Age-Dependent Variations in Kawasaki Disease Incidence in Japan

Importance

The etiology of Kawasaki disease (KD) remains elusive, with immunologic and epidemiologic data suggesting different triggers in individuals who are genetically susceptible. KD remains the most common cause of acquired heart disease in pediatric patients, and Japan is the country of highest incidence, with an increasing number of cases.

Objective

To investigate whether an analysis of the epidemiologic KD record in Japan stratified by age and prefecture (subregion) may yield new clues regarding mechanisms of exposure to etiologic agents associated with KD.

Design, Setting, and Participants

This cross-sectional study was conducted using a dataset of patients with KD with detailed information on location and age at onset created through nationwide surveys of hospitals caring for pediatric patients with KD throughout Japan. Pediatric patients hospitalized in Japan for KD from 1970 to 2020 were included. Data were analyzed from January 2022 to January 2024.

Exposure

Pediatric patients with KD.

Main Outcomes and Measures

The KD dataset was analyzed by patient age (infants [aged <6 months], toddlers [aged 6 to <24 months], children aged 2 years [aged 24 to <36 months], and children and adolescents aged 3 years or older [aged ≥36 months]), with investigations of seasonal cycles, interannual variations, and correlations across regions.

Results

Among 422 528 pediatric patients (243 803 males [57.7%] and 178 732 females [42.3%]; median [IQR] age, 23.69 [11.96-42.65] months), infants, toddlers, and patients aged 3 years or older exhibited different rates of increase in KD incidence, seasonality, and degrees of coherence of seasonality across prefectures. Although the mean (SD) incidence of KD among infants remained relatively stable over the past 30 years compared with older patients (1.00 [0.07] in 1987-1992 to 2.05 [0.11] in 2011-2016), the mean (SD) incidence rate for children and adolescents aged 3 years or older increased 5.2-fold, from 1.00 (0.08) in 1987 to 1992 to 5.17 (0.46) in 2014 to 2019. Patients aged 3 years or older saw a reduction in mean (SD) incidence, from peaks of 5.71 (0.01) in October 2014 through June 2015 and July 2018 through March 2019 to 4.69 (0.11) in 2016 to 2017 (17.8% reduction) not seen in younger children. The seasonal cycle varied by age group; for example, mean (SD) incidence peaked in July and August (5.63 [0.07] cases/100 000 individuals) for infants and in December and January (4.67 [0.13] cases/100 000 individuals) for toddlers. Mean (SD) incidence changed dramatically for toddlers beginning in the early 2010s; for example, the normalized mean (SD) incidence among toddlers for October was 0.74 (0.03) in 1992 to 1995 and 1.10 (0.01) in 2016 to 2019. Across Japan, the seasonal cycle of KD incidence of older children and adolescents exhibited mean (SD) correlation coefficients between prefectures as high as 0.78 (0.14) for prefecture 14 among patients aged 3 years or older, while that of infants was much less (highest mean [SD] correlation coefficient, 0.43 [0.23]).

Conclusions and Relevance

This study found distinct temporal signatures and changing spatial consistency of KD incidence across age groups, suggesting different age-related mechanisms of exposure. Some results suggested that social factors may modulate exposure to etiologic agents of KD; however, the increase in KD incidence in older children coupled with the correlation across prefectures of KD incidence suggest that the intensity of an environmental exposure that triggers KD in this age group may have increased over time.

Epidemiological and Clinical Features of Kawasaki Disease During the COVID-19 Pandemic in the United States

IMPORTANCE

Public health measures implemented during the COVID-19 pandemic had widespread effects on population behaviors, transmission of infectious diseases, and exposures to environmental pollutants. This provided an opportunity to study how these factors potentially influenced the incidence of Kawasaki disease (KD), a self-limited pediatric vasculitis of unknown etiology.

OBJECTIVES

To examine the change in KD incidence across the United States and evaluate whether public health measures affected the prevalence of KD.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter cohort study included consecutive, unselected patients with KD who were diagnosed between January 1, 2018, and December 31, 2020 (multicenter cohort with 28 pediatric centers), and a detailed analysis of patients with KD who were diagnosed between January 1, 2002, and November 15, 2021 (Rady Children's Hospital San Diego [RCHSD]).

