An indicator is a quantitative or qualitative measure of how close we are to achieving a set goal (policy outcome).

They help analyse and compare performance across population groups or geographic areas, and can be useful for determining policy priorities.

Over mortality due to European heat wave in 2007

The 2007 European heat wave affected most of Southern Europe and the Balkans as well as Turkey. The phenomenon began affecting Italy and Turkey on 17 June and expanded into Greece and the rest of the Balkans, Hungary and Ukraine on 18 June. South-eastern and central Europe was hit this past June and July by a brutal heat wave. Temperatures in Greece exceeded 40°C for seven straight days during the end of June. From 21-25 July, most parts of Greece, Italy, Bulgaria, Romania, and Serbia had soaring temperatures reaching or exceeding 45°C. In the beginning of August, Croatia was also affected. These resulted in the countries energy infrastructure buckling under the combined strain of high demand and the record high temperatures exceeding the physical parameters of infrastructure. Furthermore, forest fires raged across Croatia, Bulgaria, Romania, Serbia, Montenegro, Greece, Albania, and Italy.

Preliminary estimates from Hungary, one of the harder hit countries, suggests that eight days of temperatures in excess of 40°C heat has resulted in more than 500 excess deaths, and there have been suggestions that these figures under-estimate the true extent of heat mortality in the country. Preliminary estimates for Bulgaria attributes 20 excess of deaths to the heat.

See 2007 European Heat wave
See 2007 Bulgarian Heat wave
See 2007. évi hőségriasztás előzményei és tapasztalataipdf(450 KB) - National Institute of Environmental Health, Hungary (in Hungarian only)
See Mortalité en Belgique pendant l'été 2007 frnl – Institut Scientifique de la Santé Publique

Over mortality due to European heat wave in 2006

The 2006 European heat wave was a period of exceptionally hot weather that arrived at the end of June and persist still the end of July 2006 in certain European countries. However the consequences in terms of excess of mortality and other health consequences are not comparable with the 2003 heat wave.

The United Kingdom, France, Belgium, Netherlands, Luxembourg, Italy, Poland, the Czech Republic and Germany were most affected. Several temperature records were broken. In The Netherlands, Belgium, Germany, Ireland and the UK, July 2006 was the warmest month since official measurements began.

Reported deaths reached 1 000 extra deaths in the Netherlands. A standard deviation of 200 deaths in relation to the baseline average was observed in Belgium. During the second hot period between 16th and 28th July 2006 there were 680 excess deaths (4.0% increase on baseline average deaths) in England and Wales. In the case of Portugal the excess of deaths calculated using the ICARO index was 1 207.7 deaths.

In Spain and Romania, an excess of 21 and 26 deaths were recorded in July. No data are available for Germany, Hungary (were the calls to emergency lines increased 30%) and Czech Republic.

In the case of France (from 11 to 28 July), about 2 065 excess deaths were observed. Considering the observed temperatures and with the hypothesis that heat-related mortality had not changed since 2003, 6 452 excess deaths were predicted for the period using a model. The observed mortality during the 2006 heat wave was thus markedly less than the expected mortality (4 400 less deaths). The excess mortality during the 2006 heat wave, which was markedly lower than that predicted by the model, may be interpreted as a decrease in the population’s vulnerability to heat, together with, since 2003, increased awareness of the risk related to extreme temperatures, preventive measures and the set-up of the warning system.

See Impact de la vague de chaleur de l’été 2006 en Europe – Institut de Veille Sanitaire, Francepdf
See Has the impact of heat waves on mortality changed in France since the European heat wave of summer 2003? A study of the 2006 heat wave
See Evaluation of the Department of Health National Heatwave Plan 2006 – Health Protection Agency UK
See 2006 European heat wave
See Système d’alerte canicule et santé 2006 - Rapport opérationnel – Institut de Veille Sanitaire (France)pdf
See Estimation de la surmortalité observée et attendue au cours de la vague de chaleur du mois de juillet 2006 - INSERM Francepdf
See Onda de calor de julho de 2006: Efeitos na mortalidade / Heatwave 2006: Effects in the mortality (in portuguese only) - Instituto Nacional de Saúde Dr Ricardo Jorge (August 2006) en
See July heat causes one thousand extra deaths – Statistics Netherlands
See Estimated daily mortality in July 2006 in England and Wales - UK National Statistics - Winter 2006pdf

