. 2024 Oct 9:387:e080944.

doi: 10.1136/bmj-2024-080944.

Rainfall events and daily mortality across 645 global locations: two stage time series analysis

Cheng He¹, Susanne Breitner-Busch^{2

3}, Veronika Huber^{2

3}, Kai Chen^{4

5}, Siqi Zhang^{4

5}, Antonio Gasparrini⁶, Michelle Bell^{7

8}, Haidong Kan⁹, Dominic Royé¹⁰, Ben Armstrong¹¹, Joel Schwartz¹², Francesco Sera¹³, Ana Maria Vicedo-Cabrera^{14

15}, Yasushi Honda¹⁶, Jouni J K Jaakkola^{17

18}, Niilo Ryti¹⁷, Jan Kyselý^{19

20}, Yuming Guo^{21

22}, Shilu Tong^{23

24}, Francesca de'Donato²⁵, Paola Michelozzi²⁵, Micheline de Sousa Zanotti Stagliorio Coelho²⁶, Paulo Hilario Nascimento Saldiva²⁷, Eric Lavigne^{28

29}, Hans Orru³⁰, Ene Indermitte³⁰, Mathilde Pascal³¹, Patrick Goodman³², Ariana Zeka³³, Yoonhee Kim³⁴, Magali Hurtado Diaz³⁵, Eunice Elizabeth Félix Arellano³⁵, Ala Overcenco³⁶, Jochem Klompmaker³⁷, Shilpa Rao³⁸, Alfonso Diz-Lois Palomares³⁸, Gabriel Carrasco^{39

40}, Xerxes Seposo⁴¹, Susana das Neves Pereira da Silva⁴², Joana Madureira^{42

43

44}, Iulian-Horia Holobaca⁴⁵, Noah Scovronick⁴⁶, Fiorella Acquaotta⁴⁷, Ho Kim⁴⁸, Whanhee Lee⁴⁹, Masahiro Hashizume⁵⁰, Aurelio Tobias^{51

41}, Carmen Íñiguez^{52

53}, Bertil Forsberg⁵⁴, Martina S Ragettli^{55

56}, Yue Leon Guo^{57

58

59}, Shih-Chun Pan⁵⁸, Samuel Osorio⁶⁰, Shanshan Li^{21

22}, Antonella Zanobetti¹², Tran Ngoc Dang⁶¹, Do Van Dung⁶², Alexandra Schneider²

Affiliations

¹ Institute of Epidemiology, Helmholtz Zentrum München - German Research Center for Environmental Health, Neuherberg, Germany cheng.he@helmholtz-munich.de.
² Institute of Epidemiology, Helmholtz Zentrum München - German Research Center for Environmental Health, Neuherberg, Germany.
³ Institute for Medical Information Processing, Biometry, and Epidemiology, Medical Faculty, Ludwig-Maximilians-Universität München, Munich, Germany.
⁴ Department of Environmental Health Sciences, Yale School of Public Health, New Haven, CT, USA.
⁵ Yale Center on Climate Change and Health, Yale School of Public Health, New Haven, CT, USA.
⁶ Environment and Health Modelling Lab, Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London, UK.
⁷ School of the Environment, Yale University, New Haven, CT, USA.
⁸ School of Health Policy and Management, College of Health Sciences, Korea University, Seoul, Republic of Korea.
⁹ Department of Environmental Health, School of Public Health, Fudan University, Shanghai, China.
¹⁰ Climate Research Foundation, CIBER of Epidemiology and Public Health, Madrid, Spain.
¹¹ Department of Public Health Environments and Society, London School of Hygiene and Tropical Medicine, London, UK.
¹² Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
¹³ Department of Statistics, Computer Science and Applications "G Parenti," University of Florence, Florence, Italy.
¹⁴ Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.
¹⁵ Oeschger Center for Climate Change Research, University of Bern, Bern, Switzerland.
¹⁶ Center for Climate Change Adaptation, National Institute for Environmental Studies, Tsukuba, Japan.
¹⁷ Center for Environmental and Respiratory Health Research, University of Oulu, Oulu, Finland.
¹⁸ Finnish Meteorological Institute, Helsinki, Finland.
¹⁹ Institute of Atmospheric Physics, Czech Academy of Sciences, Prague, Czech Republic.
²⁰ Faculty of Environmental Sciences, Czech University of Life Sciences, Prague, Czech Republic.
²¹ School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
²² Climate, Air Quality Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
²³ National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing, China.
²⁴ School of Public Health and Social Work, Queensland University of Technology, Brisbane, QLD, Australia.
²⁵ Department of Epidemiology, Lazio Regional Health Service, ASL ROMA 1, Rome, Italy.
²⁶ Department of Pathology, Faculty of Medicine, University of Sao Paulo, Sao Paulo, Brazil.
²⁷ INSPER, Sao Paulo, Brazil.
²⁸ School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.
²⁹ Environmental Health Science and Research Bureau, Health Canada, Ottawa, ON, Canada.
³⁰ Department of Family Medicine and Public Health, University of Tartu, Tartu, Estonia.
³¹ Department of Environmental and Occupational Health, French National Public Health Agency, Saint Maurice, France.
³² Technological University Dublin, Dublin, Ireland.
³³ Institute for Global Health, University College London, UK.
³⁴ Department of Global Environmental Health, Graduate School of Medicine, University of Tokyo, Tokyo, Japan.
³⁵ Department of Environmental Health, National Institute of Public Health, Cuernavaca, Morelos, Mexico.
³⁶ National Agency for Public Health of Ministry of Health, Labour and Social Protection of the Republic of Moldova, Chisinau, Republic of Moldova.
³⁷ National Institute for Public Health and the Environment (RIVM), Centre for Sustainability and Environmental Health, Bilthoven, Netherlands.
³⁸ Norwegian institute of Public Health, Oslo, Norway.
³⁹ Institute of Tropical Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru.
⁴⁰ Division of Infectious Diseases, Department of Medicine, University of California, San Diego, CA, USA.
⁴¹ School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan.
⁴² National Institute of Health Dr Ricardo Jorge, Portugal.
⁴³ EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal.
⁴⁴ Laboratório para a Investigação Integrativa e Translacional em Saúde Pública (ITR), Porto, Portugal.
⁴⁵ Faculty of Geography, Babeș-Bolyai University, Cluj-Napoca, Romania.
⁴⁶ Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA.
⁴⁷ Department of Earth Sciences, University of Turin, Turin, Italy.
⁴⁸ Graduate School of Public Health, Seoul National University, Seoul, Republic of Korea.
⁴⁹ School of Biomedical Convergence Engineering, College of Information and Biomedical Engineering, Pusan National University, Yangsan, Republic of Korea.
⁵⁰ Department of Global Health Policy, Graduate School of Medicine, University of Tokyo, Tokyo, Japan.
⁵¹ Institute of Environmental Assessment and Water Research, Spanish Council for Scientific Research, Barcelona, Spain.
⁵² Department of Statistics and Computational Research, University of Valencia, Valencia, Spain.
⁵³ Ciberesp, Madrid, Spain.
⁵⁴ Department of Public Health and Clinical Medicine, Umea University, Umea, Sweden.
⁵⁵ Swiss Tropical and Public Health Institute, Allschwil, Switzerland.
⁵⁶ University of Basel, Basel, Switzerland.
⁵⁷ Environmental and Occupational Medicine, National Taiwan University (NTU) College of Medicine and NTU Hospital, Taipei, Taiwan.
⁵⁸ National Institute of Environmental Health Science, National Health Research Institutes, Zhunan, Taiwan.
⁵⁹ Graduate Institute of Environmental and Occupational Health Sciences, NTU College of Public Health, Taipei, Taiwan.
⁶⁰ Department of Environmental Health, University of Sao Paulo, Sao Paulo, Brazil.
⁶¹ Institute of Research and Development, Duy Tan University, Da Nang, Vietnam.
⁶² Department of Environmental Health, Faculty of Public Health, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam.

PMID: 39384295
PMCID: PMC12036573
DOI: 10.1136/bmj-2024-080944

Rainfall events and daily mortality across 645 global locations: two stage time series analysis

Cheng He et al. BMJ. 2024.

. 2024 Oct 9:387:e080944.

doi: 10.1136/bmj-2024-080944.

