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.

Green CURIOCITY: a study protocol for a European birth cohort study analysing childhood heat-related health impacts and protective effects of urban natural environments.

INTRODUCTION: The European climate is getting warmer and the impact on childhood health and development is insufficiently understood. Equally, how heat-related health risks can be reduced through nature-based solutions, such as exposure to urban natural environments, is unknown. Green CURe In Outdoor CITY spaces (Green CURIOCITY) will analyse how heat exposure during pregnancy affects birth outcomes and how long-term heat exposure may influence children's neurodevelopment. We will also investigate if adverse effects can be mitigated by urban natural environments. A final goal is to visualise intraurban patterns of heat vulnerability and assist planning towards healthier cities. METHODS AND ANALYSIS: We will use existing data from the Human Early-Life Exposure cohort, which includes information on birth outcomes and neurodevelopment from six European birth cohorts. The cohort is linked to data on prenatal heat exposure and impact on birth outcomes will be analysed with logistic regression models, adjusting for air pollution and noise and sociobehavioural covariates. Similarly, impact of cumulative and immediate heat exposure on neurodevelopmental outcomes at age 5 will be assessed. For both analyses, the potentially moderating impact of natural environments will be quantified. For visualisation, Geographical information systems data will be combined to develop vulnerability maps, demonstrating urban 'hot spots' where the risk of negative impacts of heat is aggravated due to sociodemographic and land use patterns. Finally, geospatial and meteorological data will be used for informing GreenUr, an existing software prototype developed by the WHO Regional Office for Europe to quantify health impacts and augment policy tools for urban green space planning. ETHICS AND DISSEMINATION: The protocol was approved by the Comité Ético de Investigación Clínica Parc de Salut MAR, Spain. Findings will be published in peer-reviewed journals and presented at policy events. Through stakeholder engagement, the results will also reach user groups and practitioners.

Tracking progress on health and climate change in Europe.

Left unabated, climate change will have catastrophic effects on the health of present and future generations. Such effects are already seen in Europe, through more frequent and severe extreme weather events, alterations to water and food systems, and changes in the environmental suitability for infectious diseases. As one of the largest current and historical contributors to greenhouse gases and the largest provider of financing for climate change mitigation and adaptation, Europe's response is crucial, for both human health and the planet. To ensure that health and wellbeing are protected in this response it is essential to build the capacity to understand, monitor, and quantify health impacts of climate change and the health co-benefits of accelerated action. Responding to this need, the Lancet Countdown in Europe is established as a transdisciplinary research collaboration for monitoring progress on health and climate change in Europe. With the wealth of data and academic expertise available in Europe, the collaboration will develop region-specific indicators to address the main challenges and opportunities of Europe's response to climate change for health. The indicators produced by the collaboration will provide information to health and climate policy decision making, and will also contribute to the European Observatory on Climate and Health.

The need for Pan-European automatic pollen and fungal spore monitoring: A stakeholder workshop position paper.

BACKGROUND: Information about airborne pollen concentrations is required by a range of end users, particularly from the health sector who use both observations and forecasts to diagnose and treat allergic patients. Manual methods are the standard for such measurements but, despite the range of pollen taxa that can be identified, these techniques suffer from a range of drawbacks. This includes being available at low temporal resolution (usually daily averages) and with a delay (usually 3-9 days from the measurement). Recent technological developments have made possible automatic pollen measurements, which are available at high temporal resolution and in real time, although currently only scattered in a few locations across Europe. MATERIALS & METHODS: To promote the development of an extensive network across Europe and to ensure that this network will respond to end user needs, a stakeholder workshop was organised under the auspices of the EUMETNET AutoPollen Programme. Participants discussed requirements for the groups they represented, ranging from the need for information at various spatial scales, at high temporal resolution, and for targeted services to be developed. RESULTS: The provision of real-time information is likely to lead to a notable decrease in the direct and indirect health costs associated with allergy in Europe, currently estimated between €50-150 billion/year.1 DISCUSSION & CONCLUSION: A European measurement network to meet end user requirements would thus more than pay for itself in terms of potential annual savings and provide significant impetus to research across a range of disciplines from climate science and public health to agriculture and environmental management.