MAIN OUTCOMES AND MEASURES

For the multicenter cohort, the date of fever onset for each patient with KD was collected. For RCHSD, detailed demographic and clinical data as well as publicly available, anonymized mobile phone data and median household income by census block group were collected. The study hypothesis was that public health measures undertaken during the pandemic would reduce exposure to the airborne trigger(s) of KD and that communities with high shelter-in-place compliance would experience the greatest decrease in KD incidence.

RESULTS

A total of 2461 KD cases were included in the multicenter study (2018: 894; 2019: 905; 2020: 646), and 1461 cases (median [IQR] age, 2.8 years [1.4-4.9 years]; 900 [61.6%] males; 220 [15.1%] Asian, 512 [35.0%] Hispanic, and 338 [23.1%] White children) from RCHSD between 2002 and 2021 were also included. The 28.2% decline in KD cases nationally during 2020 (646 cases) compared with 2018 (894 cases) and 2019 (905 cases) was uneven across the United States. For RCHSD, there was a disproportionate decline in KD cases in 2020 to 2021 compared with the mean (SD) number of cases in earlier years for children aged 1 to 5 years (22 vs 44.9 [9.9]; P = .02), male children (21 vs 47.6 [10.0]; P = .01), and Asian children (4 vs 11.8 [4.4]; P = .046). Mobility data did not suggest that shelter-in-place measures were associated with the number of KD cases. Clinical features including strawberry tongue, enlarged cervical lymph node, and subacute periungual desquamation were decreased during 2020 compared with the baseline period (strawberry tongue: 39% vs 63%; P = .04; enlarged lymph node: 21% vs 32%; P = .09; periungual desquamation: 47% vs 58%; P = .16). School closures, masking mandates, decreased ambient pollution, and decreased circulation of respiratory viruses all overlapped to different extents with the period of decreased KD cases. KD in San Diego rebounded in the spring of 2021, coincident with lifting of mask mandates.

CONCLUSIONS AND RELEVANCE

In this study of epidemiological and clinical features of KD during the COVID-19 pandemic in the United States, KD cases fell and remained low during the period of masking and school closure. Mobility data indicated that differential intensity of sheltering in place was not associated with KD incidence. These findings suggest that social behavior is associated with exposure to the agent(s) that trigger KD and are consistent with a respiratory portal of entry for the agent(s).

Temporal clustering of Kawasaki disease cases around the world

In a single-site study (San Diego, CA, USA), we previously showed that Kawasaki Disease (KD) cases cluster temporally in bursts of approximately 7 days. These clusters occurred more often than would be expected at random even after accounting for long-term trends and seasonality. This finding raised the question of whether other locations around the world experience similar temporal clusters of KD that might offer clues to disease etiology. Here we combine data from San Diego and nine additional sites around the world with hospitals that care for large numbers of KD patients, as well as two multi-hospital catchment regions. We found that across these sites, KD cases clustered at short time scales and there were anomalously long quiet periods with no cases. Both of these phenomena occurred more often than would be expected given local trends and seasonality. Additionally, we found unusually frequent temporal overlaps of KD clusters and quiet periods between pairs of sites. These findings suggest that regional and planetary range environmental influences create periods of higher or lower exposure to KD triggers that may offer clues to the etiology of KD.

