Overview of Existing Heat-Health Warning Systems in Europe
2.1. Weather Forecast System
- For which country or region is the forecast produced?
- Which is the provider institution?
- What is the model or forecast system producing the forecast? Is it deterministic or probabilistic (i.e., ensemble forecast)?
- What is the spatial resolution of the warnings, i.e., city/regional/country level?
- What is the temporal resolution of the forecast, i.e., how often are the updates made?
- What is the lead time, i.e., how much time in advance are the warnings issued?
2.2. Heat-Health Warning System
- Which index or variable is used for the heat warnings?
- Which threshold(s) triggers the warnings or warning levels?
- What is the rationale behind the threshold used to issue heat warnings? Is it based on specific epidemiological studies, climatological percentiles or taken from literature?
- In addition to the general public, are there other specific target groups?
2.3. Heat-Health Action Plans
- Are the heat warnings part of a heat action plan?
- If yes, which are the intervention strategies (i.e., actions taken based on the warning level)?
- Is the warning system subject to evaluation and revision? How and how often?
2.4. Communication and Dissemination of the Heat Warnings
- In which language are the warnings delivered?
- Which kind of notification system is used to inform target groups? (i.e., do they receive any user-oriented notification and, if yes, by which means?)
- How is the information provided to stakeholders?
3. Existing Warning Systems and Action Plans
3.1. Evolution of Warning Systems
3.2. Heat-Health Action Plans
4.1. Weather Forecast Systems
4.2. Heat-Health Warning Systems
4.3. Intervention Strategies
4.4. Communication and Dissemination of the Heat Warnings
4.5. Comparison with Non-European National Heat-Health Systems
- The experience from previous extreme heat situations shows that a significant proportion of excess summer deaths occurs before the health heat wave alert is triggered, which emphasizes the importance of long-term planning actions as well as pre-alert levels by local authorities and the health sector.
- The variables that trigger the warnings should present a clear link with the impact under consideration (i.e., mortality rate, productivity losses). Therefore, the effect of all relevant meteorological variables for heat stress (including minimum and maximum temperature, humidity, wind speed, solar radiation) should be taken into account .
- The optimal index to use strongly depends on the purpose of the warning. The combination of several indices and/or different user-tailored thresholds needs to be considered to ensure an effective warning system (see Ref.  in the present Special Issue).
- The thresholds of the warning indicator should allow for short-term (throughout the year) and long-term (under a warmer climate) adaptation to heat.
- The thresholds should be based on a probability (risk) approach, i.e., they are set by considering the probability of exceeding certain mortality thresholds rather than an absolute number of deaths .
- Good coordination between the meteorological agency and health ministry or agency is necessary. Heat health warning systems should speak with “one voice” .
- Educational and communication strategies are very important to raise the awareness of the hazard, so that the population is prepared when a heat-wave occurs.
- The regular evaluation of the effectiveness of heat health warning system and associated interventions is advisable . The revision might include, in the long-term, the effect of changes in city architecture, such as including building passive systems and more green spaces.
- Information should not be limited to the local language. This is particularly relevant in countries receiving many (potentially unacclimatized) tourists in the summer season.
