The Effect of Air Pollution on the Incidence of Asthma in School-Aged Children
Keywords:
air pollution, asthma incidence, school-aged children, nitrogen dioxide, PM2.5, IndonesiaAbstract
Asthma is the most common chronic disease of childhood, and a growing body of epidemiological evidence indicates that outdoor air pollution contributes not only to the worsening of established disease but also to the development of new cases in children who were previously free of asthma. This article reviews the published literature and publicly available data on the effect of air pollution on the incidence of asthma in school-aged children, with particular attention to fine particulate matter, nitrogen dioxide, and ozone, and with a focus on the Indonesian urban context. Evidence was synthesised from peer reviewed cohort studies, meta analyses, burden of disease assessments, the World Health Organization global air quality guidelines of 2021, and Indonesian national health survey data. Meta analyses report modest but consistent increases in asthma incidence per unit increase in nitrogen dioxide and fine particulate matter, and global assessments attribute between roughly two and four million new paediatric asthma cases each year to nitrogen dioxide alone. The biological pathway runs through oxidative stress, airway inflammation, and interference with normal lung development during the years when the lungs are still growing. Indonesian cities record annual fine particulate concentrations many times higher than the World Health Organization guideline value, yet local incidence studies remain scarce, ecological in design, and constrained by limited monitoring. The review concludes that reducing traffic related pollution around homes and schools is a defensible prevention strategy, and that Indonesia needs prospective cohort research, denser exposure monitoring, and school level mitigation to convert global evidence into local protection.
References
[1] M. I. Asher et al., "Worldwide trends in the burden of asthma symptoms in school-aged children: Global Asthma Network Phase I study," The Lancet, vol. 398, no. 10311, pp. 1569-1580, 2021, doi: 10.1016/S0140-6736(21)01450-1.
[2] GBD Chronic Respiratory Disease Collaborators, "Prevalence and attributable health burden of chronic respiratory diseases, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017," The Lancet Respiratory Medicine, vol. 8, no. 6, pp. 585-596, 2020.
[3] Badan Penelitian dan Pengembangan Kesehatan, Kementerian Kesehatan Republik Indonesia, Laporan Nasional Riskesdas 2018. Jakarta, Indonesia: Kementerian Kesehatan RI, 2019.
[4] World Health Organization, Air Pollution and Child Health: Prescribing Clean Air. Geneva, Switzerland: World Health Organization, 2018.
[5] World Health Organization, WHO Global Air Quality Guidelines: Particulate Matter (PM2.5 and PM10), Ozone, Nitrogen Dioxide, Sulfur Dioxide and Carbon Monoxide. Geneva, Switzerland: World Health Organization, 2021.
[6] IQAir, 2024 World Air Quality Report. Goldach, Switzerland: IQAir, 2025.
[7] B. Brunekreef and S. T. Holgate, "Air pollution and health," The Lancet, vol. 360, no. 9341, pp. 1233-1242, 2002, doi: 10.1016/S0140-6736(02)11274-8.
[8] N. Künzli et al., "Public-health impact of outdoor and traffic-related air pollution: a European assessment," The Lancet, vol. 356, no. 9232, pp. 795-801, 2000, doi: 10.1016/S0140-6736(00)02653-2.
[9] GBD 2019 Risk Factors Collaborators, "Global burden of 87 risk factors in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019," The Lancet, vol. 396, no. 10258, pp. 1223-1249, 2020, doi: 10.1016/S0140-6736(20)30752-2.
[10] M. Kampa and E. Castanas, "Human health effects of air pollution," Environmental Pollution, vol. 151, no. 2, pp. 362-367, 2008, doi: 10.1016/j.envpol.2007.06.012.
[11] A. J. Cohen et al., "Estimates and 25-year trends of the global burden of disease attributable to ambient air pollution: an analysis of data from the Global Burden of Diseases Study 2015," The Lancet, vol. 389, no. 10082, pp. 1907-1918, 2017, doi: 10.1016/S0140-6736(17)30505-6.
[12] P. J. Landrigan et al., "The Lancet Commission on pollution and health," The Lancet, vol. 391, no. 10119, pp. 462-512, 2018.
