Early Human Development xxx (xxxx) xxxx

Contents lists available at ScienceDirect

Early Human Development

journal homepage: www.elsevier.com/locate/earlhumdev

The effect of global warming on mortality

ABSTRACT

There is a significant relationship between ambient temperature and mortality. In healthy individuals with no underlying co-morbid conditions, there is an efficient
heat regulation system which enables the body to effectively handle thermal stress. However, in vulnerable groups, especially in elderly over the age of 65 years,
infants and individuals with co-morbid cardiovascular and/or respiratory conditions, there is a deficiency in thermoregulation. When temperatures exceed a certain
limit, being cold winter spells or heat waves, there is an increase in the number of deaths. In particular, it has been shown that at temperatures above 27 °C, the daily
mortality rate increases more rapidly per degree rise compared to when it drops below 27 °C.
This is especially of relevance with the current emergency of global warming. Besides the direct effect of temperature rises on human health, global warming will
have a negative impact on primary producers and livestock, leading to malnutrition, which will in turn lead to a myriad of health related issues. This is further
exacerbated by environmental pollution.
Public health measures that countries should follow should include not only health-related information strategies aiming to reduce the exposure to heat for
vulnerable individuals and the community, but improved urban planning and reduction in energy consumption, among many others. This will reduce the carbon
footprint and help avert global warming, thus reducing mortality.

1. Introduction associated with climate change. The definitions of heat wave vary by
location with different geography, climate and acclimatization of the
Naked skin, sweat glands and bipedalism have offered an evolu- local people. Therefore, when conducting epidemiological studies, a
tionary survival mechanism in humans to be able to especially regulate local definition of heat wave is needed whenever studies are carried
high temperatures [1]. Ambient temperature is related to mortality, out, in order to better characterize the quantitative association between
especially in susceptible individuals, who lack an efficient thermo- mortality risk and heatwaves. Based on the different definitions in
regulatory system to cope with thermal stress [2]. Heat and cold-related temperature metric, intensity, threshold, and duration different heat
deaths are often mis-classified and rarely coded as being deaths directly wave definitions can be drawn out. Such studies can better pinpoint the
caused due to cold or hot temperatures [3]. These are instead attributed significant association with heat waves daily mortality in different
to the underlying pre-existing conditions such as cardiovascular, re- countries [10]. The resultant vulnerability curves can help improve the
spiratory and other causes, which in themselves do contribute to in- heat-health warning systems and avoid tragic consequences such as the
creased susceptibility and vulnerability to extremes in temperature [4]. 2003 European heat wave which resulted in more than 70,000 deaths
One of the main challenges in associating mortality to climate [11] and the 2010 Russian heat wave where over 11,000 people died
change is first of all by having standard definitions of what is a heat [12]. Of course, exacerbating factors also caused by the excessive heat,
wave and what is a cold spell [5,6]. The vulnerability curve, that is how like bush fires and the resultant smoke, together with the lack of agri-
much the mortality rate change with the heat intensity is still unknown. cultural crops, will further contribute to mortality [13]. Of note, hu-
It is also important to understand that, not only does climate change midity further contributes to heat tolerance. A wet-bulb temperature
have a direct impact on our health, but it also has a multitude of in- (TW) of 35 °C marks the upper physiological limit that humans can
direct impacts which effect our environment. This leads to a negative tolerate, and much lower values have serious health consequences.
impact on primary producers and livestock, leading to malnutrition, Comprehensive evaluation of data from weather stations shows that,
which will in turn lead to a myriad of health related issues [7]. Global over the last forty years, the frequency of extreme humid heat has more
warming, which is exacerbated with environmental pollution, has also than doubled, and that some coastal subtropical locations have already
been associated with an increase in adverse health effects, including reported a TW of 35 °C [14].
vector-borne, waterborne and foodborne diseases, respiratory and al-
lergic disorders, mental health problems and collective violence [8,9]. 3. The impact of heat waves on mortality rates

2. Definition of heatwaves Heatwaves have a negative impact on mortality in high, middle and
low-income countries [15,16]. An international study across 400 com-
One of the main factors which contribute to disparity when recoding munities in 18 countries indicates that high temperatures create a
data related to climate change and mortality is the consensus on the substantial health burden. People living in moderate hot and moderate
definition which surround ‘heat waves’ and ‘cold spells’. Heat wave is a cold areas may more sensitive to heat waves than those living in hot
prolonged period of excessive heat and is an extreme weather event and cold areas [17]. Interestingly, the effects of high temperatures over

https://doi.org/10.1016/j.earlhumdev.2020.105222

0378-3782/ © 2020 Elsevier B.V. All rights reserved.