Authors

Affiliations

¹ Institute of Epidemiology, Helmholtz Zentrum München - German Research Center for Environmental Health, Neuherberg, Germany cheng.he@helmholtz-munich.de.
² Institute of Epidemiology, Helmholtz Zentrum München - German Research Center for Environmental Health, Neuherberg, Germany.
³ Institute for Medical Information Processing, Biometry, and Epidemiology, Medical Faculty, Ludwig-Maximilians-Universität München, Munich, Germany.
⁴ Department of Environmental Health Sciences, Yale School of Public Health, New Haven, CT, USA.
⁵ Yale Center on Climate Change and Health, Yale School of Public Health, New Haven, CT, USA.
⁶ Environment and Health Modelling Lab, Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London, UK.
⁷ School of the Environment, Yale University, New Haven, CT, USA.
⁸ School of Health Policy and Management, College of Health Sciences, Korea University, Seoul, Republic of Korea.
⁹ Department of Environmental Health, School of Public Health, Fudan University, Shanghai, China.
¹⁰ Climate Research Foundation, CIBER of Epidemiology and Public Health, Madrid, Spain.
¹¹ Department of Public Health Environments and Society, London School of Hygiene and Tropical Medicine, London, UK.
¹² Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
¹³ Department of Statistics, Computer Science and Applications "G Parenti," University of Florence, Florence, Italy.
¹⁴ Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.
¹⁵ Oeschger Center for Climate Change Research, University of Bern, Bern, Switzerland.
¹⁶ Center for Climate Change Adaptation, National Institute for Environmental Studies, Tsukuba, Japan.
¹⁷ Center for Environmental and Respiratory Health Research, University of Oulu, Oulu, Finland.
¹⁸ Finnish Meteorological Institute, Helsinki, Finland.
¹⁹ Institute of Atmospheric Physics, Czech Academy of Sciences, Prague, Czech Republic.
²⁰ Faculty of Environmental Sciences, Czech University of Life Sciences, Prague, Czech Republic.
²¹ School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
²² Climate, Air Quality Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
²³ National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing, China.
²⁴ School of Public Health and Social Work, Queensland University of Technology, Brisbane, QLD, Australia.
²⁵ Department of Epidemiology, Lazio Regional Health Service, ASL ROMA 1, Rome, Italy.
²⁶ Department of Pathology, Faculty of Medicine, University of Sao Paulo, Sao Paulo, Brazil.
²⁷ INSPER, Sao Paulo, Brazil.
²⁸ School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.
²⁹ Environmental Health Science and Research Bureau, Health Canada, Ottawa, ON, Canada.
³⁰ Department of Family Medicine and Public Health, University of Tartu, Tartu, Estonia.
³¹ Department of Environmental and Occupational Health, French National Public Health Agency, Saint Maurice, France.
³² Technological University Dublin, Dublin, Ireland.
³³ Institute for Global Health, University College London, UK.
³⁴ Department of Global Environmental Health, Graduate School of Medicine, University of Tokyo, Tokyo, Japan.
³⁵ Department of Environmental Health, National Institute of Public Health, Cuernavaca, Morelos, Mexico.
³⁶ National Agency for Public Health of Ministry of Health, Labour and Social Protection of the Republic of Moldova, Chisinau, Republic of Moldova.
³⁷ National Institute for Public Health and the Environment (RIVM), Centre for Sustainability and Environmental Health, Bilthoven, Netherlands.
³⁸ Norwegian institute of Public Health, Oslo, Norway.
³⁹ Institute of Tropical Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru.
⁴⁰ Division of Infectious Diseases, Department of Medicine, University of California, San Diego, CA, USA.
⁴¹ School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan.
⁴² National Institute of Health Dr Ricardo Jorge, Portugal.
⁴³ EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal.
⁴⁴ Laboratório para a Investigação Integrativa e Translacional em Saúde Pública (ITR), Porto, Portugal.
⁴⁵ Faculty of Geography, Babeș-Bolyai University, Cluj-Napoca, Romania.
⁴⁶ Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA.
⁴⁷ Department of Earth Sciences, University of Turin, Turin, Italy.
⁴⁸ Graduate School of Public Health, Seoul National University, Seoul, Republic of Korea.
⁴⁹ School of Biomedical Convergence Engineering, College of Information and Biomedical Engineering, Pusan National University, Yangsan, Republic of Korea.
⁵⁰ Department of Global Health Policy, Graduate School of Medicine, University of Tokyo, Tokyo, Japan.
⁵¹ Institute of Environmental Assessment and Water Research, Spanish Council for Scientific Research, Barcelona, Spain.
⁵² Department of Statistics and Computational Research, University of Valencia, Valencia, Spain.
⁵³ Ciberesp, Madrid, Spain.
⁵⁴ Department of Public Health and Clinical Medicine, Umea University, Umea, Sweden.
⁵⁵ Swiss Tropical and Public Health Institute, Allschwil, Switzerland.
⁵⁶ University of Basel, Basel, Switzerland.
⁵⁷ Environmental and Occupational Medicine, National Taiwan University (NTU) College of Medicine and NTU Hospital, Taipei, Taiwan.
⁵⁸ National Institute of Environmental Health Science, National Health Research Institutes, Zhunan, Taiwan.
⁵⁹ Graduate Institute of Environmental and Occupational Health Sciences, NTU College of Public Health, Taipei, Taiwan.
⁶⁰ Department of Environmental Health, University of Sao Paulo, Sao Paulo, Brazil.
⁶¹ Institute of Research and Development, Duy Tan University, Da Nang, Vietnam.
⁶² Department of Environmental Health, Faculty of Public Health, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam.

PMID: 39384295
PMCID: PMC12036573
DOI: 10.1136/bmj-2024-080944

Abstract

Objective: To examine the associations between characteristics of daily rainfall (intensity, duration, and frequency) and all cause, cardiovascular, and respiratory mortality.

