2. Experimental Section
3. Results and Discussion
3.1. Characteristics of Identified HEWS
3.2. Triggers, Thresholds and Notification
|Country||Developed by||Level||Year of identified plan||Frequency of updates||Heatwave alert coordinating body||Trigger Indicator||Threshold trigger||Lead time||Indicator monitoring/forecasting body|
|Belgium  accessed on 20 March 2011||Federal Public Service Health, Food Chain Safety and Environment||National||2008||Not described (updated 2011)||Unclear||Tmax; Tmin||3 day mean|
Tmax: ≥30 °C; Tmin: ≥18 °C
|France  Accessed on 11 March 2011||Ministry of Health and Sports||National and Regional plans||2010||Updated every year since 2004 (updated 2011)||Institut de veille sanitaire and Meteo-France||Tmax; Tmin|
|3 days mean of Tmax > regionally dependent thresholds and 3 days mean of Tmin > regionally dependent thresholds,|
HSI: risk: 27 °C; high risk: 32 °C, danger: 41 °C
|5 day forecast;|
24 hr alert (NB: if >2 days of alert forecasted—bulletin also includes health indices)
|Germany  accessed on 11 March 2011||Federal Environment Agency & German Weather Service||National with warnings on county level||2008||Initiated in 2004, update frequency not described||German Weather Service||PT, Tmin||Severe heat stress: PT ≥ 32 °C (exact threshold depends on weather situation of last 30 days but does not exceed 34 °C); Extreme heat stress: PT ≥ 38 °C. Warnings if thresholds are exceeded for 2 consecutive days and Tmin (night between) > 16–18 °C)||48 hour||German weather service|
|Hungary  accessed on 11 March 2011||The National Public Health Central Hungary||National (Local temp and morality monitoring—Budapest)||2006||Not described||The National Public Health co-ordinating body–Alert issued by National Chief Medical Officer||Tmean||3 day Tmean > 26.6 °C (98% frequency)||10 day forecast (Euroheat) & 3 day (MS)|
|Euroheat and Meteorological service (MS)|
|Italy  Accessed on 16 May 2011||Department of Civil Protection and the Ministry of Health||National and local (outlines temp thresholds for 27 Cities)||2009–2011||Updates every two years since 2004 (Last updated 2011)||National: The Lazio Region Department of Epidemiology. Regional: Local Civil Protection, Municipality, or Local Health Authority||Tapp max||3 days Tapp max thresholds (increasing monthly) range: 25.5 °C to 37.5 °C for 10–20% excess mortality & for >20% excess mortality range: 27.5 °C to 39.5 °C.|
Airmass models: Excess mortality in 65+ population (%): Dry Tropical (DT): 7% to 20% Moist Tropical plus (MT+): 15% to 46% Moist Tropical (MT): 4% to 8.6%
|Up to 72 hours in advance in 27 cities||Meteorological Service of the Department of Civil Protection, Ministry of Health|
|The Former Yugoslav Republic of Macedonia  accessed on 29 April 2011||Ministry of health (National Commission for Climate Change and Health)||National with 6 regional thresholds||2011||Annually||Ministry of health (National Commission for heat-waves protection )||Tmax||Specifies Tmax specific monthly trigger threshold for each of the 4 phases for 13 cities in 6 regions from May to Sept||2 day forecast;|
24 hr alert
|Netherlands  accessed on 5 May 2011||Ministry of Health, RIVM, the Netherlands Red Cross, and ActiZ GGD Netherlands||National||2007||Not described||National Institute of Health (RIVM)||Tmax||5+ days above 27 °C||At least 24 hours||Meteorological Services|
|Portugal  accessed on 18 April 2011||The Directorate-General of Health and Ministry of Environmental and Occupational Health||National (with regional thresholds)||2010||Annually (updated 2011)||Tmax, Tmin, plus regional Tmax, ICARUS index, HSI, data considered||6 day Tmax >5 °C higher than Tmax mean of 1961–1990 period;|
Yellow alert: Icarus 0.01 to 0.99, or 1 day observed Tmax + 2 days forecasted Tmax May–Sept ≥ 32 °C and <35 °C; Tmax all regions; ≥35 °C to <38 °C July–Sept Alentejo only, or Tmin: May–Sept ≤24 °C & <26 °C (all regions) 2 days Tmin observed & > 2 days Tmin expected.
