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• W2085371710 abstract "The prevalence of asthma and allergic diseases has been found to be increasingly rapidly, especially in developing countries. Environmental factors have been found to be important contributors to the manifestations of allergic diseases. Air pollution has been extensively studied in different regions of the world. The levels of ambient air pollutants in many Asian countries are very high when compared with those in developed Western countries. However, the prevalence of asthma was relatively low across many Asian countries. Many studies have clearly documented that environmental air pollution is an important factor resulting in exacerbations of asthma. In particular, levels of traffic-related pollutants are increasing rapidly across many Asian countries in parallel with the level of urbanization and economic development. The loss of protective factors associated with a rural environment will further contribute to the adverse effect on patients with allergic diseases such as asthma. In this review the roles of air pollution were examined in relation to the inception and exacerbations of allergic diseases in Asia. The prevalence of asthma and allergic diseases has been found to be increasingly rapidly, especially in developing countries. Environmental factors have been found to be important contributors to the manifestations of allergic diseases. Air pollution has been extensively studied in different regions of the world. The levels of ambient air pollutants in many Asian countries are very high when compared with those in developed Western countries. However, the prevalence of asthma was relatively low across many Asian countries. Many studies have clearly documented that environmental air pollution is an important factor resulting in exacerbations of asthma. In particular, levels of traffic-related pollutants are increasing rapidly across many Asian countries in parallel with the level of urbanization and economic development. The loss of protective factors associated with a rural environment will further contribute to the adverse effect on patients with allergic diseases such as asthma. In this review the roles of air pollution were examined in relation to the inception and exacerbations of allergic diseases in Asia. Global epidemiologic data indicate that currently the increase in childhood asthma and allergies is most pronounced in developing countries.1Asher M.I. Montefort S. Bjorksten B. Lai C.K. Strachan D.P. Weiland S.K. et al.Worldwide time trends in the prevalence of symptoms of asthma, allergic rhinoconjunctivitis, and eczema in childhood: ISAAC Phases One and Three repeat multicountry cross-sectional surveys.Lancet. 2006; 368: 733-743Abstract Full Text Full Text PDF PubMed Scopus (3051) Google Scholar This trend could be attributed to changes associated with environmental and lifestyle factors during the modernization process. Among others, the increasing level of ambient air pollution might affect children’s asthma and allergies,2Watts J. Doctors blame air pollution for China’s asthma increases.Lancet. 2006; 368: 719-720Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar and indoor air pollution is another major health problem in developing countries. Many countries in Asia are densely populated; even a slight increase in asthma and allergy prevalence will translate into a large number of affected persons. Coal is still the major source of energy in many Asian countries, and consequently, there is an increase in coal smoke, with suspended particulate matter and sulfur dioxide (SO2) as the predominant pollutants. The rapidly growing number of motor vehicles accelerates emissions of other ambient air pollutants, such as nitrogen dioxide (NO2) and ozone (O3). Indoor air pollution is another important issue in Asia. Wood and coal burning are widely used for cooking or heating in dwellings in rural areas, which generates significant particle pollution. Such methods have been widely replaced by cleaner energy sources, such as gas and electricity, in homes in urban Asian cities. Nonetheless, new building materials and furniture emit chemicals, such as formaldehyde and volatile organ compounds, in urban areas. High indoor levels of these chemicals have been reported in China,3Tang X. Bai Y. Duong A. Smith M.T. Li L. Zhang L. Formaldehyde in China: production, consumption, exposure levels, and health effects.Environ Int. 2009; 35: 1210-1224Crossref PubMed Scopus (526) Google Scholar Korea,4Park J.S. Ikeda K. Variations of formaldehyde and VOC levels during 3 years in new and older homes.Indoor Air. 2006; 16: 129-135Crossref PubMed Scopus (154) Google Scholar and Hong Kong.5Guo H. Kwok N.H. Cheng H.R. Lee S.C. Hung W.T. Li Y.S. Formaldehyde and volatile organic compounds in Hong Kong homes: concentrations and impact factors.Indoor Air. 2009; 19: 206-217Crossref PubMed Scopus (110) Google Scholar Air pollution is consistently shown to be a potent trigger for asthma exacerbations both in children and adults, but there is limited and inconclusive evidence about its role in the initiation of allergic disorders. This review aimed to summarize the evidence of ambient air pollutant exposures as risk factors for the susceptibility of asthma and allergy in the Asian population (Table I)6Hwang B.F. Lee Y.L. Air pollution and prevalence of bronchitic symptoms among children in Taiwan.Chest. 