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Original article
Can meteorological factors forecast asthma exacerbation in a paediatric population?
D. Hervása,b,
Corresponding author
dhmdhm@hotmail.com

Corresponding author.
, J.F. Utrerab, J. Hervás-Masipa, J.A. Hervása, L. García-Marcosc
a University Institute of Health Sciences-IUNICS, University of the Balearic Islands, Spain
b Department of Paediatrics, Inca Hospital, Mallorca Spain
c Respiratory Medicine and Allergy Units, Virgen de la Arrixaca University Children's Hospital, University of Murcia, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Asthma is the most prevalent chronic disease in childhood and an important cause of visits to the emergency department (ED).<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Seasonal exacerbation of asthma is a well-known phenomenon especially in children. Johnston and Sears<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> studying hospitalisations and ED visits for asthma in Canada found that asthma exacerbations followed a cyclic pattern in school-age children 5&#8211;15 years. There was a minor increase through the first six months of the year, then declined during the summer and peaked in September about two weeks after school return from the summer holidays. The patterns in the distribution of asthma exacerbations may be explained by a combination of geographical differences in allergen sensitisation, pollution levels, viral exposure and/or weather conditions. In general, understanding the determinants of asthma exacerbation is poor because of the difficulty in determining exposure to causal factors and the complexity of the interactions between them.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">There are not many reports on the association between asthma attacks and specific weather conditions.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#8211;19</span></a> Relative humidity, mean temperature, rainfall, wind speed, sunshine and barometric pressure have been evaluated as a cause of asthma exacerbations in children. However, it is not clear whether climatic factors affect asthma exacerbations directly or indirectly through their effect on other environmental agents. To date, no model based on climatic factors has been able to accurately predict exacerbations of asthma. The aim of this study was to determine the epidemiology of asthma exacerbations in the children attended in a paediatric ED. We evaluated the association of these exacerbations with some meteorological factors and school attendance.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Materials and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Study population</span><p id="par0015" class="elsevierStylePara elsevierViewall">The study was conducted in the paediatric ED of a district hospital on the island of Mallorca, Spain. From July 1, 2007, to June 30, 2011, the medical records of children 5&#8211;14 years of age visited at the ED with a diagnosis of asthma exacerbation were retrospectively reviewed. Diagnosis, age, sex, and date of admission of all children attended were codified prior to their discharge and these data were automatically stored in a computerised database. Subjects were selected from this database after revision of the hospital discharge codes with a primary or secondary diagnosis of asthma exacerbation. The episodes of asthma exacerbation were identified via the International Classification of Diseases, 9th revision, with 493.0-9 discharge codes.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Meteorological data</span><p id="par0020" class="elsevierStylePara elsevierViewall">During the study period, data on barometric pressure, humidity, wind speed, wind distance, rainfall, global solar radiation and temperature were obtained from the Spanish Meteorology Agency. This agency collects daily information from a weather station located close by at latitude 39.55&deg;<span class="elsevierStyleHsp" style=""></span>N, longitude 2.73&deg;<span class="elsevierStyleHsp" style=""></span>E and 4<span class="elsevierStyleHsp" style=""></span>m height. Water vapour pressure was obtained using an equation described elsewhere.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Data analysis</span><p id="par0025" class="elsevierStylePara elsevierViewall">Descriptive analysis was performed using frequency distributions or rates. All continuous variables were confirmed to be normally distributed, or to have skewness not significantly different from zero. Results are presented as mean<span class="elsevierStyleHsp" style=""></span>&plusmn;<span class="elsevierStyleHsp" style=""></span>standard deviation (SD) or median and interquartile (IQR) as required. Co-linearity was studied performing tolerance testing. For analyses, variables were paired throughout the 12 months of the year; the meteorological data were the mean of the different monthly means, and asthma exacerbations was the sum of admissions in the ED for this reason during the months of the year. The association between asthma exacerbations and the meteorological variables was determined after multivariate linear regression. Backward elimination method was used for variable selection. The effect of two lag months period was also evaluated. The effect of a unit increase for each independent variable was calculated transforming the <span class="elsevierStyleItalic">¿</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">i</span></span> coefficients into percentages ([<span class="elsevierStyleItalic">¿</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">i</span></span>/<span class="elsevierStyleItalic">N</span>&deg; asthma exacerbations]<span class="elsevierStyleHsp" style=""></span>&times;<span class="elsevierStyleHsp" style=""></span>100). To determine the effect of school attendance we considered that one or more weeks of school holidays during a month period could be considered a relevant decrease in schooling. In consequence, a dummy variable that defined schooling as the absence of this holiday period was introduced in the multivariate analyses. Statistical significance was set at <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0.05. Data were analysed with the statistical software package IBM SPSS 20.0 (New York, USA).</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Results</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">General characteristics and seasonality</span><p id="par0030" class="elsevierStylePara elsevierViewall">From July 1, 2007, through June 30, 2011, 371 children aged 5&#8211;14 years were attended at the ED for asthma exacerbation. This accounted for 7.9% of the attended children of this age group in the paediatric ED. The median age was eight years (IQR: 6&#8211;11), and 59% were males. The monthly distribution of the children attended for asthma is shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>. Monthly asthma exacerbations showed a bimodal distribution with two annual peaks, one in spring and the other in autumn. <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the monthly variation of the meteorological variables.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Association with meteorological factors</span><p id="par0035" class="elsevierStylePara elsevierViewall">After multivariate analyses asthma exacerbation was independently associated to several meteorological variables: mean temperature, water vapour pressure, relative humidity and maximum wind speed (see <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). The resulting model (including schooling) was able to explain 98.4% of the variability of monthly asthma exacerbations during the study period. The regression equation showed a 7.3% increase in the number of monthly asthma exacerbations for each degree decrease in temperature; and 1.5% and 2.1% increase for each unit rise in wind speed and relative humidity, respectively. A 100<span class="elsevierStyleHsp" style=""></span>hPa increase in water vapour pressure decreased the number of asthma exacerbations by 7.8%. The use of one and two lag months did not provide better models.