Death toll exceeded 70,000 in Europe during the summer of 2003

Abstract

Daily numbers of deaths at a regional level were collected in 16 European countries. Summer mortality was analyzed for the reference period 1998-2002 and for 2003. More than 70,000 additional deaths occurred in Europe during the summer 2003. Major distortions occurred in the age distribution of the deaths, but no harvesting effect was observed in the months following August 2003. Global warming constitutes a new health threat in an aged Europe that may be difficult to detect at the country level, depending on its size. Centralizing the count of daily deaths on an operational geographical scale constitutes a priority for Public Health in Europe.

Full text

C. R. Biologies 331 (2008) 171–178
http://france.elsevier.com/direct/CRASS3/
Epidemiology / Épidémiologie
Death toll exceeded 70,000 in Europe during the summer of 2003
Jean-Marie Robine a,∗, Siu Lan K. Cheung a, Sophie Le Roy a, Herman Van Oyen b,
Clare Griffiths c, Jean-Pierre Michel d, François Richard Herrmann d
aINSERM, Démographie et santé, CRLC, centre Val-d’Aurelle, parc Euromédecine, 34298 Montpellier cedex 5, France
bUnit of Epidemiology, Scientific Institute of Public Health, J. Wytsmanstraat 14, 1050 Bruxelles, Belgium
cOffice of National Statistics, Mortality Statistics, 1 Drummond Gate, London SW1V 2QQ, London, UK
dDepartment of Rehabilitation and Geriatrics, Geneva Medical School and University Hospitals, 3, ch. Pont-Bochet,
1226 Thonex-Genève, Switzerland
Received 22 August 2007; accepted after revision 2 December 2007
Available online 31 December 2007
Presented by Alain-Jacques Valleron
Abstract
Daily numbers of deaths at a regional level were collected in 16 European countries. Summer mortality was analyzed for the
reference period 1998–2002 and for 2003. More than 70,000 additional deaths occurred in Europe during the summer 2003. Major
distortions occurred in the age distribution of the deaths, but no harvesting effect was observed in the months following August
2003. Global warming constitutes a new health threat in an aged Europe that may be difficult to detect at the country level,
depending on its size. Centralizing the count of daily deaths on an operational geographical scale constitutes a priority for Public
Health in Europe. To cite this article: J.-M. Robine et al., C. R. Biologies 331 (2008).
©2007 Académie des sciences. Published by Elsevier Masson SAS. All rights reserved.
Résumé
Plus de 70 000 décès en Europe au cours de l’été 2003. Nous avons collecté le nombre quotidien de décès par région dans
16 pays européens et analysé la mortalité estivale pour la période de référence (1998–2002) et pour 2003. Il s’est produit plus de
70 000 décès supplémentaires au cours de l’été 2003. On observe des distorsions importantes dans la distribution par âge des décès,
mais pas d’effet de rattrapage dans les mois suivants. Le réchauffement climatique constitue une nouvelle menace pour la santé des
personnes âgées, qui peut être difficile à détecter au niveau d’un pays, en fonction de la taille de ce dernier. Le décompte centralisé
des décès journaliers à une échelle géographique opérationnelle constitue une priorité de santé publique en Europe. Pour citer cet
article :J.-M. Robine et al., C. R. Biologies 331 (2008).
©2007 Académie des sciences. Published by Elsevier Masson SAS. All rights reserved.
Keywords: Human; Elderly; Daily mortality; Europe; Heat wave; Global warming
Mots-clés : Humain ; Personnes âgées ; Mortalité quotidienne; Europe ; Vague de chaleur ; Réchauffement climatique
*Corresponding author.
E-mail address: robine@valdorel.fnclcc.fr (J.-M. Robine).
1. Background
Everyone remembers the 15,000 additional deaths
caused by the heat wave of August 2003 in France [1].
1631-0691/$ – see front matter ©2007 Académie des sciences. Published by Elsevier Masson SAS. All rights reserved.
doi:10.1016/j.crvi.2007.12.001

172 J.-M. Robine et al. / C. R. Biologies 331 (2008) 171–178
However, four years later, no one knows precisely the
cumulative number of European victims, although more
than 70 scientific reports related to this event have al-
ready been published [2]. A first assessment, made in
March 2004 by the United Nations Environment Pro-
gramme (UNEP), estimated the death toll on a Euro-
pean scale to exceed 30,000 [3]. A similar estimation
was published two years later, although the available
studies pertain to different periods of the summer [4].
A range between 27,000 and 40,000 excess deaths has
been proposed, depending on data sources, methodol-
ogy and reference period [5]. A total higher than 38,000
excess deaths during August 2003 has been declared in
seven European countries [6]. These divergent figures
indicate that a global assessment of excess mortality is
difficult, if not impossible, because no standardized esti-
mates across European countries have been made for the
2003 heat wave [7]. Press releases issued by statistical
institutes referred to major excess mortality, potentially
reaching 13,000 deaths in Spain and 20,000 deaths in
Italy. This situation, in combination with current con-
cerns about global warming [8], led the European Union
to instigate a global study on the excess mortality in Eu-
rope during the summer of 2003.
2. Methods
Mortality in the summer 2003 is compared to the
period 1998–2002. This five-year reference period is a
compromise between the necessity of gathering enough
years to get an average reference and the need of not
being influenced by too far values, which may be due
to higher past mortality level. Daily numbers of deaths
were collected at regional level (NUTS 2 – http://en.
wikipedia.org/wiki/Nomenclature_of_Territorial_Units
_for_Statistics), from 1 January 1998 onwards, by gen-
der and age, in France and nine neighbouring coun-
tries (Belgium, England, Germany, Italy, Luxemburg,
the Netherlands, Portugal, Spain, and Switzerland) for
which prior information on their involvement in the heat
wave of August 2003 was available [9–16], as well as in
six surrounding countries (Austria, Croatia, the Czech
Republic, Denmark, Poland, and Slovenia), for which
no information was available. The aim of this selec-
tion was to delimit better the area affected by the Au-
gust heat wave. Indeed, it turns out that two countries,
Croatia and Slovenia, were partially affected. The four
remaining unaffected countries were kept as potential
controls for the study. Altogether 19,098,574 daily mor-
tality counts were collected for 177 NUTS belonging to
these 16 European countries. Daily death frequencies
were calculated by dividing, for each year, the daily
number of deaths by the annual total to compare coun-
tries and regions. Assuming no seasonal variations or
daily fluctuations, 0.27% (1/365 ×100)of all annual
deaths should be observed on any given day. Computa-
tions were performed by gender, single age, and NUTS,
and then aggregated for analysis at the requested level.
Seasonality of deaths and the characteristics of the
summer mortality in Europe during the reference pe-
riod of 1998–2002 were analysed to set thresholds for
extreme values. Robust polynomial regression models
(1 to 4 degrees), weighted by the numbers of deaths
in each country, were applied to the mortality profiles
(summer and non-summer) to determine the propor-
tion of variance in the daily death frequency explained
by the days of the year. The multivariate models were
adjusted for year and country by introducing dummy
variables. Such models (in the form: m(d, i, j ) =a0+
a1d1+a2d2+a3d3+a4d4+a5y(i) +a6c(j), where
mis the daily mortality, anare constants, dis the day
of the year at the power 1 to 4, y(i) each year and
c(j) each country) assess the relative contribution of a
specific day within two broad seasons, summer or not
summer, controlling for years and countries. The vari-
ables ‘year’ and ‘country’ allow the secular trend in
mortality decline as well as the geographical variation
to be taken into account. The four selected polynomial
degrees let the principal shapes of the potential rela-
tionship between mortality and days to be appraised
within the two broad seasons. A horizontal linear fit
(a1=0, a2=0, a3=0, a4=0) would mean that mor-
tality is independent of days. A quadratic fit (a2= 0,
a3=0, a4=0) would indicate a single mortality peak
or hollow, whereas higher-degree polynomials would fit
a more complex shape.
The first and third quartiles (Q1and Q3), in combi-
nation with the inter-quartile range (IQR), allow identi-
fication of minor outliers (Q1−1.5×IQR; Q3+1.5×
IQR) and exceptionally extreme values (Q1−3×IQR;
Q3+3×IQR) [17].
