Vulnerabilities - Overview
The World Health Organization (WHO) estimates that about 20% of mortality in Europe is attributable to environmental causes. Climate change is in fact an emerging environmental risk factor and a priority on the political agenda of the majority of countries (1).
Climate change is expected to have mixed effects on infectious diseases, and might bring some benefits to health, through, for example, fewer deaths from exposure to the cold. However, this is expected to be outweighed by the negative effects of rising temperatures worldwide, in particular in developing countries (2).
Vulnerabilities - Heat stress - Europe
Heat waves combined with urban heat islands (10) can result in large death tolls with the elderly, the unwell, the socially isolated, and outdoor workers (11) being especially vulnerable. Heat waves thus pose a future challenge for major cities (12).
The heat wave in 2003 caused more than 35,000 excess deaths across Europe, maybe even over 44,000 (6,9). Europe was not prepared to predict, detect and prevent the health impacts of heat waves, nor did it expect a heat wave of such extend to occur. Since the dramatic death toll of the 2003 heat wave in Europe some effort has been directed towards the prevention of health impacts and the research of health impacts of heat. Heat–related mortality does not affect the entire population but there are a series of individual factors that make specific subgroups more susceptible to the effect of heat (3).
Descriptive analyses of individual heat wave events have suggested that hot weather predominantly affects people with limited adaptive responses living in urban areas. The elderly, small children, people who live in deprived areas and socially isolated. Furthermore, people with chronic diseases, such as cardiovascular, respiratory and cerebrovascular diseases (3).
The experience of 2003 shows that those most likely to die of the heat are the old, the chronically ill, and the isolated. Both northern and southern Europe are at risk (9).
The PESETA health project has attempted to quantify all the above effects under changed climate conditions in 2020 and 2080, but has initially concentrated on cold and heat related mortality. The preliminary results indicate that at an overall European level, the increase in the number of heat related deaths could be larger than the reduction in cold related deaths for the 2080s. The analysis shows almost 86,000 net extra deaths per year under a scenario A2 with a global mean temperature increase of 3°C in 2071-2100 relative to 1961-1990. Under scenario B2 with a global mean temperature increase of 2.2°C in 2071-2100 relative to 1961-1990, this number of net extra deaths per year halves to 36,000. These results are preliminary and do not assume acclimatisation and do not yet separate out the impact of non-climate changes (socio-economic changes in age structure or population movements) (3).
Vulnerabilities - Heat stress - Italy
In Italy, a recent study conducted in the four Italian cities of Bologna, Milan, Rome and Turin, analysed the relationship between maximum apparent temperature and mortality during summer (June–September) in 2003, 2004 and in a previous reference period (4). Results from this study show that during the summer of 2003 a dramatic increase in mortality was observed in the four Italian cities during the heat-wave.
Italian populations have been affected by heat waves. An average of 5% increase in excess deaths per degree increase of temperature has been observed. Excess mortality increased dramatically with age, with the greatest impact in the over 85 years old and in the 75-84 years old. The greatest excess in mortality was observed for the central nervous system, cardiovascular, respiratory diseases and metabolic\endocrine gland and psychological illnesses. A recent case-crossover analysis carried out in Italy showed a higher risk of dying during hot days also for people suffering from psychiatric disorders and depression. Results show that the low socio-economic levels are an important risk factor. Assuming no further planned adaptation or effective adaptation, these rates could be increasing in the years to come (3).
Compared to 2002 there was an overall increase in mortality in Italy of 3,134 (from 20,564 in 2002 to 23,698 in 2003) during the three summer months, with the greatest increase among people aged 75 years and older (+92%). The increase in mortality was not homogeneous. In terms of the spatial distribution, the highest increase were observed in the North-West; again especially for the elderly in Turin (44.9%), Trento (35.2%), Milan (30.6%) and Genoa (22.2%) (3).
An empiric estimate of the excess mortality in the summer of 2003 among individuals of 65 years of age and older of more than 7000 deaths (7.659) was calculated. These deaths occurred within 45 days from 16 July up to the end of August 2003. The mean percentage of higher mortality in 2003 compared with 2002 was 19.1. The percentages were higher for more populated cities (39.8% for those cities with more than 500.000 inhabitants) and lower for the smaller towns (13.8% for towns with a population equal or less than 100.000 inhabitants and 29.2% for towns with a population of 100.000 up to 500.000 inhabitants) (3).
The urban heat island of Rome
The urban heat island of Rome in recent years (2013-2015) was 1 °C most of the time. Higher values are frequently registered, however, especially during spring and summer, with urban heat island values reaching > 1.5 °C and even exceeding 3 °C (23).