Red alert is triggered if the indices > yellow alert.
|Daily 3 day forecast||Monitored and co-ordinated by Operation group health (GOS) *:|
|Romania  accessed on 11 March 2011||Public Health Ministry and Meteo Romania||National||2008||Not described||Ministry of Public Health||Tmax||Alert: Tmax 35–38 °C;|
Maximum response: Tmax 35–40 °C
|48 hours||National Institute of Meteorology and Hydrology|
|Spain  accessed on 11 March 2011||Ministry of health; Directorate general of public health||National (with thresholds for each province, #52) NB each region has a HEWS||2011||Frequency not described (First iteration 2004)||The Ministry of Health||Tmax; Tmin||Tmax and Tmin (simultaneously) >95% of the past series (sic, ‘historical series’) for the next 5 days|
Some exceptions for some regions (i.e., coastal northern region)
The level is assigned depending on the number of forecasted days exceeding the threshold
Level 0: 0/5
Level 1: 1–2/5
Level 2: 3–4/5
Level 3: 5/5
|Monitored and co-ordinated by Ministry of Health (General Directorate of Public Health) and Ministry of Environment (Spanish Agency of Meteorology and Climate Change Spanish Office). Other ministries and agencies are also involved in the national plan.|
|UK  Accessed on 11 March 2011||UK Department of Health and the Welsh Assembly.||National (with regional thresholds)||2010||Annually (updated 2011)||Department of Health||Tmin, Tmax||Level 2 alert: 60% chance of trigger; Temp ≥ 30 °C by day & 15 °C overnight for 2 days and night b/n (range of regional Temps specified).|
Level 3 alert: heatwave conditions met in 1 or more regions.
|Level 2: 2–3 days|
Level 3: 1 day of threshold conditions met and next day forecast meets threshold
|The Met Office|
|Switzerland  accessed: 15 March 2011||The Federal Office of Public Health and the Federal Office for the Environment||National (with links to 3 regional plans)||2007||Last updated 2007||The Federal Office of Public Health and the Federal Office for the Environment||HI||NOAA’s Heat Index threshold: 90 as a max daily value—which equals an air temperature of 32 °C at a humidity of 40%.||The next day||Meteo Swiss|
|Country||Air pollution (actions)||Mortality (actions)||Other health indicators|
|Belgium ||✓ |
Ozone; info phase threshold = 180 µg/m3; alert = 240 µg/m3. sends press releases to press agencies
Mortality data from the National Institute of Statistics and Studies (INSEE) collected and sent to Institut de veille sanitaire (InVS) daily, analyses weekly
Institut de veille sanitaire monitors health care data from OSCOUR (Organization for the Coordinated Monitoring Emergencies) for heat related illnesses. Also difficulty with drinking water or electricity supply, hospitals being overwhelmed with patients, or drought.
(Mentions ozone and air-pollutants as an added risk factor during heatwaves)
Air pollution-ozone; info phase threshold = 180 µg/m3; alert = 240 µg/m3.
Real-time National monitoring of mortality from May to Sept
Real-time National monitoring of emergency ambulance calls from May to Sept
Real-time National monitoring of mortality in 34 cities, data collected by local Municipal Registry Offices sent to National Coordination Centre. Data includes: date and place of birth and death, gender, residence and the cause of the event (accidental\non-accidental))
|The Former Yugoslav Republic of Macedonia ||✓|
Sulphur dioxide, nitrogen dioxide, ozone and carbon monoxide
(Daily mortality in Skopje (capital); records grouped by age and sex and compared with meteorological data)
Monitors # of calls to emergency in 2 cities (Skopje and Strumica) daily (records and groups symptoms and compares with meteorological data)
Alert if water scarcity or power failure, can be scaled up to a crisis.