Variations in daily mortality in combined data of all
the 16 countries were examined by calculating the delta
between the number of daily deaths recorded during
the summer of 2003 and the average number of deaths
recorded on the same day during the reference period.
A positive delta means that the number of deaths in 2003
is higher than the 1998–2002 average, while a negative
delta indicates a lower number. Daily death frequencies
were divided by the value of the median frequency ex-
perienced during the summers of 1998–2002 to estimate
the magnitude of the excess mortality. This conversion
rescales all the frequencies around the unit. It is there-

J.-M. Robine et al. / C. R. Biologies 331 (2008) 171–178 173
fore immediately possible to interpret the daily mortal-
ity on any given day as a multiple of the median value.
Next, daily excess mortality in 2003 was calculated
for each country. Results were grouped per month and
mortality profile. Special attention was devoted to the
mortality peak of August 2003. Maps at NUTS 2 level
allow the geographical boundaries of this mortality cri-
sis to be specified better. In order to identify shifts in
the age of death, we estimated the ratio of 65+as the
proportion of deaths above the age of 65 years on a
given day divided by the average share of the 65+ob-
served over the summer of 2003. A series of such ratios
(by age: 65+,75+,85+and 95+and by gender) were
plotted on the calendar time scale to examine the co-
occurrence in the distortions in the proportion of deaths
involving older people and women. More detailed infor-
mation on the methods used is available on request [18].
3. Results
The distribution of daily deaths between 1998 and
2002 reveals an identical seasonality in the 16 European
countries, with (i) a low summer mortality from June to
September, where the daily mortality appears to be con-
stant, and (ii) non-summer conditions from October to
May, with a rise in mortality from October to Decem-
ber, a winter peak in January and February, followed by
a drop in mortality from March to May. The regression
models with a degree higher than 1 do not improve the
prediction quality for the summer period. In all mod-
els, the summer days explain only between 2% and 3%
of the variance, whereas the year and the country ex-
plain each between 5% and 6%. As this is negligible,
the summer mortality was analysed as a single block.
By contrast, outside of the summer period, the day ex-
plains around 40% of the variance of the daily death
frequency in all models with a degree higher than 1.
The 9760 daily summer death frequencies (122 sum-
mer days ×16 countries ×5 years) experienced in Eu-
rope between 1998 and 2002 are distributed symmet-
rically around a median frequency of 0.2506 (average
0.2525). The distribution seems very concentrated com-
pared to a normal distribution; 50% of observations are
between 0.2377 (25th percentile) and 0.2655 (75th per-
centile). The boundaries defining the extreme values are
0.1961 and 0.3072 for the minor outliers, and 0.1544
and 0.3489 for the exceptional values. 554 days (5.68%)
are outliers of which 174 days (1.78%) are exceptional
outliers.
Using the delta between the numbers of daily deaths
recorded during the summer of 2003 and the average
number recorded on the same day during years 1998–
Fig. 1. Delta between the number of daily deaths recorded in the sum-
mer of 2003 and the average number of deaths recorded on the same
day during the 1998–2002 reference period for the 16 European coun-
tries studied. DOY 152, the 152nd day of the year corresponds to 1
June, DOY 181 to 30 June, DOY 212 to 31 July, DOY 243 to 31 Au-
gust and DOY 273 to 30 September.
2002, Fig. 1 represents the variations in daily mortality
during the summer of 2003 for the 16 European coun-
tries together. Out of the 122 days, 27 days presented
a delta lower than zero, inducing a total deficit of 5045
deaths compared to 95 days, with a delta higher than
zero, creating a total excess mortality of 74,483 deaths.
Both gaps do not balance each other. Excess mortality
was a characteristic of the summer of 2003 affecting a
major part of Europe. In particular, three main peaks ex-
ceeding 1000 additional daily deaths were observed on
13 June, between 16 and 21 July and on 12 and 13 Au-
gust, days in which the mortality peak was exceptional.
Excess mortality was also observed at the end of June
and persisted during the month of September.
