Using a novel two-stage strategy to characterize the spatial distribution of associations between temperature and COVID-19: A case study in the continental United States

BACKGROUND: Numerous studies have studied the association between daily average temperature (DAT) and daily COVID-19 confirmed cases, which show considerable heterogeneity, even opposite results, among different regions. Such heterogeneity suggests that characterizing the association on a large area scale would ignore the local variation, even obtain false results in some local regions. So, characterizing the spatial distribution of heterogeneous DAT-COVID-19 associations and exploring the causes plays an important role on making temperature-related region-specific intervention measures and early-warning systems. METHODS: Aiming to characterize the spatial distribution of associations between DAT and COVID-19 confirmed cases in the continental United States, we proposed a novel two-stage strategy. In the first stage, we used the common stratified distributed lag nonlinear model to obtain the rough state-specific associations. In the second stage, conditional autoregression was used to spatially smooth the rough estimations. Furtherly, based on the idea, two modified strategies were used to investigate the time-varying associations and the modification effects derived from the vaccination campaign. RESULTS: Around one-third of states exhibit no significant association between DAT and daily confirmed COVID-19 cases. Most of the remaining states present a low risk at low DAT and a high risk at high DAT, but several states present opposite associations. The average association curve presents a ‘S’ shape with positive association between −8 – 18 °C and keeping flat out of the range. An increased vaccination coverage rate will increase the risk when DAT < 12 °C, but slightly affect the risk when DAT > 12 °C. CONCLUSION: A considerable spatial heterogeneity of DAT-COVID-19 associations exists in America and the average association curve presents a ‘S’ shape. The vaccination campaign significantly modifies the association when DAT is low, but only make a slight modification when DAT is high.