The 2022 Europe report of the Lancet Countdown on health and climate change: towards a climate resilient future

Abstract

In the past few decades, major public health advances have happened in Europe, with drastic decreases in premature mortality and a life expectancy increase of almost 9 years since 1980. European countries have some of the best health-care systems in the world. However, Europe is challenged with unprecedented and overlapping crises that are detrimental to human health and livelihoods and threaten adaptive capacity, including the COVID-19 pandemic, the Russian invasion of Ukraine, the fastest-growing migrant crisis since World War 2, population displacement, environmental degradation, and deepening inequalities. Compared with pre-industrial times, the mean average European surface air temperature increase has been almost 1°C higher than the average global temperature increase, and 2022 was the hottest European summer on record. As the world's third largest economy and a major contributor to global cumulative greenhouse gas emissions, Europe is a key stakeholder in the world's response to climate change and has a global responsibility and opportunity to lead the transition to becoming a low-carbon economy and a healthier, more resilient society. The Lancet Countdown in Europe is a collaboration of 44 leading researchers, established to monitor the links between health and climate change in Europe and to support a robust, evidence-informed response to protect human health. Mirroring the Global Lancet Countdown, this report monitors the health effects of climate change and the health co-benefits of climate action in Europe. Indicators will be updated on an annual basis and new indicators will be incorporated to provide a broad overview to help guide policies to create a more climate-resilient future. The 2022 Intergovernmental Panel on Climate Change report exposed how dangerously close the world is to reaching climate-driven points of no return. Alarming increases in health-related hazards, vulnerabilities, exposures, and impacts from climate change across Europe show the urgent need for ambitious mitigation targets that restrict the global temperature rise to less than 1·5°C above pre-industrial levels and effective adaptation strategies to build resilience to the increasing health threats of climate change. Population exposure to heatwaves increased by 57% on average in 2010–19 compared with 2000–09, and by more than 250% in some regions, putting older people, young children, people with underlying chronic health conditions, and people who do not have adequate access to health care at high risk of heat-related morbidity and mortality (indicator 1.1.2). Global warming observed between 2000 and 2020 has been associated with an estimated temperature-related mortality increase in most regions monitored, with an average of 15·1 additional deaths per million inhabitants per decade (95% CI –1·51 to 31·6; indicator 1.1.4). Besides the direct health impacts, heat exposure also undermines people's livelihoods and the social determinants of health by reducing labour capacity. Labour supply in highly exposed sectors (eg, agriculture) was lower in 2016–19 compared with 1965–94 because of increased heat exposure (indicator 4.1.2). Climate change is also driving increasingly intense and frequent climate-related extreme events in Europe, with both direct and indirect health impacts, loss of infrastructure, and economic costs. Between 2011 and 2020, 55% of the European regions have had extreme-to-exceptional summer drought (indicator 1.2.2), and climate-related extreme events were associated with record economic losses in 2021, totalling almost €48 billion (indicator 4.1.1). The changing environmental conditions are also shifting the environmental suitability for the transmission of various infectious diseases. An increasing percentage of coastal waters in Europe are showing suitable conditions for the transmission of pathogenic non-cholerae Vibrio (indicator 1.3.1), the climatic suitability for the transmission of dengue increased by 30% in the past decade compared with the 1950s (indicator 1.3.3), and the environmental risk of West Nile virus outbreaks increased by 149% in southern Europe and 163% in central and eastern Europe in 1986–2020 compared with 1951–85 (indicator 1.3.2). Warmer temperatures are also shifting flowering seasons of several allergenic tree species, with birch, olive, and alder seasons beginning 10–20 days earlier than 41 years ago, affecting the health of around 40% of the population in Europe who have pollen allergies (indicator 1.4.1). These overlapping and interconnecting health impacts, which are evolving against a backdrop of a pandemic and a devastating war in Ukraine, reveal the urgent need for interventions that build resilience in the health sector and protect people from increasing health hazards. Some progress has been made in Europe's health adaptation. In 2021, 15 (68%) of 22 European countries reported having national health and climate change strategies or plans (indicator 2.1.2), and 10 (45%) reported conducting a climate change and health vulnerability and adaptation assessment (indicator 2.1.1). 150 European cities (76%) reported performing city-level climate assessments, with 118 (59·9%) reporting that climate change threatens their public health or health services (indicator 2.1.3). Population-weighted greenness increased from 2000 to 2020 in most European countries, with the largest percentage increase in southern Europe and the smallest increase in western Europe (indicator 2.2.2). Climate adaptation often needs to compete for scarce financial resources, and the enactment of adaptation plans alone is not sufficient to advance adaptive capacity. With the impacts of climate change on the rise, adaptation efforts must rapidly accelerate and be carefully implemented alongside mitigation strategies. In a world 1·2°C warmer than pre-industrial times, the magnitude of the overlapping and interconnected health impacts of climate change is a warning of the consequences of exceeding the 1·5°C target of the Paris Agreement. Europe should reach net-zero greenhouse gas emission by 2050 to meet the Paris Agreement commitments. However, Europe's current emissions are excessively high at 5·6 tonnes (t)CO2 per person just from the combustion of fossil fuels for energy production (indicator 3.1.1). The region's delayed response could be costing millions of lives each year, not only by exacerbating the health impacts of climate change, but also given the missed direct and indirect health co-benefits that more ambitious climate action could deliver. The continued burning of fossil fuels led to 117 000 deaths in 2020 from exposure to particulate matter of less than 2·5 μm in diameter (PM2·5) air pollution, with the transport sector being the main contributor (indicator 3.2). Importantly, coal contributed to 12% of the total energy supply in Europe in 2020, an inefficient fuel source that substantially contributes to air pollution (indicator 3.1.2). The excessive consumption of high-carbon, meat-rich diets contributed to an estimated 2·2 million deaths in 2019 (indicator 3.4.1), and European food demand was estimated to be responsible for 2·5 tCO2 equivalent (eq) emitted per person, accounting for 37% of the carbon footprint of the average person in EU27 (ie, the 27 countries in the EU after the UK left; indicator 3.4.2). However, despite the clear health impacts of climate change and the substantial health opportunities of climate action, 23 (43%) of 53 European countries analysed are allocating public funds to deliver overall fossil fuel subsidies, financially constraining decarbonisation targets (indicator 4.2.1). The delayed implementation of locally generated, low-carbon energy sources has made Europe susceptible to volatile energy prices, which reached record high values in 2022. The Russian invasion of Ukraine has shown Europe's over-reliance on fossil fuels, exacerbating the energy crisis. While the world is trying to recover from the COVID-19 pandemic and responding to multiple coinciding disasters, recovery is hindered by the negative climate change impacts on health and its determinants, emphasising the urgent need for action. To avoid a catastrophic increase in global temperatures, the Intergovernmental Panel on Climate Change makes it clear that Europe must fully decarbonise its power sector by 2035, with all coal-fired power plants globally closing by 2040. Despite the scarce climate action in Europe to date, indicators within this report suggest that change might be underway. Although engagement with the intersection of health and climate change is low compared with overall engagement with climate change more generally, political engagement with health and climate change in the European Parliament has slightly increased since 2014 (indicator 5.3). Engagement of the scientific sector (indicator 5.1) since 2014 and engagement of the corporate sector (indicator 5.4) since 1990 have also increased. These increases have been accompanied by small changes in the energy system; energy generation from renewable sources is increasing at a rate of 16% per year (indicator 3.1.3), and if this rate is maintained, Europe's energy system could almost fully decarbonise within 10 years. Europe's response to the war in Ukraine and the energy crisis will be important in forming Europe's new geopolitical situation. The energy crisis and decades of delay in switching to low-carbon energy generation risks a change to greater coal power generation in the short term. Even as a temporary measure, an increase in coal use could add to the approximately 8000 annual deaths associated with coal-fired power plants, in the domestic sector (indicator 3.2), reversing the health gains made in the past decade and undermining efforts to meet Paris Agreement commitments. Increasing Europe's reliance on fossil fuels would further accelerate global warming, increase air pollution, and be detrimental to health and wellbeing. The REPowerEU plan published in March, 2022, aiming to accelerate the transition to clean energy sources, provides hope, reaffirming Europe's leadership in low-carbon systems by providing direct economic benefits, energy sovereignty, and security, the net creation of more equitable jobs, and added health benefits with the reduced burning of fossil fuels. The indicators in this report show that an accelerated transition to clean energy could save lives each year. With a world dangerously close to reaching climate-driven points of no return and an increasing energy crisis, and with the health of populations increasingly undermined by global warming, Europe is at a crucial point for change. If climate mitigation and adaptation plans are designed and implemented with health, wellbeing, and equity as the main focus, this could represent the biggest public health policy opportunity of the century. Ambitious European adaptation and mitigation strategies will not only protect lives and wellbeing in Europe, but also in countries that have contributed least to anthropogenic climate change. The danger of reaching a point of no return means that Europe cannot afford to miss such opportunity. Major public health gains have been made in Europe, with life expectancy increases of almost 9 years since 1980.1World Population ReviewBest healthcare in the world.https://worldpopulationreview.com/country-rankings/best-healthcare-in-the-worldDate: 2022Date accessed: April 11, 2022Google Scholar, 2GBD 2019 Disease and Injuries CollaboratorsGlobal burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019.Lancet. 2020; 396: 1204-1222Summary Full Text Full Text PDF PubMed Scopus (3097) Google Scholar, 3World BankLife expectancy at birth, total (years)—European Union.https://data.worldbank.org/indicator/SP.DYN.LE00.IN?locations=EUDate accessed: April 10, 2022Google Scholar However, Europe is challenged with unprecedented and overlapping crises that are detrimental to health and threaten resilience to climate change; these include the COVID-19 pandemic, the Russian invasion of Ukraine, population displacement, environmental degradation, and deepening socioeconomic inequalities.4Romanello M McGushin A Di Napoli C et al.The 2021 report of the Lancet Countdown on health and climate change: code red for a healthy future.Lancet. 2021; 398: 1619-1662Summary Full Text Full Text PDF PubMed Scopus (211) Google Scholar, 5Romanello M van Daalen K Anto JM et al.Tracking progress on health and climate change in Europe.Lancet Public Health. 