Environment International 159 (2022) 107023

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Environment International
journal homepage: www.elsevier.com/locate/envint

Communicating respiratory health risk among children using a global air

quality index☆
Laura A. Gladson a, b, Kevin R. Cromar a, b, *, Marya Ghazipura a, b, K. Emma Knowland c, d,
Christoph A. Keller c, d, Bryan Duncan d
a
Marron Institute of Urban Management, New York University, New York, USA
b
New York University Grossman School of Medicine, New York, NY, USA
c
Universities Space Research Association, Columbia, MD, USA
d
NASA Goddard Space Flight Center, Greenbelt, MD, USA

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

Handling Editor: Hanna Boogaard Air pollution poses a serious threat to children’s respiratory health around the world. Satellite remote-sensing
technology and air quality models can provide pollution data on a global scale, necessary for risk communica­
Keywords: tion efforts in regions without ground-based monitoring networks. Several large centers, including NASA, pro­
Air pollution model duce global pollution forecasts that may be used alongside air quality indices to communicate local, daily risk
Air quality index
information to the public. Here we present a health-based, globally applicable air quality index developed
Children’s health
specifically to reflect the respiratory health risks among children exposed to elevated outdoor air pollution.
Global health
Respiratory disease Additive, excess-risk air quality indices were developed using 51 different coefficients derived from time-series
Risk communication health studies evaluating the impacts of ambient fine particulate matter, nitrogen dioxide, and ozone on chil­
dren’s respiratory morbidity outcomes. A total of four indices were created which varied based on whether or not
the underlying studies controlled for co-pollutants and in the adjustment of excess risks of individual pollutants.
Combined with historical estimates of air pollution provided globally at a 25 × 25 km2 spatial resolution from
the NASA’s Goddard Earth Observing System composition forecast (GEOS-CF) model, each of these indices were
examined in a global sample of 664 small and 140 large cities for study year 2017. Adjusted indices presented the
most normal distributions of locally-scaled index values, which has been shown to improve associations with
health risks, while indices based on coefficients controlling for co-pollutants had little effect on index perfor­
mance. We provide the steps and resources need to apply our final adjusted index at the local level using freely-
available forecasting data from the GEOS-CF model, which can provide risk communication information for cities
around the world to better inform individual behavior modification to best protect children’s respiratory health.

1. Introduction
In 2019, the World Health Organization (WHO) declared air pollu­
tion to be the greatest environmental threat to human health (WHO,
2019), with globally 93% of children under the age of 18 exposed to
annual air pollution concentrations above levels recommended by WHO
(WHO, 2018). Children are especially susceptible to these effects;
extensive research supports the link between children’s exposure to
ambient air pollution and various health impacts, including respiratory
disease, birth effects, infant mortality, childhood obesity, and neuro­
developmental outcomes (e.g., Sun and Zhu, 2019; Parasin et al., 2021;
Lee, 2021). Respiratory impacts are especially prevalent, and both short-
and long-term exposures to ambient air pollution in children can impair
lung function, increase acute respiratory infection risk and exacerbation,
and lead to greater incidences of asthma and its symptoms (Goldizen
et al., 2016). Air pollution has significant mortality impacts as well; in
2016, approximately 286,000 children under 15-years-old died from
exposures to ambient air pollution. The majority of these deaths occur in
low- and middle-income countries (Landrigan et al., 2018; Lelieveld
et al., 2018), yet reliable air quality data, along with accompanying risk
communication information, is rarely available outside of the world’s
most developed nations (Shaddick et al., 2018; Katoto et al., 2019;

☆
Funding and resources for this project were provided by NASA and New York University’s Marron Institute of Urban Management.
* Corresponding author at: 370 Jay Street, 12th Floor, Brooklyn, NY 11201, USA.
E-mail address: kevin.cromar@nyu.edu (K.R. Cromar).

