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Haze, health and disease

With the increasing pace of industrialization and urbanization in Asia, there has been a marked increase in the severity of urban air pollution, making many Asian cities, particularly those in China, amongst the most polluted in the world (1). Levels of fine particulate matter (PM2.5) are frequently in the levels of hundreds of micrograms per cubic meter in cities like Beijing, where there are now so few days where the air quality can be considered as being safe for health. Severe episodes of air pollution have enveloped large parts of China, a phenomenon that has been dubbed as episodes of haze or ‘Chinese haze’. As we write this article in November 2014, the Northern part of China has just had its most recent episode of haze when levels of PM2.5 in Beijing had climbed to the levels of 450 to 600 µg/m 3 , up to 25 times above the recommended World Health Organisation (WHO) safe levels.

The magnitude of the health effects of such unprecedented levels of air pollution is likely to be important but many questions remain unanswered. During the week-long episode of “killer smog” in December 1952 in London, UK, it has been well established that the smoke mainly emitted from coal combustion was responsible for approximately 4,000 premature deaths (2). As yet, there have been no scientifically-based reports linking extra mortality with a particular episode of haze in China. The recent Beijing marathon took place on October 19 th 2014, a hazy day when levels of PM2.5 were recorded at 344 μg/m 3 . Despite this, there were no apparent problems experienced by the thousands of participants, except that there were many who pulled out before or during the marathon run. The chronic effect of such high levels of pollutants, particularly on respiratory health, including lung cancer, may not be easily quantifiable but efforts need to be put in place to do so.

In this series of articles in the Journal of Thoracic Diseases (JTD) that describes the potential respiratory risk hazards of environmental pollution, the focus will be on studies of pollution in the Western world in relation to respiratory health. One needs to realise that the levels of pollution in the Western world are usually modest compared to those seen in China. Nevertheless, these are the best pieces of epidemiological data available so far with regards to effects on respiratory health focusing on outdoor air pollution especially in relation to air pollution in China.

The series of review articles start with an evaluation of the differences in the constituents and levels of air pollution between China and the West by Drs. Zhang and Samet. This series will not deal with indoor air pollution, where there are also important differences between China and the West; we may deal with this aspect in another series. Allergic disease, particularly asthma, has been linked in the West to environmental pollution both in terms of its prevalence and as an inducer of exacerbations. Drs. Zhang, Qiu, Chung and Huang report on data available in the Far East on its effect on asthma and also review mechanisms underlying the effect of pollution on asthma. The question is whether environmental air pollution is contributory to the increasing asthma prevalence. The relationship of haze effects on another respiratory condition usually associated with cigarette smoking but increasingly perceived as a condition that could be secondary to environmental pollution is reviewed by Drs. Hu, Zhong and Ran. The question is whether there is a positive interaction between active smoking, the prevalence of which is high in China, and exposure to pollution in terms of initiating this disease and inducing exacerbations.

Susceptibility to the effects of environmental pollution may be increased at the extremes of the age span. Dr. Viegi and colleagues (Simoni, Baldacci, Maio, Cerrai, Sarno and Viegi) describe the adverse effects in the elderly while Dr. Gilliland and colleagues (Chen, Salam, Eckel, Breton and Gilliland) focus on children. Air pollutants have now been classified as a leading environmental cause of lung cancer by the WHO International Agency for Research on Cancer (IARC) in the same category as cigarette smoke and ultraviolet radiation. Drs. Demetriou and Veneis review the evidence for this. Finally, Drs. Laumbach, Meng and Kipen provide a review on whether there are any useful measures and advice that can be given to both the healthy and chronically ill patients, particularly with regards to minimising the health effects of air pollution. We thank all the contributors to this issue for taking time to write these reviews.

While the ultimate solution to reducing the health risks of air pollution is to eliminate sources of air pollution, this will take time. These episodes of haze are likely due to a combination of exhaust emissions from motor vehicles, coal burning, dust storms and construction dust, but the contribution of secondary sources from interaction of components of the pollutants to produce high concentration of sulphates, ammonium and nitrates together with high levels of organic matter is now recognised (3). In addition to reducing primary particulate emissions, mitigating the emissions of secondary aerosol precursors from fossil fuel combustion and biomass burning is going to be important for controlling China’s PM2.5 levels and for reducing the environmental, economic and health impacts resulting from particulate pollution. The recorded levels of pollution in China are at an unprecedented level. In the face of this, the Chinese government has produced an action plan aimed at reducing PM2.5 by 25% by 2017. Levels of pollution can certainly be controlled as was demonstrated during the 2008 Beijing Olympics, with a reduction in particulate matter and other pollutants that led to detectable improvement in circulating biomarkers (4). In November 2014, levels of pollution were improved for the Asia-Pacific Economic Cooperation meeting held in Beijing by reducing use of cars and closing factories, but these measures can only be taken on a temporary basis since there are important economic implications of shutting down industrial production.

