image of Assessment of Temperature–Hand, Foot, and Mouth Disease Association and Its Variability across Urban and Rural Populations in Wuxi, China: A Distributed Lag Nonlinear Analysis
  • ISSN: 0002-9637
  • E-ISSN: 1476-1645


Hand, foot, and mouth disease (HFMD) has brought millions of attacks and a substantial burden in the Asia-Pacific region. Previous studies assessed disease risks around the world, which demonstrated great heterogeneity, and few determined the modification effect of social factors on temperature–disease relationship. We conducted a time-series study to evaluate the temperature-associated HFMD morbidity risk using daily data (from 2011 to 2017) and to identify potential modifiers relating to urban–rural status and aggregation mode of children. By applying a distributed lag nonlinear model (DLNM) and controlling for time-varying factors and other meteorological factors, we found that the relationship between daily mean temperature and the cumulative risk of HFMD was an approximately M-shaped curve. The effects of higher temperature appeared to be greater and more persistent than those of lower temperature. With the reference of −6°C, the cumulative relative risk (RR) values of high temperature (95 percentile) and low temperature (5 percentile) were 3.74 (95% CI: 2.50–5.61) and 1.72 (95% CI: 1.24–2.37) at lag 4–7, respectively. Temperature-associated HFMD morbidity risks were more pronounced among rural children and those attending kindergartens or schools at specific lags and temperatures. Relative risk values for temperature–disease association was highest among the 3- to 6-year group, whereas no gender difference was observed. Studying effect estimates and their modifications using the DLNM on a daily scale helps to identify susceptible groups and guide policy-making and resource allocation according to specific local conditions.


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  • Received : 21 Apr 2020
  • Accepted : 01 Jul 2020
  • Published online : 03 Aug 2020
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