 Early Human Development xxx (xxxx) xxxx

consecutive days are similar to what is experienced if high temperature (at 29.0 °C, the 97.5th centile) which appeared immediately and lasted
days occur independently. However, another study conducted in 19 only for a maximum of three days [29]. The cold-induced cardiovas-
French cities shows that, while the population is better adapted to cular morbidity increases in young and middle-age people
warm temperatures, this is applicable only to a certain intensity (above (RR = 1.009, 95% CI: 1.004–1.015) and also in the elderly
percentile 99) when heat becomes an acute health emergency due to (RR = 1.013, 95% CI: 1.007–1.018) [30].
the rapid increase in mortality risk at very high temperatures percen-
tiles [18]. This is also evident in other regions such as Northwest India, 6. Demographics
where there is a significant rise in health risks associated with heat
waves in communities with high baseline temperatures [19]. Infants, children, pregnant women, older people, chronically ill,
Different physiological mechanisms are triggered by heat exposure outdoor workers, socio-economically disadvantaged and urban dwellers
(inflammatory response, ischemia, disseminated intravascular coagu- are the most heat vulnerable; with the food systems and the health
lation, heat cytotoxicity and rhabdomyolysis). These mechanisms can sector facing the highest heat-health challenges [31].
critically impact the brain, heart, lungs, kidneys, intestines, liver,
pancreas and other vital organs. There is evidence that heat can trigger 6.1. The effect of age
at least twenty-seven different pathways by which these physiological
mechanisms triggered can lead to organ failure and possibly death [20]. Age is an important variable when investigating the effect of climate
change and mortality. Children have been higher core temperature
4. Definition of cold spells responses and lower sweat rates, leading to lower thermoregulatory
capabilities when compared to adults. The increasingly common
Cold spells (or cold waves) have been described as an excessive long childhood diseases and comorbidities, such as obesity, respiratory dis-
periods of extreme cold or sudden temperature drop. Official meteor- orders and the onset of preventable ‘adult’ diseases, can adversely affect
ological definitions of a cold spell include “at least 8 °C temperature the long-term health effects of future generations due to the rapidly
decrease in 24 h or at least 10 °C temperature decrease in 48 h or at changing climate [32]. Similarly, undernutrition as a consequence of
least 12 °C temperature decrease in 72 h with daily minimum tem- drought or other factors has serious short and long term consequences
perature below 4 °C” [21] or even more generally, “a rapid fall in on infants and children [33].
temperature within 24 hours to temperatures requiring substantially A multi-city study in Korea showed that there is a significantly
increased protection to agriculture, industry, commerce, and social positive association between infant mortality from total deaths or
activities” [22]. However, while the former definition is based on the sudden infant death syndrome (SIDS) and ambient temperature, with
absolute threshold and may not be easily applied at national and in- an overall hazard ratio of infant mortality for a 1 °C increase during
ternational level due to temperature variation and diverse climates and 1 month before death being 1.52 (95% CI, 1.46–1.57) for total deaths
spatial difference, the latter definition is very vague when it comes to and 1.50 (95% CI, 1.35–1.66) for SIDS [34]. Similar findings were
assess the impact on mortality. For Kysely et al., a cold spell was de- noted in Montreal, Canada where high ambient temperature was as-
fined a period of days with temperature of no more than −3.5 °C [23], sociated with SIDS, especially at 3 to 12 months of age [35].
while Lee et al. defined it as a period where daily mean temperature Direct and indirect effects of climate change place children at risk of
