The main and added effects of heat on mortality in 33 Chinese cities from 2007 to 2013

● The main and added effect from heat co-existed in China. ● Both of the main and added effect could increase the mortality risk of population. ● Females, the elderly, the less educated and inland residents were more vulnerable. Increases in ambient temperatures and the frequency of extreme heat events constitute important burdens on global public health. However, evidence on their effects on public health is limited and inconclusive in China. In this study, data on daily deaths recorded in 33 Chinese cities from 2007 to 2013 was used to evaluate the effect of heat on mortality in China. In addition to the definition of a heatwave established by the China Meteorological Administration, we combined four city-specific relative thresholds (90th, 92.5th, 95th, and 97.5th percentiles) of the daily mean temperature during the study period and three durations of ≥ 2, ≥ 3, and ≥ 4 days, from which 13 heatwave definitions were developed. Then, we estimated the main and added effects of heat at the city level using a quasi-Poisson generalized additive model combined with a distributed lag nonlinear model. Next, the estimates for the effects were pooled at the national level using a multivariable meta-analysis. Subgroup analysis was performed according to sex, age, educational attainment, and spatially stratified heterogeneity. The results showed that the mortality risk increased from 22.3% to 37.1% due to the effects of the different heatwave definitions. The added effects were much lower, with the highest increase of 3.9% (95% CI: 1.7%–6.1%) in mortality risk. Females, the elderly, populations with low educational levels, and populations living inland in China were found to be the most vulnerable to the detrimental effects of heat. These findings have important implications for the improvement of early warning systems for heatwaves.