https://doi.org/10.1016/j.envint.2021.107023
Received 12 July 2021; Received in revised form 29 November 2021; Accepted 2 December 2021
Available online 15 December 2021
0160-4120/© 2021 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
L.A. Gladson et al.
Table 1
Pollutant-specific relative risk and coefficient values from meta-analyses of
studies on children’s respiratory outcomes. RR is reported per 10 unit increase in
pollution concentration (µg/m3 for PM2.5; ppb for O3 and NO2) using an inverse
variance, random effects model. RRs are shown to facilitate comparison with
forest plots in Figs. 1 and 2, but only coefficients were incorporated into index
equations.
Associations Between Air Pollution and Children’s Respiratory
Morbidity
Pollutant Studies Not Controlling for Studies Controlling for
Co-pollutants Co-pollutants*
Relative Risk Coefficient Relative Risk Coefficient
(95% CI) (95% CI)
PM2.5 1.02 (1.01–1.03) 0.002 1.02 (1.02–1.03) 0.002
O3 1.03 (1.01–1.04) 0.003 1.02 (1.00–1.04) 0.002
NO2 1.06 (1.03–1.09) 0.006 1.04 (1.02–1.06) 0.004
* Co-pollutants include study pollutants (PM2.5, O3, NO2), carbon monoxide
(CO), coarse particulate matter (PM10), photochemical oxidants (Ox), sulfur
dioxide (SO2), suspended particulate matter (SPM), and total number concen­
tration of particles (NCtot). Breakdown by study is available in Table A.2.
Weigand et al., 2019).
Monitored or estimated air pollution concentrations are at the
foundation of effective risk communication. To provide air pollution
information in regions without in-situ monitoring networks, satellite
remote-sensing technologies can observe daily global pollution levels at
increasingly refined spatial scales (Zhang and Li, 2015; Goldberg et al.,
2017; Cromar et al., 2019). These observations are incorporated and
further defined using computer model simulations, which rely on known
chemical characteristics and pollutant behaviors to provide air quality
forecasts (Brauer et al., 2016; Kimet al., 2016; van Donkelaar et al.,
2016; Guoet al., 2017; Akritidis et al., 2018; Malings et al., 2021). Short-
term forecasts can provide the lead time decision makers and the public
need to take precautionary measures to avoid the greatest impacts of
pollution events (Zhang et al., 2012). Many countries have created
regional forecasting models to meet these needs (e.g., Bai et al., 2018);
additionally, a number of research and operational centers provide
global composition forecasts including WACCM (0.95◦ × 1.25◦ latitude/
longitude resolution) (Gettelman et al., 2019; Emmons et al., 2020),
SILAM (1.44◦ × 1.44◦ latitude/longitude resolution) (Korhonen et al.,
2019; https://silam.fmi.fi/aqforecast.html), and CAMS (0.4◦ × 0.4◦
latitude/longitude resolution) (Wu et al., 2020; https://www.ecmwf.
int/en/forecasts/dataset/cams-global-archived-analysis-and-forecas
t-daily-data). Most recently developed is the NASA Goddard Earth
Observing System composition forecast (GEOS-CF) model, which pro­
vides worldwide, daily air pollution concentration historical estimates
and 5-day forecasts at high spatial and temporal resolutions in near real-
time (Keller et al., 2021). By including reactive gas-phase chemistry
calculations, this model can estimate concentrations of health-relevant
gaseous pollutants such as ozone (O3) and nitrogen dioxide (NO2) in
addition to fine particulate matter (PM2.5). Coupled with its fine hori­
zontal spatial resolution (0.25◦ × 0.25◦ latitude/longitude resolution,
approximately 25 × 25 km2), the GEOS-CF product provides air quality
forecasts well-suited for health risk communication.
Air quality forecasts are commonly communicated to the public
using an air pollution index, which summarizes current air quality
conditions into a single number or category. These indices are intended
to provide daily warnings of local air quality risks to vulnerable pop­
ulations and the general public. A primary goal of any air quality
communication tool is to encourage behavior changes that reduce per­
sonal exposures to air pollution and the associated health impacts
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Environment International 159 (2022) 107023
(Borbet et al., 2018). Relevant avoidance behaviors may include altering
when and where daily activities take place, using personal protective
equipment, or taking medication. To encourage these behaviors, an air
quality index should be simple to access and understand, reliable, and
communicated frequently and consistently. There is a general consensus
among the scientific and public health communities that communicating
air quality through aggregated index values instead of individual
pollutant concentrations conveys a clearer message to the public, who
may be unfamiliar with the health relevance of specific pollutant con­
centrations and ranges (Shooter and Brimblecombe, 2008; Plaia and
Ruggieri, 2011).
The most widespread index design is the Air Quality Index (AQI),
created in the U.S. and since implemented in a number of countries
throughout the world (Zhang et al., 2012; Chang et al., 2016; Han et al.,
2018; Li et al., 2019). More recently, health-based air quality indices
have been designed which base index values on measured health risks
from air pollutants and reflect the potentially compounded health risks
of multiple pollutants in one value (Stieb et al., 2008; Kanchan and
Pramila, 2015; Perlmutt et al., 2017). The original health-based index,
the Air Quality Health Index (AQHI), was developed by Canadian re­
searchers and bases index values on the measured mortality risks asso­
ciated with individual pollutants (Stiebet al., 2008). The AQHI has been
validated throughout Canada and number of other countries and
demonstrated to be more informative of real-world health risks
compared to the AQI (Chen et al., 2013; Wong et al., 2013; Li et al.,
2017; Gayer et al., 2018; Mason et al., 2019; Olstrup et al., 2019; Perl­
mutt and Cromar, 2019b).
With the increasingly global reach of air quality estimates comes the
potential to introduce air quality index alerts to regions without local
monitoring. One suggested method for doing so is to use globally stan­
dardized cutoffs for each reported level of risk, where an index value
represents the same pollution level everywhere in the world. Examples
include the Common Air Quality Index (CAQI), created as an attempt at
a uniform index across Europe (van den Elshoutet al., 2014; Lokyset al.,
2015); the World Air Quality Index (https://waqi.info/) developed by
Beijing scientists, a platform for reporting real-time air quality for over
10,000 global monitoring stations using the U.S. EPA’s AQI; and the Air
Quality Life Index (AQLI) developed by researchers at the Energy Policy
Institute at the University of Chicago, which reports the expected gains
in life expectancy by meeting WHO air quality recommendations
throughout the world (Greenstone and Fan, 2018). Universal indices can
be useful in many ways, such as reducing confusion when comparing air
quality between cities, benefiting individuals traveling abroad, and
providing important information to researchers and policymakers as
they work to improve international public health (van den Elshoutet al.,
2014). However, by using the same scaling worldwide, this approach
does a poor job reflecting the pollution distributions and health risks
most relevant to those living in a specific location.
Considering the available air quality models, index designs, and risk
communication needs of global populations, we have created the first
health-based air quality index built specifically to communicate chil­
dren’s respiratory risk worldwide. This paper outlines the process of
index construction, demonstrating various designs in 804 global cities in
order to select a final index with the best representation of health risks.
Four index designs were created to compare the impacts co-pollutants
on risk estimates and the effects of logarithmic adjustments of pollu­
tion concentrations. We used historical (2017) GEOS-CF forecasts of
PM2.5, O3, and NO2 as index exposure data, three pollutants with sig­
nificant implications on children’s respiratory outcomes. By scaling the
index according to city-specific pollution distributions, our design pro­
vides locally relevant health risk information for children in regions that
L.A. Gladson et al. Environment International 159 (2022) 107023