[13] M. Guarnieri and J. R. Balmes, "Outdoor air pollution and asthma," The Lancet, vol. 383, no. 9928, pp. 1581-1592, 2014, doi: 10.1016/S0140-6736(14)60617-6.
[14] D. E. Schraufnagel et al., "Air pollution and noncommunicable diseases: a review by the Forum of International Respiratory Societies' Environmental Committee, part 1: the damaging effects of air pollution," Chest, vol. 155, no. 2, pp. 409-416, 2019, doi: 10.1016/j.chest.2018.10.042.
[15] D. E. Schraufnagel et al., "Air pollution and noncommunicable diseases: a review by the Forum of International Respiratory Societies' Environmental Committee, part 2: air pollution and organ systems," Chest, vol. 155, no. 2, pp. 417-426, 2019, doi: 10.1016/j.chest.2018.10.041.
[16] C. A. Pope III and D. W. Dockery, "Health effects of fine particulate air pollution: lines that connect," Journal of the Air & Waste Management Association, vol. 56, no. 6, pp. 709-742, 2006, doi: 10.1080/10473289.2006.10464485.
[17] X.-Y. Zheng, P. Orellano, H.-L. Lin, M. Jiang, and W.-J. Guan, "Short-term exposure to ozone, nitrogen dioxide, and sulphur dioxide and emergency department visits and hospital admissions due to asthma: a systematic review and meta-analysis," Environment International, vol. 150, art. 106435, 2021, doi: 10.1016/j.envint.2021.106435.
[18] G. Favarato et al., "Traffic-related pollution and asthma prevalence in children: quantification of associations with nitrogen dioxide," Air Quality, Atmosphere & Health, vol. 7, no. 4, pp. 459-466, 2014, doi: 10.1007/s11869-014-0265-8.
[19] H. Khreis et al., "Exposure to traffic-related air pollution and risk of development of childhood asthma: a systematic review and meta-analysis," Environment International, vol. 100, pp. 1-31, 2017, doi: 10.1016/j.envint.2016.11.012.
[20] H. R. Anderson, G. Favarato, and R. W. Atkinson, "Long-term exposure to air pollution and the incidence of asthma: meta-analysis of cohort studies," Air Quality, Atmosphere & Health, vol. 6, no. 1, pp. 47-56, 2013, doi: 10.1007/s11869-011-0144-5.
[21] G. Bowatte et al., "The influence of childhood traffic-related air pollution exposure on asthma, allergy and sensitization: a systematic review and a meta-analysis of birth cohort studies," Allergy, vol. 70, no. 3, pp. 245-256, 2015, doi: 10.1111/all.12561.
[22] U. Gehring et al., "Exposure to air pollution and development of asthma and rhinoconjunctivitis throughout childhood and adolescence: a population-based birth cohort study," The Lancet Respiratory Medicine, vol. 3, no. 12, pp. 933-942, 2015, doi: 10.1016/S2213-2600(15)00426-9.
[23] E. Fuertes et al., "Associations between air pollution and pediatric eczema, rhinoconjunctivitis and asthma: a meta-analysis of European birth cohorts," Environment International, vol. 136, art. 105474, 2020, doi: 10.1016/j.envint.2020.105474.
[24] M. Jerrett et al., "Traffic-related air pollution and asthma onset in children: a prospective cohort study with individual exposure measurement," Environmental Health Perspectives, vol. 116, no. 10, pp. 1433-1438, 2008, doi: 10.1289/ehp.10968.
[25] T. To et al., "Early life exposure to air pollution and incidence of childhood asthma, allergic rhinitis and eczema," European Respiratory Journal, vol. 55, no. 2, art. 1900913, 2020, doi: 10.1183/13993003.00913-2019.
[26] H. Zhang et al., "A systematic review and meta-analysis of the effects of prenatal ambient air pollution exposure on asthma in children," Environmental Research, vol. 159, pp. 519-530, 2017, doi: 10.1016/j.envres.2017.08.038.
[27] W. J. Gauderman et al., "Association of improved air quality with lung development in children," New England Journal of Medicine, vol. 372, no. 10, pp. 905-913, 2015.