Ozone; info phase threshold = 180 µg/m3; alert = 240 µg/m3.
Daily mortality data fed back to GOS
Monitors daily demand for emergency services, hospital admissions, 24 Health service demand from 15 May to 30 Sept. Ultraviolet, fire and local events
Implements uniform same day reporting of death due to heatwaves
# people fallen in the street; #. first aid points; #. requests to SAJ; % increase in the number of requests from the previous day to SAJ; # intervention mobilized ambulances in the county; # necessary additional ambulances; Staff SAJ enough; If not, what staffing; # control actions carried out by ISS
(Monitors daily funeral data from 10 municipals, records of age/sex/death & daily coroner death certificates from 4 hospitals in Barcelona)
Sulphur dioxide, nitrogen dioxide, ozone and carbon monoxide
HPA monitors the number of calls people make to NHS Direct and the number of visits made to a sample of GP practices. Emergency level reached if power or water shortages
Ozone; info phase threshold = 180 µg/m3; alert = 240 µg/m3.
(Monitors mortality weekly)
|Country||HEWS active period||Phases||Actions prior to heatwave||Actions during heatwave or heatwave forecasted|
|Belgium ||15 May to 30 Sept||3 phases: 2 levels of monitoring; and heatwave action phase||Forecasting, monitoring; warning (press release bulletin) (2 levels);||Heatwave alert; suggest public cooling areas, provides phone hotline (general).|
|France ||1 June to 1 Oct||3 phases: monitoring (1/6 to 31/8); warning and action (mise en garde et d’actions MIGA): heatwave forecasted & maximum mobilization: heat wave with implications beyond the health field||Monitoring: Seasonal surveillance & monitoring (1/6 to 31/8) leaflet and poster (seniors, parents athletes, workers); pre-heatwave prevention/ management media campaign; heat-hotline||Warning & action, & maximum mobilization: Upscale hotline staff, tracking & supporting homeless (lockers, t-shirt, water, sun-cap, map of drinking fountains, emergency shelter venues), voluntary registry of vulnerable, monitors vulnerable (NGO, including Red Cross, visits); installation & maintenance of air-conditioned commonroom in residential care; additionally health departments & residential institutions have white & blue heat action plans PM decides when to cease maximum mobilisation & communicates this decision to relevant stakeholders & ministries|
|Germany ||Not described||3 phases: forecasting: pre-warning: official warnings||Forecasting, monitoring; phoneline up to week in advance; pre-warning information, heat illness prevention and recognition information campaign||Phone in line; heatwave information -based official warnings: update daily-internet: website 24 hours notice.|
|Hungary ||Not described||3 phases: Alert (Gr1): 25 °C (15% mortality increase); Preparedness (Gr2): 3 days forecast ≥25 ºC or 1 day Tmean 27 ºC (15% mortality increase); Alarm (Gr3): 3 days Tmean 27 ºC (30% increase mortality)||Alert: National Institute of Environmental Health notifies National Ambulance Service, pre-season awareness campaign||Forecasted: info to health care system & public. During heatwave, provide portable water in public places, water roads & parks in evenings, monitor water supply and quality, planned disruption of electricity. Extraordinary measures: increase hospital beds, ambulance units, hospital staff, cool bodies at morgues, extend opening hours public air-conditioned places and pools, transport action, defer non-essential surgery.|
|Italy ||15 May to 15 Sept||3 phases, Level 1 attention: pre-warning conditions & low risk of mortality, Level 2 alarm: meteorological conditions associated with a high risk. Level 3 Emergency : 3 or more consecutive days of level 2||Level 1: flyers in centres for elderly and public places, local pharmacies health centres and GPs.|
Information through national/local help-lines and via the media.
