2021 - Effects of PM10 Andweather On Respiratory and Cardiovascular

atmosphere
Article
Effects of PM10 and Weather on Respiratory and Cardiovascular
Diseases in the Ciuc Basin (Romanian Carpathians)
Katalin Bodor 1,2,3 , Miruna Mihaela Micheu 4 , Ágnes Keresztesi 1,2,3 , Marius-Victor Birsan 5 ,
Ion-Andrei Nita 5,6 , Zsolt Bodor 2 , Sándor Petres 7 , Attila Korodi 2,8 and Róbert Szép 1,2,3, *
1 Doctoral School of Chemistry, Faculty of Natural Sciences, University of Pécs, Ifjúság 6, 7624 Pécs, Hungary;
bodorkatalin@uni.sapientia.ro (K.B.); keresztesiagnes@uni.sapientia.ro (Á.K.)
2 Department of Bioengineering, Faculty of Economics, Socio-Human Sciences and Engineering,
Sapientia Hungarian University of Transylvania, Piaţa Libertăţii 1, 530104 Miercurea Ciuc, Romania;
bodorzsolt@uni.sapientia.ro (Z.B.); info.korodiattila@gmail.com (A.K.)
3 Institute for Research and Development of Hunting and Mountain Resources, Str. Progresului 35B,
530240 Miercurea Ciuc, Romania
4 Clinical Emergency Hospital of Bucharest, Calea Floreasca 8, 014461 Bucharest, Romania;
mirunamicheu@yahoo.com
5 Meteo Romania (National Meteorological Administration), Sos. Bucures, ti-Ploies, ti 97, 013686 Bucharest,
Romania; marius.birsan@gmail.com (M.-V.B.); nitaandru@gmail.com (I.-A.N.)
6 Faculty of Geography, Doctoral School, Alexandru Ioan Cuza University of Ias, i, Bulevardul Carol I 11,
700506 Ias, i, Romania
7 Department of Analytical Chemistry and Environmental Engineering, Politehnica University of Bucharest,
1-7 Gheorghe Polizu, 011061 Bucharest, Romania; sandor.petres@prefecturahr.ro
8 Bucharest University of Economic Studies, 6 Piat, a Romana, 010374 Bucharest, Romania

* Correspondence: szeprobert@uni.sapientia.ro
Citation: Bodor, K.; Micheu, M.M.; Abstract: This study presents the PM10 concentration, respiratory and cardiovascular disease hospital
Keresztesi, Á.; Birsan, M.-V.; Nita, admissions evolution in the Ciuc basin for a period of 9 years (2008–2016), taking into consideration
I.-A.; Bodor, Z.; Petres, S.; Korodi, A.;
different meteorological conditions: boundary layer, lifting condensation level, temperature-humidity
Szép, R. Effects of PM10 and Weather
index, and wind chill equivalent chart index. The PM10 and hospital admissions evolution showed
on Respiratory and Cardiovascular
a very fluctuated hourly, weekly, monthly, yearly tendency. The PM10 concentration in winter
Diseases in the Ciuc Basin (Romanian
(34.72 µg/m3 ) was 82% higher than the multiannual average (19.00 µg/m3 ), and almost three
Carpathians). Atmosphere 2021, 12,
289. https://doi.org/10.3390/
times higher than in summer (11.71 µg/m3 ). During the winter, PM10 concentration increased
atmos12020289 by an average of 9.36 µg/m3 due to the increased household heating. Climatological parameters
have a demonstrable effect on the PM10 concentration variation. Children, the elderly and men
Academic Editor: Hsiao-Chi Chuang are more sensitive to air pollution, the calculated relative risk for men was (RR = 1.45), and for
women (RR = 1.37), respectively. A moderate correlation (0.51) was found between PM10 and
Received: 28 January 2021 pneumonia (P), while a relatively weak correlation (0.39) was demonstrated in the case of PM10
Accepted: 18 February 2021 and upper respiratory tract infections (URTI). Furthermore, except thermal humidity index (THI),
Published: 23 February 2021 strong negative correlations were observed between the multiannual monthly mean PM10 and the
meteorological data. The PM10 followed a moderate negative correlation with the boundary layer
Publisher’s Note: MDPI stays neutral
(−0.61). In the case of URTI and P, the highest number of hospital admissions occurred with a 5 to
with regard to jurisdictional claims in
7-day lag, while the 10 µg/m3 PM10 increase resulted in a 2.04% and 8.28% morbidity increase. For
published maps and institutional affil-
lung cancer (LC) and cardiovascular diseases (AMI, IHD, CCP), a maximum delay of 5–6 months
iations.
was found. Three-month delay and an average growth of 1.51% was observed in the case of chronic
obstructive pulmonary disease (COPD). Overall, these findings revealed that PM10 was and it is
responsible for one-third of the diseases.
Copyright: © 2021 by the authors.

Keywords: PM10 ; health impact; specific atmospheric conditions; Carpathian Mountains
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
1. Introduction
creativecommons.org/licenses/by/ Ambient air pollution plays an important role in a broad spectrum of health disorders,
4.0/). emerging as a leading worldwide environmental health problem. The World Health Organi-
Atmosphere 2021, 12, 289. https://doi.org/10.3390/atmos12020289 https://www.mdpi.com/journal/atmosphere

Atmosphere 2021, 12, 289 2 of 21
zation estimates that 22% of global death and disability can be attributed to environmental
factors [1].
Epidemiological studies revealed worsening life quality and health symptoms, such
as deterioration of lung function due to elevated particle pollution levels resulting in an
increased use of medication [2–5]. Short-term symptoms from exposure to air pollution
include itchy eyes, nose and throat, wheezing, coughing, shortness of breath, chest pain,
headaches, nausea, as well as respiratory infections [6]. Long-term exposure to high concen-
trations of PM10 (particulate matter with a diameter of 10 µm or less) can result in several
health impacts and premature death like lung cancer, cardiovascular disease, chronic respi-
ratory illness, and allergies [7,8]. PM10 can reach the trachea bronchial and alveolar regions
of the respiratory tract, having a greater impact on human health. Noteworthy, specific
groups, people with cardiovascular risk factors or pre-existing cardiovascular disease
(CVD) are more vulnerable to the aforesaid harmful effects.
There is an increasing body of evidence showing air pollution as a critical risk factor
for cardio-respiratory morbidity and mortality. Numerous studies have shown that there
is a strong association between exposure to particulate matter and the increased risk of
cardiovascular and respiratory disease [9–16]. In 2004, the American Heart Association
(AHA) published a scientific statement regarding air pollution and cardiovascular disease,
concluding that particulate matter is a large contributor to cardiovascular morbidity and
mortality [12]. In 2010, the abovementioned statement was updated, providing a compre-
hensive review of new evidence linking exposure to PM with cardiovascular disease [12].
Existing statistics are based on large cohort studies conducted mostly in North Amer-
ica and Western Europe, with less information available from Eastern Europe [17–24].
According to air monitoring databases [25], people living in Eastern Europe are generally
subjected to higher levels of PM10 than those in Western Europe. The PM10 exposure on
human health shows variability, so the data cannot be extrapolated to other regions and
populations, for the reason that various specific factors such as demographic and genetic
factors, may affect the impact of PM10 on human health.
It has been shown that air particulates with a diameter of less than 10 µm (PM10 )
can reach the trachea bronchial and alveolar regions of the respiratory tract, having a
substantial impact on human health [26]. Particulate matter is often divided into two main
groups based on characteristics, sources, and potential health effects: fine particles, PM2.5
(with a diameter between 0.1 and 2.5 µm) and coarse particles, PM10-2.5 (having a diameter
between 2.5–10 µm).
In Romania, only a few studies have been published in terms of respiratory health
effects of PM10 [27]. There is an unmet need for studies addressing the burden of pollution-
attributable cardio-respiratory diseases in our country.
The purpose of this study is twofold: firstly, to analyze the temporal distribution of
ambient particulate matter (PM10 ) in the Ciuc basin over a period of 9 years (2008–2016),
and secondly, to assess the short- and long-term effects on respiratory and cardiovascular
morbidity taking into account the meteorological conditions.
2. Materials and Methods

2.1. Studied Region
The Ciuc basin is located in the middle of the Eastern Carpathians, at an altitude of
650 m, with a population of ~150,000 (Figure 1). Due to its enclosed character, the Ciuc
basin is known for its specific microclimatic and meteorological conditions, with long
episodes of static stability and thermal inversion periods, hence favoring the accumulation
of pollutants.
2.2. Air Pollution, Medical and Meteorological Data

