Relationship Between Air Pollutants and Mortality from Cardiorespiratory

Archive of SID فصلٌبهِ علویپضٍّطی، آهَسش ه حیظسیست ٍ تَسعِ پبیذار Quarterly Journal of Environmental Education and Sustainable Development ؾبَ ٞفشٓ، قٕبضٜ چٟبضْ، سبثؿشبٖ Vol. 7, No. 4, Summer 2019 (117-126) )117-126( 1398 ارتثاط آالیىذٌَای ًَای ضُز مطُذ تا مزگيمیز واضی اس تیماریَای للثی ي عزيلی ي تىفسی، ﮔﺎﻣﯽ در راﺳﺘﺎي ﺷﻨﺎﺧﺖ و آﮔﺎﻫﯽ ﺷﻬﺮوﻧﺪان از اﺛﺮات ﻣﻨﻔﯽ آﻻﯾﻨﺪهﻫﺎ

*ﻋﻠﯽاﮐﺒﺮ ﻣﻠﮑﯽراد1، ﻓﻬﯿﻤﻪ ﺗﻨﺠﺎه2، ﻏﻼﻣﺤﺴﻦ واﻋﻈﯽ3 1. استادیار گزيٌ رياوشىاسی، داوشگاٌ پیام وًر، تُزان، ایزان 2. کارشىاس ارشد فیشیًلًصی، داوشگاٌ آساد اسالمی ياحد دامغان، دامغان، ایزان 3. استاد، گزيٌ سیستشىاسی، داوشکدٌ علًم پایٍ، ياحد علًم ي تحقیقات، داوشگاٌ آساد اسالمی، تُزان، ایزان )دریافت: 21/7/1397 پذیزش: 1397/11/6(

Relationship between Air Pollutants and Mortality from Cardiorespiratory Diseases in Mashhad: A Step Towards Increasing Citizens’ Awareness of Adverse Effects of Pollutants

*Ali Akbar Maleki Rad1, Fahimeh Tanja2, Gholamhassan Vaezi3 1. Assistant Professor, Department of Psychology, Payame Noor University, Tehran, Iran 2. Master of Physiology, Department of Biology, Islamic Azad University, Damghan, Iran 3. Professor of Physiology, Department of Biology, Islamic Azad University, Tehran, Iran (Received: 13/10/2018 Accepted: 26/1/2019)

