Environmental Research 208 (2022) 112671

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Environmental Research
journal homepage: www.elsevier.com/locate/envres

Coordinated health effects attributable to particulate matter and other

pollutants exposures in the North China Plain
Aifang Gao a, b, c, Junyi Wang d, James Poetzscher e, Shaorong Li a, Boyi Gao a, Peng Wang f, g, *,
Jianfei Luo a, Xiaofeng Fang a, Jingyi Li b, Jianlin Hu b, Jingsi Gao h, **, Hongliang Zhang e
a
School of Water Resources and Environment, Hebei GEO University, Shijiazhuang, 050031, China
b
Jiangsu Key Laboratory of Atmospheric Environment Monitoring and Pollution Control, Collaborative Innovation Center of Atmospheric Environment and Equipment
Technology, Nanjing University of Information Science & Technology, Nanjing, 210044, China
c
Hebei Center for Ecological and Environmental Geology Research, Hebei Province Collaborative Innovation Center for Sustainable Utilization of Water Resources and
Optimization of Industrial Structure, Hebei Province Key Laboratory of Sustained Utilization and Development of Water Resources, Shijiazhuang, 050031, China
d
School of Energy and Environmental Engineering, University of Science and Technology Beijing, Beijing, 100083, China
e
Department of Environmental Science and Engineering, Fudan University, Shanghai, 200438, China
f
Department of Atmospheric and Oceanic Sciences, Fudan University, Shanghai, 200438, China
g
IRDR ICoE on Risk Interconnectivity and Governance on Weather/Climate Extremes Impact and Public Health, Fudan University, Shanghai, 200438, China
h
Department of Civil and Environmental Engineering, Shenzhen Polytechnic, Shenzhen, 518055, China

A R T I C L E I N F O A B S T R A C T

Keywords: Hebei Province, located in the North China Plain (NCP) and encircling Beijing and Tianjin, has been suffering
Mortality from severe air pollution. The monthly average fine particulate matter (PM2.5) concentration was up to 276 μg/
Morbidity m3 in Hebei Province, which adversely affects human health. However, few studies evaluated the coordinated
Exposure-response function
health impact of exposure to PM (PM2.5 and PM10) and other key air pollutants (SO2, NO2, CO, and surface ozone
Health effects
(O3)). In this study, we systematically analyzed the health risks (both mortality and morbidity) due to multiple
Hebei province
air pollutants exposures in Hebei Province. The economic loss associated with these health consequences was
estimated using the value of statistical life (VSL) and cost of illness (COI) methods. Our results show the health
burden and economic loss attributable to multiple ambient air pollutants exposures in Hebei Province is sub­
stantial. In 2017, the total premature mortality from multiple air pollutants exposures in Hebei Province was
69,833 (95% CI: 55,549–83,028), which was 2.9 times higher than that of the Pearl River Delta region (PRD).
Most of the potential economic loss (79.65%) was attributable to premature mortality from air pollution. The
total economic loss due to the health consequences of multiple air pollutants exposures was 175.16 (95% CI:
134.61–224.61) billion Chinese Yuan (CNY), which was 4.92% of Hebei Province’s annual gross domestic
product (GDP). Thus, the adverse health effects and economic loss caused by exposure to multiple air pollutants
should be seriously taken into consideration. To alleviate these damages, Hebei’s government ought to establish
more stringent measures and regulations to better control air pollution.

1. Introduction
With the acceleration of industrialization and urbanization in China,
air pollution has become one of the nation’s most severe environmental
problems (Chen et al., 2017a; Fang et al., 2016; Hu et al., 2015a;
Kuerban et al., 2020). Severe air pollution threatens human health, and
exposure to multiple air pollutants increases mortality, morbidity, and
corresponding economic loss (Cohen et al., 2017; Lu et al., 2016). Yao
et al. (2020) reported that the premature mortalities due to air pollut­
ants exposure was 1.35 million in China. The health risks and economic
losses due to air pollution have attracted significant attention in China
(Chen et al., 2017a; Giannadaki et al., 2018; Kuerban et al., 2020; Lu
et al., 2016; Yao et al., 2020).
Fine particulate matter (PM2.5), coarse particulate matter (PM10),
nitrogen dioxide (NO2), sulfur dioxide (SO2), carbon dioxide (CO), and
surface ozone (O3), the major air pollutants, induce adverse impacts,

* Corresponding author.Department of Atmospheric and Oceanic Sciences, Fudan University, Shanghai, 200438, China.
** Corresponding author.
E-mail addresses: w_peng@fudan.edu.cn (P. Wang), gaojingsi@szpt.edu.cn (J. Gao).

