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A cautionary note to prevent the heat effects on human health
Science of the Total Environment 439 (2012) 238–239
Contents lists available at SciVerse ScienceDirect
Science of the Total Environment journal homepage: www.elsevier.com/locate/scitotenv
A cautionary note to prevent the heat effects on human health Aurelio Tobías a, Julio Díaz b,⁎, Cristina Linares c a b c
Institute of Environmental Assessment and Water Research (IDAEA), Spanish Council for Scientific Research, Barcelona, Spain National School of Public Health, Carlos III Institute of Health, Madrid, Spain Department of Environmental Epidemiology and Cancer, National Centre of Epidemiology, Carlos III Institute of Health, Madrid, Spain
a r t i c l e
i n f o
Article history: Received 15 June 2012 Received in revised form 4 September 2012 Accepted 7 September 2012 Available online 16 October 2012 Keywords: Heat waves Prevention plans Elderly Saharan dust intrusions
a b s t r a c t The deaths of two British tourists caused by heat in the island of Gran Canaria last May while conducting outdoor physical exercise leads us to make several reflections. We discuss the subject on, the adaptation of the people to the heat, the vulnerability of individuals over 65 years and the effectiveness of prevention plans against heat waves. This study questions the appropriateness of the activation timing of these plans by the Ministry of Health, Social Services and Equality, and also questions the temperature thresholds established for their implementation. © 2012 Elsevier B.V. All rights reserved.
On May 13th two British women died, from cardiopulmonary cause (CIE-10: I46) and from respiratory failure (CIE-10: J96), as a result of high temperatures on the Gran Canary Island (Spain), whilst doing trekking in the central area of the island. Five other people were also treated for diseases related to exposure to heat (CIE-10: T67). All cases involved tourists older than 65 years. The severity of these events does not imply that it was not predictable from current knowledge on health effects of high temperatures. There are several factors related to this event. The high temperatures recorded that day, where the maximum daily temperature reached 40.7 °C (http://www.aemet.es/es/eltiempo/observacion/ultimosdatos? k=coo&w=2&datos=img&x=d04&f=tmax), in the Gran Canary Island and the lack of acclimatisation to heat of all British tourists affected. Many studies have described a J- or V-shaped relationship between daily mortality and air temperature, showing a temperature of comfort, which varies geographically (Keating et al., 2000). In Europe, the comfort temperature decreases as the latitude increases due to a biological adaptation of the population to their environment. For example, the comfort mean temperature in London is 22.3 °C, whilst in the Finnish provinces of Kuopio, Vaasa and Oulu moves down to 17.3 °C (Keating et al., 2000). This would mean that on May 13th the British tourists could be acclimated to a daily maximum temperature of, approximately, 17 °C (http://wwis.aemet.es/010/c00032.htm), that is 24 °C below the temperature of exposure at the time of their death.
⁎ Corresponding author at: Escuela Nacional de Sanidad, Instituto de Salud Carlos III, C/Monforte de Lemos 5, 08029 Madrid, Spain. Tel.: +34 91 822 22 02; fax: +34 91 387 78 62. E-mail address: [email protected] (J. Díaz). 0048-9697/$ – see front matter © 2012 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.scitotenv.2012.09.007
This lack of acclimatisation to heat is similar to that at local level that makes the first heat wave of the year has the strongest effect on daily mortality (Montero et al., 2012). However, a key factor was their age. It is wide known that people older than 65 years are those with a higher risk of mortality from heat waves. For example, in the city of Madrid the risk of cardiovascular mortality increases 23% for each degree that exceeds the threshold temperature for heat wave (Díaz et al., 2002). Furthermore, all heat response plans warn against physical exercise outdoors under the meteorological conditions attended that day in the Gran Canary Island (Ministerio de Sanidad, Servicios Sociales e Igualdad). Although the weather alarm was activated, the public health alarm was not because the National plan for preventive actions against the effects of excesses of