Environmental Pollution 231 (2017) 1344e1350

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Environmental Pollution
journal homepage: www.elsevier.com/locate/envpol

Air pollution and outpatient visits for conjunctivitis: A case-crossover

study in Hangzhou, China*
Qiuli Fu a, 1, Zhe Mo b, 1, Danni Lyu a, Lifang Zhang a, Zhenwei Qin a, Qiaomei Tang a,
Houfa Yin a, Peiwei Xu b, Lizhi Wu b, Xiaoming Lou b, Zhijian Chen b, **, Ke Yao a, *
a
Eye Center of the 2nd Affiliated Hospital, School of Medicine, Zhejiang Provincial Key Lab of Ophthalmology, Hangzhou, Zhejiang Province, China
b
Department of Environmental and Occupational Health, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, Zhejiang Province,
China

a r t i c l e i n f o a b s t r a c t

Article history: BACKGROUND: Conjunctivitis, one of the most common ocular surface diseases, can be caused by many
Received 6 August 2017 factors.
Received in revised form OBJECTIVES: The objective of this study was to investigate the potential association between conjunc-
30 August 2017
tivitis and air pollutants.
Accepted 30 August 2017
Available online 22 September 2017
MATERIALS AND METHODS: Data of 9737 outpatient visits for conjunctivitis from July 1, 2014 to June 30,
2016 were obtained from the Eye Center of the Second Affiliated Hospital of Zhejiang University School of
Medicine, Hangzhou, China. The data were linked to data on the concentrations of carbon monoxide
Keywords:
Air pollution
(CO), nitrogen dioxide (NO2), ozone (O3), sulfur dioxide (SO2), and fine particulate matter with a median
Conjunctivitis aerometric diameter of less than 10 and 2.5 mm (PM10 and PM2.5, respectively), which were obtained
Pollutants from the Environmental Protection Department of Zhejiang Province. A time-stratified case-crossover
Case-crossover study study design and conditional logistic regression were applied to analyze the association between air
pollutants and outpatient visits for conjunctivitis.
RESULTS: A 10 mg/m3 increase in PM10, PM2.5, SO2, NO2, and CO concentrations on the same day as the
hospital visit or on lag days before the hospital visit date was associated with outpatient visits for
conjunctivitis. The strongest association was observed between SO2 and conjunctivitis patients aged 2e5
years. Variation occurs between warm and cold seasons, between genders, and among different age
groups.
CONCLUSIONS: Our study provided evidence that outpatient visits for conjunctivitis were significantly
associated with air pollution in Hangzhou, China.
© 2017 Elsevier Ltd. All rights reserved.

1. Introduction
Like other large regions such as the Beijing-Tianjin-Hebei area
and the Pearl River Delta region, the Yangtze River Delta (YRD)
region, where Hangzhou is located, is one of the most socioeco-
nomically developed and rapidly urbanizing city clusters in eastern
* sociation between air pollution and ocular diseases such as
This paper has been recommended for acceptance by David Carpenter.
* Corresponding author. Eye Center of the 2nd Affiliated Hospital, Medical College
of Zhejiang University, Hangzhou 310009, Zhejiang Province, China.
** Corresponding author. Department of Environmental and Occupational Health,
Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou 310051,
Zhejiang Province, China.
E-mail addresses: zhjchen@cdc.zj.cn (Z. Chen), xlren@zju.edu.cn (K. Yao).
1
Q.F. and Z.M. contributed equally to this work.
China (Ming et al., 2017). With the improvement of living stan-
dards, increasing attention has been paid to air pollution caused by
industrialization because of its adverse effects on human health
([Anonymous] 2014). Increasing evidence has shown the significant
effects of air pollution on cardiovascular and chronic cardiopul-
monary morbidity and mortality, as well as on semen quality in
males (Guo et al., 2009; Ma et al., 2011; Wu et al. 2010, 2017; Yang
et al., 2012). However, only a few studies have focused on the as-
conjunctivitis (Chang et al., 2012; Hong et al., 2016; Jalbert and
Golebiowski, 2015; Li et al., 2016; Mimura et al., 2014; Nucci
et al., 2016; Szyszkowicz et al., 2012).
The conjunctiva, which lines the inside of the eyelids and covers
the sclera, is composed of non-keratinized, both stratified squamous
and stratified columnar epithelium, together with interspersed