In 2003, out of a total of 1952 summer days in the
16 countries, 145 days (7.5%) are outliers beyond the
boundary of [Q3+1.5×IQR], marking high extreme
values. Fifty days (2.6%) are extreme outliers. This is
more than three times the figures observed during the
1998–2002 period. The countries most affected by these
exceptionally high death frequencies are Luxemburg
(20 days), Portugal (eleven days), France (nine days)
and Italy (four days). The first peak in mid-June is found
mainly in Italy and Croatia and, to a lesser degree, in
Spain. The peak seems to be delayed a few days in Por-
tugal where it occurred on 20 June. All these days cre-
ated a considerable number of excess deaths at the start
of the summer, limited to southern countries. This pe-
riod of excess mortality remained almost unnoticed. The
second peak is centred on 16–21 July and involves the
Netherlands, England and Wales, Belgium, Luxemburg,
France, Germany, Switzerland and, to a lesser degree,

174 J.-M. Robine et al. / C. R. Biologies 331 (2008) 171–178
Spain. Although excess mortality occurred simultane-
ously in all of these countries, it remained unnoticed,
with the exception of the Netherlands [19]. The third
peak, centred on 12 and 13 August is first observed
in France, Italy, Portugal, and Luxemburg. It is clearly
visible in Germany, England and Wales, Belgium and
Switzerland. It also appears, although less sharply, in
the Netherlands and in Spain.
The cumulative daily death frequencies over the
summer of 2003 show a contrast between (i) countries
such as France and Germany, which deviate abruptly
from the anticipated trend during the first two weeks of
August, by cumulating excess mortality, which will not
be compensated later on in the summer, (ii) countries
like Spain and Italy that move far more gradually away
from the trend in several waves covering the beginning
of the summer until the August peak, (iii) countries like
Portugal, which tend towards a deficit of mortality prior
to the August peak and which recover excess mortality
before the end of the summer, and lastly (iv) countries
like England and Wales, which ultimately drift away
only slightly from the anticipated trend, just like the
control countries not affected by the heat wave.
Table 1 presents the excess mortality, both as the
absolute and the percentage difference between the ob-
served daily number of deaths and the average number
of deaths on the same day during the reference period.
The absolute numbers and percentages of the excess
mortality are given by country for the period before,
during and after the summer of 2003 and by month
for the summer period. Overall, more than 80,000 ad-
ditional deaths were recorded in 2003 in the 12 coun-
tries affected by excess mortality, i.e. an excess of 2.5%
compared to 1998–2002. Although about 70,000 out
of these additional deaths occurred during the summer,
over 3000 additional deaths occurred before and there
were more than 8000 deaths in excess afterwards. The
countries most affected by this excess summer mortality
were Luxemburg, Spain, France, and Italy, where mor-
tality increased by 14.3%, 13.7%, 11.8% and 11.6%,
respectively. The female deaths represent 65% of the to-
tal number of the excess deaths during this period.
In August 2003 alone, nearly 45,000 additional
deaths were recorded in the 12 countries, including
15,251 in France (+37%), 9713 in Italy (+21.8%),
7295 in Germany (+11%), 6461 in Spain (+22.9%) and
1987 in England and Wales (+4.9%). In less-populated
countries, the numbers are lower, but excess mortal-
ity can be relatively very significant, as in Luxemburg,
where 73 additional deaths increased mortality by 25%.
Belgium, the Netherlands, and Switzerland each num-
bered about five hundred additional deaths, respectively
+5.3%, +5.2%, and +9.8%. Excess mortality reached
9.9% in Slovenia, with 144 additional deaths, and 6.8%
in Croatia with 269 additional deaths, while mortality
dropped by more than 1% during August 2003 in the
control countries.
August aside, 11,000 additional deaths were recorded
in June (including 5274 in Italy and 4268 in Spain),
over 10,000 in July (including 4318 in Italy and 2751
in Spain), and nearly 5000 in September. Therefore,
France and Italy totalized the same excess mortality
from 1 June to 30 September 2003, of 19,490 and
20,089 excess deaths, respectively, with very different
cumulative profiles during the summer.
