Exposure to air pollution during the first 1000 days of life and subsequent health service and medication usage in children☆
Graphical abstract
Introduction
The first thousand days of life includes the periods in utero which usually lasts for about 9 months, and the first two years after birth (i.e. ). It is recognised as a critical window for the development and growth of the respiratory and immune systems (Dietert et al., 2000). There is emerging evidence that air pollution exposure during this period could result in long-term adverse immunological or respiratory outcomes. For example, previous studies have demonstrated that early life exposure to industrial and traffic-related air pollution is associated with the development of childhood asthma and allergic diseases (Hehua et al., 2017; Bowatte et al., 2015; Deng et al., 2015). Intrauterine exposure to both particulate matter with an aerodynamic diameter <2.5 μm (PM2.5) and second-hand smoke (SHS) has been associated with increased risk of infantile eczema (Jedrychowski et al., 2011). Epidemiological studies have also shown significant associations between air pollution exposure in utero or during the first year of life and childhood pneumonia, bronchiolitis and ear infections (Soh et al., 2018; Kennedy et al., 2018; Rice et al., 2015), further highlighting potential susceptibility during this period. Exposure to air pollution prompts immediate immune responses (Carlsen et al., 2016; Adetona et al., 2013) and can modulate later immune expression (Yi et al., 2017; Rice et al., 2015). It is therefore plausible that short-term exposure to air pollution in the critical first 1000 days of life, from conception to age 2 years, could affect later immunological function (Wopereis et al., 2014). However very few studies have evaluated this.
Smoke from outdoor landscape fires including burning forest, grass and peat makes a significant contribution to air pollution (Johnston et al., 2012) and is an increasing global concern due to the rising frequency and severity of fires resulting from climate change (Liu et al., 2016). Epidemiological studies suggest that smoke exposure is associated with short-term increases in medication usage, physician/emergency department visits, hospitalisations and death (Reid et al., 2016; Black et al., 2017b). However, evidence of long-term health outcomes following exposure to short-to-medium duration smoke events (i.e. weeks) is extremely limited (Melody and Johnston, 2015; Black et al., 2017b).
Embers from a bushfire in the Latrobe Valley region of Victoria, Australia, ignited a fire in an open cast coal mine located close to several rural towns in February 2014 that lasted for about 45 days. The episode resulted in dramatically increased concentrations of PM2.5. The peak daily average PM2.5 concentration reached 731 μg m−3 in the closest town, Morwell, which is substantially higher than the national daily air quality standard of 25 μg m−3 (Reisen et al., 2017, Department of the Environment and Heritage, 2005). One of the main concerns of the community during this period was the possible risks to their long-term health. As there was little existing evidence to draw on, the state government initiated a long-term study, the Hazelwood Health Study, to investigate the health and wellbeing of adults and children affected by the smoke episode (Melody et al., 2018).
We hypothesised that exposure to air pollution from the coal mine fire during the intrauterine or infant periods would increase the risk of common allergic or infective illnesses in the year following exposure. The aim of this study was to test if exposure to smoke from the coal mine fire during the first 1000 days of life was associated with increased physician visits or dispensing of medications used to treat infections, asthma or atopic skin conditions.
Section snippets
Study design
We linked data from a cohort of children recruited to the Latrobe Early Life Follow-up (ELF) Study (Melody et al., 2018) to two national Australian administrative health datasets: the Medicare Benefits Schedule (MBS) and the Pharmaceutical Benefits Scheme (PBS). Data were extracted by the Australian Department of Human Services for the period from each child’s date of birth to 31/12/2016. The MBS dataset contained de-identified information on claims to Medicare, the national insurance system,
Participant characteristics
Parents/carers of 311 (54.5%) children from the full Latrobe ELF cohort (n = 571) consented to be linked to the MBS/PBS datasets. There were 88 children in the intrauterine exposure group, 77 in the no exposure group, 121 in the infant exposure group, and 25 children born during the fire period. Therefore, 218 children were included in the intrauterine exposure analysis, while 198 were included in the infant exposure analysis.
In the intrauterine exposure analysis, no statistically significant
Discussion
To our knowledge, this study provides the first evidence that infant exposure to increased PM2.5 derived from coal mine fire emissions over a medium duration was associated with increased dispensations of antibiotics during the year following the fire. The association was independent of potential confounders including age of the child, tobacco smoke exposure, socio-economic status and background air pollution exposure. In contrast, we did not observe significant associations for other outcomes
Conclusions
In conclusion, our study suggested that infant exposure to a short-term severe air pollution event was associated with increased childhood antibiotic dispensations, which might reflect increased childhood infections. Future follow-up of the participants will be necessary to confirm these findings and evaluate long-term effects.
Declaration of competing interest
The authors declare no conflict of interest with this study. Fay Johnston received payment for expert testimony from Environment Protection Authority Victoria (Australia). Amanda Wheeler’s fellowship was funded by the Centre for Air pollution, energy and health Research.
Acknowledgements
The Latrobe Early Life Follow-up (ELF) Study constitutes the child health and development stream of the Hazelwood Health Study. The Latrobe ELF Study forms part of the wider research program of the Hazelwood Health Study (HHS) and is run by a multidisciplinary group of researchers and administrative staff from the University of Tasmania, Monash University, the University of Melbourne, the University of Sydney and CSIRO. We would like to acknowledge all of these staff for their important
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This paper has been recommended for acceptance by Wen Chen.