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Multicenter Study
. 2020 Feb 10:368:m108.
doi: 10.1136/bmj.m108.

Short term association between ozone and mortality: global two stage time series study in 406 locations in 20 countries

Ana M Vicedo-Cabrera  1   2   3 , Francesco Sera  4 , Cong Liu  5 , Ben Armstrong  4 , Ai Milojevic  4 , Yuming Guo  6 , Shilu Tong  7   8   9 , Eric Lavigne  10   11 , Jan Kyselý  12   13 , Aleš Urban  12 , Hans Orru  14 , Ene Indermitte  14 , Mathilde Pascal  15 , Veronika Huber  16   17 , Alexandra Schneider  18 , Klea Katsouyanni  19   20 , Evangelia Samoli  19 , Massimo Stafoggia  21 , Matteo Scortichini  21 , Masahiro Hashizume  22 , Yasushi Honda  23 , Chris Fook Sheng Ng  24 , Magali Hurtado-Diaz  25 , Julio Cruz  25 , Susana Silva  26 , Joana Madureira  27   28 , Noah Scovronick  29 , Rebecca M Garland  30   31   32 , Ho Kim  33 , Aurelio Tobias  34 , Carmen Íñiguez  35   36 , Bertil Forsberg  37 , Christofer Åström  37 , Martina S Ragettli  38   39 , Martin Röösli  38   39 , Yue-Liang Leon Guo  40 , Bing-Yu Chen  40 , Antonella Zanobetti  41 , Joel Schwartz  41 , Michelle L Bell  42 , Haidong Kan  43 , Antonio Gasparrini  4   44   45
Affiliations
Multicenter Study

Short term association between ozone and mortality: global two stage time series study in 406 locations in 20 countries

Ana M Vicedo-Cabrera et al. BMJ. .

Abstract

Objective: To assess short term mortality risks and excess mortality associated with exposure to ozone in several cities worldwide.

Design: Two stage time series analysis.

Setting: 406 cities in 20 countries, with overlapping periods between 1985 and 2015, collected from the database of Multi-City Multi-Country Collaborative Research Network.

Population: Deaths for all causes or for external causes only registered in each city within the study period. MAIN OUTCOME MEASURES: Daily total mortality (all or non-external causes only).

Results: A total of 45 165 171 deaths were analysed in the 406 cities. On average, a 10 µg/m3 increase in ozone during the current and previous day was associated with an overall relative risk of mortality of 1.0018 (95% confidence interval 1.0012 to 1.0024). Some heterogeneity was found across countries, with estimates ranging from greater than 1.0020 in the United Kingdom, South Africa, Estonia, and Canada to less than 1.0008 in Mexico and Spain. Short term excess mortality in association with exposure to ozone higher than maximum background levels (70 µg/m3) was 0.26% (95% confidence interval 0.24% to 0.28%), corresponding to 8203 annual excess deaths (95% confidence interval 3525 to 12 840) across the 406 cities studied. The excess remained at 0.20% (0.18% to 0.22%) when restricting to days above the WHO guideline (100 µg/m3), corresponding to 6262 annual excess deaths (1413 to 11 065). Above more lenient thresholds for air quality standards in Europe, America, and China, excess mortality was 0.14%, 0.09%, and 0.05%, respectively.

Conclusions: Results suggest that ozone related mortality could be potentially reduced under stricter air quality standards. These findings have relevance for the implementation of efficient clean air interventions and mitigation strategies designed within national and international climate policies.

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Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: support from UK Medical Research Council, China Medical Board Collaborating Program, Fundação para a Ciência e a Tecnologia, Spanish Ministry of Economy, Industry and Competitiveness, German Federal Ministry of Education and Research, Czech Science Foundation, Estonian Ministry of Education and Research, Japanese Society for the Promotion of Science, Australian National Health and Medical Research Council, Science and Technology Commission of Shanghai Municipality, Global Research Laboratory, through the National Research Foundation of Korea, Future Planning and Korea Ministry of Environment, CSIR parliamentary grant, and the National Institute of Environmental Health Sciences funded HERCULES Centre; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

Figures

Fig 1
Fig 1
Geographical distribution of city specific average annual means of ozone (O3, maximum eight hour average) of 406 cities of the Multi-City Multi-Country Collaborative Research Network included in the study
Fig 2
Fig 2
Overall and country specific short term ozone-mortality association, expressed as relative risk per 10 µg/m3 increase in ozone (O3, maximum eight hour average) (lag 01)
Fig 3
Fig 3
Overall and country specific excess mortality (%) associated with ozone by specific ranges defined between thresholds consistent with current air quality standards. (No excess mortality associated with ozone was found in Australia, as daily ozone levels were below the maximum background level of 70 µg/m3). 100 µg/m3, World Health Organization guideline; 120 µg/m3, European Union directive; 140 µg/m3 (about 0.070 parts per million); National Ambient Air Quality Standard (NAAQS) in the US; 160 µg/m3 Chinese Ambient Air Quality Standard (CAAQS)
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