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Association with school attendance</span><p id="par0040" class="elsevierStylePara elsevierViewall">Peak asthma exacerbations occurred 15 days after school return from the summer holidays (week 39 of the year). The number of attended asthma exacerbations decreased the following week but maintained at a high rate for several months with scarce variations (see <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Multivariate analysis showed that school attendance was also an independent variable associated to asthma exacerbations.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discussion</span><p id="par0045" class="elsevierStylePara elsevierViewall">Asthma exacerbations show a seasonal variability in adults and children in both hemispheres, with grade school children being the most vulnerable to seasonal changes.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21,22</span></a> In our study, we observed a bimodal seasonal pattern of asthma exacerbations with peaks in April and October, similar to those described in Tokyo (Japan) and Ontario (Canada).<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14,15</span></a> Studies that have evaluated the association between meteorological factors and asthma exacerbations in the ED are limited and have obtained disparate results. They differ in the meteorological variables associated, their positive or negative correlation and/or the strength of the association. The resulting models of the reported studies on meteorological factors and exacerbation of asthma have shown low predictive power (<span class="elsevierStyleItalic">R</span><span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0.4).<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#8211;9,17</span></a> In our study, we observed an association between asthma exacerbation, measured by the rates of ED visits for asthma, and several meteorological variables such as mean temperature, water vapour pressure, relative humidity and maximum wind speed. This model has given a very high predictive power (<span class="elsevierStyleItalic">R</span><span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.98), making it very useful for forecasting.</p><p id="par0050" class="elsevierStylePara elsevierViewall">We observed that mean temperature was inversely correlated with ED visits for asthma, which is consistent with other studies that showed a weaker correlation.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,17</span></a> However, this variable has given contradictory results in some reports. Mohr et al.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> reported a positive association with ED visits for asthma in summer and negative during the winter time. Hashimoto et al.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> observed a positive association for mean temperature but inverse for maximum average temperature. In addition, other studies have found a weak positive correlation.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> It is likely that these results are not mutually exclusive, and that the association between temperature and asthma exacerbations in the ED depends on the aetiological trigger; probably negative with respiratory viruses,<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> and positive in the case of air pollutants and pollens.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18,25,26</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">In our study, asthma exacerbations in the ED were associated to a decrease in the water vapour pressure and to an increase in relative humidity. The association between vapour pressure and asthma exacerbations has not been previously studied, but several studies have reported a relationship between this variable and respiratory viruses (respiratory syncytial virus and influenza), which are believed to trigger asthma exacerbations.<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20,24</span></a> Similarly, increased relative humidity has been correlated in some studies to an increase in viral activity and mite concentration.<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27,28</span></a> In our study, for each one percent increase in relative humidity there was a 1.8% increase in asthma attacks, as also described by others.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Overall, the association of asthma attacks with temperature, vapour pressure and humidity is in agreement with the increasing evidence of the role of viral respiratory infections as important triggers of asthma exacerbations, especially serotype C human rhinovirus.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> A recent study performed in Madrid (Spain) evaluated the seasonal distribution of rhinovirus C infections in children.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> We compared their data with our monthly incidence of asthma attacks, observing a good correlation (<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.61, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0.05; data not shown). Despite the limitations of comparing populations with environmental and weather differences, this correlation suggests that the asthma exacerbations in our study could also be caused by rhinovirus infections in certain periods of the year.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The maximum wind speed was another independent factor that we found associated to asthma exacerbations. Until now, reports correlating this meteorological factor to viral infections and/or asthma exacerbations have been anecdotal.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15,28</span></a> In our study, the correlation was more marked during the spring time. An increase in wind speed during this season could favour a higher concentration, transport and/or exposure to pollen grains. In a similar way, wind speed favours higher concentrations of asthma-related air pollutants such as low weight particle matter (e.g. PM<span class="elsevierStyleInf">10</span>).<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> However, we did not observe an association with rainfall or barometric pressure, which have been related to the concentration of air pollutants.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15,16</span></a> The absence of association between these two variables and asthma exacerbations in our study points to a scarce influence of pollutants as asthma triggers in our population.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Meteorological factors could also play a direct role as triggers of asthma exacerbations, as occurs with bronchoconstriction due to low air temperature or exercise-induced asthma in low humidity conditions. However, the real impact of the direct effect of climatic factors on asthma exacerbations requiring an ED visit remains unknown.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> A study performed in Ottawa (Canada), evaluating the association with asthma ED visits in an hourly time scale, suggested that the direct role of meteorological factors was scarce.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Finally, we evaluated the effect of schooling to see if this variable acted as a confounding factor due to seasonal overlapping with meteorological factors. Schooling was an independent variable that increased the monthly risk of asthma attacks. Previous studies have analysed the effect of schooling especially after the summer holidays. We observed that the highest asthma exacerbation peak occurred 15 days after the beginning of school in September. This is in accordance with the 10&#8211;18 days lag from school opening previously described.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22,33,34</span></a> As has been suggested, the &#8220;September epidemic&#8221; coinciding with school opening is probably due to various factors such as a favourable weather, increase of viral proliferation and exposure (especially rhinovirus), stress, and low compliance of inhaled corticosteroid therapy during the summer.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,35</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The present report is an ecological retrospective study with the limitations of this type of study. We are aware that our results cannot be extrapolated to other populations with different sociodemographic, environmental, and climatic characteristics. Despite these limitations, we have shown that meteorological factors and schooling can efficiently forecast the asthma exacerbations that need to visit the ED. This could have potential implications for the organisation of health resources, prevention and etiological study of asthma.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Ethical disclosures</span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Protection of human subjects and animals in research</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this investigation.</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Patients&#8217; data protection</span><p id="par0090" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work centre on the publication of patient data and that all the patients included in the study have received sufficient information and have given their informed consent in writing to participate in that study.</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Right to privacy and informed consent</span><p id="par0095" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflicts of interest</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors have no funding or conflicts of interest to disclose.</p></span></span>"
    "textoCompletoSecciones" => array:1 [
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          "identificador" => "xres414321"
          "titulo" => array:6 [
            0 => "Abstract"
            1 => "Background"
            2 => "Objectives"
            3 => "Methods"
            4 => "Results"
            5 => "Conclusions"
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          "titulo" => "Introduction"
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          "titulo" => "Materials and methods"
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            0 => array:2 [
              "identificador" => "sec0015"
              "titulo" => "Study population"
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            1 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Meteorological data"
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            2 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Data analysis"
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          ]
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        4 => array:3 [
          "identificador" => "sec0030"
          "titulo" => "Results"
          "secciones" => array:3 [
            0 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "General characteristics and seasonality"
            ]
            1 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "Association with meteorological factors"
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            2 => array:2 [
              "identificador" => "sec0045"
              "titulo" => "Association with school attendance"
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          ]
        ]
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          "titulo" => "Discussion"
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        6 => array:3 [
          "identificador" => "sec0055"
          "titulo" => "Ethical disclosures"
          "secciones" => array:3 [
            0 => array:2 [
              "identificador" => "sec0060"
              "titulo" => "Protection of human subjects and animals in research"
            ]
            1 => array:2 [
              "identificador" => "sec0065"
              "titulo" => "Patients&#8217; data protection"
            ]
            2 => array:2 [
              "identificador" => "sec0070"
              "titulo" => "Right to privacy and informed consent"
            ]
          ]
        ]
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          "identificador" => "sec0075"
          "titulo" => "Conflicts of interest"
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        8 => array:1 [
          "titulo" => "References"
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    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2013-06-10"
    "fechaAceptado" => "2013-07-06"
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec389962"
          "palabras" => array:6 [
            0 => "Humidity"
            1 => "Barometric pressure"
            2 => "Wind speed"
            3 => "Climate"
            4 => "Asthma exacerbation"
            5 => "Epidemiology"
          ]
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      ]
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      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Asthma exacerbations attended in emergency departments show a marked seasonality in the paediatric age. This seasonal pattern can change from one population to another and the factors involved are poorly understood.</p> <span class="elsevierStyleSectionTitle" id="sect0015">Objectives</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To evaluate the association between meteorological factors and schooling with asthma exacerbations in children attended in the paediatric emergency department of a district hospital.</p> <span class="elsevierStyleSectionTitle" id="sect0020">Methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">We conducted a retrospective review of the medical records of children 5&#8211;14 years of age attended for asthma exacerbations during a 4-year period (2007&#8211;2011). Climatic data were obtained from a weather station located very close to the population studied. The number of asthma exacerbations was correlated to temperature, barometric pressure, relative humidity, rainfall, wind speed, wind distance, solar radiation, water vapour pressure and schooling, using regression analyses.</p> <span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">During the study period, 371 children were attended for asthma exacerbations; median age was eight years (IQR: 6&#8211;11), and 59% were males. Asthma exacerbations showed a bimodal pattern with peaks in spring and summer. Maximum annual peak occurred in week 39, within 15 days from school beginning after the summer holidays. A regression model with mean temperature, water vapour pressure, relative humidity, maximum wind speed and schooling could explain 98.4% (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0.001) of monthly asthma exacerbations.</p> <span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The combination of meteorological factors and schooling could predict asthma exacerbations in children attended in a paediatric emergency department.</p>"
      ]
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Seasonality of asthma exacerbations in the paediatric emergency department.</p>"
