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Public Health (2008) 122, 809 820

www.elsevierhealth.com/journals/pubh

Original Research

Cardiorespiratory health effects associated with sulphurous volcanic air pollution

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

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

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

KEYWORDS
Air pollution; Sulphur dioxide; Chronic obstructive pulmonary disease; Cardiovascular diseases; Blood pressure; Volcano

Summary Objective: To investigate cardiorespiratory health effects associated with chronic exposure to volcanogenic sulphur dioxide (SO2) and ne sulphate particle (p0.3 mm) 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 downwind area, and to conrm non-exposure in a reference area. Cross-sectional health data were collected from 335 adults, X20 years of age, who had resided for X7 years in the study areas. Prevalence was estimated for cardiorespiratory signs, and selfreported symptoms and diseases. Logistic regression analysis estimated effect measures between exposed and unexposed groups considering potential confounding including age, gender, race, smoking, dust and body mass index (BMI). Students t-tests compared mean differences in blood pressure (BP), pulse and respiratory rates. Results: There were statistically signicant positive associations between chronic exposure and increased prevalence of cough, phlegm, rhinorrhoea, sore/dry throat, sinus congestion, wheezing, eye irritation and bronchitis. The magnitude of the associations differed according to SO2 and ne sulphate particulate exposure. Group analyses found no differences in pulse rate or BP; however, signicantly faster mean pulse rates were detected in exposed non-medicated, non-smoking participants with BMI o25, and in participants aged X65 years. Higher mean systolic BP was found in exposed 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 is recommended, and the authors encourage investigations in communities near active

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

fax: +1 775 784 4262. E-mail address: longo@unr.edu (B.M. Longo). 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

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810 B.M. Longo et al.
volcanoes worldwide. Public health interventions of community education, and smoking prevention and cessation are suggested. & 2007 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved.

Introduction
Eruption at Kilauea Volcano has persisted since 1983 on the Island of Hawaii, United States. The volcanic emissions are primarily composed of water vapour, sulphur dioxide (SO2) gas (averaging 1600 metric ton/day),1 and ne sulphates, principally sulphuric acid aerosol (mean diameter p0.3 mm).2 Unlike explosive volcanic eruptions that send particulates and gases into the stratosphere, Kilaueas effusive eruption emits gases and aerosols into the lower troposphere where humans reside; thus, long-standing effusive eruptions may create an environment detrimental to health. The purpose of this investigation was to evaluate the health status of adults chronically exposed to Kilaueas air pollution. Human health effects from sulphurous air pollutants can occur. SO2 is an irritant that affects changes in the mechanical functioning of the upper airways, resulting in bronchoconstriction or increased pulmonary resistance.3,4 In healthy, nonasthmatic adults, doseresponse relationships exist at various thresholds for different exposure durations and activity levels.35 Several population subgroups are sensitive to SO2 at lower concentrations: asthmatics; children and adolescents; respiratory- and cardiac-compromised individuals; and healthy but SO2-sensitive individuals.47 Some paediatric asthmatics can show effects at even lower levels of SO2 than identied previously.8,9 Public health concentrations for SO2 that consider these sensitive population subgroups are the World Health Organizations (WHO) guideline10 and the minimal risk level (MRL).11 Fine sulphates are ocular and respiratory irritants that can have a negative effect on both sensitive and general populations by inducing respiratory tract irritation and altering lung defences, including airway reactivity, alveolar particle clearance and mucociliary transport.4,12 No threshold has been identied10 but current evidence suggests that secondary sulphates sized p2.5 mm, at ambient levels from 4 to 7 mg/m3, have little adverse impact on public health.13 An estimated 500 million people live near the worlds 600 active volcanoes.14 These volcanoes degass pollutants continuously during eruption and in states of quiescence between eruptions.15 Health may be affected adversely from continual

emissions of SO2, carbon dioxide, radon and/or hydrogen sulphide.14,1618 At Kilauea, studies have focused on acute health effects associated with the eruption, identifying increased hospital visits for respiratory conditions1921 and respiratory effects in known paediatric asthmatics.22 A recent study, however, found the highest prevalence of paediatric asthma in Hawaiian communities with the lowest exposure to volcanic pollution, suggesting other causal factors.23

Methods
Design
Kilaueas ongoing eruption provided a natural laboratory for investigating chronic, adverse health effects from sulphurous air pollution in a non-mixed air polluted environment. An environmentalepidemiological, cross-sectional design was used to measure the prevalence of cardiorespiratory signs, self-reported symptoms and diagnosed diseases in exposed groups and an unexposed reference group. Groups were identied based on exposure status without prior knowledge of disease status.