Conflicts of Interest
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|ID||Country||Provider, Institution||Model System||Spatial Resolution||Temporal Resolution||Lead Time|
|AU||Austria||Zentralanstalt für Meteorologie und Geodynamik (ZAMG)||INCA (1 km), ALARO (5 km), ECMWF ENS (15 km)||Regional||Several times a day||6 h (INCA), 72 h (ALARO)|
|BE||Belgium||Royal Meteorological Institute of Belgium (RMI)||ALADIN (deterministic) + RMI EPS (probabilistic, based on AROME and ALARO, 2.5 km)||Provinces||Several times a day||12–48 h, depending on the warning level|
|EN||England||Met Office and Public Health England (PHE)||Deterministic UK (UKV, 1.5 km) + Ensemble UK (MOGREPS-UK, 2.2 km)||Regional and local||Several times a day||120 h (UKV) to 5 days (MOGREPS-UK)|
|FR||France||MeteoFrance and Santé Publique France||AROME (1.3 km) + ARPEGE (16 km), deterministic||Regional||Twice a day (6 and 18 h)||36 h (AROME), 4 days (ARPEGE)|
|DE||Germany||German Weather Service (DWD)||MOSMIX (optimizes and interprets the forecasts of ICON-DWD and IFS-ECMWF)||County level||Daily||2 days (8 days for pre-information)|
|GR||Greece||Hellenic National Meteorological Service (HNMS)||ECMWF deterministic and ENS model||Regional (16 regions)||Several times a day||3 days|
|HU||Hungary||Hungarian Meteorological Service (HMS) and National Public Health and Medical Officer Service (ANTSZ)||ECMWF and GFS, both with deterministic and probabilistic versions||Minimum unit is county level||Four times a day||4 days to the public, 8 days to the authorities|
|IT||Italy (HHWS Rome)||Servizio Meteorologico Aeronautica Militare (Italian Meteorological Service), Lazio Health Authority and Department of Epidemiology||COSMO deterministic (5 and 2.2 km, depending on the domain) + COSMO-EPS (probabilistic, 7 and 2.2 km)||Regional capitals and cities with more than 250,000 inhabitants (27 cities)||Several times a day||48–72 h, depending on domain size|
|NE||Netherlands||National Institute for Public Health and the Environment (RIVM) and Royal Netherlands Meteorological Institute (KNMI)||HIRLAM + HARMONIE (2.5 km) + ECMWF ENS (9 km)||Regional||Several times a day||6 days|
|NM||North Macedonia||Macedonian Meteorology||-||National and regional||-||2 days|
|PT||Portugal (HHWS Lisbon)||Portuguese Meteorological Institute, Portuguese National Institute of Health, Portuguese General Health Directorate and Portuguese Civil Protection Service||ALADIN (12 km)||Regional and specific for Lisbon||Daily||3 days|
|RO||Romania||Public Health Ministry and Meteo Romania||-||-||-||2 days|
|SL||Slovenia||Slovenian Environment Agency (ARSO)||ECMWF incl. MOS and ensembles + ALADIN||5 regions—approximately 4000 km2 each||Daily||5 days|
|SP||Spain||National Plan joining several institutions (e.g., National Meteorological Agency AEMET, Health Ministry)||HARMONIE-AROME (deterministic) + IFS-ECMWF (probabilistic, longer lead times)||Regions and provinces||Several times a day (9, 11:30 and 23 h)||3 days (HARMONY-AROME), 5 days (IFS-ECMWF)|
|SW||Sweden||Swedish Meteorological and Hydrological Institute (SMHI)||HARMONIE-AROME (0–48h, deterministic + probabilistic with 9 members) + ECMWF (longer lead times, deterministic and ENS)||40 warning districts of variable size. The warning is limited, if necessary, to a smaller part of the district||Every morning. Rather often updates in the afternoon or in the evening, considering the latest run of the model and observed temperatures.||3–5 days ahead depending on the warning criterion|
|CH||Switzerland||Federal Office of Meteorology and Climatology (MeteoSwiss)||COSMO CLM deterministic + MOSMIX + ENS ECMWF (longer lead times)||Regional||At least once a day. Updates if necessary.||COSMO 3 days, ENS ECMWF 5 days|
|ID||Heat index||Warning thresholds/alerts levels||Nature of the warning thresholds||Target groups|
|AU||Perceived Temperature (PT) and Tmin||PT > 35 °C for at least 3 days without night cooling below 20 °C|
Thresholds are subject to modifications depending on weather in preceding days.
