Background Climate change driven by human activities has increased annual temperatures in Spain by around 1°C since 1980. However, little is known regarding the extent to which the association between temperature and mortality has changed among the most susceptible population groups as a result of the rapidly warming climate. We aimed to assess trends in temperature-related cardiovascular disease mortality in Spain by sex and age, and we investigated the association between climate warming and changes in the risk of mortality. MethodsWe did a country-wide time-series analysis of 48 provinces in mainland Spain and the Balearic Islands between Jan 1, 1980, and Dec 31, 2016. We extracted daily cardiovascular disease mortality data disaggregated by sex, age, and province from the Spanish National Institute of Statistics database. We also extracted daily mean temperatures from the European Climate Assessment and Dataset project. We applied a quasi-Poisson regression model for each province, controlling for seasonal and long-term trends, to estimate the temporal changes in the province-specific temperaturemortality associations with distributed lag non-linear models. We did a multivariate random-effects meta-analysis to derive the best linear unbiased prediction of the temperature-mortality association and the minimum mortality temperature in each province. Heat-attributable and cold-attributable fractions of death were computed by separating the contributions from days with temperatures warmer and colder than the minimum mortality temperature, respectively.Findings Between 1980 and 2016, 4 576 600 cardiovascular deaths were recorded. For warm temperatures, the increase in relative risk (RR) of death from cardiovascular diseases was higher for women than men and higher for older individuals (aged ≥90 years) than younger individuals (aged 60-74 years), whereas for cold temperatures, RRs were higher for men than women, with no clear pattern by age group. The heat-attributable fraction of cardiovascular deaths was higher for women in all age groups, and the cold-attributable fraction was larger in men. The heat-attributable fraction increased with age for both sexes, whereas the cold-attributable fraction increased with age for men and decreased for women. Overall minimum mortality temperature increased from 19•5°C between 1980 and 1994 to 20•2°C between 2002 and 2016, which is similar in magnitude to, and occurred in parallel with, the observed mean increase of 0•77°C that occurred in Spain between these two time periods. In general, between 1980 and 2016, the risk and attributable fraction of cardiovascular deaths due to warm and cold temperatures decreased for men and women across all age groups. For all the age groups combined, between 1980-94 and 2002-16, the heat-attributable fraction decreased by -42•06% (95% empirical CI -44•39 to -41•06) for men and -36•64% (-36•70 to -36•04) for women, whereas the cold-attributable fraction was reduced by -30•23% (-30•34 to -30•05) for men and -44•87% (-46•77 to -42•94) for wome...

Over 70,000 excess deaths occurred in Europe during the summer of 2003. The resulting societal awareness led to the design and implementation of adaptation strategies to protect at-risk populations. We aimed to quantify heat-related mortality burden during the summer of 2022, the hottest season on record in Europe. We analyzed the Eurostat mortality database, which includes 45,184,044 counts of death from 823 contiguous regions in 35 European countries, representing the whole population of over 543 million people. We estimated 61,672 (95% confidence interval (CI) = 37,643–86,807) heat-related deaths in Europe between 30 May and 4 September 2022. Italy (18,010 deaths; 95% CI = 13,793–22,225), Spain (11,324; 95% CI = 7,908–14,880) and Germany (8,173; 95% CI = 5,374–11,018) had the highest summer heat-related mortality numbers, while Italy (295 deaths per million, 95% CI = 226–364), Greece (280, 95% CI = 201–355), Spain (237, 95% CI = 166–312) and Portugal (211, 95% CI = 162–255) had the highest heat-related mortality rates. Relative to population, we estimated 56% more heat-related deaths in women than men, with higher rates in men aged 0–64 (+41%) and 65–79 (+14%) years, and in women aged 80+ years (+27%). Our results call for a reevaluation and strengthening of existing heat surveillance platforms, prevention plans and long-term adaptation strategies.

