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Mortality on extreme heat days using official thresholds in Spain: a multi-city time series analysis

Aurelio Tobias1*, Ben Armstrong2, Ines Zuza3, Antonio Gasparrini2, Cristina Linares5 and Julio Diaz4

Author Affiliations

1 Institute of Environmental Assessment and Water Research (IDAEA), Spanish Council for Scientific Research (CSIC), Barcelona, Spain

2 Department of Social and Environmental Health Research, London School of Hygiene and Tropical Medicine (LSHTM), London, UK

3 Biomedical Research Foundation of the Gregorio Marañón University Hospital, Madrid, Spain

4 National School of Public Health (ENS), Instituto de Salud Carlos III (ISCIII), Madrid, Spain

5 National Centre for Epidemiology (CNE), Instituto de Salud Carlos III (ISCIII), Madrid, Spain

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BMC Public Health 2012, 12:133  doi:10.1186/1471-2458-12-133

Published: 17 February 2012



The 2003 heat wave had a high impact on mortality in Europe, which made necessary to develop heat health watch warning systems. In Spain this was carried-out by the Ministry of Health in 2004, being based on exceeding of city-specific simultaneous thresholds of minimum and maximum daily temperatures. The aim of this study is to assess effectiveness of the official thresholds established by the Ministry of Health for each provincial capital city, by quantifying and comparing the short-term effects of above-threshold days on total daily mortality.


Total daily mortality and minimum and maximum temperatures for the 52 capitals of province in Spain were collected during summer months (June to September) for the study period 1995-2004. Data was analysed using GEE for Poisson regression. Relative Risk (RR) of total daily mortality was quantified for the current day of official thresholds exceeded.


The number of days in which the thresholds were exceeded show great inconsistency, with provinces with great number of exceeded days adjacent to provinces that did not exceed or rarely exceeded. The average overall excess risk of dying during an extreme heat day was about 25% (RR = 1.24; 95% confidence interval (CI) = [1.19-1.30]). Relative risks showed a significant heterogeneity between cities (I2 = 54.9%). Western situation and low mean summer temperatures were associated with higher relative risks, suggesting thresholds may have been set too high in these areas.


This study confirmed that extreme heat days have a considerable impact on total daily mortality in Spain. Official thresholds gave consistent relative risk in the large capital cities. However, in some other cities thresholds