The association between PM2.5 and MetS, AO, elevated fasting glucose and reduced HDL-C were only significant in rural areas, not in urban areas. The association between NDVI and AO was only significant in areas with low PM2.5, not under high PM2.5. Conclusions We found air pollution and greenness had independent and interactive effect on MetS components, which may ultimately manifest in pre-mature mortality. These study findings call for green space planning in urban areas and air pollution mitigation in rural areas.

Abstract Objectives This study aims to further investigate the association of COVID-19 disease severity with numerous patient characteristics, and to develop a convenient severity prediction scale for use in self-assessment at home or in preliminary screening in community healthcare settings. Setting and participants Data from 45,450 patients infected with COVID-19 from January 1 to February 27, 2020 were extracted from the municipal Notifiable Disease Report System in Wuhan, China. Primary and secondary outcome measures We categorized COVID-19 disease severity, based on The Chinese Diagnosis and Treatment Protocol for COVID-19, as “nonsevere” (which grouped asymptomatic, mild, and ordinary disease) versus “severe” (grouping severe and critical illness). Results Twelve scale items—age, gender, illness duration, dyspnea, shortness of breath (clinical evidence of altered breathing), hypertension, pulmonary disease, diabetes, cardio/cerebrovascular disease, number of comorbidities, neutrophil percentage, and lymphocyte percentage—were identified and showed good predictive ability (area under the curve = 0·72). After excluding the community healthcare laboratory parameters, the remaining model (the final self-assessment scale) showed similar area under the curve (= 0·71). Conclusions Our COVID-19 severity self-assessment scale can be used by patients in the community to predict their risk of developing severe illness and the need for further medical assistance. The tool is also practical for use in preliminary screening in community healthcare settings. Summary Our study constructed a COVID-19 severity self-assessment scale that can be used by patients in the community to predict their risk of developing severe illness and the need for further medical assistance.

Abstract It is unequivocal that human influence has warmed the planet, which is seriously affecting the planetary health including human health. Adapting climate change should not only be a slogan, but requires a united, holistic action and a paradigm shift from crisis response to an ambitious and integrated approach immediately. Recognizing the urgent needs to tackle the risk connection between climate change and One Health, the four key messages and recommendations that with the intent to guide further research and to promote international cooperation to achieve a more climate-resilient world are provided. Graphical Abstract

Ambient fine particulate matter (PM2.5) pollution is a major environmental and public health challenge in China. In the recent decade, the PM2.5 level has decreased mainly driven by reductions in particulate sulfate as a result of large-scale desulfurization efforts in coal-fired power plants and industrial facilities. Emerging evidence also points to the differential toxicity of particulate sulfate affecting human health. However, estimating the long-term spatiotemporal trend of sulfate is difficult because a ground monitoring network of PM2.5 constituents has not been established in China. Spaceborne sensors such as the Multi-angle Imaging SpectroRadiometer (MISR) instrument can provide complementary information on aerosol size and type. With the help of state-of-the-art machine learning techniques, we developed a sulfate prediction model under support from available ground measurements, MISR-retrieved aerosol microphysical properties, and atmospheric reanalysis data at a spatial resolution of 0.1°. Our sulfate model performed well with an out-of-bag cross-validation R2 of 0.68 at the daily level and 0.93 at the monthly level. We found that the national mean population-weighted sulfate concentration was relatively stable before the Air Pollution Prevention and Control Action Plan was enforced in 2013, ranging from 10.4 to 11.5 µg m−3. But the sulfate level dramatically decreased to 7.7 µg m−3 in 2018, with a change rate of −28.7 % from 2013 to 2018. Correspondingly, the annual mean total non-accidental and cardiopulmonary deaths attributed to sulfate decreased by 40.7 % and 42.3 %, respectively. The long-term, full-coverage sulfate level estimates will support future studies on evaluating air quality policies and understanding the adverse health effect of particulate sulfate.