Summary of previous exposure assessment

To assess exposure concentrations, environmental sampling was conducted on a regional scale in 2003 for SO2 and ne aerosol (p0.3 mm) pollution in exposed Kau district, and in Hawi, an unexposed reference area on the north side of the island.24 Sampling conditions were representative of typical regional meteorology (e.g. trade winds and afternoon upslope showers).25 Volcanic emissions were continual and consistent with recent data.24 Ambient and indoor SO2 concentrations were measured over 3 weeks using a network of 70 SO2-specic passive diffusion tubes that provided a timeaveraged concentration but could not resolve temporal variation in exposures. Concurrently, 58 grab samples were collected using a quartz crystal microbalance cascade impactor that determined mass concentrations of ne aerosol particles sized 0.8, 0.3 and 0.1 mm. Using these measurements to estimate chronic exposure levels seems justied

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Cardiorespiratory health effects associated with sulphurous volcanic air pollution because of over two decades of eruption and the representative exposure conditions that prevailed during sampling. 811

Study locations
Based on environmental data, epidemiological sites from exposed Kau district (Fig. 1) and unexposed Hawi were selected (averages: SO2 0.7 ppbv, particles p0.3 mm 0.31 mg/m3).24 The SO2exposed group was from Naalehu town, located 68 km downwind from the eruption. Naalehu averaged 24.5 [standard deviation (SD) 4.3] ppbv of SO2 (range 19.532.5 ppbv) and was low in ne particles (p1 mg/m3).24 The SO2 concentration was above the WHO 24-h average guideline of 20 mg/m3 (7.5 ppbv)10 and the acute 14-day MRL of 10 ppbv.11 The sulphate-exposed group was from the Ocean View subdivision, located 85 km downwind of the eruption. Ocean View averaged 4.1 (SD 2.8) mg/m3 of ne particles (p0.3 mm) during typical trade winds, 9.6 (SD 1.9) mg/m3 during variable light winds and SO2 o10 ppbv.24 The exposed and unexposed sites are rural, and have accessible healthcare facilities that serve low-income clients. These sites are comparable in meteorology (e.g. rainfall), vegetation, grazing lands and crops. No site has substantial anthropogenic air pollution. Residents of Naalehu and Hawi share similar histories and ethnicity, both formerly sugar plantations that brought immigration from

the Philippines, Japan and the US mainland. In comparison, Ocean View is a large, isolated subdivision with fewer long-term residents. Data from the 1999 US Census26 showed a higher median family income for Hawi than for towns in Kau district.

Data collection
To obtain a geographically representative sample, participants were selected systematically by every third household on all streets in exposed Naalehu and unexposed Hawi. In exposed Ocean View, systematic selection of every third mile-squared block in the subdivision, followed by random selection of two households per block, was employed. Sampling in all study areas was restricted to no more than two participants per household 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 was 92% in Naalehu, 98% in Ocean View and 96% in Hawi. The study protocol was approved by the Institutional Review Board of Oregon State University. Written informed consent was obtained prior to data collection. Data were collected in participants homes between April and June 2004 using an interview and assessment conducted in English or Tagalog (the language of the Filipino immigrants) by an experienced registered nurse investigator. The assessment interview comprised standardized, yes/no questions on cardiorespiratory symptoms and lifestyle factors taken from the validated 19992000 National Health and Nutrition Examination Survey27 and the American Thoracic Societys Respiratory Symptom Questionnaire.28 A history of diseases diagnosed by a doctor, medication use, style of home and demographic information was obtained. Participants were not asked their income because of cultural norms; instead, education level, employment status, insurance coverage and access to medical care were relied on to indicate socio-economic status. To assess volcanic-associated health effects specically, participants were asked questions about disease diagnosis while in residency since Kilaueas eruption began in 1983, instead of over their entire lifetimes. Air quality data were not released until after completion of the study to prevent any positive or negative inuence on participants responses.

Figure 1 Concentration contour map of volcanogenic air pollution in Kau district, Island of Hawaii, USA, 2003 (modied with permission).24 The sulphur-dioxideexposed group was from Naa ` lehu, and the sulphateaerosol-exposed group was from Ocean View. Base map provided by State of Hawaii GIS Program I-Map.

