title: Mortality attributable to extreme temperatures in Spain: A comparative analysis by city.
abstract: BACKGROUND
  The Low Temperature Days (LTD) have attracted far less attention than that of High Temperature Days (HTD), though its impact on mortality is at least comparable. This lower degree of attention may perhaps be due to the fact that its influence on mortality is less pronounced and longer-term, and that there are other concomitant infectious winters factors. In a climate-change scenario, the studies undertaken to date report differing results. The aim of this study was to analyse mortality attributable to both thermal extremes in Spain's 52 provinces across the period 2000-2009, and estimate the related economic cost to show the benefit or "profitability" of implementing prevention plans against LTD.
  
  
  METHODS
  Previous studies enabled us: to obtain the maximum daily temperature above which HTD occurred and the minimum daily temperature below which LTD occurred in the 52 provincial capitals analysed across the same study period; and to calculate the relative and attributable risks (%) associated with daily mortality in each capital. These measures of association were then used to make different calculations to obtain the daily mean mortality attributable to both thermal extremes. To this end, we obtained a summary of the number of degrees whereby the temperature exceeded (excess °C) or fell short (deficit °C) of the threshold temperature for each capital, and calculated the respective number of extreme temperatures days. The economic estimates rated the prevention plans as being 68% effective.
  
  
  RESULTS
  Over the period considered, the number of HTD (4373) was higher than the number of LTD (3006) for Spain as a whole. Notwithstanding this, in every provincial capital the mean daily mortality attributable to heat was lower (3deaths/day) than that attributable to cold (3.48deaths/day). In terms of the economic impact of the activation of prevention plans against LTD, these could be assumed to avoid 2.37 deaths on each LTD, which translated as a saving of €0.29M. Similarly, in the case of heat, 2.04 deaths could be assumed to be avoided each day on which the prevention plan against HTD was activated, amounting to a saving of €0.25M. While the economic cost of cold-related mortality across the ten-year period 2000-2009 was €871.7M, that attributable to heat could be put at €1093.2M.
  
  
  CONCLUSIONS
  The effect of extreme temperatures on daily mortality was similar across the study period for Spain overall. The lower number of days with LTD meant, however, that daily cold-related mortality was higher than daily heat-related mortality, thereby making prevention plans against LTD more "profitable" prevention plans against HTD in terms of avoidable mortality.
authors.affiliation: National School of Public Health, Carlos III Institute of Health, Avda. Monforte de Lemos, 5, 28029 Madrid, Spain.
authors.forename: R
authors.initials: R
authors.lastname: Carmona
authors.affiliation: National School of Public Health, Carlos III Institute of Health, Avda. Monforte de Lemos, 5, 28029 Madrid, Spain. Electronic address: j.diaz@isciii.es.
authors.forename: J
authors.initials: J
authors.lastname: Díaz
authors.affiliation: Torrijos Public Health District, Castile-La Mancha Regional Health & Social Affairs Authority (Consejería de Sanidad y Asuntos Sociales de Castilla-La Mancha), Torrijos, Toledo, Spain.
authors.forename: I J
authors.initials: IJ
authors.lastname: Mirón
authors.affiliation: National School of Public Health, Carlos III Institute of Health, Avda. Monforte de Lemos, 5, 28029 Madrid, Spain.
authors.forename: C
authors.initials: C
authors.lastname: Ortiz
authors.affiliation: State Meteorological Agency, (AEMET), Madrid, Spain.
authors.forename: M Y
authors.initials: MY
authors.lastname: Luna
authors.affiliation: National School of Public Health, Carlos III Institute of Health, Avda. Monforte de Lemos, 5, 28029 Madrid, Spain.
authors.forename: C
authors.initials: C
authors.lastname: Linares
mesh_terms: D002947:Cities / Q000453:epidemiology; D057231:Climate Change; D055873:Extreme Cold / Q000009:adverse effects*; D055874:Extreme Heat / Q000009:adverse effects*; D006801:Humans; D009026:Mortality; D012307:Risk Factors; D012621:Seasons; D013030:Spain / Q000453:epidemiology
keywords: Cost-benefit; Extreme temperatures; Mortality; Prevention plans