Association between air quality index and effects on emergency department visits for acute respiratory and cardiovascular diseases

Panumas Surit; Wachira Wongtanasarasin; Chiraphat Boonnag; Borwon Wittayachamnankul

doi:10.1371/journal.pone.0294107

. 2023 Nov 16;18(11):e0294107. doi: 10.1371/journal.pone.0294107

Association between air quality index and effects on emergency department visits for acute respiratory and cardiovascular diseases

Panumas Surit ¹, Wachira Wongtanasarasin ¹, Chiraphat Boonnag ^2,³, Borwon Wittayachamnankul ^1,^*

Editor: Oyelola A Adegboye⁴

PMCID: PMC10653395 PMID: 37972204

Abstract

Background and objective

Several studies suggest that air pollution, particularly PM2.5, increases morbidity and mortality, Emergency Department (ED) visits, and hospitalizations for acute respiratory and cardiovascular diseases. However, no prior study in Southeastern Asia (SEA) has examined the effects of air pollutants on ED visits and health outcomes. This study focused on the association of the Air Quality Index (AQI) of PM_2.5 and other pollutants’ effects on ED visits, hospitalization, and unexpected deaths due to acute respiratory disease, acute coronary syndrome (ACS), acute heart failure (AHF), and stroke.

Methods

We conducted a retrospective study with daily data from ED visits between 2018 and 2019 at Maharaj Nakorn Chiang Mai Hospital, Chiang Mai, Thailand. The AQI of air pollution data was collected from outdoor air quality from the Smoke Haze Integrated Research Unit and the Air Quality Index Visual Map. A distributed lag, non-linear and quasi-Poisson models were used to explore the relationship between air quality parameters and ED visits for each disease.

Results

3,540 ED visits were recorded during the study period. The mean daily AQI of PM_2.5 was 89.0 ± 40.2. We observed associations between AQI of PM_2.5 and the ED visits due to ACS on the following day (RR = 1.023, 95% confidence interval [CI]: 1.002–1.044) and two days after exposure (RR = 1.026, 95% CI: 1.005–1.047). Also, subgroup analysis revealed the association between AQI of PM_2.5 and the ED visits due to pneumonia on the current day (RR = 1.071, 95% CI: 1.025–1.118) and on the following day after exposure (RR = 1.024, 95% CI: 1.003–1.046). AQI of PM_2.5 associated with increased mortality resulted from ACS on lag day 3 (OR = 1.36, 95% CI: 1.08–1.73). The AQI of PM₁₀ is also associated with increased ED visits due to COPD/asthma and increased hospitalization in AHF. In addition, the AQI of O₃ and AQI of NO₂ is associated with increased ICU admissions and mortality in AHF.

Conclusion

Short-term PM2.5 exposure escalates ED visits for ACS and pneumonia. PM10’s AQI associates with COPD/asthma ED visits and AHF hospitalizations. AQI of O₃ and NO₂’s link to increased ICU admissions and AHF mortality. Urgent action against air pollution is vital to safeguard public health.

Introduction

Air pollution is a major public health concern worldwide and represents one of the largest environmental problems [1]. Outdoor air pollution is a complex mixture of components affecting human health, including airborne particulate matter (PM), pollutants ozone (O₃), nitrogen dioxide (NO₂), and sulfur dioxide (SO₂) [2]. The most health-damaging PMs are those with a diameter of less than 10 μm (PM₁₀) and 2.5 μm (PM_2.5), which can penetrate and lodge deep inside the lungs. The principal air pollutant of PM_2.5 shows the greatest threat to global public health [2, 3]. Both short- and long-term exposure to PM_2.5 has been associated with health impacts in multiple organ systems via many pathways with the role of oxidative stress in PM-mediated effects, systemic vascular dysfunction, and cardiovascular modeling with air pollution, and autonomic dysfunction and activation of central nervous system pathways. Exposure to PM_2.5 also leads to respiratory problems and the development of atherosclerosis which increases the risk for coronary artery disease and cerebrovascular disease [3]. Several studies have demonstrated the effects of PM_2.5 on increased morbidity and mortality, emergency visit, and hospitalization for acute respiratory problems, including pneumonia, chronic obstructive pulmonary disease (COPD) and asthma, acute coronary syndrome (ACS), acute heart failure (AHF), and stroke [2–8].

According to the World Health Organization (WHO) global assessment of ambient air pollution exposure and the resulting burden of disease in 2016, the Eastern Mediterranean, South-East Asian (SEA), and Western Pacific Regions had some of the highest exposures to air pollution [9–11]. Thailand is a SEA country with exposure to high annual mean WHO Air Quality Guidelines (AQG) [11, 12]. The area with the highest air pollution concentrations is northern Thailand, specifically from January to May. The pollution originates from human activity and wildfires; [12] however, few study in SEA mentions the effects of PM_2.5 on health impacts in ED visits. Therefore, the primary objective of this study was to determine the association between the increase of fine particulate matter (PM_2.5) and other pollutants, and its effect on acute respiratory disease, ACS, AHF, and stroke in the ED visits, ED disposition, and in-hospital mortality.

Material and methods

Data collection

Data was retrospectively collected between April 2018 and March 2019 at Maharaj Nakorn Chiang Mai Hospital, a tertiary care and university hospital. Inclusion criteria were patients who visited the ED older than 18 with a current address in Chiang Mai. The exclusion criteria were patients referred from other hospitals and trauma patients. The study protocol was approved by the Research Ethics Committee, Faculty of Medicine, Chiang Mai University (Permit No. EXEMPTION-6698/2562). The institutional Ethics Committee waived the need for consent.

From the electronic medical record (EMR), we extracted patient data of ED patients with the principal diagnosis of acute respiratory disease, ACS, AHF, and stroke, using only the International Classification of Diseases (ICD) 10^th revision codes of J00-J99, I20-I25, I50, and I60-I69, respectively. The principal diagnosis was recorded in EMR by ED physicians. Data collection derived from the EMR included age, gender, visit date, diagnosis, Emergency Department disposition, and in-hospital mortality.

We examined the daily outdoor Air Quality Index (AQI) for pollutants including PM2.5, PM10, ozone (O₃), nitrogen dioxide (NO₂), and sulfur dioxide (SO₂). The AQI serves as a standardized metric for assessing and communicating air pollution levels. It is calculated by converting the concentrations of these pollutants into sub-index values using established equations or algorithms (S1 File). These sub-index values are then combined to derive the overall AQI value, indicating the air quality level daily. However, we utilized these individual AQI values (sub-index value) collectively to conduct our analysis. These were collected from the Smoke Haze Integrated Research Unit (SHIRU) and the Air Pollution in Chiang Mai: Real-time Air Quality Index Visual Map website [13]. Twelve stations are on the map in the Muang Chiang Mai District of Chiang Mai Province in Thailand, managed by The World AQI project team. The outcome of this study has measured the effects of air pollutions on ED visits, hospitalization, Intensive Care Unit (ICU) admissions, and mortality from acute respiratory disease, ACS, AHF, and stroke.