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812 Vital sign data of resting blood pressure (BP), radial pulse rate and respiratory rate were taken on all participants after 1520 min rest in a sitting position, between 9 am and 3 pm. BP was measured with calibrated aneroid sphygmomanometers, placed at heart level, with proper cuff to arm size, using the slow-deation auscultory method (US National Institute of Health).29 For systolic pressures X160 mmHg, two measurements were taken approximately 5 min apart. Radial pulse rates were taken for 30 s with regular rhythm and 1 min for irregular rhythms. Respiratory rate was assessed over 1 min. The sampling and interview method and materials were the same for each group, regardless of exposure status, to prevent interviewer bias and to minimize misclassication bias. B.M. Longo et al. mal weight without known cardiovascular disease for evaluating cardiopulmonary effects.33 Therefore, the potential physiological effects on vital signs from differences in gender, race, age, smoking (i.e. hypoxaemia and stimulant effects), being overweight or obese (BMI X25), and use of hypertensive and cardiac medications for existing disease were considered in planning the data analyses. All analyses employed a 5% probability of a Type I error (a 0.05). Data were analysed with PEPI Version 4.034 and SPSS Version 8.0.

Results
Characteristics of the participants
Table 1 describes characteristics of the 335 participants. All groups had nearly equal distributions for gender, occupational dust exposure and medication usage, and no statistical difference in current smoking prevalence. The unexposed group was younger and had a higher mean BMI than the exposed groups. Distributions of birth place, residency and education were similar between the SO2-exposed and the unexposed group. The sulphate-exposed group was primarily White, more educated, had a lower percentage of never smokers, and viewed themselves as being in better health. The exposed groups had seasonal unemployment with temporary loss of health insurance.

Statistical analyses
Prevalence and odds ratios (ORs) were estimated for dichotomous variables of cardiorespiratory symptoms and diseases. The 95% condence interval (CI) of the OR point estimate was used for signicance testing. Initially, stratied analyses were conducted to evaluate confounding and test for effect modication (EM). The MantelHaenszel estimator was used to control confounding for a uniform OR, whereas Chi-square test for heterogeneity was used to test for EM. The Mantel Haenszel extension test was used for analysis of trend. Logistic regression analyses were used to adjust an OR for a priori-selected potential confounders, including those identied by stratied analyses. Final adjusted ORs and 95% CIs were calculated after controlling for categorical variables and prespecied groups of gender, smoking (never, former, current), occupational dust exposure, race (Hawaiian, Filipino, Japanese, White and other), age (years) and body mass index (BMI). For the SO2 group, adjustments were also made for home style because plantation homes can penetrate up to 71% of ambient SO2 compared with p23% for modern homes.24 As the symptoms of cough, dry cough and sinus congestion are known side-effects from certain medications30 (i.e. antihypertensives), the analysis for each symptom was restricted to participants not taking medications with these effects. Students t-tests with non-directional hypotheses were performed on vital sign measures between the unexposed and exposed groups. Previous studies on health and air pollution have identied effects in subgroups of age (elderly X65 years)31 and gender (female participants),32 and have recommended using non-smoking subjects of nor-

SO2 exposure
SO2 exposure was associated with substantially increased odds of self-reported respiratory symptoms (Table 2). The OR for cough was four times higher in the SO2-exposed group compared with the unexposed group, and showed a negative trend of decreasing cough with increasing age (OR 5.50 for 2029 years, 5.19 for 4059 years and 3.38 for 60+ years; P2o0.001). SO2-exposed participants were 5.5 times more likely to report a nocturnal dry cough lasting 414 days, not associated with a cold or respiratory illness. Phlegm showed a positive trend of increasing odds with increase in smoking (OR 2.2 for never smokers, 3.81 for former smokers and 5.5 for current smokers; P2 0.001) The ORs for reported rhinorrhoea, sore/dry throat and eye irritation were 5.45, 13.45 and 6.08, respectively. The prevalence of reported adult asthma was 21.7% (Table 3), which was not signicantly different from the unexposed group. Wheeze on most days/nights was reported twice as often in the SO2-exposed group (Table 2), with a positive trend of increasing wheeze with increasing

