Empirical evidence of declining global vulnerability to climate-related hazards.

Death tolls and economic losses from natural hazards continue to rise in many parts of the world. With the aim to reduce future impacts from natural disasters it is crucial to understand the variability in space and time of the vulnerability of people and economic assets. In this paper we quantified the temporal dynamics of socio-economic vulnerability, expressed as fatalities over exposed population and losses over exposed GDP, to climate-related hazards between 1980 and 2016. Using a global, spatially explicit framework that integrates population and economic dynamics with one of the most complete natural disaster loss databases we quantified mortality and loss rates across income levels and analyzed their relationship with wealth. Results show a clear decreasing trend in both human and economic vulnerability, with global average mortality and economic loss rates that have dropped by 6.5 and nearly 5 times, respectively, from 1980-1989 to 2007-2016. We further show a clear negative relation between vulnerability and wealth, which is strongest at the lowest income levels. This has led to a convergence in vulnerability between higher and lower income countries. Yet, there is still a considerable climate hazard vulnerability gap between poorer and richer countries.

Changes in climate extremes, fresh water availability and vulnerability to food insecurity projected at 1.5°C and 2°C global warming with a higher-resolution global climate model.

We projected changes in weather extremes, hydrological impacts and vulnerability to food insecurity at global warming of 1.5°C and 2°C relative to pre-industrial, using a new global atmospheric general circulation model HadGEM3A-GA3.0 driven by patterns of sea-surface temperatures and sea ice from selected members of the 5th Coupled Model Intercomparison Project (CMIP5) ensemble, forced with the RCP8.5 concentration scenario. To provide more detailed representations of climate processes and impacts, the spatial resolution was N216 (approx. 60 km grid length in mid-latitudes), a higher resolution than the CMIP5 models. We used a set of impacts-relevant indices and a global land surface model to examine the projected changes in weather extremes and their implications for freshwater availability and vulnerability to food insecurity. Uncertainties in regional climate responses are assessed, examining ranges of outcomes in impacts to inform risk assessments. Despite some degree of inconsistency between components of the study due to the need to correct for systematic biases in some aspects, the outcomes from different ensemble members could be compared for several different indicators. The projections for weather extremes indices and biophysical impacts quantities support expectations that the magnitude of change is generally larger for 2°C global warming than 1.5°C. Hot extremes become even hotter, with increases being more intense than seen in CMIP5 projections. Precipitation-related extremes show more geographical variation with some increases and some decreases in both heavy precipitation and drought. There are substantial regional uncertainties in hydrological impacts at local scales due to different climate models producing different outcomes. Nevertheless, hydrological impacts generally point towards wetter conditions on average, with increased mean river flows, longer heavy rainfall events, particularly in South and East Asia with the most extreme projections suggesting more than a doubling of flows in the Ganges at 2°C global warming. Some areas are projected to experience shorter meteorological drought events and less severe low flows, although longer droughts and/or decreases in low flows are projected in many other areas, particularly southern Africa and South America. Flows in the Amazon are projected to decline by up to 25%. Increases in either heavy rainfall or drought events imply increased vulnerability to food insecurity, but if global warming is limited to 1.5°C, this vulnerability is projected to remain smaller than at 2°C global warming in approximately 76% of developing countries. At 2°C, four countries are projected to reach unprecedented levels of vulnerability to food insecurity.This article is part of the theme issue 'The Paris Agreement: understanding the physical and social challenges for a warming world of 1.5°C above pre-industrial levels'.

Escalating impacts of climate extremes on critical infrastructures in Europe.

Extreme climatic events are likely to become more frequent owing to global warming. This may put additional stress on critical infrastructures with typically long life spans. However, little is known about the risks of multiple climate extremes on critical infrastructures at regional to continental scales. Here we show how single- and multi-hazard damage to energy, transport, industrial, and social critical infrastructures in Europe are likely to develop until the year 2100 under the influence of climate change. We combine a set of high-resolution climate hazard projections, a detailed representation of physical assets in various sectors and their sensitivity to the hazards, and more than 1100 records of losses from climate extremes in a prognostic modelling framework. We find that damages could triple by the 2020s, multiply six-fold by mid-century, and amount to more than 10 times present damage of €3.4 billion per year by the end of the century due only to climate change. Damage from heatwaves, droughts in southern Europe, and coastal floods shows the most dramatic rise, but the risks of inland flooding, windstorms, and forest fires will also increase in Europe, with varying degrees of change across regions. Economic losses are highest for the industry, transport, and energy sectors. Future losses will not be incurred equally across Europe. Southern and south-eastern European countries will be most affected and, as a result, will probably require higher costs of adaptation. The findings of this study could aid in prioritizing regional investments to address the unequal burden of impacts and differences in adaptation capacities across Europe.