was below 5th percentile, 3rd percentile, and 1st percentile for two or mental health consequences including depression, anxiety, phobias,
more consecutive days [24]. Earlier research generally focused on the sleep disorders and substance abuse, which in turn can lead to adverse
duration and severity of cold days, with varying definitions. A recent adult mental health outcomes and eventually contribute to an increase
study carried out in China in order to find the optimum model to pre- in mortality [36].
dict the health impact of the whole nation, concluded that the best The elderly are a high-risk population for mortality related to ex-
definition of a cold spell is when there are at least two consecutive days tremes of temperature, being vulnerable to both cold spells [25] and
with daily mean temperature below the 5th percentile [25]. A parti- heatwaves [37]. The sudomotor function is attenuated by aging due to
cular challenge when studying the effect of the health impacts of ex- nerve demyelination and the decreased peripheral sensitivity to acet-
tremely cold weather is that places with adverse weather conditions ylcholine [38]. Particular risk factors for heat-related deaths include
such as the Arctic towns in the circumpolar region have very small cardiovascular, pulmonary, mental and other chronic illnesses; lower
population sizes, making it difficult to carry out proper statistical fitness levels polypharmacy; as well as having a lack of mobility; living
analysis [26]. on the top floor; lack of air conditioning; living alone; being unable to
care for oneself; and reluctance to change behaviour during a heat wave
5. The impact of cold spells on mortality rates [39,40]. These health-related, socio-economic and behavioural risk
factors which are more prevalent among the elderly, increase the risk of
Compared with heat waves, there has been overall less research dying during extremes of temperature. A study carried out in Malta,
carried out to investigate the harmful health effects of cold spells [27], which is a small island nation in the middle of the Mediterranean Sea,
especially in developing countries where the population is more vul- with a temperate climate, 27 °C was identified as the optimum average
nerable. Cold spells represent a significant public health burden, mostly temperature during which mortality rate was at its lowest. During the
caused by moderate temperatures (between percentiles 2.5 and 25). In period 1992–2005 in summer, the average mean apparent temperature
France, a study carried out between 2000 and 2010 showed that 3.9% was 29.93 °C with an average mortality rate of 0.57/10,000 in persons
[CI 95% 3.2:4.6] of the total mortality was attributed to cold, as com- under 65 years versus 12.46/100,000 in persons over the age of 65. In
pared to 1.2% [1.1:1.2] due to heat [18]. This corresponded to another contrast, in winter, the average mean apparent temperature was
bigger multicountry observational study, where 74,225,200 deaths 11.57 °C with an average mortality rate of 0.64/10,000 in persons
were analysed in various periods between 1985 and 2012 in 384 lo- under 65 years versus 18.07/100,000 in persons over the age of 65. In
cations in Australia, Brazil, Canada, China, Italy, Japan, South Korea, particular, it has been shown that at temperatures above 27 °C, the
Spain, Sweden, Taiwan, Thailand, UK, and USA. Even in this study, daily mortality rate increases more rapidly per degree rise compared to
more temperature-attributable deaths were caused by cold (7·29%, when it drops below 27 °C [3]. So even in a temperate climate like in
7·02–7·49) than by heat (0·42%, 0·39–0·44) [28]. A time-series analysis the Mediterranean, it is recommended that health advice is issued both
carried out in 272 locations in China, concluded that, the mortality risk during heat waves and cold spells. This is comparable to other Eur-
of extreme cold temperature (at −1.4 °C, the 2.5th centile) lasted for opean cities where high ambient summer temperatures influence daily
more than two weeks, in contrast to the risk of extreme hot temperature mortality, particularly effecting the elderly [41,42]. Elderly women are