Data analysis

The results were presented as medians and interquartile ranges for non-normally distributed variables and frequency with percentages for categorical variables. The primary exposure variable was the AQI of PM_2.5. Considering the nonlinear exposure-lag-response relationship between exposure to air pollution and health effects, an additional dimension, temporal dependency of exposure and outcome, was required to characterize and control the model [14–17]. Distributed lag non-linear model (DLNM) is a model in which the relationship between air quality parameters and ED visits is described in the usual predictor and the additional dimension of time lags. The model is defined by the following formula:

\log (E (Y_{t})) = α + n s (R H_{t}, 3) + n s (T e m p e r a t u r e, 3) + n s (F o c u s e d_A P_{t}, 3) + \sum_{i = 0}^{q} β_{i} {(F o c u s e d_A P)}_{t - i} + ε_{t}

W h e r e F o c u s e d_A P \in {A Q I o f P M_{2.5}, A Q I o f P M_{10}} a n d

O t h e r_A P \in {A Q I o f P M_{2.5}, A Q I o f P M_{10}, A Q I o f O_{3}, A Q I o f N_{2}} - {F o c u s e d_A P}

E(Y_t) is the expected number of ED visits on day t, and α is the model intercept. Focused_AP_t-q represented the focused daily average AQI of PM_2.5 or PM₁₀ (based on which pollutant we focused) q days before the ED visit. The model was adjusted for other environmental confounding variables using a natural cubic spline with three df for relative humidity (RH_t), temperature and AQI of other air pollutants (Other_AP_t; PM₁₀ (or PM_2.5 for model that focused on PM₁₀), O_3, and NO₂). We investigated the lag structure of AQI of PM_2.5 effects on ED visits using a polynomial function with seven days from lag day 0 to lag day 6. The outcome of the DLNM was the number of ED visits for each disease. A multivariable logistic regression model was employed to explore the independent AQI of each pollutant (PM_2.5, PM₁₀, O₃, NO₂, and SO₂) predictors of hospital admission, ICU admission, and in-hospital death. All statistical analyses were performed using R (version 4.0.0). Two-tailed p < 0.05 was considered statistically significant. DLNM package version 2.4.2 was used for model development.

Results

Of the total, 3,540 ED visits were recorded for acute respiratory diseases, ACS, AHF, and stroke, from April 2018 to March 2019, with respiratory disease accounting for the largest proportion (55.7%). Most patients were over 65 (46.3%) and male (51.5%). The highest percentage of daily ED visits for cause-specific respiratory diseases were upper respiratory tract infections (URTI) (28.5%), followed by pneumonia (27.3%), chronic obstructive pulmonary disease (COPD), and asthma (26%), respectively. 1,664 out of 3,540 (47%) were admitted to the hospital, and 16.6% were admitted to the ICU. Patients diagnosed with ACS had the highest admission rate (80.6%). Table 1 describes the characteristics of patients presented to the ED during the study period. The overall median daily AQI of PM_2.5 was 75.0 (Interquartile range; IQR 63–102), and the mean daily AQI of PM_2.5 was 89.0 ± 40.2 above from “Good level” (0–50) AQI recommendations. The median daily AQI of PM₁₀, O₃, NO_2, and SO₂ were 39 (IQR 32–53), 19 (IQR 15–24), 8 (IQR 6–12), and 0, respectively, as shown in Fig 1 and S1 Table in S1 File. The onset of the summer season heralded the culmination of peak levels in the AQI for all air pollutants. Specifically, this phenomenon was observed from April 2018 to March 2019, as demonstrated in S2 Fig in S1 File.

Table 1. Descriptive summary for the study period (April 2018 to March 2019), emergency department visits, ICU admission, and in-hospital deaths for acute respiratory diseases, acute coronary syndrome, acute heart failure, and stroke.

Characteristics	Total	Acute Respiratory Disease (ICD10 code: J00-J99)	Acute Coronary Syndrome (ICD10 code: I20-I25)	Acute Heart Failure (ICD10 code: I50)	Stroke (ICD10 code: I60-69)
Characteristics	N (%)	N (%)	N (%)	N (%)	N (%)
ED visit	3540 (100)	1973 (55.7)	470 (13.3)	365 (10.3)	732 (20.7)
Median age–year (IQR)	63 (29)	59 (44)	65 (15.8)	69 (20)	63 (21)
Age (year) ^*
18–34	637 (18.0)	596 (30.2)	1 (0.2)	8 (2.2)	32 (4.4)
35–44	207 (5.8)	135 (6.8)	18 (3.8)	14 (3.8)	40 (5.5)
45–54	349 (9.9)	141 (7.2)	59 (12.6)	35 (9.6)	114 (15.6)
55–64	705 (20.0)	291 (14.8)	140 (29.8)	67 (18.4)	207 (28.3)
≥ 65	1638 (46.3)	810 (41.0)	252 (53.6)	241 (66.0)	335 (45.8)
Gender
Male	1824 (51.5)	988 (50.1)	293 (62.3)	158 (43.3)	385 (52.6)
Female	1716 (48.5)	985 (49.9)	177 (37.7)	207 (56.7)	347 (47.4)
Disposition
Discharge	1876 (53.0)	1414 (71.7)	91 (19.4)	156 (42.7)	215 (29.4)
Total Admission	1664 (47.0)	559 (28.3)	379 (80.6)	209 (57.3)	517 (70.6)
ICU Admission	276 (16.6)	22 (3.9)	218 (57.5)	20 (9.6)	16 (3.09)
In-hospital death	153 (9.2)	75 (13.4)	27 (7.1)	19 (9.1)	32 (6.2)

Open in a new tab

* Note: Age (N/A = 4; ICD10 I60-I69 = 4

Fig 2 shows the association between the adjusted lag-effect of AQI of PM_2.5 > 50 on ED visits to acute respiratory disease, ACS, AHF, and stroke. We observed statistically significant associations between ED visits due to ACS and AQI of PM_2.5 on the following days (lag day 1) (RR = 1.023; 95% CI: 1.002–1.044), two days after exposure (lag day 2) (RR = 1.026; 95% CI: 1.005–1.047) and returned to normal three days after exposure to PM_2.5 (lag day 3). No statistically significant associations were found between AQI of PM_2.5 and ED visits due to acute respiratory disease, AHF, and stroke for any lag day.