The PM10 concentration data were obtained from the HR01 regional monitoring station
located near the municipality of Miercurea Ciuc, the “Cold Pole” of Romania [28,29],
at 46.33◦ N, 25.81◦ E, at an elevation of 697 m a.s.l. PM10 data were sampled with an
Atmosphere 2021, 12, 289 3 of 21
ere 2021, 12, x FOR PEER REVIEW

automated analyzer type LSPM10; for further analysis, the daily gravimetric and hourly
values (µg/m3 ) were used.
Figure 1. Sampling site location. The main parts of the Ciuc basin are marked with red lines.
Figure 1. Sampling site location. The main parts of the Ciuc basin are marked with red lines.
The daily respiratory and cardiovascular hospital admission data from 1 January 2008
to 31 December
2.2. Air Pollution, 2016 (3288
Medical anddays) were obtainedData
Meteorological from the Regional Emergency Hospital
of Miercurea Ciuc, which is the single regional hospital in the studied region. During
The
the PM 10 concentration
studied data were
period, 18,286 hospital obtained
admissions from the
were registered HR01
[27]. regional
The selection wasmonitor
made according
tion located near the to municipality
the Internationalof Classification
Miercurea of Disease,
Ciuc, the 10th“Cold
Revision (ICD-10)
Pole” by
of Romania
the World Health Organization. Seven different types of diseases were studied: lung
at 46.33° N, 25.81° E, at an elevation of 697 m a.s.l. PM10 data were sampled with a
cancer -LC (ICD-10 code C33–C34); acute myocardial infarction -AMI (ICD-10 code I21);
matedischemic
analyzer type
heart LSPM10;(ICD-10
diseases-IHD for further analysis,
code I20-I25 exceptthe I21);daily
chronicgravimetric and hourly
cardiopulmonary
(μg/m ) were used.
3disease-CCP (ICD-10 code I27.9); upper respiratory tract infections-URTI (ICD-10 code J00-
J06); pneumonia-P (ICD-10 code J12–J18); chronic obstructive pulmonary diseases-COPD
The daily respiratory and cardiovascular hospital admission data from 1
(ICD-10 code J44). Hospital admissions were examined based on sex and age groups [0–5],
2008 to(5–14],
31 December
(14–40], (40–60] 2016and(3288 days)
60+ years, were obtained
respectively. The number from the Regional
of patients coming fromEmergen
pital ofoutside
Miercurea
the basin Ciuc, which is the single regional hospital in the studied region.
was negligible.
Climatological parameters such as daily temperature, precipitation amount and the
the studied period, 18,286 hospital admissions were registered [27]. The selecti
relative humidity index were provided by the National Meteorological Administration (Me-
made according
teo Romania).to the International
Regarding Classification
the lifting condensation level (LCL)of itDisease, 10thaccording
was calculated Revision (ICD
the World Health Organization. Seven different types of diseases were studied: lu
to Equation (1):
T
cer -LC (ICD-10 code C33–C34); LCLacute
= 20 + myocardial
5
(100 − RH ) infarction -AMI (ICD-10 (1) code
chemicwhere:
heartLCL—lifting
diseases-IHD (ICD-10
condensation level,code
T—airI20-I25
temperatureexcept I21); chronic
(◦ C), RH—relative cardiopulmon
humidity (%).
ease-CCP Furthermore,
(ICD-10 code I27.9); upper respiratory
the temperature-humidity index (THI) tract
and infections-URTI (ICD-10 co
the wind chill equivalent
chart index (WCT)
J06); pneumonia-P were alsocode
(ICD-10 calculated, LCL and
J12–J18); THI, being
chronic strongly related
obstructive to the PM10
pulmonary diseases
concentration evolution, while WCT is a dimensionless human comfort index. Lastly, the
(ICD-10 code
daily valueJ44). Hospital
of the boundaryadmissions werefrom
layer was extracted examined based using
ERA5 reanalysis on sex
theand
meanage gro
5], (5–14],
value (14–40], (40–60]
of all the pixels andthe60+
covering Ciucyears, respectively.
basin region [30,31]. The number of patients
from outside the basin was negligible.
2.3. Statistical Analysis
Climatological parameters
In order to determine such asseasonal
the monthly, daily and
temperature,
yearly PM10 precipitation amount
concentrations, the
relative humidity
daily gravimetric index were provided
measurements by the
were used, while National
the diurnal Meteorological
and weekly variations wereAdmini
(Meteoestimated
Romania). by using the hourlythe
Regarding PMlifting
10 concentrations. The relationship
condensation level (LCL)between the daily
it was calculated
hospital admissions, meteorological conditions, and PM10 concentration, was determined
ing to Equation
using different(1):statistical indices: mean, standard deviation, coefficient of variation, min-
imum, median, maximum, 25th and 75th percentile values, and confidence interval. To
𝑇
𝐿𝐶𝐿 = 20 + (100 − 𝑅𝐻)
5
where: LCL—lifting condensation level, T—air temperature (°C), RH—relative hu

Atmosphere 2021, 12, 289 4 of 21
assess the impact of PM10 contribution to respiratory and cardiovascular morbidity, dif-
ferent methods were used, such as the Pearson correlation, the Fourier transform, the
Aunan’s calculation procedures, relative risk, as well as the morbidity increase caused by
a 10 µg/m3 rise in PM10 . The Pearson correlation coefficient was considered statistically
significant (p-level < 0.05), if the r value was greater than 0.203 or below −0.203.
On the other hand, the PM10 values resulted during the household heating with
wood (HPM10 ) were estimated using Equation (2), hence the residential heating contri-
bution to outdoor PM10 was determined by considering the average winter and summer
concentrations as well as the average boundary layer (BL) height ratio:
BLs
HPM10 = CPM10w − ( × CPM10s ) (2)
BLw
where: HPM10 —the average PM10 increase during winter caused by heating (µg/m3 ),
CPM10w —the average PM10 in winter period (µg/m3 ), CPM10s —the average PM10 in sum-
mer period (µg/m3 ), BLs—the average boundary layer in summer (m), BLw—the average
boundary layer in winter (m).
In order to estimate the health effects of cold and heat extremes, according to Dobri-
nescu et al. [32], five discomfort classes can be established: severe danger from cold (WCT
≤ −35 ◦ C), extremely cold (−35 ◦ C > W ≤ −20 ◦ C), uncomfortably cold (−20 ◦ C > THI ≤
0 ◦ C), uncomfortably hot (66 ≤ THI < 80), severe danger from heat THI ≥ 80, respectively:

0.55RH
TH I = (1.8TA + 32) − 0.55 − (1.8TA − 26) (3)
100
where: TA is the air temperature (◦ C) measured at a standard level (2 m).

The critical threshold above which the human body feels strong discomfort is 80 units.
THI is expressed in dimensionless form.
In the winter season, the severe danger from cold, extremely cold and uncomfortably
cold was estimated, using WCT:
0.16 0.16
WCT = 13.12 + 0.6215TA − 11037FF10 + 0.3965TA FF10 (4)
where: FF10 is the wind speed (km/h) measured at 10 m a.g.l.

Usually, WCT only expresses a human sensation and it is linked to the way the human
skin perceives the temperature on a calm day.
Regarding the PM10 concentration data, four classes were established: low < 25 µg/m3 ,
moderate between 25 µg/m3 and 37.5 µg/m3 , high ranging from 37.5 µg/m3 to 50 µg/m3 ,
and very high concentrations > 50 µg/m3 , respectively.
Since there is a latency period between exposure and appearance of disease the Fourier
transform method was used to decipher the relation. The Fourier transform is a mathe-
matical technique that transforms a signal from the time domain to the frequency domain,
showing that any wave form can be rewritten as the sum of sinusoidal functions [33], the
method has been applied to the air pollution, medical and meteorological time series as
well. The Fourier transform gives us a point of view in order to better understand the
association between exposure to PM10 and the influence of climate on hospital admissions.
It is formed by a set Wn (t) = eint , n = 0.1 . . . orthogonal functions, of period 2π:
Z ∞
F(ω ) = f (t)e−iωt ∂t (5)
−∞
ω = 2π f (6)
where: | f (ω )| is the amplitude of each component ω of the signal [34].
Atmosphere 2021, 12, 289 5 of 21
To assess the total damage of PM10 to human health in the Ciuc basin Aunan’s
calculations procedures were used, briefly, the annual number of symptom-days was
calculated from the daily mean PM10 concentration variation [35].
The odds ratio (OR) was estimated from the regression coefficient β and the increase
of concentration level from baseline to Ci :
ORi = e β∗∆Ci (7)
Pab s = (OR − 1) × 100 (8)

The hypothetical zero-concentration prevalence is given by:
p abs (Ci )
p0 = (9)
ORi − ORi × p abs (Ci ) + p abs (Ci )
The health effects of exposure-response functions generally are derived from the
relation between daily mean concentrations, Ci , and the daily prevalence of the effects, p(Ci ):
365 365
Ssum = ∑ ( p(Ci ) ×N = ∑ p0 × exp( β × Ci ) N (10)
i=1 i=1
According to the literature the annual number of symptom days (Ssum ) in a population
(N) ideally can be estimated by calculating the daily number of affected persons in the
respective population and sum over the year (Equation (10)).
Starting from daily hospital admission and PM10 concentration databases, we analyzed
the evolution of respiratory diseases from a 1 to 10 days delay. In the case of CVD, a time
delay of 1 to 10 months was used. As boundary condition was set, that only positive values
will be followed, in the case of PM10 only the changes larger than 5 µg/m3 were evaluated,
and the baseline was set to 10 µg/m3 . The two variables had to meet the set conditions
at the same time: if ∆PM10 > 5 µg/m3 and Morbidity > 0. In addition, we considered
the percentage increase of cases concerning the PM10 change of 10 µg/m3 , comparing the
average increase to the number of days tested. To determine the time delay, the day/month
corresponding to the maximum value obtained with the time difference tested was taken.
3. Results
The results show that the multiannual PM10 concentration is 19.00 µg/m3 and on an
average day 6 respiratory and cardiovascular diseases have been recorded (Table 1). The
coefficient of variation (CV) for PM10 and WCT was 0.61, and 0.93, respectively. The lowest
coefficient variation was found in the case of P and COPD with a value of 0.37.
3.1. Ambient PM10 Trend