It is important to assess and quantify the potential harms of environmental pollution and take any potential measures to combat its ill-effects. We expect that over the coming ten years there will be many more studies that will be assessing the health impact of the pollution in China. This series of articles should help public health scientists and health workers to have a greater understanding of the challenges of air pollution which not only affect respiratory health but also many other aspects of healthy living which are not covered here. For health workers, it is important to have a rational series of advice or measures that could be given to the general public that could help mitigate the health effects of environmental pollution.

Haze, health and disease With the increasing pace of industrialization and urbanization in Asia, there has been a marked increase in the severity of urban air pollution, making many Asian cities,

The effect of pollutional haze on pulmonary function

Abstract

Detrimental health effects of atmospheric exposure to ambient particulate matter (PM) have been investigated in numerous studies. Exposure to pollutional haze, the carrier of air pollutants such as PM and nitrogen dioxide (NO2) has been linked to lung and cardiovascular disease, resulting increases in both hospital admissions and mortality. This review focuses on the constituents of pollutional haze and its effects on pulmonary function. The article presents the available information and seeks to correlate pollutional haze and pulmonary function.

Introduction

Historically, several incidents of extreme air pollution, such as the incident in the Meuse Valley, Belgium, in December 1930 (1), the incident in Donora, Pennsylvania in 1948 (2), and the incidents in London, England (3,4) drove attention on the potential for adverse health effects of air pollution. Studies have suggested that pollutional haze is associated with jeopardized lung function, respiratory symptoms (5-7). Among these health problems, pulmonary function as an objective indicator of respiratory health is of special interest in evaluating effects of ambient particulate in most studies (8-11). China, the largest developing country, has experienced rapid economic development and urbanization over the past few decades. The fast urbanization and economic expansion are principally driven by the tremendous use of fossil fuels, bringing about a dramatic increase in emissions of both ambient air pollutants and greenhouse gases. Although the levels of indoor coal smoke pollution have decreased rapidly since the increasing use of gas or electric power, the quality of air has not been improved due to the rapid increasing use of motor vehicles. As a result, the type of urban air pollution has changed from the coal combustion type to mixed coal smoke and motor vehicle emission type since the mid of 1990s. Meanwhile, the rapidly growing use of new building materials, the increase of pet raising, and tobacco smoking have made the air quality even worse (12,13). Currently, China is suffering the worst air pollution in the world. Based on the reports of China Meteorological Administration, in 2013 China experienced the worst pollutional haze. Thirty provinces including about 100 large and medium-sized cities were invaded by severe pollutional haze. The yearly number of haze day on average was 43 days national wide, which had reached the record high since 1961. In the past, pollutional haze occurred mostly in cities of north China due to the massive use of coal for both industry and heating, especially in winter. For instance, several cities in the Liaoning province, including Shenyang, Anshan and Benxi, were historically among the most polluted cities in China. While the cities in south China rarely confronted the pollutional haze. However, since last year the cities in the middle east of China have been harassed by pollutional haze frequently and the haze weather has increased apparently. Statistic data showed that the number of pollutional haze day of Hangzhou city was more than 201 days in 2013. In December 2013, there was only 5 days of good air quality in Changsha, the capital city of Hunan province, while the days of moderate and severe air pollution were as many as 19 days ( Figure 1 ). Even the most southern city of China, Sanya city in Hainan province, once experienced a pollutional haze day in December 2013. Because of the remarkable increasing of pollutional haze days, the air quality is getting worse national wide. The levels of particulate matter (PM), SO2, O3, and NO2 are reported to be higher than those of the national standard and criterion concentration of WHO in many cities (7,12-16). These particles and toxic compounds of high concentration can dramatically impair pulmonary function of human being, consequently resulting respiratory disorders or even death.

Haze weather of Changsha on Dec 22, 2013.

This review highlights the constituents of pollutional haze and its effects on pulmonary function. We summarize the available information and assess the correlation between pollutional haze and pulmonary function. Our intention is to provide general information of what the pollutional haze is and how pulmonary function and pollutional haze are related rather than to introduce a detailed, or complete review.

What is pollutional haze

Traditionally haze is an atmospheric phenomenon where dust, smoke and other dry PM composed of various components obscure the clarity of the sky. The coefficient of haze (COH) is used to measure the visibility interference in the atmosphere. To determine COH, 1,000 feet of air sample is taken from an air filter and obtain radiation intensity. Then, the coefficient is calculated based on following absorbance formula:

where I1 is the radiation (400 nm light) intensity transmitted through the sampled filter, and I0 is the radiation intensity transmitted through a clean (control) filter (17).

Pollutional haze is quite different from fog or mist. Fog is an aerosol system and more than 90% of its component is water, which causes visibility less than one kilometer. Therefore the occurrence of fog mainly affects traffic condition but has no much harmful effect on health when air is not polluted. However, when air is polluted with dry particles like PM2.5 and PM10 and gases like ozone, nitric oxide, nitrogen dioxide and sulfur dioxide, pollutional haze may occur if the relative humidity is less than 80%. Because nitrogen dioxide and sulfur dioxide may react with tiny water drops in the air and form nitric acid and sulfuric acid respectively, in most cases the pollutional haze is of yellow or orange gray color since the particles of nitric acid and sulfuric acid primarily scatter visible light with relative long wavelength. So, pollutional haze particles are comprised of a complex range of chemically and physically diverse substances that exist in the atmosphere as discrete, suspended liquid or solid particles. The basic components of pollutional haze are gases (e.g., ozone, sulfur dioxide, nitric oxide, nitrogen dioxide, carbon monoxide, carbon dioxide), volatile organic compounds (e.g., Benzene), and PM (e.g., metals, nitrates, sulfates, organic carbon, microbial components, pollen) (18,19). These haze particulates are characterized by various physical and chemical properties due to their sources, size ranges, formation mechanisms, and chemical composition. The effects of the pollutional haze particle on health mainly depend on its size and chemical composition.

The size and sources of haze particles

Particulate of pollutional haze refers to an air suspended mixture of solid and liquid particles varying in size, composition, and origin. It is a mixture including numerous classes and subclasses of contaminants. The size of haze particles is one of the leading factors that determine their behavior in the respiratory system. The size of airborne PM has been basically divided into there principal groups according to their aerodynamic diameter: coarse particles, fine particles, and ultrafine particles (UFPs).

Coarse particles (PM10)

Coarse particles are the particles that can penetrate the thoracic airways, but they are also called inhalable particles. Coarse particles often defined as those with an aerodynamic diameter in the range of 2.5–10 μm. These particles can suspend and float in the atmosphere over a long period of time, and are often naturally occurring and derived primarily from soil and other crustal materials.

Fine particles (PM2.5)

In 1997, the U.S. EPA promulgated a standard (20) for an even finer cut of particulate air pollution-particles PM2.5 with aerodynamic diameter less than 2.5 μm. Currently, fine particles are often defined as those with an aerodynamic diameter in the range of 0.1–2.5 μm. Fine particles are derived chiefly from primary pollution, which is caused directly by gases like nitrogen oxides, sulfur dioxide and carbon monoxide from combustion processes in transportation, manufacturing, power generation, etc. Secondary pollution, the products formed by reactions between primary pollutes and components in the atmosphere or the reactions between primary pollutes, also contributes to the formation of fine particles. For instance, sulfate and nitrate particles commonly generated by conversion from primary sulfur and nitrogen oxide emissions are common components of fine particles. Although fine particles PM2.5 are dominantly comprised of primary pollution-source particles and secondary pollution in most urban areas, soil dust, sea salts, pollen, spore, smoking, etc. are the sources of fine particles as well. The existence of PM2.5 dramatically affects air quality and visibility although it accounts for a quite small part of the atmosphere. Compared to coarse particle PM10, PM2.5 is characterized by smaller diameter, larger area, stronger activity, easier carrier of harmful substance like heavy metal and microbe, more time suspending in the atmosphere, and longer distance to be delivered, therefore, PM2.5 has more significant effect on human health and atmosphere quality.

Ultrafine particles (UFPs)

UFPs are often defined as particles with aerodynamic diameter less than 0.1 μm. UFPs are the particles of nanoscale size. There are two types of UFPs, carbon-based type or metallic type. So, UFPs can be further subdivided by their magnetic properties. Airborne UFPs can be measured using a condensation particle counter (21). UFPs can be either naturally occurring or derived from manufacturing processes. Ocean spray, hot volcanic lava, and smoke are common natural UFPs sources as well. Other UFPs sources are byproducts, like emissions from specific processes, combustion reactions, or equipment such as printer toner and automobile exhaust (22,23). In 2014, it was reported that harmful UFPs from the takeoffs and landings at Los Angeles International Airport were of much greater magnitude than previously thought (24). There are a number of indoor sources of UFPs like laser printers, fax machines, photocopiers, cooking, tobacco smoke, chimney cracks, vacuum cleaners, etc. Although UFPs have relatively short residence times in the atmosphere because they readily accumulate or coagulate to form larger fine particles, UFPs are the main constituent of airborne PM. Research shows that these ambient particles are far smaller than the PM10 and PM2.5 particles and are believed to have several more aggressive health implications than those classes of larger particulates (25).

All three types of haze particles have contributions from both primary sources (emitted directly into the atmosphere) and secondary processes (formed in the atmosphere from precursor emissions). Both primary emissions and secondary emissions can originate from either anthropogenic or natural sources.

The chemistry of pollutional haze

Generally haze particulates are produced from either primary pollution process or secondary pollution process. Not matter from which process does the PM of haze generate, the basic components of haze particles are chemical substances, including ozone, sulfur dioxide, nitric oxide, nitrogen dioxide, carbon monoxide, carbon dioxide, volatile organic compounds, metals, nitric acid, nitrates, sulfuric acid, sulfates, organic carbon, etc. Among these substances, sulfur dioxide, nitrogen dioxide, ozone, nitric acid, nitrates, sulfuric acid, and sulfates are the most common components of haze particles. These chemical substances have different effects on human health because they have different physical and chemical properties.

Sulfur dioxide (SO2)

Sulfur dioxide is a colorless gaseous substance at normal temperature, which is a toxic gas with a pungent, irritating and rotten smell. Sulfur dioxide is found on earth and exists in very small concentrations in the atmosphere at approximately 1 ppbv (26,27). The oxidation number of sulfur in Sulfur dioxide molecule is +4, it can function either as a reducing agent or as a oxidizing agent. For instance, Sulfur dioxide can be oxidized to form sulfur trioxide (SO3), which is widely used in the production of sulfuric acid in industry. In the presence of water, sulfur dioxide is able to decolorize substances due to its oxidizing capability. The main source of sulfur dioxide in the atmosphere is the by-product of combustion of fossil fuels that contains sulfur, like coals, liquid fuels and natural gas. Sulfur dioxide is a noticeable component in the atmosphere, especially following volcanic eruptions. Because sulfur dioxide is a polar molecule and an acidic oxide, it can combine with water to form sulfurous acid, H2SO3. For the same reason, sulfur dioxide emissions are a precursor to acid rain, which is the common component of haze particulates. According to United States Environmental Protection Agency, Sulfur dioxide is a major air pollutant and has significant impacts upon human health. The concentration of sulfur dioxide in the atmosphere can influence the habitat suitability for plant communities as well as animal life (28). Exposure to SO2, even at low level is linked to increased bronchoconstriction in people with asthma, and reduction in lung function has been observed at higher concentrations.

Nitrogen dioxide (NO2)

Nitrogen dioxide is a gaseous substance with reddish-brown color at normal temperature. It is a toxic gas with a characteristic sharp, biting odor. NO2 is an intermediate in the industrial synthesis of nitric acid, which is produced each year with millions of tons. Because the oxidation number of nitrogen in NO2 molecule is +4, it can function either as a reducing agent or as an oxidizing agent. Nitrogen dioxide plays an important role in atmospheric chemistry, including the formation of tropospheric ozone. Nitrogen dioxide is generated from most combustion processes using air as the oxidant. At elevated temperature nitrogen combines with oxygen to form nitric oxide, NO. Nitric oxide can be oxidized in air to form nitrogen dioxide though at normal atmospheric concentrations this process is a very slow. The most prominent sources of NO2 in the atmosphere are internal combustion engines, thermal power stations. Butane gas heaters and stoves are also its sources. Nitrogen dioxide is a polar molecule and an acidic oxide, it can combine with water to form nitric acid, HNO3. So, Nitrogen is a large scale pollutant that can form acid rain due to the formation of HNO3 when combining with airborne water. Nitric acid is also a common component of haze particulates. Compared to SO2, NO2 is more likely to reach the lower airways due to its lower water solubility. Exposure even at low levels of NO2 induces inflammatory response.