2021; 6: e858-e865Summary Full Text Full Text PDF PubMed Scopus (8) Google Scholar In Europe, average surface air temperatures have increased by 2·2°C since pre-industrial times (1850–1900),6CopernicusTemperature.https://climate.copernicus.eu/climate-indicators/temperatureDate accessed: July 9, 2021Google Scholar, 7Rocha M Krapp M Guetschow J Jeffferey L Hare B Schaeffer M Historical responsibility for climate change—from countries emissions to contribution to temperature increase.https://climateanalytics.org/media/historical_responsibility_report_nov_2015.pdfDate: 2015Date accessed: August 18, 2021Google Scholar about 1°C higher compared with the corresponding global temperature increase of 1·2°C.7Rocha M Krapp M Guetschow J Jeffferey L Hare B Schaeffer M Historical responsibility for climate change—from countries emissions to contribution to temperature increase.https://climateanalytics.org/media/historical_responsibility_report_nov_2015.pdfDate: 2015Date accessed: August 18, 2021Google Scholar The hottest summer on record was in 2022.8Press OfficeClimate change drives Europe's record 2021 summer. Met Office.https://www.metoffice.gov.uk/about-us/press-office/news/weather-and-climate/2021/2021-european-summer-temperature-impossible-without-climate-changeDate accessed: March 9, 2022Google Scholar Without accelerated mitigation and adaptation, ongoing climate change will have irreversible, multidimensional impacts on human health resulting from exposure to extreme climatic events, heat-related morbidity and mortality, altered environmental suitability, and exposure to infectious diseases.5Romanello M van Daalen K Anto JM et al.Tracking progress on health and climate change in Europe.Lancet Public Health. 2021; 6: e858-e865Summary Full Text Full Text PDF PubMed Scopus (8) Google Scholar, 9Watts N Adger WN Agnolucci P et al.Health and climate change: policy responses to protect public health.Lancet. 2015; 386: 1861-1914Summary Full Text Full Text PDF PubMed Scopus (996) Google Scholar As the world's third largest economy, the EU has contributed 17% of global cumulative greenhouse gas emissions (1950–2012).7Rocha M Krapp M Guetschow J Jeffferey L Hare B Schaeffer M Historical responsibility for climate change—from countries emissions to contribution to temperature increase.https://climateanalytics.org/media/historical_responsibility_report_nov_2015.pdfDate: 2015Date accessed: August 18, 2021Google Scholar Europe is a key stakeholder in the world's response to climate change, and has the opportunity to lead the way in the transition to low carbon, healthier economies, and increased climate resilience.5Romanello M van Daalen K Anto JM et al.Tracking progress on health and climate change in Europe.Lancet Public Health. 2021; 6: e858-e865Summary Full Text Full Text PDF PubMed Scopus (8) Google Scholar In 2021, the EU's commitment to reduce greenhouse gas emissions was accepted into law, with the aim to reduce greenhouse gases by at least 55% from emission levels in 1990 by 2030 and reach net-zero emissions by 2050.10European CommissionA European green deal.https://ec.europa.eu/info/strategy/priorities-2019-2024/european-green-deal_enDate: 2019Date accessed: April 11, 2022Google Scholar Russia's invasion of Ukraine in Feb, 2022, has brought a new context of political instability and human crisis and highlighted Europe's dependency on fossil fuel imports. This dependency highlights the urgent need to transition to clean energy sources to reduce greenhouse gas emissions while ensuring energy security and affordability.11International Energy AgencyHow Europe can cut natural gas imports from Russia significantly within a year.https://www.iea.org/news/how-europe-can-cut-natural-gas-imports-from-russia-significantly-within-a-yearDate: March 3, 2022Date accessed: March 9, 2022Google Scholar This is the first report of the Lancet Countdown Europe.2GBD 2019 Disease and Injuries CollaboratorsGlobal burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019.Lancet. 