temperatures on health enabled, by the Ministry of Health becomes active on 1st June (Ministerio de Sanidad, Servicios Sociales e Igualdad). So, we do not know if this information was properly and timely transmitted. In this sense, a recent study suggests that the threshold for heat waves in some Spanish capital cities, like Las Palmas in the Gran Canary Island, should be updated (Tobías et al., 2012). Although less obvious, another concomitant factor on May 13th was the advection East flows, which caused an intrusion of Saharan dust. Thus, in the Gran Canary Island the daily average of PM10 from 28.6 μg/m 3 on days without Saharan dust intrusion to 105.7 μg/m 3 on days with dust intrusions rises. Similarly, daily-average levels of PM2.5 also rose from 13.4 to 41.4 μg/m 3 (López et al., 2008). This abrupt increase in the PM levels during days with Saharan dust intrusions exceeds the threshold level of 50 μg/m 3 for PM10 daily average established by the European air quality guidelines (Official Journal of the European Union, 2008), even reaching daily averages up to
A. Tobías et al. / Science of the Total Environment 439 (2012) 238–239
600 μg/m 3 in Gran Canary (López et al., 2008). In this sense, it has been shown in the city of Barcelona that during Saharan dust days, a daily increase of 10 μg/m 3 of PM10–2.5 increased daily mortality of people older than 65 years by 8.4% compared with 1.4% during non-Saharan dust days (Perez et al., 2008). This has also been found in other Southern Mediterranean cities (Tobías et al., 2011; Mallone et al., 2011). From the public health viewpoint the activation of prevention- or warning-plans, may be preferably done using thresholds that reflect their impact on human health according the current scientific research on the subject. A special emphasis should also be done on those people at higher risk of health effects due to their exposure to the main environmental risk factors. These must be properly considered in those circumstances in which exposed people are not acclimated to the weather conditions of their holiday place, although being of short duration. References Díaz J, López C, Jordán A, Alberdi JC, García R, Hernández E, Otero A. Heat waves in Madrid, 1986–1997: effects on the health of the elderly. Int Arch Occup Environ Health 2002;75:163–70. http://wwis.aemet.es/010/c00032.htm. Last accessed: 13th May 2012. http://www.aemet.es/es/eltiempo/observacion/ultimosdatos?k=coo&w=2&datos= img&x=d04&f=tmax. Last accessed: 13th May 2012.
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Keating WR, Donaldson GC, Cordial E, Martin Elli M, Kent AE, Mackenbach JP, et al. Heat related mortality in warm and cold regions of Europe: observational study. Br Med J 2000;321:670–3. López E, Pérez MD, Pérez N, Ballester F, Iñiguez C, Pita ML. Caracterización del ambiente atmosférico en Las Palmas de Gran Canaria y Santa Cruz de Tenerife de 2000 a 2004. Rev Esp Salud Publica 2008;82:493–507. Mallone S, Stafoggia M, Faustini A, Gobbi GP, Marconi A, Forastiere F. Saharan dust and associations between particulate matter and daily mortality in Rome, Italy. Environ Health Perspect 2011;119:1409–14. Ministerio de Sanidad Servicios Sociales e Igualdad. Acciones preventivas frente a los efectos sobre la salud por el exceso de temperaturas. http://www.msc.es/ ciudadanos/saludAmbLaboral/planAltasTemp/2007/docs/planDefinitivoOlaDeCalor2007.pdf. Last accessed: 18th May 2012; 2012. Montero JC, Mirón IJ, Criado JJ, Linares C, Díaz J. Influence of local factors in the relationship between mortality and heat waves: Castile-La Mancha (1975–2003). Sci Total Environ 2012;414:73–80. Official Journal of the European Union. Directive 2008/50 CE of the European Parliament and Council of 21th May 2008 on Ambient and Air Quality and Cleaner Air for Europe. 11th June; 2008. L152/1-L152/44. Perez L, Tobias A, Querol X, Künzli N, Pey J, Alastuey A, et al. Coarse particles from Saharan dust and daily mortality. Epidemiology 2008;19:800–7. Tobías A, Pérez L, Díaz J, Linares C, Pey J, Alastruey A, et al. Short-term effects of particulate matter on total mortality during Saharan dust outbreaks: a case-crossover analysis in Madrid (Spain). Sci Total Environ 2011;412–413:386–9. Tobías A, Armstrong B, Zuza I, Gasparrini A, Linares C, Díaz J. Mortality on extreme heat days using official thresholds in Spain: a multi-city time series analysis. BMC Public Health 2012;12:133.
