Germany Germany Germany Germany

Health Germany

Vulnerabilities - Overview

Potential impacts of climate change on the health sector in Germany can be direct or indirect. Heat and cold stress, and the consequences of increasing frequency of extreme weather events such as flood or storm, are direct impacts. Extreme events can on the one hand cause direct physical injuries, and on the other hand have strong impacts on human mental health, through stress, anxiety states, and depression (1).

Indirect potential impacts are the increasing frequency of vector borne diseases, algal toxins, the import of new diseases through worldwide ecological changes, the long-term exacerbation of ozone and smog related problems, health impacts of skin and eyes due to changes in solar radiation, and the consequences of negative changes in environmental conditions, such as the quality of water, air and food (1).

In general, there is still great uncertainty in the specific impacts of climate change on health, particularly concerning indirect impacts (1).

People whose health is already stressed are especially vulnerable to impacts of climate change. This is particularly the case for elderly and infirm people. Children can also be particularly susceptible. Furthermore, social factors, such as lacking access to information and material resources or lacking connection to a social network can increase the vulnerability of a person to the negative impacts of climate change on health (1).

Regionally, the upper Rhine rift and congested urban areas, especially in climatically unfavourable locations (closed valleys) are particularly hit by the direct impacts of climate change (1).

Vulnerabilities - Cold stress

Fewer problems with frost (frostbite, deaths through cold) are considered to be the only potential indirect impact of climate change that is understood as an opportunity by experts (1).

Most European countries have between 5 and 30 % higher death rates in winter than in summer. Winter‑related mortality in many European populations has declined since the 1950s (7). Cold days, cold nights and frost days have become rarer, but explain only a small part of this reduction: improved home heating, better general health and improved prevention and treatment of winter infections have played a more significant role (8).

Vulnerabilities - Heat stress

Heat waves combined with urban heat islands (13) can result in large death tolls with the elderly, the unwell, the socially isolated, and outdoor workers (14) being especially vulnerable. Heat waves thus pose a future challenge for major cities (15).

Heat stress on the human body that can lead to death is the most important direct impact. Particularly the cardiovascular system is strained. As a result of the heat wave, some 7,000 people in Germany died of heart attacks, cardiovascular diseases, kidney failure, respiratory problems or metabolic disorders. Such extreme events can affect the somatic and psychosomatic health of large numbers of people in affected areas (1,3).

Heat and heat wave related health problems will become more frequent in future, and finding a solution to these will become one of the essential tasks of the health care system (2). Germany is especially vulnerable to the impact of climate change on health, because of the continuous enlargement of the most susceptible demographic group, the elderly.

In Germany, a 20 % increase in heat-related mortality is projected. This increase is not likely to be compensated by reductions in cold-related mortality (9).

The urban heat island of Augsburg

For the city of Augsburg, an urban heat island (UHI) up to 6°C was measured. The UHI intensity is highest in calm and clear situations, especially in summer in the evening (27).

Vulnerabilities - Food poisoning

The quality of food can be impacted, e.g. through increased infestation with Salmonella as a consequence of higher temperatures. However, professional storage and distribution of the food can prevent this (1).

Vulnerabilities - Mosquito-borne diseases

Many animal pathogens, such as viruses and bacteria are transmitted to humans by vectors. Such vectors can be certain insects (mosquitoes, ticks), but also higher species (birds, mammals) (1).

Changes in the distribution, population and infectious potential of disease vectors such as blood-sucking insects, ticks and rodents are indirect impacts of climate change. Increasing temperatures improve the conditions for distribution and infection, so that an increasing danger is assumed, even though the causal interactions between vector-borne diseases and climate change are not yet fully understood (1).

Further important disease vectors in Germany are mosquitoes, sand flies, black flies, midges, fleas, bugs, human lice, flies and mites (4). Rodents and other mammals (foxes, stray dogs) can also carry pathogens and can contaminate human food and surroundings, leading to infections (1).

