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Summary: Effects of Ambient Air Pollution on Emergency Room Visits of Children for Acute Respiratory Symptoms in Delhi, India

Yadav et al., Environmental Science and Pollution Research (2021), 28:45853-45866

Background and Objective

Delhi is among the world's most air-polluted cities, with PM2.5 annual mean levels of 209 µg/m³ reported in 2017. Children are particularly vulnerable to air pollution due to developing lungs, higher respiration rates, and greater outdoor activity. Despite existing evidence from Europe, America, and China, similar studies from India were scarce. This study aimed to quantify the association between daily ambient air pollutant concentrations and emergency room visits (ERV) among children in Delhi for acute respiratory symptoms.

Methods

This time-series study was conducted from June 2017 to February 2019 at two major Delhi hospitals: All India Institute of Medical Sciences (AIIMS) and Kalawati Saran Children's Hospital (KSCH). Children aged ≤15 years with acute respiratory symptoms (onset ≤2 weeks) residing continuously in Delhi for at least 4 weeks were enrolled. Daily concentrations of six pollutants - PM10, PM2.5, NO2, SO2, CO, and O3 - were sourced from four continuous ambient air quality monitoring stations operated by the Delhi Pollution Control Committee.
Statistical analysis used K-means machine learning clustering to categorise all 674 study days into three air quality clusters (high, moderate, low pollution). Multi-pollutant generalised additive models (GAM) with a Poisson link function were applied to estimate lagged associations (same day through previous 6 days) between pollutant exposures and daily ERV counts, adjusting for temperature, relative humidity, day of the week, and public holidays.

Results

Of 132,029 children screened, 19,120 were enrolled. The median age was 1.1 years; 66% were boys. The most common symptoms were cough (98%), difficulty breathing (84%), and nasal symptoms (83%).
Cluster analysis showed a 29% increase in the proportion of children with acute respiratory ERV on high-pollution cluster days, and a 21% increase on moderate-pollution days, compared to low-pollution days - with effects persisting for up to 6 days after exposure.
Individual pollutant effects (multi-pollutant model):
  • NO2: 1.50% (95% CI: 0.76, 2.25) increase in respiratory ERV per 10 µg/m³ rise, with a 1-day lag (delayed effect, consistent with patients managing symptoms at home initially).
  • SO2: 13.15% (9.95, 16.45) increase per 10 µg/m³ on the same day (immediate irritant effect).
  • CO: 46.78% (21.01, 78.05) increase per 10 mg/m³ at a 3-day lag (largest single-pollutant effect).
  • O3: Negative association (-4.58%) with respiratory ERV, possibly due to scavenging by roadside nitric oxide or individuals seeking care before peak ozone levels.
  • PM2.5: Lost significance in the multi-pollutant model, possibly because high-pollution days prompt protective behaviours (mask use, staying indoors).

Limitations

  • Air quality data from only four fixed monitoring stations may not capture personal exposure accurately.
  • The study period of 21 months limits statistical power.
  • Only two hospitals covered; multi-hospital, longer-duration studies are needed.

Conclusion

Short-term exposure to ambient air pollution - particularly SO2, NO2, and CO - significantly increases daily ER visits by children for acute respiratory symptoms in Delhi, with effects lasting up to six days after exposure. The findings support targeted hospital preparedness and public health policies on bad air quality days, and provide a basis for predictive tools to warn vulnerable populations ahead of high-pollution episodes.
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