Time Trends in the Burden of Environmental Heat and Cold Exposure Among Children and Adolescents

Yi-Sheng He; Fan Cao; Xiao Hu; Yu-Chen Liu; Sha-Sha Tao; Peng Wang; Shengping Hou; Hai-Feng Pan

doi:10.1001/jamapediatrics.2024.4392

. 2024 Nov 4;179(1):55–64. doi: 10.1001/jamapediatrics.2024.4392

Time Trends in the Burden of Environmental Heat and Cold Exposure Among Children and Adolescents

Yi-Sheng He ^1,^2,³, Fan Cao ⁴, Xiao Hu ⁵, Yu-Chen Liu ⁶, Sha-Sha Tao ^1,^2,³, Peng Wang ⁵, Shengping Hou ^4,^✉, Hai-Feng Pan ^1,^2,^3,^✉

¹Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University; Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, Hefei, Anhui, China

²Institute of Kidney Disease, Inflammation & Immunity-mediated Diseases, The Second Affiliated Hospital of Anhui Medical University, Hefei, China

³Center for Big Data and Population Health of IHM, Anhui Medical University, Hefei, Anhui, China

⁴Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Ophthalmology & Visual Sciences Key Laboratory, Beijing, China

⁵Department of Health Promotion and Behavioral Sciences, School of Public Health, Anhui Medical University, Hefei, Anhui, China

⁶Department of Otolaryngology, Head and Neck Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China

Accepted for Publication: August 9, 2024.

Published Online: November 4, 2024. doi:10.1001/jamapediatrics.2024.4392

^✉

Corresponding Authors: Hai-Feng Pan, PhD, Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Inflammation and Immune Mediated Diseases Laboratory of Anhui Province, Hefei 230032, Anhui, China (panhaifeng@ahmu.edu.cn); Shengping Hou, PhD, Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Ophthalmology & Visual Sciences Key Laboratory, Beijing, China (sphou828@mail.ccmu.edu.cn).

Author Contributions: Drs Hou and Pan had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drs He, Cao, and Wang and Ms Hu contributed equally to this work and should be considered co–first authors.

Concept and design: Cao, Hu, Wang, Hou, Pan.

Acquisition, analysis, or interpretation of data: He, Cao, Liu, Tao.

Drafting of the manuscript: He, Liu.

Critical review of the manuscript for important intellectual content: Cao, Hu, Tao, Wang, Hou, Pan.

Statistical analysis: He, Cao, Hu, Liu, Tao, Hou.

Obtained funding: Pan.

Administrative, technical, or material support: Cao, Tao.

Supervision: Wang, Hou, Pan.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was funded by grants from the Postgraduate Innovation Research and Practice Program of Anhui Medical University (YJS20230107) and the National Natural Science Foundation of China (82273710).

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 2.

Additional Contributions: We appreciate the excellent work by the Global Burden of Disease Study 2019 collaborators.

^✉

Corresponding author.

PMCID: PMC11536307 PMID: 39495532

Key Points

Question

What are the trends in the burden of environmental heat and cold exposure (EHCE) among children and adolescents at the global, regional, national, and sociodemographic index subgroup levels from 1990 to 2019?

Finding

In this cross-sectional study among children and adolescents aged 0 to 19 years, although EHCE incidence (measured per 100 000 population individuals) decreased from 169.39 to 152.31 from 1990 to 2019, respectively, an upward trend was observed from 2010 to 2019.

Meaning

The EHCE burden among children and adolescents remains high, demonstrating the necessity to include climate change and the health of children and adolescents in the United Nations Sustainable Development Goals.

Abstract

Importance

Environmental heat and cold exposure (EHCE) remains the principal preventable cause of morbidity and mortality in children and adolescents globally.

Objective

To report EHCE-related burden and analyze its temporal trends among children and adolescents from 1990 to 2019.

Design, Setting, and Participants

This repeated cross-sectional study used data from the Global Burden of Disease Study 2019, which encompassed 204 countries and territories from 1990 to 2019. Children and adolescents aged 0 to 19 years were included in the study. Data analysis occurred from December 2023 to March 2024.

Exposure

EHCE in children and adolescents from January 1990 to December 2019.

Main Outcomes and Measures

The primary outcomes were cases and rates of EHCE incidence, prevalence, mortality, disability-adjusted life-years (DALYs), and average annual percentage changes (AAPCs). Global trends in these metrics were also analyzed by sex, age, and sociodemographic index (SDI), which is a comprehensive indicator of the socioeconomic status of a country or region. A linear regression model was used to calculate AAPCs and a joinpoint regression model was used to identify the years in which trends changed significantly.

Results

From 1990 to 2019, EHCE-related incidence, prevalence, mortality, and DALYs showed a downward trend globally. However, an upward trend in EHCE incidence and prevalence was detected between 2010 and 2019 (incidence AAPC, 1.46; 95% CI, 1.05-1.87; prevalence AAPC, 1.25; 95% CI, 1.01-1.50). Regionally, although EHCE-related incidence showed a decreasing trend in most regions from 1990 to 2019, there were still some regions with an increasing trend (Southern sub-Saharan Africa AAPC, 0.23; 95% CI, 0.01-0.44). In 2019, the mortality and DALYs of EHCE were higher among children and adolescents in countries with low SDI levels. Additionally, the burden of EHCE among children and adolescents varied according to sex and age.

Conclusions and Relevance

In this cross-sectional study, a global increase was observed in EHCE incidence and prevalence since 2010. Furthermore, children and adolescents in low-SDI regions, which bear the brunt of the climate crisis, were disproportionately impacted. This suggests that future responses to climate change crises should emphasize health equity, which implies that vulnerable populations, such as children and adolescents, should be given priority in the allocation of resources to address climate change.

This cross-sectional study reports on environmental heat and cold exposure–related burden and analyzes its temporal trends among children and adolescents from 1990 to 2019 using data from the Global Burden of Disease Study 2019.

Introduction

Climate change, which refers to significant, long-term alterations in the statistical distribution of weather patterns over a period of decades to millions of years, has emerged as the greatest challenge to human health in the 21st century.^1,2 The Lancet Countdown on health and climate change and United Nations (UN) Inter-agency Group for Child Mortality Estimation have stated that without timely action to address the risks of climate change, populations around the world will face an unacceptably high risk of current and future health issues, with nearly 59 million children and adolescents expected to die by 2030.^3,4 Approximately 1 billion children globally live in countries at “extremely high risk” of climate change impacts, according to the Children’s Climate Risk Index.⁵ Children and adolescents bear the brunt of climate change’s impacts due to their weaker ability to adapt to environmental changes compared to adults.² Children and adolescents account for half of the global population but are the least responsible for greenhouse gas emissions, deforestation, and other environmentally harmful behaviors.⁶ Despite their vulnerabilities, children and adolescents continue to be neglected in addressing climate change. Only 2.4% of climate funding from the major multilateral climate funds was used to support projects that include child-responsive activities,⁵ suggesting insufficient attention to this population.

