Air Quality, Atmosphere & Health

, Volume 11, Issue 3, pp 301–309 | Cite as

The January 2013 Beijing “Airpocalypse” and its acute effects on emergency and outpatient visits at a Beijing hospital

  • Joshua M. Ferreri
  • Roger D. Peng
  • Michelle L. Bell
  • Liu Ya
  • Tiantian LiEmail author
  • G. Brooke AndersonEmail author


Severe air pollution episodes in Europe and the USA in the early- to mid-twentieth century caused large health impacts, spurring national legislation. Similarly severe episodes currently affect developing regions, as exemplified by a particularly extreme episode in January 2013 in Beijing, China. We investigated associations between this episode and medical visits at a Beijing hospital. We obtained fine particulate matter (PM2.5) measurements from the US State Department’s Embassy monitor and daily counts of all-cause, cardiovascular, and respiratory emergency visits, and outpatient visits from a nearby hospital in the Liufang Nanli community. We analyzed whether risks increased during this episode (with daily PM2.5 ≥ 350 μg/m3) using generalized linear modeling, controlling for potential confounders. The episode brought exceptionally high PM2.5 (peak daily average, 569 μg/m3). Risk increased during the episode for all-cause (relative risk 1.29 [95% CI 1.13, 1.46]), cardiovascular (1.55 [0.90, 2.68]) and respiratory (1.33 [1.10, 1.62]) emergency medical visits, and respiratory outpatient visits (1.16 [1.00, 1.33]). Relative risks of all-cause (0.95 [0.82, 1.10]) and cardiovascular (0.83 [0.67, 1.02]) outpatient visits were not statistically significant. Results were robust to modeling choices and episode definitions. This episode was extraordinarily severe, with maximum daily PM2.5 concentration nearly 22-fold above the World Health Organization guideline. During the episode, risk increased for all-cause, cardiovascular, and respiratory emergency medical visits, and respiratory outpatient visits, consistent with previous US-based research. However, no association was found for all-cause or cardiovascular outpatient visits. China-based studies like this one provide critical evidence in developing efforts regarding air pollution remediation in China.


Air pollution epidemiology China Fine particulate matter Cardiorespiratory outcomes 



The authors acknowledge the U.S. Embassy in Beijing for publically providing the PM2.5 measurements used in this study and JL Peel and M Yan for helpful suggestions in interpreting results. This article was developed under Assistance Agreement No. 83587101, awarded by the U.S. Environmental Protection Agency to Yale University (ML Bell). It has not been formally reviewed by EPA. The views expressed in this document are solely those of the authors and do not necessarily reflect those of the Agency. EPA does not endorse any products or commercial services mentioned in this publication.

Funding information

This research was funded by grants from Colorado State University’s College of Veterinary Medicine & Biomedical Sciences (JM Ferreri, GB Anderson), National Institute of Environmental Health Science grant R00ES022631 (GB Anderson, RD Peng), National Institute of Environmental Health Science grant R01ES019560 (RD Peng), and National Natural Science Foundation of China grants 21277135 and 91543111 (T Li).

Compliance with ethical standards

Conflicts of interest

The authors declare that they have no conflicts of interest.


