Global, national, and urban burdens of paediatric asthma incidence attributable to ambient NO pollution: estimates from global datasets.

Lancet Planet Health 2019 Apr 11;3(4):e166-e178. Epub 2019 Apr 11.

Milken Institute School of Public Health, George Washington University, Washington, DC, USA. Electronic address:

Background: Paediatric asthma incidence is associated with exposure to traffic-related air pollution (TRAP), but the TRAP-attributable burden remains poorly quantified. Nitrogen dioxide (NO) is a major component and common proxy of TRAP. In this study, we estimated the annual global number of new paediatric asthma cases attributable to NO exposure at a resolution sufficient to resolve intra-urban exposure gradients.

Methods: We obtained 2015 country-specific and age-group-specific asthma incidence rates from the Institute for Health Metrics and Evaluation for 194 countries and 2015 population counts at a spatial resolution of 250 × 250 m from the Global Human Settlement population grid. We used 2010-12 annual average surface NO concentrations derived from land-use regression at a resolution of 100 × 100 m, and we derived concentration-response functions from relative risk estimates reported in a multinational meta-analysis. We then estimated the NO-attributable burden of asthma incidence in children aged 1-18 years in 194 countries and 125 major cities at a resolution of 250 × 250 m.

Findings: Globally, we estimated that 4·0 million (95% uncertainty interval [UI] 1·8-5·2) new paediatric asthma cases could be attributable to NO pollution annually; 64% of these occur in urban centres. This burden accounts for 13% (6-16) of global incidence. Regionally, the greatest burdens of new asthma cases associated with NO exposure per 100 000 children were estimated for Andean Latin America (340 cases per year, 95% UI 150-440), high-income North America (310, 140-400), and high-income Asia Pacific (300, 140-370). Within cities, the greatest burdens of new asthma cases associated with NO exposure per 100 000 children were estimated for Lima, Peru (690 cases per year, 95% UI 330-870); Shanghai, China (650, 340-770); and Bogota, Colombia (580, 270-730). Among 125 major cities, the percentage of new asthma cases attributable to NO pollution ranged from 5·6% (95% UI 2·4-7·4) in Orlu, Nigeria, to 48% (25-57) in Shanghai, China. This contribution exceeded 20% of new asthma cases in 92 cities. We estimated that about 92% of paediatric asthma incidence attributable to NO exposure occurred in areas with annual average NO concentrations lower than the WHO guideline of 21 parts per billion.

Interpretation: Efforts to reduce NO exposure could help prevent a substantial portion of new paediatric asthma cases in both developed and developing countries, and especially in urban areas. Traffic emissions should be a target for exposure-mitigation strategies. The adequacy of the WHO guideline for ambient NO concentrations might need to be revisited.

Funding: George Washington University.

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April 2019
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