Association between air temperature and COVID-19 emergency department visits in Ontario, Canada: a population-based case-crossover study

Background — The impact of air temperature on COVID-19-related health outcomes, particularly in the context of extreme weather, remains underexplored.

Methods — This time-stratified case-crossover study included 200,679 laboratory-confirmed COVID-19 emergency department (ED) visits in Ontario, Canada, from 2020 to 2023. Conditional logistic regression with distributed lag nonlinear models was used to assess the association of mean daily temperature with COVID-19 ED visits. Cumulative 0-5-day lag associations of cold and heat exposure were presented as odds ratios (ORs) with 95% confidence intervals (CIs) at the 1st and 99th percentiles of the temperature distribution, referenced to the minimum risk temperature (MRT).

Results — A non-linear, W-shaped relationship was observed between temperature and COVID-19 ED visits, with associations in extreme to very cold (−35.7°C to −21.6°C), cold (−14.1°C to −10.3°C), lightly cold to moderate (−10.2°C to 21.6°C), and warm to very hot (21.7°C to 29.2°C) temperature ranges (MRT: −17.2°C). Notably, heat exposure (24.6°C) showed stronger associations (OR: 1.53, 95% CI: 1.40-1.67) than cold exposure (−17.6°C, OR: 1.00, 95% CI: 0.996-1.005). Risk patterns varied across viral variants, with cold exposure associated with increased ED visits for Omicron and Wild variants, while heat exposure was linked to increased visits for Alpha, Delta, and Gamma variants. Associations were more pronounced for females, individuals aged <65 years, and those with a primary COVID-19 diagnosis.

Conclusion — Short-term exposure to non-optimal temperatures significantly increases COVID-19-related emergency healthcare demand, with variant- and demographic-specific differences. Temperature-responsive public health strategies are needed to reduce the burden of COVID-19 and other infectious diseases as climate extremes intensify.