2
 Early Human Development xxx (xxxx) xxxx

at higher risk of dying than men according to gender-stratified data on ultraviolet radiation and malnutrition. This is because the overall en-
mortality after heat waves [43]. This may be related to biological fac- vironmental pollution is leading to a rise in non-communicable and
tors, as women show less sudomotor activity than men, and also be- communicable disease. These include injuries and deaths during nat-
havioural factors [38]. There are also ethnic variations in the function ural disasters, malnutrition during famine, apart from the increased
of the sudomotor system, with residents of tropical areas sweating less mortality during climate changes due to complications in chronically ill
and more slowly than those residing in temperate areas. Short-term patients. The accumulation of toxic substances in the food chain can
heat acclimation enhances the sweating response, and conversely, lead to the creation of habitats suitable to the transmission of human
seasonal change or migration leading to long-term heat acclimation, and animal pathogens. Climate change is influencing the quantity and
diminishes the sweating response [38]. quality of food that is produced, as well as its equitable distribution
[54]. Low to middle-income countries are particularly vulnerable to a
6.2. The link with co-morbid conditions changing climate [55,56].
Climate change is leading to a change in distribution of infectious
Co-morbid conditions exacerbate the risk of heat-related mortality. diseases. Floods lead to more insect breeding sites, drive rodents from
Higher cardiovascular mortality has been associated with low and high burrows, and contaminate clean water systems. These lead to increased
temperatures in many countries, including Brazil [44], United States cases of leptospirosis, campylobacter infections, and cryptosporidiosis
[45], United Kingdom and China [37]. Exposure to cold, heat and [57,58]. Water-borne pathogens and pathogens transmitted by vectors
especially heatwaves are associated with an increased risk of myo- are particularly sensitive to climate change because they spend a good
cardial infarction [46]. part of their life cycle in a cold-blooded host invertebrate whose tem-
perature is similar to the environment [52]. A warmer climate presents
6.3. The effect of the location more favorable conditions for the survival and the completion of the life
cycle of the vector, going as far as to speed it up as in the case of
Interactions between health, mortality and climate are very specific mosquitoes. Diseases transmitted by mosquitoes include some of the
to individual location and latitude. There is a variation between po- most widespread worldwide illnesses such as malaria and viral diseases.
pulations in the optimum or threshold temperature, and may be a The ranges of several vector-borne diseases or their vectors are already
function of the adaptation to local climate. Generally, it has been shown changing in altitude due to warming [59]. The same applies for tick-
that the warmer the climate, heat related mortality is detected at higher borne diseases such as tick-borne encephalitis, which have increased in
threshold temperatures [17]. Similarly, residents in subtropical cli- the past years in cold regions [52]. Climate-related increases in sea
mates such as southern China are more vulnerable to cold spells [25]. In temperature lead to higher incidence of cholera, seafood intoxication
cold climates effecting towns located in the North Polar area, heatwaves and other waterborne infectious and toxin-related illnesses. Meteor-
are detrimental to health to the same extent as cold spells, and in both ological factors might also possibly have a role in the COVID-19
scenarios, the adverse health effects of temperature extremes are de- transmission after controlling for population migration, but further
layed rather than immediate with time lags between the temperature studies will need to be carried out to investigate this [60].
wave and observed increase in mortality varying between 8 and 14 days
[26].
Urban environments are considered more at risk of increased tem- 8. The way forward
perate-related mortality. There is an increased mortality impact asso-
ciated with higher population density, fine particles, gross domestic It is about time to move from a state of global inaction to a trans-
product (GDP) and income inequality (measured by the Gini index) formation in public health in order to decrease the mortality related to
[47]. However, temperature variability has also been shown to have a climate change [61]. Countries have started to include climate change
negative impact even in rural areas. A case in point is a study carried as a key consideration in their national public health policies. For ex-
out in China, where rural areas generally suffer greater mortality re- ample, developed countries are designing urban areas to include more
lated to temperature variability than urban areas in the warm season vegetation in a move to reduce heat-related mortality [62]. This is
[48]. because heat waves are associated with the “urban heat island (UHI)
effect” that can increase the ambient temperature in urban regions,
7. Environmental pollution, global warming and mortality exacerbated by higher population density and more pollution, thus
posing a serious threat on the health of residents, with an increased risk
In a time-series analysis involving more than 600 cities in 24 of mortality [10,63].
countries mostly in the northern hemisphere, there is a strong asso- However, further efforts are needed to develop evidence-based re-
ciation between daily mortality (all-cause mortality, cardiovascular and sponses and gather the necessary support from partner ministries.
respiratory) in locations with lower annual mean concentrations of Cooperation needs to be strengthened between the services of human,
particulate matter and higher annual mean temperatures [49]. This animal and plant health [59]. Funding needs to be accessed for activ-
correlates well to previous studies assessing cumulative effects of the ities related to health and climate change. Not only do action plans
multiple environmental factors influencing mortality [50]. The synergic need to be drawn up in the event of extreme weather conditions, in
effect between high temperature and air pollution on mortality has also order to be better prepared and to react in the best way, but also to
been shown in other regions such as in Northeast Asia [51]. obtain more reliable information on how to avoid the risks of climate
The increased release of carbon dioxide, methane, and nitrous oxide change while maintaining international cooperation. Population health
in the Earth's atmosphere as resulted in increased average temperature is typically listed as one of the national priorities for each individual
due to the greenhouse effect. This has lead to an increase in morbidity country, but there is a lack of clarity on implementation processes.
and mortality due to a cascade of adverse events [52]. Of note is the While there is evidence of progress at both national and international
increased rate of soil degradation, loss of productivity of agricultural levels, efforts are needed to increase the capacity of health systems to
land and desertification, with the consequent loss of biodiversity and manage the health risks of climate change, particularly in low- to
degradation of ecosystems. The reduced fresh-water resources are middle-income countries [55]. The resilience of health systems needs to
leading to acidification of the oceans. The disruption and depletion of be enhanced in order to ensure a sustainable path in improving popu-
stratospheric ozone is associated with increased mortality [53]. Human lation and global health [64].
susceptibility to fatal diseases might be further aggravated due to al-
terations in the human immune system caused by increased exposure to