Fig. 1. Meta-analysis results for children’s respiratory health studies controlling for co-pollutants. Analysis was performed in Review Manager (v. 5.3) using an
inverse variance, random effects model.

lack ground-based monitoring networks. Finally, we discuss the ad­
vantages of the final index and best practices for air quality managers
using this tool at the local level.
2. Methods
An umbrella review (limited to systematic reviews and meta-
analyses) was conducted to identify all relevant studies evaluating the
associations of outdoor air pollution and children’s respiratory health.
Initial search terms, restricted to English-language only, were run
through the Ovid Medline, Embase, CINAHL, Wiley Cochrane, CEN­
TRAL, and Web of Science databases in October 2017. Terms included
air pollution terminology, specific respiratory outcomes (including
asthma, chronic obstructive pulmonary infection, bronchitis, cough, and
respiratory infections), and a list of all non-Western nations in order to
capture any studies with data from low- and middle-income countries.

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L.A. Gladson et al. Environment International 159 (2022) 107023

Fig. 2. Meta-analysis results for children’s respiratory health studies not controlling for co-pollutants. Analysis was performed in Review Manager (v. 5.3) using an
inverse variance, random effects model.

The resulting 5,868 matching studies were then screened using the on­ (such as gene-environment interactions or prenatal exposures), studies
line review management software, Covidence (Veritas Health Innova­ with mortality-only outcomes, and studies focused on adult-only pop­
tion). First, results were restricted to systematic reviews and meta- ulations. Remaining articles were downloaded and a full text screening
analyses. Next, title and abstract screening removed irrelevant topics was performed to remove remaining mortality-only studies, as well as

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L.A. Gladson et al. Environment International 159 (2022) 107023

Fig. 3. Daily health-based air quality index value distributions for Buenos Aires, Argentina and Delhi, India (2017) for four study designs. Indices are adjusted to a
0–10 scale relative to the city’s maximum index values. Adjusted indices have a relatively normal distribution, while unadjusted indices are right-skewed and
leptokurtic.

Table 2
Counts of 664 small cities by health-based air quality index skewness and kurtosis values (2017) across four index variations. Small cities are defined as having an area
between 125 and 2,500 km2 and at least 2 grid cells using 25x25 km2 horizontal resolution GEOS-CF data (where the city’s area fills each cell to at least 30%). The
overall index is a summation of individual pollutant indices. Adjusted index designs have greater normality in their index distributions across this subset compared to
unadjusted index values.
Skewness Adjusted Index Unadjusted Index

Not controlling for co-pollutants Controlling for co-pollutants Not controlling for co-pollutants Controlling for co-pollutants
Excess Kurtosis Excess Kurtosis Excess Kurtosis Excess Kurtosis

<− 0.5 − 0.5 to 0.5 >0.5 <− 0.5 − 0.5 to 0.5 >0.5 <− 0.5 − 0.5 to 0.5 >0.5 <− 0.5 − 0.5 to 0.5 >0.5

