Excess mortality attributed to heat and cold: a health impact assessment study in 854 cities in Europe.

BACKGROUND: Heat and cold are established environmental risk factors for human health. However, mapping the related health burden is a difficult task due to the complexity of the associations and the differences in vulnerability and demographic distributions. In this study, we did a comprehensive mortality impact assessment due to heat and cold in European urban areas, considering geographical differences and age-specific risks. METHODS: We included urban areas across Europe between Jan 1, 2000, and Dec 12, 2019, using the Urban Audit dataset of Eurostat and adults aged 20 years and older living in these areas. Data were extracted from Eurostat, the Multi-country Multi-city Collaborative Research Network, Moderate Resolution Imaging Spectroradiometer, and Copernicus. We applied a three-stage method to estimate risks of temperature continuously across the age and space dimensions, identifying patterns of vulnerability on the basis of city-specific characteristics and demographic structures. These risks were used to derive minimum mortality temperatures and related percentiles and raw and standardised excess mortality rates for heat and cold aggregated at various geographical levels. FINDINGS: Across the 854 urban areas in Europe, we estimated an annual excess of 203 620 (empirical 95% CI 180 882-224 613) deaths attributed to cold and 20 173 (17 261-22 934) attributed to heat. These corresponded to age-standardised rates of 129 (empirical 95% CI 114-142) and 13 (11-14) deaths per 100 000 person-years. Results differed across Europe and age groups, with the highest effects in eastern European cities for both cold and heat. INTERPRETATION: Maps of mortality risks and excess deaths indicate geographical differences, such as a north-south gradient and increased vulnerability in eastern Europe, as well as local variations due to urban characteristics. The modelling framework and results are crucial for the design of national and local health and climate policies and for projecting the effects of cold and heat under future climatic and socioeconomic scenarios. FUNDING: Medical Research Council of UK, the Natural Environment Research Council UK, the EU's Horizon 2020, and the EU's Joint Research Center.

Perinatal Health Inequalities in the Industrial Region of Estonia: A Birth Registry-Based Study.

Despite the increasing number of studies on industrially contaminated sites (ICS) and their health effects, there are very few studies on perinatal health outcomes in ICSs. In the present study, we examined the perinatal health inequalities by comparing adverse birth outcomes (ABOs) in the oil shale industry region of Ida-Viru County in Estonia with national-level figures and investigated the effects of maternal environmental and sociodemographic factors. Based on the 208,313 birth records from 2004-2018, Ida-Viru ICS has a birth weight 124.5 g lower than the average of 3544 g in Estonia. A higher prevalence of preterm birth (4.3%) and low birth weight (4.8%) in Ida-Viru ICS is found compared to 3.3% on both indicators at the national level. Multiple logistic regression analysis shows the statistically significant association of ABOs with fine particle (PM2.5) air pollution, mother's ethnicity, and education throughout Estonia. However, in Ida-Viru ICS, the ABOs odds are remarkably higher in these characteristics except for the mother's ethnicity. Furthermore, the ABOs are associated with the residential proximity to ICS. Thus, the Ida-Viru ICS has unequally higher odds of adverse perinatal health across the environmental and sociodemographic factors. In addition to reducing the air pollutants, policy actions on social disparities are vital to address the country's unjustly higher perinatal health inequalities, especially in the Ida-Viru ICS.

Effect modification of greenness on the association between heat and mortality: A multi-city multi-country study.

BACKGROUND: Identifying how greenspace impacts the temperature-mortality relationship in urban environments is crucial, especially given climate change and rapid urbanization. However, the effect modification of greenspace on heat-related mortality has been typically focused on a localized area or single country. This study examined the heat-mortality relationship among different greenspace levels in a global setting. METHODS: We collected daily ambient temperature and mortality data for 452 locations in 24 countries and used Enhanced Vegetation Index (EVI) as the greenspace measurement. We used distributed lag non-linear model to estimate the heat-mortality relationship in each city and the estimates were pooled adjusting for city-specific average temperature, city-specific temperature range, city-specific population density, and gross domestic product (GDP). The effect modification of greenspace was evaluated by comparing the heat-related mortality risk for different greenspace groups (low, medium, and high), which were divided into terciles among 452 locations. FINDINGS: Cities with high greenspace value had the lowest heat-mortality relative risk of 1·19 (95% CI: 1·13, 1·25), while the heat-related relative risk was 1·46 (95% CI: 1·31, 1·62) for cities with low greenspace when comparing the 99th temperature and the minimum mortality temperature. A 20% increase of greenspace is associated with a 9·02% (95% CI: 8·88, 9·16) decrease in the heat-related attributable fraction, and if this association is causal (which is not within the scope of this study to assess), such a reduction could save approximately 933 excess deaths per year in 24 countries. INTERPRETATION: Our findings can inform communities on the potential health benefits of greenspaces in the urban environment and mitigation measures regarding the impacts of climate change. FUNDING: This publication was developed under Assistance Agreement No. RD83587101 awarded by the U.S. Environmental Protection Agency to Yale University. It has not been formally reviewed by EPA. The views expressed in this document are solely those of the authors and do not necessarily reflect those of the Agency. EPA does not endorse any products or commercial services mentioned in this publication. Research reported in this publication was also supported by the National Institute on Minority Health and Health Disparities of the National Institutes of Health under Award Number R01MD012769. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Also, this work has been supported by the National Research Foundation of Korea (2021R1A6A3A03038675), Medical Research Council-UK (MR/V034162/1 and MR/R013349/1), Natural Environment Research Council UK (Grant ID: NE/R009384/1), Academy of Finland (Grant ID: 310372), European Union's Horizon 2020 Project Exhaustion (Grant ID: 820655 and 874990), Czech Science Foundation (22-24920S), Emory University's NIEHS-funded HERCULES Center (Grant ID: P30ES019776), and Grant CEX2018-000794-S funded by MCIN/AEI/ 10.13039/501100011033 The funders had no role in the design, data collection, analysis, interpretation of results, manuscript writing, or decision to publication.

Health impact assessment of transportation noise in two Estonian cities.

Transportation noise is a growing public health concern worldwide, especially in urban areas, causing annoyance, sleep disturbance, cardiovascular diseases and other health effects. Recently, European Commission (EC) has developed a mutual methodology for assessing health impacts of transportation noise in European Union using strategic noise mapping. Applying this methodology, our aim was to quantify the health effects of road, rail and aircraft noise in two Estonian cities, Tallinn and Tartu. We also aimed to assess sensitivity of this methodology, while implementing lower threshold values and employing additional health outcomes. The proportion of highly annoyed residents due to road traffic noise was 11.6% in Tallinn, and 9.2% in Tartu; around 2.5% residents in both cities could have high sleeping disturbances. As exposure to railway and aircraft noise was relatively low in both cities, people with high annoyance and high sleep disturbance caused by railway and aircraft noise was below 1%. Ischemic heart disease (IHD) cases attributable to road traffic noise was estimated to be 122.6 in Tallinn and 21.5 in Tartu. Altogether transportation noise was estimated to cause 1807 disability adjusted life years (DALYs) in Tallinn and 370 DALYs in Tartu. The health costs were calculated as €126.5 and €25.9 million annually, respectively in the two cities. When we included higher number of health outcomes (stroke incidence, IHD deaths) and lowered exposure threshold by 5 dB, the annual burden of disease was doubled. As the latest epidemiological studies showed transportation noise having larger number of effects on lower noise levels, the results with the currently applied European Commission health impact assessment (HIA) methodology were rather conservative. Despite of uncertainties associated to applied methodology, transportation noise, especially road traffic noise, is an important environmental risk factor, that leads to considerable loss of healthy life years and causes large health costs in urban areas.

A review of exposure assessment methods for epidemiological studies of health effects related to industrially contaminated sites.

BACKGROUND: this paper is based upon work from COST Action ICSHNet. Health risks related to living close to industrially contaminated sites (ICSs) are a public concern. Toxicology-based risk assessment of single contaminants is the main approach to assess health risks, but epidemiological studies which investigate the relationships between exposure and health directly in the affected population have contributed important evidence. Limitations in exposure assessment have substantially contributed to uncertainty about associations found in epidemiological studies. OBJECTIVES: to examine exposure assessment methods that have been used in epidemiological studies on ICSs and to provide recommendations for improved exposure assessment in epidemiological studies by comparing exposure assessment methods in epidemiological studies and risk assessments. METHODS: after defining the multi-media framework of exposure related to ICSs, we discussed selected multi-media models applied in Europe. We provided an overview of exposure assessment in 54 epidemiological studies from a systematic review of hazardous waste sites; a systematic review of 41 epidemiological studies on incinerators and 52 additional studies on ICSs and health identified for this review. RESULTS: we identified 10 multi-media models used in Europe primarily for risk assessment. Recent models incorporated estimation of internal biomarker levels. Predictions of the models differ particularly for the routes 'indoor air inhalation' and 'vegetable consumption'. Virtually all of the 54 hazardous waste studies used proximity indicators of exposure, based on municipality or zip code of residence (28 studies) or distance to a contaminated site (25 studies). One study used human biomonitoring. In virtually all epidemiological studies, actual land use was ignored. In the 52 additional studies on contaminated sites, proximity indicators were applied in 39 studies, air pollution dispersion modelling in 6 studies, and human biomonitoring in 9 studies. Exposure assessment in epidemiological studies on incinerators included indicators (presence of source in municipality and distance to the incinerator) and air dispersion modelling. Environmental multi-media modelling methods were not applied in any of the three groups of studies. CONCLUSIONS: recommendations for refined exposure assessment in epidemiological studies included the use of more sophisticated exposure metrics instead of simple proximity indicators where feasible, as distance from a source results in misclassification of exposure as it ignores key determinants of environmental fate and transport, source characteristics, land use, and human consumption behaviour. More validation studies using personal exposure or human biomonitoring are needed to assess misclassification of exposure. Exposure assessment should take more advantage of the detailed multi-media exposure assessment procedures developed for risk assessment. The use of indicators can be substantially improved by linking definition of zones of exposure to existing knowledge of extent of dispersion. Studies should incorporate more often land use and individual behaviour.

Heat-related respiratory hospital admissions in Europe in a changing climate: a health impact assessment.

OBJECTIVES: Respiratory diseases are ranked second in Europe in terms of mortality, prevalence and costs. Studies have shown that extreme heat has a large impact on mortality and morbidity, with a large relative increase for respiratory diseases. Expected increases in mean temperature and the number of extreme heat events over the coming decades due to climate change raise questions about the possible health impacts. We assess the number of heat-related respiratory hospital admissions in a future with a different climate. DESIGN: A Europe-wide health impact assessment. SETTING: An assessment for each of the EU27 countries. METHODS: Heat-related hospital admissions under a changing climate are projected using multicity epidemiological exposure-response relationships applied to gridded population data and country-specific baseline respiratory hospital admission rates. Times-series of temperatures are simulated with a regional climate model based on four global climate models, under two greenhouse gas emission scenarios. RESULTS: Between a reference period (1981-2010) and a future period (2021-2050), the total number of respiratory hospital admissions attributed to heat is projected to be larger in southern Europe, with three times more heat attributed respiratory hospital admissions in the future period. The smallest change was estimated in Eastern Europe with about a twofold increase. For all of Europe, the number of heat-related respiratory hospital admissions is projected to be 26 000 annually in the future period compared with 11 000 in the reference period. CONCLUSIONS: The results suggest that the projected effects of climate change on temperature and the number of extreme heat events could substantially influence respiratory morbidity across Europe.

Health impact assessment of particulate pollution in Tallinn using fine spatial resolution and modeling techniques.

BACKGROUND: Health impact assessments (HIA) use information on exposure, baseline mortality/morbidity and exposure-response functions from epidemiological studies in order to quantify the health impacts of existing situations and/or alternative scenarios. The aim of this study was to improve HIA methods for air pollution studies in situations where exposures can be estimated using GIS with high spatial resolution and dispersion modeling approaches. METHODS: Tallinn was divided into 84 sections according to neighborhoods, with a total population of approx. 390,000 persons. Actual baseline rates for total mortality and hospitalization with cardiovascular and respiratory diagnosis were identified. The exposure to fine particles (PM2.5) from local emissions was defined as the modeled annual levels. The model validation and morbidity assessment were based on 2006 PM10 or PM2.5 levels at 3 monitoring stations. The exposure-response coefficients used were for total mortality 6.2% (95% CI 1.6-11%) per 10 microg/m3 increase of annual mean PM2.5 concentration and for the assessment of respiratory and cardiovascular hospitalizations 1.14% (95% CI 0.62-1.67%) and 0.73% (95% CI 0.47-0.93%) per 10 microg/m3 increase of PM10. The direct costs related to morbidity were calculated according to hospital treatment expenses in 2005 and the cost of premature deaths using the concept of Value of Life Year (VOLY). RESULTS: The annual population-weighted-modeled exposure to locally emitted PM2.5 in Tallinn was 11.6 microg/m3. Our analysis showed that it corresponds to 296 (95% CI 76528) premature deaths resulting in 3859 (95% CI 10236636) Years of Life Lost (YLL) per year. The average decrease in life-expectancy at birth per resident of Tallinn was estimated to be 0.64 (95% CI 0.17-1.10) years. While in the polluted city centre this may reach 1.17 years, in the least polluted neighborhoods it remains between 0.1 and 0.3 years. When dividing the YLL by the number of premature deaths, the decrease in life expectancy among the actual cases is around 13 years. As for the morbidity, the short-term effects of air pollution were estimated to result in an additional 71 (95% CI 43-104) respiratory and 204 (95% CI 131-260) cardiovascular hospitalizations per year. The biggest external costs are related to the long-term effects on mortality: this is on average euro 150 (95% CI 40-260) million annually. In comparison, the costs of short-term air-pollution driven hospitalizations are small euro 0.3 (95% CI 0.2-0.4) million. CONCLUSION: Sectioning the city for analysis and using GIS systems can help to improve the accuracy of air pollution health impact estimations, especially in study areas with poor air pollution monitoring data but available dispersion models.