https://doi.org/10.1016/j.envpol.2017.08.109
0269-7491/© 2017 Elsevier Ltd. All rights reserved.
 Q. Fu et al. / Environmental Pollution 231 (2017) 1344e1350
goblet cells. As it is highly vascularized and constantly exposed to the
external environment, the conjunctiva is vulnerable to various
harmful factors such as viruses, bacteria, allergens, and chemicals,
thereby resulting in conjunctivitis. In the United States, three to six
million people suffer from conjunctivitis per year (Azari and Barney,
2013; NEI, 2015). Unlike other organs, the ocular surface has its own
protection and cleansing mechanisms, which mainly refer to the thin
tear film secreted by the lacrimal glands and the conjunctiva,
contributing to immune surveillance and preventing harmful sub-
stances from entering the eyes (London Eye Center, 2003). Never-
theless, this protection barrier could easily be broken down by both
acute and chronic external factors such as air pollution, leading to
symptoms such as redness, swelling, watering, burning, itchiness,
and pain (Azari and Barney, 2013). People living in areas with severe
air pollution frequently experience these symptoms, thus increasing
the probability of emergency department and outpatient visits for
conjunctivitis (Camara and Lagunzad, 2011; Chang et al., 2012; Li
et al., 2016; Szyszkowicz et al., 2016).
Only a few epidemiological studies have been conducted to
evaluate the relationship between air pollution and conjunctivitis
(Chang et al., 2012; Hong et al., 2016; Mimura et al., 2014). In
Mimura's study, 3002 patients were recruited in Tokyo, Japan; their
findings over a period of six months suggested that fine particulate
matter with a median aerometric diameter of less than 2.5 mm
(PM2.5) played a role in the development of allergic conjunctivitis
during the non-pollen season (Mimura et al., 2014). Chang et al.
found that air pollutants including nitrogen dioxide (NO2), ozone
(O3), sulfur dioxide (SO2), and fine particulate matter with a median
aerometric diameter of less than 10 mm (PM10) increased the chance
of outpatient visits for nonspecific conjunctivitis in Taiwan.
Although their study used a case-crossover design, it did not
evaluate the association between multiple pollutants and outpa-
tient visits for conjunctivitis, as well as the effects of air pollution in
specific conditions or specific groups (Chang et al., 2012). Similar
results were observed in Hong's study, which found that higher
levels of ambient NO2, O3, and temperature increased the chances
of outpatient visits for allergic conjunctivitis in Shanghai, China
(Hong et al., 2016).
Several studies have evaluated the air pollution level and its
effects on health in Hangzhou City which is one of the largest cities
in the YRD region. Ming et al. thoroughly analyzed the chemical
composition, seasonal variation, and toxicity of PM2.5 at four sites in
the YRD region, including Hangzhou (Ming et al., 2017). Lu et al.
mainly focused on seasonal variations of PM2.5-bound polycyclic
aromatic hydrocarbons, which are acknowledged as an air
pollutant (Lu et al., 2008). Health problems caused by air pollution
in Hangzhou have gained much attention because of the resulting
financial burden and increasing number of outpatient and emer-
gency department visits, as Shen et al. reported in their study about
the cost of the increase in respiratory diseases due to severe air
pollution (Shen et al., 2017).
Our previous study in biomedical science showed that air pol-
lutants (specifically PM2.5 collected in Hangzhou) significantly
inhibited the viability and proliferation of ocular surface epithelial
cells (human corneal epithelial cells or HCECs); the study also
found that the interference of autophagy activity may be one of the
potential treatments for air pollutanteinduced ocular surface dis-
eases (Fu et al., 2017). To investigate the adverse effects of air pol-
lutants on ocular surface diseases in Hangzhou using an
epidemiological study, we applied a time-stratified case-crossover
study design to estimate the effects of ambient air pollution on
outpatient visits for conjunctivitis in Hangzhou. Our hypothesis is
that the likelihood of outpatient visits for conjunctivitis increases as
the ambient air pollutant concentrations increase, since exposure
to air pollutants may be an important risk factor for conjunctivitis.
1345
2. Materials and methods
2.1. Air pollution and meteorology data
Air pollution data from July 1, 2014 to June 30, 2016 were ob-
tained from the Environmental Protection Department of Zhejiang
Province using urban background fixed air-quality monitors from
eight stations covering the main city: Hemuxiaoxue (HMXX), Xixi
(XX), Yunxi (YX), Zhejiangnongda (ZJND), Binjiang (BJ), Xiasha (XS),
Wolongqiao (WLQ), and Zhaohuiwuqu (ZJWQ). Data on the loca-
tions, latitude, and longitude of the stations are provided (see Fig. 1
and Table S1). The mean 24-h values for PM2.5, PM10, SO2, NO2, and
carbon monoxide (CO), as well as the 8-h maximum value for O3,
were collected and analyzed. Meteorology data including the daily
mean temperature, relative humidity, and atmospheric pressure
were provided by the Meteorological Administration of Zhejiang
Province.
2.2. Outpatient visit data
Data on outpatient visits from July 1, 2014 to June 30, 2016 were
obtained from the Eye Center of the Second Affiliated Hospital at
the School of Medicine in Zhejiang University (Hangzhou, Zhejiang
Province, China), which is the biggest ophthalmology clinic in
Zhejiang Province. Most patients with ophthalmologic diseases
living in Hangzhou or the surrounding regions prefer to visit this
hospital. The ethics committee of Zhejiang University approved all
the procedures performed in this study.
Data on the daily general outpatient visits (excluding emergency
department visits) were obtained, including the date of the visits;
the age, gender, and home address (including the ZIP code) of the
outpatients; whether the visit was the patient's first visit or a
revisit; and diagnosis of conjunctivitis using the International
Classification of Diseases, 10th Revision including H10.901, H10.301,
and H10.402. Detail of the hospital location is provided (see Fig. 1
and Table S1).
2.3. Statistical analysis
A p-value less than 0.05 was considered significant in the sta-
tistical analysis. The associations between ambient air pollutants
and outpatient visits for conjunctivitis were analyzed using a time-
stratified case-crossover approach, which is suitable for studying
individual exposure, the disease process, and an induction period
with short time intervals. As the design takes the subjects as self-
controls, it is widely accepted in air pollution studies and other
epidemiological studies (Ding et al., 2017; Zemek et al., 2010).
“Time-stratified” denotes the method of comparing the concen-
trations of air pollutants on the day of the hospital visit for
conjunctivitis with the concentrations on other days on the same
week day of this month.
Descriptive statistics and correlation coefficients were obtained
for outpatients, air pollutants, and meteorological factors using SAS
9.4 software (Cary, NC, USA). Spearman's correlation was used to
evaluate the correlation between air pollutants and meteorological
factors.
Patients were divided into five age groups: 0e1, 2e5, 6e18,
19e64, and
65, and two gender groups: male and female. The
whole year was divided into two seasons, warm season (April to
September) and cold season (January to March and October to
December), according to the seasonal characteristics of Hangzhou.
The data analysis of outpatient visits for conjunctivitis was
performed as follows. First, only the first outpatient visits
(n ¼ 15,217) without missing information were included; revisits
(n ¼ 22,728) were excluded. Second, based on the latitude and
1346 Q. Fu et al. / Environmental Pollution 231 (2017) 1344e1350