Multiannual average concentrations of PM10 were used to detect hourly, daily, and
weekly changes. The hourly mean concentration of PM10 ranged between 17.0 and
30.1 µg/m3 . Daily PM10 values show the bimodal daily pattern, the first peak is in the
morning correlated to the rush hours of road traffic (8–11 a.m.) and the second peak occurs
at midnight (Figure 2).
The lowest concentration values were found on Sundays (20.8 µg/m3 ) and Mondays
(19.8 µg/m3 ), known as the “holiday and after holiday effect”, because of lower emissions
from vehicle traffic and other sources [36]. At the beginning of the week, the daily PM10
concentrations are starting to increase, and reach the maximum on Wednesdays 25.9 µg/m3
and Thursdays 25.5 µg/m3 . The monthly PM10 concentrations show significant fluctuations
over the year (Figure 3). The lowest PM10 value was measured in June: 10.36 µg/m3 , when
the boundary layer level is three-time higher than in winter.
Table 1. Summary statistics of daily hospital admission numbers, meteorological conditions and PM10 concentration. –LC:
lung cancer; AMI: acute myocardial infarction; IHD: ischemic heart diseases; CCP: chronic cardiopulmonary disease;
URTI: upper respiratory tract infections; P: pneumonia; COPD: chronic obstructive pulmonary diseases; GT: global trends;
Prec.: precipitation; LCL: lifting condensation level; BL: boundary layer; THI: thermal humidity index; WCT: wind chill
equivalent chart index.
Atmosphere 2021, 12, 289 6 of 21
Types of
Mean + SD CV Min P(25) P(50) P(75) Max CI95− CI95+
Diseases
LC 0.48 ± 0.34 0.70 0.03 0.21 0.39 0.68 1.39 0.42 0.54
Table 1. Summary
AMI statistics of0.62
0.13 ± 0.08 daily hospital admission0.07
0.00 numbers, meteorological
0.13 conditions 0.35
0.19 and PM10 concentration.
0.12 –LC:
0.15
lung cancer;0.38
IHD AMI: acute myocardial
± 0.33 0.88 infarction;
0.00 IHD: ischemic
0.13 heart diseases;
0.23 CCP:
0.55chronic cardiopulmonary
1.35 0.31disease; URTI:
0.44
upper
CCP respiratory tract
0.39 ± 0.26 infections;
0.66 P: pneumonia;
0.00 COPD: chronic
0.17 obstructive
0.39 pulmonary
0.55 diseases;
1.32 GT: global
0.34 trends; Prec.:
0.44
precipitation;
URTI LCL:
0.77 lifting condensation
± 0.45 0.58 level; BL: boundary
0.10 0.45 layer; THI:
0.69thermal humidity
1.03 index;
2.39WCT: wind chill equivalent
0.69 0.86
chart
P index.2.71 ± 1.13 0.37 1.13 1.90 2.57 3.45 5.82 2.52 2.90
COPD 0.70 ± 0.26 0.37 0.19 0.51 0.68 0.84 1.65 0.66 0.75
Types
GT of Diseases
5.57 ± 1.65Mean + SD 0.30 CV2.74 Min4.30 P(25) 5.41 P(50) 6.32 P(75) 11.82 Max CI95−
5.26 CI95+
5.88
Meteo. LC 0.48 ± 0.34 0.70 0.03 0.21 0.39 0.68 1.39 0.42 0.54
conditionsAMI 0.13 ± 0.08 0.62 0.00 0.07 0.13 0.19 0.35 0.12 0.15
Prec ** IHD 49.31 ± 34.41 0.38 ± 0.33
0.70 0.880.20 0.0024.05 0.13 38.50 0.23 70.63 0.55 177.30 1.35 42.820.31 0.44
55.80
LCL * CCP 462.23 ± 208.500.39 ± 0.26
0.45 0.661.43 0.00
289.59 0.17497.90 0.39 600.38 0.55 1000.63 1.32 422.910.34 0.44
501.56
URTI 0.77 ± 0.45 0.58 0.10 0.45 0.69 1.03 2.39 0.69 0.86
BL * 428.87 ±156.49 0.36 135.78 278.89 467.57 549.40 748.20 399.35 458.38
P 2.71 ± 1.13 0.37 1.13 1.90 2.57 3.45 5.82 2.52 2.90
THI *COPD 32.33 ± 11.530.70 ± 0.26 0.36 -2.80
0.37 0.19
25.83 0.51 35.13 0.68 40.25 0.84 54.17 1.65 30.160.66
34.51
0.75
WCT * GT 4.95 ± 4.63 5.57 ± 1.65 0.93 -7.41
0.30 2.742.04 4.30 5.34 5.41 7.90 6.32 15.3211.82 4.085.26 5.82
5.88
Meteo. 19.00 ± 11.59
PM10 conditions 0.61 4.39 11.61 14.51 21.50 57.71 16.82 21.19
Prec ** 49.31 ± 34.41 * monthly
0.70average 0.20
values ** monthly
24.05 summaries
38.50 values. 70.63 177.30 42.82 55.80
462.23 ±
LCL * 0.45 1.43 289.59 497.90 600.38 1000.63 422.91 501.56
208.50
3.1. Ambient PM10 Trend
428.87
BL * 0.36 135.78 278.89 467.57 549.40 748.20 399.35 458.38
±156.49 Multiannual average concentrations of PM10 were used to detect hourly, daily, and
THI * weekly
32.33 ± 11.53 changes.
0.36 The hourly
−2.80 mean
25.83 concentration
35.13 of PM
40.25 10 ranged
54.17 between30.1617.0 and 30.1
34.51
WCT * 4.95 ±μg/m
4.63 . Daily
3 PM10 values
0.93 −7.41show 2.04the bimodal 5.34daily pattern,
7.90 the 15.32first peak is in the morning
4.08 5.82
PM10 19.00 ±correlated
11.59 0.61
to the rush4.39 11.61 traffic14.51
hours of road (8–11 a.m.) 21.50
and the 57.71
second peak 16.82
occurs at21.19
mid-
night (Figure 2).average values ** monthly summaries values.
* monthly
30
28 Monday Tuesday Wednesday Thursday Friday Saturday Sunday
26
24
PM10 (μg/m3)
22
20
18
16
14
12
10
0 5 10 15 20 0 5 10 15 20 0 5 10 15 20 0 5 10 15 20 0 5 10 15 20 0 5 10 15 20 0 5 10 15 20
Atmosphere 2021, 12, x FOR PEER REVIEW Hour 7 of 22
Figure 2. Weekly evolution of hourly PM concentration (multiannual means).

Figure 2. Weekly evolution of hourly PM1010concentration (multiannual means).
The
70 lowest concentration values were found on Sundays (20.8 μg/m3) and Mondays
(19.8 μg/m3), known as the “holiday and after holiday effect”, because of lower emissions
60
from vehicle traffic and other sources [36]. At the beginning of the week, the daily PM10
PM10 concentration (μg/m3)
concentrations
50 are starting to increase, and reach the maximum on Wednesdays 25.9
μg/m3 and Thursdays 25.5 μg/m3. The monthly PM10 concentrations show significant fluc-
40 over the year (Figure 3). The lowest PM10 value was measured in June: 10.36
tuations
μg/m3, when the boundary layer level is three-time higher than in winter.
30
20
10
0
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Figure 3.
Figure Box-plot analysis
3. Box-plot analysisofofmonthly
monthly PMPM 10 concentrations (multiannual
10 concentrations means).
(multiannual The lower
means). The(grey)
lower (grey)
andupper
and upper (yellow)
(yellow) limits
limits represent
representthe
thefirst
first(25P) and
(25P) third
and (75P)
third quartiles,
(75P) andand
quartiles, the the
endsends
of the
of the
whiskers represent
whiskers represent the
theminimum
minimum and
andthethe
maximum
maximum values.
values.
Annual evolution shows that in the first three studied years (2008–2010) a constant
increase was detected, with an average of 10.08%. The PM10 concentration was higher than
the annual WHO Air Quality admissible level (20 μg/m3) in 2009 (22.39 μg/m3), and in
Annual evolution shows that in the first three studied years (2008–2010) a constant
increase was detected, with an average of 10.08%. The PM10 concentration was higher than
the annual WHO Air Quality admissible level (20 μg/m3) in 2009 (22.39 μg/m3), and in
Atmosphere 2021, 12, 289 2010 (23.00 μg/m3), respectively. This rise was followed by a longer fluctuating 7 of 21
period
(2011–2015) with an average decrease of 3.23%, and a significant 30.56% drop in the year
of 2016, when was recorded the minimum concentration level (13.08 μg/m3) (Figure 4a).
This decreasing trend could
Annual evolution showsbethat
explained bythree
in the first the implementation of environmental
studied years (2008–2010) a constant regu-
increase
lations was detected,
imposed by the with
EU. an average of 10.08%. The PM10 concentration was higher than
theThe
annual WHOseasonal
average Air QualityPMadmissible µg/m3considerably
level (20varies
10 concentration µg/m3 ), andthe
) in 2009 (22.39throughout in year
2010 (23.00 µg/m 3 ), respectively. This rise was followed by a longer fluctuating period
(Figure 4b); in winter (34.72 μg/m3), they are 82% higher than the multiannual average
(2011–2015) with an average decrease of 3.23%, and a significant 30.56% drop in the year of
(19.00 μg/m3), and almost three times higher than in summer (11.71 3 μg/m3). The highest
2016, when was recorded the minimum concentration level (13.08 µg/m ) (Figure 4a). This
seasonal concentration was measured during the winter of 2009–2010 (47.62 μg/m3), close
decreasing trend could be explained by the implementation of environmental regulations
to the WHO’s
imposed daily
by the EU.acceptable limit of 50 μg/m [37].
3
60 60