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Cardiorespiratory health effects associated with sulphurous volcanic air pollution
Table 1 Participant characteristics by exposure status. Hawi (unexposed group) Number of participants Age in years: mean (SD) Gender (%) Female Male Ethnicity (%) Hawaiian Filipino White Japanese Others Number of Tagalog interviews Body mass index: mean (SD) Body mass index X25(%) Born in Hawaii (%) Residence in years: mean (SD) Home: plantation style (%) Home: age in years (mean) Education in years (median) Employment (%) Working Unemployed Retired Disabled Smoking status (%) Never Former Current Occupational exposure (%) Sugarcane Dust Health insurance (%) Medication usage (%) Respiratory Antihypertensives Subjective view of health (%) Excellent Very good Average Worse than average Very poor 110 52.1 (17.4) 58 42 27 24 17 16 16 5 27.7 (5.2) 74 77 36.1 (22.3) 39 42 12 60 8 29 3 44 33 23 13 46 95 15 27 11 42 45 3 0 Naa ` lehu (sulphur-dioxide-exposed group) 115 56.4 (18.9) 60 40 26 41 6 20 7 5 26.9 (6.6) 55 69 37.4 (18.9) 64 52 12 44 23 32 2 45 37 18 20 52 86 14 34 6 34 53 5 2 Ocean View (sulphate-exposed group) 110 57.9 (12.9) 56 44 16 5 73 2 5 0 26.4 (6.8) 50 23 14.4 (6.2) 0 17 14 45 16 32 8 29 44 27 1 42 77 19 30 26 36 31 6 1

813

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 2

Prevalence of self-reported cardiorespiratory symptoms in adults chronically exposed to volcanogenic sulphur dioxide gas and ne sulphates.
Unexposed group P% Sulphur-dioxide-exposed group P% Crude OR (95%CI) 0.61 (0.361.05) 1.45 (0.792.75) 4.23 (2.018.93)*** 5.55 (2.1814.13)*** 2.03 (1.133.64)** 3.15 (1.536.50)** 6.00 3.43 1.51 2.03 12.03 1.44 2.21 2.10 1.81 3.40 5.39 4.64 4.64 4.55 (1.7021.19) (1.318.95)** (0.763.02) (0.934.44) (3.5440.8)*** (0.732.86) (0.915.36) (1.153.81) (0.774.3) (1.209.62) (2.4611.84)*** (1.5114.28)** (1.5114.28)** (1.2616.42) AORa (95%CI) 0.61 (0.341.08) 1.66 (0.853.25) 4.07 (1.839.02)*** 5.53 (2.0415.0)*** 2.59 (1.315.14) ** 3.15 (1.456.83)** 4.58 5.45 1.63 1.90 13.45 1.27 2.33 2.04 1.92 3.29 6.08 5.82 4.57 3.35 (1.2017.43) (1.7816.71)** (0.723.71) (0.834.33) (3.7448.4)*** (0.612.64) (0.906.06) (1.073.86) (0.764.89) (1.089.98) (2.5914.26)*** (1.7219.66)** (1.4314.59)** (0.8712.98) Sulphate-exposed group P% 49.1 25.5 48.0 15.3 30.9 29.1 24.5 33.6 47.3 16.5 19.1 32.7 15.5 33.6 11.8 23.6 43.6 35.5 12.7 11.8 Crude OR (95%CI) 0.84 (0.491.45) 1.37 (0.722.58) 6.95 (3.3114.62)*** 2.65 (0.987.16) 1.48 (0.812.70) 3.35 (1.626.93)** 9.84 8.79 4.07 1.78 8.42 2.66 2.33 1.92 1.50 6.44 8.69 14.56 3.87 4.78 (2.8533.96)*** (3.5321.89)*** (2.097.91)*** (0.803.97) (2.4329.14)*** (1.395.11)** (0.965.65) (1.053.52) (0.623.68) (2.3717.49)*** (3.9918.93)*** (4.9842.5)*** (1.2312.14) (1.3217.28) AORb (95%CI) 0.91 (0.511.64) 1.51 (0.772.98) 6.60 (2.9414.82)*** 2.44 (0.847.10) 2.38 (1.125.06) 3.16 (1.466.86)** 7.25 7.65 5.22 1.71 12.45 2.67 3.00 2.12 1.78 6.76 8.85 12.99 4.02 5.74 (1.9227.43)** (2.97 19.74)*** (2.4910.94)*** (0.734.03) (3.2547.7)*** (1.345.38)** (1.128.01) (1.104.06) (0.674.75) (2.3619.32)*** (3.9319.90)*** (4.3638.7)*** (1.2013.46) (1.4223.17)