https://doi.org/10.1016/j.envres.2021.112671
Received 29 September 2021; Received in revised form 16 December 2021; Accepted 31 December 2021
Available online 6 January 2022
0013-9351/© 2022 Elsevier Inc. All rights reserved.
A. Gao et al.
including premature mortality and morbidity (hospital admissions and
outpatient visits) on human health (Han et al., 2019). The health risks
arising from these key pollutants exposure have caused widespread
public attention in China (Li et al., 2018; Lu et al., 2016; Maji et al.,
2018a). PM2.5 in China accounted for more than one-quarter of total
PM2.5-attributable mortalities (4.2 million) worldwide in 2015 (Cohen
et al., 2017). Maji and Namdeo (2021) reported that all-cause premature
mortalities attributable to maximum daily 8-h average ozone (MDA8
O3) exposure was 181,000 (95% CI: 91,500–352,000) in 350 Chinese
cities. However, most of the existing studies did not consider the coor­
dinated health impacts from PM2.5 and other pollutants (mainly focusing
on deaths resulting from individual pollutant) (Li et al., 2018; Maji et al.,
2018b; Zhu et al., 2019). To comprehend the total health burden due to
multiple pollutants and compare health effects caused by different pol­
lutants, Han et al. (2019) investigated that short-term all-cause mor­
tality values due to PM10, SO2, and NO2 exposures were 48,098 (19,
972–75,973) in Guangxi, China. Yao et al. (2020) estimated the health
burden of six air pollutants in China and found that the contributions of
NO2 and SO2 to mortality and morbidity were significantly more
remarkable than those of PM2.5 and PM10. However, the health burden
of multiple pollutants obtained by the direct addition of health effects of
a single pollutant could be inaccurate, owing to the overlapping effects
of multiple pollutants on human health (Lu et al., 2016). Therefore, we
assessed the health effects (including both mortality and morbidity) of
exposures to PM2.5 and other pollutants after considering the over­
lapping effects.
The adverse health impacts also have negative effects on economic
productivity, resulting in sizable economic losses (Giannadaki et al.,
2018; Han et al., 2019; Lu et al., 2016; Yao et al., 2020). The economic
costs of labor resource loss and the medical expenses associated with the
health consequences are significant and must be considered. For
example, Giannadaki et al. (2018) determined that China’s economic
loss resulting from premature mortality due to PM2.5 exposure in 2010
was roughly 1.3 trillion USD. Lu et al. (2016) calculated that the eco­
nomic loss resulting from the health burden attributable to four pol­
lutants (SO2, NO2, O3, and PM10) exposures was between 14,768 and 25,
305 million USD, equivalent to 1.4–2.3% of the local GDP of 2013 in the
PRD region. However, these studies that mainly considering premature
deaths may underestimate the economic losses. A more comprehensive
assessment of the economic losses is needed.
Hebei Province, which is located in the NCP, encircles Beijing and
Tianjin, in fronting severe air pollution. In recent years, according to the
Ministry of Environmental Protection (https://www.mee.gov.cn/), six
cities in Hebei Province (SJZ - Shijiazhuang, HD - Handan, XT - Xingtai,
BD - Baoding, TS -Tangshan, and HS - Hengshui) are represented in the
ten most heavily polluted cities in China. For example, in December
2016, the average monthly concentration of PM2.5 was up to 276 μg/m3
in SJZ, experiencing extremely severe haze weather (https://www.aqist
udy.cn/historydata/, last access: September 14, 2021). Coal consump­
tion for energy, heavy industry, and transportation are the driving fac­
tors cause Hebei Province’s air pollution (Hao and Yin, 2016; Xiao et al.,
2020). In addition, the meteorology and geographical conditions also
play important roles in the air pollution, which are not conducive to
diffusion of air pollutants (Guo et al., 2014; Liu et al., 2019; Wang et al.,
2019). It is urgent to conduct coordinated health effects study in Hebei
to better control air pollution.
The objectives of this study are to analyze the health consequences
(both mortality and morbidity) and the related economic losses due to
exposure to six pollutants (PM2.5, PM10, SO2, NO2, CO, and O3) in Hebei
Province, which is the major pollutant of air quality monitoring sites.
Specifically, we aimed (1) to evaluate air pollution levels across Hebei
Province in 2017; (2) to estimate the resulting health burden, in terms of
premature mortality and morbidity (hospital admission and outpatient
visit) in 11 cities in Hebei, and evaluate total health impact due to
exposure to multiple air pollutants; (3) to assess the associated economic
losses due to the premature mortality and morbidity induced by PM2.5
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Environmental Research 208 (2022) 112671
and other air pollutants exposure. Our results aim to provide the sci­
entific basis for the prevention and control of air pollution in Hebei
Province and provide crucial reference data for public health.
2. Data and methods
2.1. Data source and study areas
The observation data of six pollutants (PM2.5, PM10, SO2, NO2, CO,
and O3) are used to evaluate the health burdens related to air pollution
(Chen et al., 2017c; Maji et al., 2018b; Yin et al., 2017). Hourly observed
concentrations of PM10 (μg/m3), PM2.5 (μg/m3), SO2 (μg/m3), NO2
(μg/m3), CO (mg/m3), and O3 (μg/m3) in 11 cities in Hebei Province
from Jan. 2017 to Dec. 2017 was collected from the website of the
Chinese Environmental Protection Bureau (http://www.cnemc.cn/) in
this study (Fig. 1). All measurements of the ambient concentration of
PM2.5, PM10, SO2, NO2, CO, and O3 were conducted at 52 national air
quality monitoring sites (44 urban sites and 8 suburb sites) according to
China Environmental Protection Standards HJ 193–2013 and HJ
655–2013, and detailed station information was listed in Table S1. The
