Impact of climate and Aedes albopictus establishment on dengue and chikungunya outbreaks in Europe: a time-to-event analysis
Authors: Zia Farooq, Leo Segelmark, Joacim Rocklöv, Kate Lillepold, Maquines Odhiambo Sewe, Olivier J T Briet, Jan C Semenza
Journal: The Lancet Planetary Health (2025)

The rapid spread of the Asian tiger mosquito (Aedes albopictus) poses a notable public health threat in Europe due to its ability to transmit tropical diseases such as dengue and chikungunya. We aimed to quantify the underlying drivers facilitating and accelerating Europe's transition from sporadic arbovirus outbreaks to Aedes-borne disease endemicity, focusing on dengue and chikungunya outbreaks. We conducted a time-to-event analysis to investigate the period between establishment of Ae albopictus and autochthonous dengue and chikungunya outbreaks across Nomenclature of Territorial Units for Statistics (NUTS) 3 regions in the EU. We incorporated data from the European Centre for Disease Prevention and Control, WHO, technical and surveillance reports, and other entomological data sources on regional Ae albopictus establishment and subsequent dengue and chikungunya outbreaks from 1990 (when Ae albopictus was first introduced to an EU country) to 2024. The main outcome was survival time (ie, the time from Ae albopictus establishment to an outbreak of dengue or chikungunya), accounting for land-use types, demographic and socioeconomic factors, imported cases, and climatic variables via univariable and multivariable regression. To address recurrent outbreaks, we applied the Andersen-Gill extension of the Cox proportional hazards model to analyse all events. We further stratified regions into warm and cool groups on the basis of mean summer temperatures above or below 20°C and conducted a stratified analysis with Kaplan-Meier curves and the log-rank test to evaluate differences between these groups. We also estimated projected outbreak hazards from the 2030s to the 2060s at a decadal scale under three distinct shared socioeconomic pathways (SSPs; SSP1-2·6, SSP3-7·0, and SSP5-8·5) to assess the future impact of climate change on outbreak hazard estimates. Between 1990 and 2024, the interval from the first NUTS 3 regional establishment of Ae albopictus to the first outbreak of dengue or chikungunya decreased from 25 years to less than 5 years. Similarly, the interval from the first outbreak to the second outbreak decreased from 12 years in 1990 to less than 1 year in 2024. Our regression analyses indicate that increasingly favourable climatic conditions play a significant role in this trend. A 1°C rise in mean summer temperature was associated with a hazard ratio of 1·55 (95% CI 1·30-1·85; p<0·0001) after controlling for health-care expenditure and imported cases and land-use type. First outbreak events might have occurred more frequently and earlier in warmer regions than cooler ones (log-rank p=0·088), reflecting a lower probability of remaining outbreak-free over time. This trend is expected to intensify under extreme climate change scenarios, with projections under the SSP5-8·5 scenario suggesting an almost five-fold increase in dengue or chikungunya outbreaks by the 2060s, relative to the 1990-2024 baseline period. The findings in this study underscore the pressing need for robust control measures, enhanced surveillance, and early warning systems in the EU to mitigate the impending risk of Aedes-borne disease endemicity in the region. European Union's Horizon Europe.