3
 Early Human Development xxx (xxxx) xxxx

Declaration of competing interest [25] J. Chen, J. Yang, M. Zhou, P. Yin, B. Wang, J. Liu, et al., Cold spell and mortality in
31 Chinese capital cities: definitions, vulnerability and implications, Environ. Int.
[Internet] 128 (2019 Jul 1) 271–278 [cited 2020 Aug 29]. Available from: https://
The authors declare that they have no conflict of interest. pubmed.ncbi.nlm.nih.gov/31071590/.
[26] B.A. Revich, D.A. Shaposhnikov, Extreme temperature episodes and mortality in
Yakutsk, East Siberia, Rural Remote Health 10 (2) (2010 Apr) 1338.
References [27] N.R.I. Ryti, Y. Guo, J.J.K. Jaakkola, Global association of cold spells and adverse
health effects: a systematic review and meta-analysis, Environmental Health
[1] T. Dávid-Barrett, R.I.M. Dunbar, Bipedality and hair loss in human evolution re- Perspectives, vol. 124, Public Health Services, US Dept of Health and Human
visited: the impact of altitude and activity scheduling, J. Hum. Evol. [Internet] 94 Services, 2016, pp. 12–22.
(2016 May 1) 72–82 [cited 2020 Aug 29]. Available from: https://pubmed.ncbi. [28] A. Gasparrini, Y. Guo, M. Hashizume, E. Lavigne, A. Zanobetti, J. Schwartz, et al.,
nlm.nih.gov/27178459/. Mortality risk attributable to high and low ambient temperature: a multicountry
[2] M.M.T.E. Huynen, P. Martens, D. Schram, M.P. Weijenberg, A.E. Kunst, The impact observational study, Lancet 386 (9991) (2015 Jul 25) 369–375.
of heat waves and cold spells on mortality rates in the Dutch population, Environ. [29] R. Chen, P. Yin, L. Wang, C. Liu, Y. Niu, W. Wang, et al., Association between
Health Perspect. [Internet] 109 (5) (2001) 463–470 [cited 2020 Aug 29]. Available ambient temperature and mortality risk and burden: time series study in 272 main
from: https://pubmed.ncbi.nlm.nih.gov/11401757/. Chinese cities, BMJ [Internet] 363 (2018) [cited 2020 Aug 29]. Available from:
[3] Kathleen England, Liberato Camilleri, Neville Calleja, Roberto Debono, https://pubmed.ncbi.nlm.nih.gov/30381293/.
Saviour Porter, S. Plapp, The relationship of ambient temperature and humidity [30] X. Song, S. Wang, Y. Hu, M. Yue, T. Zhang, Y. Liu, et al., Impact of ambient tem-
with mortality on the Maltese Islands 1992–2005 [Internet], Available from: perature on morbidity and mortality: an overview of reviews, Sci. Total Environ.
https://www.um.edu.mt/library/oar/handle/123456789/55773. [Internet] 586 (2017 May 15) 241–254 [cited 2020 Aug 29]. Available from:
[4] Y. Cui, F. Yin, Y. Deng, E. Volinn, F. Chen, K. Ji, et al., Heat or cold: which one https://pubmed.ncbi.nlm.nih.gov/28187945/.
exerts greater deleterious effects on health in a basin climate city? Impact of am- [31] S.K. Paterson, C.N. Godsmark, Heat-health vulnerability in temperate climates:
bient temperature on mortality in Chengdu, China, Int. J. Environ. Res. Public lessons and response options from Ireland, Glob. Health 16 (1) (2020 Mar 30).
Health 13 (12) (2016 Dec 10). [32] C.J. Smith, Pediatric thermoregulation: considerations in the face of global climate
[5] Z. Xu, G. FitzGerald, Y. Guo, B. Jalaludin, S. Tong, Impact of heatwave on mortality change, Nutrients [Internet] 11 (9) (2019 Sep 1) [cited 2020 Aug 29]. Available
under different heatwave definitions: a systematic review and meta-analysis, from: https://pubmed.ncbi.nlm.nih.gov/31454933/.
Environment International, vols. 89–90, Elsevier Ltd, 2016, pp. 193–203. [33] B.A. Swinburn, V.I. Kraak, S. Allender, V.J. Atkins, P.I. Baker, J.R. Bogard, et al.,
[6] J. Yang, P. Yin, J. Sun, B. Wang, M. Zhou, M. Li, et al., Heatwave and mortality in The global syndemic of obesity, undernutrition, and climate change: the Lancet
31 major Chinese cities: definition, vulnerability and implications, Sci. Total Commission report [Internet], The Lancet, vol. 393, Lancet Publishing Group, 2019,
Environ. 649 (2019 Feb 1) 695–702. pp. 791–846 [cited 2020 Aug 29]. Available from: https://pubmed.ncbi.nlm.nih.
