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  • 1. Analitis, Antonis
    et al.
    De' Donato, Francesca
    Scortichini, Matteo
    Lanki, Timo
    Basagana, Xavier
    Ballester, Ferran
    Åström, Christofer
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Paldy, Anna
    Pascal, Mathilde
    Gasparrini, Antonio
    Michelozzi, Paola
    Katsouyanni, Klea
    Synergistic Effects of Ambient Temperature and Air Pollution on Health in Europe: Results from the PHASE Project2018In: International Journal of Environmental Research and Public Health, ISSN 1661-7827, E-ISSN 1660-4601, Vol. 15, no 9, p. 1-11, article id E1856Article in journal (Refereed)
    Abstract [en]

    We studied the potential synergy between air pollution and meteorology and their impact on mortality in nine European cities with data from 2004 to 2010. We used daily series of Apparent Temperature (AT), measurements of particulate matter (PM10), ozone (O₃), and nitrogen dioxide (NO₂) and total non-accidental, cardiovascular, and respiratory deaths. We applied Poisson regression for city-specific analysis and random effects meta-analysis to combine city-specific results, separately for the warm and cold seasons. In the warm season, the percentage increase in all deaths from natural causes per °C increase in AT tended to be greater during high ozone days, although this was only significant for all ages when all causes were considered. On low ozone days, the increase in the total daily number of deaths was 1.84% (95% CI 0.87, 2.82), whilst it was 2.20% (95% CI 1.28, 3.13) in the high ozone days per 1 °C increase in AT. Interaction with PM10 was significant for cardiovascular (CVD) causes of death for all ages (2.24% on low PM10 days (95% CI 1.01, 3.47) whilst it is 2.63% (95% CI 1.57, 3.71) on high PM10 days) and for ages 75+. In days with heat waves, no consistent pattern of interaction was observed. For the cold period, no evidence for synergy was found. In conclusion, some evidence of interactive effects between hot temperature and the levels of ozone and PM10 was found, but no consistent synergy could be identified during the cold season.

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  • 2.
    Andersson, Louise
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Oudin Åström, Daniel
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Pettersson-Strömbäck, Anita
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Åström, Christofer
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Med värme ihågkommen2012Report (Other academic)
    Abstract [en]

    The purpose of this project has been to use an interview study and literature survey to show how the outdoor environment, public facilities and housing can be designed to reduce the risk for elderly and persons with disabilities to die prematurely during heat waves. The goal is to raise awareness and interest in the adaptation of the environment and buildings of the persons responsible for planning, housing stock, social service, health care and homes for elderly.

    Cities are generally warmer and less windy than the surrounding landscape. The urban "warmer climate" is mainly due to the greater heat storage that can be found in buildings, streets, sidewalks, etc., limited vegetation that can shade and release moisture and activities such as traffic and domestic heating, which generate heat. During heat waves the increase in mortality is larger in cities. To live alone, be confined to bed and stay on the top floor has been shown to be additional risk factors.

    Measures to reduce the city's urban heat island and effects on humans are sometimes divided into "soft measures" (information, warning systems for heat waves, interventions for vulnerable groups), "green actions" (make the city a greener environment) and “technical measures” (shaded structures, changes of the walls, refrigeration /air conditioning indoors, etc.), which all are complementary. In some countries, the care homes for elderly should have a common room that can be kept cool even during heat waves.

    The aim of the interview study was to describe how personnel in the elderly care experience these problems in Sweden. The data collection method was 20 semi structured interviews with elderly care

    Sid 3 (49)

    personnel in Botkyrka municipality during October 2011. Content analysis was performed on the transcribed interview data and categories and subcategories were created on repeated themes in the text. The conclusions suggest intensified education for and information to personnel in the elderly care sector and that already in the planning of new homes for elderly the personnel's knowledge and experience of the needs among the elderly should be taken into account. 

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  • 3. Barnett, A. G.
    et al.
    Åström, Christofer
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Commentary: What measure of temperature is the best predictor of mortality?2012In: Environmental Research, ISSN 0013-9351, E-ISSN 1096-0953, Vol. 118, p. 149-151Article in journal (Other academic)
  • 4.
    Béguin, Andreas
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hales, Simon
    University of Otago, Wellington, New Zealand.
    Rocklöv, Joacim
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Åström, Christofer
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Louis, Valérie R
    Institute for Public Health, Heidelberg University Hospital, Heidelberg, Germany.
    Sauerborn, Rainer
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    The opposing effects of climate change and socio-economic development on the global distribution of malaria2011In: Global Environmental Change, ISSN 0959-3780, E-ISSN 1872-9495, Vol. 21, no 4, p. 1209-1214Article in journal (Refereed)
    Abstract [en]

    The current global geographic distribution of malaria results from a complex interaction between climatic and non-climatic factors. Over the past century, socio-economic development and public health measures have contributed to a marked contraction in the distribution of malaria. Previous assessments of the potential impact of global changes on malaria have not quantified the effects of non-climate factors. In this paper, we describe an empirical model of the past, present and future-potential geographic distribution of malaria which incorporates both the effects of climate change and of socio-economic development. A logistic regression model using temperature, precipitation and gross domestic product per capita (GDPpc) identifies the recent global geographic distribution of malaria with high accuracy (sensitivity 85% and specificity 95%). Empirically, climate factors have a substantial effect on malaria transmission in countries where GDPpc is currently less than US$20,000. Using projections of future climate, GDPpc and population consistent with the IPCC A1B scenario, we estimate the potential future population living in areas where malaria can be transmitted in 2030 and 2050. In 2050, the projected population at risk is approximately 5.2 billion when considering climatic effects only, 1.95 billion when considering the combined effects of GDP and climate, and 1.74 billion when considering GDP effects only. Under the A1B scenario, we project that climate change has much weaker effects on malaria than GDPpc increase. This outcome is, however, dependent on optimistic estimates of continued socioeconomic development. Even then, climate change has important effects on the projected distribution of malaria, leading to an increase of over 200 million in the projected population at risk.

  • 5. Chen, Gongbo
    et al.
    Guo, Yuming
    Yue, Xu
    Tong, Shilu
    Gasparrini, Antonio
    Bell, Michelle L.
    Armstrong, Ben
    Schwartz, Joel
    Jaakkola, Jouni J. K.
    Zanobetti, Antonella
    Lavigne, Eric
    Nascimento Saldiva, Paulo Hilario
    Kan, Haidong
    Royé, Dominic
    Milojevic, Ai
    Overcenco, Ala
    Urban, Aleš
    Schneider, Alexandra
    Entezari, Alireza
    Vicedo-Cabrera, Ana Maria
    Zeka, Ariana
    Tobias, Aurelio
    Nunes, Baltazar
    Alahmad, Barrak
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Pan, Shih-Chun
    Íñiguez, Carmen
    Ameling, Caroline
    De la Cruz Valencia, César
    Åström, Christofer
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Houthuijs, Danny
    Van Dung, Do
    Samoli, Evangelia
    Mayvaneh, Fatemeh
    Sera, Francesco
    Carrasco-Escobar, Gabriel
    Lei, Yadong
    Orru, Hans
    Institute of Family Medicine and Public Health, University of Tartu, Tartu, Estonia..
    Kim, Ho
    Holobaca, Iulian-Horia
    Kyselý, Jan
    Teixeira, João Paulo
    Madureira, Joana
    Katsouyanni, Klea
    Hurtado-Díaz, Magali
    Maasikmets, Marek
    Ragettli, Martina S.
    Hashizume, Masahiro
    Stafoggia, Massimo
    Pascal, Mathilde
    Scortichini, Matteo
    de Sousa Zanotti Stagliorio Coêlho, Micheline
    Valdés Ortega, Nicolás
    Ryti, Niilo R. I.
    Scovronick, Noah
    Matus, Patricia
    Goodman, Patrick
    Garland, Rebecca M.
    Abrutzky, Rosana
    Garcia, Samuel Osorio
    Rao, Shilpa
    Fratianni, Simona
    Dang, Tran Ngoc
    Colistro, Valentina
    Huber, Veronika
    Lee, Whanhee
    Seposo, Xerxes
    Honda, Yasushi
    Guo, Yue Leon
    Ye, Tingting
    Yu, Wenhua
    Abramson, Michael J.
    Samet, Jonathan M.
    Li, Shanshan
    Mortality risk attributable to wildfire-related PM2·5 pollution: a global time series study in 749 locations2021In: The Lancet Planetary Health, E-ISSN 2542-5196, Vol. 5, no 9, p. e579-e587Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Many regions of the world are now facing more frequent and unprecedentedly large wildfires. However, the association between wildfire-related PM2·5 and mortality has not been well characterised. We aimed to comprehensively assess the association between short-term exposure to wildfire-related PM2·5 and mortality across various regions of the world.

    METHODS: For this time series study, data on daily counts of deaths for all causes, cardiovascular causes, and respiratory causes were collected from 749 cities in 43 countries and regions during 2000-16. Daily concentrations of wildfire-related PM2·5 were estimated using the three-dimensional chemical transport model GEOS-Chem at a 0·25° × 0·25° resolution. The association between wildfire-related PM2·5 exposure and mortality was examined using a quasi-Poisson time series model in each city considering both the current-day and lag effects, and the effect estimates were then pooled using a random-effects meta-analysis. Based on these pooled effect estimates, the population attributable fraction and relative risk (RR) of annual mortality due to acute wildfire-related PM2·5 exposure was calculated.

    FINDINGS: 65·6 million all-cause deaths, 15·1 million cardiovascular deaths, and 6·8 million respiratory deaths were included in our analyses. The pooled RRs of mortality associated with each 10 μg/m3 increase in the 3-day moving average (lag 0-2 days) of wildfire-related PM2·5 exposure were 1·019 (95% CI 1·016-1·022) for all-cause mortality, 1·017 (1·012-1·021) for cardiovascular mortality, and 1·019 (1·013-1·025) for respiratory mortality. Overall, 0·62% (95% CI 0·48-0·75) of all-cause deaths, 0·55% (0·43-0·67) of cardiovascular deaths, and 0·64% (0·50-0·78) of respiratory deaths were annually attributable to the acute impacts of wildfire-related PM2·5 exposure during the study period.

    INTERPRETATION: Short-term exposure to wildfire-related PM2·5 was associated with increased risk of mortality. Urgent action is needed to reduce health risks from the increasing wildfires.

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  • 6.
    Chen, Kai
    et al.
    Department of Environmental Health Sciences, Yale School of Public Health, CT, New Haven, United States.
    Breitner, Susanne
    Institute of Epidemiology, Helmholtz Zentrum München–German Research Center for Environmental Health, Neuherberg, Germany; Institute for Medical Information Processing, Biometry and Epidemiology, Ludwig-Maximilians-Universität München, Munich, Germany.
    Wolf, Kathrin
    Institute of Epidemiology, Helmholtz Zentrum München–German Research Center for Environmental Health, Neuherberg, Germany.
    Stafoggia, Massimo
    Department of Epidemiology, Lazio Regional Health Service, Rome, Italy.
    Sera, Francesco
    Department of Public Health, Environments and Society, London School of Hygiene & Tropical Medicine, London, United Kingdom; Department of Statistics, Computer Science and Applications “G. Parenti”, University of Florence, Florence, Italy.
    Vicedo-Cabrera, Ana M.
    Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland; Oeschger Center for Climate Change Research, University of Bern, Bern, Switzerland.
    Guo, Yuming
    Climate, Air Quality Research Unit, School of Public Health and Preventive Medicine, Monash University, VIC, Melbourne, Australia.
    Tong, Shilu
    Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China; School of Public Health, Institute of Environment and Population Health, Anhui Medical University, Hefei, China; School of Public Health and Social Work, Queensland University of Technology, QLD, Brisbane, Australia; Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, China.
    Lavigne, Eric
    Air Health Science Division, Health Canada, ON, Ottawa, Canada; School of Epidemiology and Public Health, University of Ottawa, ON, Ottawa, Canada.
    Matus, Patricia
    Department of Public Health, Universidad de los Andes, Santiago, Chile.
    Valdés, Nicolás
    Faculty of Nursing and Midwifery, Universidad de los Andes, Santiago, Chile.
    Kan, Haidong
    School of Public Health, Key Lab of Public Health Safety of the Ministry of Education and Key Lab of Health Technology Assessment of the Ministry of Health, Fudan University, Shanghai, China; Shanghai Key Laboratory of Atmospheric Particle Pollution and Prevention (LAP3), Fudan University, Shanghai, China.
    Jaakkola, Jouni J. K.
    Center for Environmental and Respiratory Health Research (CERH), University of Oulu, Oulu, Finland; Biocenter Oulu, University of Oulu, Oulu, Finland; Finnish Meteorological Institute, Helsinki, Finland.
    Ryti, Niilo R. I.
    Center for Environmental and Respiratory Health Research (CERH), University of Oulu, Oulu, Finland; Biocenter Oulu, University of Oulu, Oulu, Finland.
    Huber, Veronika
    Department of Physical, Chemical and Natural Systems, Universidad Pablo de Olavide, Seville, Spain; Potsdam Institute for Climate Impact Research, Potsdam, Germany.
    Scortichini, Matteo
    Department of Epidemiology, Lazio Regional Health Service, Rome, Italy.
    Hashizume, Masahiro
    Department of Global Health Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
    Honda, Yasushi
    Faculty of Health and Sport Sciences, University of Tsukuba, Tsukuba, Japan.
    Nunes, Baltazar
    Department of Epidemiology, Instituto Nacional de Saúde Dr Ricardo Jorge, Lisbon, Portugal; Centro de Investigação em Saúde Pública, Escola Nacional de Saúde Pública, Universidade NOVA de Lisboa, Lisbon, Portugal.
    Madureira, Joana
    Department of Enviromental Health, Instituto Nacional de Saúde Dr Ricardo Jorge, Porto, Portugal; EPIUnit – Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal.
    Holobâcă, Iulian Horia
    Faculty of Geography, Babes-Bolay University, Cluj-Napoca, Romania.
    Fratianni, Simona
    Department of Earth Sciences, University of Torino, Turin, Italy.
    Kim, Ho
    Graduate School of Public Health, Seoul National University, Seoul, South Korea.
    Lee, Whanhee
    Graduate School of Public Health, Seoul National University, Seoul, South Korea.
    Tobias, Aurelio
    Institute of Environmental Assessment and Water Research, Spanish Council for Scientific Research, Barcelona, Spain; School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan.
    Íñiguez, Carmen
    Department of Statistics and Computational Research, University of Valencia, Valencia, Spain; , Ciberesp, Madrid, Spain.
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Åström, Christofer
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Ragettli, Martina S.
    Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland.
    Guo, Yue-Liang Leon
    Environmental and Occupational Medicine, National Taiwan University and NTU Hospital, Taipei, Taiwan; National Institute of Environmental Health Science, National Health Research Institutes, Zhunan, Taiwan.
    Chen, Bing-Yu
    National Institute of Environmental Health Science, National Health Research Institutes, Zhunan, Taiwan.
    Li, Shanshan
    Climate, Air Quality Research Unit, School of Public Health and Preventive Medicine, Monash University, VIC, Melbourne, Australia.
    Milojevic, Ai
    Department of Public Health, Environments and Society, London School of Hygiene & Tropical Medicine, London, United Kingdom.
    Zanobetti, Antonella
    Department of Environmental Health, Harvard T H Chan School of Public Health, MA, Boston, United States.
    Schwartz, Joel
    Department of Environmental Health, Harvard T H Chan School of Public Health, MA, Boston, United States.
    Bell, Michelle L.
    School of the Environment, Yale University, CT, New Haven, United States.
    Gasparrini, Antonio
    Department of Public Health, Environments and Society, London School of Hygiene & Tropical Medicine, London, United Kingdom; Centre for Statistical Methodology, London School of Hygiene & Tropical Medicine, London, United Kingdom; Centre on Climate Change and Planetary Health, London School of Hygiene & Tropical Medicine, London, United Kingdom.
    Schneider, Alexandra
    Institute of Epidemiology, Helmholtz Zentrum München–German Research Center for Environmental Health, Neuherberg, Germany.
    Ambient carbon monoxide and daily mortality: a global time-series study in 337 cities2021In: The Lancet Planetary Health, E-ISSN 2542-5196, Vol. 5, no 4, p. e191-e199Article in journal (Refereed)
    Abstract [en]

    Background: Epidemiological evidence on short-term association between ambient carbon monoxide (CO) and mortality is inconclusive and limited to single cities, regions, or countries. Generalisation of results from previous studies is hindered by potential publication bias and different modelling approaches. We therefore assessed the association between short-term exposure to ambient CO and daily mortality in a multicity, multicountry setting. Methods: We collected daily data on air pollution, meteorology, and total mortality from 337 cities in 18 countries or regions, covering various periods from 1979 to 2016. All included cities had at least 2 years of both CO and mortality data. We estimated city-specific associations using confounder-adjusted generalised additive models with a quasi-Poisson distribution, and then pooled the estimates, accounting for their statistical uncertainty, using a random-effects multilevel meta-analytical model. We also assessed the overall shape of the exposure–response curve and evaluated the possibility of a threshold below which health is not affected. Findings: Overall, a 1 mg/m3 increase in the average CO concentration of the previous day was associated with a 0·91% (95% CI 0·32–1·50) increase in daily total mortality. The pooled exposure–response curve showed a continuously elevated mortality risk with increasing CO concentrations, suggesting no threshold. The exposure–response curve was steeper at daily CO levels lower than 1 mg/m3, indicating greater risk of mortality per increment in CO exposure, and persisted at daily concentrations as low as 0·6 mg/m3 or less. The association remained similar after adjustment for ozone but was attenuated after adjustment for particulate matter or sulphur dioxide, or even reduced to null after adjustment for nitrogen dioxide. Interpretation: This international study is by far the largest epidemiological investigation on short-term CO-related mortality. We found significant associations between ambient CO and daily mortality, even at levels well below current air quality guidelines. Further studies are warranted to disentangle its independent effect from other traffic-related pollutants. Funding: EU Horizon 2020, UK Medical Research Council, and Natural Environment Research Council.

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  • 7. Choi, Hayon Michelle
    et al.
    Lee, Whanhee
    Roye, Dominic
    Heo, Seulkee
    Urban, Aleš
    Entezari, Alireza
    Vicedo-Cabrera, Ana Maria
    Zanobetti, Antonella
    Gasparrini, Antonio
    Analitis, Antonis
    Tobias, Aurelio
    Armstrong, Ben
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Íñiguez, Carmen
    Åström, Christofer
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Indermitte, Ene
    Lavigne, Eric
    Mayvaneh, Fatemeh
    Acquaotta, Fiorella
    Sera, Francesco
    Orru, Hans
    Department of Family Medicine and Public Health, University of Tartu, Tartu, Estonia..
    Kim, Ho
    Kyselý, Jan
    Madueira, Joana
    Schwartz, Joel
    Jaakkola, Jouni J. K.
    Katsouyanni, Klea
    Diaz, Magali Hurtado
    Ragettli, Martina S.
    Pascal, Mathilde
    Ryti, Niilo
    Scovronick, Noah
    Osorio, Samuel
    Tong, Shilu
    Seposo, Xerxes
    Guo, Yue Leon
    Guo, Yuming
    Bell, Michelle L.
    Effect modification of greenness on the association between heat and mortality: A multi-city multi-country study2022In: EBioMedicine, E-ISSN 2352-3964, Vol. 84, article id 104251Article in journal (Refereed)
    Abstract [en]

    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.

