Heat-health warning systems and action plans, referred to as heat prevention plans (HPPs), are key public health interventions aimed at reducing heat-related mortality. Despite their importance, prior assessments of their effectiveness have yielded inconsistent results. The objective of this study is to systematically assess the effectiveness of HPPs in reducing heat-related mortality risk across Europe. We analysed daily mortality and mean temperature data from 102 locations in 14 European countries between 1990 and 2019. Using data from national experts, we identified the year of HPP implementation and categorised their development class. A three-stage analysis was conducted: (1) quasi-Poisson time series models were used to estimate location-specific warm-season exposure-response functions in 3 year subperiods; (2) mixed-effect meta-regression models with multilevel longitudinal structures were employed to quantify changes in pooled exposure-response functions due to HPP implementation, adjusted for long-term trends in heat-related mortality risks; and (3) the heat-related excess mortality due to HPP was calculated by comparing factual (with HPP) and counterfactual (without HPP) scenarios. Estimates are reported by country, region, and HPP class. HPP implementation was associated with a 25.2% [95% CI: 19.8% to 31.9%] reduction in excess deaths attributable to extreme heat, corresponding to 1.8 [95% CI: 1.3-2.4] avoided deaths annually per 100 000 inhabitants. This equates to an estimated 14 551 [95% CI: 10 118-19 072] total deaths avoided across all study locations following HPP implementation. No significant differences in HPP effectiveness were observed by European region or HPP class. Our findings provide robust evidence that HPPs substantially reduce heat-related mortality across Europe, accounting for temporal changes and geographical differences in risks. These results emphasise the importance of monitoring and evaluating HPPs to enhance adaptation to a warming climate.

AgroParisTech Paris France

Center for Environmental and Respiratory Health Research Research Unit of Population Health University of Oulu Oulu Finland

Centre of Numerical Weather Prediction Institute of Meteorology and Water Management National Research Institute Warsaw Poland

Centro de Investigaciones sobre Desertificación Consejo Superior de Investigaciones Científicas Moncada Valencia Spain

Centro Euro Mediterraneo sui Cambiamenti Climatici Venezia Italy

Copenhagen Business School Copenhagen Denmark

Department of Economics Ca' Foscari University of Venice Venice Italy

Department of Epidemiology Instituto Nacional de Saúde Dr Ricardo Jorge Lisbon Portugal

Department of Epidemiology Lazio Regional Health Service ASL ROMA 1 Rome Italy

Department of Land and Water Resources Management Faculty of Civil Engineering Slovak University of Technology Bratislava Slovakia

Department of Public Health University of Helsinki Helsinki Finland

Department of Statistics Computer Science and Applications G Parenti University of Florence Florence Italy

Department of Water and Climate Vrije Universiteit Brussel Brussels Belgium

Doñana Biological Station Sevilla Spain

Environment and Health Modelling Lab Department of Public Health Environments and Society London School of Hygiene and Tropical Medicine London United Kingdom

ESPACE DEV Univ Montpellier IRD Montpellier France

European Centre for Medium Range Weather Forecasts Reading United Kingdom

Faculty of Environmental Sciences Czech University of Life Sciences Prague Prague Czech Republic

Institute of Atmospheric Physics Czech Academy of Sciences Prague Czech Republic

Institute of Epidemiology Helmholtz Zentrum München German Research Center for Environmental Health Neuherberg Germany

Institute of Social and Preventive Medicine University of Bern Bern Switzerland

Oeschger Centre for Climate Change Research University of Bern Bern Switzerland

Rotterdam School of Management Erasmus University Rotterdam Rotterdam The Netherlands

Santé Publique France Department of Environmental and Occupational Health French National Public Health Agency Saint Maurice France

School of Geography University of Nottingham Nottingham United Kingdom

School of Sustainability Reichman University Herzliya Israel

Swiss Tropical and Public Health Institute Allschwill Switzerland

University of Basel Basel Switzerland

Upgötva AB Stockholm Sweden

Weather and Climate Change Impact Research Finnish Meteorological Institute Helsinki Finland

Weather and Climate Risks Group Institute for Environmental Decisions ETH Zürich Switzerland

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