BackgroundAnthropogenic greenhouse gas emissions have increased summer temperatures in Spain by nearly one degree Celsius on average between 1980 and 2015. However, little is known about the extent to which the association between heat and human mortality has been modified. We here investigate whether the observed warming has been associated with an upward trend in excess mortality attributable to heat or, on the contrary, a decrease in the vulnerability to heat has contributed to a reduction of the mortality burden.Methods and findingsWe analysed a dataset from 47 major cities in Spain for the summer months between 1980 and 2015, which included daily temperatures and 554,491 deaths from circulatory and respiratory causes, by sex. We applied standard quasi-Poisson regression models, controlling for seasonality and long-term trends, and estimated the temporal variation in heat-related mortality with time-varying distributed lag nonlinear models (DLNMs). Results pointed to a reduction in the relative risks of cause-specific and cause-sex mortality across the whole range of summer temperatures. These reductions in turn explained the observed downward trends in heat-attributable deaths, with the only exceptions of respiratory diseases for women and both sexes together. The heat-attributable deaths were consistently higher in women than in men for both circulatory and respiratory causes. The main limitation of our study is that we were not able to account for air pollution in the models because of data unavailability.ConclusionsDespite the summer warming observed in Spain between 1980 and 2015, the decline in the vulnerability of the population has contributed to a general downward trend in overall heat-attributable mortality. This reduction occurred in parallel with a decline in the vulnerability difference between men and women for circulatory and cardiorespiratory mortality. Despite these advances, the risk of death remained high for respiratory diseases, and particularly in women.

Background Europe has emerged as a major climate change hotspot, both in terms of an increase in seasonal averages and climate extremes. Projections of temperature-attributable mortality, however, have not been comprehensively reported for an extensive part of the continent. Therefore, we aim to estimate the future effect of climate change on temperature-attributable mortality across Europe. MethodsWe did a time series analysis study. We derived temperature-mortality associations by collecting daily temperature and all-cause mortality records of both urban and rural areas for the observational period between 1998 and 2012 from 147 regions in 16 European countries. We estimated the location-specific temperature-mortality relationships by using standard time series quasi-Poisson regression in conjunction with a distributed lag non-linear model. These associations were used to transform the daily temperature simulations from the climate models in the historical period and scenario period (2006-2099) into projections of temperature-attributable mortality. We combined the resulting risk functions with daily time series of future temperatures simulated by four climate models (ie, GFDL-ESM2M, HadGEM2-ES, IPSL-CM5A-LR, and MIROC5) under three greenhouse gas emission scenarios (ie, Representative Concentration Pathway [RCP]2.6, RCP6.0, and RCP8.5), providing projections of future mortality attributable fraction due to moderate and extreme cold and heat temperatures.Findings Overall, 7•17% (95% CI 5•81-8•50) of deaths registered in the observational period were attributed to nonoptimal temperatures, cold being more harmful than heat by a factor of ten (6•51% [95% CI 5•14-7•80] vs 0•65% [0•40-0•89]), and with large regional differences across countries-eg, ranging from 4•85% (95% CI 3•75-6•00) in Germany to 9•87% (8•53-11•19) in Italy. The projection of temperature anomalies by RCP scenario depicts a progressive increase in temperatures, more exacerbated in the high-emission scenario RCP8.5 (4•54°C by 2070-2099) than in RCP6.0 (2•89°C) and RCP2.6 (1•67°C). This increase in temperatures was transformed into attributable fraction. Projections consistently indicated that the increase in heat attributable fraction will start to exceed the reduction of cold attributable fraction in the second half of the 21st century, especially in the Mediterranean and in the higher emission scenarios. The comparison between scenarios highlighted the important role of mitigation, given that the total attributable fraction will only remain stable in RCP2.6, whereas the total attributable fraction will rapidly start to increase in RCP6.0 by the end of the century and in RCP8.5 already by the middle of the century. InterpretationThe increase in heat attributable fraction will start to exceed the reduction of cold attributable fraction in the second half of the 21st century. This finding highlights the importance of implementing mitigation policies. These measures would be especially beneficial in the Mediterranean, where the high vulnerability to...

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A growing number of epidemiological studies have recently assessed temporal variations in vulnerability and/or mortality attributable to hot and cold temperatures. However, the eventual changes in the seasonal distribution of temperature-attributable mortality remain unexplored. Here, we analyse countrywide daily time-series of temperature and mortality counts from respiratory diseases by sex, age group and province of residence during the period 1980-2016 in Spain. We show the complete reversal of the seasonality of temperature-attributable mortality, with a significant shift of the maximum monthly incidence from winter to summer, and the minimum monthly incidence from early and late summer to winter. The reversal in the seasonal distribution of the attributable deaths is not driven by the observed warming in both winter and summer temperatures, but rather by the very large decrease in the risk of death due to cold temperatures and the relatively much smaller reduction due to hot temperatures. We conclude that the projected decrease in the number of moderate and extreme cold days due to climate warming will not contribute to a further reduction of cold-attributable respiratory deaths.