2010; 138: 956-964Crossref PubMed Scopus (41) Google Scholar, 7Pan G. Zhang S. Feng Y. Takahashi K. Kagawa J. Yu L. et al.Air pollution and children’s respiratory symptoms in six cities of Northern China.Respir Med. 2010; 104: 1903-1911Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar, 8Zhao Z. Zhang Z. Wang Z. Ferm M. Liang Y. Norbäck D. Asthmatic symptoms among pupils in relation to winter indoor and outdoor air pollution in schools in Taiyuan, China.Environ Health Perspect. 2008; 116: 90-97Crossref PubMed Scopus (144) Google Scholar, 9Ho W.C. Hartley W.R. Myers L. Lin M.H. Lin Y.S. Lien C.H. et al.Air pollution, weather, and associated risk factors related to asthma prevalence and attack rate.Environ Res. 2007; 104: 402-409Crossref PubMed Scopus (86) Google Scholar, 10Hwang B.F. Lee Y.L. Lin Y.C. Jaakkola J.J. Guo Y.L. Traffic related air pollution as a determinant of asthma among Taiwanese school children.Thorax. 2005; 60: 467-473Crossref PubMed Scopus (70) Google Scholar, 11Delfino R.J. Staimer N. Tjoa T. Gillen D. Kleinman M.T. Sioutas C. et al.Personal and ambient air pollution exposures and lung function decrements in children with asthma.Environ Health Perspect. 2008; 116: 550-558Crossref PubMed Scopus (129) Google Scholar, 12Dong G.H. Chen T. Liu M.M. Wang D. Ma Y.N. Ren W.H. et al.Gender differences and effect of air pollution on asthma in children with and without allergic predisposition: northeast Chinese children health study.PLoS One. 2011; 6: e22470Crossref PubMed Scopus (83) Google Scholar, 13Pereira G. Cook A. De Vos A.J. Holman C.D. A case-crossover analysis of traffic-related air pollution and emergency department presentations for asthma in Perth, Western Australia.Med J Aust. 2010; 193: 511-514PubMed Google Scholar, 14von Mutius E. Fritzsch C. Weiland S.K. Röll G. Magnussen H. Prevalence of asthma and allergic disorders among children in united Germany: a descriptive comparison.BMJ. 1992; 305: 1395-1399Crossref PubMed Scopus (417) Google Scholar, 15Shima M. Adachi M. Effect of outdoor and indoor nitrogen dioxide on respiratory symptoms in schoolchildren.Int J Epidemiol. 2000; 29: 862-870Crossref PubMed Scopus (137) Google Scholar, 16Shima M. Nitta Y. Ando M. Adachi M. Effects of air pollution on the prevalence and incidence of asthma in children.Arch Environ Health. 2002; 57: 529-535Crossref PubMed Scopus (65) Google Scholar, 17Guo Y.L. Lin Y.C. Sung F.C. Huang S.L. Ko Y.C. Lai J.S. et al.Climate, traffic-related air pollutants, and asthma prevalence in middle-school children in Taiwan.Environ Health Perspect. 1999; 107: 1001-1006Crossref PubMed Scopus (145) Google Scholar and will only include articles that reported the measurements of individual air pollutants. Because many of these studies are based on proximity of the home to the nearest main road or pollution data obtained from monitoring stations, detailed personal exposures of different pollutants were not assessed, and one must interpret the results of these studies with caution.6Hwang B.F. Lee Y.L. Air pollution and prevalence of bronchitic symptoms among children in Taiwan.Chest. 2010; 138: 956-964Crossref PubMed Scopus (41) Google Scholar, 7Pan G. Zhang S. Feng Y. Takahashi K. Kagawa J. Yu L. et al.Air pollution and children’s respiratory symptoms in six cities of Northern China.Respir Med. 2010; 104: 1903-1911Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar, 8Zhao Z. Zhang Z. Wang Z. Ferm M. Liang Y. Norbäck D. Asthmatic symptoms among pupils in relation to winter indoor and outdoor air pollution in schools in Taiyuan, China.Environ Health Perspect. 2008; 116: 90-97Crossref PubMed Scopus (144) Google Scholar, 9Ho W.C. Hartley W.R. Myers L. Lin M.H. Lin Y.S. Lien C.H. et al.Air pollution, weather, and associated risk factors related to asthma prevalence and attack rate.Environ Res. 2007; 104: 402-409Crossref PubMed Scopus (86) Google Scholar, 10Hwang B.F. Lee Y.L. Lin Y.C. Jaakkola J.J. Guo Y.L. Traffic related air pollution as a determinant of asthma among Taiwanese school children.Thorax. 2005; 60: 467-473Crossref PubMed Scopus (70) Google Scholar, 11Delfino R.J. Staimer N. Tjoa T. Gillen D. Kleinman M.T. Sioutas C. et al.Personal and ambient air pollution exposures and lung function decrements in children with asthma.Environ Health Perspect. 2008; 116: 550-558Crossref PubMed Scopus (129) Google ScholarTable ISummary of published studies on the effects of ambient air pollution on prevalence rates of asthma in Asian children and adultsReferenceStudy design and populationFindings for individual pollutantsNOx/NO2SO2O3PM10PM2.5COOthersChildren Hwang and Lee, 20106Hwang B.F. Lee Y.L. Air pollution and prevalence of bronchitic symptoms among children in Taiwan.Chest. 2010; 138: 956-964Crossref PubMed Scopus (41) Google ScholarCross-sectional; Taiwanese (n = 5,052)NO2: OR, 1.81 per 8.79 ppb; 95% CI, 1.14 to 2.86NSOR, 1.32 per 8.77 ppb; 95% CI, 1.06 to 1.63XNSOR, 1.31 per 105 ppb; 95% CI, 1.04 to 1.64 Pan et al, 20107Pan G. Zhang S. Feng Y. Takahashi K. Kagawa J. Yu L. et al.Air pollution and children’s respiratory symptoms in six cities of Northern China.Respir Med. 2010; 104: 1903-1911Abstract Full Text Full Text PDF PubMed Scopus (57) Google ScholarCross-sectional; Liaoning, China (n = 11,860)NO2: OR, 1.39; 95% CI, 1.11 to 1.74OR, 1.52; 95% CI, 1.21 to 1.92XXXXTSP: OR, 1.41; 95% CI, 1.22 to 1.65 Zhao et al, 20088Zhao Z. Zhang Z. Wang Z. Ferm M. Liang Y. Norbäck D. Asthmatic symptoms among pupils in relation to winter indoor and outdoor air pollution in schools in Taiyuan, China.Environ Health Perspect. 