چك ذٌ:ی :Abstract آِٛز٣ٌ ٛٞا زض قٟطٞب٢ خٟبٖ، ٔرّٛط د٥چ٥سٜ ا٢ اظ اخعا٢ ٣ٕؾ اؾتز وتAir pollution in different cities of the world is a complex ٝ mixture of toxic components, including particulate PM فٕسسبً ٔحهَٛ فطآٙ٤سٞب٢ احشطاق اؾز ٚ شضار ٔقّك ) ( فضت٥ٕٞ ٛكتmatter (PM), mainly produced by combustion processes. ٝ حبضط ا٤ٗ ٔرّٛط ؿٞشٙس. ٔغبِقٝ حبضط ثٝ ثطض٣ؾ اضسجبط آالٙ٤تسٞ ٜتب٢ ٞتٛا A cross-sectional analytical study was conducted to ثب ٥ٔعاٖ ٔطي ٥ٔٚط ٘بق٣ اظ ث٥ٕبض٢ ٞب٢ لّجت٣ فطٚلت٣ ٚ سٙفؿت٣ زض ٔكتٟس investigate the relationship between air pollutants and mortality from cardiorespiratory diseases in Mashhad. ٣ٔ دطزاظز. ع٣ ٤ه ٔغبِقٝ ٔمغق٣ سح٣ّ٥ّ ٥ٔعاٖ ٔطي٥ٔٚط ثتط اثتط ث٥ٕتبض٢ To this end, the data on mortality from cardiorespiratory لّج٣ ٚ فطٚل٣ اظ ؾبظٔبٖ ثٟساقز اؾتشبٖ ذطاؾتبٖ زض ثتبظٜ ظٔتب٣٘ ) diseases in 2012-2013 were obtained from Razavi -1391 Khorasan Health Organization. The mean daily 1392( زض٤بفز ٌطز٤س. ؾذؽ ٥ٔب٥ٍ٘ٗ ضٚظاٝ٘ آِٛز٣ٌ ٞتٛا قتبُٔ ٛ٘ٛٔوؿت٥س concentration of air pollutants, including carbon وطثٗ ٛٔ ،coاز ٔقّك ثب لغط وٕشط اظ 10 ٥ٔىطٛٔ ،PM10 ٖٚاز ٔقّك ثب لغتط monoxide (CO), PM with a diameter of 10 micrometers or less (PM ), and PM was calculated. The results of وٕشط اظ PM2.5 2/5 اذص ٌطز٤س. ٘شت ب٤ح ٔتٛضز سدع٤تٚ ٝسح٥ّتُ آٔتبض٢ لتطاض 2.5 10 data analysis showed that there was a relationship PM10 ٌطفز. شضار ٔقّك زاضا٢ اضسجبط ٔق٣ٙ زاض٢ ثب ٥ٔعاٖ ٔطي ٥ٔٚط ٘بق٣ between PM10 concentration and the rate of mortality اظ ث٥ٕبضٞ٢ب٢ لّج٣ ٚ فطٚلت٣ زض ٔتطزاٖ اؾتز. ٕٞچٙت٥ٗ ا٤تٗ شضار زاضا٢ from cardiovascular diseases in men. In addition, a significant relationship was observed between PM10 اضسجبط ٔق٣ٙ زاض٢ ثب ٥ٔعاٖ ٔطي٥ٔٚط ٘بق٣ اظ ث٥ٕبضٞ٢ب٢ سٙفؿت٣ زض ٔتطزاٖ concentration and the rate of mortality from respiratory ٚ ظ٘بٖ ثٛز. فالٜٚ ثط ا٤ٗ اضسجبط ٔق٣ٙ زاض٢ ث٥ٗ ٥ٔعاٖ شضار ٔقّتك diseases in both men and women. The results indicated PM2.5 ٚ ٥ٔعاٖ ٔطي ٥ٔٚط ٘بق٣ اظ ث٥ٕبض٢ ٞب٢ لّج٣ ٚ فطٚل٣ ٚ ٥ٔتعاٖ ٔتطي ٥ٔٚتط that there was a significant relationship between PM2.5 concentration and the rate of mortality from ٘بق٣ اظ ث٥ٕبض٢ ٞب٢ سٙف٣ؿ زض ٔطزاٖ ٚ ظ٘بٖ ٔكبٞسٜ قس. ٕٞچٙت٥ٗ اضسجتبط .cardiorespiratory diseases in both men and women ٔق٣ٙ زاض٢ ث٥ٗ شضار ٚ CO ٥ٔعاٖ ٔطي٥ٔٚط ٘بق٣ اظ ث٥ٕتبض٢ ٞتب٢ سٙفؿت٣ There was also a significant relationship between CO concentration and the rate of mortality from respiratory زض ظ٘بٖ ٔكبٞسٜ قس. شضار ٔقّك PM2.5 زاض٢ ث٥كشط٤ٗ سأث٥ط زض ٔطي ٥ٔٚتط diseases in women. The results demonstrated that PM2.5 سؾٛظ ث٥ٕبض٢ ٞب٢ لّج٣ ٚ فطٚل٣ ٚ سٙف٣ؿ ٣ٔ ثبقٙس. ٘شب٤ح ا٤ٗ دتٞٚػف زض has the greatest effect on mortality from چبضچٛة اضسجبعبر ٔح٥ظ ظؿ٤ش٣ ٚ اؾشفبزٜ اظ اثعاض ضؾبٝ٘ ثطا٢ اضسمب٢ آٌتب٣ٞ cardiorespiratory diseases. The study findings were reported within the context of environmental ٚ قٙبذز ف٣ٕٔٛ اظ اثطار آالٙ٤سٜٞب، ٌعاضـ قسٜ اؾز.. communication by using the media tools to raise public awareness of the adverse effects of pollutants. ياصٌَا ی کل یذی : آِٛز٣ٌ ٛٞا، ث٥ٕبض٢ لّج٣ ٚ فطٚل٣، ث٥ٕبض٢ سٙف٣ؿ، Keywords: Air Pollution, Cardiorespiratory Diseases, ٔطي٥ٔٚط، قٙبذز ٚ آٌب٣ٞ. .Mortality, Awareness