Design: Two stage time series analysis.

Setting: 645 locations across 34 countries or regions.

Population: Daily mortality data, comprising a total of 109 954 744 all cause, 31 164 161 cardiovascular, and 11 817 278 respiratory deaths from 1980 to 2020.

Main outcome measure: Association between daily mortality and rainfall events with return periods (the expected average time between occurrences of an extreme event of a certain magnitude) of one year, two years, and five years, with a 14 day lag period. A continuous relative intensity index was used to generate intensity-response curves to estimate mortality risks at a global scale.

Results: During the study period, a total of 50 913 rainfall events with a one year return period, 8362 events with a two year return period, and 3301 events with a five year return period were identified. A day of extreme rainfall with a five year return period was significantly associated with increased daily all cause, cardiovascular, and respiratory mortality, with cumulative relative risks across 0-14 lag days of 1.08 (95% confidence interval 1.05 to 1.11), 1.05 (1.02 to 1.08), and 1.29 (1.19 to 1.39), respectively. Rainfall events with a two year return period were associated with respiratory mortality only, whereas no significant associations were found for events with a one year return period. Non-linear analysis revealed protective effects (relative risk <1) with moderate-heavy rainfall events, shifting to adverse effects (relative risk >1) with extreme intensities. Additionally, mortality risks from extreme rainfall events appeared to be modified by climate type, baseline variability in rainfall, and vegetation coverage, whereas the moderating effects of population density and income level were not significant. Locations with lower variability of baseline rainfall or scarce vegetation coverage showed higher risks.

Conclusion: Daily rainfall intensity is associated with varying health effects, with extreme events linked to an increasing relative risk for all cause, cardiovascular, and respiratory mortality. The observed associations varied with local climate and urban infrastructure.

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Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/disclosure-of-interest/ and declare: Support from the Alexander von Humboldt Foundation no financial relationships with any organizations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

Figures

**Fig 1**
Equation to calculate percentage of daily accumulated rainfall exceeding a two year return period. The return period is the expected average time between occurrences of an extreme event of a certain magnitude

**Fig 2**
Daily cumulative thresholds for extreme rainfall events in 645 locations. Analysis used the intensity-duration-frequency model across the three return periods. The return period is the expected average time between occurrences of an extreme event of a certain magnitude

**Fig 3**
Cumulative relative risks of all cause, cardiovascular, and respiratory mortality associated with exposure to extreme rainfall events with three different return periods across all locations, and by territory or region. CI=confidence interval; NA=not available

**Fig 4**
Exposure-response function of the relative risks of all cause, cardiovascular, and respiratory mortality associated with daily accumulated rainfall exceeding the two year return period threshold (PE₂). The return period is the expected average time between occurrences of an extreme event of a certain magnitude

See this image and copyright information in PMC

Comment in

Rainfall events and adverse health outcomes.
Ji JS. Ji JS. BMJ. 2024 Oct 9;387:q2053. doi: 10.1136/bmj.q2053. BMJ. 2024. PMID: 39384299 No abstract available.

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References

1. Arisco NJ, Sewe MO, Bärnighausen T, Sié A, Zabre P, Bunker A. The effect of extreme temperature and precipitation on cause-specific deaths in rural Burkina Faso: a longitudinal study. Lancet Planet Health 2023;7:e478-89. 10.1016/S2542-5196(23)00027-X - DOI - PubMed
1. Ingole V, Juvekar S, Muralidharan V, Sambhudas S, Rocklöv J. The short-term association of temperature and rainfall with mortality in Vadu Health and Demographic Surveillance System: a population level time series analysis. Glob Health Action 2012;5:44-52. 10.3402/gha.v5i0.19118 - DOI - PMC - PubMed
1. Aune KT, Davis MF, Smith GS. Extreme precipitation events and infectious disease risk: a scoping review and framework for infectious respiratory viruses. Int J Environ Res Public Health 2021;19:165. 10.3390/ijerph19010165 - DOI - PMC - PubMed
1. Kraay ANM, Man O, Levy MC, Levy K, Ionides E, Eisenberg JNS. Understanding the impact of rainfall on diarrhea: testing the concentration-dilution hypothesis using a systematic review and meta-analysis. Environ Health Perspect 2020;128:126001. 10.1289/EHP6181 - DOI - PMC - PubMed
1. Peirce AM, Espira LM, Larson PS. Climate change related catastrophic rainfall events and non-communicable respiratory disease: a systematic review of the literature. Climate (Basel) 2022;10:101 10.3390/cli10070101. - DOI

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Rainfall events and daily mortality across 645 global locations: two stage time series analysis

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Rainfall events and daily mortality across 645 global locations: two stage time series analysis

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