Ozone

Ozone is a colorless or slightly bluish gas, which is slightly soluble in water and much more soluble in inert non-polar solvents such as carbon tetrachloride or fluorocarbons, where it forms a blue solution. Ozone is of a distinctively pungent, sharp, reminiscent of chlorine smell at standard conditions. It is an allotrope of oxygen but it is much less stable than O2, easily breaking down in the lower atmosphere to normal dioxygen. Ozone is produced from oxygen either by the action of ultraviolet light or by atmospheric electrical discharges. Throughout the Earth’s atmosphere ozone is present in low concentrations. Even in ozone layer the ozone concentrations are only 2–8 ppm. Ozone mostly exists in ozone layer, which is below stratosphere, the region 20–35 kilometers away from earth surface. In total, ozone makes up only 0.6 ppm of the atmosphere. Ozone is one of the most powerful oxidizing agents (far stronger than O2) and has many industrial and consumer applications related to oxidation. Due to its high oxidizing ability, ozone may damage respiratory tissues in animals and tissues in plants if its atmosphere concentration is more than 100 ppb. In heavy concentrations, ozone is irritating to the eyes, nose and throat. This makes ozone a potent respiratory hazard and pollutant near ground level although the so-called ozone layer is beneficial since it is able to prevent damaging ultraviolet light from reaching the Earth’s surface. Therefore, low level ozone (or tropospheric ozone) is reported to be an atmospheric pollutant (29). In the atmosphere ozone precursors are a group of pollutants, predominantly those emitted during the combustion of fossil fuels. Ground-level ozone pollution is created near the Earth’s surface by the action of daylight UV rays on these precursors. There is evidence that Ozone can act either as a greenhouse gas, absorbing some of the infrared energy emitted by the earth or as a component to facilitate the formation of photochemical smog (30,31).

Nitric acid and nitrates

Nitric acid is one of the strongest mineral acids with high corrosiveness, which can be produced using different processes. The process to manufacture nitric acid in industry is called Ostwald process. In this process, anhydrous ammonia is oxidized to form nitric oxide, NO, at a high temperature and pressure in the presence of platinum or rhodium gauze catalyst. Nitric oxide is then reacted with oxygen in air to form nitrogen dioxide. Nitrogen dioxide is subsequently absorbed in water to form nitric acid and nitric oxide. In this process nitric oxide is cycled back for reoxidation. In laboratory, nitric acid is generally produced from the reaction between sulfuric acid, H2SO4 and sodium nitrate, NaNO3. The chief industrial use of nitric acid is for the production of fertilizers. Nitric acid is neutralized with ammonia to give ammonium nitrate, NH4NO3. The other main applications are for the productions of explosives, nylon precursors, and special organic compounds. As a strong acid, nitric acid is highly soluble in water, resulting a strong acidic solution. Highly acidic nitric acid is able to reacts with bases to form nitrates, for instance, nitric acid reacts with sodium hydroxide to form sodium nitrate, NaNO3. Nitric acid is also a powerful oxidizing agent. It reacts violently with many organic materials and the reactions may be explosive. In the atmosphere, nitric acid may be generated from the reaction between pollutant NO2 and airborne water, forming acidic haze particles. These haze particles are very harmful to environment because of the presence of nitric acid. Nathan S. Bryan composed a review targeted to the current state of the science on nitrate in human health and disease (32).

Sulfuric acid and sulfates

Sulfuric acid, H2SO4, is one of the strongest diprotic acid, which is highly corrosive. It is a pungent, colorless or slightly yellow viscous liquid at room temperature. Its corrosiveness on other materials, like metals, living tissues or even stones, can be mainly ascribed to its strong acidic nature. Concentrated sulfuric acid has strong dehydrating and oxidizing property, able to cause very serious damage upon contact. Because of its strong oxidizing property, damage posed by sulfuric acid is potentially more severe than that caused by other comparable strong acids, such as hydrochloric acid and nitric acid. It causes not only chemical burns via hydrolysis, but also secondary thermal burns via dehydration. It burns the cornea, leading to permanent blindness if splashed onto eyes. It readily decomposes proteins and lipids through amide hydrolysis and ester hydrolysis upon contact with living tissues. If ingested, sulfuric acid damages internal organs irreversibly and may even be fatal. Sulfuric acid is soluble in water at all concentrations, generating a highly acidic solution. It reacts with most bases to give the corresponding sulfate. The reaction between sulfuric acid and potassium nitrate can be used to produce nitric acid. Also, its strong oxidizing property makes it highly corrosive to many metals. Due to its chemical properties, sulfuric acid is a central substance in the chemical industry. It has a wide range of applications including domestic acidic drain cleaner, electrolyte in lead-acid batteries and various cleaning agents. Sulfuric acid is widely produced with different methods, such as contact process, wet sulfuric acid process and some other methods. Sulfuric acid is formed naturally by the oxidation of sulfide minerals, such as iron sulfide. Because sulfur dioxide is the main byproduct produced when sulfur-containing fuels such as coal or oil are burned, dilute sulfuric acid, which is formed by atmospheric oxidation of sulfur dioxide in the presence of water, is a constituent of acid rain. For the same reason, in some cases pollutant SO2 is oxidized in the atmosphere to form sulfuric acid haze particles or sulfate aerosol in wet air.

