Effects of extreme temperature events on deaths and its interaction with air pollution

<bold>Background: </bold>Both extreme temperature events (ETEs) and air pollution affected human health, and their effects were often not independent. Previous studies have provided limited information on the interactions between ETEs and air pollution. <bold>Methods: </bold>We collected data on deaths (non-accidental, cardiovascular, and respiratory) in Zibo City along with daily air pollution and meteorological data from January 2015 to December 2019. Distributed lag non-linear model was used to explore the health effects of ETEs on deaths. Non-parametric binary response model, hierarchical model and joint effect model were used to further explore the interaction between ETEs and air pollution in different seasons. Meanwhile, subgroup analysis by gender and age (>= 65 years old and < 65 years old) was conducted to identify the vulnerable population. <bold>Results: </bold>ETEs increased death risk, especially for cardiovascular and respiratory deaths. Heat waves had a stronger impact than cold spells. Cold spells had a longer lag and fluctuating trend. Heat waves had a short-term impact, followed by a decrease. Females and those aged >= 65 were more affected, but subgroup differences were not significant. During ETEs and non-ETEs, there were different effects on deaths with per IQR increase in air pollutant concentrations. Joint effect models revealed that there was a significant interaction between ETEs and air pollution on non-accidental deaths. The interaction between PM2.5 and cold spells was antagonistic in the cold season. In the warm season, the health effects of heat waves and high O-3 concentration were enhanced. The relative excess risk due to interaction (RERI) of cold spells and PM2.5 in total population was -0.09 (95 % CI: -0.17, -0.01), and 9 % (95 % CI: 1 %, 17 %) of the total effect was attributable to interaction. Subgroup analysis confirmed the interactions in females and those aged >= 65. <bold>Conclusions: </bold>Significant association observed between ETEs and deaths. Females and >= 65 age groups were vulnerable. There were interactions between ETEs and air pollution. The effect of PM2.5 on deaths decreased during cold spells, while the effect of O-3 increased during heat waves. In addition to improving air quality, it is necessary to further strengthen the prevention and control of ETEs.