>1.0 0 (0%) 2 (0%) 71 (11%) 0 (0%) 1 (0%) 76 (11%) 0 (0%) 1 (0%) 204 (31%) 0 (0%) 1 (0%) 310 (47%)
0.5 to 1.0 8 (1%) 57 (9%) 36 (5%) 7 (1%) 68 (10%) 31 (5%) 3 (0%) 93 (14%) 122 (18%) 0 (0%) 88 (13%) 120 (18%)
0.0 to 0.5 82 (12%) 121 (18%) 2 (0%) 78 (12%) 129 (19%) 3 (0%) 56 (8%) 130 (20%) 21 (3%) 28 (4%) 90 (14%) 11 (2%)
− 0.5 to 0 67 (10%) 147 (22%) 10 (2%) 79 (12%) 130 (20%) 9 (1%) 22 (3%) 11 (2%) 0 (0%) 9 (1%) 6 (1%) 0 (0%)
− 1.0 to − 0.5 5 (1%) 30 (5%) 25 (4%) 5 (1%) 30 (5%) 17 (3%) 0 (0%) 0 (0%) 1 (0%) 0 (0%) 0 (0%) 1 (0%)
<− 1.0 0 (0%) 0 (0%) 1 (0%) 0 (0%) 0 (0%) 1 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%)

Table 3
Counts of 140 large cities by health-based air quality index skewness and kurtosis values (2017) across four index variations. Large cities are defined as having an area
over 2,500 km2 and at least 2 grid cells using 25x25 km2 horizontal resolution GEOS-CF data (where the city’s area fills each cell to at least 30%). The overall index is a
summation of individual pollutant indices. Adjusted indices have greater normality in their index distributions across this subset compared to unadjusted index values.
Skewness Adjusted Index Unadjusted Index

Not controlling for co-pollutants Controlling for co-pollutants Not controlling for co-pollutants Controlling for co-pollutants
Excess Kurtosis Excess Kurtosis Excess Kurtosis Excess Kurtosis

<− 0.5 − 0.5 to 0.5 >0.5 <− 0.5 − 0.5 to 0.5 >0.5 <− 0.5 − 0.5 to 0.5 >0.5 <− 0.5 − 0.5 to 0.5 >0.5

>1.0 0 (0%) 0 (0%) 1 (1%) 0 (0%) 0 (0%) 1 (1%) 0 (0%) 1 (1%) 29 (21%) 0 (0%) 0 (0%) 53 (38%)
0.5 to 1.0 1 (1%) 2 (1%) 3 (2%) 1 (1%) 2 (1%) 3 (2%) 0 (0%) 29 (21%) 31 (22%) 0 (0%) 22 (16%) 25 (18%)
0.0 to 0.5 10 (7%) 28 (20%) 0 (0%) 13 (9%) 30 (21%) 1 (1%) 9 (6%) 34 (24%) 1 (1%) 9 (6%) 28 (20%) 0 (0%)
− 0.5 to 0 21 (15%) 56 (40%) 1 (1%) 23 (16%) 53 (38%) 1 (1%) 3 (2%) 3 (2%) 0 (0%) 1 (1%) 2 (1%) 0 (0%)
− 1.0 to − 0.5 2 (1%) 9 (6%) 6 (4%) 2 (1%) 5 (4%) 5 (4%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%)
<− 1.0 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%)