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Weekly distribution of the asthma exacerbations.</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Month&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Vapour pressure (hPa)&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Barometric pressure (hPa)&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Relative humidity (%)&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Solar radiation (10<span class="elsevierStyleHsp" style=""></span>kJ/m<span class="elsevierStyleSup">2</span>)&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean <span class="elsevierStyleItalic">T</span>&ordf; (&deg;C)&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Maximum wind speed (km/h)&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Wind distance (km)&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Rainfall (mm)&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">January&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">987.2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1016.8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">81.1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">763.1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9.9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">37.6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">243.2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1.6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">February&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">993.5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1016.6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">79.3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1093.2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10.3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">37.9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">258.0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1.2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">March&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1037.6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1016.1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">76.6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1460.8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11.5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">41.4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">284.2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1.2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">April&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1238.2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1014.8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">75.4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1956.3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14.4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">39.0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">279.9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0.9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">May&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1494.7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1015.0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">71.2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2157.2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18.2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">38.6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">270.4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2.5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">June&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1759.7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1015.5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">68.2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2738.6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21.6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">37.2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">262.2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0.6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">July&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2055.1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1016.0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">64.8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2691.4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25.0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">38.4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">288.8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0.0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">August&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2142.8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1015.2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">67.8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2298.9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24.9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">39.2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">284.1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0.5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">September&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1870.2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1016.1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">70.9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1862.6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21.9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">37.7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">251.4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2.9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">October&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1644.4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1016.0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">78.3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1142.1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18.3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">37.5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">253.2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3.2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">November&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1196.7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1014.9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">78.1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">858.2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13.3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">38.5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">251.4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1.5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">December&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1020.5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1015.5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">80.5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">676.3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10.4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">38.3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">249.7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1.7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0.0001&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Multiple linear regression analyses.<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">&sect;</span></a></p>"
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    "bibliografia" => array:2 [
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ISSN: 03010546
Original language: English
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos