Association of Long-Term Exposure to Fine Particulate Matter and Cardio-Metabolic Diseases in Low- and Middle-Income Countries: A Systematic Review

Background: Numerous epidemiological studies indicated high levels of particulate matter less than2.5 μm diameter (PM 2.5 ) as a major cardiovascular risk factor. Most of the studies have been conducted in high-income countries (HICs), where average levels of PM 2.5 are far less compared to low- and middle- income countries (LMICs), and their socio-economic profile, disease burden, and PM speciation/composition are very different. We systematically reviewed the association of long-term exposure to PM 2.5 and cardio-metabolic diseases (CMDs) in LMICs. Methods: Multiple databases were searched for English articles with date limits until March 2018. We included studies investigating the association of long-term exposure to PM 2.5 (defined as an annual average/average measure for 3 more days of PM 2.5 exposure) and CMDs, such as hospital admissions, prevalence, and deaths due to CMDs, conducted in LMICs as defined by World Bank. We excluded studies which employed exposure proxy measures, studies among specific occupational groups, and specific episodes of air pollution. Results: A total of 5567 unique articles were identified, of which only 17 articles were included for final review, and these studies were from Brazil, Bulgaria, China, India, and Mexico. Outcome assessed were hypertension, type 2 diabetes mellitus and insulin resistance, and cardiovascular disease (CVD)-related emergency room visits/admissions, death, and mortality. Largely a positive association between exposure to PM 2.5 and CMDs was found, and CVD mortality with effect estimates ranging from 0.24% to 6.11% increased per 10 μg/m 3 in PM 2.5 . CVD-related hospitalizations and emergency room visits increased by 0.3% to 19.6%. Risk factors like hypertension had an odds ratio of 1.14, and type 2 diabetes mellitus had an odds ratio ranging from 1.14–1.32. Diversity of exposure assessment and health outcomes limited the ability to perform a meta-analysis. Conclusion: Limited evidence on the association of long-term exposure to PM 2.5 and CMDs in the LMICs context warrants cohort studies to establish the association.