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Objectives: to estimate the impact of daily exposure to extreme air temperatures (heat and cold) on cause-specific mortality in Italy and to evaluate the differences in the association between urban, suburban and rural municipalities., Design: time series analyses with two-stage approach were applied: in the first stage, multiple Poisson regression models and distributed lag non-linear models (DLNM) were used to define the association between temperature and mortality; in the second one, meta-analytic results were obtained by adopting BLUP (Best Linear Unbiased Prediction) coefficients at provincial level, which were then used to estimate the Attributable Fractions of cause-specific deaths., Setting and Participants: cause-specific deaths from 2006to 2015 in Italy have been analysed by region and overall., Main Outcome Measures: 5,648,299 total deaths included. Fractions (and relative 95% empirical confidence interval) of deaths attributable to increases from 75th to 99th percentiles of temperature, for heat, and decreases from 25th to 1st percentile, for cold., Results: the overall impact of air temperature on causespecificmortality is higher for heat than for cold. When considering heat, the attributable fraction is higher for diseases of the central nervous system (3.6% 95% CI 1.9-4.9) and mental health disease (3.1% 95% CI 1.7-4.4), while considering cold, ischemic disease (1.3% 95% CI 1.1-1.6) and diabetes (1.3% 95% CI 0.7-1.8) showed the greater impact. By urbanization level, similar impacts were found for cold temperature, while for heat there was an indication of higher vulnerability in rural areas emerged., Conclusions: results are relevant for the implementation and promotion of preventive measures according to climate change related increase in temperature. The available evidence can provide the basis to identify vulnerable areas and population subgroups to which address current and future heat and cold adaptation plans in Italy.

Air temperature has been the most commonly used exposure metric in assessing relationships between thermal stress and mortality. Lack of the high-quality meteorological station data necessary to adequately characterize the thermal environment has been one of the main limitations for the use of more complex thermal indices. Global climate reanalyses may provide an ideal platform to overcome this limitation and define complex heat and cold stress conditions anywhere in the world. In this study, we explored the potential of the Universal Thermal Climate Index (UTCI) based on ERA5 - the latest global climate reanalysis from the European Centre for Medium-Range Weather Forecasts (ECMWF) - as a health-related tool. Employing a novel ERA5-based thermal comfort dataset ERA5-HEAT, we investigated the relationships between the UTCI and daily mortality data in 21 cities across 9 European countries. We used distributed lag nonlinear models to assess exposure-response relationships between mortality and thermal conditions in individual cities. We then employed meta-regression models to pool the results for each city into four groups according to climate zone. To evaluate the performance of ERA5-based UTCI, we compared its effects on mortality with those for the station-based UTCI data. In order to assess the additional effect of the UTCI, the performance of ERA5-and station-based air temperature (T) was evaluated. Whilst generally similar heat- and cold-effects were observed for the ERA5-and station-based data in most locations, the important role of wind in the UTCI appeared in the results. The largest difference between any two datasets was found in the Southern European group of cities, where the relative risk of mortality at the 1st percentile of daily mean temperature distribution (1.29 and 1.30 according to the ERA5 vs station data, respectively) considerably exceeded the one for the daily mean UTCI (1.19 vs 1.22). These differences were mainly due to the effect of wind in the cold tail of the UTCI distribution. The comparison of exposure-response relationships between ERA5-and station-based data shows that ERA5-based UTCI may be a useful tool for definition of life-threatening thermal conditions in locations where high-quality station data are not available., (Copyright © 2021 The Author(s). Published by Elsevier Inc. All rights reserved.)

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 (PM 10 ), 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 PM 10 was significant for cardiovascular (CVD) causes of death for all ages (2.24% on low PM 10 days (95% CI 1.01, 3.47) whilst it is 2.63% (95% CI 1.57, 3.71) on high PM 10 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 PM 10 was found, but no consistent synergy could be identified during the cold season.

This study evaluates the impact of the 2003 heat wave on cause-specific mortality and the role of demographic characteristics and socioeconomic conditions that may have increased the risk of mortality in four Italian cities: Bologna, Milan, Rome and Turin. Daily mortality counts, for the resident population by age, sex and cause of death were considered. Daily excess mortality was calculated as the difference between the number of deaths observed and the smoothed average. The impact of heat on health is measured in terms of maximum apparent temperature. The greatest excess in mortality was observed in the north west of Italy (Turin, +23% and Milan, +23%). The old (75-84 years) and the very old (85+ years) were the age groups most affected, and when stratifying by sex, the increase in mortality seemed to be greater among females. The greatest excess in mortality was registered in those with low socioeconomic status in Rome (+17.8%) and in those with lower education levels in Turin (+43%). The analysis of cause-specific mortality not only confirms results from previous studies of an increase in heat-related mortality by respiratory and cardiovascular diseases, but also shows a significant excess in mortality for diseases of the central nervous system and for metabolic/endocrine disorders. Results from 2003 highlight the necessity of targeting future prevention programmes at the susceptible sub-groups identified. The introduction of warning systems alongside efficient preventive plans and the monitoring of mortality during heat waves may represent a valid tool for the reduction of heat-related deaths.