values from the monitoring sites at each city were released after being
validated based on the Technical Guideline on Environmental Moni­
toring Quality Management HJ 630–2011. These files are available at
Zenodo website (https://doi.org/10.5281/zenodo.5761703). The city­
wide average concentrations of each air pollutant were calculated by
averaging the concentrations at all sites in each city.
2.2. Health effect assessment
The total health burden attributable to multiple air pollutant expo­
sure accounts for premature mortality, hospital admission, and outpa­
tient visit. Health effect represents the expected number (EN) of
premature deaths or morbidities due to individual air pollution exposure
and was calculated by Eq. (1) (Shang et al., 2013):
EN = Pop × y0 × AF (1)
RR − 1 ER
AF = = (2)
RR ER + 1
Where EN represents health effects, such as non-accident premature
mortality or mortality due to air pollutants, AF is the attributable frac­
tion of individual air pollution to assess the impact of exposure,
assuming all the residents are exposed to the average concentration in
every city (Eq. (2)), y0 is the case base rate of health endpoint per unit
population obtained from the statistical yearbook of the National Health
and Planning Commission, detailed information was listed in Text S1;
Pop is the resident population of each city in Hebei Province, as shown
in Table S2. The relative risks (RR) were calculated using Eq. (3), which
was a related health point in the epidemiological studies (Anenberg
et al., 2010; Jerrett et al., 2009; Lu et al., 2015; Shang et al., 2013). The
excess risk (ER) of each pollutant, was calculated with RR minus 1.
Higher values of ER indicate higher health risks. The city-specific pop­
ulation was obtained from the National Statistical Yearbook and the
Statistical Bulletin of National Economic and Social Development in 11
cities in Hebei Province (http://tjj.hebei.gov.cn/) (Table S2). The total
number of deaths and morbidities in each city was presented in Table S3.
In Eq. (3), the exposure-response coefficient (β) is very important,
resulting from the fitted models. The log-linear exposure-response
functions were adopted to estimate the adverse health effects attribut­
able to ambient air pollution in previous studies (Chen et al., 2017a;
Fang et al., 2016; Hu et al., 2015a; Lu et al., 2016; Shang et al., 2013).
The log-linear exposure-response functions are used for assessing the
potential contributions of multiple air pollutants to mortality and
morbidity.
RR = exp[β(C − C0 )], C > C0 (3)
A. Gao et al.
Fig. 1. The annual average major pollutants concentrations in 11 cities in Hebei in 2017: (a) PM2.5, (b) PM10, (c) SO2, (d) NO2, (e) O3, and (f) CO.
where β is the exposure-response coefficient (or the regression coeffi­
cient) and represents the excess risk of health effect (such as mortality or
morbidity) per unit increase of each air pollutant (such as 10 μg/m3 of
PM2.5). In this study, we selected β values from meta-analysis from
previous studies in China (Dong et al., 2016; Liu et al., 2018a, 2018b; Lu
et al., 2015; Ma and Cui, 2016; Qiu et al., 2018; Shang et al., 2013; Tian
et al., 2018, 2019a; Wang et al., 2018; Wong et al., 1999; Xie et al., 2009;
Yang et al., 2015; Zhang and Wang, 2019) (Table 1). These results of the
meta-analysis were obtained by summarizing the massive time-series or
case-crossover study on health effects attributed to air pollutants. The
results were more credible and representative than individual study. To
accord with our research area and time, most studies were conducted in
cities in China with severe air pollution in the last decade. C is the
concentration of each air pollutant, and C0 is the threshold concentra­
tion of each air pollutant, for which it is believed the individual air
pollutant has no obvious adverse health effects (i.e. RR = 1). C0 adopted
the natural background concentrations of PM10, PM2.5, SO2, NO2, O3,
and zero for CO compared with some literature (Table S4) (Apte et al.,
2015; Fiore, 2002; Organization, 2000; Veira et al., 2013).
In this study, we also estimated the overall health effects of multiple
pollutants. Studies have demonstrated that the direct addition of health
effects of a single pollutant may cause the overestimation of results,
3
Environmental Research 208 (2022) 112671
owing to the compounding effects of multiple air pollutants on human
health (Han et al., 2019; Hu et al., 2015b; Lu et al., 2016). To avoid or
decrease the uncertainty of the estimation result caused by overlapping
effects of multiple air pollutants on human health effect, we adjusted the
ER values based on some current research of multipollutant models and
the WHO’s recommendation (Bell et al., 2007; Cesaroni et al., 2013;
Chen et al., 2012; Hart et al., 2011; Samoli et al., 2007; Tao et al., 2012;
Walton et al., 2015; WHO, 2013b; Zhang et al., 2006) (Table S5 and
Table S6). In this study, We divided PM into fine particulate matter
(PM2.5) and coarse particulate matter (PM2.5-10), PM2.5-10-related health
effects were equal to the health impact of PM10 minus the health impact
of PM2.5. The ER value for O3 was maintained. The ER values of NO, SO2,
and CO were reduced by 30%, 63%, and 55%, respectively. The detailed
method is discussed in Text S2. Therefore, we used the ER value after
adjustment to calculate the overall health effects. As shown in Eq. (4).
( )
Mortalitytotal ≈ ΔMort PM2.5 + PM2.5− 10 + NOa2 + COa + SOa2 + O3 (4)
Where NO2a, SO2a, and COa represent the health effect for NO2, SO2, and
CO after adjustment. Although the exposure-response coefficients of
these pollutants were adjusted, it should be noted that the total health
impact assessments are still uncertain due to the complicated nature of
multiple pollutants and the lack of existing literature.
A. Gao et al. Environmental Research 208 (2022) 112671

