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Ozone Exposure and Health Effects: a Protocol for an Umbrella Review and Effect-­Specific Systematic Maps

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Ozone Exposure and Health Effects: a Protocol for an Umbrella Review and Effect-­Specific Systematic Maps Open access Protocol BMJ Open: first published as 10.1136/bmjopen-2019-034854 on 13 August 2020. Downloaded from Ozone exposure and health effects: a protocol for an umbrella review and effect-­specific­systematic­maps Tianyu Zhao ,1,2,3,4 Iana Markevych,1,2,3,5 Christian Janßen,4 Dennis Nowak,1,2 Nadine Steckling- Muschack,1,6 Joachim Heinrich1,2,3,7 To cite: Zhao T, Markevych I, ABSTRACT Strengths and limitations of this study Janßen C, et al. Ozone Introduction Ambient ozone exposure may be adverse exposure and health effects: to health. Since the reported associations between ozone ► To the best of our knowledge, this protocol is the a protocol for an umbrella and health effects are heterogeneous and the underlying review and effect- specific first one for an umbrella review or a systematic map pathways are indistinct, the overall relationship remains systematic maps. BMJ Open focusing on ozone exposure and health outcomes. unclear. Only a few overall syntheses of the evidence 2020;10:e034854. doi:10.1136/ ► The umbrella review will provide a comprehensive regarding ozone and health effects are available to date. bmjopen-2019-034854 outline of the currently available systematic reviews Methods and analysis We plan to summarise the current on ambient ozone exposure and health outcomes, ► Prepublication history and evidence on ozone- related health effects systematically. and an epidemiological evidence reservoir accessi- additional material for this First, to identify the possible associations between paper are available online. To ble to the public. ambient ozone exposure and health outcomes, we will view these files, please visit ► The systematic map of a specific ozone-rela ted conduct an umbrella review. PubMed, Web of Science and the journal online (http:// dx. doi. health effect would be the first of this kind to syn- grey literature will be searched for systematic reviews org/ 10. 1136/ bmjopen- 2019- thesise evidence from both epidemiological and ex- on exposure to ambient ozone and any possible health 034854). perimental studies. endpoints published before 31 May 2019. Data selection ► Since the umbrella review will include only pub- NS- M and JH contributed and extraction will be carried out by one reviewer, and a lished systematic reviews, the quality of evidence equally. second reviewer will check the agreement of a sample will, thus, depend on the included reviews, and of the studies. The methodological quality of the eligible Received 08 October 2019 some latest original high-quality studies may be systematic reviews and level of evidence regarding Revised 01 April 2020 neglected. ozone and every specific health effect will be evaluated. Accepted 09 June 2020 ► Publication bias and quality of the original studies Second, for each of the identified effects with a high might affect the evidence synthesised by a system- level of evidence, comprehensive information retrievals http://bmjopen.bmj.com/ atic map. will be conducted, considering both epidemiological and experimental studies. The study selection and data mapping will be carried out by one reviewer and checked by the second reviewer. We will summarise the information (132.0–162.0 million) disability- adjusted life 2 of the filtered epidemiological and experimental studies to years (DALYs) in 2017. conduct several systematic maps presenting the currently Although the majority of the air pollution- available evidence for the specific health effect. Because related burden is attributed to particulate the association between ozone exposure and chronic matter (PM) in the GBD studies,2–4 the on October 2, 2021 by guest. Protected copyright. obstructive pulmonary disease (COPD) is relatively well burden from ambient ozone pollution is investigated, we will at least conduct one systematic map also alarming. In 2017, ambient ozone expo- of ozone and COPD. sure caused 472 000 (95% UI 177 000–768 Ethics and dissemination No ethical approval is required 000) deaths and a loss of 7.4 million (2.7– for this study. The completed umbrella review and 2 systematic maps will be considered for publication and 12.0 million) DALYs. In addition, consid- presentation. We will additionally upload the relevant data ering climate change, global warming and © Author(s) (or their to publicly accessible online databases. increased emissions of ozone precursors, employer(s)) 2020. Re- use PROSPERO registration number CRD42019123064. the long- term ambient ozone is expected permitted under CC BY-NC. No to increase in concentration.5 Thus, ozone- commercial re- use. See rights 6 and permissions. Published by related mortality might grow in the future. BMJ. INTRODUCTION The association between ozone and chronic For numbered affiliations see Ambient air pollution has been considered a obstructive pulmonary disease (COPD) is end of article. leading cause of the global burden of disease regarded to be in line with the basis of