title: Mortality displacement of heat-related deaths: a comparison of Delhi, São Paulo, and London.
abstract: BACKGROUND
  Mortality increases with hot weather, although the extent to which lives are shortened is rarely quantified. We compare the extent to which short-term mortality displacement can explain heat deaths in Delhi, São Paulo, and London given contrasting demographic and health profiles.
  
  
  METHODS
  We examined time-series of daily mortality data in relation to daily ambient temperature using Poisson models and adjusting for season, relative humidity, rainfall, particulate air pollution, day of the week, and public holidays. We used unconstrained distributed lag models to identify the extent to which heat-related excesses were followed by deficits (mortality displacement).
  
  
  RESULTS
  For each city, an increase in all-cause mortality was observed with same-day (lag 0) and previous day (lag 1) temperatures greater than a threshold of 20 degrees C. At lag 0, the excess risk was greatest in Delhi and smallest in London. In Delhi, an excess was apparent up to 3 weeks after exposure, after which a deficit was observed that offset just part of the overall excess. In London, the heat excess persisted only 2 days and was followed by deficits, such that the sum of effects was 0 by day 11. The pattern in São Paulo was intermediate between these. The risk summed over the course of 28 days was 2.4% (95% confidence interval = 0.1 to 4.7%) per degree greater than the heat threshold in Delhi, 0.8% (-0.4 to 2.1%) in São Paulo and -1.6% (-3.4 to 0.3%) in London. Excess risks were sustained up to 4 weeks for respiratory deaths in São Paulo and London and for children in Delhi.
  
  
  CONCLUSIONS
  Heat-related short-term mortality displacement was high in London but less in Delhi, where infectious and childhood mortality still predominate.
authors.affiliation: London School of Hygiene & Tropical Medicine, United Kingdom. shakoor.hajat@lshtm.ac.uk
authors.forename: Shakoor
authors.initials: S
authors.lastname: Hajat
authors.forename: Ben G
authors.initials: BG
authors.lastname: Armstrong
authors.forename: Nelson
authors.initials: N
authors.lastname: Gouveia
authors.forename: Paul
authors.initials: P
authors.lastname: Wilkinson
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000397:Air Pollution; D001938:Brazil / Q000453:epidemiology; D002423:Cause of Death; D002648:Child; D002675:Child, Preschool; D005260:Female; D018882:Heat Stress Disorders / Q000401:mortality*; D006693:Holidays; D006801:Humans; D006813:Humidity; D007194:India / Q000453:epidemiology; D007223:Infant; D007231:Infant, Newborn; D008131:London / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D016012:Poisson Distribution; D011891:Rain; D012307:Risk Factors; D012621:Seasons; D014505:Urban Population