4. The mortality crisis of August 2003
The mortality crisis of August extended over the two
weeks between 3 and 16 August. In the 12 countries,
15,000 additional deaths were recorded during the first
week and nearly 24,000 during the second. The ex-
cess mortality ratio reached the exceptional value of
96.5% during the second week in France and very high
values in Portugal (+48.9%), Italy (+45.4%), Spain
(+41.2%), and Luxemburg (+40.8%). Excess mortality
reached 28.9%, 26.7%, and 21.6% in Germany, Switzer-
land, and Belgium, respectively. It exceeded 10% in all
countries, except Denmark, Poland, and the Czech Re-
public. Even in Austria, mortality increased by 12.6%
during this week. Beyond a return to normal, no overall
harvesting effect was observed in the weeks and months
following the mortality crisis of August. Mortality re-
mained high just about everywhere until the end of the
summer. Only in Germany, Italy and Switzerland, slight
drops in deaths after the summer were recorded (see Ta-
ble 1).
The regions most affected by the mortality crisis of
August lie in a southwest–northeast axis (see Fig. 2),
from the Algarve in southern Portugal to Westphalia in
Germany. A secondary axis starts in southern England
and continues towards Latium in central Italy and Croa-
tia. The most significant mortality focal spots are in Île-
de-France and the neighbouring region of Centre, where
mortality recorded between 3 and 16 August is twice
what was expected. Six regions – two in southern Por-
tugal (Algarve and Alentejo) and four in France (Pays
de la Loire, Poitou-Charentes, Burgundy, and Franche-
Comté) recorded a very high excess mortality during
these two weeks (between 65% and 125%). Switzerland
as well as some coastal regions (among others, Brittany
in France and Galicia, Murcia and Valencia in Spain)
seems to have been relatively spared. The southeastern
limits of the mortality crisis are poorly defined due to

J.-M. Robine et al. / C. R. Biologies 331 (2008) 171–178 175
Tab le 1
Delta between the number of deaths recorded in 2003 and the average number of deaths recorded during the 1998–2002 reference period and excess mortality ratio (expressed as a percentage) for
various periods in 2003 (before the summer, during the summer and after the summer) and for various countries
Before summer Summer After summer Total of the year
Nb Ratio June July August September Total Nb Ratio Nb Ratio
Nb Ratio Nb Ratio Nb Ratio Nb Ratio Nb Ratio
Countries affected by the August 2003 heat wave
Belgium −4−0.01 139 1.72 162 1.97 438 5.31 436 5.57 1175 3.62 1356 5.11 2528 2.41
Switzerland 92 0.34 253 5.30 187 3.89 469 9.81 130 2.75 1039 5.45 −148 −0.93 984 1.58
Germany 9290 2.55 642 0.98 1159 1.73 7295 10.97 259 0.40 9355 3.56 −5760 −2.69 12885 1.53
Spain −1464 −0.90 4268 15.49 2751 9.64 6461 22.86 1611 6.21 15090 13.68 7249 7.95 20875 5.74
France −3977 −1.70 1482 3.60 1706 4.06 15251 36.93 1051 2.62 19490 11.84 3415 2.53 18928 3.55
Croatia 882 3.95 193 4.85 157 3.98 269 6.83 169 4.49 788 5.04 5 0.04 1675 3.29
Italy 5575 2.24 5274 12.12 4318 9.72 9713 21.81 783 1.94 20089 11.63 −2487 −1.76 23177 4.12
Luxemburg 69 3.47 33 10.81 27 9.29 75 25.00 34 12.22 170 14.34 79 7.85 318 7.95
Netherlands 304 0.50 78 0.71 11 0.10 578 5.24 297 2.79 965 2.20 503 1.42 1771 1.26
Portugal −2068 −4.26 220 2.83 100 1.28 2196 27.75 179 2.44 2696 8.73 2072 7.76 2699 2.54
Slovenia 351 4.30 13 0.87 62 4.21 144 9.93 70 4.86 289 4.96 74 1.55 714 3.81
England & Wales −5695 −2.41 −1080 −2.64 −504 −1.21 1987 4.90 −103 −0.26 301 0.18 2025 1.44 −3369 −0.62
Tot a l 3355 0.23 11516 4.50 10137 3.88 44878 17.34 4917 1.99 71449 6.99 8382 0.99 83186 2.50
Countries used as controls
Austria 708 2.12 −42 −0.71 172 2.86 159 2.63 57 0.99 345 1.45 −645 −3.30 408 0.53
Czech Republic 2408 5.17 207 2.43 190 2.18 58 0.67 −37 −0.43 418 1.22 −335 −1.20 2491 2.29
Poland 1916 1.21 −487 −1.71 −543 −1.85 −918 −3.21 −652 −2.29 −2600 −2.26 −3436 −3.60 −4119 −1.12
Denmark −113 −0.44 −43 −0.95 −92 −1.95 −49 −1.04 14 0.31 −170 −0.92 92 0.61 −191 −0.32
Tot a l 4920 1.86 −365 −0.77 −273 −0.56 −750 −1.56 −618 −1.31 −2006 −1.05 −4325 −2.74 −1411 −0.23

176 J.-M. Robine et al. / C. R. Biologies 331 (2008) 171–178
Fig. 2. Standardized daily death frequencies (1 means equal to the me-
dian death number, 2 means twice the median death number) between
3 and 16 August 2003, in 16 European countries, for 177 NUTS.
