Cardiorespiratory health effects of gaseous ambient air pollution exposure in low and middle income countries: a systematic review and meta-analysis

Katherine Newell, Christiana Kartsonaki, Kin Bong Hubert Lam, Om Kurmi

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BACKGROUND: Lack of research on the effects of gaseous pollutants (nitrogen oxides [NOx], sulfur dioxide [SO2], carbon monoxide [CO] and ozone [O3]) in the ambient environment on health outcomes from within low and middle income countries (LMICs) is leading to reliance on results from studies performed within high income countries (HICs). This systematic review and meta-analysis examines the cardiorespiratory health effects of gaseous pollutants in LMICs exclusively.

METHODS: Systematic searching was carried out and estimates pooled by pollutant, lag and outcome, and presented as excess relative risk per 10 μg/m3 (NOx, SO2, O3) or 1 ppm (CO) increase pollutant. Sub-group analysis was performed examining estimates by specific outcomes, city and co-pollutant adjustment.

RESULTS: Sixty studies met the inclusion criteria, most (44) from the East Asia and Pacific region. A 10 μg/m3 increase in same day NOx was associated with 0.92% (95% CI: 0.44, 1.39), and 0.70% (0.01, 1.40) increases in cardiovascular and respiratory mortality respectively, same day NOx was not associated with morbidity. Same day sulfur dioxide was associated with 0.73% (0.04, 1.42) and 0.50% (0.01, 1.00) increases in respiratory morbidity and in cardiovascular mortality respectively.

CONCLUSIONS: Acute exposure to gaseous ambient air pollution (AAP) is associated with increases in morbidity and mortality in LMICs, with greatest associations observed for cardiorespiratory mortality.

Original languageEnglish
Article number41
Number of pages14
JournalEnvironmental health : a global access science source
Issue number1
Publication statusPublished - 18 Apr 2018
Externally publishedYes

Bibliographical note

This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.


  • Air Pollutants/adverse effects
  • Air Pollution/adverse effects
  • Cardiovascular Diseases/chemically induced
  • Developing Countries
  • Environmental Exposure
  • Humans
  • Respiratory Tract Diseases/chemically induced


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