Climate change and public health in Germany - A synthesis of options for action from the German status report on climate change and health 2023.

Background: This article represents the conclusion of the updated German status report on climate change and health, which was jointly written by authors from over 30 national institutions and organisations. The objectives are (a) to synthesise the options for action formulated in the report, (b) to combine them into clusters and guiding principles, (c) to address the success factors for implementation, and (d) to combine the options for action into target parameters. Methods: The options for action from the individual contributions of the status report were systematically recorded and categorised (n=236). Topical clusters were then formed with reference to Essential Public Health Functions, and options for action were assigned to them. Results: Eight topical clusters of options for action and ten guiding principles were identified. These can be summarised in four overarching meta-levels of action: (a) cross-sectorally coordinated structural and behavioural prevention, (b) monitoring, surveillance, and digitalisation (including early warning systems), (c) development of an ecologically sustainable and resilient public health system, and (d) information, communication, and participation. The main success factors for implementation are the design of governance, positive storytelling and risk communication, proactive management of conflicting goals, and a cross-sectoral co-benefit approach. Conclusions: Based on the status report, systematically compiled target parameters and concrete options for action are available for public health.

Climate change and public health in Germany - An introduction to the German status report on climate change and health 2023.

Global warming of 1.5°C and even 2°C is likely to be exceeded during the 21st century. Climate change poses a worldwide threat and has direct and indirect effects on infectious diseases, on non-communicable diseases and on mental health. Not all people are equally able to protect themselves against the impacts of climate change; particularly populations that are vulnerable due to individual factors (children, older persons, those immunocompromised or with pre-existing conditions), social factors (the socially disadvantaged), or living and working conditions (e. g. people who work outdoors) are subject to an increased risk. Concepts such as One Health or Planetary Health provide a framework to frame both climate change itself and adaptation strategies or sets of actions for environmental human and animal health. Knowledge of climate change impacts has grown in recent years, and mitigation and adaptation strategies have been developed.

[The implications of the concepts One Health and Planetary Health for the environmental medicine of the 21st century]. / Die Bedeutung der Konzepte One Health und Planetary Health für die Umweltmedizin im 21. Jahrhundert.

In the 21st century, an accumulation of complex crises such as climate change, biodiversity loss, environmental pollution, wars, and pandemics is leading to economic, social, and health problems for people of current and future generations. These problems are essentially due to the disregard of natural regenerative capacities of ecosystems. Health approaches such as One Health and Planetary Health have gained popularity since the early 2000s and are increasingly used in politics, science, and the health professions. Environmental medicine is also influenced by the growing number of crises and environmental problems and the increasing interest in the concepts of One Health and Planetary Health.In this discussion paper, the development of the two concepts is first presented. Then, their significance for environmental medicine will be discussed. Health professionals working on environmental medicine issues must now consider both local and global causes and health effects when assessing environmental impacts, which can complicate decisions and lead to conflicting objectives.

Heat-Related Mortality in Germany From 1992 to 2021.

BACKGROUND: 2018-2020 were unusually warm years in Germany, and the summer of 2018 was the second warmest summer since record-keeping began in 1881. Higher temperatures regularly lead to increased mortality, particularly among the elderly. METHODS: We used weekly data on all-cause mortality and mean temperature from the period 1992-2021 and estimated the number of heat-related deaths in all of Germany, and in the northern, central, and southern regions of Germany, employing a generalized additive model (GAM). To characterize long-term trends, we compared the effect of heat on mortality over the decades. RESULTS: Our estimate reveals that the unusually high summer temperatures in Germany between 2018 and 2020 led to a statistically significant number of deaths in all three years. There were approximately 8700 heat-related deaths in 2018, 6900 in 2019, and 3700 in 2020. There was no statistically significant heat-related increase in deaths in 2021. A comparison of the past three decades reveals a slight overall decline in the effect of high temperatures on mortality. CONCLUSION: Although evidence suggests that there has been some adaptation to heat over the years, the data from 2018-2020 in particular show that heat events remain a significant threat to human health in Germany.

Heat-Related Mortality.

BACKGROUND: As a consequence of global warming, heat waves are expected to become more frequent, more intense, and longer. The elderly and persons with chronic diseases are especially vulnerable to health problems due to heat. This article is devoted to the question of the extent to which the effects of heat waves in Germany are changing over time, and whether preventive health measures are working. METHODS: We use a statistical model to quantify the effect of high mean temperatures on mortality. Within this model, different exposure-response curves for the three temporal intervals 1992-2000, 2001-2010, and 2011-2017 are estimated. Attention is also paid to the delayed effect on mortality of high mean temperatures in the preceding week. RESULTS: Our analysis reveals a clear, systematic association of the mean temperature in the current week, as well as the mean temperature in the preceding week, with weekly mortality. This association is more pronounced for higher age groups and decreases over the years under analysis, with the exception of a relatively weak effect of heat in southern Germany in 1992-2000. The strongest effects were related to the heat waves in 1994 and 2003, with approximately 10 200 and 9600 fatalities, respectively. Approximately 7800 fatalities were estimated for the summer of 2006, and 4700 and 5200 for 2010 and 2015, respectively. CONCLUSION: In Germany, as elsewhere, climate change has been causing more frequent, more intense, and longer periods of heat in the summer. The harmful effect of heat on health is reduced by adaptive processes, presumably including successful preventive measures. Such measures should be extended in the future, and perhaps complemented by other measures in order to further diminish the effect of heat on mortality .