[28] P. Achakulwisut, M. Brauer, P. Hystad, and S. C. Anenberg, "Global, national, and urban burdens of paediatric asthma incidence attributable to ambient NO2 pollution," The Lancet Planetary Health, vol. 3, no. 4, pp. e166-e178, 2019, doi: 10.1016/S2542-5196(19)30046-4.
[29] S. C. Anenberg et al., "Long-term trends in urban NO2 concentrations and associated paediatric asthma incidence: estimates from global datasets," The Lancet Planetary Health, vol. 6, no. 1, pp. e49-e58, 2022, doi: 10.1016/S2542-5196(21)00255-2.
[30] G. Hoek et al., "A review of land-use regression models to assess spatial variation of outdoor air pollution," Atmospheric Environment, vol. 42, no. 33, pp. 7561-7578, 2008, doi: 10.1016/j.atmosenv.2008.05.057.
[31] I. Rivas et al., "Child exposure to indoor and outdoor air pollutants in schools in Barcelona, Spain," Environment International, vol. 69, pp. 200-212, 2014, doi: 10.1016/j.envint.2014.04.009.
[32] H. Boogaard et al., "Long-term exposure to traffic-related air pollution and selected health outcomes: a systematic review and meta-analysis," Environment International, 2022. (Health Effects Institute Panel on the Health Effects of Long-Term Exposure to Traffic-Related Air Pollution.)
[33] B. Haryanto, B. Jalaludin, A. Asyary, N. Roestandy, and F. Nugraha, "Associations between ambient PM2.5 levels and children's pneumonia and asthma during the COVID-19 pandemic in Greater Jakarta (Jabodetabek)," Annals of Global Health, vol. 91, no. 1, art. 10, 2025, doi: 10.5334/aogh.4623.
[34] H. Krismanuel and P. Tjhin, "The association between PM2.5 level and respiratory tract infections among children: a cross-sectional study," AIMS Public Health, vol. 12, no. 4, pp. 1084-1114, 2025, doi: 10.3934/publichealth.2025055.
[35] D. Norbäck et al., "Asthma and rhinitis among Chinese children: indoor and outdoor air pollution and indicators of socioeconomic status (SES)," Environment International, vol. 115, pp. 1-8, 2018, doi: 10.1016/j.envint.2018.02.023.
[36] E. Garcia et al., "Modelling the impact of aggressive emission reduction scenarios on NO2-attributable paediatric asthma incidence in Southern California," Proceedings of the National Academy of Sciences of the United States of America, vol. 116, no. 32, pp. 15883-15888, 2019, doi: 10.1073/pnas.1815678116.
[37] G. S. Lovasi et al., "Children living in areas with more street trees have lower prevalence of asthma," Journal of Epidemiology and Community Health, vol. 62, no. 7, pp. 647-649, 2008, doi: 10.1136/jech.2007.071894.
[2] GBD Chronic Respiratory Disease Collaborators, "Prevalence and attributable health burden of chronic respiratory diseases, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017," The Lancet Respiratory Medicine, vol. 8, no. 6, pp. 585-596, 2020.
[3] Badan Penelitian dan Pengembangan Kesehatan, Kementerian Kesehatan Republik Indonesia, Laporan Nasional Riskesdas 2018. Jakarta, Indonesia: Kementerian Kesehatan RI, 2019.
[4] World Health Organization, Air Pollution and Child Health: Prescribing Clean Air. Geneva, Switzerland: World Health Organization, 2018.
[5] World Health Organization, WHO Global Air Quality Guidelines: Particulate Matter (PM2.5 and PM10), Ozone, Nitrogen Dioxide, Sulfur Dioxide and Carbon Monoxide. Geneva, Switzerland: World Health Organization, 2021.
[6] IQAir, 2024 World Air Quality Report. Goldach, Switzerland: IQAir, 2025.
[7] B. Brunekreef and S. T. Holgate, "Air pollution and health," The Lancet, vol. 360, no. 9341, pp. 1233-1242, 2002, doi: 10.1016/S0140-6736(02)11274-8.