Ambient nitrogen dioxide (NO2)-induced adverse health effects have been studied, but documented evidence on neural systems is limited. This study aimed to determine the acute effect of NO2 exposure on nervous system damage biomarker levels in healthy older adults. Five rounds of follow-up among 34 healthy retired people were scheduled from December 2018 to April 2019 in Xinxiang, China. The real-time NO2 concentrations were measured using a fixed site monitor. Serum samples were acquired during each round to measure nervous system damage biomarker levels: brain-derived neurotrophic factor (BDNF), neurofilament light chain (NfL), neuron-specific enolase (NSE), protein gene product 9.5 (PGP9.5), and S100 calcium-binding protein B (S100B). A linear mixed-effect model was incorporated to analyze the association between short-term NO2 exposure and serum concentrations of the above-mentioned biomarkers. Stratification analysis based on sex, educational attainment, glutathione S-transferase theta 1 gene (GSTT1) polymorphism, and physical activity intensity was conducted to explore their potential modification effect. The NO2 concentration ranged from 34.7 to 59.0 µg/m3 during the study period. Acute exposure to ambient NO2 was significantly associated with elevated serum levels of NfL, PGP9.5, and BDNF. In response to a 10 µg/m3 increase in NO2 concentration, NfL and PGP9.5 levels increased by 76 % (95 % confidence interval [CI]: 12–140 %) and 54 % (95 % CI: 1–107 %) on the lag0 day, respectively, while BDNF levels increased by 49 % (95 % CI: 2–96 %) at lag4 day. The estimated effect of NO2 on NSE levels in GSTT1-sufficient participants was significantly higher than that in GSTT1-null participants. Intriguingly, the estimation of NO2 on PGP9.5 levels in females was significantly higher than that in males. Most two-pollutant models showed robust results, except for O3, which might have had confounding effects on NO2-induced BDNF stimulation. In summary, acute exposure to NO2 was associated with increased levels of serum nervous system damage biomarker levels including NFL, PGP9.5, and BDNF. The present study provided insights into NO2 exposure-induced adverse neural effects.

Background: Residential greenness has been linked to respiratory mortality, but its long-term effect on incident chronic obstructive pulmonary disease (COPD) has rarely been investigated. Methods: This prospective cohort study was based on over 350 000 participants aged 38–70 of the UK Biobank, followed from 2006 to 2010 baseline to 2021. COPD cases were ascertained through linkages to health administrative datasets. Residential greenness was measured by satellite-derived normalized difference vegetation index (NDVI) within the 500- and 1 000-m buffer. Effects of greenness on COPD incidence were assessed using Cox proportional hazards models. We also explored mediation by physical activity, particular matter

Although fine particulate matter (PM2.5) is a neurotoxicant, little is known about whether early-life PM2.5 exposure is associated with an increased risk of developmental coordination disorder (DCD). We conducted a cohort study of 109 731 children aged 3–5 years from 551 county-level cities in China between April 2018 and December 2019. Residential PM2.5 exposure was estimated using a hybrid satellite-based exposure model. Children’s motor performance was assessed using the Little DCD Questionnaire (LDCDQ). Linear mixed-effect models and generalized linear mixed models with a binomial distribution were used to examine the associations of PM2.5 exposure with LDCDQ scores and risk of DCD, respectively. Both prenatal and postnatal exposure to a higher level of PM2.5 was significantly associated with reduced total LDCDQ score, and the impacts were evident on subscales of control during movement and general coordination function but not fine motor function. For example, an interquartile range increase in PM2.5 exposure in ages 0–3 was associated with a 0.19 (95% confidence interval [CI]: 0.05, 0.33) decrement in the total score. Additionally, higher PM2.5 exposure was associated with increased risk of DCD, and the adjusted odds ratios were 1.06 (95% CI: 1.01, 1.10) and 1.06 (95% CI: 1.01, 1.13) for each interquartile range increase in PM2.5 exposure during the first trimester and the first 3 years, respectively. Children who were from rural areas, had neonatal intensive care unit admission, or were exclusively breastfed for less than 6 months appeared to be more susceptible to PM2.5 exposure than their counterparts. Our findings provide robust evidence that early-life PM2.5 exposure contributes to an elevated risk of DCD.