*Corresponding Author: Ali Akbar Malekirad E-mail: [email protected] www.SID.ir Archive of SID Maleki Rad et al.: Relationship between Air Pollutants and Mortality from Cardiorespiratory … 118

Introduction expectancy, mainly due to mortality from The number of studies on the health effects of cardiorespiratory diseases (Anderson, 2004). air pollution has significantly increased over It is believed that PM2.5 is a more serious the past 15-10 years. It is now well threat than PM10 to human health because established that exposure to air pollution is smaller particles are more likely to associated with a wide range of acute and accumulate on deeper layers of lungs. chronic health problems from minor Moreover, studies have shown that small physiological disorders to mortality from particles are able to penetrate into the deepest cardiorespiratory diseases (Pope III, 2006; layers of the body (Ostro, 2004). PM2.5 Bascom, 1996). Air pollution in different seriously threats human health and increases cities of the world is a complex mixture of the rate of mortality from cardiorespiratory toxic components, including particulate matter diseases and lung cancer (Anderson, 2004; (PM), mainly produced by combustion Ostro, 2004). processes (Cohen, 2005). PM is a mixture of World Health Organization (WHO) estimates liquid and solid particles with different sizes show that about 800,000 premature deaths and chemical compositions. Fuel combustion caused by air pollution occur annually around of mobile sources (such as cars, trucks, and the world (Goldberg, 2001). WHO's an buses) and stationary sources (such as power estimation of the global burden of diseases plants and boilers) is the main source of PM (GBD) caused by air pollution indicates that in large cities. However, dusty roads, biomass 89% of all deaths attributed to air pollution burning, manufacturing processes, and were caused by cardiorespiratory diseases primary pollutants from diesel engines are (Cohen, 2004). According to death data of also involved in PM production (Ostro, 2004). Behesht-e Zahra Organization (2007), about Many PM-related health effects have been 43% of all non-accidental deaths in 2006 were reported, such as mortality, lung cancer, caused by cardiorespiratory diseases. The data hospitalization due to cardiorespiratory published by this organization also diseases, visiting the emergency units or demonstrate that more than 90% of deaths doctor's office, deterioration of respiratory caused by cardiorespiratory diseases in symptoms, absenteeism, restricted daily Tehran were related to individuals aged over activities, and acute and chronic bronchitis 30 years (Behesht-e Zahra Organization, (WHO, 2003). Many studies around the world 2007). have shown the relationship between non- Epidemiological studies have shown that the accidental daily mortality and PM (Zmirou, 24-hour high mean of air pollution is 1998; Goldberg, 2001). Epidemiological associated with an increased rate of mortality studies in Europe and around the world over from cardiorespiratory diseases and all other the past decade have indicated that one-day causes of death (Bascom, 1996; Schwartz, and the several-day mean of PM are 1991). However, little information is available associated with total mortality and mortality on the effects of short-term exposure to air from cardiorespiratory diseases (Schwartz, pollution. Many studies have reported that

1999; Dominici, 2002). PM10, PM2.5, black adverse effects of increased concentration of fume, and sulfates seem to have the highest PM, CO, and other pollutants include association with mortality and prevalence of increased admission to hospital and diseases (Ostro, 2004). Group studies have emergency units for respiratory diseases. In demonstrated that long-term exposure to PM addition, numerous studies conducted in the results in a substantial reduction in life US, Canada, and Europe have shown that