5
L.A. Gladson et al.
Fig. 4. Guide for calculating daily air quality index values for children’s respiratory health risk communication. Coefficient values were calculated from risk ratios
based on meta-analyses of studies controlling for co-pollutants (see Table 1).
those that did not include one of the three focus pollutants (PM2.5, O3,
NO2), report on child-exclusive health outcomes, and provide risk ratios
by continuous pollutant concentration change at annual (not seasonal)
aggregations. Ultimately, 32 systematic reviews and meta-analyses were
extracted and from these, a total of 75 relevant time-series health studies
were pulled and summarized in a preliminary database. Database
studies focused on all children’s respiratory outcome hospital admis­
sions (HA) or emergency department (ED) visits.
The following exclusion criteria reduced the database to 23 studies
available for analysis (see Appendix A), with a total of 26 coefficients
that did not control for co-pollutants (13 for PM2.5, 8 for O3, and 7 for
NO2) and 23 coefficients that did control for co-pollutants (9 for PM2.5, 5
for O3, and 9 for NO2). Selected studies include regional representation
for North America, Europe, Eastern Asia, and Australia. Only co­
efficients using a 24-hour mean metric for PM2.5 and NO2 and an 8-hour
max metric for O3 were selected for analysis, except for NO2 studies
reporting RR in 1-hour metrics which were converted to 24-hour mean
values (see Appendix B). In cases where multiple lag day options were
available in the same study, preference was given to those closest to a
0–2 day lag. Additionally, coefficients with and without controlling for
co-pollutants were kept for analysis. Where an individual study reported
results for more than one combination of co-pollutants, coefficients
controlling for particulate matter were preferred for the two gaseous
pollutants. In cases where age was divided into multiple groups, age
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Environment International 159 (2022) 107023
groups containing older children were preferred over those limited to
infancy.
Meta-analyses were performed on this subset of RRs to produce
pollutant-specific coefficients for use in the health-based index calcu­
lation. Units for the RRs reported by database studies were standardized
to a risk per 10 ppb average annual concentration increase for O3 and
NO2 and a risk per 10 µg/m3 average annual concentration increase for
PM2.5. Database studies were imported into Review Manager (version
5.3) (The Cochrane Collaboration, 2014), a tool used to group and run
each meta-analyses. Studies were aggregated by pollutant using an in­
verse variance, random effects model to produce summary RRs. Two
runs were performed per pollutant with coefficients that were generated
with and without controlling for co-pollutant exposures. The associa­
tions between individual pollutants and increased risk of children’s
respiratory morbidity are presented in Table 1.
Using these associations, two approaches were used to create a
children’s respiratory health-based air quality index based on the work
of Perlmutt and Cromar (2019a, 2019b). Both index functions assumed a
no-threshold relationship between air pollutant concentrations and
health outcomes, following the methodology and validation of Canada’s
air quality health index (AQHI) designed by Stieb et al. (2008). The first
function is pulled directly from the AQHI design, and sums the excess
health risk associated with each pollutant; it is hereafter referred to as
the “unadjusted health-based index” (Equation (1)). In order to
L.A. Gladson et al.
minimize the contribution of extreme values of any one pollutant, a
second function (Equation (2)) was constructed in which individual
pollutant index values are adjusted using a natural logarithm function
before summation, referred to as the “adjusted health-based index.”
∑ ( ) shows the overall risk ratios produced in the meta-analysis by pollutant
Unadjusted Health-Based Index = 100 eβi Xit − 1 (1)
t=1⋯p
∑ ( ) studies that control for co-pollutants, risk ratios were 1.02, 1.02, and
Adjusted Health-Based Index = ln[100 eβi Xit − 1 ] (2)
t=1⋯p
Here, βi is the coefficient for the ith air pollutant and Xit is the con­
centration of ith pollutant at the tth day. Daily concentrations use an 8-
hour max metric in ppb for O3, a 24-hour mean metric in ppb for NO2,
and a 24-hour mean metric in µg/m3 for PM2.5. Before summing indi­
vidual pollutant indices, any negative daily index values should be
adjusted to zero.
Daily pollution concentrations were obtained from the GEOS-CF
system (Keller et al., 2021), provided by NASA’s Global Modeling and
Assimilation Office (GMAO). GEOS-CF produces a historical estimate of
the atmospheric composition and weather prior to running the 5-day
forecast of atmospheric pollutants at a 25 × 25 km2 horizontal spatial
resolution. Both the historical estimate and forecast model output is
freely and immediately available at https://gmao.gsfc.nasa.gov/weath
er_prediction/GEOS-CF/data_access/. This site also provides documen­
tation and additional resources for using these data files, currently
provided in netCDF-4 format. GEOS-CF has demonstrated to realistically
capture the spatial and temporal variation of all three pollutants, albeit
it tends to overestimate PM2.5 compared to observations (Keller et al.,
2021). This systematic PM2.5 bias is acceptable for this study because the
model still successfully captures the relative concentrations between
pollutants, which is most critical for our communication approach. For
this study, we calculated 24-hour averages of PM2.5 and NO2 and
maximum daily 8-hour average (MDA8) O3 in local time based on 15◦
longitude segments using the GEOS-CF historical estimates for PM2.5,
NO2 and O3.
Combining variations of 1) coefficients based on studies controlling
vs. not controlling for pollutants, and 2) unadjusted vs. adjusted index
equations, we had four possible index designs. In order to evaluate each
design, daily index values were calculated from each of these functions
for a sample of 804 global cities over the 365 days in 2017 using the
aggregated GEOS-CF pollution estimates. Using ArcMAP software
(version 10.6.1), urban extent shapefiles, provided by Columbia Uni­
versity’s Global Rural-Urban Mapping Project version 1 (GRUMPv1)
(Balket al., 2006; Center for International Earth Science Information
Network - CIESIN - Columbia University et al., 2017), were linked
spatially to the GEOS-CF model grid. Cities with less than 2 grid cells
overlapping the city layer were excluded from the analysis, and only
grid cells filled to at least 30% of their area by the city extent were
included in city calculations. For each of the four index designs, index
values were then calculated for each city grid cell, then averaged to
produce daily index estimates by city for each day in 2017. For each city,
index values were scaled so that the city’s maximum index value was
represented by a value of 10. Individual city index results were then
examined for normality both visually and with skewness and kurtosis
tests to compare distributions among the four index designs.
3. Results
Graphical representations of individual pollutant meta-analyses are
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Environment International 159 (2022) 107023
presented in Figs. 1 and 2, divided by studies that do and do not control
for co-pollutants. Pollutant concentrations among the included studies
provided a fair representation of daily exposures globally, ranging from
8–96 µg/m3 for PM2.5, 14–45 ppb for ozone, and 9–67 for NO2. Table 1
and index type. For studies that do not control for co-pollutants, risk
ratios were 1.02, 1.03, and 1.06 for PM2.5, O3, and NO2, respectively; for
1.04 for PM2.5, O3, and NO2, respectively. Functionally, the difference
between these two sets of risk ratios results in a greater weighting of
PM2.5 when calculating index values using studies that control for co-
pollutants.
City indices were examined to identify which function produced the
greater normality in its index distributions. This method was based on
work done by Perlmutt and Cromar (2019), who found that more
normally-distributed air quality indices most effectively predict respi­
ratory morbidity. Fig. 3 show histograms for Buenos Aires, Argentina
and Delhi, India as examples of these normality trends. In both cities, the
adjusted indices are more normally distributed than the unadjusted
indices. Tables 2 and 3 compare adjusted and unadjusted index results,
subdivided by the use of pollutant coefficients that do and do not control
for co-pollutants, by presenting index skewness and kurtosis distribu­
tions across each index design. These results are further divided by city
size, with 664 small cities (containing 2 to 4 grid cells) in Table 2 and
140 large cities (containing 5 or more grid) in Table 3. For both city size
groups, adjusted index results present greater normality in their distri­