2020; 396: 1204-1222Summary Full Text Full Text PDF PubMed Scopus (3097) Google Scholar The report draws on broad expertise, including that of epidemiologists and public health experts, climate scientists, economists, social scientists, and political scientists from 29 leading European academic and UN institutions. Together, 44 contributors report on 33 indicators, monitoring and quantifying the health impacts of climate change and the health co-benefits of accelerated action since the 1950s. The report mirrors that of the global Lancet Countdown report, tracking progress on health and climate change in five areas: climate change impacts, exposures, and vulnerabilities; adaptation, planning, and resilience for health; mitigation actions and health co-benefits; economics and finance; and politics and governance. The geographical coverage of each indicator is reported (appendix pp 4–5), with most indicators covering all 38 European Environment Agency (EEA) member and cooperating countries, plus the UK. Methods and underlying data are presented in the appendix (pp 12–193). Europe is experiencing multidimensional health impacts due to climate change. This section presents indicators tracking the change in hazards, exposures, vulnerabilities, and risks for a selection of climate-sensitive health outcomes. The indicators are distributed into four clusters, with a total of 11 indicators monitoring health outcomes associated with rising temperatures (indicators 1.1.1 to 1.1.4), extreme events (indicators 1.2.1 and 1.2.2), climate-sensitive infectious diseases (indicators 1.3.1 to 1.3.4), and allergens (indicator 1.4). Heat exposure poses acute health risks, particularly to older people (ie, people older than 65 years), people with underlying, chronic respiratory, kidney, or heart disease, people living in urban areas, and people with little means to access cooling mechanisms.12Li M Gu S Bi P Yang J Liu Q Heat waves and morbidity: current knowledge and further direction—a comprehensive literature review.Int J Environ Res Public Health. 2015; 12: 5256-5283Crossref PubMed Scopus (149) Google Scholar, 13Kovats RS Hajat S Heat stress and public health: a critical review.Annu Rev Public Health. 2008; 29: 41-55Crossref PubMed Scopus (1064) Google Scholar, 14Basu R Samet JM Relation between elevated ambient temperature and mortality: a review of the epidemiologic evidence.Epidemiol Rev. 2002; 24: 190-202Crossref PubMed Scopus (938) Google Scholar These heat-related health risks are of particular relevance to Europe, as the continent is experiencing ageing populations, urbanisation, and a high prevalence of chronic diseases. In this indicator, a heat vulnerability index was computed by combining the proportion of the population who are older than 65 years, live in urban areas, and have a chronic disease (cardiovascular disease, respiratory disease, diabetes, and kidney disease). Vulnerability to heat exposure has increased steadily across all European regions, with an increase of 6% from 1990 to 2019. Although northern Europe is the most vulnerable region, the highest relative increase of 9·8% is observed in central Europe (appendix pp 12–14). European populations are being exposed to increasingly frequent, intense, and extensive heatwaves,15Chambers J Global and cross-country analysis of exposure of vulnerable populations to heatwaves from 1980 to 2018.Clim Change. 2020; 163: 539-558Crossref Scopus (19) Google Scholar with the unprecedented heatwaves in June and July, 2022, exceeding all-time national temperature records in multiple European countries.16Press OfficeReflecting on an historic spell for weather and climate. Met Office.https://www.metoffice.gov.uk/about-us/press-office/news/weather-and-climate/2022/record-temperatures-2022-a-reviewDate accessed: July 20, 2022Google Scholar This indicator monitors the exposure of vulnerable populations, defined here as people older than 65 years and infants between 0 years and 1 years to heatwaves. Comparing the decadal mean average of heatwave exposure days from 2000 to 2009 with exposure days from 2010 to 2020, heatwave exposure in vulnerable groups increased by 57% across Europe (appendix pp 15–17), from a yearly mean average of 0·65 billion person-days between 2000 and 2009 to 1·07 billion person-days between 2010 and 2020 in populations older than 65 years. In some areas, the increase has exceeded 157% (appendix pp 15–17). In 2020, 1·21 billion person-days of heatwave exposure were calculated, mostly comprising exposure of people older than 65 years, with an additional 3·1 million person-days in infants under 1 year old. Regular physical activity provides major