Contents lists available at SciVerse ScienceDirect
Science of the Total Environment journal homepage: www.elsevier.com/locate/scitotenv
A cautionary note to prevent the heat effects on human health Aurelio Tobías a, Julio Díaz b,⁎, Cristina Linares c a b c
Institute of Environmental Assessment and Water Research (IDAEA), Spanish Council for Scientific Research, Barcelona, Spain National School of Public Health, Carlos III Institute of Health, Madrid, Spain Department of Environmental Epidemiology and Cancer, National Centre of Epidemiology, Carlos III Institute of Health, Madrid, Spain
a r t i c l e
i n f o
Article history: Received 15 June 2012 Received in revised form 4 September 2012 Accepted 7 September 2012 Available online 16 October 2012 Keywords: Heat waves Prevention plans Elderly Saharan dust intrusions
a b s t r a c t The deaths of two British tourists caused by heat in the island of Gran Canaria last May while conducting outdoor physical exercise leads us to make several reflections. We discuss the subject on, the adaptation of the people to the heat, the vulnerability of individuals over 65 years and the effectiveness of prevention plans against heat waves. This study questions the appropriateness of the activation timing of these plans by the Ministry of Health, Social Services and Equality, and also questions the temperature thresholds established for their implementation. © 2012 Elsevier B.V. All rights reserved.
On May 13th two British women died, from cardiopulmonary cause (CIE-10: I46) and from respiratory failure (CIE-10: J96), as a result of high temperatures on the Gran Canary Island (Spain), whilst doing trekking in the central area of the island. Five other people were also treated for diseases related to exposure to heat (CIE-10: T67). All cases involved tourists older than 65 years. The severity of these events does not imply that it was not predictable from current knowledge on health effects of high temperatures. There are several factors related to this event. The high temperatures recorded that day, where the maximum daily temperature reached 40.7 °C (http://www.aemet.es/es/eltiempo/observacion/ultimosdatos? k=coo&w=2&datos=img&x=d04&f=tmax), in the Gran Canary Island and the lack of acclimatisation to heat of all British tourists affected. Many studies have described a J- or V-shaped relationship between daily mortality and air temperature, showing a temperature of comfort, which varies geographically (Keating et al., 2000). In Europe, the comfort temperature decreases as the latitude increases due to a biological adaptation of the population to their environment. For example, the comfort mean temperature in London is 22.3 °C, whilst in the Finnish provinces of Kuopio, Vaasa and Oulu moves down to 17.3 °C (Keating et al., 2000). This would mean that on May 13th the British tourists could be acclimated to a daily maximum temperature of, approximately, 17 °C (http://wwis.aemet.es/010/c00032.htm), that is 24 °C below the temperature of exposure at the time of their death.
⁎ Corresponding author at: Escuela Nacional de Sanidad, Instituto de Salud Carlos III, C/Monforte de Lemos 5, 08029 Madrid, Spain. Tel.: +34 91 822 22 02; fax: +34 91 387 78 62. E-mail address: [email protected] (J. Díaz). 0048-9697/$ – see front matter © 2012 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.scitotenv.2012.09.007
This lack of acclimatisation to heat is similar to that at local level that makes the first heat wave of the year has the strongest effect on daily mortality (Montero et al., 2012). However, a key factor was their age. It is wide known that people older than 65 years are those with a higher risk of mortality from heat waves. For example, in the city of Madrid the risk of cardiovascular mortality increases 23% for each degree that exceeds the threshold temperature for heat wave (Díaz et al., 2002). Furthermore, all heat response plans warn against physical exercise outdoors under the meteorological conditions attended that day in the Gran Canary Island (Ministerio de Sanidad, Servicios Sociales e Igualdad). Although the weather alarm was activated, the public health alarm was not because the National plan for preventive actions against the effects of excesses of temperatures on health enabled, by the Ministry of Health becomes