the absence of data for Bosnia-Herzegovina and Serbia.
On the most lethal day – 12 August – mortality recorded
in Île-de-France was over five times more than expected.
It was over four times the expected mortality in the Cen-
tre region (France) and twice the expected mortality in
Algarve in Portugal, in six other French regions, in three
Belgian regions, in Piedmont in Italy and in the Greater
London Area in England.
The August mortality crisis caused major distortions
in the deaths’ age and gender structure, which are il-
lustrated in Fig. 3, using France and Italy as examples.
On 12 August, the share of 65+deaths increased by
9.5% in France, the share of 75+deaths increased by
16.5%, the share of 85+deaths by 26.8% and the share
of 95+deaths by 46%. These distortions in the deaths’
age structure imply that excess mortality increased as
age rose. The structure of deaths by gender also varied
considerably during the mortality crisis. The share of fe-
male deaths increased by 21% in France on 12 August
and by 14% in Italy on 13 August.
5. Interpretation
One original aspect of our work was to begin by ana-
lyzing the seasonality of mortality at the European wide
scale. This study disclosed the existence of two broad
mortality patterns: a constant one during the four sum-
mer months from June to September and a platykurtic
pattern (flattened peak, centred on January–February)
during the remaining months. Therefore, the mortality
crisis of the summer 2003 was studied within this con-
text.
More than three years after the 2003 heat wave, the
total number of victims was still unknown on a Euro-
pean scale. The methods used for estimating the ex-
cess mortality covered various periods (from June to
September or in August only) and different popula-
tions (countries, major cities), preventing comparisons
among countries and therefore global appraisal [7].
Fig. 3. Distortion of the death structure by age and gender in France and Italy during the summer of 2003. DOY 152, the 152nd day of the year
corresponds to 1 June, DOY 181 to 30 June, DOY 212 to 31 July, DOY 243 to 31 August and DOY 273 to 30 September.

J.-M. Robine et al. / C. R. Biologies 331 (2008) 171–178 177
Gathering data from 16 European countries, our
study disclosed that more than 70,000 additional deaths
occurred in Europe during the summer of 2003, of
which more than 20,000 before August. Excess mortal-
ity reached exceptionally high levels during the second
week of the August heat wave in France. However,
France and Italy totalized the same excess mortality,
19,490 and 20,089 excess deaths, respectively, with very
different cumulative profiles during the summer. Ob-
viously, this computed amount of excess mortality is
sensitive to the reference period. However, a compari-
son with a French study of the August heat wave using
a 3-year reference period [1] demonstrates a negligible
impact of the duration of the reference period, ranging
from 3 to 5-year, on the results.
Our study is limited to 16 European countries, ba-
sically France and its neighbouring countries, plus a
group of surrounding countries kept as controls. The
southeastern boundaries of the mortality crisis are
poorly defined, as it was not possible to obtain the
necessary data from Bosnia-Herzegovina and Serbia.
These limitations probably lead to an underestimation
of the real death toll in Europe due to the summer of
2003, as Bulgaria, Greece, Romania, and the south of
the Balkans may have been affected by excess mortal-
ity.