[Adverse health effects due to environmental noise exposure in urban areas]. / Gesundheitliche Auswirkungen von Umgebungslärm im urbanen Raum.

Environmental noise is a great burden for the population in Germany, especially in urban areas. People are often exposed not only to one but several noise sources. Long-term exposure to environmental noise can have several and severe adverse effects on human health, such as noise annoyance, sleep disturbances, ischaemic heart disease and depression. Additional burdens arise from multiple exposure to particulate matter or air pollutants. The current article describes the relevant adverse health effects due to long-term environmental noise exposure, discusses the challenges of environmental noise in urban areas different and introduces measures and instruments to abate environmental noise.

[Estimation of heat-related deaths in Germany between 2001 and 2015]. / Schätzung hitzebedingter Todesfälle in Deutschland zwischen 2001 und 2015.

BACKGROUND: During the summers of 2003 and 2015, heat was found to be the cause of a substantial number of deaths in Germany. Until now, estimates for the total number of heat-related deaths were only available regionally in Germany. For the summer of 2003, an analysis for Baden-Württemberg was extrapolated to the whole of Germany. OBJECTIVES: Our analysis tries to prove a stable statistical relationship between heat and mortality and to use this to quantify the number of heat-related deaths in Germany between the years 2001 and 2015. MATERIALS AND METHODS: By fitting a nonlinear statistical model, we estimated exposure-response curves that describe the influence of heat on the mortality rate. The performance of different indicators for heat stress was compared. RESULTS: The comparison of the different indicators for heat showed that the weekly mean temperature was most useful to explain the course of the weekly mortality during the summer. The relation between mortality rate and weekly mean temperature varied between age groups and regions in Germany (north, middle, south). The age groups (75-84) and (85+) were most affected by heat. The highest number of heat-related deaths was 7600 (95% CI 5500-9900), found for the summer 2003, followed by 6200 (4000; 8000) in the summer 2006 and 6100 (4000; 8300) in the summer 2015. CONCLUSIONS: We could show that even in weekly data on mortality, a clear influence of heat could be identified. A national surveillance of mortality that allows real-time monitoring would be desirable.

[Epidemiological studies with environmental relevance in Germany]. / Epidemiologische Studien mit Umweltbezug in Deutschland.

Our environment is a major factor in determining health and well-being throughout life, from conception into old age. This overview illustrates the most important epidemiological studies and health monitoring systems in Germany, which investigate environmental influences in various population subgroups and estimate related health effects. Environmental factors examined in each study are described. The mentioned studies in children and adults build the basis for predictions and preventive measures. The number of the assessed environmental factors, the depth of the examinations as well as the (phenotypical) characterization of the study participants differ. Still, the obtained data build a base for important future research. However, for this, a permanent and Germany-wide assessment of environmental factors is necessary.The proportion of the European population living in urban areas is projected to increase in the future. Therefore, environmental factors such as air pollution, air temperature, and noise, but also social inequality, are likely to have a negative effect on health and quality of life of the population. The challenge of the aging population as well as potential adaptation processes to the diverse environmental stimuli requires multidisciplinary approaches. From an environmental epidemiology view, the collected data from the described studies are of immense value because only with this data can associations between environment and health be investigated and public health-relevant preventive measures be identified.The NAKO health study will be the largest resource of health data and should therefore be included in future activities related to the investigation of environmental health effects in Germany.

[What potential do geographic information systems have for population-wide health monitoring in Germany? : Perspectives and challenges for the health monitoring of the Robert Koch Institute]. / Welches Potenzial haben Geoinformationssysteme für das bevölkerungsweite Gesundheitsmonitoring in Deutschland? : Perspektiven und Herausforderungen für das Gesundheitsmonitoring am Robert Koch-Institut.

Geographic information systems (GISs) are computer-based systems with which geographical data can be recorded, stored, managed, analyzed, visualized and provided. In recent years, they have become an integral part of public health research. They offer a broad range of analysis tools, which enable innovative solutions for health-related research questions. An analysis of nationwide studies that applied geographic information systems underlines the potential this instrument bears for health monitoring in Germany. Geographic information systems provide up-to-date mapping and visualization options to be used for national health monitoring at the Robert Koch Institute (RKI). Furthermore, objective information on the residential environment as an influencing factor on population health and on health behavior can be gathered and linked to RKI survey data at different geographic scales. Besides using physical information, such as climate, vegetation or land use, as well as information on the built environment, the instrument can link socioeconomic and sociodemographic data as well as information on health care and environmental stress to the survey data and integrate them into concepts for analyses. Therefore, geographic information systems expand the potential of the RKI to present nationwide, representative and meaningful health-monitoring results. In doing so, data protection regulations must always be followed. To conclude, the development of a national spatial data infrastructure and the identification of important data sources can prospectively improve access to high quality data sets that are relevant for the health monitoring.