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  • 8.
    de Bont, Jeroen
    et al.
    Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
    Pickford, Regina
    Institute of Epidemiology (EPI), Helmholtz Zentrum München – Deutsches Forschungszentrum für Gesundheit und Umwelt GmbH, Neuherberg, Germany.
    Åström, Christofer
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Colomar, Fabian
    ISGlobal, Barcelona, Spain; Universitat Pompeu Fabra (UPF), Barcelona, Spain; CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain.
    Dimakopoulou, Konstantina
    Department of Hygiene, Epidemiology and Medical Statistics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.
    de Hoogh, Kees
    Swiss Tropical and Public Health Institute, Allschwil, Switzerland; University of Basel, Basel, Switzerland.
    Ibi, Dorina
    Institute for Risk Assessment Sciences, Utrecht University, Utrecht, Netherlands.
    Katsouyanni, Klea
    Department of Hygiene, Epidemiology and Medical Statistics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece; MRC Centre for Environment and Health, Environmental Research Group, Imperial College London, United Kingdom; NIHR HPRU in Environmental Exposures and Health, Imperial College London, London, United Kingdom.
    Melén, Erik
    Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.
    Nobile, Federica
    Department of Epidemiology, Lazio Region Health Service /ASL Roma 1, Rome, Italy.
    Pershagen, Göran
    Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
    Persson, Åsa
    Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
    Samoli, Evangelia
    Department of Hygiene, Epidemiology and Medical Statistics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.
    Stafoggia, Massimo
    Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden; Department of Epidemiology, Lazio Region Health Service /ASL Roma 1, Rome, Italy.
    Tonne, Cathryn
    ISGlobal, Barcelona, Spain; Universitat Pompeu Fabra (UPF), Barcelona, Spain; CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain.
    Vlaanderen, Jelle
    Institute for Risk Assessment Sciences, Utrecht University, Utrecht, Netherlands.
    Wolf, Kathrin
    Institute of Epidemiology (EPI), Helmholtz Zentrum München – Deutsches Forschungszentrum für Gesundheit und Umwelt GmbH, Neuherberg, Germany.
    Vermeulen, Roel
    Institute for Risk Assessment Sciences, Utrecht University, Utrecht, Netherlands.
    Peters, Annette
    Institute of Epidemiology (EPI), Helmholtz Zentrum München – Deutsches Forschungszentrum für Gesundheit und Umwelt GmbH, Neuherberg, Germany; Chair of Epidemiology, Institute for Medical Information Processing, Biometry and Epidemiology, Medical Faculty, Ludwig-Maximilians-Universität München, Munich, Germany; Munich Heart Alliance, German Center for Cardiovascular Health (DZHK e.V., partner-site Munich), Munich, Germany.
    Ljungman, Petter
    Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden; Department of Cardiology, Danderyd Hospital, Stockholm, Sweden.
    Mixtures of long-term exposure to ambient air pollution, built environment and temperature and stroke incidence across Europe2023In: Environment International, ISSN 0160-4120, E-ISSN 1873-6750, Vol. 179, article id 108136Article in journal (Refereed)
    Abstract [en]

    Introduction: The complex interplay of multiple environmental factors and cardiovascular has scarcely been studied. Within the EXPANSE project, we evaluated the association between long-term exposure to multiple environmental indices and stroke incidence across Europe.

    Methods: Participants from three traditional adult cohorts (Germany, Netherlands and Sweden) and four administrative cohorts (Catalonia [region Spain], Rome [city-wide], Greece and Sweden [nationwide]) were followed until incident stroke, death, migration, loss of follow-up or study end. We estimated exposures at residential addresses from different exposure domains: air pollution (nitrogen dioxide (NO2), particulate matter < 2.5 μm (PM2.5), black carbon (BC), ozone), built environment (green/blue spaces, impervious surfaces) and meteorology (seasonal mean and standard deviation of temperatures). Associations between environmental exposures and stroke were estimated in single and multiple-exposure Cox proportional hazard models, and Principal Component (PC) Analyses derived prototypes for specific exposures domains. We carried out random effects meta-analyses by cohort type.

    Results: In over 15 million participants, increased levels of NO2 and BC were associated with increased higher stroke incidence in both cohort types. Increased Normalized Difference Vegetation Index (NDVI) was associated with a lower stroke incidence in both cohort types, whereas an increase in impervious surface was associated with an increase in stroke incidence. The first PC of the air pollution domain (PM2.5, NO2 and BC) was associated with an increase in stroke incidence. For the built environment, higher levels of NDVI and lower levels of impervious surfaces were associated with a protective effect [%change in HR per 1 unit = −2.0 (95 %CI, −5.9;2.0) and −1.1(95 %CI, −2.0; −0.3) for traditional adult and administrative cohorts, respectively]. No clear patterns were observed for distance to blue spaces or temperature parameters.

    Conclusions: We observed increased HRs for stroke with exposure to PM2.5, NO2 and BC, lower levels of greenness and higher impervious surface in single and combined exposure models.

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  • 9. de' Donato, Francesca K.
    et al.
    Leone, Michela
    Scortichini, Matteo
    De Sario, Manuela
    Katsouyanni, Klea
    Lanki, Timo
    Basagaña, Xavier
    Ballester, Ferran
    Åström, Christofer
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Paldy, Anna
    Pascal, Mathilde
    Gasparrini, Antonio
    Menne, Bettina
    Michelozzi, Paola
    Changes in the effect of heat on mortality in the last 20 years in nine European cities: results from the PHASE project2015In: International Journal of Environmental Research and Public Health, ISSN 1661-7827, E-ISSN 1660-4601, Vol. 12, no 12, p. 15567-15583Article in journal (Refereed)
    Abstract [en]

    The European project PHASE aims to evaluate patterns of change in the temperature–mortality relationship and in the number of deaths attributable to heat in nine European cities in two periods, before and after summer 2003 (1996–2002 and 2004–2010). We performed age-specific Poisson regression models separately in the two periods, controlling for seasonality, air pollution and time trends. Distributed lag non-linear models were used to estimate the Relative Risks of daily mortality for increases in mean temperature from the 75th to 99th percentile of the summer distribution for each city. In the recent period, a reduction in the mortality risk associated to heat was observed only in Athens, Rome and Paris, especially among the elderly. Furthermore, in terms of heat-attributable mortality, 985, 787 and 623 fewer deaths were estimated, respectively, in the three cities. In Helsinki and Stockholm, there is a suggestion of increased heat effect. Noteworthy is that an effect of heat was still present in the recent years in all cities, ranging from +11% to +35%. In Europe, considering the warming observed in recent decades and population ageing, effective intervention measures should be promoted across countries, especially targeting vulnerable subgroups of the population with lower adaptive resources.

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  • 10.
    Domingo, Nina G.G.
    et al.
    Department of Environmental Health Sciences, Yale School of Public Health, CT, New Haven, United States; Yale Center on Climate Change and Health, Yale School of Public Health, CT, New Haven, United States.
    Fiore, Arlene M.
    Department of Earth, Atmospheric, and Planetary Sciences, Massachusetts Institute of Technology, MA, Cambridge, United States.
    Lamarque, Jean-Francois
    Climate and Global Dynamics Laboratory, National Center for Atmospheric Research, CO, Boulder, United States.
    Kinney, Patrick L.
    Department of Environmental Health, School of Public Health, Boston University, MA, Boston, United States.
    Jiang, Leiwen
    Asian Demographic Research Institute, Shanghai University, Shanghai, China; Population Council, NY, New York, United States.
    Gasparrini, Antonio
    Environment & Health Modelling (EHM) Lab, Department of Public Health Environments and Society, London School of Hygiene & Tropical Medicine, London, United Kingdom.
    Breitner, Susanne
    IBE-Chair of Epidemiology, Faculty of Medicine, LMU Munich, Munich, Germany; Institute of Epidemiology, Helmholtz Zentrum München – German Research Center for Environmental Health, Neuherberg, Germany.
    Lavigne, Eric
    School of Epidemiology & Public Health, Faculty of Medicine, University of Ottawa, ON, Ottawa, Canada; Environmental Health and Science Bureau, Heatlh Canada, ON, Ottawa, Canada.
    Madureira, Joana
    Environmental Health Department of the National Health Institute of Health Dr. Ricardo Jorge, Porto, Portugal; EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal; Laboratório para a Investigação Integrativa e Translacional em Saúde Populacional (ITR), Porto, Portugal.
    Masselot, Pierre
    Department of Public Health Environments and Society, London School of Hygiene & Tropical Medicine, London, United Kingdom.
    Silva, Susana das Neves Pereira da
    Environmental Health Department of the National Health Institute of Health Dr. Ricardo Jorge, Porto, Portugal.
    Sheng Ng, Chris Fook
    Department of Global Health Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan.
    Kyselý, Jan
    Institute of Atmospheric Physics, Czech Academy of Sciences, Prague, Czech Republic; Faculty of Environmental Sciences, Czech University of Life Sciences, Prague, Czech Republic.
    Guo, Yuming
    Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, NSW, Melbourne, Australia; Climate, Air Quality Research Unit, School of Public Health and Preventive Medicine, Monash University, NSW, Melbourne, Australia.
    Tong, Shilu
    School of Public Health and Social Work, Queensland University of Technology, QLD, Brisbane, Australia; School of Public Health and Institute of Environment and Human Health, Anhui Medical University, Hefei, China; Shanghai Children's Medical Centre, Shanghai Jiao-Tong University, Shanghai, China.
    Kan, Haidong
    Department of Environmental Health, School of Public Health, Fudan University, Shanghai, China.
    Urban, Aleš
    Institute of Atmospheric Physics, Czech Academy of Sciences, Prague, Czech Republic; Faculty of Environmental Sciences, Czech University of Life Sciences, Prague, Czech Republic.
    Orru, Hans
    Department of Family Medicine and Public Health, University of Tartu, Tartu, Estonia.
    Maasikmets, Marek
    Estonian Environmental Research Centre, Tallinn, Estonia.
    Pascal, Mathilde
    Santé Publique France, Department of Environmental Health, French National Public Health Agency, Saint Maurice, France.
    Katsouyanni, Klea
    Department of Hygiene, Epidemiology and Medical Statistics, National and Kapodistrian University of Athens, Athens, Greece; Environmental Research Group, School of Public Health, Imperial College London, London, United Kingdom.
    Samoli, Evangelia
    Department of Hygiene, Epidemiology and Medical Statistics, National and Kapodistrian University of Athens, Athens, Greece.
    Scortichini, Matteo
    Department of Epidemiology, Lazio Regional Health Service, Rome, Italy.
    Stafoggia, Massimo
    Department of Epidemiology, Lazio Regional Health Service, Rome, Italy.
    Hashizume, Masahiro
    Department of Global Health Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
    Alahmad, Barrak
    Department of Environmental Health, Harvard T.H. Chan School of Public Health, Harvard University, MA, Boston, United States.
    Diaz, Magali Hurtado
    Department of Environmental Health, National Institute of Public Health, Morelos, Cuernavaca, Mexico.
    De la Cruz Valencia, César
    Department of Environmental Health, National Institute of Public Health, Morelos, Cuernavaca, Mexico.
    Scovronick, Noah
    Department of Environmental Health, Rollins School of Public Health, Emory University, GA, Atlanta, United States.
    Garland, Rebecca M.
    Department of Geography, Geoinformatics and Meteorology, University of Pretoria, Pretoria, South Africa.
    Kim, Ho
    Graduate School of Public Health, Seoul National University, Seoul, South Korea.
    Lee, Whanhee
    Department of Occupational and Environmental Medicine, College of Medicine, Ewha Womans University, Seoul, South Korea; Institute of Ewha-SCL for Environmental Health (IESEH), Seoul, South Korea.
    Tobias, Aurelio
    School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan; Institute of Environmental Assessment and Water Research (IDAEA), Spanish Council for Scientific Research (CSIC), Barcelona, Spain.
    Íñiguez, Carmen
    Department of Statistics and Computational Research, Universitat de València, València, Spain; Ciberesp, Madrid, Spain.
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Åström, Christofer
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Ragettli, Martina S.
    Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland.
    Guo, Yue Leon
    Environmental and Occupational Medicine, National Taiwan University (NTU) College of Medicine and NTU Hospital, Taipei, Taiwan.
    Pan, Shih-Chun
    National Institute of Environmental Health Science, National Health Research Institutes, Zhunan, Taiwan.
    Colistro, Valentina
    The Centre on Climate Change and Planetary Health, London School of Hygiene & Tropical Medicine, London, United Kingdom; Department of Quantitative Methods, School of Medicine, University of the Republic, Montevideo, Uruguay.
    Bell, Michelle
    School of the Environment, Yale University, CT, New Haven, United States.
    Zanobetti, Antonella
    Department of Environmental Health, Harvard T.H. Chan School of Public Health, Harvard University, MA, Boston, United States.
    Schwartz, Joel
    Department of Environmental Health, Harvard T.H. Chan School of Public Health, Harvard University, MA, Boston, United States.
    Schneider, Alexandra
    Institute of Epidemiology, Helmholtz Zentrum München – German Research Center for Environmental Health, Neuherberg, Germany.
    Vicedo-Cabrera, Ana M.
    Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland; Oeschger Center for Climate Change Research, University of Bern, Bern, Switzerland.
    Chen, Kai
    Department of Environmental Health Sciences, Yale School of Public Health, CT, New Haven, United States; Yale Center on Climate Change and Health, Yale School of Public Health, CT, New Haven, United States.
    Ozone-related acute excess mortality projected to increase in the absence of climate and air quality controls consistent with the Paris Agreement2024In: One Earth, ISSN 2590-3330, E-ISSN 2590-3322, Vol. 7, no 2, p. 325-335Article in journal (Refereed)
    Abstract [en]

    Short-term exposure to ground-level ozone in cities is associated with increased mortality and is expected to worsen with climate and emission changes. However, no study has yet comprehensively assessed future ozone-related acute mortality across diverse geographic areas, various climate scenarios, and using CMIP6 multi-model ensembles, limiting our knowledge on future changes in global ozone-related acute mortality and our ability to design targeted health policies. Here, we combine CMIP6 simulations and epidemiological data from 406 cities in 20 countries or regions. We find that ozone-related deaths in 406 cities will increase by 45 to 6,200 deaths/year between 2010 and 2014 and between 2050 and 2054, with attributable fractions increasing in all climate scenarios (from 0.17% to 0.22% total deaths), except the single scenario consistent with the Paris Climate Agreement (declines from 0.17% to 0.15% total deaths). These findings stress the need for more stringent air quality regulations, as current standards in many countries are inadequate.

  • 11.
    Ebi, Kristie L.
    et al.
    Department of Global Health, University of Washington, in Seattle, Washington..
    Åström, Christofer
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Boyer, Christopher J.
    Harrington, Luke J.
    Hess, Jeremy J.
    Honda, Yasushi
    Kazura, Eileen
    Stuart-Smith, Rupert F.
    Otto, Friederike E. L.
    Using Detection And Attribution To Quantify How Climate Change Is Affecting Health2020In: Health Affairs, ISSN 0278-2715, E-ISSN 1544-5208, Vol. 39, no 12, p. 2168-2174Article in journal (Refereed)
    Abstract [en]

    The question of whether, how, and to what extent climate change is affecting health is central to many climate and health studies. We describe a set of formal methods, termed detection and attribution, used by climatologists to determine whether a climate trend or extreme event has changed and to estimate the extent to which climate change influenced that change. We discuss events where changing weather patterns were attributed to climate change and extend these analyses to include health impacts from heat waves in 2018 and 2019 in Europe and Japan, and we show how such impact attribution could be applied to melting ice roads in the Arctic. Documenting the causal chain from emissions of greenhouse gases to observed human health outcomes is important input into risk assessments that prioritize health system preparedness and response interventions and into financial investments and communication about potential risk to policy makers and to the public.

  • 12. Lee, Jae Young
    et al.
    Kim, Ho
    Gasparrini, Antonio
    Armstrong, Ben
    Bell, Michelle L
    Sera, Francesco
    Lavigne, Eric
    Abrutzky, Rosana
    Tong, Shilu
    Coelho, Micheline de Sousa Zanotti Stagliorio
    Saldiva, Paulo Hilario Nascimento
    Correa, Patricia Matus
    Ortega, Nicolas Valdes
    Kan, Haidong
    Garcia, Samuel Osorio
    Kyselý, Jan
    Urban, Aleš
    Orru, Hans
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health. Institute of Family Medicine and Public Health, University of Tartu, Tartu, Estonia.
    Indermitte, Ene
    Jaakkola, Jouni J K
    Ryti, Niilo R I
    Pascal, Mathilde
    Goodman, Patrick G
    Zeka, Ariana
    Michelozzi, Paola
    Scortichini, Matteo
    Hashizume, Masahiro
    Honda, Yasushi
    Hurtado, Magali
    Cruz, Julio
    Seposo, Xerxes
    Nunes, Baltazar
    Teixeira, João Paulo
    Tobias, Aurelio
    Íñiguez, Carmen
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Åström, Christofer
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Vicedo-Cabrera, Ana Maria
    Ragettli, Martina S
    Guo, Yue-Liang Leon
    Chen, Bing-Yu
    Zanobetti, Antonella
    Schwartz, Joel
    Dang, Tran Ngoc
    Do Van, Dung
    Mayvaneh, Fetemeh
    Overcenco, Ala
    Li, Shanshan
    Guo, Yuming
    Predicted temperature-increase-induced global health burden and its regional variability2019In: Environment International, ISSN 0160-4120, E-ISSN 1873-6750, Vol. 131, article id 105027Article in journal (Refereed)
    Abstract [en]

    An increase in the global health burden of temperature was projected for 459 locations in 28 countries worldwide under four representative concentration pathway scenarios until 2099. We determined that the amount of temperature increase for each 100 ppm increase in global CO2 concentrations is nearly constant, regardless of climate scenarios. The overall average temperature increase during 2010-2099 is largest in Canada (1.16 °C/100 ppm) and Finland (1.14 °C/100 ppm), while it is smallest in Ireland (0.62 °C/100 ppm) and Argentina (0.63 °C/100 ppm). In addition, for each 1 °C temperature increase, the amount of excess mortality is increased largely in tropical countries such as Vietnam (10.34%p/°C) and the Philippines (8.18%p/°C), while it is decreased in Ireland (-0.92%p/°C) and Australia (-0.32%p/°C). To understand the regional variability in temperature increase and mortality, we performed a regression-based modeling. We observed that the projected temperature increase is highly correlated with daily temperature range at the location and vulnerability to temperature increase is affected by health expenditure, and proportions of obese and elderly population.

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  • 13. Liu, Cong
    et al.
    Cai, Jing
    Chen, Renjie
    Sera, Francesco
    Guo, Yuming
    Tong, Shilu
    Li, Shanshan
    Lavigne, Eric
    Correa, Patricia Matus
    Ortega, Nicolas Valdes
    Orru, Hans
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health. Institute of Family Medicine and Public Health, University of Tartu, Tartu, Estonia.
    Maasikmets, Marek
    Jaakkola, Jouni J.K.
    Ryti, Niilo
    Breitner, Susanne
    Schneider, Alexandra
    Katsouyanni, Klea
    Samoli, Evangelina
    Hashizume, Masahiro
    Honda, Yasushi
    Ng, Chris Fook Sheng
    Diaz, Magali Hurtado
    Valencia, César De la Cruz
    Rao, Shilpa
    Palomares, Alfonso Diz-Lois
    Silva, Susana Pereira da
    Madureira, Joana
    Holobâc, Iulian Horia
    Fratianni, Simona
    Scovronick, Noah
    Garland, Rebecca M.
    Tobias, Aurelio
    Íñiguez, Carmen
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Åström, Christofer
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Vicedo-Cabrera, Ana Maria
    Ragettli, Martina S.
    Guo, Yue-Liang Leon
    Pan, Shih-Chun
    Milojevic, Ai
    Bell, Michelle L.
    Zanobetti, Antonella
    Schwartz, Joel
    Gasparrini, Antonio
    Kan, Haidong
    Coarse particulate air pollution and daily mortality: a global study in 205 cities2022In: American Journal of Respiratory and Critical Care Medicine, ISSN 1073-449X, E-ISSN 1535-4970, Vol. 206, no 8, p. 999-1007Article in journal (Refereed)
    Abstract [en]

    RATIONALE: The associations between ambient coarse particulate matter (PM2.5-10) and daily mortality is not fully understood at a global scale.

