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Many of the studies that analyze the future impact of climate change on mortality assume that the temperature that constitutes a heat wave will not change over time. This is unlikely, however, given the process of adapting to heat changes, prevention plans, and improvements in social and health infrastructure. The objective of this study is to analyze whether, during the 1983–2013 period, there has been a temporal change in the maximum daily temperatures that constitute a heat wave (T threshold ) in Spain, and to investigate whether there has been variation in the attributable risk (AR) associated with mortality due to high temperatures in this period. This study uses daily mortality data for natural causes except accidents CIEX: A00-R99 in municipalities of over 10,000 inhabitants in 10 Spanish provinces and maximum temperature data from observatories located in province capitals. The time series is divided into three periods: 1983–1992, 1993–2003 and 2004–2013. For each period and each province, the value of T threshold was calculated using scatter-plot diagram of the daily mortality pre-whitened series. For each period and each province capitals, it has been calculated the number of heat waves and quantifying the impact on mortality through generalized linear model (GLM) methodology with the Poisson regression link. These models permits obtained the relative risks (RR) and attributable risks (AR). Via a meta-analysis, using the Global RR and AR were calculated the heat impact for the total of the 10 provinces. The results show that in the first two periods RR remained constant RR: 1.14 (CI95%: 1.09 1.19) and RR: 1.14 (CI95%: 1.10 1.18), while the third period shows a sharp decrease with respect to the prior two periods RR: 1.01 (CI95%: 1.00 1.01); the difference is statistically significant. In Spain there has been a sharp decrease in mortality attributable to heat over the past 10 years. The observed variation in RR puts into question the results of numerous studies that analyze the future impact of heat on mortality in different temporal scenarios and show it to be constant over time. [ABSTRACT FROM AUTHOR]

Spain’s current heat wave prevention plans are activated according to administrative areas. This study analyses the determination of threshold temperatures for triggering prevention-plan activation by reference to isoclimatic areas, and describes the public health benefits. We subdivided the study area – the Madrid Autonomous Region (MAR) – into three, distinct, isoclimatic areas: ‘North’, ‘Central’ and ‘South’, and grouped daily natural-cause mortality (ICD-10: A00-R99) in towns of over 10,000 inhabitants (2000–2009 period) accordingly. Using these three areas rather than the MAR as a whole would have resulted in a possible decrease in mortality of 73 persons (38–108) in the North area, and in aborting unnecessary activation of the plan 153 times in the Central area and 417 times in the South area. Our results indicate that extrapolating this methodology would bring benefits associated with a reduction in attributable mortality and improved effectiveness of public health interventions. [ABSTRACT FROM PUBLISHER]

Background The Low Temperature Days (LTD) have attracted far less attention than that of High Temperature Days (HTD), though its impact on mortality is at least comparable. This lower degree of attention may perhaps be due to the fact that its influence on mortality is less pronounced and longer-term, and that there are other concomitant infectious winters factors. In a climate-change scenario, the studies undertaken to date report differing results. The aim of this study was to analyse mortality attributable to both thermal extremes in Spain's 52 provinces across the period 2000–2009, and estimate the related economic cost to show the benefit or “profitability” of implementing prevention plans against LTD. Methods Previous studies enabled us: to obtain the maximum daily temperature above which HTD occurred and the minimum daily temperature below which LTD occurred in the 52 provincial capitals analysed across the same study period; and to calculate the relative and attributable risks (%) associated with daily mortality in each capital. These measures of association were then used to make different calculations to obtain the daily mean mortality attributable to both thermal extremes. To this end, we obtained a summary of the number of degrees whereby the temperature exceeded (excess °C) or fell short (deficit °C) of the threshold temperature for each capital, and calculated the respective number of extreme temperatures days. The economic estimates rated the prevention plans as being 68% effective. Results Over the period considered, the number of HTD (4373) was higher than the number of LTD (3006) for Spain as a whole. Notwithstanding this, in every provincial capital the mean daily mortality attributable to heat was lower (3 deaths/day) than that attributable to cold (3.48 deaths/day). In terms of the economic impact of the activation of prevention plans against LTD, these could be assumed to avoid 2.37 deaths on each LTD, which translated as a saving of €0.29M. Similarly, in the case of heat, 2.04 deaths could be assumed to be avoided each day on which the prevention plan against HTD was activated, amounting to a saving of €0.25M. While the economic cost of cold-related mortality across the ten-year period 2000–2009 was €871.7M, that attributable to heat could be put at €1093.2M. Conclusion The effect of extreme temperatures on daily mortality was similar across the study period for Spain overall. The lower number of days with LTD meant, however, that daily cold-related mortality was higher than daily heat-related mortality, thereby making prevention plans against LTD more “profitable” prevention plans against HTD in terms of avoidable mortality. [ABSTRACT FROM AUTHOR]

