• Qi Zhao, Shanshan Li, Micheline S Z S Coelho, Saldiva Paulo H N PHN Institute of Advanced Studies, University of São Paulo, São Paulo, Brazil., Kejia Hu, Michael J Abramson, Rachel R Huxley, and Yuming Guo.
• Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
• JAMA Netw Open. 2019 Feb 1; 2 (2): e187901.

ImportanceThe onset of the hot season is known to be adversely associated with a range of health outcomes. However, little is known about whether the association is constant over the course of the hot season.ObjectiveTo quantify the change in the association between heat exposure and hospitalization from the early to late hot season in the Brazilian population.Design, Setting, And ParticipantsThis time-stratified case-crossover study used daily data on hospitalization and weather conditions during the 2000 to 2015 hot seasons in 1814 Brazilian cities. There were 49 145 997 admissions during the study period. Data analysis was conducted between May 12, 2018, and July 2, 2018.ExposuresIncrease in daily mean temperature.Main Outcomes And MeasuresDaily hospitalizations were recorded. Conditional quasi-Poisson regression with time-varying constrained distributed lag model was used to examine the city-specific association between heat and hospitalization in the early or late hot season. City-specific estimates were then pooled at the national level using random-effect meta-analysis. Stratified analyses were conducted by 5 regions, sex, 10 age groups, and 7 cause-specific categories.ResultsOf the 49 145 997 admissions (59% women), the median (interquartile range) age was 33.3 (19.8-55.7) years. At the national level, the risk of hospitalization increased by 4.6% (95% CI, 4.3%-4.9%) and 2.3% (95% CI, 1.9%-2.6%) for every 5°C increase in daily mean temperature in the early and late hot season, respectively. Exposure to early heat was associated with greater risk of hospitalization for residents in the northeast (6.4%; 95% CI, 5.5%-7.3%) and central west (7.1%; 95% CI, 6.1%-8.2%) compared with other regions. Children aged 0 to 9 years and elderly individuals (aged ≥80 years) were most susceptible. Admissions due to endocrine, nutritional, and metabolic diseases were most strongly associated with heat exposure. There was an attenuation in the heat-associated risk of hospitalization from the early to late hot season for all subgroups except young children and patients with hospitalization caused by respiratory illness.Conclusions And RelevanceIn this study, the association between heat exposure and hospitalization attenuated temporally for most of the Brazilian population. Preventive strategies to mitigate the association of high temperature with population health should focus in particular on the first few days of heat exposure.

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