Karine Laaidi

Has the impact of heat waves on mortality changed in France since the European heat wave of summer 2003? A study of the 2006 heat wave

BACKGROUND In July 2006, a lasting and severe heat wave occurred in Western Europe. Since the 2003 heat wave, several preventive measures and an alert system aiming at reducing the risks related to high temperatures have been set up in France by the health authorities and institutions. In order to evaluate the effectiveness of those measures, the observed excess mortality during the 2006 heat wave was compared to the expected excess mortality. METHODS A Poisson regression model relating the daily fluctuations in summer temperature and mortality in France from 1975 to 2003 was used to estimate the daily expected number of deaths over the period 2004-2006 as a function of the observed temperatures. RESULTS During the 2006 heat wave (from 11 to 28 July), about 2065 excess deaths occurred in France. Considering the observed temperatures and with the hypothesis that heat-related mortality had not changed since 2003, 6452 excess deaths were predicted for the period. The observed mortality during the 2006 heat wave was thus markedly less than the expected mortality (approximately 4400 less deaths). CONCLUSIONS The excess mortality during the 2006 heat wave, which was markedly lower than that predicted by the model, may be interpreted as a decrease in the populations vulnerability to heat, together with, since 2003, increased awareness of the risk related to extreme temperatures, preventive measures and the set-up of the warning system.

The impact of heat islands on mortality in Paris during the August 2003 heat wave.

Background: Heat waves have a drastic impact on urban populations, which could increase with climate change. Objectives: We evaluated new indicators of elderly people’s exposure to heat in Paris, from a public health prevention perspective, using satellite thermal images. Methods: We used a time series of 61 images from the satellites of the National Oceanic and Atmospheric Administration’s (NOAA) Advanced Very High Resolution Radiometer (AVHRR) taken from 1 to 13 August 2003 to produce thermal indicators of minimum, maximum, and mean surface temperatures and diurnal temperature amplitude, with different lags between the meteorological data and the health impact. Health data came from a case–control study involving 241 people ≥ 65 years of age who died in the city of Paris or the nearby suburban area of Val-de-Marne during the August 2003 heat wave, and 241 controls who were matched to cases on age, sex, and residential zone. For each person, we integrated the thermal indicators in a conditional logistic regression model, adjusted for age and other potential confounders. We computed odds ratios (ORs) comparing the 90th and 50th percentiles of the temperature differences between cases and controls for various indicators. Results: Mortality risk was significantly associated with exposure for two indicators: minimum temperatures averaged for 1–13 August [for a 0.41°C increase, OR = 2.17; 95% confidence interval (CI): 1.14, 4.16] and minimum temperature averaged on the day of death and the 6 preceding days (for a 0.51°C increase: OR = 2.24; 95% CI: 1.03, 4.87). Conclusions: Our results support the influence of night temperatures on the health impact of heat waves in urban areas. Urban heat exposure indicators based on satellite imagery have the potential to identify areas with higher risk of death, which could inform intervention decisions by key stakeholders.

Heat-health warning systems: a comparison of the predictive capacity of different approaches to identifying dangerously hot days.

OBJECTIVES We compared the ability of several heat-health warning systems to predict days of heat-associated mortality using common data sets. METHODS Heat-health warning systems initiate emergency public health interventions once forecasts have identified weather conditions to breach predetermined trigger levels. We examined 4 commonly used trigger-setting approaches: (1) synoptic classification, (2) epidemiologic assessment of the temperature-mortality relationship, (3) temperature-humidity index, and (4) physiologic classification. We applied each approach in Chicago, Illinois; London, United Kingdom; Madrid, Spain; and Montreal, Canada, to identify days expected to be associated with the highest heat-related mortality. RESULTS We found little agreement across the approaches in which days were identified as most dangerous. In general, days identified by temperature-mortality assessment were associated with the highest excess mortality. CONCLUSIONS Triggering of alert days and ultimately the initiation of emergency responses by a heat-health warning system varies significantly across approaches adopted to establish triggers.

Ragweed in France: an invasive plant and its allergenic pollen

BACKGROUND Ragweed is an annual, herbaceous, wind-pollinated plant that is responsible for strong allergies. In France, it is mainly present in the region of Lyon, where it threatens the health of the population. OBJECTIVE To analyze annual, daily, and bihourly pollen concentrations in the air to determine the characteristics of ragweed pollination and in particular its diurnal rhythm. METHODS Ragweed pollens were sampled from 1987 to 2001 by a Hirst volumetric trap calibrated to handle a flow of 10 L/min of air, which roughly corresponds to a human breathing rhythm. Pollen counts were performed on a daily and bihourly basis, which is of particular importance in allergologic practice. RESULTS Ragweed pollination occurs from the beginning of August to the end of September. Annual and daily levels of pollen have increased significantly since 1987. The pronounced diurnal periodicity shows a peak from 9 to 11 AM. Pollen counts increased from the early morning with temperature increase and relative humidity decrease. CONCLUSIONS Daily pollen counts of this strongly allergic plant are above the allergic thresholds commonly defined, limiting the interest of eradication campaigns. Thus, prevention of ragweed allergy depends on informing and educating the public through reports and updates. Diurnal variations seem to be the most crucial part of such a report, allowing allergy patients to adapt their daily outdoor activities in respect to the pollen peaks and off-peaks.