Fig. 1. Locations of environmental monitoring stations and hospital in HZ of Zhejiang Province, China. The location of each air-quality monitor was labeled by red points; the
location of the hospital was labeled by the brown point; the home address of each patient recruited was labeled by the black point. HMXX: Hemuxiaoxue; XX: Xixi; YX: Yunxi;
ZJND: Zhejiangnongda; BJ: Binjiang; XS: Xiasha; WLQ: Wolongqiao; ZJWQ: Zhaohuiwuqu.

longitude of the patients' home addresses, which were obtained by pollutants; and b refers to the coefficient for each covariate. Results
package Baidu Map version 0.2 in R, only the patients (n ¼ 11,264) are expressed as changes in the percentage and 95% confidence
living in the main districts of Hangzhou, including Shangcheng, interval (CI) of outpatient visits per 10 mg/m3 increase in pollutants.
Xiacheng, Jianggan, Xihu, Gongshu, and Binjiang, were included. In our study, the acute effects of air pollution were analyzed
Third, since most of the patients live near the hospital (Fig. 1), the with both single-day lags (lag 0 to lag 7) and successive-day lags
data of the patients who live within 5 (n ¼ 7269) or 10 (n ¼ 9737) (lag 0e1 to lag 0e7). We defined same-day exposure as lag 0 and
kilometers from the hospital were included in the analysis. Fourth, examined daily exposure for up to seven days before the outpatient
the distance between the patient's home and the location of the air- visits. In lag models, the best lag periods were obtained according
quality monitor was calculated using SoDA version 1.0e6, and the to the maximum values of odds ratios and the minimum values of p.
corresponding air pollution data for each patient were obtained
from the nearest monitor. Fifth, as a preliminary analysis, consid- 3. Results
ering the two different ranges of the distance between the patient's
home and the hospital (within 5 or 10 km), two models were used In the present study, slightly more than half (57.6%) of the
to analyze the odds ratios (O'Donnell et al., 2011) of six air pollut- recruited patients were female, and the majority (72.6%) of the
ants (PM2.5, PM10, SO2, NO2, CO and O3). Based on the results (see patients were 19e64 years old (Table 1). More cases of conjuncti-
Figures S1 to S2), the model of 10 km was chosen for the data vitis (56.6%) were diagnosed in the cold season than in the warm
analysis, as it was the most reasonable and stable model. season (43.4%) (Table 1).
Conditional logistic regression using a Cox proportional hazards
regression model was performed with SAS 9.4 software to calculate
Table 1
the odds ratios (O'Donnell et al., 2011) using the number of daily
Characteristics of outpatient for conjunctivitis in Eye Center of the 2nd Affiliated
conjunctivitis outpatient visits as weights after case controls were Hospital of ZJU (7/1/2014 to 6/30/2016).
selected and matched by the program.
Characteristics Number of patients Percentage (%)
Meteorological factors that may lead to the exacerbation of
conjunctivitis and air pollutant levels were viewed as covariates in Sex
Male 4126 42.4
the model. The model is as follows:
Female 5611 57.6
Age (years)
ln(h(t, X)) ¼ ln(h0i(t)) þ (Tß1 þ RHß2 þ Pß3 þ C(PM10)b4 þ C(PM2.5) 0-1 383 3.9
b5 þ C(SO2)b6 þ C(NO2)b7 þ C(O3)b8 þ C(CO)b9) 2-5 792 8.1
6-18 1063 10.9
19-64 7069 72.6
where t refers to the day; X refers to the hospital visit; ln(h(t, X))
65- 430 4.4
refers to the risk function; ln(h0i(t)) refers to the baseline risk Season
function; T, RH, and P refer to the temperature, relative humidity, Warm season 4227 43.4
and atmospheric pressure, respectively; C(PM10), C(PM2.5), C(SO2), Cold season 5510 56.6
C(NO2), C(O3), and C(CO) are the corresponding concentrations of Total patients 9737 100.0
 Q. Fu et al. / Environmental Pollution 231 (2017) 1344e1350 1347