Table 1 Table 1 (continued )

β values (%) in Cause-Specific Health Endpoints along with their 95% confi­ Health endpoints Pollutants β Study area Sources
dence intervals (in the bracket) for each pollutant (PM2.5, PM10, SO2, NO2, CO,
and O3 pollutants for per 10 μg/m3 except CO for per 1 mg/m3). Total outpatient PM2.5 0.17 Shanghai, Zhang and
visits (0.06–0.28) China Wang
Health endpoints Pollutants β Study area Sources (2019)
Total mortality PM2.5 0.38 multiple Shang et al. PM10 0.16 Shanghai, Zhang and
(0.31–0.45) Chinese cities (2013) (0.13–0.19) China Wang
PM10 0.32 multiple Shang et al. SO2 1.39 Shanghai, (2019)
(0.28–0.35) Chinese cities (2013) (0.42–2.36) China Zhang and
SO2 0.90 multiple Ma and Cui NO2 0.60 Shanghai, Wang
(0.60–1.10) Chinese cities (2016) (0.14–1.06) China (2019)
NO2 1.40 multiple Ma and Cui Zhang and
(1.10–1.60) Chinese cities (2016) Wang
CO 3.70 multiple Shang et al. (2019)
(2.88–4.51) Chinese cities (2013) CO – –
O3 0.40 multiple Dong et al. O3 0.10 Shanghai, Zhang and
(0.30–0.50) Chinese cities (2016) (0.02–0.18) China Wang
Cardiovascular PM2.5 0.44 multiple Shang et al. (2019)
mortality (0.33–0.54) Chinese cities (2013)
PM10 0.43 multiple Shang et al.
(0.37–0.49) Chinese cities (2013) We directly added the number of outpatients and hospitalizations for
SO2 0.70 multiple Ma and Cui each pollutant to evaluate the total incidence rate (Yao et al., 2020),
(0.50–0.80) Chinese cities (2016) without adjusting ER values of morbidity due to lack of data.
NO2 1.40 multiple Ma and Cui
(1.10–1.50) Chinese cities (2016)
CO 4.77 multiple Shang et al.
(3.53–6.00) Chinese cities (2013)
2.3. Economic loss estimation
O3 0.45 multiple Dong et al.
(0.17–0.72) Chinese cities (2016) Besides evaluating the health effects of air pollutants, we also esti­
Respiratory PM2.5 0.51 multiple Shang et al. mated the total economic loss due to the health burden. This study used
mortality (0.30–0.73) Chinese cities (2013)
the VSL and COI methods to evaluate the economic loss resulting from
PM10 0.32 multiple Shang et al.
(0.23–0.40) Chinese cities (2013) the health consequences of multiple air pollutant exposure. The VSL was
SO2 1.20 multiple Ma and Cui used to assess economic losses due to air pollution-related premature
(0.90–1.60) Chinese cities (2016) death in Hebei in 2017. VSL is a measure of the total monetary value of
NO2 1.60 multiple Ma and Cui individual mortality risk reduction and is widely used in the economic
(1.20–1.90) Chinese cities (2016)
CO 2.99 Beijing, China Yang et al.
assessment of environmental health and safety risk policies (Huang and
(0.85–5.11) (2015) Zhang, 2013).
O3 0.46 multiple Dong et al. In this work, the unit economic loss of health impacts comes from
(0.23–0.70) Chinese cities (2016) historical research results. Authoritative results from previous publica­
Total hospital PM2.5 0.19 multiple Tian et al.,
tions of similar study scopes or years were selected to provide reliable
admissions (0.07–0.30) Chinese cities (2019b)
PM10 0.29 multiple Tian et al. benchmarks for estimating economic benefits. Eq. (5) (Mu and Zhang,
(0.23–0.36) Chinese cities (2018) 2015; Zeng et al., 2019) was used to estimate the VSL of Handan.
SO2 1.16 multiple Tian et al. ( )β
(0.92–1.40) Chinese cities (2018) Incomen
VSLn = VSLbase × (5)
NO2 1.68 multiple Tian et al. Incomebase
(1.40–1.95) Chinese cities (2018)
CO 2.59 multiple Tian et al.
where VSLn indicates the unit VSL in the year of n, Income is the per
(1.69–3.50) Chinese cities (2018)
O3 0.77 Shenzhen, Liu et al., capita disposable income, VSLbase is the value of a statistical life of the
(0.10–1.43) China (2018b) base year (2010), and β is the income elasticity. Studies have shown that
Cardiovascular PM2.5 0.87 Wuhan, Wang et al. the income elasticity was greater than 1 in areas with an income gap
hospital (0.05–1.7) China (2018) (Costa and Kahn, 2004). Mu and Zhang (2015) investigated that the
admissions PM10 0.66 Hongkong, Xie et al.
(0.36–0.95) China (2009)
reasonable range of income elasticity was from 1 to 1.4 in assessing
SO2 3.41 Wuhan, Wang et al. economic loss of health effects due to PM2.5 exposure in China. There­
(-0.21–7.17) China (2018) fore, we chose the income elasticity of 1.4 in agreement with the value of
NO2 2.98 Wuhan, Wang et al. Mu and Zhang.
(0.66–5.37) China (2018)
The COI method directly estimated the economic loss associated with
CO 4.39 multiple Liu et al.,
(4.07–4.70) Chinese cities (2018a) the health burden by calculating the disease-related expenses, including
O3 1.30 Hongkong, Wong et al. the medical cost, hospitalization cost, outpatient service cost, and loss of
(0.50–2.10) China (1999) income due to sickness. The COI method is used to evaluate the cost of
Respiratory PM2.5 0.53 Sichuan Qiu et al. various diseases (Han et al., 2019; Lu et al., 2016; Zhao et al., 2016). The
hospital (0.39–0.68) Basin, China (2018)
admissions PM10 0.51 multiple Lu et al.
COI for morbidity (hospital admissions and outpatient visits) were
(0.23–0.79) Chinese cities (2015) calculated using Eq. (6):
SO2 2.54 Sichuan Qiu et al.
(1.51–3.59) Basin, China (2018)
M = (Mm + GDPd × T) × EN (6)
NO2 2.36 Sichuan Qiu et al.
(1.75–2.98) Basin, China (2018) where M represents the total economic loss of hospital admissions or
CO 4.44 multiple Liu et al., outpatient visits due to exposure to ambient air pollutants, Mm is the
(3.97–4.92) Chinese cities (2018a) average cost for medical treatment for each case, GDPd is the daily
O3 2.20 Hongkong, Wong et al.
(1.50–2.90) China (1999)
average of GDP per capita, T is the average labor time loss due to illness,
and EN represents the number of cases of hospital admission or outpa­
tient visit. Values of parameters in economic loss estimation are

