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.

Center for Climate Change Adaptation National Institute for Environmental Studies Tsukuba Japan

Center for Environmental and Respiratory Health Research University of Oulu Oulu Finland

Ciberesp Madrid Spain

Climate Air Quality Research Unit School of Public Health and Preventive Medicine Monash University Melbourne VIC Australia

Climate Research Foundation CIBER of Epidemiology and Public Health Madrid Spain

Department of Earth Sciences University of Turin Turin Italy

Department of Environmental and Occupational Health French National Public Health Agency Saint Maurice France

Department of Environmental Health Faculty of Public Health University of Medicine and Pharmacy at Ho Chi Minh City Ho Chi Minh City Vietnam

Department of Environmental Health Harvard T H Chan School of Public Health Boston MA USA

Department of Environmental Health National Institute of Public Health Cuernavaca Morelos Mexico

Department of Environmental Health School of Public Health Fudan University Shanghai China

Department of Environmental Health Sciences Yale School of Public Health New Haven CT USA

Department of Environmental Health University of Sao Paulo Sao Paulo Brazil

Department of Epidemiology Lazio Regional Health Service ASL ROMA 1 Rome Italy

Department of Family Medicine and Public Health University of Tartu Tartu Estonia

Department of Global Environmental Health Graduate School of Medicine University of Tokyo Tokyo Japan

Department of Global Health Policy Graduate School of Medicine University of Tokyo Tokyo Japan

Department of Pathology Faculty of Medicine University of Sao Paulo Sao Paulo Brazil

Department of Public Health and Clinical Medicine Umea University Umea Sweden

Department of Public Health Environments and Society London School of Hygiene and Tropical Medicine London UK

Department of Statistics and Computational Research University of Valencia Valencia Spain

Department of Statistics Computer Science and Applications G Parenti University of Florence Florence Italy

Division of Infectious Diseases Department of Medicine University of California San Diego CA USA

Environment and Health Modelling Lab Department of Public Health Environments and Society London School of Hygiene and Tropical Medicine London UK

Environmental and Occupational Medicine National Taiwan University College of Medicine and NTU Hospital Taipei Taiwan

Environmental Health Science and Research Bureau Health Canada Ottawa ON Canada

EPIUnit Instituto de Saúde Pública Universidade do Porto Porto Portugal

Faculty of Environmental Sciences Czech University of Life Sciences Prague Czech Republic

Faculty of Geography Babeș Bolyai University Cluj Napoca Romania

Finnish Meteorological Institute Helsinki Finland

Gangarosa Department of Environmental Health Rollins School of Public Health Emory University Atlanta GA USA

Graduate Institute of Environmental and Occupational Health Sciences NTU College of Public Health Taipei Taiwan

Graduate School of Public Health Seoul National University Seoul Republic of Korea

INSPER Sao Paulo Brazil

Institute for Global Health University College London UK

Institute for Medical Information Processing Biometry and Epidemiology Medical Faculty Ludwig Maximilians Universität München Munich Germany

Institute of Atmospheric Physics Czech Academy of Sciences Prague Czech Republic

Institute of Environmental Assessment and Water Research Spanish Council for Scientific Research Barcelona Spain

Institute of Epidemiology Helmholtz Zentrum München German Research Center for Environmental Health Neuherberg Germany

Institute of Research and Development Duy Tan University Da Nang Vietnam

Institute of Social and Preventive Medicine University of Bern Bern Switzerland

Institute of Tropical Medicine Universidad Peruana Cayetano Heredia Lima Peru

Laboratório para a Investigação Integrativa e Translacional em Saúde Pública Porto Portugal

National Agency for Public Health of Ministry of Health Labour and Social Protection of the Republic of Moldova Chisinau Republic of Moldova

National Institute for Public Health and the Environment Centre for Sustainability and Environmental Health Bilthoven Netherlands

National Institute of Environmental Health Chinese Center for Disease Control and Prevention Beijing China

National Institute of Environmental Health Science National Health Research Institutes Zhunan Taiwan

National Institute of Health Dr Ricardo Jorge Portugal

Norwegian institute of Public Health Oslo Norway

Oeschger Center for Climate Change Research University of Bern Bern Switzerland

School of Biomedical Convergence Engineering College of Information and Biomedical Engineering Pusan National University Yangsan Republic of Korea

School of Epidemiology and Public Health Faculty of Medicine University of Ottawa Ottawa ON Canada

School of Health Policy and Management College of Health Sciences Korea University Seoul Republic of Korea

School of Public Health and Preventive Medicine Monash University Melbourne VIC Australia

School of Public Health and Social Work Queensland University of Technology Brisbane QLD Australia

School of the Environment Yale University New Haven CT USA

School of Tropical Medicine and Global Health Nagasaki University Nagasaki Japan

Swiss Tropical and Public Health Institute Allschwil Switzerland

Technological University Dublin Dublin Ireland

University of Basel Basel Switzerland

Yale Center on Climate Change and Health Yale School of Public Health New Haven CT USA

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