Multiple climate change-driven tipping points for coastal systems

As the climate evolves over the next century, the interaction of accelerating sea level rise (SLR) and storms, combined with confining development and infrastructure, will place greater stresses on physical, ecological, and human systems along the ocean-land margin. Many of these valued coastal systems could reach "tipping points," at which hazard exposure substantially increases and threatens the present-day form, function, and viability of communities, infrastructure, and ecosystems. Determining the timing and nature of these tipping points is essential for effective climate adaptation planning. Here we present a multidisciplinary case study from Santa Barbara, California (USA), to identify potential climate change-related tipping points for various coastal systems. This study integrates numerical and statistical models of the climate, ocean water levels, beach and cliff evolution, and two soft sediment ecosystems, sandy beaches and tidal wetlands. We find that tipping points for beaches and wetlands could be reached with just 0.25 m or less of SLR (~ 2050), with > 50% subsequent habitat loss that would degrade overall biodiversity and ecosystem function. In contrast, the largest projected changes in socioeconomic exposure to flooding for five communities in this region are not anticipated until SLR exceeds 0.75 m for daily flooding and 1.5 m for storm-driven flooding (~ 2100 or later). These changes are less acute relative to community totals and do not qualify as tipping points given the adaptive capacity of communities. Nonetheless, the natural and human built systems are interconnected such that the loss of natural system function could negatively impact the quality of life of residents and disrupt the local economy, resulting in indirect socioeconomic impacts long before built infrastructure is directly impacted by flooding.

Temporal Clusters of Kawasaki Disease Cases Share Distinct Phenotypes That Suggest Response to Diverse Triggers

OBJECTIVE

To test the hypothesis that cases of Kawasaki disease within a temporal cluster have a similar pattern of host response that is distinct from cases of Kawasaki disease in different observed clusters and randomly constructed clusters.

STUDY DESIGN

We designed a case-control study to analyze 47 clusters derived from 1332 patients with Kawasaki disease over a 17-year period (2002-2019) from a single clinical site and compared the cluster characteristics with those of 2 control groups of synthetic Kawasaki disease clusters. We defined a "true" Kawasaki disease cluster as at least 5 patients within a 7-day moving window. The observed and synthetic Kawasaki disease clusters were compared with respect to demographic and clinical characteristics and median values for standard laboratory data using univariate analysis and a multivariate, rotated empirical orthogonal function analysis.

RESULTS

In a univariate analysis, the median values for age, coronary artery z-score, white blood cell count, erythrocyte sedimentation rate, C-reactive protein, and age-adjusted hemoglobin for several of the true Kawasaki disease clusters exceeded the 95th percentile for the 2 synthetic clusters. REOF analyses revealed distinct patterns of demographic and clinical measures within clusters.

CONCLUSIONS

Cases of Kawasaki disease within a cluster were more similar with respect to demographic and clinical features and levels of inflammation than would be expected by chance. These observations suggest that different triggers and/or different intensities of exposures result in clusters of cases of Kawasaki disease that share a similar response pattern. Analyzing cases within clusters or cases who share demographic and clinical features may lead to new insights into the etiology of Kawasaki disease.

Atmospheric rivers drive flood damages in the western United States

Atmospheric rivers (ARs) are extratropical storms that produce extreme precipitation on the west coasts of the world's major landmasses. In the United States, ARs cause significant flooding, yet their economic impacts have not been quantified. Here, using 40 years of data from the National Flood Insurance Program, we show that ARs are the primary drivers of flood damages in the western United States. Using a recently developed AR scale, which varies from category 1 to 5, we find that flood damages increase exponentially with AR intensity and duration: Each increase in category corresponds to a roughly 10-fold increase in damages. Category 4 and 5 ARs cause median damages in the tens and hundreds of millions of dollars, respectively. Rising population, increased development, and climate change are expected to worsen the risk of AR-driven flood damage in future decades.

A spatially comprehensive, hydrometeorological data set for Mexico, the U.S., and Southern Canada 1950-2013

A data set of observed daily precipitation, maximum and minimum temperature, gridded to a 1/16° (~6 km) resolution, is described that spans the entire country of Mexico, the conterminous U.S. (CONUS), and regions of Canada south of 53° N for the period 1950–2013. The dataset improves previous products in spatial extent, orographic precipitation adjustment over Mexico and parts of Canada, and reduction of transboundary discontinuities. The impacts of adjusting gridded precipitation for orographic effects are quantified by scaling precipitation to an elevation-aware 1981–2010 precipitation climatology in Mexico and Canada. Differences are evaluated in terms of total precipitation as well as by hydrologic quantities simulated with a land surface model. Overall, orographic correction impacts total precipitation by up to 50% in mountainous regions outside CONUS. Hydrologic fluxes show sensitivities of similar magnitude, with discharge more sensitive than evapotranspiration and soil moisture. Because of the consistent gridding methodology, the current product reduces transboundary discontinuities as compared with a commonly used reanalysis product, making it suitable for estimating large-scale hydrometeorologic phenomena.