Over mortality due to European heat wave in 2003

The consequences of the heat wave 2003 were probably underestimated in many countries, at least those based on the first estimates. This excess mortality affects vulnerable groups, particularly those who are old or ill. Identification of risk factors is a priority if the necessary prevention actions are to be implemented. The next few decades will be marked by the convergence of three events that will transform the exceptional circumstances of 2003 into a recurrent risk that must be considered as a priority in the EU health policies.

These three events are population trends, air pollution and global warming.
  • Population trends: as life expectancy increases, there will be increasing numbers of highly vulnerable people aged 80 years and over. Human population is aging worldwide and that the proportion of those aged over 60 will double in the next 30 years.

    This aging trend is most marked in industrialised countries, particularly in Europe.

  • Air pollution played an undeniable role in 2003.
    The respective roles of temperature and ozone in the excess mortality are difficult to assess. The relationship between ozone pollution and excess mortality was estimated to be between 3% and 85% in nine French towns. The reason for this high heterogeneity between towns remains unclear, and demands further study.

  • Analysis of long term meteorological trends carried out in recent years underlines that global warming is a reality, and that more heat waves are highly likely to occur in the future.

    It will no longer be possible to express surprise at these climatic events and their consequences. We must reinforce policies for forecast, alert and prevention.

Which was the mortality impact of the 2003 heat wave?

The cumulated excess mortality during summer 2003 has been assessed by the project Etude de l'impact de la canicule d'août 2003 sur la population européenne, coordinated by the INSERM, Montpellier, France, at the request of the European Commission. The study covers sixteen countries. The numbers of deaths are available for each day by gender, age and region (NUTS 2), since January 1st 1998, i.e. 19 098 574 non-empty cells for the daily number of deaths.

To be able to compare the years and European countries with very different population sizes, the daily death frequency in relation to the yearly total number of deaths was calculated. The Project defined standard boundaries. An analysis of the reference period - 1998-2002 - shows that the day only explains between 2% and 3% of the variance in deaths observed during the summer period, whereas the year of observation and the country each explain between 5% and 6%.

Three main mortality peaks are apparent during summer 2003: the peak on 13 June, the double peak on 16-21 July and lastly the peak on 12-13 August which seems exceptionally pronounced. A persistent excess mortality at the end of June and during September was observed. Out of a total of 1 952 summer days corresponding to the sixteen countries studied, 147 exceed the boundaries marking the high extreme values, i.e. 7.5% of the total. Fifty days exceed the boundaries marking the exceptional values. In total, more than 80 000 additional deaths were recorded in 2003 in the twelve countries concerned by excess mortality compared to the 1998-2002 period. Whereas 70 000 of these additional deaths occurred during the summer, still over 7 000 occurred afterwards. Nearly 45 000 additional deaths were recorded in August alone, as well as more than 11 000 in June, more than 10 000 in July and nearly 5 000 in September. The mortality crisis of early August extended over the two weeks between 3 and 6 August; 15 000 additional deaths were recorded in the first week and nearly 24 000 in the second. The excess mortality in this second week reached the exceptional value of 96.5% in France and over 40% in Portugal, Italy, Spain, and Luxembourg. Excess mortality exceeded 20% in Germany, Switzerland, and Belgium and 10% in all the other countries. European regional maps (NUTS 2) outline the early August mortality crisis breaking national frontiers. The crisis caused major distortions in the gender and age structure of death. On August 12th in France the proportion of deaths of the over-95s reached 8.9% of the total, an increase of 46% compared with the expected figure.

