title: Individual-level and community-level effect modifiers of the temperature-mortality relationship in 66 Chinese communities.
abstract: OBJECTIVE
  To examine the modification of temperature-mortality association by factors at the individual and community levels.
  
  
  METHODS
  This study investigated this issue using a national database comprising daily data of 66 Chinese communities for 2006-2011. A 'threshold-natural cubic spline' distributed lag non-linear model was utilised to estimate the mortality effects of daily mean temperature, and then examined the modification of the relationship by individual factors (age, sex, education level, place of death and cause of death) using a meta-analysis approach and community-level factors (annual temperature, population density, sex ratio, percentage of older population, health access, household income and latitude) using a meta-regression method.
  
  
  RESULTS
  We found significant effects of high and low temperatures on mortality in China. The pooled excess mortality risk was 1.04% (95% CI 0.90% to 1.18%) for a 1°C temperature decrease below the minimum mortality temperature (MMT), and 3.44% (95% CI 3.00% to 3.88%) for a 1°C temperature increase above MMT. At the individual level, age and place of death were found to be significant modifiers of cold effect, while age, sex, place of death, cause of death and education level were effect modifiers of heat effect. At the community level, communities with lower socioeconomic status and higher annual temperature were generally more vulnerable to the mortality effects of high and low temperatures.
  
  
  CONCLUSIONS
  This study identifies susceptibility based on both individual-level and community-level effect modifiers; more attention should be given to these vulnerable individuals and communities to reduce adverse health effects of extreme temperatures.
authors.affiliation: National Center of Non-Communicable Chronic Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China.
authors.forename: Zhengjing
authors.initials: Z
authors.lastname: Huang
authors.affiliation: Division of Environmental Health, Guangdong Provincial Institute of Public Health, Guangdong Provincial Center for Disease Control and Prevention, Guangzhou, China.
authors.forename: Hualiang
authors.initials: H
authors.lastname: Lin
authors.affiliation: National Center of Non-Communicable Chronic Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China.
authors.forename: Yunning
authors.initials: Y
authors.lastname: Liu
authors.affiliation: National Center of Non-Communicable Chronic Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China.
authors.forename: Maigeng
authors.initials: M
authors.lastname: Zhou
authors.affiliation: Division of Environmental Health, Guangdong Provincial Institute of Public Health, Guangdong Provincial Center for Disease Control and Prevention, Guangzhou, China.
authors.forename: Tao
authors.initials: T
authors.lastname: Liu
authors.affiliation: Division of Environmental Health, Guangdong Provincial Institute of Public Health, Guangdong Provincial Center for Disease Control and Prevention, Guangzhou, China.
authors.forename: Jianpeng
authors.initials: J
authors.lastname: Xiao
authors.affiliation: Division of Environmental Health, Guangdong Provincial Institute of Public Health, Guangdong Provincial Center for Disease Control and Prevention, Guangzhou, China.
authors.forename: Weilin
authors.initials: W
authors.lastname: Zeng
authors.affiliation: Division of Environmental Health, Guangdong Provincial Institute of Public Health, Guangdong Provincial Center for Disease Control and Prevention, Guangzhou, China.
authors.forename: Xing
authors.initials: X
authors.lastname: Li
authors.affiliation: Guangdong Provincial Center for Disease Control and Prevention, Guangzhou, China.
authors.forename: Yonghui
authors.initials: Y
authors.lastname: Zhang
authors.affiliation: Departments of Global Health and Occupational and Environmental Health Sciences, University of Washington, Washington, USA.
authors.forename: Kristie L
authors.initials: KL
authors.lastname: Ebi
authors.affiliation: School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia.
authors.forename: Shilu
authors.initials: S
authors.lastname: Tong
authors.affiliation: Division of Environmental Health, Guangdong Provincial Institute of Public Health, Guangdong Provincial Center for Disease Control and Prevention, Guangzhou, China.
authors.forename: Wenjun
authors.initials: W
authors.lastname: Ma
authors.affiliation: National Center of Non-Communicable Chronic Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China.
authors.forename: Lijun
authors.initials: L
authors.lastname: Wang
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D002675:Child, Preschool; D002681:China / Q000453:epidemiology; D016208:Databases, Factual; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data; D006801:Humans; D007223:Infant; D008297:Male; D008875:Middle Aged; D009026:Mortality; D017711:Nonlinear Dynamics; D011156:Population Density; D012044:Regression Analysis; D012307:Risk Factors; D012959:Socioeconomic Factors; D013696:Temperature; D055815:Young Adult
keywords: EPIDEMIOLOGY; PUBLIC HEALTH