Identification of at-risk subgroups sent to GPs and Health/Social services
|Diffusion of warnings via the media, Ministry of Health/Civil Protection websites. Active monitoring of vulnerable subgroups 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).|
|The Former Yugoslav Republic of Macedonia ||1 May to 30 Sept||4 phases. Phase 0 (green) no danger; phase 1 (yellow) alert temp , phase 2 (orange) Heatwaves; Phase 3: (red) dangerous (catastrophic) temp:||Monitoring, information provided to retirement homes & 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 & 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, lead by National Crises Management Center|
|Netherlands ||1 June to 1 Sept||3 phases: Vigilance; Diligence: heightened monitoring 20% probability of temps for 5 or more days reaching 27ºC, Warning Phase-probability of a period of five days or more above 27ºC is 90%.||Monitoring, institution aware of need to plan for heatwaves.||Media alert, press release from the National Institute of Health and Meteorological Services; assess needs (e.g., shelter) of homeless; volunteers or GP monitor vulnerable.|
|Portugal ||15 May to 30 Sept||2 phases: surveillance and daily alert; 3 alert levels: green, amber and red. Green Alert: normal temperatures, Amber Alert: high temperatures; Red Alert: serious high temperatures.||Surveillance. Monitoring and forecasting, Green alert: general measures of heat health information.||Amber alert: Info to public, authorities, health sectors, and media. Increase capacity of health care services, upscale staff for telephone hotline. Red alert: info to public, authorities, health sectors & media. Activate local refuge shelters, monitor need for transportation to places of refuge; notify most vulnerable (by referral); increase capacity of health care services.|
|Romania ||Seasonally when Tmax < 35 °C between the hours 11:00–17:00||3 phases: Code green (<35 °C b/n 11:00–17:00); Code Yellow (35–38 °C b/n 11:00–17:00) specific measures of alert; Code Orange (35–40 °C between 11:00–17:00); Code Red (>40 °C b/n 11:00–17:00) maximum mobilization measures.||Green: no specific measures; seasonal activation; yellow monitoring & support; general advice to public health authorities & monitors hospital needs (water supply, ventilation, storage tanks); municipalities to prepare list of persons with social dependency.||Free phone-in line (10:00–17:00); daily information to health ministry, health authorities; monitors sanitary, water, food prep, med storage, microclimate compliance of public services, housing & jobs, outreach people with social dependence (nurses & health mediators). Emergency response: according to public health priorities identified; increase support to ambulance or emergency services; hospitals emergency cases only.|
|Spain ||1 June to 15 Sept||2 phases :Phase 0: 1 June to 15 Sept;|
Phase 1: 15 June to 31 Aug.