These observations suggest that in addition to the exceptional mortality crisis, which occurred at the beginning of August 2003 and which was so large that none could ignore it, there may have been a sequence of minor crises, which passed almost unnoticed. Yet, the cumulative result over the whole summer period can globally be just as significant. In France and Italy the cumulated excess mortality from 1 June to 30 September, 2003 (+19 490 and +20 089 deaths, respectively) have different accumulating profiles. These results suggest that centralising daily deaths on sufficiently large scale, including grouping regions or countries with small populations, should improve the monitoring of summer excess mortality potentially due to global warming.

image
Source: European Union Project Etude de l'impact de la canicule d'août 2003 sur la population européenne

The regions most affected lie in a south-west north-east axis, from the Algarve in Southern Portugal to Westphalia in Germany. A secondary axis starts in Southern England and continues towards Latium in Central Italy and towards Croatia. The most significant mortality focal spots are in France (Île-de-France and the neighbouring region of Centre), where mortality recorded between 3 and 16 August is double that expected. Six regions—two in Southern Portugal (Algarve and Alentejo) and four in France to the west and east of the Île-de-France and Centre (Pays-de-la-Loire, Poitou-Charentes, Burgundy and Franche-Comté)—recorded a very high excess mortality during these two weeks (between 65% and 125%). The south-eastern boundaries of the mortality crisis are poorly defined as it was not possible to obtain the necessary data in Bosnia-Herzegovina or other countries of the former Yugoslavia.

image
Source: European Union Project Etude de l'impact de la canicule d'août 2003 sur la population européenne

According to most of the previous studies, the potential mortality impact of heat waves is most likely data and method-driven. Those national studies suggest that the number and magnitude of excess deaths is highly sensitive to the reference period, the time of studied, the choice of age groups and geographical variations. In short, a comparison of the various national studies of the magnitude of 2003, excess mortality across countries becomes extremely difficult due to five major reasons: (1) no universal definitions of a heat wave and different durations of heat waves; (2) different methods used to estimate the magnitude of excess mortality; (3) different period of time studied; (4) different age selections; and (5) different geographic description. No standardized estimates across European countries have been made for the 2003 heat wave event (Kovats and Ebi 2006). To make comparisons of excess mortality in 2003 summer period possible, the foremost pathway is to have the same period of time studies for estimating the excess mortality to the dataset. Second, an appropriate method of estimation shall be used and standardized. Third, when compared to different age groups of excess mortality, the truncation of age groups shall be consistent. Last, a single uniform breakdown of geographic units shall be used for a comparison of excess mortality, not with a city to a country, vice versa.

The EU publication Eurosurveillance has provided a special study about updates and additional context. According to the report in early 2004, an estimated 22 080 excess deaths occurs in England and Wales, France, Italy and Portugal during and immediately after the heat waves of the summer of 2003. To these should be added 6 595-8 648 excess deaths in Spain, of which approximately 54% occurred in August, and 1 400-2 200 in the Netherlands, of which an estimated 500 occurred during the heat wave of 31 July-13 August.

Data for Italy, provided here for the cities of Bologna, Milan, Rome, and Turin, are compatible with the earlier estimate that 3 134 excess deaths occurred in the 21 Italian regional capitals during the period 1 June-15 August; the Italian National Institute of Statistics however, reported an excess of 19 780 deaths country-wide during June-September 2003 as compared to 2002.

Reports elsewhere indicate that approximately 1 250 heat-related deaths occurred in Belgium during the summer of 2003, that there were 975 excess deaths during June-August in Switzerland and 1 410 during the period August 1-24 in Baden-Württemberg, Germany. At this point, it seems reasonable to speculate that with evidence of heat wave-associated deaths beyond England and Wales, France, Italy, and Portugal, the previously published estimate of 22 080 early August excess deaths should be revised upward by at least 50% for all of western Europe, and by 100% or more if heat events that occurred during June and July 2003 are also taken into account.

Experts employed a variety of methods to estimate the number of excess deaths during and just after the 2003 heat episodes and to relate daily death counts to weather, to concentrations of air pollutants, and to demographic and social characteristics. Indeed, the varying emphases and methods demonstrated by the six national contributors provide complementary evidence of what happened in 2003, and to whom. While the absence of uniform methods does limit between-country comparisons of the health impact of the 2003 heat waves, these reports taken together suggest that weather alone does not explain the varying tolls of excess death within and between countries.