Although the mortality crisis caused major distor-
tions in the age and gender death structure, increasing
the share of women and oldest ones, no overall har-
vesting effect was observed in the weeks and months
following the mortality crisis. A French study proposed
a late or postponed ‘harvesting’ effect that occurred in
the first months of 2004 [20]. However, a subsequent
study showed that the French regions with excessively
low mortality in 2004 were not the most affected by the
2003 heat wave [21,22]. The most recent studies found
little evidence in favour of a compensating harvesting
effect [23].
Relating the number of death to person-years will
provide, in the next step of our study, a better descrip-
tion of the populations at risk (gender, age groups...).
Nevertheless, the current results, analyzed at the NUTS
2 level, strongly suggest that the excess mortality is not
limited to urban areas.
Our observations showed that during the summer
of 2003, a series of minor mortality crises throughout
Europe, occurring almost unnoticed, led to a signifi-
cant cumulative number of victims in comparison to the
huge number of victims due to the August heat wave.
Global warming may constitute a new threat to health
in an aged Europe [8,24] that may be difficult to mon-
itor at the level of a country or of a major city only.
Centralising the count of daily deaths on a sufficiently
large scale, like grouping neighbouring regions across
the border and countries with small populations, should
improve detecting early excess mortality due to various
causes. Anticipation of excess summer mortality poten-
tially due to global warming [25,26], through daily mor-
tality monitoring alongside meteorological and pollu-
tion warning, may constitute a priority for Public Health
in Europe.
Acknowledgements
Barbara Leitner, Statistik Österreich, Austria, Her-
man van Oyen and Bianca Cox, Scientific Institute
of Public Health, Belgium, Robert Jurak and Maga
Francic, Croatian Central Bureau of Statistics, Croatia,
Terezie Kretschmerova, Czech Statistical Office, Czech
Republic, Jesper Marcussen, National Board of Health,
Denmark, Eric Jougla, INSERM–CépiDc, France, Ste-
fan Rübenach, Federal Statistical Office, Germany, Sil-
via Bruzzone, ISTAT, Italy, Guy Weber, direction de la
Santé, Luxembourg, Carel Harmsen, Central Bureau of
Statistics, The Netherlands; Artur Satora, Central Statis-
tical Office of Poland, Poland, Eduarda Góis, Instituto
Nacional de Estatistica, Portugal, Raquel Álvarez Es-
teban, Instituto Nacional de Estadistica, Spain, Tatjana
Rokavec, Institute of Public Health of the Republic of
Slovenia, Slovenia; Dominik Ullmann, Office Fédéral
de la Statistique, Switzerland, Clare Griffiths, Office
for National Statistics, United Kingdom are thanked,
as well as Anne Scherrer-Herrmann for editorial help.
This study was supported by the EU Community Ac-
tion Programme for Public Health (Grant Agreement
No. 2005114).
References
[1] D. Hémon, E. Jougla, La canicule du mois d’août 2003 en
France, Rev. Epidemiol. Sante Publique 52 (2004) 3–5.
[2] S.L.K. Cheung, J.-M. Robine, H. van Oyen, C. Griffiths, F.R.
Herrmann, The 2003 heat wave in Europe, a review of the litera-
ture, The 2003 Heat Wave Project, Montpelier, 2007 (EU Com-
munity Action Programme for Public Health. Grant Agreement
2005114, available on request).
[3] United Nations Environment Programme, Early Warning on
Emerging Environmental Threats: Impacts of summer 2003 heat
wave in Europe, UNEP, Nairobi, March 2004.
[4] A. Haines, R.S. Kovats, D. Campbell-Lendrum, C. Corvalan,
Climate change and human health: impacts, vulnerability, and
mitigation, Lancet 367 (9528) (2006) 2101–2109.
[5] R. Kovats, G. Jendritzky, Heat waves and human health, in: B.E.
Menne, L. Kristie (Eds.), Climate Change and Adaptation Strate-
gies for Human Health, Springer, New York, 2006, p. 449.
[6] J.-P. Sardon, Recent demographic trends in developed countries,
Population-E 61 (3) (2006) 197–266.