Reported symptoms

Chest colds Chest pain Cough on most days for 3 consecutive months or more per year Dry cough at night for 414 days Headaches often Phlegm on most days for 3 consecutive months or more peryear Cough and phlegm combined Rhinorrhoea frequently Sinus/nasal congestion often SOB without exertion Sore or dry throat frequently Wheeze within the last 12 months Wheeze most days or nights Wheeze only with a cold Wheeze during or after exercise Outdoor symptoms Cough Eye irritation Rhinorrhoea and sinus congestion Shortness of breath Wheezing
a

53.8 20.0 11.7 6.4 22.7 10.9 3.2 5.5 18.1 10.0 2.7 15.5 7.3 20.9 8.2 4.6 8.2 3.6 3.6 2.7

41.7 27.0 35.9 27.5 37.4 27.8 16.5 16.5 25.0 18.4 25.2 20.9 14.8 35.7 13.9 14.0 32.5 14.9 14.9 11.3

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P, prevalence; CI, condence interval; SOB, shortness of breath. AOR, adjusted odds ratio for age, gender, race, smoking status, body mass index, occupational dust exposure and home style. b AOR, adjusted odds ratio for age, gender, race, smoking status, body mass index and occupational dust exposure. Statistically signicant at Po0.05, **Po0.01, ***Po0.001.

B.M. Longo et al.

Cardiorespiratory health effects associated with sulphurous volcanic air pollution

Table 3

Prevalence of cardiorespiratory diseases in adults chronically exposed to volcanogenic sulphur dioxide gas and ne sulphates. Unexposed group P% Sulphur-dioxide-exposed group P% Crude OR (95%CI) 1.42 1.02 2.22 1.29 0.96 1.25 2.37 0.54 0.96 2.25 1.29 0.95 1.76 1.98 (0.732.78) (0.561.88) (0.756.62) (0.285.88) (0.194.88) (0.682.27) (1.105.26) (0.261.14) (0.442.12) (0.677.53) (0.285.88) (0.352.64) (1.023.02) (0.488.13) AORa (95%CI) 1.06 1.13 2.25 0.98 0.80 1.25 2.24 0.55 0.99 2.03 2.15 0.72 1.84 1.84 (0.492.27) (0.582.19) (0.677.61) (0.147.18) (0.125.91) (0.652.40) (0.945.31) (0.251.20) (0.422.37) (0.567.41) (0.3214.40) (0.242.18) (0.943.58) (0.428.08) Sulphate-exposed group P% 16.4 45.0 11.8 5.5 1.8 27.3 17.3 19.1 19.1 8.2 6.4 9.1 37.3 7.3 21.3 28.2 51.8 28.2 Crude OR (95%CI) 1.00 2.48 2.81 2.06 0.66 1.21 2.09 1.00 1.62 2.36 2.42 1.28 1.22 2.80 (0.492.04) (1.404.41)** (0.978.19) (0.508.45) (0.124.03) (0.662.23) (0.924.73) (0.511.96) (0.783.38) (0.717.91) (0.619.63) (0.483.36) (0.702.12) (0.7210.84) AORb (95%CI) 1.18 2.77 2.32 1.63 0.50 1.62 2.51 0.93 2.18 2.16 4.19 1.14 1.19 5.35 (0.542.58) (1.495.15)*** (0.747.24) (0.377.29) (0.073.39) (0.823.18) (1.026.15) (0.461.90) (0.974.92) (0.617.63) (0.5531.86) (0.393.35) (0.602.36) (0.9231.26)

Reported diseases diagnosed by a doctor Respiratory diseases Asthma Bronchitis Chronic bronchitis COPD Emphysema Hayfever (non-food allergies) Chronic hayfever Pneumonia Chronic sinusitis Cardiovascular diseases Angina Congestive heart failure Coronary artery disease Hypertension Myocardial infarction Field-measured vital signs Pulse rate X90 beats/minc Respirations X20 breaths/min High blood pressure (mmHg) X140 systolic or X90 diastolic Restricted to non-medicatedd
a

16.4 24.5 4.5 2.7 2.7 23.6 9.0 19.1 12.7 3.6 2.7 7.3 32.7 2.7 16.2 19.1 39.1 20.9

21.7 25.2 9.6 3.5 2.6 27.8 19.1 11.3 12.3 7.8 3.5 7.0 46.1 5.3 16.0 17.4 53.6 29.1