Table 2
Information of air pollutants and meteorological factors (2014e2016).

Variable Mean Standard Deviation Minimum P25 P50 P75 Maximum

PM10 (mg/m3) 85.7 46.5 4.0 51.0 76.0 111.0 375.0

PM25 (mg/m3) 56.2 32.7 3.0 33.0 49.0 72.0 264.0
SO2 (mg/m3) 15.3 9.9 3.0 8.0 13.0 19.0 94.0
NO2 (mg/m3) 47.9 20.8 2.0 33.0 46.0 61.0 143.0
O3 (mg/m3) 66.2 44.1 1.0 34.0 57.0 87.0 312.0
CO (mg/m3) 0.9 0.3 0.0 0.7 1.0 1.0 3.0
Temperature ( C) 17.9 8.4 5.0 10.8 19.3 24.5 34.4
Relativehumidity(%) 74.6 13.8 27.0 66.0 76.0 85.0 98.0
Pressure (hpa) 1011.3 8.9 989.3 1003.7 1010.8 1018.5 1036.6

The mean, standard deviation, minimum, 25th and 75th per-
centiles, median, and maximum of the daily average concentrations
of the ambient air pollutants (SO2, NO2, CO, O3, and PM) and
meteorological factors (temperature, relative humidity, and pres-
sure) are shown in Table 2. The daily 24-h mean concentrations of
SO2, NO2, CO, PM10, and PM2.5 were 15.3, 47.9, 0.9, 85.7, and 56.2 mg/
m3, respectively. The daily 8-h mean concentration of O3 was
66.2 mg/m3.
The correlations between air pollutants and weather variables
were also analyzed. In addition to the strong correlation between
PM10 and PM2.5 (r ¼ 0.90, p < 0.0001), there were also correlations
between PMs and other pollutants or between different pollutants.
As shown in Table 3, NO2 concentration was strongly correlated
with the concentrations of PM10 (r ¼ 0.65, p < 0.0001), PM2.5
(r ¼ 0.62, p < 0.0001), SO2 (r ¼ 0.53, p < 0.0001), and CO (r ¼ 0.47,
p < 0.0001). PM10 and PM2.5 were correlated with SO2 (r ¼ 0.55,
p < 0.0001 and r ¼ 0.54, p < 0.0001, respectively). PM10 and PM2.5
were also correlated with CO (r ¼ 0.49, p < 0.0001 and r ¼ 0.55,
p < 0.0001, respectively).
To investigate the association between single pollutants and
outpatient visits for conjunctivitis, the single-pollutant model was
applied. The results showed significant associations between
outpatient visits for conjunctivitis and a 10 mg/m3 increase in the
concentrations of PM10, PM2.5, SO2, NO2, and CO (Table 4). We
observed significant associations between outpatient visits for
conjunctivitis and PM10 in lags of 0, and 0e1days (OR ¼ 1.0068, 95%
CI: 1.0011, 1.0124; OR ¼ 1.0077, 95% CI: 1.0011, 1.0145, respectively).
We also observed a significant association between outpatient
visits for conjunctivitis and PM2.5 on lag 0, 5, and 0e1 days
(OR ¼ 1.0092, 95% CI: 1.0002, 1.0183; OR ¼ 0.9905, 95% CI: 0.9817,
0.9993; OR ¼ 1.0107, 95% CI: 1.0002, 10213, respectively).
Significant associations were discovered between outpatient
visits for conjunctivitis and a 10 mg/m3 increase in the concentra-
tion of SO2 in lags of 0, 6, 7, and 0e1 days (OR ¼ 1.0418, 95% CI:
1.0046, 1.0803; OR ¼ 0.9553, 95% CI: 0.9234, 0.9883; OR ¼ 0.9627,
95% CI: 0.9307, 0.9958; and OR ¼ 1.0480, 95% CI: 1.0040, 1.0939,
respectively). Strong associations were revealed between outpa-
tient visits for conjunctivitis and NO2 in lags of 0, 1, 7, 0e1, 0e2,

Table 3
Spearman's correlation between different pollutants and meteorological factors.

