Heat-health action planning in the WHO European Region: Status and policy implications.

Adverse health effects from extreme heat remain a major risk, especially in a changing climate. Several European countries have implemented heat health action plans (HHAPs) to prevent ill health and excess mortality from heat. This paper assesses the state of implementation of HHAPs in the WHO European Region and discusses barriers and successes since the early 2000s. The results are based on a web-based survey among 53 member states on the current national and federal HHAPs in place. Guided by the eight core elements of HHAPs as outlined by the WHO Regional Office for Europe guidance from 2008, we analyzed which elements were fully or partially implemented and which areas of improvement countries identified. HHAP adaptations to account for COVID-19 were sought via literature search and expert consultations. 27 member states provided information, of which 17 countries reported having a HHAP. Five out of eight core elements, namely agreement on a lead body, accurate and timely alert systems, heat-related health information plans, strategies to reduce health exposure, and care for vulnerable groups, were at least partially implemented in all 17 plans. Alert systems were implemented most often at 94%. The least often implemented items were real-time surveillance, long-term urban planning, and preparedness of health and social systems. Five countries had published COVID-19 guidance online. Our findings suggest a progressive improvement in the development and rollout of HHAPs overall and awareness of vulnerable population groups in WHO/Europe, while integration of HHAPs into long-term climate change and health planning remains a challenge.

Piloting a city health adaptation typology with data from climate-engaged cities: Toward identification of an urban health adaptation gap.

Climate change has important population health impacts, and cities are often on the frontlines. However, health is reported to be less active in climate adaptation than other sectors. To contribute to better understanding urban health adaptation efforts and identifying gaps we developed a City Climate Health Adaptation Typology and tested it with adaptation actions of 106 large world cities (population > 1 million) reported to a major publicly-available adaptation database. We found two-thirds of actions of these 'active adapter' cities were health-associated. Half were health information activities (e.g., hazard mapping, early warnings); and nearly one-third addressed climate-relevant health determinants in the urban built environment (e.g., green space). Forty percent of cities were in low- or middle-income countries. Our proposed typology provides a systematic framework for monitoring and comparing city health adaptation actions. Reported city actions are suggestive of increasing depth and breadth of urban health-associated adaptation. However, even among these adaptation-engaged cities, a health adaptation gap was apparent in key climate health services (e.g., mental health), and in climate-related public health governance and capacity building. The COVID-19 pandemic has demonstrated pressing need for strong public health institutions. We recommend better integration of public health agencies into local climate action planning, enhanced modes of collaboration between health and non-health agencies and with non-governmental actors, and strengthening of city public health adaptive capacity including through networking.

Impacts of climate change on the public health of the Mediterranean Basin population - Current situation, projections, preparedness and adaptation.

The Mediterranean Basin is undergoing a warming trend with longer and warmer summers, an increase in the frequency and the severity of heat waves, changes in precipitation patterns and a reduction in rainfall amounts. In this unique populated region, which is characterized by significant gaps in the socio-economic levels particularly between the North (Europe) and South (Africa), parallel with population growth and migration, increased water demand and forest fires risk - the vulnerability of the Mediterranean population to human health risks increases significantly. Indeed, climatic changes impact the health of the Mediterranean population directly through extreme heat, drought or storms, or indirectly by changes in water availability, food provision and quality, air pollution and other stressors. The main health effects are related to extreme weather events (including extreme temperatures and floods), changes in the distribution of climate-sensitive diseases and changes in environmental and social conditions. The poorer countries, particularly in North Africa and the Levant, are at highest risk. Climate change affects the vulnerable sectors of the region, including an increasingly older population, with a larger percentage of those with chronic diseases, as well as poor people, which are therefore more susceptible to the effects of extreme temperatures. For those populations, a better surveillance and control systems are especially needed. In view of the climatic projections and the vulnerability of Mediterranean countries, climate change mitigation and adaptation become ever more imperative. It is important that prevention Health Action Plans will be implemented, particularly in those countries that currently have no prevention plans. Most adaptation measures are "win-win situation" from a health perspective, including reducing air pollution or providing shading solutions. Additionally, Mediterranean countries need to enhance cross-border collaboration, as adaptation to many of the health risks requires collaboration across borders and also across the different parts of the basin.

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.

Cold-related mortality vs heat-related mortality in a changing climate: A case study in Vilnius (Lithuania).