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1.00 (0.482.08) 0.90 (0.451.78) 1.80 (1.063.08) 2.00 (0.994.03)

0.92 (0.412.10) 0.92 (0.431.95) 2.45 (1.284.67)** 2.94 (1.147.63)

1.42 (0.712.85) 1.66 (0.893.13) 1.68 (0.982.86) 1.72 (0.863.45)

1.82 (0.814.09) 1.37 (0.702.69) 2.10 (1.103.99) 2.82 (1.127.12)

P, prevalence; CI, condence interval; COPD, chronic obstructive pulmonary disease; mmHg, millimetres of mercury. AOR, adjusted odds ratio for age, gender, race, smoking status, body mass index, occupational dust exposure and home style. b AOR, adjusted odds ratio for age, gender, race, smoking status, body mass index and occupational dust exposure. c Regular rhythm pulse rates. d Non-medicated, participants not taking medication affecting blood pressure. Statistically signicant at Po0.05, **Po0.01, ***Po0.001.

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816 age (OR 1.35 for 2039 years, 3.68 for 4059 years and 4.47 for 60+ years; P2 0.04). Cardiovascular diseases were not associated with SO2 exposure (Table 3); however, there were signicant cardiovascular signs. SO2 exposure was associated with higher odds of having eldmeasured high BP (Table 3). Signicantly elevated mean systolic BP was observed in SO2-exposed Filipino participants (Table 4), with the highest mean difference in systolic BP (+16.7 mmHg) found among female Filipinos. Mean systolic BPs were signicantly elevated (+14.4 mmHg) for SO2exposed participants with a BMI o25. SO2-exposed elderly participants (X65 years) and elderly non-smokers not taking pulse-affecting medications had resting mean pulse rates that were signicantly faster than those of their unexposed counterparts by 7.6 and 9.9 beats/min, respectively (Table 4). The pulse rate in the SO2-exposed group 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 faster than that for their unexposed counterparts. B.M. Longo et al. OR 1.63 for 2039 years, 2.44 for 4059 years, 5.86 for 60+ years). The OR for bronchitis was almost doubled in the sulphate-exposed group compared with the exposed group (Table 3). Cardiovascular diseases were not associated with chronic sulphate exposure (Table 3). Signicant cardiovascular signs were similar to those seen with SO2 exposure. The odds of having eld-measured high BP was doubled in sulphate-exposed individuals. A signicantly higher mean systolic BP (+8.1 mmHg) was observed for participants with a BMI o25 (Table 4). Resting mean pulse rates among elderly sulphate participants (X65 years) were signicantly faster (average +8.5 beats/min) compared with their unexposed counterparts, even when restricted to non-smokers not taking pulseaffecting medications (+11.5 beats/min). A faster resting mean pulse rate (+8.3 beats/min) was measured in the sulphate-exposed group when controlling for BMIX25, smoking and medications.

Discussion
This study revealed signicant associations between exposure to long-standing volcanogenic sulphurous air pollution and cardiorespiratory health effects. The relevance of the study, its limitations, major ndings and the implications for clinical practice are discussed below.

Sulphate aerosol exposure

Sulphate exposure was associated with increased odds of self-reported respiratory symptoms (Table 2), and relatively higher odds than with SO2 exposure. The OR for cough was 6.5 times higher in the sulphate-exposed group compared with the unexposed group. A positive trend was identied of increasing odds of phlegm with increase in smoking (OR 1.2 for never smokers, 3.86 for former smokers and 5.61 for current smokers; P2 0.002). Cough combined with phlegm was over seven times more likely to be reported with sulphate exposure. The odds of reported sinus/nasal congestion was 5.2 times higher in the sulphate-exposed group; this was not signicant for the SO2-exposed group. Frequent rhinorrhoea, sore/dry throat, eye irritation, and outdoor rhinorrhoea and congestion had substantially elevated odds associated with sulphate exposure (Table 2). The prevalence of reported asthma was equal in the exposed and unexposed groups (Table 3). Within the sulphate-exposed asthmatics, 22% had a known hereditary component, half that of the unexposed group, along with 61% reporting adultonset asthma. Wheezing symptoms were 1.85.7 times more likely with sulphate exposure than nonexposure (Table 2). The elderly were most affected by wheeze on most days/nights (trend P2 0.03;

Relevance of the study

Exposure to SO2 is associated with increased morbidity and mortality worldwide.10,35,36 WHO7 has requested assessments of regional air pollution and the associated burdens of disease, especially on vulnerable populations. Urban populations in both high- and low-income countries are vulnerable to health effects from air pollution.6 Many of the worlds active volcanoes are proximal to urban population centres, potentially adding to the local pollution burden37 and likely contributing to an insidious, elevated morbidity of disease. Data on human health in volcanic areas are sparse. To the authors knowledge, this study provides the rst measures of volcanic-associated cardiorespiratory effects.