PM10 PM2.5 SO2 NO2 O3 CO Temperature Relative humidity Pressure

PM10 1
PM2.5 0.90** 1
SO2 0.55** 0.54** 1
NO2 0.65** 0.62** 0.53** 1
O3 0.08** 0.01 0.05** 0.23** 1
CO 0.49** 0.55** 0.22** 0.47** 0.22** 1
Temperature 0.28** 0.35** 0.34** 0.39** 0.47** 0.23** 1
Relative humidity 0.28** 0.15** 0.35** 0.05** 0.33** 0.09** 0.11** 1
Pressure 0.30** 0.32** 0.39** 0.38** 0.37** 0.19** 0.89** 0.26** 1

**P < 0.01.

Table 4
Correlation of air pollutants and outpatients for conjunctivitis: Single-pollutant model.

Lag PM10 PM2.5 SO2 NO2 O3 CO

0 1.0068(1.0011e1.0124) * 1.0092(1.0002e1.0183) * 1.0418(1.0046e1.0803) * 1.0287(1.0139e1.0436) ** 1.0063(0.9961e1.0165) 1.0013(1.0003e1.0022) **

1 1.0044(0.9987e1.0101)
2 1.0000(0.9945e1.0055)
3 1.0034(0.9979e1.0089)
4 0.9967(0.9911e1.0023)
5 0.9959(0.9904e1.0014)
6 0.9964(0.9910e1.0018)
7 0.9997(0.9943e1.0051)
0e1 1.0077(1.0011e1.0145) * 1.0107(1.0002e1.0213) * 1.0480(1.0040e1.0939) *
0e2 1.0066(0.9990e1.0141)
0e3 1.0078(0.9996e1.0161)
0e4 1.0056(0.9968e1.0145)
0e5 1.0033(0.9939e1.0128)
0e6 1.0014(0.9914e1.0114)
0e7 1.0013(0.9907e1.0120)
1.0066(0.9975e1.0158) 1.0232(0.9891e1.0584) 1.0326(1.0171e1.0484) ** 1.0014(0.9921e1.0108) 1.0007(0.9997e1.0016)
0.9989(0.9899e1.0080) 1.0082(0.9746e1.0431) 1.0135(0.9986e1.0286) 0.9964(0.9875e1.0054) 1.0002(0.9993e1.0011)
1.0009(0.9920e1.0100) 1.0001(0.9668e1.0346) 1.0125(0.9978e1.0275) 0.9958(0.9868e1.0048) 1.0004(0.9995e1.0013)
0.9916(0.9825e1.0007) 0.9686(0.9365e1.0018) 0.9995(0.9848e1.0144) 0.9992(0.9902e1.0084) 0.9999(0.9990e1.0008)
0.9905(0.9817e0.9993) * 0.9723(0.9398e1.0060) 0.9950(0.9804e1.0098) 1.0006(0.9916e1.0098) 0.9999(0.9990e1.0008)
0.9922(0.9834e1.0010) 0.9553(0.9234e0.9883) ** 0.9883(0.9738e1.0031) 1.0039(0.9949e1.0129) 1.0003(0.9994e1.0011)
0.9959(0.9870e1.0047) 0.9627(0.9307e0.9958) * 0.9821(0.9676e0.9968) * 1.0031(0.9941e1.0122) 0.9996(0.9987e1.0004)
1.0403(1.0228e1.0581) ** 1.0056(0.9936e1.0177) 1.0014(1.0004e1.0024) **
1.0083(0.9965e1.0202) 1.0466(0.9970e1.0986) 1.0430(1.0230e1.0633) ** 1.0018(0.9887e1.0152) 1.0016(1.0005e1.0027) **
1.0079(0.9951e1.0209) 1.0411(0.9878e1.0972) 1.0465(1.0244e1.0692) ** 0.9987(0.9845e1.0131) 1.0016(1.0004e1.0027) **
1.0035(0.9898e1.0173) 1.0192(0.9636e1.0780) 1.0434(1.0194e1.0679) ** 0.9983(0.9828e1.0139) 1.0014(1.0002e1.0026) *
0.999(0.98460e1.0136) 1.0035(0.9454e1.0651) 1.0385(1.0132e1.0645) ** 0.9987(0.9822e1.0156) 1.0012(0.9999e1.0025)
0.9956(0.9804e1.0110) 0.9806(0.9205e1.0446) 1.0321(1.0052e1.0597) * 1.0005(0.9828e1.0185) 1.0012(0.9998e1.0025)
0.9940(0.9780e1.0104) 0.9622(0.8996e1.0292) 1.0234(0.9951e1.0526) 1.0021(0.9833e1.0213) 1.0010(0.9996e1.0024)

*P < 0.05, **P < 0.01.

1348 Q. Fu et al. / Environmental Pollution 231 (2017) 1344e1350

Table 5
Correlation of air pollutants and outpatients for conjunctivitis: Multipollutant model.