evidence (GBD).1 According to the GBD study, air rules by the GBD study group,2 and COPD Correspondence to Dr Joachim Heinrich; pollution was estimated to account for 4.9 is, thus, the only one ozone-related health 2 joachim. heinrich@ med. uni- million deaths (95% uncertainty interval outcome included in the GBD study 2017. muenchen. de (UI) 4.4–5.49 million) and 147.0 million A lack of evidence for other effects is largely Zhao T, et al. BMJ Open 2020;10:e034854. doi:10.1136/bmjopen-2019-034854 1 Open access BMJ Open: first published as 10.1136/bmjopen-2019-034854 on 13 August 2020. Downloaded from explained by ozone is under investigated compared with METHODS AND ANALYSIS PM, and because based on the hierarchy of evidence,7 the This project has been registered on the International conducted epidemiological observational studies are not Prospective Register of Systematic Reviews (https:// considered as a high quality. www. crd. york. ac. uk/ prospero/) on 24 April 2019.28 The Regarding the evidence, a systematic review is a standard present protocol was developed and modified in accor- method for summarising and analysing available evidence dance with the Preferred Reporting Items for Systematic on health issues. Systematic reviews are regarded to be of Review and Meta- Analysis Protocols (PRISMA-P) 2015 high evidence hierarchy and of low risk of bias.7 Currently, checklist29 and the guidance on systematic maps published as systematic reviews have synthesised a growing number by the Collaboration for Environmental Evidence.30 31 of original studies, more evidence is accumulating. From these reviews, we can find out ozone exposure linked to Patient and public involvement different kinds of health effects, not only to the respi- This study will have no patient or public involvement and ratory system but also to the cardio-cerebrovascular ,8 9 will collect no primary data. central nervous system10 11 or mental health.12 13 Conse- quently, the possibility of tracing evidence up to date has Study design been overwhelmed by the rapidly increased number of The project will be divided into two processes. The first 14 systematic reviews. process will be an umbrella review. In other words, a Remarkably, an umbrella review, systematically systematic review to identify the published systematic reviewing previously published systematic reviews, could reviews on the association between ambient ozone expo- 7 generate a higher level of the hierarchical evidence and sure and any health endpoints. We will further grade the has attracted increasing research attention. This trend evidence of ozone- effect pairs based on parameters from can be identified by the number of newly published the systematic reviews with meta-analysis. 32 33 The second 15 16 17–19 umbrella reviews and protocols on various process will be the development of systematic maps for topics. An umbrella review would be a feasible way to the specific health effects with high evidence levels iden- outline the associations between ozone exposure and tified by the umbrella review. For example, if COPD were health effects. to be identified as an ozone-related health effect with a On the other hand, biological mechanisms that high evidence level, we would conduct a systematic map possibly lie behind the associations reported by epidemi- of ozone exposure and COPD. Every systematic map will ological studies are relatively unclear—although expo- contain all of the published original epidemiological sure to ozone has been postulated to be associated with studies, as well as the currently available experimental adverse health effects via oxidative stress and inflamma- studies of the specific health effect. tory response.20 21 More and more efforts are trying to bridge the gap between epidemiological associations Umbrella review http://bmjopen.bmj.com/ and biological relevance, yet they are largely restricted to In our registered protocol,28 we specified that the first descriptive discussion of the results from relevant exper- process will contain three search paths: a systematic review 22 23 imental studies or narrative review of studies with a of systematic reviews, of the burden of disease studies 24 similar setting. There still is an absence of any systematic and of relevant study reports. The current protocol has syntheses of evidence on a specific ozone-related health been renamed ‘systematic review of systematic reviews’ to effect. ‘umbrella review’, and contains no systematic review of 25 26 Therefore, a systematic map or a systematic evidence the burden of disease studies. The detailed table of PRIS- map,27 which uses systematic search and strategical selec- MA- P is listed in the Supplementary (online supplemen- on October 2, 2021 by guest. Protected copyright. tion but seeks no evidence synthesis, is an appropriate tary table S1). emerging method to comprehensively summarise and The process of the umbrella review will be guided by catalogue the ozone- related broad and miscellaneous the PRISMA guideline.34 Given no agreed method for evidence from original experimental studies, as well as conducting an umbrella review,7 our methodology will original epidemiological studies.
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