Perucci ISCB2007

Slide1: 

Temperature and total mortality in Rome Summer 1983

Slide4: 

IPCC SRES CO2 emissions

Slide5: 

Scenarios B1, A1B, A2, Atmospheric Tsurf, difference from 1980-99

Slide8: 

EU projects to assess the short-term effect of summer temperature on health in Europe: Phewe project (Assessment and Prevention of Acute Health Effect of Weather conditions in Europe) Time series approach to evaluate the effect of high temperature on mortality and hospital admissions in 15 cities (11 countries) by group of causes and by age group, Period 1990 - 2000 EuroHEAT project To evaluate the effect of temperature on mortality during heat waves In 9 cities (7 countries) by group of causes, gender and age group. Period 1990 – 2004.

“HEAT” vs HEAT WAVES: 

“HEAT” vs HEAT WAVES DEFINITION OF EXPOSURE

Slide11: 

Time series approach vs heat waves (time window) approach

Slide12: 

Time series approach vs heat waves (time window) approach Rome 2003

Slide13: 

Time series approach vs heat waves (time window) approach Paris 2003

Main results of the PHEWE project: summer mortality: 

Main results of the PHEWE project: summer mortality

Slide15: 

PHEWE: effect of Tappmax andTappmin on total mortality fixed-effect meta-analyitic curves Mediterranean and North-continental cities

Slide16: 

PHEWE: relationship between Tappmax and total mortatlity in 15 European cities, adjusted for co-variates

Slide17: 

Carson C, Hajat S, Armstrong B, Wilkinson P. Declining vulnerability to temperature-related mortality in London over the 20th century. Am J Epidemiol. 2006 Jul 1;164(1):77-84.

Slide18: 

PHEWE: city specific threshold and % variation of total mortality associated to 1°C increase of Tappmax above city threshold

Slide19: 

PHEWE: % variation of total, and cause-specific mortality per 1°C increase of Tappmax above city threshold, by age groups

Slide20: 

PHEWE: cumulative effect (% variation associated to 1°C increase of Tappmax above city threshold) on total mortality at different lags

Slide21: 

PHEWE: pooled estimates of the smooth seasonal effect Tappmax above the threshold total mortality, Mediterranean and North-continental cities

Main results of the PHEWE project: summer hospital admissions: 

Main results of the PHEWE project: summer hospital admissions

Slide25: 

PHEWE: Summer Cardiovascular – Pooled Results

Slide26: 

PHEWE: Summer Cerebrovascular – Pooled Results

Slide27: 

PHEWE : Meta-analytic curves of the effect of Tappmax on hospital admissions for respiratory causes in Mediterranean and North-continental cities (Michelozzi et al, 2007, submitted)

Slide28: 

Summer Cardiovascular Meta-analysis Effect of extreme Temperature (dummy variable for days with maximum apparent temperature greater than 90°annual percentile).

Slide29: 

Summer Cerebrovascular Meta-analysis Extreme Temperature

Slide30: 

Summer Respiratory by age – Pooled Results

Slide31: 

PHEWE : Effect of Tappmax > 95° percentile on hospital admissions for respiratory causes (Michelozzi et al.2007)

Slide32: 

Summer Respiratory Meta-analysis. Age 75+. Extreme Temperature

Slide33: 

Summer Respiratory Meta-analysis Extreme Temperature* dummy variable for days with maximum apparent temperature greater than 90°annual percentile

Bias: differential ascertainment of outcome related to the level of exposure?: 

Bias: differential ascertainment of outcome related to the level of exposure? Respiratory disease/symptoms: Availability of hospital services (probability of hospital admission) related to temperature? heterogeneous bias between cities?

