Response to heat waves, in a municipality in the North of Portugal

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Response to heat waves, in a municipality in the North of Portugal
Clima e saúde
Response to heat waves, in a municipality
in the North of Portugal
The negative effects of heat waves on health have been
described. The Portuguese Health Ministry has developed a
contingency plan to be executed by health services, with the
cooperation of other institutions. Following those central
guidelines, regional and municipal contingency plans were
set up. This paper describes the activities that took place in
2008, in a municipality of the North of Portugal, preparing
and implementing the contingency plan for heath waves.
During the summer of 2008 the temperature has not been
sustainably high to cause major problems; the “yellow
alert” activities were triggered only for 3 days. Though the
impact of the intervention has not been assessed, the
authors believe that these “calm” years are important not
to loose memory of past consequences of heath waves and
to maintain logistic capacities and know how.
Keywords: heath waves; contingency plans; health services.
Guilherme Gonçalves é Autoridade Concelhia de Saúde e professor associado convidado do Instituto de Ciências Biomédicas de
Abel Salazar, Universidade do Porto.
Maria de Fátima Moreira é enfermeira chefe no Centro de Saúde
de Vila Nova de Famalicão.
Manuel Dias é adjunto da Autoridade Concelhia de Saúde.
Eduardo Gouveia é adjunto da Autoridade Concelhia de Saúde.
Submetido à apreciação: 15 de Dezembro de 2008
Aceite para publicação: 19 de Janeiro de 2009
VOL. 27, N.o 1 — JANEIRO/JUNHO 2009
1. Introduction
In Portugal, the negative effect of heat waves (HW)
on health, namely on mortality, has been
documented in 1981, 1991 and 2003 (Falcão, Castro e Falcão, 1988; Garcia, Nogueira e Falcão,1999;
Paixão e Nogueira, 2003; Nogueira et al., 2005). In
2004, a contingency plan (CP) was developed by
the Directorate-General of Health (Portugal. Ministério da Saúde. DGS, 2004a; 2004b) to be
implemented by health services with the
cooperation of other institutions. Since then, CPs
have been updated every year. In 2008, the
Directorate-General of Health (DGH) issued the
national guidelines for a CP to be implemented
between 15 May and 30 September, by the regional
and local National Health Service (NHS) units (Portugal. Ministério da Saúde. DGS, 2008); three “alert
levels” where defined: green, yellow and red. The
criteria to define the level of alert, by district, on a
daily basis, were described, and included the
“ÍCARO” index, developed by the National
Institute of Health and previously published
(Nogueira et al., 2005).
There are five health regions in Portugal (not
including the Atlantic Islands). The Northern
Region, where we are located, includes 5 districts.
The regional public health department issued a
regional CP (Portugal. Ministério da Saúde. Administração Regional de Saúde do Norte, 2008)
establishing the type of activity to be included in
Clima e saúde
each of the three alert levels of the CP to be setup
and executed by each local health authority (LHA).
Our LHA covers the population and area of one
municipality (Vila Nova de Famalicão), with a
population around 130,000 inhabitants, in the
district of Braga (850,000 inhabitants). We have
written and executed a contingency plan (LHA
at the municipal level). We describe here the
2008 activities carried on during the preparatory
phase and each of the alert levels: green, yellow and
2. Preparation
Initial meetings were held with the LHA the
head nurse of the local health centre (LHC)
and the local social security (LSS) staff
member specifically appointed for the heat
waves CP;
The LHC and LSS staff made a census (names,
addresses and telephone numbers) of elderly
people living alone and/or in vulnerable health
Private and public institutions caring for the
elderly and very young children (below 3 years of
age) were identified and listed.
Leaflets with information on the negative effect
of heat waves on health and recommended
preventive measures were sent to all NHS units
and Juntas de Freguesia (local boroughs, which
are he smallest administrative elected bodies of
the Portuguese administrative organization – in
our municipality there 49 of such local
The information in the leaflets was also
transmitted by the local press and the two local
A big meeting was conducted with all entities
potentially involved with activities during heath
waves alert levels “yellow” and “red”: nurses and
SS staff in charge of home visiting activities,
representatives from 14 institutions caring for the
elderly and/or very young children (below 3 years
of age), 2 staff members of the Health
Environment Unit (HEU) of the LHA and a
representative of the local Civil Protection
Service. In that meeting, the medical aspects of
heat waves were presented by a medical doctor,
issues related with water quality control were
presented by the staff of HEU and finally the
2008 LHA health waves contingency plan was
presented and discussed; special emphasis was
put in the discussion of planed activities and
“actors” during yellow and red alert periods.
Leaflets and posters were distributed to all
entities, to be publicised.
3. Green level
Every day, from May 15 to September 30, the local
health authority checked the map of the DGH internet
site, to know the “colour” of the alert level attributed
to the district of Braga. Furthermore, the regional
public health department sent a daily mail with the
alert level for each of the 5 districts of the Northern
Region. After initial transmitting of information by
local press and radios, the health waves issue was not
tackled in media during the “green” days.