All reports demonstrate that the mortality impact of the 2003 heat wave was greatest on the very old: for example, excess mortality in France was estimated at 20% for those aged 45-74 years, at 70% for the 75-94 year age group, and at 120% for people over 94 years. There was no evidence of excess mortality in infants and children in any of the six reports. Among the elderly in France, Portugal and Italy, the three countries which stratified deaths by sex, rates were higher in females.

Investigators in Rome and Turin calculated rates of excess death as a function of socioeconomic level. They report that the greatest excess was in people living in areas of the lowest socioeconomic level, and suggest that finding may be upwardly biased, due in part to the phenomenon that those who have the means to do so leave Italian cities in summer, leading to an overestimate of the denominator for economically advantaged elderly people resident in the city in summer.

It has been observed that few deaths during heat waves are declared to be due to hyperthermia, heatstroke and other classic heat-related illnesses. Reports from both France and Portugal observe that in 2003, deaths certified as caused by ambient heat constituted an important proportion of the death excess; in France, 2 852 of 11 891 (24%) excess deaths among people over 74 years were medically certified as directly heat-related.

Between-city comparisons offer insight into the influence on deaths during heat waves of air pollution, population adaptation, and community preparedness. In Portugal, August forest fires led to a reported 18 accidental casualties: presumably the attendant air pollution may also have had an impact on short-term mortality. Coincident to the high temperatures, elevated concentrations of ground-level ozone and PM10 were recorded in London and the south east of England, those areas of England and Wales where excess mortality was most in evidence. In France, varying concentrations of ground-level ozone in cities subject to differing meteorological circumstances has allowed investigators to assess the joint effects of ozone and heat: these appear to be additive; while the apportionment of deaths to heat versus ozone differed markedly between cities, it appears that for France overall, during the period 3-17 August 2003, heat had the preponderant impact on mortality.

Are those who die during heat waves already near death, with extreme heat advancing the date of their demise by only a few days to weeks, and thus creating a compensatory deficit in expected deaths during the days following the heat event? US investigators have suggested so, and the very high rates of excess death in Europe during 2003 among the very old tend to support that concept. However, while deaths for all ages in England and Wales declined by 4% between 24-29 August when compared with expected numbers, there was no evidence of mortality displacement in France or Spain, neither during late August, nor during September, October, and November.

From the European Union Canicule Project:

• See Report on excess mortality in Europe during summer 2003 - EU Canicule Project - 2007pdf(2 MB)
• See Summary of Data Collection - EU Canicule Project - 2007pdf(127 KB)

From the European Union/WHO EuroHeat Project:

• See Heat waves and public health in Europe - 2006

From the Eurosurveillance report:

• See What lessons can be learnt from the exceptionally long and severe heat wave experienced in Europe in 2003? from Gilles Brücker, Director, Institut de Veille Sanitaire, France
• See The 2003 European heat waves from Tom Kosatsky, Direction de santé publique, Montréal
• See Summary of the mortality impact assessment of the 2003 heat wave in France
• See Mortality in Spain during the heat waves of summer 2003
• See The impact of the summer 2003 heat waves on mortality in four Italian cities
• See The effect of the summer 2003 heat wave on mortality in the Netherlands
• See The impact of the 2003 heat wave on daily mortality in England and Wales and the use of rapid weekly mortality estimates
• See Mortality in Portugal associated with the heat wave of August 2003: Early estimation of effect, using a rapid method

From other sources:

• See The impact of the 2003 heat wave on mortality and hospital admissions in England
• See Mortalidade em Portugal no Verão de 2003: influência das ondas de calorpdf(96 KB)
• See Heat wave 2003 and mortality in Switzerlandpdf
• See Die Auswirkungen der Hitzewelle 2003 auf die Gesundheitde
• See Impacts of summer 2003 heat wave in Europepdf
• See The heat wave in France in august 2003: consequences on the level of mortality and on the evolution of the system of production of mortality datapdf
• See Santé: rapport public sur la canicule de l'été 2003 fr
• See Étude des facteurs individuels et des comportements ayant pu influencer la santé des personnes âgées pendant la vague de chaleur de 2003 fr
• See Mortality and displaced mortality during heat waves in the Czech Republicpdf
• See Vpliv vro?inskih valov na umrljivost Vro?inski val avgusta 2003 v Sloveniji - Institute of Public Health of the Republic of Sloveniapdf(197 KB) (in Slovenian only)
• See Effects of the 2003 European heat wave on the Central Mediterranean Sea: surface fluxes and the dynamical responsepdf
• See Mortality in southern England during the 2003 heat wave by place of deathpdf

Deaths of European Union residents caused by the tsunami in south-east Asia in 2004

Flooding is one of the most widespread of climatic hazards and poses multiple risks to human health, yet there has been little systematic research work on health outcomes and the means by which vulnerable populations and health systems respond to those risks. Given the prospect that flood hazards may increase as a result of climate change, it is timely to make a strategic assessment of the existing knowledge base on health and flood risk (Tyndall Centre for Climate Change Research, 2004).

Flood events can take many forms, including slow-onset riverine floods, rapid-onset (flash) floods, accumulation of rainwater in poorly-drained environments, and coastal floods caused by tidal and wave extremes. Both inland and coastal flooding may be associated with windstorm events. Floods also vary greatly in scale and impact, according to depth, velocity of flow, area covered, content, speed of onset, duration and seasonality. A flood event that has severe consequences (variously defined) may be termed a flood disaster, and the human impact of flood disasters is concentrated disproportionately in developing countries. Though major limitations remain in our ability to make robust projections of future rates of climate change and its effects, increasing predictive evidence of heightened global risk of inland and coastal flooding is emerging. Over the next 100 years, flooding is likely to become more common or more intense in many areas, especially in low-lying coastal sites and in areas that currently experience high rainfall. Marginal changes in the geographical distribution of flooding are also possible. However, it is not feasible to predict the precise locations at increased risk of flooding due to climate change: part of the problem is that flood risk dynamics have multiple social, technical and environmental drivers.

See Floods, health and climate change: a strategic review - Tyndall Centre for Climate Change Researchpdf

Health effects of flood events

There is very limited quantitative evidence of the health impacts of floods. The European Centre for Disease Prevention and Control (ECDC) has undertaken a preliminary review of the adverse health effects of flood events.

Flood events are the most frequently occurring natural disasters worldwide, and may increase in the future as a result of climate change. A limited number of short term epidemiological studies have been conducted to assess the health impacts of flooding, but studies of long-term health and economic impacts are lacking.

Limited data on flood events shows that the greatest "burden of mortality" is from drowning, heart attacks, hypothermia, trauma and vehicle-related accidents. The speed of onset of floodwaters is a determining factor in the number of immediate flood-related deaths.

Adverse effects on human health include the following:

  • Trauma deaths, mainly by drowning. Drowning is the leading cause of death in case of flash floods and coastal floods. Fatal injuries can occur during evacuation or during cleanup activities.
  • Flood-related injuries, such as contusions, cuts and sprains have been reported in several studies, as have burns, electrocutions, snake bites and wound infections. However, the number of serious injuries observed after violent flooding events generally turns out to be much lower than initial estimates predict.
  • Enteric infections due to the disruption of sewage disposal and safe drinking water infrastructure.
  • Increases in mental health problems such as anxiety, depression, sleeplessness, and post-traumatic stress disorder among flood victims. The risk estimates for physical illness in adults declined after adjustment for psychological distress, while psychological distress remained strongly associated with flooding after adjustment for physical illnesses.
  • Vectorborne disease, such as malaria, dengue and dengue hemorrhagic fever, yellow fever, West Nile fever and rodent-borne disease, such as leptospirosis. There is some evidence that diarrhoeal disease increases after flooding, particularly in developing countries but also in Europe. Standing water caused by heavy rainfall or overflow of rivers can act as breeding sites for mosquitoes, and therefore increase potential exposure to infections such as dengue, malaria and West Nile fever among people affected by the disaster and among emergency workers. West Nile fever has emerged in Europe after heavy rains and flooding, with outbreaks in Romania in 1996-97, the Czech Republic in 1997 and Italy in 1998.
  • There is also an increased risk of infection from diseases contracted through direct contact with polluted waters, such as wound infections, dermatitis, conjunctivitis, and ear, nose and throat infections.
  • Contamination by toxic chemicals during floods is theoretically possible but no verifiable correlation has been observed or measured so far.
  • Other negative health outcomes, for example related to the disruption of healthcare services and population displacement.