Slide35: 

Heat wave: when maximum apparent temperature (Tappmax) and minimum temperature (Tmin) are > the 90th percentile of the monthly distribution for 2+ days. It is also characterized by: EuroHEAT WP2 results Heat wave definition: 1. Duration based on median value: short: if duration ≤ median value long: if duration > median value 2. Intensity based on days with extreme values for tappmax low: if tappmax ≤ monthly 95° pct high: if tappamax > monthly 95° pct

Slide36: 

Effect of heat-waves with different characteristics (all, with long duration and high intensity) on total mortality among people aged 65+ (% increase and 90% CI)

Slide37: 

Effect of all heat-waves among people over 65+ by gender (% variation and 90% CI)

Slide38: 

Effect of all heat-waves on total mortality among males by ages (% increase and 90% CI)

Slide39: 

Effect of all heat-waves on total mortality among females by ages (% increase and 90% CI)

Slide40: 

Effect of all heat-waves on mortality among people aged 65+ by causes (% increase and 90% CI)

Slide41: 

Comparison of the effect of heat-waves on total mortality age 65+ in summer 2003 and in the other years (%variation and 90% CI)

Slide42: 

Effect of Tappmax on mortality: J shaped relationship, with a threshold value varying between 29.4°C in Mediterranean cities and 23.3°C in North-continental cities. Stronger effect in Mediterranean cities (3.12 % variation per 1°C increase; 95% CI: 0.60-5.72) than in North-continental cities (1.84 % variation; 95% CI: 0.06-3.64). Highest effect for respiratory mortality. Results for hospital admissions were not always consistent with results on mortality; no effect was observed on cardiovascular and cerebrovascular admissions. An effect on hospital admissions for respiratory causes observed in several cities in the age group +75. Effect on respiratory admissions higher in Mediterranean than in North continental cities. PHEWE PROJECT CONCLUSION:

Slide43: 

Heat waves: large heterogeneity of the effect, % increase in daily mortality ranges between 7.6 in Munich and 33.6 in Milan. Impact of heat waves characterized by longer duration from 1.5 to 5 times higher than for “short” heat waves. In all cities a stronger effect of heat-waves on mortality found among females. The increasing effect observed with increasing ages, more evident among males. The highest impact of heat waves was observed on respiratory causes both among females and males 2003 heat wave: highest impact only in Paris and London; in other cities (like Rome and Milan) the effect was not higher since the impact on mortality was observed during all summer EuroHEAT PROJECT - WP2 CONCLUSION:

Slide44: 

Public Health Implications Large heterogeneity of the effect: higher impact of high temperature on mortality in the Mediterranean than in the North-continental cities Heat-waves characterized by long duration and high intensity have the highest impact on mortality. High impact of unusual “heat waves episodes” (i.e. in Paris and London during 2003)

Slide45: 

National Department of Civil Protection. Development and implementation of city-specific warning systems Implementation of a rapid surveillance\monitoring of mortality Ministry of Health. Local network for the warning bulletin National guide lines for prevention programs Identification of “susceptible” population Evaluation of summer mortality, warning systems and prevention programs PREVENTION OF HEALTH EFFECTS OF HEATH WAVES IN ITALY

Susceptible population: 

Susceptible population Susceptibility: The likelihood of producing a significantly larger-than-average response to a specified exposure to air pollutants. Vulnerability: The likelihood of being unusually severely affected by air pollutants either as a result of susceptibility to the effects of these substances or as a result of a greater than average exposure. “Susceptibility” is thus seen as a subset of “vulnerability”. (WHO working Group, 2004)

Model of susceptibility : 

Model of susceptibility GENERAL POPULATION CHRONIC CONDITIONS ACUTE CONDITIONS DEATH Susceptibility Exposure levels and defense mechanisms (Vulnerability)

Slide50: 

Case cross-over study. Individual risk factors AJRCCM

Slide51: 

Susceptibility Living in urban areas Elderly Females Low socio economic status Living alone or socially isolated Poor housing conditions/no air conditioning Medical conditions: Respiratory, Cardiovascular and cerebrovascular disease, metabolic/endocrine gland disorders, depression, diseases of the central nervous system and psychiatric disorders. Subject under constant medication

Slide52: 

Roma 2006: susceptible population by risk level, age, gender Males Females

Slide53: 

HEALTH IMPACT OF THE HEAT WAVES IN JUNE 2007

Slide54: 

NATIONALE HHWWS: Risk Levels in the Italian cities, 19-30 June 2007

Slide55: 

NATIONALE HHWWS: Risk Levels in the Italian cities, 19-30 June 2007

Slide56: 

HEAT WAWE JUNE 2007 : Excess mortality (n and %) in the age group +65

Slide57: 

HEAT WAWE JUNE 2007 : Excess mortality (n and %) in the age group +65

Slide58: 