4. Yellow level
The situation of yellow alert occurred in the district
of Braga, from the 17th to the 19th of July. Following
the CP instructions, in the morning of the 17th of
July, the LHA on permanent duty “alerted” by
telephone the following entities/staff: the head of the
emergency service of the local hospital, the doctor on
duty (for urgent situations — consulta aberta) in the
LHC, the two local radios, the head nurse of the
LHC, the local Civil Protection and social security
services. In July 20 and 21, all these entities/staff
members were informed by the LHA that alert level
was back on the “green”. During the 3 days of yellow
alert, many activities were carried on by the
following institutions/staff:
Local health centre (part of the NHS). Fifty one
elderly people were visited in their homes by nurses;
their health status was checked and advice was given,
with special emphasis on avoiding heat exposure and
drinking water; not a single danger situation was
spotted. Twenty three elderly people were contacted
by telephone, because it was not logistically possible
to visit all listed people; in one case a neighbour was
contacted. Five institutions with elderly domiciliary
support activities were contacted; we do not know
the details of their interventions on those days. The
nurses from the School Health Program contacted 29
institutions which care for very young children
Local radios transmitted pre recorded spots and
information on preventive measures, warning the
population that the situation was “yellow alert”.
Social security staff visited elderly people in their
homes and some institutions but we do not know
detailed numbers on those activities.
Fortunately, the “red” level of alert was never
reached in Portugal, in 2008.
Clima e saúde
5. Preliminary assessment
This was not a “hot summer”. We only had 3 days in
yellow level but in 2007 there were none, while
yellow alert had been triggered 4 times in the
summer of 2006.
Very few deaths occurred in the three days of the
heath wave and in the three subsequent days (20 to
21 July). Numbers are too small to make possible a
valid statistical analysis. Nevertheless, there seem not
to have been an excess of mortality (Table I).
Meanwhile data analysis at national level has shown
numbers of deaths below expected levels in the
summer of 2008 (Nogueira, 2008).
Checking the death certificates of the 9 deaths
recorded between the 17th and the 22nd of July 2008,
all have occurred in people aged 65+ (2 males and 7
females). The causes of death (main cause) recorded
were: undetermined (n = 3), congestive heart failure
(n = 2), stroke (n = 1), pneumonia (n = 1), renal
failure (n = 1) and infection (n = 1). This information
cannot confirm or reject causal relations with the heat
wave, but observed causes were very similar to those
recorded in the equivalent period 2003-2007.
On the days 24, 28 and 29th of July 2008, 130 people
attending a local health centre were interviewed
about their behaviour during the heat wave and
questioned on their sources of information. Thirty
eight were males and 92 females; they were aged 19
to 74 with mean age of 49 years SD (17.6). Ninety
six (74%) of those interviewed had known about the
health wave alert. Most of them were alerted by a
national television and/or radio station. Only 16.2%
of all interviewed people had heard the health wave
messages on the local radios.
It is methodologically difficult to assess the impact of
this type of intervention both on behaviours and on
health status. How useful was it to undertake this
special surveillance-response plan? We should
consider what might have happened if no activities
had been implemented (Gonçalves et al., 2005).
Elsewhere we will describe in detail the results of the
questionnaire, and, as years go by, we may
accumulate data needed to contribute to the
assessment of these interventions; to comply with the
paradigm of “evidence-based public health”
assessment is essential (Brownson et al., 2003;
Mastrangelo et al., 2006). Meanwhile these “calm”
years are important not to loose memory of past
consequences of heath waves and, to keep
surveillance and response “alive” (Nogueira, 2008).
We acknowledge all nurses and social security staff
who performed the visits to elderly and very young
children, at home and in institutions. We also
acknowledge the work of staff members of
institutions carrying for very young children and the
Rosa Cunha was the social security professional
responsible for HW and her contribution was very
important. Arlete Silva and Glória Afonso were the
staff members of the HEU of the LHA who made the
presentation on water quality in the meeting with
several entities. Adelaide Fernandes and Arminda
Azevedo were the nurses in charge of contacting
nurseries and kindergarten. Maria João Silva and
Nelson Oliveira, young doctors training in our unit,
developed and applied a questionnaire to local NHS
Center users, in order to access knowledge and
behaviours during the only yellow alert. Ana Quelhas
helped in the data collection on mortality.
Table I
Number of deaths in the municipality of Vila Nova de Famalicão during the health wave of 2008,
compared with the daily average number on previous years
July 17
July 18
July 19
July 20
July 21
July 22
2003-2007 average
VOL. 27, N.o 1 — JANEIRO/JUNHO 2009
Clima e saúde
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=&id=5510&acess=0 .
São conhecidos os potenciais efeitos negativos para a saúde
humana das ondas de calor. O Ministério da Saúde português
estabeleceu um plano de contingência que contém linhas de
orientação para a elaboração e execução de planos de contingência em resposta a ondas de calor, aos níveis regional e local.
Aqui se faz uma breve descrição das actividades preparatórias e
da execução do plano de contingência, pelos serviços de saúde
de Vila Nova de Famalicão, durante o Verão de 2008. Apesar de
apenas terem ocorrido 3 dias de «alerta amarelo» é importante
manter a logística e a capacidade humana (profissionais de
saúde) de intervenção nestes «anos calmos», não esquecendo as
consequências nefastas de anteriores ondas de calor.
Palavras-chave: ondas de calor; planos de contingência; serviços de saúde.
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