|Threshold from epidemiological studies (based on thermophysiological strain) in Germany by DWD adapted to Austria.||Nursing facilities, hospitals and health resorts, childcare facilities (kindergartens, schools, etc.), mobile nursing services, medical chambers and emergency organizations|
|BE||Tmax, Tmin, Tcumul||Green: No warning, all indices below thresholds.|
Yellow: Tcumul ≥ 17 °C
Orange: 2 day mean with Tmax ≥ 32 °C and Tmin ≥ 20 °C or 3 day mean Tmax ≥ 30 °C and Tmin ≥ 18 °C
Red: 3 day mean Tmax ≥ 32 °C and Tmin ≥ 20 °C
|-||Belgium Interregional Environment Agency (IR-CEL), authorities|
|EN||Tmax and Tmin||Region-specific (for Tmax and Tmin).|
Average thresholds: 30 °C for Tmax and 15 °C for Tmin for at least two consecutive days.
Five alert levels (Levels 0–4).
|Epidemiological (15–20% increased risk of mortality)||National Health Service, local authorities, social care, other public agencies, professionals working with people at risk, individuals, local communities, voluntary groups.|
|FR||Combination of Tmin and Tmax averaged over three days (BMI)||3 days mean of Tmax > regionally dependent thresholds |
3 days mean of Tmin > regionally dependent thresholds
|Biometeorological||Local authorities, Santé Publique France|
|DE||PT and Tmin||Thresholds are region-specific and consider acclimatization (previous 30 days). Benchmark:|
Level 1: 20 °C < PT < 26 °C
Level 2: 26 °C < PT < 32 °C
Level 3—Strong heat stress: 32 °C < PT < 38 °C & Tmin ≥ 17 °C
Level 4—Extreme heat stress: PT ≥ 38 °C & Tmin ≥ 17 °C
Only Levels 3 and 4 are relevant for heat warnings.
|Epidemiological research, based on thermophysiological strain||General public, health system, elderly, people living socially isolated, people needing care, obese persons, chronically ill, working people outdoors, homeless, babies and infants.|
|GR||Tmax and heat index||a. For Tmax over the northern Greek regions:|
35 °C ≤ Tmax < 39 °C (yellow), 39 °C ≤ Tmax < 42 °C (amber), Tmax ≥ 42 °C (red)
b. For Tmax over the Central and Southern parts of Greece:
37 °C ≤ Tmax < 41 °C (yellow), 41 °C ≤ Tmax < 44 °C (amber), Tmax ≥ 44 °C (red)
c. For Tmax over the islands:
33 °C ≤ Tmax < 37 °C (yellow), 37 °C ≤ Tmax ≤ 40 °C (amber), Tmax ≥ 40 °C (red)
Heat index used as a supplementary tool in order to enhance the conclusions from the consideration of each synoptic situation. No thresholds related.
|Climatological percentiles and the respective literature||General Public. Other target groups are managed by the Ministry of Health|
|HU||Tmean||Yellow: 25 °C > Tmean > 27 °C |
Orange: 27 °C > Tmean > 29 °C
Red: Tmean ≥ 29 °C
|Epidemiological, link to mortality||National Public Health and Medical Officer Service|
|IT||Tappmax and “air mass-based approach” in larger cities||City-specific||Epidemiological, related to excess of mortality||Ministry of Health, local health authorities, local civil protection, stakeholders (hospitals, retirement homes etc.) GPs, health resorts, media, registered individuals|
|NE||Tmax||more than 10% probability of 4 or more days with |
Tmax > 27 °C
|Practical: not too many warnings in a year||Elderly, people in care institutions, and chronically ill and overweight people. Public health services, trade associations and the Dutch Red Cross|
|NM||Tmax||Monthly thresholds for each of the 4 phases for 13 cities in 6 regions from May to September||-||Retirement homes, GPs, workers.|
|PT||For heat wave definition: TemperatureFor alert levels: ÍCARO index||Heat wave: Temperature > 32 °C for at least 2 days|
Level 1 & 2: ÍCARO index < 0.31
Level 3: ÍCARO index 0.31–0.93
Level 4 (Heat-wave alert): ÍCARO index > 0.93
|Epidemiological||Portuguese National Institute of Health, the Portuguese Meteorological Institute, Portuguese General Health Directorate and the Portuguese Civil Protection Service|
|RO||Tmax||Alert: Tmax 35–38 °C, Maximum response: Tmax 35–40 °C||-||-|
|SL||Tmean and Tmax||Yellow: Tmax > 31 °C|
Orange: Tmax > 34 °C and/or Tmean > 26 °C
Red: Tmax > 37 °C and/or Tmean > 28 °C
Tresholds are regionally-based
|Climatology-based percentiles||Public (general population), civil defense in case of orange or red warning|
|SP||Heat wave: TmaxHHAP: Tmax and Tmin||Heat wave: At least 3 days with at least 10% of stations in the region with Tmax > 95th percentile. Warnings for single-day events (yellow | orange | red corresponding to different Tmax for each region: North 34 | 37 | 40; Center and Med. 36 | 39 | 42; South 38 | 40 | 44).|
Level 1: 1–2 days Tmax and Tmin above threshold simultaneously
Level 2: 3–4 days above threshold
Level 3: 5 days above threshold
|Heat wave: Climatological percentiles for each region.|
HHAP: temperature triggering mortality.
|General population, Civil Protection, Maritime Rescue Centers, Department of Traffic, Military Unit for Emergencies, Red Cross, other Met Services, government and ministries, media.|
|SW||Tmax||Heat warning class 1: Tmax ≥ 30 °C for 3 or 4 days |
Heat warning class 2: Tmax ≥ 30 °C for at least 5 days or Tmax > 33 °C for at least 3 days.
Notification: Tmax ≥ 26 °C for at least 3 days.
Risk: same thresholds as for the class 2 warning,
but the risk concept is used when the forecast is more uncertain.
“notification” and “risk” are not considered warnings
|Epidemiological, based on the relation between temperature and rate of mortality.||General public and health providers as hospitals, elderly care etc.|
|CH||Heat index||Level 3 (orange): at least 3 days with HI > 90|
Level 4 (red): at least 5 days with HI > 93
|-||Construction industry, the trade unions (e.g., UNIA) and cantonal authorities|
|ID||Component ofa HHAP (Yes/No)||If Component of a HAP, Intervention Strategies||Evaluation and Revision|
|AU||Yes||Level 0—Long-term development and planning for the summer: Elaboration and updating of information material and ensure information flow with stakeholders and other administrations.|
Level 1—protection during summer, between heat waves: preparation of information (general public and specific target groups), check and update emergency phone list.
Level 2—during heat wave:
- Transmission of heat warnings to umbrella organizations and sponsors of care facilities for the elderly andparticularly heat-sensitive population groups.
- Management of hospitals, residential and care facilities and mobile services:
- Increased attention to signs of heat-related illnesses.
- Recording and documenting room-related heat stress (room temperature, solar radiation) and taking acute adaptation measures (ventilation behaviour, sun protection, changing the occupied zone)
- Ensure sufficient availability and use of suitable beverages, monitor liquid balance of endangered persons.
- Support cooling of the body (e.g., showers, hand and foot baths) and appropriate clothing, bed linen.
- Ensure appropriate nutrition and food safety.
- Avoidance of outdoor activities at peak times.
- Family and neighborly contacts consciously activate
- Phone line available for the population.
|BE||Yes||Public cooling areas, phone hotline. -|
|EN||Yes||From long-term planning for severe heat, through summer and heatwave preparedness, to a major national emergency. |
Social and healthcare services target specific actions at high-risk groups.
Potential discontinuation of public or sporting events, closure of schools, provision of local cool centers, reduce urban heat & deteriorating air quality by minimizing unnecessary transport and energy use.
Implications for trains: staged preventative measures at 22 °C, extreme precautions at 36 °C, measures to prevent track buckling.Bottled water supply.
|FR||Yes||Upscale hotline staff.|
Track and support homeless (t-shirt, water, sun-cap, map of drinking fountains, emergency shelter venues).
Voluntary registry of vulnerable people and monitoring (NGO, including Red Cross).
Installation and maintenance of air-conditioned in residential care.
Installation of public water provision or open up public swimming pools.
|DE||Yes, in some federal states of Germany||Depending on the federal states of Germany. Overall phone hotline and information campaign.|
Example in Berlin: “heat bus”, supplying refreshments, sun protection and information.
|GR||General Secretariat for Civil Protection responsible for actions||-||No|
|HU||Yes||Forecasted heat wave: info to health care system and general public.|
During heatwave: provide portable water in public places, water roads and parks, monitor water supply and quality, planned disruption of electricity, special rules for employers and restrictions for public transport.
Extraordinary measures: increase hospital beds, ambulance units, hospital staff, cool bodies at morgues, extend opening hours public air-conditioned places and pools, defer non-essential surgery.
|IT||Yes||Active monitoring of vulnerable groups by GPs, social workers, volunteers (phone calls & home visits by GPs).|
Activation of emergency protocols in care and retirement homes and in hospitals (postpone non-emergency surgery, discharge planning, staff rotation restrictions, increased hospital beds).
|NE||Yes||Several organizations warn their target groups and regional contacts.|
Measures to limit the impact of hot weather conditions provided through the heat plan.
|Regular meetings to discuss the method of the heat plan and the effects|
|NM||Yes||Monitoring, information provided to retirement homes and GPs, installation or maintenance of public drinking fountains & springs, education to public. |
Phase 1: preventative measures media campaign, home visits to elderly, socially isolated and homeless (red cross); phone line.
Phase 2: supply food to elderly and at risk media alert, specific measure for health care preparedness, protection measures for occupationally heat exposed workers; including activating redistribution in residential settings to air-conditioned rooms, extra staff on hotline.
Phase 3: Emergency, led by National Crises Management Center
|PT||Yes||Public health emergency telephone used as hotline and reinforced with nursing personnel.|
Increase capacity of health care services, upscale staff for telephone hotline.
Info to public, authorities, health sectors & media. Activate local refuge shelters, monitor need for transportation to places of refuge; notify most vulnerable; increase capacity of health care services.
|In specific, extreme years.|
|RO||Yes||Monitoring and general advice to public and health institutions.|
Phone hotline; daily information to health ministry, health authorities; monitors sanitary, water, food prep, med storage, outreach people with social dependence. Emergency response: increase support to ambulance or emergency services.
|SP||Yes||Levels 0, 1: information (media, social services, institutions) and monitoring. |
Level 2: intensify communication (hospitals and social services), evaluation of specific measures.
Level 3: recommendations to population under risk, evaluation by the Centre of Warnings and Health Emergencies.
|At least once a year|
|SW||The SMHI is only in charge of the heat warnings, not the actions.||It is up to each county to develop strategies.||All class 2 warnings are evaluated. The whole warning system will be revised in the next few years with the introduction of impact-based warnings and flexible warning districts.|
|CH||Yes, cantonal heat plans||The strategies depend on the cantonal authorities. For instance, in Ticino: |
-During the period of health surveillance, from 1 June to 15 September, constant monitoring of the weather.
-In the event of a heat wave: continuous communication with the main partners (Service for the Protection of the Population, Labour Inspectorate Office, municipalities, homes for the elderly, home care and assistance services, representatives of the world of work) and health monitoring in collaboration with the emergency department of the Ente Ospedaliero Cantonale
|Feedback from cantons after each warning and annual warnings’ conference.|
|ID||Language||Notification System to Target Groups||Notification System to Stakeholders||Source||Website|
|AU||German||Website||Internally, all warnings above a certain category are subject to a certified process, which determines which bodies have to be informed and in which form.|
Email-Newsletter with detailed forecasts, tips, links etc. to nursing homes, kindergardens, hospitals, civil protection, firefighters, red cross.
|EN||English||Media, website, emails, social media, leaflet (via pharmacies, GPs, national health system, advice centres, hospitals, care homes)||Email-Newsletter|||
|FR||French||Communicated to the media and the general population by MétéoFrance through a vigilance map||-||[69,70]||http://vigilance.meteofrance.com/|
|DE||German||Email-Newsletter, website, Apps, radio, internet, newspaper, television||Email-Newsletter|||
|GR||Greek||Website, twitter||The Ministry of Health issues the notifications to all the stakeholders.||-||www.emy.gr/emy/en|
|HU||Hungarian and English, via web and Meteoalarm||Website, mobile app (Meteora)||E-mails to the National Public Health and Medical Officer Service|||
|IT||Italian||City-specific warning bulletins are distributed at both national and local level and published online.Information through national/local help-lines and via the media. Diffusion of warnings via the media, Ministry of Health/Civil Protection websites.||Warning bulletins published daily on the website and sent to stakeholders. Flyers in centres for elderly and public places, local pharmacies health centres and GPs.||; www.ccm-network.it/documenti_Ccm/prg_area3/Piano_caldo_2009-2012/report/4semestre/Allegato4.2_poster-Eph2011.pdf|
|NE||Dutch||Letters, media (press release), emails etc.||Public health services, trade associations and the Dutch Red Cross warn their supporters and regional contacts.Practical information on measures in the toolkit ‘Hitte’ (‘heat’). It contains: list of questions and answers, public brochure, sample letters, press announcement, text of the National Heat Plan. It is aimed at environmental health experts, environmental nurses, medical environmentalists, communication staff, etc.||www.rivm.nl/publicaties/nationaal-hitteplan-versie-2015|
|RO||Romanian||-||Daily information to health ministry and health authorities.||||www.meteoromania.ro/avertizari|
|SL||Slovene||ARSO web pages, Twitter, Facebook, radio, TV||Website, Twitter, Facebook, radio, TV. Civil defense by E-mail.||www.meteo.si/met/sl/warning|
|SP||Spanish (and CAP in English)||Website (maps, bulletins and CAP), social media (especially Twitter), Open Data server for further analyses.||Direct/automatic distribution to public bodies. CAP and bulletins.||www.aemet.es/documentos/es/eltiempo/prediccion/avisos/plan_meteoalerta/plan_meteoalerta.pdf|
|SW||Swedish and English||Authorities and institutions in the health sector and in the elderly care can register to receive emails when heat warnings are issued.||Stakeholders are notified by email, via mobile application, website, social media and/or via early warning telephone conference.||-||www.smhi.se/en/weather/sweden-weather/warnings|
|CH||German/French/Italian and the SMS also inEnglish.||MeteoSwiss app and website.Postal code subscription via app for receiving region-specific warnings.||The dissemination of the warning message to the stakeholders (hospitals, retirement homes, etc...) is handled differently depending on the region. In Ticino and French-speaking Switzerland, some heat products are sent daily in summer (forecasts of Tmax, Tmin).||www.meteoswiss.admin.ch/home/weather/gefahren.html|
© 2019 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).
Share and Cite
Casanueva, A.; Burgstall, A.; Kotlarski, S.; Messeri, A.; Morabito, M.; Flouris, A.D.; Nybo, L.; Spirig, C.; Schwierz, C. Overview of Existing Heat-Health Warning Systems in Europe. Int. J. Environ. Res. Public Health 2019, 16, 2657. https://doi.org/10.3390/ijerph16152657
Casanueva A, Burgstall A, Kotlarski S, Messeri A, Morabito M, Flouris AD, Nybo L, Spirig C, Schwierz C. Overview of Existing Heat-Health Warning Systems in Europe. International Journal of Environmental Research and Public Health. 2019; 16(15):2657. https://doi.org/10.3390/ijerph16152657Chicago/Turabian Style
Casanueva, Ana, Annkatrin Burgstall, Sven Kotlarski, Alessandro Messeri, Marco Morabito, Andreas D. Flouris, Lars Nybo, Christoph Spirig, and Cornelia Schwierz. 2019. "Overview of Existing Heat-Health Warning Systems in Europe" International Journal of Environmental Research and Public Health 16, no. 15: 2657. https://doi.org/10.3390/ijerph16152657