4
A. Gao et al.
discussed in Text S3.
3. Results and discussion
3.1. Air pollutants
Spatial distributions of particulate matter (PM2.5 and PM10) and
gaseous pollutants (SO2, NO2, CO, and O3) in 11 cities in Hebei Province
are shown in Fig. 1. Among this study, the annual average concentra­
tions of PM10, PM2.5, SO2, NO2, CO, and MDA8 O3 were 120 ± 29 μg/m3,
65 ± 19 μg/m3, 27 ± 9 μg/m3, 46 ± 9 μg/m3, 1.3 ± 0.4 mg/m3, and 108
± 6 μg/m3, respectively. The annual average concentrations of PM10 and
PM2.5 were relatively high and greatly exceed the Chinese National
Ambient Air Quality Standard (CNAAQS) Grade II (70 and 35 μg/m3).
Cities with relatively high PM2.5 and PM10 levels are mainly located in
the Southern Hebei (HD, SJZ, XT, and HS) and Central Hebei (BD). These
cities had industrial boilers, steel, power, building materials, and
cooking industries emission sources, which were the primary contribu­
tors to particulate matter pollution (Hao and Yin, 2016). Air pollutant
emissions as well as meteorological conditions were the main factors
that determine air quality (Xiao et al., 2020). The highest average
annual PM2.5 and PM10 concentrations in HD were 86 ± 54 and 157 ±
Fig. 2. All-cause premature mortality attributed to each air pollutant in 11 cities in Hebei in 2017. (a) PM2.5, (b) PM10, (c) SO2, (d) NO2, (e) O3, and (f) CO.
5
Environmental Research 208 (2022) 112671
83 μg/m3, respectively. HD was a heavy industrial (coal, steel, and
mining operations) city with a dense population. These result in high
anthropogenic emissions, worsened by adverse weather conditions (Gao
et al., 2021).
For gaseous pollutants, most cities (excluding ZJK and CD) exceeded
the CAAQS Grade II cutoff [NO2 (40 μg/m3)]. Cities with relatively high
concentrations of SO2, NO2, and CO were mostly located in TS, XT, and
HD in Hebei Province. TS had the highest SO2, NO2, and CO average
annual concentrations (39 ± 19 μg/m3, 58 ± 18 μg/m3, and 2.0 ± 1.1
mg/m3, respectively) among 11 cities (Table S7 and Fig. 1). TS was a
heavy industrial city, with coal, iron, and steel industries. MDA8 O3
concentration was almost evenly distributed across all studied cities and
exceeded 100 μg/m3 everywhere in Hebei Province except for in CD. In
recent years, the concentration of O3 had increased year on year (Yao
et al., 2020). The coordinated control of PM2.5 and other important
pollutants (for instance O3) should be also urgently implemented in this
area (Zhao et al., 2021).
In Hebei Province, air pollutant emissions are generally high and air
pollution is severe (Zhao et al., 2019). The serious air pollution in Hebei
not only significantly impacts the people in the region, but also poses a
serious threat to people in adjacent regions such as Beijing and Tianjin
through regional atmospheric transmission (Jiang et al., 2020). As air
A. Gao et al. Environmental Research 208 (2022) 112671

pollution ultimately results in health damage, these findings indicate Table 2

that further improvements are needed in ambient air quality control in Total premature mortality, total hospital admissions, and total outpatient visits
Hebei Province and the surrounding areas. due to multiple air pollutants exposure in Hebei Province in 2017.
City Total premature Total hospital Total outpatient visits
3.2. Health effects assessment mortality (thousand) admissions (million) (million)

SJZ 9.61 (7.68,11.37) 0.4 (0.24,0.54) 5.72 (2.32,9.03)