Engaging GPs in insulin therapy initiation: a qualitative study evaluating a support program in the Belgian context.

BACKGROUND: A program supporting the initiation of insulin therapy in primary care was introduced in Belgium, as part of a larger quality improvement project on diabetes care. This paper reports on a study exploring factors influencing the engagement of general practitioners (GPs) in insulin therapy initiation (research question 1) and exploring factors relevant for future program development (research question 2). METHODS: We have used semi-structured interviews to answer the first research question: two focus group interviews with GPs who had at least one patient in the insulin initiation program and 20 one-to-one interviews with GPs who were not regular users of the overall support program in the region. To explore factors relevant for future program development, the data from the GPs were triangulated with data obtained from individual interviews with patients (n = 10), the diabetes nurse educator (DNE) and the specialist involved in the program, and data extracted from meeting reports evaluating the insulin initiation support program. RESULTS: We found differences between GPs engaged and those not engaged in insulin initiation in attitude, subjective norm and perceived behavioural control regarding insulin initiation. In general the support program was evaluated in a positive way by users of the program. Some aspects need further consideration: job boundaries between the DNE and GPs, job boundaries between GPs and specialists, protocol adherence and limited case load. CONCLUSION: The study shows that the transition of insulin initiation from secondary care to the primary care setting is a challenge. Although a support program addressing known barriers to insulin initiation was provided, a substantial number of GPs were reluctant to engage in this aspect of care. Important issues for future program development are: an interdisciplinary approach to job clarification, a dynamic approach to the integration of expertise in primary care and feedback on protocol adherence. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT00824499.

Physical and economic consequences of climate change in Europe.

Quantitative estimates of the economic damages of climate change usually are based on aggregate relationships linking average temperature change to loss in gross domestic product (GDP). However, there is a clear need for further detail in the regional and sectoral dimensions of impact assessments to design and prioritize adaptation strategies. New developments in regional climate modeling and physical-impact modeling in Europe allow a better exploration of those dimensions. This article quantifies the potential consequences of climate change in Europe in four market impact categories (agriculture, river floods, coastal areas, and tourism) and one nonmarket impact (human health). The methodology integrates a set of coherent, high-resolution climate change projections and physical models into an economic modeling framework. We find that if the climate of the 2080s were to occur today, the annual loss in household welfare in the European Union (EU) resulting from the four market impacts would range between 0.2-1%. If the welfare loss is assumed to be constant over time, climate change may halve the EU's annual welfare growth. Scenarios with warmer temperatures and a higher rise in sea level result in more severe economic damage. However, the results show that there are large variations across European regions. Southern Europe, the British Isles, and Central Europe North appear most sensitive to climate change. Northern Europe, on the other hand, is the only region with net economic benefits, driven mainly by the positive effects on agriculture. Coastal systems, agriculture, and river flooding are the most important of the four market impacts assessed.

Temperature-related mortality burden and projected change in 1368 European regions: a modelling study.

