Long-term changes in the heat-mortality relationship according to heterogeneous regional climate: A time-series study in South Korea

Objectives: Several studies identified a heterogeneous impact of heat on mortality in hot and cool regions during a fixed period, whereas less evidence is available for changes in risk over time due to climate change in these regions. We compared changes in risk during periods without (1996-2000) and with (2008-2012) heatwave warning forecasts in regions of South Korea with different climates. Methods: Study areas were categorised into 3 clusters based on the spatial clustering of cooling degree days in the period 1993-2012: hottest cluster (cluster H), moderate cluster (cluster M) and cool cluster (cluster C). The risk was estimated according to increases in the daily all-cause, cardiovascular and respiratory mortality per 1°C change in daily temperature above the threshold, using a generalised additive model. Results: The risk of all types of mortality increased in cluster H in 2008-2012, compared with 1996-2000, whereas the risks in all-combined regions and cooler clusters decreased. Temporal increases in mortality risk were larger for some vulnerable subgroups, including younger adults (<75 years), those with a lower education and blue-collar workers, in cluster H as well as allcombined regions. Different patterns of risk change among clusters might be attributable to large increases in heatwave frequency or duration during study periods and the degree of urbanisation in cluster H. Conclusions: People living in hotter regions or with a lower socioeconomic status are at higher risk following an increasing trend of heat-related mortality risks. Continuous efforts are needed to understand factors which affect changes in heat-related mortality risks.