title: Excess winter deaths in Europe: a multi-country descriptive analysis.
abstract: BACKGROUND
  Winter deaths are a known health and social care challenge for many countries. A previous international comparison showed significant differences in excess winter deaths across Europe in the 1990s, with the northern countries having lower excess winter mortality than those in southern Europe.
  
  
  METHODS
  The Excess Winter Deaths Index (EWDI) is the ratio of deaths in the winter period (December to March) compared with deaths in the non-winter period. Data from the Eurostat database and national registries were used to calculate the EWDI for 31 countries in Europe across the time period 2002/2003 to 2010/2011.
  
  
  RESULTS
  National EWDI values show heterogeneity, with a broad pattern of increasing EWDI values from northern to southern Europe and increasing mean winter temperature (r(2) = 0.50, P > 0.0001). Malta, Portugal, Spain, Cyprus and Belgium all had an EWDI that was statistically significantly higher than the average EWDI for the other 30 European countries. There was no clear association between country-level EWDI and the level of inter-annual variability in winter temperature across Europe.
  
  
  CONCLUSIONS
  This article demonstrates the differences in EWDI that exist between European countries with implications for both research and policy. Many deaths may be avoidable as environmental, social and personal factors are known to contribute to winter mortality. We now need to work to better understand the causes of inter-country differences.
authors.affiliation: 1 Field Epidemiology Services - West Midlands, Public Health England, Birmingham, UK 2 Department of Public Health, Epidemiology and Biostatistics, University of Birmingham, Birmingham, UK tom.fowler@nhs.net.
authors.forename: Tom
authors.initials: T
authors.lastname: Fowler
authors.affiliation: 3 Extreme Events and Health Protection Section, Public Health England, Birmingham, UK.
authors.forename: Rosamund J
authors.initials: RJ
authors.lastname: Southgate
authors.affiliation: 3 Extreme Events and Health Protection Section, Public Health England, Birmingham, UK.
authors.forename: Thomas
authors.initials: T
authors.lastname: Waite
authors.affiliation: 1 Field Epidemiology Services - West Midlands, Public Health England, Birmingham, UK.
authors.forename: Ruth
authors.initials: R
authors.lastname: Harrell
authors.affiliation: 4 Department of Social and Environmental Health Research, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Sari
authors.initials: S
authors.lastname: Kovats
authors.affiliation: 3 Extreme Events and Health Protection Section, Public Health England, Birmingham, UK.
authors.forename: Angie
authors.initials: A
authors.lastname: Bone
authors.affiliation: 5 London Region, Public Health England, Birmingham, UK 6 Faculty of Health Sciences, University of Surrey, Guildford, UK.
authors.forename: Yvonne
authors.initials: Y
authors.lastname: Doyle
authors.affiliation: 3 Extreme Events and Health Protection Section, Public Health England, Birmingham, UK 7 MRC-HPA Centre for Environment and Health, Imperial College and King's College, London, UK.
authors.forename: Virginia
authors.initials: V
authors.lastname: Murray
mesh_terms: D005060:Europe / Q000453:epidemiology; D006801:Humans; D038622:Internationality; D009026:Mortality; D012042:Registries; D012307:Risk Factors; D012621:Seasons; D013696:Temperature