    OBJECTIVES: To evaluate the short-term associations between PM2.5-10 and total, cardiovascular, and respiratory mortality across multiple countries/regions worldwide.

    METHODS: We collected daily mortality (total, cardiovascular, respiratory) and air pollution data from 205 cities in 20 countries/regions. Concentrations of PM2.5-10 were computed as the difference between inhalable and fine particulate matter. A two-stage time-series analytic approach was applied, with over-dispersed generalized linear models and multilevel meta-analysis. We fitted two-pollutant models to test the independent effect of PM2.5-10 from co-pollutants (fine particulate matter, nitrogen dioxide, sulfur dioxide, ozone, and carbon monoxide). Exposure-response relationship curves were pooled and regional analyses were conducted.

    MEASUREMENTS AND MAIN RESULTS: A 10 μg/m3 increase in PM2.5-10 concentration on lag 0-1 day was associated with increments of 0.51% (95% confidence interval [CI]: 0.18%, 0.84%), 0.43% (95%CI: 0.15%, 0.71%) and 0.41% (95%CI: 0.06%, 0.77%) in total, cardiovascular, and respiratory mortality, respectively. The associations varied by country and region. These associations were robust to adjustment by all co-pollutants in two-pollutant models, especially for PM2.5. The exposure-response curves for total, cardiovascular, and respiratory mortality were positive, with steeper slopes at lower exposure ranges and without discernible thresholds.

    CONCLUSIONS: This study provides novel global evidence on the robust and independent associations between short-term exposure to ambient PM2.5-10 and total, cardiovascular and respiratory mortality, suggesting the need to establish a unique guideline or regulatory limit for daily concentrations of PM2.5-10.

  • 14. Liu, Cong
    et al.
    Chen, Renjie
    Sera, Francesco
    Vicedo-Cabrera, Ana M
    Guo, Yuming
    Tong, Shilu
    Coelho, Micheline S Z S
    Saldiva, Paulo H N
    Lavigne, Eric
    Matus, Patricia
    Valdes Ortega, Nicolas
    Osorio Garcia, Samuel
    Pascal, Mathilde
    Stafoggia, Massimo
    Scortichini, Matteo
    Hashizume, Masahiro
    Honda, Yasushi
    Hurtado-Díaz, Magali
    Cruz, Julio
    Nunes, Baltazar
    Teixeira, João P
    Kim, Ho
    Tobias, Aurelio
    Íñiguez, Carmen
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Åström, Christofer
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Ragettli, Martina S
    Guo, Yue-Leon
    Chen, Bing-Yu
    Bell, Michelle L
    Wright, Caradee Y
    Scovronick, Noah
    Garland, Rebecca M
    Milojevic, Ai
    Kyselý, Jan
    Urban, Aleš
    Orru, Hans
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health. The Institute of Family Medicine and Public Health, University of Tartu, Tartu, Estonia.
    Indermitte, Ene
    Jaakkola, Jouni J K
    Ryti, Niilo R I
    Katsouyanni, Klea
    Analitis, Antonis
    Zanobetti, Antonella
    Schwartz, Joel
    Chen, Jianmin
    Wu, Tangchun
    Cohen, Aaron
    Gasparrini, Antonio
    Kan, Haidong
    Ambient Particulate Air Pollution and Daily Mortality in 652 Cities2019In: New England Journal of Medicine, ISSN 0028-4793, E-ISSN 1533-4406, Vol. 381, no 8, p. 705-715Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The systematic evaluation of the results of time-series studies of air pollution is challenged by differences in model specification and publication bias.

    METHODS: We evaluated the associations of inhalable particulate matter (PM) with an aerodynamic diameter of 10 μm or less (PM10) and fine PM with an aerodynamic diameter of 2.5 μm or less (PM2.5) with daily all-cause, cardiovascular, and respiratory mortality across multiple countries or regions. Daily data on mortality and air pollution were collected from 652 cities in 24 countries or regions. We used overdispersed generalized additive models with random-effects meta-analysis to investigate the associations. Two-pollutant models were fitted to test the robustness of the associations. Concentration-response curves from each city were pooled to allow global estimates to be derived.

    RESULTS: On average, an increase of 10 μg per cubic meter in the 2-day moving average of PM10 concentration, which represents the average over the current and previous day, was associated with increases of 0.44% (95% confidence interval [CI], 0.39 to 0.50) in daily all-cause mortality, 0.36% (95% CI, 0.30 to 0.43) in daily cardiovascular mortality, and 0.47% (95% CI, 0.35 to 0.58) in daily respiratory mortality. The corresponding increases in daily mortality for the same change in PM2.5 concentration were 0.68% (95% CI, 0.59 to 0.77), 0.55% (95% CI, 0.45 to 0.66), and 0.74% (95% CI, 0.53 to 0.95). These associations remained significant after adjustment for gaseous pollutants. Associations were stronger in locations with lower annual mean PM concentrations and higher annual mean temperatures. The pooled concentration-response curves showed a consistent increase in daily mortality with increasing PM concentration, with steeper slopes at lower PM concentrations.

    CONCLUSIONS: Our data show independent associations between short-term exposure to PM10 and PM2.5 and daily all-cause, cardiovascular, and respiratory mortality in more than 600 cities across the globe. These data reinforce the evidence of a link between mortality and PM concentration established in regional and local studies. (Funded by the National Natural Science Foundation of China and others.).

  • 15. Masselot, Pierre
    et al.
    Sera, Francesco
    Schneider, Rochelle
    Kan, Haidong
    Lavigne, Éric
    Stafoggia, Massimo
    Tobias, Aurelio
    Chen, Hong
    Burnett, Richard T.
    Schwartz, Joel
    Zanobetti, Antonella
    Bell, Michelle L.
    Chen, Bing-Yu
    Leon Guo, Yue-Liang
    Ragettli, Martina S.
    Vicedo-Cabrera, Ana Maria
    Åström, Christofer
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Íñiguez, Carmen
    Garland, Rebecca M.
    Scovronick, Noah
    Madureira, Joana
    Nunes, Baltazar
    De la Cruz Valencia, César
    Hurtado Diaz, Magali
    Honda, Yasushi
    Hashizume, Masahiro
    Fook Cheng Ng, Chris
    Samoli, Evangelia
    Katsouyanni, Klea
    Schneider, Alexandra
    Breitner, Susanne
    Ryti, Niilo R. I.
    Jaakkola, Jouni J. K.
    Maasikmets, Marek
    Orru, Hans
    Department of Family Medicine and Public Health, University of Tartu, Tartu, Estonia.
    Guo, Yuming
    Valdés Ortega, Nicolás
    Matus Correa, Patricia
    Tong, Shilu
    Gasparrini, Antonio
    Differential mortality risks associated with PM2.5 components: a multi-country, multi-city study2022In: Epidemiology, ISSN 1044-3983, E-ISSN 1531-5487, Vol. 33, no 2, p. 167-175Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The association between fine particulate matter (PM2.5) and mortality widely differs between as well as within countries. Differences in PM2.5 composition can play a role in modifying the effect estimates, but there is little evidence about which components have higher impacts on mortality.

    METHODS: We applied a two-stage analysis on data collected from 210 locations in 16 countries. In the first stage, we estimated location-specific relative risks (RR) for mortality associated with daily total PM2.5 through time series regression analysis. We then pooled these estimates in a meta-regression model that included city-specific logratio-transformed proportions of seven PM2.5 components as well as meta-predictors derived from city-specific socio-economic and environmental indicators.

    RESULTS: We found associations between RR and several PM2.5 components. Increasing the ammonium (NH4+) proportion from 1% to 22%, while keeping a relative average proportion of other components, increased the RR from 1.0063 (95%CI: 1.0030-1.0097) to 1.0102 (95%CI:1.0070-1.0135). Conversely, an increase in nitrate (NO3-) from 1% to 71% resulted in a reduced RR, from 1.0100 (95%CI: 1.0067-1.0133) to 1.0037 (95%CI: 0.9998- 1.0077). Differences in composition explained a substantial part of the heterogeneity in PM2.5 risk.

    CONCLUSIONS: These findings contribute to the identification of more hazardous emission sources. Further work is needed to understand the health impacts of PM2.5 components and sources given the overlapping sources and correlations among many components.

  • 16. Meng, Xia
    et al.
    Liu, Cong
    Chen, Renjie
    Sera, Francesco
    Vicedo-Cabrera, Ana Maria
    Milojevic, Ai
    Guo, Yuming
    Tong, Shilu
    Coelho, Micheline de Sousa Zanotti Stagliorio
    Saldiva, Paulo Hilario Nascimento
    Lavigne, Eric
    Correa, Patricia Matus
    Ortega, Nicolas Valdes
    Osorio Garcia, Samuel
    Kyselý, Jan
    Urban, Aleš
    Orru, Hans
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health. Institute of Family Medicine and Public Health, University of Tartu, Tartu, Estonia.
    Maasikmets, Marek
    Jaakkola, Jouni J. K.
    Ryti, Niilo
    Huber, Veronika
    Schneider, Alexandra
    Katsouyanni, Klea
    Analitis, Antonis
    Hashizume, Masahiro
    Honda, Yasushi
    Ng, Chris Fook Sheng
    Nunes, Baltazar
    Teixeira, João Paulo
    Holobaca, Iulian Horia
    Fratianni, Simona
    Kim, Ho
    Tobias, Aurelio
    Íñiguez, Carmen
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Åström, Christofer
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Ragettli, Martina S.
    Guo, Yue-Liang Leon
    Pan, Shih-Chun
    Li, Shanshan
    Bell, Michelle L.
    Zanobetti, Antonella
    Schwartz, Joel
    Wu, Tangchun
    Gasparrini, Antonio
    Kan, Haidong
    Short term associations of ambient nitrogen dioxide with daily total, cardiovascular, and respiratory mortality: multilocation analysis in 398 cities.2021In: The BMJ, E-ISSN 1756-1833, Vol. 372, article id n534Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To evaluate the short term associations between nitrogen dioxide (NO2) and total, cardiovascular, and respiratory mortality across multiple countries/regions worldwide, using a uniform analytical protocol.

    DESIGN: Two stage, time series approach, with overdispersed generalised linear models and multilevel meta-analysis.

    SETTING: 398 cities in 22 low to high income countries/regions.

    MAIN OUTCOME MEASURES: Daily deaths from total (62.8 million), cardiovascular (19.7 million), and respiratory (5.5 million) causes between 1973 and 2018.

    RESULTS: On average, a 10 μg/m3 increase in NO2 concentration on lag 1 day (previous day) was associated with 0.46% (95% confidence interval 0.36% to 0.57%), 0.37% (0.22% to 0.51%), and 0.47% (0.21% to 0.72%) increases in total, cardiovascular, and respiratory mortality, respectively. These associations remained robust after adjusting for co-pollutants (particulate matter with aerodynamic diameter ≤10 μm or ≤2.5 μm (PM10 and PM2.5, respectively), ozone, sulfur dioxide, and carbon monoxide). The pooled concentration-response curves for all three causes were almost linear without discernible thresholds. The proportion of deaths attributable to NO2 concentration above the counterfactual zero level was 1.23% (95% confidence interval 0.96% to 1.51%) across the 398 cities.

    CONCLUSIONS: This multilocation study provides key evidence on the independent and linear associations between short term exposure to NO2 and increased risk of total, cardiovascular, and respiratory mortality, suggesting that health benefits would be achieved by tightening the guidelines and regulatory limits of NO2.

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  • 17.
    Olstrup, Henrik
    et al.
    Atmospheric Science Unit, Department of Environmental Science and Analytical Chemistry, Stockholm University, 11418 Stockholm, Sweden..
    Johansson, Christer
    Atmospheric Science Unit, Department of Environmental Science and Analytical Chemistry, Stockholm University, 11418 Stockholm, Sweden. Environment and Health Administration, SLB, Box 8136, 104 20 Stockholm, Sweden..
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Åström, Christofer
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Association between Mortality and Short-Term Exposure to Particles, Ozone and Nitrogen Dioxide in Stockholm, Sweden2019In: International Journal of Environmental Research and Public Health, ISSN 1661-7827, E-ISSN 1660-4601, Vol. 16, no 6, article id E1028Article in journal (Refereed)
    Abstract [en]

    In this study, the effects on daily mortality in Stockholm associated with short-term exposure to ultrafine particles (measured as number of particles with a diameter larger than 4 nm, PNC₄), black carbon (BC) and coarse particles (PM2.5⁻10) have been compared with the effects from more common traffic-pollution indicators (PM10, PM2.5 and NO₂) and O₃ during the period 2000⁻2016. Air pollution exposure was estimated from measurements at a 20 m high building in central Stockholm. The associations between daily mortality lagged up to two days (lag 02) and the different air pollutants were modelled by using Poisson regression. The pollutants with the strongest indications of an independent effect on daily mortality were O₃, PM2.5⁻10 and PM10. In the single-pollutant model, an interquartile range (IQR) increase in O₃ was associated with an increase in daily mortality of 2.0% (95% CI: 1.1⁻3.0) for lag 01 and 1.9% (95% CI: 1.0⁻2.9) for lag 02. An IQR increase in PM2.5⁻10 was associated with an increase in daily mortality of 0.8% (95% CI: 0.1⁻1.5) for lag 01 and 1.1% (95% CI: 0.4⁻1.8) for lag 02. PM10 was associated with a significant increase only at lag 02, with 0.8% (95% CI: 0.08⁻1.4) increase in daily mortality associated with an IQR increase in the concentration. NO₂ exhibits negative associations with mortality. The significant excess risk associated with O₃ remained significant in two-pollutant models after adjustments for PM2.5⁻10, BC and NO₂. The significant excess risk associated with PM2.5⁻10 remained significant in a two-pollutant model after adjustment for NO₂. The significantly negative associations for NO₂ remained significant in two-pollutant models after adjustments for PM2.5⁻10, O₃ and BC. A potential reason for these findings, where statistically significant excess risks were found for O₃, PM2.5⁻10 and PM10, but not for NO₂, PM2.5, PNC₄ and BC, is behavioral factors that lead to misclassification in the exposure. The concentrations of O₃ and PM2.5⁻10 are in general highest during sunny and dry days during the spring, when exposure to outdoor air tend to increase, while the opposite applies to NO₂, PNC₄ and BC, with the highest concentrations during the short winter days with cold weather, when people are less exposed to outdoor air.

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  • 18.
    Olstrup, Henrik
    et al.
    Institute of Family Medicine and Public Health, Faculty of Medicine, University of Tartu, Ravila 19, Tartu, Estonia.
    Johansson, Christer
    Atmospheric Science Unit, Department of Environmental Science, Stockholm University, Stockholm, Sweden; Environment and Health Administration, SLB-analys, Box 8136, Stockholm, Sweden.
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Åström, Christofer
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Orru, Hans
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Seasonal variations in the daily mortality associated with exposure to particles, nitrogen dioxide, and ozone in stockholm, sweden, from 2000 to 20162021In: Atmosphere, E-ISSN 2073-4433, Vol. 12, no 11, article id 1481Article in journal (Refereed)
    Abstract [en]

    Urban air pollutant emissions and concentrations vary throughout the year due to various factors, e.g., meteorological conditions and human activities. In this study, seasonal variations in daily mortality associated with increases in the concentrations of PM10 (particulate matter), PM2.5–10 (coarse particles), BC (black carbon), NO2 (nitrogen dioxide), and O3 (ozone) were calculated for Stockholm during the period from 2000 to 2016. The excess risks in daily mortality are presented in single and multi-pollutant models during the whole year and divided into four different seasons, i.e., winter (December–February), spring (March–May), summer (June–August), and autumn (September–November). The excess risks in the single-pollutant models associated with an interquartile range (IQR) increase for a lag 02 during the whole year were 0.8% (95% CI: 0.1–1.4) for PM10, 1.1% (95% CI: 0.4–1.8) for PM2.5–10, 0.5% (95% CI: −0.5–1.5) for BC, −1.5% (95% CI: −0.5–−2.5) for NO2, and 1.9% (95% CI: 1.0–2.9) for O3. When divided into different seasons, the excess risks for PM10 and PM2.5–10 showed a clear pattern, with the strongest associations during spring and autumn, but with weaker associations during summer and winter, indicating increased risks associated with road dust particles during these seasons. For BC, which represents combustion-generated particles, the pattern was not very clear, but the strongest positive excess risks were found during autumn. The excess risks for NO2 were negative during all seasons, and in several cases even statistically significantly negative, indicating that NO2 in itself was not harmful at the concentrations prevailing during the measurement period (mean values < 20 µg m−3). For O3, the excess risks were statistically significantly positive during “all year” in both the single and the multi-pollutant models. The excess risks for O3 in the single-pollutant models were also statistically significantly positive during all seasons.

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  • 19.
    Olstrup, Henrik
    et al.
    Institute of Family Medicine and Public Health, Faculty of Medicine, University of Tartu, Ravila 19, Tartu, Estonia.
    Åström, Christofer
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Orru, Hans
    Institute of Family Medicine and Public Health, Faculty of Medicine, University of Tartu, Ravila 19, Tartu, Estonia.
    Daily Mortality in Different Age Groups Associated with Exposure to Particles, Nitrogen Dioxide and Ozone in Two Northern European Capitals: Stockholm and Tallinn2022In: Environments, E-ISSN 2076-3298, Vol. 9, no 7, article id 83Article in journal (Refereed)
    Abstract [en]

    Although the association between air pollution and mortality is well established, less is known about the effects in different age groups. This study analyzes the short-term associations between mortality in different age groups (0–14 years of age, 15–64 years of age, and 65+ years of age) and a number of air pollutants in two relatively clean northern European capitals: Stockholm and Tallinn. The concentrations in PM10 (particles with an aerodynamic diameter smaller than or equal to 10 µm), PM2.5–10 (coarse particles), PM2.5 (particles with an aerodynamic diameter smaller than or equal to 2.5 µm), BC (black carbon), PNC4 (particle number count of particles larger than or equal to 4 nm), NO2 (nitrogen dioxide), and O3 (ozone) were measured during the period of 2000–2016 in Stockholm and 2001–2018 in Tallinn (except for BC and PNC4 which were only measured in Stockholm). The excess risks in daily mortality associated with an interquartile range (IQR) increase in the measured air pollutants were calculated in both single- and multi-pollutant models for lag01 and lag02 (average concentration during the same and the previous day, and the same and the previous two days, respectively) using a quasi-Poisson regression model with a logistic link function. In general, the calculated excess risks per IQR increase were highest in the age group 0–14 years of age in both Stockholm and Tallinn. However, in Stockholm, a statistically significant effect was shown for PM2.5–10, and in Tallinn for O3. In the oldest age group (65+), statistically significant effects were shown for both PM2.5–10, PM10, and O3 in Stockholm, and for O3 in Tallinn.

