title: Short-Term Effects of Climatic Variables on Hand, Foot, and Mouth Disease in Mainland China, 2008-2013: A Multilevel Spatial Poisson Regression Model Accounting for Overdispersion.
abstract: BACKGROUND
  Hand, Foot, and Mouth Disease (HFMD) is a worldwide infectious disease. In China, many provinces have reported HFMD cases, especially the south and southwest provinces. Many studies have found a strong association between the incidence of HFMD and climatic factors such as temperature, rainfall, and relative humidity. However, few studies have analyzed cluster effects between various geographical units.
  
  
  METHODS
  The nonlinear relationships and lag effects between weekly HFMD cases and climatic variables were estimated for the period of 2008-2013 using a polynomial distributed lag model. The extra-Poisson multilevel spatial polynomial model was used to model the exact relationship between weekly HFMD incidence and climatic variables after considering cluster effects, provincial correlated structure of HFMD incidence and overdispersion. The smoothing spline methods were used to detect threshold effects between climatic factors and HFMD incidence.
  
  
  RESULTS
  The HFMD incidence spatial heterogeneity distributed among provinces, and the scale measurement of overdispersion was 548.077. After controlling for long-term trends, spatial heterogeneity and overdispersion, temperature was highly associated with HFMD incidence. Weekly average temperature and weekly temperature difference approximate inverse "V" shape and "V" shape relationships associated with HFMD incidence. The lag effects for weekly average temperature and weekly temperature difference were 3 weeks and 2 weeks. High spatial correlated HFMD incidence were detected in northern, central and southern province. Temperature can be used to explain most of variation of HFMD incidence in southern and northeastern provinces. After adjustment for temperature, eastern and Northern provinces still had high variation HFMD incidence.
  
  
  CONCLUSIONS
  We found a relatively strong association between weekly HFMD incidence and weekly average temperature. The association between the HFMD incidence and climatic variables spatial heterogeneity distributed across provinces. Future research should explore the risk factors that cause spatial correlated structure or high variation of HFMD incidence which can be explained by temperature. When analyzing association between HFMD incidence and climatic variables, spatial heterogeneity among provinces should be evaluated. Moreover, the extra-Poisson multilevel model was capable of modeling the association between overdispersion of HFMD incidence and climatic variables.
authors.affiliation: West China School of Public Health, Sichuan University, Chengdu, Sichuan Province, China.
authors.forename: Jiaqiang
authors.initials: J
authors.lastname: Liao
authors.affiliation: Office of Epidemiology, Chinese Center for Disease Prevention and Control, Beijing, China.
authors.forename: Shicheng
authors.initials: S
authors.lastname: Yu
authors.affiliation: West China School of Public Health, Sichuan University, Chengdu, Sichuan Province, China.
authors.forename: Fang
authors.initials: F
authors.lastname: Yang
authors.affiliation: West China School of Public Health, Sichuan University, Chengdu, Sichuan Province, China.
authors.forename: Min
authors.initials: M
authors.lastname: Yang
authors.affiliation: Office of Epidemiology, Chinese Center for Disease Prevention and Control, Beijing, China.
authors.forename: Yuehua
authors.initials: Y
authors.lastname: Hu
authors.affiliation: West China School of Public Health, Sichuan University, Chengdu, Sichuan Province, China.
authors.forename: Juying
authors.initials: J
authors.lastname: Zhang
mesh_terms: D002681:China / Q000453:epidemiology; D002980:Climate; D016000:Cluster Analysis; D004196:Disease Outbreaks; D062305:Geographic Mapping; D006232:Hand, Foot and Mouth Disease / Q000453:epidemiology*; D006801:Humans; D006813:Humidity; D015994:Incidence; D008685:Meteorological Concepts; D008962:Models, Theoretical; D016012:Poisson Distribution; D011891:Rain; D013472:Sunlight; D013696:Temperature; D014919:Wind