title: The impact of temperature on mortality in Tianjin, China: a case-crossover design with a distributed lag nonlinear model.
abstract: BACKGROUND
  Although interest in assessing the impacts of temperature on mortality has increased, few studies have used a case-crossover design to examine nonlinear and distributed lag effects of temperature on mortality. Additionally, little evidence is available on the temperature-mortality relationship in China or on what temperature measure is the best predictor of mortality.
  
  
  OBJECTIVE
  Our objectives were to use a distributed lag nonlinear model (DLNM) as a part of case-crossover design to examine the nonlinear and distributed lag effects of temperature on mortality in Tianjin, China and to explore which temperature measure is the best predictor of mortality.
  
  
  METHODS
  We applied the DLNM to a case-crossover design to assess the nonlinear and delayed effects of temperatures (maximum, mean, and minimum) on deaths (nonaccidental, cardiopulmonary, cardiovascular, and respiratory).
  
  
  RESULTS
  A U-shaped relationship was found consistently between temperature and mortality. Cold effects (i.e., significantly increased mortality associated with low temperatures) were delayed by 3 days and persisted for 10 days. Hot effects (i.e., significantly increased mortality associated with high temperatures) were acute and lasted for 3 days and were followed by mortality displacement for nonaccidental, cardiopulmonary, and cardiovascular deaths. Mean temperature was a better predictor of mortality (based on model fit) than maximum or minimum temperature.
  
  
  CONCLUSIONS
  In Tianjin, extreme cold and hot temperatures increased the risk of mortality. The effects of cold last longer than the effects of heat. Combining the DLNM and the case-crossover design allows the case-crossover design to flexibly estimate the nonlinear and delayed effects of temperature (or air pollution) while controlling for season.
authors.affiliation: School of Public Health, Queensland University of Technology, Brisbane, Australia. guoyuming@yahoo.cn
authors.forename: Yuming
authors.initials: Y
authors.lastname: Guo
authors.forename: Adrian G
authors.initials: AG
authors.lastname: Barnett
authors.forename: Xiaochuan
authors.initials: X
authors.lastname: Pan
authors.forename: Weiwei
authors.initials: W
authors.lastname: Yu
authors.forename: Shilu
authors.initials: S
authors.lastname: Tong
mesh_terms: D002681:China / Q000453:epidemiology; D018592:Cross-Over Studies; D006801:Humans; D009026:Mortality; D017711:Nonlinear Dynamics; D012044:Regression Analysis; D013696:Temperature