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  • 20.
    Orru, Hans
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Andersson, Camilla
    Swedish Meteorological and Hydrological Institute, Norrköping, Sweden.
    Ebi, Kristie L
    ClimAdapt, Los Altos, California, USA.
    Langner, Joakim
    Swedish Meteorological and Hydrological Institute, Norrköping, Sweden.
    Åström, Christofer
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Impact of climate change on ozone-related mortality and morbidity in Europe2013In: European Respiratory Journal, ISSN 0903-1936, E-ISSN 1399-3003, Vol. 41, no 2, p. 285-294Article in journal (Refereed)
    Abstract [en]

    Ozone is a highly oxidative pollutant formed from precursors in the presence of sunlight, associated with respiratory morbidity and mortality. All else being equal, concentrations of ground-level ozone are expected to increase due to climate change.Ozone-related health impacts under a changing climate are projected using emission scenarios, models and epidemiological data. European ozone concentrations are modelled with MATCH-RCA3 (50×50 km). Projections from two climate models, ECHAM4 and HadCM3, are applied, under greenhouse gas emission scenarios A2 and A1B respectively. We apply a European-wide exposure-response function to gridded population data and country-specific baseline mortality and morbidity.Comparing the current situation (1990-2009) with the baseline period (1961-1990), the largest increase in ozone-associated mortality and morbidity due to climate change (4-5%) have occurred in Belgium, Ireland, Netherlands and UK. Comparing the baseline period and the future periods (2021-2050 and 2041-2060), much larger increase in ozone-related mortality and morbidity are projected for Belgium, France, Spain and Portugal with the impact being stronger using the climate projection from ECHAM4 (A2). However, in Nordic and Baltic countries the same magnitude of decrease is projected.The current study suggests that projected effects of climate change on ozone concentrations could differentially influence mortality and morbidity across Europe.

  • 21.
    Orru, Hans
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health. Institute of Family Medicine and Public Health, University of Tartu, Tartu, Estonia.
    Åström, Christofer
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Andersson, Camilla
    Tamm, Tanel
    Ebi, Kristie L.
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Ozone and heat-related mortality in Europe in 2050 significantly affected by changes in climate, population and greenhouse gas emission2019In: Environmental Research Letters, E-ISSN 1748-9326, Vol. 14, no 7, article id 074013Article in journal (Refereed)
    Abstract [en]

    Climate change is expected to increase to extreme temperatures and lead to more intense formation of near-surface ozone. Higher temperatures can cause heat stress and ozone is a highly oxidative pollutant; both increase cardiorespiratory mortality. Using greenhouse gas and ozone precursor emission scenarios, global and regional climate and chemistry-transport models, epidemiological data, and population projections, we projected ozone- and heat-related health risks under a changing climate. European near-surface temperature was modelled with the regional climate model (RCA4), forced by the greenhouse gas emission scenario RCP4.5 and the global climate model EC-EARTH, and near-surface ozone was modelled with the Multi-scale Atmospheric Transport and Chemistry (MATCH) model. Two periods were compared: recent climate in 1991-2000 and future climate in 2046-2055, projecting around a 2 degrees increase in global temperatures by that time. Projections of premature mortality considered future climate, future population, and future emissions separately and jointly to understand the relative importance of their contributions. Ozone currently causes 55 000 premature deaths annually in Europe due to long-term exposure, including a proportion of the estimated 26 000 deaths per year due to short-term exposures. When only taking into account the impact of a changing climate, up to an 11% increase in ozone-associated mortality is expected in some countries in Central and Southern Europe in 2050. However, projected decreases in ozone precursor emissions are expected to result in a decrease in ozone-related mortality (-30% as EUaverage). Due to aging and increasingly susceptible populations, the decrease in 2050 would be smaller, up to -24%. During summer months, ozone risks could combine with increasing temperatures, especially during the hottest periods and in densely populated urban areas. While the heat burden is currently of the same order of magnitude as ozone, due to increasing temperatures and decreasing ozone precursor emissions, heat-related mortality could be twice as large as ozone-related mortality in 2050.

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  • 22.
    Oudin Åström, Daniel
    et al.
    Center for Primary Health Care Research, Department of Clinical Sciences, Malmö, Lund University, Lund.
    Åström, Christofer
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Vicedo-Cabrera, Ana M.
    Department of Public Health, Environments and Society, London School of Hygiene & Tropical Medicine, UK.
    Gasparrini, Antonio
    Department of Public Health, Environments and Society, London School of Hygiene & Tropical Medicine, UK.
    Oudin, Anna
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine. Occupational and Environmental Medicine, Lund University, Sweden.
    Sundquist, Kristina
    Center for Primary Health Care Research, Department of Clinical Sciences, Malmö, Lund University, Lund.
    Heat wave-related mortality in Sweden: a case-crossover study investigating effect modification by neighbourhood deprivation2020In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 48, no 4, p. 428-435Article in journal (Refereed)
    Abstract [en]

    AIMS: The present study aimed to investigate if set thresholds in the Swedish heat-wave warning system are valid for all parts of Sweden and if the heat-wave warning system captures a potential increase in all-cause mortality and coronary heart disease (CHD) mortality. An additional aim was to investigate whether neighbourhood deprivation modifies the relationship between heat waves and mortality.

    METHODS: From 1990 until 2014, in 14 municipalities in Sweden, we collected data on daily maximum temperatures and mortality for the five warmest months. Heat waves were defined according to the categories used in the current Swedish heat-wave warning system. Using a case-crossover approach, we investigated the association between heat waves and mortality in Sweden, as well as a modifying effect of neighbourhood deprivation.

    RESULTS: On a national as well as a regional level, heat waves significantly increased both all-cause mortality and CHD mortality by approximately 10% and 15%, respectively. While neighbourhood deprivation did not seem to modify heat wave-related all-cause mortality, CHD mortality did seem to modify the risk.

    CONCLUSIONS: It may not be appropriate to assume that heat waves in Sweden will have the same impact in a northern setting as in a southern, or that the impact of heat waves will be the same in affluent and deprived neighbourhoods. When designing and implementing heat-wave warning systems, neighbourhood, regional and national information should be incorporated.

  • 23.
    Oudin Åström, Daniel
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine. Department of Family Medicine and Public Health, University of Tartu, Tartu, Estonia; Centre for Primary Health Care Research, Department of Clinical Science, Malmö, Lund University, Lund, Sweden.
    Åström, Christofer
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine. Department of Family Medicine and Public Health, University of Tartu, Tartu, Estonia.
    Rekker, Kaidi
    Indermitte, Ene
    Orru, Hans
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine. Department of Family Medicine and Public Health, University of Tartu, Tartu, Estonia.
    High Summer Temperatures and Mortality in Estonia2016In: PLOS ONE, E-ISSN 1932-6203, Vol. 11, no 5, article id e0155045Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: On-going climate change is predicted to result in a growing number of extreme weather events-such as heat waves-throughout Europe. The effect of high temperatures and heat waves are already having an important impact on public health in terms of increased mortality, but studies from an Estonian setting are almost entirely missing. We investigated mortality in relation to high summer temperatures and the time course of mortality in a coastal and inland region of Estonia.

    METHODS: We collected daily mortality data and daily maximum temperature for a coastal and an inland region of Estonia. We applied a distributed lag non-linear model to investigate heat related mortality and the time course of mortality in Estonia.

    RESULTS: We found an immediate increase in mortality associated with temperatures exceeding the 75th percentile of summer maximum temperatures, corresponding to approximately 23°C. This increase lasted for a couple of days in both regions. The total effect of elevated temperatures was not lessened by significant mortality displacement.

    DISCUSSION: We observed significantly increased mortality in Estonia, both on a country level as well as for a coastal region and an inland region with a more continental climate. Heat related mortality was higher in the inland region as compared to the coastal region, however, no statistically significant differences were observed. The lower risks in coastal areas could be due to lower maximum temperatures and cooling effects of the sea, but also better socioeconomic condition. Our results suggest that region specific estimates of the impacts of temperature extremes on mortality are needed.

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  • 24.
    Rai, Masna
    et al.
    Institute of Epidemiology, Helmholtz Munich, - German Research Center for Environmental Health, Neuherberg, Germany; Institute for Medical Information Processing, Biometry, and Epidemiology – IBE, Pettenkofer School of Public Health, LMU Munich, Munich, Germany.
    Stafoggia, Massimo
    Department of Epidemiology, Lazio Regional Health Service, ASL Roma 1, Rome, Italy.
    de'Donato, Francesca
    Department of Epidemiology, Lazio Regional Health Service, ASL Roma 1, Rome, Italy.
    Scortichini, Matteo
    Department of Epidemiology, Lazio Regional Health Service, ASL Roma 1, Rome, Italy.
    Zafeiratou, Sofia
    epartment of Hygiene, Epidemiology and Medical Statistics, Medical School, National and Kapodistrian University of Athens, Greece.
    Vazquez Fernandez, Liliana
    Department of Air Pollution and Noise, Norwegian Institute of Public Health, Oslo, Norway.
    Zhang, Siqi
    Institute of Epidemiology, Helmholtz Munich, - German Research Center for Environmental Health, Neuherberg, Germany.
    Katsouyanni, Klea
    epartment of Hygiene, Epidemiology and Medical Statistics, Medical School, National and Kapodistrian University of Athens, Greece.
    Samoli, Evangelia
    epartment of Hygiene, Epidemiology and Medical Statistics, Medical School, National and Kapodistrian University of Athens, Greece.
    Rao, Shilpa
    Department of Air Pollution and Noise, Norwegian Institute of Public Health, Oslo, Norway.
    Lavigne, Eric
    School of Epidemiology & Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Canada and Environmental Health Science & Research Bureau, Health Canada, Ottawa, Canada.
    Guo, Yuming
    Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
    Kan, Haidong
    Department of Environmental Health, School of Public Health, Fudan University, Shanghai, China.
    Osorio, Samuel
    Department of Environmental Health, University of São Paulo, São Paulo, Brazil.
    Kyselý, Jan
    Institute of Atmospheric Physics, Czech Academy of Sciences, Prague, Czech Republic Faculty of Environmental Sciences, Czech University of Life Sciences, Prague, Czech Republic.
    Urban, Aleš
    Institute of Atmospheric Physics, Czech Academy of Sciences, Prague, Czech Republic Faculty of Environmental Sciences, Czech University of Life Sciences, Prague, Czech Republic.
    Orru, Hans
    Department of Family Medicine and Public Health, University of Tartu, Tartu, Estonia.
    Maasikmets, Marek
    Estonian Environmental Research Centre, Tallinn, Estonia.
    Jaakkola, Jouni J.K.
    Center for Environmental and Respiratory Health Research (CERH), University of Oulu, Oulu, Finland.
    Ryti, Niilo
    Center for Environmental and Respiratory Health Research (CERH), University of Oulu, Oulu, Finland.
    Pascal, Mathilde
    Santé Publique France, Department of Environmental Health, French National Public Health Agency, Saint Maurice, France.
    Hashizume, Masahiro
    Department of Global Health Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
    Fook Sheng Ng, Chris
    School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan.
    Alahmad, Barrak
    Department of Environmental Health, Harvard T.H. Chan School of Public Health, MA, Boston, United States.
    Hurtado Diaz, Magali
    Department of Environmental Health, National Institute of Public Health, Morelos, Cuernavaca, Mexico.
    De la Cruz Valencia, César
    Department of Environmental Health, National Institute of Public Health, Morelos, Cuernavaca, Mexico.
    Nunes, Baltazar
    Department of Environmental Health, Instituto Nacional de Saúde Dr. Ricardo Jorge, Porto, Portugal.
    Madureira, Joana
    Department of Environmental Health, Instituto Nacional de Saúde Dr. Ricardo Jorge, Porto, Portugal.
    Scovronick, Noah
    Department of Environmental Health. Rollins School of Public Health, Emory University, Atlanta, United States.
    Garland, Rebecca M.
    Department of Geography, Geoinformatics and Meteorology, University of Pretoria, Pretoria, South Africa.
    Kim, Ho
    Graduate School of Public Health, Seoul National University, Seoul, South Korea.
    Lee, Whanhee
    School of Biomedical Convergence Engineering, Pusan National University, Yangsan, South Korea.
    Tobias, Aurelio
    Institute of Environmental Assessment and Water Research (IDAEA), Spanish Council for Scientific Research (CSIC), Barcelona, Spain.
    Íñiguez, Carmen
    Department of Statistics and Computational Research, Universitat de València, València, Spain.
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Åström, Christofer
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Maria Vicedo-Cabrera, Ana
    Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.
    Ragettli, Martina S.
    Swiss Tropical and Public Health Institute, Basel, Switzerland.
    Leon Guo, Yue-Liang
    Environmental and Occupational Medicine, Institute of Occupational Medicine and Industrial Hygiene, National Taiwan University (NTU) and NTU Hospital, Taipei, Taiwan.
    Pan, Shih-Chun
    National Institute of Environmental Health Science, National Health Research Institutes, Zhunan, Taiwan.
    Li, Shanshan
    Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
    Gasparrini, Antonio
    Department of Public Health Environments and Society, London School of Hygiene & Tropical Medicine, London, United Kingdom.
    Sera, Francesco
    Department of Statistics, Computer Science and Applications “G. Parenti”, University of Florence, Florence, Italy.
    Masselot, Pierre
    Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
    Schwartz, Joel
    Department of Environmental Health, Harvard T.H. Chan School of Public Health, MA, Boston, United States.
    Zanobetti, Antonella
    Department of Environmental Health, Harvard T.H. Chan School of Public Health, MA, Boston, United States.
    Bell, Michelle L.
    School of Forestry and Environmental Studies, Yale University, CT, New Haven, United States.
    Schneider, Alexandra
    Institute of Epidemiology, Helmholtz Munich, - German Research Center for Environmental Health, Neuherberg, Germany.
    Breitner, Susanne
    Institute of Epidemiology, Helmholtz Munich, - German Research Center for Environmental Health, Neuherberg, Germany; Institute for Medical Information Processing, Biometry, and Epidemiology – IBE, Pettenkofer School of Public Health, LMU Munich, Munich, Germany.
    Heat-related cardiorespiratory mortality: effect modification by air pollution across 482 cities from 24 countries2023In: Environment International, ISSN 0160-4120, E-ISSN 1873-6750, Vol. 174, article id 107825Article in journal (Refereed)
    Abstract [en]

    Background: Evidence on the potential interactive effects of heat and ambient air pollution on cause-specific mortality is inconclusive and limited to selected locations. Objectives: We investigated the effects of heat on cardiovascular and respiratory mortality and its modification by air pollution during summer months (six consecutive hottest months) in 482 locations across 24 countries.

    Methods: Location-specific daily death counts and exposure data (e.g., particulate matter with diameters ≤ 2.5 µm [PM2.5]) were obtained from 2000 to 2018. We used location-specific confounder-adjusted Quasi-Poisson regression with a tensor product between air temperature and the air pollutant. We extracted heat effects at low, medium, and high levels of pollutants, defined as the 5th, 50th, and 95th percentile of the location-specific pollutant concentrations. Country-specific and overall estimates were derived using a random-effects multilevel meta-analytical model.

    Results: Heat was associated with increased cardiorespiratory mortality. Moreover, the heat effects were modified by elevated levels of all air pollutants in most locations, with stronger effects for respiratory than cardiovascular mortality. For example, the percent increase in respiratory mortality per increase in the 2-day average summer temperature from the 75th to the 99th percentile was 7.7% (95% Confidence Interval [CI] 7.6–7.7), 11.3% (95%CI 11.2–11.3), and 14.3% (95% CI 14.1–14.5) at low, medium, and high levels of PM2.5, respectively. Similarly, cardiovascular mortality increased by 1.6 (95%CI 1.5–1.6), 5.1 (95%CI 5.1–5.2), and 8.7 (95%CI 8.7–8.8) at low, medium, and high levels of O3, respectively.

    Discussion: We observed considerable modification of the heat effects on cardiovascular and respiratory mortality by elevated levels of air pollutants. Therefore, mitigation measures following the new WHO Air Quality Guidelines are crucial to enhance better health and promote sustainable development.

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  • 25. Scortichini, Matteo
    et al.
    de'Donato, Francesca
    De Sario, Manuela
    Leone, Michela
    Åström, Christofer
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Ballester, Ferran
    Basagaña, Xavier
    Bobvos, Janos
    Gasparrini, Antonio
    Katsouyanni, Klea
    Lanki, Timo
    Menne, Bettina
    Pascal, Mathilde
    Michelozzi, Paola
    The inter-annual variability of heat-related mortality in nine European cities (1990–2010)2018In: Environmental Health, E-ISSN 1476-069X, Vol. 17, no 1, article id 66Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The association between heat and daily mortality and its temporal variation are well known. However, few studies have analyzed the inter-annual variations in both the risk estimates and impacts of heat. The aim is to estimate inter-annual variations in the effect of heat for a fixed temperature range, on mortality in 9 European cities included in the PHASE (Public Health Adaptation Strategies to Extreme weather events) project for the period 1990-2010. The second aim is to evaluate overall summer effects and heat-attributable deaths for each year included in the study period, considering the entire air temperature range (both mild and extreme temperatures).

    METHODS: A city-specific daily time-series analysis was performed, using a generalized additive Poisson regression model, restricted to the warm season (April-September). To study the temporal variation for a fixed air temperature range, a Bayesian Change Point analysis was applied to the relative risks of mortality for a 2 °C increase over the 90th percentile of the city-specific distribution. The number of heat attributable deaths in each summer were also calculated for mild (reference to 95th percentile) and extreme heat (95th percentile to maximum value).

    RESULTS: A decline in the effects of heat over time was observed in Athens and Rome when considering a fixed interval, while an increase in effects was observed in Helsinki. The greatest impact of heat in terms of attributable deaths was observed in the Mediterranean cities (Athens, Barcelona and Rome) for extreme air temperatures. In the other cities the impact was mostly related to extreme years with 2003 as a record breaking year in Paris (+ 1900 deaths) and London (+ 1200 deaths).

    CONCLUSIONS: Monitoring the impact of heat over time is important to identify changes in population vulnerability and evaluate adaptation measures.

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  • 26. Sera, Francesco
    et al.
    Armstrong, Ben
    Tobias, Aurelio
    Vicedo-Cabrera, Ana Maria
    Åström, Christofer
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Bell, Michelle L
    Chen, Bing-Yu
    de Sousa Zanotti Stagliorio Coelho, Micheline
    Matus Correa, Patricia
    Cruz, Julio Cesar
    Dang, Tran Ngoc
    Hurtado-Diaz, Magali
    Do Van, Dung
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Guo, Yue Leon
    Guo, Yuming
    Hashizume, Masahiro
    Honda, Yasushi
    Iñiguez, Carmen
    Jaakkola, Jouni J K
    Kan, Haidong
    Kim, Ho
    Lavigne, Eric
    Michelozzi, Paola
    Ortega, Nicolas Valdes
    Osorio, Samuel
    Pascal, Mathilde
    Ragettli, Martina S
    Ryti, Niilo R I
    Saldiva, Paulo Hilario Nascimento
    Schwartz, Joel
    Scortichini, Matteo
    Seposo, Xerxes
    Tong, Shilu
    Zanobetti, Antonella
    Gasparrini, Antonio
    How urban characteristics affect vulnerability to heat and cold: a multi-country analysis2019In: International Journal of Epidemiology, ISSN 0300-5771, E-ISSN 1464-3685, Vol. 48, no 4, p. 1101-1112Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The health burden associated with temperature is expected to increase due to a warming climate. Populations living in cities are likely to be particularly at risk, but the role of urban characteristics in modifying the direct effects of temperature on health is still unclear. In this contribution, we used a multi-country dataset to study effect modification of temperature-mortality relationships by a range of city-specific indicators.

