Climate change as a threat to health and well-being in Europe : focus on heat and infectious diseases.
Date: 2022-11-15
Institutions: European Environment Agency
Subjects: bad weather, climate change, health risk, infectious disease, report, social well-being

EEA Report 

No 07/2022

Climate change as a threat to health and 
well-being in Europe: focus on heat and 
infectious diseases

EEA Report  No 07/2022

Climate change as a threat to health and 
well-being in Europe: focus on heat and 
infectious diseases

Cover design: EEA
Cover photo: EEA
Layout: Formato Verde

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institutions of the European Union. Neither the European Environment Agency nor any person or company.

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Reproduction is authorised provided the source is acknowledged.

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(see https://european-union.europa.eu/index_en).

Luxembourg: Publications Office of the European Union, 2022
(https://op.europa.eu/en/web/general-publications/publications).

ISBN: 978-92-9480-508-9
ISSN: 1977-8449
doi: 10.2800/67519

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Contents

Acknowledgements ....................................................................................................................................4

Key messages ..............................................................................................................................................6

Executive summary ....................................................................................................................................7

1   Introduction ........................................................................................................................................10

2   Climate change impacts on health in the policy framework in Europe .......................................12

2.1  European policies ................................................................................................................................ 12

2.2  National policies ................................................................................................................................... 14

2.3  Local and subnational policies ........................................................................................................... 14

3   Heat as major threat to human health in Europe ..........................................................................16

3.1 

Increasing hazard of high temperatures in Europe ......................................................................... 16

3.2  Population vulnerability to extremes of heat in Europe ................................................................. 17

3.3  Exposure of population to heatwaves and high temperatures in Europe ................................... 19

3.4  Health impacts of heat ........................................................................................................................ 19

3.5  Reducing the health impacts of heat through adaptation measures ........................................... 25

4  Climate-sensitive infectious diseases as an emerging threat to human health in Europe 

36

4.1 

Infectious diseases sensitive to climatic and weather factors ....................................................... 37

4.2 

Incidence of climate-sensitive infectious diseases over time  ........................................................ 37

4.3  Changing climate suitability for transmission of selected infectious diseases ............................ 40

4.4  People at risk from infectious diseases ............................................................................................ 48

4.5  Responding to the growing threat of infectious diseases  ............................................................. 49

5  Conclusions and outlook ....................................................................................................................54

Abbreviations ............................................................................................................................................57

References .................................................................................................................................................58

Annex 1 Sources for Figure 4.1 ................................................................................................................67

3

Climate change as a threat to health and well-being in Europe: focus on heat and infectious diseasesAcknowledgements

Lead author: Aleksandra Kaźmierczak (EEA)

Sewe (Lancet Countdown in Europe; Umeå University), Hendrik 

Contributing authors: Rachel Lowe (European Topic Centre 
on Climate Change Adaptation and LULUCF, ETC/CA; Catalan 

Sjödin (Lancet Countdown in Europe; Umeå University), Joaquin 

Triñanes (Lancet Countdown in Europe; Universidade de Santiago 

de Compostela) and Professor Elizabeth J. Z Robinson (Lancet 

Institution for Research and Advanced Studies, ICREA; Barcelona 

Countdown in Europe; Grantham Research Institute on Climate 

Supercomputing Center; Lancet Countdown in Europe), Kim 

Change and the Environment, London School of Economics).

van Daalen (University of Cambridge; Lancet Countdown; 

Lancet Countdown in Europe), Katie Johnson (ETC/CA; 

The EEA acknowledges comments and additional input received 

Euro-Mediterranean Centre on Climate Change, CMCC) and 

on the draft report from the following members within the 

Shouro Dasgupta (ETC/CA; CMCC; Lancet Countdown in Europe).

European Environment Information and Observation Network 

— France, Germany, Norway, Spain and Sweden; from the 

The authors would like to thank all experts who contributed 

European Commission (DG Climate Action); from other 

data and information to this report: Joacim Röcklov (Lancet 

organisations — Eurofound; European Food Safety Authority; 

Countdown in Europe; Heidelberg Institute of Global Health; 

European Centre for Medium-Range Weather Forecasts; World 

Umeå University), Jan C. Semenza (Lancet Countdown in Europe; 

Health Organization Regional Office for Europe; and from 

Heidelberg Institute for Global Health, Umeå University); Cathryn 

individual experts — Dario Piselli, Hans-Martin Füssel, Stéphane 

Tonne (Lancet Countdown in Europe; Barcelona Institute for 

Quefelec, Eline Vanuytrecht (European Environment Agency); 

Global Health); Joan Ballester (Lancet Countdown in Europe; 

Marina Romanello (University College London and Lancet 

Barcelona Institute for Global Health), Jonathan Chambers 

Countdown), Maria Nilsson (Professor in Public Health Science 

(Lancet Countdown in Europe; University of Geneva), Zia Farooq 

at Umeå University and Chair of the Lancet Countdown in 

(Lancet Countdown in Europe; Umeå University), Marin Lotto 

Europe) and Josep M. Antó (Professor at the Barcelona Institute 

Batista (Lancet Countdown in Europe; Barcelona Supercomputing 

for Global Health and Co-chair of the Lancet Countdown in 

Center), Mark Nieuwenhuijsen (Lancet Countdown in Europe; 

Europe). These suggestions were taken on board in the final 

Barcelona Institute for Global Health), Maquins Odhiambo 

version of the report as far as possible. 

4

Climate change as a threat to health and well-being in Europe: focus on heat and infectious diseases© Daniel Kusak, My City/EEA

5

Climate change as a threat to health and well-being in Europe: focus on heat and infectious diseasesKey messages

• 

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The severity of the current and projected impacts of climate on health in Europe call for a stepping up of action in 
both mitigation of and adaptation to climate change.

Heatwaves cause the largest number of deaths among weather- and climate-related events in  Europe. Over the 
next few decades, more frequent extreme heat episodes and increasing vulnerability of the population to extreme 
heat will lead to a substantial increase in morbidity and mortality unless adaptation measures are taken.

Increasingly frequent, long and intense heatwaves in combination with an ageing population and growing 
urbanisation mean that more vulnerable populations are exposed to high temperatures, particularly in southern 
and central Europe. The location of many schools and hospitals in areas experiencing the urban heat island effect, 
further exacerbating high temperatures, calls for urgent adaptation of those facilities.

Increasing temperatures in Europe also affect occupational health and safety, with an average annual loss of 
16 hours per worker (compared with the 20th century baseline) in highly exposed sectors, with the largest losses 
in southern Europe.

Climatic conditions across Europe are becoming more suitable for emergence and transmission of climate-sensitive 
infectious diseases, which may particularly affect those working in agriculture, forestry or emergency services 
(through higher exposure) or the elderly, young children and those with compromised immune systems (through 
higher vulnerability).

The projected lengthening of the transmission season and wider distribution of mosquito species that act as 
vectors for malaria and dengue, combined with the growing number of travel-imported disease cases, increases 
the likelihood of local outbreaks.

Higher temperatures increase the risk of West Nile fever outbreaks in central, eastern and southern Europe and 
expand the risk of transmission to previously unaffected areas of northern and western Europe.

The warming sea waters are increasingly suitable for the dangerous Vibrio bacteria, in particular along the Baltic 
Sea coastlines.

Reducing the health impacts of heat requires implementing a wide range of solutions, including effective heat 
health action plans, urban greening, appropriate building design and construction, and adjusting working times 
and conditions. Effective monitoring of vectors and disease surveillance enable the development of early warnings 
and targeting of vector control or vaccination.

Cross-sectoral collaboration between public health and the built environment, spatial planning and employment 
sectors is needed to prevent climate threats where people live and work. Interventions aimed at reducing 
exposure to heat or diseases should prioritise vulnerable groups, as well as people and locations that are 
particularly exposed.

Adapting to the existing and emerging health threats arising from climate change requires better preparedness of 
the health sector through increasing awareness, improving knowledge and widening engagement of public health 
and healthcare professionals; improving the resilience of healthcare facilities to climate hazards; and ensuring that 
health systems have the capacity to respond to increased demand for patient care or diagnostics.

The need to better understand and address the impacts of climate change on human health and well-being is 
increasingly recognised in EU and national policies, albeit the subject is covered to a greater extent in policies 
focused on adaptation than those focused on health. At the local level, the engagement of health or social care 
stakeholders with climate adaptation planning remains low.

6

Climate change as a threat to health and well-being in Europe: focus on heat and infectious diseasesExecutive summary

Climate change poses multiple threats to human health 

in southern Europe, resulting in increasing mortality rates 

and well-being in Europe. Extreme weather events, such 

and negative impacts on labour. Central and eastern Europe 

as devastating floods, extensive wildfires or intense and 

emerge as having the highest current climatic suitability for 

long-lasting heatwaves, that are more likely and more severe 

the transmission of dengue, malaria and West Nile virus. The 

due to the changing climate have become part of our reality in 

population's vulnerability to high temperatures is highest 

recent years. The greatest direct climate-related threat to human 

in northern and western Europe as a result of high levels 

health in Europe is heat, and the large number of excess deaths 

of urbanisation and high proportions of the elderly in the 

attributable to extremely high temperatures and prolonged 

population. These two regions have also recorded the highest 

heatwaves during the summer of 2022 is a case in point.

increase in climatic suitability for dengue, malaria and West 

Despite high average living standards, Europe's ageing society 

and prevalence of chronic diseases make its population 

particularly vulnerable to heat. The exposure of vulnerable 

Nile virus over the past few decades, which potentially has 

contributed to the expansion of those diseases to previously 
unaffected regions. The risk of Vibrio infections is highest around 
the Baltic Sea coastlines. These regional differences necessitate 

groups to heat is increasing, driven not only by more frequent 

the development of specific strategies addressing both the 

and intense heatwaves but also by ongoing urbanisation and 

established and the emergent climate-related health threats.

the associated urban heat island effect, the fact that buildings 

and cities in most of Europe have not been constructed to 

In addition, the report draws attention to social inequalities 

protect people from high temperatures, or outdated work 

as drivers of vulnerability and exposure to climate-related 

practices that ignore the dangers of heat exposure to human 

health threats. Most of those at risk from heat are older people 

health. Vulnerable socio-economic groups are particularly 

or those with pre-existing health conditions; in addition, the 

affected by heat. This high vulnerability, combined with the 

health of elderly people and young children can be more 

projected substantial global warming, creates a dire picture 

seriously affected if they contract an infectious disease. 

of a future with growing numbers of heat-related deaths and 

Low-income groups tend to be overrepresented in dense, urban 

ailments, as well as reduced labour productivity, affecting 

environments and poor-quality housing prone to overheating. 

well-being and prosperity across Europe.

People on the lowest incomes tend to work in manual jobs that 

Climate-sensitive infectious diseases are another type of 

exposing them to high temperatures or infection risk through 

are often performed in hot indoor environments or outside, 

emerging threat discussed in this report. The increasing 

contact with vectors.

suitability of the climate for various pathogens or their vectors 

may translate into higher likelihood of disease transmission 

Nearly all deaths associated with high temperatures are 

in larger parts of Europe. The arrival of travellers and goods 
into Europe from regions where dengue or malaria is endemic, 

preventable in the European context. Prevention of and better 
preparation for outbreaks of climate-sensitive infectious 

combined with the increasing suitability of climate conditions 

diseases can lessen the health implications. Therefore, the 

for the mosquitoes that carry those diseases becoming 

report also looks at measures to reduce the health impacts of 

permanent in parts of Europe, increases the probability of 

heat and infectious diseases in Europe. The monitoring and 

disease outbreaks.

surveillance of climate-related threats is an effective measure 

and the most frequently mentioned in national health or 

The key finding of the report is the marked increase in the scale 

climate adaptation strategies. It is essential to develop early 

and geographical extent of heat and infectious diseases that 

warnings: swift, well-organised and effective actions as part of 

pose a threat to human health. This is corroborated by both the 

heat health action plans and providing appropriate information 

trends over past decades and the projections for the future.

to the public can reduce the risk of disease transmission. 

Another aspect is the regional differences in the presence of 

The adaptation measures planned by the EEA member and 

threats. The current and projected exposure to heat is highest 

collaborating countries emphasise the need to raise awareness 

7

Climate change as a threat to health and well-being in Europe: focus on heat and infectious diseasesExecutive summary 

of the health threats associated with the changing climate 

as the G7, in the EU policy framework or by professional 

among the population (particularly vulnerable and exposed 

associations in the sphere of public health can help to push 

groups in terms of both working and living conditions) but also 

the subject up the political agenda of the EEA member 

among public health and healthcare professionals. Inclusion 

countries. This occurs predominantly at the national level, 

of the topic of climate change in medical schools' curricula 

where monitoring and surveillance actions are decided, early 

and the training of healthcare workers is key. Furthermore, 

warnings may be activated and decisions are made about 

improving the resilience of healthcare facilities across Europe 

the roll-out of vaccination programmes. Nonetheless, the 

is necessary to both the direct impacts of heat (especially given 

local implementation of actions — such as information and 

the high proportion of hospitals in areas experiencing the urban 

check-up services for the elderly during heatwaves, targeted 

heat island effect) and the pressure on their capacity to deliver 

urban greening activities or raising awareness of the threat 

patient care during heatwaves or diagnostics during outbreaks 

of disease outbreaks — is key to the successful reduction 

of climate-sensitive infectious diseases.

of health threats associated with heat or climate-sensitive 

However, involving actors beyond the health sector when 

climate change impacts on human health requires a systemic 

planning responses to climate-related threats is also essential. 

approach to problems and a collaborative way of planning and 

Preventing the negative impacts of heat on health can be 

implementing measures that involves all levels of governance.

infectious diseases. Thus, addressing the complex problem of 

achieved by climate-proofing buildings to ensure thermal 

comfort during heatwaves or by integrating green spaces into 

The EU, while having limited competences in the area of 

urban planning and redevelopment. Changing work schedules 

health, can support Member States by facilitating knowledge 

and applying heat-aware working conditions and facilities can 

development and sharing through research programmes, 

reduce heat stress at work, especially for outdoor workers. 

including the EU Mission for adaptation to climate change, and 

To successfully plan and implement such measures needs 

through specific initiatives such as the European Climate and 

cross-disciplinary collaboration between the health sector and 

Health Observatory or the Health Emergency Preparedness and 

the built environment, planning or employment sectors.

Response Authority. Furthermore, regulatory proposals such as 

The recent recognition of the climate-related threats to 

the role of the EU in developing early warnings and addressing 

human health and the call for action in political fora such 

the threats associated with climate change.

that on serious cross-border threats to health can strengthen 

8

Climate change as a threat to health and well-being in Europe: focus on heat and infectious diseasesExecutive summary 

© Jonas Persson, Environment Me/EEA

9

Climate change as a threat to health and well-being in Europe: focus on heat and infectious diseases1 
Introduction

Climate change is increasingly recognised as a threat to 

human existence (Kemp et al., 2022). In Europe, despite the 

predominantly temperate climate and relatively prosperous 

socio-economic situation in comparison with other world 

regions, the climate change threats to human health and 

well-being are becoming increasingly severe. Alongside the 

intensification of efforts to mitigate climate change, adaptation 

to climate change is an urgent necessity, not just to protect a 

healthy standard of living but also to prevent loss of life and 

reduce health impacts associated with extreme weather events 

and ongoing climate change.

The aim of this report is to highlight two particular threats to 

human health associated with climate change. First, the report 

focuses on high temperatures, which are already responsible 

for the largest number of fatalities associated with natural 

hazards in Europe and are projected to increase substantially 

because of anthropogenic climate change. Second, the 

The climate change threats to 
human health and well‑being 
are increasingly severe. 
Alongside the intensification 
of the efforts on climate 
mitigation, adaptation to 
climate change is a necessity.

report covers infectious diseases as an emerging threat in 

threats to human health. The chapter shows the increasing 

Europe. The COVID-19 pandemic highlighted that everyone's 

interest in this area, but it also highlights the lesser integration 

well-being can be threatened by infectious diseases and 

of health into adaptation policies at subnational levels than at 

drew attention to diseases spreading through global travel 

national and EU levels.

and originating from complex interactions between people, 

biodiversity, environmental degradation and climate change. 

Chapter 3 examines the vulnerability and exposure of the 

Both climate-sensitive infectious diseases and heat consistently 

European population to high temperatures, considering 

emerge in various policy analyses as the most frequently 

the characteristics of the population and the geographical 

tackled topics in European countries (IANPHI, 2021; WHO, 2021; 

distribution of hazards. It also looks at the impacts of heat 

European Climate and Health Observatory, 2022a).

on mortality and on labour supply and productivity. Finally, 

it discusses the solutions that can be applied to mitigate 

The report draws on the knowledge collated and developed 

heat stress.

for the European Climate and Health Observatory under 
its 2021-22 work plan, which has an explicit focus on high 

Chapter 4 explores climate-sensitive infectious disease threats 

temperatures and climate-sensitive infectious diseases. 

in Europe, in particular the changing climatic suitability for the 

The knowledge includes the set of indicators developed 

transmission of four selected diseases (dengue, malaria, West 

by the Lancet Countdown in Europe and the Copernicus 

Nile fever and vibriosis). It also identifies the groups in society 

Climate Change Service, case studies undertaken in various 

that are particularly vulnerable or exposed to diseases and 

European countries, and national policy analyses. These are 

provides an overview of preventive actions.

supplemented in the report with additional scientific evidence.

Chapter 2 provides a brief overview of the policy frameworks 

on the state of play in policy and practice and recommends 

at EU, national and local levels that consider climate change 

opportunities for action.

The report closes with Chapter 5, which draws conclusions 

10

Climate change as a threat to health and well-being in Europe: focus on heat and infectious diseases© Edgaras Vaicikevicius, My City/EEA

2 
Climate change impacts on 
health in the policy framework 
in Europe

Key messages

• 

• 

• 

The need to better understand and address the climate change threats to human health and well-being is increasingly reflected in 
EU policies, with an emphasis on better preparedness and collaboration among Member States.

Most national adaptation policies across Europe cover the climate threats to human health and propose countermeasures. 
However, national health strategies less frequently focus on climate threats. Furthermore, the actions proposed in both types of 
document are largely explorative or preparatory, rather than practical.

At the local and subnational levels, adaptation efforts rarely engage health or social sector stakeholders and are primarily driven by 
environmental or urban design agendas. There is a great need to focus on health in local adaptation plans, in particular in relation 
to vulnerable groups. 

2.1 

European policies

The need to better understand and urgently address the 

impacts of climate change on human health is becoming 

increasingly recognised in both national and European 

policies. The European Green Deal (EC, 2019) aims to protect, 

conserve and enhance the EU's natural capital and 'to protect 

the health and well-being of citizens from environment-related 

risks and impacts'.