Background: Prelabor rupture of the fetal membranes (PROM) is a major contributor to adverse perinatal outcomes. Some epidemiologic studies explored the association between maternal PM2.5 exposure and PROM but failed to treat the labor induction and prelabor cesarean section as censored observations. Objective: We aimed to evaluated whether acute and chronic maternal ambient PM2.5 exposure may increase the risk of PROM in China. Methods: This study was based on the China Labor and Delivery Survey, a nationwide multicenter investigation. Included in the current analysis were 45,879 singleton spontaneous births in 96 hospitals in mainland China from 2015 to 2017. Outcomes were PROM, preterm PROM (

Background: Ambient fine particulate matter (PM2.5) exposure increases local and systemic interleukin-6 (IL-6). However, the pathogenic role of IL-6 signalling following PM2.5 exposure, particularly in the development of pulmonary dysfunction and abnormal glucose homeostasis, has hardly been investigated. Results: In the study, IL-6 receptor (IL-6R)-deficient (IL-6R-/-) and wildtype littermate (IL-6R+/+) mice were exposed to concentrated ambient PM2.5 (CAP) or filtered air (FA), and their pulmonary and metabolic responses to these exposures were analyzed. Our results demonstrated that IL-6R deficiency markedly alleviated PM2.5 exposure-induced increases in lung inflammatory markers including the inflammation score of histological analysis, the number of macrophages in bronchoalveolar lavage fluid (BALF), and mRNA expressions of TNFα, IL-1β and IL-6 and abnormalities in lung function test. However, IL-6R deficiency did not reduce the hepatic insulin resistance nor systemic glucose intolerance and insulin resistance induced by PM2.5 exposure. Conclusion: Our findings support the crucial role of IL-6 signalling in the development of pulmonary inflammation and dysfunction due to PM2.5 exposure but question the putative central role of pulmonary inflammation for the extra-pulmonary dysfunctions following PM2.5 exposure, providing a deep mechanistic insight into the pathogenesis caused by PM2.5 exposure.

Background: Stroke is a leading cause of death and disability in East Asia. Owing to the aging population and high prevalence of stroke, East Asia might suffer a disproportionately heavy burden of stroke under the changing climate. However, the evidence relevant is still limited in this area. Objective: To evaluate the stroke mortality risk due to heat exposure in East Asia and predict its burden under various future climate change scenarios. Methods: We conducted a multi-center observational study and collected data from 22 representative cities in three main East Asian countries (i.e., China, Japan, and South Korea) from 1972 to 2015. The two-stage time-series analyses were applied to estimate the effects of heat on stroke mortality at the regional and country level. We further projected the burden of heat-related stroke mortality using 10 global climate models (GCMs) under four shared socioeconomic pathway and representative concentration pathway (SSP–RCP) scenarios, including SSP1–RCP1.9, SSP1–RCP2.6, SSP2–RCP4.5, and SSP5–RCP8.5 scenarios. Results: In the present study, a total of 287,579 stroke deaths were collected during the warm season. Heat was significantly associated with an increased risk of stroke mortality. Overall, compared with the 2010 s, the heat-related attributable fraction (AF) was projected to increase in the 2090 s, with increments ranging from 0.8 % to 7.5 % across various climate change scenarios. The heat-related AF was projected to reach 11.9 % (95 % empirical confidence interval [eCI]: 6.1 %, 17.5 %) in the 2090 s under the SSP5–RCP8.5 scenario in China, while the corresponding estimates were 6.6 % (95 % eCI: 2.5 %, 11.0 %) and 5.1 % (95 % eCI: 1.2 %, 9.1 %) for Japan and South Korea, respectively. Conclusions: Climate change will exacerbate the burden of heat-related stroke mortality but with considerable geographical heterogeneity in East Asia.

