Association of ambient particulate matter pollution and stroke in Indonesia 2011-2020: Insights from the global burden of disease study 2021
DOI:
https://doi.org/10.61511/phraj.v4i1.2026.3234Keywords:
air pollution, global burden of disease, intracerebral hemorrhage, ischemic stroke, strokeAbstract
Background: Ambient particulate matter ≤2.5 μm (PM2.5) is a major environmental health risk contributing to global morbidity and mortality. Although its link with cardiovascular diseases is well established, evidence on the stroke burden attributable to PM2.5 exposure remains limited in Indonesia. Methods: This ecological study used Global Burden of Disease (GBD) 2021 data to analyze the association between PM2.5 exposure and stroke burden, including incidence, prevalence, and mortality, across 34 Indonesian provinces from 2011 to 2020. Age-standardized rates (ASRs) were assessed using a linear mixed model, with year as a repeated measure and province as a random effect to account for spatial and temporal variations. Findings: Mean PM2.5 concentrations ranged from 16.96 to 20.10 µg/m³, exceeding WHO and national air quality standards. Despite minor annual fluctuations in PM2.5, stroke mortality attributable to air pollution showed an increasing trend. Higher PM2.5 levels were significantly associated with ischemic stroke (IS) incidence (β = -0.117, p <0.001) and mortality (β = 0.152, p <0.001), as well as intracerebral hemorrhage (ICH) incidence (β = 0.017, p = 0.015), prevalence (β = 1.641, p <0.001), and mortality (β = 0.773, p = 0.004). The effect of PM2.5 exposure was greater for ICH than for IS. Conclusion: Long-term exposure to PM2.5 is significantly associated with stroke burden in Indonesia, particularly for ICH. Strengthening air quality management and stroke prevention policies is crucial, especially in high-risk regions. Novelty/Originality of this article: This study is the first to comprehensively assess the long-term association between PM2.5 and stroke subtypes using national-level GBD data across all Indonesian provinces, providing spatially and temporally robust evidence for public health policy in low- and middle-income tropical settings.
References
Alexeeff, S. E., Liao, N. S., Liu, X., Van Den Eeden, S. K., & Sidney, S. (2021). Long‐Term PM2.5 Exposure and Risks of Ischemic Heart Disease and Stroke Events: Review and Meta‐Analysis. Journal of the American Heart Association, 10(1), e016890. https://doi.org/10.1161/JAHA.120.016890
Azizah, A. I., Wijayanti, P., & Syaukat, Y. (2024). Spatial dependency of air pollution in Jabodetabek urban agglomerates cities. Sustinere: Journal of Environment and Sustainability, 8(2), 150–165. https://doi.org/10.22515/sustinere.jes.v8i2.393
Badan Kebijakan Pembangunan Kesehatan. (2023). Survei Kesehatan Indonesia (SKI) Dalam Angka. Kementerian Kesehatan. https://www.badankebijakan.kemkes.go.id/ski-2023-dalam-angka/
Badan Meteorologi, Klimatologi, dan Geofisika (BMKG). (2025). Konsentrasi Partikulat (PM2.5)—Kualitas Udara—BMKG. BMKG-Badan Meteorologi, Klimatologi, dan Geofisika. https://www.bmkg.go.id/kualitas-udara/pm25
Bo, Y., Zhu, Y., Zhang, X., Chang, H., Zhang, J., Lao, X. Q., & Yu, Z. (2023). Spatiotemporal Trends of Stroke Burden Attributable to Ambient PM2.5 in 204 Countries and Territories, 1990–2019. Neurology, 101(7), e764–e776. https://doi.org/10.1212/WNL.0000000000207503
BPS-Statistics Indonesia. (2019). Statistik Komuter Jabodetabek 2019 (No. 2301024). BPS-Statistics Indonesia.
BPS-Statistics Indonesia. (2021). Hasil Sensus Penduduk (SP2020) pada September 2020 mencatat jumlah penduduk sebesar 270,20 juta jiwa. BPS-Statistics Indonesia.