Environmental Noise Annoyance and Mental Health in Adults: Findings from the Cross-Sectional German Health Update (GEDA) Study 2012.

The health implications of environmental noise, especially cardiovascular effects, have been studied intensively. Research on associations between noise and mental health, however, has shown contradictory results. The present study examined associations between individual levels of noise annoyance due to noise from various sources in the living environment and mental health of adults in Germany. It evaluated whether these associations persisted after adjusting for potential covariates. Data were obtained from the cross-sectional "German Health Update" study 2012 (GEDA 2012), a national health interview survey among adults in Germany conducted by the Robert Koch Institute (n = 19,294). Noise annoyance questions referred to overall noise and that from road traffic, neighbours, and air traffic. Mental health was measured with the five-item Mental Health Inventory. Bivariate analysis showed associations between high levels of noise annoyance and impaired mental health for all noise sources except air traffic. After adjusting for covariates (sociodemographic factors, chronic disease, and social support), both men and women who reported high overall noise annoyance showed more than doubled odds of impaired mental health compared to those who were not annoyed. The odds of impaired mental health in the highest noise annoyance category from road traffic and neighbours were also significantly increased. These findings indicate that high noise annoyance is associated with impaired mental health and that this association can vary with the source of environmental noise. Further research on covariates of this association is necessary. Particularly, longitudinal data are required to establish the direction of associations and to address questions of causality.

Current status of allergy prevalence in Germany: Position paper of the Environmental Medicine Commission of the Robert Koch Institute.

The lifetime prevalence of allergic diseases in adults in Germany [self-reported doctor diagnosed allergic diseases, Study on Adult Health in Germany (Studie zur Gesundheit Erwachsener in Deutschland, DEGS1, 2008-2011) of the Robert Koch Institute] is 8.6 % for asthma, 14.8 % for hay fever, 3.5 % for atopic dermatitis, 8.1 % for contact dermatitis, 4.7 % for food allergies, and 2.8 % for insect venom allergies. Almost 20 % of German adults are currently affected by at least one allergy. In tests on 50 common single allergens and two mixtures comprising either inhalant allergens or grass pollen allergens, 48.6 % of participants exhibited at least one allergic sensitization (specific IgE antibody detection). Overall, 33.6 % of participants were sensitized to inhalant allergens, 25.5 % to at least one food allergens, and 22.6 % to at least one insect venom allergens. A comparison of data on adults from 1998 [Federal Health Survey 1998 (Bundes-Gesundheitssurvey 1998, BGS98) of the Robert Koch Institute] and 2008-2011 (DEGS1) shows an increase in prevalence over time of almost three percentage points, while the rate of sensitization to inhalant allergens has increased from 29.8 % to 33.6 %. The prevalence of doctor diagnosed hay fever, atopic dermatitis, and food allergies, on the other hand, has remained virtually unchanged over the last 15 years. The Germany-wide lifetime prevalence of allergic diseases in children and adolescents [Study on the Health of Children and Adolescents in Germany (Studie zur Gesundheit von Kindern und Jugendlichen in Deutschland, KiGGS initial survey, 2003-2006) of the Robert Koch Institute] was 4.7 % for asthma, 10.7 % for hay fever, and 13.2 % for atopic dermatitis. Altogether, 40.8 % of German children and adolescents were sensitized to at least one of the inhalant or food allergens measured, while 20.0 % were sensitized to at least one food allergen. A marked increase in hay fever prevalence among East German children in the 1990s has resulted in an alignment of prevalence rates in East and West Germany. In contrast to adults, there was no longer a discernible difference in the prevalence of asthma, hay fever, and allergic sensitization in children between the western and eastern German federal states. In international comparisons with prevalence data from other studies, the participating German centers are in the lower third of the distribution of frequency for both children and adults.

Noise effects and morbidity: WHO LARES final report

This document represents the final report of an analysis on the health effects of noise exposure. The analysis is based on the WHO Large Analysis and Review of European housing and health Status (LARES),which combines the data of eight city studies in European countries. It was presented at a WHO housing and health technical meeting on the analysis of evidence, and was subject to peer review by other analysisteams of the LARES study and three external reviewers.The document presents the analytical approach and the statistical procedures used for assessing theimpact of residential noise exposure on noise induced annoyance and noise induced sleep disturbances.Split into traffic noise and neighbourhood noise for annoyance. The results are identified individually for children, adults and elderly, acknowledging that each age group is affected by noise in a different way and consequently shows a different pattern of morbidity potentially related to noise subjective exposure. One of the main conclusions of this work is that for noise induced sleep disturbances, traffic noise annoyance and neighbourhood noise annoyance, the identified health effects are independent of socioeconomic status and housing conditions. The elevated relative risks are expressed in the cardiovascular system, the respiratory system and the musculoskeletal system, as well as through depression.