MAY - JULY 2007 : Maximum apparent temperature and daily mortality in the age group +65

Slide59: 

MAY - JULY 2007 : Maximum apparent temperature and daily mortality in the age group +65

Slide60: 

MAY - JULY 2007 : Maximum apparent temperature and daily mortality in the age group +65

Slide61: 

MAY - JULY 2007 : Maximum apparent temperature and daily mortality in the age group +65

Slide62: 

EVALUATION OF PREVENTION PROGRAMS IN ROMA, SUMMER 2006

Slide63: 

Summer 2006. Rome: relationship between maximum apparent temperature and daily mortality Daily mortality Apparent maximum temperature Rome

Slide64: 

Summer 2006. Rome: relationship between maximum apparent temperature and daily mortality by gender

Slide65: 

Summer 2006. Rome: relationship between maximum apparent temperature and daily mortality comparison: Rome vs LHA RM/E

Slide66: 

Apparent maximum temperature

Slide67: 

Summer 2006. Comparison heat days - no heat days, between Rome except RM/E and RM/E. MEN

Slide68: 

Summer 2006. Comparison heat days - no heat days, between Rome except RM/E and RM/E. WOMEN

Slide69: 

UOMINI Summer 2006. Comparison heat days - no heat days, between Rome except RM/E and RM/E, by risk level.

Slide70: 

01/01/1987 01/01/1988 01/01/1989 01/01/1990 01/01/1991 01/01/1992 01/01/1993 01/01/1994 01/01/1995 01/01/1996 01/01/1997 01/01/1998 01/01/1999 01/01/2000 01/01/2001 01/01/2002 01/01/2003 01/01/2004 01/01/2005 01/01/2006 Calendar time (days) Number of deaths (age 65+ years) Time-series of natural mortality among people 65+ year old, Rome 1987-2005

Slide71: 

Carson C, Hajat S, Armstrong B, Wilkinson P. Declining vulnerability to temperature-related mortality in London over the 20th century. Am J Epidemiol. 2006 Jul 1;164(1):77-84.

Slide72: 

Carson C, Hajat S, Armstrong B, Wilkinson P. Declining vulnerability to temperature-related mortality in London over the 20th century. Am J Epidemiol. 2006 Jul 1;164(1):77-84.

Slide73: 

7-day Moving average

Slide74: 

01/01/1998 02/01/1998 03/01/1998 04/01/1998 05/01/1998 06/01/1998 07/01/1998 08/01/1998 09/01/1998 10/01/1998 11/01/1998 12/01/1998 Calendar time (days) Number of deaths (age 65+ years) Time-series of natural mortality among people 65+ year old, Rome 1998-1999 01/01/1999 02/01/1999 03/01/1999 04/01/1999 05/01/1999 06/01/1999 07/01/1999 08/01/1999 09/01/1999 10/01/1999 11/01/1999 12/01/1999 01/01/2000

Slide75: 

01/01/2000 02/01/2000 03/01/2000 04/01/2000 05/01/2000 06/01/2000 07/01/2000 08/01/2000 09/01/2000 10/01/2000 11/01/2000 12/01/2000 Calendar time (days) Number of deaths (age 65+ years) 01/01/2001 02/01/2001 03/01/2001 04/01/2001 05/01/2001 06/01/2001 07/01/2001 08/01/2001 09/01/2001 10/01/2001 11/01/2001 12/01/2001 01/01/2002 Time-series of natural mortality among people 65+ year old, Rome 2000-2001

Slide76: 

01/01/2003 02/01/2003 03/01/2003 04/01/2003 05/01/2003 06/01/2003 Calendar time (days) Number of deaths (age 65+ years) 07/01/2003 08/01/2003 09/01/2003 10/01/2003 11/01/2003 12/01/2003 01/01/2004 Time-series of natural mortality among people 65+ year old, Rome 2003

Slide77: 

Influenza surveillance. Italy 1999 - 2007

Slide79: 

7-day Moving average

OUTCOMES: 

OUTCOMES “avoidable deaths” Versus Years (time) potential life lost (quality adjusted)

EFFECTIVENESS: 

EFFECTIVENESS “BENEFICIENCY” Vs RATIONALITY