butions than unadjusted index results, which are more right-skewed and
leptokurtic. Because the adjusted formula (Equation (2)) had relatively
normal distributions across the sample cities, it was selected for the
index design.
In contrast, index designs controlling and not controlling for co-
pollutants had very comparable distribution patterns across our sam­
ple, revealing little skewness or excess kurtosis in the results of Tables 2
and 3. This is also demonstrated in the examples in Fig. 3, where dis­
tributions of index designs controlling and not controlling for co-
pollutants are very similar, especially when compared against the var­
iations seen between the adjusted and unadjusted designs. Generally,
controlling for other pollutants when calculating air quality risk is
preferred in order to avoid potential confounding, particularly between
ozone and other pollutants during the ozone season. Since city index
results showed no preference for either design, and given the greater
balance in risk identified from the meta-analysis controlling for co-
pollutants, pollutant coefficients based on studies controlling for co-
pollutants (see the final column of Table 1) were selected for the final
index.
The final children’s respiratory health-based index formula uses risk
ratios from the meta-analysis controlling for co-pollutants to determine
coefficient values, and includes a logarithmic step to adjust for the wide
range of global pollutant concentrations. Fig. 4 provides a step-by-step
guide to calculating daily index values using the final design, based on
a global weighting. Because of the wide distribution of global air quality,
we provide instructions in Steps 4–5 for scaling these values according to
local air quality conditions. These steps scale the numeric index values
to a maximum value of 10 based on local air pollution concentration
distributions, which makes for much cleaner messaging. The local
scaling value should only be calculated once, ideally using local data
from a multi-year time period; after the scaling value is determined, it
will be used moving forward to calculate all locally-scaled index values
to preserve the integrity of index messaging.
L.A. Gladson et al.
4. Discussion
This study presents a novel air quality index, health-based and global
in scale, intended to inform behavior modification decisions that can
reduce childhood exposure to unhealthy levels of air pollution. We
examined the distributions of various index functions in a sample of
global cities to determine the most effective communication tool for a
broad range of pollution concentrations. In an effort to better reflect the
real-world health risks of air pollution, every index value is calculated
using measured risk values from three criteria pollutants. Incorporating
multiple pollutants allows us to better mimic air mixtures, while the
health-based design brings us closer to true risks compared to indices
based on concentrations alone. Used in conjunction with NASA’s global
and publicly available air quality forecasting system, GEOS-CF, this
index can function as an air quality communication tool anywhere in the
world, providing locally-relevant risk values for children in high-risk
groups and regions.
The primary guide in our selection of the final index design was the
work of Perlmutt and Cromar (2019a, 2019b), who conclude that nor­
mally distributed indices are most effective in reflecting health risk.
Specifically, their design of a health-based air quality index in New York
City found that indices with normal distributions were the most highly
correlated to locally measured respiratory health outcomes. Cromar
et al. (2021) observed similar conclusions in an index designed using
Mexico City health and air quality data. In our global sample of cities, we
determined that an adjusted index is the best representation of local
respiratory health risks given its consistent normality across the study
sample. While the unadjusted index performed well at mid-range
pollution levels, inconsistencies arose at the extremes as demonstrated
by the unbalanced skewness values seen in both small (Table 2) and
large (Table 3) cities.
Instead of creating categorized risk groups, our index is designed to
report numerical values on a 1–10 scale to communicate local risk. It is
important to deconstruct the notion that predetermined cut points are
necessary for the messaging associated with a global index. Declaring
specific pollution levels as “healthy” or “unhealthy” ignores the wide
range of concentrations in the ambient environment and the no-
threshold impacts of air pollution on health. Even in relatively clean
regions, there are still differences in risk between the highest and lowest
pollution days (Kelly and Fussell, 2015; Corriganet al., 2018;
Schwartzet al., 2018) which would be masked by a universal messaging
system. Instead, a “know your number” messaging approach such as that
used with the Canadian AQHI would allow individuals to avoid the
worst health impacts relative to their personal exposures (see “airhealth.
ca”). In the present study, we use a local scaling adjustment for each
city’s index to reflect its unique range of pollution concentrations and
provide cleaner messaging. This does not impact the global rank order of
health risks day-to-day, only the numerical value of the local alert,
thereby preserving the relative exposures individuals experience while
making index interpretation more manageable. Ideally, individuals will
learn to recognize the index values where they personally experience
health effects and discomfort, and reduce their exposure accordingly.
There are a number of issues that arise when trying to create an air
quality index that best represents local health risk. These may include
the complexity of multi-pollutant interactions, the challenge of
combining various pollutant averaging times, the wide variety of local
concentrations and health risks, and the inevitable loss of information
when pollution data is averaged across so many variables (Shooter and
Brimblecombe, 2008). Additionally, there is at present no other index
being used to assess children’s health risk from air pollution on a global
8
Environment International 159 (2022) 107023
scale using measured risk values, so comparisons of risk values or index
design with similar tools is not possible. As such, we strongly advise
verifying this study’s index design, and any other global health-based
indices, against local respiratory data in order to ensure they are
communicating real local health risks. For example, during the creation
of the Mexico City health-based index referenced above, the authors
found that the precise weightings of pollutants in the index mattered less
than their relationships to one another, which were successfully vali­
dated using local respiratory health data (Cromar et al., 2021). Future
research should take a similar approach of validating global indices
using regional health data to gain greater insight into their efficacy at
the local level.
5. Conclusion
Communities in low- and middle-income countries are highly sus­
ceptible to air pollution health impacts, and rarely have local air quality
alert systems in place. In this study, we present the first health-based air
quality index reflecting children’s respiratory risk that can be used in
cities around the world. Our analysis suggests that an index adjusted for
extreme pollution values and controlling for co-pollutants most effec­
tively communicates respiratory risk from air pollution on a global scale.
This index design uses simple calculations based on daily index values
from three criteria pollutants, and can be used by environmental
agencies throughout the world to provide local air quality alerts, either
using regional observations or publicly available model forecasts such as
NASA’s GEOS-CF. Ideally, as more global health data is acquired, this
and other air quality indices can be evaluated and improved to best
reflect local health risks to the public. Ideally, any air quality index
would be further validated using local health data to confirm associa­
tions with local population-level heath risks.
CRediT authorship contribution statement
Laura A. Gladson: Formal Analysis, Investigation, Methodology,
Visualization, Writing – original draft, Writing – review & editing. Kevin
R. Cromar: Conceptualization, Funding acquisition, Methodology, Su­
pervision. Marya Ghazipura: Investigation, Writing – review & editing.
K. Emma Knowland: Formal analysis, Resources, Writing – review &
editing. Christoph A. Keller: Software, Resources, Writing – review &
editing. Bryan Duncan: Funding acquisition, Writing – review &
editing.
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.
Acknowledgements
Resources supporting the model simulations were provided by the
NASA Center for Climate Simulation at the Goddard Space Flight Center
(https://www.nccs.nasa.gov/services/discover).
Appendix A. Studies used in meta-analyses
Tables A1 and A2
L.A. Gladson et al. Environment International 159 (2022) 107023

Table A1
Studies that do not control for co-pollutants used in a meta-analysis to produce pollutant coefficients for a global children’s health-based air quality index. Note that for
Alhanti et al. (2016), data for three U.S. cities (Atlanta, Dallas, and St. Louis) was available, and their risk ratios were entered individually in the analysis. ED =
emergency department visits; HA = hospital admissions; O3 = ozone; NO2 = nitrogen dioxide; PM2.5 = fine particulate matter.
STUDIES THAT DO NOT CONTROL FOR CO-POLLUTANTS

Pollutant Study Country Health endpoint Age Lag

NO2 Andersen et al. (2008) Denmark Asthma HA 5–18 L0-5

Ding et al. (2017) China Asthma HA 0–18 L0-3
Halonen et al. (2008) Finland Asthma ED 0–15 L2
Ko et al. (2007) Hong Kong Asthma HA 1–14 L0-4
Lv et al. (2017) China Pneumonia HA 0–15 L2
Santus et al. (2012) Italy Asthma ED 0–16 L0-2
Strickland et al. (2010) United States Asthma ED 5–17 L0-2

O3 Alhanti et al. (2016) United States Asthma ED 5–18 L0-2

Ding et al. (2017) China Asthma HA 0–18 L0-3
Ko et al. (2007) Hong Kong Asthma HA 1–14 L0-5
Strickland et al. (2010) United States Asthma ED 5–17 L0-2
Strickland et al. (2014) United States Asthma or Wheeze ED 2–16 L0-2
Winquist et al. (2012) United States Respiratory ED 2–18 L0-4