50 50
40 Annual
40
Winter
30
Spring
30
20
Summer 20
10 Autumn
10
0
0
2008
2009
2010
2011
2012
2013
2014
2015
2016
Total Winter Spring Summer Autumn
(a) (b)
Figure 4. Annual
Figure (a) and
4. Annual seasonal
(a) and (b) (b)
seasonal mean PMPM
mean 10 concentration. 4.b Box-plot analysis of seasonal PM10 concentrations The
10 concentration. 4.b Box-plot analysis of seasonal PM10 concentrations
lowerThe
(grey)
lower (grey) and upper (yellow) limits represent the first (25P)and
and upper (yellow) limits represent the first (25P) andthird (75P)quartiles,
third (75P) quartiles, and
and thethe ends
ends ofwhiskers
of the the whiskers
represent the minimum and the maximum values.
represent the minimum and the maximum values.
The average
According seasonal
to the PM10 concentration
calculations, the increased varies considerably
PM10 concentrationthroughout
dependsthe
onyear
the high
(Figure 4b); in winter (34.72 µg/m 3 ), they are 82% higher than the multiannual average
changes in the3 winter and summer boundary layer and from the increased emission from
(19.00 µg/m ), and almost three times higher than in summer (11.71 µg/m3 ). The highest
heating in the winter period. During the winter, PM10 concentration increased3 by an aver-
seasonal concentration was measured during the winter of 2009–2010 (47.62 µg/m ), close
age of 9.36 μg/m3 due to the heating season. 3
to the WHO’s daily acceptable limit of 50 µg/m [37].
According
Accordingtotothe
the PM 10 classification (low, moderate, high and very high concentra-
calculations, the increased PM10 concentration depends on the high
tion), the PM
changes 10 concentration
in the was higher
winter and summer boundarythan 50 μg/m
layer
3 in 177 cases; 88% of them were in
and from the increased emission from
heating in the winter period. During the winter, PM10 concentration increased by an
average of 9.36 µg/m3 due to the heating season.
According to the PM10 classification (low, moderate, high and very high concentration),
the PM10 concentration was higher than 50 µg/m3 in 177 cases; 88% of them were in winter,
8.5% occurred in spring, and 2.8% in autumn (Figure 5). The number of days with very high
pollution and high pollution were 3.81 5.42%7.01 and 3.71 4.43%5.16 of the total, respectively.
Thus, taking into consideration the annual PM10 evolution categories the number
of exceedances represents 5.42%, on the other hand, significant changes were observed
between seasons. The highest 18.95% was found in winter, due to the main reasons stated
out earlier, while in autumn and spring the value was only 1.81% and 0.61%, respectively,
meanwhile, there were no exceedances during summer.
3.2. Relationship between PM10 Concentration and Meteorological Variables

Climatological parameters have a demonstrable effect on the PM10 concentration
variation. Except for THI, the multiannual monthly mean of PM10 and the meteorological
data show strong negative correlations (Figure 6).
very high pollution and high pollution were 3.815.42%7.01 and 3.714.43%5.16 of the total, re-
spectively.
Thus, taking into consideration the annual PM10 evolution categories the number of
exceedances represents 5.42%, on the other hand, significant changes were observed be-
tween seasons. The highest 18.95% was found in winter, due to the main reasons stated
Atmosphere 2021, 12, 289 8 of 21
out earlier, while in autumn and spring the value was only 1.81% and 0.61%, respectively,
meanwhile, there were no exceedances during summer.
Low (<25μg/m³) Moderate (25-37.5 μg/m³)

High (37.5-50 μg/m³) Very high (>50 μg/m³)
100
90
80
Percentace of days
70
60
50
40
30
20 (a)
10
0
2008 2009 2010 2011 2012 2013 2014 2015 2016
Years
100 100
80 80
% of Winter days
% of Spring days
60 60
40 40
20 20
(b) (c)
0 0
2008
2009
2010
2011
2012
2013
2014
2015
2016
2008
2009
2010
2011
2012
2013
2014
2015
2016
100 100
% of Summer days
98
80
%of Autumn days
96
94
92 60
90 40
88
86 20
84 (d) (e)
82 0
2008
2009
2010
2011
2012
2013
2014
2015
2016
2008
2009
2010
2011
2012
2013
2014
2015
2016
Atmosphere 2021, 12, x FOR PEER REVIEW 9 of 22
Figure
Figure 5. Annual
5. Annual andand seasonal
seasonal PMPM 10 categories
10 categories
evolution
evolution during
during thethe studied
studied period
period ((a)—total days,
((a)—total
(b)—winter
days, days,
(b)—winter (c)—spring
days, days,
(c)—spring (d)—summer
days, (d)—summer days, (e)—autumn
days, (e)—autumn days).
days).
Prec, mm 3.2. Relationship between PM10 Concentration and Meteorological Variables

BL, (m)
50 -20°C<WCT≤0°C 66≤THI<80
Climatological parameters have a demonstrable
45 effect on the PM10 concentration var-
LCL, (m) PM10 (μg/m³)
700 iation. Except for THI, the
40 multiannual monthly mean
40 of PM10 and the meteorological data
600 show strong negative correlations (Figure 6). 35
500 30 30
25
(μg/m3)
(%)
400
(m/mm)
20 20
300
15
200 10 10
100
5
0 0
0
Jul
Jan
May
Jun
Aug
Nov
Mar
Apr
Oct
Dec
Feb
Sep
Jul
Jan
Feb
May
Jun
Aug
Sep
Nov
Mar
Apr
Oct
Dec
(a) (b)
Figure 6. Monthly
Figure 6. MonthlyPM
PM1010 concentrations
concentrationsand
andmeteorological
meteorological parameters:
parameters: (a):(a): Prec.,
Prec., BL,BL, LCL,
LCL, (b): (b):
WCT, WCT,
THI.THI.
Two classes of human discomfort were detected (Figure 6b): uncomfortably cold and
uncomfortably hot. Uncomfortably cold represented 40.96% of the total winter days,
3.22% resulting from the spring days, and 2.59% from the autumn days, while uncomfort-
ably hot occurred during the summer, exhibiting 16.23% of the total summer days, respec-
Atmosphere 2021, 12, 289 9 of 21
Two classes of human discomfort were detected (Figure 6b): uncomfortably cold and
uncomfortably hot. Uncomfortably cold represented 40.96% of the total winter days, 3.22%
resulting from the spring days, and 2.59% from the autumn days, while uncomfortably
hot occurred during the summer, exhibiting 16.23% of the total summer days, respectively.
For the entire studied period, 28.59% of the total days were uncomfortable. Precipitation
has a positive effect, by reducing through wet scavenging the PM10 concentration. This
effect is more significant during summer, when the quantity of precipitation is the highest
(avg. 81.44 mm). The monthly PM10 evaluation shows a reverse trend with the boundary
layer and lifting condensation level. There are two categories of accumulation conditions
if the values of boundary layer and air pressure are high, strong anticyclonic systems are
formed, leading to the Brunt Vaisala effect that often produces thermal inversions, favoring
pollutant accumulation. The second accumulation condition occurs when the cloud base is
low and the relative humidity is high, leading to fog formation.
3.3. Hospital Admission Evaluation

Admissions in Ciuc Emergency Hospital due to respiratory and cardiovascular causes
were analyzed in detail. The incidence of the disease was examined in five different age
groups: [0–5], (5–14], (14–40], (40–60], 60+. In 2010, 2012 and 2014, the number of days
with high and very high pollution was higher in comparison with other years, resulting in
the surge of hospital admissions. Diseases were found to be most common in the elderly
age group 60+ representing 41.3%. The second large number of patients were children;
below 5 years old, with 28.9% followed by the patients between (40–60], accounting for
up to 20.4%. A lower rate was found in the case of children (5–14] years with 3.4% and
young people (14–40] years with 6.0%, respectively. Furthermore, hospital admissions also
show a weekly, and monthly cycle. The maximum hospital admission is on Monday and
Friday and the minimum on Sunday. The average number of monthly hospital admissions
shows a maximum in March (n = 230) and a minimum in August (n = 122). Most hospital
Atmosphere 2021, 12, x FOR PEER REVIEW
admissions were for P in the children’s age group [0–5] years with 19.5% and in the 10 of 22
case of
elderly people 60+ years with 14.9% proportion (Figure 7).
25 25
[0,5] LC
20 20
AMI
(5,14]
15 15 IHD
(%)
(%)
(14,40]
CCP
10 10
URTI
5 (40,60] 5
P
0 0 COPD
LC IHD URTI COPD [0,5] (5,14] (14,40] (40,60] >60
Figure 7. Diseases occurrence in different age groups.