PM10 PM2.5 SO2 NO2 O3 CO

Adjusted for PM10 e e 1.0247(0.9812 1.0296(1.0131 1.0048(0.9946 1.0011(1.0000

e1.0701) e1.0465) ** e1.0151) e1.0023) *
Adjusted for PM2.5 e e 1.0299(0.9871 1.0307(1.0141 1.0044(0.9941 1.0012(1.0001
e1.0747) e1.0475) ** e1.0149) e1.0024) *
Adjusted for SO2 1.0047(0.9980 1.0054(0.9950 e 1.0304(1.0147 1.0053(0.9951 1.0011(1.0002
e1.0114) e1.0160) e1.0464) ** e1.0156) e1.0021) *
Adjusted for NO2 1.0030(0.9970 1.0032(0.9936 1.0275(0.9901 e 1.0069(0.9967 1.0009(0.9999
e1.0091) e1.0128) e1.0663) e1.0171) e1.0019)
Adjusted for O3 1.0067(1.0010 1.0089(0.9997 1.0408(1.0035 1.0324(1.0169 e 1.0013(1.0003
e1.0124) * e1.0181) e1.0795) * e1.0482) ** e1.0022) **
Adjusted for CO 1.0013(0.9944 1.0003(0.9894 1.0248(0.9866 1.0284(1.0123 1.0064(0.9963 e
e1.0082) e1.0113) e1.0644) e1.0447) ** e1.0167)
Adjusted for the other 4 0.9949(0.9867 0.9889(0.9759 1.0313(0.9879 1.0312(1.0144 1.0085(0.9980 1.0013(1.0001
pollutants e1.0032) e1.0020) e1.0765) e1.0482) ** e1.0192) e1.0025) *

*P < 0.05, **P < 0.01.

0e3, 0e4, 0e5, and 0e6 days, as well as between outpatient visits
for conjunctivitis and CO in lags of 0, 0e1, 0e2, 0e3, and 0e4 days
(see Table 4). These results are consistent with the previous finding
that NO2 was correlated with CO (Table 3). In this model, no sig-
nificant association was found between O3 and outpatient visits for
conjunctivitis.
As previously mentioned, PM2.5 and PM10 were highly corre-
lated (r ¼ 0.90) (Table 3). Given that results obtained by concurrent
predictors may lack reliability, only PM2.5 was selected for the
multipollutant model, as its odds ratio for conjunctivitis outpatient
visits was higher than that of PM10 (Table 3). Levels of pollutants in
the best lags were chosen for this model, and meteorological var-
iables were included as control variables. NO2 was strongly asso-
ciated with outpatient visits for conjunctivitis even after adjusting
for the other six factors. Neither SO2 nor CO were significantly
associated with conjunctivitis outpatient visits after adjusting for
NO2, indicating the vital role of NO2 in outpatient visits for
conjunctivitis (Table 5).
Different effects of air pollutants in certain conditions or certain
groups were also analyzed. A significant association between
outpatient visits for conjunctivitis and PM10 and NO2 was only
observed among females, while the association between SO2 and
outpatient visits for conjunctivitis was only significant among
males. No significant association was observed between outpatient
visits for conjunctivitis and PM2.5, CO and O3 for both genders
(Table 6). PM10 was strongly associated with outpatient visits for
conjunctivitis in patients aged 19e64. The association between SO2
and outpatient visits for conjunctivitis was significant in patients
aged 2e5, while the association between NO2 and outpatient visits
for conjunctivitis was significant in patients aged 19e64. The as-
sociation between CO and outpatient visits for conjunctivitis was
also significant in patients aged 19e64 (Table 6). Lastly, PM10, SO2,
and CO were strongly correlated with outpatient visits for
conjunctivitis in the warm season, while NO2 were significantly
associated with outpatient visits for conjunctivitis in the cold sea-
son, when air pollution was more severe (Table 6).
4. Discussion
In this study, significant associations were observed between
various ambient air pollutants and outpatient visits for conjuncti-
vitis among 9737 patients in Hangzhou, China. The number of
outpatient visits for conjunctivitis increased along with a 10 mg/m3
increase in the concentrations of PM10, PM2.5, SO2, NO2, and CO,
suggesting that exposure to outdoor air pollution is an important
risk factor for conjunctivitis.

Table 6
Correlation of air pollutants and outpatients for conjunctivitis, and effect modification through stratified analyses by patients characteristics.

