Background: Climate change has increased the frequency, intensity, duration, and spatial extent of some extreme weather events, for instance heat waves. Societies today are experiencing an ongoing change in the population structure yielding an increasing proportion elderly due to increased longevity, resulting in higher prevalence of chronic and degenerative diseases. Literature suggests that the elderly and certain susceptible subgroups with chronic disease are among the most vulnerable to heat waves and elevated temperatures. Aim: The main aims of this thesis were to expand the scientific knowledge on the short-term effects of extreme heat on mortality for the general population and certain susceptible groups in society, to investigate the development of this relationship over time and to attribute mortality to observed climate change. Methods: Daily numbers of deaths and daily meteorological observations during three different periods were collected for present day Stockholm County, Sweden. The analyses of the relationship between mortality and temperature extremes were analysed using a time series approach. The regression models assumed the daily counts of mortality to follow an overdispersed Poisson distribution and adjustments were made for time-trends as well as confounding factors. Results: The literature review of recent studies identified a strong relationship between heat and heat waves and increasing death rates among the elderly, particularly for respiratory and cardiovascular mortality. A statistically significant increase in total daily mortality during heat extremes in all decades investigated, as well as over the entire period, during the period 1901-2009 with a declining trend over time for the relative risk associated with heat extremes, was reported in paper II. For the period 1901-2009 cold extremes significantly increased mortality, with a more disperse pattern over individual decades and no declining trend over time. Paper III attributed increased mortality due to climate change between 1900-1929 and 1980-2009. This increase was mainly due to a large number of excess heat extremes in the latter time period. Furthermore certain subgroups of the population above 50, were in paper IV found to have significantly increased mortality during heat waves as compared to non-heat wave days. Conclusions: Although the relative risk of dying during extreme temperature events appears to have fallen in Stockholm, Sweden, such events still pose a threat to public health. The elderly population and certain susceptible subgroups of the population experience higher relative risks of dying on heat waves days as compared to normal summer days. Some of the groups most susceptible during heat waves were identified. In order to minimize future impacts of heat waves on public health, identifying susceptible subgroups in an ageing society as well as develop strategies to reduce the impact of future temperature extremes on public health will be important.

Four different heat wave definitions (as outlined by Hajat et al, 2006; D’lppoliti et al, 2010; Anderson and Bell, 2011; Nairn and Fawcett, 2013) were used to characterize heat wave mortality across the United States. The goal was to identify if certain definitions perform better or worse than others. Overall every definition performed poorly, resulting in high False-Alarm Ratios and low Heidke Skill Scores. However, the Nairn and Fawcett (2013) and Anderson and Bell (2011) definitions performed consistently better than the other definitions. Despite several limitations, the results of this study indicate that the heat wave definitions need refinement. Additionally, the Nairn and Fawcett (2013) definition could be one of the best definitions for assessing heat waves and heat-related mortality.

Global climate change is anticipated to raise overall temperatures and has the potential to increase future mortality attributable to heat. Urban areas are particularly vulnerable to heat because of high concentrations of susceptible people. As the world's largest developing country, China has experienced noticeable changes in climate, partially evidenced by frequent occurrence of extreme heat in urban areas, which could expose millions of residents to summer heat stress that may result in increased health risk, including mortality. While there is a growing literature on future impacts of extreme temperatures on public health, projecting changes in future health outcomes associated with climate warming remains challenging and underexplored, particularly in developing countries. This is an exploratory study aimed at projecting future heat-related mortality risk in major urban areas in China. We focus on the 51 largest Chinese cities that include about one third of the total population in China, and project the potential changes in heat-related mortality based on 19 different global-scale climate models and three Representative Concentration Pathways (RCPs). City-specific risk estimates for high temperature and all-cause mortality were used to estimate annual heat-related mortality over two future twenty-year time periods. We estimated that for the 20-year period in Mid-21st century (2041-2060) relative to 1970-2000, incidence of excess heat-related mortality in the 51 cities to be approximately 37,800 (95% CI: 31,300-43,500), 31,700 (95% CI: 26,200-36,600) and 25,800 (95% CI: 21,300-29,800) deaths per year under RCP8.5, RCP4.5 and RCP2.6, respectively. Slowing climate change through the most stringent emission control scenario RCP2.6, relative to RCP8.5, was estimated to avoid 12,900 (95% CI: 10,800-14,800) deaths per year in the 51 cities in the 2050s, and 35,100 (95% CI: 29,200-40,100) deaths per year in the 2070s. The highest mortality risk is primarily in cities located in the North, East and Central regions of China. Population adaptation to heat is likely to reduce excess heat mortality, but the extent of adaptation is still unclear. Future heat mortality risk attributable to exposure to elevated warm season temperature is likely to be considerable in China's urban centers, with substantial geographic variations. Climate mitigation and heat risk management are needed to reduce such risk and produce substantial public health benefits.

