Journal of Choice

7/27/2019 Journal of Choice

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Public Health (2008) 122, 809820

Original Research

Cardiorespiratory health effects associated with

sulphurous volcanic air pollution

B.M. Longoa,b,, A. Rossignola, J.B. Greena,c

aDepartment of Public Health, Oregon State University, 254 Waldo Hall, Corvallis, OR 97331, USAbUniversity of Nevada-Reno, Orvis School of Nursing, MS 134, Reno, NV 89557, USAcKau Hospital, Pahala, HI 96777, USA

Received 14 March 2006; received in revised form 26 July 2007; accepted 28 September 2007Available online 21 February 2008

KEYWORDSAir pollution;Sulphur dioxide;Chronic obstructivepulmonary disease;Cardiovasculardiseases;Blood pressure;

Volcano

Summary Objective: To investigate cardiorespiratory health effects associatedwith chronic exposure to volcanogenic sulphur dioxide (SO2) and fine sulphateparticle (p0.3mm) air pollution emitted from Kilauea Volcano, Hawaii.Study design: Environmentalepidemiological cross-sectional study.Methods: An air study was conducted to measure exposure levels in the downwindarea, and to confirm non-exposure in a reference area. Cross-sectional health datawere collected from 335 adults, X20 years of age, who had resided for X7 years inthe study areas. Prevalence was estimated for cardiorespiratory signs, and self-

reported symptoms and diseases. Logistic regression analysis estimated effectmeasures between exposed and unexposed groups considering potential confoundingincluding age, gender, race, smoking, dust and body mass index (BMI). Studentst-tests compared mean differences in blood pressure (BP), pulse and respiratory rates.Results: There were statistically significant positive associations between chronicexposure and increased prevalence of cough, phlegm, rhinorrhoea, sore/dry throat,sinus congestion, wheezing, eye irritation and bronchitis. The magnitude of theassociations differed according to SO2 and fine sulphate particulate exposure. Groupanalyses found no differences in pulse rate or BP; however, significantly faster meanpulse rates were detected in exposed non-medicated, non-smoking participants withBMIo25, and in participants aged X65 years. Higher mean systolic BP was found inexposed participants with BMI o25.Conclusions: Long-term residency in active degassing volcanic areas may have an

adverse effect on cardiorespiratory health in adults. Further study at Kilauea isrecommended, and the authors encourage investigations in communities near active

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0033-3506/$ - see front matter & 2007 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved.doi:10.1016/j.puhe.2007.09.017

Corresponding author. University of Nevada-Reno, Orvis School of Nursing, MS 134, Reno, NV 89557, USA. Tel.: +1 775 682 7149;fax: +17757844262.

E-mail address: [email protected] (B.M. Longo).
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volcanoes worldwide. Public health interventions of community education, andsmoking prevention and cessation are suggested.& 2007 The Royal Institute of Public Health. Published by Elsevier Ltd. All rightsreserved.

Introduction

Eruption at Kilauea Volcano has persisted since 1983on the Island of Hawaii, United States. The volcanicemissions are primarily composed of water vapour,sulphur dioxide (SO2) gas (averaging 1600 metricton/day),1 and fine sulphates, principally sulphuricacid aerosol (mean diameter p0.3mm).2 Unlikeexplosive volcanic eruptions that send particulatesand gases into the stratosphere, Kilaueas effusiveeruption emits gases and aerosols into the lowertroposphere where humans reside; thus, long-stand-ing effusive eruptions may create an environment

detrimental to health. The purpose of this investiga-tion was to evaluate the health status of adultschronically exposed to Kilaueas air pollution.

Human health effects from sulphurous air pollu-tants can occur. SO2 is an irritant that affectschanges in the mechanical functioning of theupper airways, resulting in bronchoconstriction orincreased pulmonary resistance.3,4 In healthy, non-asthmatic adults, doseresponse relationships existat various thresholds for different exposure dura-tions and activity levels.35 Several populationsubgroups are sensitive to SO2 at lower concentra-

tions: asthmatics; children and adolescents;respiratory- and cardiac-compromised individuals;and healthy but SO2-sensitive individuals.

