Article Text

Download PDFPDF

Ozone exposure and health effects: a protocol for an umbrella review and effect-specific systematic maps
  1. Tianyu Zhao1,2,3,4,
  2. Iana Markevych1,2,3,5,
  3. Christian Janßen4,
  4. Dennis Nowak1,2,
  5. Nadine Steckling-Muschack1,6,
  6. Joachim Heinrich1,2,3,7
  1. 1 Institute and Clinic for Occupational, Social and Environmental Medicine, University Hospital, Ludwig Maximilian University of Munich, Munich, Germany
  2. 2 Comprehensive Pneumology Center (CPC) Munich, member DZL; German Center for Lung Research, Munich, Germany
  3. 3 Institute of Epidemiology, Helmholtz Zentrum München - German Research Center for Environmental Health, Neuherberg, Germany
  4. 4 Department of Applied Social Sciences, Munich University of Applied Sciences, Munich, Germany
  5. 5 Institute of Psychology, Jagiellonian University, Krakow, Poland
  6. 6 Department of Public Health and Health Technology Assessment, University for Health Sciences, Medical Computer Science and Technology, Hall in Tirol, Austria
  7. 7 Allergy and Lung Health Unit, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
  1. Correspondence to Dr Joachim Heinrich; joachim.heinrich{at}


Introduction Ambient ozone exposure may be adverse to health. Since the reported associations between ozone and health effects are heterogeneous and the underlying pathways are indistinct, the overall relationship remains unclear. Only a few overall syntheses of the evidence regarding ozone and health effects are available to date.

Methods and analysis We plan to summarise the current evidence on ozone-related health effects systematically. First, to identify the possible associations between ambient ozone exposure and health outcomes, we will conduct an umbrella review. PubMed, Web of Science and grey literature will be searched for systematic reviews on exposure to ambient ozone and any possible health endpoints published before 31 May 2019. Data selection and extraction will be carried out by one reviewer, and a second reviewer will check the agreement of a sample of the studies. The methodological quality of the eligible systematic reviews and level of evidence regarding ozone and every specific health effect will be evaluated. Second, for each of the identified effects with a high level of evidence, comprehensive information retrievals 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 of the filtered epidemiological and experimental studies to conduct several systematic maps presenting the currently available evidence for the specific health effect. Because the association between ozone exposure and chronic obstructive pulmonary disease (COPD) is relatively well investigated, we will at least conduct one systematic map of ozone and COPD.

Ethics and dissemination No ethical approval is required for this study. The completed umbrella review and systematic maps will be considered for publication and presentation. We will additionally upload the relevant data to publicly accessible online databases.

PROSPERO registration number CRD42019123064.

  • epidemiology
  • public health
  • thoracic medicine

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

Statistics from


  • NS-M and JH contributed equally.

  • Contributors TZ, NS-M, IM and JH had the original idea of this work. TZ drafted the protocol with assistance from NS-M. IM, CJ, and DN provided revision in the editing and write-up process. All authors approved the final version of the protocol. TZ is the guarantor of the umbrella review and systematic maps. NSM and JH contributed equally as last author.

  • Funding The planned umbrella review and systematic maps are supported by the project ‘Quantifizierung der Krankheitslast verursacht durch Ozon-Exposition in Deutschland für die Jahre 2007–2016’ on behalf of the German Environment Agency (UBA), funded by the Federal Ministry of Environment, Nature Conservation, and Nuclear Safety (Bundesministerium für Umwelt, Naturschutz und nukleare Sicherheit, BMU, grant number 3718622080).This work is supported by the Bavarian Academic Forum (BayWISS) - Doctoral Consortium ‘Health Research’ and is funded by the Bavarian State Ministry of Science and the Arts.TZ is supported by the China Scholarship Council (CSC, grant number 201708120056). IM is supported from the ‘NeuroSmog: Determining the impact of air pollution on the developing brain’ (Nr. POIR.04.04.00-1763/18-00) which is implemented as part of the TEAM-NET programme of the Foundation for Polish Science, co-financed from EU resources, obtained from the European Regional Development Fund under the Smart Growth Operational Programme.

  • Competing interests No.

  • Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.