A spatially comprehensive, hydrometeorological data set for Mexico, the U.S., and Southern Canada 1950-2013

A data set of observed daily precipitation, maximum and minimum temperature, gridded to a 1/16° (~6 km) resolution, is described that spans the entire country of Mexico, the conterminous U.S. (CONUS), and regions of Canada south of 53° N for the period 1950-2013. The dataset improves previous products in spatial extent, orographic precipitation adjustment over Mexico and parts of Canada, and reduction of transboundary discontinuities. The impacts of adjusting gridded precipitation for orographic effects are quantified by scaling precipitation to an elevation-aware 1981-2010 precipitation climatology in Mexico and Canada. Differences are evaluated in terms of total precipitation as well as by hydrologic quantities simulated with a land surface model. Overall, orographic correction impacts total precipitation by up to 50% in mountainous regions outside CONUS. Hydrologic fluxes show sensitivities of similar magnitude, with discharge more sensitive than evapotranspiration and soil moisture. Because of the consistent gridding methodology, the current product reduces transboundary discontinuities as compared with a commonly used reanalysis product, making it suitable for estimating large-scale hydrometeorologic phenomena.

Remote Hydrology. Ongoing drought-induced uplift in the western United States

The western United States has been experiencing severe drought since 2013. The solid earth response to the accompanying loss of surface and near-surface water mass should be a broad region of uplift. We use seasonally adjusted time series from continuously operating global positioning system stations to measure this uplift, which we invert to estimate mass loss. The median uplift is 5 millimeters (mm), with values up to 15 mm in California's mountains. The associated pattern of mass loss, ranging up to 50 centimeters (cm) of water equivalent, is consistent with observed decreases in precipitation and streamflow. We estimate the total deficit to be ~240 gigatons, equivalent to a 10-cm layer of water over the entire region, or the annual mass loss from the Greenland Ice Sheet.

The key role of dry days in changing regional climate and precipitation regimes

Future changes in the number of dry days per year can either reinforce or counteract projected increases in daily precipitation intensity as the climate warms. We analyze climate model projected changes in the number of dry days using 28 coupled global climate models from the Coupled Model Intercomparison Project, version 5 (CMIP5). We find that the Mediterranean Sea region, parts of Central and South America, and western Indonesia could experience up to 30 more dry days per year by the end of this century. We illustrate how changes in the number of dry days and the precipitation intensity on precipitating days combine to produce changes in annual precipitation, and show that over much of the subtropics the change in number of dry days dominates the annual changes in precipitation and accounts for a large part of the change in interannual precipitation variability.

Human-induced changes in the hydrology of the western United States

Observations have shown that the hydrological cycle of the western United States changed significantly over the last half of the 20th century. We present a regional, multivariable climate change detection and attribution study, using a high-resolution hydrologic model forced by global climate models, focusing on the changes that have already affected this primarily arid region with a large and growing population. The results show that up to 60% of the climate-related trends of river flow, winter air temperature, and snow pack between 1950 and 1999 are human-induced. These results are robust to perturbation of study variates and methods. They portend, in conjunction with previous work, a coming crisis in water supply for the western United States.

Warming and Earlier Spring Increase Western U.S. Forest Wildfire Activity

Western United States forest wildfire activity is widely thought to have increased in recent decades, yet neither the extent of recent changes nor the degree to which climate may be driving regional changes in wildfire has been systematically documented. Much of the public and scientific discussion of changes in western United States wildfire has focused instead on the effects of 19th- and 20th-century land-use history. We compiled a comprehensive database of large wildfires in western United States forests since 1970 and compared it with hydroclimatic and land-surface data. Here, we show that large wildfire activity increased suddenly and markedly in the mid-1980s, with higher large-wildfire frequency, longer wildfire durations, and longer wildfire seasons. The greatest increases occurred in mid-elevation, Northern Rockies forests, where land-use histories have relatively little effect on fire risks and are strongly associated with increased spring and summer temperatures and an earlier spring snowmelt.