PM2.5 Alhanti et al. (2016) United States Asthma ED 5–18 L0-2

Andersen et al. (2008) Denmark Asthma HA 5–18 L0-5
Byers et al. (2016) United States Asthma ED 5–17 L0-3
Chen et al. (2016) Australia Asthma HA 0–17 L0-4
Ding et al. (2017) China Asthma HA 0–18 L0-3
Halonen et al. (2008) Finland Asthma ED 0–15 L2
Kim et al. (2017) Korea Asthma HA 0–18 L0-4
Ko et al. (2007) Hong Kong Asthma HA 1–14 L0-4
Santus et al. (2012) Italy Asthma ED 0–16 L0-2
Strickland et al. (2010) United States Asthma ED 5–17 L0-2
Winquist et al. (2012) United States Respiratory ED 2–18 L0-4

Table A2
Studies that control for co-pollutants used in a meta-analysis to produce pollutant coefficients for a global children’s health-based air quality index. ED = emergency
department visits; HA = hospital admissions; O3 = ozone; NO2 = nitrogen dioxide; PM2.5 = fine particulate matter; NCtot = total number concentration of particles; SO2 = sulfur
dioxide; CO = carbon monoxide; PM10 = coarse particulate matter; SPM = suspended particulate matter; Ox = photochemical oxidants.
STUDIES THAT CONTROL FOR CO-POLLUTANTS

Pollutant Study Country Health endpoint Age Lag Controlled Pollutant(s)

NO2 Andersen et al. (2008) Denmark Asthma HA 5–18 L0-5 NCtot

Ding et al. (2017) China Asthma HA 0–18 L0-7 SO2, O3, CO
Farhat et al. (2005) Brazil Asthma or Bronchiolitis HA 0–13 L0-1 PM10, SO2, O3, CO
Iskandar et al. (2012) Denmark Asthma HA 0–18 L0-4 PM2.5
Jalaludin et al. (2008) Australia Asthma ED 1–14 L0 PM2.5
Lee et al. (2002) Korea Asthma HA 0–15 L2-3 O3, CO, PM10, SO2
Lee et al. (2006) Hong Kong Asthma HA 0–18 L3 PM10, PM2.5, SO2, O3
Strickland et al. (2014) United States Asthma or Wheeze ED 2–16 L0-2 O3
Ueda et al. (2010) Japan Asthma ED 0–12 L0-1 SPM, Ox, SO2

O3 Ding et al. (2017) China Asthma HA 0–18 NA SO2, NO2, CO

Lee et al. (2006) Hong Kong Asthma HA 0–18 L2 PM10, PM2.5, SO2, NO2
Sacks et al. (2014) United States Asthma ED 5–17 L0-2 PM2.5
Samoli et al. (2011) Greece Asthma HA 0–14 L0 PM10
Xiao et al. (2016) United States Upper Respiratory Infection ED 0–18 L0-2 CO, NO2, SO2, PM2.5

PM2.5 Andersen et al. (2008) Denmark Asthma HA 5–18 L0-5 NCtot

Chen et al. (2016) Australia Asthma HA 0–17 L0-4 NO2, O3
Hua et al. (2014) China Asthma HA 5–14 L2 NO2, SO2
Iskandar et al. (2012) Denmark Asthma HA 0–18 L0-4 NO2
Jalaludin et al. (2008) Australia Asthma ED 1–14 L0 O3
Lee et al. (2006) Hong Kong Asthma HA 0–18 L4 PM10, SO2, NO2, O3
Lv et al. (2017) China Pneumonia HA 0–15 L5 NO2
Strickland et al. (2014) United States Asthma or Wheeze ED 2–16 L0-2 O3
Xiao et al. (2016) United States Upper Respiratory Infection ED 0–18 L0-2 O3, CO, NO2, SO2

Appendix B. Conversion of NO2 relative risks from 1-hour to 24-
hour averages
For each of our studies with NO2 values based on a 1-hour maximum
or mean, a companion study was identified which shared the same or
similar study location and similar study years and provided NO2
concentrations using a 24-hour mean (see Table B.1). Conversion factors
came from ratios of mean 24-hour to 1-hour concentrations, and were
used to convert concentrations associated with RRs in the original study
to values comparable to other NO2 24-hour mean RRs used in the meta-
analyses.

9
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Table B1
Companion studies and conversion factors for 1-hour metric NO2 studies.
Pair Study Location Years Metric Mean Concentration (ppb) Conversion Factor

1 Jalaludin et al. (2008)* Sydney, Australia 1997–2001 1-hour mean 23.20 0.4957
(Barnett et al., 2005) Sydney, Australia 1998–2001 24-hour mean 11.50
2 Santus et al. (2012)* Milan, Italy 2007–2008 1-hour mean 54.59 0.5185
(Giovannini et al., 2010) Milan, Italy 2007–2008 24-hour mean 28.31
3 Strickland et al. (2014)* Atlanta, USA 2002–2010 1-hour max 20.17 0.8428
(Henneman et al., 2015) Atlanta, USA 2000–2012 24-hour mean 17.00

* Included in study meta-analyses.

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