3.2.1. Mortality TS 8.8 (6.96,10.5) 0.42 (0.25,0.58) 5.78 (2.29,9.18)
The health damage due to exposure to the six studied air pollutants QHD 2.68 (2.11,3.21) 0.25 (0.14,0.35) 3.57 (1.34,5.75)
HD 10.62 (8.47,12.58) 0.08 (0.04,0.12) 0.97 (0.38,1.55)
was significant in the 11 analyzed cities. All-cause mortality, cardio­
XT 8.45 (6.73,10.03) 0.37 (0.23,0.51) 5.41 (2.17,8.55)
vascular mortality, and respiratory mortality effects associated with BD 11.42 (9.11,13.57) 0.14 (0.08,0.19) 1.7 (0.73,2.66)
exposure to the six ambient air pollutants were estimated in this study ZJK 2.27 (1.79,2.72) 0.15 (0.08,0.2) 1.6 (0.63,2.55)
(Fig. 2 and Table S8). The all-cause premature mortality figures and CD 2.3 (1.82,2.75) 0.1 (0.06,0.14) 1.28 (0.45,2.08)
CZ 6.47 (5.12,7.73) 0.32 (0.2,0.44) 4.64 (1.71,7.49)
their 95% confidence intervals (CI) were presented in Fig. 2 and
LF 3.64 (2.89,4.33) 0.3 (0.19,0.41) 4.42 (1.72,7.04)
Table S8. In our study, the PM10 air pollutants resulted in 2.5 premature HS 3.58 (2.87,4.24) 0.1 (0.05,0.15) 1.1 (0.43,1.75)
mortalities per 10,000 people in Hebei, which was around 3 times HB 69.83 (55.55,83.03) 2.63 (1.56,3.64) 36.17 (14.18,57.63)
higher than that of PRD (Lu et al., 2016). NO2 exposure resulted in 26,
791 total premature mortality for Hebei Province in 2017, the most of
any air pollutant. This is because the exposure-response coefficient of suffered heavily from ambient air pollution exposure and the related
NO2 is much larger than that of other pollutants. The four cities with the adverse health effects were severe. As the result in Table 2, the total
highest total premature mortality due to NO2 exposure were BD [4417 premature mortality of Hebei Province is 69,833 people after adjust­
(95% CI: 3497–5025)], HD [3856 (95% CI: (3050–4386)], TS [3696 ment (Text S1) in 2017. The consequences of air pollution exposure in
(95% CI: (2926–4202), and SJZ [3638 (95% CI: (2877–4139)], respec­ BD were the most serious compared to all analyzed cities. The impact
tively. These cities had developed industry, dense populations, and was also serious in HD, SJZ, TS, and XT, which ranked second to fifth in
significant air pollutant emissions, resulting in relatively severe health terms of adverse health effects caused by multiple air pollutants, with
consequences for the local people. CO led to 24,696 premature mor­ between 8450 and 11,422 deaths. This is due to the surge in population
talities in Hebei, the second most of any pollutant, while PM10 and O3 and industrial development in these cities, resulting in increased emis­
caused 18,993 and 16,433 deaths, respectively. In Hebei Province, the sions of atmospheric pollutants, which ultimately negatively impacts the
contribution of PM2.5 exposure to health damage was more significant health of the local people.
than that of PM10. Excluding CD, ZJK, and QHD, the ratio values
(PM2.5/PM10) in the remaining eight cities are relatively high (above 3.2.2. Morbidity
62%). These results indicate that particulate matter consists primarily of The health effects due to multiple air pollutants exposures also ac­
PM2.5, and PM2.5 is more toxic so it poses greater health risks. SO2 and count for morbidity (hospital admission and outpatient visit) that
CO exposures had the most serious health consequences in HD (1938 doesn’t result in premature mortality (Guo et al., 2018; Tian et al.,
and 3966 premature mortalities) and TS (1695 and 3900 premature 2019b; Wong et al., 1999). In the case of air pollution, the occurrence of
deaths). BD had the highest premature mortalities in all cities, with 2.35, disease will also lead to the increase of outpatient and hospitalization,
3.23, 4.41, and 2.75 thousand total premature deaths per thousand resulting in a loss of labor time and production efficiency, and subse­
resulting from PM2.5, PM10, NO2, and O3, respectively. This is because quently the increase of personal economic losses (Lu et al., 2016; Yao
BD has the largest exposed population, and is also one of three major et al., 2020). It is, therefore, crucial that morbidity was analyzed. The
industrial cities in Hebei meaning higher air pollutant emissions in BD consideration of morbidity also made health assessment more system­
(Cheng et al., 2018). HD, TS, and SJZ also suffered relatively serious atic and comprehensive. Exposure to air pollution results in a certain
health damage from ambient air pollutants. hospitalization rate and outpatient visit rate.
Exposure to air pollution can lead to many health damages, espe­ The total hospital admissions, cardiovascular hospital admissions
cially serious respiratory and circulatory systems. In this study, we and respiratory hospital admissions attributable to the analyzed six air
found that the premature deaths from circulatory diseases were much pollutants in the 11 cities are displayed in Fig. 3 and Table S10. The
higher than those from respiratory diseases, which is in agreement with total, cardiovascular, and respiratory hospital admissions attributable to
the results of some previous reports (Han et al., 2019; Lelieveld et al., the six air pollutants were 2.63 (95% CI: 1.56–3.64) million, 0.28 (95%
2019; Lu et al., 2016; Yao et al., 2020). The cardiovascular mortality and CI: 0.11–0.44) million, and 0.26 (95% CI: 0.18–0.34) million, respec­
respiratory mortality due to the six analyzed air pollutants in Hebei tively. For total hospital admissions, the contributions of NO2 and O3
Province in 2017 are listed in Table S8. PM10, NO2, and O3 were rela­ were much greater than those of other pollutants. For cardiovascular
tively large contributors, with 11.30 thousand (1.5 per 10,000 people), hospital admissions, the contributions of NO2, and O3 were still largest
11.90 thousand (1.6 per 10,000), and 8.24 thousand (1.1 per 10,000) with 0.07 million, and 0.07 million, respectively. For respiratory hos­
cardiovascular mortality, respectively. The premature deaths due to pital admissions, the contribution of O3 was largest, resulting in 39.7%
respiratory disease resulting from PM10, NO2, and O3 were 2.07 thou­ (0.10 million) of all respiratory hospital admissions, and NO2 was sec­
sand (0.3 per 10,000), 3.31 thousand (0.4 per 10,000), and 2.06 thou­ ond at 20.0% (0.05 million). The contributions of PM2.5 were smallest at
sand (0.3 per 10,000), respectively. These results were larger than the about 7.8% (0.02 million).
respiratory mortality deaths per 10,000 figures from Lu et al. (2016) Total outpatient visits due to exposure to multiple air pollutants are
(0.4, 0.8, and 0.5 for cardiovascular mortality, 0.1, 0.3, and 0.2 for listed in Table S10. The number of outpatients admissions in Hebei
respiratory mortality, respectively). This also reflects that although Province in 2017 attributable to exposure to multiple air pollutants was
Hebei’s air pollution has improved significantly, it still requires further 36.17 (95% CI: 14.18–57.63) million. SO2 was the largest contributor to
control. The city-specific contributions to premature mortalities from total outpatient visits. Specifically, SO2 resulted in a staggering 14.21
cardiovascular disease and respiratory disease were similar (BD was the (95% CI: 4.37–23.70) million total outpatient visits. Data for CO was not
largest contributor and CD was the smallest contributor). obtained as no necessary coefficients exist. In 11 cities, the three leaders
We also estimated the overlapping effects of multiple air pollutants in terms of outpatient admissions are BD with 5.78 (95% CI:2.29–9.18)
on human health effect to decrease the uncertainty of the estimation million, SJZ with 5.72 (95% CI:2.32–9.03) million, and HD with 5.41
result. The ER values of multipollutant models are listed in Table S9. We (95% CI: 2.17–8.55) million, respectively. This result was consistent
evaluated the overall health effects as shown in Table 2. Hebei Province with the high pollutant emissions across all three cities. CD had the