Analysis of the effect of AQI of PM_2.5 on cause-specific respiratory diseases, including URTI, pneumonia, COPD, and asthma (Fig 3) found statistically significant associations in ED visits of pneumonia on the current day (lag day 0) (RR = 1.071; 95% CI: 1.025–1.118), lag day 1 (RR = 1.024; 95% CI: 1.003–1.046) then reverted to normal levels at two days after exposure (lag day 2), with the effects rebounding four days after exposure (lag day 4) (RR = 0.970; 95% CI: 0.948–0.993) and five days after exposure (lag day 5) (RR = 0.979; 95% CI: 0.961–0.998). The largest effect was observed on the current day (lag day 0). Moreover, we investigated the effects of AQI of other air pollutants, such as PM₁₀, O₃, and NO₂, on ED visits and hospitalizations. Above the moderate level of AQI of PM₁₀ (>120) were associated with increased ED visits due to COPD and asthma on lag day three (RR = 1.159; 95% CI: 1.007–1.1335) and lag day four (RR = 1.138; 95% CI: 1.009–1.284) (S3 Fig in S1 File). For O₃ and NO₂, no conclusions could be drawn since their AQI was within the standard references across the study period.

Fig 4 demonstrates the association between air pollutants and hospitalization for specific diseases on any lag day. We observed statistically significant associations between the hospitalization and AHF with every 10 increase of AQI in PM₁₀ on lag day two (OR = 1.32; 95% CI: 1.04–1.67). However, the statistical results show no significant associations between air pollutants and other diseases. Additionally, this study found statistically significant air pollutants increase the risk effect of ICU admissions and mortality on any lag day, as shown in S4 and S5 Figs in S1 File. Every 10 AQI increase of NO₂ on the previous two days was associated with an increase in ICU admission for AHF (OR = 1.13; 95% CI: 1.02–1.26). An AQI of PM_2.5 was associated with increased ACS mortality three days after exposure (OR = 1.36; 95% CI: 1.08–1.73). Furthermore, AQI of O₃ was associated with increased AHF mortality on the current day (OR = 1.16; 95% CI: 1.04–1.29), the following day (OR = 1.13; 95% CI: 1.04–1.23), and the next two days after exposure (OR = 1.17; 95% CI: 1.05–1.30).

Discussion

This study found that the AQI of PM2.5 was associated with increased ED visits due to ACS and pneumonia (lag days 1 and 2). A significant relationship was observed between PM2.5 AQI and pneumonia on the current day and the following day after exposure. Consistent with previous studies, ED visits due to acute respiratory diseases were associated with an increased PM_2.5 concentration on the same day [4, 6, 18–20]. Interestingly, the previous report investigated the effects of PM_2.5 on daily mortality and hospitalization in cardiovascular and respiratory diseases, which found PM_2.5 affecting COPD and community-acquired pneumonia [21]. Our findings correlated with the previous study showing that PM_2.5 is associated with increased mortality of ACS patients three days after exposure [19]. Additionally, we found that the effect of PM_2.5 pollution on respiratory disease hospitalization was significantly greater in males over 65 years. Compared with previous studies, the subgroup analysis results suggested that older people might be more susceptible to PM_2.5 exposure. They may have a weaker immune system and a higher prevalence of chronic respiratory diseases [6, 21].

PM_2.5 was hypothesized to have the most effects on the respiratory and cardiovascular systems. PM-mediated effects directly affects the respiratory system via the oxidative stress generation through inhaled PM_2.5 depositing deep within pulmonary tissues, interacting with local cells, and modifying endogenous structures. Also, PM-mediated effects influence the development of atherosclerosis, resulting in an increased risk of coronary artery disease [2–4]. The results of this study indicate that the short-term effect of ambient PM_2.5 exposure is associated with increased daily ED visits with ACS. The number of ACS patients increased following the rising of PM_2.5 AQI by one to two days. Increased AQI of PM2.5 did not affect the number of ED visits in lag days regarding AHF and stroke. Previous literature demonstrated that most PM_2.5 effects were delayed, ranging from seven days or more after exposure to PM_2.5; moreover, stroke was associated with long exposure to air pollution [5, 8, 22, 23].

Other air pollutants also demonstrated some effects on ED patients. Interestingly, PM₁₀ is another significant air pollutant that can precipitate emergency illnesses, especially cardiovascular and respiratory diseases; however, studies exploring the effect of PM₁₀ concentration and specific conditions are limited [3, 24]. We found that AQI of PM₁₀ was associated with an increased risk of ED visits due to COPD and asthma. Furthermore, our study revealed the association between AQI of PM₁₀ and an increased risk of hospitalization due to AHF. Correlated to the previous research, PM₁₀ concentrations between 50–200 μg/m³ were an isolated risk factor for hospitalization in AHF patients in Saharan desert dust [25]. Also, NO₂ and O₃ also took part in the pathogenesis of inflammation, oxidative stress, and autonomic abnormality, resulting in an increased risk of unfavorable outcomes in AHF patients [3, 26, 27].

This is the first study in SEA studying the effects of AQI of PM_2.5 and PM₁₀ on ED visits in a place where the daily AQI of PM_2.5 and PM₁₀ were higher than the standard level (US AQI). Also, this study demonstrated the possible health effects of exposure to air pollution, especially the effects of PM_2.5 on the cardiovascular and respiratory systems, as mentioned. This is important for both healthcare providers and public health authorities and could contribute to health promotion for the general public by increasing awareness of the effects of air pollution and preventative measures. Also, to raise government awareness of the gravity of air pollution issues to be aware of harmfulness and health hazards to the populations in this area. Finally, to help guide systems planning for health care professionals, especially those in the emergency services, to prepare for increases in ACS and respiratory disease visits to the ED in seasons where PM_2.5 concentrations are abnormally high, especially during winter (December to February), and peak again in forest fire season (April) (S1 Fig in S1 File). A well-prepared protocol during the season, which has a high level of PM_2.5, is warranted to ensure patients and healthcare personnel that ED and hospital are administering this issue.

Some limitations of our study should be mentioned. First, it is a single-center study conducted only in one district; thus, the sample size studied in subgroup analyses was small, and only one year of data was included. Furthermore, patients referred from other hospitals were excluded from the study. As this was conducted in a tertiary teaching hospital, the admission criteria were strict, which may influence the number of admissions in disease subgroup analyses. Second, patient data obtained from the principal diagnosis made in the ED according to ICD-10 did not include disease severity, risk factors, and initial management. Moreover, our data explored the effects of short-term exposure. Finally, we did not collect data on preventative measures taken by the sample population to lessen PM_2.5 exposure, such as using home air purifiers and wearing face masks. Further study should focus on two primary issues: multiple meteorological factors and the long-term effects of air pollutants.

