Health impacts of the Southeast Asian haze problem – A time-stratified case crossover study of the relationship between ambient air pollution and sudden cardiac deaths in Singapore

Andrew Fu Wah Ho, Win Wah, Arul Earnest, Yih Yng Ng, Zhenjia Xie, Nur Shahidah, Susan Yap, Pin Pin Pek, Nan Liu, Sean Shao Wei Lam, Marcus Eng Hock Ong, the Singapore PAROS Investigator

Research output: Contribution to journalArticleResearchpeer-review

20 Citations (Scopus)


Objectives: To investigate the association between air pollution and out-of-hospital cardiac arrest (OHCA) incidence in Singapore. Design: A time-stratified case-crossover design study. Setting: OHCA incidences of all etiology in Singapore. Participants: 8589 OHCA incidences reported to Pan-Asian Resuscitation Outcomes Study (PAROS) registry in Singapore between 2010 and 2015. Main outcome measures: A conditional Poisson regression model was applied to daily OHCA incidence that included potential confounders such as daily temperature, rainfall, wind speed, Pollutant Standards Index (PSI) and age. All models were adjusted for over-dispersion, autocorrelation and population at risk. We assessed the relationship with OHCA incidence and PSI in the entire cohort and in predetermined subgroups of demographic and clinical characteristics. Results: 334 out of 8589 (3.89%) cases survived. Moderate (Risk ratio/RR = 1.1, 95% CI = 1.07–1.15) and unhealthy (RR =1.37, 95% CI = 1.2–1.56) levels of PSI showed significant association with increased OHCA occurrence. Sub-group analysis based on individual demographic and clinical features showed generally significant association between OHCA incidence and moderate/unhealthy PSI, except in age < 65, Malay and other ethnicity, traumatic arrests and history of heart disease and diabetes. The association was most pronounced among cases age > 65, male, Indian and non-traumatic. Each increment of 30 unit in PSI on the same day and previous 1–5 days was significantly associated with 5.8–8.1% increased risk of OHCA (p < 0.001). Conclusions: We found a transient effect of short-term air pollution on OHCA incidence after adjusting for meteorological indicators and individual characteristics. These finding have public health implications for prevention of OHCA and emergency health services during haze.

Original languageEnglish
Pages (from-to)352-358
Number of pages7
JournalInternational Journal of Cardiology
Publication statusPublished - 15 Nov 2018


  • Air pollution
  • Cardiac arrest
  • Survival
  • Time-stratified

Cite this