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

High temperatures have periodically affected large areas in Europe and urban settings. In particular, the deadly 2003 summer heat waves precipitated a multitude of national and subnational health prevention and research efforts. Building on these and other international experiences the WHO Regional Office for Europe developed and published in 2008 a comprehensive framework for prevention, the heat-health action plans (HHAPs). This provided a blueprint used by several national and subnational authorities to design their prevention efforts. A decade after the publication of the WHO guidance, a wealth of new evidence and acquired implementation experience has emerged around HHAP effectiveness; heat exposure; acclimatization and adaptation; heat-health governance and stakeholder involvement; and the role of urban design and greening interventions in prevention. This evidence and experience can guide the strategies to tackle current and upcoming challenges in protecting health from heat under a warming climate.

Priorities for protecting health from climate change in the WHO European Region: recent regional activities.

Evidence of the impact of climate change on health is growing. Health systems need to be prepared and gradually adapt to the effects of climate change, including extreme weather events.Fossil fuel combustion as the driver of climate change poses a tremendous burden of disease. In turn, cutting greenhouse gas emissions in all sectors will achieve health co-benefits. If all countries meet the Paris Agreement by 2030, the annual number of avoidable premature deaths could total 138,000 across the entire European Region of the World Health Organization (WHO).Several international frameworks promote a stronger commitment by countries to implementing the necessary adaptations in the health sector and to addressing health considerations in adaptation measures in other sectors. The WHO has a mandate from its member states to identify solutions and help prevent or reduce health impacts, including those from climate change.National governments are continuing to establish public health adaptation measures, which provide a rationale for and trigger action on climate change by the health community. Effective national responses to climate risks require strategic analyses of current and anticipated threats. Health professionals need to play a proactive role in promoting health arguments and evidence in the formulation of national climate change adaptation and mitigation responses. To this end, country capacities need to be further strengthened to identify and address local health risks posed by climate change and to develop, implement and evaluate health-focused interventions through integrated approaches. Building climate-resilient and environmentally sustainable health care facilities is an essential pillar of health sector leadership to address climate change.

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.

The public health impacts of climate change in the former Yugoslav Republic of Macedonia.

Projected climatic changes for the former Yugoslav Republic of Macedonia for the period 2025-2100 will be most intense in the warmest period of the year with more frequent and more intense heat-waves, droughts and flood events compared with the period 1961-1990. The country has examined their vulnerabilities to climate change and many public health impacts have been projected. A variety of qualitative and quantitative methodologies were used in the assessment: literature reviews, interviews, focus groups, time series and regression analysis, damage and adaptation cost estimation, and scenario-based assessment. Policies and interventions to minimize the risks and development of long-term adaptation strategies have been explored. The generation of a robust evidence base and the development of stakeholder engagement have been used to support the development of an adaptation strategy and to promote adaptive capacity by improving the resilience of public health systems to climate change. Climate change adaptation has been established as a priority within existing national policy instruments. The lessons learnt from the process are applicable to countries considering how best to improve adaptive capacity and resilience of health systems to climate variability and its associated impacts.

A cross-cultural segmentation of western Balkan consumers: focus on preferences toward traditional fresh cow cheese.

BACKGROUND: Western Balkan countries (WBCs) have a long-standing culinary tradition. The promotion of traditional foods may be a tool for coping with modernisation trends in such transition economies. This paper explores consumer preferences toward food in this region, focusing on a traditional fresh cow cheese locally called 'Mladi Sir'. This product was quoted in all the preliminary focus groups as a common traditional product present in the six WBCs studied: Bosnia-Herzegovina, Croatia, Macedonia, Montenegro, Serbia and Slovenia. RESULTS: After a literature review investigating the concept of traditional food in WBCs and the implementation of focus groups, a survey including a conjoint analysis on preferences for fresh cow cheese was carried out in 2011 to collect data from 1200 respondents. Four clusters of consumers were identified: one focused more on the local origin; one oriented more toward the scale of production (on-farm and small dairy); the third favouring low prices and the fourth preferring high prices and industrial products. CONCLUSION: Policy makers and the supply chain could take these differences in consumer preferences regarding traditional food products into account in order to develop specific strategies.

Nutritional status and growth parameters of school-age Roma children in the Republic of Macedonia.