47 Somepaediatric asthmatics can show effects at evenlower levels of SO2 than identified previously.

8,9

Public health concentrations for SO2 that considerthese sensitive population subgroups are the WorldHealth Organizations (WHO) guideline10 and theminimal risk level (MRL).11

Fine sulphates are ocular and respiratory irritantsthat can have a negative effect on both sensitiveand general populations by inducing respiratorytract irritation and altering lung defences, includ-ing airway reactivity, alveolar particle clearanceand mucociliary transport.4,12 No threshold hasbeen identified10 but current evidence suggeststhat secondary sulphates sized p2.5mm, at ambi-ent levels from 4 to 7 mg/m3, have little adverseimpact on public health.13

An estimated 500 million people live near theworlds 600 active volcanoes.14 These volcanoesdegass pollutants continuously during eruption andin states of quiescence between eruptions.15

Health may be affected adversely from continual

emissions of SO2, carbon dioxide, radon and/orhydrogen sulphide.14,1618 At Kilauea, studies havefocused on acute health effects associated with theeruption, identifying increased hospital visits forrespiratory conditions1921 and respiratory effectsin known paediatric asthmatics.22 A recent study,however, found the highest prevalence of paedia-tric asthma in Hawaiian communities with thelowest exposure to volcanic pollution, suggestingother causal factors.23

Methods

Design

Kilaueas ongoing eruption provided a naturallaboratory for investigating chronic, adverse healtheffects from sulphurous air pollution in a non-mixedair polluted environment. An environmentalepi-demiological, cross-sectional design was used tomeasure the prevalence of cardiorespiratory signs,self-reported symptoms and diagnosed diseases inexposed groups and an unexposed reference group.

Groups were identified based on exposure statuswithout prior knowledge of disease status.

Summary of previous exposure assessment

To assess exposure concentrations, environmentalsampling was conducted on a regional scale in 2003for SO2 and fine aerosol (p0.3mm) pollution inexposed Kau district, and in Hawi, an unexposedreference area on the north side of the island.24

Sampling conditions were representative of typicalregional meteorology (e.g. trade winds and after-noon upslope showers).25 Volcanic emissions werecontinual and consistent with recent data.24 Ambi-ent and indoor SO2 concentrations were measuredover 3 weeks using a network of 70 SO2-specificpassive diffusion tubes that provided a time-averaged concentration but could not resolvetemporal variation in exposures. Concurrently, 58grab samples were collected using a quartz crystalmicrobalance cascade impactor that determinedmass concentrations of fine aerosol particles sized0.8, 0.3 and 0.1mm. Using these measurements toestimate chronic exposure levels seems justified

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because of over two decades of eruption and therepresentative exposure conditions that prevailedduring sampling.

Study locations

Based on environmental data, epidemiological sites

from exposed Kau district (Fig. 1) and unexposedHawi were selected (averages: SO2 0.7 ppbv,particles p0.3mm 0.31 mg/m3).24 The SO2-exposed group was from Naalehu town, located68 km downwind from the eruption. Naalehuaveraged 24.5 [standard deviation (SD) 4.3] ppbvof SO2 (range 19.532.5 ppbv) and was low in fineparticles (p1 mg/m3).24 The SO2 concentration wasabove the WHO 24-h average guideline of 20 mg/m3

(7.5ppbv)10 and the acute 14-day MRL of10 ppbv.11 The sulphate-exposed group was fromthe Ocean View subdivision, located 85 km down-

wind of the eruption. Ocean View averaged 4.1 (SD2.8) mg/m3 of fine particles (p0.3mm) duringtypical trade winds, 9.6 (SD 1.9)mg/m3 duringvariable light winds and SO2 o10 ppbv.

24

The exposed and unexposed sites are rural, andhave accessible healthcare facilities that servelow-income clients. These sites are comparable inmeteorology (e.g. rainfall), vegetation, grazinglands and crops. No site has substantial anthropo-genic air pollution. Residents of Naalehu and Hawishare similar histories and ethnicity, both formerlysugar plantations that brought immigration from

the Philippines, Japan and the US mainland. Incomparison, Ocean View is a large, isolatedsubdivision with fewer long-term residents. Datafrom the 1999 US Census26 showed a higher medianfamily income for Hawi than for towns in Kaudistrict.

Data collection

To obtain a geographically representative sample,participants were selected systematically by everythird household on all streets in exposed Naalehuand unexposed Hawi. In exposed Ocean View,systematic selection of every third mile-squaredblock in the subdivision, followed by randomselection of two households per block, wasemployed. Sampling in all study areas wasrestricted to no more than two participants perhousehold to avoid over-representation of any one

household.The eligible participants were adults aged 20

years or older with a minimum residency of 7 years,thereby allowing assessment of chronic exposure.The participation rate among eligible residents was92% in Naalehu, 98% in Ocean View and 96% inHawi. The study protocol was approved by theInstitutional Review Board of Oregon State Uni-versity. Written informed consent was obtainedprior to data collection.

Data were collected in participants homesbetween April and June 2004 using an interview

and assessment conducted in English or Tagalog(the language of the Filipino immigrants) by anexperienced registered nurse investigator. Theassessment interview comprised standardized,yes/no questions on cardiorespiratory symptomsand lifestyle factors taken from the validated19992000 National Health and Nutrition Examina-tion Survey27 and the American Thoracic SocietysRespiratory Symptom Questionnaire.28 A historyof diseases diagnosed by a doctor, medicationuse, style of home and demographic informationwas obtained. Participants were not askedtheir income because of cultural norms; instead,education level, employment status, insurancecoverage and access to medical care were reliedon to indicate socio-economic status. To assessvolcanic-associated health effects specifically, par-ticipants were asked questions about diseasediagnosis while in residency since Kilaueas erup-tion began in 1983, instead of over their entirelifetimes. Air quality data were not released untilafter completion of the study to prevent anypositive or negative influence on participantsresponses.

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Figure 1 Concentration contour map of volcanogenicair pollution in Kau district, Island of Hawaii, USA, 2003(modified with permission).24 The sulphur-dioxide-exposed group was from Naalehu, and the sulphate-aerosol-exposed group was from Ocean View. Base mapprovided by State of Hawaii GIS Program I-Map.

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Vital sign data of resting blood pressure (BP),radial pulse rate and respiratory rate were taken onall participants after 1520min rest in a sittingposition, between 9 am and 3 pm. BP was measuredwith calibrated aneroid sphygmomanometers,placed at heart level, with proper cuff to arm size,using the slow-deflation auscultory method (US

National Institute of Health).

29

For systolic pres-sures X160 mmHg, two measurements were takenapproximately 5 min apart. Radial pulse rates weretaken for 30s with regular rhythm and 1min forirregular rhythms. Respiratory rate was assessedover 1 min. The sampling and interview method andmaterials were the same for each group, regardlessof exposure status, to prevent interviewer bias andto minimize misclassification bias.

Statistical analyses

Prevalence and odds ratios (ORs) were estimatedfor dichotomous variables of cardiorespiratorysymptoms and diseases. The 95% confidence inter-val (CI) of the OR point estimate was used forsignificance testing. Initially, stratified analyseswere conducted to evaluate confounding and testfor effect modification (EM). The MantelHaenszelestimator was used to control confounding for auniform OR, whereas Chi-square test for hetero-geneity was used to test for EM. The MantelHaenszel extension test was used for analysis oftrend. Logistic regression analyses were used to

adjust an OR for a priori-selected potentialconfounders, including those identified by stratifiedanalyses. Final adjusted ORs and 95% CIs werecalculated after controlling for categorical vari-ables and prespecified groups of gender, smoking(never, former, current), occupational dust expo-sure, race (Hawaiian, Filipino, Japanese, White andother), age (years) and body mass index (BMI). Forthe SO2 group, adjustments were also made forhome style because plantation homes can pene-trate up to 71% of ambient SO2 compared withp23% for modern homes.24 As the symptoms ofcough, dry cough and sinus congestion are knownside-effects from certain medications30 (i.e. anti-hypertensives), the analysis for each symptom wasrestricted to participants not taking medicationswith these effects.