[7] E. Morignat, E. Gay, J.L. Vinard, C. Sala, D. Calavas, V. Hénaux, Impact of heat and gov/30700377/.
cold waves on female cattle mortality beyond the effect of extreme temperatures, J. [34] J.Y. Son, J.T. Lee, M.L. Bell, Is ambient temperature associated with risk of infant
Therm. Biol. 78 (2018 Dec 1) 374–380. mortality? A multi-city study in Korea, Environ. Res. [Internet] 158 (2017)
[8] J. Cheng, H. Bambrick, L. Yakob, G. Devine, F.D. Frentiu, D.T.T. Toan, et al., 748–752 [cited 2020 Aug 29]. Available from: https://pubmed.ncbi.nlm.nih.gov/
Heatwaves and dengue outbreaks in Hanoi, Vietnam: new evidence on early 28750343/.
warning, PLoS Negl. Trop. Dis. 14 (1) (2020 Jan 1) 1–15. [35] N. Auger, W.D. Fraser, A. Smargiassi, T. Kosatsky, Ambient heat and sudden infant
[9] B.S. Levy, J.A. Patz, Climate change, human rights, and social justice, Annals of death: a case-crossover study spanning 30 years in Montreal, Canada, Environ.
Global Health, vol. 81, Elsevier, USA, 2015, pp. 310–322. Health Perspect. 123 (7) (2015 Jul 6) 712–716.
[10] L. Zhang, Z. Zhang, T. Ye, M. Zhou, C. Wang, P. Yin, et al., Mortality effects of heat [36] S.E.L. Burke, A.V. Sanson, J. Van Hoorn, The psychological effects of climate change
waves vary by age and area: a multi-area study in China, Environ. Heal. A Glob. on children, Current Psychiatry Reports, vol. 20, Current Medicine Group LLC,
Access Sci. Source [Internet] 17 (1) (2018 Jun 11) [cited 2020 Aug 29]. Available 2018, p. 1.
from: https://pubmed.ncbi.nlm.nih.gov/29890973/. [37] Y. Zhang, Q. Xiang, C. Yu, J. Bao, H.C. Ho, S. Sun, et al., Mortality risk and burden
[11] J.M. Robine, S.L.K. Cheung, S. Le Roy, H. Van Oyen, C. Griffiths, J.P. Michel, et al., associated with temperature variability in China, United Kingdom and United
Death toll exceeded 70,000 in Europe during the summer of 2003, Comptes Rendus States: comparative analysis of daily and hourly exposure metrics, Environ. Res.
- Biol. [Internet] 331 (2) (2008 Feb) 171–178 [cited 2020 Aug 29]. Available from: (2019 Dec 1) 179.
https://pubmed.ncbi.nlm.nih.gov/18241810/. [38] J.B. Lee, J.H. Kim, H. Murota, Perspiration functions in different ethnic, age, and
[12] D. Shaposhnikov, B. Revich, T. Bellander, G.B. Bedada, M. Bottai, T. Kharkova, sex populations: modification of sudomotor function, Curr. Probl. Dermatology
et al., Mortality related to air pollution with the Moscow heat wave and wildfire of [Internet] 51 (2016) 109–119 [cited 2020 Aug 29]. Available from: https://
2010, Epidemiology [Internet] 25 (3) (2014) 359–364 [cited 2020 Aug 29]. pubmed.ncbi.nlm.nih.gov/27584970/.
Available from: https://pubmed.ncbi.nlm.nih.gov/24598414/. [39] A. Hansen, P. Bi, D. Pisaniello, M. Nitschke, G. Tucker, J. Newbury, et al., Heat-
[13] Q. Sun, C. Miao, M. Hanel, A.G.L. Borthwick, Q. Duan, D. Ji, et al., Global heat health behaviours of older people in two Australian states, Australas J. Ageing 34
stress on health, wildfires, and agricultural crops under different levels of climate (1) (2015 Mar 1) E19–E25.
warming, Environ. Int. 128 (2019 Jul 1) 125–136. [40] A. Hansen, P. Bi, M. Nitschke, D. Pisaniello, J. Newbury, A. Kitson, Older persons
[14] C. Raymond, T. Matthews, R.M. Horton, The emergence of heat and humidity too and heat-susceptibility: the role of health promotion in a changing climate, Health
severe for human tolerance, Sci. Adv. 6 (19) (2020 May 1). Promot. J. Austr. 22 (2011) (Spec No).
[15] H. Green, J. Bailey, L. Schwarz, J. Vanos, K. Ebi, T. Benmarhnia, Impact of heat on [41] M. Baccini, T. Kosatsky, A. Analitis, H.R. Anderson, M. D’Ovidio, B. Menne, et al.,
mortality and morbidity in low and middle income countries: a review of the epi- Impact of heat on mortality in 15 European cities: attributable deaths under dif-
demiological evidence and considerations for future research, Environmental ferent weather scenarios, J. Epidemiol. Community Health [Internet] 65 (1) (2011
