Respiratory mortality associated with ozone in China: A systematic review and meta-analysis

Highlights: • Significant association was found between ozone and respiratory mortality. • The estimated risk in Northern China was larger than that in Southern China. • Higher estimated risk was found in the single-day lag structure. This systematic review and meta-analysis was performed to obtain updated evidence regarding the short-term effect of ozone on respiratory mortality in China. We systematically searched the Embase, PubMed, Scopus, Web of Science, China National Knowledge Internet, and Wanfang databases for relevant studies. After screening based on the inclusion criteria, 12 studies with 19 estimates were selected for further meta-analysis. The results revealed that respiratory mortality significantly increased by 0.55% (95% confidence interval: 0.24%–0.85%; Q = 39.47, I² = 54.4%, P = 0.002, tau² < 10⁻⁵) for every 10-μg/m³ increase in the maximum 8-h average concentration of ozone. Furthermore, differences in combined estimates were observed between various regions and lag structures. The combined effect of single-day lags was generally larger than that of multiday lags; the estimate of mortality for the population in the north was larger than that for the population in the south. The sensitivity analysis demonstrated that the main findings were stable; funnel plots with Egger's and Begg's tests indicated no significant publication bias in our analysis.