    METHODS: We collected ambient temperature and mortality daily time-series data for 340 cities in 22 countries, in periods between 1985 and 2014. Standardized measures of demographic, socio-economic, infrastructural and environmental indicators were derived from the Organisation for Economic Co-operation and Development (OECD) Regional and Metropolitan Database. We used distributed lag non-linear and multivariate meta-regression models to estimate fractions of mortality attributable to heat and cold (AF%) in each city, and to evaluate the effect modification of each indicator across cities.

    RESULTS: Heat- and cold-related deaths amounted to 0.54% (95% confidence interval: 0.49 to 0.58%) and 6.05% (5.59 to 6.36%) of total deaths, respectively. Several city indicators modify the effect of heat, with a higher mortality impact associated with increases in population density, fine particles (PM2.5), gross domestic product (GDP) and Gini index (a measure of income inequality), whereas higher levels of green spaces were linked with a decreased effect of heat.

    CONCLUSIONS: This represents the largest study to date assessing the effect modification of temperature-mortality relationships. Evidence from this study can inform public-health interventions and urban planning under various climate-change and urban-development scenarios.

  • 27.
    Sjödin, Henrik
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Johansson, Anders F.
    Umeå University, Faculty of Medicine, Molecular Infection Medicine Sweden (MIMS). Umeå University, Faculty of Medicine, Department of Clinical Microbiology.
    Brännström, Åke
    Umeå University, Faculty of Science and Technology, Department of Mathematics and Mathematical Statistics. Evolution and Ecology Program, International Institute for Applied Systems Analysis, Laxenburg, Austria..
    Farooq, Zia
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Kriit, Hedi Katre
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Wilder-Smith, Annelies
    Umeå University, Faculty of Medicine, Department of Epidemiology and Global Health. Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK; Heidelberg Institute of Global Health, University of Heidelberg, Heidelberg, Germany.
    Åström, Christofer
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Thunberg, Johan
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Anaesthesiology.
    Söderquist, Mårten
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Rocklöv, Joacim
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health. Heidelberg Institute of Global Health, University of Heidelberg, Heidelberg, Germany..
    COVID-19 healthcare demand and mortality in Sweden in response to non-pharmaceutical mitigation and suppression scenarios2020In: International Journal of Epidemiology, ISSN 0300-5771, E-ISSN 1464-3685, Vol. 49, no 5, p. 1443-1453Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: While the COVID-19 outbreak in China now appears suppressed, Europe and the USA have become the epicentres, both reporting many more deaths than China. Responding to the pandemic, Sweden has taken a different approach aiming to mitigate, not suppress, community transmission, by using physical distancing without lockdowns. Here we contrast the consequences of different responses to COVID-19 within Sweden, the resulting demand for care, intensive care, the death tolls and the associated direct healthcare related costs.

    METHODS: We used an age-stratified health-care demand extended SEIR (susceptible, exposed, infectious, recovered) compartmental model for all municipalities in Sweden, and a radiation model for describing inter-municipality mobility. The model was calibrated against data from municipalities in the Stockholm healthcare region.

    RESULTS: Our scenario with moderate to strong physical distancing describes well the observed health demand and deaths in Sweden up to the end of May 2020. In this scenario, the intensive care unit (ICU) demand reaches the pre-pandemic maximum capacity just above 500 beds. In the counterfactual scenario, the ICU demand is estimated to reach ∼20 times higher than the pre-pandemic ICU capacity. The different scenarios show quite different death tolls up to 1 September, ranging from 5000 to 41 000, excluding deaths potentially caused by ICU shortage. Additionally, our statistical analysis of all causes excess mortality indicates that the number of deaths attributable to COVID-19 could be increased by 40% (95% confidence interval: 0.24, 0.57).

    CONCLUSION: The results of this study highlight the impact of different combinations of non-pharmaceutical interventions, especially moderate physical distancing in combination with more effective isolation of infectious individuals, on reducing deaths, health demands and lowering healthcare costs. In less effective mitigation scenarios, the demand on ICU beds would rapidly exceed capacity, showing the tight interconnection between the healthcare demand and physical distancing in the society. These findings have relevance for Swedish policy and response to the COVID-19 pandemic and illustrate the importance of maintaining the level of physical distancing for a longer period beyond the study period to suppress or mitigate the impacts from the pandemic.

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  • 28.
    Stafoggia, Massimo
    et al.
    Department of Epidemiology, Lazio Region Health Service / ASL, Rome, Italy.
    Michelozzi, Paola
    Department of Epidemiology, Lazio Region Health Service / ASL, Rome, Italy.
    Schneider, Alexandra
    Institute of Epidemiology, Helmholtz Zentrum München – German Research Center for Environmental Health (GmbH), Neuherberg, Germany.
    Armstrong, Ben
    Department of Public Health Environments and Society, London School of Hygiene & Tropical Medicine, London, United Kingdom.
    Scortichini, Matteo
    Department of Epidemiology, Lazio Region Health Service / ASL, Rome, Italy.
    Rai, Masna
    Institute of Epidemiology, Helmholtz Zentrum München – German Research Center for Environmental Health (GmbH), Neuherberg, Germany.
    Achilleos, Souzana
    Department of Primary Care and Population Health, University of Nicosia Medical School, Nicosia, Cyprus.
    Alahmad, Barrak
    Department of Environmental Health, Harvard T.H. Chan School of Public Health, MA, Boston, United States.
    Analitis, Antonis
    Department of Hygiene, Epidemiology and Medical Statistics, National and Kapodistrian University of Athens, Greece.
    Åström, Christofer
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Bell, Michelle L.
    School of the Environment, Yale University, CT, New Haven, United States.
    Calleja, Neville
    Directorate for Health Information and Research, Malta.
    Krage Carlsen, Hanne
    School of Public Health and Community Medicine, University of Gothenburg, Gothenburg, Sweden.
    Carrasco, Gabriel
    Institute of Tropical Medicine “Alexander von Humboldt”, Universidad Peruana Cayetano Heredia, Lima, Peru.
    Paul Cauchi, John
    Queen Mary University of London, London, United Kingdom.
    D.S.Z.S. Coelho, Micheline
    Department of Pathology, Faculty of Medicine, University of São Paulo, São Paulo, Brazil.
    Correa, Patricia M.
    Department of Public Health, Universidad de los Andes, Santiago, Chile.
    Diaz, Magali H.
    Department of Environmental Health, National Institute of Public Health, Morelos, Cuernavaca, Mexico.
    Entezari, Alireza
    Faculty of Geography and Environmental Sciences, Hakim Sabzevari University, Khorasan Razavi, Sabzevar, Iran.
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Garland, Rebecca M.
    Department of Geography, Geoinformatics and Meteorology, University of Pretoria, Pretoria, South Africa.
    Leon Guo, Yue
    Environmental and Occupational Medicine, Institute of Environmental and Occupational Health Sciences, National Taiwan University (NTU) and NTU Hospital, Taipei, Taiwan.
    Guo, Yuming
    Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
    Hashizume, Masahiro
    Department of Global Health Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
    Holobaca, Iulian H.
    Faculty of Geography, Babes-Bolay University, Cluj-Napoca, Romania.
    Íñiguez, Carmen
    Department of Statistics and Computational Research, Universitat de València, València, Spain.
    Jaakkola, Jouni J.K.
    Center for Environmental and Respiratory Health Research (CERH), University of Oulu, Oulu, Finland.
    Kan, Haidong
    Department of Environmental Health, School of Public Health, Fudan University, Shanghai, China.
    Katsouyanni, Klea
    Department of Hygiene, Epidemiology and Medical Statistics, National and Kapodistrian University of Athens, Greece; Environmental Research Group, School of Public Health, Faculty of Medicine, Imperial College London, London, United Kingdom.
    Kim, Ho
    Graduate School of Public Health, Seoul National University, Seoul, South Korea.
    Kyselý, Jan
    Institute of Atmospheric Physics, Czech Academy of Sciences, Prague, Czech Republic; Faculty of Environmental Sciences, Czech University of Life Sciences, Prague, Czech Republic.
    Lavigne, Eric
    School of Epidemiology & Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Canada; Environmental Health Science and Research Bureau, Health Canada, Ottawa, Canada.
    Lee, Whanhee
    School of the Environment, Yale University, CT, New Haven, United States.
    Li, Shanshan
    Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
    Maasikmets, Marek
    Estonian Environmental Research Centre, Tallinn, Estonia.
    Madureira, Joana
    Department of Environmental Health, Instituto Nacional de Saúde Dr. Ricardo Jorge, Porto, Portugal; EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal; Laboratório para a Investigação Integrativa e Translacional em Saúde Populacional (ITR), Porto, Portugal.
    Mayvaneh, Fatemeh
    Faculty of Geography and Environmental Sciences, Hakim Sabzevari University, Khorasan Razavi, Sabzevar, Iran.
    Fook Sheng Ng, Chris
    Department of Global Health Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
    Nunes, Baltazar
    Department of Epidemiology, Instituto Nacional de Saúde Dr. Ricardo Jorge, Lisbon, Portugal.
    Orru, Hans
    Department of Family Medicine and Public Health, University of Tartu, Tartu, Estonia.
    V. Ortega, Nicolás
    Department of Public Health, Universidad de los Andes, Santiago, Chile.
    Osorio, Samuel
    Department of Environmental Health, University of São Paulo, São Paulo, Brazil.
    Palomares, Alfonso D.L.
    Norwegian Institute of Public Health, Oslo, Norway.
    Pan, Shih-Chun
    National Institute of Environmental Health Science, National Health Research Institutes, Zhunan, Taiwan.
    Pascal, Mathilde
    Santé Publique France, Department of Environmental Health, French National Public Health Agency, Saint Maurice, France.
    Ragettli, Martina S.
    Swiss Tropical and Public Health Institute, Basel, Switzerland.
    Rao, Shilpa
    Norwegian Institute of Public Health, Oslo, Norway.
    Raz, Raanan
    Braun School of Public Health and Community Medicine, The Hebrew University of Jerusalem, Israel.
    Roye, Dominic
    Climate Research Foundation, Madrid, Spain; Spanish Consortium for Research on Epidemiology and Public Health (CIBERESP), Spain.
    Ryti, Niilo
    Center for Environmental and Respiratory Health Research (CERH), University of Oulu, Oulu, Finland.
    H.N. Saldiva, Paulo
    Department of Pathology, Faculty of Medicine, University of São Paulo, São Paulo, Brazil.
    Samoli, Evangelia
    Department of Hygiene, Epidemiology and Medical Statistics, National and Kapodistrian University of Athens, Greece.
    Schwartz, Joel
    Department of Environmental Health, Harvard T.H. Chan School of Public Health, MA, Boston, United States.
    Scovronick, Noah
    Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, United States.
    Sera, Francesco
    Department of Public Health Environments and Society, London School of Hygiene & Tropical Medicine, London, United Kingdom; Department of Statistics, Computer Science and Applications “G. Parenti”, University of Florence, Florence, Italy.
    Tobias, Aurelio
    Institute of Environmental Assessment and Water Research (IDAEA), Spanish Council for Scientific Research (CSIC), Barcelona, Spain.
    Tong, Shilu
    School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia.
    D.L.C. Valencia, César
    Department of Environmental Health, National Institute of Public Health, Morelos, Cuernavaca, Mexico.
    Maria Vicedo-Cabrera, Ana
    Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland; Oeschger Center for Climate Change Research, University of Bern, Bern, Switzerland.
    Urban, Aleš
    Institute of Atmospheric Physics, Czech Academy of Sciences, Prague, Czech Republic; Faculty of Environmental Sciences, Czech University of Life Sciences, Prague, Czech Republic.
    Gasparrini, Antonio
    Department of Public Health Environments and Society, London School of Hygiene & Tropical Medicine, London, United Kingdom.
    Breitner, Susanne
    IBE-Chair of Epidemiology, LMU Munich, Munich, Germany.
    de' Donato, Francesca K.
    Department of Epidemiology, Lazio Region Health Service / ASL, Rome, Italy.
    Joint effect of heat and air pollution on mortality in 620 cities of 36 countries2023In: Environment International, ISSN 0160-4120, E-ISSN 1873-6750, Vol. 181, article id 108258Article in journal (Refereed)
    Abstract [en]

    Background: The epidemiological evidence on the interaction between heat and ambient air pollution on mortality is still inconsistent.

    Objectives: To investigate the interaction between heat and ambient air pollution on daily mortality in a large dataset of 620 cities from 36 countries.

    Methods: We used daily data on all-cause mortality, air temperature, particulate matter ≤ 10 μm (PM10), PM ≤ 2.5 μm (PM2.5), nitrogen dioxide (NO2), and ozone (O3) from 620 cities in 36 countries in the period 1995–2020. We restricted the analysis to the six consecutive warmest months in each city. City-specific data were analysed with over-dispersed Poisson regression models, followed by a multilevel random-effects meta-analysis. The joint association between air temperature and air pollutants was modelled with product terms between non-linear functions for air temperature and linear functions for air pollutants.

    Results: We analyzed 22,630,598 deaths. An increase in mean temperature from the 75th to the 99th percentile of city-specific distributions was associated with an average 8.9 % (95 % confidence interval: 7.1 %, 10.7 %) mortality increment, ranging between 5.3 % (3.8 %, 6.9 %) and 12.8 % (8.7 %, 17.0 %), when daily PM10 was equal to 10 or 90 μg/m3, respectively. Corresponding estimates when daily O3 concentrations were 40 or 160 μg/m3 were 2.9 % (1.1 %, 4.7 %) and 12.5 % (6.9 %, 18.5 %), respectively. Similarly, a 10 μg/m3 increment in PM10 was associated with a 0.54 % (0.10 %, 0.98 %) and 1.21 % (0.69 %, 1.72 %) increase in mortality when daily air temperature was set to the 1st and 99th city-specific percentiles, respectively. Corresponding mortality estimate for O3 across these temperature percentiles were 0.00 % (-0.44 %, 0.44 %) and 0.53 % (0.38 %, 0.68 %). Similar effect modification results, although slightly weaker, were found for PM2.5 and NO2.

    Conclusions: Suggestive evidence of effect modification between air temperature and air pollutants on mortality during the warm period was found in a global dataset of 620 cities.

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  • 29. Tobías, Aurelio
    et al.
    Hashizume, Masahiro
    Honda, Yasushi
    Sera, Francesco
    Ng, Chris Fook Sheng
    Kim, Yoonhee
    Roye, Dominic
    Chung, Yeonseung
    Dang, Tran Ngoc
    Kim, Ho
    Lee, Whanhee
    Íñiguez, Carmen
    Vicedo-Cabrera, Ana
    Abrutzky, Rosana
    Guo, Yuming
    Tong, Shilu
    Coelho, Micheline de Sousa Zanotti Stagliorio
    Saldiva, Paulo Hilario Nascimento
    Lavigne, Eric
    Correa, Patricia Matus
    Ortega, Nicolás Valdés
    Kan, Haidong
    Osorio, Samuel
    Kyselý, Jan
    Urban, Aleš
    Orru, Hans
    Department of Family Medicine and Public Health, University of Tartu, Tartu, Estonia..
    Indermitte, Ene
    Jaakkola, Jouni J K
    Ryti, Niilo R I
    Pascal, Mathilde
    Huber, Veronika
    Schneider, Alexandra
    Katsouyanni, Klea
    Analitis, Antonis
    Entezari, Alireza
    Mayvaneh, Fatemeh
    Goodman, Patrick
    Zeka, Ariana
    Michelozzi, Paola
    de'Donato, Francesca
    Alahmad, Barrak
    Diaz, Magali Hurtado
    De la Cruz Valencia, César
    Overcenco, Ala
    Houthuijs, Danny
    Ameling, Caroline
    Rao, Shilpa
    Di Ruscio, Francesco
    Carrasco, Gabriel
    Seposo, Xerxes
    Nunes, Baltazar
    Madureira, Joana
    Holobaca, Iulian-Horia
    Scovronick, Noah
    Acquaotta, Fiorella
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Åström, Christofer
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Ragettli, Martina S
    Guo, Yue-Liang Leon
    Chen, Bing-Yu
    Li, Shanshan
    Colistro, Valentina
    Zanobetti, Antonella
    Schwartz, Joel
    Dung, Do Van
    Armstrong, Ben
    Gasparrini, Antonio
    Geographical Variations of the Minimum Mortality Temperature at a Global Scale: A Multicountry Study2021In: Environmental epidemiology, ISSN 2474-7882, Vol. 5, no 5, article id e169Article in journal (Refereed)
    Abstract [en]

    Background: Minimum mortality temperature (MMT) is an important indicator to assess the temperature-mortality association, indicating long-term adaptation to local climate. Limited evidence about the geographical variability of the MMT is available at a global scale.

    Methods: We collected data from 658 communities in 43 countries under different climates. We estimated temperature-mortality associations to derive the MMT for each community using Poisson regression with distributed lag nonlinear models. We investigated the variation in MMT by climatic zone using a mixed-effects meta-analysis and explored the association with climatic and socioeconomic indicators.

    Results: The geographical distribution of MMTs varied considerably by country between 14.2 and 31.1 °C decreasing by latitude. For climatic zones, the MMTs increased from alpine (13.0 °C) to continental (19.3 °C), temperate (21.7 °C), arid (24.5 °C), and tropical (26.5 °C). The MMT percentiles (MMTPs) corresponding to the MMTs decreased from temperate (79.5th) to continental (75.4th), arid (68.0th), tropical (58.5th), and alpine (41.4th). The MMTs indreased by 0.8 °C for a 1 °C rise in a community's annual mean temperature, and by 1 °C for a 1 °C rise in its SD. While the MMTP decreased by 0.3 centile points for a 1 °C rise in a community's annual mean temperature and by 1.3 for a 1 °C rise in its SD.

    Conclusions: The geographical distribution of the MMTs and MMTPs is driven mainly by the mean annual temperature, which seems to be a valuable indicator of overall adaptation across populations. Our results suggest that populations have adapted to the average temperature, although there is still more room for adaptation.