2008; 116: 90-97Crossref PubMed Scopus (144) Google ScholarCross-sectional; Taiyuan, China (n = 1,993)NSNSNSXXXFormaldehyde: OR, 4.61; 95% CI, 1.09 to 19.5 Ho et al, 20079Ho W.C. Hartley W.R. Myers L. Lin M.H. Lin Y.S. Lien C.H. et al.Air pollution, weather, and associated risk factors related to asthma prevalence and attack rate.Environ Res. 2007; 104: 402-409Crossref PubMed Scopus (86) Google ScholarCross-sectional; Taiwanese (n = 64,660)NSNSMale: OR, 1.02; 95% CI, 1.00 to 1.03Female: OR, 0.99; 95% CI, 0.99 to 1.00XFemale: OR, 1.98; 95% CI, 1.54 to 2.56Male: OR, 1.78; 95% CI, 1.38 to 2.30 Hwang et al, 200510Hwang B.F. Lee Y.L. Lin Y.C. Jaakkola J.J. Guo Y.L. Traffic related air pollution as a determinant of asthma among Taiwanese school children.Thorax. 2005; 60: 467-473Crossref PubMed Scopus (70) Google ScholarCross-sectional; Taiwanese (n = 32,672)NSNSOR, 1.14; 95% CI, 1.00-1.29OR, 0.93; 95% CI, 0.91-0.96XOR, 1.05; 95% CI, 1.02-1.07 Shima et al, 200216Shima M. Nitta Y. Ando M. Adachi M. Effects of air pollution on the prevalence and incidence of asthma in children.Arch Environ Health. 2002; 57: 529-535Crossref PubMed Scopus (65) Google ScholarProspective; Japan (n = 3,049)NO2 for baseline prevalence: OR, 0.75; 95% CI, 0.31 to 1.82Incidence: OR, 3.62; 95% CI, 1.11 to 11.87NSXNSXX Shima et al, 200015Shima M. Adachi M. Effect of outdoor and indoor nitrogen dioxide on respiratory symptoms in schoolchildren.Int J Epidemiol. 2000; 29: 862-870Crossref PubMed Scopus (137) Google ScholarCross-sectional; Japan (n = 842)Outdoor NO2: OR, 2.10; 95% CI, 1.10 to 4.75Indoor NO2: OR, 0.87; 95% CI, 0.51 to 1.43XXXXX Guo et al, 199917Guo Y.L. Lin Y.C. Sung F.C. Huang S.L. Ko Y.C. Lai J.S. et al.Climate, traffic-related air pollutants, and asthma prevalence in middle-school children in Taiwan.Environ Health Perspect. 1999; 107: 1001-1006Crossref PubMed Scopus (145) Google ScholarCross-sectional; Taiwanese (n = 331,686)NOx for girls: OR, 0.50; 95% CI, 0.03-0.97NSBoys: OR, −0.89; 95% CI, −1.51 to −0.27Boys: OR, −0.96; 95% CI, −1.82 to −0.09XNSAdults Padhi et al, 200823Padhi B.K. Padhy P.K. Assessment of intra-urban variability in outdoor air quality and its health risks.Inhal Toxicol. 2008; 20: 973-979Crossref PubMed Scopus (21) Google ScholarCross-sectional; Indians (n = 750 male subjects aged 20-40 y)NANAXNAXXWithin 0.5 km of the main road: OR, 3.57; 95% CI, 3.00 to 3.95Within 1.0 km of the main road: OR, 3.00; 95% CI, 2.85 to 3.50Within 5.0 km of the main road: OR, 1.00; 95% CI, 0.85 to 1.50 Wilson et al, 200824Wilson D. Takahashi K. Pan G. Chan C.-C. Zhang S. Feng Y. et al.Respiratory symptoms among residents of a heavy-industry province in China: prevalence and risk factors.Respir Med. 2008; 102: 1536-1544Abstract Full Text Full Text PDF PubMed Scopus (29) Google ScholarCross-sectional; Liaoning, China (n = 31,704 aged 47.7 y [15.2 y])NO2: OR, 0.73; 95% CI, 0.46 to 1.17OR, 1.67; 95% CI, 0.86 to 3.23XNSXXTSP: OR, 0.64; 95% CI, 0.40 to 1.04NA, Not analyzed; NS, not significant; X, not measured. Open table in a new tab NA, Not analyzed; NS, not significant; X, not measured. Researchers from Taiwan published a number of epidemiologic studies for the association between asthma prevalence and ambient pollutant exposures. Hwang and Lee6Hwang B.F. Lee Y.L. Air pollution and prevalence of bronchitic symptoms among children in Taiwan.Chest. 2010; 138: 956-964Crossref PubMed Scopus (41) Google Scholar analyzed the nationwide data of 5049 children in the Taiwan Children Health Study. The exposure parameters for SO2, NO2, O3, carbon monoxide (CO), and particulate matter with an aerodynamic diameter of 2.5 μm or less (PM2.5) were calculated by using the between-community 3-year average concentration. The prevalence of bronchitic symptoms with asthma was positively associated with the 3-year average concentrations of NO2 (adjusted odds ratio [OR], 1.81 per 8.79 ppb; 95% CI, 1.14-2.86), suggesting that long-term exposure to outdoor NO2 was a risk factor for the prevalence of bronchitic symptoms among children. However, the same group reported in an earlier study that the risk of childhood asthma was not associated with levels of nitrogen oxides (NOx; adjusted OR, 1.01; 95% CI, 0.95-1.12) among 32,672 Taiwanese schoolchildren.10Hwang B.F. Lee Y.L. Lin Y.C. Jaakkola J.J. Guo Y.L. Traffic related air pollution as a determinant of asthma among Taiwanese school children.Thorax. 2005; 60: 467-473Crossref PubMed Scopus (70) Google Scholar On the other hand, Guo et al17Guo Y.L. Lin Y.C. Sung F.C. Huang S.L. Ko Y.C. Lai J.S. et al.Climate, traffic-related air pollutants, and asthma prevalence in middle-school children in Taiwan.Environ Health Perspect. 1999; 107: 1001-1006Crossref PubMed Scopus (145) Google Scholar found asthma prevalence to be associated with NOx levels for both girls and boys. Furthermore, Ho et al9Ho W.C. Hartley W.R. Myers L. Lin M.H. Lin Y.S. Lien C.H. et al.Air pollution, weather, and associated risk factors related to asthma prevalence and attack rate.Environ Res. 2007; 104: 402-409Crossref PubMed Scopus (86) Google Scholar also failed to replicate the above findings. It should be emphasized that the levels of environmental pollutants, such as particulate matter with an aerodynamic diameter of 10 μm or less (PM10) and NO2, in China are 4 to 10 times higher than those in other Western countries,12Dong G.H. Chen T. Liu M.M. Wang D. Ma Y.N. Ren W.H. et al.Gender differences and effect of air pollution on asthma in children with and without allergic predisposition: northeast Chinese