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increased concentration of PM and CO leads Malekafzali (2001) reported that there was a to an increase in hospital admission for significant relationship between the

cardiovascular diseases. These findings concentration of SO2, CO, and PM10 and indicate that air pollution is a risk factor for mortality rate. Ghorbani et al. (2007) studied both respiratory diseases and acute coronary the relationship between exposure to air events, including acute coronary syndrome pollution and the onset of ACS attacks in 250 (ACS) and myocardial infarction (MI) patients admitted to hospitals of Tehran and (Jaakkola, 2001). reported a significant positive relationship Polluted air inhalation can aggravate acute between the occurrence of ACS and the 24- heart attacks through lung inflammation and hour mean of CO (CI 95%: 1.34-1.03, increasing coagulability due to protein C OR:18.1) per unit increase in CO. However, deficiency (Schwartz, 1995). The increased the relationship between ACS and the 24-hour

concentration of reactive plasma protein has mean of PM10 (CI 95%: 1.01-0.99, OR: 1.005) been observed in healthy individuals after a was not statistically significant. There was period of exposure to polluted air (Peters et also a significant difference between men and al., 2001). Increased heart rate and increased women in terms of the relationship between risk of disruption of the implantable the 24-hour mean of CO and ACS, as women cardioverter-defibrillator (ICD) indicate the were more sensitive than men (CI 95%: 2.26- automatic response of the nervous system to 1.25, OR: 1.75). However, the relationship

exposure to air pollutants, especially CO between ACS and the 24-hour mean of PM10 (Routledge and Ayres, 2005). Peters et al. did not change by effect-moderating variables. showed that the risk of MI is associated with Their findings showed that the increased 24-

the high PM2.5 concentration within one to hour mean of CO increases the risk of ACS, three hours just before MI in hospital (Peters which is greater in women. The results et al., 2001). showed no significant relationship between

In another study, Joneidy et al. (2006) ACS and the 24-hour mean of PM10 (Ghorbani investigated the relationship between the et al., 2007). number of deaths caused by cardiorespiratory Farajzadeh (2008) showed that most of the diseases attributed to Tehran air pollution and deaths occur during the cold months of the

PM concentration. In this study, PM2.5 year. Gholizadeh (2009) also reported that concentration, as an indicator of air pollution, there is a high correlation between air was equal to 11.34 µg/m3 in 2006, which was pollution and mortality rate in the fall.

calculated using the PM10-PM2.5 ratio (0.5) Shireepour (2009) showed that the maximum

and the mean daily concentration of PM10. SO2 level occurs in the winter, while the

Their estimates demonstrated that the number maximum O3 level occurs during spring and of deaths attributable to PM contamination summer. was equal to 5388 cases (CI 95%: 7505- In a study conducted by Azhdarpour et al. 2360), accounting for 39.90% of all deaths (2011) in Shiraz, Iran, it was shown that there caused by cardiorespiratory diseases among is a significant relationship between car

individuals aged over 30 years in Tehran in accidents and air pollutants, such as CO, SO2,

2006. Their findings suggested a weak but NO, NO2, O3, and PM (p<0.05). The results significant correlation between PM on CO indicate that the number of accidents concentration and the rate of mortality from increases by 1.1 times per unit increase in CO. cardiorespiratory diseases (Joneidy et al., They also found a significant relationship 2009). between respiratory diseases and NO level,