In general, there are few studies that analyse the impact of low temperatures on mortality and fewer still that use cold-wave-definition thresholds based on epidemiological and non-climatological criteria. Such a threshold definition, which took into account population features such as socio-economic and demographic characteristics, made it possible for a specific threshold temperature to be obtained for each of Spain's 52 provincial capitals in this study. Using generalised linear models with the Poisson regression link, and controlling for trend, autocorrelations and seasonalities of the series, and influenza epidemics, we obtained the impact of low temperatures on mortality in each provincial capital by calculating the relative risks (RRs) and attributable risks (ARs) for natural as well as circulatory and respiratory causes. The study showed higher minimum temperature thresholds in coastal areas, and an overall impact of cold on mortality in Spain due to natural causes RR = 1.13 (95% CI: 1.11–1.16), circulatory causes RR = 1.18 (95% CI: 1.15–1.22) and respiratory causes RR = 1.24 (95% CI: 1.20–1.29) slightly greater than that obtained to date for heat. From a public health standpoint, there is a need for specific cold wave prevention plans at a regional level which would enable mortality attributable to low temperatures to be reduced. These plans have shown themselves to be effective in decreasing heat-related mortality, and we feel that they are essential for reducing cold-related effects on morbidity and mortality. [ABSTRACT FROM AUTHOR]

A decade after the implementation of prevention plans designed to minimise the impact of high temperatures on health, some countries have decided to update these plans in order to improve the weakness detected in these ten years of operation. In the case of Spain, this update has fundamentally consisted of changing the so-called “threshold” or “trigger” temperatures used to activate the plan, by switching from temperature values based on climatological criteria to others obtained by epidemiological studies conducted on a provincial scale. This study reports the results of these “trigger” temperatures for each of Spain's 52 provincial capitals, as well as the impact of heat on mortality by reference to the relative risks (RRs) and attributable risks (ARs) calculated for natural as well as circulatory and respiratory causes. The results obtained for threshold temperatures and RRs show a more uniform behaviour pattern than those obtained using temperature values based on climatological criteria; plus a clear decrease in RRs of heat-associated mortality due to the three causes considered, at both a provincial and regional level as well as for Spain as a whole. The updating of prevention plans is regarded as crucial for optimising the operation of these plans in terms of reducing the effect of high temperatures on population health. [ABSTRACT FROM AUTHOR]

A number of studies have shown that there is a time trend towards a reduction in the effects of heat on mortality. In the case of cold, however, there is practically no research of this type and so there is no clearly defined time trend of the impact of cold on mortality. Furthermore, no other specific studies have yet analysed the time trend of the impact of both thermal extremes by age group. We analysed data on daily mortality due to natural causes (ICD-10: A00-R99) in the city of Madrid across the period 2001–2009 and calculated the impact of extreme temperatures on mortality using Poisson regression models for specific age groups. The groups of age selected coinciding with the pre-existing age-groups analyzed in previous papers. For heat waves the groups of age used were: <10 years, 10–17 years, 18–44 years, 45–64 years, 65–74 years and over-75 years. For cold waves the groups of age used were: <1 year; 1–5 years, 6–17 years, 18–44 years, 45–64 years, 65–74 years and over-75 years. <1, 1–17, 18–44, 45–66, 65–74 and over-75 years. We controlled for confounding variables, such as air pollution, noise, influenza, pollen, pressure and relative humidity, trend of the series, as well as seasonalities and autoregressive components of the series. The results of these models were compared to those obtained for the same city during the period 1986–1997 and published in different studies. Our results show a lightly reduction in the effects of heat, especially in the over-45-year age group. In the case of cold, the behaviour pattern was the opposite, with an increase in its effect. Heat adaptation and socio-economic and public-health prevention and action measures may be behind this amelioration in the effects of heat, whereas the absence of such actions in respect of low temperatures may account for the increase in the effects of cold on mortality. From a public health point of view, the implementation of cold wave prevention plans covering all age groups is thus called for. [ABSTRACT FROM AUTHOR]