Conclusion

In summary, our study provides robust evidence demonstrating the association between short-term PM_2.5 pollution exposure and increased risks of ED visits for ACS and respiratory diseases, particularly pneumonia. Moreover, the AQI of PM10 shows associations with elevated ED visits related to COPD and asthma, as well as heightened hospitalization in AHF cases. Furthermore, the AQI of O₃ and NO₂ is linked to an increase in ICU admissions and mortality in AHF cases. These findings emphasize the need for effective measures to reduce PM_2.5 and other pollution levels and protect vulnerable populations from the adverse health impacts of air pollution.

Supporting information

S1 File. PM2.5 and ED visits supplementary.docx.

(DOCX)

Click here for additional data file.^{(2.3MB, docx)}

S1 Data

(ZIP)

Click here for additional data file.^{(13.1KB, zip)}

Acknowledgments

The authors would like to thank the Smoke Haze Integrated Research Unit (SHIRU) for supporting the air pollution data. Also, our thanks go to Miss Rudklao Sairai and colleagues, the Research Unit of the Department of Emergency Medicine, Chiang Mai University, for supporting this study. We appreciate Dr. Nattikarn Atthapreyangkul for their English language editing and Dr. Phichayut Phinyo for their methodology and statistical advice. Finally, we would like to thank the Medical Records and Statistics Section of Maharaj Nakorn Chiang Mai Hospital for providing the data of patients in this study.

Data Availability

All relevant data are within the paper and its Supporting Information files.

Funding Statement

Faculty of Medicine, Chiang Mai University funded this research (Fund No. 089-2563). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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PLoS One. doi: 10.1371/journal.pone.0294107.r001

Decision Letter 0

Oyelola A Adegboye

15 Aug 2022

PONE-D-22-17550Association Between PM 2.5 and Effect of Emergency Department Visits for Acute Respiratory Disease, Acute Coronary Syndrome, Acute Heart Failure, and StrokePLOS ONE

Dear Dr. Wittayachmnankul,

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Oyelola A. Adegboye, PhD

Academic Editor

PLOS ONE

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"The authors would like to thank the Faculty of Medicine, Chiang Mai University for funding this research and the Smoke Haze Integrated Research Unit (SHIRU) for supporting the air pollution data. Also, our thanks goes to Miss Rudklao Sairai and colleagues, the Research Unit of Department of Emergency Medicine, Chiang Mai University for providing support to this study. We appreciate Dr. Nattikarn Atthapreyangkul for English language editing and Dr.Phichayut Phinyo for methodology and statistical advice. Finally, we would like to thank the Medical Records and Statistics Section of Maharaj Nakorn Chiang Mai Hospital for providing the data of patients in this study."

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: No

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: No

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: No

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Dear Dr. Oyelola A. Adegboye,

Thank you for inviting me to review this manuscript. Overall this study is well done and interesting. The paper could be accepted for publication into PLOS ONE after minor revisions.

Comments to the Authors:

Title P.1

The title of your study is “association between PM 2.5 and effect of emergency department visits for acute respiratory disease, acute coronary syndrome, acute heart failure, and stroke.” However, the authors didn’t only focus on PM2.5, but also on other air pollutants, including PM10, O3, NO2, SO2. A suitable study title should contain the critical keywords and predict the content of the research. Therefore, the keyword "PM 2.5" may be revised as "air pollutants."

Material and Methods P. 4

Your study investigated short-term air pollutant exposures and emergency department visits for acute respiratory diseases and cardiovascular diseases between 2018 and 2019. In general, the study periods of epidemiologic studies regarding the relationship between short-term exposure to particulate matter and diseases are more than one year or at least two years. It would be better if the time series analysis from 2018 to 2020 could be conducted.

Material and Methods P. 4

The sampling of this study is not representative of the exposure-outcome distributions in the overall population. Selection bias could have occurred when investigators use only one hospital data.

Material and Methods P. 4

The inclusion criteria of the study subjects are not clear. How did you define daily counts of emergency department visits for acute respiratory diseases and cardiovascular diseases? by ICD10 or ICD10 plus some kind of treatments from hospital electronic medical records?

Material and Methods P. 5

The analyses consider several important confounding variables, including age, gender, and season.

Discussion P.9

Although unmeasured confounding remained in this study, you provide important new evidence that short-term PM2.5, PM10 and other air pollutant exposures is significantly related to emergency department visits for acute respiratory diseases and cardiovascular diseases. Further research might be conducted to investigate the associations of long-term exposure to fine particulate matter and air pollutants with healthcare utilization.

Discussion P.10

According to previous studies, Chiang Mai has been facing severe problem of haze pollution over the past years. Did emergency department visits to treat respiratory diseases and cardiovascular diseases increase during haze episodes in your study? Had Maharaj Nakorn Chiang Mai Hospital been prepared to meet the surge in demand for medical treatment? It could be one of the confounding factors in your study and may produce spurious or distorted associations between exposure to air pollutants and increased emergency department visits. So, the authors may add methods to decrease the impact of confounding variables in the study design. This requires clarification.

Discussion P.10

Chiang Mai is surrounded by the mountain ranges of the Thai highlands and has a tropical savanna climate with hot, wet temperatures year-round. Many studies have shown the meteorological factors could impact the PM concentrations, including the dispersion, growth, chemical production, photolysis, and deposition of PM. Besides, the dominant meteorological factors for PM concentrations are closely related to geographical conditions. Also, weather conditions could trigger respiratory symptoms in patients with respiratory diseases. Thus, I suggest that the effects of PM concentrations on multiple meteorological factors, including cloud cover, temperature, wind, humidity, relative humidity, pressure, precipitation, rainfall, radiation and planetary boundary layer height might be included and carefully examined in the further study.

Conclusion P.10

The authors should be cautious in interpreting your results. Many studies focusing on PM2.5 and health outcomes may overstate conclusions of their findings.

Reviewer #2: This is an important research study into the acute effects of ambient air pollutants on ED visits for a variety of impotant outcomes. However, there are several limitations that either make me doubt the results and/or formations of the analysis that are unclear and incomplete. Major and minor comments are provided below.

Major Comments:

1. The exposure assessment metrics are not clearly stated in the abstract or in the methods. How were pollutants measured? What is the LOD and how were below LOD values addressed? So2 cannot be 0ug/m3, which makes me concerned about how below LOD values were handled.