Airborne pollen of Ambrosia in Burgundy (France) 1996–1997

Pollen counts in Burgundy were monitored by means of four Hirst volumetric traps. Their analysis revealed a sharp rise of Ambrosia from 1996 to 1997. The minimum amount of ragweed pollen likely to provoke allergies (13 grains m−3) was reached or exceeded several days every year, but without leading to clinical symptoms. The circadian variation of Ambrosia pollen showed two peaks: the first one in the morning was suggested to coincide with local pollination, although the second one, in the afternoon, seemed to result from a long range transport which was confirmed by the study of wind roses.

Definition of temperature thresholds: the example of the French heat wave warning system

Heat-related deaths should be somewhat preventable. In France, some prevention measures are activated when minimum and maximum temperatures averaged over three days reach city-specific thresholds. The current thresholds were computed based on a descriptive analysis of past heat waves and on local expert judgement. We tested whether a different method would confirm these thresholds. The study was set in the six cities of Paris, Lyon, Marseille, Nantes, Strasbourg and Limoges between 1973 and 2003. For each city, we estimated the excess in mortality associated with different temperature thresholds, using a generalised additive model, controlling for long-time trends, seasons and days of the week. These models were used to compute the mortality predicted by different percentiles of temperatures. The thresholds were chosen as the percentiles associated with a significant excess mortality. In all cities, there was a good correlation between current thresholds and the thresholds derived from the models, with 0°C to 3°C differences for averaged maximum temperatures. Both set of thresholds were able to anticipate the main periods of excess mortality during the summers of 1973 to 2003. A simple method relying on descriptive analysis and expert judgement is sufficient to define protective temperature thresholds and to prevent heat wave mortality. As temperatures are increasing along with the climate change and adaptation is ongoing, more research is required to understand if and when thresholds should be modified.

A simple indicator to rapidly assess the short-term impact of heat waves on mortality within the French heat warning system

We propose a simple method to provide a rapid and robust estimate of the short-term impacts of heat waves on mortality, to be used for communication within a heat warning system. The excess mortality during a heat wave is defined as the difference between the observed mortality over the period and the observed mortality over the same period during the N preceding years. This method was tested on 19 French cities between 1973 and 2007. In six cities, we compared the excess mortality to that obtained using a modelling of the temperature-mortality relationship. There was a good agreement between the excess mortalities estimated by the simple indicator and by the models. Major differences were observed during the most extreme heat waves, in 1983 and 2003, and after the implementation of the heat prevention plan in 2006. Excluding these events, the mean difference between the estimates obtained by the two methods was of 13 deaths [1:45]. A comparison of mortality with the previous years provides a simple estimate of the mortality impact of heat waves. It can be used to provide early and reliable information to stakeholders of the heat prevention plan, and to select heat waves that should be further investigated.

How to use near real-time health indicators to support decision-making during a heat wave: the example of the French heat wave warning system

Introduction The French warning system for heat waves is based on meteorological forecasts. Near real-time health indicators are used to support decision-making, e.g. to extend the warning period, or to choose the most appropriate preventive measures. They must be analysed rapidly to provide decision-makers useful and in-time information. The objective of the study was to evaluate such health indicators. Methods A literature review identified a range of possible mortality and morbidity indicators. A reduced number were selected, based on several criteria including sensitivity to heat, reactivity, representativity and data quality. Two methods were proposed to identify indicator-based statistical alarms: historical limits or control charts, depending on data availability. The use of the indicators was examined using the 2006 and 2009 heat waves. Results Out of 25 possible indicators, 5 were selected: total mortality, total emergency calls, total emergency visits, emergency visits for people aged 75 and over and emergency visits for causes linked to heat. In 2006 and 2009, no clear increases were observed during the heat waves. The analyses of real-time health indicators showed there was no need to modify warning proposals based on meteorological parameters. Discussion These findings suggest that forecasted temperatures can be used to anticipate heat waves and promote preventive actions. Health indicators may not be needed to issue a heat wave alert, but daily surveillance of health indicators may be useful for decision-makers to adapt prevention measures.

French Heat Health Watch Warning System: Validation of Temperature Thresholds

Contrary to the empirical method used in the French HHWWS, our method takes into account confounding factors and temporal events. Thus, it is not surprising that the thresholds resulting from a time series analysis are somewhat different to those from the HHWWS. Moreover, these predictive models made it possible to estimate daily excess mortality that could be used as an additional criterion in the proposal of an alert in the framework of the French warning system for heat waves. French Heat Health Watch Warning System: Validation of Temperature Thresholds

Réduire les impacts de la chaleur dans un contexte de changement climatique

The impact of climate change on the health of individuals raises fears of significant long-term effects. Certain repercussions are already evident. Health professionals, particularly those working with vulnerable people, play a key role in health promotion and taking into account the challenges posed by hot weather. They need to be better trained in order to promote behaviours more favourable to health.