See Global Health Impacts of Floods: Epidemiologic Evidence
See What are the human health consequences of flooding and the strategies to reduce them? - WHO
See Flooding and communicable diseases fact sheet - WHO

See WHO Rapid Health Assessment of Flooding in Bulgaria, 2005pdf, which covers the main public health issues that should be considered during and after a flood and is one of the most consistent documents assessing the current situation and providing recommendations for local response to flooding.

The European Flood Alert System

Between 1998 and 2004, Europe suffered over 100 major damaging floods, including the catastrophic floods along the Danube and Elbe rivers in summer 2002. Severe floods in 2005 and 2007 further reinforced the need for concerted action. Since 1998 floods in Europe have caused some 700 deaths, the displacement of about half a million people and at least €25 billion in insured economic losses.

Directive 2007/60/EC on the assessment and management of flood risks entered into force on 26 November, 2007. This Directive now requires Member States to assess if all water courses and coast lines that are at risk from flooding, to map the flood extent and assets and humans at risk in these areas and to take adequate and coordinated measures to reduce this flood risk.

Since the beginning of 2003 the European Commission DG Joint Research Centre (JRC) is developing a prototype of European Flood Alert System (EFAS) in close collaboration with relevant institutions in the Member States. The JRC benefits from experience gained already during the European Flood Forecasting System (EFFS)pdf project financed by the EU DG Research.

The European Flood Alert System (EFAS) is a research project that aims at improving preparedness for oncoming flood events by:

• informing the authorities in the Member States of the possibility of a flood before the local systems capture the event with their own monitoring and forecasting systems;
• providing catchment based information that gives downstream authorities an overview of the current and forecasted flood situation also in upstream countries.

This does not only include the immediate upstream country but also any further potentially useful upstream information. EFAS provides medium-term (3 to 10 days) flood forecasts, based on different meteorological inputs, as complementary information to the typical short-term (less than 48 hours) forecasts performed by national centres. The challenge of EFAS is to combine all hydrographs, calculated from different medium-range weather forecasts, into one early flood warning information that is useful for local flood forecasting centres. EFAS forecasts are supposed to be used as a pre-alert to allow the receiving authorities to be aware of the possibility of a flood taking place. In other words, with EFAS forecasts in hand, local forecasters can already play through a number of different “what if” scenarios and, as the event approaches and its location and magnitude become more certain, national authorities can act more quickly and accurately, increasing the economic value of their forecasts.

The EU Project (FLOODSite: Integrated Flood Risk Analysis and Management Methodologies) aims to deliver: (i) an integrated, European, methodology for flood risk analysis and management; (ii) consistency of approach to the causes, control and impacts of flooding from rivers, estuaries and the sea; (iii) techniques and knowledge to support integrated flood risk management; (iv) sustainable “pre-flood” measures (spatial planning, flood defence infrastructure and measures to reduce vulnerability); (v) flood event management (early warning, evacuation and emergency response); (vi) post-event activities (review and regeneration); (vii) dissemination of this knowledge and networking and integration with other EC national and international research.