Figure 7. Diseases occurrence in different age groups.
In addition, the URTI was also common with 13.55%, in this case, the most affected
In addition, the URTI was also common with 13.55%, in this case, the most affected
age category was children [0–5] with a weight of 9.12%. The next most frequent disease was
age category was children [0–5] with a weight of 9.12%. The next most frequent disease
COPD with 12.5%, followed by LC 9.01%, CCP 6.99, IHD 6.73%, and AMI 2.5%, respectively.
was COPD with 12.5%, followed by LC 9.01%, CCP 6.99, IHD 6.73%, and AMI 2.5%, re-
3.4.spectively.
Fourier Transformation
The
3.4. PM10Transformation
Fourier concentration and climatological data (LCL, BL, THI, WCT) impact on the
seven different types of diseases, during all seasons, and based on the five age group cate-
The PM10 concentration and climatological data (LCL, BL, THI, WCT) impact on the
gory was calculated (Table 2). From the total 459 Fourier transform significant correlation
seven different types of diseases, during all seasons, and based on the five age group cat-
was found, using Pearson’s correlation coefficient approach, in the case of 255, representing
egory was calculated (Table 2). From the total 459 Fourier transform significant correlation
55.56%. After the transformation, the Pearson correlation was applied to ten samples,
was found, using Pearson’s correlation coefficient approach, in the case of 255, represent-
knowing that in that case if n is between 0.01 and 0.02 the correlation should be 0.745.
ing 55.56%. After the transformation, the Pearson correlation was applied to ten samples,
knowing that in that case if n is between 0.01 and 0.02 the correlation should be 0.745.
Predominantly the PM10 effects were accountable in all age groups in case of URTI
and Pneumonia, and all types of diseases occurred at ages higher than 40 years old. The
PM10 effects were linked with the WCT and BL, marked with gray backgrounds, based on
the numerous assimilations identified during analysis (Table 2). Examining the overlap
Atmosphere 2021, 12, 289 10 of 21
Table 2. Significant Pearson correlation coefficients between PM10 , climatological data, and disease occurrence after the
Fourier transforms.
PM10
Age
[0–5] (5–14] (14–40] (40–60] >60
Categories
W Sp Su A W Sp Su A W Sp Su A W Sp Su A W Sp Su A
1. LC * * * * * * * *
2. AMI * * * * * *
3. IHD * * * * * * *
4.CCP * * * * * * *
5. URTI * * * * * * * * * *
6. P * * * * * * * * * * * * * * *
7. COPD * * * * * * * *
BL
Age
[0–5] (5–14] (14–40] (40–60] >60
categories
1. LC * * * * * *
2. AMI * * * * * * *
3. IHD * * * * *
4.CCP * * * * * *
5. URTI * * * * * * * * *
6. P * * * * * * * * * * * * * * * * * * * *
7. COPD * * * * * * * *
WCT
Age
[0–5] (5–14] (14–40] (40–60] >60
categories
1. LC * * * *
2. AMI * * *
3. IHD * *
4.CCP *
5. URTI * * *
6. P * * * * * * *
7. COPD * * *
(Where: W = winter, Sp = spring, Su = summer, A = autumn,). *- climatological effects; gray background: PM10 effects.
Predominantly the PM10 effects were accountable in all age groups in case of URTI
and Pneumonia, and all types of diseases occurred at ages higher than 40 years old. The
PM10 effects were linked with the WCT and BL, marked with gray backgrounds, based on
the numerous assimilations identified during analysis (Table 2). Examining the overlap
between the PM10 and studied meteorological parameters, it was observed that on average
68.9% had the same effect. The highest association was between the PM10 -BL with 86.9%
similarity. A significant effect was found in the case of WCT’s which was reflected in
increased IHD in the winter period. The results showed that the climatological parameters
(BL, WCT) had additional effects on morbidity, which are marked with red dots (Table 2).
On the other hand, BL had additional effects on P and URTI diseases in autumn for all age
categories. In winter the WCT shows a strong positive correlation.
3.5. Gender Distribution of Morbidity and Relative Risk Calculation

A significant gender difference was found between men and women. According to
the statistics, 60.7% of the total number of hospitalized patients were men (Figure 8). With
the exception of IHD, where men showed significantly higher susceptibility.
7. COPD * * *
(Where: W = winter, Sp = spring, Su = summer, A = autumn,). *- climatological effects; gray background: PM10 effects.
3.5. Gender Distribution of Morbidity and Relative Risk Calculation

Atmosphere 2021, 12, 289 A significant gender difference was found between men and women. According to21
11 of
the statistics, 60.7% of the total number of hospitalized patients were men (Figure 8). With
the exception of IHD, where men showed significantly higher susceptibility.
70
60.7
60
50
39.3
40
F
%
30
M
20
10
0
LC AMI IHD CCP URTI P COPD GT
Figure 8. 8.
Figure Disease frequency
Disease inin
frequency different age
different categories
age and
categories gender
and distribution.
gender distribution.
The
The relative
relative risk
risk is isthe
theratio
ratioofofthe
theprobability
probabilityofofananoutcome
outcomeininananexposed
exposedgroup
grouptoto
the probability of an outcome in an unexposed
the probability of an outcome in an unexposed group. group.
𝐸𝐸𝑅
EER 𝐴/(𝐴
A/( A++𝐵)
B)
𝑅𝑅==
RR =
= (11)
(11)
𝐶𝐸𝑅
CER 𝐶/(𝐶
C/(C++𝐷)D)
where:
where:EER
EER is isthe
theexperimental
experimentalevent
eventrate
rateand
andCERCERisisthe
thecontrol
controlevent
eventrate.
rate.
The
ThePM PM10 concentration level in summer was the lowest (10 μg/m3),3 hence August
10 concentration level in summer was the lowest (10 µg/m ), hence August
was
wasselected
selectedasasa acontrol
controlmonth.
month.The Thelowest
lowestPM PM10 concentration and morbidity rate was
10 concentration and morbidity rate was
taken as a reference value.
taken as a reference value.
Relative
Relative riskriskcalculation
calculationwas
wascarried
carriedout
outinindifferent
differentageageand
andgender
gendergroups.
groups.There
There
was
was substantial variation in risk between male and female and different agecategories.
substantial variation in risk between male and female and different age categories.
The
Themean
Atmosphere 2021, 12, x FOR PEER REVIEW meanvalue
valueofofRR RRwas
was1.37
1.37for
forwomen
womenand and1.45
1.45for
formen.
men.The
Themost
mostsignificant
significanteffect
effect
12 of 22
was seen in the case of PM 10 and P and URTI (Figure
was seen in the case of PM10 and P and URTI (Figure 9). 9).
4
4
3.5 3.5
Daily mean (person/day)
Daily mean (person/day)
3 3
2.5 2.5
2 2
1.5 1.5
1 1
0.5 0.5
0 0
1.1
1.3
1.5
2.2
2.4
3.1
3.3
3.5
4.2
4.4
5.1
5.3
5.5
6.2
6.4
7.1
7.3
7.5
12345123451234512345123451234512345
LC AMI IHD CCP URTI P COPD LC AMI IHD CCP URTI P COPD
(a) (b)
Figure 9.
Figure 9. Box-plot
Box-plotanalysis
analysisofofrelative
relativerisk
riskevaluation
evaluationin in different
different gender
gender groups:
groups: (a) men;
(a) men; (b)-women.
(b)-women. The The
lowerlower (grey)
(grey) and
and upper (yellow) limits represent the first (25P) and third (75P) quartiles, and the ends of the whiskers represent
upper (yellow) limits represent the first (25P) and third (75P) quartiles, and the ends of the whiskers represent the minimum the
minimum and the maximum
and the maximum values. values.
3.6. Correlation Analysis

The Pearson correlation coefficient was used to determine the correlation between
The Pearson correlation coefficient was used to determine the correlation between the
the multiannual monthly PM10 concentration and morbidity. Except the AMI for each dis-
multiannual monthly PM10 concentration and morbidity. Except the AMI for each disease,
ease, the Person correlation coefficient was significant: URTI (0.61), P (0.68), IHD (0.56),
the Person correlation coefficient was significant: URTI (0.61), P (0.68), IHD (0.56), LC
LC (0.53), CCP (−0.44), and COPD (0.47), respectively. The median multiannual monthly
(0.53), CCP (−0.44), and COPD (0.47), respectively. The median multiannual monthly PM10
PM 10 concentration is marked with the blue line, and the other hand the morbidity
concentration is marked with the blue line, and the other hand the morbidity monthly
monthly
evaluationevaluation
is markediswith
marked with the
the green linegreen line10).
(Figure (Figure 10).
1.6 40 0.4 AMI (0.03) 40
n hospital admissions
LC (0.53)
hospital admissions
1.4 35 0.4 35
1.2 30 0.3 30
(μg/m3)
1.0 25 0.3 25
0 (μg/m )
3
0.8 20 0.2 20
10
0.6 15 0.2 15
The Pearson correlation coefficient was used to determine the correlation between
the multiannual monthly PM10 concentration and morbidity. Except the AMI for each dis-
ease, the Person correlation coefficient was significant: URTI (0.61), P (0.68), IHD (0.56),
Atmosphere 2021, 12, 289 12 of 21
LC (0.53), CCP (−0.44), and COPD (0.47), respectively. The median multiannual monthly
PM10 concentration is marked with the blue line, and the other hand the morbidity
monthly evaluation is marked with the green line (Figure 10).
1.6 40 0.4 AMI (0.03) 40
Daily mean hospital admissions

LC (0.53)

1.4 35 0.4 35
1.2 30 0.3 30
PM10 (μg/m3)
1.0 25 0.3 25
PM10 (μg/m3)
0.8 20 0.2 20
0.6 15 0.2 15
0.4 10 0.1 10
0.2 5 0.1 5
0.0 0 0.0 0
Jul
Jan
Feb
May
Jun
Aug
Sep
Nov
Mar
Apr
Oct
Dec
May
Jun
Mar
Apr
Jul
Oct
Jan
Feb
Aug
Sep
Nov
Dec
1.6 40 1.4 40
CCP (₋0.44)

IHD (0.56)
1.4 35 1.2 35
1.2 30 30
1.0
PM10 (μg/m3)
PM10 (μg/m3)
1.0 25 25
0.8
0.8 20 20
0.6
0.6 15 15
0.4 10
0.4 10
0.2 5 0.2 5
0.0
Atmosphere 2021, 12, x FOR PEER REVIEW 0 0.0 0 13 of 22
Jul
Jan
May
Jun
Aug
Nov
Mar
Apr
Oct
Dec
Feb
Sep
Jul
May
Jun
Aug
Mar
Nov
Apr
Oct
Dec
Jan
Feb
Sep
3.0 40 7.0 40
P (0.68)
URTI (0.61)
35 6.0 35
2.5
30 5.0 30
PM10 (μg/m3)
2.0
PM10 (μg/m3)
25 25
4.0
1.5 20 20
3.0
15 15
1.0
2.0 10
10
0.5 1.0
5 5
0.0 0 0.0 0
May
Jun
Mar
Apr
Jul
Oct
Jan
Feb
Aug
Sep
Nov
Dec
Jul
Jan
May
Jun
Aug
Nov
Mar
Apr
Oct
Dec
Feb
Sep
2.0 COPD (0.47) 40