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although such a significant relationship was insignificant. Their results indicated that the not observed between respiratory diseases and rate of hospitalization due to cardiorespiratory other pollutants. In addition, there was a diseases is highly sensitive to haze significant relationship between concentration. This sensitivity increased from cardiovascular diseases and the concentration 2010 to 2011 and was greater for men than

of NO2 and SO2. It can be generally concluded women. During the second and third quarters that the number of accidents substantially of 2011, there was at least a 29% increase in increases with the increase in the mortality from cardiovascular diseases for

concentration of NO2, O3, and NO every 100% increase in haze concentration (Azhdarpour et al., 2011). (Delangizan and Motlagh, 2013). The results reported by Alidadi et al. (2013) Levy et al. (2001) found no significant

for the city of Mashhad in Iran showed that relationship between PM2.5 concentration and there is a significant relationship between air cardiac arrest outside the hospital. Yang et al.

pollutants and mortality from (2014) reported that SO2 and CO have the cardiorespiratory diseases. The Pearson greatest impact on mortality from respiratory correlation coefficient between cardiovascular diseases.

diseases in women and concentration of NO2, In a study conducted by Amiri in 2011 in

SO, CO, and NO was obtained as 0.447, Karaj, it was shown that the 8-hour mean O3

0.404, 0.397, and 0.323, respectively, with a concentration and the mean annual PM10 significance level of 1%. There was a concentration were about 17 and 3.9 times,

significant relationship between SO2 respectively, above the Iranian national concentration and respiratory diseases in men, standard and WHO guidelines. Total mortality

with a Pearson correlation coefficient of caused by PM10 and O3 in Karaj during the 0.639. Their results also showed that the study period was estimated as 282 and 164, mortality rate was higher in men than women. respectively, accounting for about 3.9% and The highest correlation between pollutants 1.53% of all deaths in Karaj (except for deaths and mortality was observed in December- from road accidents). The mean cases January, and there was an increasing trend in attributed to O3 for chronic obstructive the concentration of pollutants over pulmonary disease (COPD) was 58, and the

December, January, February, and March. mean cases attributed to PM10 for They also reported that there was an increase hospitalization due to cardiovascular diseases in the rate of mortality from cardiorespiratory was obtained as 492. The findings indicate diseases with the increase in the concentration that air pollution in Karaj accounted for the of pollutants during the study period (Alidadi lion‘s share of mortality and hospitalization et al., 2013). cases from January 2012 to January 2013. In a study conducted by Delangizan and Therefore, relevant authorities should use Motlagh in Kermanshah in 2011, it was appropriate, sustainable, and applicable shown that a 1% increase in haze-borne air solutions based on comprehensive scientific pollution increases the rate of hospitalization research to control the air pollution crisis in due to cardiovascular diseases and respiratory Karaj (Amiri, 2013). diseases by about 5% and 1%, respectively, Some studies have shown that the rate of and the rate of mortality from cardiovascular mortality from lung cancer and cardiovascular diseases by about 3%. The relationship diseases caused by air pollution is high among between haze and mortality from respiratory Chinese, Koreans, and Iranians (Chen, 2017; diseases was positive but statistically Khaniabadi, 2017; Badyda, 2016). Another

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study indicates that there is a relationship cardiorespiratory diseases in 2012-2013 were

between long-term exposure to PM2.5 and obtained from Razavi Khorasan Health increased rate of mortality from Organization. In addition, the mean daily cardiovascular diseases and increased rate of concentration of air pollutants, including CO,

hospitalization due to respiratory conditions SO2, O3, PM10, and PM2.5, were received from (Kollanus, 2016). Razavi Khorasan Department of Environment There is also a relationship between short- and Mashhad Air Quality Control Company.

term exposure to PM2.5 and the increased rate The annual concentration of air pollutants was of mortality from cardiovascular diseases obtained from different measurement stations. (Chen, 2017). The findings of Miri (2016) The number of deaths from cardiorespiratory

showed that PM2.5 concentration is more diseases for each month of the year was then

effective than O3, NO2, SO2, and PM10 in obtained from Mashhad Emergency Center in increasing the mortality rate. order to find the relationship between Some studies have demonstrated that acute environmental pollutants and the rate of effects of pollutants vary in different seasons mortality from cardiorespiratory diseases. and geographical conditions (Miri, 2016). Descriptive and inferential statistical methods However, another study suggested the need were employed to study the effects of air for further longitudinal studies to prove the pollutants on the rate of mortality from relationship between mortality from cardiorespiratory diseases, and the results cardiovascular diseases and the concentration were extracted using Kendall's Tau rank of pollutants (Kim, 2017). correlation coefficient. Nowadays, various pollutants are released into the air through motor vehicles, industries, and Findings commercial and domestic sources in Tehran In a descriptive-analytical study, the rate of and many industrialized and large cities mortality from cardiorespiratory diseases and around the world, especially in developing the mean daily concentration of air pollutants,

countries (Mo, 1997). including CO, SO2, O3, PM10, and PM2.5, in Although technological development has 2012-2013 were investigated. brought various achievements to human life, The mean values of variables and their technological tools sometimes produce and descriptive indices (mean and standard discharge unwanted and often harmful waste deviation) are shown in Table 1. As shown in into the environment. Given the threat of this table, the mean number of deaths from pollution to human health, it is necessary to respiratory diseases was more than that of increase society‘s knowledge and awareness cardiovascular diseases. In addition, the mean of different aspects of this issue in order to number of deaths among men was relatively prevent or reduce environmental hazards of more than that of women. air pollution. Hence, the present study aims to Based on the results shown in Table 2, there is investigate the relationship between air a positive and significant relationship between

pollutants and mortality from PM10 concentration and the rate of mortality cardiorespiratory diseases in Mashhad. from cardiovascular diseases among men in Mashhad. However, no significant

Methodology relationship was observed between PM10 A descriptive-analytical study was conducted concentration and the rate of mortality from on all people of Mashhad as the statistical cardiovascular diseases among women in this population. The data on mortality from city.

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Table 1. Descriptive indices of research variables significant relationship between CO Standard Variable Mean concentration and the rate of mortality from deviation cardiovascular diseases among men and PM2.5 78.71 15.80

PM10 47.15 14.01 women in Mashhad. CO 3.67 0.58 The results presented in Table 3 show that Male mortality from 39 5.91 there was a positive and significant respiratory diseases Female mortality from relationship between PM10 concentration and 38 3.37 respiratory diseases the rate of mortality from respiratory diseases Male mortality from 16 2.88 among men and women in Mashhad. In fact, cardiovascular diseases the higher the PM concentration, the higher Female mortality from 10 15 2.54 cardiovascular diseases the rate of mortality from respiratory diseases among both men and women. Table 2. The relationship between the The results also demonstrated that there was a concentration of PM10, PM2.5, and CO and the rate positive and significant relationship between of mortality from cardiovascular diseases in men PM concentration and the rate of mortality and women (Kendall's Tau rank correlation 2.5 coefficient) from respiratory diseases among men and Kendall's Samp women in Mashhad. It can be thus concluded Significa Variable Tau rank le nce level that the higher the PM2.5 concentration, the correlation size Male 0.259 0.024 12 higher the rate of mortality from respiratory PM 10 Female 0.050 0.660 12 diseases among both men and women in this Male 0.240 0.037 12 city. PM2.5 Female 0.281 0.013 12 Table 3 shows that there was no significant Male 0.155 0.177 12 CO relationship between CO concentration and Female 0.017 0.883 12 the rate of mortality from respiratory diseases Table 3. The relationship between the among men in Mashhad, whereas a positive concentration of PM10, PM2.5, and CO and the rate and significant relationship was found of mortality from respiratory diseases in men and between CO concentration and the rate of women (Kendall's Tau rank correlation coefficient) mortality from respiratory diseases among Kendall's Significance Sample Variable Tau rank women in this city. In fact, the higher the CO level size correlation concentration, the higher the rate of mortality Male 0.682 0.001 12 PM from respiratory diseases among women. 10 Female 0.860 0.001 12

Male 0.467 0.001 12 PM 2.5 Female 0.414 0.001 12 Discussion and conclusion Male 0.167 0.141 12 CO The study findings showed that there was a Female 0.276 0.017 12 significant relationship between PM10 concentration and the rate of mortality from Table 2 shows that there was a significant and cardiovascular diseases among men, but not positive relationship between PM2.5 women, in Mashhad. In addition, there was a concentration and the rate of mortality from significant relationship between PM10 cardiovascular diseases among both men and concentration and the rate of mortality from women in Mashhad. In other words, it can be respiratory diseases among both men and stated that the higher the PM2.5 concentration, women of Mashhad. The results also indicated the higher the rate of mortality from that there was a significant relationship cardiovascular diseases in men and women. between PM2.5 concentration and the rate of The results also indicated that there was no mortality from cardiorespiratory diseases

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among both men and women of Mashhad. In observed between CO concentration and the this study, no significant relationship was rate of mortality from cardiorespiratory observed between CO concentration and the diseases in this study, which is not consistent rate of mortality from cardiovascular diseases with the findings of Ghorbani et al. (2007). In among men and women. The results also this study, there was a significant relationship

demonstrated that there was a significant between the concentration of PM2.5 and PM10 relationship between CO concentration and and the rate of mortality from the rate of mortality from respiratory diseases cardiorespiratory diseases. However, the

among women, whereas such a significant relationship between PM10 concentration and relationship was not found between CO the rate of mortality from cardiovascular concentration and the rate of mortality from diseases was not statistically significant respiratory diseases among men. among women, which indicates the greater

The study findings suggested that the most risk of PM10 for men. The higher sensitivity of

important air pollutants in Mashhad are PM2.5, women to CO can be considered the reason

PM10, and CO, in the order of significance. It for the greater susceptibility of women‘s was also observed that men are more sensitive respiratory and pulmonary tract to smoke and

than women to PM10 in terms of affliction pollutants. with cardiovascular disease, and women are The study findings concerning the more sensitive than men to CO in respiratory significance of CO is not consistent with the diseases. The results demonstrated that the results of Yang et al. (2004). The present risk of affliction with cardiovascular diseases study suggested that CO have the least effect was higher than that of respiratory diseases at on mortality from cardiorespiratory diseases.

high concentrations of PM2.5 and PM10. These This difference can be attributed to climatic results are consistent with the findings of and racial changes or the sample size. Many Peters et al. (2011) concerning the biological effects indicate that elevated levels relationship between the risk of myocardial of CO lead to cardiac events. First, inhalation

infarction and PM2.5 concentration and of CO particles causes the activation of Joneidy et al. (2006) about the significant cytokines by alveolar macrophages and

correlation between PM2.5 concentration and epithelial cells and the utilization of the rate of mortality from cardiorespiratory inflammatory cells. In addition, increased diseases. The results of this study are also concertation of plasma C-reactive protein in consistent with the findings of Malekafzali exposure to CO has been observed in previous

(2001) about the relationship between PM10 studies. concentration and mortality rate, as well as The results of this study about the those reported by Alidadi (2013) in terms of insignificant relationship between haze the significant relationship between the concentration and the rate of mortality from respiratory diseases are not consistent with the concentration of pollutants and affliction with findings of Delangizan (2011). This difference cardiorespiratory diseases. In this study, there can be attributed to climatic and racial was a significant relationship between PM2.5 changes or the sample size. The differences concentration and mortality from between the results of studies conducted in cardiovascular diseases. This is not consistent different cities and countries can be attributed with the results of Levy et al. (2001) who to the confounding factors such as observed no significant relationship between geographical location, temperature, humidity, air pressure, smoking, job, seasonal changes, PM concentration and cardiac arrest outside 2.5 socioeconomic stresses, duration of exposure the hospital. No significant relationship was

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to the outside environment, and cultural issues especially in chronic diseases, angina pectoris,

such as low frequency of visiting a physician, and COPD.

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