The effects of pollutional haze on pulmonary function

It is widely reported that polluted air has negative effects on human health (7,33,34). Currently, pollutional haze is one of the main air pollution types which occur frequently worldwide, especially in China. More and more attention has been driven to the study of possible adverse effects of pollutional haze on health. What adverse effects the pollutional haze exert to health and how the adverse effect works are the major concerns among scientists. Studies show that these adverse effects include increased respiratory symptoms and diseases, aggravation of asthma, and a decrease in lung function, etc. (35,36). The effect of pollutional haze on lung function is closely related to its particle size and chemical composition.

The effects of particle size of haze on pulmonary function

Pollutional haze refers to an air suspended mixture of solid and liquid particles that vary in size, composition, and origin. The size distribution of total suspended particles (TSPs.) in the atmosphere is generally categorized into three types: coarse particles (PM10–PM2.5), fine particles (PM2.5–PM0.1), and UFPs (aerodynamic diameter less than 0.1 μm). In 1987 the U.S. Environmental Protection Agency (U.S. EPA) defined that all particles with aerodynamic diameter less than 10μm are the inhalable particles. The guideline value of WHO based upon TSPs is 90 μg/m 3 . This level is commonly exceeded in many of the Asian megacities. All these inhalable particles have negative effects on health (37), especially the fine and UFPs, although their health effects may differ by size and composition.

Coarse particles, derived dominantly from soil and other crustal materials, are easily stopped in mouth and nose and settle in upper airway. Most of them are discharged out of body as sputum or mucus. It is believed that the harmful effects of coarse particles on health are limited due to their larger size. A study projected by Chang et al. using a mass screening program investigated the association between air pollutants exposure and the lung function of junior high school students in a mass screening program in Taipei city, Taiwan. Forced vital capacity (FVC) and forced PM with diameter of 10 μm or less (PM10) were assessed by regression models controlling for the age, gender, height, weight, student living districts, rainfall and temperature. Results showed that FVC, had a significant negative association with short-term exposure to PM10 measured on the day of spirometry testing. FVC values also were reversely associated with means of PM10. Namely, the short-term exposure to PM10 was associated with reducing FVC and FEV1 (38).

Compared to coarse particles, fine particles more readily penetrate indoors. They are transported over longer distances, and are somewhat uniform within communities, resulting in highly ubiquitous exposure. Fine particles may be comprised of sulfur dioxide, nitrogen dioxide, sulfates, nitrates, acids, metals, and carbon particles with various chemicals adsorbed onto their surfaces. Due to their smaller size, fine particles are deemed to be more biologically active than coarse PM and be breathed readily deep in the lungs, suggesting that exposure to fine particles is a more serious health concern. Study from Peters group demonstrated that PM2.5 was significantly associated with lower FVC, FEV1, and maximal midexpiratory flow (MMEF). His group also reported that stepwise regression of adjusted pulmonary function values for girls in the 12 communities showed that PM2.5 was most strongly associated with FEV1 (r=–0.72, P 3 PM2.5 (45).