The emergence of the COVID-19 pandemic forced most countries to put in place lockdown measures to slow down the transmission of the virus. These lockdowns have led to temporal improvements in air quality. Here, we evaluate the changes in NO2 and O3 levels along with the associated impact upon premature mortality during the COVID-19 lockdown and deconfinement periods along the first epidemic wave across the provincial capital cities of Spain. We first quantify the change in pollutants solely due to the lockdown as the difference between business-as-usual (BAU) pollution levels, estimated with a machine learning-based meteorological normalization technique, and observed concentrations. Second, instead of using exposure-response functions between the pollutants and mortality reported in the literature, we fit conditional quasi-Poisson regression models to estimate city-specific associations between daily pollutant levels and non-accidental mortality during the period 2010-2018. Significant relative risk values are observed at lag 1 for NO2 (1.0047 [95% CI: 1.0014 to 1.0081]) and at lag 0 for O3 (1.0039 [1.0013 to 1.0065]). On average NO2 changed by -51% (intercity range -65.7 to -30.9%) and -36.4% (-53.7 to -11.6%), and O3 by -1.1% (-20.2 to 23.8%) and 0.6% (-12.4 to 23.0%), during the lockdown (57 days) and deconfinement (42 days) periods, respectively. We obtain a reduction in attributable mortality associated with NO2 changes of -119 (95% CI: -273 to -24) deaths over the lockdown, and of -53 (-114 to -10) deaths over the deconfinement. This was partially compensated by an increase in the attributable number of deaths, 14 (-72 to 99) during the lockdown, and 8 (-27 to 50) during the deconfinement, associated with the rise in O3 levels in the most populous cities during the analysed period, despite the overall small average reductions. Our study shows that the potential trade-offs between multiple air pollutants should be taken into account when evaluating the health impacts of environmental exposures.

<p>The mobility restrictions implemented to slow down the transmission of the new coronavirus disease (COVID-19) drastically altered Spanish anthropogenic emissions in several sectors, leading to substantial impacts on air pollutant concentrations. In order to reliably quantify these changes, the confounding effects of meteorological variability need to be properly taken into account. We thus designed an innovative methodology relying on the use of machine learning (ML) models fed with ERA5 meteorological reanalysis data and other time features, to estimate more accurately the so-called business-as-usual (BAU) pollutant concentrations that would have been observed in the absence of lockdown (Petetin et al., 2020). The difference with concentrations actually observed during the lockdown give meteorology-normalized estimates of the AQ changes due to the altered anthropogenic emission forcing, independently from the meteorological variability. Importantly, our methodology includes a conservative estimation of the uncertainties, which allows to highlight statistically significant changes. This study focuses on NO2 and O3. We applied this analysis for a selection of urban background and traffic stations covering more than 50 Spanish provinces and islands. Validation results indicate that the method usually performs well for estimating BAU concentrations (mean absolute bias below +6%, root mean square error around 25-30% and correlation above 0.80).</p><p>The COVID-19-related lockdown has induced a strong reduction (-50% on average) of NO2 concentrations in Spanish urban areas, although with some spatial variability among the provinces. In largest cities, stronger reductions were found at traffic stations compared to urban background ones, reflecting the major impact of the lockdown on traffic emissions. Substantial discrepancies with changes obtained considering a climatological averaged NO2 concentrations were found, highlighting the interest of such ML-based weather-normalization method. Compared to NO2, the impact on O3 is lower and more heterogeneous. In many cities, O3 levels slightly increased (likely due to a reduced titration by NO), but these increments often remain within the (95% confidence level) uncertainties of our methodology. However, during the most stringent phase of the lockdown (beginning of April and the few following days), a clearer O3 increase is found, reaching the statistical significance in several Spanish cities (e.g. Albacete, Barcelona, Castellón, Mallorca, Murcia, Málaga).</p><p>These results are of strong interest for quantifying the corresponding health impacts of these AQ changes, especially for showing the potential trade-offs between health benefits induced by the reduction of NO2 and enhanced mortality due to higher O3.</p><p>Petetin, H., Bowdalo, D., Soret, A., Guevara, M., Jorba, O., Serradell, K., and Pérez García-Pando, C.: Meteorology-normalized impact of the COVID-19 lockdown upon NO<sub>2</sub> pollution in Spain, Atmos. Chem. Phys., 20, 11119–11141, https://doi.org/10.5194/acp-20-11119-2020, 2020.</p>