physical and mental health benefits.17WHOGlobal Action Plan on physical activity 2018–2030: more active people for a healthier world. World Health Organization, Geneva2018https://apps.who.int/iris/bitstream/handle/10665/272722/9789241514187-eng.pdfDate accessed: March 14, 2022Google Scholar, 18de Nazelle A Nieuwenhuijsen MJ Antó JM et al.Improving health through policies that promote active travel: a review of evidence to support integrated health impact assessment.Environ Int. 2011; 37: 766-777Crossref PubMed Scopus (391) Google Scholar However, exercising during extreme heat has an acute risk of heat stress and heatstroke (figure 1A; appendix pp 18–23).19Andrews O Le Quéré C Kjellstrom T Lemke B Haines A Implications for workability and survivability in populations exposed to extreme heat under climate change: a modelling study.Lancet Planet Health. 2018; 2: e540-e547Summary Full Text Full Text PDF PubMed Scopus (35) Google Scholar This indicator reports the number of hours in which heat exposure poses a risk to health during physical exercise unless actions are taken to reduce the risk, while accounting for the intensity of the activity.20Jay O Broderick C Smallcombe J Sports Medicine AustraliaExtreme Heat Policy.https://sma.org.au/sma-site-content/uploads/2021/02/SMA-Extreme-Heat-Policy-2021-Final.pdfDate: February 2021Date accessed: July 20, 2022Google Scholar, 21Beggs PJ Zhang Y McGushin A et al.The 2021 report of the MJA–Lancet Countdown on health and climate change: Australia increasingly out on a limb.Med J Aust. 2021; 215: 390-392.e22Crossref PubMed Scopus (13) Google Scholar Overall, the number of hours of risk per person is increasing across all European regions. In southern Europe, the number of hours with heat-related health risks during medium-intensity activities (eg, football or tennis) increased relatively by 106% between 1990 and 2020, and increased to 429 hours per person in 2020. For strenuous activities (eg, mountain biking), there was a relative increase of 77% in southern Europe, leading to 627 hours at risk per person in 2020.20Jay O Broderick C Smallcombe J Sports Medicine AustraliaExtreme Heat Policy.https://sma.org.au/sma-site-content/uploads/2021/02/SMA-Extreme-Heat-Policy-2021-Final.pdfDate: February 2021Date accessed: July 20, 2022Google Scholar, 21Beggs PJ Zhang Y McGushin A et al.The 2021 report of the MJA–Lancet Countdown on health and climate change: Australia increasingly out on a limb.Med J Aust. 2021; 215: 390-392.e22Crossref PubMed Scopus (13) Google Scholar Without accelerated mitigation and adaptation actions, climate change projections for Europe suggest a progressive reduction in cold-related deaths and a simultaneous increase in heat-related deaths,22Quijal-Zamorano M Martínez-Solanas È Achebak H et al.Seasonality reversal of temperature attributable mortality projections due to previously unobserved extreme heat in Europe.Lancet Planet Health. 2021; 5: e573-e575Summary Full Text Full Text PDF PubMed Scopus (2) Google Scholar, 23Martínez-Solanas È Quijal-Zamorano M Achebak H et al.Projections of temperature-attributable mortality in Europe: a time series analysis of 147 contiguous regions in 16 countries.Lancet Planet Health. 2021; 5: e446-e454Summary Full Text Full Text PDF PubMed Scopus (20) Google Scholar with projections consistently indicating that the increase in heat-related deaths will exceed reductions of cold-related deaths by the second half of the 21st century.23Martínez-Solanas È Quijal-Zamorano M Achebak H et al.Projections of temperature-attributable mortality in Europe: a time series analysis of 147 contiguous regions in 16 countries.Lancet Planet Health. 2021; 5: e446-e454Summary Full Text Full Text PDF PubMed Scopus (20) Google Scholar Indicator 1.1.4 combines epidemiological models with weekly European Centre for Medium Range Weather Forecasts (ERA5-Land) temperatures and Eurostat mortality counts24Gasparrini A Armstrong B Kenward MG Distributed lag non-linear models.Stat Med. 2010; 29: 2224-2234Crossref PubMed Scopus (1110) Google Scholar, 25CopernicusERA5-Land hourly data from 1950 to present.https://cds.climate.copernicus.eu/cdsapp#!