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Indicator Assessment
Associations between temperature and mortality in four European cities
Note: Exposure-response associations between temperature and mortality in four European cities, together with related temperatures distributions. The shaded grey area delineates the 95 % empirical confidence interval. Solid grey vertical lines are minimum mortality temperatures and dashed grey vertical lines delineate the 2.5th and 97.5th percentile temperatures.
Past trends
In large parts of Europe, summertime temperature records, which are associated with prolonged heat waves, have increased substantially in recent decades. The summer of 2003 broke temperature records in large parts of western Europe; temperature records were again broken in different parts of Europe during the summers of 2006, 2007, 2010, 2013, 2014 and 2015 [i]. The record warm summer of 2003 was an outstanding example of increased mortality during periods of extreme temperatures, with an estimated premature mortality of 70 000 people in Europe [ii]. The heat waves of the summer of 2015 caused more than 3 000 deaths in France alone [iii].
The largest effect of heat has been observed among the elderly, but in some cities younger adults have also been affected [iv]. Elderly people are more vulnerable to the effects of heat waves, owing, in part, to poorer physical health and the effects of cognitive impairment on the perception of heat-related health risk; this is the population considered most at risk of heat-related mortality [v]. In addition to the elderly, those with chronic diseases and persons of lower socio-economic status also have a heightened risk of heat-related mortality [vi]. Furthermore, health risks during heat extremes are greater in people who are physically very active. This has importance for outdoor recreational activities, and it is especially relevant for the impacts of climate change on occupational health (e.g. for manual labourers) [vii].
The above-mentioned multi-country global observational study found that (moderate) cold was responsible for a higher proportion of deaths than (moderate) heat. The study collected data for daily mortality, temperature and other confounding variables from Italy (11 cities, 1987–2010), Spain (51 cities, 1990–2010), Sweden (one county, 1990–2002), the United Kingdom (10 regions, 1993–2006) and other areas outside Europe [viii]. The results should be interpreted with caution when applied to other regions that were not included in the database.
Figure 1 shows the overall cumulative exposure–response curves for four European cities with the corresponding minimum mortality temperature and the cut-offs used to define extreme temperatures. Risk increases slowly and linearly for cold temperatures below the minimum mortality temperature, although some locations (e.g. London and Madrid) showed a higher increase for extreme cold than others. Risk generally escalated quickly and non-linearly at high temperatures. Deaths attributable to extreme heat are roughly as frequent as those attributable to moderate heat, while those attributable to extreme cold are negligible compared with those caused by moderate cold [ix]. Other studies have estimated that 1.6–2.0 % of total mortality in the warm season is attributable to heat; about 40 % of these deaths occur on isolated hot days in periods that would not be classified as heat waves [x].
Comparison of these estimates should be made with caution, as not only the methods used to estimate the excess deaths, but also the exposures were different. The impact of high temperatures later in the summer is sometimes diminished after an early heat wave. In Europe, heat waves occurring in June result in relatively high mortality compared with those occurring later in the summer [xi].
Synergistic effects between high temperature and air pollution (Particles in the atmosphere with a diameter of less than or equal to a nominal 10 micrometres (PM10) and ozone) have been observed to have led to an increase in hospital admissions as a result of cardiovascular and respiratory diseases. Furthermore, long warm and dry periods, in combination with other factors, can lead to forest fires, which can also have severe health impacts [xii].
Projections
It is virtually certain that heat extremes will continue to become more frequent over most land areas in the future. The number of monthly heat records globally is projected to be more than 12 times as high under a medium global warming scenario by the 2040s as in a climate with no long-term warming [xiii]. The projected return period of extreme heat events, such as those experienced in 2003 in western Europe, will significantly shorten. This increase in heat extremes will lead to a marked increase in heat-attributable deaths under future warming, unless adaptation measures are taken. Highly urbanised areas are projected to be at an increased risk of heat stress compared with surrounding areas. Projections of future heat effects on human health need to consider that the European population is projected to age, because elderly populations are especially vulnerable [xiv].
Several studies have estimated future heat-related mortality in Europe using similar methods and have arrived at largely comparable results, namely PESETA, ClimateCost and PESETA II [xv].
The PESETA study estimates that, without adaptation and physiological acclimatisation, heat-related mortality in Europe would increase by between 60 000 and 165 000 deaths per year by the 2080s compared with the present baseline, with the highest impacts in southern Europe. The results vary across climate models and emissions scenarios, with high emissions scenarios leading to much higher heat-related mortality than low emissions scenarios. Heat-related mortality would be significantly lower under full acclimatisation if, for example, currently cool regions were able to achieve the temperature–mortality relationship of currently warm regions [xvi]. The results from the PESETA II study confirm, to a large extent, the results of earlier assessments (in particular, those from the PESETA and ClimateCost projects), although with slightly higher impacts (both in physical and economic terms) [xvii]. Comparable estimates were made by the World Health Organization (WHO) for the WHO European Region [xviii].
Another study estimates that climate change will lead to an increase in hospital admissions owing to heat-related respiratory diseases from 11 000 admissions (0.18 %) in the period 1981–2010 to 26 000 (0.4 %) in 2021–2050. The total number of hospital admissions and the increase as a result of climate change are largest in southern Europe, with the proportion of heat-related admissions for respiratory conditions expected to approximately triple in this region over this time period [xix].
The PESETA study estimated that cold-related mortality would decrease by between 60 000 and 250 000 deaths per year by the 2080s, which is about the same magnitude as the projected increase in heat-related mortality [xx]. The PESETA II study no longer considers a potential reduction in cold-related mortality in its climate impact estimates [xxi]. The choice not to include cold spells reflects recent evidence that does not suggest a significant shift in the balance of deaths between winters and summers because of lower cold-related mortality [xxii]. However, the risk from (moderate) cold is expected to continue to account for most of the temperature-related risk throughout this century [xxiii].
[i] D. Barriopedro et al., ‘The Hot Summer of 2010: Redrawing the Temperature Record Map of Europe’,Science 332, no. 6026 (17 March 2011): 220–24, doi:10.1126/science.1201224; Dim Coumou, Alexander Robinson, and Stefan Rahmstorf, ‘Global Increase in Record-Breaking Monthly-Mean Temperatures’,Climatic Change 118, no. 3–4 (1 June 2013): 771–82, doi:10.1007/s10584-012-0668-1.
[ii] Jean-Marie Robine et al., ‘Death Toll Exceeded 70,000 in Europe during the Summer of 2003’,Comptes Rendus Biologies 331, no. 2 (February 2008): 171–78, doi:10.1016/j.crvi.2007.12.001.
[iii] CRED, ‘Disaster Data: A Balanced Perspective’, Cred Crunch Newsletter (Brussels: CRED, 3 March 2016), http://reliefweb.int/report/world/cred-crunch-newsletter-issue-no-41-february-2016-disaster-data-balanced-perspective.
[iv] Daniela D’Ippoliti et al., ‘The Impact of Heat Waves on Mortality in 9 European Cities: Results from the EuroHEAT Project’,Environmental Health: A Global Access Science Source 9 (2010): 37, doi:10.1186/1476-069X-9-37; M. Baccini et al., ‘Impact of Heat on Mortality in 15 European Cities: Attributable Deaths under Different Weather Scenarios’,Journal of Epidemiology and Community Health 65, no. 1 (January 2011): 64–70, doi:10.1136/jech.2008.085639.
[v] Loïc Josseran et al., ‘Syndromic Surveillance and Heat Wave Morbidity: A Pilot Study Based on Emergency Departments in France’,BMC Medical Informatics and Decision Making 9 (2009): 14, doi:10.1186/1472-6947-9-14.
[vi] Tanja Wolf et al., ‘The Health Effects of Climate Change in the WHO European Region’,Climate 3, no. 4 (16 November 2015): 901–36, doi:10.3390/cli3040901.
[vii] Rebekah A. I. Lucas, Yoram Epstein, and Tord Kjellstrom, ‘Excessive Occupational Heat Exposure: A Significant Ergonomic Challenge and Health Risk for Current and Future Workers’,Extreme Physiology & Medicine 3, no. 1 (23 July 2014): 14, doi:10.1186/2046-7648-3-14.
[viii] Antonio Gasparrini et al., ‘Mortality Risk Attributable to High and Low Ambient Temperature: A Multicountry Observational Study’,Lancet (London, England) 386, no. 9991 (25 July 2015): 369–75, doi:10.1016/S0140-6736(14)62114-0.
[ix] Gasparrini et al., ‘Mortality Risk Attributable to High and Low Ambient Temperature’.
[x] Baccini et al., ‘Impact of Heat on Mortality in 15 European Cities’; Xavier Basagaña et al., ‘Heat Waves and Cause-Specific Mortality at All Ages’,Epidemiology (Cambridge, Mass.) 22, no. 6 (November 2011): 765–72, doi:10.1097/EDE.0b013e31823031c5.