[8] N. Künzli et al., "Public-health impact of outdoor and traffic-related air pollution: a European assessment," The Lancet, vol. 356, no. 9232, pp. 795-801, 2000, doi: 10.1016/S0140-6736(00)02653-2.
[9] GBD 2019 Risk Factors Collaborators, "Global burden of 87 risk factors in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019," The Lancet, vol. 396, no. 10258, pp. 1223-1249, 2020, doi: 10.1016/S0140-6736(20)30752-2.
[10] M. Kampa and E. Castanas, "Human health effects of air pollution," Environmental Pollution, vol. 151, no. 2, pp. 362-367, 2008, doi: 10.1016/j.envpol.2007.06.012.
[11] A. J. Cohen et al., "Estimates and 25-year trends of the global burden of disease attributable to ambient air pollution: an analysis of data from the Global Burden of Diseases Study 2015," The Lancet, vol. 389, no. 10082, pp. 1907-1918, 2017, doi: 10.1016/S0140-6736(17)30505-6.
[12] P. J. Landrigan et al., "The Lancet Commission on pollution and health," The Lancet, vol. 391, no. 10119, pp. 462-512, 2018.
[13] M. Guarnieri and J. R. Balmes, "Outdoor air pollution and asthma," The Lancet, vol. 383, no. 9928, pp. 1581-1592, 2014, doi: 10.1016/S0140-6736(14)60617-6.
[14] D. E. Schraufnagel et al., "Air pollution and noncommunicable diseases: a review by the Forum of International Respiratory Societies' Environmental Committee, part 1: the damaging effects of air pollution," Chest, vol. 155, no. 2, pp. 409-416, 2019, doi: 10.1016/j.chest.2018.10.042.
[15] D. E. Schraufnagel et al., "Air pollution and noncommunicable diseases: a review by the Forum of International Respiratory Societies' Environmental Committee, part 2: air pollution and organ systems," Chest, vol. 155, no. 2, pp. 417-426, 2019, doi: 10.1016/j.chest.2018.10.041.
[16] C. A. Pope III and D. W. Dockery, "Health effects of fine particulate air pollution: lines that connect," Journal of the Air & Waste Management Association, vol. 56, no. 6, pp. 709-742, 2006, doi: 10.1080/10473289.2006.10464485.
[17] X.-Y. Zheng, P. Orellano, H.-L. Lin, M. Jiang, and W.-J. Guan, "Short-term exposure to ozone, nitrogen dioxide, and sulphur dioxide and emergency department visits and hospital admissions due to asthma: a systematic review and meta-analysis," Environment International, vol. 150, art. 106435, 2021, doi: 10.1016/j.envint.2021.106435.
[18] G. Favarato et al., "Traffic-related pollution and asthma prevalence in children: quantification of associations with nitrogen dioxide," Air Quality, Atmosphere & Health, vol. 7, no. 4, pp. 459-466, 2014, doi: 10.1007/s11869-014-0265-8.
[19] H. Khreis et al., "Exposure to traffic-related air pollution and risk of development of childhood asthma: a systematic review and meta-analysis," Environment International, vol. 100, pp. 1-31, 2017, doi: 10.1016/j.envint.2016.11.012.
[20] H. R. Anderson, G. Favarato, and R. W. Atkinson, "Long-term exposure to air pollution and the incidence of asthma: meta-analysis of cohort studies," Air Quality, Atmosphere & Health, vol. 6, no. 1, pp. 47-56, 2013, doi: 10.1007/s11869-011-0144-5.
[21] G. Bowatte et al., "The influence of childhood traffic-related air pollution exposure on asthma, allergy and sensitization: a systematic review and a meta-analysis of birth cohort studies," Allergy, vol. 70, no. 3, pp. 245-256, 2015, doi: 10.1111/all.12561.
[22] U. Gehring et al., "Exposure to air pollution and development of asthma and rhinoconjunctivitis throughout childhood and adolescence: a population-based birth cohort study," The Lancet Respiratory Medicine, vol. 3, no. 12, pp. 933-942, 2015, doi: 10.1016/S2213-2600(15)00426-9.