35
1.5 30
PM10 (μg/m3)
25
1.0 20
15
0.5 10
5
0.0 0
May
Jun
Mar
Apr
Jul
Oct
Jan
Feb
Aug
Sep
Nov
Dec
10. Box-plot
FigureFigure analysis
10. Box-plot of daily
analysis mean
of daily hospital
mean admissions.
hospital admissions. The
Thelower
lower(grey)
(grey)and
andupper
upper(yellow)
(yel-
low) limits represent the first (25P) and third (75P) quartiles, and the ends of the whiskers
limits represent the first (25P) and third (75P) quartiles, and the ends of the whiskers represent repre- the
sent the
minimum andminimum and thevalues.
the maximum maximum values.
The Pearson
The Pearson correlation
correlation between
between monthly
monthly meansofofPM
means PM10, ,hospital
hospital admissions
admissions and
and
10
meteorological parameters over the entire period 2008–2016 has been studied.
meteorological parameters over the entire period 2008–2016 has been studied. Pearson’s Pearson’s
correlation
correlation in many
in many casescases
showsshows a significant
a significant correlation
correlation (r =(r±=0.23)
±0.23) (Figure
(Figure 11).
11). AAmoderate
moder-
ate correlation was found between PM10 and P (0.51) and URTI (0.39), respectively. Fur-
correlation was found between PM10 and P (0.51) and URTI (0.39), respectively. Further-
thermore, the PM10 followed a moderate negative correlation with the boundary layer (-
more, the PM10 followed a moderate negative correlation with the boundary layer (−0.61).
0.61). As the THI index shows in summer has an additional effect on disease evolution,
As the THI index shows in summer has an additional effect on disease evolution, hence
hence moderate correlation was found between the LC (0.63), IHD (0.52), CCP (0.45), and
a weak correlation with the COPS (0.31). In winter the WCT showed moderate correlation
with the LC (0.54), IHD (0.48), and CCP (0.41).
Atmosphere 2021, 12, 289 13 of 21
moderate correlation was found between the LC (0.63), IHD (0.52), CCP (0.45), and a weak
Atmosphere 2021, 12, x FOR PEER REVIEW
correlation with the COPS (0.31). In winter the WCT showed moderate correlation 14 of 22
with
the LC (0.54), IHD (0.48), and CCP (0.41).
Figure11.
Figure 11.Pearson’s
Pearson’srank
rankcorrelation
correlation coefficients
coefficients between
between PM10
10,, health
healtheffect
effectand
andmeteorological
meteorological
data.
data.
3.7. 3
3.7.Morbidity
MorbidityIncrease
IncreaseDue
Duetotoa a1010µg/m
μg/m3Rise
RiseininPM
PM1010
The 3
Thedaily
dailymorbidity
morbidityincrease
increaseassociated
associatedwith
witha a1010 μg/m3change
µg/m changeininPM1010was
PM wascalcu-
calcu-
lated
lated(Equation
(Equation(12)).
(12)).
1 1 n 1010
∗%∗% 𝑀𝑜𝑟𝑏𝑖𝑑𝑖𝑡𝑦𝑖𝑛𝑐𝑟𝑒𝑎𝑠𝑒
Morbidityincrease
10µg/m3/ = = ∗ ∑
1− n
% 𝑀𝑜𝑟𝑏𝑖𝑑𝑖𝑡𝑦𝑖𝑛𝑐
% Morbidityinc ∗ ( ( ) ) (12)
(12)
n𝑛 1 ∆C𝛥𝐶
PM10
where: %
where: % 𝑀𝑜𝑟𝑏𝑖𝑑𝑖𝑡𝑦𝑖𝑛𝑐
Morbidityinc10µg/m3 / —10 µg/m
—10 μg/m33 PM
PM1010 disease
disease caused
caused by by average
average growth;
growth;
%𝑀𝑜𝑟𝑏𝑖𝑑𝑖𝑡𝑦𝑖𝑛𝑐𝑟𝑒𝑎𝑠𝑒(1
%Morbidityincrease (1 − n− 𝑛)—individual
)—individual current
current disease
disease growth
growth ∆CPM10𝛥𝐶
in percent;
in percent; —PM10—
PM10 concentration
concentration changechange compared
compared to theto previous
the previous
one one (1–10
(1–10 days);
days); n—the
n—the numberofof
number
daystested.
days tested.
Themost
The mostsignificant
significantincrease
increase caused
caused byby
1010 μg/m3 3increase
increaseininPM
PM concentrationwas
was
µg/m 1010concentration
foundfor
found forP,P,with
with6.84 8.28%8.95
8.28%
6.84 12).
8.95 after five days (Figure 12).
In the case of URTI and P, the highest number of hospital admissions occurred be-
tween the 5th10 to 7th day, while the 10 µg/m3 PM10 increase resulted in a 2.04% and 8.28%
% increment in daily morbidity
9
morbidity increase. For lung cancer (LC) and CVD (AMI, IHD, CCD), a maximum de-
coused by 10 μg/m3 PM10
8
lay of 5–6 months was found. Except for AMI (<0.1%), an increase of 0.5% was found.
7
Three months of time offset was observed in the case of COPD, identifying an average of
6
1.51% growth. 5
4
3.8. Theoretical
3
Calculation of Hospital Admissions
The ratio
2 between the theoretical and practical disease evaluation was analyzed
(Figure 13). 1The PM10 contribution to the hospital admissions on average was 0.34 from
0
LC AMI IHD CCP URTI P COPD
Figure 12. Box-plot analysis of percent increase of hospitalizations for each 10 μg/m3 increment of
PM10.The lower (grey) and upper (yellow) limits represent the first (25P) and third (75P) quartiles,
and the ends of the whiskers represent the minimum and the maximum values.
lated (Equation (12)).
1 10 ∗ % 𝑀𝑜𝑟𝑏𝑖𝑑𝑖𝑡𝑦𝑖𝑛𝑐𝑟𝑒𝑎𝑠𝑒
% 𝑀𝑜𝑟𝑏𝑖𝑑𝑖𝑡𝑦𝑖𝑛𝑐 / = ∗ ( ) (12)
𝑛 𝛥𝐶
Atmosphere 2021, 12, 289 where: % 𝑀𝑜𝑟𝑏𝑖𝑑𝑖𝑡𝑦𝑖𝑛𝑐 / —10 μg/m3 PM10 disease caused by average growth; 14 of 21
%𝑀𝑜𝑟𝑏𝑖𝑑𝑖𝑡𝑦𝑖𝑛𝑐𝑟𝑒𝑎𝑠𝑒(1 − 𝑛)—individual current disease growth in percent; 𝛥𝐶 —
PM10 concentration change compared to the previous one (1–10 days); n—the number of
days tested.
theThe
total number
most of hospitalizations.
significant increase caused Thebyminimum
10 μg/m3value of 0.27
increase was
in PM obtained in 2012 for
10 concentration was
AMI while the highest PM 10 contribution was observed
found for P, with 6.848.28%8.95 after five days (Figure 12). in 2011—0.49 in the case of IHD.
10
% increment in daily morbidity

9
coused by 10 μg/m3 PM10

8
7
6 In the case of URTI and P, the highest number of hospital admissions occurred be-
5
tween the 5th to 7th day, while the 10 μg/m3 PM10 increase resulted in a 2.04% and 8.28%
4
morbidity increase. For lung cancer (LC) and CVD (AMI, IHD, CCD), a maximum delay
3
of 5–6 months was found. Except for AMI (<0.1%), an increase of 0.5% was found. Three
2
months of time offset was observed in the case of COPD, identifying an average of 1.51%
1
growth.
0
3.8. Theoretical Calculation of Hospital Admissions
Figure 12.12.
Figure Box-plot
Box-plotanalysis
The ratio of percent
between
analysis of the increase
theoretical
percent ofand
increase hospitalizations
of practical disease
hospitalizations forfor
each 10 10
μg/m
evaluation
each
3 increment
was
µg/m 3 analyzedof (Fig-
increment of
10.Theure
PMPM lower (grey)
13). The and
PMandupper (yellow)
10 contribution limits
to the represent
hospital the first
admissions (25P) and third
on average (75P)
was quartiles,
0.34quartiles,
from the
10 .The lower (grey) upper (yellow) limits represent the first (25P) and third (75P)
and the ends of the whiskers represent the minimum and the value
maximum values.
and thetotal
endsnumber of hospitalizations.
of the whiskers represent the The minimum
minimum and the maximum of 0.27 was obtained in 2012 for
values.
AMI while the highest PM10 contribution was observed in 2011—0.49 in the case of IHD.
3.5 LC, R=0.33 0.6 3.5
Number of cases (x102)
AMI, R=0.35
IHD, R=0.34