Students t-tests with non-directional hypotheseswere performed on vital sign measures betweenthe unexposed and exposed groups. Previousstudies on health and air pollution have identifiedeffects in subgroups of age (elderly X65 years)31

and gender (female participants),32 and haverecommended using non-smoking subjects of nor-

mal weight without known cardiovascular diseasefor evaluating cardiopulmonary effects.33 There-fore, the potential physiological effects on vitalsigns from differences in gender, race, age, smok-ing (i.e. hypoxaemia and stimulant effects), beingoverweight or obese (BMI X25), and use ofhypertensive and cardiac medications for existing

disease were considered in planning the dataanalyses. All analyses employed a 5% probabilityof a Type I error (a 0.05). Data were analysedwith PEPI Version 4.034 and SPSS Version 8.0.

Results

Characteristics of the participants

Table 1 describes characteristics of the 335participants. All groups had nearly equal distribu-tions for gender, occupational dust exposure and

medication usage, and no statistical difference incurrent smoking prevalence. The unexposed groupwas younger and had a higher mean BMI than theexposed groups. Distributions of birth place,residency and education were similar between theSO2-exposed and the unexposed group. The sul-phate-exposed group was primarily White, moreeducated, had a lower percentage of neversmokers, and viewed themselves as being in betterhealth. The exposed groups had seasonal unem-ployment with temporary loss of health insurance.

SO2 exposure

SO2 exposure was associated with substantiallyincreased odds of self-reported respiratory symp-toms (Table 2). The OR for cough was four timeshigher in the SO2-exposed group compared with theunexposed group, and showed a negative trend ofdecreasing cough with increasing age (OR 5.50for 2029 years, 5.19 for 4059 years and 3.38 for60+ years; P2o0.001). SO2-exposed participantswere 5.5 times more likely to report a nocturnal drycough lasting 414 days, not associated with a coldor respiratory illness. Phlegm showed a positivetrend of increasing odds with increase in smoking(OR 2.2 for never smokers, 3.81 for formersmokers and 5.5 for current smokers; P2 0.001)The ORs for reported rhinorrhoea, sore/dry throatand eye irritation were 5.45, 13.45 and 6.08,respectively. The prevalence of reported adultasthma was 21.7% (Table 3), which was notsignificantly different from the unexposed group.Wheeze on most days/nights was reported twice asoften in the SO2-exposed group (Table 2), with apositive trend of increasing wheeze with increasing

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Table 1 Participant characteristics by exposure status.

Hawi Naalehu Ocean View(unexposed group) (sulphur-dioxide-exposed

group)(sulphate-exposed group)

Number of participants 110 115 110

Age in years: mean (SD) 52.1 (17.4) 56.4 (18.9) 57.9 (12.9)Gender (%)

Female 58 60 56Male 42 40 44

Ethnicity (%)Hawaiian 27 26 16Filipino 24 41 5White 17 6 73Japanese 16 20 2Others 16 7 5

Number of Tagalog interviews 5 5 0

Body mass index: mean (SD) 27.7 (5.2) 26.9 (6.6) 26.4 (6.8)

Body mass index X25(%) 74 55 50

Born in Hawaii (%) 77 69 23

Residence in years: mean (SD) 36.1 (22.3) 37.4 (18.9) 14.4 (6.2)

Home: plantation style (%) 39 64 0

Home: age in years (mean) 42 52 17

Education in years (median) 12 12 14

Employment (%)Working 60 44 45Unemployed 8 23 16Retired 29 32 32Disabled 3 2 8

Smoking status (%)Never 44 45 29Former 33 37 44Current 23 18 27

Occupational exposure (%)Sugarcane 13 20 1Dust 46 52 42

Health insurance (%) 95 86 77

Medication usage (%)Respiratory 15 14 19

Antihypertensives 27 34 30

Subjective view of health (%)Excellent 11 6 26Very good 42 34 36Average 45 53 31Worse than average 3 5 6Very poor 0 2 1

SD, standard deviation.All participants were aged 20 years or older with a minimum of 7 years residency in the study areas on Big Island, Hawaii.



