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Home Eurosurveillance Weekly Release  2004: Volume 8/ Issue 11 Article 7
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Eurosurveillance, Volume 8, Issue 11, 11 March 2004

Citation style for this article: Kovats S. Heatwave of August 2003 in Europe: provisional estimates of the impact on mortality. Euro Surveill. 2004;8(11):pii=2409. Available online:

Heatwave of August 2003 in Europe: provisional estimates of the impact on mortality

Sari Kovats (, Tanja Wolf2 and Bettina Menne2.

1Public and Environmental Health Research Unit, London School of Hygiene and Tropical Medicine, London, United Kingdom;
2World Health Organization European Centre for Environment and Health, WHO Regional Office for Europe, Rome, Italy

This report may be of interest to those involved in the rapid response to communicable disease threats since much of the capacity and resources for rapid response to public health emergencies in Europe and elsewhere are to be found within the field of communicable disease. In response to the heatwave related mortality in France in summer 2003, it is interesting to note that three fellows from the European Programme for Intervention Epidemiology Training (EPIET) and six fellows from the French National training programme in Field Epidemiology (PROFET) were involved in the response to the heatwave in France, particularly in investigations and epidemiological studies carried out in nursing homes (personal communication, Alain Moren, 9 March 2004).

The French experience in 2003 shows that heatwaves in the European Region have not previously been considered a serious risk to human health with ‘epidemic’ features. Basic questions such as whether or not a heatwave can be predicted, detected or prevented, and how respond to it, must be addressed (1).

In August 2003, Europe lay sweltering under a heatwave. Although the hot weather was initially welcome, a more sinister outcome soon became apparent. As France experienced the highest temperatures for 50 years, more than 14 000 people died than would have be expected for that time of year. Paris experienced the highest nighttime temperatures ever recorded on 11 and 12 August (25.5oC), and death rates more than doubled. The heatwave was unusual in that it affected several countries and persisted for at least 10 days; in fact the whole summer (June, July, August) was much hotter than usual (2).

This paper summarises the preliminary findings officially reported from several countries of the effects of this heatwave on total mortality (Table). The estimates compare observed deaths in a defined period with those expected during the same period in previous years. Estimates are sensitive to the method used to calculate the ’expected’ mortality. Further, countries experienced differing exposures in terms of magnitude, duration and levels of weather variables, such as humidity, which makes direct comparison of impacts between countries difficult. Due to inherent delays in the death registration systems, it will be at least a year before the total burden of the heatwave can be formally estimated from complete mortality datasets.

Table. Provisional estimates for mortality attributed to heatwave event, by country.

Country Heatstroke deaths + Excess deaths(%**), all ages Time period Method for estimating baseline mortality Reference
England and Wales § 2045 (16%) 4 to 13 August Average of deaths for same period in years 1998 to 2002 3
France § 14802 (60%) 1 to 20 August Average of deaths for same period in years 2000 to 2002 4,5
Italy § 3134 (15%) 1 June to 15 August Deaths in same period in 2002 6
Portugal 7 2099 (26 %) 1 to 31 August Deaths in same period in 1997-2001 7, Personal communication from Ministério da Saúde (ministry of health), Portugal, 17 November 2003.
Spain 59 Evaluation in progress   - 8

+ coded under ICD10 X30 or ICD9 E900
§ not reported
** % excess death =[observed-expected]/expected * 100

The preliminary results in the table show that there is a lack of information on the number of reported deaths due to classical heat illnesses. Lessons learned from other countries have shown that most excess deaths are due to other causes such as cardiovascular and respiratory diseases. Data from France indicate that the main burden of excess mortality was in those aged 75 and over, and across a wide range of causes of death. More than 60% of these deaths occurred in hospitals, private healthcare institutions and retirement homes (4). Although the heatwave affected most of western Europe, there were important spatial variations, with some cities in central France reporting more than 100% increases in mortality during the heatwave.

High levels of air pollution (tropospheric ozone) were recorded in Paris, London and other cities, and there is a need to understand better the interactions between air pollutants and temperature exposures. It is also possible that death rates will have fallen after the heatwave because of some short term displacement in mortality of the very ill. More detailed investigations of the impact of the heatwave can be expected from research groups throughout Europe this year.

The summer of 2003 has shown that Europe is vulnerable to the effects of heatwaves on human health. A number of concomitant factors contributed to the high excess mortality in some countries, such as the unexpected length and intensity of the heatwave, a lack of preparedness of healthcare and social systems for such an extreme event and the lack of community-based intervention plans. Local and national governments need to start thinking about whether they should develop heatwave intervention plans. The World Health Organization has recommendations for short term and long term strategies for reducing the health impacts of heatwaves (9).

  1. WHO Regional Office for Europe. Public health responses to extreme weather and climate events. EUR/04/5046269/15. Prepared for the fourth intergovernmental preparatory meeting in Malta, 26-27 March 2004 for the development of the Fourth Ministerial Conference on Environment and Health 2004. Copenhagen: World Health Organization Regional Office for Europe; 1 March 2004.
  2. Schar C, Vidale PL, Luthi D, Frei C, Haberli C, Liniger MA, et al. The role of increasing temperature variability in European summer heatwaves. Nature 2004; 427: 332-6. Epub 2004 Jan 11. (
  3. Office for National Statistics [homepage on the internet]. Summer mortality - deaths up in August heatwave. [Posted 3 October 2003; cited 8 March 2004]. Available from:
  4. Institut de Veille Sanitaire. Impact sanitaire de la vague de chaleur en France survenue en août 2003. Progress report, 29 August 2003. ( [accessed 10 March 2004]
  5. Hémon D, Jougla E. Surmortalité liée à la canicule d’août 2003- Rapport d’étape (1/3). Estimation de la surmortalité et principales caractéristiques epidemiologiques. Paris: Institut national de la santé et de la recherché médicale (INSERM); 25 September 2003. ( [accessed 10 March 2004]
  6. Centro Nazionale de Epidemiologia, Sorveglianza e Promozione della Salute, Ufficio di Statistica. Indagine Epidemiologica sulla Mortalità Estiva. Presentazione dei dati finali (Susanna Conti). Rome: Istituto Superiore di Sanità; 2003. (à%20estiva2.pdf)
  7. Falcão JM, Nogueira PJ, Contreiras MT, Paixão E, Brandão J, Batista I. Projecto ICARO. Onda de calor de agosto de 2003: Repercussões sobre a saúde da população. Estimativas Provisorias (até 12.08.2003). Lisbon: Instituto Nacional de Saudé, Observatorio Nacional de Saudé Dr Ricardo Jorge; 20 July 2004 ( [accessed 10 March 2004]
  8. MSC. Informe sobre el potencial impacto sanitario de la ola de calor y la evolución reciente de la mortalidad general y por causas en España. Madrid: Ministerio de sanidad y consumo; 2003 (press release available at [accessed 10 March 2004]
  9. Koppe C, Kovats RS, Jendritzky G, Menne B. Heat-waves: impacts and responses. In: Health and Global Environmental Change Series, No. 2. Copenhagen: WHO Regional Office for Europe; 2004

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