All-cause, cardiovascular, and respiratory mortality and wildfire-related ozone: a multicountry two-stage time series analysis

Background: Wildfire activity is an important source of tropospheric ozone (O₃) pollution. However, no study to date has systematically examined the associations of wildfire-related O₃ exposure with mortality globally. Methods: We did a multicountry two-stage time series analysis. From the Multi-City Multi-Country (MCC) Collaborative Research Network, data on daily all-cause, cardiovascular, and respiratory deaths were obtained from 749 locations in 43 countries or areas, representing overlapping periods from Jan 1, 2000, to Dec 31, 2016. We estimated the daily concentration of wildfire-related O₃ in study locations using a chemical transport model, and then calibrated and downscaled O₃ estimates to a resolution of 0·25° × 0·25° (approximately 28 km² at the equator). Using a random-effects meta-analysis, we examined the associations of short-term wildfire-related O₃ exposure (lag period of 0–2 days) with daily mortality, first at the location level and then pooled at the country, regional, and global levels. Annual excess mortality fraction in each location attributable to wildfire-related O₃ was calculated with pooled effect estimates and used to obtain excess mortality fractions at country, regional, and global levels. Findings: Between 2000 and 2016, the highest maximum daily wildfire-related O₃ concentrations (≥30 μg/m³) were observed in locations in South America, central America, and southeastern Asia, and the country of South Africa. Across all locations, an increase of 1 μg/m³ in the mean daily concentration of wildfire-related O₃ during lag 0–2 days was associated with increases of 0·55% (95% CI 0·29 to 0·80) in daily all-cause mortality, 0·44% (–0·10 to 0·99) in daily cardiovascular mortality, and 0·82% (0·18 to 1·47) in daily respiratory mortality. The associations of daily mortality rates with wildfire-related O₃ exposure showed substantial geographical heterogeneity at the country and regional levels. Across all locations, estimated annual excess mortality fractions of 0·58% (95% CI 0·31 to 0·85; 31 606 deaths [95% CI 17 038 to 46 027]) for all-cause mortality, 0·41% (–0·10 to 0·91; 5249 [–1244 to 11 620]) for cardiovascular mortality, and 0·86% (0·18 to 1·51; 4657 [999 to 8206]) for respiratory mortality were attributable to short-term exposure to wildfire-related O₃. Interpretation: In this study, we observed an increase in all-cause and respiratory mortality associated with short-term wildfire-related O₃ exposure. Effective risk and smoke management strategies should be implemented to protect the public from the impacts of wildfires. Funding: Australian Research Council and the Australian National Health and Medical Research Council.