In recent years, a number of studies have been conducted with the aim of analysing the impact that high temperatures will have on mortality over different time horizons under different climate scenarios. Very few of these studies take into account the fact that the threshold temperature used to define a heat wave will vary over time, and there are practically none which calculate this threshold temperature for each geographical area on the assumption that there will be variations at a country level. To analyse the impact that high temperatures will have on mortality across the periods 2021–2050 and 2051–2100 under a high-emission climate scenario (RCP8.5), in a case: (a) where adaptation processes are not taken into account; and (b) where complete adaptation processes are taken into account. Based on heat-wave definition temperature (T threshold) values previously calculated for the reference period, 2000–2009, for each Spanish provincial capital, and their impact on daily mortality as measured by population attributable risk (PAR), the impact of high temperatures on mortality will be calculated for the above-mentioned future periods. Two hypotheses will be considered, namely: (a) that T threshold does not vary over time (scenario without adaptation to heat); and, (b) that T threshold does vary over time, with the percentile to which said T threshold corresponds being assumed to remain constant (complete adaptation to heat). The temperature data were sourced from projections generated by Coupled Model Intercomparison Project (CMIP5) climate models adapted to each region's local characteristics by the State Meteorological Agency (Agencia Estatal de Meteorología/AEMET). Population-growth projections were obtained from the National Statistics Institute (Instituto Nacional de Estadística/INE). In addition, an economic estimate of the resulting impact will be drawn up. The mean value of maximum daily temperatures will rise, in relation to those of the reference period (2000–2009), by 1.6⁰C across the period 2021–2050 and by 3.3⁰C across the period 2051–2100. In a case where there is no heat-adaptation process, overall annual mortality attributable to high temperatures in Spain would amount to 1414 deaths/year (95% CI: 1089–1771) in the period 2021–2050, rising to 12,896 deaths/year (95% CI: 9852–15,976) in the period 2051–2100. In a case where there is a heat-adaptation process, annual mortality would be 651 deaths/year (95% CI: 500–807) in the period 2021–2050, and 931 deaths per year (95% CI: 770–1081) in the period 2051–2100. These results display a high degree of heterogeneity. The savings between a situation that does envisage and one that does not envisage an adaptive process is €49,100 million/year over the 2051–2100 time horizon. A non-linear increase in maximum daily temperatures was observed, which varies widely from some regions to others, with an increase in mean values for Spain as a whole that is not linear over time. The high degree of heterogeneity found in heat-related mortality by region and the great differences observed on considering an adaptive versus a non-adaptive process render it necessary for adaptation plans to be implemented at a regional level. • In 2050–2100 the mean of the maximum temperatures in Spain will increase at a rate of 0.66 ºC / decade. • Without adaptation, the annual mortality by heat in 2050–2100 will be 12,900 deaths / year. • With complete adaptation the mortality attributable to heat would be 1400 deaths / year. • The economic cost of not adapting to full adaptation would amount to 49,100 million / year. [ABSTRACT FROM AUTHOR]

In general, there are few studies that analyse the impact of low temperatures on mortality, and even fewer that extend this analysis to specific causes of mortality. This study had a twofold aim: Firstly, to analyse the trend in natural-, circulatory- and respiratory-cause mortality associated with cold waves in Castile-La Mancha (Spain) across a period of analysis of 34 years, which would confer an important degree of temporal representativeness on the results obtained; and secondly, to ascertain whether this impact had decreased over the years. Time series analysis using multivariate ARIMA models with data on daily natural-, circulatory- and respiratory-cause mortality in Castile-La Mancha. The independent variables were minimum daily temperature, mean daily pressure and mean daily relative humidity. We controlled for seasonalities and trend of the series, as well as influenza epidemics, cold-wave duration and chronological number in any given year. Data were stratified in three ten-year stages, i.e., 1975-1985, 1986-1996 and 1997-2008. The mortality trigger temperature was set at a minimum daily temperature of −2 °C, corresponding to the 4th ‰ of the minimum temperature series for the winter months considered. The impact on daily natural-cause mortality for each degree that the minimum daily temperature was below −2 °C was: 10.4 % (95 % CI 9.6-11.2) in the first decade; 11.9 % (95 % CI 11.0-12.8) in the second decade; and fell to 1.6 % (95 % CI 0.9-2.3) in the third. This same pattern was observed for circulatory- and respiratory-cause mortality, with the effect of cold being greater for respiratory causes. Socio-economic factors -both of adaptation and demographic- could account for this sharp decrease in mortality associated with low temperatures. These results question climate models which predict the effects of cold over long-term time horizons, while maintaining the risk attributable to low temperatures constant. Studies similar to ours should be undertaken in other regions to confirm whether it is solely local characteristics that explain this pattern or, on the contrary, whether the pattern is generalised. [ABSTRACT FROM AUTHOR]

