Spatio-temporal analysis of pneumonia and influenza hospitalizations in Ontario, Canada

Pneumonia and influenza represent a significant public health and health care system burden that is expected to increase with the aging of developed nations' populations. The burden of these illnesses is far from uniform however, with recent studies showing that they are both highly spatially and temporally variable. We have combined spatial and time-series analysis techniques to examine pneumonia and influenza hospitalizations in the province of Ontario, Canada, to determine how temporal patterns vary over space, and how spatial patterns of hospitalizations vary over time. Knowledge of these patterns can provide clues to disease aetiology and inform the effective management of health care system resources. Spatial analysis revealed significant clusters of high hospitalization rates in northern and rural counties (Moran's I = 0.186; P <0.05), while county level time series analysis demonstrated significant upward trends in rates in almost a quarter of the counties (P <0.05), and significant seasonality in all but one county (Fisher-Kappa and Barlett Kolmogorov Smirnov tests significant at the level P <0.01). Areas of weak seasonality were typically seen in rural areas with high rates of hospitalizations. The highest levels of spatial clustering of pneumonia and influenza hospitalizations were found to occur in months when rates were lowest. The findings provide evidence of spatio-temporal interaction over the study period, with marked spatial variability in temporal patterns, and temporal variability in spatial patterns. Results point to the need for the effective allocation of services and resources based on regional and seasonal demands, and more regionally focused prevention strategies. This research represents an important step towards understanding the dynamic nature of these illnesses, and sets the stage for the application of spatio-temporal modelling techniques to explain them.