In principle, climate change also causes the risk of malaria infections in Germany. Besides the occurrence of the mosquito Anopheles (presently mainly in the upper Rhine area), heat is a decisive factor in the infestation of the pathogen within the Anopheles mosquito. The risk increases significantly if the day and night temperatures do not fall below 18ºC for two weeks. However, an epidemic spread is not expected (5).

Analysis of the present situation reveals that many non-native, thermophilic disease vectors have already entered Germany. However, other factors, such as e.g. international animal trade, as well as increased transport of goods and people also lead to an increased risk of importing disease vectors. … The health risk due to vector-borne diseases will increase in Germany in future. The specific contribution of climate change to this process can presently not be definitely clarified (4).

While climatic factors may favor autochthonous transmission, increased vector density, and accelerated parasite development, other factors (socioeconomic, building codes, land use, treatment, etc) limit the likelihood of climate related re-emergence of malaria in Europe (10). A milder climate could, however, result in the “Asian tiger mosquito”, becoming established in Germany (12).

Vulnerabilities - Tick-borne diseases

Among the vector-borne diseases, the danger through diseases transmitted by ticks, mainly Ixodes ricinus, is most pressing. Some studies from Sweden and Czechia indicate an expansion of the distribution toward North and to higher altitudes. However, it is not yet established how the distribution of (infested) ticks is actually affected and enhanced by climate change (4). Particularly lyme disease (borreliosis), which is transmitted by ticks, is a distinct and increasing threat to public health (1).

A national reference laboratory for diseases transmitted by ticks does exist, however, skilled professionals for the practical and scientific work in this field are lacking almost everywhere, according to the status of 2003 (4). The number of infections with borreliosis may be high due to the fact that this disease is often not identified and treated as such (1).

Vulnerabilities - Sand-fly-borne diseases

Leishmaniasis is a protozoan parasitic infection caused by Leishmania infantum that is transmitted to human beings through the bite of an infected female sandfly. Sandfly distribution in Europe is south of latitude 45⁰N and less than 800 m above sea level, although it has recently expanded as high as 49⁰N. Currently, sandfly vectors have a substantially wider range than that of L infantum, and imported cases of infected dogs are common in central and northern Europe. Once conditions make transmission suitable in northern latitudes, these imported cases could act as plentiful source of infections, permitting the development of new endemic foci. Conversely, if climatic conditions become too hot and dry for vector survival, the disease may disappear in southern latitudes. Thus, complex climatic and environmental changes (such as land use) will continue to shift the dispersal of leishmaniasis in Europe (10).

Vulnerabilities - Water-borne diseases

Along the Baltic Sea coast, and in lakes, nutrient inputs, in combination with mild temperatures, can lead to blue-green algal blooms (blooms of cyanobacteria). Since certain types of cyanobacteria produce numerous toxins, such blooms can considerably impair water quality in affected bodies of water, especially with regard to their use for swimming. Contact with polluted water can trigger skin and gastrointestinal irritations and can even cause liver damage and other serious types of health disorders (1,3).

Future water shortages can decrease the availability of clean drinking water and impair wastewater treatment. This could increase the occurrence of diseases (1).

Vulnerabilities - Air quality

Climate Change may result in the deterioration of environmental conditions. This includes the distribution of allergens in the air, degradation of the quality and quantity of water and food, as well as the degradation of ecosystems, which humans need for their recreation (6).

The concentration of air-borne allergens, such as pollen depends strongly on season. Climate change could cause a shift and elongation of the relevant seasons, and therefore cause an increased health threat (1).

Furthermore, the burden of air pollution in congested urban centres with pollutants such as nitrous oxides (NOx), ozone (O3) and dust (PM: particulate matter) depends on the climate (1).

Vulnerabilities - Urban heat island

The urban heat island effect is the difference between the temperature in the urban area and in the surroundings. For Hamburg the annual average urban heat island effect at night is 1.2 K. The highest temperature values were found in industrial areas or within the city centre (about 2 K) where soil sealing rate and heat storage capability of the urban materials are high. Nocturnal heat island intensities in Hamburg are highest in spring and summer and lowest in winter (26). 

Vulnerabilities in cities

High air temperatures in congested urban areas causes additional heath threats due to air pollution (1).

