ABSTRACT
Along with the rapid industrialization and motorization, various mobile and stationary emission sources contribute high level of air pollution� The health impacts of ambient air pollution began to being noticed since the year of 1980s in Europe and North America� Numerous epidemiological studies in Western countries have provided strong evidences on the hazardous effects of ambient air pollution on human beings, especially in cardiopulmonary diseases (Anderson et al�, 2012; Brook et al�, 2010; Carlsten and Georas, 2014)� However, the study results from Western countries may not completely reflect the health burden of air pollution in Asian countries because of disparities in air pollution levels and constituents, population structure, disease patterns, lifestyle, and environmental stressors� In the past decades, Asian countries experienced enormous economic development and rapid transitions in urbanization, motorization, and industrialization, which was accompanied by high air pollution levels� In addition to urban air pollution, the long-ranged transboundary air pollution, such as Asian dust storm (ADS) or smoke haze, from Southeast Asia contributes additional health impacts� As a result, some Asian countries, including Japan, South Korea, China, Taiwan, and Hong-Kong (China), became aware of this issue and conducted many studies on the health impacts of air pollution� Since the first Taiwan Environmental Protection Administration’s air quality monitoring (AQM) station was officially operated in 1993, there have been more than 150 studies in evaluation of health effects of air pollution published in peer-reviewed English journals� Of these scientific papers, approximately 80% addressed the cardiorespiratory effects with short-term exposures to air pollution� Others investigated the effects of air pollution on central nervous system, allergic responses, reproductive and developmental diseases, and cancers� This chapter reviews, summarizes, and integrates the evidence of relationships between exposures to air pollution and cardiopulmonary health endpoints from studies in the past 20 years in Taiwan, as in Figure 2�1�
FIGURE 2.1 The framework describing the relationships among source, pollutants, and health effects�
In Taiwan, the case-crossover, time series, and cross-sectional designed cohort studies were conducted in epidemiological studies� Diseases of cardiovascular, central nervous, and respiratory systems are of the most concern� More details, such as their relevant biological mechanisms of toxicity, study design, outcome of measurements, and so on, are described in the following sections�
Large numbers of epidemiological studies in Taiwan have consistently demonstrated the effects of short-term exposures to particulate matter (PM) and gaseous pollutants on a variety of cardiovascular effects, from morbidity or mortality of cardiovascular disease (CVD) to subtle clinical manifestations (e�g�, blood pressure [BP] change)� The possible biological pathways linking PM and CVD also have been well evaluated in serial panel and experimental studies� More detailed descriptions for each study are discussed in the following sections�
2.2.2.1 Cardiovascular Mortality Four epidemiological studies either with case-crossover design or time-series design consistently demonstrated a positive association between PM and CVD (Figure 2�2)� Two case-crossover studies conducted in southern and northern Taiwan consistently reported PM2�5 was associated to increased risk of death from circulatory disease with risk estimates 1�44 (95% confidence interval [CI]: 1�21-1�71) for an interquartile range (IQR) of PM2�5 (39�4 μg/m3) in southern Taiwan and 1�07 (95% CI: 1�01-1�15) for an IQR of PM2�5 (17�2 μg/m3) in northern Taiwan, respectively (Tsai et al�, 2014b, 2014a)� Another two time-series studies also found that cardiovascular mortality was associated with PM10 in central Taiwan, with risk estimates of 1�041 (95% CI: 1�015-1�068) and 1�12 (95% CI: 0�998-1�258) for increments of 46�4 μg/m3 and 40�0 μg/m3of PM10, respectively (Tsai et al�, 2010; Liang et al�, 2009)� The effect estimates of cardiovascular mortality are especially higher in Kaohsiung City, which has the
FIGURE 2.2 Summary of risk estimates of mortality for cardiovascular disease with shortterm exposures to PM2�5 and PM10 in Taiwan� Studies presented in this figure were conducted with either case-crossover or time-series design�
largest heavy and petrochemical industrial complex in Taiwan� The geographical variance may indicate a constituent-specific or concentration-response effects on relationship of PM-related cardiovascular mortality�
In addition to PM, Chan and Ng (2011) demonstrated that the long-range transported (LRT) ADS is also associated with the excess deaths for cardiovascular events (odds ratio: 1�045 [95% CI: 1�001-1�081]) among populations above 65 years old�
2.2.2.2 Hospital Admissions and Emergency Department Visits More than 10 epidemiological studies either with case-crossover design or timeseries design consistently showed an excess risk of hospital admissions or emergency department visits for a variety of cardiovascular events with short-term exposures to PM (Figure 2�3)� Serial case-crossover studies using the National Health Insurance research database demonstrate the short-term exposures to PM10 are associated with increased hospital admissions or emergency room visits for a variety of CVD, including congestive heart failure, cardiac arrhythmia, and acute myocardial infarction (Hsieh et al�, 2010; Tsai et al�, 2009; Chiu and Yang, 2009; Cheng et al�, 2009b; Yang, 2008; Lee et al�, 2007b; Chang et al�, 2005; Yang et al�, 2004)� PM2�5 is also associated with hospital admissions or emergency room visits for congestive heart failure, cardiac arrhythmia, and acute myocardial infarction (Hsieh et al�, 2013; Chiu et al�, 2013; Chang et al�, 2013)� Still, the risk estimates of cardiovascular hospital admissions in response to short-term exposures to PM are significantly higher in Kaohsiung than in other cities� The study results also indicated that seasonality may modify the relationships between PM and CVD morbidity (Chang et al�, 2005, 2013; Chiu et al�, 2013; Hsieh et al�, 2010, 2013; Yang et al�, 2004; Yang, 2008; Cheng et al�, 2009b)�
FIGURE 2.3 Summary of risk estimates of hospital admissions or emergency room visits for cardiovascular disease with short-term exposures to PM2�5 and PM10 in Taiwan� Studies presented in this figure were conducted with either case-crossover or time-series design�
2.2.2.3 Biological Pathway There has been substantial improvement in our understanding of the biological mechanisms involved in PM-mediated cardiovascular effects� The American Heart Association scientific statements in 2010 proposed the plausible biological pathways linking PM inhalation and extrapulmonary effects on the cardiovascular system (Brook et al�, 2010)� These include autonomic nerve system imbalance, systemic inflammation and oxidative stress, and the translocation of PM or particle constituents (organic compounds, metals) into the systemic circulation and breaking the integrity of vasculature� In Taiwan, serial panel studies were also conducted to elucidate the possible biological pathways in relation to PM and CVD�
2.2.2.4 Systemic Inflammation, Oxidative Stress, and Thrombogenicity A panel study recruited 49 patients with coronary heart disease or with two or more cardiovascular risk factors revealed that high air pollution days with PM10 concentration greater than 100 μg/m3 during 8-18 hours could increase plasma levels of plasminogen activator inhibitor-1 (PAI-1) compared with that in low PM10 days (Su et al�, 2006)� Another panel study on 76 healthy and young adults in Taiwan demonstrated that PM10, PM2�5, and PM components of sulfate and nitrate were associated with increases in high-sensitivity C-reactive protein, fibrinogen, and PAI-1 (Chuang et al�, 2007)� The 8-hydroxy-2′-deoxyguanosine, an oxidative stress marker, was also observed in association with PM fraction size and components (Chuang et al�, 2007)�
2.2.2.5 Heart Rate Variability A panel study with nine young subjects in Taipei showed that 1-4-hour moving average number concentrations of submicron particles with a size range of 0�02-1 μm (NC0�02-1) were associated with decreases in both time-and frequency-domain heart rate variability (HRV) indices (Chan et al�, 2004)� This is the first study to examine the effects of personal exposure to ultrafine particles on HRV� Another Taiwanese study also observed a time-domain HRV reduction with exposures to PM with diameters between 0�3 and 1�0 μm (PM0�3-1) in cardiac and hypertensive populations (Chuang et al�, 2005)� Chuang et al� (2007) further found that, in addition to PM2�5, the components of PM2�5, such as sulfate and organic carbon (OC), were associated with HRV reduction in 46 patients with risk for CVD�
2.2.2.6 Blood Pressure One of the important air pollution-mediated alternations on cardiovascular outcomes is the variation in BP� However, the results from both epidemiological and experimental studies are still inconclusive on PM-related changes in BP� In Taiwan, two experimental studies were conducted to evaluate the changes in BP with exposures of concentrated particles (Cheng et al�, 2003; Chang et al�, 2004)� Cheng et al� (2003) found that the hourly mean BP decreased in pulmonary hypertensive rats after the particle exposure� Contrarily, Chang et al� (2004) reported the maximum increase of mean BP up to 8�7 mmHg in spontaneous hypertensive rats at the end of exposure to concentrated PM2�5� Chan et al� (2004) conducted a panel study and found that with 1-3 hours of NC0�02-1 exposure, systolic and diastolic BP significantly increased in 10 patients with lung function impairment� The population-based
study conducted by Chuang et al� (2010) observed slightly elevated systolic BP with exposures to PM10 among 7578 subjects� However, another population-based study with 9238 nonsmoking adults found that both PM10 and gaseous pollutants, including sulfur dioxide (SO2), nitrogen dioxide (NO2), carbon monoxide (CO), and ozone (O3), were all associated with decreases in systolic BP and pulse pressure (Chen et al�, 2012)� This study also found that the estimates of reduction in pulse pressure with exposures to PM10 were stronger among men, persons more than 60 years of age, those with hypertension, and those living in the industrial township (Chen et al�, 2012)� Chen et al� (2014a) further found that 10 μg/m3 increase in PM2�5 was associated with 1�0 mmHg (95% CI: 0�2-1�8 mmHg) narrowing in the pulse pressure, but not systolic and diastolic BP, among nondippers (subjects with nocturnal BP dip of <10% and in high CVD risk)� The inconsistent results may indicate that short-term BP variation in response to PM is a complicated physiological response and is tightly regulated by numerous cardiac and vascular homeostatic mechanisms, which are worth more investigation� Also, individual susceptibility or particulate constituents may modify the BP variation in response to air pollution�
2.2.2.7 Cardiac Contractility Two animal studies observed decreased left ventricular fractional shortening or the maximum rate of left ventricular pressure rise (LV dP/dt max), which indicated cardiac systolic or diastolic dysfunction, with exposure to short-term exposure to diesel exhaust particles (DEPs) in rats (Huang et al�, 2010; Yan et al�, 2008)� Chen et al� (2014a) conducted a panel study with 161 health subjects by 24-hour continuous hemodynamic monitoring and demonstrated that nondippers had a decrease in LV dP/dt max to 3�1% (95% CI: 1�4%–4�8%) for a 10 μg/m3 increase in PM2�5�
2.2.2.8 Vasomotor Function One recent panel study in Taiwan reported that an IQR increase in personal exposures to O3 or PM1�0-2�5 was associated with a 4�8% and 2�5% increase, respectively, in cardio-ankle vascular index, a surrogate marker of vascular tone, among young, healthy mail carriers (Wu et al�, 2010)� The panel study by Chen et al� (2014a) used Dynapulse to continuously monitor hemodynamic parameters and directly demonstrated the systemic vascular resistance (SVR) increased 3�6% (95% CI: 1�6%–5�7%) for a 10 μg/m3 increase in PM2�5 among 79 nondippers�
Cerebrovascular disease (CBVD) is one of the leading causes of mortality, especially for East Asian populations, accounting for 10%–16% of total deaths� The proportions of cerebral hemorrhage, small artery lacunar infarct, and intracranial atherosclerosis are more common in Asian populations than in white populations� Studies in Western countries have not yet provided the sufficient evidence on the relationship between PM and CBVD; however, serial epidemiological studies in
Taiwan have demonstrated there is prominent ethnic difference in air pollutionrelated CBVD between Asian and white populations (Figure 2�4)� Chan et al� (2006) conducted a time-series study and found that PM2�5 was positively associated with increased emergency room visits for CBVD� Chen et al� (2014b) further demonstrated that PM2�5 chemical components, nitrate and elemental carbon, were associated with increased risk of emergency room visits for hemorrhagic stroke, while PM2�5 and its chemical component, OC, were associated with increased risk of emergency visits for ischemic stroke in patients aged 65 years or older and female patients� Two case-crossover studies also confirmed the positive associations between stroke admissions and short-term exposures to PM10 and PM2�5 (Chiu and Yang, 2013; Tsai et al�, 2003a)� The effect of PM on stroke morbidity was found to be stronger in the warm season (Chiu and Yang, 2013; Tsai et al�, 2003a; Chen et al�, 2014a)�
ADS was also demonstrated to associate with stroke admissions� Yang et al� (2005) conducted a case-crossover study and found the risk of intracranial hemorrhagic stroke admissions was increased 3 days after ADS events� Kang et al� (2013) reported that the numbers of ischemic stroke admissions were significantly higher 1-to 2-days after ADS events�
The effects of short-term exposures to PM on respiratory outcomes were most studied and addressed worldwide� In Taiwan, a large number of epidemiological and experimental studies have provided strong evidence on the hazardous effects of short-term PM exposures on the respiratory system, including decrease in lung function and increase in morbidity of pulmonary diseases� However, the current studies in Taiwan have not yet provided sufficient evidence to demonstrate the relationship between respiratory mortality and PM� The findings for the associations of various respiratory outcomes and short-term exposures to PM are described in further detail below�
FIGURE 2.4 Summary of risk estimates of hospital admissions or emergency room visits for ischemic stroke with short-term exposures to PM2�5 and PM10 in Taiwan� Studies presented in this figure were conducted with either case-crossover or time-series design�
2.2.4.1 Respiratory Mortality Three case-crossover studies and one time-series study were conducted to evaluate the associations of respiratory-related mortality and short-term exposures to PM (Tsai et al�, 2003b, 2014a, 2014b; Liang et al�, 2009)� However, the results all failed to find the significantly positive effects of PM10 or PM2�5 on the mortality of respiratory diseases� Another case-crossover study also did not find the excess death for respiratory deaths during ADS (Chan and Ng, 2011)� Only an epidemiological study conducted by Chen et al� (2004) reported that the effects of ADS increased 7�66% in the risk for respiratory deaths 1 day after the ADS event�
2.2.4.2 Respiratory Morbidity A number of cross-sectional studies were conducted at the end of the 20th century to evaluate the associations between air pollution and respiratory symptoms and asthma prevalence among children and adolescents� Using the nationwide questionnaire survey, these study results found positive associations between air pollution and respiratory symptoms (e�g�, cough, chronic cough, shortness of breath, and nasal symptoms) and asthma prevalence among children and adolescents (Chen et al�, 1998, 1999; Guo et al�, 1999; Wang et al�, 1999; Lin et al�, 2001)� Some epidemiological studies also reported an exacerbation of allergic rhinitis following exposures to ambient air pollution (Lee et al�, 2003; Yu et al�, 2005; Hwang et al�, 2006)� Serial case-crossover studies using National Health Insurance research database in Taiwan further demonstrated that PM10 was associated with both of outpatient and inpatient visits of respiratory diseases, including asthma, chronic obstructive pulmonary disease (COPD), and pneumonia (Tsai et al�, 2006; Cheng et al�, 2007, 2009a; Lee et al�, 2007a; Yang et al�, 2007; Yang and Chen, 2007; Chiu et al�, 2009)� Two time-series studies also found the positive associations between PM10 and the outpatient visits for COPD, asthma, and pneumonia (Wang and Chau, 2013; Pan et al�, 2014)� PM2�5 was also demonstrated to associate with hospital admissions for pneumonia, COPD, and asthma (Tang et al�, 2007; Tsai et al�, 2013; Tsai and Yang, 2014)� In addition to PM, four epidemiological studies found that the respiratory clinic visits and hospital admissions for COPD and pneumonia were significantly higher during and after high dust events (Chiu et al�, 2008; Chan et al�, 2008; Kang et al�, 2013; Yu et al�, 2013)�
2.2.4.3 Pulmonary Function The associations between pulmonary function and exposures to urban air pollution have been widely surveyed among different study populations� One cross-sectional study observed the inversely associations between PM10 and forced vital capacity (FVC) among adolescents (Chang et al�, 2012)� Others found that gaseous pollutants, including O3, and nitrogen oxides (NOx) are demonstrated to associate with the reduction of a variety of pulmonary function parameters, including FVC, forced expiratory volume in one second (FEV1), and peak expiratory flow rate (PEFR) among school-aged children (Chen et al�, 1999; Lee et al�, 2011; Chang et al�, 2012)� One panel study conducted by Chan and Wu (2005) demonstrated that the night PEFR for 43 mail carriers was maximally decreased by 0�69% for 10-ppb increase in the 8-hour average O3 concentration at a 1-day lag�
In Taiwan, the air pollutants data are obtained from two approaches� One is from an active queue management (AQM) network by using automatic instruments maintained by Taiwan Environment Protection Administration (TEPA), and the other one is from academy researches by using manual sampling methods� Hourly based data can be obtained and showed geographically from the website (https://taqm�epa�gov� tw/taqm/tw/default�aspx)� The principles for installing the AQM stations should take into account many reasons such as station types, source distributions and categories, pollutants distributions, geographical and meteorological conditions, population distributions and traffic status, and urban, regional, and other land-use plans� Now, 79 AQM stations are online, including 60, 5, 6, 2, 4, and 2 for general, industrial, traffic, national park, background, and other purposes, respectively� In addition, nine fixed stations and two mobile trucks are installed for photochemical purposes�
In the general AQM station, beta-gauge method is always used for monitoring PM10 and PM2�5; however, ultraviolet (UV) fluorescence and chemiluminescence methods are used for monitoring the SOx and NOx levels� UV absorption method and nondispersive infrared spectroscopy (NDIR) are used to analyze the O3 and CO, respectively� These regular ambient AQM instruments installed by TEPA, including VEREWA-F701, Met-One BAM-1020, Ecotech 9850, Ecotech 9841, Ecotech 9810, and Horiba for automatically monitoring the PM10, PM2�5, SOx, NOx, O3, and CO, respectively� Recently, R&P 1400 was added for monitoring the 24-hour PM2�5 level each three days by using manually weighting method� In photochemical AQM stations, however, 54 major precursors of ozone production can be obtained by using gas chromatography with flame ionization detector (GC-FID)�
For manual sampling methods, high-volume and dichotomous samplers were selected in early researches� The former one were measuring total suspended particles (TSP) or PM10 with over 1 cubic meters air sampling per minute; however, the latter one was always used to measure finer two size fractions such as PM2�5 and PM2�5-10 with 16�7 liters per minute� In fact, the particle-size distributions from any microenvironment or any season are also concerned� The particle-size distribution generally uses 8-stages cascade or 10-stages micro-orifice uniform deposition impactor (MOUDI)� The personal environmental monitor (PEM) and Harvard impactor (HI), however, are currently selected to measure the personal PM2�5 or PM10 exposures� The above manual sampling methods are based on the impact mechanism of particles in the collected filter� Specially, the dichotomous has a virtual impactor to split two streams on the filters and collect two size fractions of particles (Chio et al�, 2004, 2014b; Lee et al�, 2010)�
Figure 2�5 shows the averaged air pollutants levels of PM10, PM2�5, SO2, NO2, O3, and CO monitored from the AQM stations during 1999-2013� Annual PM10 levels ranged from 51�2 μg/m3 (in 2012) to 63�2 μg/m3 (in 2005); however, annual PM2�5 levels
ranged from 27�7 μg/m3 (in 2012) to 46�9 μg/m3 (in 2004)� They showed the trend since 2005� At the same time, the annual SO2 levels ranged from 3�4 ppb (in 2012) to 5�5 ppb (in 2005) and had same decay trends like PM� Annual NO2 levels showed a decreasing trend since 1999 with peak levels of 23 ppb (in 1999) and minimum value of 15�2 ppb (in 2013)� Basically, the annual CO levels were also shown a decay trend since 2004� The annual O3 levels showed an inverse trend compared with other pollutants, the values ranged from 24 ppb (in 1999) to 30�7 ppb (in 2009)� General speaking, most air pollutants levels are decreasing each year, except for O3�
Recently, Cheng et al (2001), Pan et al� (2008), Hu et al� (2011), and Yuan et al� (2014) showed the biomarkers measured such as metals, 1-hydroxypyrene (1-OHP), thiodiglycolic acid (TdGA), and so on in urine or blood� Blood and urinary metals can be monitored for long-and short-term exposures of metals from ingestion, inhalation, and dermal contact pathways to such pollutants emitted from industrial and nonindustrial sources by using inductively coupled plasma mass spectrometry (ICP-MS)� For example, vanadium in urine can be considered as a good biomarker emitted from oil burning/refinery industrial source� Urinary 1-OHP is a suggested biomarker for polycyclic aromatic hydrocarbons (PAHs) metabolite by using high-performance liquid chromatography with postcolumn fluorescence derivatization (HPLC/FLD)� The urinary TdGA is the major metabolite and a suggested biomarker of vinyl chloride monomer (VCM) emissions� In addition, Lee et al� (2010) showed that urinary 8-hydroxydeoxyquanosine (8-OHdG) level is a biomarker of cellular oxidative stress for exposure to ambient PM2�5 or occupational DEP�
FIGURE 2.5 Major monitoring pollutants in Taiwan during 1999-2013�
In Taiwan, many sources are concerned because of their large emissions� The following sections describe these sources and their emitted pollutants, including PM, O3, SO2, NOx, CO, CO2, volatile organic compounds (VOCs), heavy metals, and so on�
2.4.1.1 Coal-Fired Power Plant In central Taiwan, the Taichung Power Plant (TCP) is considered as the world’s largest coal-fired power plant, with a full designed capacity of 5780 MW (Taiwan Power Company [TPC], 2011; Kuo et al�, 2014)� The Carbon Monitoring for Action (CARMA, 2014) reported that the TCP was the largest CO2 contributor in the world, with about 36 × 106 ton per year in 2014� This amount of CO2 is equivalent 0�1% and 13% emissions in the world and Taiwan� Even when electrostatic precipitators (ESP), flue gas desulfurization (FGD), and selective catalyst reduction (SCR) control devices were installed, over 14,000 and 25,000 ton per year of SO2 and NOx still emitted from TCP in 2007 (CTCI, 2009)�
2.4.1.2 No. 6 Naphtha Cracking Complex The No� 6 Naphtha Cracking Complex, located on the west coast of central Taiwan (Mailiao Township, Yunlin County), has an overall developed area of 2603 ha� This complex contains 64 plants and 381 stacks, including oil refineries, naphtha cracking plants, cogeneration plants, coal-fired power plants, heavy machinery plants, boiler plants, and downstream petrochemical-related plants (FPCC, 2012; Shie et al�, 2013; Shie and Chan, 2013)� Six categories of the SOx emission sources are listed, including cogeneration plants (2549 ton/yr, 41�0% of overall complex), coal-fired power plant (1803 ton/yr, 29�0%), oil refineries (654 ton/yr, 10�5%), aromatics and plastics plants (493 ton/yr, 7�9%), naphtha cracking plants (403 ton/yr, 6�5%), and downstream petrochemical plants (314 ton/yr, 5�1%) in 2009 (Shie et al�, 2013)� Not only petrochemical manufacturing processes but also power generation facilities in the complex contribute to the major SOx emissions� In 2010, a report shows the annual air pollutants emitted by the complex were 3,340 tons, 16,000 tons, 19,622 tons, 4,302 tons for PM, SO2, NOx, and VOCs, respectively (Formosa Plastic Group, 2010; Chen et al�, 2014d)�
2.4.1.3 Asian Dust Storm Taiwan is located at the center of the western Asia Pacific Rim by geographic point of view� Yet the climate change of Taiwan is strongly correlated with the monsoon from Eastern Asia areas, such as Mainland China, Mongolia, and Siberia, especially for spring season every year� Based on the mesoscale meteorology, the LRT aerosols (or ADS) have been evidenced to exacerbate the air quality and impact the human health in Taiwan� The possible pollutants include PM, viruses, and fungi (Cheng et al� 2005; Lee et al� 2006; Chao et al� 2012)� On the other hand, many adverse outcomes and mortality are also found to be associated with these ADS events (Lei et al� 2004; Chan et al� 2008)�
Recently, several approaches are developed to study these impacts of air quality and human health� Except for monitoring methods, various mechanistic and statistical model approaches are also reviewed here� Both qualitative and quantitative analyses can obtain a better solution for evaluating the impacts from the LRT aerosols�
During ADS periods, about 3%–12% and 25%–150% impact of PM10 mass concentrations for annually and maximum monthly, respectively, are determined by analyzing the AQM station� Precisely, the concentrations of coarse particles (PM2�5-10) and their crustal elements are significantly elevated (Liu and Shiu 2001)� In the epidemiological approach, results show that the cardiovascular death for residents of age greater than 65 may rise 4�5% (95% CI: 1�1%–8�1%) with analyzing multiyears datasets during the ADS periods (Chan and Ng 2011)�
According to the aforementioned reviews, the air quality and human health in Taiwan had evidenced to be impacted by the LRT aerosols from Mainland China, Mongolia, and Siberia� Obviously, the major reason of ADS event came from the monsoon in spring every year, and then the coarse particles (PM2�5-10) might have twofold increased� Reviews also showed that the susceptible elder groups might have death risk with CVDs� Therefore, the appropriate protections for the susceptible groups should be proposed as soon as possible�
Several modeling approaches were applied for evaluating the human exposure or source apportionment problems� The air quality model support center website (https:// aqmc�epa�gov�tw) is installed and maintained in accord with TEPA funding support� The website collected several used and available models to lead researchers to estimate the air quality or personal exposure� Some models were released from US Environmental Protection Agency (USEPA), yet some models were developed or improved by Taiwan researchers� Industrial source complex short-term dispersion model version 3 (ISCST3) is widely used for estimating the grid-based exposures (Chio et al� 2014b)� AERMOD model developed by American Meteorological Society (AMS) and EPA Regulatory model Improvement Committee (AERMIC) is also a dispersion-based model with more improvements compared with the ISCST3 model� Gaussian trajectory transfer-coefficient modeling systems (GTx) can be used to model the pollutant levels and associated trajectories with forward and backward approaches (Tsuang 2003)� The model results can also be applied to quantify the risks of mortality (Kuo et al� 2014)� Trajectory photochemical air quality mode (TPAQM) can model ozone production with VOCs and NOx precursors� Taiwan air quality model (TAQM) is based on USEPA’s regional acid deposition model (RADM)�
On the other hand, many receptor-based models were applied for PM source apportionment� The approaches include Bayesian model, chemical mass balance (CMB), principal component analysis (PCA), positive matrix factorization (PMF), and others (Chan et al� 1996; Chio et al 2004; Liao et al 2013)� Furthermore, Chio et al� (2007, 2014a) integrated the PM source contributions into risk assessment issues� Lee et al� (2014) applied the land-use regression (LUR) models to estimate personal SOx and SOx exposures in Taipei� In the near future, several cohorts can be established and combined with LUR models to construct the precise exposure-effect relationships�
The epidemiological, panel, and experimental studies in Taiwan have provided the sufficient evidence that short-term exposures to air pollution, especially PM, are associated with a variety of adverse cardiopulmonary effects� Several studies also demonstrate that not only particulate mass concentration but also chemical constituents contribute to PM-related cardiovascular effects� Individual susceptibility and meteorological factors can modify the effects of air pollution on cardiovascular systems�
Nevertheless, several priority research issues should be addressed in future studies� One important issue is the health effect of long-term air pollution exposures� Only one study with secondary data analysis demonstrated that increased 1-yearaveraged PM10, PM2�5, O3, and NO2 were associated with elevated systolic and diastolic BP (Chuang et al�, 2011)� However, using nearby AQM station to estimate personal long-term air pollution exposures probably resulted in measurement error� The research team from National Taiwan University participated in the European Study of Cohorts for Air Pollution Effects (ESCAPE) project-the most up-to-date, largest multicenter study in the European union-and developed the LUR model to estimate residential long-term exposures to PM and NOx (Lee et al�, 2014)� Some important findings in long-term exposures to air pollution on cardiovascular system have been obtained� Using LUR to estimate individual 1-year exposures of PM and NOx, the results of a population-based study demonstrate that 1-year exposures to fine and coarse particles and NOx are associated with higher diastolic BP� And such associations are stronger among susceptible subjects who are hypertensive, diabetic, or obese (Chen et al�, 2014c)� Another panel study shows that 1-year exposures to PM2�5 absorbance are associated with increase in carotid intima-media thickness, which is an indicator of atherosclerosis (Su et al�, 2014)�
To date, a large body of evidence is suggestive of a causal relationship between air pollution and a variety of health outcomes; however, other emerging environmental stressors, such as noise, green spaces, and heat islands, were rarely surveyed� Also, individual or neighborhood socioeconomic status and lifestyle are not investigated with sufficient rigor� Such comprehensive assessments require large longitudinal studies and interdisciplinary expertise to harmonize and analyze data spanning from birth to old age�
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