Seasonality and temporal clustering of Kawasaki syndrome

BACKGROUND

The distribution of a syndrome in space and time may suggest clues to its etiology. The cause of Kawasaki syndrome, a systemic vasculitis of infants and children, is unknown, but an infectious etiology is suspected.

METHODS

Seasonality and clustering of Kawasaki syndrome cases were studied in Japanese children with Kawasaki syndrome reported in nationwide surveys in Japan. Excluding the years that contained the 3 major nationwide epidemics, 84,829 cases during a 14-year period (1987-2000) were analyzed. To assess seasonality, we calculated mean monthly incidence during the study period for eastern and western Japan and for each of the 47 prefectures. To assess clustering, we compared the number of cases per day (daily incidence) with a simulated distribution (Monte Carlo analysis).

RESULTS

Marked spatial and temporal patterns were noted in both the seasonality and deviations from the average number of Kawasaki syndrome cases in Japan. Seasonality was bimodal with peaks in January and June/July and a nadir in October. This pattern was consistent throughout Japan and during the entire 14-year period. Some years produced very high or low numbers of cases, but the overall variability was consistent throughout the entire country. Temporal clustering of Kawasaki syndrome cases was detected with nationwide outbreaks.

CONCLUSIONS

Kawasaki syndrome has a pronounced seasonality in Japan that is consistent throughout the length of the Japanese archipelago. Temporal clustering of cases combined with marked seasonality suggests an environmental trigger for this clinical syndrome.

Climate-Ocean Variability and Ecosystem Response in the Northeast Pacific

The role of climatic variation in regulating marine populations and communities is not well understood. To improve our knowledge, the sign, amplitude, and frequency of climatic and biotic variations should be compared as a necessary first step. It is shown that there have been large interannual and interdecadal sea-surface temperature changes off the West Coast of North America during the past 80 years. Interannual anomalies appear and disappear rather suddenly and synchronously along the entire coastline. The frequency of warm events has increased since 1977. Although extensive, serial, biological observations are often incomplete, it is clear that climate-ocean variations have disturbed and changed our coastal ecosystems.

A 5000-Year Record of Extreme Floods and Climate Change in the Southwestern United States

A 5000-year regional paleoflood chronology, based on flood deposits from 19 rivers in Arizona and Utah, reveals that the largest floods in the region cluster into distinct time intervals that coincide with periods of cool, moist climate and frequent El Niño events. The floods were most numerous from 4800 to 3600 years before present (B.P.), around 1000 years B.P., and after 500 years B.P., but decreased markedly from 3600 to 2200 and 800 to 600 years B.P. Analogous modern floods are associated with a specific set of anomalous atmospheric circulation conditions that were probably more prevalent during past flood epochs.

Climate and Chlorophyll a: Long-Term Trends in the Central North Pacific Ocean

Since 1968 a significant increase in total chlorophyll a in the water column during the summer in the central North Pacific Ocean has been observed. A concomitant increase in winter winds and a decrease in sea surface temperature suggest that long-period fluctuations in atmospheric characteristics have changed the carrying capacity of the central Pacific epipelagic ecosystem.

Large-Scale Air-Sea Interactions and Short-Period Climatic Fluctuations

Research during the last 15 years has shown that there is order in large-scale air-sea interactions, so that space scales of abnormalities of the lower atmosphere's circulation and the upper oceanic thermal structure are comparable. Because of this air-sea coupling, each oceanic or atmospheric pattern can be reasonably well specified by the other. Patterns of oceanic thermal anomalies are about an order of magnitude more persistent than those of atmospheric circulations, and empirical studies have had some success in using sea surface temperature patterns in long-range weather prediction. In addition to empirical studies, efforts continue in the development of numerical-dynamical models in order to understand the complex linkages of the large-scale air-sea system.