INTRODUCTION: Direct health effects of extreme temperatures are a significant environmental health problem in Lithuania, and could worsen further under climate change. This paper attempts to describe the change in environmental temperature conditions that the urban population of Vilnius could experience under climate change, and the effects such change could have on excess heat-related and cold-related mortality in two future periods within the 21st century. METHODS: We modelled the urban climate of Vilnius for the summer and winter seasons during a sample period (2009-2015) and projected summertime and wintertime daily temperatures for two prospective periods, one in the near (2030-2045) and one in the far future (2085-2100), under the Representative Concentration Pathway (RCP) 8.5. We then analysed the historical relationship between temperature and mortality for the period 2009-2015, and estimated the projected mortality in the near future and far future periods under a changing climate and population, assuming alternatively no acclimatisation and acclimatisation to heat and cold based on a constant-percentile threshold temperature. RESULTS: During the sample period 2009-2015 in summertime we observed an increase in daily mortality from a maximum daily temperature of 30 °C (the 96th percentile of the series), with an average of around 7 deaths per year. Under a no acclimatisation scenario, annual average heat-related mortality would rise to 24 deaths/year (95% CI: 8.4-38.4) in the near future and to 46 deaths/year (95% CI: 16.4-74.4) in the far future. Under a heat acclimatisation scenario, mortality would not increase significantly in the near or in the far future. Regarding wintertime cold-related mortality in the sample period 2009-2015, we observed increased mortality on days on which the minimum daily temperature fell below - 12 °C (the 7th percentile of the series), with an average of around 10 deaths a year. Keeping the threshold temperature constant, annual average cold-related mortality would decrease markedly in the near future, to 5 deaths/year (95% CI: 0.8-7.9) and even more in the far future, down to 0.44 deaths/year (95% C: 0.1-0.8). Assuming a "middle ground" between the acclimatisation and non-acclimatisation scenarios, the decrease in cold-related mortality will not compensate the increase in heat-related mortality. CONCLUSION: Thermal extremes, both heat and cold, constitute a serious public health threat in Vilnius, and in a changing climate the decrease in mortality attributable to cold will not compensate for the increase in mortality attributable to heat. Study results reinforce the notion that public health prevention against thermal extremes should be designed as a dynamic, adaptive process from the inception.

Health Impacts and Economic Costs of Air Pollution in the Metropolitan Area of Skopje.

BACKGROUND: Urban outdoor air pollution, especially particulate matter, remains a major environmental health problem in Skopje, the capital of the former Yugoslav Republic of Macedonia. Despite the documented high levels of pollution in the city, the published evidence on its health impacts is as yet scarce. METHODS: we obtained, cleaned, and validated Particulate Matter (PM) concentration data from five air quality monitoring stations in the Skopje metropolitan area, applied relevant concentration-response functions, and evaluated health impacts against two theoretical policy scenarios. We then calculated the burden of disease attributable to PM and calculated the societal cost due to attributable mortality. RESULTS: In 2012, long-term exposure to PM2.5 (49.2 µg/m³) caused an estimated 1199 premature deaths (CI95% 821-1519). The social cost of the predicted premature mortality in 2012 due to air pollution was estimated at between 570 and 1470 million euros. Moreover, PM2.5 was also estimated to be responsible for 547 hospital admissions (CI95% 104-977) from cardiovascular diseases, and 937 admissions (CI95% 937-1869) for respiratory disease that year. Reducing PM2.5 levels to the EU limit (25 µg/m³) could have averted an estimated 45% of PM-attributable mortality, while achieving the WHO Air Quality Guidelines (10 µg/m³) could have averted an estimated 77% of PM-attributable mortality. Both scenarios would also attain significant reductions in attributable respiratory and cardiovascular hospital admissions. CONCLUSIONS: Besides its health impacts in terms of increased premature mortality and hospitalizations, air pollution entails significant economic costs to the population of Skopje. Reductions in PM2.5 concentrations could provide substantial health and economic gains to the city.

Heat and health in Antwerp under climate change: Projected impacts and implications for prevention.

BACKGROUND: Excessive summer heat is a serious environmental health problem in several European cities. Heat-related mortality and morbidity is likely to increase under climate change scenarios without adequate prevention based on locally relevant evidence. METHODS: We modelled the urban climate of Antwerp for the summer season during the period 1986-2015, and projected summer daily temperatures for two periods, one in the near (2026-2045) and one in the far future (2081-2100), under the Representative Concentration Pathway (RCP) 8.5. We then analysed the relationship between temperature and mortality, as well as with hospital admissions for the period 2009-2013, and estimated the projected mortality in the near future and far future periods under changing climate and population, assuming alternatively no acclimatization and acclimatization based on a constant threshold percentile temperature. RESULTS: During the sample period 2009-2013 we observed an increase in daily mortality from a maximum daily temperature of 26°C, or the 89th percentile of the maximum daily temperature series. The annual average heat-related mortality in this period was 13.4 persons (95% CI: 3.8-23.4). No effect of heat was observed in the case of hospital admissions due to cardiorespiratory causes. Under a no acclimatization scenario, annual average heat-related mortality is multiplied by a factor of 1.7 in the near future (24.1deaths/year CI 95%: 6.78-41.94) and by a factor of 4.5 in the far future (60.38deaths/year CI 95%: 17.00-105.11). Under a heat acclimatization scenario, mortality does not increase significantly in the near or in the far future. CONCLUSION: These results highlight the importance of a long-term perspective in the public health prevention of heat exposure, particularly in the context of a changing climate, and the calibration of existing prevention activities in light of locally relevant evidence.

Quantifying Projected Heat Mortality Impacts under 21st-Century Warming Conditions for Selected European Countries.

Under future warming conditions, high ambient temperatures will have a significant impact on population health in Europe. The aim of this paper is to quantify the possible future impact of heat on population mortality in European countries, under different climate change scenarios. We combined the heat-mortality function estimated from historical data with meteorological projections for the future time laps 2035-2064 and 2071-2099, developed under the Representative Concentration Pathways (RCP) 4.5 and 8.5. We calculated attributable deaths (AD) at the country level. Overall, the expected impacts will be much larger than the impacts we would observe if apparent temperatures would remain in the future at the observed historical levels. During the period 2071-2099, an overall excess of 46,690 and 117,333 AD per year is expected under the RCP 4.5 and RCP 8.5 scenarios respectively, in addition to the 16,303 AD estimated under the historical scenario. Mediterranean and Eastern European countries will be the most affected by heat, but a non-negligible impact will be still registered in North-continental countries. Policies and plans for heat mitigation and adaptation are needed and urgent in European countries in order to prevent the expected increase of heat-related deaths in the coming decades.

Projected heat-related mortality under climate change in the metropolitan area of Skopje.

BACKGROUND: Excessive summer heat is a serious environmental health problem in Skopje, the capital and largest city of the former Yugoslav Republic of Macedonia. This paper attempts to forecast the impact of heat on mortality in Skopje in two future periods under climate change and compare it with a historical baseline period. METHODS: After ascertaining the relationship between daily mean ambient air temperature and daily mortality in Skopje, we modelled the evolution of ambient temperatures in the city under a Representative Concentration Pathway scenario (RCP8.5) and the evolution of the city population in two future time periods: 2026-2045 and 2081-2100, and in a past time period (1986-2005) to serve as baseline for comparison. We then calculated the projected average annual mortality attributable to heat in the absence of adaptation or acclimatization during those time windows, and evaluated the contribution of each source of uncertainty on the final impact. RESULTS: Our estimates suggest that, compared to the baseline period (1986-2005), heat-related mortality in Skopje would more than double in 2026-2045, and more than quadruple in 2081-2100. When considering the impact in 2081-2100, sampling variability around the heat-mortality relationship and climate model explained 40.3 and 46.6 % of total variability. CONCLUSION: These results highlight the importance of a long-term perspective in the public health prevention of heat exposure, particularly in the context of a changing climate.

Protecting health from climate change in the WHO European Region.

"How far are we in implementing climate change and health action in the WHO European Region?" This was the question addressed to representatives of WHO European Member States of the working group on health in climate change (HIC). Twenty-two Member States provided answers to a comprehensive questionnaire that focused around eight thematic areas (Governance; Vulnerability, impact and adaptation (health) assessments; Adaptation strategies and action plans; Climate change mitigation; Strengthening health systems; Raising awareness and building capacity; Greening health services; and Sharing best practices). Strong areas of development are climate change vulnerability and impact assessments, as well as strengthening health systems and awareness raising. Areas where implementation would benefit from further action are the development of National Health Adaptation Plans, greening health systems, sharing best practice and reducing greenhouse gas emissions in other sectors. At the Parma Conference in 2010, the European Ministerial Commitment to Act on climate change and health and the European Regional Framework for Action to protect health from climate change were endorsed by fifty three European Member States. The results of this questionnaire are the most comprehensive assessment so far of the progress made by WHO European Member States to protecting public health from climate change since the agreements in Parma and the World Health Assembly Resolution in 2008.

Local heat stroke prevention plans in Japan: characteristics and elements for public health adaptation to climate change.

The adverse health effects from hot weather and heat waves represent significant public health risks in vulnerable areas worldwide. Rising temperatures due to climate change are aggravating these risks in a context of fast urbanization, population growth and societal ageing. However, environmental heat-related health effects are largely preventable through adequate preparedness and responses. Public health adaptation to climate change will often require the implementation of heat wave warning systems and targeted preventive activities at different levels. While several national governments have established such systems at the country level, municipalities do not generally play a major role in the prevention of heat disorders. This paper analyzes selected examples of locally operated heat-health prevention plans in Japan. The analysis of these plans highlights their strengths, but also the need of local institutions for assistance to make the transition towards an effective public health management of high temperatures and heat waves. It can also provide useful elements for municipal governments in vulnerable areas, both in planning their climate change and health adaptation activities or to better protect their communities against current health effects from heat.