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Table 3 Prevalence of cardiorespiratory diseases in adults chronically exposed to volcanogenic sulphur dioxide gas and fin

Reported diseases diagnosed by adoctor

Unexposedgroup P%

Sulphur-dioxide-exposed group Sulphate-expo

P% Crude OR (95%CI) AOR a (95%CI) P% Cr

Respiratory diseasesAsthma 16.4 21.7 1.42 (0.732.78) 1.06 (0.492.27) 16.4 1.0Bronchitis 24.5 25.2 1.02 (0.561.88) 1.13 (0.582.19) 45.0 2.4Chronic bronchitis 4.5 9.6 2.22 (0.756.62) 2.25 (0.677.61) 11.8 2.8COPD 2.7 3.5 1.29 (0.285.88) 0.98 (0.147.18) 5.5 2.0Emphysema 2.7 2.6 0.96 (0.194.88) 0.80 (0.125.91) 1.8 0.6Hayfever (non-food allergies) 23.6 27.8 1.25 (0.682.27) 1.25 (0.652.40) 27.3 1.2Chronic hayfever 9.0 19.1 2.37 (1.105.26) 2.24 (0.945.31) 17.3 2.0Pneumonia 19.1 11.3 0.54 (0.261.14) 0.55 (0.251.20) 19.1 1.0Chronic sinusitis 12.7 12.3 0.96 (0.442.12) 0.99 (0.422.37) 19.1 1.6

Cardiovascular diseases

Angina 3.6 7.8 2.25 (0.67

7.53) 2.03 (0.56

7.41) 8.2 2.3Congestive heart failure 2.7 3.5 1.29 (0.285.88) 2.15 (0.3214.40) 6.4 2.4Coronary artery disease 7.3 7.0 0.95 (0.352.64) 0.72 (0.242.18) 9.1 1.2Hypertension 32.7 46.1 1.76 (1.023.02) 1.84 (0.943.58) 37.3 1.2Myocardial infarction 2.7 5.3 1.98 (0.488.13) 1.84 (0.428.08) 7.3 2.8

Field-measured vital signsPulse rate X90 beats/minc 16.2 16.0 1.00 (0.482.08) 0.92 (0.412.10) 21.3 1.4Respirations X20 breaths/min 19.1 17.4 0.90 (0.451.78) 0.92 (0.431.95) 28.2 1.6High blood pressure (mmHg)

X140 systolic or X90 diastolic 39.1 53.6 1.80 (1.063.08) 2.45 (1.284.67)** 51.8 1.6Restricted to non-medicatedd 20.9 29.1 2.00 (0.994.03) 2.94 (1.147.63) 28.2 1.7

P, prevalence; CI, confidence interval; COPD, chronic obstructive pulmonary disease; mmHg, millimetres of mercury.aAOR, adjusted odds ratio for age, gender, race, smoking status, body mass index, occupational dust exposure and home style.bAOR, adjusted odds ratio for age, gender, race, smoking status, body mass index and occupational dust exposure.cRegular rhythm pulse rates.dNon-medicated, participants not taking medication affecting blood pressure.Statistically significant at Po0.05, **Po0.01, ***Po0.001.


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age (OR 1.35 for 2039 years, 3.68 for 4059years and 4.47 for 60+ years; P2 0.04).

Cardiovascular diseases were not associated withSO2 exposure (Table 3); however, there weresignificant cardiovascular signs. SO2 exposure wasassociated with higher odds of having field-measured high BP (Table 3). Significantly elevated

mean systolic BP was observed in SO2-exposedFilipino participants (Table 4), with the highestmean difference in systolic BP (+16.7 mmHg) foundamong female Filipinos. Mean systolic BPs weresignificantly elevated (+14.4mmHg) for SO2-exposed participants with a BMI o25.

SO2-exposed elderly participants (X65 years)and elderly non-smokers not taking pulse-affectingmedications had resting mean pulse rates that weresignificantly faster than those of their unexposedcounterparts by 7.6 and 9.9 beats/min, respec-tively (Table 4). The pulse rate in the SO2-exposedgroup was, on average, 7.7 beats/min faster after

controlling for BMI X25, smoking and medications.The mean pulse rate in SO2-exposed, non-smoking,non-medicated females was 6.0 beats/min fasterthan that for their unexposed counterparts.

Sulphate aerosol exposure

Sulphate exposure was associated with increasedodds of self-reported respiratory symptoms(Table 2), and relatively higher odds than withSO2 exposure. The OR for cough was 6.5 times

higher in the sulphate-exposed group comparedwith the unexposed group. A positive trend wasidentified of increasing odds of phlegm withincrease in smoking (OR 1.2 for never smokers,3.86 for former smokers and 5.61 for currentsmokers; P2 0.002). Cough combined withphlegm was over seven times more likely to bereported with sulphate exposure. The odds ofreported sinus/nasal congestion was 5.2 timeshigher in the sulphate-exposed group; this wasnot significant for the SO2-exposed group. Frequentrhinorrhoea, sore/dry throat, eye irritation, andoutdoor rhinorrhoea and congestion had substan-tially elevated odds associated with sulphateexposure (Table 2).

The prevalence of reported asthma was equal inthe exposed and unexposed groups (Table 3).Within the sulphate-exposed asthmatics, 22% hada known hereditary component, half that of theunexposed group, along with 61% reporting adult-onset asthma. Wheezing symptoms were 1.85.7times more likely with sulphate exposure than non-exposure (Table 2). The elderly were most affectedby wheeze on most days/nights (trend P2 0.03;

OR 1.63 for 2039 years, 2.44 for 4059 years,5.86 for 60+ years). The OR for bronchitis wasalmost doubled in the sulphate-exposed groupcompared with the exposed group (Table 3).

Cardiovascular diseases were not associated withchronic sulphate exposure (Table 3). Significantcardiovascular signs were similar to those seen with

SO2 exposure. The odds of having field-measuredhigh BP was doubled in sulphate-exposed indivi-duals. A significantly higher mean systolic BP(+8.1 mmHg) was observed for participants with aBMIo25 (Table 4). Resting mean pulse rates amongelderly sulphate participants (X65 years) weresignificantly faster (average +8.5 beats/min) com-pared with their unexposed counterparts, evenwhen restricted to non-smokers not taking pulse-affecting medications (+11.5 beats/min). A fasterresting mean pulse rate (+8.3 beats/min) wasmeasured in the sulphate-exposed group whencontrolling for BMIX25, smoking and medications.

Discussion

This study revealed significant associationsbetween exposure to long-standing volcanogenicsulphurous air pollution and cardiorespiratoryhealth effects. The relevance of the study, itslimitations, major findings and the implications forclinical practice are discussed below.

Relevance of the study

Exposure to SO2 is associated with increased morbid-ity and mortality worldwide.10,35,36 WHO7 hasrequested assessments of regional air pollution andthe associated burdens of disease, especially onvulnerable populations. Urban populations in bothhigh- and low-income countries are vulnerable tohealth effects from air pollution.6 Many of the worldsactive volcanoes are proximal to urban populationcentres, potentially adding to the local pollutionburden37 and likely contributing to an insidious,elevated morbidity of disease. Data on human health

in volcanic areas are sparse. To the authors knowl-edge, this study provides the first measures ofvolcanic-associated cardiorespiratory effects.

