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Janneane F. Gent, PhD; Elizabeth W. Triche, PhD; Theodore R. Holford, PhD; Kathleen Belanger, PhD; Michael B. Bracken, PhD; William S. Beckett, MD; Brian P. Leaderer, PhD

JAMA. 2003;290:1859-1867.

Context  Exposure to ozone and particulate matter of 2.5 µm or less (PM_2.5) in air at levels above current US Environmental Protection Agency (EPA) standards is a risk factor for respiratory symptoms in children with asthma.

Objective  To examine simultaneous effects of ozone and PM_2.5 at levels below EPA standards on daily respiratory symptoms and rescue medication use among children with asthma.

Design, Setting, and Participants  Daily respiratory symptoms and medication use were examined prospectively for 271 children younger than 12 years with physician-diagnosed, active asthma residing in southern New England. Exposure to ambient concentrations of ozone and PM_2.5 from April 1 through September 30, 2001, was assessed using ozone (peak 1-hour and 8-hour) and 24-hour PM_2.5. Logistic regression analyses using generalized estimating equations were performed separately for maintenance medication users (n = 130) and nonusers (n = 141). Associations between pollutants (adjusted for temperature, controlling for same- and previous-day levels) and respiratory symptoms and use of rescue medication were evaluated.

Main Outcome Measures  Respiratory symptoms and rescue medication use recorded on calendars by subjects' mothers.

Results  Mean (SD) levels were 59 (19) ppb (1-hour average) and 51 (16) ppb (8-hour average) for ozone and 13 (8) µg/m³ for PM_2.5. In copollutant models, ozone level but not PM_2.5 was significantly associated with respiratory symptoms and rescue medication use among children using maintenance medication; a 50-ppb increase in 1-hour ozone was associated with increased likelihood of wheeze (by 35%) and chest tightness (by 47%). The highest levels of ozone (1-hour or 8-hour averages) were associated with increased shortness of breath and rescue medication use. No significant, exposure-dependent associations were observed for any outcome by any pollutant among children who did not use maintenance medication.

Conclusion  Asthmatic children using maintenance medication are particularly vulnerable to ozone, controlling for exposure to fine particles, at levels below EPA standards.

Author Affiliations: Center for Perinatal, Pediatric, and Environmental Epidemiology, Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Conn (Drs Gent, Triche, Holford, Belanger, Bracken, and Leaderer); Department of Environmental Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY (Dr Beckett).

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