  1. Anderson HR (2009) Air pollution and mortality: a history. Atmos Environ 43(1):142–152. CrossRefGoogle Scholar
  2. Armstrong BG, Gasparrini A, Tobias A (2014) Conditional Poisson models: a flexible alternative to conditional logistic case cross-over analysis. BMC Med Res Methodol 14(1):122. CrossRefGoogle Scholar
  3. Armstrong P, Ke F (2013) Beijing announces emergency measures amid fog of pollution. CNN. Accessed 15 December 2015
  4. Associated Press in Beijing (2013) China’s air pollution again at danger levels. The Guardian. Accessed 15 December 2015
  5. Atkinson RW, Kang S, Anderson HR, Mills IC, Walton HA (2014) Epidemiological time series studies of PM2. 5 and daily mortality and hospital admissions: a systematic review and meta-analysis. Thorax 69(7):660–665. CrossRefGoogle Scholar
  6. Beijing Air (@BeijingAir) (2008).
  7. Bell ML, Davis DL (2001) Reassessment of the lethal London fog of 1952: novel indicators of acute and chronic consequences of acute exposure to air pollution. Environ Health Persp 109(Suppl 3):389–394CrossRefGoogle Scholar
  8. British Broadcasting Company (BBC) (2015) China smog sparks red alerts in 10 cities. British Broadcasting Company. Accessed 02 March 2016
  9. Brook RD, Franklin B, Cascio W et al (2004) Air pollution and cardiovascular disease: a statement for healthcare professionals from the expert panel on population and prevention science of the American Heart Association. Circulation 109(21):2655–2671. CrossRefGoogle Scholar
  10. Burnett RT, Pope CA III, Ezzati M et al (2014) An integrated risk function for estimating the global burden of disease attributable to ambient fine particulate matter exposure. Environ Health Persp 122(4):397–403. Google Scholar
  11. Chen R, Kan H, Chen B et al (2012) Association of particulate air pollution with daily mortality the China air pollution and health effects study. Am J Epidemoil 175(11):1173–1181. CrossRefGoogle Scholar
  12. Chen R, Zhao Z, Kan H (2013a) Heavy smog and hospital visits in Beijing, China. Am J Resp Crit Care 188(9):1170–1171. CrossRefGoogle Scholar
  13. Chen Z, Wang JN, Ma GX, Zhang YS (2013b) China tackles the health effects of air pollution. Lancet 382(9909):1959–1960. CrossRefGoogle Scholar
  14. Davis DL, Bell ML, Fletcher T (2002) A look back at the London smog of 1952 and the half century since. Environ Health Persp 110(12):A734–A735CrossRefGoogle Scholar
  15. Ezzati M, Lopez AD, Rodgers A, Murray CJ (2004) Comparative quantification of health risks. Global and regional burden of disease attributable to selected major risk factors. Geneva: World Health Organization. 1987–97Google Scholar
  16. Firket J (1936) Fog along the Meuse valley. T Faraday Soc 32:1192–1196CrossRefGoogle Scholar
  17. Greater London Authority (2002) Years on: the struggle for air quality in London since the great smog of December 1952. Greater London Authority, LondonGoogle Scholar
  18. Hao J, Wang L (2005) Improving urban air quality in China: Beijing case study. J Air Waste Manag Assoc 55(9):1298–1305. CrossRefGoogle Scholar
  19. He K, Yang F, Ma Y et al (2001) The characteristics of PM2.5 in Beijing, China. Atmos Environ 35(29):4959–4970. CrossRefGoogle Scholar
  20. Huang K, Zhang X, Lin Y (2015) The “APEC blue” phenomenon: regional emission control effects observed from space. Atmos Res 164:65–75. CrossRefGoogle Scholar
  21. Huang RJ, Zhang Y, Bozzetti C, Ho KF, Cao JJ, Han Y, Daellenbach KR, Slowik JG, Platt SM, Canonaco F, Zotter P, Wolf R, Pieber SM, Bruns EA et al (2014) High secondary aerosol contribution to particulate pollution during haze events in China. Nature 514:218–222. CrossRefGoogle Scholar
  22. Huang W, Wang G, Lu S, Kipen H, Wang Y, Hu M, Lin W, Rich D, Ohman-Strickland P, Diehl SR, Zhu P, Tong J, Gong J, Zhu T, Zhang J (2012) Inflammatory and oxidative stress response of healthy young adults to changes in air quality during the Beijing Olympics. Am J Respir Crit Care Med 186(11):1150–1159. CrossRefGoogle Scholar
  23. Ji D, Li L, Wang Y et al (2014) The heaviest particulate air-pollution episodes occurred in northern China in January, 2013: insights gained from observation. Atmos Environ 92:546–556. CrossRefGoogle Scholar
  24. Kan H, Jia J, Chen B (2003) Acute stroke mortality and air pollution: new evidence from Shanghai, China. J Occup Health 45(5):321–323.
  25. Liang X, Zou T, Guo B et al (2015) Assessing Beijing’s PM2.5 pollution: severity, weather impact, APEC and winter heating. Proc R Soc A 471:20150257. CrossRefGoogle Scholar
  26. Ma W (2013) Beijing pollution hits highs. The Wall Street Journal. Accessed 15 December 2015
  27. Metzger KB, Tolbert PE, Klein M et al (2004) Ambient air pollution and cardiovascular emergency department visits. Epidemiology 15(1):46–56. CrossRefGoogle Scholar
  28. Ministry of Environmental Protection (2013) Atmospheric pollution prevention and control action plan. Accessed 15 December 2015
  29. Olivares E (2014) China: air quality standards. Accessed 02 March 2016
  30. Peel JL, Tolbert PE, Klein M et al (2005) Ambient air pollution and respiratory emergency department visits. Epidemiology 16(2):164–174. CrossRefGoogle Scholar
  31. Peng RD, Bell ML, Geyh AS et al (2009) Emergency admissions for cardiovascular and respiratory diseases and the chemical composition of fine particle air pollution. Environ Health Persp 117(6):957–963. CrossRefGoogle Scholar
  32. Pope CA III, Dockery DW (2006) Health effects of fine particulate air pollution: lines that connect. J Air Waste Manag Assoc 56(6):709–742. CrossRefGoogle Scholar
  33. Rich DQ, Kipen HM, Wang G, Wang Y, Zhu P, Ohman-Strickland P, Hu M, Philipp C, Diehl SR, Lu S, Tong J, Gong J, Thomas D, Zhu T, Zhang J (2012) Association between changes in air pollution levels during the Beijing Olympics and biomarkers of inflammation and thrombosis in healthy young adults. JAMA 307(19):2068–2078CrossRefGoogle Scholar
  34. Rich DQ, Liu K, Zhang J, Thurston SW, Stevens TP, Pan Y, Kane C, Weinberger B, Ohman-Strickland P, Woodruff TJ, Duan X, Assibey-Mensah V, Zhang J (2015) Differences in birth weight associated with the 2008 Beijing Olympics air pollution reduction: results from a natural experiment. Environ Health Persp 123(9):880–887. Google Scholar
  35. Schrenk HH, Heimann H, Clayton GD, Gafafer WM, Wexler H (1950) Air pollution in Donora, PA. Epidemiology of the unusual smog episode of October 1948. Preliminary report. JAMA 143(3):323. Google Scholar
  36. Snyder LP (1994) The death-dealing smog over Donora, Pennsylvania: industrial air pollution, public health policy, and the politics of expertise, 1948–1949. Environ Hist Rev 18(1):117–139. CrossRefGoogle Scholar
  37. Voorhees AS, Wang J, Wang C, Zhao B, Wang S, Kan H (2014) Public health benefits of reducing air pollution in Shanghai: a proof-of-concept methodology with application to BenMAP. Sci Total Environ 485:396–405. CrossRefGoogle Scholar
  38. Wang H, Tan SC, Wang Y et al (2014a) A multisource observation study of the severe prolonged regional haze episode over eastern China in January 2013. Atmos Environ 89:807–815. CrossRefGoogle Scholar
  39. Wang Y, Yao L, Wang L et al. (2014b) Mechanism for the formation of the January 2013 heavy haze pollution episode over central and eastern China. Sci China Earth Sci 57(1):14–25. Doi: 0.1007/s11430-013-4773-4Google Scholar
  40. World Health Organization (WHO) (2006) Air quality guidelines: global update 2005: particulate matter, ozone, nitrogen dioxide, and sulfur dioxide. World Health Organization Accessed 15 December 2015
  41. Xi X, Xu Y, Jiang L, Li A, Duan J, Du B (2010) Hospitalized adult patients with 2009 influenza A (H1N1) in Beijing, China: risk factors for hospital mortality. BMC Infect Dis 10(1):1–8. CrossRefGoogle Scholar
  42. Zhang J, Zhu T, Wang G, Huang W, Rich D, Zhu P, Wang Y, Lu S, Ohman-Strickland P, Diehl S, Hu M, Tong J, Gong J, Thomas D (2012) Cardiorespiratory biomarker responses in healthy young adults to drastic air quality changes surrounding the 2008 Beijing Olympics. Res Rep Health Eff Inst 174:5–174Google Scholar
  43. Zheng M, Salmon LG, Schauer JJ et al (2005) Seasonal trends in PM2.5 source contributions in Beijing, China. Atmos Environ 39(22):3967–3976. CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media B.V., part of Springer Nature 2017

Authors and Affiliations

  • Joshua M. Ferreri
    • 1
  • Roger D. Peng
    • 2
  • Michelle L. Bell
    • 3
  • Liu Ya
    • 4
  • Tiantian Li
    • 5
    Email author
  • G. Brooke Anderson
    • 1
    Email author
  1. 1.Department of Environmental & Radiological Health SciencesColorado State UniversityFort CollinsUSA
  2. 2.Johns Hopkins Bloomberg School of Public Health, Department of BiostatisticsBaltimoreUSA
  3. 3.School of Forestry & Environmental StudiesYale UniversityNew HavenUSA
  4. 4.China Meitan General HospitalBeijingChina
  5. 5.National Institute of Environmental Health, Chinese Center for Disease Control and PreventionBeijingChina

Personalised recommendations