|Information, site specific actions, lists of at risk (AR) individuals, checks with regional services.||Dissemination of temperature and mortality data; prevention information to AR patients (personal fan health advice leaflets); general hotline activated; AR social services, monitoring (phone call &/ visit) vulnerable (referral through social services); relocation of residential AR populations to air-conditioned environment; activation of emergency services.|
|UK ||1 June to 15 Sept||4 phases. Green: Summer vigilance Yellow: Alert & readiness. Amber: Heatwave, T-threshold for one or more regions reached for one day & next night, & the forecast next day > 90% confidence. Red: Emergency situation, severe prolonged heatwave.||Green: monitors, preparedness & long-term cool & energy efficient planning (urban housing, workplaces, transport systems & the built environment). Yellow: Disseminates forecasts, leaflet (via pharmacies, GPs, NHS, advice centres, HPA & national websites, hospitals, care homes), identifies & monitors at risk. Homes at risk from hot weather can request, home audit using the Housing Health and Safety Rating System.||Amber. Social and healthcare services target specific actions at high-risk groups. Red: Emergency measures; potential discontinuation of public or sporting events, closure of schools; provision of local cool centres, reduce urban heat & deteriorating air quality by minimising unnecessary transport and energy use. Implications for trains, staged preventative measures at 22 °C, extreme precautions at 36 °C; deploy hot weather notices & bottled water supply, as well as measures to prevent track buckling; implications for power supply.|
|Switzerland ||Not described||4 phases: Caution: 27–32 °C; HI: <32 °C. Extreme caution: 32–41 °C; Danger: 41–54 °C; Extreme danger: HI >54 °C. NB. HI:> 32 °C||Monitoring, forecasting, and dissemination of heat illness recognition and prevention information||Warning to GOS&A & population; no broader adaption strategies mentioned|
3.3. Tailoring Messages for Vulnerable Populations
|Action||Proportion of action plans addressing action|
|Identifies dissemination methods||12/12|
|Other (commercials (1), media kit on intranet (1), posters (1), dedicated phone in line (1))||3/12|
|Other (newsletter sign up)||1/12|
|Specifies sources of messages||2/12|
|Health centre nurse||0/12|
|Identifies at risk populations||11/12|
|Socio economic status||3/12|
|Refined to most vulnerable||2/12|
|Other (Ramadan (1); institutionalized (1); people with fever (3), pregnant women(1))||4/12|
|Individual adaptation advice||11/12|
|Limit physical/outdoor activity||11/12|
|Wear loose light colour clothes||9/12|
|Spend time in aircon env||4/12|
|Help vulnerable individuals||9/12|
|Seek advice for health problems||6/12|
|Seek advice changing medications use||5/12|
|Replenish electrolyte intake||4/12|
|Protect against sunburn||4/12|
|Know forecasted temp||4/12|
|Monitor room temp||3/12|
|Travel by night/cooler hours||2/12|
|Rational working hours||2/12|
|Other (mitigation pale/reflective paint, shading sun-facing aspects (2), turn off unused appliances (4))||4/12|
|Outlines carer child adaptation advice||9/12|
|Outlines carer adult adaptation advice||9/12|
|Outlines any carer adaptation advice||10/12|
|Identify at risk individuals||7/12|
|Increase monitoring of at risk individuals||8/12|
|Heat audit rooms||7/12|
|Consider staffing issues||3/12|
|Provide AC or common cool room||6/12|
|Install thermometers/monitor room temp||4/12|
|Freq. change of bed linen & storage||4/12|
|Structural/mitigation (shading, painting, greening of sun facing aspects (1), water roofs, grasses & vegetation at night (1), water sun facing walls (1))||4/12|
|Other (avoid excessive cooling (<28 °C) (1), avoid plastic continence pants/pads (2), weight loss is a measure of dehydration, weigh regularly (1), discuss adjustments of meds with GP before heatwave (1), adjust physiotherapy schedules to outside 11–16:00 (1), collaborate with family and residence (1)).||7/12|
|Considers broader support measures||11/12|
|Suggests attend public cooling area||8/12|
|Provides list of cooling areas||6/12|
|Monitors/supports public cooling area||4/12|
|Maintains list of vulnerable individuals||2/12|
|Monitors vulnerable individuals||8/12|
|Provides outreach to identified vulnerable||5/12|
|Addresses shelter/water needs of homeless||3/12|
|Seeks to identify transport needy||2/12|
|Provides support for transport needy||0/12|
|Provides heat health phone line||8/12|
|Includes evacuation plan||1/12|
|Discusses power outage||1/12|
|Explains heat adverse health effects||11/12|
|Provides advice only||11/12|
|Provides emergency contact list||9/12|
|Provides primary prevention advice||12/12|
|Provides secondary prevention||12/12|
|Addresses pre-existing beliefs||0/12|
3.4. Implications of the Timing of Heatwaves
3.5. Heat Adaptation Advice
3.6. Heatwave Mitigation
3.7. Comparison with Past Research
3.8. Limitations of This Study
Conflict of Interest
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