6
A. Gao et al.
Fig. 3. Total hospital admissions attributed to each air pollutant in 11 cities in Hebei in 2017. (a) PM2.5, (b) PM10, (c) SO2, (d) NO2, (e) O3, and (f) CO.
fewest outpatient visits with only 0.97 (95% CI:0.38–1.55) million.
Cities with high total premature mortality, total hospital admissions,
and total outpatient visits were primarily located in the severely
polluted and priority control regions such as BD, HD, SJZ, and TS. Air
pollution in BD had serious health consequences because the city has the
largest population of all cities studied and relatively high concentrations
of the analyzed pollutants. ZJK, CD, and QHD were less impacted by air
pollution. Therefore, the implementation of one-city-one-policy on air
pollution control measures is necessary and reasonable to account for air
pollution’s differing impact in these different cities. NO2 and O3 were
the largest contributors to total premature mortality and total hospital
admissions. Similar results were found in several estimations (Chen
et al., 2017a; Fang et al., 2016; Lu et al., 2016; Yao et al., 2020). The
most possible reason may be that the exposure-response coefficient of
NO2 was the largest. NO2 had a larger relative risk (RR) because of the
large coefficients. These results suggested that we must pay particularly
close attention to the health consequences of gaseous pollutants (such as
NO2 and O3), in addition to focusing on the link with PM2.5 in Hebei
Province. In terms of the overall health effects of air pollution exposure,
we estimated roughly 69,833 (95% CI: 55,549–83,028) premature
mortalities, 2.63 (95% CI: 1.56–3.64) million total hospital admissions,
and 36.17 (95% CI: 14.18–57.63) million total outpatient visits in Hebei
Province in 2017.
7
Environmental Research 208 (2022) 112671
3.3. Economic loss assessment
In addition to its serious health consequences, severe air pollution
results in significant economic losses. The total economic loss in Hebei
Province was especially large. The results of the COI and VSL analysis,
with respect to total premature mortality, total hospital admissions, and
total outpatient admissions, are shown in Table S11. The total economic
loss in Hebei Province related to total premature mortality, total hospital
admissions, and total outpatient admissions in 2017 are listed in Table 3.
It can be seen from Table 3 and Fig. 4 that premature mortality was most
responsible for the economic loss (accounting for as much as 80%),
while total hospital admissions was the second largest contributor (ac­
counting for 14% of the total), and total outpatient visits were the
smallest contributor (6%). Clearly, the economic cost of outpatient ad­
missions and hospital admissions were considerably lower than that
resulting from total premature mortalities. In terms of total figures, total
premature mortality cost the region 139.52 (95% CI: 110.95–165.91)
billion CNY, while total hospital admissions cost 25.18 (95% CI:
14.96–34.88) billion CNY, and total outpatient visits cost 10.47 (95% CI:
8.71–23.81) billion CNY. In total, these three factors resulted in a 175.22
(95% CI: 134.61–224.61) billion CNY loss, 4.92% of the total GDP in
Hebei Province. The total economic loss as a percentage of GDP was
significantly higher in Hebei than in the PRD region in 2013 (1.4%–2.3%
A. Gao et al. Environmental Research 208 (2022) 112671

Table 3
The economic losses and percentage (%) due to exposure to multiple air pollutants in Hebei Province in 2017 (unit: million CNY).
The proportion

City Total premature mortality Total hospital admissions Total outpatient visits Total premature mortality Total hospital admissions Total outpatient visits

SJZ 20,697 (16,547–24,500) 3,898 (2,392–5,339) 1,742 (1,432–3,871) 78.6 14.8 6.6
TS 21,620 (17,099–25,797) 3,438 (2,145–4,671) 1,606 (1,455–3,926) 81.1 12.9 6
QHD 5,883 (4,631–7,061) 948 (554–1,323) 369 (322–898) 81.7 13.2 5.1
HD 19,242 (15,350–22,794) 3,466 (2,129–4,744) 1,491 (1,281–3,408) 79.5 14.3 6.2
XT 14,384 (11,455–17,075) 2,759 (1,709–3,759) 1,169 (979–2,670) 78.5 15.1 6.4
BD 20,939 (16,703–24,868) 3,858 (2,275–5,353) 1,531 (1,242–3,414) 79.5 14.7 5.8
ZJK 4,365 (3,439–5,231) 914 (430–1,369) 297 (117–475) 78.3 16.4 5.3
CD 4,112 (3,247–4,914) 789 (418–1,143) 272 (250–659) 79.5 15.3 5.3
CZ 13,420 (10,623–16,028) 2,418 (1,394–3,386) 1,042 (753–2,242) 79.5 14.3 6.2
LF 8,715 (6,929–10,375) 1,437 (809–2,029) 492 (472–1,213) 81.9 13.5 4.6
HS 6,139 (4,925–7,270) 1,252 (708–1,769) 460 (403–1,037) 78.2 15.9 5.9
HB 139,515 (110,945–165,913) 25,177 (14,962–34,883) 10,471 (8,707–23,811) 79.6 14.4 6

Fig. 4. (a) The contributions of three health burden economic losses to total losses in 2017; (b) The economic losses contributions in 11 cities of Hebei in 2017.