Study limitations
This cross-sectional study has several potential limitations. First, prevalence may be underestimated in the exposed areas due to a potential healthy resident-survivor effect. Second, the ndings are based on a relatively small sample size

Cardiorespiratory health effects associated with sulphurous volcanic air pollution

Table 4

Students t-test analysis of vital sign measurements in unexposed and exposed groups. Unexposed group Mean SD 11.7 10.7 9.7 7.5 12.9 8.7 7.5 19.6 17.7 21.3 16.6 16.9 22.1 20.2 16.1 16.4 18.8 10.6 2.8 n 105 65 22 16 21 44 15 110 53 46 64 30 26 19 29 28 81 110 110 Sulphur-dioxide-exposed group Mean 79.2 79.0 78.8 81.2 78.3 79.5 77.2 135.0 131.7 144.1 128.6 128.0 139.0 y 131.6 130.8 137.6 82.8 16.7 SD 12.7 10.8 12.6 11.3 9.4 11.9 10.1 20.6 20.2 19.1 19.2 18.5 22.4 y 20.8 20.3 20.2 13.2 2.2 n 106 59 40 27 25 34 30 110 49 45 65 27 45 y 50 44 59 110 109 P(2) 0.20 0.07 0.02 0.003 0.67 0.01 0.01 0.08 0.61 0.12 0.26 0.70 0.01 y 0.002 0.004 0.40 0.94 0.08 Sulphate-exposed group Mean 78.7 78.3 79.7 82.8 82.4 75.6 77.8 132.0 130.3 135.6 129.2 132.3 y 131.6 125.3 124.5 138.1 83.8 17.2 SD 12.7 11.8 13.2 10.5 13.0 10.3 13.1 20.3 22.6 17.8 21.8 20.7 y 20.7 17.8 17.4 20.4 10.5 2.4 n 103 50 25 13 20 30 27 110 48 48 62 18 y 80 55 52 54 110 110 P(2) 0.30 0.18 0.02 0.002 0.51 0.34 0.03 0.50 0.78 0.66 0.24 0.66 y 0.18 0.04 0.08 0.34 0.42 0.002

Field-measured vital sign

Pulse rate, beats/min (regular rhythm) Non-smokers; non-medicateda Elderly X65 years of age Non-smokers; non-medicated Males (non-smokers; non-medicated) Females (non-smokers; non-medicated) BMI o25 (non-smokers; non-medicated) Systolic blood pressure (mmHg) Non-smokers; non-medicatedb Males Females Hawaiians Filipinos Whites BMI o25 Normal weight (BMI 18.524.9) BMI X25 Diastolic blood pressure (mmHg) Respirations, breaths/min

77.0 75.5 71.2 71.3 79.7 73.5 69.5 130.2 129.8 137.4 125.0 129.9 125.9 124.3 117.2 117.3 134.8 82.6 16.1

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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. Signicant ndings are shown in bold type.