Environmental science is an interdisciplinary science developed in the process of understanding and solving ecological and environmental problems. In order to tackle these problems, environmental science research is expected to reveal the source, behavior, fate, exposure, and risks of pollutants in the environment and develop potential solutions to control pollution. It provides the scientific basis for decision-makers to establish environmental and economic policies, and promote concerted efforts for the sustainable development of society. Here, we articulate the development patterns, challenges, and future research needs of environmental science in China based on literature review and expert panel discussion. Environmental science research has evolved significantly in the past decade with an increasing diversity of environmental pollutants and health impacts, new technologies and methods, deepening fusion of multiple disciplines, and emerging solutions for pollution control. Its future development relies on the advances in our knowledge on the fate and transport of pollutants, regional environmental processes, ecotoxicological effects, environmental exposure and health effects, environmental analysis and monitoring, source control and reduction, environmental remediation, as well as environmental risk management. For each of these fields, we summarize the significant challenges and highlight the research demands for China. Based on the status quo of China's environmental science research and future needs, we provide recommendations to promote its future development, including encouraging innovation and interdisciplinary research, providing decision support for national needs, encouraging international collaboration, and improving collaboration mechanisms.

Ambient particulate matter (PM) pollution in China continues to be a major public health challenge. With the release of the new WHO air quality guidelines in 2021, there is an urgent need for China to contemplate a revision of air quality standards (AQS). In the recent decade, there has been an increase in epidemiological studies on PM in China. A comprehensive evaluation of such epidemiological evidence among the Chinese population is central for revision of the AQS in China and in other developing countries with similar air pollution problems. We thus conducted a systematic review on the epidemiological literature of PM published in the recent decade. In summary, we identified the following: (1) short-term and long-term PM exposure increase mortality and morbidity risk without a discernible threshold, suggesting the necessity for continuous improvement in air quality; (2) the magnitude of long-term associations with mortality observed in China are comparable with those in developed countries, whereas the magnitude of short-term associations are appreciably smaller; (3) governmental clean air policies and personalized mitigation measures are potentially effective in protecting public and individual health, but need to be validated using mortality or morbidity outcomes; (4) particles of smaller size range and those originating from fossil fuel combustion appear to show larger relative health risks; and (5) molecular epidemiological studies provide evidence for the biological plausibility and mechanisms underlying the hazardous effects of PM. This updated review may serve as an epidemiological basis for China’s AQS revision and proposes several perspectives in designing future health studies.

Summary: Background: Acute aortic dissection (AAD) is a life-threatening cardiovascular emergency with high mortality, so identifying modifiable risk factors of AAD is of great public health significance. The associations of non-optimal temperature and temperature variability with AAD onset and the disease burden have not been fully understood. Methods: We conducted a time-stratified case-crossover study using a nationwide registry dataset from 1,868 hospitals in 313 Chinese cities. Conditional logistic regression and distributed lag models were used to investigate associations of temperature and temperature changes between neighboring days (TCN) with the hourly AAD onset and calculate the attributable fractions. We also evaluated the heterogeneity of the associations. Findings: A total of 40,270 eligible AAD cases were included. The exposure-response curves for temperature and TCN with AAD onset risk were both inverse and approximately linear. The risks were present on the concurrent hour (for temperature) or day (for TCN) and lasted for almost 1 day. The cumulative relative risks of AAD were 1.027 and 1.026 per 1°C lower temperature and temperature decline between neighboring days, respectively. The associations were significant during the non-heating period, but were not present during the heating period in cities with central heating. 23.13% of AAD cases nationwide were attributable to low temperature and 1.58% were attributable to temperature decline from the previous day. Interpretation: This is the largest nationwide study demonstrating robust associations of low temperature and temperature decline with AAD onset. We, for the first time, calculated the corresponding disease burden and further showed that central heating may be a modifier for temperature-related AAD risk and burden. Funding: This work was supported by the National Natural Science Foundation of China (92043301 and 92143301), Shanghai International Science and Technology Partnership Project (No. 21230780200), the Medical Research Council-UK (MR/R013349/1), and the Natural Environment Research Council UK (NE/R009384/1).