2. It is unclear why PM2.5 was only modeled as 50ug/m3 as the reference group. What is the rationnale for this? Why not model a continuous measure? This analysis seems quite incomplete to me.

3. PM10 was substantially lower than PM2.5. This practically speaking cannot be possible because PM2.5 is a fraction of PM10. Authors need to explain this oddity. Was PM2.5 and PM10 somehow swapped? This is a major gap in the data that is not addressed by the authors.

4. There is a lot of ambiguities that need clearing up, which I believe is largely due to issues with the grammar. For instance, referring to exposure on the following day in the abstract, and repeating it later, makes it sound like exposure effects on the day after ED visit was associated with ED visits. This is inconsistent with how other day lags are talked about in the paper.

5. Overall, there needs to be much more extensive english language editing to fix the clarity of this manuscript.

6. Study figures, especially the last two, are of very poor quality and mostly unreadable. These must be more clear for the reader to understand the data.

Minor Comments:

1. The abstact background is lacking background information.

2. the abstract methods need to specify the study area (city, country) and the exposure assessment method.

3. What statistical package (and version number) did authors use for dlnm modeling? Need to specify these

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Reviewer #1: Yes: Man-Ju Ting

Reviewer #2: Yes: Eric S Coker

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PLoS One. 2023 Nov 16;18(11):e0294107. doi: 10.1371/journal.pone.0294107.r002

Author response to Decision Letter 0

28 Oct 2022

Response to reviewer and editor

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

Answer: thank you for suggestion. We edit the revised manuscript to PLOS ONE's style requirements

Answer: We retrospective collected data and the need for consent was waived by the ethics committee. We add this information in the revised manuscript.

3. Thank you for stating the following financial disclosure:

"Faculty of Medicine, Chiang Mai University funded this research (Fund No. 089-2563)."

If this statement is not correct you must amend it as needed.

Please include this amended Role of Funder statement in your cover letter; we will change the online submission form on your behalf.

Answer: Thanks, we change this in revised manuscript.

4. Thank you for stating the following in the Acknowledgments Section of your manuscript:

Please remove any funding-related text from the manuscript and let us know how you would like to update your Funding Statement. Currently, your Funding Statement reads as follows:

"Faculty of Medicine, Chiang Mai University funded this research (Fund No. 089-2563)."

Answer: Thanks, we change this in revised manuscript.

Answer: We will update your Data Availability statement to reflect the information you provide in your cover letter.

6. Please upload a copy of Supporting Information Figures 1, 2, 3, 4 and 5 which you refer to in your text on page 10,6,7 .

Answer: Thank you, we just upload this information in revised manuscript

7. Please upload a copy of Supporting Information Table 1 which you refer to in your text on page 6.

Answer: Thank you, we just upload this information in revised manuscript

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes

Reviewer #2: Partly

________________________________________

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: No

________________________________________

3. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #1: Yes

Reviewer #2: No

________________________________________

4. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #1: Yes

Reviewer #2: No

________________________________________

5. Review Comments to the Author

Reviewer #1: Dear Dr. Oyelola A. Adegboye,

Thank you for inviting me to review this manuscript. Overall this study is well done and interesting. The paper could be accepted for publication into PLOS ONE after minor revisions.

Comments to the Authors:

Title P.1

Answer: Thanks, we change this in revised manuscript.

Material and Methods P. 4

Answer: Thank you for your suggestion, however, we have only one year of ER visit data we add this in limitation of revised manuscript.

Material and Methods P. 4

The sampling of this study is not representative of the exposure-outcome distributions in the overall population. Selection bias could have occurred when investigators use only one hospital data.

Answer: Thank you, we already mentioned in discussion.

Material and Methods P. 4

Answer: Thanks, we already edited this in methods part

Material and Methods P. 5

The analyses consider several important confounding variables, including age, gender, and season.

Answer: Thank you.

Discussion P.9

� Answer: We add this point in discussion section, thanks for suggestion.

Discussion P.10

� Answer: Our ED has a plan for ED overcrowding, since haze pollution occur this does not impact care process in our ED. However ED overcrowded may not impact the outcome of this research.

Discussion P.10

Answer: Thank you for your suggestion, we add this in limitation of revised manuscript.

Conclusion P.10

The authors should be cautious in interpreting your results. Many studies focusing on PM2.5 and health outcomes may overstate conclusions of their findings.

Major Comments:

Answer: Sorry about the mistakes, we check this with SHIRU and found that this data was AQI not concentration, we have change to AQI not concentration.

2. It is unclear why PM2.5 was only modeled as 50ug/m3 as the reference group. What is the rationnale for this? Why not model a continuous measure? This analysis seems quite incomplete to me.

Answer: 50 (AQI) is the upper limit of good level of AQI, from our reference.

Answer: From the mistake that we mention earlier, we check this with SHIRU and found that this data was AQI not concentration, we have change to AQI not concentration.

Answer: Thank you for your suggestion. We edit our manuscript many points.

5. Overall, there needs to be much more extensive english language editing to fix the clarity of this manuscript.

Answer: In revised version, we edit by English language specialist.

6. Study figures, especially the last two, are of very poor quality and mostly unreadable. These must be more clear for the reader to understand the data.

Answer: Our picture was more than 900 DPI, in our opinion, the publisher was reduce resolution of before send to the reviewer.

Minor Comments:

1. The abstact background is lacking background information.

Answer: we just added this in formation in abstract.

2. the abstract methods need to specify the study area (city, country) and the exposure assessment method

Answer: Thank you, we just added this in formation in abstract.

3. What statistical package (and version number) did authors use for dlnm modeling? Need to specify these

Answer: Thank you, we just added this in formation in abstract.

________________________________________

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Man-Ju Ting

Reviewer #2: Yes: Eric S Coker

________________________________________

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Submitted filename: P_ONE_cb.docx

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PLoS One. doi: 10.1371/journal.pone.0294107.r003

Decision Letter 1

Oyelola A Adegboye

5 Feb 2023

PONE-D-22-17550R1Association Between Air Quality Index and Effect of Emergency Department Visits for Acute Respiratory Disease, Acute Coronary Syndrome, Acute Heart Failure, and StrokePLOS ONE

Dear Dr. Wittayachmnankul,

Please submit your revised manuscript by Mar 22 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Oyelola A. Adegboye, PhD

Academic Editor

PLOS ONE

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #3: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Partly

Reviewer #3: Partly

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #3: Yes

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4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #1: Yes

Reviewer #3: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #1: No

Reviewer #3: Yes

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6. Review Comments to the Author

Reviewer #1: Dear editors and authors,

Thank you for your thoughtful revisions to the manuscript. Authors have revised some issues of concern that I outlined and have stated the study limitations that may affect the interpretation of the results in a balanced tone. I appreciate the effort the authors put into this work. The article is clearer, and the research question is interesting. However, there are still several points should be addressed before this manuscript can be suitable for publication.