[xi] WMO and WHO,Heatwaves and Health: Guidance on Warning-System Development, ed. Glenn R McGregor et al., WMO-No. 1142 (Geneva: World Meteorological Organization and World Health Organization, 2015), http://www.who.int/globalchange/publications/heatwaves-health-guidance/en/.
[xii] A. Analitis, I. Georgiadis, and K. Katsouyanni, ‘Forest Fires Are Associated with Elevated Mortality in a Dense Urban Setting’,Occupational and Environmental Medicine 69, no. 3 (3 January 2012): 158–62, doi:10.1136/oem.2010.064238; Antonis Analitis et al., ‘Effects of Heat Waves on Mortality: Effect Modification and Confounding by Air Pollutants’,Epidemiology 25, no. 1 (January 2014): 15–22, doi:10.1097/EDE.0b013e31828ac01b; Christofer Aström et al., ‘Heat-Related Respiratory Hospital Admissions in Europe in a Changing Climate: A Health Impact Assessment’,BMJ Open 3, no. 1 (2013): e001842, doi:10.1136/bmjopen-2012-001842.
[xiii] Coumou, Robinson, and Rahmstorf, ‘Global Increase in Record-Breaking Monthly-Mean Temperatures’.
[xiv] Tobias Lung et al., ‘A Multi-Hazard Regional Level Impact Assessment for Europe Combining Indicators of Climatic and Non-Climatic Change’,Global Environmental Change 23, no. 2 (April 2013): 522–36, doi:10.1016/j.gloenvcha.2012.11.009; Nick Watts et al., ‘Health and Climate Change: Policy Responses to Protect Public Health’,The Lancet 386, no. 10006 (2015): 1861–1914, doi:10.1016/S0140-6736(15)60854-6.
[xv] J. C. Ciscar et al., ‘Physical and Economic Consequences of Climate Change in Europe’,Proceedings of the National Academy of Sciences 108, no. 7 (31 January 2011): 2678–83, doi:10.1073/pnas.1011612108; R.S. Kovats et al., ‘The Impacts and Economic Costs on Health in Europe and the Costs and Benefits of Adaptation. Results of the EC RTD ClimateCost Project. Final Report’, The ClimateCost Project. Volume 1: Europe (Sweden: Stockholm Environment Institute, 2011), http://www.climatecost.cc/reportsandpublications.html; Paul Watkiss and Alistair Hunt, ‘Projection of Economic Impacts of Climate Change in Sectors of Europe Based on Bottom up Analysis: Human Health’,Climatic Change 112, no. 1 (2012): 101–26, doi:10.1007/s10584-011-0342-z; Daniele Paci, ‘Human Health Impacts of Climate Change in Europe. Report for the PESETA II Project’ (Seville: Joint Research Centre, European Commission, 2014), https://ec.europa.eu/jrc/sites/default/files/pesetaii_health_2014_1694__jrc_86970_correcteddp2.pdf.
[xvi] Ciscar et al., ‘Physical and Economic Consequences of Climate Change in Europe’; Cunrui Huang et al., ‘Projecting Future Heat-Related Mortality under Climate Change Scenarios: A Systematic Review’,Environmental Health Perspectives 119, no. 12 (4 August 2011): 1681–90, doi:10.1289/ehp.1103456.
[xvii] J. C. Ciscar et al., ‘Climate Impacts in Europe: The JRC PESETA II Project’, JRC Scientific and Policy Reports (European Commission — Joint Research Centre, Institute for Prospective Technological Studies, Institute for Environment and Sustainability, 2014), http://ipts.jrc.ec.europa.eu/publications/pub.cfm?id=7181.
[xviii] S Hales et al.,WHO | Quantitative Risk Assessment of the Effects of Climate Change on Selected Causes of Death, 2030s and 2050s (World Health Organization, Geneva, 2014), http://www.who.int/globalchange/publications/quantitative-risk-assessment/en/; Yasushi Honda et al., ‘Heat-Related Mortality Risk Model for Climate Change Impact Projection’,Environmental Health and Preventive Medicine 19, no. 1 (January 2014): 56–63, doi:10.1007/s12199-013-0354-6.
[xix] Aström et al., ‘Heat-Related Respiratory Hospital Admissions in Europe in a Changing Climate’.
[xx] Ciscar et al., ‘Physical and Economic Consequences of Climate Change in Europe’.
[xxi] Paci, ‘Human Health Impacts of Climate Change in Europe. Report for the PESETA II Project’.