Article 5 of the European Climate Law (EU, 2021a) makes 

adaptation to climate change a legal obligation for EU 

institutions and Member States, requiring them to 'ensure 

continuous progress in enhancing adaptive capacity, 

strengthening resilience and reducing vulnerability to climate 

change in accordance with Article 7 of the Paris Agreement'. 

The European Climate 
and Health Observatory 
was launched to better 
understand, anticipate and 
minimise the health threats 
caused by climate change. 

In addition, Member States' adaptation policies 'shall take into 

states the need for a deeper understanding of the climate risks 

account the particular vulnerability of the relevant sectors', 

to health. Key to this strategy is the European Climate and 

integrate 'adaptation to climate change in a consistent 

Health Observatory. In accordance with the European Climate 

manner in all policy areas', and 'focus, in particular, on the 

Law (EU, 2021a), the Observatory was launched to 'better 

most vulnerable and impacted populations and sectors'. The 

understand, anticipate and minimise the health threats caused 

new EU strategy on adaptation to climate change (EC, 2021a) 

by climate change'.

12

Climate change as a threat to health and well-being in Europe: focus on heat and infectious diseasesTo strengthen the preparedness and the coordination of 

responses to health threats, the 2013 Decision on serious 

cross-border threats to health (EU, 2013) (including climate 

change) is proposed to be replaced by a regulation (EC, 2020a). 

With this stronger and more comprehensive legal base, the 

EU will be able to react rapidly and trigger preparedness and 

response measures.

The European Health Union (EC, 2020b) builds on the EU's 

joint effort to reconcile the relationship with the natural 

environment by engaging in different and more sustainable 

patterns of economic growth, including mitigating carbon 

emissions, and finding ways to adapt to climate change. Set 

up in 2021, the European Health Emergency Preparedness 

and Response Authority (HERA) takes EU preparedness and 

response capacity to serious cross-border health threats to a 

new level and will be a key element in establishing a stronger 

European Health Union. The EU4Health programme (EU, 

2021b) is the biggest EU health funding programme to date, 

which intends, among other things, to 'contribute to tackling 

the negative impact of climate change and environmental 

degradation on human health'. In parallel, the EU supports 

knowledge developments in the area of climate change and 

health. Horizon Europe, the EU's key funding programme 

for research and innovation that will run until 2027, offers 

numerous funding opportunities for work on the health 

effects of climate change.

In addition, the World Health Organization (WHO) Regional 

Office for Europe has been advocating action on climate-related 

health threats since the 1990s, including through the European 

Environment and Health Process. Climate change and health is 

one of the seven priority areas of the 2017 Ostrava Declaration 

of the Sixth Ministerial Conference on Environment and Health 

(WHO Europe, 2017a), in which the 53 Member States of the 

WHO European Region committed to developing national 

portfolios of actions on environment and health. The WHO 

'Zero Regrets' (WHO Europe, 2021b) initiative aims to scale 

up action on climate change mitigation and adaptation for 

health. It addresses policymakers, particularly from the health 

sector, to raise awareness about the links between health and 
climate change. The initiative provides relevant evidence, offers 

areas for policy action that can maximise health benefits and 

promotes collaboration across sectors and actors.

More detail on the European policies and activities relevant to 

climate threats to human health can be found on the European 

Climate and Health Observatory web pages.

© Nikos Kasiktsis, My City/EEA

13

Climate change impacts on health in the policy framework in Europe

2.2 

National policies

2.3 

Local and subnational policies

National adaptation strategies, plans and climate risk 

According to the EU adaptation strategy (EC, 2021b), the local 

assessments emerge as the national policies most relevant to 

level is the bedrock of adaptation. Most European countries 

addressing climate change impacts on health at the country 

recognise the crucial role of local authorities in implementing 

level. Climate change impacts on health are more commonly 

national adaptation strategies (EEA, 2020a). In addition, local 

addressed in national adaptation strategies than in national 

authorities have the best knowledge of local population 

health strategies. Health impact assessments and response 

characteristics, locally occurring climate-related hazards and 

strategies are often integral parts of national adaptation 

opportunities for engagement with local communities. Therefore, 

policies. Only a few countries have a specific sectoral climate 

embedding health in planning and implementing adaptation 

adaptation strategy for health. The climate hazards most 

measures matters most at the subnational and local levels.

frequently covered in national adaptation and health policy 

documents are heatwaves and drought; heavy precipitation 

Health is the fourth most frequently targeted sector for local 

and flooding; general rise in temperature; increasing 

adaptation actions (EEA, 2020a), and the risks to vulnerable 

threat of pathogens and infectious diseases; and more 

people such as the elderly, children and those in poor health 

intense and frequent storms. The most frequently planned 

are increasingly recognised in local adaptation plans (Reckien 

interventions to address climate change impacts on health are 

et al., 2022). Yet the local authority departments responsible 

monitoring and surveillance, including early-warning systems; 

for implementation of the planned adaptation actions are 

awareness-raising campaigns for the general public; and 

continued research into climate change impacts on health. 

For a comprehensive analysis of the national adaptation 

most often those dealing with spatial planning, urban design, 
open spaces or architecture, followed by those concerned with 
environment or sustainability. In contrast, very few actions are 

policies and national health strategies, see the European 

implemented by social care or health and housing departments. 

Climate and Health Observatory (2022a).

In addition, the engagement of stakeholders from the health 

Only a few countries have 
a specific sectoral climate 
adaptation strategy for health. 

and social care sectors is minimal at the local level. As a result, 

many climate adaptation measures focus on technological 

interventions, without accounting for the social characteristics 

of cities, and thus fail to address the climate impacts on 
health. For example, projects and policies targeted at the most 
vulnerable groups were listed only 12th among the types of 
climate adaptation actions reported by cities across Europe. 

Thus, at the local level, the policy link between adaptation and 

health needs to be reinforced (EEA, 2020a). In over half of 

European countries, health is at least partially or fully included 

in the competences of local authorities (CEMR, 2011), thereby 

lending itself to closer links with local adaptation actions. 

14

Climate change as a threat to health and well-being in Europe: focus on heat and infectious diseases© Francesca Fabiano, My City/EEA

3 
Heat as major threat to 
human health in Europe

Key messages

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Europe is warming fast. The duration and intensity of heatwaves dangerous to human health are increasing and are projected to 
further increase substantially across Europe under all climate scenarios, especially in southern Europe.

Vulnerability to heat exposure associated with ageing, prevalence of diseases and urbanisation is highest in northern Europe, while 
between 1990 and 2019 the largest increase in vulnerability was observed in central and southern Europe.

Across Europe, 1.21 billion person-days of exposure to heatwaves among people over 65 years old were estimated in 2020. The 
exposure of elderly people to heatwaves has particularly increased in parts of central and southern Europe.

The exposure of people to heat is driven by the characteristics of the built environment and their occupation, which tends to put 
lower socio-economic groups at a disadvantage.

Nearly half of hospitals and schools in European cities are in areas with strong urban heat island effects (>2°C), meaning that their 
vulnerable users and staff are exposed to high temperatures.

Heat-related mortality has been increasing across Europe since the beginning of the 21st century, particularly in southern Europe. 
Under a scenario of 3°C global warming, without adaptation measures, 90,000 Europeans could die from extreme heat every year.

Increasing temperatures resulted in an estimated annual loss of 16 working hours per person employed in high-exposure jobs in 
the period 2016-2019 compared with 1965-1994. The largest declines in working hours occur in parts of southern Europe.

Reducing the health impacts of heat requires the implementation of different solutions, including effective heat health action 
plans, urban greening, climate-proofing of buildings, and changing working times and conditions.

Interventions should prioritise vulnerable groups (e.g. elderly, children, those in poor health and outdoor workers) and facilities 
(e.g. hospitals and schools), as well as people particularly exposed to heat. 

3.1 

Increasing hazard of high temperatures 
in Europe

the summer of 2021 was the warmest in Europe on record 

(ESOTC, 2021), it was trumped by summer 2022, with the 

average temperatures during June, July and August 0.4°C 

Europe is warming faster than the global average. Between 

higher than those in 2021 (Copernicus, 2022c). In summer 

2017 and 2021, the average temperature in Europe has 

2022, during the subsequent heatwaves, several temperature 

increased by around 2°C above late 19th century values 

records were broken; Spain, Italy and France in particular 

(C3S, 2022a). Much of Europe has experienced intense and 

experienced long spells of exceptionally high temperatures 

recurrent heatwaves since 2000 (EEA, 2022c). The conditions 

(Copernicus, 2022a).

dangerous to human health — hotter days, higher night-time 

temperatures and an increasing number of humid heatwaves 

Land temperature in Europe is projected to increase by 

— have become more frequent in Europe over the past few 

up to 3.4°C under RCP 2.6 scenario (a low greenhouse gas 

decades and are projected to increase (EEA, 2021a). While 

emissions scenario) and by up to 8.5°C under RCP 8.5 scenario 

16

Climate change as a threat to health and well-being in Europe: focus on heat and infectious diseasesHeat as major threat to human health in Europe

(a high-emissions scenario) by the end of the 21st century, 

well as an increase in the duration of extremely humid and hot 

compared with the period 1981-2010 (EEA 2022c). Accordingly, 

conditions particularly dangerous to human health, are projected 

the frequency, duration and intensity of hot periods are projected 

to increase substantially across Europe under all climate 

to increase in the future. The number of hot days is expected 

scenarios, especially in southern regions (EEA, 2022c). With 

to double and almost quadruple during the 21st century under 

climate change, the number of health-related heatwave days (a 

the medium- and high-emissions scenarios (RCP4.5 and RCP8.5), 

prolonged period of extremely high temperature and humidity) 

respectively, with more limited increases expected under the 

is projected to increase. While in the baseline period nowhere in 

low-emissions scenario (RCP2.6)  (EEA, 2021a). Southern Europe 

Europe had more than five such days per year, by the end of the 

may experience up to 100 'tropical nights' (with a minimum 

century, under the high-emissions scenario, in parts of southern 

temperature over 20°C) per year by the end of the century under 

Europe the annual number of health heatwave days will exceed 

a high-emissions scenario. Prolonged waves of extreme heat, as 

60 per year (Map 3.1).

Map 3.1 

Number of health-related heatwave days in the baseline period (1971-2000), 2031-2060 and 
2070-2099 under RCP 8.5 scenario

-30°

-20°

-10°

0°

10°

20°

30°

40°

50°

60°

70°

-30°

-20°

-10°

0°

10°

20°

30°

40°

50°

60°

70°

-30°

-20°

-10°

0°

10°

20°

30°

40°

50°

60°

70°

1971-2000

2031-2060

2070-2099

60°

50°

40°

50°

40°

60°

50°

40°

50°

40°

60°

50°

40°

50°

40°

0°

10°

20°

30°

40°

0°

10°

20°

30°

40°

0°

10°

20°

30°

40°

Reference data: ©ESRI

Number of health-related heatwave days in the baseline period (1971-2000), in 2031-2060 and in 2070-2099 under RCP 8.5 scenario 

<5

5-10

10-20

20-30

30-40

40-50

50-60

60-70

No data

Outside coverage

0

500

1,000

1,500  

km

Notes: 

A health-related heatwave is a period of at least two consecutive days on which the maximum apparent temperature (Tappmax) exceeds 
the 90th percentile of Tappmax and the minimum temperature (Tmin) exceeds the 90th percentile of Tmin. The apparent temperature is a 
measure of relative discomfort due to combined heat and high humidity. Health-related heatwaves are calculated for June, July and August.

Source: 

Climate-ADAPT (2022a).

While this report focuses solely on the direct impacts of high 

disease, diabetes and mental health disorders; see Box 3.1) 

temperatures on human health, the European Climate and 

and marginalised or underresourced people are among the 

Health Observatory also includes web pages focused on the 

most vulnerable to extreme heat (WHO Europe, 2021a).

health impacts of wildfires and air pollution combined with heat.

3.2 

Population vulnerability to extremes of 
heat in Europe

Older people in particular are at a higher risk of death from 

cardiac and respiratory disease during heatwaves. Population 

ageing in Europe will continue over the next couple of decades. 

In 2021, one fifth of the EU population was aged 65 years or 

over (Eurostat, 2022). In 2040, when 155 million Europeans will 

The vulnerability of a population to heat-related morbidity 

be over 65 years, the incidence of cardiovascular diseases is set 

and mortality is influenced by individual factors and 

to increase (MedTechEurope, 2020). In addition, the current 

socio-economic characteristics. Elderly people, children, 

number of people with diabetes (61 million) is expected to 

pregnant women, outdoor workers, people with pre-existing 

69 million by 2045 (IDF, 2021), further increasing the population 

health conditions (such as cardiovascular disease, respiratory 

vulnerability to extreme heat.

17

Climate change as a threat to health and well-being in Europe: focus on heat and infectious diseasesHeat as major threat to human health in Europe

Box 3.1 

Impacts of high temperatures on mental health

High temperatures and heatwaves are associated with mood and behavioural disorders, including increases in aggressive 
behaviour and crime. Links between high temperatures and an increase in suicide risk were found, particularly for men, as 
well as in the risk of mental health-related admissions and emergency department visits (Thompson et al., 2018).

A specific group vulnerable to the effects of extreme hot temperatures are people with pre-existing mental health 
conditions (Page et al., 2012; Palinkas and Wong, 2020), for whom heat is associated with psychological distress, worsened 
mental health, increased psychiatric hospitalisations, heightened suicide rates and higher mortality rates (Charlson 
et al., 2021). The interaction of heat with diuretics and psychotropic drugs increases the risk of dying for people with mental 
health problems during hot periods (Page et al., 2012).

For more information, see European Climate and Health Observatory (2022d).

The vulnerability of European populations to heat due to 

vulnerable region, given its high urbanisation level and the 

ageing, urbanisation and disease prevalence has been 

high proportion of elderly people in the population, the highest 

increasing steadily since 1990 (European Climate and Health 

relative increase in population vulnerability (9.8% since 1990) 

Observatory, 2021a). While northern Europe is the most 

has been observed in central and eastern Europe (Figure 3.1).

Figure 3.1 

Trends in vulnerability to heat by European region, 1990-2019, in EEA member and cooperating countries

Vulnerability Index (0-100)

44

42

40

38

36

34

32

0

1990

Notes: 

Northern Europe

Southern Europe
Western Europe

Europe

Central and Eastern Europe

1995

2000

2005

2010

2015

2019

Heat vulnerability index (ranging from 0 to 100) was calculated for the period 1990-2019 based on the proportion of the population over 
65 years, proportion of urban populations, and chronic disease prevalence (diabetes and kidney diseases, cardiovascular diseases and 
respiratory illnesses). Central and eastern Europe includes Albania, Bulgaria, Czechia, Estonia, Croatia, Hungary, Lithuania, Latvia, North 
Macedonia, Poland, Romania, Slovenia, Slovakia. Northern Europe includes Denmark, Finland, Iceland, Norway, Sweden. Southern Europe 
includes Cyprus, Greece, Spain, Italy, Malta, Portugal, Türkiye. Western Europe includes Austria, Belgium, Switzerland, Germany, France, 
Ireland, Luxembourg, Netherlands, United Kingdom.

Source: 

van Daalen et al. (2022). 

18

Climate change as a threat to health and well-being in Europe: focus on heat and infectious diseasesHeat as major threat to human health in Europe

3.3 

Exposure of population to heatwaves and 
high temperatures in Europe

The increasing number of people over 65 years old in Europe, 

combined with the higher temperatures in summer, has resulted 

3.3.1  Exposure of vulnerable groups across Europe

people to heatwaves since 1980 (European Climate and Health 

in a substantial increase in the overall exposure of elderly 

Observatory, 2021b). According to modelling that includes 

Southern Europe consistently emerges as the region with the 

the number of infants under 1 year old as a vulnerable group 

greatest and fastest-increasing risk of high temperatures to 

alongside elderly people, the decade 2010-2019 had heatwave 

human health (EEA, 2021a). In addition, many regions affected 

exposure 64.4% higher (yearly mean of 1.07 billion person-days) 

by high temperature are characterised by populations with low 

compared with 2000-2009 (0.65 billion person-days). In 2020, 

socio-economic status. For example, parts of Bulgaria, Croatia, 

1.21 billion vulnerable person-days of heatwave exposure were 

Greece, Italy and Spain are among the European regions 

calculated. This was principally driven by the exposure of the 

most affected by both long-term unemployment and high 

over-65s. However, 3.1 million person-days were related to the 

temperatures. In addition, the areas with a large number of hot 
days (1) tend to have higher proportions of elderly people in 
their populations, for example Greece, Italy, Portugal and parts 

heatwave exposure of infants. Furthermore, increases in specific 

locations may be significantly higher than average. Particular hot 

spots for increased heatwave exposure are in central and eastern 

of Spain (EEA, 2018).

Spain and central Europe (van Daalen et al., 2022; Map 3.2).

Map 3.2 

Percentage change in total heatwave exposure of people over 65 years old during the period 2010-2020 
compared with 2000-2009 in EEA member and cooperating countries and the United Kingdom

-30°

-20°

-10°

0°

10°

20°

30°

40°

50°

60
60°

70
70°

Percentage change in total
Percentage change in total
heatwave exposure of people
heatwave exposure of people
over 65 years old during the
over 65 years old during the
period 2010-2020 compared
period 2010-2020 compared
with 2000-2009 in EEA member
with 2000-2009 in EEA member
and cooperating countries and
and cooperating countries and
the United Kingdom 
the United Kingdom 

250

200

150

100

50

0

-50

-100

No data

Outside coverage

50°

40°

60°

50°

40°

0

500

1,000

1,500 km

0°

10°

20°

30°

40°

Reference data: ©ESRI

Notes: 

The indicator has been calculated by multiplying the number of heatwave days by the vulnerable population count (i.e., those aged 
65 years and over), producing an indicator of 'person-days' reflecting both the change in frequency and duration of heatwaves. Heatwaves 
are defined as periods of 2 or more days on which both the minimum and the maximum temperatures are above the local 95th percentile 
(defined using the 1986-2005 baseline).

Source: 

van Daalen et al. (2022).

(1)  Days on which maximum temperature exceeds 35°C.

19

Climate change as a threat to health and well-being in Europe: focus on heat and infectious diseasesHeat as major threat to human health in Europe

3.3.2  Exposure to heat at home, work and school

actions targeted at housing inhabited by people in low-income 

groups (see Section 3.5.3).