BACKGROUND: Excessively high and low temperatures substantially affect human health. Climate change is expected to exacerbate heat-related morbidity and mortality, presenting unprecedented challenges to public health systems. Since localised assessments of temperature-related mortality risk are essential to formulate effective public health responses and adaptation strategies, we aimed to estimate the current and future temperature-related mortality risk under four climate change scenarios across all European regions. METHODS: We modelled current and future mortality due to non-optimal temperatures across 1368 European regions, considering age-specific characteristics and local socioeconomic vulnerabilities. Overseas territories were excluded from the analysis. We applied a three-stage method to estimate temperature-related risk continuously across age and spatial dimensions. Age and city-specific exposure-response functions were obtained for a comprehensive list of 854 European cities from the Urban Audit dataset of Eurostat. Regional aggregates were calculated using an aggregation and extrapolation method that incorporates the risk incidence in neighbouring cities. Mortality was projected for present conditions observed in 1991-2020 and for four different levels of global warming (1·5°C, 2°C, 3°C, and 4°C increase) by regions, and subregions using an ensemble of 11 climate models produced by the Coordinated Regional Climate Downscaling Experiment-CMIP5 over Europe, and population projection data from EUROPOP2019. FINDINGS: Our results highlight regional disparities in temperature-related mortality across Europe. Between 1991 and 2020, the number of cold-related deaths was 2·5 times higher in eastern Europe than western Europe, and heat-related deaths were 6 times higher in southern Europe than in northern Europe. During the same time period, there were a median of 363 809 cold-related deaths (empirical 95% CI 362 493-365 310) and 43 729 heat-related deaths (39 880-45 921), with a cold-to-heat-related death ratio of 8·3:1. Under current climate policies, aligned with 3°C increase in global warming, it is estimated that temperature-related deaths could increase by 54 974 additional deaths (24 112-80 676) by 2100, driven by rising heat-related deaths and an ageing population, resulting in a cold-to-heat-related death ratio of 2·6:1. Climate change is also expected to widen disparities in regional mortality, particularly impacting southern regions of Europe as a result of a marked increase in heat-related deaths. INTERPRETATION: This study shows that regional disparities in temperature-related mortality risk in Europe are substantial and will continue to increase due to the effects of climate change and an ageing population. The data presented can assist policy makers and health authorities in mitigating increasing health inequalities by prioritising the protection of more susceptible areas and older population groups. We identify the projected areas of heightened risk (southern Europe), where policy intervention aimed at building adaptation and enhancing resilience should be prioritised. FUNDING: European Commission.

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.

National water shortage for low to high environmental flow protection.

Global freshwater biodiversity has been decreasing rapidly, requiring the restoration and maintenance of environmental flows (EFs) in streams and rivers. EFs provide many ecosystem services that benefit humans. Reserving such EFs for aquatic ecosystems, implies less renewable water availability for direct human water use such as agriculture, industry, cities and energy. Here we show that, depending on the level of EF protection, global annual renewable water availability for humans decreases between 41 and 80% compared to when not reserving EFs. With low EF protection, currently 53 countries experience different levels of water shortage, which increases to 101 countries for high EF protection. Countries will carefully have to balance the amount of water allocated to humans and the environment.

Comparison of weather station and climate reanalysis data for modelling temperature-related mortality.

Epidemiological analyses of health risks associated with non-optimal temperature are traditionally based on ground observations from weather stations that offer limited spatial and temporal coverage. Climate reanalysis represents an alternative option that provide complete spatio-temporal exposure coverage, and yet are to be systematically explored for their suitability in assessing temperature-related health risks at a global scale. Here we provide the first comprehensive analysis over multiple regions to assess the suitability of the most recent generation of reanalysis datasets for health impact assessments and evaluate their comparative performance against traditional station-based data. Our findings show that reanalysis temperature from the last ERA5 products generally compare well to station observations, with similar non-optimal temperature-related risk estimates. However, the analysis offers some indication of lower performance in tropical regions, with a likely underestimation of heat-related excess mortality. Reanalysis data represent a valid alternative source of exposure variables in epidemiological analyses of temperature-related risk.

Why do GPs hesitate to refer diabetes patients to a self-management education program: a qualitative study.

BACKGROUND: Self-management support is seen as a cornerstone of good diabetes care and many countries are currently engaged in initiatives to integrate self-management support in primary care. Concerning the organisation of these programs, evidence is growing that engagement of health care professionals, in particular of GPs, is critical for successful application. This paper reports on a study exploring why a substantial number of GPs was (initially) reluctant to refer patients to a self-management education program in Belgium. METHODS: Qualitative analysis of semi-structured face-to-face interviews with a purposive sample of 20 GPs who were not regular users of the service. The Greenhalgh diffusion of innovation framework was used as background and organising framework. RESULTS: Several barriers, linked to different components of the Greenhalgh model, emerged from the interview data. One of the most striking ones was the limited readiness for innovation among GPs. Feelings of fear of further fragmentation of diabetes care and frustration and insecurity regarding their own role in diabetes care prevented them from engaging in the innovation process. GPs needed time to be reassured that the program respects their role and has an added value to usual care. Once GPs considered referring patients, it was not clear enough which of their patients would benefit from the program. Some GPs expressed the need for training in motivational skills, so that they could better motivate their patients to participate. A practical but often mentioned barrier was the distance to the centre where the program was delivered. Further, uncertainty about continuity interfered with the uptake of the offer. CONCLUSIONS: The study results contribute to a better understanding of the reasons why GPs hesitate to refer patients to a self-management education program. First of all, the role of GPs and other health care providers in diabetes care needs to be clarified before introducing new functions. Feelings of security and a basic trust of providers in the health system are a prerequisite for participation in care innovation. Moreover, some important lessons regarding the implementation of an education program in primary care have been learned from the study.

The number of people exposed to water stress in relation to how much water is reserved for the environment: a global modelling study.

BACKGROUND: Increasing human demand for water and changes in water availability due to climate change threatens water security worldwide. Additionally, exploitation of water resources induces stress on freshwater environments, leading to biodiversity loss and reduced ecosystem services. We aimed to conduct a spatially detailed assessment of global human water stress for low to high environmental flow (EF) protection. METHODS: In this modelling study, we used the LISFLOOD model to generate daily natural flows without anthropogenic water use for 1980-2018. On the basis of these flows, we selected three EF methods (EF with high ecological protection [EFPROT], EF with minimum flow requirements [EFMIN], and variable monthly flow [EFVMF]) to calculate monthly EFs. We assessed monthly consumptive water use for industry, agricultural crops, livestock, municipalities, and energy production for 2010. We then estimated the corresponding number of people under water stress per month on a global and national level using a spatially detailed population database for 2010. FINDINGS: We estimate that 3·2 billion (EFPROT), 2·4 billion (EFVMF), and 2·2 billion (EFMIN) people lived under water stress for at least 1 month per year, corresponding to 46%, 35%, and 32% of the world's population in 2010, respectively. Around 80% of people living under water stress lived in Asia; in particular, India, Pakistan, and northeast China. Compared with EFMIN, imposing EFPROT globally would have put between 710 million (March) to 1 billion (June) additional people under water stress on a monthly basis, whereas this would have been 72 million (August) to 218 million (April) additional people if EFVMF were imposed. INTERPRETATION: Ensuring high ecological protection would put nearly half of the world's population (3·2 billion people) under water stress for at least 1 month per year. Policy makers and water managers have to make an important trade-off when allocating limited water resources between direct human needs and the environment. A better understanding of local ecosystem needs is crucial to alleviating current and future human water stress, while sustaining healthy ecosystems. FUNDING: None.

Emergent vulnerability to climate-driven disturbances in European forests.

Forest disturbance regimes are expected to intensify as Earth's climate changes. Quantifying forest vulnerability to disturbances and understanding the underlying mechanisms is crucial to develop mitigation and adaptation strategies. However, observational evidence is largely missing at regional to continental scales. Here, we quantify the vulnerability of European forests to fires, windthrows and insect outbreaks during the period 1979-2018 by integrating machine learning with disturbance data and satellite products. We show that about 33.4 billion tonnes of forest biomass could be seriously affected by these disturbances, with higher relative losses when exposed to windthrows (40%) and fires (34%) compared to insect outbreaks (26%). The spatial pattern in vulnerability is strongly controlled by the interplay between forest characteristics and background climate. Hotspot regions for vulnerability are located at the borders of the climate envelope, in both southern and northern Europe. There is a clear trend in overall forest vulnerability that is driven by a warming-induced reduction in plant defence mechanisms to insect outbreaks, especially at high latitudes.

Effectiveness of the introduction of a Chronic Care Model-based program for type 2 diabetes in Belgium.

BACKGROUND: During a four-year action research project (2003-2007), a program targeting all type 2 diabetes patients was implemented in a well-defined geographical region in Belgium. The implementation of the program resulted in an increase of the overall Assessment of Chronic Illness Care (ACIC) score from 1.45 in 2003 to 5.5 in 2007. The aim of the follow-up study in 2008 was to assess the effect of the implementation of Chronic Care Model (CCM) elements on the quality of diabetes care in a country where the efforts to adapt primary care to a more chronic care oriented system are still at a starting point. METHODS: A quasi-experimental study design involving a control region with comparable geographical and socio-economic characteristics and health care facilities was used to evaluate the effect of the intervention in the region. In collaboration with the InterMutualistic Agency (IMA) and the laboratories from both regions a research database was set up. Study cohorts in both regions were defined by using administrative data from the Sickness Funds and selected from the research database. A set of nine quality indicators was defined based on current scientific evidence. Data were analysed by an institution experienced in longitudinal data analysis. RESULTS: In total 4,174 type 2 diabetes patients were selected from the research database; 2,425 patients (52.9% women) with a mean age of 67.5 from the intervention region and 1,749 patients (55.7% women) with a mean age of 67.4 from the control region. At the end of the intervention period, improvements were observed in five of the nine defined quality indicators in the intervention region, three of which (HbA1c assessment, statin therapy, cholesterol target) improved significantly more than in the control region. Mean HbA1c improved significantly in the intervention region (7.55 to 7.06%), but this evolution did not differ significantly (p = 0.4207) from the one in the control region (7.44 to 6.90%). The improvement in lipid control was significantly higher (p = 0.0021) in the intervention region (total cholesterol 199.07 to 173 mg/dl) than in the control region (199.44 to 180.60 mg/dl). The systematic assessment of long-term diabetes complications remained insufficient. In 2006 only 26% of the patients had their urine tested for micro-albuminuria and only 36% had consulted an ophthalmologist. CONCLUSION: Although the overall ACIC score increased from 1.45 to 5.5, the improvement in the quality of diabetes care was moderate. Further improvements are needed in the CCM components delivery system design and clinical information systems. The regional networks, as they are financed now by the National Institute for Health and Disability Insurance (NIHDI), are an opportunity to explore how this can be achieved in consultation with the GPs. But it is clear that, simultaneously, action is needed on the health system level to realize the installation of an accurate quality monitoring system and the necessary preconditions for chronic care delivery in primary care (patient registration, staff support, IT support). TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Identifier: NCT00824499.

Accounting for changes in flood control delivered by ecosystems at the EU level.

Ecosystem service accounts require quantifying the contribution of ecosystems to the society. However, estimation of the ecosystem service used (actual flow) remains still very challenging for regulating services. We developed an experimental ecosystem service account for flood control delivered by ecosystems including: 1) Biophysical modelling of ecosystem service potential, demand and actual flow. 2) Translation of the actual flow in monetary terms. 3) Compilation of accounting tables. Ultimately, we analysed changes in flood control between 2006 and 2012. The value of flood control delivered by ecosystems in 2012 is estimated at about 16 billion euro. This value increased by 1.14% between 2006 and 2012. This increase is mainly due to the sprawl of artificial areas into floodplains that benefit from flood control delivered by ecosystems. However, the role of natural capital to control floods is slightly decreasing. This is confirmed by the increase of artificial areas not protected by ecosystems (+1.9%, unmet demand). The role of natural capital to control floods could be enhanced by restoring ecosystems upstream from this unmet demand and increase the ecosystems contribution to human well-being. The methodology makes a significant contribution to the assessment of ecosystem services flow and the accounting framework.

More meteorological events that drive compound coastal flooding are projected under climate change.

Compound flooding arises from storms causing concurrent extreme meteorological tides (that is the superposition of storm surge and waves) and precipitation. This flooding can severely affect densely populated low-lying coastal areas. Here, combining output from climate and ocean models, we analyse the concurrence probability of the meteorological conditions driving compound flooding. We show that, under a high emissions scenario, the concurrence probability would increase globally by more than 25% by 2100 compared to present. In latitudes above 40o north, compound flooding could become more than 2.5 times as frequent, in contrast to parts of the subtropics where it would weaken. Changes in extreme precipitation and meteorological tides account for most (77% and 20%, respectively) of the projected change in concurrence probability. The evolution of the dependence between precipitation and meteorological tide dominates the uncertainty in the projections. Our results indicate that not accounting for these effects in adaptation planning could leave coastal communities insufficiently protected against flooding.

Economic motivation for raising coastal flood defenses in Europe.

Extreme sea levels (ESLs) in Europe could rise by as much as one metre or more by the end of this century due to climate change. This poses significant challenges to safeguard coastal communities. Here we present a comprehensive analysis of economically efficient protection scenarios along Europe's coastlines during the present century. We employ a probabilistic framework that integrates dynamic simulations of all ESL components and flood inundation, impact modelling and a cost-benefit analysis of raising dykes. We find that at least 83% of flood damages in Europe could be avoided by elevating dykes in an economically efficient way along 23.7%-32.1% of Europe's coastline, specifically where high value conurbations exist. The European mean benefit to cost ratio of the investments varies from 8.3 to 14.9 while at country level this ranges between 1.6 and 34.3, with higher efficiencies for a scenario with high-end greenhouse gas emissions and strong socio-economic growth.

Implementation of a program for type 2 diabetes based on the Chronic Care Model in a hospital-centered health care system: "the Belgian experience".

