Short term effects of weather on hand, foot and mouth disease

Abstract

Background: Hand, foot, and mouth disease (HFMD) outbreaks leading to clinical and fatal complications have increased since late 1990s; especially in the Asia Pacific Region. Outbreaks of HFMD peaks in the warmer season of the year, but the underlying factors for this annual pattern and the reasons to the recent upsurge trend have not yet been established. This study analyzed the effect of short-term changes in weather on the incidence of HFMD in Singapore.

Methods: The relative risks between weekly HFMD cases and temperature and rainfall were estimated for the period 2001-2008 using time series Poisson regression models allowing for over-dispersion. Smoothing was used to allow non-linear relationship between weather and weekly HFMD cases, and to adjust for seasonality and long-term time trend. Additionally, autocorrelation was controlled and weather was allowed to have a lagged effect on HFMD incidence up to 2 weeks.

Results: Weekly temperature and rainfall showed statistically significant association with HFMD incidence at time lag of 1-2 weeks. Every 1°C increases in maximum temperature above 32°C elevated the risk of HFMD incidence by 36% (95% CI = 1.341-1.389). Simultaneously, one mm increase of weekly cumulative rainfall below 75 mm increased the risk of HFMD by 0.3% (CI = 1.002-1.003). While above 75 mm the effect was opposite and each mm increases of rainfall decreased the incidence by 0.5% (CI = 0.995-0.996). We also found that a difference between minimum and maximum temperature greater than 7°C elevated the risk of HFMD by 41% (CI = 1.388-1.439).

Conclusion: Our findings suggest a strong association between HFMD and weather. However, the exact reason for the association is yet to be studied. Information on maximum temperature above 32°C and moderate rainfall precede HFMD incidence could help to control and curb the up-surging trend of HFMD.

Figure 1. Time series of weekly HFMD cases, cumulative rainfall (rain), maximum temperature (tmax) >32°C, and temperature difference (Tp)>7°C in year 2001–2008.

Figure 2. a–f: Relationship between HFMD incidence and weather.

Relative risks of HFMD incidence as function of weekly (2a) temperature difference (Tp) & (2b) weekly cumulative rainfall at time lag of 1–2 weeks using model A; (2c) maximum temperature & (2d) minimum temperature at time lag of 1–2 weeks using model B; (2e) maximum temperature tested singly & (2f) minimum temperature tested singly at time lag of 1–2 weeks using model B (Shaded area: confidence interval).