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  • 30.
    Vicedo-Cabrera, A.M.
    et al.
    Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland; Oeschger Center for Climate Change Research, University of Bern, Bern, Switzerland; Department of Public Health, Environments and Society, London School of Hygiene & Tropical Medicine, London, United Kingdom.
    Scovronick, N.
    Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, GA, Atlanta, United States.
    Sera, F.
    Department of Public Health, Environments and Society, London School of Hygiene & Tropical Medicine, London, United Kingdom; Department of Statistics, Computer Science and Applications ‘G. Parenti’, University of Florence, Florence, Italy.
    Royé, D.
    Department of Geography, University of Santiago de Compostela, Santiago de Compostela, Spain; CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain.
    Schneider, R.
    Department of Public Health, Environments and Society, London School of Hygiene & Tropical Medicine, London, United Kingdom; Ф-Lab, European Space Agency (ESA-ESRIN), Frascati, Italy; The Centre on Climate Change and Planetary Health, London School of Hygiene & Tropical Medicine, London, United Kingdom; European Centre for Medium-Range Weather Forecast (ECMWF), Reading, United Kingdom.
    Tobias, A.
    Institute of Environmental Assessment and Water Research, Spanish Council for Scientific Research, Barcelona, Spain; School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan.
    Åström, Christofer
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Guo, Y.
    Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, VIC, Melbourne, Australia.
    Honda, Y.
    Faculty of Health and Sport Sciences, University of Tsukuba, Tsukuba, Japan.
    Hondula, D.M.
    School of Geographical Sciences and Urban Planning, Arizona State University, AZ, Tempe, United States.
    Abrutzky, R.
    Facultad de Ciencias Sociales, Instituto de Investigaciones Gino Germani, Universidad de Buenos Aires, Buenos Aires, Argentina.
    Tong, S.
    Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China; School of Public Health, Institute of Environment and Population Health, Anhui Medical University, Hefei, China; School of Public Health and Social Work, Queensland University of Technology, QLD, Brisbane, Australia; Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, China.
    Coelho, M. de Sousa Zanotti Stagliorio
    Faculty of Medicine - ArqFuturo INSPER, University of São Paulo, São Paulo, Brazil.
    Saldiva, P. H. Nascimento
    Faculty of Medicine - ArqFuturo INSPER, University of São Paulo, São Paulo, Brazil.
    Lavigne, E.
    Air Health Science Division, Health Canada, ON, Ottawa, Canada; School of Epidemiology and Public Health, University of Ottawa, ON, Ottawa, Canada.
    Correa, P. Matus
    Department of Public Health, Universidad de los Andes, Santiago, Chile.
    Ortega, N. Valdes
    Department of Public Health, Universidad de los Andes, Santiago, Chile.
    Kan, H.
    School of Public Health, Fudan University, Shanghai, China.
    Osorio, S.
    Department of Environmental Health, University of São Paulo, São Paulo, Brazil.
    Kyselý, J.
    Institute of Atmospheric Physics of the Czech Academy of Sciences, Prague, Czech Republic; Faculty of Environmental Sciences, Czech University of Life Sciences, Prague, Czech Republic.
    Urban, A.
    Institute of Atmospheric Physics of the Czech Academy of Sciences, Prague, Czech Republic; Faculty of Environmental Sciences, Czech University of Life Sciences, Prague, Czech Republic.
    Orru, H.
    Institute of Family Medicine and Public Health, University of Tartu, Tartu, Estonia.
    Indermitte, E.
    Institute of Family Medicine and Public Health, University of Tartu, Tartu, Estonia.
    Jaakkola, J.J.K.
    Center for Environmental and Respiratory Health Research (CERH), University of Oulu, Oulu, Finland; Finnish Meteorological Institute, Helsinki, Finland.
    Ryti, N.
    Center for Environmental and Respiratory Health Research (CERH), University of Oulu, Oulu, Finland.
    Pascal, M.
    Santé Publique France, Department of Environmental Health, French National Public Health Agency, Saint Maurice, France.
    Schneider, A.
    Institute of Epidemiology, Helmholtz Zentrum München—German Research Center for Environmental Health (GmbH), Neuherberg, Germany.
    Katsouyanni, K.
    Department of Hygiene, Epidemiology and Medical Statistics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece; MRC-PHE Centre for Environment and Health, Environmental Research Group, School of Public Health, Imperial College London, London, United Kingdom.
    Samoli, E.
    Department of Hygiene, Epidemiology and Medical Statistics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.
    Mayvaneh, F.
    Faculty of Geography and Environmental Sciences, Hakim Sabzevari University, Sabzevar, Iran.
    Entezari, A.
    Faculty of Geography and Environmental Sciences, Hakim Sabzevari University, Sabzevar, Iran.
    Goodman, P.
    School of Physics, Technological University Dublin, Dublin, Ireland.
    Zeka, A.
    Institute for Environment, Health and Societies, Brunel University London, London, United Kingdom.
    Michelozzi, P.
    Department of Epidemiology, Lazio Regional Health Service, Rome, Italy.
    de’Donato, F.
    Department of Epidemiology, Lazio Regional Health Service, Rome, Italy.
    Hashizume, M.
    Department of Global Health Policy, School of International Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
    Alahmad, B.
    Department of Environmental Health, Harvard T.H. Chan School of Public Health, Harvard University, MA, Boston, United States.
    Diaz, M. Hurtado
    Department of Environmental Health, National Institute of Public Health, Cuernavaca Morelos, Mexico.
    Valencia, C. De La Cruz
    Department of Environmental Health, National Institute of Public Health, Cuernavaca Morelos, Mexico.
    Overcenco, A.
    Laboratory of Management in Science and Public Health, National Agency for Public Health of the Ministry of Health, Chisinau, Moldova.
    Houthuijs, D.
    Centre for Sustainability and Environmental Health, National Institute for Public Health and the Environment (RIVM), Bilthoven, Netherlands.
    Ameling, C.
    Centre for Sustainability and Environmental Health, National Institute for Public Health and the Environment (RIVM), Bilthoven, Netherlands.
    Rao, S.
    Norwegian Institute of Public Health, Oslo, Norway.
    Di Ruscio, F.
    Norwegian Institute of Public Health, Oslo, Norway.
    Carrasco-Escobar, G.
    Health Innovation Laboratory, Institute of Tropical Medicine ‘Alexander von Humboldt’, Universidad Peruana Cayetano Heredia, Lima, Peru.
    Seposo, X.
    Department of Environmental Engineering, Graduate School of Engineering, Kyoto University, Kyoto, Japan.
    Silva, S.
    Department of Epidemiology, Instituto Nacional de Saúde Dr Ricardo Jorge, Lisbon, Portugal.
    Madureira, J.
    Department of Enviromental Health, Instituto Nacional de Saúde Dr Ricardo Jorge, Porto, Portugal; EPIUnit—Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal.
    Holobaca, I.H.
    Faculty of Geography, Babes-Bolay University, Cluj-Napoca, Romania.
    Fratianni, S.
    Department of Earth Sciences, University of Torino, Turin, Italy.
    Acquaotta, F.
    Department of Earth Sciences, University of Torino, Turin, Italy.
    Kim, H.
    Graduate School of Public Health & Institute of Health and Environment, Seoul National University, Seoul, South Korea.
    Lee, W.
    Graduate School of Public Health & Institute of Health and Environment, Seoul National University, Seoul, South Korea.
    Iniguez, C.
    CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain; Department of Statistics and Computational Research, Universitat de València, València, Spain.
    Forsberg, B.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Ragettli, M.S.
    Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland.
    Guo, Y.L.L.
    Environmental and Occupational Medicine, and Institute of Environmental and Occupational Health Sciences, National Taiwan University (NTU) and NTU Hospital, Taipei, Taiwan; National Institute of Environmental Health Science, National Health Research Institutes, Zhunan, Taiwan.
    Chen, B.Y.
    National Institute of Environmental Health Science, National Health Research Institutes, Zhunan, Taiwan.
    Li, S.
    Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, VIC, Melbourne, Australia.
    Armstrong, B.
    Department of Public Health, Environments and Society, London School of Hygiene & Tropical Medicine, London, United Kingdom; The Centre on Climate Change and Planetary Health, London School of Hygiene & Tropical Medicine, London, United Kingdom.
    Aleman, A.
    Department of Preventive Medicine, School of Medicine, University of the Republic, Montevideo, Uruguay.
    Zanobetti, A.
    Department of Environmental Health, Harvard T.H. Chan School of Public Health, Harvard University, MA, Boston, United States.
    Schwartz, J.
    Department of Environmental Health, Harvard T.H. Chan School of Public Health, Harvard University, MA, Boston, United States.
    Dang, T.N.
    Department of Environmental Health, Faculty of Public Health, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Viet Nam.
    Dung, D.V.
    Department of Environmental Health, Faculty of Public Health, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Viet Nam.
    Gillett, N.
    Canadian Centre for Climate Modelling and Analysis, Environment and Climate Change Canada, BC, Victoria, Canada.
    Haines, A.
    Department of Public Health, Environments and Society, London School of Hygiene & Tropical Medicine, London, United Kingdom; Ф-Lab, European Space Agency (ESA-ESRIN), Frascati, Italy.
    Mengel, M.
    Potsdam Institute for Climate Impact Research, Potsdam, Germany.
    Huber, V.
    Potsdam Institute for Climate Impact Research, Potsdam, Germany; Department of Physical, Chemical and Natural Systems, Universidad Pablo de Olavide, Seville, Spain.
    Gasparrini, A.
    Department of Public Health, Environments and Society, London School of Hygiene & Tropical Medicine, London, United Kingdom; The Centre on Climate Change and Planetary Health, London School of Hygiene & Tropical Medicine, London, United Kingdom; Centre for Statistical Methodology, London School of Hygiene & Tropical Medicine, London, United Kingdom.
    The burden of heat-related mortality attributable to recent human-induced climate change2021In: Nature Climate Change, ISSN 1758-678X, E-ISSN 1758-6798, Vol. 11, no 6, p. 492-500Article in journal (Refereed)
    Abstract [en]

    Climate change affects human health; however, there have been no large-scale, systematic efforts to quantify the heat-related human health impacts that have already occurred due to climate change. Here, we use empirical data from 732 locations in 43 countries to estimate the mortality burdens associated with the additional heat exposure that has resulted from recent human-induced warming, during the period 1991–2018. Across all study countries, we find that 37.0% (range 20.5–76.3%) of warm-season heat-related deaths can be attributed to anthropogenic climate change and that increased mortality is evident on every continent. Burdens varied geographically but were of the order of dozens to hundreds of deaths per year in many locations. Our findings support the urgent need for more ambitious mitigation and adaptation strategies to minimize the public health impacts of climate change.

  • 31. Vicedo-Cabrera, Ana M
    et al.
    Sera, Francesco
    Liu, Cong
    Armstrong, Ben
    Milojevic, Ai
    Guo, Yuming
    Tong, Shilu
    Lavigne, Eric
    Kyselý, Jan
    Urban, Aleš
    Orru, Hans
    Institute of Family Medicine and Public Health, University of Tartu, Tartu, Estonia..
    Indermitte, Ene
    Pascal, Mathilde
    Huber, Veronika
    Schneider, Alexandra
    Katsouyanni, Klea
    Samoli, Evangelia
    Stafoggia, Massimo
    Scortichini, Matteo
    Hashizume, Masahiro
    Honda, Yasushi
    Ng, Chris Fook Sheng
    Hurtado-Diaz, Magali
    Cruz, Julio
    Silva, Susana
    Madureira, Joana
    Scovronick, Noah
    Garland, Rebecca M
    Kim, Ho
    Tobias, Aurelio
    Íñiguez, Carmen
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Åström, Christofer
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Ragettli, Martina S
    Röösli, Martin
    Guo, Yue-Liang Leon
    Chen, Bing-Yu
    Zanobetti, Antonella
    Schwartz, Joel
    Bell, Michelle L
    Kan, Haidong
    Gasparrini, Antonio
    Short term association between ozone and mortality: global two stage time series study in 406 locations in 20 countries2020In: The BMJ, E-ISSN 1756-1833, Vol. 368, article id m108Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: To assess short term mortality risks and excess mortality associated with exposure to ozone in several cities worldwide.

    DESIGN: Two stage time series analysis.

    SETTING: 406 cities in 20 countries, with overlapping periods between 1985 and 2015, collected from the database of Multi-City Multi-Country Collaborative Research Network.

    POPULATION: Deaths for all causes or for external causes only registered in each city within the study period.

    MAIN OUTCOME MEASURES: Daily total mortality (all or non-external causes only).

    RESULTS: A total of 45 165 171 deaths were analysed in the 406 cities. On average, a 10 µg/m3 increase in ozone during the current and previous day was associated with an overall relative risk of mortality of 1.0018 (95% confidence interval 1.0012 to 1.0024). Some heterogeneity was found across countries, with estimates ranging from greater than 1.0020 in the United Kingdom, South Africa, Estonia, and Canada to less than 1.0008 in Mexico and Spain. Short term excess mortality in association with exposure to ozone higher than maximum background levels (70 µg/m3) was 0.26% (95% confidence interval 0.24% to 0.28%), corresponding to 8203 annual excess deaths (95% confidence interval 3525 to 12 840) across the 406 cities studied. The excess remained at 0.20% (0.18% to 0.22%) when restricting to days above the WHO guideline (100 µg/m3), corresponding to 6262 annual excess deaths (1413 to 11 065). Above more lenient thresholds for air quality standards in Europe, America, and China, excess mortality was 0.14%, 0.09%, and 0.05%, respectively.

    CONCLUSIONS: Results suggest that ozone related mortality could be potentially reduced under stricter air quality standards. These findings have relevance for the implementation of efficient clean air interventions and mitigation strategies designed within national and international climate policies.

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  • 32.
    Wen, Bo
    et al.
    Climate, Air Quality Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
    Wu, Yao
    Climate, Air Quality Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
    Guo, Yuming
    Climate, Air Quality Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
    Gasparrini, Antonio
    Department of Public Health, Environments and Society, London School of Hygiene & Tropical Medicine, London, United Kingdom; Centre for Statistical Methodology, London School of Hygiene & Tropical Medicine, London, United Kingdom; Centre on Climate Change & Planetary Health, London School of Hygiene & Tropical Medicine, London, United Kingdom.
    Tong, Shilu
    Shanghai Children's Medical Centre, Shanghai Jiao Tong University, Shanghai, China; School of Public Health, Institute of Environment and Population Health, Anhui Medical University, Hefei, China; Center for Global Health, Nanjing Medical University, Nanjing, China; School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia.
    Overcenco, Ala
    National Agency for Public Health of the Ministry of Health, Labour and Social Protection of the Republic of Moldova, Moldova.
    Urban, Aleš
    Institute of Atmospheric Physics, Czech Academy of Sciences, Prague, Czech Republic; Faculty of Environmental Sciences, Czech University of Life Sciences, Prague, Czech Republic.
    Schneider, Alexandra
    Institute of Epidemiology, Helmholtz Zentrum München – German Research Center for Environmental Health, Neuherberg, Germany.
    Entezari, Alireza
    Faculty of Geography and Environmental Sciences, Hakim Sabzevari University, Sabzevar, Iran.
    Vicedo-Cabrera, Ana Maria
    Department of Public Health, Environments and Society, London School of Hygiene & Tropical Medicine, London, United Kingdom; Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland; Oeschger Center for Climate Change Research, University of Bern, Bern, Switzerland.
    Zanobetti, Antonella
    Department of Environmental Health, Harvard T.H. Chan School of Public Health, Harvard University, MA, Boston, United States.
    Analitis, Antonis
    Department of Hygiene, Epidemiology and Medical Statistics, National and Kapodistrian University of Athens, Athens, Greece.
    Zeka, Ariana
    Institute for Environment, Health and Societies, Brunel University London, London, United Kingdom.
    Tobias, Aurelio
    Institute of Environmental Assessment and Water Research, Spanish Council for Scientific Research, Barcelona, Spain; School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan.
    Nunes, Baltazar
    Department of Epidemiology, Instituto Nacional de Saúde Dr Ricardo Jorge, Porto, Portugal; Centro de Investigação em Saúde Pública, Escola Nacional de Saúde Pública, Universidade NOVA de Lisboa, Lisbon, Portugal.
    Alahmad, Barrak
    Department of Environmental Health, Harvard T.H. Chan School of Public Health, Harvard University, MA, Boston, United States.
    Armstrong, Ben
    Department of Public Health, Environments and Society, London School of Hygiene & Tropical Medicine, London, United Kingdom.
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Pan, Shih-Chun
    National Institute of Environmental Health Science, National Health Research Institutes, Zhunan, Taiwan.
    Íñiguez, Carmen
    Department of Statistics and Computational Research, Universitat de València, València, Spain; CIBER of Epidemiology and Public Health, Madrid, Spain.
    Ameling, Caroline
    National Institute for Public Health and the Environment (RIVM), Centre for Sustainability and Environmental Health, Bilthoven, Netherlands.
    Valencia, César De la Cruz
    Department of Environmental Health, National Institute of Public Health, Cuernavaca Morelos, Mexico.
    Åström, Christofer
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Houthuijs, Danny
    National Institute for Public Health and the Environment (RIVM), Centre for Sustainability and Environmental Health, Bilthoven, Netherlands.
    Van Dung, Do
    Department of Environmental Health, Faculty of Public Health, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Viet Nam.
    Royé, Dominic
    CIBER of Epidemiology and Public Health, Madrid, Spain; Department of Geography, University of Santiago de Compostela, Santiago de Compostela, Spain.
    Indermitte, Ene
    Institute of Family Medicine and Public Health, University of Tartu, Tartu, Estonia.
    Lavigne, Eric
    School of Epidemiology & Public Health, Faculty of Medicine, University of Ottawa, ON, Ottawa, Canada; Air Health Science Division, Health Canada, ON, Ottawa, Canada.
    Mayvaneh, Fatemeh
    Faculty of Geography and Environmental Sciences, Hakim Sabzevari University, Sabzevar, Iran.
    Acquaotta, Fiorella
    Department of Earth Sciences, University of Torino, Turin, Italy.
    de'Donato, Francesca
    Department of Epidemiology, Lazio Regional Health Service, Rome, Italy.
    Rao, Shilpa
    Norwegian Institute of Public Health, Oslo, Norway.
    Sera, Francesco
    Department of Statistics, Computer Science and Applications “G. Parenti”, University of Florence, Florence, Italy.
    Carrasco-Escobar, Gabriel
    Health Innovation Lab, Institute of Tropical Medicine “Alexander von Humboldt”, Universidad Peruana Cayetano Heredia, Lima, Peru; Scripps Institution of Oceanography, University of California San Diego, La Jolla, CA, United States.
    Kan, Haidong
    Department of Environmental Health, School of Public Health, Fudan University, Shanghai, China.
    Orru, Hans
    Institute of Family Medicine and Public Health, University of Tartu, Tartu, Estonia.
    Kim, Ho
    Graduate School of Public Health, Seoul National University, Seoul, South Korea.
    Holobaca, Iulian-Horia
    Faculty of Geography, Babeş-Bolyai University, Cluj-Napoca, Romania.
    Kyselý, Jan
    Institute of Atmospheric Physics, Czech Academy of Sciences, Prague, Czech Republic; Faculty of Environmental Sciences, Czech University of Life Sciences, Prague, Czech Republic.
    Madureira, Joana
    Environmental Health Department, Instituto Nacional de Saúde Dr Ricardo Jorge, Porto, Portugal; EPIUnit – Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal; Laboratório para a Investigação Integrativa e Translacional em Saúde Populacional (ITR), Porto, Portugal.
    Schwartz, Joel
    Department of Environmental Health, Harvard T.H. Chan School of Public Health, Harvard University, MA, Boston, United States.
    Jaakkola, Jouni J.K.
    Center for Environmental and Respiratory Health Research (CERH), University of Oulu, Oulu, Finland; Medical Research Center Oulu (MRC Oulu), Oulu University Hospital and University of Oulu, Oulu, Finland.
    Katsouyanni, Klea
    Department of Hygiene, Epidemiology and Medical Statistics, National and Kapodistrian University of Athens, Athens, Greece; School of Population Health and Environmental Sciences, King's College London, London, United Kingdom.
    Diaz, Magali Hurtado
    Department of Environmental Health, National Institute of Public Health, Cuernavaca Morelos, Mexico.
    Ragettli, Martina S.
    Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland.
    Hashizume, Masahiro
    Department of Global Health Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
    Pascal, Mathilde
    Santé Publique France, Department of Environmental and Occupational Health, French National Public Health Agency, Saint Maurice, France.
    Coélho, Micheline de Sousa Zanotti Stagliorio
    Department of Pathology, Faculty of Medicine, University of São Paulo, Brazil.
    Ortega, Nicolás Valdés
    Department of Public Health, Universidad de los Andes, Santiago, Chile.
    Ryti, Niilo
    Center for Environmental and Respiratory Health Research (CERH), University of Oulu, Oulu, Finland; Medical Research Center Oulu (MRC Oulu), Oulu University Hospital and University of Oulu, Oulu, Finland.
    Scovronick, Noah
    Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, GA, Atlanta, United States.
    Michelozzi, Paola
    Department of Epidemiology, Lazio Regional Health Service, Rome, Italy.
    Matus Correa, Patricia
    Department of Public Health, Universidad de los Andes, Santiago, Chile.
    Goodman, Patrick
    School of Physics, Technological University Dublin, Dublin, Ireland.
    Saldiva, Paulo Hilario Nascimento
    INSPER, São Paulo, Brazil.
    Raz, Raanan
    Braun School of Public Health and Community Medicine, The Hebrew University of Jerusalem, Israel.
    Abrutzky, Rosana
    Universidad de Buenos Aires, Facultad de Ciencias Sociales, Instituto de Investigaciones Gino Germani, Buenos Aires, Argentina.
    Osorio, Samuel
    Department of Environmental Health, University of São Paulo, São Paulo, Brazil.
    Dang, Tran Ngoc
    Department of Environmental Health, Faculty of Public Health, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Viet Nam.
    Colistro, Valentina
    Department of Quantitative Methods, School of Medicine, University of the Republic, Montevideo, Uruguay.
    Huber, Veronika
    IBE-Chair of Epidemiology, LMU Munich, Munich, Germany; Department of Physical, Chemical and Natural Systems, Universidad Pablo de Olavide, Sevilla, Spain.
    Lee, Whanhee
    School of the Environment, Yale University, CT, New Haven, United States; Department of Occupational and Environmental Medicine, School of Medicine, Ewha Womans University, Seoul, South Korea.
    Seposo, Xerxes
    School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan.
    Honda, Yasushi
    Center for Climate Change Adaptation, National Institute for Environmental Studies, Tsukuba, Japan.
    Kim, Yoonhee
    Department of Global Environmental Health, Graduate School of Medicine, University of Tokyo, Tokyo, Japan.
    Guo, Yue Leon
    National Institute of Environmental Health Science, National Health Research Institutes, Zhunan, Taiwan; Environmental and Occupational Medicine, National Taiwan University College of Medicine and NTU Hospital, National Taiwan University, Taipei, Taiwan; Graduate Institute of Environmental and Occupational Health Sciences, National Taiwan University College of Public Health, National Taiwan University, Taipei, Taiwan.
    Bell, Michelle L.
    School of the Environment, Yale University, CT, New Haven, United States.
    Li, Shanshan
    Climate, Air Quality Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
    Comparison for the effects of different components of temperature variability on mortality: A multi-country time-series study2024In: Environment International, ISSN 0160-4120, E-ISSN 1873-6750, Vol. 187, article id 108712Article in journal (Refereed)
    Abstract [en]