Climate change, ambient temperature, and public health are intricately linked. Namely, climate change can affect human health not only indirectly, through various pathways like sea level rise, water supply, and food security, but also directly, by increasing exposure to environmental heat and cold.⁷ Environmental heat and cold exposure (EHCE) may disturb the normal physiological temperature regulation functions of the human body, cause autonomic nervous dysfunction, and increase cardiovascular load, thereby affecting health.⁸ EHCE is a pivotal yet underappreciated cause of environmental mortality and is already having a profound effect on the well-being of people globally.^9,10 The World Health Organization (WHO) conservatively predicts that climate change could cause an additional 250 000 deaths per year from 2030 to 2050.¹¹ A multicenter observational study revealed that nonoptimal temperatures (both heat and cold) accounted for approximately 11.8% of total mortality from 2014 to 2017, resulting in more than 1.3 million deaths.¹² An analysis of temperature-related deaths in the US from 2006 to 2010 by the Centers for Disease Control and Prevention revealed that approximately 2000 US residents died each year from weather-related causes, with approximately 31% and 63% of deaths attributable to heat and cold exposures, respectively.¹³ Climate change has a profound impact on EHCE-related incidence, which seriously endangers the health of the public. Children and adolescents are vulnerable to physical, physiological, and cognitive impairment due to EHCE. Children and adolescents are included in both the Global Strategy for Women’s, Children’s, and Adolescents’ Health and the Countdown to 2030, illustrating the significance of tracking their health.¹⁴ Yet regarding aspects of EHCE and health, children and adolescents remain a neglected group,¹⁰ which hinders the achievement of the UN Sustainable Development Goal 3: “Ensure healthy lives and promote well-being for all at all ages.”¹⁵ Therefore, this study used the Global Burden of Disease Study 2019 (GBD 2019) to provide a comprehensive description of the EHCE-related disease burden including incidence, prevalence, mortality, and disability-adjusted life-years (DALYs) and to further analyze these factors’ temporal trends among children and adolescents at the global, regional, and national levels from 1990 to 2019.

Methods

Overview

This cross-sectional study was exempt from review, and the requirement for informed consent was waived by the institutional review board of Anhui Medical University because the data were assessed at an aggregate level and did not involve personal identification. For the usage of deidentified data in the GBD 2019 study, a waiver of informed consent was approved by the University of Washington Institutional Review Board, whose Institute for Health Metrics and Evaluation led the GBD 2019 study. The cases and rates of incidence, prevalence, mortality, and DALYs due to EHCE for children and adolescents were collected from the Global Health Data Exchange query tool established by GBD collaborators.¹⁶ According to WHO definitions¹⁷ and earlier publications,¹⁸ children and adolescents were defined as aged 0 to 19 years and were further categorized into 5 age subgroups: (1) less than 1 year old, (2) 1 to 4 years old, (3) 5 to 9 years old, (4) 10 to 14 years old, and (5) 15 to 19 years old.

GBD 2019 covers 204 countries and territories and includes 369 diseases, injuries, and impairments, as well as 87 risk factors from 1990 to 2019. GBD 2019 estimates the impact of diseases, injuries, and risk factors on health by age, sex, and region (eMethods 1 in Supplement 1). GBD 2019 reports 13 tertiary causes of injuries, including EHCE. EHCE is defined by GBD 2019 as death or disability caused by exposure to high or low temperatures in the environment (excluding exposure to fire, heat, or hot substances), which was coded in the International Classification of Diseases, Ninth Revision (ICD-9) as codes E900-E902.99, E926-E926.99, and E929.5 and in the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) as codes L55-L55.9, L58-L58.9, W88-W99.9, X30-X32.9, and X39-X39.9.¹⁹ GBD 2019 also reports a sociodemographic index (SDI; eMethods 2 in Supplement 1). This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines.

Statistical Analysis

First, a linear regression model was used to calculate the average annual percentage changes (AAPCs) and 95% confidence intervals. In this model, the rates (such as EHCE-related incidence) were taken as the dependent variable on a logarithmic scale, with each year as the independent variable. A detailed description of the AAPC is available in eMethods 3 in Supplement 1. Second, a joinpoint regression model was used to identify the years in which trends changed significantly. A detailed description of the jointpoint regression model is available in eMethods 4 in Supplement 1. Third, stratified analyses were conducted to determine global trends in different age, sex, and SDI subgroups. Fourth, regional and national trends in EHCE-related incidence, prevalence, mortality, and DALYs were also explored using the approach just described. Statistical analyses were performed using R versions 4.1.2 and 4.9.0.0 (The R Foundation). Statistical significance was set at 2-sided P < .05.

Results

Global Trends

Globally, the EHCE-related incidence among children and adolescents decreased from 1990 to 1999 (AAPC, −2.02; 95% CI, −2.16 to −1.88) and continued to decline, albeit at a slower pace, from 2000 to 2009 (AAPC, −0.45; 95% CI, −0.51 to −0.38). However, an upward trend was detected between 2010 and 2019 (AAPC, 1.46; 95% CI, 1.05-1.87). Overall, a decreasing trend was observed in the incidence due to EHCE from 1990 to 2019 (AAPC, −0.36; 95% CI, −0.50 to −0.22). EHCE-related prevalence in children and adolescents exhibited similar trends, whereas EHCE-related mortality and DALYs continued to decrease (Table 1). During the period 1990 to 2019, a joinpoint was present in the EHCE-related incidence for children and adolescents in 1994, 2004, 2014, and 2017 (Figure 1; eTable 1 in Supplement 1).

Table 1. Global Average Annual Percentage Changes (AAPCs) in Incidence, Prevalence, Mortality, and Disability-Adjusted Life-Years (DALYs) of Environmental Heat and Cold Exposure Among Children and Adolescents Aged 0 to 19 Years.

Period	Incidence		Prevalence		Mortality		DALYs
Period	AAPC (95% CI)	P value	AAPC (95% CI)	P value	AAPC (95% CI)	P value	AAPC (95% CI)	P value
1990-1999	−2.02 (−2.16 to −1.88)	<.001	−1.79 (−2.03 to −1.56)	<.001	−3.64 (−4.03 to −3.25)	<.001	−3.50 (−3.84 to −3.15)	<.001
2000-2009	−0.45 (−0.51 to −0.38)	<.001	−0.62 (−0.68 to −0.55)	<.001	−3.97 (−4.11 to −3.83)	<.001	−3.23 (−3.51 to −2.96)	<.001
2010-2019	1.46 (1.05 to 1.87)	<.001	1.25 (1.01 to 1.50)	<.001	−3.77 (−4.19 to −3.35)	<.001	−2.31 (−2.44 to −2.19)	<.001
1990-2019	−0.36 (−0.5 to −0.22)	<.001	−0.41 (−0.52 to −0.3)	<.001	−3.81 (−4.01 to −3.61)	<.001	−3.04 (−3.2 to −2.88)	<.001

Open in a new tab

Figure 1. — By incidence (A), prevalence (B), mortality (C), and disability-adjusted life-years (DALYs) (D). APC indicates annual percentage changes.