children health study.PLoS One. 2011; 6: e22470Crossref PubMed Scopus (83) Google Scholar, 13Pereira G. Cook A. De Vos A.J. Holman C.D. A case-crossover analysis of traffic-related air pollution and emergency department presentations for asthma in Perth, Western Australia.Med J Aust. 2010; 193: 511-514PubMed Google Scholar yet the prevalence of asthma is much lower in China, suggesting that environmental pollution might have a minor role in the inception of asthma. Several studies from China addressed the deleterious effects of ambient air pollution on allergy and asthma susceptibility. Pan et al7Pan G. Zhang S. Feng Y. Takahashi K. Kagawa J. Yu L. et al.Air pollution and children’s respiratory symptoms in six cities of Northern China.Respir Med. 2010; 104: 1903-1911Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar from Liaoning, a major industrial province of northeastern China, studied 11,860 preschool and school-aged children. They found large variation for NO2 levels (29-94 μg/m3) across the 18 districts of 6 cities in this province. Such exposure increased the subjects’ risks for persistent cough, persistent phlegm, and current asthma. Rates of respiratory symptoms were significantly higher for younger children and those with atopy, early-onset respiratory disease, family history of asthma or chronic bronchitis, and tobacco smoke exposure. Zhao et al8Zhao Z. Zhang Z. Wang Z. Ferm M. Liang Y. Norbäck D. Asthmatic symptoms among pupils in relation to winter indoor and outdoor air pollution in schools in Taiyuan, China.Environ Health Perspect. 2008; 116: 90-97Crossref PubMed Scopus (144) Google Scholar investigated children’s respiratory heath and air pollution in schools in urban Taiyuan, a coal-burning city in north China. They assessed the effects of both indoor and outdoor air pollution in schools, as well as selected home exposures. Among these 1993 children, 1.8% had cumulative asthma, 8.4% had wheezing, and 29.8% had daytime attacks of breathlessness. They found that either wheeze or daytime or nocturnal attacks of breathlessness were positively associated with NO2 exposure. It is interesting to note that the prevalence of respiratory symptoms is much higher than that of asthma in polluted cities. This finding is similar to those data comparing the former East and West Germany, where ambient pollution is higher in the East.14von Mutius E. Fritzsch C. Weiland S.K. Röll G. Magnussen H. Prevalence of asthma and allergic disorders among children in united Germany: a descriptive comparison.BMJ. 1992; 305: 1395-1399Crossref PubMed Scopus (417) Google Scholar Shima and Adachi15Shima M. Adachi M. Effect of outdoor and indoor nitrogen dioxide on respiratory symptoms in schoolchildren.Int J Epidemiol. 2000; 29: 862-870Crossref PubMed Scopus (137) Google Scholar investigated concurrently the effects of outdoor and indoor NO2 levels on the prevalence and incidence of respiratory symptoms among 842 Japanese schoolchildren. Indoor NO2 levels over 24 hours were measured in both winter and summer, and a 3-year average of outdoor NO2 levels was calculated. They observed a significant increase in the prevalence rates of bronchitis, wheeze, and asthma with increasing indoor NO2 levels among girls but not boys. Interestingly, girls might be more susceptible to indoor air pollution than boys. In addition, a 10 ppb increase in outdoor NO2 levels was associated with an increased incidence rate of wheeze (OR, 1.76; 95% CI, 1.04-3.23) and asthma (OR, 2.10; 95% CI, 1.10-4.75). Such associations were not detected with indoor NO2 concentrations. These investigators subsequently evaluated the effects of air pollution on asthmatic symptoms in a prospective cohort study of 3049 Japanese schoolchildren.16Shima M. Nitta Y. Ando M. Adachi M. Effects of air pollution on the prevalence and incidence of asthma in children.Arch Environ Health. 2002; 57: 529-535Crossref PubMed Scopus (65) Google Scholar The incidence rates of asthma were associated with ambient NO2 concentrations during follow-up. Several groups of Taiwanese researchers could not detect any association between the prevalence of asthma or bronchitic symptoms and ambient SO2 exposure.6Hwang B.F. Lee Y.L. Air pollution and prevalence of bronchitic symptoms among children in Taiwan.Chest. 2010; 138: 956-964Crossref PubMed Scopus (41) Google Scholar, 9Ho W.C. Hartley W.R. Myers L. Lin M.H. Lin Y.S. Lien C.H. et al.Air pollution, weather, and associated risk factors related to asthma prevalence and attack rate.Environ Res. 2007; 104: 402-409Crossref PubMed Scopus (86) Google Scholar, 10Hwang B.F. Lee Y.L. Lin Y.C. Jaakkola J.J. Guo Y.L. Traffic related air pollution as a determinant of asthma among Taiwanese school children.Thorax. 2005; 60: 467-473Crossref PubMed Scopus (70) Google Scholar, 13Pereira G. Cook A. De Vos A.J. Holman C.D. A case-crossover analysis of traffic-related air pollution and emergency department presentations for asthma in Perth, Western Australia.Med J Aust. 2010; 193: 511-514PubMed Google Scholar On the other hand, large variation was detected for SO2 levels (14-140 μg/m3) across the 18 districts of 6 cities in the heavily industrialized Liaoning.7Pan G. Zhang S. Feng Y. Takahashi K. Kagawa J. Yu L. et al.Air pollution and children’s respiratory symptoms in six cities of Northern China.Respir Med. 2010; 104: 1903-1911Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar Pan et al7Pan G. Zhang S. Feng Y. Takahashi K. Kagawa J. Yu L. et al.Air pollution and children’s respiratory symptoms in six cities of Northern China.Respir Med. 2010; 104: 1903-1911Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar reported such exposure to be associated with the risks for persistent cough, persistent phlegm, and current asthma. Rates of respiratory symptoms were significantly higher for younger children and those with atopy, early-onset respiratory disease, family history of asthma or chronic bronchitis, and tobacco smoke exposure. In Taiyuan, another industrial city in northern China, Zhao et al8Zhao Z. Zhang Z. Wang Z. Ferm M. Liang Y. Norbäck D. Asthmatic symptoms among pupils in relation to winter indoor and outdoor air pollution in schools in Taiyuan, China.Environ Health Perspect. 