1 table omitted
During June-August 2003, record high temperatures were reported across
Europe; Italy was one of the countries most affected. To assess the impact
of the summer 2003 heat waves on mortality, the Rome Local Health Authority
analyzed temperature and daily mortality data for June-August 2003. This report
summarizes the results of that analysis, which indicated that an estimated
1,094 excess deaths occurred during three major heat wave periods in 2003,
an increase of 23% compared with the average annual number of deaths during
1995-2002. Improvements have been made in warning systems and prevention programs
that target persons at high risk to reduce excess mortality during future
Data on daily deaths during June-August 2003 were obtained from the
Mortality Registry Office of Rome. Deaths caused by injury and poisoning (International Classification of Deaths, Ninth Revision:
800-999) and deaths that occurred outside Rome were excluded from the analysis.
Maximum apparent temperature (MAT)* was defined as an index of human discomfort
on the basis of air temperature and dew point temperature.1 A
major heat wave period was defined as MAT >90th annual percentile and an increase
of 4°F (2°C) compared with the previous day. Daily excess mortality
was defined as the difference between the number of deaths observed on a given
day and the smoothed average daily value for the reference period (1995-2002).
Confidence limits were determined by assuming a Poisson distribution. Association
between excess mortality and socioeconomic status was evaluated for the census
tract of residence by using a deprivation index based on education, occupation,
unemployment, number of family members, overcrowding, and household ownership.2
During June-August 2003, the mean daily temperature was 5°F (3°C)
above the mean for the reference period, and MAT was 95°F (35°C),
compared with 88°F (31°C) for the reference period. During June-August
2003, MAT was >91°F (>33°C) (90th annual percentile) on 55 days (72%),
compared with 35% of days during the reference period. Three major heat wave
periods occurred during June-August 2003. The first episode (June 9–July
(2) registered a mean MAT of 97°F (36°C), with peaks of 100°F
(38°C) and 104°F (40°C); the second episode (July 10-30) had a
mean MAT of 97°F (36°C) and registered two peaks >104°F (>40°C);
and the third episode (August 3-13) was shorter but registered a mean MAT
of 100°F (38°C), with 3 days >104°F (>40°C).
Daily mortality trends followed temperature trends, with peaks in deaths
occurring on the same day as or ≤2 days from peaks in MAT. During June-August
2003, both temperatures and mortality trends were consistently above the long-term
trend, and total mortality was 22.8% higher than expected, with an estimated
1,094 excess deaths (Table). The first heat wave was associated with an increase
in mortality of 352, with peaks in mortality of 87 deaths on June 14 (daily
excess mortality: 58%) and 88 deaths on June 26 (daily excess mortality: 54%),
corresponding to peaks in MAT of 100°F (38°C) and 104°F (40°C),
respectively. During the second heat wave, 319 excess deaths occurred; a peak
in mortality (89 deaths) occurred on July 25 (daily excess mortality: 68%),
with a lag of 1 day. A second peak in mortality (84 deaths) occurred on July
27 (daily excess mortality: 55%), coinciding with the peak MAT (106°F
[41°C]). During the third heat wave, 170 excess deaths were reported.
Peaks in mortality occurred on August 8 and August 12, with 77 (excess mortality:
48%) and 78 (excess mortality: 59%) daily deaths registered ≤2 days after
peaks in MAT (102°F [39°C] and 106°F [41°C]).
Excess mortality occurred only among persons aged ≥65 years and increased
with age, with the greatest impact on persons aged ≥85 years (623 deaths;
excess mortality: 45.7%) (Table). The greatest increase in mortality occurred
among females (estimated daily excess: 35%), reflecting the higher proportion
of women aged ≥85 years (age distribution: women, 72%; men, 28%). A higher
excess mortality was observed for out-of-hospital deaths (22.6%) than for
in-hospital deaths (6.4%). Excess mortality was associated with socioeconomic
status, with an excess mortality of 5.9% among persons in the highest level
and 17.8% among those in the lowest level (Table).
P Michelozzi, MS, F de' Donato, MS, G Accetta, PhD, F Forastiere, PhD,
M D'Ovidio, MS, C Perucci, MD, Dept of Epidemiology, Rome Local Health Authority,
Italy. L Kalkstein, PhD, Center for Climatic Research, Univ of Delaware, Newark,
During summer 2003, the early onset of hot weather, unusually high temperatures,
and prolonged heat-stress conditions caused extreme peaks in mortality throughout
Europe. The total number of heat-related deaths that occurred during the summer
2003 heat wave is unknown. However, excess mortality data from five countries
(France, Italy, Portugal, Spain, and the United Kingdom) indicate that the
potential impact of heat waves on health was underestimated and that health
authorities were unprepared to cope with this emergency.
During June-August 2003, record excess mortality occurred in Rome during
three intense heat waves. The greatest increase in mortality occurred among
persons aged ≥65 years living in the most economically disadvantaged areas
of the city. The high number of excess deaths in this population might reflect
the number of elderly persons of low socioeconomic status who remained in
the city during the summer. Other socioeconomic factors that might have an
impact on health include poor housing quality, absence of air conditioning,
lack of access to social and health services, and individual behaviors (e.g.,
alcohol consumption and taking medication). Although the third heat wave was
shorter, it was more intense, with higher temperatures. Lower peaks in mortality
observed during the third wave might be attributed to a reduction in the susceptible
population, as observed in other cities.3
Episodes of heat-related mortality in Rome have been reported in previous
summers.4 In 1999, Rome was included in
a World Meteorological Organization project on cities at high risk for heat-related
morbidity and mortality. In 2002, the city implemented a heat health-watch
warning system (HHWWS) for the prevention of heat-related deaths during heat
waves9- 10 and a public health
intervention program targeted at persons at high risk (e.g., persons aged
≥65 years and those suffering from chronic disease) during extreme weather
conditions.5- 6 In 2001,
of the estimated 2.7 million persons living in Rome, 486,000 (18%) were aged
≥65 years (National Italian Institute of Statistics, unpublished data,
2001), and the mean annual number of deaths recorded was 26,000.7- 8
Rome's HHWWS analyzes meteorological forecast data during May-September
to predict oppressive air masses and related excess mortality and issues an
alarm when these two conditions are forecast. The alarm is upgraded to an
emergency when these conditions persist for >2 consecutive days. During summer
2003, the HHWWS called an alarm on 23 days (25%) and an emergency on 20 days
(22%). During heat waves, warning bulletins are posted on a municipal website
and disseminated to health authorities. Guidelines for the general population
and for patients suffering from specific diseases were developed in collaboration
with the Association for General Practitioners. The plan is activated on alarm
and emergency days to alert public and private subjects (e.g., clinicians,
nursing homes, social centers for the elderly, and hospitals) and to provide
information to the public.3 A telephone
assistance service for elderly persons is available 24 hours a day, 7 days
a week. This service provides regular check-in calls, counseling, home delivery
of food and medicine, and other services to registered users. A network of
social services, volunteers, and street units trained to handle emergencies
is activated during the summer months. The Rome Municipality continuously
informs elderly persons on the location of social centers and public buildings
with air conditioning.
In Italy, as in most of Europe, the increasing proportion of elderly
persons and the possible effects of global warming could make the susceptible
population more vulnerable to heat waves, leading to increased heat-related
mortality. To prepare for possible heat waves in 2004, Rome health authorities
have improved the technical capacity of the HHWWS and strengthened municipal
prevention programs targeting susceptible populations.
The authors acknowledge the assistance of the National Center for Environmental
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and
Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early
dhildhood mortality and growth failure data and their association with maternal
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