Relatively, UFPs, also named as nanoparticles, have short residence times in the atmosphere because they accumulate to form larger fine particles. However, these particles are a serious health concern as they are able to penetrate deep into alveoli, pass through the lining of the lung, and be distributed systemically in the body. Recently, much attention has been focused on the adverse effects of UFPs [PM 3 may decrease lung function and increase the risk of respiratory symptoms (66). Long term exposures to NO2 induce neurasthenic syndrome, chronic airway inflammation, and pulmonary fibrosis. Nitrates are toxic and humans are subject to its toxicity. Infants are especially vulnerable to methemoglobinemia due to nitrate metabolizing triglycerides present at higher concentrations than at other stages. Some adults can be more susceptible to the effects of nitrates than others (67). In the study of Kerr et al. (68), twenty human subjects with asthma and chronic bronchitis and 10 normal, healthy adults were exposed to 0.5 ppm of nitrogen dioxide for 2 h in a confined environment. This study unveiled that exposure of subjects with asthma and chronic bronchitis to 0.5 ppm NO2 for 2 h does not produce a significant decrement in their pulmonary function. In the investigation published by Drechsler-Parks et al. (69), the pulmonary function of eight men and eight women (51 to 76 years of age), all nonsmokers, was measured before and after 2-hr exposures to filtered air (FA) and 0.60 ppm nitrogen dioxide (NO2). The results showed that there were no statistically significant (P>0.05) differences between the responses of men and women to FA or NO2 exposure. There were no significant (P>0.05) changes in any variable consequent to FA or NO2 exposure. Earlier reports from this group also indicated that older subjects had responses to NO2 exposure similar to those of young adults, suggesting that, at least for healthy people, exposure to 0.60 ppm NO2 has little effect. One study aimed to investigate whether or not well characterized groups of healthy adolescents and adolescents with asthma differed in their sensitivity to ozone and nitrogen dioxide at near ambient concentrations of these pollutants was projected by Koenig group (70). It is concluded that there were no differences in pulmonary function responses between asymptomatic, allergic asthmatic adolescents and healthy adolescents exposed to nitrogen dioxide under the conditions of these studies.

In 1989, Fischer et al. (71) investigated the health effects of indoor NO2 pollution among two populations of adult women. One population was living in a rural area, one in an urban area. The results stated that significant associations were found between exposure to NO2 and pulmonary function among the non-smoking women living in the rural area, but no significant associations among the smoking women in that area, or among the non-smoking and smoking women living in the urban area. However, Ackermann-Liebrich group (72) found that short-term exposure is associated with increased mortality and hospital admissions. The study carried by Chang et al. (38) using a mass screening program indicated that FVC values also were reversely associated with means of NO2 exposed 1 d earlier. Study from Ponsonby et al. (73) also reported that no associations were found between NO2 exposure or gas appliance use and asthma, wheeze or baseline lung function. The effect of low-level NO2 exposure on these respiratory outcomes was not marked. This study suggested that the possible effect of low-level NO2 exposure on non-specific bronchial reactivity required confirmation. The study from Ichinose et al. (58) revealed that exposure to O3 + NO2 or NO2 + H2SO4 aerosol produced an additional increase in incidence of lung tumor. These results suggest that the exposure to O3 + NO2 or NO2 + H2SO4 even at ambient levels of each pollutant may have a synergistic action and that free radical generation and lipid peroxide production by exposure to those air pollutants may be related to lung tumor promotion. The report from Peters JM group in 1999 suggested that Stepwise regression of adjusted pulmonary function values for girls in the 12 communities showed that NO2 was most strongly associated with lower FVC (r=−0.74, P 3 ) for 10 min showed no significant changes in lung volumes, distribution of ventilation, ear oximetry, dynamic mechanics of breathing, and oscillation mechanics of the chest-lung system. NaNO3 aerosol (1,000 μg/m 3 ) for 10 min did not significantly change pulmonary capillary blood flow, diffusing capacity, oxygen consumption, and pulmonary tissue volume as measured by a rebreathing technique. Thus, it was concluded that brief exposure to high concentrations of submicronic aerosol of sodium nitrate does not produce immediate adverse effects on cardiopulmonary function of anesthetized dogs, conscious sheep, and normal and asthmatic adults. Kleinman et al. (76) published a report in 1980 which demonstrated that no substantial alterations in pulmonary function or overall reported symptoms attributable to the NH4NO3 exposure were found for two subject groups: volunteers, 20 normal and 19 asthmatic, were exposed to clean air (sham) and to ammonium nitrate (NH4NO3) aerosol (exposure) under conditions which simulated a “worst case” ambient pollution episode. Possibly meaningful pulmonary function changes or symptom increases were seen in a few individuals, but these showed no obvious pattern and may well have been chance occurrences. A study from Loscutoff group (77) discovered that rats exposed to NH4NO3 aerosols showed no consistent exposure-related changes. Compared with air-exposed animals, rats exposed to (NH4)2SO4 aerosols had increased values of residual volume and functional residual capacity and decreased slope of single-breath N2 washout curves. It was deduced that elastase treatment had no significant effect on lung function changes resulting from inhalation of (NH4)2SO4 aerosols. Lung function was more affected by (NH4)2SO4 exposure than by NH4NO3 exposure, and lung function changes were more pronounced in rats than in guinea pigs. Obviously, based on these studies there are still some disagreements.

