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The associations between meteorological factors and mortality have been well documented worldwide, but limited evidence is available for the non-fatal health impacts of ambient temperature, particularly there are few population-based investigations on the impacts of emergency ambulance dispatches in Asia. In this study, based on 809,906 ambulance emergency call-outs (AECOs) for the total population from 2010–2016 in the subtropical city of Shenzhen, China, a Poisson regression combined with a distributed lag nonlinear model was used to simultaneously assess the nonlinear and lag effects of daily mean temperature on AECOs. Stratified analyses by age and sex were performed to identify vulnerable subpopulations. A U-shaped relationship was found between temperature and AECOs. Cold effects were delayed and persisted for 3–4 weeks, with a cumulative relative risk (RR) and 95% confidence interval (CI) of 1.23 (1.10–1.38) and 1.25 (1.16–1.35) over lag 0–28 when comparing the 1st and 5th percentile of the temperature distribution to the optimal (i.e. minimum AECOs) temperature, respectively. Hot effects were immediate and diminished quickly in 5 days, with an increase of 19% (RR = 1.19, 95%CI: 1.14–1.23) and 21% (RR = 1.21, 95%CI: 1.16–1.26) in AECOs over lag 0–5 when comparing the 95th and 99th percentile of temperature to the optimal temperature. Children and the elderly were more vulnerable to cold effects. The youth and middle-aged people suffered more from high temperature. The effects of temperature were similar between males and females. In summary, significant increases were observed in the frequency of AECOs during cold and hot days, and the weather-associated increases in AECOs are different among age groups. This information has valuable implications in ambulance demand prediction and service provision planning.

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Background People are exposed to mixtures of highly correlated gaseous, liquid and solid pollutants. However, in previous studies, the assessment of air pollution effects was mainly based on single-pollutant models or was simultaneously included as multiple pollutants in a model. It is essential to develop appropriate methods to accurately estimate the health effects of multiple pollutants in the presence of a high correlation between pollutants. Methods The flexible tensor product smooths of multiple pollutants was applied for the first time in a quasi-Poisson model to estimate the health effects of SO 2 , NO 2 and PM 10 on daily all-cause deaths during 2005–2012 in Guangzhou, China. The results were compared with those from three other conventional models, including the single-pollutant model and the three-pollutant model with and without first-order interactions. Results The tensor product model revealed a complex interaction among three pollutants and significant combined effects of PM 10 , NO 2 and SO 2 , which revealed a 2.53% (95%CI: 1.03–4.01%) increase in mortality associated with an interquartile-range (IQR) increase in the concentrations of all three pollutants. The combined effect estimated by the single-pollutant model was 5.63% (95% CI: 3.96–7.34%). Although the conventional three-pollutant models produced combined effect estimates (2.20, 95%CI, 1.18–3.23%; 2.78, 95%CI: 1.35–4.23%) similar to those of the tensor product model, they distorted the estimates and inflated the variances of the estimates when attributing the combined health effects to individual pollutants. Conclusions The single-pollutant model or conventional multi-pollutant model may yield misleading results in the presence of collinearity. The tensor product quasi-Poisson regression provides a novel approach to the assessment of the health impacts of multiple pollutants by flexibly fitting the interaction effects and avoiding the collinearity problem. Electronic supplementary material The online version of this article (10.1186/s12940-019-0473-7) contains supplementary material, which is available to authorized users.

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