of the local GDP) (Lu et al., 2016). This is because Hebei Province saw
relatively large economic losses with about 4.1% of the total 4.92% loss
due to the high levels of total premature mortality and total hospital
admissions. The economic losses due to NO2, CO, and O3 were signifi­
cantly higher than those due to SO2 and PM2.5-10. The reason is that the
health burdens due to NO2, CO, and O3 exposure are considerably
higher. The economic losses (top four) attributable to NO2, O3, PM2.5,
and CO were 47,973, 41,197, 27,353, and 26,669 million CNY,
respectively (Table S12). The three cities with the highest total eco­
nomic loss (based on premature deaths, hospital admissions, and
outpatient visits) from air pollutants are TS (26,664 million CNY), SJZ
(26,337 million CNY), and BD (26,329 million CNY) (Table 3). Once
again, this was because the air pollutant emissions were relatively high
in BD, TS, and SJZ and the exposure populations were also large (top
three) in 11 cities of Hebei Province. These led to more premature
mortality and corresponding economic loss (the contributions about
15% in Fig. 4). Next, the economic losses of HD (24,199 million CNY)
and XT (18,312 million CNY) were also relatively large. In summary, the
health effects and economic losses are considerable in Hebei Province,
and effective measures should be adopted to reduce air pollutant con­
centrations and ultimately improve health outcomes for residents.
3.4. Uncertainty analysis
In our study, uncertainty also existed in the health burden analysis.
First, we assume that the baseline incidence rates of mortality and
hospitalization for circulatory and respiratory disease and outpatient
admissions are the same for 11 cities in Hebei Province due to date
limitation. These rates should depend on local economic development
levels, health services, and environments. Second, we assumed that the
exposure-response coefficients were the same among the 11 cities. The
coefficients may differ due to population’s age structure, medical and
health conditions (Liang et al., 2019; Yao et al., 2020; Zhang et al.,
2017). PM may even have different chemical compositions and polluted
sources and may result in different health effects (Ostro et al., 2015; Yao
et al., 2020). Third, we set the threshold concentration to relatively low
values due to there is no evidence shows that has an exact threshold
concentration between air pollution and health effects (mortality and
morbidity) (Chen et al., 2017b; Li et al., 2020; Qian et al., 2007; Zhang
et al., 2019), which may cause the overestimation of the results. Fourth,
we have made some adjustments in the estimate of the total health
burden from multiple pollutants exposure. However, the combined ef­
fects of multiple pollutants on human health are complex. We consid­
ered the overlapping issue due to negative health effects simultaneously
caused by multiple pollutants (Walton et al., 2015). However, the air
pollution co-exposure may increase health risks due to the synergistic
effect of pollutants on human effects (Kurhanewicz et al., 2014). Our
results may be underestimated. The issue of health risk from air pollu­
tion co-exposure is still controversial, and we will study it deeply in
future work. Fifth, the economic loss estimation method may lead to
certain uncertainties. The method we used is generally considered as the
upper limit (Zeng et al., 2019) of statistical premature death value, so
the economic loss may be higher than that of other methods.
4. Conclusions
In this study, we discussed the coordinated health burden and the
corresponding economic losses from PM2.5 and other key air pollutants
in Hebei Province. The health burden and economic loss were estimated
using a log-linear exposure-response function. The contributions of
PM2.5, NO2, and O3 (the three primary contributors) to all-cause pre­
mature mortality (accounting for overlapping effects), were 17.6%,
27.3%, and 23.5%, respectively. Exposure to multiple air pollutants
seriously impacts the cardiovascular system. In terms of morbidity,
roughly 2.63 million total hospital admissions and 36.17 million
outpatient visits were recorded due to multiple air pollutants exposures.

8
A. Gao et al.
As the primary contributor, total premature mortality accounts for 80%
of the economic loss (139.52 billion CNY). The health burden (total
premature mortality) and economic loss associated with NO2, O3, and
PM2.5 exposure are much higher than that associated with SO2 and
PM2.5-10. This study provides a valuable reference in the assessment of
the health burden associated with multiple air pollution in Hebei
Province. This study obtained crucial information about the health ef­
fects and economic losses due to ambient air pollutants. These results
highlight that we must pay attention to the health burden and economic
losses attributable to multiple air pollutants exposures. Stringent control
policies should be implemented to control air pollution in the region,
ultimately helping improve the health and economic conditions of local
citizens.
Credit author statement
Aifang Gao: Conceptualization, Methodology, Formal analysis,
Writing – original draft. Junyi Wang: Data curation, Formal analysis,
Validation, Investigation, Writing – review & editing. James Poet­
zscher: Writing - Reviewing and Editing. Shaorong Li: Data curation,
Investigation. Boyi Gao: Formal analysis, Drawing figure, Validation.
Peng Wang: Methodology, Supervision, Writing- Reviewing and Edit­
ing. Jianfei Luo: Data curation. Xiaofeng Fang: Writing- Reviewing and
Editing. Jingyi Li: Validation. Jianlin Hu: Writing- Reviewing and
Editing. Jingsi Gao: Writing- Reviewing and Editing. Hongliang
Zhang: Conceptualization, Supervision, Project administration.
Declaration of competing interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
Acknowledgments
The work is supported by the open fund by Jiangsu Key Laboratory of
Atmospheric Environment Monitoring and Pollution Control
(KHK1906), Science and Technology Project of Hebei Education
Department (ZD2020135), Overseas Talents Introduction Funded Proj­
ect of Hebei Province (C20200308), Research and Practice of Teaching
Reform in Hebei GEO University (2019J28), and the project of Shenzhen
Science and Technology Plan (Grand No. KJYY20180206180737010;
6020320003K).
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.
org/10.1016/j.envres.2021.112671.
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