The effects of ozone on pulmonary function

Ozone is a powerful oxidant and toxic air pollutant. As one of main gaseous pollutants in pollutional haze, ozone in the atmosphere is generally produced from secondary pollution. Ozone precursors are a group of pollutants, predominantly those emitted during the combustion of fossil fuels. Although very low natural background level of ozone is considered safe, it can be hazardous at even low concentrations. The Canadian Center for Occupation Safety and Health reports that: “Even very low concentrations of ozone can be harmful to the upper respiratory tract and the lungs. The severity of injury depends on both the concentration of ozone and the duration of exposure. Severe and permanent lung injury or death could result from even a very short-term exposure to relatively low concentrations (78).” Exposure to 0.5–1 ppm ozone in the atmosphere may bring some adverse reaction and exposure to 1–4 ppm ozone may induce cough. Long-term exposure to ozone has been shown to increase risk of death from respiratory illness. A study of 450,000 people living in United States cities showed a significant correlation between ozone levels and respiratory illness over the 18-year follow-up period. The study found that people living in cities with high ozone levels such as Houston or Los Angeles had an over 30% increased risk of dying from lung disease (79,80). Ozone is one of the most powerful oxidant, it is able to react with almost all biological tissues, causing various detrimental health effects like harming lung function, irritating therespiratory system, and impairing tissues. Exposure to ozone or the pollutants that produce ozone is linked to asthma, bronchitis, heart attack, and other cardiopulmonary problems (81,82). Those persons with asthma, bronchitis or emphysema are more susceptive to ozone. Bock et al. (83) designed a study to investigate the acute effects of exposure to ambient-air pollution choosing children who were 7 to 13 years old and healthy active in a summer recreational camp. They found that a general tendency for decreased lung function with increasing ozone concentration; however only peak expiratory flow rate (PEFR) mean slopes for girls and for all subjects were statistically significantly different from zero. In the regression analysis, decrements in PEFR were significantly correlated with the ozone exposure. Overall, the decrements were small. In the investigation from Deborah group (84), the pulmonary function of 8 men and 8 women (51 to 76 years of age), all nonsmokers, was measured before and after 2-h exposures to FA and 0.45 ppm ozone (O3). The study demonstrated that there were no statistically significant (P>0.05) differences between the responses of men and women to FA or O3 exposure. Since men and women had similar decrements in pulmonary function when women inhaled less O3, the data suggested that women may be somewhat more responsive to O3 than men. The results also indicated that older individuals may be less responsive to O3 than young individuals based on the results from the study projected by Koenig group (70). It is concluded that there were no differences in pulmonary function responses between asymptomatic, allergic asthmatic adolescents and healthy adolescents exposed to ozone under the conditions of these studies. However, an increase in total respiratory resistance was observed in both asthmatic and healthy adolescent subjects after their exercise exposure to 0.18 ppm ozone. A study focused on the dose-response relationship for the effects of ozone on pulmonary function in humans was launched by Kleinman et al. (85). The effects of ozone on pulmonary function in adults and children were evaluated using the model. On the basis of dose of ozone (micrograms O3 per kg body mass), children, aged 8 to 15 years, and adults were equally sensitive. When dose is analyzed as a function of age, the data suggest that children, under the age of 6 years, receive greater doses to respiratory tract tissues than do older children or adults, under equivalent conditions of exposure. Ichinose group (58) investigated the promoting effects of a combined exposure to two pollutants (NO2, O3 or H2SO4-aerosol) at near ambient levels on lung tumorigenesis induced by N-bis (2-hydroxypropyl) nitrosamine (BHPN) in male Wistar rats. Their study showed that exposure to O3 alone enhances tumor development and that the combined exposure to O3 with NO2 produces an additional increase in incidence of lung tumor. Exposure to each air pollutant had no effect on the development of bronchiolar mucosal hyperplasia in lungs of rats treated with BHPN. These results suggest that the exposure to O3 + NO2 even at ambient levels of each pollutant may have a synergistic action as a tumor promoter and that free radical generation and lipid peroxide production by exposure to those air pollutants may be related to lung tumor promotion. A report from Korrick group suggested that prolonged outdoor exercise, low-level exposures to O3, PM2.5, and strong aerosol acidity were associated with significant effects on pulmonary function among adults. Stepwise regression of adjusted pulmonary function values for girls in the 12 communities showed that O3 was most strongly associated with PEFR (r=−0.75, P Firket J. Fog along the Meuse Valley. Trans Faraday Soc 1936; 32 :1192-6. [Google Scholar]

The effect of pollutional haze on pulmonary function Abstract Detrimental health effects of atmospheric exposure to ambient particulate matter (PM) have been investigated in numerous studies. ]]>