817

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818 (25% of each sites adult population), making identication of small effects difcult. Third, the potential signicance of confounding on these measures should be recognized. Participants characteristics were more comparable between the referent group and the SO2 group than between the referent group and the sulphate group. There were a variety of differences in socio-economic status between the groups (i.e. current employment, health insurance, education and ethnicity). Economic underdevelopment of these rural areas has existed since the loss of the sugarcane industry in the 1990s. Multivariate analyses adjusted the ORs for any confounding by characteristics in Table 1; however, other possible confounders cannot be discounted. Finally, there was no medical record conrmation of reported diseases, although a medical history with medications was obtained by the nurse investigator. Nevertheless, participant recall bias may have affected these self-reported data. B.M. Longo et al. The substantial prevalence of sinus congestion and rhinorrhoea may reect an overload of these defence mechanisms. Chronic cough and phlegm are likely related to reex mechanisms that are effective at absorbing and neutralizing the irritants, and clearing large proximal airways.42 A frequent sore/dry throat may reect irritation and a drying of the airways. Eye irritation suggests a dermal reaction to both sulphur species. Differences in chronic effects between the sulphurous air pollutants were identied. Specic to SO2 exposure was an increased nocturnal dry cough, likely indicating gas sensitivity reactions. Specic to sulphate exposure were increased wheeze symptoms and bronchitis, suggesting repeated insults to lower airways with responsive inammatory processes. Most intriguing was a clustering of rhinorrhoea, sore/dry throat, sinus congestion and eye irritation in sulphate participants. Historical records reveal similar health effects reported in Europe after the 1783 eruption of Laki Volcano in Iceland: eye sensitivity, sore throat, bronchitis, headache and asthma-like exacerbations.43 Current and former smokers may experience more detrimental effects than non-smokers from volcanic sulphurous air pollution. Chronic bronchitis is diagnosed by clinical presentation and history. Although reported chronic bronchitis was not signicant, using the diagnostic criteria of a cough along with phlegm for 3 months or more in at least 2 consecutive years,44,45 the sulphateexposed group had considerably increased odds (adjusted OR 7.96, 95%CI 2.1629.39). Repeated irritation from smoking combined with air pollution perpetuates chronic inammatory processes that potentially lead to lung disease.44

Major ndings
These results support current hypotheses38 that air pollution is associated with adverse cardiovascular functioning. Faster mean pulse rates were measured in exposed participants when restricting the effects of smoking, medication and BMI, and faster pulse rates were also found in exposed elders. Short-term exposure to PM10 has been associated with a delayed increase in pulse rate in elderly subjects,31 and SO2 has been associated with changes in heart rate variability.39 Elevated systolic BP has also been associated with exposure to SO2 and PM in mixed pollutant environments.40,41 This study found signicantly elevated mean systolic BP in exposed normal-weight participants, suggesting an association between BP and sulphurous air pollution that is independent of an elevated BMI cardiac risk. The sample size was insufcient to assess smoking and medication effects on this nding. Chronic exposure to volcanogenic sulphurous air pollution was associated with increased respiratory symptoms, regardless of chemical species. The location of airway exposure is dependent on nasal vs mouth breathing. A high prevalence of rhinorrhoea indicates the use of nasal defence mechanisms to the irritants. Breathing SO2 through the nose lters out up to 99% of the gas, but also increases nasal congestion.4 If the nose becomes blocked by vascular congestion, mouth breathing may occur, potentially exposing the larynx and lower respiratory tract to more of the irritants.42

Clinical practice and public health promotion

The authors recommend further investigation and public health interventions at Kilauea Volcano and other degassing volcanoes located near residential areas. An important risk factor for cardiovascular disease is systolic BP 4140 mmHg in people over 50 years of age;29 a guideline exceeded by 48% of exposed participants. Prehypertension,29 a risk for hypertension with recommended health counselling, was observed in 29% of exposed participants. Cardiovascular assessments and pulmonary function testing would allow for early diagnosis and, if appropriate, initiation of treatment. Patients with diagnosed asthma or hypertension should be encouraged to comply with treatment regimens to reduce disease progression. Smoking prevention

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Cardiorespiratory health effects associated with sulphurous volcanic air pollution and cessation are likely to be the most effective interventions for exposed residents. Eruption continues at Kilauea Volcano. Environmental ndings24 and public concern prompted the State of Hawaii to pass legislation to monitor air quality in exposed areas.46 Temporal exposure patterns can be assessed with continual monitoring; a key to designing interventions (e.g. hours for outdoor activity with lowest exposure). Success has occurred at Japans Mt. Oyama, where residents received education and employ prevention measures.47 It is concluded that long-term residency in degassing volcanic areas may have an adverse effect on cardiorespiratory health in adults. Further investigations to evaluate health effects are vital for the growing populations that reside near active volcanoes. 819

Acknowledgements
The authors wish to thank: international health specialist Dr. Chunhuei Chi; air physicist Dr. Raymond Chuan; IAVCEI volcanologists Dr. Anita Grunder and Dr. Anthony Longo; toxicologist Dr. Cathy Neumann; Big Island pulmonologist Dr. Benjamin Ono; Dr. Jennifer Orme-Zavaletta (EPA); Dr. Jackie Paulson, RN; the Hawaiian Volcano Observatory; and the Kau Hospital physicians. Ethical approval Institutional Review Board Approval of Oregon State University. Funding None declared. Competing interests None declared.

References
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