Global climate change is anticipated to raise overall temperatures and is likely to increase future mortality attributable to heat. Urban areas are particularly vulnerable to heat because of high concentrations of susceptible people. As the world’s largest developing country and the largest carbon emitter, China has experienced noticeable changes in climate, partially evidenced by frequent occurrence of extreme heat in urban areas, which could expose millions of residents to summer heat stress that may result in increased health risk, including mortality. While there is a growing literature on future impacts of extreme temperatures on public health, projecting changes in future health outcomes associated with climate warming remains challenging, with the related health impacts in developing countries largely unexplored. This is an exploratory study aimed at projecting future heat-related mortality risk in major metropolitan areas in China. We focus on 50 large Chinese cities that cover about 1/3 of the total population in China, and propose to assess the potential changes in heat-related mortality under 19 different global-scale climate models and three Representative Concentration Pathways (RCPs) used in the latest Intergovernmental Panel on Climate Change Fifth Assessment Report (IPCC AR5). We project future changes in heat-related mortality in the 2050s and 2070s relative to the base period of 1950-2000. The projections are based on an integrated assessment framework that combines high-resolution climate model outputs, city-specific temperature-mortality relationships, population projections and baseline mortality rates. Future temperature changes in the study areas are estimated based on downscaled climate model outputs at a spatial resolution of about 1 square kilometer. City-specific historical temperature-mortality associations are obtained from the epidemiological literature. Population projections are based on the China census 2010 survey and projected population growth rates from the 2015 Revision of World Population Prospects by the United Nations. Baseline mortality rates are obtained from China’s national and local health statistics publications. Our findings suggest that future heat mortality risk attributable to elevated warm season temperature is likely to be significant in China’s urban areas, with substantial geographic variations, highlighting the significance of climate mitigation and local-level heat risk management.

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The rising global temperatures are a consequence of the increasing concentrations of the greenhouse gases (GHG) in our atmosphere. This unprecedented yet steady increase in GHG concentrations has led to an increase in the incidence of adverse high-temperature weather phenomena. The aim of this study was to perform a detailed and systematic literature review to study the global dynamic between elevated ambient Page 28 2016 Appalachian Student Research Forum temperatures and heat-related mortality. The review also aimed at exploring the effect of pollutants as possible confounders, to identify vulnerable populations and to study population adaptations to heat that might mitigate heat-related mortality in urban settings. The review was performed exclusively on PubMed. Only epidemiological studies were selected. A time constraint ranging from 2009 to 2015 was applied to the review findings. Only peer-reviewed journals published in the English language were included. The following key terms were used for heat-related mortality associations - heat, high temperature and mortality. Additional keywords were used for the confounders, vulnerable populations and adaptations sections, such as “ozone”, “vulnerable subgroups” or “adaptations”. Studies reporting data on cold effects were excluded from the review. The search resulted in a total of 83 studies, which were included in the review based on the selection criteria. These studies were categorized and presented in four sections - heatmortality associations, effects of pollutants as confounders, vulnerable populations and adaptations. It was found that elevated ambient temperature was associated with high mortality. Additionally, risks of mortality were found to be higher for certain populations, particularly the elderly (65 years or older), infants and the socioeconomically disadvantaged groups. In conclusion, the heat-associated risks of mortality have increased with the escalating climate-change scenario. However, it is important to note that these risks are dependent on factors such as geographical location, socioeconomic status, age, and occupational status. Adaptations to heat are possible in the form of increased use of air-conditioning and promotion of “green” living spaces.

Studies of the adverse impacts of high temperature on human health have been primarily focusing on urban areas, due in part to the facts that urban centers generally have higher population density and are often significantly warmer than its surrounding rural areas (Heat Island Effect), and thus urban areas are considered to be more vulnerable to summer heat. However, heat vulnerability can also be affected by other population characteristics such as age, education, income and social isolation, which are likely to mark greater vulnerability among rural population. Here we explore the vulnerability to heat-related mortality in rural areas through a systematic review and meta-analysis of existing evidence. We searched studies that examined the association between high ambient temperature and morality in rural areas published in English between 2000 and 2016. Heat-mortality effect estimates from selected studies are grouped into two: (1) Rural effect estimates (RRrural) and their corresponding urban effect estimates (RRurban), from studies that reported risk estimates for both urban and their surrounding rural areas (7 studies included); (2) Rural effect estimates only (12 studies included). For Group 1, we performed a meta-analysis of the ratio of the rural estimate to the urban estimate in order to compare the magnitude of effects in rural versus urban areas. For Group 2, we performed a meta-analysis of the effect estimates in rural areas only. The pooled ratio estimate (RRrural/RRurban) for Group 1 is 1.051 (95% CI: 0.954, 1.160), which indicates the rural relative risk is about 5% larger than the urban relative risk. The pooled estimate for Group 2 is 1.191 (95% CI: 1.13, 1.251). Our preliminary results suggest that vulnerability to heat in rural areas may be similar to or even higher than urban areas, indicating that more studies are needed to understand rural vulnerability to heat-related hazards.

It is believed that the extremely hot European summer in 2003, where tens of thousands died in buildings, will become the norm by the 2040s, and hence there is the urgent need to accurately assess the risk that buildings pose. Thermal simulations based on warmer than typical years will be key to this. Unfortunately, the existing warmer than typical years, such as probabilistic Design Summer Years (pDSYs) are not robust measures due to their simple selection method, and can even be cooler than typical years. This study developed two new summer reference years: one (pHSY-1) is suitable for assessing the occurrence and severity of overheating while the other (pHSY-2) is appropriate for evaluating the thermal stress. Both have been proven to be more robust than the pDSYs. In addition, this study investigated the spatial variation in overheating driven by variability in building characteristics and the local environment. This variation had been ignored by previous studies, as most of them either created thermal models using building archetypes with little or no concern about the influence of local shading, or assumed little variation in climate across a landscape. For the first time, approximately a thousand more accurate thermal models were created for a UK city based on the remote measurement including building characteristics and their local shading. By producing overheating and mortality maps this study found that spatial variation in the risk of overheating was considerably higher due to the variability of vernacular forms, contexts and climates than previously thought, and that the heat-related mortality will be tripled by the 2050s if no building and human thermal adaptations are taken. Such maps would be useful to Governments when making cost-effective adaptation strategies against a warming climate.