See Directive 2007/60/EC on the assessment and management of flood risks
See European Flood Alert System - European Commission
See Integrated Flood Risk Analysis and Management Methodologies
See European Flood Forecasting System (EFFS) projectpdf
See The benefit of probabilistic flood forecasting on European scale - Results of the European Flood Alert System for 2005/2006, Joint Research Centre, European Commissionpdf

Technical preparedness and response to flood crisis:

See Technical Guidelines - Emergency Management Essentials - WHO
See FLOODS - Technical Hazard Sheet - Natural Disaster Profile - WHO
See Emergency preparedness and response - WHO
See Flooding – Health Protection Agency, UK

Mapping the flood events

The Dartmouth Flood Observatory detects, maps, and measures major flood events worldwide using satellite remote sensing. The record of such events is preserved as a "World Atlas of Flood Hazard". An Active Archive of Large Floods, 1985-2006, describes these events individually. Maps and images accompany many of the floods, and can be accessed by links in the yearly catalogues. As the archive of reliable data grows, it is increasingly possible to predict where and when major flooding will occur, and to analyse trends over time. "Surface Water Watch™" is a satellite-based surface water monitoring system. Orbital AMSR-E microwave measurements over selected river reaches are used to measure discharge and watershed runoff every two days. The system can be used to determine where flooding is under way, to predict inundation extents, and to assess the surface water status of seasonal wetlands.

See floods in Romania and Bulgaria - Lower Danube River - 2006
See floods in Czech Republic and Austria - 2006jpeg
See floods in Eastern Europe - Danube and Tisza Rivers and tributaries - 2006
See floods in Serbia, Croatia and Bosnia - Danube, Sava and Velika Morava Rivers - 2006

Mortality due to flood events

Deaths associated with flood disasters are reported in the EM-DAT disaster events database. The most readily identified flood deaths are those that occur acutely from drowning or trauma, such as being hit by objects in fast-flowing waters. The number of such deaths is determined by the characteristics of the flood, including its speed of onset, depth, and extent. Information on risk factors for flood-related death remains limited, but men appear more at risk than women. Those drowning in their own homes are largely the elderly.

See from EM-DAT disaster events database - flood victims in the EU 1990-2005
Although the risk of deaths is most obviously increased during the period of flooding, a controlled study of the 1969 floods in Bristol, United Kingdom, reported a 50% increase in all-cause deaths in the flooded population in the year after the flood, most pronounced among those aged 45-64 years.

Inconclusive evidence for diarrhoeal deaths has been reported from several studies of floods in low-income countries.

See Global Health Impacts of Floods: Epidemiologic Evidence

Deaths of European Union residents caused by the tsunami in south-east Asia in 2004

European Union residents (most of whom were holidaying in the region) fell victim to the tsunami that struck south-east Asia on 26 December 2004. Therefore, the tsunami has an impact on the statistics on causes of death at both European and Member State level, particularly for Sweden where the number of citizens killed in the tsunami was comparatively high. In the Member States, statistics on the causes of death are based on medical certificates which are completed by doctors for each death.

However some residents die in a country other than their country of residence and, in certain Member States, there is no procedure for collecting and inputting information on the cause of death in such cases. As a result, the death is registered in the statistics of the country in which this person lived as "cause unknown" (or may even not be registered at all in the statistics on causes of death). Although the effects of this type of under-coverage have relatively little influence on the overall statistical picture, they do become important and visible in the case of accidents and catastrophes involving a large number of victims, such as aircraft accidents. Furthermore, the number of residents dying abroad can increase in tandem with the increased mobility of European citizens. Given the scale of the catastrophe (the media reported thousands of victims from the EU), there was a possibility that seriously insufficient or erroneous coverage could have long-term effects on the comparability of European statistics on the causes of death.

See Deaths of European Union residents caused by the tsunami in south-east Asia in 2004 - Eurostatpdf

EU studies impact and adaptation assessment for possible climate-related health outcomes in Europe

The cCASHh (Climate Change and Adaptation Strategies for Human Health in Europe) project is a European Union FP5-funded project, coordinated by the WHO Europe, with the aim of assessing and enhancing EU potential to adapt to climate-related effects on human health.

See EU projects to improve public health knowledge on extreme weather/heat waves: risks and responses