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Zhang, S. ; Breitner-Busch, S. ; Stafoggia, M.* ; Donato, F.D.* ; Samoli, E.* ; Zafeiratou, S.* ; Katsouyanni, K.* ; Rao, S.* ; Diz-Lois Palomares, A.* ; Gasparrini, A.* ; Masselot, P.* ; Nikolaou, N. ; Aunan, K.* ; Peters, A. ; Schneider, A.E.

Effect modification of air pollution on the association between heat and mortality in five European countries.

Environ. Res. 263:120023 (2024)

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BACKGROUND: Evidence suggests that air pollution modifies the association between heat and mortality. However, most studies have been conducted in cities without rural data. This time-series study examined potential effect modification of particulate matter (PM) and ozone (O₃) on heat-related mortality using small-area data from five European countries, and explored the influence of area characteristics. METHODS: We obtained daily non-accidental death counts from both urban and rural areas in Norway, England and Wales, Germany, Italy, and the Attica region of Greece during the warm season (2000-2018). Daily mean temperatures and air pollutant concentrations were estimated by spatial-temporal models. Heat effect modification by air pollution was assessed in each small area by over-dispersed Poisson regression models with a tensor smoother between temperature and air pollution. We extracted temperature-mortality relationships at the 5^th (low), 50^th (medium), and 95^th (high) percentiles of pollutant distributions. At each air pollution level, we estimated heat-related mortality for a temperature increase from the 75^th to the 99^th percentile. We applied random-effects meta-analysis to derive the country-specific and overall associations, and mixed-effects meta-regression to examine the influence of urban-rural and coastal typologies and greenness on the heat effect modification by air pollution. RESULTS: Heat-related mortality risks increased with higher PM levels, rising by 6.4% (95% CI: -2.0%-15.7%), 10.7% (2.6%-19.5%), and 14.1% (4.4%-24.6%) at low, medium, and high PM levels, respectively. This effect modification was consistent in urban and rural regions but more pronounced in non-coastal regions. In addition, heat-mortality associations were slightly stronger at high O₃ levels, particularly in regions with low greenness. CONCLUSION: Our analyses of both urban and rural data indicate that air pollution may intensify heat-related mortality, particularly in non-coastal and less green regions. The synergistic effect of heat and air pollution implies a potential pathway of reducing heat-related health impacts by improving air quality.

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