Research, vol. 171, Academic Press Inc., 2019, pp. 80–91. Jan 1) 64–70 [cited 2020 Aug 29]. Available from: https://pubmed.ncbi.nlm.nih.
[16] B.S. Levy, J.A. Patz, Climate change, human rights, and social justice, Ann. Glob. gov/19858539/.
Heal. [Internet] 81 (3) (2015 Nov 27) 310 [cited 2020 Aug 29]. Available from: [42] M. Baccini, T. Kosatsky, A. Biggeri, Impact of summer heat on urban population
https://annalsofglobalhealth.org/articles/10.1016/j.aogh.2015.08.008. mortality in Europe during the 1990s: an evaluation of years of life lost adjusted for
[17] Y. Guo, A. Gasparrini, B.G. Armstrong, B. Tawatsupa, A. Tobias, E. Lavigne, et al., harvesting, PLoS One [Internet] 8 (7) (2013 Jul 22) [cited 2020 Aug 29]. Available
Heat wave and mortality: a multicountry, multicommunity study, Environ. Health from: https://pubmed.ncbi.nlm.nih.gov/23894516/.
Perspect. [Internet] 125 (8) (2017 Aug 1) [cited 2020 Aug 29]. Available from: [43] Y. van Steen, A.M. Ntarladima, R. Grobbee, D. Karssenberg, I. Vaartjes, Sex dif-
https://pubmed.ncbi.nlm.nih.gov/28886602/. ferences in mortality after heat waves: are elderly women at higher risk?
[18] M. Pascal, V. Wagner, M. Corso, K. Laaidi, A. Ung, P. Beaudeau, Heat and cold International Archives of Occupational and Environmental Health, vol. 92, Springer
related-mortality in 18 French cities, Environ. Int. [Internet] 121 (Pt 1) (2018 Dec Verlag, 2019, pp. 37–48.
1) 189–198 [cited 2020 Aug 29]. Available from: https://pubmed.ncbi.nlm.nih. [44] I.H. Silveira, B.F.A. Oliveira, T.R. Cortes, W.L. Junger, The effect of ambient tem-
gov/30216771/. perature on cardiovascular mortality in 27 Brazilian cities, Sci. Total Environ.
[19] A. Nori-Sarma, G.B. Anderson, A. Rajiva, G. ShahAzhar, P. Gupta, M.S. Pednekar, [Internet] 691 (2019 Nov 15) 996–1004 [cited 2020 Aug 29]. Available from:
et al., The impact of heat waves on mortality in Northwest India, Environ. Res. https://pubmed.ncbi.nlm.nih.gov/31326821/.
[Internet] 176 (2019 Sep 1) [cited 2020 Aug 29]. Available from: https://pubmed. [45] Y. Zhang, Q. Xiang, Y. Yu, Z. Zhan, K. Hu, Z. Ding, Socio-geographic disparity in
ncbi.nlm.nih.gov/31247430/. cardiorespiratory mortality burden attributable to ambient temperature in the
[20] C. Mora, C.W.W. Counsell, C.R. Bielecki, L.V. Louis, Twenty-seven ways a heat wave United States, Environ. Sci. Pollut. Res. Int. [Internet] 26 (1) (2019 Jan 1) 694–705
can kill you: deadly heat in the era of climate change, Circulation: Cardiovascular [cited 2020 Aug 29]. Available from: https://pubmed.ncbi.nlm.nih.gov/
Quality and Outcomes, Vol. 10 Lippincott Williams and Wilkins, 2017. 30414026/.
[21] China Meteorological Administration, No Title [Internet], Available from: http:// [46] Z. Sun, C. Chen, D. Xu, T. Li, Effects of ambient temperature on myocardial in-
www.cma.gov.cn/. farction: A systematic review and meta-analysis [Internet], Environmental
[22] American Meteorological Society, Glossary of Meteorology [Internet], Available Pollution, vol. 241, Elsevier Ltd, 2018, pp. 1106–1114 [cited 2020 Aug 29].
from: http://amsglossary.allenpress.com/glossary/search?id=cold-wave1. Available from: https://pubmed.ncbi.nlm.nih.gov/30029319/.
[23] J. Kysely, L. Pokorna, J. Kyncl, B. Kriz, Excess cardiovascular mortality associated [47] F. Sera, B. Armstrong, A. Tobias, A.M. Vicedo-Cabrera, C. Åström, M.L. Bell, et al.,
with cold spells in the Czech Republic, BMC Public Health 9 (2009). How urban characteristics affect vulnerability to heat and cold: a multi-country
[24] W. Lee, H.M. Choi, J.Y. Lee, D.H. Kim, Y. Honda, H. Kim, Temporal changes in analysis, Int. J. Epidemiol. [Internet] 48 (4) (2019 Aug 1) 1101–1112 [cited 2020
mortality impacts of heat wave and cold spell in Korea and Japan, Environ. Int. 116 Aug 29]. Available from: https://pubmed.ncbi.nlm.nih.gov/30815699/.
(2018 Jul 1) 136–146. [48] K. Hu, Y. Guo, X. Yang, J. Zhong, F. Fei, F. Chen, et al., Temperature variability and

