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BMJ. 2018 Oct 31;363:k4306. doi: 10.1136/bmj.k4306.

Association between ambient temperature and mortality risk and burden: time series study in 272 main Chinese cities.

Author information

School of Public Health, Key Lab of Public Health Safety of the Ministry of Education and NHC Key Laboratory of Health Technology Assessment, Fudan University, Shanghai, China.
Shanghai Key Laboratory of Atmospheric Particle Pollution and Prevention (LAP), Fudan University, Shanghai, China.
National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, 27 Nanwei Road, Xicheng District, Beijing 100050, China.
Key Laboratory of Reproduction Regulation of National Population and Family Planning Commission, Shanghai Institute of Planned Research, Institute of Reproduction and Development, Fudan University, Shanghai, China.
National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, 27 Nanwei Road, Xicheng District, Beijing 100050, China



To examine the association between temperature and cause specific mortality, and to quantify the corresponding disease burden attributable to non-optimum ambient temperatures.


Time series analysis.


272 main cities in China.


Non-accidental deaths in 272 cities covered by the Disease Surveillance Point System of China, from January 2013 to December 2015.


Daily numbers of deaths from all non-accidental causes and main cardiorespiratory diseases. Potential effect modifiers included demographic, climatic, geographical, and socioeconomic characteristics. The analysis used distributed lag non-linear models to estimate city specific associations, and multivariate meta-regression analysis to obtain the effect estimates at national and regional levels.


1 826 186 non-accidental deaths from total causes were recorded in the study period. Temperature and mortality consistently showed inversely J shaped associations. At the national average level, relative to the minimum mortality temperature (22.8°C, 79.1st centile), the mortality risk of extreme cold temperature (at -1.4°C, the 2.5th centile) lasted for more than 14 days, whereas the risk of extreme hot temperature (at 29.0°C, the 97.5th centile) appeared immediately and lasted for two to three days. 14.33% of non-accidental total mortality was attributable to non-optimum temperatures, of which moderate cold (ranging from -1.4 to 22.8°C), moderate heat (22.8 to 29.0°C), extreme cold (-6.4 to -1.4°C), and extreme heat (29.0 to 31.6°C) temperatures corresponded to attributable fractions of 10.49%, 2.08%, 1.14%, and 0.63%, respectively. The attributable fractions were 17.48% for overall cardiovascular disease, 18.76% for coronary heart disease, 16.11% for overall stroke, 14.09% for ischaemic stroke, 18.10% for haemorrhagic stroke, 10.57% for overall respiratory disease, and 12.57% for chronic obstructive pulmonary diseases. The mortality risk and burden were more prominent in the temperate monsoon and subtropical monsoon climatic zones, in specific subgroups (female sex, age ≥75 years, and ≤9 years spent in education), and in cities characterised by higher urbanisations rates and shorter durations of central heating.


This nationwide study provides a comprehensive picture of the non-linear associations between ambient temperature and mortality from all natural causes and main cardiorespiratory diseases, as well as the corresponding disease burden that is mainly attributable to moderate cold temperatures in China. The findings on vulnerability characteristics can help improve clinical and public health practices to reduce disease burden associated with current and future abnormal weather.

[Indexed for MEDLINE]
Free PMC Article

Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform disclosure form at and declare: support from the National Natural Science Foundation of China, and China Medical Board Collaborating Programme for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work.

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