Characteristics PM10 PM2.5 SO2 NO2 O3 CO

Sex
Male 1.0036(0.9949e1.0123) 1.0087(0.9950 1.0761(1.0186e1.1367) 1.0214(0.9981e1.0453) 1.0072(0.9916 1.0015(1.0001e1.0030)
e1.0225) ** e1.0230)
Female 1.0090(1.0016e1.0165) 1.0097(0.9979 1.0158(0.9677e1.0663) 1.0412(1.0205e1.0622) 1.0057(0.9924 1.0010(0.9998e1.0023)
* e1.0217) ** e1.0193)
Age (years)
0-1 1.0081(0.9818e1.0351) 1.0086(0.9672 1.1058(0.9352e1.3074) 1.0430(0.9695e1.1221) 1.0192(0.9667 1.0012(0.9967e1.0058)
e1.0519) e1.0746)
2-5 1.0147(0.9945e1.0353) 1.0268(0.9956 1.1518(1.0176e1.3036) * 1.0659(1.0108e1.1240) 1.0308(0.9939 1.0006(0.9972e1.0039)
e1.0590) e1.0691)
6-18 0.9975(0.9796e1.0157) 0.9994(0.9714 1.0254(0.9128e1.1518) 1.0028(0.9567e1.0511) 1.0000(0.9724 1.0018(0.9989e1.0048)
e1.0282) e1.0284)
19-64 1.0069(1.0003e1.0135) 1.0081(0.9976 1.0259(0.9830e1.0706) 1.0321(1.0139e1.0506) 1.0040(0.9921 1.0012(1.0001e1.0023) *
* e1.0188) ** e1.0161)
65- 1.0083(0.983e1.0343) 1.0151(0.9760 1.0706(0.9013e1.2716) 1.0391(0.9685e1.1148) 1.0108(0.9604 1.0018(0.9975e1.0061)
e1.0557) e1.0639)
Season
Warm season 1.0113(1.0009e1.0218) 1.0162(0.9996 1.0772(1.0132e1.1454) * 1.0220(0.9960e1.0486) 1.0046(0.9931 1.0025(1.0010e1.0040)
* e1.0331) e1.0162) **
Cold season 1.0058(0.9990e1.0126) 1.0073(0.9966 1.0297(0.9838e1.0777) 1.0421(1.0224e1.0621) 1.0116(0.9888 1.0006(0.9994e1.0018)
e1.0181) ** e1.0349)

*P < 0.05, **P < 0.01.

