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.

Air Health Science Division Health Canada Ottawa Canada

Centre for Statistical Methodology London School of Hygiene and Tropical Medicine London UK

Centre on Climate Change and Planetary Health London School of Hygiene and Tropical Medicine London UK

Department of Environmental Health Harvard T H Chan School of Public Health Boston MA USA

Department of Environmental Health Instituto Nacional de Saúde Dr Ricardo Jorge Porto Portugal

Department of Environmental Health National Institute of Public Health Cuernavaca Morelos Mexico

Department of Environmental Health Rollins School of Public Health Emory University Atlanta USA

Department of Epidemiology and Preventive Medicine School of Public Health and Preventive Medicine Monash University Melbourne Australia

Department of Epidemiology Instituto Nacional de Saúde Dr Ricardo Jorge Lisbon Portugal

Department of Epidemiology Lazio Regional Health Service ASL Roma 1 Rome Italy

Department of Geography Geo informatics and Meteorology University of Pretoria Pretoria South Africa

Department of Global Health Policy School of International Health Graduate School of Medicine University of Tokyo Tokyo Japan

Department of Hygiene Epidemiology and Medical Statistics National and Kapodistrian University of Athens Greece

Department of Physical Chemical and Natural Systems Universidad Pablo de Olavide Sevilla Spain

Department of Public Health and Clinical Medicine Umeå University Umeå Sweden

Department of Public Health Environments and Society London School of Hygiene and Tropical Medicine London WC1H 9SH UK

Department of Statistics and Computational Research University of Valencia Valencia Spain

Environmental and Occupational Medicine National Taiwan University and NTU Hospital Taiwan

EPIUnit Instituto de Saúde Pública Universidade do Porto Porto Portugal

Faculty of Environmental Sciences Czech University of Life Sciences Prague Czech Republic

Faculty of Health and Sport Sciences University of Tsukuba Tsukuba Japan

Graduate School of Public Health and Institute of Health and Environment Seoul National University Seoul Republic of Korea

Institute of Atmospheric Physics Czech Academy of Sciences Prague Czech Republic

Institute of Environmental Assessment and Water Research Spanish Council for Scientific Research Barcelona Spain

Institute of Epidemiology Helmholtz Zentrum München German Research Center for Environmental Health Neuherberg Germany

Institute of Family Medicine and Public Health University of Tartu Tartu Estonia

Institute of Social and Preventive Medicine University of Bern Bern Switzerland

Natural Resources and the Environment Unit Council for Scientific and Industrial Research Pretoria 0001 South Africa

Oeschger Centre for Climate Change Research University of Bern Bern Switzerland

Potsdam Institute for Climate Impact Research Potsdam Germany

Santé Publique France French National Public Health Agency Saint Maurice France

School of Epidemiology and Public Health University of Ottawa Ottawa Canada

School of Forestry and Environmental Studies Yale University New Haven CT USA

School of Population Health and Environmental Sciences King's College London London UK

School of Public Health and Social Work Queensland University of Technology Brisbane Australia

School of Public Health Institute of Environment and Population Health Anhui Medical University Hefei China

School of Public Health Key Lab of Public Health Safety of the Ministry of Education and Key Lab of Health Technology Assessment of the Ministry of Health Fudan University Shanghai China

School of Tropical Medicine and Global Health Nagasaki University Nagasaki Japan

Shanghai Children's Medical Centre Shanghai Jiao Tong University School of Medicine Shanghai China

Shanghai Key Laboratory of Atmospheric Particle Pollution and Prevention Fudan University Shanghai China

Spanish Consortium for Research on Epidemiology and Public Health Madrid Spain

Swiss Tropical and Public Health Institute Basel Switzerland

Unit for Environmental Sciences and Management North West University Potchefstroom South Africa

University of Basel Basel Switzerland

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