4
 Early Human Development xxx (xxxx) xxxx

mortality in rural and urban areas in Zhejiang province, China: an application of a [58] A. Lal, E. Fearnley, E. Wilford, Local weather, flooding history and childhood
spatiotemporal index, Sci. Total Environ. [Internet] 647 (2019 Jan 10) 1044–1051 diarrhoea caused by the parasite Cryptosporidium spp.: a systematic review and
[cited 2020 Aug 29]. Available from: https://pubmed.ncbi.nlm.nih.gov/ meta-analysis, Sci. Total Environ. [Internet] 674 (2019 Jul 15) 300–306 [cited 2020
30180312/. Aug 30]. Available from: https://pubmed.ncbi.nlm.nih.gov/31004904/.
[49] C. Liu, R. Chen, F. Sera, A.M. Vicedo-Cabrera, Y. Guo, S. Tong, et al., Ambient [59] C. Bezirtzoglou, K. Dekas, E. Charvalos, Climate changes, environment and infec-
particulate air pollution and daily mortality in 652 cities, N. Engl. J. Med. [Internet] tion: facts, scenarios and growing awareness from the public health community
381 (8) (2019 Aug 22) 705–715 [cited 2020 Aug 29]. Available from: https:// within Europe, Anaerobe [Internet] 17 (6) (2011 Dec) 337–340 [cited 2020 Aug
pubmed.ncbi.nlm.nih.gov/31433918/. 29]. Available from: https://pubmed.ncbi.nlm.nih.gov/21664978/.
[50] Y. Jian, L.C. Messer, J.S. Jagai, K.M. Rappazzo, C.L. Gray, S.C. Grabich, et al., [60] J. Liu, J. Zhou, J. Yao, X. Zhang, L. Li, X. Xu, et al., Impact of meteorological factors
Associations between environmental quality and mortality in the contiguous United on the COVID-19 transmission: a multi-city study in China, Sci. Total Environ.
States, 2000–2005, Environ. Health Perspect. [Internet] 125 (3) (2017) 355–362 (2020 Jul 15) 726.
[cited 2020 Aug 29]. Available from: https://pubmed.ncbi.nlm.nih.gov/ [61] N. Watts, M. Amann, S. Ayeb-Karlsson, K. Belesova, T. Bouley, M. Boykoff, et al.,
27713110/. The Lancet Countdown on health and climate change: from 25 years of inaction to a
[51] W. Lee, H.M. Choi, D. Kim, Y. Honda, Y.L. Leon Guo, H. Kim, Synergic effect be- global transformation for public health [Internet], The Lancet, vol. 391, Lancet
tween high temperature and air pollution on mortality in Northeast Asia, Environ. Publishing Group, 2018, pp. 581–630 [cited 2020 Aug 29]. Available from: https://
Res. [Internet] 178 (2019 Nov 1) [cited 2020 Aug 29]. Available from: https:// pubmed.ncbi.nlm.nih.gov/29096948/.
pubmed.ncbi.nlm.nih.gov/31539825/. [62] D. Chen, X. Wang, M. Thatcher, G. Barnett, A. Kachenko, R. Prince, Urban vege-
[52] A. Rossati, Global warming and its health impact, International Journal of tation for reducing heat related mortality, Environ. Pollut. 192 (2014) 275–284.
Occupational and Environmental Medicine, vol. 8, NIOC Health Organization, [63] M.A. Beenackers, J. Oude Groeniger, Kamphuis CBM, F.J. Van Lenthe, Urban po-
2017, pp. 7–20. pulation density and mortality in a compact Dutch city: 23-year follow-up of the
[53] K. Chen, A.M. Fiore, R. Chen, L. Jiang, B. Jones, A. Schneider, et al., Future ozone- Dutch GLOBE study, Heal. Place [Internet] 53 (2018 Sep 1) 79–85 [cited 2020 Aug
related acute excess mortality under climate and population change scenarios in 29]. Available from: https://pubmed.ncbi.nlm.nih.gov/30056264/.
China: a modeling study, PLoS Med. 15 (7) (2018 Jul 1). [64] V. Kendrovski, O. Schmoll, Priorities for protecting health from climate change in
[54] S.S. Myers, M.R. Smith, S. Guth, C.D. Golden, B. Vaitla, N.D. Mueller, et al., Climate the WHO European Region: recent regional activities [Internet],
change and global food systems: potential impacts on food security and under- Bundesgesundheitsblatt - Gesundheitsforschung - Gesundheitsschutz, vol. 62,
nutrition, Annual Review of Public Health, vol. 38, Annual Reviews Inc., 2017, pp. Springer Verlag, 2019, pp. 537–545 [cited 2020 Aug 29]. Available from: https://
259–277. pubmed.ncbi.nlm.nih.gov/31016365/.
[55] K.J. Bowen, K.L. Ebi, Health risks of climate change in the World Health
Organization South-East Asia Region, WHO South-East Asia J. Public Heal. 6 (2)
Jean Calleja-Agiusa, , Kathleen Englandb, Neville Callejac,
⁎
(2017 Sep 1) 3–8.
a
[56] G. Cissé, Food-borne and water-borne diseases under climate change in low- and Department of Anatomy, Faculty of Medicine and Surgery, University of
middle-income countries: further efforts needed for reducing environmental health Malta, Malta
exposure risks [Internet], Acta Tropica, vol. 194, Elsevier B.V., 2019, pp. 181–188 b
[cited 2020 Aug 29]. Available from: https://pubmed.ncbi.nlm.nih.gov/
Department of Health Information and Research, Ministry of Health, Malta
c
30946811/. Department of Public Health, Faculty of Medicine and Surgery, University
[57] C. Naing, S.A. Reid, S.N. Aye, N.H. Htet, S. Ambu, Risk factors for human leptos- of Malta, Malta
pirosis following flooding: a meta-analysis of observational studies, PLoS One
[Internet] 14 (5) (2019 May 1) [cited 2020 Aug 30]. Available from: https://
E-mail address: [email protected] (J. Calleja-Agius).
pubmed.ncbi.nlm.nih.gov/31141558/.

⁎
Corresponding author.