Few studies have analysed the impact of heat and cold waves on mortality in a given population over the same time period and still fewer studies have analysed this impact in terms of cause-specific mortality. This study analysed the impact of both heat and cold waves on daily all-cause, circulatory-cause and respiratory-cause mortality in the region of Castile-La Mancha (CLM) 1975-2008. The dependent variable was daily all-, circulatory- and respiratory-cause mortality registered in CLM from 01-01-75 to 31-12-08, and the independent variables were maximum, minimum, mean daily temperature daily relative humidity and mean daily air pressure and other related variables, such as heat-wave duration, heat-wave number and pressure trend. Time-series analyses were performed using autoregressive integrated moving average models. The impact of heat on daily mortality was greater than that of cold, with a difference which proved statistically significant for all- and circulatory-cause mortality but not for respiratory-cause mortality. While 16.5 % CI 95 % (15.5-17.4) of summer mortality in CLM was attributable to heat, 12.9 % CI 95 % (12.2-13.8) of daily winter mortality was attributable to low temperatures. The variable, heat-wave duration, was of major importance in all-cause and respiratory-cause mortality, with wave persistence being related to a mean 3.5 % increase in daily organic-cause mortality. Although heat waves have a greater impact on daily mortality than do cold waves, the fact that there were more cold-wave than heat-wave days during the period analysed, coupled with the diseases implicated, means that specific prevention plans should be implemented for both extreme thermal events. [ABSTRACT FROM AUTHOR]

Global warming is resulting in an increase in temperatures which is set to become more marked by the end of the century and depends on the accelerating pace of greenhouse gas emissions into the atmosphere. Yet even in this scenario, so-called "cold waves" will continue to be generated and have an impact on health. This study sought to analyse the impact of cold waves on daily mortality at a provincial level in Spain over the 2021–2050 and 2051–2100 time horizons under RCP4.5 and RCP 8.5 emission scenarios, on the basis of two hypotheses: (1) that the cold-wave definition temperature (T threshold) would not vary over time; and, (2) that there would be a variation in T threshold. The results of a retrospective study undertaken for Spain as a whole across the period 2000–2009 enabled us to ascertain the cold-wave definition temperature at a provincial level and its impact on health, measured by reference to population attributable risk (PAR). The minimum daily temperatures projected for each provincial capital considering the above time horizons and emission scenarios were provided by the State Meteorological Agency. On the basis of the T threshold definition values and minimum daily temperatures projected for each province, we calculated the expected impact of low temperatures on mortality under the above two hypotheses. Keeping the PAR values constant, it was assumed that the mortality rate would vary in accordance with the available data. If T threshold remained constant over the above time horizons under both emission scenarios, there would be no cold-related mortality. If T threshold were assumed to vary over time, however, then cold-related mortality would not disappear: it would instead remain practically constant over time and give rise to an estimated overall figure of around 250 deaths per year, equivalent to close on a quarter of Spain's current annual cold-related mortality and entailing a cost of approximately €1000 million per year. Given that cold waves are not going to disappear and that their impact on mortality is far from negligible and is likely to remain so, public health prevention measures must be implemented to minimise these effects as far as possible. • If the coldwave definition temperature remain constant mortality associated not occur. • Mortality from cold-waves in the future will be reduced respect to 2000–2009 in Spain. • Important regional differences exist in Spain in relation to cold-waves impact. • Regional approach will be highly useful in implement regional cold prevention plans. [ABSTRACT FROM AUTHOR]