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Introduction: The COVID-19 pandemic overwhelmed health systems, resulting in a surge in excess deaths. This study clustered countries based on excess mortality to understand their response to the pandemic and the influence of various factors on excess mortality within each cluster. Materials and Methods: This ecological study is part of the COVID-19 MORtality (C-MOR) Consortium. Mortality data were gathered from 21 countries and were previously used to calculate weekly all-cause excess mortality. Thirty exposure variables were considered in five categories as factors potentially associated with excess mortality: population factors, health care resources, socioeconomic factors, air pollution, and COVID-19 policy. Estimation of Latent Class Linear Mixed Model (LCMM) was used to cluster countries based on response trajectory and Generalized Linear Mixture Model (GLMM) for each cluster was run separately. Results: Using LCMM, two clusters were reached. Among 21 countries, Brazil, the USA, Georgia, and Poland were assigned to a separate cluster, with the mean of excess mortality z-score in 2020 and 2021 around 4.4, compared to 1.5 for all other countries assigned to the second cluster. In both clusters the population incidence of COVID-19 had the greatest positive relationship with excess mortality while interactions between the incidence of COVID-19, fully vaccinated people, and stringency index were negatively associated with excess mortality. Moreover, governmental variables (government revenue and government effectiveness) were the most protective against excess mortality. Conclusion: This study highlighted that clustering countries based on excess mortality can provide insights to gain a broader understanding of countries' responses to the pandemic and their effectiveness.

Ambient air pollution, including particulate matter (such as PM10and PM2·5) and nitrogen dioxide (NO2), has been linked to increases in mortality. Whether populations’ vulnerability to these pollutants has changed over time is unclear, and studies on this topic do not include multicountry analysis. We evaluated whether changes in exposure to air pollutants were associated with changes in mortality effect estimates over time.

ABSTRACTIn many regions of the world, the relationship between ambient temperature and mortality is well-documented, but little is known about Cyprus, a Mediterranean island country where climate change is progressing faster than the global average. We Examined the association between daily ambient temperature and all-cause mortality risk in Cyprus. We conducted a time-series analysis with quasipoisson distribution and distributed lag non-linear models to investigate the association between temperature and all-cause mortality from 1 January 2004 to 31 December 2019 in five districts in Cyprus. We then performed a meta-analysis to estimate the overall temperature-mortality dose-response relationship in Cyprus. Excess mortality was computed to determine the public health burden caused by extreme temperatures. We did not find evidence of heterogeneity between the five districts (p = 0.47). The pooled results show that for cold effects, comparing the 1st, 2.5th, and 5th percentiles to the optimal temperature (temperature associated with least mortality, 25 ℃), the overall relative risks of mortality were 1.55 (95% CI: 1.32, 1.82), 1.41 (95% CI: 1.21, 1.64), and 1.32 (95% CI: 1.15, 1.52), respectively. For heat effects, the overall relative risks of mortality at the 95th, 97.5th and 99th percentiles were 1.10 (95% CI: 1.04, 1.16), 1.17 (95% CI: 1.07, 1.29), and 1.29 (95% CI: 1.11, 1.5), respectively. The excess mortality attributable to cold days accounted for 8.0 deaths (95% empirical CI: 4.5–10.8) for every 100 deaths, while the excess mortality attributable to heat days accounted for 1.3 deaths (95% empirical CI: 0.7–1.7) for every 100 deaths. The results prompt additional research into environmental risk prevention in this under-studied hot and dry region that could experience disproportionate climate change related exposures.Implications:The quantification of excess mortality attributable to temperature extremes shows an urgent need for targeted public health interventions and climate adaptation strategies in Cyprus and similar regions facing rapid climate change. Future steps should look into subpopulation sensitivity, coping strategies, and adaptive interventions to reduce potential future risks.

IntroductionElevated particulate matter (PM) concentrations of anthropogenic and/or desert dust origin are associated with increased morbidity among children with asthma.ObjectiveThe Mitigating the Health Effects of Desert Dust Storms Using Exposure-Reduction Approaches randomised controlled trial assessed the impact of exposure reduction recommendations, including indoor air filtration, on childhood asthma control during high desert dust storms (DDS) season in Cyprus and Greece.Design, participants, interventions and settingPrimary school children with asthma were randomised into three parallel groups: (a) no intervention (controls); (b) outdoor intervention (early alerts notifications, recommendations to stay indoors and limit outdoor physical activity during DDS) and (c) combined intervention (same as (b) combined with indoor air purification with high efficiency particulate air filters in children’s homes and school classrooms. Asthma symptom control was assessed using the childhood Asthma Control Test (c-ACT), spirometry (forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC)) and fractional exhaled nitric oxide (FeNO).ResultsIn total, 182 children with asthma (age; mean=9.5, SD=1.63) were evaluated during 2019 and 2021. After three follow-up months, the combined intervention group demonstrated a significant improvement in c-ACT in comparison to controls (β=2.63, 95% CI 0.72 to 4.54, p=0.007), which was more profound among atopic children (β=3.56, 95% CI 0.04 to 7.07, p=0.047). Similarly, FEV1% predicted (β=4.26, 95% CI 0.54 to 7.99, p=0.025), the need for any asthma medication and unscheduled clinician visits, but not FVC% and FeNO, were significantly improved in the combined intervention compared with controls.ConclusionRecommendations to reduce exposure and use of indoor air filtration in areas with high PM pollution may improve symptom control and lung function in children with asthma.Trial registration numberNCT03503812.