Brauer, M., Roth, G. A., Aravkin, A. Y., Zheng, P., Abate, K. H., Abate, Y. H., Abbafati, C., Abbasgholizadeh, R., Abbasi, M. A., Abbasian, M., Abbasifard, M., Abbasi-Kangevari, M., Abd ElHafeez, S., Abd-Elsalam, S., Abdi, P., Abdollahi, M., Abdoun, M., Abdulah, D. M., Abdullahi, A., … Gakidou, E. (2024). Global burden and strength of evidence for 88 risk factors in 204 countries and 811 subnational locations, 1990–2021: A systematic analysis for the Global Burden of Disease Study 2021. The Lancet, 403(10440), 2162–2203. https://doi.org/10.1016/S0140-6736(24)00933-4
Cha, Y., Song, C.-K., Jeon, K., & Yi, S.-M. (2023). Factors affecting recent PM2.5 concentrations in China and South Korea from 2016 to 2020. Science of The Total Environment, 881, 163524. https://doi.org/10.1016/j.scitotenv.2023.163524
Chang, Y., Hwang, S.-H., Bai, H., Park, S., Cho, E., Kim, D., Lee, H., & Lee, J. Y. (2025). The Impact of COVID-19 on Admissions and In-hospital Mortality of Patients With Stroke in Korea: An Interrupted Time Series Analysis. Journal of Preventive Medicine and Public Health, 58(1), 60–71. https://doi.org/10.3961/jpmph.24.432
Chen, H., Zhou, Z., Li, Z., Liang, S., Zhou, J., Zou, G., & Zhou, S. (2022). Time trends in the burden of stroke and subtypes attributable to PM2.5 in China from 1990 to 2019. Frontiers in Public Health, 10. https://doi.org/10.3389/fpubh.2022.1026870
Corda, M. O., Charalampous, P., Haagsma, J. A., Assunção, R., & Martins, C. (2024). Mortality burden of cardiovascular disease attributable to ambient PM2.5 exposure in Portugal, 2011 to 2021. BMC Public Health, 24(1), 1188. https://doi.org/10.1186/s12889-024-18572-0
Fang, T., Di, Y., Xu, Y., Shen, N., Fan, H., Hou, S., & Li, X. (2025). Temporal trends of particulate matter pollution and its health burden, 1990–2021, with projections to 2036: A systematic analysis for the global burden of disease study 2021. Frontiers in Public Health, 13, 1579716. https://doi.org/10.3389/fpubh.2025.1579716
Feigin, V. L., Abate, M. D., Abate, Y. H., Abd ElHafeez, S., Abd-Allah, F., Abdelalim, A., Abdelkader, A., Abdelmasseh, M., Abd-Elsalam, S., Abdi, P., Abdollahi, A., Abdoun, M., Abd-Rabu, R., Abdulah, D. M., Abdullahi, A., Abebe, M., Abeldaño Zuñiga, R. A., Abhilash, E. S., Abiodun, O. O., … Murray, C. J. L. (2024). Global, regional, and national burden of stroke and its risk factors, 1990–2021: A systematic analysis for the Global Burden of Disease Study 2021. The Lancet Neurology, 23(10), 973–1003. https://doi.org/10.1016/S1474-4422(24)00369-7
Feigin, V. L., Brainin, M., Norrving, B., Martins, S. O., Pandian, J., Lindsay, P., F Grupper, M., & Rautalin, I. (2025). World Stroke Organization: Global Stroke Fact Sheet 2025. International Journal of Stroke, 20(2), 132–144. https://doi.org/10.1177/17474930241308142
Government Regulation Number 22 of 2021 on the Implementation of Environmental Protection and Management. (2021). Database Peraturan | JDIH BPK. http://peraturan.bpk.go.id/Details/161852/pp-no-22-tahun-2021
Government Regulation Number 41 of 1999 on the Air Pollution Control. (1999). Database Peraturan | JDIH BPK. http://peraturan.bpk.go.id/Details/54332/pp-no-41-tahun-1999
Hägg-Holmberg, S., Dahlström, E. H., Forsblom, C. M., Harjutsalo, V., Liebkind, R., Putaala, J., Tatlisumak, T., Groop, P.-H., Thorn, L. M., & the FinnDiane Study Group. (2019). The role of blood pressure in risk of ischemic and hemorrhagic stroke in type 1 diabetes. Cardiovascular Diabetology, 18(1), 88. https://doi.org/10.1186/s12933-019-0891-4
Hameed, S., Khan, M., Fatmi, Z., & Wasay, M. (2021). Exploring the Relationship Between Air Quality and Ischemic Stroke Admissions During the COVID-19 Pandemic. Journal of Stroke and Cerebrovascular Diseases, 30(8). https://doi.org/10.1016/j.jstrokecerebrovasdis.2021.105860