In urban areas, where most Europeans live, exposure to heat 

may be compounded by the urban heat island (UHI) effect, 

An analysis of the distribution of hospitals and schools in relation 

whereby the urban structure, its materials and its landscapes 

to UHIs in 100 European cities found that almost half  are in areas 

tend to increase ambient temperatures and reduce night-time 

at least 2°C warmer than the average for that city (European 

cooling (EEA, 2021a). In many European countries, it is the 

Climate and Health Observatory, 2022b). Hospitals and schools 

more vulnerable communities that tend to live in dense, urban 

are particularly exposed to intense UHIs (>4°C in comparison with 

environments and, therefore, may be exposed to higher 

the city average) in Greece, Italy, Romania and Spain (Map 3.3). 

temperatures because of the UHI effect (EEA, 2018). In addition, 

This may pose heightened heat-related threats to schoolchildren 

the quality of the built environment, which substantially affects 

or hospital patients, as well as teachers and health workers. The 

the indoor thermal comfort, tends to be the lowest among 

risk of losing electricity supply in hospitals during periods when 

lower socio-economic status groups, which also may not be 

the power grid is overused may not only disrupt care, but also 

able to afford mechanical cooling in their homes (EEA, 2018). 

reduce or remove air conditioning capacity and expose highly 

Consequently, in nearly all European countries, the lowest-

vulnerable people to high temperatures (Patel et al., 2022). The 

income households are less able to keep cool during summer 

COVID-19 pandemic showed that the healthcare workforce can 

than wealthier households. In Bulgaria, Greece, Spain and 

be particularly at risk of occupational exposure to heat through 

Italy, those on the lowest incomes are twice as likely to be 

the use of special protective equipment (Jegodka et al., 2021), 

uncomfortably hot in their home as those on the highest 

emphasising further the need for the urgent adaptation of 

incomes (Eurostat, 2012). This requires urgent adaptation 

healthcare facilities.

Map 3.3 

Percentage of educational facilities (left) and healthcare services (right) in areas experiencing the 
urban heat island effect greater than 2°C in 100 European cities

-30°
Educational facilities 

-10°

-20°

0°

10°

20°

30°

40°

50°

60°

70°

-30°
Healthcare services 

-10°

-20°

0°

60°

50°

40°

50°

40°

60°

50°

40°

10°

20°

30°

40°

50°

60°

70°

50°

40°

0°

10°

20°

30°

40°

0°

10°

20°

30°

40°

Reference data: ©ESRI

Percentage of educational facilities (left) and healthcare services (right) located within Urban Heat Island Effect greater than 2°C 
in 100 European cities

Outside coverage

No data

<20

20-40

40-60

60-80

>80

Source: 

European Climate and Health Observatory (2022b).

0

500

1,000

1,500 km

20

Climate change as a threat to health and well-being in Europe: focus on heat and infectious diseasesHeat as major threat to human health in Europe

People who perform physical work, use protective equipment 

With regard to exposure to heat at work, in large parts of Europe 

or clothing, work outdoors exposed to the sun or work in 

future heat exposure will exceed critical levels for physically active 

poorly cooled buildings with machinery that generates heat are 
disproportionately exposed to high temperatures (Pogačar et al., 
2018; WHO Europe, 2021). Many agricultural workers' tasks need 

to be performed to a fixed schedule, sometimes requiring the 

most physically demanding tasks to take place during either the 

people far more often than in today's climate. This may result 

in substantially reduced labour productivity in southern Europe 

(Casanueva et al., 2020; see Section 3.4.2).

hottest part of the day or the hottest time of year. Construction 

3.4 

Health impacts of heat

workers in cities are also exposed to the UHI effect. Low-income 

workers exposed to heat stress through their jobs tend also to 

3.4.1  Heat-related mortality

be more exposed on the way to work (e.g. on foot or commuting 

in vehicles without air conditioning), in their homes (due to 

High temperatures can cause heat stress, which increases the 

poor insulation, lack of air conditioning and inability to afford 

risk of death from heat exhaustion and heatstroke. Moreover, 

mechanical cooling) and in their neighbourhoods (e.g. urban 

indirect heat impacts on cardiovascular and respiratory 

areas are highly susceptible to the heat island effect) (Narocki, 

systems and the exacerbation of existing health conditions 

2021).

by heat are another cause of increased mortality during hot 

weather (WHO Europe, 2021a). High temperatures also affect 

mental health and may increase the mortality risk of people 

3.3.3  Projected exposure of European population to 

with mental health problems (see Box 3.1). These direct and 

high temperatures

indirect impacts of heat have been recognised in over half of 

the national adaptation policies and health strategies across 

The projected increase in the intensity, frequency and length of 

the 33 EEA member countries and six cooperating countries 

heatwaves will result in a strong rise in the number of people 

(EEA-38) (European Climate and Health Observatory, 2022a).

exposed to extreme heat. Even if global temperatures are 

stabilised at 1.5°C above pre-industrial levels, by the end of 

No consistent reporting of heat-related mortality exists in 

this century more than 100 million people annually in the EU 

Europe. According to information held by various databases 

and United Kingdom are expected to be exposed to a present 
50-year heatwave intensity (2), compared with nearly 10 million 
per year under the baseline climatic conditions (1981-2010). 

on natural disasters and catastrophes, heatwave events are 

responsible for 86-91% of fatalities caused by weather- and 

climate-related extreme events in EEA member countries 

The number of people exposed to a present 50-year heatwave 

(1980-2020), which corresponds to 77,000-129,000 deaths 

intensity grows to 172 million per year at the end of the 

over that period (EEA, 2022d) (Figure 3.2). The death toll 

century with a global temperature increase of 2°C above 

from the 2003 European heatwave alone is believed to have 

pre-industrial levels and to nearly 300 million per year with 

exceeded 70,000 (Robine et al., 2008). An early indication of 

unmitigated climate change (3°C warming in 2100). This means 

the mortality associated with the 2022 heatwaves in Europe is 

that in 80 years more than half of the European population 

given in Box 3.2. 

could be exposed each year to a present 50-year heatwave 

(Naumann et al., 2020).

In addition, continued urbanisation in Europe will increase the 

number of people exposed to extreme heat conditions due to the 

UHI effect. Europe's level of urbanisation is projected to  increase 
to approximately 83.7% in 2050. Built-up areas are likely to 

expand by more than 3% between 2015 and 2030, constituting 

7% of EU territory by 2030 (Perpiña Castillo et al., 2019). Smid et 

al. (2019) project increased exposure to heatwaves in all capital 

cities across Europe, but particularly those in southern Europe. 

No consistent reporting of 
heat‑related mortality exists 
in Europe.

(2)  A heatwave that has a 2% probability of occurring every year (i.e. on average that would happen every 50 years).

21

Climate change as a threat to health and well-being in Europe: focus on heat and infectious diseasesHeat as major threat to human health in Europe

Figure 3.2 

Fatalities associated with natural disasters and catastrophes in EEA member countries in the period 
1980-2020 based on CATDAT (left) and NatCatService (right)

CATDAT database

NatCatSERVICE database

Meteorological
events 
3%

Hydrological 
events 
4%

Other climatological 
events
2%

Meteorological
events
4%

Other climatological
events
4%

Hydrological
events
6%

Total number of fatalities
142,101

Total number of fatalities
89,525

Climatological -
Heatwave events
91%

Climatological -
Heatwave events
86%

Source: 

EEA (2022d). 

Box 3.2  Deaths associated with heatwaves in summer 2022

The summer of 2022 was the summer of heatwaves. In 
2022, the first high temperatures dangerous to human 
health were already experienced in southern Europe in the 
second half of May; these continued into June, peaking on 
17 June (Copernicus, 2022a). Subsequently, July was the 
warmest on record in south-western Europe in terms of 
average maximum temperatures. Around mid-July, heatwave 
conditions affected most of western Europe (Copernicus 
2022b). During the July heatwave, temperatures exceeded 
40°C in France, 45°C in Spain and 46°C in Portugal (ECMWF, 
2022). The average temperatures in August were the highest 
on record (0.8°C higher than in 2018) (Copernicus, 2022c).

At the time of publishing this report, it was too early to have 
a robust overview of the deaths related to the heatwaves; in 
addition, the information disclosed by national authorities 
on the deaths associated with high temperatures varies. 
However, in June, July and August 2022, Spain alone recorded 
over 4,600 deaths attributable to temperatures exceeding 
40°C (MoMo, 2022). In Germany, in July, 9,130 (or 12%) more 
deaths were recorded than the median of the years 2018 
to 2021 for this month (Federal Statistical Office, 2022). 
In Portugal, over 1,000 extra deaths had been reported 
by 18 July (Reuters, 2022). In the Netherlands, in week 29, 
the authorities recorded 559 non-COVID-19 excess deaths 
compared with the previous 5 years (Politico, 2022). 

© Tobias Terman Olsen

22

Climate change as a threat to health and well-being in Europe: focus on heat and infectious diseasesHeat as major threat to human health in Europe

In the paucity of consistently recorded heatwave mortality, 

for the general population is estimated (Map 3.4). This upwards 

the modelling utilising weekly mortality and temperature data 

trend in heat-related deaths has been more pronounced in 

suggests an increase in heat-related mortality between 2000 

southern Europe, especially in Spain and Portugal. Country-level 

and 2020 in 94% of the 990 European regions assessed. An 

values range from the average of 30.6 (95% CI: 6.32 to 54.9) 

overall average increase of 15.1 (95% confidence interval (CI): 

annual deaths per million per decade in Spain to -1.53 (95% 

-1.51 to 31.6) annual deaths per million inhabitants per decade 

CI: -6.33 to 3.27) in Iceland (van Daalen et al., 2022).

Map 3.4 

Trends in heat-related mortality incidence over 2000-2020 in Europe (annual deaths per million per decade)

-30°

-20°

-10°

0°

10°

20°

30°

40°

50°

60
60°

70
70°

Trends in heat-related mortality 
Trends in heat-related mortality 
incidence over 2000-2020 in 
incidence over 2000-2020 in 
Europe (annual deaths per million 
Europe (annual deaths per million 
per decade)
per decade)

60°

50°

40°

-20°

Canary Is.

-30°

Azores Is.

30°

40°

Madeira Is.

<-30

-30 to -20

-20 to -10

-10 to 0

0 to 10

10 to 20 

20 to 30 

30 to 40 

>40 

No data

Outside coverage

555
50°

40°

30°

0

500

1,000

1,500

km

20°

30°

40°

Reference data: ©ESRI

Notes: 

Epidemiological models were combined with with weekly temperature and mortality data to estimate the number of heat-related deaths 
over the period 2000-2020. A linear trend was fitted to the yearly time series of heat-related mortality incidence, whose slope represents 
the indicator expressed as annual deaths per million inhabitants per decade. The smallest regions possible were used, depending on the 
spatial resolution of the mortality data in a given country, ranging from NUTS (3) to countries. Data were not available for Türkiye, Bosnia 
and Herzegovina, Kosovo (under UN Security Council Resolution 1244/99) and North Macedonia.

Source: 

van Daalen et al. (2022).

(3)  NUTS (French Nomenclature des unités territoriales statistiques) is a hierarchical system for dividing up the territory of the EU for the purpose 
of collecting, developing and harmonising European statistics, carrying out socio-economic analyses of the regions and framing EU policies. 
NUTS 3 are areas with 150,000-800,000 inhabitants (Eurostat, 2015).

23

Climate change as a threat to health and well-being in Europe: focus on heat and infectious diseasesHeat as major threat to human health in Europe

However, the above calculations do not consider the adaptation 

pace of work under heat stress and take additional breaks to 

measures present (heat health action plans, improvements in 

rehydrate and cool down (Dasgupta et al., 2021; Ioannou et al., 

health services, better insulated buildings that provide cooling; 

2021; Szewczyk et al., 2021).

see Section 3.5) or human adaptability to higher temperatures, 

which may mean that the increasing temperatures do not 

The relationship between temperature and labour is non-linear, 

directly translate into increased mortality. For example, in 

with labour supply and productivity declining beyond certain 

Spain, the minimum mortality temperature (i.e. temperature 

optimal thresholds (Dasgupta et al., 2021; Schleypen et al., 

above which mortality increases) has increased in parallel 

2021). The optimal annual mean temperature beyond which 

with the general increase in the temperatures over the past 

labour supply in Europe declines has been estimated to 

decades (Achebak et al., 2019; Follos et al., 2021), indicating a 

be 9.3°C (95% CI: 7.9°C to 10.6°C) for high-exposure work 

level of population acclimatisation and possibly reducing the 

conditions (in agriculture, forestry, mining and quarrying, 

temperature effect on mortality.

and construction) (van Daalen et al., 2022). In these four 

high-exposure sectors, the increased temperature caused a 

Over the following decades, accelerating climate change 

0.23% decline in the number of working hours in the period 

may lead to a substantial increase in morbidity and mortality 

1995-2000, compared with the reference period of 1965-1994. 

unless adaptation measures are taken. Without adaptation 

This amounts to just over 4 hours per worker per year. In the 

measures, and under a scenario of 3°C global warming by 2100, 

period 2016-2019, a 0.98% decline (equivalent to 16 hours per 

90,000 Europeans could die from extreme heat annually. With 

worker per year) was observed in comparison with the same 

1.5°C global warming, this is reduced to 30,000 deaths annually 

baseline. The largest declines in working hours are estimated 

(Naumann et al., 2020). In addition, according to the sixth 

to be in Cyprus, the South Aegean in Greece and the Balearic 

assessment report of the Intergovernmental Panel on Climate 

Islands in Spain. Northern European countries generally show 

Change (IPCC), the number of deaths from and people who may 

small gains in labour supply (van Daalen et al., 2022; Map 3.5).

experience heat stress in Europe will be double or treble at the 

end of the century at a global warming level of 3°C compared 

According to the International Labour Organization (ILO, 2019), 

with a 1.5°C level (IPCC WGII, 2022a). The projected decrease in 

by 2030, 0.03% of total working hours could be lost as a result 

mortality associated with exposure to low temperatures will be 

of heat stress in Europe and Central Asia, the equivalent of 

much smaller and will not offset the increase in mortality from 

around 103,000 full-time jobs. In the worst-case scenario, 

high temperatures (Naumann et al., 2020; Martínez-Solanas 

European labour productivity losses could be around 0.3%, 

et al., 2021). Therefore, climate mitigation and adaptation 

0.8% and 1.6% by the 2020s, 2050s and 2080s, respectively, 

measures are both necessary and urgent. According to Díaz 

with southern Europe experiencing the highest losses 

et al. (2019), in the case of Spain, the number of deaths in the 

(Szewczyk et al., 2021). Effective labour (the combination of 

second half of the 21st century could be nearly 10 times smaller 

the number of working hours and output during these working 

using a comprehensive set of adaptation measures than in a 

hours) in southern Europe is expected to decrease by up to 

scenario without adaptations.

13.6 percentage points under 1.5°C of warming (2030-2050), 

18.2 percentage points under 2.0°C of warming (2050-2070) and 

28.5 percentage points under 3.0°C of warming (2070-2090) 

3.4.2  Heat impacts on labour

(Dasgupta et al., 2021).

While Europe has been relatively less affected by heat stress 

in the work environment than other parts of the world, the 

increasing temperatures have nevertheless already had 
adverse effects on the European labour force, especially on 

workers in highly exposed sectors such as agriculture and 

construction (van Daalen et al., 2022). Heat stress in the 

working environment can cause dehydration, which in turn 

may reduce concentration and speed of reflexes, increasing 

the risk of work-related injuries (Narocki, 2021). For office 

workers, increasing temperatures impact cognitive abilities, 

negatively affecting concentration and decision-making 

capacity. Therefore, warming directly affects labour supply 

(number of working hours, i.e. the amount of time people 

allocate to work) and reduces performance during working 

hours (labour productivity), as workers need to slow the 

Heat stress in the working 
environment can cause 
dehydration, which in turn 
may reduce concentration and 
speed of reflexes, increasing the 
risk of work‑related injuries. 

24

Climate change as a threat to health and well-being in Europe: focus on heat and infectious diseasesHeat as major threat to human health in Europe

Map 3.5 

Percentage change in labour supply due to temperature change in high-exposure sectors (agriculture; 
forestry; mining and quarrying; construction) in relation to the baseline period 1965-1994

-30°

-20°

-10°

0°

10°

20°

30°

40°

50°

60°

70°

-30°

-20°

-10°

0°

10°

20°

30°

40°

50°

60°

70°

-30°

-20°

-10°

0°

10°

20°

30°

40°

50°

60°

70°

1995-2000

Lorem ipsum

Lorem ipsum

2006-2010

2016-2019

60°

50°

40°

50°

40°

60°

50°

40°

50°

40°

60°

50°

40°

50°

40°

0

500

1,000

1,500 km

0°

10°

20°

30°

40°

0°

10°

20°

30°

40°

0°

10°

20°

30°

40°

Reference data: ©ESRI

Percentage change in labour supply due to temperature change in high-exposure sectors (agriculture; forestry; mining and
quarrying; construction) for three periods (1995-2000; 2006-2010; 2016-2020) in relation to the baseline period 1965-1994

<-8
-8 to -6

-6 to -4

-4 to -2

-2 to 0

0 to 2

2 to 4

4 to 6

No data

Outside coverage

>6

0

500

1,000

1,500  

km

Notes: 

This indicator uses longitudinal data controlling for non-linear mean annual temperature and total annual precipitation as climatic 
stressors. The dependent variable is the log of the number of working hours at the NUTS 2 level. The econometric estimates are combined 
with temperature deviation from the 1965-1994 average to estimate the impact of temperature change on the number of hours worked in 
each NUTS 2 region.

Source: 

van Daalen et al. (2022).

The projected impacts of high temperatures on effective 

labour supply are likely to have negative implications for 

both economic growth and poverty in Europe. Over the 

period 1981-2010, the average European loss of gross 

domestic product (GDP) associated with heatwaves was 

0.2%, amounting to 0.3-0.5% GDP in years with substantial 

heatwaves (2003, 2010, 2015 and 2018), with southern Europe 

experiencing up to 1% loss of GDP (García-León et al., 2021). 

By 2050 the construction sector in Europe is projected to 

suffer a loss of about EUR4.7 billion, followed by transport 

(EUR2.8 billion) and agriculture (EUR2.4 billion) (Flouris et al., 

2017). Other industries such as tourism and manufacturing 
will also be affected, albeit to a lesser extent.

Adaptation options to manage 
heat risks in Europe include 
behavioural change combined 
with building interventions, space 
cooling and urban planning.

3.5 

Reducing the health impacts of heat 
through adaptation measures

The effectiveness of public policies aimed at reducing the 

health impacts of heat can be exemplified by the difference in 

heatwave fatalities in France: while the 2003 heatwave caused 

an estimated 15,000 deaths, the June 2017 heatwave caused 

Heat-related health impacts will increase across Europe if 

only 580 additional deaths nationally (Mairie de Paris, 2018), 

adequate adaptation efforts are not implemented (WHO 

and around 2,000 deaths were associated with the heatwaves 

Europe, 2021a). Heat prevention requires a portfolio of actions 

of 2018 and 2019 (Adélaïde et al., 2022). The actions taken 

at different levels, across different sectors and over different 

include the introduction of the national heatwave plan to 

time-frames. According to the IPCC, adaptation options to 

increase awareness among the population about the risks 

manage heat risks in Europe include behavioural change 

combined with building interventions, space cooling and urban 

planning (IPCC WGII, 2022a).

associated with high temperatures, the establishment of 
more green areas in cities and the provision of cool rooms 
(CSMonitor, 2019; EEA, 2020a).

25

Climate change as a threat to health and well-being in Europe: focus on heat and infectious diseasesHeat as major threat to human health in Europe

However, little is yet known about the effectiveness and efficiency 

of the specific adaptation measures, leading to calls for the 

development of knowledge on the subject and the effective 

sharing of information (EEA, 2020a). In addition, the actions 

taken to date may not constitute the most efficient approach, 

given the increasing frequency and intensity of recurring climatic 

events and the disproportionate impact of these on vulnerable 

populations (Mairie de Paris, 2018). The following sections discuss 

some of the approaches to reducing heat impacts on health.

3.5.1  Heat health action plans including early 

warnings

Heat health action plans (HHAPs) that incorporate early-warning 

and response systems emerge as a key tool for reducing extreme 

heat threats to human health (WHO Europe, 2021a; IPCC WGII, 

2022b). HHAPs offer short-term responses: to heat-health 

threats associated with heatwaves and extreme heat events. 

They comprise early-warning meteorological systems ensuring 

timely alerts, which trigger national-, regional- or city-level 

actions; define institutional responsibilities and coordination 

mechanisms; and list measures to be deployed. Well-designed 

and well-implemented heat action plans can successfully reduce 

mortality from extreme temperatures (EEA, 2020a).

HHAPs can be applied in urban and other settings to target both 

the general population and vulnerable groups, such as the elderly 

or those working outside (IPCC WGII, 2022b). The iteratively 

updated response strategies incorporate weather-based alerts 

and timely public and medical advice, as well as improvements to 

housing and urban planning, while ensuring that healthcare and 

social systems are ready to act in the case of an extreme heat event 

(Climate-ADAPT, 2021). The measures in heat action plans include 

informing vulnerable individuals about the risk and preventive 

measures, accompanied in many cases by the provision of cooling 

rooms and medical support (EEA, 2020a). Communicating risks 

and giving behavioural advice are essential components of an 

HHAP to improve the population's awareness of health-related 

threats and prevention measures (WHO Europe, 2021a).

WHO Europe (2008) guidance on heat health action planning names 

eight elements for the successful implementation of an HHAP:

1.  agreement on a lead body;

2.  accurate and timely alert systems;

3.  a heat-related health information plan;

4.  a reduction in indoor heat exposure;

5.  particular care for vulnerable population groups;

6.  preparedness of the health and social care system;

7. 

long-term urban planning;

8.  real-time surveillance and evaluation.

26

© Daniel Nicolae, My City/EEA

Heat as major threat to human health in Europe

According to a 2021 World Health Organization (WHO) Europe 

Among the countries with HHAPs, France, Germany, Italy and 

survey, HHAPs at national or federal level have been confirmed 
in 16 EEA member and collaborating countries (4); eight 
countries responded that they did not have an HHAP in place (5) 
(WHO Europe, 2021a). Specific state, regional, provincial or 

the Netherlands, at least, have revised their HHAPs to account 

for COVID-19 risks and have given additional information 

on heat and COVID-19 risks and diversified measures given 

the related restrictions in place. In addition, WHO European 

municipal HHAPs are listed by 10 countries: Austria, Belgium, 

Region has adjusted its regularly issued summertime advice to 

France, Germany, Italy, North Macedonia, Portugal, Spain, 

include information on minimising the adverse health effects 

Sweden and Switzerland. In the 16 countries with HHAPs, five 

of hot weather, integrating it with advice on protection from 

of the eight elements (agreement on a lead body, accurate 

COVID-19 (Sanchez Martinez et al., 2022).

and timely alert systems, a heat-related health information 

plan, a reduction in indoor health exposure, and particular 

The European Climate and Health Observatory includes case 

care for vulnerable population groups) have been either fully 

studies of heatwave plans from Austria, Portugal and North 

or partially implemented. Among the countries with HHAPs, all 

Macedonia (see Box 3.3).

but one have implemented alert systems. The least commonly 

implemented items were real-time surveillance, long-term 

urban planning and preparedness of health and social care 

systems (Sanchez Martinez et al., 2022).

Box 3.3 

Examples of national heatwave action plans

The Austrian Heat Protection Plan, led by the Ministry of Health and Women's Affairs with the involvement of several 
relevant actors at the national and provincial levels, was prepared and put into action in 2017. The plan describes the 
connection between climate change and health and sets out the baseline meteorological information for heat warnings, 
which is provided by the national meteorological service (ZAMG). The information and warnings are directed to citizens via 
a network of institutions and actors in the health field.

Following the 2003 heatwave, the Portuguese heatwave contingency plan was established, which operates every year 
from May to September and covers the whole of continental Portugal. The aim of the current plan is to prevent the adverse 
health effects of heat stress on the population during periods of elevated temperatures. Daily alerts are a key factor of the 
successful implementation of this plan, as they indicate what protection measures must be carried out.

The national heat-health action plan of North Macedonia (approved in 2012) lead to implementation of a heat-health 
warning system, as well as a series of actions aimed at mainstreaming health protection in other relevant policies, raising 
citizens' and health sector workers' awareness about the consequences of climate change and mobilising resources for 
managing the effects of heat on health.

The development of monitoring and surveillance systems 
to track climate change-related impacts, including the 

Italy, the heat health watch warning system was implemented in 
2005 to provide warnings of heatwaves that activate preventive 

implementation of early-warning systems, was the most 

actions at the local level. In Germany, the second progress 

common measure planned to address climate change impacts 

report on the strategy for adaptation to climate change includes 

on health in national climate adaptation strategies and national 

several ongoing, planned and proposed research projects, 

health strategies, according to the analysis by the European 

including analyses of the effectiveness of health adaptation 

Climate and Health Observatory (2022a). The establishment 

measures in the context of heat action plans (European Climate 

of integrated national structures for public health surveillance 

and Health Observatory, 2022a).

and response was frequently identified in national policies as 

the vital element of an effective health system. For example, in 

(4)  Countries participating in the survey: Austria, Belgium, Croatia, France, Germany, Hungary, Italy, Lithuania, Malta, the Netherlands, North 

Macedonia, Portugal, Slovenia, Spain, Sweden and Switzerland.

(5)  Cyprus, Denmark, Estonia, Finland, Montenegro, Norway, Poland and Serbia.

27

Climate change as a threat to health and well-being in Europe: focus on heat and infectious diseasesHeat as major threat to human health in Europe

There are also examples of heatwave action plans at the 

heat stress. In 2021, the WHO European Region adjusted 

subnational level (see Box 3.4) that focus on vulnerable groups. 

its regularly issued summertime advice to include tips 

For example, in Lisbon, the social care department of the 

for minimising the adverse health effects of hot weather, 

municipality implements a contingency plan for homeless 

integrating this with advice on protection from COVID-19. 

people whenever alerts for various extreme weather-related 

The advice was summarised in a fact sheet, available in 

events are recorded (EEA, 2020a). In addition to organised and 

15 languages, which was promoted in a broad communication 

proactive action by the public sector, one way of preventing 

and outreach campaign with four short video clips featuring 

health impacts from heat is through encouraging community 

public health advice on how people can 'keep cool in the 

solidarity and self-help. For example, the city of Paris holds a 

heat'. The Swiss climate change adaptation plan describes 

register of people vulnerable to heatwaves and encourages 

several measures in place to improve citizens' awareness of 

solidarity networks to ensure that neighbours look after each 

the health threats from high temperatures, including a public 

other during heatwaves. Similarly, in Bologna, Italy, volunteers 

website on which the Federal Office of Public Health provides 

and non-governmental organisations assist vulnerable 

an overview of and behavioural recommendations on the 

individuals during heatwaves through a payment-free call 

subject. Similarly, in Italy, in accordance with the national 

centre, looking after people at risk and accompanying them to 

prevention plan 2020-2025, the Ministry of Health website 

cooling centres or hospitals (ETC/CCA, 2018).

publishes bulletins on heatwaves, which are also available 

through a mobile application (European Climate and Health 

An effective HHAP involves raising awareness among the 

Observatory, 2022a).

public, particularly vulnerable groups, of the threats from 

Box 3.4 

Examples of subnational heat action plans

The city of Kassel in Germany provides the 'heat hotline parasol', a free service that, during the summer months, calls 
registered citizens to give them information about heat warnings from the German Weather Service and suggest ways 
to best deal with and adapt to higher temperatures and heat. The hotline provides support to elderly residents and 
their families in particular. The service is run by volunteers from the elderly committee and is coordinated by the health 
department of the Kassel region.

The municipality of Botkyrka in Sweden experienced a heatwave in 2010 that affected the health and well-being of the 
residents of nursing homes. Since then, extensive efforts have been made in Botkyrka to reduce the health impacts of 
heatwaves. Staff of establishments for elderly people have been educated on heatwave threats, and procedures to follow 
in case of heatwave warnings have been. If necessary, additional staff can be mobilised to ensure further support for safe 
care. Botkyrka also supports actions aimed at improving indoor thermal comfort and creating 'cool spots' in various areas 
of the municipality.

In Belgium, heat health action plans are triggered based on temperature forecasts in rural settings, which leads to an 
underestimation of heat stress in cities such as Antwerp where the urban heat island (UHI) effect causes twice as many 
heatwave days as in rural surroundings. A 5-day neighbourhood-level heatwave forecasting system was set up for Antwerp 
that takes into account the UHI effect. This efficiently targets help to vulnerable people (elderly and children) in locations 
where it is needed most. Furthermore, a web platform was developed by the city to issue heatwave warnings and advice on 
action to healthcare workers and other relevant stakeholders.

When extremely hot weather is predicted in Tatabánya, Hungary, a heatwave and UV radiation protocol is set in motion. 
The Hungarian Meteorological Service and the National Public Health Office report warnings of heatwaves or high UV 
radiation to the local authorities. After that, citizens receive an alert in printed or electronic form, advice about preparing 
for the forecast heatwave and details of who to contact in case of health problems. A key aspect is that information reaches 
citizens rapidly and through different channels (local radio, television, the city's home page, social media). Instructions for 
citizens, public institutions, healthcare organisations and the media are updated every 30 minutes.

28

Climate change as a threat to health and well-being in Europe: focus on heat and infectious diseasesHeat as major threat to human health in Europe

© Toni García, My City/EEA

3.5.2  Urban greening

Vegetation in cities helps to reduce temperatures through 

evapotranspiration, shading and lower heat absorption and 

thus can help to decrease the heat-related mortality (Pascal 

et al., 2021). Parks, trees and green roofs emerge as effective 

measures for reducing ambient air temperature and improving 

both outdoor and indoor thermal comfort (EEA, 2020a). 

UBA (2022) identifies maintaining existing trees and planting 

new ones, supplemented by roof and facade greening, among 

the heat adaptation options suitable for temperate climates.

Apart from reducing temperatures, urban greening increases 

water retention (thereby reducing the likelihood of flooding), 

filters the air, dampens noise and improves mental well-being of 

urban residents (EEA, 2019a). The benefits of urban greening to 

health are so significant that, beyond contributing to sustainable, 

liveable and healthy cities, increasing exposure to green space 

could prevent a large number of premature deaths in European 

cities (Pereira Barboza et al., 2021). WHO recommends that 

urban residents have access to at least 0.5-1ha of public green 

space within 300m of their home (WHO Europe, 2017b).

European cities contain an average of 42% green space (EEA, 

2021b), and 30% of the average city area is urban  tree cover 

(EEA, 2021c), but the extent of greenness varies widely between 

and within cities. For example, cities in Finland and Norway have 

the highest proportion of tree cover, at over half of the area, 

while cities in Cyprus, Iceland and Malta have the lowest, at 

below 10%. In addition, the degree of greening varies across city 

neighbourhoods, with less and lower quality green space typically 

found in communities of lower socio-economic status. Therefore, 

ensuring equitable access to green space, and that urban greening 

efforts do not result in gentrification, is paramount (EEA, 2022a).

Furthermore, in European cities, the average proportion of green 

space around schools (within a straight-line distance of 300m as 

per the WHO recommendation) is well below the city average. On 

average, only 9% of the area in close proximity of schools is green, 

with urban tree cover constituting 6%. For hospitals, the amount 

of green space cover within 300m is 16%, and urban tree cover 
is 11% (Figure 3.3; European Climate and Health Observatory, 

2022e), which emphasises the need to prioritise adaptation to heat 

of those facilities to improve the thermal comfort of their users.

European policies promote the use of nature-based solutions and 

urban greening. The EU's 2030 biodiversity strategy encourages 

bringing nature back into cities by creating biodiverse and 

accessible green infrastructure. The strategy also emphasises the 

importance of developing urban greening plans in larger cities 

and towns (EC, 2020c). The role of nature-based solutions in 

climate resilience is recognised by the EU strategy on adaptation 

to climate change (EC, 2021a). The proposal for a nature 

restoration law sets targets of no net loss and an increase in 

urban green spaces in cities, towns and suburbs (EC, 2022a).

Heat as major threat to human health in Europe

Figure 3.3 

Average percentage of urban green space and urban tree cover within 300m of hospitals in European 
cities, per country

All countries

Austria (78)

Belgium (104)

Bulgaria (187)

Croatia (20)

Cyprus (5)

Czechia (64)

Denmark (10)

Finland (108)

France (1417)

Germany (988)

Greece (24)

Hungary (64)

Ireland (53)

Italy (478)

Latvia (14)

Lithuania (58)

Luxembourg (9)

Malta (5)

Netherlands (124)

Norway (125)

Poland (181)

Portugal (31)

Romania (64)

Slovakia (42)

Slovenia (7)

Spain (529)

Sweden (27)

Switzerland (82)

0

5

10

15

20

25

30

35

40

45

Percentage

Urban green space

Urban tree cover

() Number of healthcare facilities analysed

Note: 

Data available for EU-27, excluding Estonia, plus Norway and Switzerland

Source: 

European Climate and Health Observatory (2022e). 

Many national adaptation strategies include measures to create 

UHI effect and therefore heat stress (European Climate and 

fresh air corridors and 'cool islands' of green spaces in cities. 

Health Observatory, 2022a).

For example, the Dutch strategy includes a plan to strengthen 

natural networks in cities to simultaneously improve biodiversity 

Adaptative actions aimed at maintaining the health and well-being 

and use the natural cooling effect of green areas as a 'climate 

of vulnerable groups through urban greening are also embedded 

buffer' for people. The 2021 climate impact and risk assessment 

in other types of national policies. For example, the 2019 German 

for Germany outlines plans to define and implement guidelines 

Federal Government's 'Urban Nature' master plan proposes more 

for the selection of tree species and other vegetation, considering 

high-quality green spaces in disadvantaged areas to encourage 

the resilience of the plants to drought and heat, as well as their 

residents to use these. Similarly, the Swedish National Board of 

allergenicity. In Czechia, the national adaptation strategy plans 

Housing, Building and Planning offers funding to projects focused 

to engage architects, developers and construction agencies in 

on greening disadvantaged neighbourhoods, with the aim of 

implementing architecture and greening aimed at reducing the 

improving equity of access to urban green spaces (ETC/CCA, 2021).

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Climate change as a threat to health and well-being in Europe: focus on heat and infectious diseasesHeat as major threat to human health in Europe

At the local level, there are examples of greening to reduce 

3.5.3  Built environment interventions

the negative impacts of high temperatures on health and 

well-being. For example, in residential areas of Trnava and 

As Europeans spend on average around 90% of their time 

Košice, Slovakia, that contain housing prone to overheating 

indoors (WHO Europe, 2013), improvements to the built 

and high proportions of older people and children, tree 

environment can substantially help to reduce heat stress. With 

planting and the construction and restoration of water features 

regard to structural solutions, various modelling studies have 

were implemented, alongside actions aimed at behaviour 

shown that shutters and solar blinds preventing heat gain 

change during heatwaves. In Paris, the OASIS — 'Openness, 

are efficient ways to lower indoor temperatures (EEA, 2020a). 

Adaptation, Sensitisation, Innovation and Social Ties' 

Other methods of preventing the heat increase in buildings 

programme greens school playgrounds and makes them 

include reflective roofs and facades. For example, in Antwerp, 

accessible to local communities, reducing the risks to vulnerable 

buildings undergoing renovation in the city centre are required 

people from heatwaves. The greening of school playgrounds is 

to be repainted in light colours, which increases reflectivity and 

also done in Flemish Brabant, Belgium.

reduces warming, thereby lowering indoor temperatures but 

also minimising heat radiation from the building outside. The 

In Antwerp, Belgium, the construction of buildings is regulated 

use of light-coloured materials for roofs and facades as well as 

by a building code that contains specific regulations to help 

streets and pavements is also recommended in Germany as 

reduce heat stress in the city over time. This includes compulsory 

an adaptation measure (UBA, 2022). Increasing the height of 

green roofs on all new or renovated roofs larger than 20m² and 

buildings (or using appropriate street orientation) can create 

with a slope of less than 15%; permeable grassed surfaces on all 

outdoor private plots; and limiting paving in gardens to one third 

of the area. In Stuttgart, Germany, a number of planning and 

more shade and wind channels, improving thermal comfort on 
the streets (EEA, 2020a). Improving ventilation is another key 
method of lowering indoor temperatures. In Dresden, Germany, 

zoning regulations preserve green space (urban forests, parks, 

a consultation with one district's residents on ways to improve 

street trees) in densely built-up areas to reduce temperatures 

thermal comfort in homes and the neighbourhood as part of 

and improve air flow. Other adaptation measures implemented 

the HeatResilientCity project led to the decision to plant more 

in Stuttgart include green roofs, greening of tram tracks, shading 

trees, install window shutters, and boost the existing ventilation 

of building facades using street trees, upgrading of smaller public 

in apartment blocks (EEA, 2020a).

spaces to 'cool spots', or provision of drinking fountains and 

other water elements.

The demand for active (mechanical) cooling is on the rise. In the 

residential sector of the euro area (19 EU Member States), the 

While urban greening seems a sustainable and effective 

amount of final energy used for space cooling tripled between 

solution to heat stress in cities, at the European scale the 

2010 and 2019. Although across Europe cooling constitutes 

conversion of abandoned, vacant or underused land into green 
spaces (6) is minuscule (EEA, 2019b). This is associated with 
land pressures in many European cities, for example the need 

0.4% of domestic energy use, in Malta, Cyprus and Greece, 

the share of energy used for domestic cooling has reached 

11.4%, 10.5% and 4.9%, respectively (Eurostat, 2021). Future 

for housing overriding plans for the development of more 

energy demand for cooling is likely to increase most in southern 

green space or a lack of long-term political vision for urban 

European countries; it is estimated that Italy, Spain, Greece 

greening (Buffam et al., 2022). Solutions integrating vegetation 

and Portugal could represent 70.8% of the EU total potential 

into existing built-up areas are therefore viable. Since 2010, 

average yearly cooling demand for residential buildings 

homeowners in Vienna have been able to apply for a subsidy 

(Jakubcionis and Carlsson, 2017).

for green facades (both living walls and climbing plants growing 

from the soil at ground level) and green roofs. The city has 
greened the facades of the Department for Waste Management 

Yet, although they improve thermal comfort indoors, air 

conditioning or heat pumps result in waste heat that disperses 

in central Vienna and the roof of the Vienna Environmental 

into the areas surrounding buildings (WHO Europe, 2021a), 

Protection Department (Eurofound, 2016). Another example 

contributing to the UHI effect (Puig, 2021) and, in the case of 

of regulating the amount of green space in cities at the level of 

fossil-fuelled electricity systems, to greenhouse gas emissions. 

individual plots is a 'green area factor' system, which requires 

Therefore, there is a need to explore sustainable and equitable 

that a proportion of the development area is constructed as 

ways of cooling residential buildings, such as district cooling 

green space. Such a system is used in Berlin, and also in Oslo 

using sea or river water (EEA, 2020a; EEA, forthcoming). This 

and Bærum in Norway and Malmö in Sweden (Kruuse, 2011).

is of particular importance for people on low incomes, who 

often live in energy-inefficient homes (see Section 3.3.2) and 

In addition, from the climate adaptation perspective, urban 

may suffer from energy poverty, reducing their ability to use 

green spaces need to be designed and maintained in a manner 

electricity-powered cooling methods. Improving the energy 

that ensures their sustainability in water-scarce conditions 

efficiency of homes and home appliances, ensuring affordable 

(e.g. by using drought-resilient species, capturing rainwater or 

electricity supply and improving building quality all contribute 

using waste water for irrigation) and does not further increase 

to the protection of vulnerable groups from high temperatures 

the risk of vector-borne diseases (EEA, 2020a).

(EEA, forthcoming).

(6)  So-called 'green recycling'; see EEA (2019b).

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Climate change as a threat to health and well-being in Europe: focus on heat and infectious diseasesHeat as major threat to human health in Europe

Implementing interventions to reduce the temperatures 

and other care facilities (see also Box 3.5). Similarly, the Maltese 

in public buildings (such as schools or hospitals) that serve 

national adaptation strategy aims to safeguard nursing homes 

vulnerable groups is paramount, especially given the 

and healthcare facilities against higher temperatures and 

disproportionate exposure of these buildings to the UHI effect 

more frequent heatwaves (European Climate and Health 

(see Section 3.3.2) and the small amount of green space usually 

Observatory, 2022a). District cooling solutions for hospitals 

available in their proximity (see Section 3.5.2). For example, 

exist in, for example, Brescia, Italy, and Copenhagen, Denmark 

Bulgaria's national adaptation strategy is specifically aimed at 

(Galindo Fernández et al., 2016). Kicked off in 2022, the Life 

adapting healthcare facilities. The German national adaptation 

Resystal project works with seven pilot hospitals to improve 

strategy highlights the need to improve building insulation and 

their resilience to climate hazards, including heatwaves.

introduce passive cooling systems in hospitals 

Box 3.5  Climate adaptation in social institutions in Germany

In 2020, the German Federal Ministry for Environment, Nature Conservation, Nuclear Safety and Consumer Protection 
launched the new funding programme 'Climate adaptation in social institutions'. With EUR150 million, the ministry 
supports social facilities such as hospitals, nursing homes, homes for the elderly and hospices, as well as kindergartens, 
schools, neighbourhood centres and facilities for refugees and homeless people. Employees and people under their 
care are to be better protected against acute climatic stress and comprehensively prepared for future climatic changes. 
For example, targeted support is provided for structural changes such as green roofs and facades, the construction of 
shady pavilions and sun sails or the purchase of drinking water dispensers. Social institutions are to receive expert advice 
and the opportunity to develop customised climate adaptation concepts for themselves. Training and further education 
programmes as well as information campaigns will raise awareness of the consequences of climate change among 
employees as well as the people being cared for and their relatives. The climate adaptation funding programme will 
run until the end of 2023 (Bundesministerium für Umwelt, Naturschutz, nukleare Sicherheit und Verbraucherschutz, 
2020). One of the largest projects includes support of over EUR5 million to the psychiatric centre in Königslutter am 
Elm for new thermally insulated windows and shading to better protect the patients and employees against heatwaves 
(Bundesministerium für Umwelt, Naturschutz, nukleare Sicherheit und Verbraucherschutz, 2022).

3.5.4  Heat-aware working conditions

down' measures. In France, labour laws require safe working 

conditions for employees, including protection from extreme 

According to EU Directive 89/391/EEC (EU, 1989), workers' 

heat. Additionally, construction sector workers must be 

health and safety should be protected from any risks, 

provided with at least 3 litres of water per day. In Spain, there 

including emerging ones. However, at the EU level, there 

are strict guidelines for the temperature to be set between 17°C 

is currently no binding legislation protecting workers from 

and 27°C for sedentary work, and between 14°C and 25°C for 

extreme temperatures.

light physical work. In Belgium, the maximum temperatures 

are set at 29°C for light physical work, 26°C for moderate-heavy 

Few Member States have developed specific plans for the 
protection of the working population from heat events, 

physical work, 22°C for heavy physical work and 18°C for very 
heavy physical work, while in Hungary the thresholds are 31°C 

including maximum temperature thresholds. Cyprus was 

for light work, 29°C for moderate work and 27°C for heavy 

the first EU Member State to include special provisions in its 

work. In Latvia, the temperature threshold for indoor work is set 

legislation covering heat stress among workers (Department of 

at 28°C. In Montenegro, the maximum temperature for outdoor 

Labour Inspection, 2022). While strategies in the workplace are 

work is 36°C, while in Slovenia the air temperature threshold 

being implemented progressively, the maximum permissible 

in work areas is set at 28°C (ETUC, 2022). With such thresholds 

working temperature varies significantly across Member 

increasingly common, various ways of reducing temperatures 

States, from as low as 18°C to as high as 35°C. Some of these 

can be applied. For example, in Oslo, Norway, green roofs have 

limits are statutory and some are collectively bargained, 

been constructed on waste treatment facilities to improve the 

while others are a combination (ETUC, 2019). For example, 

thermal comfort of workers on hot days (Box 3.6).

in Germany, a workplace temperature is normally defined as 

26°C, and beyond 35°C the employer must implement 'cool 

32

Climate change as a threat to health and well-being in Europe: focus on heat and infectious diseasesHeat as major threat to human health in Europe

Box 3.6  Green roofs and natural ventilation in waste treatment facilities in Oslo, Norway

In Oslo, three waste treatment facilities (Haraldrud, Ryen and Smestad) have green roofs on their buildings. Haraldrud 
waste treatment facility, constructed in 2007, has the largest green roof in the Nordic region (28,000 square metres). Not 
only does the roof have a positive effect on heat regulation in the building, but the sedum plants also absorb rainwater 
and trap dust (Official Norwegian Reports NOU, 2010). In addition, the slats on the facade push outside air into the facility, 
ensuring natural ventilation (GASA, no date).

The Smestad waste treatment facility has a sedum roof and an open hall construction. The openings in the facade provide 
air flow and daylight in the hall, at the same time ensuring protection from the sun, as the screening facing south-west is 
most dense (City of Oslo Architecture Award, 2016).

The roof of the Ryen waste treatment facility also includes solar panels (see Image 3.1), which are more effective thanks to cooling 
by the sedum roof underneath. The green roof cools the air underneath as well as reducing noise (Oslo Kommune, 2022).

Image 3.1 Green roof and solar panels on Ryen waste treatment facility in Oslo

© David Brasfield.

According to Casanueva et al. (2019), Germany, the 

Netherlands and Switzerland specifically target workers and 

trade unions in their heat-health warning systems. Local 

guidelines are also in place. For example, according to the 

heatwave action plan in Tatabanya, Hungary, employers 

should supply employees working outside with drinking water 

and proper clothing and should take care to implement an 

appropriate working regime (1 hour of working outdoors in a 

heatwave should be followed by 30 minutes of rest). In Puglia, 

Italy, regulations limiting hours working in intense heat have 
been introduced for agricultural workers (Box 3.7).

A large share of the 
European workforce lacks 
information on effective 
measures to mitigate 
occupational heat stress.

33

Climate change as a threat to health and well-being in Europe: focus on heat and infectious diseasesHeat as major threat to human health in Europe

Practical solutions to occupational heat stress, alongside 

a large share of the European workforce lacks information on 

changes in working hours, include technical measures such as 

effective measures to mitigate occupational heat stress. For 

air conditioning, increased ventilation and window shades (Day 

example, 60% of Slovenian and 50% of Greek workers stated 

et al., 2019). Artificial cooling (especially in the short term) and 

in a survey that they lacked information on heat impacts on 

robotic solutions as adaptation measures to combat heat stress 

health (Morris et al., 2021). With teleworking becoming more 

among workers have the potential to reduce economic and 

common, regulations are also likely to be needed to protect 

productivity losses by 30-40%  (Szewczyk et al., 2021). Raising 

workers' physiological and psychological health when working 

awareness of the threats posed by high temperatures is crucial: 

at home (Eurofound, 2020).

Box 3.7  Protecting workers from heat stress in Puglia, Italy

Increases in the average temperature and the frequency and intensity of heatwaves affect the health of workers. Therefore, 
regulations are required to protect workers from high heat stress. Against this backdrop, and following the heat-related 
death of a farm worker, authorities in the Puglia region of Italy passed a regulation in June 2021 prohibiting farm work 
between 12:30 and 16:00 on 'high-risk' days between June and September. The definition of risky conditions is based on the 
results of Worklimate (a), a national initiative aimed at assessing the impact of environmental thermal stress on workers' 
health and productivity.

The main objectives of the ordinance implemented in the Puglia region are to (1) protect agricultural workers in the region 
from prolonged exposure to extreme heat, (2) inform relevant stakeholders (employees, employers and public health 
authorities) of the risks of extreme heat, and (3) inform citizens about the issue of extreme heat and physical activity. 
This integrated weather-climatic and epidemiological heat health warning system, specifically developed for the outdoor 
occupational sectors, aims to improve knowledge about the effect of thermal stress conditions on workers, specifically on 
the estimation of the social costs of associated injuries at work.

The ordinance has succeeded in raising awareness about heat-related injuries in the workforce. Given that temperatures in 
the Puglia region exceed 40°C during the summer, the regulation has been well received by workers and labour unions. This 
is despite the rigidity of the warning system, as outdoor work is prohibited only during the hours of 12:30 and 16:00, and 
heat stress could pose 'high risks' at other times of the day. The ordinance was reissued in June 2022, with the prohibition 
extended until 31 August 2022. Other regional ordinances were implemented in 2021 in Campania, Molise, Basilicata, Calabria 
and selected municipalities of Sardinia. However, the uptake of such policies across Italy remains a challenge.

Image 3.2 

Fields in Puglia in summer

© Giuseppe Gallo, Unsplash

Note: 

(a) https://www.worklimate.it/il-progetto

Source: Climate-ADAPT (2022d).

34

Climate change as a threat to health and well-being in Europe: focus on heat and infectious diseases© Turan Topalar, Climate Change PIX/EEA

4
Climate-sensitive infectious 
diseases as an emerging threat 
to human health in Europe

Key messages

• 

• 

• 

• 

• 

• 

• 

• 

The prevalence or outbreaks of many vector-, food- or water-borne diseases is affected by climatic conditions or exacerbated by 
extreme weather events such as heavy rain and flooding.

Climate trends and projections show that climate suitability will increase for the Aedes albopictus mosquito, a vector carrying 
dengue, chikungunya and Zika virus disease across Europe, which, combined with increased international connectivity, increases 
the probability of local transmission of these diseases.

The annual length of season suitable for malaria transmission by Anopheles mosquitoes has increased across Europe since 1950, 
with central and eastern Europe experiencing the largest number of suitable months. This increases the likelihood of local malaria 
transmission.

Europe has experienced a steady increase in the risk of West Nile virus transmission since the turn of the century. Warmer winters 
and springs drive outbreaks in southern, central and eastern Europe and are projected to expand West Nile virus to previously 
unaffected regions.

Climate change has contributed to the increased suitability of marine waters for the dangerous Vibrio bacteria in Europe, 
increasingly affecting regions on the coast of the Baltic Sea.

Tick-borne diseases are common across Europe but predominantly occur in central Europe, where milder winters and warmer 
summers are increasing the number of cases. Climate change facilitates the further spread of ticks and related diseases to 
northern and western Europe.

People working in agriculture or forestry are particularly exposed to mosquito- and tick-borne diseases. Through contact with 
contaminated flood water, emergency workers are most exposed to water-borne diseases. Those suffering most from severe 
disease courses are elderly people, young children, pregnant women, and those with compromised immune systems.

Effective monitoring of vectors and surveillance of diseases support the development of early warnings and prevent outbreaks 
of diseases. Further awareness raising is needed among both the public and health professionals about the threats of 
climate-sensitive infectious diseases and prevention methods. Vaccination programmes (for tick-borne encephalitis) and vector 
control measures emerge as actions that limit the number of locally transmitted infectious disease cases.

36

Climate change as a threat to health and well-being in Europe: focus on heat and infectious diseasesClimate-sensitive infectious diseases as an emerging threat to human health in Europe

4.1 

Infectious diseases sensitive to climatic 
and weather factors

The probability of infectious disease outbreaks is affected by 

factors such as land use, vector control, human behaviour, 

global trade and travel, and public health capacities. In 

addition, climatic conditions (temperature, humidity and 

precipitation levels) affect the geographical distribution and 

seasonal occurrence of infectious diseases, and extreme 

weather events can affect the timing and intensity of disease 

The impact of climate change 
on the threat from infectious 
diseases is well recognised in 
national policies.

outbreaks. Globally, most of the pathogenic diseases 

species (see Section 4.3.4). Other water-borne and food-borne 

influenced by climate hazards are aggravated by them: 

diseases of relevance to Europe include Legionnaires' disease, 

19% are made either worse or better by climate hazards, 

salmonellosis, cryptosporidiosis and campylobacteriosis. High air 

depending on the situation, and only 3% are exclusively 

temperatures can adversely affect food quality during transport, 

diminished by climate hazards (Mora et al., 2022).

storage and handling. The disruption of electrical, refrigeration 

and cooking systems —caused by flooding, for example, but also 

Figure 4.1 provides an overview of the key infectious diseases 

power blackouts during heatwaves, intense storms or wildfires 

in Europe grouped by pathogen type (virus, bacteria, parasite). 

— may facilitate the transmission of food-borne illnesses, 

Many of them are vector-borne diseases. Disease-carrying 

particularly during warm summer months (EFSA, 2020; ECDC, 

vectors of particular relevance for Europe are the following:

2021).

• 

• 

Aedes albopictus, or tiger, mosquitoes (a vector for 
chikungunya and dengue; see Section 4.3.1)

Aedes aegypti mosquitoes (a vector for chikungunya, dengue, 
yellow fever and Zika virus disease)

Severe floods, more of which are projected in large parts of Europe 

as part of the changing climate (Dottori et al., 2020), can lead to 

higher immediate, medium- and long-term likelihood of food- and 

water-borne infections and zoonoses, as they may cause animal 

faeces in soil or sewage to flow over land, into buildings or into 

water systems, increasing the likelihood of human contact with 

• 

Anopheles mosquitoes (a vector for malaria; see Section 4.3.2)

viruses, bacteria and parasites, causing diseases (ECDC, 2021).

•  Culex mosquitoes (a vector for West Nile virus (WNV); 

The impact of climate change on the threat from infectious 

see Section 4.3.3)

disease is well recognised in national policies; among other 

climate-related hazards, this is included in the largest number of 

• 

Phlebotomus sandflies (a vector for leishmaniasis)

national adaptation policy and national health strategy documents 

• 

Ixodes ricinus ticks (a vector for Lyme borreliosis and 
tick-borne encephalitis (TBE)).

(European Climate and Health Observatory, 2022a). In addition, 

according to a WHO (2021) report analysing the overall progress 

made by governments around the world in including health risks 

from climate change in policy and institutional arrangements, 

Higher temperatures have already allowed many of these 

vector-borne diseases are the most frequently addressed 

vectors to expand their distribution further north and to 

climate-related health threats in surveillance, early-warning 

higher altitudes. Locally transmitted outbreaks of dengue, 

systems and/or response plans (14 out of 15 EEA member and 

chikungunya, West Nile fever and even malaria have occurred 

cooperating countries). Similarly, according to a global survey by 

in southern and south-eastern Europe in recent years. Several 
European countries have reported that Ixodes ricinus has 
migrated north and to higher altitudes. A high incidence of both 

the International Association of National Public Health Institutes 
(IANPHI, 2021), national public health institutes seem to prioritise 

risks from vector-borne diseases, followed by heat-related 

Lyme borreliosis and tick-borne encephalitis is correlated with 

morbidity and mortality.

mild winters and warm, humid summers.

In addition, populations of I. ricinus are persistent and 
potentially increasing in green spaces in European cities, where 

4.2 

Incidence of climate-sensitive infectious 
diseases over time 

humans and domestic animals can be subject to infected 

tick bites. Climate change, in combination with increasing 

The European Centre for Disease Control and Prevention 

urbanisation, the propensity for more pets in smaller spaces 

collects data reported by EU Member States on cases of all of 

and the popularity of outdoor sports and leisure activities, 

the infectious diseases listed in Figure 4.1 except vibriosis. The 

may increase exposure to ticks in urban and peri-urban areas 

reporting of Lyme neuroborreliosis started only in 2018. The 

(Rizzoli et al., 2014).

In addition, elevated water temperatures accelerate the 
growth of certain water-borne pathogens, such as Vibrio 

changes in the number of cases reported over the years can be 

seen in Figure 4.2. In some instances, the increase in reported 

cases is associated with the development of more robust detection 

methods and diagnosis.

37

Climate change as a threat to health and well-being in Europe: focus on heat and infectious diseases

Figure 4.1 

 Overview of the key climate-, weather- and ﬂooding-sensitive infectious diseases in Europe

Disease
(references,
see Annex 1)

Viral 
diseases

Chikungunya

(4, 5, 6)  

Bacterial 
diseases

Dengue 

 (7, 8, 9, 41)

Tick-borne 
encephalitis  

 (25, 26, 27, 28, 29)

West Nile fever

(13, 14) 

Campylo-
bacteriosis  

(1, 2, 3)  

Legionnaires’ 
disease 

(18, 19, 20, 21) 

Leptospirosis 

(36, 37)

Lyme disease

Salmonellosis 

(22, 23, 24) 

Shigellosis 

(38, 39)

‘STEC/VTEC
(toxin-producing 
Escherichia coli)

 (15, 16, 17) 

Vibriosis

(40)

Parasitic 
diseases 

Crypto-
sporidiosis 

(30, 31, 32) 

Giardiasis

(33, 34, 35)

Malaria 

(10, 11, 12)

Climatic factors,
aggravated to diminished ratio (a) 

Modes of transmission

Conﬁrmed cases per 
100,000 population 
in 2019 (b)

Symptoms and severity 

Prevention and treatment (c)

50:3

163:3

42:0

119:4

27:1

12:1

116:1

47:2

41:1 

16:0 

39:1

69:0

67:4

25:1

235:24

0.07 

0.68

0.73 

0.06 

High fever, myalgia, skin rash, fatigue, muscle pains and joint stiﬀness. Severe cases 
may progress to ophthalmological, neurological or heart complications. Shock or severe 
haemorrhage is very rarely observed.

Prevention: Individual protection against mosquito bites; vector control.

Treatment: No speciﬁc and eﬀective antiviral therapy.

High fever, headache, vomiting, myalgia, joint pain, pain behind eyes, swollen glands 
and sometimes rash. Most patients show only mild symptoms and recover without 
complications, but severe dengue can be fatal.

Prevention: Individual protection against mosquito bites; vector control; 
limited vaccine use.

Treatment: No speciﬁc and eﬀective antiviral therapy, symptom treatment 
only.

Fever, fatigue, headache, muscular ache and nausea. Leads to meningitis and/or 
encephalitis

Prevention: Vaccines; avoidance of tick-infested areas individual protection 
against ticks; pasteurisation of milk.

Mortality rates of 0.5-2% (European subtype) (26).

Treatment: No speciﬁc and eﬀective antiviral therapy.

Headache, vomiting, fatigue, weakness, nausea, aching body parts and rash. Only 20% of 
infected people develop symptoms. Sever illness may progress to meningitis, encephalitis 
or poliomyelitis, which may cause partial paralysis.

Prevention: Individual protection against mosquito bites; vector control; virus 
surveillance in other vertebrate hosts and vectors; testing for viral agents in 
the blood of organ donors.

Case fatality of 12% (13).

Treatment: No speciﬁc and eﬀective antiviral therapy. 

Diarrhoea (sometimes bloody), abdominal pain, fever, headache, nausea and vomiting.

34.25

Most cases are sporadic and self-limiting. Severe cases may progress to hepatitis or 
pancreatitis.

Fever, chills, headache, muscle pain, dry cough, diarrhoea and later pneumonia

Case fatality rate of 5-15% (19).

Prevention: Vaccine; clean drinking water; enhanced biosecurity; improved 
sanitary conditions.

Treatment: Electrolyte replacement and rehydration; antimicrobials (only in 
severe cases).

Prevention: High ﬂow in hot- and cold-water systems; control of rainwater 
harvesting systems; drinking water quality; bioﬁlm prevention.

Treatment: Antibiotics.

Mild ﬂu-like symptoms (fever with sudden onset, headache, chills) that may develop into 
meningitis, rashes, haemolytic anaemia, haemorrhage into skin and mucous membranes, 
hepatorenal failure, jaundice, mental confusion and depression, myocarditis and 
pulmonary involvement with or without haemorrhage and hemoptysis, rarely liver failure. 
Case fatality rate of 6-17% (37).

Prevention: Flood risk reduction;  rodent control; protective clothing; 
avoidance of swimming and wading in contaminated waters; avoidance of 
contact with infected animals.

Treatment: Antibiotics.

2.26

0.21

Limited
reporting since 2018

Fever, headache, fatigue, rash (erythema migrans).

Prevention: Avoidance of tick-infested areas; individual protection against tick 
bites.

Treatment: Antibiotics.

17.35

1.10

1.52

Not reported

1.07

1.89

1.44

Diarrhoea, fever, stomach cramps, nausea and sometimes vomiting. Symptoms are 
usually mild, but the associated dehydration can in rare cases be severe.

Prevention: Control measures for food-producing animals; good hygiene 
practices around animals and food.

Case-fatality rate of 0.25% (23).

Treatment: Antibiotics for severe cases or people at risk. 

Diarrhoea (sometimes bloody), fever, nausea, toxaemia, tenesmus and stomach cramps.

Prevention: Good hygiene practices to prevent faecal-oral transmission.

Most infections are rather mild and asymptotic so that most people recover without 
needing antibiotics. The severity of the disease depends very much on the serotype. 
While S. dysenteriae often results in a severe illness and is associated with a high case 
fatality, almost none of the S. sonnei infections results in death.

Treatment: Antibiotics.

Symptoms range from gastrointestinal symptoms with mild diarrhoea to severe bloody 
diarrhoea, which is often associated with abdominal cramps, nausea, vomiting and fever 
or haemorrhagic colitis. Severe cases may result in permanent damages of the nervous 
system, pancreas or heart.

Prevention: Good hygiene in household and premises dealing with animals. 
Adequate cooking of food. Milk pasteurisation, avoiding cross-contamination.

Treatment: No speciﬁc therapy; mixed recommendations on antibiotics.

Case-fatality rate of 0.2% (15).

Wound infections, ear infections, gastroenteritis, and primary septicaemia.

Prevention: Avoidance of raw or undercooked seafood; avoidance of 
swimming in salt- or brackish water with wounds.

Treatment: Antibiotics for wounds; no speciﬁc treatment for gastroenteritis. 

Diarrhoea, abdominal pain, less commonly fever, nausea and vomiting.

Most people with normal immune system recover, but patients with an impaired immune 
system may undergo prolonged and severe clinical course contributing to death.

Prevention: Vaccination programmes; protective technologies; improved 
sanitary conditions.

Treatment: Anti-diarrhoeal medicine.

Low-grade diarrhoea with severe ﬂatulence, stomach cramps or pain, upset stomach or 
nausea, dehydration. Most people recover, but some experience long-term complications.

Prevention: Good hand hygiene; avoidance of contaminated food and water; 
good hygiene.

Headache, back pain, muscle ache, fatigue, sweats, fever, chills, vomiting and enlarged 
spleen. Most patients have a relatively mild disease outcome, but severe malaria can be 
fatal due to one of the following clinical manifestations: acute encephalopathy, severe 
anaemia, icterus, renal failure, hypoglycaemia, respiratory distress, lactic acidosis, 
coagulation defects. Severe malaria is a possible cause of coma and other central nervous 
system symptoms.

Treatment: Prescription drugs.

Prevention: Individual protection against mosquito bites; vector control; 
prophylactic drugs; limited vaccine use.

Treatment: Therapeutics (artemisinin-based combination therapy believed to 
be most eﬃcient).

Climatic conditions aﬀecting transmission

Modes of transmission

Note: (a)  Aggravated-to-diminished ratio presents the number of scientiﬁc sources with evidence that a given disease has been aggravated by 
climatic factors and the number of sources containing evidence that climatic factors have diminished the disease (Mora et al., 2022). 

           (b) EEA-32 excluding Switzerland and Türkiye (ECDC, 2022a).

           (c) Prevention of all diseases should include raising awareness of the public and development of early-warning systems.

Higher 
temperatures

Heatwaves

Heavy 
precipitation

Flooding

Extended
warm season

Drought

Mosquito

Tick

Water

Food

Animals

Human
contact

Organ, blood 
donor

Bathing
water

Source: EEA compilation based on the references in the ﬁgure (see Annex 1), ECDC (2022a) and Mora et al. (2022).

Climate change as a threat to health and well-being in Europe: focus on heat and infectious diseases 39

38

Climate change as a threat to health and well-being in Europe: focus on heat and infectious diseasesClimate-sensitive infectious diseases as an emerging threat to human health in Europe

Figure 4.2 

Number of confirmed cases of selected climate-sensitive infectious diseases in EEA32 countries 
(excluding Switzerland and Türkiye)

Number of conﬁrmed cases

200,000

180,000

160,000

140,000

120,000

100,000

80,000

60,000

40,000

20,000

0

12,000

10,000

8,000

6,000

4,000

2,000

0

4,000

3,500

3,000

2,500

2,000

1,500

1,000

500

0

Campylobacteriosis

Salmonellosis

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Legionnaires’ disease

Shiga toxin/verocytotoxin-producing
Escherichia coli (STEC/VTEC)

Giardiasis
Tick-borne encephalitis

Cryptosporidiosis

Malaria

Shigellosis

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Dengue

Leptospirosis

West Nile Fever

Chikungunya

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Note: 

Travel-related cases are included. The 2020 reduction in the number of cases may be associated with the COVID-19 pandemic.

Source: 

ECDC (2022a).

39

Climate change as a threat to health and well-being in Europe: focus on heat and infectious diseases 
In addition, the reported cases of some diseases are largely 

associated with international travel; for example, 86% of 

chikungunya cases and over 93% of the dengue cases reported 

in 2019 were travel associated (ECDC, 2022b). The number 

of reported cases of these diseases decreased in 2020 due to 

the COVID-19 restrictions in place. However, links between the 

number of reported cases and unusually warm weather, in 

particular early in the year, have been observed, for example in 

the case of WNV in 2018 (see also Section 4.3.3).

4.3 

Changing climate suitability for 
transmission of selected infectious 
diseases

4.3.1  Dengue

Dengue is transmitted by the mosquitoes Aedes aegypti and 
Aedes albopictus (tiger mosquito), which are widespread in 
tropical and subtropical areas. Aedes albopictus is present in 
Europe and is expanding its territory. Alongside accelerated 

human global mobility, climate change has been suggested 

as a driver of the emergence of dengue and other arboviral 

diseases in Europe (Semenza et al., 2014; Lillepold et al., 

2019; Colón-González et al., 2021), illustrated by recent 

autochthonous outbreaks in countries such as France and Spain.

The climatic suitability for the transmission of dengue 

is influenced by shifts in temperature and precipitation 

caused by climate change. Higher temperatures increase the 

mosquito bite rate and viral replication (IPCC WGII, 2022a). 

Mosquito larval development and adult emergence rates 

are also boosted by higher temperatures, and high humidity 

lengthens the lifespan of mosquitoes, and therefore it 

increases the potential for virus transmission. However, lower 

rainfall may prompt people to store water in containers, which 

mosquitoes then use for egg laying, also boosting mosquito 

numbers (WHO Europe, no date).

One way of measuring the health threats associated with 

dengue under the changing climate is to estimate the changes 
in the basic reproduction rate (R0) (7) associated with climatic 
conditions. When R0 is higher than one, outbreaks have the 
potential to grow. The higher R0 is, the faster the outbreak will 
grow. In the period 1986-2020, the R0 of dengue in Europe 
increased by 17.3% compared with 1951-1985 (Figure 4.3). 
The R0 value for the whole of Europe in 2020 was estimated as 
0.07 (European Climate and Health Observatory, 2022c). The 
highest R0 value is modelled for central and eastern Europe, 
followed by southern Europe.

(7)  R0 estimates the expected number of secondary infections from 
one infectious case in a completely susceptible population.

© Erik Karits, Unsplash

40

Climate-sensitive infectious diseases as an emerging threat to human health in Europe

Figure 4.3 

Basic reproduction rate (R0) for dengue transmitted by Aedes albopictus (1951 and 2020) and 
the estimated change (% relative to 1990) in the yearly number of dengue cases imported to 
transmission-suitable NUTS 3 regions in EEA-38 and the UK from dengue-endemic regions (1990-2019)

R0 (dimensionless)

0.40

0.35

0.30

0.25

0.20

0.15

0.10

0.05

0.00

1951

1960

1970

1980

1990

2000

2010

2020

Central and Eastern Europe

Southern Europe

Western Europe

Northern Europe

All Europe

Trend lines

Percentage change, relative to 1990

700

600

500

400

300

200

100

0

-100

1951

1960

1970

1980

1990

2000

2010

2020

Number of dengue cases imported to transmission-suitable NUTS 3 regions

Note: 

Central and Eastern Europe: Albania, Bulgaria, Czechia, Estonia, Croatia, Hungary, Lithuania, Latvia, North Macedonia, Poland, Romania, 
Slovenia, Slovakia; Northern Europe: Denmark, Finland, Iceland, Norway, Sweden.

Southern Europe: Cyprus, Greece, Spain, Italy, Malta, Portugal, Türkiye; Western Europe: Austria, Belgium, Switzerland, Germany, France, 
Ireland, Luxembourg, Netherlands.

Source: 

van Daalen et al. (2022).

Furthermore, Europe has experienced a lengthening of the 

to the accidental introduction of exotic mosquito species   

dengue transmission season. Central and eastern Europe 

(Ibáñez-Justicia, et al., 2020). Aedes albopictus can be common 

observed the greatest increase in the length of the transmission 

in the peri-domestic environment, particularly in urban areas 

season in 1986-2020 compared with 1951-1985, with an 

with abundant vegetation (ECDC, 2020). Moreover, the urban 

increase of about 0.2 suitable months (van Daalen et al., 

heat island (UHI) effect may increase climatic suitability for 

2022). In addition, between 1990 and 2019 an increase of 

mosquitoes. The most suitable cities emerge as those near the 

over 600% in imported cases from dengue-endemic world 

Adriatic coast, in France and Italy, but some Belgian and Dutch 

regions to European locations with conditions suitable for 
dengue transmission (8) was observed (van Daalen et al., 
2022; Figure 4.3). The combination of more imported cases 

and increased climatic suitability for disease transmission via 

mosquito vectors results in a higher likelihood of outbreaks.

The probability of dengue infection may be higher in cities, 

which, as international travel and trade hubs, may contribute 

cities are also suitable (Map 4.1).

The probability of dengue 
infection may be higher in cities.

(8)  Conditions suitable for dengue transmission are defined by R0 above 1 for at least 1 month.

41

Climate change as a threat to health and well-being in Europe: focus on heat and infectious diseases 
Climate-sensitive infectious diseases as an emerging threat to human health in Europe

Map 4.1 

Climatic suitability index values for Aedes albopictus (90th percentile) in 2008-2009 for 
100 European cities

-30°

-20°

-10°

0°

10°

20°

30°

40°

50°

60
60°

70
70°

Climatic suitability index values
for Aedes albopictus (90th
percentile) in 2008-2009 for
100 European cities

≤40
40-50
50-60
60-70
70-80
80-90
>90

No data

Outside coverage

50°

40°

60°

50°

40°

0

500

1,000

1, 500 km

0°

10°

20°

30°

40°

Reference data: ©ESRI

Notes: 

The climatic suitability is expressed as an index ranging from 0 to 100. The P90 indicator of the climatic suitability is the 90th percentile 
value of the range modelled across the city. The modelling is based on 100m-resolution hourly temperature data (based on simulations 
with the urban climate model UrbClim). From this data set, this climate suitability data set has been generated based on annual 
precipitation and the average temperature in January and during the summer months for the years 2008 and 2009. The selection of cities 
comes from the source data.

Source: 

Adapted from VITO (2019); based on data from the Copernicus European Health contract for the Copernicus Climate Change Service. See 
the EEA geospatial catalogue for more details (EEA, 2020b).

The climate suitability for Aedes albopictus is projected to 
increase in large parts of Europe, with western Europe 

albopictus will increase in the majority of European countries 
(Map 4.3). Given the increasing dengue reproduction rate, 

emerging as a hot spot by the end of the century. However, 

the rising number of imported cases of dengue and the 

in some countries with favourable baseline conditions (Italy, 

projected increased climate suitability, dengue outbreaks could 

Portugal, Spain), the changing climate will reduce the suitability 
for Aedes albopictus (Map 4.2). In line with the changing 
climate suitability, the length of the activity season of Aedes 

become a health risk in Europe in the future if no appropriate 

preparedness and disease management actions are taken.

42

Climate change as a threat to health and well-being in Europe: focus on heat and infectious diseasesClimate-sensitive infectious diseases as an emerging threat to human health in Europe

Map 4.2 

Projected climatic suitability index for Aedes albopictus under RCP 8.5 scenario, NUTS 2 level

-30°

-20°

-10°

0°

10°

20°

30°

40°

50°

60°

70°

-30°

-20°

-10°

0°

10°

20°

30°

40°

50°

60°

70°

-30°

-20°

-10°

0°

10°

20°

30°

40°

50°

60°

70°

1971-2000

2031-2060

2070-2099

60°

50°

40°

50°

40°

60°

50°

40°

50°

40°

60°

50°

40°

50°

40°

0°

10°

20°

30°

40°

0°

10°

20°

30°

40°

0°

10°

20°

30°

40°

Reference data: ©ESRI

Projected climatic suitability index for Aedes albopictus under RCP 8.5 scenario, NUTS 2 level 

No data

Outside coverage

<20

20-40

40-60

60-70

70-75

75-80

80-85

85-90

90-95

95-100

0

500

1,000

1,500  km

Notes: 

A suitability index of 0 indicates that an area has no favourable environmental conditions for Aedes albopictus, whereas an area with 
an index of 100 is totally suitable. The climatic suitability index is determined by annual rainfall, summer temperatures and January 
temperatures. For annual rainfall, the suitability is zero when rainfall is lower than 450mm; maximum suitability is reached when the 
annual rainfall is higher than 800mm. For summer temperatures, the suitability is zero when temperatures are lower than 15°C and higher 
than 30°C, and maximum between 20°C and 25°C. For January temperatures, the suitability is zero when temperatures are lower than -1°C 
and maximum when temperatures are higher than 3°C.

Source: 

Climate-ADAPT (2022b).

Map 4.3 

Projected season length for Aedes albopictus under RCP 8.5 scenario

-30°

-20°

-10°

0°

10°

20°

30°

40°

50°

60°

70°

-30°

-20°

-10°

0°

10°

20°

30°

40°

50°

60°

70°

-30°

-20°

-10°

0°

10°

20°

30°

40°

50°

60°

70°

1971-2000

2031-2060

2070-2099

60°

50°

40°

50°

40°

60°

50°

40°

50°

40°

60°

50°

40°

50°

40°

0°

10°

20°

30°

40°

0°

10°

20°

30°

40°

0°

10°

20°

30°

40°

Reference data: ©ESRI

Baseline and projected season length for Aedes albopictus under RCP 8.5 scenario

Days

No data

Outside coverage

<5

5-20

20-40

40-60

60-80

100-120
80-100

120-140

140-160

160-180

0

500

1,000

1,500  

km

Notes: 

The duration of Aedes albopictus presence is also known as the mosquito season. It begins when the insect's eggs hatch after winter and 
continues until the eggs no longer hatch (go into diapause) in autumn.

Source: 

 Climate-ADAPT (2022c).

43

Climate change as a threat to health and well-being in Europe: focus on heat and infectious diseasesClimate-sensitive infectious diseases as an emerging threat to human health in Europe

4.3.2  Malaria

widespread presence in Europe of the malaria vector (Anopheles 
mosquitoes) (ECDC, 2022c; see Map 4.4) and the increasing 

Malaria was endemic in Europe until the 1970s, when its 

climatic suitability for this vector may lead to the re-emergence 

elimination was achieved through a combination of public 

of malaria in Europe. While most of the confirmed cases 

health interventions and improved socio-economic conditions 

of malaria in Europe reflect patterns of travel to and from 

(Zhao et al., 2016; Boualam, et al. 2021). The increasing 

malaria-endemic countries (Alenou and Etang, 2021; see 

number of malaria cases currently being registered in Europe 

also Section 4.2), locally transmitted cases have already been 

(see Figure 4.2) is largely attributable to international travel and 

reported in France, Germany, Greece, Italy, the Netherlands and 

immigration from malaria-endemic countries. In addition, the 

Spain (Fischer et al., 2020).

Map 4.4 

Distribution of Anopheles maculipennis s.l. complex in Europe (March 2022)

-80°

-60°

90°

100°

Distribution of Anopheles
maculipennis s.l. complex in 
Europe (March 2022)

Present

Conﬁrmed absent

No data

Outside coverage

50°

40°

30°

50°

40°

30°

0

500

1,000

1,500 km

-20°

-10°

0°

10°

20°

30°

40°

20°

Reference data: ©ESRI

Notes: 

Present: The species has been observed to be present in at least one municipality within the administrative unit; Confirmed absent: the 
species has never been reported within the administrative unit and there have been field surveys or studies on mosquitoes within the last 
5 years of the distribution status date; No Data: No sampling has been performed and no data on the species is available (ECDC, 2022d). 
The data is provided at NUTS 3 level.

Source: 

ECDC (2022c).

44

Climate change as a threat to health and well-being in Europe: focus on heat and infectious diseasesClimate-sensitive infectious diseases as an emerging threat to human health in Europe

Malaria is caused by Plasmodium parasites that are spread 
to humans through the bites of infected female Anopheles 
mosquitoes. The spatial limits of the distribution of female 

croplands (Grover-Kopec et al., 2006; Benali et al., 2014; van 

Daalen et al., 2022).

Anopheles species and seasonal activity are sensitive to 

climatic factors (Caminade et al., 2014). Increased rainfall 

On average, in areas suitable for Anopheles mosquitoes across 
Europe, the number of months suitable for malaria transmission 

creates more habitat for mosquitoes (stagnant water), and 

increased from 0.4 in 1951-1960 to 0.51 in 2011-2020. Central and 

warmer temperatures increase the rates of mosquito bite and 

eastern Europe are the most suitable regions, with 1.3 months, 

parasite development (IPCC WGII, 2022a). The transmission of 
Plasmodium vivax requires accumulated precipitation of above 
80mm per month, a monthly mean temperature of between 

followed by western Europe with around 1 month (see Figure 4.4). 

However, a substantial increase was also detected in northern 

Europe (van Daalen et al., 2022). These results suggest that, 

14.5°C and 33°C, monthly relative humidity above 60%, and 

although currently sporadic, local transmission could increase 

the presence of land cover classes suitable for mosquito 

following importation events where Anopheles mosquitoes are 

breeding, such as rice fields or permanently irrigated 

present or can become established (Fischer et al., 2020).

Figure 4.4 

Mean number of months suitable for Plasmodium vivax transmission between 1950 and 2020 in EEA 
member and cooperating countries plus the United Kingdom, grouped by European region

Mean number of months

3.0

2.5

2.0

1.5

1.0

0.5

0.0

1950

1954

1958

1962

1966

1970

1974

1978

1982

1986

1990

1994

1998

2002

2006

2010

2014

2018 2020

Central and Eastern Europe

Western Europe

Northern Europe

Southern Europe

Trend lines

Note: 

The number of suitable months was calculated as the number of months per year with precipitation above 80mm, average temperature 
between 14.5°C and 33°C, and relative humidity above 60%, in land types highly suitable for Anopheles mosquitoes (e.g. rice fields, 
permanently irrigated croplands). Linear regression was used for trend estimation. Central and Eastern Europe: Albania, Bulgaria, Czechia, 
Estonia, Croatia, Hungary, Lithuania, Latvia, Macedonia, Poland, Romania, Slovenia, Slovakia; Northern Europe: Denmark, Finland, Iceland, 
Norway, Sweden; Southern Europe: Cyprus, Spain, Greece Italy, Malta, Portugal, Türkiye; Western Europe: Austria, Belgium, Switzerland, 
Germany, France, Ireland, Liechtenstein, Luxembourg, Netherlands, United Kingdom.

Source: 

van Daalen et al. (2022).

45

Climate change as a threat to health and well-being in Europe: focus on heat and infectious diseasesClimate-sensitive infectious diseases as an emerging threat to human health in Europe

A further projected northward spread of Anopheles mosquitoes 

of vector populations, higher temperatures decrease the 

and an extension of seasonality in Europe will enable malaria 

interval between blood meals, shorten the virus incubation 

transmission for up to 6 months of the year in 2051-2080, 

time in mosquitoes, accelerate the virus evolution rate and 

particularly in southern and south-eastern Europe (Kulkarni 

increase viral transmission efficiency to birds (Paz, 2015). 

et al., 2022). Disease surveillance and vector control measures 

Warmer winters allow mosquitoes to survive the cold months 

should be intensified in areas with increasing climatic suitability 

and spread the virus earlier in the year (Farooq et al., 2022). 

to avoid the importation and onward spread of malaria in 

Furthermore, as a result of an early increase in the mean spring 

Europe (see Section 4.4).

4.3.3  West Nile Virus infection

temperatures, some bird species that are hosts for the virus 

have migrated to their breeding grounds earlier (Paz, 2015).

Drought may increase the intensity of disease outbreaks, 

as scarce water resources lead mosquitoes and birds to 

West Nile Virus (WNV) infection is a mosquito-borne zoonosis 
that is endemo-epidemic (9) in southern, eastern and western 
Europe. WNV is brought to Europe through migratory birds 

congregate around water bodies, increasing the likelihood of 

potential transmission events and amplifying the prevalence 

of the WNV, which can then spill over into human populations 

travelling from sub-Saharan Africa, North Africa or the Middle 

(Paz, 2015; Farooq et al., 2022). Therefore, changes in climatic 

East. It is usually transmitted among birds via the bite of 

conditions, particularly increases in ambient temperature and 

infected mosquitoes, but it can also infect humans and other 

fluctuations in rainfall amounts, contribute to the maintenance 

mammals, particularly horses (ECDC, 2022e). In Europe, the 
mosquito species Culex pipiens and Culex modestus are the main 
vectors of WNV (ECDC, 2019).

of WNV in various locations in southern Europe (Paz and 
Semenza, 2013).

WNV cases were sporadic in Europe until the mid-1990s, when, 

introduced by migratory birds, it started to spread quickly, 

Overall, the probability of WNV outbreaks increased between 
1951 and 2020 across Europe (10). The highest absolute 
risk of WNV outbreaks was in central and eastern Europe, 

leading to outbreaks in some countries (Paz and Semenza, 

followed by southern Europe (see Figure 4.5). While the WNV 

2013; Zeller and Schuffenecker, 2004). Since 2010, there have 

transmission risk has remained low in northern and western 

been more recurrent, intense and geographically expansive 

Europe, comparing 1951-1985 with 1986-2020, these regions 

WNV outbreaks, with the largest in terms of geographical extent 

have experienced respective relative increases in risk of 

and human infections occurring in 2018 (ECDC, 2018; Farooq 

445% and 242%. This suggests that increasing temperature 

et al., 2022). In 2019, 11 EU Member States reported 443 WNV 

suitability is likely to result in longer WNV transmission 

infections; 96% of these had been locally acquired, most of 

seasons and further expansion of the virus to previously 

which were reported by Greece and Italy, representing 65% and 

unaffected European regions.

13% of EU cases, respectively (ECDC, 2019).

Higher temperatures accelerate the ability of Culex mosquitoes 
to spread WNV to humans (Leggewie et al., 2016; Mordecai 

et al., 2019). Warm weather in the spring and summer months 

speeds mosquito development and extends their breeding 

season, which can, in turn, increase their numbers (Farooq 

et al., 2022). Apart from increasing the growth rate 

The probability of WNV 
outbreaks increased between 
1951 and 2020 across Europe.

(9)  Endemo-epidemic refers to a temporary large increase in the number of cases of an endemic disease.
(10)  The decline in 2020 could be associated with COVID-19 pandemic restrictions in place, but also the depletion of susceptible people following 

the WNV outbreaks in 2018 and natural immunity developed by those previously infected, or suboptimal environmental and climate conditions 
for a big outbreak year (Jan Semenza, Heidelberg Institute for Global Health, personal communication, 6 September 2022).

46

Climate change as a threat to health and well-being in Europe: focus on heat and infectious diseasesClimate-sensitive infectious diseases as an emerging threat to human health in Europe

Figure 4.5 

Change in the estimated WNV outbreak risk between 1951 and 2020 in the EEA member and 
cooperating countries and the UK, grouped by European region

West Nile virus (WNV) outbreak risk (0-1)

0.35

0.30

0.25

0.20

0.15

0.10

0.05

0.00

1950

1955

1960

1965

1970

1975

1980

1985

1990

1995

2000

2005

2010

2015

2020

Central and Eastern Europe

Southern Europe

Western Europe

Northern Europe

Trend lines

Note: 

Central and Eastern Europe: Albania, Bulgaria, Czechia, Estonia, Croatia, Hungary, Lithuania, Latvia, Macedonia, Poland, Romania, Slovenia, 
Slovakia; Northern Europe: Denmark, Finland, Iceland, Norway, Sweden; Southern Europe: Cyprus, Spain, Greece, Italy, Malta, Portugal, 
Türkiye; Western Europe: Austria, Belgium, Switzerland, Germany, France, Ireland, Liechtenstein Luxembourg, Netherlands, United Kingdom.

Source: 

van Daalen et al. (2022).

4.3.4  Vibriosis

Exposure to the Vibrio bacteria in seawater can lead to severe 
gastrointestinal, skin and ear infections, and in some cases to 
necrotising fasciitis, septicaemia and death. Vibrio bacteria grow 
extremely well in warm water (up to 37°C) and moderate salinity 
(below 30 parts per thousand). According to a study of Vibrio 
presence in German coastal waters, water temperature is the main 
driving factor of Vibrio abundance, whereas salinity modulates 
Vibrio community composition (Fleischmann et al., 2022).

Vibrio has one of the fastest replication times of any studied 
bacteria, making it extremely responsive to environmental 

change. Climate change has led to increased sea surface 

likelihood of Vibrio infections. An increase in reported infections 
in northern Europe corresponds in both time and space to 

heatwaves (Le Roux et al., 2015). Although vibriosis is not a 

notable disease in the EU, Europe has observed steady increases 

in cases in the 21st century (Semenza et al., 2017).

The Baltic Sea is particularly suitable for Vibrio due to its brackish 
water (11). The number of days in a year suitable for Vibrio 
infections in the Baltic region has been growing since 1980 
(see4.6). The entire coastline of Estonia, Latvia, Lithuania (12) and 
Poland showed suitable conditions for Vibrio in 2020. In contrast, 
the Vibrio suitability in Southern Europe is low, with only 4% of 
the coast suitable for non-cholera Vibrio in Spain and 2% suitable 
in Italy, because of higher surface salinity in the Mediterranean 

temperatures in all European seas, with the Baltic Sea and the 

(van Daalen et al., 2022; see Figure 4.7). As the conditions 

North Sea having seen the largest absolute increase. In 2021 the 

suitable for the transmission of Vibrio pathogens are spreading 

annual sea surface temperature around Europe was between the 

to the considerable percentage of coastlines in previously 

sixth and eighth highest on record (ESOTC, 2021). The warming 

unaffected countries, early-warning systems and preventive 

of marine and saline inland waters is likely to support larger 
numbers of Vibrio populations and consequently increase the 

measures are essential to protect the population from the severe 

infections that could result.

(11)  'Brackish' describes water that is saltier than fresh water, but not as salty as seawater (EEA glossary).
(12)  The coastlines of Estonia, Latvia and Lithuania have had an above 96% suitability for Vibrio since 2003, see Figure 4.7. 

47

Climate change as a threat to health and well-being in Europe: focus on heat and infectious diseasesClimate-sensitive infectious diseases as an emerging threat to human health in Europe

Figure 4.6 

Annual number of days suitable for Vibrio infections in the Baltic region

Number of days

120

100

80

60

40

20

0

1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 2020

Source: 

van Daalen et al. (2022).

Figure 4.7 

Estimated annual percentage of coastline with suitable conditions for non-cholerae Vibrio (2003-2020) 
for selected countries

Percentage

100

90

80

70

60

50

40

30

20

10

0

Latvia/Lithuania
Estonia
Poland

Finland
Denmark

Sweden
Germany

Netherlands

Belgium

France

Portugal

Spain
Norway

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

2018

2019

2020

Source: 

van Daalen et al. (2022).

48

Climate change as a threat to health and well-being in Europe: focus on heat and infectious diseasesClimate-sensitive infectious diseases as an emerging threat to human health in Europe

4.4 

People at risk from infectious diseases

4.5 

Responding to the growing threat of 
infectious diseases 

Pregnant women, fetuses and young children are considered 

among the most vulnerable humans, which means that they are 

4.5.1  Monitoring, surveillance, and early-warning 

also most at risk of infectious diseases. Some mosquito-borne 

systems

diseases, such as malaria, dengue and Zika virus disease, are 

known to harm fetal health and development, putting both 

Surveillance systems provide information for monitoring 

pregnant women and fetuses at risk (Rylander et al., 2013). 

communicable disease trends, helping to identify risk factors 

Younger children may be at risk of more severe dengue (Khan 

and areas for intervention. They provide information for priority 

et al., 2021). Children can also be more exposed to some 

setting, planning, implementation and resource allocation 

diseases, for example cryptosporidosis, through play. In 2013, 
an outbreak of Cryptosporidium hominis infection was detected 
in Germany among children who had been playing on a 

for preventive programmes and for evaluating preventive 

programmes and control measures. At the European level, 

around 50 infectious diseases are monitored through the 

floodplain after it had dried out (Gertler et al., 2015).

EU's epidemiological surveillance network, whereby Member 

States report to the European Centre for Disease Prevention 

Advanced age and pre-existing health conditions, especially 

and Control (ECDC), including climate-sensitive diseases (see 

those associated with weaker immune systems, can also make 

Figure 4.1). The list was updated in 2018 to include recently 

the course of disease more severe in certain people. People 

emerging or re-emerging diseases such as chikungunya, dengue, 

over the age of 50 years and some immunocompromised 

Lyme neuroborreliosis and Zika virus disease (EC, 2022b).

people are at the highest risk of becoming severely ill when 

infected with WNV (WHO, 2017). Those over the age of 60 years  

The European Early Warning and Response System (EWRS) 

have a higher risk of mortality and other consequences of 

is a rapid system for providing alerts at EU level on serious 

tick-borne encephalitis than younger people (WHO Europe and 

cross-border threats to health. This confidential web-based 

ECDC, no date).

system enables the European Commission and the designated 

competent authorities responsible at national level to be in 

Certain environments and activities are conducive to 

permanent communication. EU Member States can alert, share 

contracting climate-sensitive infectious diseases. For example, 

information and coordinate national responses to serious 

agriculture and forestry workers are exposed to animal- and 

cross-border threats in a timely and secure manner (EC, 2022b).

insect-borne diseases. The numbers of these workers exposed 

to tick-borne diseases is increasing, as the climate suitable 

At country level, the systematic monitoring and reporting 

for tick-borne diseases (such as Lyme disease and tick-borne 

systems for surveillance of invasive species and infectious or 

encephalitis) moves to north and west Europe (De Keukeleire 

vector-borne diseases are frequently identified in national 

et al., 2018; EU-OSHA, 2021). In relation to flooding, first 

adaptation strategies and national health strategies of the 

responders (for example fire and rescue service workers) 

European countries as vital elements of an effective health 

and those involved in clean-up operations have a higher 

system. For example, the Belgian national adaptation strategy 

likelihood of contracting acute gastroenteritis (ECDC, 2021). 

mentions the Modirisk initiative, aimed at monitoring and 

Contamination of bathing waters after heavy rainfall increases 
the rate of infection with Campylobacter, Giardia lamblia and 
E. coli among swimmers because of the risk of swallowing 
water (Harder-Lauridsen, 2013). There is a need to identify 

those vulnerable or highly exposed populations and to adjust 
prevention and response measures to their needs.

eradicating exotic mosquitoes that may transmit infectious 

diseases. The Norwegian national adaptation strategy highlights 

a plan to implement a reporting system dedicated to the 

monitoring of diseases associated with climate change. The 

system will be operated by the Norwegian Institute of Public 

Health, with health professionals expected to report every 

instance of more than 50 cases of communicable diseases. 

The EU's legislative frameworks emerge as a driver of disease 

monitoring in EU Member States; for example, Austria notes 

that strategies were developed on the basis of the European 

Surveillance Systems TESSy (now integrated into EpiPulse 

alongside other surveillance systems) (European Climate and 

Health Observatory, 2022a).

49

Climate change as a threat to health and well-being in Europe: focus on heat and infectious diseasesIn Czechia, increasing numbers of tick-borne diseases identified 

through its national surveillance system have led to the 

establishment of tick activity forecasting aimed at informing the 

general public of the threat levels across the country (Box 4.1). 

In Greece, surveillance of human WNV infection has been 

carried out annually since 2010 (May-November) by the Hellenic 

National Public Health Organization (NPHO). The goal is to 

promptly identify human cases of WNV infection and monitor 

their temporal and geographical distribution to guide targeted 

prevention measures. In the long term, the aim of surveillance 

is to quantify the disease burden and identify seasonal, 

geographical and demographic patterns, and populations at 

risk. In addition, the enhanced surveillance of animal WNV 

infection (in horses and wild birds) has been implemented.

In Germany, citizen science supplements traditional monitoring 
methods. The German Mückenatlas ('mosquito atlas') asks 
citizens to submit mosquito samples, which are then identified 
and used for research by experts. The Mückenatlas therefore 
contributes to knowledge on native and invasive mosquito 

species and related diseases in Germany and seeks to establish 

an information base for policymakers and researchers to assess 

future threats. A similar initiative is the ZEPAK (Zecken und ihre 

Pathogene im Klimawandel), the Tick-Atlas for Germany run by 

the Robert Koch Institute and funded by the German Federal 

Ministry of Health, whereby citizens can send the ticks they 

find for identification and mapping. The results are presented 

on the ZEPAK website together with information about the 

tick species, the diseases carried by ticks and the association 

of the emerging tick species and tick-borne diseases with 

climate change.

In relation to climate-sensitive vector-borne diseases, the ECDC 

is currently developing the 'ArboRisk' online tool, which displays 

near-real-time interactive maps showing the level of risk of an 

Aedes-borne disease outbreak. The tool combines weekly data 

and forecasts of rainfall and temperature from with a dynamic 

transmission model to predict the likelihood of an outbreak of 

dengue, chikungunya or Zika virus disease occurring in Europe, 

depending on the location and timing of imported viraemic 

cases. EYWA (EarlY WArning System for Mosquito borne 
diseases) — a research-based cross-border early-warning 

system to forecast and monitor mosquito-borne diseases 

— combines interdisciplinary scientific fields (entomology, 

epidemiology, ecology, Earth observation, big data analytics, 

citizen science and others) for outbreak forecasting and 

decision support modelling for vector control applications and 

other mitigation actions.

© Pixabay

Climate-sensitive infectious diseases as an emerging threat to human health in Europe

Box 4.1  Monitoring of ticks and tick-borne encephalitis in Czechia

In Czechia, which has one of the highest incidences of tick-borne encephalitis (TBE) in Europe, laboratory-confirmed cases 
have been reported since 1970. Each case of TBE is reported by the diagnosing physician to public health authorities, 
which carry out epidemiological investigations. Through an interview with the patient, the medical epidemiologist or 
infection physician obtains the medical history, including the probable time and place of infection and the possible route of 
transmission. The data are recorded in a standardised questionnaire, which includes the location (geographical information 
system grid) and route of transmission. These data are electronically transferred on a weekly basis to a safeguarded data 
depository of the Ministry of Health, from which they are transmitted to the National Institute of Public Health. The system 
has been computerised since 1993 (Kriz et al., 2012).

Due to the increasing incidence of TBE in Czechia, in 2007 the National Institute of Public Health in collaboration with the 
Czech Hydrometeorological Institute developed an early-warning system for tick activity and disease risk. The forecasts, 
available online 3 days in advance, show the predicted tick activity (proportion of ticks in a given locality that are ready to 
attack the host). The activity is translated into levels of risk, and preventative measures are suggested (Map 4.5). The website 
also provides information on the environmental, weather and climate factors affecting the activity of ticks (CHMI, 2022).

Map 4.5 

Projected tick activity in Czechia and examples of risk-level descriptions and preventive measures

Index of tick activity, 23 June 2022

Tick activity

1-Very low

2-Low

3-Medium

4-High

5-Exceptionally high

Level 4: High risk

Use repellent. Do not sit or lie in thickets; 
do not enter bushes and herbaceous 
vegetation, especially at the edge of 
forests, at the edge of watercourses, and 
deciduous shrubs. Evening and morning 
examination of the body, and possibly 
removal of ticks.

Level 5: Exceptionally high risk

Use repellent. Do not enter freely into 
deciduous and mixed forests; stick to 
paved roads. Evening and morning 
examination of the body, and possibly 
removal of ticks.

4.5.2  Awareness raising among the public and health 

professionals

The citizen science initiatives described above are powerful tools 

for public engagement and empowerment in policymaking and 

for raising awareness of environmental and climate change 

issues (EC, 2020d). However, only a fraction of the population 

engages in such activities; therefore, raising awareness of 

the health threats associated with infectious diseases among 

the general public is crucial. Awareness-raising campaigns 

and public outreach was the second most frequent measure 

for addressing climate-related threats to health in national 

Raising awareness of the 
health threats associated with 
infectious diseases among the 
general public is crucial.

adaptation strategies and the third most frequent in national 

and information, including activities aimed at adapting curricula 

health strategies according to the European Climate and Health 

for schools and early-childhood education institutions; the 

Observatory (2022a). For example, the second progress report 

provision of information materials to vulnerable groups; and 

on the German strategy for adaptation to climate change plans 

the establishment of warning systems for ticks and tick-borne 

multiple activities around public awareness, communication 

infections. France's fourth national health and environment 

51

Climate change as a threat to health and well-being in Europe: focus on heat and infectious diseasesClimate-sensitive infectious diseases as an emerging threat to human health in Europe

plan cites actions aimed at educating citizens about adopting 

recommends universal vaccination against TBE (Steffen, 2019); 

behaviours that reduce the health impacts from ticks (European 

here the vaccination rate against TBE in the general population 

Climate and Health Observatory, 2022a). In Italy, awareness and 

is 82% (the highest worldwide) (Kunze and Kunze, 2015). Before 

behaviour change measures are included in plans for addressing 

the introduction of a massive TBE vaccination campaign in 1981, 

WNV and Usutu virus (Ministero della Salute, 2019).

Austria had the highest recorded TBE morbidity rate in Europe, 

with up to 700 patients hospitalised per year as a result of 

Awareness needs to be raised of threats and preventive 

the disease (Kunz, 2003). A high awareness of TBE among the 

measures, such as avoiding areas with a high abundance of 

Austrian population was achieved by an annual social marketing 

vectors, using tick or mosquito repellent (see e.g. Box 4.1), 

programme, emphasising awareness raising as a precondition 

and employing good hand hygiene and appropriate food 

for action (see Section 4.3.2). The national vaccination coverage 

preparation practices to avoid food- and water-borne diseases 

increased from 6% in 1980 to 82% in 2013, and it exceeds 90% 

(see Figure 4.1). In a global review (Bowman et al., 2016), simple 

in some high-risk areas. This has led to a steady decline in the 

protection measures, such as using mosquito nets and screens 

number of TBE cases from several hundred to 50-100 per year 

in windows and doors, were found to be the most effective 

(Kunze and Kunze, 2015). In Slovenia, vaccination against TBE 

against dengue transmission. The ECDC (2021) recommends 

is mandatory and reimbursed for those at risk of occupational 

providing information on pathogen threats to humanitarian 

exposure, and otherwise recommended. In Slovakia and 

workers, first responders, construction workers and anyone 

Estonia,  vaccination is officially recommended only for those 

else involved in the recovery and cleaning of flooded areas, 

professionally exposed. In other countries, it is recommended 

including that they should wear appropriate personal protective 

only for people with a high likelihood of exposure (e.g. in 

equipment to avoid potential exposure to pathogens.

Poland, children and adolescents in youth camps); in others, 

In addition, awareness of the emerging threats needs to be 

raised among health professionals, coupled with the building 

In relation to other diseases, the Czech national adaptation 

of knowledge about the symptoms of and treatments for 

strategy includes plans to participate in research aimed at 

ailments related to extreme weather or climate-sensitive 

developing new vaccines, for example against Lyme disease 

infectious diseases, in particular those that are likely to appear 

(European Climate and Health Observatory, 2022a).

vaccination is just to be considered (Steffen, 2019).

in hitherto unaffected regions. Education and training of 

health professionals on climate change impacts on health 

is the fourth most frequently included measure addressing 

4.5.4  Vector control

climate risks to health in national health strategies, according 

to the European Climate and Health Observatory (2022a). In 

As many infectious diseases in Europe have the potential to 

Slovakia, the national adaptation strategy notes the necessity 

be spread by mosquitoes (see Figure 4.1), actions aimed at 

of complementing in-service medical training with information 

vector control can reduce human exposure to pathogens. 

on the health consequences of climate change. This would 

In areas affected by outbreaks, elimination of adult 

increase knowledge among medical staff, allowing them to 

mosquitoes through aerial spraying with insecticides can be 

detect symptoms of heat-related diseases earlier. Czechia's 

considered (ECDC, 2020). Non-pesticide control measures are 

national health strategy notes the need to improve the capacity 

recommended to avoid pesticide resistance. Biological control 

of health professionals to diagnose and treat diseases that are 

methods — such as microbes, crustaceans or fish that eat 

becoming more widespread under the changing climate. The 

mosquito larvae — are another route to reducing the number 

Turkish national adaptation strategy includes plans to increase 

of mosquitoes (ECDC, 2017).

awareness among public health providers of climate-related 
health impacts in areas vulnerable to infectious diseases 

An example of biological vector control is the communal 

(European Climate and Health Observatory, 2022a).

action group to control mosquitoes in the Upper Rhine Plain, 

4.5.3  Vaccination programmes

While the number of cases of dengue and malaria remains 

small and mainly travel-associated, the relatively large number 

which has a task force dedicated to taking action against 
Aedes albopictus. If these mosquitoes are detected, a targeted 
monitoring and vector control programme is initiated. The 

vector control measures include using the biological control 
agent Bti (Bacillus thuringiensis subspecies israelensis strain 
AM65-52), releasing sterile male adults and using lethal trap 

of TBE cases in Europe lends itself to vaccination programmes. 

systems specifically for female adults. Over the years, biological 

In areas where the disease is highly endemic, the World Health 

Organization (WHO) recommends that vaccination be offered 

to all age groups, including children (WHO, 2022a). However, 

mosquito control with Bti has resulted in a significant reduction 
in the abundance of Aedes albopictus, which has substantially 
reduced the problem and in some cases led to a complete 

Austria is the only country in western and central Europe that 

elimination of subpopulations.

52

Climate change as a threat to health and well-being in Europe: focus on heat and infectious diseasesClimate-sensitive infectious diseases as an emerging threat to human health in Europe

© Samir Proučil, My City/EEA

53

Climate change as a threat to health and well-being in Europe: focus on heat and infectious diseases5
Conclusions and outlook

This report shows that the threats to human health associated 

with high temperatures and climate-sensitive infectious 

diseases are already substantial and likely to increase in 

the future with climate change. While in parts of Europe 

temperatures have been high (e.g. the Mediterranean region) 

or tick-borne diseases have been endemic (e.g. central Europe), 

climate change is contributing to the amplification of risk in 

those locations and expansion of disease to other, previously 

unaffected, areas of Europe.

Increasing the resilience of 
health systems to climate 
change is key.

The EU policy framework increasingly considers the impacts 

education for health professionals. Nurses Climate Challenge 

of climate change on health (see Section 2.1), but the limited 

Europe is an initiative delivered by Health Care Without Harm 

competences of the EU in areas relevant to the development 

Europe in partnership with the Alliance of Nurses for Health 

and implementation of many solutions (e.g. health, spatial 

Environments that aims to support nurses who want to educate 

planning, education) mean that most of this needs to happen 

their colleagues and communities about the health impacts 

within countries. At the national level, where the mandate lies to 

of climate change. The Planetary Health Academy is a free 

bring about change, the recognition of climate-related threats 

online lecture series in Germany focusing on transformative 

to health seems to be more advanced in climate adaptation 

action in addition to scientific foundations and transdisciplinary 

strategies than in national health policies (European Climate 

perspectives on planetary health. Yet broader inclusion of 

and Health Observatory, 2022a). This misalignment may mean 

climate change in professional training and education is 

that climate change threats to human health remain a low 

needed. An initiative to raise awareness is being taken by 

priority for the health sector in Europe.

medical practitioners and organisations in some countries, for 

example the Medical Alliance against Climate Change in Spain 

Therefore, several important actions are needed to reduce 

and Doctors for the Climate in Poland.

climate impacts on human health. First, there is an urgent need 

for education and training of public health and healthcare 

Second, increasing the resilience of health systems to climate 

professionals on the threats from climate change. The joint 

change is key. This report shows that healthcare facilities 

statement by the EU Health Policy Platform's thematic network 

in European cities can be more severely affected by heat 

on climate action through public health education and training, 

because of their location in densely built urban environments. 

led by the Association of Schools of Public Health in the European 

In addition, the European Climate and Health Observatory 

Region (ASPHER) and endorsed by 96 key stakeholders in Europe 
and beyond, calls for (among other things) building climate 

(2022b) shows that flooding poses a threat to one tenth 
of healthcare services across Europe. According to a WHO 

resilience, climate-health literacy and political literacy among 

(2021) survey, climate change impacts on healthcare facilities 

public health and healthcare professionals and intensifying 

are considered by only 5 out of the 15 EEA member and 

the investment in interdisciplinary education and training for 

collaborating countries that responded. This calls for greater 

these professionals in existing curricula and including this in EU 

consideration of the effect that heat and other climate hazards 

legislation for professionals' education requirements to facilitate 

can have on hospitals and their staff and patients, and the 

intersectoral action (Aspher, 2022). The 2022 Communique of the 

possible responses to this. This consideration should also 

G7 Health Ministers, which includes a focus on climate-resilient 

extend to home, community, and residential healthcare 

and sustainable, climate-neutral systems, calls for climate 

and long-term care providers, most of which work outside 

change-related aspects to be integrated into the education 

the physical structures associated with health systems but 

and training of healthcare and public health professionals 

have an important role in caring for vulnerable members 

(G7 Germany, 2022). Some such training initiatives already 

of society. The COVID-19 pandemic has exemplified how a 

exist. For example, the WHO Bonn School on Environment and 

crisis that creates difficulty in obtaining adequate care from 

Health for public health professionals addresses technical gaps 

outside the household can leave many care recipients with 

and raises awareness on environment and health challenges 

unmet needs (Eurofound, 2022). Ensuring continued access 

in countries, including climate change. The European Climate 

to care providers is an important element of increasing health 

and Health Observatory presents examples of training and 

systems' resilience to climate change.

54

Climate change as a threat to health and well-being in Europe: focus on heat and infectious diseasesConclusions and outlook

In addition, health systems' capacity to respond to increased 

health under climate change (European Climate and Health 

demand for healthcare during heatwaves, or for diagnostics 

Observatory, 2022a). National public health institutes are 

during disease outbreaks, may not be sufficient. While 

seen as actors that could usefully become more engaged with 

60 countries across the globe committed to climate-resilient 

the subject of climate change (EuroHealthNet, 2021; IANPHI, 

health systems under the WHO COP26 Health Programme, in 

2021) and play a stronger role as connectors between the 

June 2022 this included only six EEA member and cooperating 

relevant sectors on climate change and health. For example, 

countries (Belgium, Germany, Ireland, Netherlands, Norway and 

collaborations in Europe between national public health 

Spain) (WHO, 2022b). The 2022 Communique of the G7 Health 

institutes and urban planning and land use sectors have not 

Ministers may be a beacon of change, with emphasis placed 

been common to date (IANPHI, 2021).

on climate-resilient and sustainable, climate-neutral health 

systems (G7 Germany, 2022). Further political commitment may 

Lastly, to enable the step up from developing policies to 

be secured at the forthcoming WHO Europe 2023 Ministerial 

implementing action on the ground, there is a need for the 

Conference on Environment and Health, with climate change 

monitoring, evaluation and dissemination of knowledge on 

planned as one of the foci.

the effectiveness of solutions. Knowledge of what works best 

and in which context is crucial to support decision-making in 

Third, to effectively address threats, the varying vulnerability 

the public, private and third sectors, in particular if upfront 

and exposure of different demographic and socio-economic 

investment is needed. The EU is supporting research, 

groups needs to be considered. Older people, children, and 

implementation and knowledge-sharing activities on climate 

people in poor health consistently emerge as those more 

affected by heat and infectious diseases. Those working outside 

or emergency service workers are more exposed to heat and 

change and health. For instance, six substantial projects on the 
health impacts of climate change and the costs and benefits 
of action and inaction started in autumn 2022. The findings 

vector- and water-borne diseases. The Communique of the 

of such research projects contribute to the knowledge base 

G7 Health Ministers recognises the disproportionate effects 

for further policy development. The EU Mission on adaptation 

on marginalised and vulnerable groups and the importance 

to climate change also kicked off in 2022, with the focus on 

of reducing health inequalities (G7 Germany, 2022). Health 

supporting subnational action on adaptation. Funding will be 

equity is also a leitmotif for WHO and is strongly emphasised 

provided to demonstrator regions and communities across 

in the joint statement led by Aspher (2022). However, although 

Europe to assess climate risks, develop adaptation strategies 

EU and national climate policies draw attention to vulnerable 

and implement actions, with a strong focus on health and 

groups and emphasise the need for equitable adaptation 

equity. The European Climate and Health Observatory is 

solutions, the practical implementation of such solutions 

expected to play a key role as a knowledge-sharing platform for 

remains rare. Stronger engagement of those working on 

those activities.

climate change threats with the health, social care, education 

and employment sectors is essential for the appropriate 

To conclude, it is important to note that this report looks 

identification and protection of vulnerable groups (EEA, 2022b).

at just two among the plethora of threats to human health 

associated with the changing climate. Other threats, including 

In general, the examples of responses to climate-related 

flooding, wildfires, droughts and aeroallergens — which are 

health threats in Sections 3.5 and 4.5 show that the adaptation 

covered by the European Climate and Health Observatory 

and prevention measures go beyond the remit of the health 

and will be explored in more detail in forthcoming reports — 

sector and require engagement with other sectors (e.g. built 

can add to or multiply the health risks of high temperatures 

environment, spatial planning, education and employment). 

and infectious diseases. In addition, the groups vulnerable to 

Examples of such collaborations emerge in some European 
countries. For example, in Bulgaria, the Ministry of Health has 

high temperatures and infectious diseases — elderly people, 

those in poor health, children, pregnant women, lower 

established an interdisciplinary coordination working group on 

socio-economic groups and those required to work outside — 

climate change and health. In Germany, the Federal/ Länder 

are vulnerable to other climate hazards. There is a need for 

Ad hoc Working Group on Adaptation to the Impacts of 

more knowledge on the cumulative effects of various climate 

Climate Change in the Health Sector that was set up in 2017 is 

and environmental threats to human health, particularly that 

now permanent to facilitate interagency dialogue on human 

of vulnerable groups.

55

Climate change as a threat to health and well-being in Europe: focus on heat and infectious diseases© Mymind, Unsplash

56

Climate change as a threat to health and well-being in Europe: focus on heat and infectious diseasesAbbreviations

Abbreviations

CI

ECDC 

EEA 

EU 

HHAP

TBE

UHI

WHO

WNV

Confidence interval

European Centre for Disease Prevention and Control

European Environment Agency

European Union

Heat health action plan

Tick-borne encephalitis

Urban heat island

World Health Organization

West Nile virus

57

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68

Climate change as a threat to health and well-being in Europe: focus on heat and infectious diseasesEuropean Environment Agency

Climate change as a threat to health and well-being in Europe: focus on heat and 
infectious diseases

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