active on 1st June (Ministerio de Sanidad, Servicios Sociales e Igualdad). So, we do not know if this information was properly and timely transmitted. In this sense, a recent study suggests that the threshold for heat waves in some Spanish capital cities, like Las Palmas in the Gran Canary Island, should be updated (Tobías et al., 2012). Although less obvious, another concomitant factor on May 13th was the advection East flows, which caused an intrusion of Saharan dust. Thus, in the Gran Canary Island the daily average of PM10 from 28.6 μg/m 3 on days without Saharan dust intrusion to 105.7 μg/m 3 on days with dust intrusions rises. Similarly, daily-average levels of PM2.5 also rose from 13.4 to 41.4 μg/m 3 (López et al., 2008). This abrupt increase in the PM levels during days with Saharan dust intrusions exceeds the threshold level of 50 μg/m 3 for PM10 daily average established by the European air quality guidelines (Official Journal of the European Union, 2008), even reaching daily averages up to
A. Tobías et al. / Science of the Total Environment 439 (2012) 238–239
600 μg/m 3 in Gran Canary (López et al., 2008). In this sense, it has been shown in the city of Barcelona that during Saharan dust days, a daily increase of 10 μg/m 3 of PM10–2.5 increased daily mortality of people older than 65 years by 8.4% compared with 1.4% during non-Saharan dust days (Perez et al., 2008). This has also been found in other Southern Mediterranean cities (Tobías et al., 2011; Mallone et al., 2011). From the public health viewpoint the activation of prevention- or warning-plans, may be preferably done using thresholds that reflect their impact on human health according the current scientific research on the subject. A special emphasis should also be done on those people at higher risk of health effects due to their exposure to the main environmental risk factors. These must be properly considered in those circumstances in which exposed people are not acclimated to the weather conditions of their holiday place, although being of short duration. References Díaz J, López C, Jordán A, Alberdi JC, García R, Hernández E, Otero A. Heat waves in Madrid, 1986–1997: effects on the health of the elderly. Int Arch Occup Environ Health 2002;75:163–70. http://wwis.aemet.es/010/c00032.htm. Last accessed: 13th May 2012. http://www.aemet.es/es/eltiempo/observacion/ultimosdatos?k=coo&w=2&datos= img&x=d04&f=tmax. Last accessed: 13th May 2012.
239
Keating WR, Donaldson GC, Cordial E, Martin Elli M, Kent AE, Mackenbach JP, et al. Heat related mortality in warm and cold regions of Europe: observational study. Br Med J 2000;321:670–3. López E, Pérez MD, Pérez N, Ballester F, Iñiguez C, Pita ML. Caracterización del ambiente atmosférico en Las Palmas de Gran Canaria y Santa Cruz de Tenerife de 2000 a 2004. Rev Esp Salud Publica 2008;82:493–507. Mallone S, Stafoggia M, Faustini A, Gobbi GP, Marconi A, Forastiere F. Saharan dust and associations between particulate matter and daily mortality in Rome, Italy. Environ Health Perspect 2011;119:1409–14. Ministerio de Sanidad Servicios Sociales e Igualdad. Acciones preventivas frente a los efectos sobre la salud por el exceso de temperaturas. http://www.msc.es/ ciudadanos/saludAmbLaboral/planAltasTemp/2007/docs/planDefinitivoOlaDeCalor2007.pdf. Last accessed: 18th May 2012; 2012. Montero JC, Mirón IJ, Criado JJ, Linares C, Díaz J. Influence of local factors in the relationship between mortality and heat waves: Castile-La Mancha (1975–2003). Sci Total Environ 2012;414:73–80. Official Journal of the European Union. Directive 2008/50 CE of the European Parliament and Council of 21th May 2008 on Ambient and Air Quality and Cleaner Air for Europe. 11th June; 2008. L152/1-L152/44. Perez L, Tobias A, Querol X, Künzli N, Pey J, Alastuey A, et al. Coarse particles from Saharan dust and daily mortality. Epidemiology 2008;19:800–7. Tobías A, Pérez L, Díaz J, Linares C, Pey J, Alastruey A, et al. Short-term effects of particulate matter on total mortality during Saharan dust outbreaks: a case-crossover analysis in Madrid (Spain). Sci Total Environ 2011;412–413:386–9. Tobías A, Armstrong B, Zuza I, Gasparrini A, Linares C, Díaz J. Mortality on extreme heat days using official thresholds in Spain: a multi-city time series analysis. BMC Public Health 2012;12:133.