Ambient ozone concentrations and the risk of perforated and nonperforated appendicitis: a multicity case-crossover study

Environ Health Perspect. 2013 Aug;121(8):939-43. doi: 10.1289/ehp.1206085. Epub 2013 Jul 11.


Background: Environmental determinants of appendicitis are poorly understood. Past work suggests that air pollution may increase the risk of appendicitis.

Objectives: We investigated whether ambient ground-level ozone (O3) concentrations were associated with appendicitis and whether these associations varied between perforated and nonperforated appendicitis.

Methods: We based this time-stratified case-crossover study on 35,811 patients hospitalized with appendicitis from 2004 to 2008 in 12 Canadian cities. Data from a national network of fixed-site monitors were used to calculate daily maximum O3 concentrations for each city. Conditional logistic regression was used to estimate city-specific odds ratios (ORs) relative to an interquartile range (IQR) increase in O3 adjusted for temperature and relative humidity. A random-effects meta-analysis was used to derive a pooled risk estimate. Stratified analyses were used to estimate associations separately for perforated and nonperforated appendicitis.

Results: Overall, a 16-ppb increase in the 7-day cumulative average daily maximum O3 concentration was associated with all appendicitis cases across the 12 cities (pooled OR = 1.07; 95% CI: 1.02, 1.13). The association was stronger among patients presenting with perforated appendicitis for the 7-day average (pooled OR = 1.22; 95% CI: 1.09, 1.36) when compared with the corresponding estimate for nonperforated appendicitis [7-day average (pooled OR = 1.02, 95% CI: 0.95, 1.09)]. Heterogeneity was not statistically significant across cities for either perforated or nonperforated appendicitis (p > 0.20).

Conclusions: Higher levels of ambient O3 exposure may increase the risk of perforated appendicitis.

Publication types

  • Multicenter Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Air Pollutants / analysis
  • Air Pollutants / toxicity*
  • Appendicitis / chemically induced*
  • Appendicitis / classification
  • Appendicitis / epidemiology*
  • Canada / epidemiology
  • Cities
  • Cross-Over Studies
  • Environmental Exposure*
  • Environmental Monitoring
  • Female
  • Humans
  • Incidence
  • Male
  • Middle Aged
  • Ozone / analysis
  • Ozone / toxicity*
  • Retrospective Studies
  • Seasons
  • Young Adult


  • Air Pollutants
  • Ozone