    Background: Temperature variability (TV) is associated with increased mortality risk. However, it is still unknown whether intra-day or inter-day TV has different effects. Objectives: We aimed to assess the association of intra-day TV and inter-day TV with all-cause, cardiovascular, and respiratory mortality.

    Methods: We collected data on total, cardiovascular, and respiratory mortality and meteorology from 758 locations in 47 countries or regions from 1972 to 2020. We defined inter-day TV as the standard deviation (SD) of daily mean temperatures across the lag interval, and intra-day TV as the average SD of minimum and maximum temperatures on each day. In the first stage, inter-day and intra-day TVs were modelled simultaneously in the quasi-Poisson time-series model for each location. In the second stage, a multi-level analysis was used to pool the location-specific estimates.

    Results: Overall, the mortality risk due to each interquartile range [IQR] increase was higher for intra-day TV than for inter-day TV. The risk increased by 0.59% (95% confidence interval [CI]: 0.53, 0.65) for all-cause mortality, 0.64% (95% CI: 0.56, 0.73) for cardiovascular mortality, and 0.65% (95% CI: 0.49, 0.80) for respiratory mortality per IQR increase in intra-day TV0–7 (0.9 °C). An IQR increase in inter-day TV0–7 (1.6 °C) was associated with 0.22% (95% CI: 0.18, 0.26) increase in all-cause mortality, 0.44% (95% CI: 0.37, 0.50) increase in cardiovascular mortality, and 0.31% (95% CI: 0.21, 0.41) increase in respiratory mortality. The proportion of all-cause deaths attributable to intra-day TV0–7 and inter-day TV0–7 was 1.45% and 0.35%, respectively. The mortality risks varied by lag interval, climate area, season, and climate type.

    Conclusions: Our results indicated that intra-day TV may explain the main part of the mortality risk related to TV and suggested that comprehensive evaluations should be proposed in more countries to help protect human health.

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  • 33.
    Wu, Yao
    et al.
    Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, VIC, Melbourne, Australia; Climate, Air Quality Research Unit, School of Public Health and Preventive Medicine, Monash University, VIC, Melbourne, Australia.
    Li, Shanshan
    Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, VIC, Melbourne, Australia; Climate, Air Quality Research Unit, School of Public Health and Preventive Medicine, Monash University, VIC, Melbourne, Australia.
    Zhao, Qi
    Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, VIC, Melbourne, Australia; Department of Epidemiology, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, China.
    Wen, Bo
    Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, VIC, Melbourne, Australia; Climate, Air Quality Research Unit, School of Public Health and Preventive Medicine, Monash University, VIC, Melbourne, Australia.
    Gasparrini, Antonio
    Department of Public Health, Environments and Society, London School of Hygiene & Tropical Medicine, UK, London, United Kingdom; Centre for Statistical Methodology, London School of Hygiene & Tropical Medicine, UK, London, United Kingdom; Centre on Climate Change & Planetary Health, London School of Hygiene & Tropical Medicine, UK, London, United Kingdom.
    Tong, Shilu
    Shanghai Children's Medical Centre, Shanghai Jiao Tong University, Shanghai, China; School of Public Health, Institute of Environment and Population Health, Anhui Medical University, Hefei, China; Center for Global Health, Nanjing Medical University, Nanjing, China; School of Public Health and Social Work, Queensland University of Technology, QLD, Brisbane, Australia.
    Overcenco, Ala
    National Agency for Public Health of the Ministry of Health, Labour and Social Protection of the Republic of Moldova, Chișinău, Moldova.
    Urban, Aleš
    Institute of Atmospheric Physics, Czech Academy of Sciences, Prague, Czech Republic; Faculty of Environmental Sciences, Czech University of Life Sciences, Prague, Czech Republic.
    Schneider, Alexandra
    Institute of Epidemiology, Helmholtz Zentrum München—German Research Center for Environmental Health, Neuherberg, Germany.
    Entezari, Alireza
    Faculty of Geography and Environmental Sciences, Hakim Sabzevari University, Sabzevar, Iran.
    Vicedo-Cabrera, Ana Maria
    Department of Public Health, Environments and Society, London School of Hygiene & Tropical Medicine, UK, London, United Kingdom; Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland; Oeschger Center for Climate Change Research, University of Bern, Bern, Switzerland.
    Zanobetti, Antonella
    Department of Environmental Health, Harvard TH Chan School of Public Health, Harvard University, MA, Boston, United States.
    Analitis, Antonis
    Department of Hygiene, Epidemiology and Medical Statistics, National and Kapodistrian University of Athens, Athens, Greece.
    Zeka, Ariana
    Institute for Environment, Health and Societies, Brunel University London, UK, London, United Kingdom.
    Tobias, Aurelio
    Institute of Environmental Assessment and Water Research, Spanish Council for Scientific Research, Barcelona, Spain; School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan.
    Nunes, Baltazar
    Department of Epidemiology, Instituto Nacional de Saúde Dr Ricardo Jorge, Porto, Portugal; Centro de Investigação em Saúde Pública, Escola Nacional de Saúde Pública, Universidade NOVA de Lisboa, Lisbon, Portugal.
    Alahmad, Barrak
    Department of Environmental Health, Harvard TH Chan School of Public Health, Harvard University, MA, Boston, United States.
    Armstrong, Ben
    Department of Public Health, Environments and Society, London School of Hygiene & Tropical Medicine, UK, London, United Kingdom.
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Pan, Shih-Chun
    NationalInstitute of Environmental Health Science, National Health Research Institutes, Zhunan, Taiwan.
    Íñiguez, Carmen
    Department of Statistics and Computational Research, Universitat de València, València, Spain; CIBER of Epidemiology and Public Health, Madrid, Spain.
    Ameling, Caroline
    National Institute for Public Health and the Environment (RIVM), Centre for Sustainability and Environmental Health, Bilthoven, Netherlands.
    De la Cruz Valencia, César
    Department of Environmental Health, National Institute of Public Health, Cuernavaca Morelos, Mexico.
    Åström, Christofer
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Houthuijs, Danny
    National Institute for Public Health and the Environment (RIVM), Centre for Sustainability and Environmental Health, Bilthoven, Netherlands.
    Van Dung, Do
    Department of Environmental Health, Faculty of Public Health, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Viet Nam.
    Royé, Dominic
    CIBER of Epidemiology and Public Health, Madrid, Spain; Department of Geography, University of Santiago de Compostela, Santiago de Compostela, Spain.
    Indermitte, Ene
    Institute of Family Medicine and Public Health, University of Tartu, Tartu, Estonia.
    Lavigne, Eric
    School of Epidemiology & Public Health, Faculty of Medicine, University of Ottawa, ON, Ottawa, Canada; Air Health Science Division, Health Canada, ON, Ottawa, Canada.
    Mayvaneh, Fatemeh
    Faculty of Geography and Environmental Sciences, Hakim Sabzevari University, Sabzevar, Iran.
    Acquaotta, Fiorella
    Department of Earth Sciences, University of Torino, Turin, Italy.
    de'Donato, Francesca
    Department of Epidemiology, Lazio Regional Health Service, Rome, Italy.
    Rao, Shilpa
    Norwegian Institute of Public Health, Oslo, Norway.
    Sera, Francesco
    Department of Statistics, Computer Science and Applications “G Parenti”, University of Florence, Florence, Italy.
    Carrasco-Escobar, Gabriel
    Health Innovation Lab, Institute of Tropical Medicine “Alexander von Humboldt”, Universidad Peruana Cayetano Heredia, Lima, Peru; Scripps Institution of Oceanography, University of California San Diego, CA, La Jolla, United States.
    Kan, Haidong
    Department of Environmental Health, School of Public Health, Fudan University, Shanghai, China.
    Orru, Hans
    Institute of Family Medicine and Public Health, University of Tartu, Tartu, Estonia.
    Kim, Ho
    Graduate School of Public Health, Seoul National University, Seoul, South Korea.
    Holobaca, Iulian-Horia
    Faculty of Geography, Babeş-Bolyai University, Cluj-Napoca, Romania.
    Kyselý, Jan
    Institute of Atmospheric Physics, Czech Academy of Sciences, Prague, Czech Republic; Faculty of Environmental Sciences, Czech University of Life Sciences, Prague, Czech Republic.
    Madureira, Joana
    Environmental Health Department, Instituto Nacional de Saúde Dr Ricardo Jorge, Porto, Portugal; EPIUnit—Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal; Laboratório para a Investigação Integrativa e Translacional em Saúde Populacional (ITR), Porto, Portugal.
    Schwartz, Joel
    Department of Environmental Health, Harvard TH Chan School of Public Health, Harvard University, MA, Boston, United States.
    Jaakkola, Jouni J K
    Center for Environmental and Respiratory Health Research (CERH), University of Oulu, Oulu, Finland; Medical Research Center Oulu (MRC Oulu), Oulu University Hospital and University of Oulu, Oulu, Finland.
    Katsouyanni, Klea
    Department of Hygiene, Epidemiology and Medical Statistics, National and Kapodistrian University of Athens, Athens, Greece; School of Population Health and Environmental Sciences, King's College London, UK, London, United Kingdom.
    Hurtado Diaz, Magali
    Department of Environmental Health, National Institute of Public Health, Cuernavaca Morelos, Mexico.
    Ragettli, Martina S
    Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland.
    Hashizume, Masahiro
    Department of Global Health Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
    Pascal, Mathilde
    Santé Publique France, Department of Environmental and Occupational Health, French National Public Health Agency, Saint Maurice, France.
    de Sousa Zanotti Stagliorio Coélho, Micheline
    Department of Pathology, Faculty of Medicine, University of São Paulo, São Paulo, Brazil.
    Ortega, Nicolás Valdés
    Department of Public Health, Universidad de los Andes, Santiago, Chile.
    Ryti, Niilo
    Center for Environmental and Respiratory Health Research (CERH), University of Oulu, Oulu, Finland; Medical Research Center Oulu (MRC Oulu), Oulu University Hospital and University of Oulu, Oulu, Finland.
    Scovronick, Noah
    Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, GA, Atlanta, United States.
    Michelozzi, Paola
    Department of Epidemiology, Lazio Regional Health Service, Rome, Italy.
    Correa, Patricia Matus
    Department of Public Health, Universidad de los Andes, Santiago, Chile.
    Goodman, Patrick
    School of Physics, Technological University Dublin, Dublin, Ireland.
    Nascimento Saldiva, Paulo Hilario
    INSPER, São Paulo, Brazil.
    Abrutzky, Rosana
    Universidad de Buenos Aires, Facultad de Ciencias Sociales, Instituto de Investigaciones Gino Germani, Buenos Aires, Argentina.
    Osorio, Samuel
    Department of Environmental Health, University of São Paulo, São Paulo, Brazil.
    Dang, Tran Ngoc
    Department of Environmental Health, Faculty of Public Health, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Viet Nam.
    Colistro, Valentina
    Department of Quantitative Methods, School of Medicine, University of the Republic, Montevideo, Uruguay.
    Huber, Veronika
    IBE-Chair of Epidemiology, LMU Munich, Munich, Germany; Department of Physical, Chemical and Natural Systems, Universidad Pablo de Olavide, Sevilla, Spain.
    Lee, Whanhee
    School of the Environment, Yale University, CT, New Haven, United States; Department of Occupational and Environmental Medicine, School of Medicine, Ewha Womans University, Seoul, South Korea.
    Seposo, Xerxes
    School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan.
    Honda, Yasushi
    Center for Climate Change Adaptation, National Institute for Environmental Studies, Tsukuba, Japan.
    Guo, Yue Leon
    NationalInstitute of Environmental Health Science, National Health Research Institutes, Zhunan, Taiwan; Environmental and Occupational Medicine, National Taiwan University College of Medicine and NTU Hospital, National Taiwan University, Taipei, Taiwan; Graduate Institute of Environmental and Occupational Health Sciences, National Taiwan University College of Public Health, National Taiwan University, Taipei, Taiwan.
    Bell, Michelle L
    School of the Environment, Yale University, CT, New Haven, United States.
    Guo, Yuming
    Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, VIC, Melbourne, Australia; Climate, Air Quality Research Unit, School of Public Health and Preventive Medicine, Monash University, VIC, Melbourne, Australia.
    Global, regional, and national burden of mortality associated with short-term temperature variability from 2000–19: a three-stage modelling study2022In: The Lancet Planetary Health, E-ISSN 2542-5196, Vol. 6, no 5, p. e410-e421Article in journal (Refereed)
    Abstract [en]

    Background: Increased mortality risk is associated with short-term temperature variability. However, to our knowledge, there has been no comprehensive assessment of the temperature variability-related mortality burden worldwide. In this study, using data from the MCC Collaborative Research Network, we first explored the association between temperature variability and mortality across 43 countries or regions. Then, to provide a more comprehensive picture of the global burden of mortality associated with temperature variability, global gridded temperature data with a resolution of 0·5° × 0·5° were used to assess the temperature variability-related mortality burden at the global, regional, and national levels. Furthermore, temporal trends in temperature variability-related mortality burden were also explored from 2000–19.

    Methods: In this modelling study, we applied a three-stage meta-analytical approach to assess the global temperature variability-related mortality burden at a spatial resolution of 0·5° × 0·5° from 2000–19. Temperature variability was calculated as the SD of the average of the same and previous days’ minimum and maximum temperatures. We first obtained location-specific temperature variability related-mortality associations based on a daily time series of 750 locations from the Multi-country Multi-city Collaborative Research Network. We subsequently constructed a multivariable meta-regression model with five predictors to estimate grid-specific temperature variability related-mortality associations across the globe. Finally, percentage excess in mortality and excess mortality rate were calculated to quantify the temperature variability-related mortality burden and to further explore its temporal trend over two decades.

    Findings: An increasing trend in temperature variability was identified at the global level from 2000 to 2019. Globally, 1 753 392 deaths (95% CI 1 159 901–2 357 718) were associated with temperature variability per year, accounting for 3·4% (2·2–4·6) of all deaths. Most of Asia, Australia, and New Zealand were observed to have a higher percentage excess in mortality than the global mean. Globally, the percentage excess in mortality increased by about 4·6% (3·7–5·3) per decade. The largest increase occurred in Australia and New Zealand (7·3%, 95% CI 4·3–10·4), followed by Europe (4·4%, 2·2–5·6) and Africa (3·3, 1·9–4·6).

    Interpretation: Globally, a substantial mortality burden was associated with temperature variability, showing geographical heterogeneity and a slightly increasing temporal trend. Our findings could assist in raising public awareness and improving the understanding of the health impacts of temperature variability. Funding: Australian Research Council, Australian National Health & Medical Research Council.