2008; 116: 90-97Crossref PubMed Scopus (144) Google Scholar reported higher outdoor than indoor levels of SO2, and either wheeze or daytime or nocturnal attacks of breathlessness were positively associated with SO2 exposures. These findings suggested that pollutants of mainly outdoor origin were risk factors for respiratory symptoms in children at school. Among 5049 children in the Taiwan Children Health Study, Hwang and Lee6Hwang B.F. Lee Y.L. Air pollution and prevalence of bronchitic symptoms among children in Taiwan.Chest. 2010; 138: 956-964Crossref PubMed Scopus (41) Google Scholar detected a positive association between the prevalence of bronchitic symptoms with asthma and 3-year average concentrations of CO (OR, 1.31 per 105 ppb; 95% CI, 1.04-1.64). Such a result supported long-term outdoor CO exposure as an important risk factor for bronchitic symptoms. They similarly identified childhood asthma prevalence to be positively associated with CO exposure (adjusted OR, 1.05; 95% CI, 1.02-1.07) from routine air pollution monitoring.10Hwang B.F. Lee Y.L. Lin Y.C. Jaakkola J.J. Guo Y.L. Traffic related air pollution as a determinant of asthma among Taiwanese school children.Thorax. 2005; 60: 467-473Crossref PubMed Scopus (70) Google Scholar Guo et al17Guo Y.L. Lin Y.C. Sung F.C. Huang S.L. Ko Y.C. Lai J.S. et al.Climate, traffic-related air pollutants, and asthma prevalence in middle-school children in Taiwan.Environ Health Perspect. 1999; 107: 1001-1006Crossref PubMed Scopus (145) Google Scholar compared asthma prevalence with climate and air pollution data in 331,686 Taiwanese children. The prevalence rates of asthmatic symptoms adjusted for age, history of atopic eczema, and parental education were found to be associated with nonsummer (June-August) temperature, winter (January-March) humidity, and traffic-related air pollution for CO for both girls and boys. These associations suggested that pollution does play an important role in the exacerbations of allergic diseases, such as asthma. In a 6-month mass screening survey of junior high school students in Taiwan, Ho et al9Ho W.C. Hartley W.R. Myers L. Lin M.H. Lin Y.S. Lien C.H. et al.Air pollution, weather, and associated risk factors related to asthma prevalence and attack rate.Environ Res. 2007; 104: 402-409Crossref PubMed Scopus (86) Google Scholar found significant associations between asthma prevalence and CO exposures in male (OR, 1.98; 95% CI, 1.54-2.56) and female (OR, 1.78; 95% CI, 1.38-2.30) subjects. Despite these preliminary findings, the influence of ambient CO exposure on asthma prevalence was not examined in studies from China.7Pan G. Zhang S. Feng Y. Takahashi K. Kagawa J. Yu L. et al.Air pollution and children’s respiratory symptoms in six cities of Northern China.Respir Med. 2010; 104: 1903-1911Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar, 8Zhao Z. Zhang Z. Wang Z. Ferm M. Liang Y. Norbäck D. Asthmatic symptoms among pupils in relation to winter indoor and outdoor air pollution in schools in Taiyuan, China.Environ Health Perspect. 2008; 116: 90-97Crossref PubMed Scopus (144) Google Scholar Several studies from Taiwan assessed the effects of ambient O3 exposure on asthma prevalence. In the 2-stage hierarchic model adjusting for confounding, the prevalence of phlegm with no asthma was related to 3-year averaged O3 concentrations (OR, 1.32 per 8.77 ppb; 95% CI, 1.06-1.63) in the Taiwan Children Health Study.6Hwang B.F. Lee Y.L. Air pollution and prevalence of bronchitic symptoms among children in Taiwan.Chest. 2010; 138: 956-964Crossref PubMed Scopus (41) Google Scholar Hwang et al10Hwang B.F. Lee Y.L. Lin Y.C. Jaakkola J.J. Guo Y.L. Traffic related air pollution as a determinant of asthma among Taiwanese school children.Thorax. 2005; 60: 467-473Crossref PubMed Scopus (70) Google Scholar analyzed routine air pollution monitoring data for O3 and found the prevalence of childhood asthma to be positively associated with O3 concentrations (adjusted OR, 1.14; 95% CI, 1.00-1.29) among 32,672 schoolchildren. Another 6-month mass screening study performed between October 1995 and March 1996 assessed asthma status in Taiwanese adolescents by using the International Study of Asthma and Allergies in Childhood questionnaire and the New England Core Questionnaire.9Ho W.C. Hartley W.R. Myers L. Lin M.H. Lin Y.S. Lien C.H. et al.Air pollution, weather, and associated risk factors related to asthma prevalence and attack rate.Environ Res. 2007; 104: 402-409Crossref PubMed Scopus (86) Google Scholar They reported ambient O3 levels to be positively associated with asthma prevalence in male subjects (OR, 1.02; 95% CI, 1.00-1.03). Nonetheless, a number of studies from Taiwan and China failed to detect such an association.7Pan G. Zhang S. Feng Y. Takahashi K. Kagawa J. Yu L. et al.Air pollution and children’s respiratory symptoms in six cities of Northern China.Respir Med. 2010; 104: 1903-1911Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar, 8Zhao Z. Zhang Z. Wang Z. Ferm M. Liang Y. Norbäck D. Asthmatic symptoms among pupils in relation to winter indoor and outdoor air pollution in schools in Taiyuan, China.Environ Health Perspect. 