1. Editing for the English language is still required. Please revise and perfect your manuscript by a professional language polishing service or a native English speaker and attach the language editing certificate when resubmitting the manuscript.

2. Title, page 1, line 1-2.

The title of your manuscript has changed to “Association Between Air Quality Index and Effect of Emergency Department Visits for Acute Respiratory Disease, Acute Coronary Syndrome, Acute Heart Failure, and Stroke.” It's probably not written in standard English, so the authors may discuss with a native English speaker about that.

3. Abstract, page 2, line 12.

It is not appropriate to add website address in the abstract section. “(https://aqicn.org/map/chiang-mai/)” could be eliminated and should be included in the reference section.

Reviewer #3: This is an important study that investigated the association between the air quality index outdoors and emergency visits for various health outcomes. These findings may contribute to policy change to improve outdoor air quality in Thailand in the future. The revision seemed to have accommodated comments from the reviewers. Additional comment is provided below.

The air quality data is collected outdoors while the location (indoor or outdoor) of the patient when the patient was transferred to ER is not clear. Most likely, the air indoors will not reflect the air outdoors due to building infiltration, filtration in HVAC systems, or the use of portable air cleaners. Can rerun your analysis by separating patients by their location when sent to ER? If this is not doable, can you explain why the air quality index outdoors can be used to hypothesize outdoor air pollution may be the cause of the ER visit?

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Man-Ju Ting

Reviewer #3: Yes: Kazukiyo Kumagai

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Submitted filename: 20221121 PLOS ONE reviewer_1.doc

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PLoS One. 2023 Nov 16;18(11):e0294107. doi: 10.1371/journal.pone.0294107.r004

Author response to Decision Letter 1

16 Feb 2023

Dear Reviewer,

Thank you for your valuable feedback on our manuscript titled "Association Between Air Quality Index and Effects on Emergency Department Visits for Acute Respiratory and Cardiovascular Diseases." We appreciate the time and effort you put into reviewing our work and providing constructive comments that have helped us improve the manuscript. We have addressed all your concerns in the revised manuscript, and we hope that you find the revised version to be suitable for publication.

We have made significant changes to the manuscript based on your suggestions, including revising the title, removing inappropriate content from the abstract, and having the manuscript professionally edited by a native English speaker. Additionally, we have addressed your concern about the location of patients when they presented to the emergency department (ED) and clarified that all air quality data used in our study were collected from outdoor sources.

As per your request, we have provided some previous articles that establish the relationship between outdoor air pollution and negative health outcomes. These articles are now included in the revised manuscript.

Once again, we appreciate your thoughtful and thorough review of our work. Your feedback has been invaluable to the development of our study, and we hope that the revised manuscript meets your expectations.

Sincerely,

BORWON WITTAYACHAMNANKUL, MD, PhD.

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Submitted filename: Response BW edit 02.16.23 .docx

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PLoS One. doi: 10.1371/journal.pone.0294107.r005

Decision Letter 2

Oyelola A Adegboye

4 May 2023

PONE-D-22-17550R2Association Between Air Quality Index and Effects on Emergency Department Visits for Acute Respiratory and Cardiovascular DiseasesPLOS ONE

Dear Dr. Wittayachmnankul,

Please submit your revised manuscript by Jun 18 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Oyelola A. Adegboye, PhD

Academic Editor

PLOS ONE

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #1: All comments have been addressed

Reviewer #4: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes

Reviewer #4: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #4: Yes

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4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #1: Yes

Reviewer #4: (No Response)

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #1: Yes

Reviewer #4: No

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6. Review Comments to the Author

Reviewer #1: Dear authors,

Thank you for your thoughtful revisions to the manuscript. Authors have revised the issues of concern that I outlined and have stated the study limitations that affect the interpretation of the results. I appreciate the effort the authors put into this work. The article is clearer, and this research is repeatable due to enough information you provide. I think your paper could be accepted for publication into PLOS ONE now.

Reviewer #4: First of all, I would like to congratulate the authors for undertaking this research as it would add to the existing body of literature in the South and South-east Asian region on the topic of air quality and its impacts on health.

Major Comments:

• In general, the authors need to get the English corrected (sentence format) either by sending it to another colleague better in English or a native English language speaker. The authors can also use various freely available websites that can be used for English editing.

• There is a major confusion, as to what is the variable used by the authors for undertaking the study, PM2.5 concentration, AQI derived from PM2.5 or AQI derived from PM2.5/PM10 or AQI derived from a calculation using concentrations of PM2.5, PM10, ozone (O3), nitrogen dioxide (NO2), and sulfur dioxide (SO2).

• Are there any adjustments done for any other physical / physiological aspects of the patients concerned for performing this study

Minor Comments:

Abstract:

1. Pg 2: Result part of the abstract, “AQI of PM2.5 concentration was 89.0 ± 40.2”, this section is creating confusion if the value is a concentration or an index. Because concentration should be followed by a unit, but AQI could just be a value. The authors can mention in the beginning that AQI was derived from PM2.5 concentrations and then follow with only one terminology that is AQI. This would reduce a lot of the confusion.

2. In the abstract itself the authors can indicate if the association was positive or negative for the purpose of clarity.

3. Could the mortality association be termed as pre-mature mortality. As this might not be the direct cause / only established cause.

Introduction

4. Pg 4: Please modify the following sentences “Air pollution is a major public health issue worldwide and represents the largest environmental problem, especially with harmful health effects.” As “Air pollution is a major public health concern worldwide and represents one of the largest environmental problems. 1”. Kindly check for these errors in the entire manuscript.

5. Pg 4: There are vague sentences that need significant modification i.e. “Thailand is a SEA country with exposure to high annual mean WHO Air Quality Guidelines (AQG).11,12”

6. Kindly refrain from using such sentences “However, no previous study in SEA mentions the effects of PM2.5 on health impacts in ED visits”. There are quiet a few studies “IJERPH | Free Full-Text | The Effects of PM2.5 from Asian Dust Storms on Emergency Room Visits for Cardiovascular and Respiratory Diseases (mdpi.com) ; Short-term PM2.5 exposure and emergency hospital admissions for mental disease - ScienceDirect”

Methodology

7. Pg 5: The authors indicate “Daily outdoor AQI of PM2.5, PM10, ozone (O3), nitrogen dioxide (NO2), and sulfur dioxide (SO2)”. So how is the AQI calculated and what has been used. There is a strong confusion in terms of the AQI terminology used in Abstract and in the text.

