title: Changes in population susceptibility to heat and cold over time: assessing adaptation to climate change.
abstract: BACKGROUND
  In the context of a warming climate and increasing urbanisation (with the associated urban heat island effect), interest in understanding temperature related health effects is growing. Previous reviews have examined how the temperature-mortality relationship varies by geographical location. There have been no reviews examining the empirical evidence for changes in population susceptibility to the effects of heat and/or cold over time. The objective of this paper is to review studies which have specifically examined variations in temperature related mortality risks over the 20(th) and 21(st) centuries and determine whether population adaptation to heat and/or cold has occurred.
  
  
  METHODS
  We searched five electronic databases combining search terms for three main concepts: temperature, health outcomes and changes in vulnerability or adaptation. Studies included were those which quantified the risk of heat related mortality with changing ambient temperature in a specific location over time, or those which compared mortality outcomes between two different extreme temperature events (heatwaves) in one location.
  
  
  RESULTS
  The electronic searches returned 9183 titles and abstracts, of which eleven studies examining the effects of ambient temperature over time were included and six studies comparing the effect of different heatwaves at discrete time points were included. Of the eleven papers that quantified the risk of, or absolute heat related mortality over time, ten found a decrease in susceptibility over time of which five found the decrease to be significant. The magnitude of the decrease varied by location. Only two studies attempted to quantitatively attribute changes in susceptibility to specific adaptive measures and found no significant association between the risk of heat related mortality and air conditioning prevalence within or between cities over time. Four of the six papers examining effects of heatwaves found a decrease in expected mortality in later years. Five studies examined the risk of cold. In contrast to the changes in heat related mortality observed, only one found a significant decrease in cold related mortality in later time periods.
  
  
  CONCLUSIONS
  There is evidence that across a number of different settings, population susceptibility to heat and heatwaves has been decreasing. These changes in heat related susceptibility have important implications for health impact assessments of future heat related risk. A similar decrease in cold related mortality was not shown. Adaptation to heat has implications for future planning, particularly in urban areas, with anticipated increases in temperature due to climate change.
authors.affiliation: Department of Social and Environmental Health Research, London School of Hygiene & Tropical Medicine, London,, WC1H 9SH, UK. Katherine.arbuthnott@lshtm.ac.uk.|Environmental Change Department, Centre for Radiation, Chemical and Environmental Hazards, Public Health England, Didcot, OX11 0RQ, UK. Katherine.arbuthnott@lshtm.ac.uk.
authors.forename: Katherine
authors.initials: K
authors.lastname: Arbuthnott
authors.affiliation: Department of Social and Environmental Health Research, London School of Hygiene & Tropical Medicine, London,, WC1H 9SH, UK. Shakoor.hajat@lshtm.ac.uk.
authors.forename: Shakoor
authors.initials: S
authors.lastname: Hajat
authors.affiliation: Department of Social and Environmental Health Research, London School of Hygiene & Tropical Medicine, London,, WC1H 9SH, UK. Clare.heaviside@phe.gov.uk.|Environmental Change Department, Centre for Radiation, Chemical and Environmental Hazards, Public Health England, Didcot, OX11 0RQ, UK. Clare.heaviside@phe.gov.uk.
authors.forename: Clare
authors.initials: C
authors.lastname: Heaviside
authors.affiliation: Department of Social and Environmental Health Research, London School of Hygiene & Tropical Medicine, London,, WC1H 9SH, UK. Sotiris.vardoulakis@phe.gov.uk.|Environmental Change Department, Centre for Radiation, Chemical and Environmental Hazards, Public Health England, Didcot, OX11 0RQ, UK. Sotiris.vardoulakis@phe.gov.uk.
authors.forename: Sotiris
authors.initials: S
authors.lastname: Vardoulakis
mesh_terms: D000064:Acclimatization; D057231:Climate Change; D003080:Cold Temperature / Q000009:adverse effects*; D062489:Health Impact Assessment; D006358:Hot Temperature / Q000009:adverse effects*; D006801:Humans; D014504:Urban Health