2008; 116: 90-97Crossref PubMed Scopus (144) Google Scholar, 17Guo Y.L. Lin Y.C. Sung F.C. Huang S.L. Ko Y.C. Lai J.S. et al.Climate, traffic-related air pollutants, and asthma prevalence in middle-school children in Taiwan.Environ Health Perspect. 1999; 107: 1001-1006Crossref PubMed Scopus (145) Google Scholar However, many of these studies are rather small with only a few hundred subjects and might not have the power to detect the relatively small magnitude of such associations. In the study by Pan et al,7Pan G. Zhang S. Feng Y. Takahashi K. Kagawa J. Yu L. et al.Air pollution and children’s respiratory symptoms in six cities of Northern China.Respir Med. 2010; 104: 1903-1911Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar a large variation was found for total suspended particles (TSPs; 188-689 μg/m3) across 6 cities in Liaoning. They recruited 11,860 preschool and school-aged children and found TSP exposure to be associated with subjects’ risks for persistent cough, persistent phlegm, and current asthma. In Taiwan, Hwang et al10Hwang B.F. Lee Y.L. Lin Y.C. Jaakkola J.J. Guo Y.L. Traffic related air pollution as a determinant of asthma among Taiwanese school children.Thorax. 2005; 60: 467-473Crossref PubMed Scopus (70) Google Scholar reported a weak association between asthma risk and PM10 exposure (adjusted OR, 0.93; 95% CI, 0.91-0.96). However, they could not detect a significant effect of ambient PM2.5 exposure on the occurrence of bronchitic symptoms.6Hwang B.F. Lee Y.L. Air pollution and prevalence of bronchitic symptoms among children in Taiwan.Chest. 2010; 138: 956-964Crossref PubMed Scopus (41) Google Scholar Inconsistent results were observed in other studies. Shima et al16Shima M. Nitta Y. Ando M. Adachi M. Effects of air pollution on the prevalence and incidence of asthma in children.Arch Environ Health. 2002; 57: 529-535Crossref PubMed Scopus (65) Google Scholar from Japan evaluated the effects of air pollution on asthmatic symptoms in a prospective cohort study of 3049 Japanese schoolchildren. They found a trend for the relationship between asthma incidence and PM10 exposure. Ho et al9Ho W.C. Hartley W.R. Myers L. Lin M.H. Lin Y.S. Lien C.H. et al.Air pollution, weather, and associated risk factors related to asthma prevalence and attack rate.Environ Res. 2007; 104: 402-409Crossref PubMed Scopus (86) Google Scholar from Taiwan found asthma prevalence to be inversely associated with PM10 exposure (OR, 0.993; 95% CI, 0.990-0.997) in female but not male subjects. However, a higher number of rainy days seemed to reduce asthma prevalence; rainy days might interact with PM10. Zhao et al8Zhao Z. Zhang Z. Wang Z. Ferm M. Liang Y. Norbäck D. Asthmatic symptoms among pupils in relation to winter indoor and outdoor air pollution in schools in Taiyuan, China.Environ Health Perspect. 2008; 116: 90-97Crossref PubMed Scopus (144) Google Scholar investigated children’s respiratory heath and air pollution in schools in urban Taiyuan, China. Among 1993 children, 1.8% had cumulative asthma, 8.4% had wheezing, and 29.8% had daytime attacks of breathlessness. The indoor average concentration of formaldehyde was 2.3 μg/m3, which was positively associated with the occurrence of asthma symptoms. Only 2 publications reported the influence of outdoor air pollutant exposures on the prevalence of childhood allergic rhinitis. Among a nationwide cross-sectional study of 32,143 Taiwanese schoolchildren, the prevalence of allergic rhinitis was associated with SO2 (adjusted OR, 1.43; 95% CI, 1.25-1.64), CO (adjusted OR, 1.05; 95% CI, 1.04-1.07), and NOx (adjusted OR, 1.11; 95% CI, 1.08-1.15) levels but not related to O3 (adjusted OR, 1.05; 95% CI, 0.98-1.12) and PM10 (adjusted OR, 1.00; 95% CI, 0.99-1.02) levels.18Hwang B.F. Jaakkola J.J. Lee Y.L. Lin Y.C. Guo Y.L. Relation between air pollution and allergic rhinitis in Taiwanese schoolchildren.Respir Res. 2006; 7: 23Crossref PubMed Scopus (88) Google Scholar Another Taiwanese study comprised 331,686 nonsmoking children who attended schools located within 2 km of 55 stations. The lifetime prevalence of physician-diagnosed allergic rhinitis and typical symptoms of allergic rhinitis was compared with air-monitoring station data on temperature, relative humidity, and SO2, NOx, O3, CO, and PM10 levels.19Lee Y.L. Shaw C.K. Su H.J. Lai J.S. Ko Y.C. Huang S.L. et al.Climate, traffic-related air pollutants and allergic rhinitis prevalence in middle-school children in Taiwan.Eur Respir J. 2003; 21: 964-970Crossref PubMed Scopus (115) Google Scholar The prevalence rates of questionnaire- and physician-diagnosed allergic rhinitis in boys were 42.4% and 28.6%, respectively, whereas those for girls were 34.0% and 19.5%, respectively. The researchers found that physician-diagnosed allergic rhinitis was associated with higher nonsummer (September-May) warmth and traffic-related air pollutant levels, including CO, NOx, and O3. Questionnaire-determined allergic rhinitis correlated only with traffic-related air pollutant levels (NOx and CO). These researchers postulated that nonsummer warmth and traffic-related air pollution probably increased the risk for allergic rhinitis through exposure to common allergens, such as dust mites. Some of the seasonal effects are likely to be confounded by the seasonal variation in pollen counts, which are known to be associated with exacerbations of allergic disease in the region.20Lee M.H. Kim Y.K. Min K.U. Lee B.J. Bahn J.W. Son J.W. et al.Differences in sensitization rates to outdoor aeroallergens, especially citrus red mite (Panonychus citri), between urban and rural children.Ann Allergy Asthma Immunol. 2001; 86: 691-695Abstract Full Text PDF PubMed Scopus (14) Google Scholar, 21Takasaki K. Enatsu K. Kumagami H. Takahashi H. Relationship between airborne pollen count and treatment outcome in Japanese cedar pollinosis patients.Eur Arch Otorhinolaryngol. 2009; 266: 673-676Crossref PubMed Scopus (12) Google Scholar There was only one study that addressed ambient pollutant exposures and childhood eczema.22Yura A. Shimizu T. Trends in the prevalence of atopic dermatitis in school children: longitudinal study in Osaka Prefecture, Japan, from 1985 to 1997.Br J Dermatol. 2001; 145: 966-973Crossref PubMed Scopus (65) Google Scholar In this study Yura and Shimizu22Yura A. Shimizu T. Trends in the prevalence of atopic dermatitis in school children: longitudinal study in Osaka Prefecture, Japan, from 1985 to 1997.Br J Dermatol. 2001; 145: 966-973Crossref PubMed Scopus (65) Google Scholar carried out serial questionnaire surveys at 2-year intervals between 1985 and 1997 in a total of about 4 million primary schoolchildren in Osaka Prefecture, Japan. They observed increasing lifetime prevalence of eczema from 15.0% in 1985 to 24.1% in 1993. Interestingly, eczema prevalence was found to correlate inversely with the level of ambient air pollution, but such association no longer remained significant after adjustment of the family income level. Although many articles addressed the effects of ambient air pollution on prevalence rates of childhood allergic diseases in Asia (Table I), such studies on prevalence rates of allergic disease in adults are scarce. Researchers from India evaluated asthma prevalence in 750 adults aged 20 to 40 years.23Padhi B.K. Padhy P.K. Assessment of intra-urban variability in outdoor air quality and its health risks.Inhal Toxicol. 2008; 20: 973-979Crossref PubMed Scopus (21) Google Scholar NO2, SO2, and PM levels decreased with increasing distance from the main road. These researchers found that, compared with those stayed 5.0 km away from a main road, subjects living within 0.5 km and 1.0 km had ORs of 3.57 (95% CI, 3.00-3.95) and 3.00 (95% CI, 2.85-3.50), respectively, for doctor-diagnosed asthma. Effects of ambient air pollution on the prevalence of allergic rhinitis and eczema were not studied. Another study that involved 31,704 adults from 6 cities in Liaoning, China, failed to find an association between asthma prevalence and ambient TSP, SO2, and NO2 exposures.24Wilson D. Takahashi K. Pan G. Chan C.-C. Zhang S. Feng Y. et al.Respiratory symptoms among residents of a heavy-industry province in China: prevalence and risk factors.Respir Med. 2008; 102: 1536-1544Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar However, certain residential exposures to air pollutants appeared to be associated with the prevalence of asthma, although such a relationship was only assessed by questionnaire and not objective measurement. Asthma risks were associated with residential exposure close to a main road, a factory or chimney, use of coal for cooking or heating, and the presence of irritating smoke during cooking (respective ORs, 1.21, 1.07, 1.45, and 2.13). Another study from China using questionnaire surveys rather than actual pollutant measurement found cooking coal smoke was associated with physician-diagnosed adult asthma (OR, 2.53; 95% CI, 1.02-6.61).25Qian Z. He Q. Kong L. Xu F. Wei F. Chapman R.S. et al.Respiratory responses to diverse indoor combustion air pollution sources.Indoor Air. 2007; 17: 135-142Crossref PubMed Scopus (33) Google Scholar Concerning the effects of air pollution on the prevalence of allergic rhinitis in adults in Asia, a cross-sectional population-based study involving 2868 adults aged 20 to 74 years (allergic rhinitis was reported by 4.5% of the subjects) from Singapore found outdoor air pollution was a significant environmental factor for the risk of allergic rhinitis.26Ng T.P. Tan W.C. Epidemiology of allergic rhinitis and its associated risk factors in Singapore.Int J Epidemiol. 1994; 23: 553-558Crossref PubMed Scopus (52) Google Scholar Interestingly, a time-series study observed an association between ambient air pollutant levels and daily outpatient visits for allergic rhinitis among 1506 patients (96% adults) in Beijing.27Zhang F. Wang W. Lv J. Krafft T. Xu J. Time-series studies on air pollution and daily outpatient visits for allergic rhinitis in Beijing, China.Sci Total Environ. 2011; 409: 2486-2492Crossref PubMed Scopus (60) Google Scholar There has not been any study addressing the effect of air pollution on the prevalence of adult eczema in Asia. Many epidemiologic studies have shown consistent associations between respiratory health and ambient air pollutant exposures in Europe and America. Our group also confirmed such findings in Hong Kong. Wong et al28Wong G.W. Ko F.W. Lau T.S. Li S.T. Hui D. Pang S.W. et al.Temporal relationship between air pollution and hospital admissions for asthmatic children in Hong Kong.Clin Exp Allergy. 