/dataset/reanalysis-era5-land?tab=overviewDate accessed: March 8, 2022Google Scholar, 26EurostatWeekly death statistics.https://ec.europa.eu/eurostat/statistics-explained/index.php?title=Weekly_death_statistics&stableDate accessed: March 14, 2022Google Scholar to track trends in heat-related mortality. Heat-related deaths are estimated to have increased in 931 (94%) of the 990 regions monitored (appendix pp 24–27) from 2000 to 2020, with an overall mean increase of 15·1 (95% CI –1·51 to 31·6) annual deaths per million inhabitants per decade for the general population (figure 1B), and 60·4 (–17·8 to 138·6) extra deaths per million inhabitants per decade for people 65 years and older (appendix pp 24–27). Country-level figures range from 30·6 (6·32 to 54·9) annual deaths per million inhabitants per decade in Spain to –1·53 (–6·33 to 3·27) in Iceland. Assuming a linear extrapolation of the mortality trend, heat-related deaths in Europe could double in 34 years.22Quijal-Zamorano M Martínez-Solanas È Achebak H et al.Seasonality reversal of temperature attributable mortality projections due to previously unobserved extreme heat in Europe.Lancet Planet Health. 2021; 5: e573-e575Summary Full Text Full Text PDF PubMed Scopus (2) Google Scholar, 23Martínez-Solanas È Quijal-Zamorano M Achebak H et al.Projections of temperature-attributable mortality in Europe: a time series analysis of 147 contiguous regions in 16 countries.Lancet Planet Health. 2021; 5: e446-e454Summary Full Text Full Text PDF PubMed Scopus (20) Google Scholar The changing climate is making weather conditions increasingly suitable for wildfires.4Romanello M McGushin A Di Napoli C et al.The 2021 report of the Lancet Countdown on health and climate change: code red for a healthy future.Lancet. 2021; 398: 1619-1662Summary Full Text Full Text PDF PubMed Scopus (211) Google Scholar Under a no-adaptation scenario, burned areas could increase by 200% in Europe this century compared with 2000–2008.27Khabarov N Krasovskii A Obersteiner M et al.Forest fires and adaptation options in Europe.Reg Environ Change. 2016; 16: 21-30Crossref Scopus (59) Google Scholar Exposure to wildfire smoke is associated with increased mortality, morbidity, and hospital admissions and exacerbates respiratory and cardiovascular conditions.28Liu JC Pereira G Uhl SA Bravo MA Bell ML A systematic review of the physical health impacts from non-occupational exposure to wildfire smoke.Environ Res. 2015; 136: 120-132Crossref PubMed Scopus (281) Google Scholar, 29Papanikolaou D Arvanitakis S Papanikolaou I et al.Local action plans for forest fire prevention in Greece: existing situation and a proposed template based on the collaboration of academics and public policy makers. NASA/ADS, 2013https://ui.adsabs.harvard.edu/abs/2013EGUGA..1510555P/abstractDate accessed: March 14, 2022Google Scholar This indicator combines atmospheric models, remote fire detection, weekly death counts, and epidemiological models on the health impacts of PM2·5 exposure to track the annual population-weighted exposure to wildfire-related PM2·5 and attributable deaths (appendix pp 28–35).30Hänninen R Sofiev M Uppstu A Kouznetsov R Daily surface concentration of fire related PM2.5 for 2003-2021, modelled by SILAM CTM when using the MODIS satellite data for the fire radiative power.Finnish Meteorological Institute. 2022; (published online June 21.)https://doi.org/10.23728/FMI-B2SHARE.A006840CCE9340E8BF11E562BB8D396EGoogle Scholar Annual average population-weighted wildfire-PM2·5 exposures varied considerably each year and showed negative trends in all European regions (figure 2A), possibly because of increased effectiveness of fire prevention and suppression measures.31Reid CE Brauer M Johnston FH Jerrett M Balmes JR Elliott CT Critical review of health impacts of wildfire smoke exposure.Environ Health Perspect. 2016; 124: 1334-1343Crossref PubMed Scopus (482) Google Scholar, 32Thonicke K Cramer W Long-term trends in vegetation dynamics and forest fires in Brandenburg (Germany) under a changing climate.Nat Hazards. 2006; 38: 283-300Crossref Scopus (28) Google Scholar From 2003 to 2020, Portugal and Greece had the highest levels of wildfire smoke exposure in southern Europe, and Bulgaria and Romania had the highest levels in central and eastern Europe. Between 2015 and 2019, an average of 603 (95% CI 410–