From 1990 to 2019, the EHCE-related incidence decreased globally for both males and females (Table 2). Specifically, the EHCE-related incidence decreased from 192.12 in 1990 to 168.68 in 2019 per 100 000 population among males, with an AAPC of −0.44 (95% CI, −0.59 to −0.29), and from 145.51 in 1990 to 134.90 in 2019 per 100 000 population among females, with an AAPC of −0.22 (95% CI, −0.35 to −0.08). From 1990 to 2019, the EHCE-related mortality rates and DALYs decreased in both males and females (Table 3). In the joinpoint regression model, a dramatic upward trend was detected in the global incidence of EHCE in both males and females since 2014 (eTable 2 in Supplement 1).

Table 2. Incidence and Prevalence of Environmental Heat and Cold Exposure and Their Average Annual Percentage Changes (AAPCs) From 1990 to 2019 Among Children and Adolescents at the Global Level, Stratified by Sex, Age, and Sociodemographic Index (SDI).

Characteristic	Incidence						Prevalence
	1990		2019		AAPC, 1990-2019 (95% CI)	P value	1990		2019		AAPC, 1990-2019 (95% CI)	P value
	Case, No. (95% CI)	Rate (per 100 000) (95% CI)	Case, No. (95% CI)	Rate (per 100 000) (95% CI)	AAPC, 1990-2019 (95% CI)	P value	Case, No. (95% CI)	Rate (per 100 000) (95% CI)	Case, No. (95% CI)	Rate (per 100 000) (95% CI)	AAPC, 1990-2019 (95% CI)	P value
Global	3 851 201.06 (2 538 800.36 to 5 523 093.00)	169.39 (111.67 to 242.93)	3 928 573.81 (2 531 609.27 to 5 687 865.84)	152.31 (98.15 to 220.52)	−0.36 (−0.5 to −0.22)	<.001	3 412 000.34 (2 447 485.62 to 4 443 954.65)	150.07 (107.65 to 195.46)	3 363 749.82 (2 396 653.54 to 4 399 772.27)	130.41 (92.92 to 170.58)	−0.41 (−0.52 to −0.3)	<.001
Sex
Female	1 613 411.87 (1 041 744.84 to 2 354 204.38)	145.51 (93.95 to 212.32)	1 685 977.04 (1 069 740.22 to 2 469 361.27)	134.90 (85.59 to 197.58)	−0.22 (−0.35 to −0.08)	.002	1 456 527.79 (1 031 390.66 to 1 915 987.26)	131.36 (93.02 to 172.80)	1 460 158.49 (1 034 130.09 to 1 914 453.08)	116.83 (82.74 to 153.18)	−0.34 (−0.44 to −0.24)	<.001
Male	2 237 789.19 (1 489 069.87 to 3 177 613.51)	192.12 (127.84 to 272.81)	2 242 596.77 (1 457 320.65 to 3 218 504.57)	168.68 (109.62 to 242.09)	−0.44 (−0.59 to −0.29)	<.001	1 955 472.55 (1 417 114.42 to 2 542 831.42)	167.89 (121.67 to 218.31)	1 903 591.34 (1 363 711.75 to 2 481 542.73)	143.18 (102.58 to 186.66)	−0.52 (−0.65 to −0.38)	<.001
Age, y
<1	234 807.85 (162 595.79 to 339 248.68)	178.45 (123.57 to 257.83)	187 039.63 (125 321.76 to 278 772.11)	141.71 (94.95 to 211.21)	−0.76 (−0.85 to −0.68)	<.001	30 502.40 (23 123.04 to 40 336.29)	23.18 (17.57 to 30.66)	24 131.00 (17 909.84 to 32 512.45)	18.28 (13.57 to 24.63)	−0.79 (−0.87 to −0.7)	<.001
1-4	826 781.89 (510 844.40 to 1 283 814.81)	165.18 (102.06 to 256.49)	751 105.24 (449 159.97 to 1 191 788.81)	141.49 (84.61 to 224.50)	−0.47 (−0.62 to −0.32)	<.001	320 335.01 (208 851.30 to 512 054.20)	64.00 (41.73 to 102.30)	273 160.04 (175 547.43 to 432 086.77)	51.46 (33.07 to 81.39)	−0.7 (−0.83 to −0.56)	<.001
5-9	878 086.82 (420 819.45 to 1 485 875.27)	150.06 (71.91 to 253.93)	903 533.96 (425 630.39 to 1 543 681.86)	138.01 (65.01 to 235.78)	−0.23 (−0.4 to −0.05)	.01	731 662.51 (488 424.65 to 1 032 822.76)	125.04 (83.47 to 176.50)	683 369.50 (449 528.58 to 967 894.66)	104.38 (68.66 to 147.84)	−0.57 (−0.72 to −0.41)	<.001
10-14	916 570.55 (451 335.79 to 1 551 862.85)	170.78 (84.10 to 289.15)	1 004 833.44 (491 877.53 to 1 709 868.13)	156.47 (76.59 to 266.26)	−0.25 (−0.4 to −0.1)	.001	989 096.45 (673 445.71 to 1 312 681.37)	184.30 (125.48 to 244.59)	1 005 149.13 (682 879.70 to 1 336 962.96)	156.52 (106.34 to 208.19)	−0.5 (−0.65 to −0.36)	<.001
15-19	994 953.95 (501 717.08 to 1 735 675.32)	191.48 (96.56 to 334.04)	1 082 061.54 (537 777.33 to 1 908 149.18)	174.66 (86.80 to 307.99)	−0.27 (−0.42 to −0.13)	<.001	1 340 403.98 (980 682.42 to 1 805 425.72)	257.97 (188.74 to 347.46)	1 377 940.16 (1 000 628.68 to 1 851 681.23)	222.41 (161.51 to 298.88)	−0.45 (−0.61 to −0.29)	<.001
SDI
High	265 438.20 (164 840.26 to 401 641.26)	113.36 (70.40 to 171.52)	224 021.62 (135 296.84 to 343 471.83)	101.45 (61.27 to 155.54)	−0.41 (−0.57 to −0.25)	<.001	206 419.73 (148 902.63 to 274 666.37)	88.15 (63.59 to 117.30)	165 052.16 (118 911.45 to 219 741.53)	74.74 (53.85 to 99.51)	−0.59 (−0.71 to −0.47)	<.001
High-middle	934 043.80 (627 589.80 to 1 315 185.11)	230.49 (154.86 to 324.54)	615 228.73 (399 411.31 to 891 645.89)	187.59 (121.78 to 271.87)	−0.69 (−0.88 to −0.5)	<.001	808 634.65 (585 085.25 to 1 061 349.96)	199.54 (144.38 to 261.90)	500 438.78 (354 723.26 to 658 180.58)	152.59 (108.16 to 200.69)	−0.87 (−1.03 to −0.7)	<.001
Middle	1 318 223.75 (849 280.28 to 1 934 012.35)	171.88 (110.74 to 252.18)	1 178 025.43 (740 449.84 to 1 735 926.08)	159.94 (100.53 to 235.68)	−0.2 (−0.33 to −0.07)	.002	1 216 848.19 (862 371.50 to 1 610 884.81)	158.67 (112.45 to 210.04)	985 077.50 (692 854.63 to 1 294 219.03)	133.74 (94.07 to 175.71)	−0.55 (−0.63 to −0.47)	<.001
Low-middle	930 803.45 (614 265.73 to 1 337 833.36)	163.13 (107.65 to 234.46)	1 108 616.30 (718 875.95 to 1 592 495.67)	159.43 (103.38 to 229.02)	−0.06 (−0.17 to 0.05)	.31	827 847.64 (597 010.18 to 1 073 209.72)	145.09 (104.63 to 188.09)	994 172.05 (717 177.58 to 1 293 171.18)	142.97 (103.14 to 185.97)	−0.03 (−0.11 to 0.06)	.57
Low	399 718.42 (272 687.91 to 564 196.99)	135.33 (92.32 to 191.01)	799 186.95 (528 830.06 to 1 144 600.25)	133.88 (88.59 to 191.74)	−0.02 (−0.12 to 0.08)	.70	349 677.15 (252 895.27 to 455 575.89)	118.39 (85.62 to 154.24)	715 962.06 (513 712.99 to 939 011.36)	119.93 (86.05 to 157.30)	0.06 (−0.02 to 0.14)	.12