2001; 31: 565-569Crossref PubMed Scopus (66) Google Scholar reported among 1217 children that daily asthma-related hospitalization increased significantly with increasing ambient NO2 (relative risk [RR], 1.08 per 10 μg/m3 increase), SO2 (RR, 1.06), and PM10 (RR, 1.03) levels. Ko et al29Ko F.W. Tam W. Wong T.W. Lai C.K. Wong G.W. Leung T.F. et al.Effects of air pollution on asthma hospitalization rates in different age groups in Hong Kong.Clin Exp Allergy. 2007; 37: 1312-1319Crossref PubMed Scopus (157) Google Scholar retrospectively reviewed the relationship between daily emergency hospital admissions to 15 major hospitals in Hong Kong for asthma and indices of air pollutants (SO2, NO2, O3, PM10, and PM2.5 levels) between January 2000 and December 2005. A total of 69,716 admissions were assessed, and significant associations were found between hospital admissions for asthma and NO2, O3, PM10, and PM2.5 levels (respective RRs, 1.04, 1.03, 1.02, and 1.02 per 10 μg/m3 increase). In a multipollutant model O3 was significantly associated with increased admissions for asthma. The influences of pollutant exposures were more pronounced in younger subjects, whereas the lag time to asthma exacerbation was shortened among the elderly (≥65 years old). Several other groups in Asia reported an association between an increase in ambient air pollutant levels and emergency department visits and hospitalizations for asthma.30Kim S.Y. O’Neill M.S. Lee J.T. Cho Y. Kim J. Kim H. Air pollution, socioeconomic position, and emergency hospital visits for asthma in Seoul, Korea.Int Arch Occup Environ Health. 2007; 80: 701-710Crossref PubMed Scopus (40) Google Scholar, 31Chen C.H. Xirasagar S. Lin H.C. Seasonality in adult asthma admissions, air pollutant levels, and climate: a population-based study.J Asthma. 2006; 43: 287-292Crossref PubMed Scopus (72) Google Scholar On the contrary, a study from Japan could not detect any association between ambient air pollution with asthma-related emergency department visits.32Abe T. Tokuda Y. Ohde S. Ishimatsu S. Nakamura T. Birrer R.B. The relationship of short-term air pollution and weather to ED visits for asthma in Japan.Am J Emerg Med. 2009; 27: 153-159Abstract Full Text Full Text PDF PubMed Scopus (75) Google Scholar The 2008 Beijing Olympic and Paralympic Games also evidenced a large natural experiment with abrupt cessation of ambient air pollution in China when its government implemented a short-term odd/even-day traffic-restriction scheme to improve the air quality in Beijing. The daily average concentrations decreased by up to 38.5% for CO, 44.0% for PM10, 33.9% for NO2, and 36.7% for O3 during this scheme.33Cai H. Xie S.-D. Traffic-related air pollution modeling during the 2008 Beijing Olympic Games: the effects of an odd-even day traffic restriction scheme.Sci Total Environ. 2011; 409: 1935-1948Crossref PubMed Scopus (69) Google Scholar Li et al34Li Y. Wang W. Kan H. Xu X. Chen B.-H. Air quality and outpatient visits for asthma in adults during the 2008 Summer Olympic Games in Beijing.Sci Total Environ. 2010; 408: 1226-1227Crossref PubMed Scopus (91) Google Scholar reported that the average numbers of outpatient visits for asthma were 12.5 per day at baseline and 7.3 per day during the Olympics. Compared with baseline, the Olympic Games were associated with a significant reduction in asthma visits (RR, 0.54; 95% CI, 0.39-0.75). These results showed that even in a heavily polluted city, decreased small-particle exposures were associated with some reduction in asthma-related outpatient visits. None of the published studies in this region examined the effect of gene-environment interactions in determining the susceptibility for asthma and allergy. Thus future studies with birth cohorts that incorporate the candidate genes for reversing the deleterious oxidizing adversity of air pollution are necessary to clearly determine the exact roles of pollutant exposure on the initiation of asthma and allergy. The relationship between air pollution and allergic diseases is likely to be confounded by other important environmental factors, such as microbial exposure. Rural environments with high exposure to microbes have been consistently shown to be protective against the development of allergic diseases, and a large percentage of the population in Asia lives in rural areas.35Ege M.J. Mayer M. Normand A.C. Genuneit J. Cookson W.O. Braun-Fahrländer C. et al.Exposure to environmental microorganisms and childhood asthma.N Engl J Med. 2011; 364: 701-709Crossref PubMed Scopus (1065) Google Scholar, 36Eriksson J. Ekerljung L. Lötvall J. Pullerits T. Wennergren G. Rönmark E. et al.Growing up on a farm leads to lifelong protection against allergic rhinitis.Allergy. 2010; 65: 1397-1403Crossref PubMed Scopus (54) Google Scholar, 37Wong G.W. Chow C.M. Childhood asthma epidemiology: insights from comparative studies of rural and urban populations.Pediatr Pulmonol. 2008; 43: 107-116Crossref PubMed Scopus (116) Google Scholar Future studies will need to address the possible interaction between the effects of pollution and other environmental factors, such as microbial exposure. In conclusion, there is inconsistent evidence regarding the roles of individual air pollutants in the initiation of asthma and allergy among Asian children and adults. Most of the published studies from Asia were cross-sectional in nature, and birth cohorts are therefore needed to confirm the findings between air pollution and susceptibility for asthma, allergic rhinitis, and eczema." @default.
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