BACKGROUND: Most research publications on Chronic Care Model (CCM) implementation originate from organizations or countries with a well-structured primary health care system. Information about efforts made in countries with a less well-organized primary health care system is scarce. In 2003, the Belgian National Institute for Health and Disability Insurance commissioned a pilot study to explore how care for type 2 diabetes patients could be organized in a more efficient way in the Belgian healthcare setting, a setting where the organisational framework for chronic care is mainly hospital-centered. METHODS: Process evaluation of an action research project (2003-2007) guided by the CCM in a well-defined geographical area with 76,826 inhabitants and an estimated number of 2,300 type 2 diabetes patients. In consultation with the region a program for type 2 diabetes patients was developed. The degree of implementation of the CCM in the region was assessed using the Assessment of Chronic Illness Care survey (ACIC). A multimethod approach was used to evaluate the implementation process. The resulting data were triangulated in order to identify the main facilitators and barriers encountered during the implementation process. RESULTS: The overall ACIC score improved from 1.45 (limited support) at the start of the study to 5.5 (basic support) at the end of the study. The establishment of a local steering group and the appointment of a program manager were crucial steps in strengthening primary care. The willingness of a group of well-trained and motivated care providers to invest in quality improvement was an important facilitator. Important barriers were the complexity of the intervention, the lack of quality data, inadequate information technology support, the lack of commitment procedures and the uncertainty about sustainable funding. CONCLUSION: Guided by the CCM, this study highlights the opportunities and the bottlenecks for adapting chronic care delivery in a primary care system with limited structure. The study succeeded in achieving a considerable improvement of the overall support for diabetes patients but further improvement requires a shift towards system thinking among policy makers. Currently primary care providers lack the opportunities to take up full responsibility for chronic care. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Identifier: NCT00824499.

HARCI-EU, a harmonized gridded dataset of critical infrastructures in Europe for large-scale risk assessments.

Critical infrastructures (CIs) are assets, systems, or parts thereof that are essential for the maintenance of socioeconomic functions, health, safety and well-being of people. The exposure of CIs to natural and man-made hazards poses a risk to the economy and society. The spatial distribution of CIs and their economic value are a prerequisite for quantifying risk and planning suitable protection and adaptation measures. However, the incompleteness and inconsistency of existing information on CIs hamper their integration into large-scale risk frameworks. We present here the 'HARmonized grids of Critical Infrastructures in EUrope' (HARCI-EU) dataset. It represents major CIs in the transport, energy, industry and social sectors at 1 km2 expressed in sector-specific, economically-relevant units. The HARCI-EU grids were produced by integrating geospatial and statistical data from multiple sources. Correlation analysis performed against independent metrics corroborates the approach showing average Pearson coefficients ranging between 0.61 and 0.95 across the sectors. HARCI-EU provides a consistent mapping of CIs in key sectors that can serve as exposure information for large-scale risk assessments in Europe.

Global long-term observations of coastal erosion and accretion.

Changes in coastal morphology have broad consequences for the sustainability of coastal communities, structures and ecosystems. Although coasts are monitored locally in many places, understanding long-term changes at a global scale remains a challenge. Here we present a global and consistent evaluation of coastal morphodynamics over 32 years (1984-2015) based on satellite observations. Land losses and gains were estimated from the changes in water presence along more than 2 million virtual transects. We find that the overall surface of eroded land is about 28,000 km2, twice the surface of gained land, and that often the extent of erosion and accretion is in the order of km. Anthropogenic factors clearly emerge as the dominant driver of change, both as planned exploitation of coastal resources, such as building coastal structures, and as unforeseen side effects of human activities, for example the installment of dams, irrigation systems and structures that modify the flux of sediments, or the clearing of coastal ecosystems, such as mangrove forests. Another important driver is the occurrence of natural disasters such as tsunamis and extreme storms. The observed global trend in coastal erosion could be enhanced by Sea Level Rise and more frequent extreme events under a changing climate.

Global probabilistic projections of extreme sea levels show intensification of coastal flood hazard.

Global warming is expected to drive increasing extreme sea levels (ESLs) and flood risk along the world's coastlines. In this work we present probabilistic projections of ESLs for the present century taking into consideration changes in mean sea level, tides, wind-waves, and storm surges. Between the year 2000 and 2100 we project a very likely increase of the global average 100-year ESL of 34-76 cm under a moderate-emission-mitigation-policy scenario and of 58-172 cm under a business as usual scenario. Rising ESLs are mostly driven by thermal expansion, followed by contributions from ice mass-loss from glaciers, and ice-sheets in Greenland and Antarctica. Under these scenarios ESL rise would render a large part of the tropics exposed annually to the present-day 100-year event from 2050. By the end of this century this applies to most coastlines around the world, implying unprecedented flood risk levels unless timely adaptation measures are taken.