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Characterization of the concentration-response curve for ambient ozone and acute respiratory morbidity in 5 US cities


Although short-term exposure to ambient ozone (O3) can cause poor respiratory health outcomes, the shape of the concentration-response (C-R) between O3 and respiratory morbidity has not been widely investigated. We estimated the effect of daily O3 on emergency department (ED) visits for selected respiratory outcomes in 5 US cities under various model assumptions and assessed model fit. Population-weighted average 8-h maximum O3 concentrations were estimated in each city. Individual-level data on ED visits were obtained from hospitals or hospital associations. Poisson log-linear models were used to estimate city-specific associations between the daily number of respiratory ED visits and 3-day moving average O3 levels controlling for long-term trends and meteorology. Linear, linear-threshold, quadratic, cubic, categorical, and cubic spline O3 C-R models were considered. Using linear C-R models, O3 was significantly and positively associated with respiratory ED visits in each city with rate ratios of 1.02–1.07 per 25 ppb. Models suggested that O3-ED C-R shapes were linear until O3 concentrations of roughly 60 ppb at which point risk continued to increase linearly in some cities for certain outcomes while risk flattened in others. Assessing C-R shape is necessary to identify the most appropriate form of the exposure for each given study setting.

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This publication is based in part upon information obtained through the Georgia Hospital Association, the Missouri Hospital Association, the Dallas Fort Worth Hospital Council Foundation Information and Quality Services Center’s collaborative hospital data initiative, and individual hospitals and hospital systems in Birmingham and Pittsburgh. We are grateful for the support of all participating hospitals. This publication was developed under Assistance Agreement No. EPA834799 awarded by the US Environmental Protection Agency (USEPA) to Emory University and Georgia Institute of Technology as well as by funding from the Electric Power Research Institute (EPRI, 10002467). Research reported in this publication was also supported by grants to Emory University from the USEPA (R82921301), the National Institute of Environmental Health Sciences (R01ES11294), and EPRI (EP-P27723/C13172, EP-P4353/C2124, EP-P34975/C15892, EP-P45572/C19698, and EP-P25912/C12525). This publication has not been formally reviewed by USEPA or NIH. The views expressed in this document are solely those of the authors and do not necessarily reflect those of either Agency. USEPA does not endorse any products or commercial services mentioned in this publication.

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Correspondence to Vaughn Barry.

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Barry, V., Klein, M., Winquist, A. et al. Characterization of the concentration-response curve for ambient ozone and acute respiratory morbidity in 5 US cities. J Expo Sci Environ Epidemiol 29, 267–277 (2019).

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  • ozone
  • respiratory health
  • concentration-response
  • linearity
  • threshold

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