Health Effects Institute. (2024). State of Global Air 2024 (Special Report). Health Effects Institute. https://www.stateofglobalair.org/resources/report/state-global-air-report-2024
Institute for Health Metrics and Evaluation (IHME). (2021). Ambient particulate matter pollution—Level 4 risk | Institute for Health Metrics and Evaluation. Ambient Particulate Matter Pollution-Level 4 Risk. https://www.healthdata.org/research-analysis/diseases-injuries-risks/factsheets/2021-ambient-particulate-matter-pollution
Institute for Health Metrics and Evaluation (IHME). (2025). GBD Results. https://vizhub.healthdata.org/gbd-results
Jamebozorgi, K., Kooshki, A., Saljoughi, M., Sanjari, M., Ahmadi, Z., & Mirzaei, S. M. M. (2025). Cerebrovascular accidents association between serum trace elements and toxic metals level, a case-control study. PLOS ONE, 20(2), e0317731. https://doi.org/10.1371/journal.pone.0317731
Kartikasari, R., Rachmansyah, A., & Leksono, A. S. (2019). Impact of Coal Mining in Forest Area to Carbon Emission in Kutai Kartanegara, East Kalimantan. Jurnal Pengelolaan Sumberdaya Alam Dan Lingkungan (Journal of Natural Resources and Environmental Management), 1066–1074. https://doi.org/10.29244/jpsl.9.4.1066-1074
Kazakos, V., Taylor, J., & Luo, Z. (2021). Impact of COVID-19 lockdown on NO2 and PM2.5 exposure inequalities in London, UK. Environmental Research, 198, 111236. https://doi.org/10.1016/j.envres.2021.111236
Krittanawong, C., Qadeer, Y. K., Hayes, R. B., Wang, Z., Thurston, G. D., Virani, S., & Lavie, C. J. (2023). PM2.5 and cardiovascular diseases: State-of-the-Art review. International Journal of Cardiology Cardiovascular Risk and Prevention, 19, 200217. https://doi.org/10.1016/j.ijcrp.2023.200217
Kulick, E. R., Kaufman, J. D., & Sack, C. (2023). Ambient Air Pollution and Stroke: An Updated Review. Stroke, 54(3), 882–893. https://doi.org/10.1161/STROKEAHA.122.035498
Li, A., Ji, Y., Zhu, S., Hu, Z., Xu, X., Wang, Y., & Jian, X. (2022). Risk probability and influencing factors of stroke in followed-up hypertension patients. BMC Cardiovascular Disorders, 22(1), 328. https://doi.org/10.1186/s12872-022-02780-w
Liao, H., Wu, L., Xiong, W., Luo, Y., Qi, J., Liu, Y., Hua, W., Fan, Y., Li, H., & Hu, M. (2025). Associations between short-term exposure to ambient air pollution and stroke mortality in Nanchang, China. Human and Ecological Risk Assessment: An International Journal, 31(1–2), 284–299. https://doi.org/10.1080/10807039.2025.2451742
Liu, H., Tian, Y., Xu, Y., Huang, Z., Huang, C., Hu, Y., & Zhang, J. (2017). Association between ambient air pollution and hospitalization for ischemic and hemorrhagic stroke in China: A multicity case-crossover study. Environmental Pollution, 230, 234–241. https://doi.org/10.1016/j.envpol.2017.06.057
Liu, J., & Wu, L. (2025). Heavy metal pollution and ischemic stroke: Multimechanistic pathogenesis and countermeasures. Frontiers in Public Health, 13. https://doi.org/10.3389/fpubh.2025.1650999
Lu, H., Wang, R., Li, J., Tong, M., Cao, M., Liu, H., Xiao, Q., Zheng, Y., Liu, Y., Guan, T., & Xue, T. (2023). Long-term exposure to the components of fine particulate matters and disability after stroke: Findings from the China National Stroke Screening Surveys. Journal of Hazardous Materials, 460, 132244. https://doi.org/10.1016/j.jhazmat.2023.132244
Lukman, K. M., Hastuti, L. P., Oktavia, D., Pratiwi, D., Uchiyama, Y., & Harding, D. (2025). Towards blue skies: A comprehensive review and regional mapping of ambient air quality in Indonesian cities. Journal of Environmental Management, 389, 126132. https://doi.org/10.1016/j.jenvman.2025.126132
