Time-weighted average of fine particulate matter exposure and cause-specific mortality in China: a nationwide analysis.

Abstract

Most previous assessments of the hazardous effects attributable to fine particulate matter (PM_2·5) exposure have used ambient PM_2·5 as an exposure metric, resulting in substantial bias in effect estimates. We did a study to examine the association between cause-specific mortality and the time-weighted average of PM_2·5 exposure after accounting for indoor exposure in 267 cities in China. We did a nationwide study, using Laser Egg air quality monitors in 36 cities to obtain data for indoor PM_2·5 concentrations from 18 484 anonymised households between Nov 1, 2015 and July 2, 2018. We developed and validated a nationwide indoor PM_2·5 prediction model for a further 302 cities by retrieving raw records of hourly concentrations from residents' air sensors; the model was used to predict indoor PM_2·5 during 2013 to 2018. Daily ambient PM_2·5 concentration data were estimated by averaging hourly ambient PM_2·5 concentrations obtained from China's National Urban Air Quality Real-time Publishing Platform. Daily numbers of deaths from all non-accidental causes were obtained from 324 cities from the Disease Surveillance Point System of China between Jan 1, 2013, to Dec 31, 2017, and calculated for 267 cities that had an average daily mortality above three, and data for PM_2·5 concentrations and meteorological information for at least 1 year between 2013 and 2017. We used distributed lag non-linear models to estimate city-specific associations between cause-specific mortality and reconstructed PM_2·5 exposure by considering indoor PM_2·5 exposure. We combined the city-specific effect estimates at the national level using a random effects meta-analysis. 13 972 records of daily indoor PM_2·5 concentrations for 36 cities, extracted from 47 459 183 raw records from the sensors were included for modelling indoor PM_2·5 levels. The nationwide indoor PM_2·5 concentration was 40 μg/m³ (SD 21) between 2013 and 2017, which was approximately 20% lower than the ambient PM_2·5 concentration of 50 μg/m³ (42). An increase of 10 μg/m³ in time-averaged PM_2·5 exposure concentrations was associated with increased daily mortality estimates of 0·44% (95% CI 0·33-0·54) for total non-accidental causes, 0·50% (0·37-0·63) for cardiovascular diseases, 0·46% (0·28-0·63) for coronary heart disease, 0·49% (0·32-0·66) for stroke, 0·59% (0·39-0·79) for respiratory diseases, and 0·69% (0·45-0·92) for chronic obstructive pulmonary disease, respectively. Compared with previous estimations based on ambient PM_2·5, our estimates approximately doubled the size of the effects related to PM_2·5. This nationwide study revealed a higher mortality risk attributed to time-averaged indoor and ambient PM_2·5 exposure compared with the risk associated with ambient PM_2·5 exposure alone, which indicates that caution should be exercised when using ambient PM_2·5 as a surrogate for PM_2·5 exposure. National Natural Science Foundation of China (Youth Program) and the Fundamental Research Project of Beihang University.