Study limitations

This cross-sectional study has several potentiallimitations. First, prevalence may be underesti-mated in the exposed areas due to a potentialhealthy resident-survivor effect. Second, thefindings are based on a relatively small sample size

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Table 4 Students t-test analysis of vital sign measurements in unexposed and exposed groups.

Field-measured vital sign Unexposed group Sulphur-dioxide-exposed group Sul

Mean SD n Mean SD n P(2) Mea

Pulse rate, beats/min (regular rhythm) 77.0 11.7 105 79.2 12.7 106 0.20 78Non-smokers; non-medicateda 75.5 10.7 65 79.0 10.8 59 0.07 78Elderly X65 years of age 71.2 9.7 22 78.8 12.6 40 0.02 79Non-smokers; non-medicated 71.3 7.5 16 81.2 11.3 27 0.003 82Males (non-smokers; non-medicated) 79.7 12.9 21 78.3 9.4 25 0.67 82Females (non-smokers; non-medicated) 73.5 8.7 44 79.5 11.9 34 0.01 75BMIo25 (non-smokers; non-medicated) 69.5 7.5 15 77.2 10.1 30 0.01 77Systolic blood pressure (mmHg) 130.2 19.6 110 135.0 20.6 110 0.08 132Non-smokers; non-medicatedb 129.8 17.7 53 131.7 20.2 49 0.61 130

Males 137.4 21.3 46 144.1 19.1 45 0.12 135Females 125.0 16.6 64 128.6 19.2 65 0.26 129Hawaiians 129.9 16.9 30 128.0 18.5 27 0.70 132Filipinos 125.9 22.1 26 139.0 22.4 45 0.01 yWhites 124.3 20.2 19 y y y y 131BMI o25 117.2 16.1 29 131.6 20.8 50 0.002 125Normal weight (BMI 18.524.9) 117.3 16.4 28 130.8 20.3 44 0.004 124BMI X25 134.8 18.8 81 137.6 20.2 59 0.40 138Diastolic blood pressure (mmHg) 82.6 10.6 110 82.8 13.2 110 0.94 83Respirations, breaths/min 16.1 2.8 110 16.7 2.2 109 0.08 17

SD, standard deviation; BMI, body mass index; mmHg, millimeters of mercury, y, too few subjects for analysis.Non-medicated, participants not taking medication affecting pulsea or blood pressureb.Significant findings are shown in bold type.


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(25% of each sites adult population), makingidentification of small effects difficult. Third, thepotential significance of confounding on thesemeasures should be recognized. Participants char-acteristics were more comparable between thereferent group and the SO2 group than between thereferent group and the sulphate group. There were

a variety of differences in socio-economic statusbetween the groups (i.e. current employment,health insurance, education and ethnicity). Eco-nomic underdevelopment of these rural areas hasexisted since the loss of the sugarcane industry inthe 1990s. Multivariate analyses adjusted the ORsfor any confounding by characteristics in Table 1;however, other possible confounders cannot bediscounted. Finally, there was no medical recordconfirmation of reported diseases, although amedical history with medications was obtainedby the nurse investigator. Nevertheless, participantrecall bias may have affected these self-reported

data.

Major findings

These results support current hypotheses38 that airpollution is associated with adverse cardiovascularfunctioning. Faster mean pulse rates were mea-sured in exposed participants when restricting theeffects of smoking, medication and BMI, and fasterpulse rates were also found in exposed elders.Short-term exposure to PM10 has been associated

with a delayed increase in pulse rate in elderlysubjects,31 and SO2 has been associated withchanges in heart rate variability.39 Elevated systolicBP has also been associated with exposure toSO2 and PM in mixed pollutant environments.

40,41

This study found significantly elevated meansystolic BP in exposed normal-weight participants,suggesting an association between BP and sulphur-ous air pollution that is independent of an ele-vated BMI cardiac risk. The sample size wasinsufficient to assess smoking and medicationeffects on this finding.