Main objective of the study was to assess the nutritional status of school age Roma children in Macedonia in order to detect precursors of possible health risks at an early age. The study was designed as a comparative case control study. Study group consisted of 229 Roma school children from the 1st and 272 from the 5th grade residing in different towns in Macedonia. The control group was recruited from other than Roma ethnic background and consisted of 283 children attending 1st and 356 children attending 5th grade. Every participant was measured for his/hers body height and weight. The t-test and Chi square (Chi2) were applied to test statistical significance of variables. The WHO's AnthroPlus software was applied to assess growth parameters and population at risk. There were significant differences in values of the body weight (p = 0.001) and height (p = 0.001) between Roma and non-Roma children attending the 1st grade of primary school. Weight-for-age, height-for-age and BMI-for-age indexes of the 1st grade children significantly differred in in the same intervals of SD (> or = -2SD and < -1SD; > or = -1SD and median; > +1SD and < or = +2SD; between Roma and non-Roma 5th graders. Anthropometric parameters of nutritional status of Roma children in Macedonia are significantly different than those of their non-Roma peers. Their health risks are predominantly related to underweight. The parameters related to health risks of overweight or obesity are lower in Roma than in non-Roma children.

Ambient maximum temperature as a function of Salmonella food poisoning cases in the Republic of Macedonia.

BACKGROUND: Higher temperatures have been associated with higher salmonellosis notifications worldwide. AIMS: The objective of this paper is to assess the seasonal pattern of Salmonella cases among humans. MATERIAL AND METHODS: The relationship between ambient maximum temperature and reports of confirmed cases of Salmonella in the Republic of Macedonia and Skopje during the summer months (i.e. June, July, August and September) beginning in 1998 through 2008 was investigated. The monthly number of reported Salmonella cases and ambient maximum temperatures for Skopje were related to the national number of cases and temperatures recorded during the same timeframe using regression statistical analyses. The Poisson regression model was adapted for the analysis of the data. RESULTS: While a decreasing tendency was registered at the national level, the analysis for Skopje showed an increasing tendency for registration of new salmonella cases. Reported incidents of salmonellosis, were positively associated (P<0.05) with temperature during the summer months. By increasing of the maximum monthly mean temperature of 1° C in Skopje, the salmonellosis incidence increased by 5.2% per month. CONCLUSIONS: THE INCIDENCE OF SALMONELLA CASES IN THE MACEDONIAN POPULATION VARIES SEASONALLY: the highest values of the Seasonal Index for Salmonella cases were registered in the summer months, i.e. June, July, August and September.

Environmental noise and annoyance in adult population of Skopje: a cross-sectional study.

The aim of this study was to identify noise exposure indicators during day and night in the city of Skopje and to see if there is an association between these noise exposure indicators and annoyance. We have performed noise measurements and interviewed 510 adult subjects, using a questionnaire, prepared according to the ISO/TS-15666 standard. Average noise level over the day (Lday) was (62+/-6.45) dB(A) and over night (Lnight) (56+/-6.52) dB(A). Thirteen percent of subjects reported a high level, and 33.5% moderate level of annoyance. The most annoying noise sources were construction activities (34% of the subjects), road traffic (24%), and leisure/entertainment activities (18%). We found a significant association between exposure to Lday in the range 61 dB(A) to 65 dB(A) and annoyance in the exposed population (chi-square = 86.14; p<0.001; Spearman's R=0.45; p<0.05). During the night time annoyance was reported with exposure to Lnight above 46 dB(A). Levels of annoyance in Macedonia are similar to levels in developed European countries. Differences are in the source of noise. This study has shown that environmental noise is a significant hazard in urban environments, and assessment of annoyance may prove a useful tool for town planners and public health policy makers.

The impact of ambient temperature on mortality among the urban population in Skopje, Macedonia during the period 1996-2000.

BACKGROUND: This study assesses the relationship between daily numbers of deaths and variations in ambient temperature within the city of Skopje, R. Macedonia. METHODS: The daily number of deaths from all causes, during the period 1996-2000, as well as those deaths from cardiovascular diseases, occurring within the city of Skopje were related to the average daily temperature on the same day using Multiple Regression statistical analyses. Temperature was measured within the regression model as two complementary variables: 'Warm' and 'Cold'. Excess winter mortality was calculated as winter deaths (deaths occurring in December to March) minus the average of non-winter deaths (April to July of the current year and August to November of the previous year). RESULTS: In this study the average daily total of deaths was 7% and 13% greater in the cold when compared to the whole period and warm period respectively. The same relationship was noticed for deaths caused by cardiovascular diseases. The Regression Beta Coefficient (b = -0.19) for the total mortality as a function of the temperature in Skopje during the period 1996-2000 was statistically significant with negative connotation as was the circulatory mortality due to average temperature (statistically significant regression Beta coefficient (b = -0.24)). A measure of this increase is provided, on an annual basis, in the form of the excess winter mortality figure. CONCLUSION: Mortality with in the city of Skopje displayed a marked seasonality, with peaks in the winter and relative troughs in the summer.