Heat-health action plans in Europe: Challenges ahead and how to tackle them

Optimal decision-making in relieving global high temperature-related disease burden by data-driven simulation

The rapid acceleration of global warming has led to an increased burden of high temperature-related diseases (HTDs), highlighting the need for advanced evidence-based management strategies. We have developed a conceptual framework aimed at alleviating the global burden of HTDs, grounded in the One Health concept. This framework refines the impact pathway and establishes systematic data-driven models to inform the adoption of evidence-based decision-making, tailored to distinct contexts. We collected extensive national-level data from authoritative public databases for the years 2010-2019. The burdens of five categories of disease causes - cardiovascular diseases, infectious respiratory diseases, injuries, metabolic diseases, and non-infectious respiratory diseases - were designated as intermediate outcome variables. The cumulative burden of these five categories, referred to as the total HTD burden, was the final outcome variable. We evaluated the predictive performance of eight models and subsequently introduced twelve intervention measures, allowing us to explore optimal decision-making strategies and assess their corresponding contributions. Our model selection results demonstrated the superior performance of the Graph Neural Network (GNN) model across various metrics. Utilizing simulations driven by the GNN model, we identified a set of optimal intervention strategies for reducing disease burden, specifically tailored to the seven major regions: East Asia and Pacific, Europe and Central Asia, Latin America and the Caribbean, Middle East and North Africa, North America, South Asia, and Sub-Saharan Africa. Sectoral mitigation and adaptation measures, acting upon our categories of Infrastructure & Community, Ecosystem Resilience, and Health System Capacity, exhibited particularly strong performance for various regions and diseases. Seven out of twelve interventions were included in the optimal intervention package for each region, including raising low-carbon energy use, increasing energy intensity, improving livestock feed, expanding basic health care delivery coverage, enhancing health financing, addressing air pollution, and improving road infrastructure. The outcome of this study is a global decision-making tool, offering a systematic methodology for policymakers to develop targeted intervention strategies to address the increasingly severe challenge of HTDs in the context of global warming.

Beliefs and behaviors associated with the first named heat wave in Seville Spain 2022

Heat waves pose a substantial and increasing risk to public health. Heat health early warning systems (HHEWSs) and response plans are increasingly being adopted to alert people to the health risks posed by days of extreme heat and recommend protective behaviors. However, evidence regarding the effectiveness of HHEWSs remains limited. We examined the impact of heat wave naming on heat-related beliefs and behaviors to ascertain the potential effectiveness of heat wave naming as a heat health risk communication and management tool. Specifically, we surveyed members of the public exposed to the proMETEO Sevilla HHEWS messaging campaign which in the summer of 2022 applied a name to heat waves considered to pose the greatest risk to public health. During the heat season we evaluated, the proMETEO Sevilla HHEWS campaign applied a name to one heat wave, heat wave "Zoe". Our analysis of the post-survey of 2022 adults indicated that the 6% of participants who recalled the name Zoe unaided reported greater engagement in heat wave safety behaviors and more positive beliefs about naming heat waves and their local governments' heat wave response. These results provide initial evidence for potential utility in naming heat waves as part of HHEWSs and HAPs.

The Exposome and Cardiovascular Health

The study of the interplay between social factors, environmental hazards, and health has garnered much attention in recent years. The term "exposome" was coined to describe the total impact of environmental exposures on an individual's health and well-being, serving as a complementary concept to the genome. Studies have shown a strong correlation between the exposome and cardiovascular health, with various components of the exposome having been implicated in the development and progression of cardiovascular disease. These components include the natural and built environment, air pollution, diet, physical activity, and psychosocial stress, among others. This review provides an overview of the relationship between the exposome and cardiovascular health, highlighting the epidemiologic and mechanistic evidence of environmental exposures on cardiovascular disease. The interplay between various environmental components is discussed, and potential avenues for mitigation are identified.

Study on thermal health and its safety management mode for the working environment

Thermal health concerns have gained significant attention due to the heightened health risks faced by workers who are exposed to extreme thermal environments for prolonged periods. To ensure the occupational health and safety of such workers, and to enhance work efficiency, it is imperative to examine the characteristics of thermal health in the working environment. This study proposes three key elements of thermal health in the working environment, namely thermal health states, absence of heat-related illnesses, and heat adaptability, which can be used to develop a safety management framework for thermal health. By exploring the interconnections between these elements, the study summarizes their features and outlines the necessary precautions to safeguard them. The PDCA (plan/do/check/action) cycle management mode is utilized as a framework, with the three components of thermal health forming the core, to establish a safety management mode for thermal health. To ensure that employees work in a safe, healthy, comfortable, and productive environment, the assessment and control objectives of the thermal environment are regularly revised through the use of labor protection technology and thermal environment control technology. This paper presents a PDCA cycle safety management mode based on the characteristics of thermal health, which offers novel insights and approaches for assessing and managing workers' thermal health.

Analysis of circulating extracellular vesicle derived microRNAs in breast cancer patients with obesity: a potential role for Let-7a

BACKGROUND

The incidence of obesity, a known risk factor for several metabolic and chronic diseases, including numerous malignancies, has risen sharply in the world. Various clinical studies demonstrate that excessive Body Mass Index (BMI) may worsen the incidence, prognosis, and mortality rates of breast cancer. Thus, understanding the link tying up obesity and breast cancer onset and progression is critically important, as it can impact patients' survival and quality of life. Recently, circulating extracellular vesicle (EV) derived miRNAs have attracted much attention for their diagnostic, prognostic and therapeutic potential in oncology research. Although the potential role of EV-derived miRNAs in the early detection of breast cancer has been repeatedly mentioned, screening of miRNAs packaged within serum EVs has not yet been reported in patients with obesity.

METHODS

Circulating EVs were isolated from normal weight (NW), and overweight/obese (OW/Ob) breast cancer patients and characterized by Transmission Electron Microscopy (TEM), Nanoparticle Tracking Analysis (NTA), and protein marker expression. Evaluation of EV-associated miRNAs was conducted in a screening (RNA-seq) and a validation (qRT-PCR) cohort. Bioinformatic analysis was performed to uncover significantly enriched biological processes, molecular functions and pathways. ROC and Kaplain-Meier survival analyses were used for clinical significance.

RESULTS

Comparison of serum EV-derived miRNAs from NW and OW/Ob patients detected seven differentially expressed miRNAs (let-7a-5p, miR-122-5p, miR-30d-5p, miR-126-3p, miR-27b-3p, miR-4772-3p, and miR-10a-5p) in the screening cohort. GO analysis revealed the enrichment of protein phosphorylation, intracellular signal transduction, signal transduction, and vesicle-mediated transport among the top biological processes. In addition, the target genes were significantly enriched in pathways related to PI3K/Akt, growth hormones, and insulin signalings, which are all involved in obesity-related diseases and/or breast cancer progression. In the validation cohort, qRT-PCR confirmed a significant down-regulation of EV-derived let-7a in the serum of OW/Ob breast cancer patients compared to NW patients. Let-7a levels also exhibited a negative correlation with BMI values. Importantly, decreased let-7a miRNA expression was associated with higher tumor grade and poor survival in patients with breast cancer.

CONCLUSION

These results suggest that serum-EV derived miRNAs may reflect a differential profile in relation to a patient's BMI, which, once validated in larger cohorts of patients, could provide insights into novel specific biomarkers and innovative targets to prevent the progression of obesity-mediated breast cancer.

Explorative Assessment of the Temperature-Mortality Association to Support Health-Based Heat-Warning Thresholds: A National Case-Crossover Study in Switzerland

Defining health-based thresholds for effective heat warnings is crucial for climate change adaptation strategies. Translating the non-linear function between heat and health effects into an effective threshold for heat warnings to protect the population is a challenge. We present a systematic analysis of heat indicators in relation to mortality. We applied distributed lag non-linear models in an individual-level case-crossover design to assess the effects of heat on mortality in Switzerland during the warm season from 2003 to 2016 for three temperature metrics (daily mean, maximum, and minimum temperature), and various threshold temperatures and heatwave definitions. Individual death records with information on residential address from the Swiss National Cohort were linked to high-resolution temperature estimates from 100 m resolution maps. Moderate (90th percentile) to extreme thresholds (99.5th percentile) of the three temperature metrics implied a significant increase in mortality (5 to 38%) in respect of the median warm-season temperature. Effects of the threshold temperatures on mortality were similar across the seven major regions in Switzerland. Heatwave duration did not modify the effect when considering delayed effects up to 7 days. This nationally representative study, accounting for small-scale exposure variability, suggests that the national heat-warning system should focus on heatwave intensity rather than duration. While a different heat-warning indicator may be appropriate in other countries, our evaluation framework is transferable to any country.

Does the meteorological origin of heat waves influence their impact on health? A 6-year morbidity and mortality study in Madrid (Spain)

BACKGROUND

In Spain, two synoptic-scale conditions influence heat wave formation. The first involves advection of warm and dry air masses carrying dust of Saharan origin (North African Dust (NAF) = 1). The second entails anticyclonic stagnation with high insolation and stability (NAF) = 0). Some studies show that the meteorological origin of these heat waves may affect their impact on morbidity and mortality.

OBJECTIVE

To determine whether the impact of heat waves on health outcomes in Madrid (Spain) during 2013-2018 varied by synoptic-scale condition.

METHODOLOGY

Outcome data consist of daily mortality and daily hospital emergency admissions (morbidity) for natural, circulatory, and respiratory causes. Predictors include daily maximum and minimum temperatures and daily mean concentrations of NO₂, PM₁₀, PM_2.5, NO₂, and O₃. Analyses adjust for insolation, relative humidity, and wind speed. Generalized linear models were performed with Poisson link between the variables controlling for trend, seasonality, and auto-regression in the series. Relative Risks (RR) and Attributable Risks (AR) were determined. The RRs for mortality attributable to high temperatures were similar regardless of NAF status. For hospital admissions, however, the RRs for hot days with NAF = 0 are higher than for days with NAF = 1. We also found that atmospheric pollutants worsen morbidity and mortality, especially PM₁₀ concentrations when NAF = 1 and O₃ concentrations when NAF = 0.

RESULTS

The effect of heat waves on morbidity and mortality depends on the synoptic situation. The impact is greater under anticyclonic stagnation conditions than under Saharan dust advection. Further, the health impact of pollutants such as PM₁₀ and O₃ varies according to the synoptic situation.

CONCLUSIONS

Based on these findings, we strongly recommend prevention plans to include data on the meteorological situation originating the heat wave, on a synoptic-scale, as well as comprehensive preventive measures against the compounding effect of high temperatures and pollution.

Climate change and cardiovascular disease: implications for global health

Climate change is the greatest existential challenge to planetary and human health and is dictated by a shift in the Earth's weather and air conditions owing to anthropogenic activity. Climate change has resulted not only in extreme temperatures, but also in an increase in the frequency of droughts, wildfires, dust storms, coastal flooding, storm surges and hurricanes, as well as multiple compound and cascading events. The interactions between climate change and health outcomes are diverse and complex and include several exposure pathways that might promote the development of non-communicable diseases such as cardiovascular disease. A collaborative approach is needed to solve this climate crisis, whereby medical professionals, scientific researchers, public health officials and policymakers should work together to mitigate and limit the consequences of global warming. In this Review, we aim to provide an overview of the consequences of climate change on cardiovascular health, which result from direct exposure pathways, such as shifts in ambient temperature, air pollution, forest fires, desert (dust and sand) storms and extreme weather events. We also describe the populations that are most susceptible to the health effects caused by climate change and propose potential mitigation strategies, with an emphasis on collaboration at the scientific, governmental and policy levels.

Climate Change and Health: Consequences of High Temperatures among Vulnerable Groups in Finland

In this article, we examine the effects of high temperatures on hospital visits and mortality in Finland. This provides new information of the topic in a context of predominantly cool temperatures. Unique, individual-level data are used to examine the relationship at the municipality-month level over a span of 20 years. Linear regression methods alongside high-dimensional fixed effects are used to minimize confounding variation. Analysis is conducted with special emphasis on the elderly population, as well as on specific elderly risk groups identified in previous literature. We show that for an additional day per month above 25°C, monthly all-cause mortality increases by 1.5 percent (95% CI: 0.4%-2.6%) and acute hospital visits increase by 1.1 percent (95% CI: 0.7%-1.6%). We also find some evidence that these effects are elevated in selected population subgroups, the low-income elderly, and people with dementia. Hospital visits also increase among younger age groups, illustrating the importance of using multiple health indicators. Such detailed evidence is important for identifying vulnerable groups as extreme heat waves are expected to become more frequent and intense in northern countries.

Evaluations of heat action plans for reducing the health impacts of extreme heat: methodological developments (2012-2021) and remaining challenges

The recent report of the Intergovernmental Panel on Climate Change is stark in its warnings about the changing climate, including future increases in the frequency and intensity of extremely hot weather. The well-established impacts of extreme heat on human health have led to widespread implementation of national and city-wide heat plans for mitigating such impacts. Evaluations of the effectiveness of some heat plans have been published, with previous reviews highlighting key methodological challenges. This article reviews methods used since and that address those challenges, so helping to set an agenda for improving evaluations of heat plans in terms of their effectiveness in reducing heat-health impacts. We examined the reviews that identified the methodological challenges and systematically searched the literature to find evaluations that had since been conducted. We found 11 evaluations. Their methods help address the key challenge of identifying study control groups and address other challenges to a limited extent. For future evaluations, we recommend: utilising recent evaluation methodologies, such as difference-in-differences quasi-experimental designs where appropriate; cross-agency working to utilise data on morbidity and confounders; adoption of a proposed universal heat index; and greater publication of evaluations. More evaluations should assess morbidity outcomes and be conducted in low- and middle-income countries. Evaluations of heat plans globally should employ robust methodologies, as demonstrated in existing studies and potentially transferrable from other fields. Publication of such evaluations will advance the field and thus help address some of the health challenges resulting from our changing climate.

Effects of local factors on adaptation to heat in Spain (1983-2018)

The European Union is currently immersed in policy development to address the effects of climate change around the world. Key plans and processes for facilitating adaptation to high temperatures and for reducing the adverse effects on health are among the most urgent measures. Therefore, it is necessary to understand those factors that influence adaptation. The aim of this study was to provide knowledge related to the social, climate and economic factors that are related to the evolution of minimum mortality temperatures (MMT) in Spain in the rural and urban contexts, during the 1983-2018 time period. For this purpose, local factors were studied regarding their relationship to levels of adaptation to heat. MMT is an indicator that allows for establishing a relationship to between mortality and temperature, and is a valid indicator to assess the capacity of adaptation to heat of a certain population. MMT is obtained through the maximum daily temperature and daily mortality of the study period. The evolution of MMT values for Spain was established in a previous paper. An ecological, longitudinal and retrospective study was carried out. Generalized linear models (GLM) were performed to identify the variables that appeared to be related to adaptation. The adaptation was calculated as the difference in variation in MMT based on the average increase in maximum daily temperatures. In terms of adaptation to heat, urban populations have adapted more than non-urban populations. Seventy-nine percent (n = 11) of urban provinces have adapted to heat, compared to twenty-one percent (n = 3) of rural provinces that have not adapted. In terms of urban zones, income level and habituation to heat (values over the 95th percentile) were variables shown to be related to adaptation. In contrast, among non-urban provinces, a greater number of housing rehabilitation licenses and a greater number of health professionals were variables associated with higher increases in MMT, and therefore, with adaptation. These results highlight the need to carry out studies that allow for identifying the local factors that are most relevant and influential in population adaptation. More studies carried out at a small scale are needed.

Effective interventions on health effects of Chinese rural elderly under heat exposure

Due to climate change, the heatwave has become a more serious public health threat with aging as an aggravating factor in recent years. There is a pressing need to detect the most effective prevention and response measures. However, the specific health effects of interventions have not been characterized on an individual scale. In this study, an intervention experiment was designed to explore the health effects of heat exposure at the individual level and assess the effects of different interventions based on a comprehensive health sensitivity index (CHSI) in Xinyi, China. Forty-one subjects were recruited randomly, and divided into one control group and three intervention groups. Interventions included education (Educate by lecturing, offering relative materials, and communication), subsidy support (offer subsidy to offset the cost of running air conditioning), and cooling-spray (install a piece of cooling-spray equipment in the yard). Results showed that systolic blood pressure (SBP) and deep sleep duration (DSD) were significantly affected by short-term heat exposure, and the effects could be alleviated by three types of interventions. The estimated CHSI indicated that the effective days of the education group were longer than other groups, while the lower CHSI of the subsidy group showed lower sensitivity than the control group. These findings provide feasible implementation strategies to optimize Heat-health action plans and evaluate the intervention performance.

ELECTRONIC SUPPLEMENTARY MATERIAL

Supplementary material is available in the online version of this article at 10.1007/s11783-022-1545-4 and is accessible for authorized users.

Analysis of vulnerability to heat in rural and urban areas in Spain: What factors explain Heat's geographic behavior?

INTRODUCTION

There is currently little knowledge and few published works on the subject of vulnerability to heat in rural environments at the country level. Therefore, the objective of this study was to determine whether rural areas are more vulnerable to extreme heat than urban areas in Spain. This study aimed to analyze whether a pattern of vulnerability depends on contextual, environmental, demographic, economic and housing variables.

METHODS

An ecological, longitudinal and retrospective study was carried out based on time series data between January 01, 2000 and December 31, 2013 in 42 geographic areas in 10 provinces in Spain. We first analyzed the functional relationship between the mortality rate per million inhabitants and maximum daily temperature (Tmax). We then determined the summer temperature threshold (Pthreshold) (June-September) at which increases in mortality are produced that are attributable to heat. In a second phase, based on Pthreshold, a vulnerability variable was calculated, and its distribution was analyzed using mixed linear models from the Poisson family (link = log). In these models, the dependent variable was vulnerability, and the independent variables were exposure to high temperatures, aridity of the climate, deprivation index, percentage of people over age 65, rurality index, percentage of housing built prior to 1980 and condition of dwellings.

RESULTS

Rurality was a protective factor, and vulnerability in urban areas was six times greater. In contrast, risk factors included aridity (RR = 5.89 (2.26 15.36)), living in cool summer zones (2.69 (1.23, 5.91)), poverty (4.05 (1.91 8.59)) and the percentage of dysfunctional housing (1.13 (1.04 1.24)).

CONCLUSIONS

Rural areas are less vulnerable to extreme heat than the urban areas analyzed. Also, population groups with worse working conditions and higher percentages of dwellings in poor conditions are more vulnerable.

Fluctuating temperature modifies heat-mortality association in the globe

Studies have investigated the effects of heat and temperature variability (TV) on mortality. However, few assessed whether TV modifies the heat-mortality association. Data on daily temperature and mortality in the warm season were collected from 717 locations across 36 countries. TV was calculated as the standard deviation of the average of the same and previous days’ minimum and maximum temperatures. We used location-specific quasi-Poisson regression models with an interaction term between the cross-basis term for mean temperature and quartiles of TV to obtain heat-mortality associations under each quartile of TV, and then pooled estimates at the country, regional, and global levels. Results show the increased risk in heat-related mortality with increments in TV, accounting for 0.70% (95% confidence interval [CI]: −0.33 to 1.69), 1.34% (95% CI: −0.14 to 2.73), 1.99% (95% CI: 0.29–3.57), and 2.73% (95% CI: 0.76–4.50) of total deaths for Q1–Q4 (first quartile–fourth quartile) of TV. The modification effects of TV varied geographically. Central Europe had the highest attributable fractions (AFs), corresponding to 7.68% (95% CI: 5.25–9.89) of total deaths for Q4 of TV, while the lowest AFs were observed in North America, with the values for Q4 of 1.74% (95% CI: −0.09 to 3.39). TV had a significant modification effect on the heat-mortality association, causing a higher heat-related mortality burden with increments of TV. Implementing targeted strategies against heat exposure and fluctuant temperatures simultaneously would benefit public health.

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Increased temperature variability (TV) poses a greater mortality risk due to heat

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TV has a more profound modification effect on extreme heat-mortality association

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Strategies against heat and TV simultaneously would benefit public health

Estimating heat-related mortality in near real time for national heatwave plans

Heatwaves are a serious threat to human life. Public health agencies that are responsible for delivering heat-health action plans need to assess and reduce the mortality impacts of heat. Statistical models developed in epidemiology have previously been used to attribute past observed deaths to high temperatures and project future heat-related deaths. Here, we investigate the novel use of summer temperature-mortality associations established by these models for monitoring heat-related deaths in regions in England in near real time. For four summers in the period 2011-2020, we find that coupling these associations with observed daily mean temperatures results in England-wide heatwave mortality estimates that are consistent with the excess deaths estimated by UK Health Security Agency. However, our results for 2013, 2018 and 2020 highlight that the lagged effects of heat and characteristics of individual summers contribute to disagreement between the two methods. We suggest that our method can be used for heatwave mortality monitoring in England because it has the advantages of including lagged effects and controlling for other risk factors. It could also be employed by health agencies elsewhere for reliably estimating the health burden of heat in near real time and near-term forecasts.

Obesity and endocrine therapy resistance in breast cancer: Mechanistic insights and perspectives

The incidence of obesity, a recognized risk factor for various metabolic and chronic diseases, including numerous types of cancers, has risen dramatically over the recent decades worldwide. To date, convincing research in this area has painted a complex picture about the adverse impact of high body adiposity on breast cancer onset and progression. However, an emerging but overlooked issue of clinical significance is the limited efficacy of the conventional endocrine therapies with selective estrogen receptor modulators (SERMs) or degraders (SERDs) and aromatase inhibitors (AIs) in patients affected by breast cancer and obesity. The mechanisms behind the interplay between obesity and endocrine therapy resistance are likely to be multifactorial. Therefore, what have we actually learned during these years and which are the main challenges in the field? In this review, we will critically discuss the epidemiological evidence linking obesity to endocrine therapeutic responses and we will outline the molecular players involved in this harmful connection. Given the escalating global epidemic of obesity, advances in understanding this critical node will offer new precision medicine-based therapeutic interventions and more appropriate dosing schedule for treating patients affected by obesity and with breast tumors resistant to endocrine therapies.

Evaluating cost benefits from a heat health warning system in Adelaide, South Australia

OBJECTIVE

To examine the cost benefits of a heat health warning system (HHWS) in South Australia.

METHODS

Information from key agencies was used to estimate the costs associated with the South Australian HHWS, including for three targeted public health interventions. Health cost savings were estimated based on previously reported HHWS-attributable reductions in hospital and emergency department (ED) admissions and ambulance callouts.

RESULTS

The estimated cost for a one-week activation of the HHWS was AU$593,000. Activation costs compare favourably with the potential costs averted through HHWS-attributable reductions in hospital admissions and ambulance callouts with an estimated benefit-cost ratio of 2.0-3.3.

CONCLUSIONS

On the basis of estimated cost benefit, the South Australian HHWS is a no-regret public health response to heatwaves. Implications for public health: As global temperatures rise there are likely to be significant health impacts from more frequent and intense heatwaves. This study indicates that HHWSs incorporating targeted supports for vulnerable groups are likely to be cost-effective public health interventions.

Climate change and infectious disease in Europe: Impact, projection and adaptation

Europeans are not only exposed to direct effects from climate change, but also vulnerable to indirect effects from infectious disease, many of which are climate sensitive, which is of concern because of their epidemic potential. Climatic conditions have facilitated vector-borne disease outbreaks like chikungunya, dengue, and West Nile fever and have contributed to a geographic range expansion of tick vectors that transmit Lyme disease and tick-borne encephalitis. Extreme precipitation events have caused waterborne outbreaks and longer summer seasons have contributed to increases in foodborne diseases. Under the Green Deal, The European Union aims to support climate change health policy, in order to be better prepared for the next health security threat, particularly in the aftermath of the traumatic COVID-19 experience. To bolster this policy process we discuss climate change-related hazards, exposures and vulnerabilities to infectious disease and describe observed impacts, projected risks, with policy entry points for adaptation to reduce these risks or avoid them altogether.

Mortality risk related to heatwaves in Finland - Factors affecting vulnerability

BACKGROUND

Heatwaves are known to increase mortality. However, there is a need for more quantitative information on factors affecting sensitivity to the adverse health effects, particularly in countries with cool summer temperatures.

OBJECTIVES

We evaluated mortality risk related to heatwave days in Finland. Risk was examined by age, sex, cause of death, and place of death, including health and social care facilities and homes. Mortality was also analysed for different patient subgroups in healthcare facilities.

METHODS

Heatwaves were defined as periods when the daily average temperature exceeded the 90th percentile of that from May to August in 2000-2014 for ≥4 days. In addition to all heatwave days, risk was analysed for short (4-5 days) and long (≥10 days) heatwaves. Mortality analyses were based on linking registry data on i) daily non-accidental and cause-specific mortality and ii) admissions to a health or social care facility. Statistical analyses were conducted using generalised estimating equations for longitudinal data analysis, assuming a Poisson distribution for the daily mortality count.

RESULTS

During all heatwave days, mortality increased among those aged 65-74 years (6.7%, 95% confidence interval 2.9-10.8%) and ≥75 years (12.8%, 95% CI 9.8-15.9%). Mortality increased in both sexes, but the risk was higher in women. Positive associations were observed for deaths due to respiratory diseases, renal diseases, mental and behavioural disorders, diseases of the nervous system, and cardiovascular diseases. Overall, effects were stronger for long than short heatwaves. During all heatwave days, mortality increased in healthcare facilities in outpatients (26.9%, 95% CI 17.3-37.2%) and inpatients. Among inpatients, the risk was higher in long-term inpatients (stay in ward > 30 days, 13.1%, 95% CI 8.6-17.7%) than others (5.8%, 95% CI 2.7-9.0%). At homes, mortality increased by 8.1% (95% CI 1.9-14.6%). Elevated risk estimates were also detected for social care facilities.

CONCLUSIONS

In Finland, a cold-climate Northern country, heatwaves increase mortality risk significantly among the elderly. Women are more susceptible than men, and many chronic diseases are important risk factors. To reduce heatwave-related deaths, preparedness should be improved particularly in hospital and healthcare centre wards, where the most vulnerable are long-term inpatients. However, measures are also needed to protect the elderly at home and in social care facilities, especially during prolonged hot periods.

Evolution of the minimum mortality temperature (1983-2018): Is Spain adapting to heat?

The objective of this study was to analyze at the level of Spain's 52 provinces province level the temporal evolution of minimum mortality temperatures (MMT) from 1983 to 2018, in order to determine whether the increase in MMT would be sufficient to compensate for the increase in environmental temperatures in Spain for the period. It also aimed to analyze whether the rate of evolution of MMT would be sufficient, were it to remain constant, to compensate for the predicted increase in temperatures in an unfavorable (RCP 8.5) emissions scenario for the time horizon 2051-2100. The independent variable was made up of maximum daily temperature data (Tmax) for the summer months in the reference observatories of each province for the 1983-2018 period. The dependent variable was daily mortality rate due to natural causes (ICD 10: A00-R99). For each year and province, MMT was determined using a quadratic or cubic fit (p < 0.05). Based on the annual MMT values, a linear fit was carried out that allowed for determining the time evolution of MMT. These values were compared with the evolution of Tmax registered in each observatory during the 1983-2018 analyzed period and with the predicted values of Tmax obtained for an RCP8.5 scenario for the period 2051-2100. The rate of global variance in Tmax in the summer months in Spain during the 1983-2018 period was 0.41 °C/decade, while MMT across the whole country increased at a rate of 0.64 °C/decade. Variations in the provinces were heterogeneous. For the 2051-2100 time horizon, there was predicted increase in Tmax values of 0.66 °C/decade, with marked geographical differences. Although at the global level it is possible to speak of adaptation, the heterogeneities among the provinces suggest that the local level measures are needed in order to facilitate adaptation in those areas where it is not occurring.

Evolution of the minimum mortality temperature (1983-2018): Is Spain adapting to heat?

The objective of this study was to analyze at the level of Spain's 52 provinces province level the temporal evolution of minimum mortality temperatures (MMT) from 1983 to 2018, in order to determine whether the increase in MMT would be sufficient to compensate for the increase in environmental temperatures in Spain for the period. It also aimed to analyze whether the rate of evolution of MMT would be sufficient, were it to remain constant, to compensate for the predicted increase in temperatures in an unfavorable (RCP 8.5) emissions scenario for the time horizon 2051-2100. The independent variable was made up of maximum daily temperature data (Tmax) for the summer months in the reference observatories of each province for the 1983-2018 period. The dependent variable was daily mortality rate due to natural causes (ICD 10: A00-R99). For each year and province, MMT was determined using a quadratic or cubic fit (p < 0.05). Based on the annual MMT values, a linear fit was carried out that allowed for determining the time evolution of MMT. These values were compared with the evolution of Tmax registered in each observatory during the 1983-2018 analyzed period and with the predicted values of Tmax obtained for an RCP8.5 scenario for the period 2051-2100. The rate of global variance in Tmax in the summer months in Spain during the 1983-2018 period was 0.41 °C/decade, while MMT across the whole country increased at a rate of 0.64 °C/decade. Variations in the provinces were heterogeneous. For the 2051-2100 time horizon, there was predicted increase in Tmax values of 0.66 °C/decade, with marked geographical differences. Although at the global level it is possible to speak of adaptation, the heterogeneities among the provinces suggest that the local level measures are needed in order to facilitate adaptation in those areas where it is not occurring.

Analysis of the impact of heat waves on daily mortality in urban and rural areas in Madrid

The objective of this study was to analyze and compare the effect of high temperatures on daily mortality in the urban and rural populations in Madrid. Data were analyzed from municipalities in Madrid with a population of over 10,000 inhabitants during the period from January 1, 2000 to December 31, 2020. Four groups were generated: Urban Metropolitan Center, Rural Northern Mountains, Rural Center, and Southern Rural. The dependent variable used was the rate of daily mortality due to natural causes per million inhabitants (CIE-X: A00-R99) between the months of June and September for the period. The primary independent variable was maximum daily temperature. Social and demographic "context variables" were included: population >64 years of age (%), deprivation index and housing indicators. The analysis was carried out in three phases: 1) determination of the threshold definition temperature of a heat wave (Tumbral) for each study group; 2) determination of relative risks (RR) attributable to heat for each group using Poisson linear regression (GLM), and 3) calculation of odds ratios (OR) using binomial family GLM for the frequency of the appearance of heat waves associated with context variables. The resulting percentiles (for the series of maximum daily temperatures for the summer months) corresponding to Tthreshold were: 74th percentile for Urban Metropolitan Center, 76th percentile for Southern Rural, 83rd for Rural Northern Mountains and 98th percentile for Center Rural (98). Greater vulnerability was found for the first two. In terms of context variables that explained the appearance of heat waves, deprivation index level, population >64 years of age and living in the metropolitan area were found to be risk factors. Rural and urban areas behaved differently, and socioeconomic inequality and the composition of the population over age 64 were found to best explain the vulnerability of the Rural Center and Southern Rural zones.

The evolution of minimum mortality temperatures as an indicator of heat adaptation: The cases of Madrid and Seville (Spain)

The increase in the frequency and intensity of heat waves is one of the most unquestionable effects of climate change. Therefore, the progressive increase in maximum temperatures will have a clear incidence on the increase in mortality, especially in countries that are vulnerable due to geographical location or their socioeconomic characteristics. Different research studies show that the mortality attributable to heat is decreasing globally, and research is centred on future scenarios. One way of detecting the existence of a lesser impact of heat is through the increase in the so-called temperature of minimum mortality (TMM). The objective of this study is to determine the temporal evolution of TMM in two Spanish provinces (Seville and Madrid) during the 1983-2018 period and to evaluate whether the rate of adaptation to heat is appropriate. We used the gross rate of daily mortality due to natural causes (CIEX: A00-R99) and the maximum daily temperature (°C) to determine the quinquennial TMM using dispersion diagrams and realizing fit using quadratic and cubic curvilinear estimation. The same analysis was carried out at the annual level, by fitting an equation to the line of TMM for each province, whose slope, if significant (p < 0.05) represents the annual rate of variation in TMM. The results observed in this quinquennial analysis showed that the TMM is higher in Seville than in Madrid and that it is higher among men than women in the two provinces. Furthermore, there was an increase in TMM in all of the quinquennium and a clear decrease in the final period. At the annual level, the linear fit was significant for Madrid for the whole population and corresponds to an increase in the TMM of 0.58 °C per decade. For Seville the linear fits were significant and the slopes of the fitted lines was 1.1 °C/decade. Both Madrid and Seville are adapting to the increase in temperatures observed over the past 36 years, and women are the group that is more susceptible to heat, compared to men. The implementation of improvements and evaluation of prevention plans to address the impact of heat waves should continue in order to ensure adequate adaptation in the future.

The impact of heat waves on daily mortality in districts in Madrid: The effect of sociodemographic factors

Although there is significant scientific evidence on the impact of heat waves, there are few studies that analyze the effects of sociodemographic factors on the impact of heat waves below the municipal level. The objective of this study was to analyze the role of income level, percent of the population over age 65, existence of air conditioning units and hectares (Ha) of green zones in districts in Madrid, in the impact of heat on daily mortality between January 1, 2010 and December 31, 2013. Seventeen districts were analyzed, and Generalized Linear (GLM) Poisson Regression Models were used to calculate relative risks (RR) and attributable risks (RA) for the impact of heat waves on mortality due to natural causes (CIEX:A00-R99). The pattern of risks obtained was analyzed using GLM univariates and multivariates of the binomial family (link logit), introducing the socioeconomic and demographic variables mentioned above. The results indicate that heat wave had an impact in only three of the districts analyzed. In the univariate models, all of the variables were statistically significant, but Ha of green zones lost significance in the multivariate model. Income level, existence of air conditioning units, and percent of the population over age 65 in the district remained as variables that modulate the impact of heat wave on daily mortality in the municipality of Madrid. Income level was the key variable that explained this behavior. The results obtained in this study show that there are factors at levels below the municipal level (district level) that should be considered as focus areas for health policy in order to decrease the impact of heat and promote the process of adaptation to heat in the context of climate change.

A new integrative perspective on early warning systems for health in the context of climate change

Climate change causes or aggravates a wide range of exposures with multiple impacts on health, both direct and indirect. Early warning systems have been established to act on the risks posed by these exposures, permitting the timely activation of action plans to minimize health effects. These plans are usually activated individually. Although they show good results from the point of view of minimizing health impacts, such as in the case of high temperature plans, they commonly fail to address the synergies across various climate-related or climate-aggravated exposures. Since several of those exposures tend to occur concurrently, failure to integrate them in prevention efforts could affect their effectiveness and reach. Thus, there is a need to carry out an integrative approach for the multiple effects that climate change has on population health. This article presents a proposal for how these plans should be articulated. The proposed integrated plan would consist of four phases. The first phase, based on early warning systems, would be the activation of different existing individual plans related to the health effects that can be caused by certain circumstances and when possible corrective measures would be implemented. The second phase would attempt to quantify the health impact foreseen by the event in terms of the different health indicators selected. The third phase would be to activate measures to minimize the impact on health, via population alerts and advisories, and additional social and health services, based on the provisions in phase two. Phase four would be related to epidemiological surveillance that permits evaluation of the effects of activating the plan. We believe that this integrative approach should be extended to all of the public health interventions related to climate change.

The impact of pace of life on pedestrian heat stress: A computational modelling approach

Elevated walking speed is an indicator of increased pace of life in cities, caused by environmental pressures inherent to urban environments, which lead to short- and long-term consequences for health and well-being. In this paper we investigate the effect of walking speed on heat stress. We define the heat-stress-optimal walking speed and estimate its values for a wide range of air temperatures with the use of computational modelling of metabolic heat production and thermal regulation. The heat-stress-optimal walking speed shows three distinct phases in relation to air temperature, determined by different modes of interaction between the environment and physiology. Simulation results suggest that different temperature regimes require walking speed adaptation to preserve heat balance. Empirical data collected for Singapore reveals elevated average walking speed, which is not responsive to slight changes in microclimate (4-5 °C). The proposed computational model predicts the amount of additional heat produced by an individual due to the high pace of life. We conclude that there are direct implications of the high pace of life in cities on the immediate heat stress of people, and we show how a lower walking speed significantly reduces self-overheating and improves thermal comfort.

The Effects of Historical Housing Policies on Resident Exposure to Intra-Urban Heat: A Study of 108 US Urban Areas

The increasing intensity, duration, and frequency of heat waves due to human-caused climate change puts historically underserved populations in a heightened state of precarity, as studies observe that vulnerable communities—especially those within urban areas in the United States—are disproportionately exposed to extreme heat. Lacking, however, are insights into fundamental questions about the role of historical housing policies in cauterizing current exposure to climate inequities like intra-urban heat. Here, we explore the relationship between “redlining”, or the historical practice of refusing home loans or insurance to whole neighborhoods based on a racially motivated perception of safety for investment, with present-day summertime intra-urban land surface temperature anomalies. Through a spatial analysis of 108 urban areas in the United States, we ask two questions: (1) how do historically redlined neighborhoods relate to current patterns of intra-urban heat? and (2) do these patterns vary by US Census Bureau region? Our results reveal that 94% of studied areas display consistent city-scale patterns of elevated land surface temperatures in formerly redlined areas relative to their non-redlined neighbors by as much as 7 °C. Regionally, Southeast and Western cities display the greatest differences while Midwest cities display the least. Nationally, land surface temperatures in redlined areas are approximately 2.6 °C warmer than in non-redlined areas. While these trends are partly attributable to the relative preponderance of impervious land cover to tree canopy in these areas, which we also examine, other factors may also be driving these differences. This study reveals that historical housing policies may, in fact, be directly responsible for disproportionate exposure to current heat events.

Projections of Temperature-Attributable Deaths in Portuguese Metropolitan Areas: A Time-Series Modelling Approach

Climate change is now widely recognised as the greatest global threat over the coming decades. This study aimed to quantify and project the effects of climate change on future temperature-attributable mortality due to circulatory system diseases (CSD) in Lisbon metropolitan area (LMA) and in Porto metropolitan area (PMA). The future time slices of Representative Concentration Pathway (RCP 8.5), mid-term (2046–2065) and long-term (2080–2099) were compared with the reference period (1986–2005). There is a significant decreasing trend in proportion to the overall extreme cold temperature-attributable mortality due to CSD in the future periods (2045–2065 and 2081–2099) in LMA, −0.63% and −0.73%, respectively, and in PMA, −0.62% for 2045–2065 and −0.69% for 2081–2099, compared to the historical period. The fraction attributable to extreme hot temperature in the summer months increased by 0.08% and 0.23%, from 0.04% in the historical period to 0.11% during 2046–2065, and to 0.27% during 2081–2099 in LMA. While there were no noticeable changes due to extreme hot temperature during the summer in PMA, significant increases were observed with warmer winter temperatures: 1.27% and 2.80%. The projections of future temperature-attributable mortality may provide valuable information to support climate policy decision making and temperature-related risk management.

Effects of Orientations, Aspect Ratios, Pavement Materials and Vegetation Elements on Thermal Stress inside Typical Urban Canyons

The analysis of local climate conditions to test artificial urban boundaries and related climate hazards through modelling tools should become a common practice to inform public authorities about the benefits of planning alternatives. Different finishing materials and sheltering objects within urban canyons (UCs) can be tested, predicted and compared through quantitative and qualitative understanding of the relationships between the microclimatic environment and subjective thermal assessment. This process can work as support planning instrument in the early design phases as has been done in this study that aims to analyze the thermal stress within typical UCs of Bilbao (Spain) in summertime through the evaluation of Physiologically Equivalent Temperature using ENVI-met. The UCs are characterized by different orientations, height-to-width aspect ratios, pavement materials, trees’ dimensions and planting pattern. Firstly, the current situation was analyzed; secondly, the effects of asphalt and red brick stones as streets’ pavement materials were compared; thirdly, the benefits of vegetation elements were tested. The analysis demonstrated that orientation and aspect ratio strongly affect the magnitude and duration of the thermal peaks at pedestrian level; while the vegetation elements improve the thermal comfort up to two thermophysiological assessment classes. The outcomes of this study, were transferred and visualized into green planning recommendations for new and consolidated urban areas in Bilbao.

An Occupational Heat-Health Warning System for Europe: The HEAT-SHIELD Platform

Existing heat-health warning systems focus on warning vulnerable groups in order to reduce mortality. However, human health and performance are affected at much lower environmental heat strain levels than those directly associated with higher mortality. Moreover, workers are at elevated health risks when exposed to prolonged heat. This study describes the multilingual "HEAT-SHIELD occupational warning system" platform (https://heatshield.zonalab.it/) operating for Europe and developed within the framework of the HEAT-SHIELD project. This system is based on probabilistic medium-range forecasts calibrated on approximately 1800 meteorological stations in Europe and provides the ensemble forecast of the daily maximum heat stress. The platform provides a non-customized output represented by a map showing the weekly maximum probability of exceeding a specific heat stress condition, for each of the four upcoming weeks. Customized output allows the forecast of the personalized local heat-stress-risk based on workers' physical, clothing and behavioral characteristics and the work environment (outdoors in the sun or shade), also taking into account heat acclimatization. Personal daily heat stress risk levels and behavioral suggestions (hydration and work breaks recommended) to be taken into consideration in the short term (5 days) are provided together with long-term heat risk forecasts (up to 46 days), all which are useful for planning work activities. The HEAT-SHIELD platform provides adaptation strategies for "managing" the impact of global warming.