Lv, S., Li, Z., Li, H., Liu, M., Wu, Z., Yu, S., Wu, B., Gao, B., Tao, L., Luo, Y., Li, X., Guo, X., & Liu, X. (2023). Long-term effects of PM2.5 components on hypertension: A national analysis in China. Environmental Research, 222, 115323. https://doi.org/10.1016/j.envres.2023.115323
Madrigano, J., Yan, D., Liu, T., Bonilla, E., Yulianti, N., Mickley, L. J., & Marlier, M. E. (2024). Air Pollution and Blood Pressure: Evidence From Indonesia. GeoHealth, 8(7), e2024GH001014. https://doi.org/10.1029/2024GH001014
Martin, B. L., Thompson, L. C., Kim, Y. H., King, C., Snow, S., Schladweiler, M., Haykal-Coates, N., George, I., Gilmour, M. I., Kodavanti, U. P., Hazari, M. S., & Farraj, A. K. (2020). Peat smoke inhalation alters blood pressure, baroreflex sensitivity, and cardiac arrhythmia risk in rats. Journal of Toxicology and Environmental Health. Part A, 83(23–24), 748–763. https://doi.org/10.1080/15287394.2020.1826375
McClure, L. A., Loop, M. S., Crosson, W., Kleindorfer, D., Kissela, B., & Al-Hamdan, M. (2017). Fine Particulate Matter (PM2.5) and the Risk of Stroke in the REGARDS Cohort. Journal of Stroke and Cerebrovascular Diseases : The Official Journal of National Stroke Association, 26(8), 1739–1744. https://doi.org/10.1016/j.jstrokecerebrovasdis.2017.03.041
Naghavi, M., Ong, K. L., Aali, A., Ababneh, H. S., Abate, Y. H., Abbafati, C., Abbasgholizadeh, R., Abbasian, M., Abbasi-Kangevari, M., Abbastabar, H., Abd ElHafeez, S., Abdelmasseh, M., Abd-Elsalam, S., Abdelwahab, A., Abdollahi, M., Abdollahifar, M.-A., Abdoun, M., Abdulah, D. M., Abdullahi, A., … Murray, C. J. L. (2024). Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990–2021: A systematic analysis for the Global Burden of Disease Study 2021. The Lancet, 403(10440), 2100–2132. https://doi.org/10.1016/S0140-6736(24)00367-2
Niu, X., Yu, J., Sun, J., Zhang, X., Zhou, L., Liu, X., He, K., Peng, Z., Niu, X., Xu, H., Cao, J., Ho, K.-F., Liu, P., & Shen, Z. (2025). New mechanisms of PM2.5 induced atherosclerosis: Source dependent toxicity and pathogenesis. Environmental Research, 266, 120535. https://doi.org/10.1016/j.envres.2024.120535
Nur’Aini, A. M., & Ananta, A. P. T. (2025, September 26). Sejarah Kebakaran Hutan di Kalimantan dan Sumatra: Pembelajaran dalam Mitigasi Karhutla. Badan Nasional Penanggulangan Bencana. Portal Literasi Sejarah Bencana. https://sejarah.dibi.bnpb.go.id/artikel/sejarah-kebakaran-hutan-di-kalimantan-dan-sumatra-pembelajaran-dalam-mitigasi-karhutla/251
Ogwu, M. C., Izah, S. C., Sawyer, W. E., & Amabie, T. (2025). Environmental Risk Assessment of Trace Metal Pollution: A Statistical Perspective. Environmental Geochemistry and Health, 47(4), 94. https://doi.org/10.1007/s10653-025-02405-z
Rahmatikal Wasi’ah, N., Iriana, W., & Qonita Ramadhina, S. (2025). Comparison of Fine Particulate Matter (PM2.5) in Urban Areas Southeast Asia in Compliance with WHO Guidelines. IOP Conference Series: Earth and Environmental Science, 1448(1), 012009. https://doi.org/10.1088/1755-1315/1448/1/012009
Sacco, R. L., Kasner, S. E., Broderick, J. P., Caplan, L. R., Connors, J. J., Culebras, A., Elkind, M. S. V., George, M. G., Hamdan, A. D., Higashida, R. T., Hoh, B. L., Janis, L. S., Kase, C. S., Kleindorfer, D. O., Lee, J. M., Moseley, M. E., Peterson, E. D., Turan, T. N., Valderrama, A. L., & Vinters, H. V. (2013). An updated definition of stroke for the 21st century: A statement for healthcare professionals from the American heart association/American stroke association. Stroke, 44(7), 2064–2089. https://doi.org/10.1161/STR.0b013e318296aeca
Sangkham, S., Phairuang, W., Sherchan, S. P., Pansakun, N., Munkong, N., Sarndhong, K., Islam, Md. A., & Sakunkoo, P. (2024). An update on adverse health effects from exposure to PM2.5. Environmental Advances, 18, 100603. https://doi.org/10.1016/j.envadv.2024.100603