178 J.-M. Robine et al. / C. R. Biologies 331 (2008) 171–178
[7] R. Kovats, K. Ebi, Heatwaves and public health in Europe, Eur.
J. Public Health 16 (6) (2006) 592–599.
[8] G.A. Meehl, C. Tebaldi, More intense, more frequent, and longer
lasting heat waves in the 21st century, Science 305 (5686) (2004)
994–997.
[9] S. Conti, P. Meli, G. Minelli, R. Solimini, V. Toccaceli, M. Vichi,
C. Beltrano, L. Perini, Epidemiology study of mortality during
the Summer 2003 heat wave in Italy, Environ. Res. 98 (3) (2005)
390–399.
[10] J. Garssen, C. Harmsen, J. De Beer, The effect of the summer
2003 heat wave on mortality in the Netherlands, Euro Surveill.
(7–9) (2005) 165–167.
[11] L. Grize, A. Huss, O. Thommen, C. Schindler, C. Braun-
Fahrländer, Heat wave 2003 and mortality in Switzerland, Swiss
Med. Wkly (135) (2005) 200–205.
[12] H. Johnson, R.S. Kovats, G. McGregor, J. Stedman, M. Gibbs,
H. Walton, The impact of the 2003 heat wave on daily mortal-
ity in England and Wales and the use of rapid weekly mortality
estimates, Euro Surveill. (7–9) (2005) 168–171.
[13] R. Kovats, H. Johnson, C. Griffiths, Mortality in southern Eng-
land during the 2003 heat wave by place of death, Health Stat.
Q. 29 (Spring) (2006) 6–8.
[14] P. Michelozzi, M. De Sario, G. Accetta, F. de’ Donato, U. Kirch-
mayer, M. D’Ovidio, C. Perucci, Temperature and summer mor-
tality: geographical and temporal variations in four Italian cities,
J. Epidemiol. Commun. Health 60 (2006) 417–423.
[15] P.J. Nogueira, J.M. Falcão, M.T. Contreiras, E. Paixão, J. Bran-
dão, I. Batista, Mortality in Portugal associated with the heat
wave of August 2003: Early estimation of effect, using a rapid
method, Euro Surveill. (7–9) (2005) 150–153.
[16] F. Simõn, G. Lopez-Abente, E. Ballester, F. Martínez, Mortality
in Spain during the heat waves of summer 2003, Euro Surveill.
(7–9) (2005) 156–160.
[17] J.W. Tukey, Easy summaries: numerical and graphical, in: Ex-
ploratory Data Analysis, Addison-Wesley Publishing Company,
Reading, Massachusetts, 1977, pp. 27–56.
[18] J.M. Robine, S.L. Cheung, S. Le Roy, H. Van Oyen, F.R. Her-
rmann, Report on excess mortality in Europe during summer
2003. EU Community Action Program for Public Health, Grant
Agreement 2005114, http://ec.europa.eu/health/ph_projects/
2005/action1/docs/action1_2005_a2_15_en.pdf, 2007, 5 p.
[19] J. De Beer, C. Harmsen, Higher temperatures push up number of
deaths, CBS Web Mag. (2003).
[20] A.-J. Valleron, A. Boumendil, Épidémiologie et canicules :
analyses de la vague de chaleur 2003 en France, C. R. Biolo-
gies 327 (12) (2004) 1125–1141.
[21] G. Pison, France 2004 : l’espérance de vie franchit le seuil des
80 ans, Popul. Soc. (2005) 410.
[22] L. Richet-Mastain, Bilan démographique 2004 : nette diminution
des décès, INSEE Première (2005) 1004.
[23] G. Rey, Surmortalité liée aux vagues de chaleur : facteurs de vul-
nérabilité socio-démographiques et causes médicales de décès,
thèse, spécialité : épidémiologie, université Paris-11, 2007.
[24] M. McKee, B. Jacobson, Public health in Europe, Lancet 356
(9230) (2000) 665–670.
[25] J. Giles, Special Report: From words to action, Nature 445
(7128) (2007) 578.
[26] M. Hopkin, Climate change 2007: Data keep flooding in, Na-
ture 445 (7128) (2007) 581.