Vulnerabilities - Floods

Floods are the most common natural disaster in Europe. The adverse human health consequences of flooding are complex and far-reaching: these include drowning, injuries, and an increased incidence of common mental disorders. Anxiety and depression may last for months and possibly even years after the flood event and so the true health burden is rarely appreciated (11).

Effects of floods on communicable diseases appear relatively infrequent in Europe. The vulnerability of a person or group is defined in terms of their capacity to anticipate, cope with, resist and recover from the impact of a natural hazard. Determining vulnerability is a major challenge. Vulnerable groups within communities to the health impacts of flooding are the elderly, disabled, children, women, ethnic minorities, and those on low incomes (11).

Adaptation strategies - Germany

Health sector

Germany is relatively under-prepared with regard to heat-related health impacts, since such problems appeared massively and widely in the history of Germany for the first time in the year 2003. There is a lack of medical knowledge, education and prevention measures and early-warning systems (1).

A number of federal states have produced a “catalogue of precautions against heat”. The German Meteorological Service (Deutscher Wetterdienst, DWD) gives heat warnings since the summer of 2005. In Hesse, an early warning-system based on information from the DWD was already installed in 2004 (1).

The recommended adaptation measures given in the health sector are (1):

  • Increased education of the public and the specialised medical and nursing staff about health risks and preventive measures. Education of the public is generally seen as an effective means to prevent a further spreading of ticks and malaria in the context of climate change;
  • The introduction of early-warning systems including locally adjusted intervention measures, which announce temporally and spatially specific warnings and recommend behavioural guidelines. By 2005 there were large differences between federal states, particularly with regard to education, warning systems, and emergency planning. Highest degrees of implementation (already “implemented”) were reported from Hesse and Thuringia for education, from Hesse for improved warning systems, and from Baden-Württemberg for improved emergency planning (1);
  • Increased medical research in this field, as well as intense monitoring of climate related diseases (existing monitoring network, such as e.g. the one in place at the Robert-Koch-Institute, can be used here);
  • Expansion of medical prevention and care. By 2005, there was only a limited range of adaptation measures to deal with vector-borne diseases. For some, vaccination is not available, and therapies are often of long duration and not always successful (e.g. borreliosis);
  • Implementation of technical protection measures (insulation, air conditioning, etc.);
  • Reference to climate–induced health problems in public health care programmes, so that suitable vaccinations and reductions of pathogens can be put in place.

Urban planning and architecture

Another set of adaptation measures concerns the sector of climate-oriented urban planning and adapted architecture. In future, sufficient ventilation and “islands” of cooler temperatures will be important particularly in congested urban areas. Buildings need to be equipped with sufficient insulation and cooling options. With regard to climate protection, the use of alternative energy sources should be favoured in this field (e.g. through solar cooling) (1).

By 2005, the lowest degree of implementation of measures that are suitable to adapt to heat waves was found for the insulation and cooling of buildings for specific groups of people. In all federal states, this measure was either “not discussed” or “currently considered” (1).

From reactive to proactive

From a inventory study of experts throughout Germany it was concluded that in 2005 the impacts of climate change were not yet (or only very slightly) considered in planning, and that the health sector was not yet adapted to climate change in many federal states (1). It was concluded that without further measures, Germany is regionally “highly”, nationwide “moderately” vulnerable in the context of heat impacts. In the context of vector-borne diseases there is great uncertainty about climate impacts, however, given the potentially high risks and the lacking adaptation measures, the health sector has been rated as “highly vulnerable” regarding this threat (1).

In future, the public health sector should be able to adapt to climate change, since there are various potentially effective adaptation measures, particularly in the form of education and warning, which also do not seem to be very complicated. On the other hand, in the field of vector-borne diseases, education and warning seem to be almost the only effective measures (1).

In the health sector, special support is needed to switch from reactive to a proactive planning of adaptation measures, which also takes into account scenarios of future climate change, in addition to weather events and climate trends of the past. It is expected that the vulnerability in the health sector will reduce to “low” if the identified adaptation measures are implemented (1).