The urban heat island of Turin
The urban heat island of Turin in recent years (analyzed up to 2016) was 0.5 - 1.5 °C. This urban heat island intensity is relatively limited, possibly due to the urban framework of the city with its central areas not ‘appropriately’ spaced from the periphery (24).
Vulnerabilities - Food poisoning
See page on the United Kingdom
Vulnerabilities - Water-borne diseases
See page on the United Kingdom
Vulnerabilities - Vector-borne diseases
There is a high potential risk of West Nile fever cases, and an increase risk of Leishmania and of bottonneuse fever moving northward. The importance of the mosquitoes as disease vectors is tied up above all to the transmission of malaria, an illness that causes today still million of deaths every year in the world (5). In Italy malaria has been eradicated at the end of the '40. The mosquito species, that were responsible of the transmission, are still present in remarkable density in Southern regions of the country, like Sicily and Sardinia (3).
The malariogenic potential for Italy is not very high, but it doesn't exclude nevertheless the possibility that autochthonous malaria cases could occur in areas "at risk", especially in the south and in the islands. The possibility that a tropical vector may settle in Italy following an increase in temperature appears highly unlikely because of the complexity of ecological factors linked to the different anopheline species (1,3).
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 (7).
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 (8).
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 (8).
Adaptation strategies - Italy
At European level few early warning systems are available, most of them generated by the national weather services. For example the German weather service produces pollen, wind and heat forecasting and a number of other services. In Italy, since 2003, the Italian Department for Civil Protection has implemented a network of alarm systems for the prevention of the effects of heat on health during the summer in major urban areas. These are able to predict dangerous weather and the public health impact up to three days in advance (HHWWS: – www.protezionecivile.it). It has to be highlighted that at European level there is also a lack of action plans and information on how to avoid health risk from flooding and fire (1).
The implementation of the Italian heat wave plan includes development of a forecasting model; identification of intervention plans for each city; identification of the network of organizations/services to be involved; and evaluation of the effectiveness of the system in preventing excess mortality. The heat/health watch/warning system (HHWWS) is to be improved and its operation to be expanded to other Italian cities. Comprehensive heat wave plans include rapid health system preparedness and response, urban planning and indoor house improvements (3).
In future, especially in spring and summer, the planning of health services will need to consider the potential health risks of heat-waves, water-, food- and vector-borne diseases. An interesting approach has been proposed by the Centers for Disease Control and Prevention (United States) and the Health Protection Agency (United Kingdom) to activate an information network and health promotion activities in the early summer months. This includes (a) information for the public, (b) planning of human resources, (c) an update of health infrastructure (e.g. air-conditioned rooms) and (d) a revision of service quality during the summer (1).
Adaptation strategies - General - Heatwaves
The outcomes from the two European heat waves of 2003 and 2006 have been summarized by the IPCC (13) 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 (14). 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 (15).
The European Network of Meteorological Services has created Meteoalarm as a way to coordinate warnings and to differentiate them across regions (16). 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 (17).
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 (18). Some evidence has even shown that top-down educational messages do not result in appropriate resultant actions (19).
More generally, research shows that communication about heat preparedness centered on engaging with communities results in increased awareness compared with top-down messages (20).
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 (21). 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 (22).
The references below are cited in full in a separate map 'References'. Please click here if you are looking for the full references for Italy.
- WHO (2007)
- Confalonieri et al. (2007), in: WHO (2007)
- Ministry for the Environment, Land and Sea of Italy (2007)
- Michelozzi et al. (2005a, 2005b), in: WHO (2007)
- WHO (2005), in: Ministry for the Environment, Land and Sea of Italy (2007)
- Swedish Government Official Reports (2007)
- Semenza and Menne (2009)
- Hajat et al. (2003)
- Kosatsky (2005)
- Basara et al. (2010); Tan et al. (2010), in: IPCC (2012)
- Maloney and Forbes (2011), in: IPCC (2012)
- Endlicher et al. (2008); Bacciniet al. (2011), both in: IPCC (2012)
- IPCC (2012)
- Health Canada (2010), in: IPCC (2012)
- WHO (2007), in: IPCC (2012)
- Bartzokas et al. (2010), in: IPCC (2012)
- McCormick (2010b), in: IPCC (2012)
- Luber and McGeehin (2008), in: IPCC (2012)
- Semenza et al. (2008)), in: IPCC (2012)
- Smoyer-Tomic and Rainham (2001), in: IPCC (2012)
- Yip et al. (2008); Silva et al. (2010), both in: IPCC (2012)
- Akbari et al. (2001), in: IPCC (2012)
- Ciardini et al. (2019)
- Garzena et al. (2019)