Background: This study investigated cause-specific mortality rates in 12 countries during the COVID-19 pandemic in 2020 and 2021. Methods: We collected weekly cause-specific mortality data from respiratory disease, pneumonia, cardiovascular disease (CVD) and cancer from national vital statistic databases. We calculated excess mortality for respiratory disease (excluding COVID-19 codes), pneumonia, and CVD in 2020 and 2021 by comparing observed weekly against expected mortality based on historical data (2015–2019), accounting for seasonal trends. We used multilevel regression models to investigate the association between country-level pandemic-related variables and cause-specific mortality. Results: Significant reductions in cumulative mortality from respiratory disease and pneumonia were observed in 2020 and/or 2021, except for Georgia, Northern Ireland, Kazakhstan, and Ukraine, which exhibited excess mortality for one or both causes. Australia, Austria, Cyprus, Georgia, and Northern Ireland experienced excess cumulative CVD mortality in 2020 and/or 2021. Australia, Austria, Brazil, Cyprus, Georgia, Northern Ireland, Scotland and Slovenia, experienced increased crude cumulative cancer mortality during 2020 and/or 2021 compared to previous years. Among pandemic-related variables, reported COVID-19 incidence was negatively associated with increased cancer mortality, excess respiratory, (2020) and pneumonia (2021) mortality, and positively associated with respiratory and CVD mortality (2021). Stringency of control measures were negatively associated with excess respiratory disease, CVD, and increased cancer mortality (2021). Conclusions: This study provides evidence of substantial excess mortality from CVD, and notable reductions in respiratory disease and pneumonia in both years across most countries investigated. Our study also highlights the beneficial impact of stringent control measures in mitigating excess mortality from most causes in 2021.

ObjectiveTo investigate potential interactive effects of fine particulate matter (PM2.5) and ozone (O3) on daily mortality at global level.DesignTwo stage time series analysis.Setting372 cities across 19 countries and regions.PopulationDaily counts of deaths from all causes, cardiovascular disease, and respiratory disease.Main outcome measureDaily mortality data during 1994-2020. Stratified analyses by co-pollutant exposures and synergy index (>1 denotes the combined effect of pollutants is greater than individual effects) were applied to explore the interaction between PM2.5and O3in association with mortality.ResultsDuring the study period across the 372 cities, 19.3 million deaths were attributable to all causes, 5.3 million to cardiovascular disease, and 1.9 million to respiratory disease. The risk of total mortality for a 10 μg/m3increment in PM2.5(lag 0-1 days) ranged from 0.47% (95% confidence interval 0.26% to 0.67%) to 1.25% (1.02% to 1.48%) from the lowest to highest fourths of O3concentration; and for a 10 μg/m3increase in O3ranged from 0.04% (−0.09% to 0.16%) to 0.29% (0.18% to 0.39%) from the lowest to highest fourths of PM2.5concentration, with significant differences between strata (P for interaction <0.001). A significant synergistic interaction was also identified between PM2.5and O3for total mortality, with a synergy index of 1.93 (95% confidence interval 1.47 to 3.34). Subgroup analyses showed that interactions between PM2.5and O3on all three mortality endpoints were more prominent in high latitude regions and during cold seasons.ConclusionThe findings of this study suggest a synergistic effect of PM2.5and O3on total, cardiovascular, and respiratory mortality, indicating the benefit of coordinated control strategies for both pollutants.

Heat and cold are established environmental risk factors for human health. However, mapping the related health burden is a difficult task due to the complexity of the associations and the differences in vulnerability and demographic distributions. In this study, we did a comprehensive mortality impact assessment due to heat and cold in European urban areas, considering geographical differences and age-specific risks.

Air quality in Cyprus is influenced by both local and transported pollution, including desert dust storms. We examined PM10concentration data collected in Nicosia (urban representative) from April 1, 1993, through December 11, 2008, and in Ayia Marina (rural background representative) from January 1, 1999, through December 31, 2008. Measurements were conducted using a Tapered Element Oscillating Micro-balance (TEOM). PM10concentrations, meteorological records, and satellite data were used to identify dust storm days. We investigated long-term trends using a Generalized Additive Model (GAM) after controlling for day of week, month, temperature, wind speed, and relative humidity. In Nicosia, annual PM10concentrations ranged from 50.4 to 63.8 μg/m3and exceeded the EU annual standard limit enacted in 2005 of 40 μg/m3every year. A large, statistically significant impact of urban sources (defined as the difference between urban and background levels) was seen in Nicosia over the period 2000–2008, and was highest during traffic hours, weekdays, cold months, and low wind conditions. Our estimate of the mean (standard error) contribution of urban sources to the daily ambient PM10was 24.0 (0.4) μg/m3. The study of yearly trends showed that PM10levels in Nicosia decreased from 59.4 μg/m3in 1993 to 49.0 μg/m3in 2008, probably in part as a result of traffic emission control policies in Cyprus. In Ayia Marina, annual concentrations ranged from 27.3 to 35.6 μg/m3, and no obvious time trends were observed. The levels measured at the Cyprus background site are comparable to background concentrations reported in other Eastern Mediterranean countries. Average daily PM10concentrations during desert dust storms were around 100 μg/m3since 2000 and much higher in earlier years. Despite the large impact of dust storms and their increasing frequency over time, dust storms were responsible for a small fraction of the exceedances of the daily PM10limit.ImplicationsThis paper examines PM10concentrations in Nicosia, Cyprus, from 1993 to 2008. The decrease in PM10levels in Nicosia suggests that the implementation of traffic emission control policies in Cyprus has been effective. However, particle levels still exceeded the European Union annual standard, and dust storms were responsible for a small fraction of the daily PM10limit exceedances. Other natural particles that are not assessed in this study, such as resuspended soil and sea salt, may be responsible in part for the high particle levels.