title: The exposure-response relationship between temperature and childhood hand, foot and mouth disease: A multicity study from mainland China.
abstract: Hand, foot and mouth disease (HFMD) is a rising public health issue in the Asia-Pacific region. Numerous studies have tried to quantify the relationship between meteorological variables and HFMD but with inconsistent results, in particular for temperature. We aimed to characterize the relationship between temperature and HFMD in various locations and to investigate the potential heterogeneity.
  
  
  
  We retrieved the daily series of childhood HFMD counts (aged 0-12 years) and meteorological variables for each of 143 cities in mainland China in the period 2009-2014. We fitted a common distributed lag nonlinear model allowing for over dispersion to each of the cities to obtain the city-specific estimates of temperature-HFMD relationship. Then we pooled the city-specific estimates through multivariate meta-regression with city-level characteristics as potential effect modifiers.
  
  
  
  We found that the overall pooled temperature-HFMD relationship was shown as an approximately inverted V shape curve, peaking at the 91th percentile of temperature with a risk ratio of 1.30 (95% CI: 1.23-1.37) compared to its 50th percentile. We found that 68.5% of the variations of city-specific estimates was attributable to heterogeneity. We identified rainfall and altitude as the two main effect modifiers.
  
  
  
  We found a nonlinear relationship between temperature and HFMD. The temperature-HFMD relationship varies depending on geographic and climatic conditions. The findings can help us deepen the understanding of weather-HFMD relationship and provide evidences for related public health decisions.
authors.affiliation: Department of Epidemiology and Biostatistics, West China School of Public Health, Sichuan University, No. 17, Section 3, South Renmin Road, Chengdu, Sichuan 610041, PR China; Department of Social and Environmental Health Research, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK. Electronic address: xiaoxiong.scu@gmail.com.
authors.forename: Xiong
authors.initials: X
authors.lastname: Xiao
authors.affiliation: Department of Social and Environmental Health Research, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK. Electronic address: Antonio.Gasparrini@lshtm.ac.uk.
authors.forename: Antonio
authors.initials: A
authors.lastname: Gasparrini
authors.affiliation: Division of Infectious Disease & Key Laboratory of Surveillance and Early Warning on Infectious Disease, Chinese Centre for Disease Control and Prevention, 155 Changbai Road, Changping District, Beijing 102206, PR China; Department of Epidemiology and Statistics & the Ministry of Education (MOE) Key Lab of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, 13 Hangkong Road, Wuhan, Hubei 430030, PR China. Electronic address: huangjiao@chinacdc.cn.
authors.forename: Jiao
authors.initials: J
authors.lastname: Huang
authors.affiliation: Division of Infectious Disease & Key Laboratory of Surveillance and Early Warning on Infectious Disease, Chinese Centre for Disease Control and Prevention, 155 Changbai Road, Changping District, Beijing 102206, PR China. Electronic address: liaoqh@chinacdc.cn.
authors.forename: Qiaohong
authors.initials: Q
authors.lastname: Liao
authors.affiliation: Division of Infectious Disease & Key Laboratory of Surveillance and Early Warning on Infectious Disease, Chinese Centre for Disease Control and Prevention, 155 Changbai Road, Changping District, Beijing 102206, PR China.
authors.forename: Fengfeng
authors.initials: F
authors.lastname: Liu
authors.affiliation: Department of Epidemiology and Biostatistics, West China School of Public Health, Sichuan University, No. 17, Section 3, South Renmin Road, Chengdu, Sichuan 610041, PR China. Electronic address: westsilverhx@163.com.
authors.forename: Fei
authors.initials: F
authors.lastname: Yin
authors.affiliation: Department of Epidemiology and Biostatistics, West China School of Public Health, Sichuan University, No. 17, Section 3, South Renmin Road, Chengdu, Sichuan 610041, PR China; Division of Infectious Disease & Key Laboratory of Surveillance and Early Warning on Infectious Disease, Chinese Centre for Disease Control and Prevention, 155 Changbai Road, Changping District, Beijing 102206, PR China. Electronic address: cfetpyhj@vip.sina.com.
authors.forename: Hongjie
authors.initials: H
authors.lastname: Yu
authors.affiliation: Department of Epidemiology and Biostatistics, West China School of Public Health, Sichuan University, No. 17, Section 3, South Renmin Road, Chengdu, Sichuan 610041, PR China. Electronic address: xiaosong_scu@163.com.
authors.forename: Xiaosong
authors.initials: X
authors.lastname: Li
mesh_terms: D002648:Child; D002675:Child, Preschool; D002681:China / Q000453:epidemiology; D004770:Enterovirus / Q000472:pathogenicity*; D006232:Hand, Foot and Mouth Disease / Q000453:epidemiology* / Q000821:virology; D006801:Humans; D015994:Incidence; D007223:Infant; D007231:Infant, Newborn; D017711:Nonlinear Dynamics; D011634:Public Health; D013696:Temperature; D014505:Urban Population
keywords: Childhood infectious disease; Modification effect; Multisite study; Nonlinear association; Temperature-disease relationship