 Q. Fu et al. / Environmental Pollution 231 (2017) 1344e1350
Six million people suffer from acute conjunctivitis annually in
the United States, with medical expenses ranging from $377 million
to $857 million for simply treating bacterial conjunctivitis (Azari
and Barney, 2013; Smith and Waycaster, 2009; Udeh et al., 2008).
Due to the uneven development of the regional economy in China,
which may influence living conditions and air quality, the cost of
medical care varies greatly among the regions. According to oph-
thalmologists at the Eye Center of the Second Affiliated Hospital at
the School of Medicine in Zhejiang University, the estimated cost of
the examination and management of conjunctivitis per episode is
about $30 in Hangzhou. Taking into consideration the income per
capita (about $8000 in 2016) and the reality of the health care
system in China, conjunctivitis exerts an enormous economic
burden on patients, especially those without health insurance.
Moreover, for a developing country like China, it is inevitable that
the higher the economic status reached, the more severe the air
pollution occurred. Therefore, the prevalence of conjunctivitis has
quickly increased because of the rapid development of the society
and economy in the YRD region (Hong et al., 2016). As a result,
conjunctivitis has become one of the most common causes of
medical visits and prescriptions in ophthalmology clinics.
Results of several studies have confirmed the link between air
pollution and ocular surface disorders (Torricelli et al., 2011, 2013;
West et al., 2013). Several pathophysiological mechanisms may
explain this association. First, pollutants can damage the tear film.
The cornea and the conjunctiva are merely protected by a thin tear
film against the external environment, which means that breaking
of the tear film would directly expose the corneal and conjunctival
epithelium to air pollutants, making the ocular surface vulnerable.
Previous studies have revealed that the tear break-up time (TBUT)
significantly decreased during acute episodes among subjects
affected by air pollutants when compared with the control group
(Berra et al., 2015). Second, pollutants can trigger and intensify the
immune reaction. Several studies have reported that the number
and density of goblet cells in the conjunctiva steadily increase in
subjects living under severe air pollution (Berra et al., 2015; Novaes
et al., 2007; Torricelli et al., 2011, 2014). The increase of interleukin-
6 (IL-6) and interleukin-8 (IL-8) expressions was also observed in
pollutant-treated HCECs and conjunctival epithelial cells (HCLEs)
(Tau et al., 2013; Xiang et al., 2016a). Third, pollutants can induce
cytotoxicity in both HCECs and HCLEs. Our previous study found
that PM2.5 led to decreased cell viability and proliferation ability, as
well as increased apoptosis (Fu et al., 2017). Xiang et al. reported
that house dust increased oxidative stress and caused mitochon-
drial dysfunction in human primary corneal epithelial cells (Xiang
et al., 2016a, 2016b). Diesel exhaust particles were also found to
be toxic in both HCECs and HCLEs because they selectively induced
proinflammatory cytokines and mucin production (Lasagni Vitar
et al., 2015; Tau et al., 2013). Taken together, all those mecha-
nisms may contribute to air pollutanterelated conjunctivitis.
Previous research has suggested that not all ambient air pol-
lutants contribute to conjunctivitis. Hong concluded that only
higher levels of ambient NO2 and O3 increased the chances of
outpatient visits for conjunctivitis (Hong et al., 2016). However,
Chang et al. found that in addition to NO2 and O3, the increase of air
pollutants SO2 and PM10 was also associated with outpatient visits
for nonspecific conjunctivitis (Chang et al., 2012). Another study
reported that the association between air pollutants and conjunc-
tivitis differed by genderdmore specifically, NO2 and PM2.5
increased emergency department visits for conjunctivitis among
females, while NO2, PM2.5, SO2, and O3 increased emergency
department visits for conjunctivitis among males (Szyszkowicz
et al., 2016). One epidemiological study in Japan suggested a
possible relationship between PM2.5 and allergic conjunctivitis
(Mimura et al., 2014).
1349
In the present study, we analyzed the associations between six
air pollutants (PM10, PM2.5, SO2, NO2, O3, and CO) and outpatient
visits for conjunctivitis and found that short-term exposure to
PM10, PM2.5, SO2, NO2, and CO increased the possibility of outpa-
tient visits. It is worth mentioning that PM2.5 only showed a sig-
nificant correlation with outpatient visits for conjunctivitis on lag0,
5 and 0e1 days in the single-pollutant model. One possible
explanation may involve self-clearance by dynamically secreting
tears, which could carry away the fine particles and thus minimize
their damage to the ocular surface.
This study has several strengths. First, a time-stratified case-
crossover design was applied to avoid the bias effects of the pa-
tients' socioeconomic status, educational level, living conditions,
and systemic health conditions, as every patient served as his/her
own control. Although Chang et al. investigated the association
between air pollution and nonspecific conjunctivitis in multiple
regions, they only used the case-crossover design in the analysis of
single regions. To estimate the average effect of air pollution in
multiple areas, they had to employ a random-effects meta-analysis
in their study. Additionally, they did not use a multipollutant
model, unlike in the present study (Chang et al., 2012). Second,
eight urban background fixed air-quality monitors covered the
main city of Hangzhou to ensure the representativeness of the air
pollution data for each patient, as there was always an air-quality
monitor nearby. To our knowledge, we are the first to use accu-
rate air pollution data corresponding to each patient, and not the
general air pollution data in an area, to analyze the association
between air pollutants and conjunctivitis. Third, to avoid some bias
effects, only outpatients on their first visits were recruited. Many
previous studies (Hong et al., 2016; Mimura et al., 2014) did not
take into account the bias effect of the first visit or revisit; even
Chang et al. only excluded the data of patients who revisited the
ophthalmologists within 10 days (Chang et al., 2012). Fourth, this
study considered covariates such as gender, age, and season, as well
as holiday and lag effects (0e7 days). Some previous studies only
analyzed the relationship between air pollution and conjunctivitis
in different seasons or months (Chang et al., 2012; Mimura et al.,
2014). Although Hong et al. also took lag effects into account, a
time lag of one to five weeks may be too long, as the effects of air
pollutants are considered more acute on conjunctivitis (Hong et al.,
2016).
Although the good reputation of the Eye Center of the Second
Affiliated Hospital at the School of Medicine in Zhejiang University
attracted about 50% conjunctivitis outpatient visits in Hangzhou,
some patients visited other hospitals for convenience or for other
reasons as there are several general hospitals containing ophthal-
mology department in the city. Thus, one of the limitations of this
study is that data on patients in other clinics or hospitals were not
included.
In this study, the data on air pollution corresponding to each
patient were acquired from the nearest air-quality monitor. In
future studies, more accurate data on air pollution corresponding to
each patient should be estimated by combining multiple factors
such as satellite remote sensing and land-use parameters, meteo-
rological data, geographical information, traffic distribution, and
population travel patterns. Additionally, more accurate data can
also be collected using an individual backpack system, which in-
volves a monitor fixed to a subject to collect dynamic data on air
pollution, location, and meteorology. This data can be used in future
research on the associations between air pollutants and ocular
surface diseases, thus contributing to uncovering their pathological
mechanisms and identifying potential treatments.
In conclusion, this study revealed associations between air
pollutants (PM10, PM2.5, SO2, NO2, and CO) and outpatient visits for
conjunctivitis in Hangzhou, China. Variations occur between warm
1350 Q. Fu et al. / Environmental Pollution 231 (2017) 1344e1350
and cold seasons, between genders, and among different age
groups. The results suggest that the pace of environmental gover-
nance should be accelerated through policies and laws regulating
air pollutants to reduce the cases of conjunctivitis and other ocular
surface disorders such as dry eye disease, et al.
Acknowledgements
This work has been supported by National Natural Science
Foundation of China (81371001, 81300641, 81502786, 81570822,
81670833), Project of National Clinical Key Discipline of Chinese
Ministry of Health, Zhejiang Key Laboratory Fund of China
(2011E10006), Zhejiang Province Key Research and Development
Program (2015C03042), Program of Zhejiang Medical technology
(2015KYA109, 2015KYA053, 2017KY288), Science and Technology
Program of Zhejiang (2014C03025), Science Foundation of Zhejiang
Province (LQ14H260003).
Funding
The authors declare they have no competing financial interests.
Appendix A. Supplementary data
Supplementary data related to this article can be found at
https://doi.org/10.1016/j.envpol.2017.08.109
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