Ambient particulate air pollution and acute lower respiratory infections: a systematic review and implications for estimating the global burden of disease

Acute lower respiratory infections (ALRI) account for nearly one fifth of mortality in young children worldwide and have been associated with exposures to indoor and outdoor sources of combustion-derived air pollution. A systematic review was conducted to identify relevant articles on air pollution and ALRI in children. Using a Bayesian approach to meta-analysis, a summary estimate of 1.12 (1.03, 1.30) increased risk in ALRI occurrence per 10 mu g/m(3) increase in annual average PM2.5 concentration was derived from the longer-term (subchronic and chronic) effects studies. This analysis strengthens the evidence for a causal relationship between exposure to PM2.5 and the occurrence of ALRI and provides a basis for estimating the global attributable burden of mortality due to ALRI that is not influenced by the wide variation in regional case fatality rates. Most studies, however, have been conducted in settings with relatively low levels of PM2.5. Extrapolating their results to other, more polluted, regions will require a model that is informed by evidence from studies of the effects on ALRI of exposure to PM2.5 from other combustion sources, such as secondhand smoke and household solid fuel use.