8. Pg 6: Again here, the authors indicate “The primary exposure variable was PM2.5”

9. Pg 6: Another statement “Xt-q represented the focused AQI of air pollutants (PM2.5 or PM10) concentration”. That means were PM10 or PM2.5 concentrations used continuously for this study or randomly any particulate concentration was used.

10. Following the four statements (three above and one in abstract), I am now in a confusion, what is the variable used by the authors for undertaking the study PM2.5 concentration, AQI derived from PM2.5 or AQI derived from PM2.5 or PM10 or AQI derived from a calculation using concentrations of PM2.5, PM10, ozone (O3), nitrogen dioxide (NO2), and sulfur dioxide (SO2).

Results and discussion

11. Pg7: 1st paragraph, the percentage of different cause specific respiratory diseases, is not coming up to 100%, kindly provide the breakup accordingly.

12. Confusing sentence “The AQI of all air pollutants was highest during April of both years (2018 and 2019), as shown in Supplementary Figure 2”. The current study period has only one April so why are the authors discussing about two Aprils.

Discussions

13. Please mention in complete sentences “This study found that AQI of PM2.5 was associated with the number of ED visits due”. What is the association?

Conclusions

14. Conclusion should be elaborated and given point wise for all the associations.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Man-Ju Ting

Reviewer #4: No

**********

PLoS One. 2023 Nov 16;18(11):e0294107. doi: 10.1371/journal.pone.0294107.r006

Author response to Decision Letter 2

11 Jun 2023

Dear Editor-in-Chief,

We hope this letter finds you well. We would like to submit the revised version of our manuscript entitled "Association Between Air Quality Index and Effects on Emergency Department Visits for Acute Respiratory and Cardiovascular Diseases" for consideration of publication in PLOS ONE.

We would like to express our gratitude to the reviewers and the editorial team for their valuable feedback and insightful comments on our initial submission. We have carefully addressed all the concerns raised and made significant revisions to improve the clarity, accuracy, and overall quality of the manuscript.

In response to the reviewers' comments, we have made the following major revisions:

1. Clarified the calculation of the Air Quality Index (AQI) and its usage throughout the study, ensuring consistency in terminology.

2. Provided a detailed breakdown of the respiratory diseases leading to ED visits, including percentages for clarity and completeness.

3. Elaborated on the associations observed in the study, specifying the increased risks of ED visits for Acute Coronary Syndrome (ACS) and respiratory diseases, particularly pneumonia, with relevant lag times.

4. Enhanced the conclusion section by summarizing the associations point-wise and emphasizing the need for effective measures to reduce PM2.5 pollution levels and protect vulnerable populations.

We believe that these revisions have significantly strengthened the manuscript and addressed all the concerns raised by the reviewers. We are confident that the revised version makes a valuable contribution to the scientific literature on the health effects of air pollution.

Please find attached the revised manuscript and the response to reviewer comments document, which provides a detailed point-by-point response to each reviewer's comments and outlines the changes made in the revised version.

We sincerely hope that you will find our revised manuscript suitable for publication in PLOS ONE. We believe that our findings have important implications for public health and contribute to the existing knowledge on the association between air quality and its effects on acute respiratory and cardiovascular diseases.

Thank you for considering our revised submission. We look forward to your positive response and the opportunity to contribute to the scientific discourse in your esteemed journal.

Yours sincerely,

Borwon Wittayachamnankul, MD, PhD

Department of Emergency Medicine, Faculty of Medicine, Chiang Mai University

Chiang Mai 50200, Thailand

Attachment

Submitted filename: Response to reviewer PM2.5 T3.docx

Click here for additional data file.^{(18.9KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0294107.r007

Decision Letter 3

Oyelola A Adegboye

21 Jul 2023

PONE-D-22-17550R3Association Between Air Quality Index and Effects on Emergency Department Visits for Acute Respiratory and Cardiovascular DiseasesPLOS ONE

Dear Dr. Wittayachmnankul,

Please submit your revised manuscript by Sep 04 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Oyelola A. Adegboye, PhD

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #4: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #4: Partly

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #4: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #4: (No Response)

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #4: Yes

**********

6. Review Comments to the Author

Reviewer #4: It is nice to see the revised version of the manuscript. While most of the comments are addressed well but one fundamental question needs more modification that the authors are not able to explain in a logical manner. Therefore, suggesting a major revision.

The response to the 3 different comments for the use of AQI are still not clear and creating confusion.

1. The terminology that should be used throughout the manuscript is only “AQI”

2. AQI is a calculation that uses values of all pollutant parameters to reach at one meaningful value. This is termed as AQI. Have the authors done it? Please provide the equation how AQI was calculated in this manuscript.

3. Refrain from mentioning “AQI of PM2.5 or AQI of PM10 because if that is the case (separately calculated) then why not directly use concentration.

4. I am still confused, has the study used AQI of PM2.5 for further deep diving? Or it is AQI of PM10, AQI of NO2, AQI of O3 etc etc. separately or only AQI derived from calculation involving all pollutants together and not separately?

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #4: No

**********

PLoS One. 2023 Nov 16;18(11):e0294107. doi: 10.1371/journal.pone.0294107.r008

Author response to Decision Letter 3

27 Jul 2023

Response to reviewer

We appreciate the editor's and the reviewers' insightful comments. The manuscript has already undergone revisions, and we are hopeful that the updated version satisfies the requirements for publication. Changes were tracks change in the revised manuscript.

The response to the 3 different comments for the use of AQI are still not clear and creating confusion.

1. The terminology that should be used throughout the manuscript is only “AQI”

Answer: Terminology: We apologize for any confusion caused by the inconsistency in AQI terminology used throughout the manuscript. We acknowledge the importance of using a standardized term consistently, and we will revise the manuscript to ensure that only "AQI" is used consistently in all sections.

Answer: AQI Calculation: We sincerely apologize for the oversight in not providing the equation for AQI calculation in the initial submission. In the revised version, we will include a detailed description of the AQI calculation method used in this study. The AQI was calculated based on the concentrations of PM2.5, PM10, ozone (O3), nitrogen dioxide (NO2), and sulfur dioxide (SO2). The precise formula used to calculate the AQI will be described in the supplementary section, which is displayed below this.