Sari, P. M., Agniana, A. M., & Ardhi, M. S. (2022). Trends of ischemic stroke admission during two years of COVID-19 pandemic: A retrospective cross-sectional study at a tertiary hospital in Indonesia. Bali Medical Journal, 11(2), 864–869. https://doi.org/10.15562/bmj.v11i2.3498
Schraufnagel, D. E., Balmes, J. R., Cowl, C. T., Matteis, S. D., Jung, S.-H., Mortimer, K., Perez-Padilla, R., Rice, M. B., Riojas-Rodriguez, H., Sood, A., Thurston, G. D., To, T., Vanker, A., & Wuebbles, D. J. (2019). Air Pollution and Noncommunicable Diseases: A Review by the Forum of International Respiratory Societies’ Environmental Committee, Part 2: Air Pollution and Organ Systems. CHEST, 155(2), 417–426. https://doi.org/10.1016/j.chest.2018.10.041
Siregar, S., Idiawati, N., Berekute, A. K., Maulana, M., Pan, W.-C., & Yu, K.-P. (2024). Association between long-term PM2.5 exposure and mortality on Sumatra Island: Indonesian Family Life Survey (IFLS) 2000–2014. Environmental Monitoring and Assessment, 196(12), 1173. https://doi.org/10.1007/s10661-024-13323-5
Soewondo, P., Johar, M., Pujisubekti, R., Halimah, H., & Irawati, D. O. (2019). Inspecting Primary Healthcare Centers in Remote Areas: Facilities, Activities, and Finances. Indonesian Journal of Health Administration (Jurnal Administrasi Kesehatan Indonesia), 7(1), 89–98. https://doi.org/10.20473/jaki.v7i1.2019.89-98
Su, W., Zhang, C., Xi, H., Lv, J., Li, S., Xu, H., Cheng, Y., & Han, B. (2025). Stroke burden analysis attributable to ambient and household PM2.5 in China from 1990 to 2021 based on GBD 2021. Scientific Reports, 15(1), 28388. https://doi.org/10.1038/s41598-025-13893-5
Tsivgoulis, G., Safouris, A., Kim, D.-E., & Alexandrov, A. V. (2018). Recent Advances in Primary and Secondary Prevention of Atherosclerotic Stroke. Journal of Stroke, 20(2), 145–166. https://doi.org/10.5853/jos.2018.00773
World Health Organization. (2021). What are the WHO Air quality guidelines? World Health Organization. https://www.who.int/news-room/feature-stories/detail/what-are-the-who-air-quality-guidelines
World Health Organization. (2025). Air pollution data portal. World Health Organization. https://www.who.int/data/gho/data/themes/air-pollution
Wu, E., Su, R., Tang, T., Zhu, G., & Geng, D. (2025). Ambient versus household PM2.5 exposure and socioeconomic disparities in intracerebral hemorrhage burden: A 32-year global analysis (1990–2021) with projections to 2050. Frontiers in Public Health, 13. https://doi.org/10.3389/fpubh.2025.1615934
Yu, T., Jiang, Y., Chen, R., Yin, P., Luo, H., Zhou, M., & Kan, H. (2025). National and provincial burden of disease attributable to fine particulate matter air pollution in China, 1990–2021: An analysis of data from the Global Burden of Disease Study 2021. The Lancet Planetary Health, 9(3), 174–185. https://doi.org/10.1016/S2542-5196(25)00024-5
Yu, W., Ye, T., Zhang, Y., Xu, R., Lei, Y., Chen, Z., Yang, Z., Zhang, Y., Song, J., Yue, X., Li, S., & Guo, Y. (2023). Global estimates of daily ambient fine particulate matter concentrations and unequal spatiotemporal distribution of population exposure: A machine learning modelling study. The Lancet Planetary Health, 7(3), e209–e218. https://doi.org/10.1016/S2542-5196(23)00008-6
Yuan, S., Wang, J., Jiang, Q., He, Z., Huang, Y., Li, Z., Cai, L., & Cao, S. (2019). Long-term exposure to PM2.5 and stroke: A systematic review and meta-analysis of cohort studies. Environmental Research, 177, 108587. https://doi.org/10.1016/j.envres.2019.108587
Zhang, R., Liu, G., Jiang, Y., Li, G., Pan, Y., Wang, Y., Wei, Z., Wang, J., & Wang, Y. (2018). Acute Effects of Particulate Air Pollution on Ischemic Stroke and Hemorrhagic Stroke Mortality. Frontiers in Neurology, 9, 827. https://doi.org/10.3389/fneur.2018.00827
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