3.0 0.5 3.0
2.5 2.5
0.4
2.0 2.0
0.3
1.5 1.5
1.0 0.2 1.0
0.5 0.1 0.5
0.0 0.0 0.0
2008
2009
2010
2011
2012
2013
2014
2015
2016
2008
2009
2010
2011
2012
2013
2014
2015
2016
2008
2009
2010
2011
2012
2013
2014
2015
2016
3.0 CCP, R=0.35 URTI, R=0.34 P, R=0.34
4.0 10.0
3.5
2.5
3.0 8.0
2.0
2.5 6.0
1.5 2.0
1.5 4.0
1.0
1.0
0.5 2.0
0.5
0.0 0.0 0.0
2008
2009
2010
2011
2012
2013
2014
2015
2016
2008
2009
2010
2011
2012
2013
2014
2015
2016
2008
2009
2010
2011
2012
2013
2014
2015
2016
3.5 COPD, R=0.33

3.0
2.5
2.0
1.5
1.0
0.5
0.0
2008
2009
2010
2011
2012
2013
2014
2015
2016
13. Health
FigureFigure endpoint
13. Health attributable
endpoint to short-
attributable and and
to short- long-term exposure
long-term to PM
exposure to PM
10. 10.
The orange line represents

The orange the total
line represents number
the total numberof cases perper
of cases year andand
year thethe
blue
blueone marks
one marks
the PMthe contribution
10PM to the
10 contribution disease
to the diseasemorbidity.
morbidity. In the studied
In the studiedregion,
region, ambient
ambient PMPM
10 con-
10
concentration had a yearly contribution of ,552, cases to the total morbidity.
centration had a yearly contribution of 500,552,603 cases to the total morbidity. Taken into
500 603 Taken
into consideration
considerationthe
thedifferent
differenttypes
typesofofdisease
diseasefrequency
frequencythe thecontribution
contributionratio
ratiois is
between
between
0.88–17.11% (Figure 14).
0.88–17.11% (Figure 14).
Atmosphere 2021, 12, 289 15 of 21
30
20
%
10
0
Figure 14.14.
Figure Box-plot analysis
Box-plot of PM
analysis 10 contribution
of PM to the
10 contribution annual
to the mean
annual disease
mean frequency.
disease TheThe
frequency. lower
lower
(grey) and
(grey) upper
and (yellow)
upper (yellow)limits represent
limits representthe
thefirst
first(25P)
(25P)and
andthird
third(75P)
(75P)quartiles,
quartiles, and
and the
the ends of the
thewhiskers
whiskersrepresent
representthe
theminimum
minimumand andthe
themaximum
maximumvalues. values.
The
The annual
annual mean
meandisease
diseaseevaluation
evaluationcaused causedbybythe thePMPM 1010isis1.85 2.71%
1.85 2.71% forfor
3.583.58 LC,LC,
2.11%
2.11%
1.211.21 for AMI
3.02 3.02 andand
for AMI IHD, 1.622.29%
IHD, 1.62 2.29%
2.96 CCP.
2.96 URTI
CCP. represented
URTI represented by 4.72%
by
3.68 3.68 P
4.72%
5.76 and
5.76 P
COPD were the
and COPD most
were thefrequent, with 13.46
most frequent, 17.13%
with and 3.99
17.13%
13.4620.8 20.84.21% 4.42, 4.21%
and 3.99 respectively.
4.42 , respectively.
4. Discussion
4. Discussion
The The study
study provides
provides comprehensive
comprehensive information
information onon thethe combined
combined effect
effect ofof
PMPM and
and
10 10
climate parameters on human health. Our results are consistent
climate parameters on human health. Our results are consistent with previous studies with previous studies
showing
showing anan increased
increased number
number of of hospital
hospital admissions
admissions duedue to to cardio-respiratory
cardio-respiratory diseases
diseases
after increased
after increased PM10-2.5 PM particulate concentration [38–41]. A meta-analysis
particulate concentration [38–41]. A meta-analysis of 23 mortality
10-2.5 of 23 mortality
and 10 hospital admissions
and 10 hospital admissions studies studiesconfirmed
confirmedincreased
increased morbidity
morbidity and and mortality
mortality as as aaresult
re-
of higher short-term PM 10-2.5 concentrations, with more robust
sult of higher short-term PM10-2.5 concentrations, with more robust correlations for respir- correlations for respiratory
thanthan
atory cardiovascular
cardiovascular endpoints
endpoints[42].[42].
Symptom exacerbations
Symptom exacerbations and disease and disease progression
progression areare prompted
prompted byby particle-triggered
particle-triggered
molecular and cellular mechanisms. Locally,
molecular and cellular mechanisms. Locally, PM10 deposited PM 10 deposited in the respiratory
in the respiratory tract tract elicit
elicit
inflammation by causing oxidative stress, with bronchial hyperactivity, increased sputum
inflammation by causing oxidative stress, with bronchial hyperactivity, increased sputum
production, and injury of the alveolar cells, including alveolar macrophages [43]. These
production, and injury of the alveolar cells, including alveolar macrophages [43]. These
processes lead to impaired lung function and weakened the local immune system, resulting
processes lead to impaired lung function and weakened the local immune system, result-
in an increased risk of respiratory disorders following pollutant exposure. Moreover, PM
ing in an increased risk of respiratory disorders following pollutant exposure. Moreover, 10
air pollution exerts deleterious effects on vascular endothelium, sympathetic nervous
PM10 air pollution exerts deleterious effects on vascular endothelium, sympathetic nerv-
system, and systemic inflammation, causing increased cardiovascular morbidity and mor-
ous system, and systemic inflammation, causing increased cardiovascular morbidity and
tality, primarily of ischemic nature [44–46]. Noteworthy, specific groups (e.g., people with
mortality, primarily of ischemic nature [44–46]. Noteworthy, specific groups (e.g., people
cardiovascular risk factors or pre-existing cardiovascular disease) are more vulnerable to
with cardiovascular risk factors or pre-existing cardiovascular disease) are more vulnera-
the aforesaid harmful effects.
ble to the aforesaid harmful effects.
On the other hand, significant differences existed frequently in PM10 concentrations
On the other hand, significant differences existed frequently in PM10 concentrations
between the weekends and weekdays. Daily mean PM10 concentration on weekdays
between
23.1 µg/m the weekends and weekdays.
3 was significantly higher Daily meanon
than those PMweekends
10 concentration on weekdays
21.8 µg/m3 . According 23.1 to
μg/m 3 was significantly higher than those on weekends 21.8 μg/m3. According to the re-
the results, diurnal variations and weekly cycles are a function of emission sources, and
sults, diurnal variations
meteorological and weekly
parameters [47,48].cycles
During are winter,
a function
thereof are
emission
several sources, and mete-
influencing factors
orological parameters [47,48]. During winter, there are several
responsible for the higher PM10 concentration, like thermal inversion, increased PM influencing factors respon-
10 emis-
sible fordue
sions the to
higher
indoorPM 10 concentration, like thermal inversion, increased PM10 emissions
heating, and stable atmospheric conditions. The uneven distribution of
due to indoor heating,
precipitation reducesand the stable atmospheric
efficiency conditions.
of the washout The uneven
mechanism by wetdistribution
scavengingof [49]pre-
and
cipitation reduces the efficiency of the washout mechanism by
the unfavorable topography conditions of the closed basin. As for summer, the evapotran- wet scavenging [49] and
thespiration
unfavorable playstopography
an important conditions
role in the of the closed
mixing basin.
of air massAsby forwet
summer, the evapotran-
convection.
spiration plays an important role in the mixing of air mass by wet
The highest correlation between the PM10 and diseases was found in the case of P convection.
The followed
(0.51), highest correlation
by URTI (0.39). between the PM
The same 10 andshows
finding diseases
thatwas found
besides PMin the case of P
10 the meteorolog-
(0.51), followed byalso
ical parameters URTIhave (0.39). The samecontribution
an important finding shows that
to the besides
disease PM10 the [50].
occurrence meteoro-
Winter
logical parameters
cold stress also have
is associated withananimportant
increase incontribution
influenza and to respiratory
the diseaseinfections
occurrence that[50].
may
Winter
affectcold stress is associated
cardiovascular disease. Inwith an increase
addition, THI playsin influenza
an important and role
respiratory
in diseaseinfections
frequency,
that may affect
except for the cardiovascular
URTI disease.disease. In addition,
Furthermore, WCTTHI hasplays
a bigan important role
contribution in disease
to the LC, IHD,
frequency, except for the URTI disease. Furthermore, WCT
CCP, COPD. The time delay between the dose-response is closely related to certain has a big contribution to the
AMI
LC, IHD, CCP,
subtypes andCOPD. The time
individual delay between
characteristics the dose-response
[51]. Studies is closely
assessing hospital related to due
admissions cer- to
Atmosphere 2021, 12, 289 16 of 21
COPD indicated that coarse PM has a stronger or as strong short-term effect as fine PM,
stating that PM10-2.5 are also capable to activate severe adverse reactions enough to require
hospitalization [52].
On the other hand, meteorological parameters might have an important impact on
PM10 concentration; a negative significant correlation between the PM10 and boundary
layer (−0.605), lifting condensation level (−0.46) and precipitation (−0.36) was observed.
The PM10 accumulation and this reverse ratio can be explained in light of clouds low
position and the presence of frequent fog phenomena which are very common in the Ciuc
basin [53].
Song et al. [54] conducted a systematic review and meta-analysis in China, United
States, and Europe, in order to assess the consequence of a 10 µg/m3 increase in PM10
concentration on COPD in the aforementioned countries. Their findings showed a similar
intensification of hospital admission number which increased by 1% in China and Europe,
and by 2% in the United States, respectively [54]. Despite the significance of the ambient
PM10 effect in the Ciuc basin, there is little information available in the literature on
temporal trend and long-term health effects of PM10 in this area. The high air pollution
level during the cold season in the Ciuc basin is likely the result of wood-burning, specific
topographical and meteorological conditions.
Particle pollution has been linked to a higher risk of exacerbations and respiratory
symptoms in subjects with pre-existing lung maladies, compared to the healthy ones.
In concordance with our results, the findings from the European Study of Cohorts for
Air Pollution Effects (ESCAPE) revealed a significant association for PM10 concentration
and the risk for LC (HR 1.22 [95% CI 1.03–1.45] per 10 µg/m3 ). The meta-analysis included
312,944 subjects from 17 cohort studies and 9 European countries, counting 2095 incident
lung cancer cases diagnosed during a mean follow-up of 12.8 years. The results were
confirmed by further studies, which also indicated that the relationship appeared to be
more manifest among men [7].
Studies assessing hospital admissions due to COPD indicated that coarse PM had a
stronger or as strong short-term effect as fine PM, which supports that PM10-2.5 are also
capable to activate severe adverse reactions enough to require hospitalization [52]. After
the increased particulate contamination, epidemiological studies have shown deterioration
in symptoms and quality of life, increased use of medication and deterioration in lung
function [2–5]. Moreover, in a recent meta-analysis of 85 studies from 12 low- and middle-
income countries (mostly East Asia and the Pacific), short-term PM10 exposure was proved
to have stronger associations with COPD morbidity [14].
In recent years, solid evidences were also gathered in relation to air pollution and the
cardiovascular system. In line with prior studies conducted in different geographical loca-
tions, our findings revealed positive associations between ambient PM10-2.5 and hospital
admissions for several cardiovascular maladies (i.e., AMI, IHD, and CCP). For example,
studies conducted in Western Europe and North America, including the ESCAPE pooled
study, detected augmented number of ischemic cardiac events due to higher PM10 expo-
sure, indicating increased risk for each 10 µg/m3 increase in PM10 concentration [55–58].
Similarly, Feng et.al. reported a significant fluctuation in emergency department admis-
sions for selective cardiovascular diseases (including IHD) in Beijing, China, following
short-term PM10 exposure [59]. As for CCP, to the best of our knowledge, there are no
existing studies that specifically addressed the PM-related disease load. According to our
observations, in the Ciuc basin, we found a linear relationship between PM10 level and
hospitalization frequency. This could be explained by the detrimental effect of PM on
the right ventricular function. Indeed, the analysis of cardiac magnetic resonance images
from 1490 participants from the Multi-Ethnic Study of Atherosclerosis evidenced robust
correlation between long-term PM10-2.5 concentrations and right ventricular mass in specific
subpopulations (i.e., individuals with emphysema and current smokers) [42].
In our study, subjects ≥ 60 years old (41.3%) and males (60.7%) were the most sus-
ceptible to respiratory illnesses owing to the increased level of PM10-2.5 . These findings
Atmosphere 2021, 12, 289 17 of 21
are consistent with literature data and offer a broader view of the demographic-specific
associations between air pollution, respiratory and cardiovascular diseases. Indeed, a
recent study conducted on a large sample size of 56,221 cardiovascular and 92,464 respi-
ratory emergency admissions in 10 general hospitals from Beijing, reported that males
and people aged ≥ 65 years were more vulnerable to air pollution [59]. The relation-
ship between pollution exposure and increased morbidity and mortality in the elderly
is well-recognized [60,61]. Due to co-morbidities, reduced lung function and weaker
immune systems, in case of elder people are prone to exacerbations of chronic diseases
(such as COPD) or to respiratory tract infections (particularly pneumonia) [62]. Existing
evidence acknowledges gender as a modifier of air pollution effects on human health,
but the current findings are inconsistent regarding which gender is more vulnerable. As
for male gender, available data indicates that men who smoke respond more intensely to
ambient pollution [59]. There is a number of possible explanations for why men are more
susceptible to develop pollution-related conditions. Several gendered behaviors (such as
alcohol consumption and smoking) have been linked to increased susceptibility to adverse
immune-related health effects, including respiratory infections [63]. Gender differences in
terms of work-related exposure may also be responsible, men generally spending signifi-
cantly more time outdoors than women (16.1 h/week versus 9.2 h/week) [64]. Last but not
least, sex-linked physiological dissimilarities (e.g., hormonal status, lung maturation and
size, airway and vascular responsiveness) are also considered as key factors [63,65].
Our data revealed that children under the age of 5 were more affected by air pollu-
tion, with increased hospitalizations for P and URTI. Previous studies have established
that outdoor pollution amplifies the burden of severe acute respiratory infections, with
increased hospital admissions and mortality, particularly in young children (under 5 years
old) [66–68].
Furthermore, the association between exposure to PM and childhood P has been
confirmed by data from 10 European birth cohorts within the ESCAPE Project [69]. The
main reasons why children face greater risks from air pollution have been comprehensively
discussed in previous papers [70,71]. First, their lungs, as well as their immune system, are
still developing, hence the susceptibility to inflammation is higher. Secondly, they usually
breathe faster than adults, inhaling more pollutants relative to their body size. Thirdly,
they spend more time out and are more active outdoors than adults, which also result in
higher doses of inhaled pollutant.
Epidemiological evidence suggests that the affinity to disease occurrence increases
with age and it is higher after 40 years [72]. The prevalence of the disease is highly depen-
dent on age since the human organism is more sensitive to increased PM10 concentration in
early childhood and elderly age. In the case of the young generation, the weaker developing
immune system is responsible for the frequent illness [73].
5. Study Limitations
Our study was subject to some limitations. First, our survey did not comprise infor-
mation on documented potential confounders such as occupational/educational/marital
status, body mass index, smoking, and alcohol consumption. Second, we were not able
to discriminate re-admission frequencies. It is possible for a few patients to have been re-
hospitalized within the analyzed timeframe, resulting in underestimation of PM10 -related
risk variance.
6. Conclusions
We analyzed the influence of meteorological data and PM10 concentration, on health
in the Ciuc basin, Romania, from 2008 to 2016. Our results indicate that increasing PM10 -
concentration is associated with increased hospital admissions for cardio-respiratory dis-
eases. In general, the highest PM10 concentration was observed in winter, especially in
January, due to the high atmospheric stability in winter period, thermal inversions, the
higher atmospheric pressure and the increased emission from the biomass burning. The
Atmosphere 2021, 12, 289 18 of 21
damaging effects of air pollution can occur from 5–7 days in the case of respiratory diseases
and to 3–6 months for pulmonary and cardiovascular diseases. Children under 5 years,
men and the elderly up to 60 years are the most likely to suffer from respiratory disease
than other age groups, due to air pollution. According to the calculation, one-third of the
affected people could be attributed to PM10 . The short-term exposure to outdoor air pollu-
tant PM10 was positively associated with respiratory admissions. Regarding the long-term
exposure, it can be concluded that PM10 had negative effect on cardiovascular disease,
however, there was a significant delay in dose-response. Furthermore, the PM10 and the
climate indexes (WCT, THI) have an important role in the increase of disease frequency.
The present study contributed to the limited information about the effects of air
pollution in Romania/Eastern Europe and emphasizes the need for additional research on
this topic.
Particulate matter (PM) air pollution is an important and modifiable risk factor for
adverse health outcomes including cardiovascular disease. Reduction in air pollution
exposures is essential to attaining global targets, such as the American Heart Association
and World Heart Federation goal of reducing premature CVD mortality by 25% by 2025 [74].
Author Contributions: Conceptualization, R.S.; methodology, K.B., Z.B., M.M.M.; S.P. and A.K.
software, Z.B., M.-V.B. and I.-A.N.; validation, R.S. and Z.B., formal analysis K.B. and Z.B., writing—
original draft preparation, K.B., M.M.M. and Á.K.; writing—review and editing, K.B., Z.B. and M.-V.B.;
and supervision, R.S. All authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.
Acknowledgments: The authors thank the Miercurea Ciuc County Hospital and the Harghita
Environmental Protection Agency for providing data on morbidity and pollution, and K.B. thanks
the Verestóy Attila Foundation for the research fellowship. We acknowledge the Copernicus Climate
Data Store and European Centre for Medium-Range Weather Forecast (ECMWF) for making available
the ERA5 dataset.
Conflicts of Interest: The authors declare no conflict of interest.
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Atmosphere 2021, 12, 289. https://doi.org/10.3390/atmos12020289 https://www.mdpi.com/journal/atmosphere