3. Refrain from mentioning “AQI of PM2.5 or AQI of PM10 because if that is the case (separately calculated) then why not directly use concentration

Answer: We have verified that the source of Smoke Haze Integrated Research Unit (SHIRU) and the Air Pollution in Chiang Mai: Real-time Air Quality Index Visual Map website came form Thailand's air and noise pollution, the Pollution Control Department under the Ministry of Natural Resources and Environment at "aqmthai.com," provides only AQI values for each individual pollutant such as PM2.5, PM10, O3, NO2 and SO2. To eliminate any confusion, we will accurately state in the revised manuscript that our study used AQI values for PM2.5, PM10, O3, NO2, and SO2 separately.

Answer: In our study, we used the Air Quality Index (AQI) values derived from individual pollutant concentrations to assess their associations with health outcomes. Specifically, we obtained separate AQI values for PM2.5, PM10, O3, NO2 and SO2.

Attachment

Submitted filename: Response to reviewer 3 PLOS ver1.docx

Click here for additional data file.^{(20.5KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0294107.r009

Decision Letter 4

Oyelola A Adegboye

2 Oct 2023

PONE-D-22-17550R4Association Between Air Quality Index and Effects on Emergency Department Visits for Acute Respiratory and Cardiovascular DiseasesPLOS ONE

Dear Dr. Wittayachmnankul,

Please submit your revised manuscript by Nov 16 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Oyelola A. Adegboye, PhD

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments (if provided):

Editor: I am happy to consider your manuscript for publication after the following revision.

1. Separate the Materials and Methods to "Data Collection" and "Data Analysis"

2. The DLNM equation is confusing. You have RH, temperature and AP, but the other variables were X_t. Why not write them to be consistent?

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

PLoS One. 2023 Nov 16;18(11):e0294107. doi: 10.1371/journal.pone.0294107.r010

Author response to Decision Letter 4

25 Oct 2023

Dear Editor,

I sincerely appreciate your consideration of my manuscript and the opportunity for revision.

Regarding your valuable feedback, I will make the following revisions:

Separate the Materials and Methods to "Data Collection" and "Data Analysis"

Answer: We separate the "Materials and Methods" section into two distinct sections, namely "Data Collection" and "Data Analysis”.

The DLNM equation is confusing. You have RH, temperature and AP, but the other variables were X_t. Why not write them to be consistent?

Answer: understand your concern about the inconsistency in variable notation within the DLNM equation. To address this, I will ensure that all variables are consistently represented as "X_t" throughout the equation, which will enhance the overall clarity and coherence of the mathematical formulation as revise as

‘log⁡(E(Y_t ))=α+ns(〖RH〗_t,3)+ns(Temperature,3)+ns(〖Focused_AP〗_t,3)+∑_(i=0)^q▒〖β_i 〖(Focused_AP)〗_(t-i) 〗+ε_t

Where Focused_AP∈{AQI of PM_2.5,AQI of PM_10} and

Other_AP∈{AQI of PM_2.5,AQI of PM_10,AQI of O_3,AQI of 〖NO〗_2 }-{Focused_AP}’

Thank you for your guidance and the opportunity to improve the manuscript. I will diligently work on these revisions and resubmit the manuscript accordingly.

Best regards,

Borwon Wittayachamnankul, MD, PhD

Department of Emergency Medicine, Faculty of Medicine, Chiang Mai University

Chiang Mai 50200, Thailand

Attachment

Submitted filename: Response to editor PM.docx

Click here for additional data file.^{(15.1KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0294107.r011

Decision Letter 5

Oyelola A Adegboye

26 Oct 2023

Association Between Air Quality Index and Effects on Emergency Department Visits for Acute Respiratory and Cardiovascular Diseases

PONE-D-22-17550R5

Dear Dr. Wittayachmnankul,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

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Kind regards,

Oyelola A. Adegboye, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

PLoS One. doi: 10.1371/journal.pone.0294107.r012

Acceptance letter

Oyelola A Adegboye

9 Nov 2023

PONE-D-22-17550R5

Association Between Air Quality Index and Effects on Emergency Department Visits for Acute Respiratory and Cardiovascular Diseases

Dear Dr. Wittayachamnankul:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Assoc Prof Oyelola A. Adegboye

Academic Editor

PLOS ONE

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

S1 File. PM2.5 and ED visits supplementary.docx.

(DOCX)

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S1 Data

(ZIP)

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Data Availability Statement

All relevant data are within the paper and its Supporting Information files.

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PERMALINK

Association between air quality index and effects on emergency department visits for acute respiratory and cardiovascular diseases

Panumas Surit

Wachira Wongtanasarasin

Chiraphat Boonnag

Borwon Wittayachamnankul

Roles

Abstract

Background and objective

Methods

Results

Conclusion

Introduction

Material and methods

Data collection

Data analysis

Results

Table 1. Descriptive summary for the study period (April 2018 to March 2019), emergency department visits, ICU admission, and in-hospital deaths for acute respiratory diseases, acute coronary syndrome, acute heart failure, and stroke.

Fig 1. Box plot of daily AQI of each pollutants for the study period (April 2018-March 2019).

Fig 2. Relative risk of the adjusted lag-effect between AQI of PM2.5 and ED visits of respiratory disease, acute coronary syndrome, acute heart failure, and stroke (Reference AQI of PM2.5 = 50).

Fig 3. Relative risk of the adjusted lag-effect between PM2.5 and ED visits of cause-specific of respiratory disease; URTI, pneumonia, COPD, and asthma.

Fig 4. Excess risk (95% confidence intervals) of association between AQI of each air pollutants (PM2.5, PM10, O3, and NO2) and hospitalization for serious specific disease at lag day 0–5.

Discussion

Conclusion

Supporting information

Acknowledgments

Data Availability

Funding Statement

References

Decision Letter 0

Oyelola A Adegboye

Roles

Author response to Decision Letter 0

Decision Letter 1

Oyelola A Adegboye

Roles

Author response to Decision Letter 1

Decision Letter 2

Oyelola A Adegboye

Roles

Author response to Decision Letter 2

Decision Letter 3

Oyelola A Adegboye

Roles

Author response to Decision Letter 3

Decision Letter 4

Oyelola A Adegboye

Roles

Author response to Decision Letter 4

Decision Letter 5

Oyelola A Adegboye

Roles

Acceptance letter

Oyelola A Adegboye

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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Cited by other articles

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Fig 2. Relative risk of the adjusted lag-effect between AQI of PM_2.5 and ED visits of respiratory disease, acute coronary syndrome, acute heart failure, and stroke (Reference AQI of PM_2.5 = 50).

Fig 3. Relative risk of the adjusted lag-effect between PM_2.5 and ED visits of cause-specific of respiratory disease; URTI, pneumonia, COPD, and asthma.