Chronic exposure to volcanogenic sulphurous airpollution was associated with increased respiratorysymptoms, regardless of chemical species. Thelocation of airway exposure is dependent on nasalvs mouth breathing. A high prevalence of rhinor-rhoea indicates the use of nasal defence mechan-isms to the irritants. Breathing SO2 through thenose filters out up to 99% of the gas, but alsoincreases nasal congestion.4 If the nose becomesblocked by vascular congestion, mouth breathingmay occur, potentially exposing the larynx andlower respiratory tract to more of the irritants.42

The substantial prevalence of sinus congestion andrhinorrhoea may reflect an overload of thesedefence mechanisms. Chronic cough and phlegmare likely related to reflex mechanisms that areeffective at absorbing and neutralizing the irri-tants, and clearing large proximal airways.42 Afrequent sore/dry throat may reflect irritation and

a drying of the airways. Eye irritation suggests adermal reaction to both sulphur species.Differences in chronic effects between the

sulphurous air pollutants were identified. Specificto SO2 exposure was an increased nocturnal drycough, likely indicating gas sensitivity reactions.Specific to sulphate exposure were increasedwheeze symptoms and bronchitis, suggestingrepeated insults to lower airways with responsiveinflammatory processes. Most intriguing was aclustering of rhinorrhoea, sore/dry throat, sinuscongestion and eye irritation in sulphate partici-pants. Historical records reveal similar health

effects reported in Europe after the 1783 eruptionof Laki Volcano in Iceland: eye sensitivity, sorethroat, bronchitis, headache and asthma-likeexacerbations.43

Current and former smokers may experiencemore detrimental effects than non-smokers fromvolcanic sulphurous air pollution. Chronic bronchi-tis is diagnosed by clinical presentation and history.Although reported chronic bronchitis was notsignificant, using the diagnostic criteria of acough along with phlegm for 3 months or more inat least 2 consecutive years,44,45 the sulphate-

exposed group had considerably increased odds(adjusted OR 7.96, 95%CI 2.1629.39). Repeatedirritation from smoking combined with air pollutionperpetuates chronic inflammatory processes thatpotentially lead to lung disease.44

Clinical practice and public health promotion

The authors recommend further investigation andpublic health interventions at Kilauea Volcano andother degassing volcanoes located near residentialareas. An important risk factor for cardiovasculardisease is systolic BP 4140 mmHg in people over 50years of age;29 a guideline exceeded by 48% ofexposed participants. Prehypertension,29 a risk forhypertension with recommended health counsel-ling, was observed in 29% of exposed participants.Cardiovascular assessments and pulmonary functiontesting would allow for early diagnosis and, ifappropriate, initiation of treatment. Patients withdiagnosed asthma or hypertension should beencouraged to comply with treatment regimens toreduce disease progression. Smoking prevention

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and cessation are likely to be the most effectiveinterventions for exposed residents.

Eruption continues at Kilauea Volcano. Environ-mental findings24 and public concern prompted theState of Hawaii to pass legislation to monitor airquality in exposed areas.46 Temporal exposurepatterns can be assessed with continual monitor-

ing; a key to designing interventions (e.g. hours foroutdoor activity with lowest exposure). Success hasoccurred at Japans Mt. Oyama, where residentsreceived education and employ prevention mea-sures.47 It is concluded that long-term residency indegassing volcanic areas may have an adverseeffect on cardiorespiratory health in adults.Further investigations to evaluate health effectsare vital for the growing populations that residenear active volcanoes.

Acknowledgements

The authors wish to thank: international healthspecialist Dr. Chunhuei Chi; air physicist Dr. RaymondChuan; IAVCEI volcanologists Dr. Anita Grunderand Dr. Anthony Longo; toxicologist Dr. CathyNeumann; Big Island pulmonologist Dr. BenjaminOno; Dr. Jennifer Orme-Zavaletta (EPA); Dr. JackiePaulson, RN; the Hawaiian Volcano Observatory; andthe Kau Hospital physicians.

Ethical approval

Institutional Review Board Approval of OregonState University.

Funding

None declared.

Competing interests

None declared.

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