2. Materials and Methods

2.2. Air Pollution, Medical and Meteorological Data

ere 2021, 12, x FOR PEER REVIEW

where: LCL—lifting condensation level, T—air temperature (°C), RH—relative hu

where: TA is the air temperature (◦ C) measured at a standard level (2 m).

where: FF10 is the wind speed (km/h) measured at 10 m a.g.l.

ORi = e β∗∆Ci (7)

Pab s = (OR − 1) × 100 (8)

3.1. Ambient PM10 Trend

Figure 2. Weekly evolution of hourly PM concentration (multiannual means).

PM10 concentration (μg/m3)

Total Winter Spring Summer Autumn

3.2. Relationship between PM10 Concentration and Meteorological Variables

Low (<25μg/m³) Moderate (25-37.5 μg/m³)

Prec, mm 3.2. Relationship between PM10 Concentration and Meteorological Variables

3.3. Hospital Admission Evaluation

Figure 7. Diseases occurrence in different age groups.

3.5. Gender Distribution of Morbidity and Relative Risk Calculation

3.5. Gender Distribution of Morbidity and Relative Risk Calculation

3.6. Correlation Analysis

Daily mean hospital admissions

Daily mean hospital admissions

Daily mean hospital admissions

2.0 COPD (0.47) 40

% increment in daily morbidity

coused by 10 μg/m3 PM10

Number of cases (x102)

3.5 COPD, R=0.33

The orange line represents

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