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  • 34.
    Wu, Yao
    et al.
    Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Climate, Air Quality Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
    Wen, Bo
    Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Climate, Air Quality Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
    Li, Shanshan
    Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Climate, Air Quality Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
    Gasparrini, Antonio
    Department of Public Health, Environments, and Society, London School of Hygiene & Tropical Medicine, UK, London, United Kingdom; Centre for Statistical Methodology, London School of Hygiene & Tropical Medicine, UK, London, United Kingdom; Centre on Climate Change & Planetary Health, London School of Hygiene & Tropical Medicine, UK, London, United Kingdom.
    Tong, Shilu
    Shanghai Children's Medical Centre, Shanghai Jiao Tong University, Shanghai, China; School of Public Health, Institute of Environment and Human Health, Anhui Medical University, Hefei, China; Center for Global Health, Nanjing Medical University, Nanjing, China; School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia.
    Overcenco, Ala
    National Agency for Public Health of the Ministry of Health, Labour, and Social Protection of the Republic of Moldova, Moldova.
    Urban, Aleš
    Institute of Atmospheric Physics, Czech Academy of Sciences, Prague, Czech Republic; Faculty of Environmental Sciences, Czech University of Life Sciences, Prague, Czech Republic.
    Schneider, Alexandra
    Institute of Epidemiology, Helmholtz Zentrum München–German Research Center for Environmental Health, Neuherberg, Germany.
    Entezari, Alireza
    Climate, Air Quality Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Faculty of Geography and Environmental Sciences, Hakim Sabzevari University, Sabzevar, Iran.
    Vicedo-Cabrera, Ana Maria
    Department of Public Health, Environments, and Society, London School of Hygiene & Tropical Medicine, UK, London, United Kingdom; Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland; Oeschger Center for Climate Change Research, University of Bern, Bern, Switzerland.
    Zanobetti, Antonella
    Department of Environmental Health, Harvard T.H. Chan School of Public Health, Harvard University, MA, Boston, United States.
    Analitis, Antonis
    Department of Hygiene, Epidemiology and Medical Statistics, National and Kapodistrian University of Athens, Athens, Greece.
    Zeka, Ariana
    Institute for Environment, Health, and Societies, Brunel University London, UK, London, United Kingdom.
    Tobias, Aurelio
    Institute of Environmental Assessment and Water Research, Spanish Council for Scientific Research, Barcelona, Spain; School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan.
    Alahmad, Barrak
    Department of Environmental Health, Harvard T.H. Chan School of Public Health, Harvard University, MA, Boston, United States.
    Armstrong, Ben
    Department of Public Health, Environments, and Society, London School of Hygiene & Tropical Medicine, UK, London, United Kingdom.
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Íñiguez, Carmen
    Department of Statistics and Computational Research, Universitat de València, València, Spain; CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain.
    Ameling, Caroline
    National Institute for Public Health and the Environment (RIVM), Centre for Sustainability and Environmental Health, Bilthoven, Netherlands.
    De la Cruz Valencia, César
    Department of Environmental Health, National Institute of Public Health, Cuernavaca Morelos, Mexico.
    Åström, Christofer
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Houthuijs, Danny
    National Institute for Public Health and the Environment (RIVM), Centre for Sustainability and Environmental Health, Bilthoven, Netherlands.
    Van Dung, Do
    Department of Environmental Health, Faculty of Public Health, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Viet Nam.
    Royé, Dominic
    CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain; Department of Geography, University of Santiago de Compostela, Santiago de Compostela, Spain.
    Indermitte, Ene
    Institute of Family Medicine and Public Health, University of Tartu, Tartu, Estonia.
    Lavigne, Eric
    School of Epidemiology & Public Health, Faculty of Medicine, University of Ottawa, ON, Ottawa, Canada; Air Health Science Division, Health Canada, ON, Ottawa, Canada.
    Mayvaneh, Fatemeh
    Faculty of Geography and Environmental Sciences, Hakim Sabzevari University, Sabzevar, Iran.
    Acquaotta, Fiorella
    Department of Earth Sciences, University of Turin, Turin, Italy.
    de'Donato, Francesca
    Department of Epidemiology, Lazio Regional Health Service, Rome, Italy.
    Sera, Francesco
    Department of Statistics, Computer Science, and Applications “G. Parenti”, University of Florence, Florence, Italy.
    Carrasco-Escobar, Gabriel
    Health Innovation Laboratory, Institute of Tropical Medicine “Alexander von Humboldt”, Universidad Peruana Cayetano Heredia, Lima, Peru; Scripps Institution of Oceanography, University of California San Diego, La Jolla, CA, United States.
    Kan, Haidong
    Department of Environmental Health, School of Public Health, Fudan University, Shanghai, China.
    Orru, Hans
    Institute of Family Medicine and Public Health, University of Tartu, Tartu, Estonia.
    Kim, Ho
    Graduate School of Public Health, Seoul National University, Seoul, South Korea.
    Holobaca, Iulian-Horia
    Faculty of Geography, Babeş-Bolyai University, Cluj-Napoca, Romania.
    Kyselý, Jan
    Institute of Atmospheric Physics, Czech Academy of Sciences, Prague, Czech Republic; Faculty of Environmental Sciences, Czech University of Life Sciences, Prague, Czech Republic.
    Madureira, Joana
    EPIUnit – Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal; Laboratório para a Investigação Integrativa e Translacional em Saúde Populacional (ITR), Porto, Portugal; Environmental Health Department, Instituto Nacional de Saúde Dr. Ricardo Jorge, Porto, Portugal.
    Schwartz, Joel
    Department of Environmental Health, Harvard T.H. Chan School of Public Health, Harvard University, MA, Boston, United States.
    Katsouyanni, Klea
    Department of Hygiene, Epidemiology and Medical Statistics, National and Kapodistrian University of Athens, Athens, Greece; School of Population Health and Environmental Sciences, King's College London, UK, London, United Kingdom.
    Hurtado-Diaz, Magali
    Department of Environmental Health, National Institute of Public Health, Cuernavaca Morelos, Mexico.
    Ragettli, Martina S.
    Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland.
    Hashizume, Masahiro
    Department of Global Health Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
    Pascal, Mathilde
    Santé Publique France, Department of Environmental Health, French National Public Health Agency, Saint Maurice, France.
    de Sousa Zanotti Stagliorio Coélho, Micheline
    Department of Pathology, Faculty of Medicine, University of São Paulo, São Paulo, Brazil.
    Scovronick, Noah
    Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, GA, Atlanta, United States.
    Michelozzi, Paola
    Department of Epidemiology, Lazio Regional Health Service, Rome, Italy.
    Goodman, Patrick
    Technological University Dublin, Dublin, Ireland.
    Nascimento Saldiva, Paulo Hilario
    INSPER, São Paulo, Brazil.
    Abrutzky, Rosana
    Instituto de Investigaciones Gino Germani, Facultad de Ciencias Sociales, Universidad de Buenos Aires, Buenos Aires, Argentina.
    Osorio, Samuel
    Department of Environmental Health, University of São Paulo, São Paulo, Brazil.
    Dang, Tran Ngoc
    Department of Environmental Health, Faculty of Public Health, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Viet Nam.
    Colistro, Valentina
    Department of Quantitative Methods, School of Medicine, University of the Republic, Montevideo, Uruguay.
    Huber, Veronika
    IBE-Chair of Epidemiology, Ludwig Maximilian University Munich, Munich, Germany; Department of Physical, Chemical, and Natural Systems, Universidad Pablo de Olavide, Sevilla, Spain.
    Lee, Whanhee
    School of the Environment, Yale University, CT, New Haven, United States; Department of Occupational and Environmental Medicine, School of Medicine, Ewha Womans University, Seoul, South Korea.
    Seposo, Xerxes
    School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan.
    Honda, Yasushi
    Center for Climate Change Adaptation, National Institute for Environmental Studies, Ibaraki, Tsukuba, Japan.
    Bell, Michelle L.
    School of the Environment, Yale University, CT, New Haven, United States.
    Guo, Yuming
    Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Climate, Air Quality Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
    Fluctuating temperature modifies heat-mortality association around the globe2022In: The Innovation, E-ISSN 2666-6758, Vol. 3, no 2, article id 100225Article in journal (Refereed)
    Abstract [en]

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

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  • 35. Zhao, Qi
    et al.
    Guo, Yuming
    Ye, Tingting
    Gasparrini, Antonio
    Tong, Shilu
    Overcenco, Ala
    Urban, Aleš
    Schneider, Alexandra
    Entezari, Alireza
    Vicedo-Cabrera, Ana Maria
    Zanobetti, Antonella
    Analitis, Antonis
    Zeka, Ariana
    Tobias, Aurelio
    Nunes, Baltazar
    Alahmad, Barrak
    Armstrong, Ben
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Pan, Shih-Chun
    Íñiguez, Carmen
    Ameling, Caroline
    De la Cruz Valencia, César
    Åström, Christofer
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Houthuijs, Danny
    Dung, Do Van
    Royé, Dominic
    Indermitte, Ene
    Lavigne, Eric
    Mayvaneh, Fatemeh
    Acquaotta, Fiorella
    de'Donato, Francesca
    Di Ruscio, Francesco
    Sera, Francesco
    Carrasco-Escobar, Gabriel
    Kan, Haidong
    Orru, Hans
    Institute of Family Medicine and Public Health, University of Tartu, Tartu, Estonia..
    Kim, Ho
    Holobaca, Iulian-Horia
    Kyselý, Jan
    Madureira, Joana
    Schwartz, Joel
    Jaakkola, Jouni J K
    Katsouyanni, Klea
    Hurtado Diaz, Magali
    Ragettli, Martina S
    Hashizume, Masahiro
    Pascal, Mathilde
    de Sousa Zanotti Stagliorio Coélho, Micheline
    Valdés Ortega, Nicolás
    Ryti, Niilo
    Scovronick, Noah
    Michelozzi, Paola
    Matus Correa, Patricia
    Goodman, Patrick
    Nascimento Saldiva, Paulo Hilario
    Abrutzky, Rosana
    Osorio, Samuel
    Rao, Shilpa
    Fratianni, Simona
    Dang, Tran Ngoc
    Colistro, Valentina
    Huber, Veronika
    Lee, Whanhee
    Seposo, Xerxes
    Honda, Yasushi
    Guo, Yue Leon
    Bell, Michelle L
    Li, Shanshan
    Global, regional, and national burden of mortality associated with non-optimal ambient temperatures from 2000 to 2019: a three-stage modelling study2021In: The Lancet Planetary Health, E-ISSN 2542-5196, Vol. 5, no 7, p. e415-e425Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Exposure to cold or hot temperatures is associated with premature deaths. We aimed to evaluate the global, regional, and national mortality burden associated with non-optimal ambient temperatures.

    METHODS: In this modelling study, we collected time-series data on mortality and ambient temperatures from 750 locations in 43 countries and five meta-predictors at a grid size of 0·5° × 0·5° across the globe. A three-stage analysis strategy was used. First, the temperature-mortality association was fitted for each location by use of a time-series regression. Second, a multivariate meta-regression model was built between location-specific estimates and meta-predictors. Finally, the grid-specific temperature-mortality association between 2000 and 2019 was predicted by use of the fitted meta-regression and the grid-specific meta-predictors. Excess deaths due to non-optimal temperatures, the ratio between annual excess deaths and all deaths of a year (the excess death ratio), and the death rate per 100 000 residents were then calculated for each grid across the world. Grids were divided according to regional groupings of the UN Statistics Division.

    FINDINGS: Globally, 5 083 173 deaths (95% empirical CI [eCI] 4 087 967-5 965 520) were associated with non-optimal temperatures per year, accounting for 9·43% (95% eCI 7·58-11·07) of all deaths (8·52% [6·19-10·47] were cold-related and 0·91% [0·56-1·36] were heat-related). There were 74 temperature-related excess deaths per 100 000 residents (95% eCI 60-87). The mortality burden varied geographically. Of all excess deaths, 2 617 322 (51·49%) occurred in Asia. Eastern Europe had the highest heat-related excess death rate and Sub-Saharan Africa had the highest cold-related excess death rate. From 2000-03 to 2016-19, the global cold-related excess death ratio changed by -0·51 percentage points (95% eCI -0·61 to -0·42) and the global heat-related excess death ratio increased by 0·21 percentage points (0·13-0·31), leading to a net reduction in the overall ratio. The largest decline in overall excess death ratio occurred in South-eastern Asia, whereas excess death ratio fluctuated in Southern Asia and Europe.

    INTERPRETATION: Non-optimal temperatures are associated with a substantial mortality burden, which varies spatiotemporally. Our findings will benefit international, national, and local communities in developing preparedness and prevention strategies to reduce weather-related impacts immediately and under climate change scenarios.

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  • 36.
    Åstrom, Christofer
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Rocklöv, Joacim
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Hales, Simon
    Beguin, Andreas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Louis, Valerie
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Sauerborn, Rainer
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Potential Distribution of Dengue Fever Under Scenarios of Climate Change and Economic Development2012In: EcoHealth, ISSN 1612-9202, E-ISSN 1612-9210, Vol. 9, no 4, p. 448-454Article in journal (Refereed)
    Abstract [en]

    Dengue fever is the most important viral vector-borne disease with similar to 50 million cases per year globally. Previous estimates of the potential effect of global climate change on the distribution of vector-borne disease have not incorporated the effect of socioeconomic factors, which may have biased the results. We describe an empirical model of the current geographic distribution of dengue, based on the independent effects of climate and gross domestic product per capita (GDPpc, a proxy for socioeconomic development). We use the model, along with scenario-based projections of future climate, economic development, and population, to estimate populations at risk of dengue in the year 2050. We find that both climate and GDPpc influence the distribution of dengue. If the global climate changes as projected but GDPpc remained constant, the population at risk of dengue is estimated to increase by about 0.28 billion in 2050. However, if both climate and GDPpc change as projected, we estimate a decrease of 0.12 billion in the population at risk of dengue in 2050. Empirically, the geographic distribution of dengue is strongly dependent on both climatic and socioeconomic variables. Under a scenario of constant GDPpc, global climate change results in a modest but important increase in the global population at risk of dengue. Under scenarios of high GDPpc, this adverse effect of climate change is counteracted by the beneficial effect of socioeconomic development.

  • 37.
    Åström, Christofer
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Health effects of heatwaves: short and long term predictions2017Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Background: Climate change is defined by the Intergovernmental Panel on Climate Change as changes in the state of the climate associated with changes in the mean and/or the variability of its properties. Climate change will affect temperatures both as an increase in mean temperature as well as changes in the frequency of temperature extremes. Health effects associated with extreme heat, both mortality and morbidity, have been observed all over the globe. Groups that are often found to be more vulnerable are the elderly and people diagnosed with certain diseases and/or on taking some specific types of medication. The health effects from climate change in the future depend on a number of underlying sociodemographic and other factors. It is difficult to predict how the underlying societal factors that are likely to alter the health effects from high temperatures will change. The aim of this thesis is to investigate the influence of the underlying assumptions and factors that are key components when predicting and projecting heat-related illness, both in the short and long term. This work aims to identify and to some extent quantify different sources of uncertainty that will have effects on the outcome of health impact assessments.

    Methods: We wanted to evaluate if different statistical models would alter the ability to identify days with elevated heat-related risk. We used observations of temperatures and daily mortality for Greater Stockholm to model different exposure-response relationships (Paper I). Along the observed data, we collected temperature forecasts for the Stockholm area. We defined what constitutes a risk day and compared the model’s ability to identify these days using both observed and forecasted temperatures to evaluate the predictive performance of models based on the different statistical approaches. To estimate how climate change will alter the heat-related health impacts we used climate change projections from a range of climate change scenarios to be able to get stable estimates as well as a measure of the uncertainty in the climate projections (Paper II-III). We estimated the change in respiratory hospital admissions (Paper II) and the future need for adaptation to keep heat-related mortality at current levels (Paper III) in Europe. We also estimated the change in heat-related mortality due to changes in climate, demographics and health status of the population in Stockholm (Paper IV).

    Results: The models using a highly complex exposure-response relationship showed lower predictive performance, especially when looking at a longer time-scale. The more complex models did also estimate a lower mortality increase compared to the less complex ones. There was however high agreement of which days to be considered risk days. The estimated increase in heat-related illness from the three health impact assessment studies showed impacts on a similar order of magnitude when looking at changes in climate only. Respiratory hospital admissions were estimated to more than double in Europe and heat-related mortality in Stockholm was estimated to increase to around 257% of current levels. Therefore, adaptation needs to lower the vulnerability to heat by around 50% in the European countries. In study III and IV we take changes in demographics into account and find that the future health burden from heat will increase due to the growing elderly population.

    Conclusion: To be able to make predictions of future health burdens from heat, both in the long and short term, we need to consider the properties of the epidemiological models and how the choice of model might limit its use within a health impact assessment. Climate change seems to be the main driver of the future health burden from extreme temperatures, but our results suggests that changing demographics will add to the burden considerably unless relevant adaptation measures are implemented. Adding this on top of the challenges posed by climate change, we find that need for adaptation will increase substantially in the future.

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  • 38.
    Åström, Christofer
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Bjelkmar, Pär
    Folkhälsomyndighe-ten, Stockholm.
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.
    Ovanligt många dödsfalli Sverige sommaren 2018: drygt 600 kan ha dött till följd av värmeböljan2019In: Läkartidningen, ISSN 0023-7205, E-ISSN 1652-7518, Vol. 116, article id FLFHArticle in journal (Refereed)
  • 39.
    Åström, Christofer
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Ebi, Kristie L
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Langner, Joakim
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Developing a heatwave early warning system for Sweden: evaluating sensitivity of different epidemiological modelling approaches to forecast temperatures2015In: International Journal of Environmental Research and Public Health, ISSN 1661-7827, E-ISSN 1660-4601, Vol. 12, no 1, p. 254-267Article in journal (Refereed)
    Abstract [en]

    Over the last two decades a number of heatwaves have brought the need for heatwave early warning systems (HEWS) to the attention of many European governments. The HEWS in Europe are operating under the assumption that there is a high correlation between observed and forecasted temperatures. We investigated the sensitivity of different temperature mortality relationships when using forecast temperatures. We modelled mortality in Stockholm using observed temperatures and made predictions using forecast temperatures from the European Centre for Medium-range Weather Forecasts to assess the sensitivity. We found that the forecast will alter the expected future risk differently for different temperature mortality relationships. The more complex models seemed more sensitive to inaccurate forecasts. Despite the difference between models, there was a high agreement between models when identifying risk-days. We find that considerations of the accuracy in temperature forecasts should be part of the design of a HEWS. Currently operating HEWS do evaluate their predictive performance; this information should also be part of the evaluation of the epidemiological models that are the foundation in the HEWS. The most accurate description of the relationship between high temperature and mortality might not be the most suitable or practical when incorporated into a HEWS.

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  • 40.
    Åström, Christofer
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Orru, Hans
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine. orru@ut.ee.
    Rocklöv, Joacim
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Strandberg, Gustav
    Rossby Centre, SMHI, Norrköping, Sweden.
    Ebi, Kristie L
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Heat-related respiratory hospital admissions in Europe in a changing climate: a health impact assessment2013In: BMJ Open, E-ISSN 2044-6055, Vol. 3, no 1, p. e001842-Article in journal (Refereed)
    Abstract [en]

    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.                                

     

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    Heat-related respiratory hospital admissions in Europe in a changing climate
  • 41.
    Åström, Christofer
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Oudin Åström, Daniel
    Lund Universitet.
    Andersson, Camilla
    SMHI.
    Ebi, Kristie L.
    University of Washington.
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Future health impact of higher ambient temperatures in Stockholm, SwedenManuscript (preprint) (Other academic)
  • 42.
    Åström, Christofer
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Oudin Åström, Daniel
    Lund Universitet.
    Andersson, Camilla
    SMHI.
    Ebi, Kristie L.
    University of Washington.
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Vulnerability reduction needed to adapt to projected future heat exposure in Europe: Magnitude and determinantsManuscript (preprint) (Other academic)
  • 43.
    Åström, Christofer
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Åström, Daniel Oudin
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine. Department of Clinical Sciences, Malmö, Lund University, Malmö, Sweden.
    Andersson, Camilla
    Ebi, Kristie L
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Vulnerability Reduction Needed to Maintain Current Burdens of Heat-Related Mortality in a Changing Climate-Magnitude and Determinants2017In: International Journal of Environmental Research and Public Health, ISSN 1661-7827, E-ISSN 1660-4601, Vol. 14, no 7, article id 741Article in journal (Refereed)
    Abstract [en]

    The health burden from heatwaves is expected to increase with rising global mean temperatures and more extreme heat events over the coming decades. Health-related effects from extreme heat are more common in elderly populations. The population of Europe is rapidly aging, which will increase the health effects of future temperatures. In this study, we estimate the magnitude of adaptation needed to lower vulnerability to heat in order to prevent an increase in heat-related deaths in the 2050s; this is the Adaptive Risk Reduction (ARR) needed. Temperature projections under Representative Concentration Pathway (RCP) 4.5 and RCP 8.5 from 18 climate models were coupled with gridded population data and exposure-response relationships from a European multi-city study on heat-related mortality. In the 2050s, the ARR for the general population is 53.5%, based on temperature projections under RCP 4.5. For the population above 65 years in Southern Europe, the ARR is projected to be 45.9% in a future with an unchanged climate and 74.7% with climate change under RCP 4.5. The ARRs were higher under RCP 8.5. Whichever emission scenario is followed or population projection assumed, Europe will need to adapt to a great degree to maintain heat-related mortality at present levels, which are themselves unacceptably high, posing an even greater challenge.

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