[23] E. Fuertes et al., "Associations between air pollution and pediatric eczema, rhinoconjunctivitis and asthma: a meta-analysis of European birth cohorts," Environment International, vol. 136, art. 105474, 2020, doi: 10.1016/j.envint.2020.105474.
[24] M. Jerrett et al., "Traffic-related air pollution and asthma onset in children: a prospective cohort study with individual exposure measurement," Environmental Health Perspectives, vol. 116, no. 10, pp. 1433-1438, 2008, doi: 10.1289/ehp.10968.
[25] T. To et al., "Early life exposure to air pollution and incidence of childhood asthma, allergic rhinitis and eczema," European Respiratory Journal, vol. 55, no. 2, art. 1900913, 2020, doi: 10.1183/13993003.00913-2019.
[26] H. Zhang et al., "A systematic review and meta-analysis of the effects of prenatal ambient air pollution exposure on asthma in children," Environmental Research, vol. 159, pp. 519-530, 2017, doi: 10.1016/j.envres.2017.08.038.
[27] W. J. Gauderman et al., "Association of improved air quality with lung development in children," New England Journal of Medicine, vol. 372, no. 10, pp. 905-913, 2015.
[28] P. Achakulwisut, M. Brauer, P. Hystad, and S. C. Anenberg, "Global, national, and urban burdens of paediatric asthma incidence attributable to ambient NO2 pollution," The Lancet Planetary Health, vol. 3, no. 4, pp. e166-e178, 2019, doi: 10.1016/S2542-5196(19)30046-4.
[29] S. C. Anenberg et al., "Long-term trends in urban NO2 concentrations and associated paediatric asthma incidence: estimates from global datasets," The Lancet Planetary Health, vol. 6, no. 1, pp. e49-e58, 2022, doi: 10.1016/S2542-5196(21)00255-2.
[30] G. Hoek et al., "A review of land-use regression models to assess spatial variation of outdoor air pollution," Atmospheric Environment, vol. 42, no. 33, pp. 7561-7578, 2008, doi: 10.1016/j.atmosenv.2008.05.057.
[31] I. Rivas et al., "Child exposure to indoor and outdoor air pollutants in schools in Barcelona, Spain," Environment International, vol. 69, pp. 200-212, 2014, doi: 10.1016/j.envint.2014.04.009.
[32] H. Boogaard et al., "Long-term exposure to traffic-related air pollution and selected health outcomes: a systematic review and meta-analysis," Environment International, 2022. (Health Effects Institute Panel on the Health Effects of Long-Term Exposure to Traffic-Related Air Pollution.)
[33] B. Haryanto, B. Jalaludin, A. Asyary, N. Roestandy, and F. Nugraha, "Associations between ambient PM2.5 levels and children's pneumonia and asthma during the COVID-19 pandemic in Greater Jakarta (Jabodetabek)," Annals of Global Health, vol. 91, no. 1, art. 10, 2025, doi: 10.5334/aogh.4623.
[34] H. Krismanuel and P. Tjhin, "The association between PM2.5 level and respiratory tract infections among children: a cross-sectional study," AIMS Public Health, vol. 12, no. 4, pp. 1084-1114, 2025, doi: 10.3934/publichealth.2025055.
[35] D. Norbäck et al., "Asthma and rhinitis among Chinese children: indoor and outdoor air pollution and indicators of socioeconomic status (SES)," Environment International, vol. 115, pp. 1-8, 2018, doi: 10.1016/j.envint.2018.02.023.
[36] E. Garcia et al., "Modelling the impact of aggressive emission reduction scenarios on NO2-attributable paediatric asthma incidence in Southern California," Proceedings of the National Academy of Sciences of the United States of America, vol. 116, no. 32, pp. 15883-15888, 2019, doi: 10.1073/pnas.1815678116.
[37] G. S. Lovasi et al., "Children living in areas with more street trees have lower prevalence of asthma," Journal of Epidemiology and Community Health, vol. 62, no. 7, pp. 647-649, 2008, doi: 10.1136/jech.2007.071894.
Downloads
Published
2026-09-30
Issue
Section
Articles
License
Copyright (c) 2026 Elsa Pavita, Alfan Ridha
This work is licensed under a Creative Commons Attribution 4.0 International License.