Adaptation strategies - General - Heatwaves

The outcomes from the two European heat waves of 2003 and 2006 have been summarized by the IPCC (16) and are summarized below. They include public health approaches to reducing exposure, assessing heat mortality, communication and education, and adapting the urban infrastructure.

1. Public health approaches to reducing exposure

A common public health approach to reducing exposure is the Heat Warning System (HWS) or Heat Action Response System. The four components of the latter include an alert protocol, community response plan, communication plan, and evaluation plan (17). The HWS is represented by the multiple dimensions of the EuroHeat plan, such as a lead agency to coordinate the alert, an alert system, an information outreach plan, long-term infrastructural planning, and preparedness actions for the health care system (18).

The European Network of Meteorological Services has created Meteoalarm as a way to coordinate warnings and to differentiate them across regions (19). There are a range of approaches used to trigger alerts and a range of response measures implemented once an alert has been triggered. In some cases, departments of emergency management lead the endeavor, while in others public health-related agencies are most responsible (20).

2. Assessing heat mortality

Assessing excess mortality is the most widely used means of assessing the health impact of heat-related extreme events.

3. Communication and education

One particularly difficult aspect of heat preparedness is communicating risk. In many locations populations are unaware of their risk and heat wave warning systems go largely unheeded (21). Some evidence has even shown that top-down educational messages do not result in appropriate resultant actions (22).

More generally, research shows that communication about heat preparedness centered on engaging with communities results in increased awareness compared with top-down messages (23).

4. Adapting the urban infrastructure

Several types of infrastructural measures can be taken to prevent negative outcomes of heat-related extreme events. Models suggest that significant reductions in heat-related illness would result from land use modifications that increase albedo, proportion of vegetative cover, thermal conductivity, and emissivity in urban areas (24). Reducing energy consumption in buildings can improve resilience, since localized systems are less dependent on vulnerable energy infrastructure. In addition, by better insulating residential dwellings, people would suffer less effect from heat hazards. Financial incentives have been tested in some countries as a means to increase energy efficiency by supporting those who are insulating their homes. Urban greening can also reduce temperatures, protecting local populations and reducing energy demands (25).


The references below are cited in full in a separate map 'References'. Please click here if you are looking for the full references for Germany.

  1. Zebisch et al. (2005)
  2. Koppe et al. (2003), in: Zebisch et al. (2005)
  3. Government of the Federal Republic of Germany (2010)
  4. Maier et al. (2003), in: Zebisch et al. (2005)
  5. Ärzte Zeitung (06.10.2004), in: Zebisch et al. (2005)
  6. McMichael et al. (2003), in: Zebisch et al. (2005)
  7. Kunst et al. (1991); Lerchl (1998); Carson et al. (2006), in: EEA, JRC and WHO (2008)
  8. Carson et al. (2006), in: EEA, JRC and WHO (2008)
  9. Koppe et al. (2003), in: EEA, JRC and WHO (2008)
  10. Semenza and Menne (2009)
  11. Hajat et al. (2003)
  12. Federal Ministry for the Environment, Nature Conservation and Nuclear Safety (2009)
  13. Basara et al. (2010); Tan et al. (2010), in: IPCC (2012)
  14. Maloney and Forbes (2011), in: IPCC (2012)
  15. Endlicher et al. (2008); Bacciniet al. (2011), both in: IPCC (2012)
  16. IPCC (2012)
  17. Health Canada (2010), in: IPCC (2012)
  18. WHO (2007), in: IPCC (2012)
  19. Bartzokas et al. (2010), in: IPCC (2012)
  20. McCormick (2010b), in: IPCC (2012)
  21. Luber and McGeehin (2008), in: IPCC (2012)
  22. Semenza et al. (2008)), in: IPCC (2012)
  23. Smoyer-Tomic and Rainham (2001), in: IPCC (2012)
  24. Yip et al. (2008); Silva et al. (2010), both in: IPCC (2012)
  25. Akbari et al. (2001), in: IPCC (2012)
  26. Arnds et al. (2017)
  27. Straub et al. (2019)