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Mortality and temperature in Sofia and London
  1. S Pattenden1,
  2. B Nikiforov2,
  3. B G Armstrong1
  1. 1London School of Hygiene and Tropical Medicine, London, UK
  2. 2National Centre of Hygiene, Medical Ecology and Nutrition, Sofia, Bulgaria
  1. Correspondence to:
 Mr S Pattenden, Environmental Epidemiology Unit, Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK; 


Study objective: Heat and cold have been associated with increased mortality, independently of seasonal trends, but details are little known. This study explores associations between mortality and temperature in two European capitals—Sofia and London—using four years of daily deaths, air pollution, and weather data.

Design: Generalised additive models were used to permit non-linear modelling of confounders such as season and humidity, and to show the shape of mortality-temperature relations—using both two day and two week average temperatures separately. Models with linear terms for heat and cold were used to estimate lags of effect, linear effects, and attributable fractions.

Participants: 44 701 all age all cause deaths in Sofia (1996–1999) and 256 464 in London (1993–1996).

Main results: In London, for each degree of extreme cold (below the 10th centile of the two week mean temperature), mortality increased by 4.2% (95% CI 3.4 to 5.1), and in Sofia by 1.8% (0.6 to 3.9). For each degree rise above the 95th centile of the two day mean, mortality increased by 1.9% (1.4 to 2.4) in London, and 3.5% (2.2 to 4.8) in Sofia. Cold effects appeared after lags of around three days and lasted—particularly in London—at least two weeks. Main heat effects occurred more promptly. There were inverse associations at later lags for heat and cold in Sofia.

Conclusions: Average temperatures over short periods do not adequately model cold, and may be inadequate for heat if they ignore harvesting effects. Cold temperatures in London, particularly, seem to harm the general population and the effects are not concentrated among persons close to death.

  • ambient temperature
  • mortality
  • generalised additive model
  • time series

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