[xxii] Aström et al., ‘Heat-Related Respiratory Hospital Admissions in Europe in a Changing Climate’; Kristie L. Ebi and David Mills, ‘Winter Mortality in a Warming Climate: A Reassessment: Winter Mortality in a Warming Climate’,Wiley Interdisciplinary Reviews: Climate Change 4, no. 3 (May 2013): 203–12, doi:10.1002/wcc.211; Patrick L. Kinney et al., ‘Winter Season Mortality: Will Climate Warming Bring Benefits?’,Environmental Research Letters 10, no. 6 (2015): 064016, doi:10.1088/1748-9326/10/6/064016.
[xxiii] Sotiris Vardoulakis et al., ‘Comparative Assessment of the Effects of Climate Change on Heat- and Cold-Related Mortality in the United Kingdom and Australia’,Environmental Health Perspectives 122, no. 12 (15 September 2014): 1285–92, doi:10.1289/ehp.1307524; Katherine Arbuthnott et al., ‘Changes in Population Susceptibility to Heat and Cold over Time: Assessing Adaptation to Climate Change’,Environmental Health 15, no. S1 (March 2016): 33, doi:10.1186/s12940-016-0102-7.
In April 2013, the European Commission (EC) presented the EU Adaptation Strategy Package. This package consists of the EU Strategy on adaptation to climate change (COM/2013/216 final) and a number of supporting documents. The overall aim of the EU Adaptation Strategy is to contribute to a more climate-resilient Europe.
One of the objectives of the EU Adaptation Strategy is Better informed decision-making, which will be achieved by bridging the knowledge gap and further developing the European climate adaptation platform (Climate-ADAPT) as the ‘one-stop shop’ for adaptation information in Europe. Climate-ADAPT has been developed jointly by the EC and the EEA to share knowledge on (1) observed and projected climate change and its impacts on environmental and social systems and on human health, (2) relevant research, (3) EU, transnational, national and subnational adaptation strategies and plans, and (4) adaptation case studies.
Further objectives include Promoting adaptation in key vulnerablesectors through climate-proofing EU sector policies and Promoting action by Member States. Most EU Member States have already adopted national adaptation strategies and many have also prepared action plans on climate change adaptation. The EC also supports adaptation in cities through the Covenant of Mayors for Climate and Energy initiative.
In September 2016, the EC presented an indicative roadmap for the evaluation of the EU Adaptation Strategy by 2018.
In November 2013, the European Parliament and the European Council adopted the 7th EU Environment Action Programme (7th EAP) to 2020, ‘Living well, within the limits of our planet’. The 7th EAP is intended to help guide EU action on environment and climate change up to and beyond 2020. It highlights that ‘Action to mitigate and adapt to climate change will increase the resilience of the Union’s economy and society, while stimulating innovation and protecting the Union’s natural resources.’ Consequently, several priority objectives of the 7th EAP refer to climate change adaptation.
No targets have been specified.
Daily temperature and mortality data for four locations in Europe from the period 1985–2012 have been used to fit a standard time-series Poisson model for each location, controlling for trends and day of the week. Temperature–mortality associations were estimated with a distributed lag non-linear model and a multivariate metaregression that included temperature average and range
Not applicable
No methodology references available.
Not applicable
The attribution of health effects to climate change is difficult owing to the complexity of interactions and the potential modifying effects of a range of other factors (such as land-use changes, public health preparedness and socio-economic conditions). Criteria for defining a climate-sensitive health impact are not always well identified, and their detection sometimes relies on complex observational or prospective studies, applying a mix of epidemiological, statistical and/or modelling methodologies. Furthermore, these criteria, as well as the completeness and reliability of observations, may differ between regions and/or institutions, and they may change over time. Data availability and quality are crucial in climate change and human health assessments, both for longer term changes in climate-sensitive health outcomes and for health impacts of extreme events. The monitoring of climate-sensitive health effects is currently fragmentary and heterogeneous. All these factors make it difficult to identify significant trends in climate-sensitive health outcomes over time, and to compare them across regions. In the absence of reliable time series, more complex approaches are often used to assess the past, current and future impacts of climate change on human health.
The links between climate change and health have been the subject of intense research in Europe in the early 2000s (e.g. the projects cCASHh, EDEN, EDENext and Climate-TRAP); more recently health has been incorporated, to a minor extent, into some cross-sectorial projects (e.g. CIRCE, PESETA II, IMPACT2C and RAMSES). Furthermore, the World Health Organization (WHO) has a policy, country support and research mandate given by its 193 Member States through the World Health Assembly on all aspects of climate change and health.
No uncertainty has been specified
For references, please go to https://www.eea.europa.eu/data-and-maps/indicators/heat-and-health-2/assessment or scan the QR code.
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