Open in a new tab

Table 3. The Mortality and Disability-Adjusted Life-Years (DALYs) of Environmental Heat and Cold Exposure and Their Average Annual Percentage Changes (AAPCs) From 1990 to 2019 Among Children and Adolescents at the Global Level, Stratified by Sex, Age, and Sociodemographic Index (SDI).

Characteristic	Mortality						DALYs
	1990		2019		AAPC, 1990-2019, (95% CI)	P value	1990		2019		AAPC, 1990-2019 (95% CI)	P value
	Case, No. (95% CI)	Rate (per 100 000) (95% CI)	Case, No. (95% CI)	Rate (per 100 000) (95% CI)	AAPC, 1990-2019, (95% CI)	P value	Case, No. (95% CI)	Rate (per 100 000) (95% CI)	Case, No. (95% CI)	Rate (per 100 000) (95% CI)	AAPC, 1990-2019 (95% CI)	P value
Global	8880.87 (3956.53 to 11 683.73)	0.39 (0.17 to 0.51)	3309.30 (1621.10 to 4781.93)	0.13 (0.06 to 0.19)	−3.81 (−4.01 to −3.61)	<.001	901 978.45 (488 814.29 to 1 160 519.55)	39.67 (21.50 to 51.04)	418 996.63 (268 966.51 to 559 546.00)	16.24 (10.43 to 21.69)	−3.04 (−3.2 to −2.88)	<.001
Sex
Female	3066.84 (935.17 to 4534.50)	0.28 (0.08 to 0.41)	1292.05 (478.28 to 1989.83)	0.10 (0.04 to 0.16)	−3.35 (−3.63 to −3.06)	<.001	330 378.43 (148 445.69 to 457 860.58)	29.80 (13.39 to 41.29)	173 487.15 (103 029.19 to 245 695.84)	13.88 (8.24 to 19.66)	−2.62 (−2.78 to −2.46)	<.001
Male	5814.03 (2275.80 to 7513.55)	0.50 (0.20 to 0.65)	2017.26 (961.56 to 2905.48)	0.15 (0.07 to 0.22)	−4.01 (−4.24 to −3.79)	<.001	571 600.02 (275 439.10 to 726 001.44)	49.07 (23.65 to 62.33)	245 509.48 (152 567.29 to 328 243.93)	18.47 (11.48 to 24.69)	−3.31 (−3.49 to −3.14)	<.001
Age, y
<1	3717.99 (1110.56 to 5186.61)	2.83 (0.84 to 3.94)	878.66 (289.03 to 1468.35)	0.67 (0.22 to 1.11)	−4.91 (−5.18 to −4.64)	<.001	331 473.78 (102 065.61 to 460 737.51)	251.92 (77.57 to 350.16)	79 713.41 (27 169.09 to 131 419.57)	60.40 (20.58 to 99.57)	−4.85 (−5.12 to −4.59)	<.001
1-4	2291.86 (964.30 to 3432.36)	0.46 (0.19 to 0.69)	923.81 (468.61 to 1427.46)	0.17 (0.09 to 0.27)	−3.31 (−3.48 to −3.14)	<.001	215 473.96 (103 336.42 to 315 336.38)	43.05 (20.65 to 63.00)	94 405.67 (55 338.52 to 139 046.89)	17.78 (10.42 to 26.19)	−3.02 (−3.17 to −2.87)	<.001
5-9	871.59 (432.58 to 1173.46)	0.15 (0.07 to 0.20)	452.96 (215.44 to 683.18)	0.07 (0.03 to 0.10)	−2.61 (−2.87 to −2.35)	<.001	107 175.21 (70 305.87 to 136 938.50)	18.32 (12.01 to 23.40)	68 525.81 (46 404.10 to 93 120.33)	10.47 (7.09 to 14.22)	−1.9 (−2.16 to −1.63)	<.001
10-14	530.83 (313.33 to 639.94)	0.10 (0.06 to 0.12)	330.18 (178.46 to 444.65)	0.05 (0.03 to 0.07)	−2.27 (−2.56 to −1.99)	<.001	86 166.75 (67 530.65 to 108 686.76)	16.06 (12.58 to 20.25)	68 915.62 (51 128.67 to 89 797.34)	10.73 (7.96 to 13.98)	−1.39 (−1.57 to −1.21)	<.001
15-19	1468.60 (1007.46 to 1690.09)	0.28 (0.19 to 0.33)	723.70 (416.47 to 920.14)	0.12 (0.07 to 0.15)	−2.97 (−3.42 to −2.53)	<.001	161 688.75 (126 983.23 to 192 369.78)	31.12 (24.44 to 37.02)	107 436.11 (81 097.69 to 138 040.96)	17.34 (13.09 to 22.28)	−1.99 (−2.22 to −1.77)	<.001
SDI
High	147.85 (139.50 to 172.56)	0.06 (0.06 to 0.07)	92.09 (87.46 to 96.85)	0.04 (0.04 to 0.04)	−1.4 (−2.22 to −0.57)	.001	19 580.72 (16 412.86 to 23 496.20)	8.36 (7.01 to 10.03)	13 411.04 (11 148.80 to 16 351.63)	6.07 (5.05 to 7.40)	−1.09 (−1.76 to −0.42)	.001
High-middle	1755.18 (1251.20 to 2040.34)	0.43 (0.31 to 0.50)	229.45 (198.02 to 255.67)	0.07 (0.06 to 0.08)	−6.03 (−7.13 to −4.92)	<.001	175 468.76 (131 729.35 to 205 421.29)	43.30 (32.51 to 50.69)	36 992.80 (29 841.89 to 46 201.57)	11.28 (9.10 to 14.09)	−4.56 (−4.98 to −4.14)	<.001
Middle	2675.00 (989.72 to 3514.80)	0.35 (0.13 to 0.46)	412.69 (183.90 to 572.73)	0.06 (0.02 to 0.08)	−6.17 (−6.5 to −5.84)	<.001	280 821.59 (139 501.64 to 359 670.64)	36.62 (18.19 to 46.90)	73 906.91 (50 486.65 to 97 254.04)	10.03 (6.85 to 13.20)	−4.37 (−4.55 to −4.2)	<.001
Low-middle	2315.86 (653.07 to 3664.80)	0.41 (0.11 to 0.64)	970.67 (287.34 to 1601.11)	0.14 (0.04 to 0.23)	−3.74 (−4.05 to −3.43)	<.001	240 812.24 (98 449.48 to 358 846.04)	42.20 (17.25 to 62.89)	128 000.31 (67 004.45 to 187 795.72)	18.41 (9.64 to 27.01)	−2.85 (−3.05 to −2.65)	<.001
Low	1983.74 (908.73 to 2821.44)	0.67 (0.31 to 0.96)	1601.64 (847.52 to 2396.00)	0.27 (0.14 to 0.40)	−3.14 (−3.42 to −2.85)	<.001	184 892.86 (96 477.30 to 255 125.95)	62.60 (32.66 to 86.37)	166 311.48 (101 181.40 to 232 612.12)	27.86 (16.95 to 38.97)	−2.77 (−3.01 to −2.52)	<.001

Open in a new tab

Globally, the incidence of EHCE in children and adolescents aged 0 to 19 years showed a downward trend between 1990 and 2019, with the most pronounced decline in children younger than 1 year (AAPC, −0.76; 95% CI, −0.85 to −0.68; Table 2). EHCE-related DALYs exhibited a similar pattern (Table 3). The EHCE-related DALYs in children younger than 1 year decreased from 251.92 cases per 100 000 population in 1990 to 60.40 cases per 100 000 population in 2019, with an AAPC of −4.85 (95% CI, −5.12 to −4.59; P < .001). Additionally, among children younger than 1 year, the incidence due to EHCE decreased mostly in the period 1990 to 1993 (APC, −2.52; 95% CI, −2.96 to −2.08), then the decreasing trend eased year by year, and finally, the incidence showed an increasing trend from 2015 to 2019 (APC, 1.5; 95% CI, 1.18-1.81; eTable 3 in Supplement 1). Overall, the incidence due to EHCE decreased, with the magnitude of change higher in high-SDI countries than in low-SDI countries (Table 2). Conversely, the EHCE-related mortality decreased most in low-SDI countries (AAPC, −3.14; 95% CI, −3.42 to −2.85), whereas in high-SDI countries, the decrease was minimal (AAPC, −1.4; 95% CI, −2.22 to −0.57; Table 3). The results of the joinpoint regression analyses of the incidence, prevalence, mortality, and DALYs due to EHCE at the global level from 1990 to 2019 according to the SDI among children and adolescents aged 0 to 19 years are shown in eTable 4 in Supplement 1.

Regional Trends

Regionally, the largest decreases in incidence due to EHCE from 1990 to 2019 were experienced in Central Europe (from 89.71 in 1990 to 56.87 in 2019 per 100 000 population; AAPC, −1.57; 95% CI, −1.76 to −1.38) and Eastern Europe (from 629.31 in 1990 to 430.47 in 2019 per 100 000 population; AAPC, −1.28; 95% CI, −1.36 to −1.20). Although the EHCE-related incidence showed a downward trend in most regions from 1990 to 2019, there was still an upward trend in some regions. The largest increase was observed in Southern sub-Saharan Africa (AAPC, 0.23; 95% CI, 0.01-0.44), followed by Eastern sub-Saharan Africa (AAPC, 0.15; 95% CI, 0.10-0.21; eTable 5 in Supplement 1). The regional prevalence, mortality, and EHCE-related AAPCs between 1990 and 2019 are depicted in eTables 6 and 7 in Supplement 1.

At the regional level, the EHCE-related DALYs showed a declining trend from 1990 to 2019, with the most pronounced decline in East Asia (from 60.50 in 1990 to 8.15 in 2019 per 100 000 population; AAPC, −6.75; 95% CI, −7.26 to −6.25). In 2019, the Caribbean had the region with the highest DALYs due to EHCE (39.73 per 100 000 population; eTable 8 in Supplement 1). The joinpoint regression analysis of EHCE for the 21 regions is presented in eTable 9 in Supplement 1.

National Trends

At the national level, the sharpest decline in the EHCE-related incidence from 1990 to 2019 was in Poland (from 102.68 in 1990 to 26.95 in 2019 per 100 000 population; AAPC, −4.51; 95% CI, −4.84 to −4.17). Poland also had the lowest EHCE-related incidence in 2019. From 1990 to 2019, the EHCE-related incidence showed a decreasing trend in China, in contrast to an increasing trend in India (Figure 2; eTable 10 in Supplement 1). Similar results were found for the prevalence of EHCE (eTable 11 in Supplement 1). For the EHCE-related DALYs and mortality from 1990 to 2019, a decreasing trend was observed in most nations, with China showing the fastest pace of decline. Contrastingly, Turkmenistan showed a markedly increasing trend (eTables 12 and 13 in Supplement 1). The joinpoint regression results for the national EHCE are shown in eTable 14 in Supplement 1.

Figure 2. — By incidence (A), prevalence (B), mortality (C), and disability-adjusted life-years (DALYs) (D).

Discussion

To our knowledge, this is the first study to comprehensively describe the changing trends in the EHCE burden among children and adolescents aged 0 to 19 years at global, regional, and national levels from 1990 to 2019. In this study, it was found that from 1990 to 2019, the incidence, prevalence, mortality, and DALYs due to EHCE globally showed a general downward trend. However, the incidence and prevalence rates have increased annually since 2010. This change indicates that the EHCE-related burden on children and adolescents may remain substantial in the future, and the development of tailored disaster risk reduction strategies for this population is urgently needed.²⁰

Joinpoint regression analysis showed that the EHCE-related incidence decreased significantly in children and adolescents from 1990 to 1994. In 1990, the Intergovernmental Panel on Climate Change released its first climate assessment report, which confirmed the scientific basis of global warming and attracted great attention.²¹ Almost simultaneously, the UN Framework Convention on Climate Change was adopted in 1992, launching an agenda for international cooperation to combat climate change.²² The next period of significant decline was 1994 to 2004, which coincided with the start of enforcement of the UN Framework Convention on Climate Change in 1994.²³ The EHCE-related incidence further decreased from 2004 to 2014. During this period, the Kyoto Protocol, which limits greenhouse gas emissions, came into force in 2005, setting an overall target for developed countries to cut emissions by 5.2% in the first commitment period (2008-2012).²⁴ These historical efforts have yielded some achievements, but progress in mitigating global climate change remains insufficient. The EHCE-related incidence increased significantly during the periods 2014 to 2017 and 2017 to 2019. This is despite the fact that the implementation of the Paris Agreement in 2016 helped reduce global greenhouse gas emissions. But the World Meteorological Organization reported that in 2016, global carbon dioxide concentrations increased by a record 50% over the average of the previous decade, representing 145% of preindustrial levels.²⁵ Simultaneously, the WHO reported that annual global temperatures have been at least 1 °C above preindustrial levels for 8 consecutive years since 2015. Therefore, in the future, solidarity and joint action are urgently needed to reduce greenhouse gases and limit the global average temperature increase to 1.5 °C to avoid climate collapse.²⁶

From 1990 to 2019, the global EHCE-related incidence showed a downward trend in different age groups, with the most pronounced decrease among children younger than 1 year. In 2019, children younger than 1 year remained the highest age group for global mortality and DALYs due to EHCE. This can be explained by the fact that children, especially children younger than 1 year, have immature body regulation and are more susceptible to extreme temperature changes.²⁷ Additionally, children less than 1 year of age are still incapable of taking care for themselves and are largely reliant on others to protect them from adverse environments.²⁸ In the context of these findings, the lack of global development assistance for the prevention of injury related to EHCE among children and adolescents is a concern. We also found sex variations in EHCE-related incidence. In 2019, the number of EHCE cases in males was 2 242 596.77, which was almost 1.3-fold that of females. This may be related to the tendency of male children and adolescents to play outdoors, which could lead to increased exposure to extreme environmental temperatures during typical playtime.^29,30 Thus, sex disparities should be considered when developing preventive interventions in the future.

In low and low-middle SDI countries, progress in decreasing the morbidity of children and adolescents due to EHCE has stagnated. In 2019, child and adolescent mortality and DALYs due to EHCE were much higher in low SDI countries than that in high SDI countries. EHCE-related incidence increased in sub-Saharan Africa between 1990 and 2019. As 1 of the regions with a lower SDI, sub-Saharan Africa (with an SDI value of 0.456 in 2019) may have lower levels of infrastructure and medical resources, which may make people in these regions more vulnerable to heat and cold exposure.³¹ Residents living in low SDI regions may have fewer opportunities to engage in climate-related work.³² Additionally, in sub-Saharan Africa, HIV/AIDS has taken a prominent position in public health advocacy, intervention strategies, and religious discourse, which may inadvertently lead to insufficient attention given to other significant noncommunicable diseases.^33,34,35 The largest decreases in incidence due to EHCE from 1990 to 2019 by region were experienced in Central Europe and Eastern Europe. The European Union is an active promoter of energy and power reform globally and a major advocate for climate change and environmental protection. In 2007, the European Union presented ambitious energy and climate change targets for 2020 through its Energy Action Plan, which included a 20% reduction in greenhouse gas emissions by 2020.³⁶

Nationally, Poland and Guyana had the lowest and highest EHCE-related incidence rates in 2019, respectively. This discrepancy may be due to intergeographic variation, as temperatures vary considerably by latitude and longitude.³⁷ Additionally, China and India, which are the 2 most populous countries globally, showed opposite directions of change in EHCE-related incidence. Specifically, from 1990 to 2019, the incidence of EHCE showed a decreasing trend in China and an increasing trend in India. Population and climate differences may explain this discrepancy. The population growth of India has been concentrated in the 15 to 19 years and 20 to 24 years age groups, which may reflect previously high fertility, a large proportion of young people, and cultural and religious beliefs (eg, emphasis on early marriage and child-rearing).³⁸ Contrastingly, coinciding with the implementation of the 1-child policy in 1979, the population aged 10 to 24 years in China declined by 37.1%.³⁹ Additionally, the main climate type of India is that of a tropical monsoon,⁴⁰ with high temperatures all year round, which makes India more vulnerable to heat injury, thereby increasing the burden of disease. These findings expand our understanding of regional and national differences in EHCE burden, suggesting priority areas for resource allocation.

Limitations

This study has some limitations. First, the study is limited by the availability of raw data. In regions lacking sufficient raw data, the assessment primarily relied on multiple statistical modeling techniques used by the GBD 2019 collaborators. Although the optimization of data processing and modeling can gradually improve the estimation accuracy, fundamental improvements require increasingly better collection of raw data. Second, due to the relatively weak health care systems in some resource-limited regions, potential issues may be present with misdiagnosis and underdiagnosis of diseases, which could lead to underestimation of disease burden estimates. Third, although we analyzed the EHCE burden in children younger than 1 year, we did not further stratify the analysis for this age group. Fourth, given the limitations of the GBD 2019 data, we were unable to consider the impact of infrastructure, such as air conditioning use, on the outcomes.

Conclusions

Children and adolescents in low SDI regions, which bore the brunt of the climate crisis, were disproportionately impacted by EHCE. This suggests that future responses should prioritize health equity, which further implies that children and adolescents should receive adequate attention when addressing climate change. Since 2010, a global increase has been observed in the incidence and prevalence of EHCE. In the future, it is imperative that climate change and the health of children and adolescents are included in the UN Sustainable Development Goals and that countries work together to advance sustainability.

Supplement 1.

eMethods 1. Data Collection

eMethods 2. Sociodemographic Index

eMethods 3. Average Annual Percentage Changes

eMethods 4. Joinpoint Regression Model

eTable 1. Joinpoint Regression Analysis of Incidence, Prevalence, Mortality, and DALYs of Environmental Heat and Cold Exposure From 1990 to 2019 Among Children and Adolescents at the Global Level

eTable 2. Joinpoint Regression Analysis of Incidence, Prevalence, Mortality, and DALYs of Environmental Heat and Cold Exposure From 1990 to 2019 Among Children and Adolescents at the Global Level, Stratified by Sex

eTable 3. Joinpoint Regression Analysis of Incidence, Prevalence, Mortality, and DALYs of Environmental Heat and Cold Exposure From 1990 to 2019 Among Children and Adolescents at the Global Level, Stratified by Age

eTable 4. Joinpoint Regression Analysis of Incidence, Prevalence, Mortality, and DALYs of Environmental Heat and Cold Exposure From 1990 to 2019 Among Children and Adolescents at the Global Level, Stratified by SDI

eTable 5. The Incidence of Environmental Heat and Cold Exposure and Their AAPCs From 1990 to 2019 Among Children and Adolescents at the Regional Level

eTable 6. The Prevalence of Environmental Heat and Cold Exposure and Their AAPCs From 1990 to 2019 Among Children and Adolescents at the Regional Level

eTable 7. The Mortality of Environmental Heat and Cold Exposure and Their AAPCs From 1990 to 2019 Among Children and Adolescents at the Regional Level

eTable 8. The DALYs of Environmental Heat and Cold Exposure and Their AAPCs From 1990 to 2019 Among Children and Adolescents at the Regional Level

eTable 9. Joinpoint Regression Analysis of Incidence, Prevalence, Mortality, and DALYs of Environmental Heat and Cold Exposure From 1990 to 2019 Among Children and Adolescents at the Regional Level

eTable 10. The Incidence of Environmental Heat and Cold Exposure and Their AAPCs From 1990 to 2019 Among Children and Adolescents at the National Level

eTable 11. The Prevalence of Environmental Heat and Cold Exposure and Their AAPCs From 1990 to 2019 Among Children and Adolescents at the National Level

eTable 12. The Mortality of Environmental Heat and Cold Exposure and Their AAPCs From 1990 to 2019 Among Children and Adolescents at the National Level

eTable 13. The DALYs of Environmental Heat and Cold Exposure and Their AAPCs From 1990 to 2019 Among Children and Adolescents at the National Level

eTable 14. Joinpoint Regression Analysis of Incidence, Prevalence, Mortality, and DALYs of Environmental Heat and Cold Exposure From 1990 to 2019 Among Children and Adolescents at the National Level

eReferences.

jamapediatr-e244392-s001.pdf^{(1.9MB, pdf)}

Supplement 2.

Data Sharing Statement

jamapediatr-e244392-s002.pdf^{(12.9KB, pdf)}

References

1.The Intergovernmental Panel on Climate Change (IPCC) . AR6 Synthesis Report: climate change 2023. Accessed May 8, 2024. https://www.ipcc.ch/report/sixth-assessment-report-cycle/
2.Anderko L, Chalupka S, Du M, Hauptman M. Climate changes reproductive and children’s health: a review of risks, exposures, and impacts. Pediatr Res. 2020;87(2):414-419. doi: 10.1038/s41390-019-0654-7 [DOI] [PubMed] [Google Scholar]
3.Watts N, Amann M, Ayeb-Karlsson S, et al. The Lancet Countdown on health and climate change: from 25 years of inaction to a global transformation for public health. Lancet. 2018;391(10120):581-630. doi: 10.1016/S0140-6736(17)32464-9 [DOI] [PubMed] [Google Scholar]
4.UNICEF . Three children or youth died every minute in South Asia in 2021. – UN report. Accessed March 9, 2024. https://www.unicef.org/rosa/press-releases/three-children-or-youth-died-every-minute-south-asia-2021-un-report#:~:text=Three%20children%20or%20youth%20died,Asia%20in%202021%20%E2%80%93%20UN%20report
5.UNICEF . The climate-changed child. Accessed January 23, 2024. https://www.unicef.org/reports/climate-changed-child
6.UNICEF . Climate change and environment: a liveable planet for every child. Accessed January 23, 2024. https://www.unicef.org/environment-and-climate-change
7.Helldén D, Andersson C, Nilsson M, Ebi KL, Friberg P, Alfvén T. Climate change and child health: a scoping review and an expanded conceptual framework. Lancet Planet Health. 2021;5(3):e164-e175. doi: 10.1016/S2542-5196(20)30274-6 [DOI] [PubMed] [Google Scholar]
8.Kang Y, Tang H, Zhang L, et al. ; China hypertension survey investigators . Long-term temperature variability and the incidence of cardiovascular diseases: A large, representative cohort study in China. Environ Pollut. 2021;278:116831. doi: 10.1016/j.envpol.2021.116831 [DOI] [PubMed] [Google Scholar]
9.Seltenrich N. Between extremes: health effects of heat and cold. Environ Health Perspect. 2015;123(11):A275-A280. doi: 10.1289/ehp.123-A275 [DOI] [PMC free article] [PubMed] [Google Scholar]
10.The Lancet Child Adolescent Health . Universal health coverage and the forgotten generation. Lancet Child Adolesc Health. 2019;3(11):749. doi: 10.1016/S2352-4642(19)30299-8 [DOI] [PubMed] [Google Scholar]
11.World Health Organization . Quantitative risk assessment of the health effects of climate change on selected causes of deaths, 2030s and 2050s. Accessed May 8, 2024. https://www.who.int/publications/i/item/9789241507691#:~:text=Even%20under%20these%20conditions%2C%20it,000%20due%20to%20childhood%20undernutrition
12.Ma Y, Zhou L, Chen K. Burden of cause-specific mortality attributable to heat and cold: a multicity time-series study in Jiangsu Province, China. Environ Int. 2020;144:105994. doi: 10.1016/j.envint.2020.105994 [DOI] [PubMed] [Google Scholar]
13.Berko J, Ingram DD, Saha S, Parker JD. Deaths attributed to heat, cold, and other weather events in the United States, 2006-2010. Natl Health Stat Report. 2014;(76):1-15. [PubMed] [Google Scholar]
14.Countdown to 2030 Collaboration . Countdown to 2030: tracking progress towards universal coverage for reproductive, maternal, newborn, and child health. Lancet. 2018;391(10129):1538-1548. doi: 10.1016/S0140-6736(18)30104-1 [DOI] [PubMed] [Google Scholar]
15.United Nations Department of Economic and Social Affairs . Goal 3. Accessed October 1, 2024. https://sdgs.un.org/goals/goal3
16.Institute for Health Metrics and Evaluation, Global Health Data Exchange . Global Burden of Disease Study 2019 (GBD 2019) data input sources tool. Accessed May 29, 2024. https://ghdx.healthdata.org/gbd-2019/data-input-sources
17.World Health Organization . Adolescent health. Accessed June 18, 2022. https://www.who.int/health-topics/adolescent-health#tab=tab_1
18.Reiner RC Jr, Olsen HE, Ikeda CT, et al. ; GBD 2017 Child and Adolescent Health Collaborators . Diseases, injuries, and risk factors in child and adolescent health, 1990 to 2017: findings from the Global Burden of Diseases, Injuries, and Risk Factors 2017 Study. JAMA Pediatr. 2019;173(6):e190337. doi: 10.1001/jamapediatrics.2019.0337 [DOI] [PMC free article] [PubMed] [Google Scholar]
19.Institute for Health Metrics and Evaluation . Environmental heat and cold exposure - level 3 cause. Accessed May 22, 2024. https://www.healthdata.org/research-analysis/diseases-injuries-risks/factsheets/2021-environmental-heat-and-cold-exposure
20.Newnham EA, Tearne J, Gao X, et al. Tailoring disaster risk reduction for adolescents: qualitative perspectives from China and Nepal. Int J Disaster Risk Reduct. 2019;34:337-345. doi: 10.1016/j.ijdrr.2018.12.020 [DOI] [Google Scholar]
21.The Intergovernmental Panel on Climate Change (IPCC) . Climate change: the IPCC 1990 and 1992 assessments. Accessed March 9, 2024. https://www.ipcc.ch/report/climate-change-the-ipcc-1990-and-1992-assessments/
22.United Nations . United Nations framework convention on climate change. Accessed February 29, 2024. https://unfccc.int/resource/docs/convkp/conveng.pdf
23.Boisson de Chazournes L. United Nations Framework Convention on Climate Change. United Nations Audiovisual Library of International Law . Accessed February 29, 2024. https://legal.un.org/avl/ha/ccc/ccc.html
24.Kuh KF. The Law of Climate Change Mitigation: An Overview. In: Dellasala DA, Goldstein MI, eds. Encyclopedia of the Anthropocene. Elsevier; 2018:505-510. doi: 10.1016/B978-0-12-809665-9.10027-8 [DOI] [Google Scholar]
25.Carbon dioxide levels surge to new high in 2016, UN weather agency reports. UN News . Accessed March 29, 2024. https://news.un.org/en/story/2017/10/569562#:~:text=The%20report%20indicates%20that%20carbon,dioxide%20concentration%2C%E2%80%9D%20said%20Mr.
26.The Intergovernmental Panel on Climate Change (IPCC) . Global warming of 1.5 °C. Accessed February 29, 2024. https://www.ipcc.ch/sr15/
27.Lakhoo DP, Blake HA, Chersich MF, Nakstad B, Kovats S. The effect of high and low ambient temperature on infant health: a systematic review. Int J Environ Res Public Health. 2022;19(15):9109. doi: 10.3390/ijerph19159109 [DOI] [PMC free article] [PubMed] [Google Scholar]
28.Xu Z, Etzel RA, Su H, Huang C, Guo Y, Tong S. Impact of ambient temperature on children’s health: a systematic review. Environ Res. 2012;117:120-131. doi: 10.1016/j.envres.2012.07.002 [DOI] [PubMed] [Google Scholar]
29.Larouche R, Kleinfeld M, Charles Rodriguez U, et al. Determinants of outdoor time in children and youth: a systematic review of longitudinal and intervention studies. Int J Environ Res Public Health. 2023;20(2):1328. doi: 10.3390/ijerph20021328 [DOI] [PMC free article] [PubMed] [Google Scholar]
30.Larson LR, Green GT. Children’s time outdoors: results and implications of the National Kids Survey. J Park Recreat Admi. 2011;29(2):1-20. Accessed May 31, 2024. https://research.fs.usda.gov/treesearch/39414 [Google Scholar]
31.Watts N, Amann M, Arnell N, et al. The 2020 report of The Lancet Countdown on health and climate change: responding to converging crises. Lancet. 2021;397(10269):129-170. doi: 10.1016/S0140-6736(20)32290-X [DOI] [PMC free article] [PubMed] [Google Scholar]
32.Gronlund CJ. Racial and socioeconomic disparities in heat-related health effects and their mechanisms: a review. Curr Epidemiol Rep. 2014;1(3):165-173. doi: 10.1007/s40471-014-0014-4 [DOI] [PMC free article] [PubMed] [Google Scholar]
33.Reiner RC Jr, Hay SI; LBD Triple Burden Collaborators . The overlapping burden of the three leading causes of disability and death in sub-Saharan African children. Nat Commun. 2022;13(1):7457. doi: 10.1038/s41467-022-34240-6 [DOI] [PMC free article] [PubMed] [Google Scholar]
34.Olivier J. Religion, cancer, and sub-Saharan African health systems. Lancet Oncol. 2022;23(6):706-708. doi: 10.1016/S1470-2045(22)00209-1 [DOI] [PubMed] [Google Scholar]
35.Olivier J, Smith S. Innovative faith-community responses to HIV and AIDS: summative lessons from over two decades of work. Rev Faith Int Aff. 2016;14(3):5-21. doi: 10.1080/15570274.2016.1215839 [DOI] [Google Scholar]
36.European Environment Agency . COM(2010) 639 final: Energy 2020 – a strategy for competitive, sustainable and secure energy. Accessed March 9, 2024. https://www.eea.europa.eu/policy-documents/com-2010-639-final-energy
37.Burkart KG, Brauer M, Aravkin AY, et al. Estimating the cause-specific relative risks of non-optimal temperature on daily mortality: a two-part modelling approach applied to the Global Burden of Disease Study. Lancet. 2021;398(10301):685-697. doi: 10.1016/S0140-6736(21)01700-1 [DOI] [PMC free article] [PubMed] [Google Scholar]
38.Pearce F. India defuses its population bomb. Science. 2021;374(6574):1422-1423. doi: 10.1126/science.acz9835 [DOI] [PubMed] [Google Scholar]
39.Zeng Y, Hesketh T. The effects of China’s universal two-child policy. Lancet. 2016;388(10054):1930-1938. doi: 10.1016/S0140-6736(16)31405-2 [DOI] [PMC free article] [PubMed] [Google Scholar]
40.Chowdary JS, Xie SP, Nanjundiah RS. Drivers of the Indian summer monsoon climate variability. In: Chowdary J, Parekh A, Gnanaseelan C, eds. Indian Summer Monsoon Variability. Elsevier; 2021:1-28. doi: 10.1016/B978-0-12-822402-1.00020-X [DOI] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials