HOPE
Ανταπόκριση στους καύσωνες στο οικοσύστημα των ηλικιωμένων
Macro
Main result
Policy document
Title
Lazio Region prevention plan
Date June 2022
Objectives
The Piano operativo regionale di intervento per la prevenzione degli effetti sulla
salute delle ondate di calore (Regional operational intervention plan for heatwaves- related effects on health) aims to prevent the effects of heatwaves on health. In particular, it wants to ensure targeted medical surveillance during heatwaves for older adults aged 65 and more at risk and living in urban areas within the territory of the Lazio Region.
Location /geographical coverage
The geographical reach of the good practice extends to the whole Lazio Region.
Organisation responsible for good practice
The Plan is prepared and launched by the Lazio Region, while it is co-implemented in strong collaboration with the Centro di Competenza Nazionale per la prevenzione degli effetti del caldo del Dipartimento della Protezione Civile (national centre for prevention of the effects of heat of the Civil Protection Department), Local Health Agencies (ASL), general practitioners, the Municipality of Rome, Local Civil Protection, and volunteering associations.
Stakeholders and partners
The target group of this plan are older adults aged 65 and more at risk, living in
urban areas within the territory of the Lazio Region.
Short summary
The Regional Operational Intervention Plan against heatwaves-related effects on
health is to be considered in the framework of the National Plan for prevention of heat-related effects on health, launched by the Italian Health Ministry in 2005, with the aim to enhance a better multi-level interinstitutional coordination and to set the stage for a centralized system for forecasting and preventing heat effects on health.
The Regional plan is founded on three main pillars: the Heat Health Watch Warning System (HHWWS), the identification of the older people at risk, and active monitoring visits by general practitioners (from now on, GPs). The first pillar refers to the national warning system, that is run by the Department of Epidemiology of the Lazio Regional Social Services in collaboration with the Health Ministry and the Civil Protection Department. Such system is specific for 27 different cities nationally (7 cities in the Lazio Region only) and is based on the proportion between the number of daily deceases and weather variables, so as to identify the climate conditions that are more connected to increases in mortality. Every day, a bulletin is published, concerning risk conditions for the same day and for the following two days, by using a set of specific and pre-defined levels (from 0 to 3) according to the seriousness of the weather conditions forecasted. The daily bulletin published by the Department of Epidemiology of the Lazio Region, is sent to the Lazio Region’s dedicated offices, to the Municipality of Rome and the Local Health Agency, which will subsequently involve other local actors to disseminate the data gathered.
In this context, each Local Health Agency (ASL) needs to nominate a coordinator,
who will be charged to run the information flow among medical and paramedical
professionals, to coordinate the prevention plan for vulnerable groups, and to
monitor the GPs’ data and patient-related data, through the online platform
Lazioadvice. In 2022, this service was active from 1st June to 16th September from Monday to Friday, and the daily bulletin was made available through the Health Ministry website, the Department of Epidemiology of the Lazio Region and the App “Caldo e Salute” (Heat and Health), that serves as online repository of updated materials, recommendations and bulletins on the topic.
The second pillar is fundamental to define the target of the prevention plan. The
Lazio Region has been a forerunner in the development of methodologies to identify people that are vulnerable to the effects of heatwaves and to apply them in Rome. The model was in fact first tested in 2001, while it entered into force around 2005-2006. Such model takes in consideration people aged 65 and more, and the related factors of risk they might be or are exposed to, among which there are socio-demographic indicators and health parameters. Their influence varies according to whether people are among 65-74 years old, or if they are above 75 years old. After the completion of the identification procedure, each person is given a vulnerability score that goes from 1 to 4. The classification is then transformed into a list of the vulnerable older people to monitor. At this point, general practitioners have to assess the need to include their patients with a score ranging from level 3 to 4 in the active monitoring system. The same task needs to be performed for people with level 2-1. Among the factors to be considered, there are: age, self-sufficiency, presence of
specific pathologies, social conditions (isolation, loneliness), and pharmacological treatments. General practitioners can continue these assessments and enlarge their lists over the entire duration of the plan. The lists are made available through the online platform Lazioadvice.
As for the third and last pillar, once a general practitioner has included a patient in the active monitoring list, the former is charged to visit physically or remotely the latter during heatwaves. Every day, GPs receive the HHWWS bulletin. Therefore, based on the warning level, GPS must visit their patients physically or remotely, fill in surveillance questionnaires and the patient diary to keep track of developments. Visits are due only when Level 1, 2 or 3 heatwaves are forecasted. Yet, if dangerous weather conditions are prolonged, visits, either physical or remote, should be repeated. At the beginning of Summer, GPs are also required to fill in an assessment questionnaire, reporting information about the socio-demographic conditions of the monitored patient, previous medical conditions, pharmaceutical treatments and Covid-19 infections and vaccinations. In this regard, the coordinator chosen by each ASL will be able to consult an updated comprehensive list reporting all the lists filled in by the GPs that respond to each ASL. In case some patients enlisted have not been taken charged of by GPs without benefitting from active monitoring, the ASL will have to check the vulnerability of such patients.
The plan finally includes various recommendations on the risks deriving from
heatwaves and on the ways to prevent them. As a matter of fact, it provides a
description of the possible symptoms, some suggestions on how to detect them and on how to act. There is a specific part dedicated to prevention and adaptation measures to be applied in hospitals, long-term care facilities, rehabilitation facilities, etc. These latter are required to prepare an operational plan to follow in case of heatwaves well before Summer. The healthcare professionals will be informed about the warning levels by the local referee (ASL). Before Summer they will be provided with the regional operational intervention plan to prevent heat-related effects on health, and, as a general norm, the same structures enlisted before will have to assess the microclimatic conditions in rooms and common spaces. The Plan envisions a series of recommendations for homecare providers and volunteers as well, who,
apart from informing their assisted on the heat-related risks, they should also make sure to adequately inform relatives and other persons that might be helping their assisted.
Impact
According to an interview released by the Lazio Region vice-president Esterino
Montino in 2009, based on the data gathered from the implementation of the plan, it appeared that the monitoring system had considerably decreased from 2007 to 2008 in Rome and in the Lazio Region, further highlighting that monitored older people didn’t undergo any negative effects from heatwaves. Already in 2009, the number of GPs subscribing to the monitoring system had started growing significantly by 30-50%. In one year, 133 GPs decided to subscribe in Rome, whereas other 89 GPs did the same in the Region.
Innovation
Apart from being one of the first operational intervention plan against heatwaves
to be adopted in Europe, it stands out for its cutting-edge methodology to identify vulnerable people. The Department of Epidemiology of the Lazio Region has been a forerunner in developing such methodology, based on cross-checking death certificates and personal details of the deceased in the population layer between 65-74 years old and over 75. The indicator obtained measures the daily increases in mortality, in order to rapidly assess the impact of heatwaves on the vulnerable population, comparing the expected mortality rate with the actual one. Having successfully studied, tested and implemented this method, since 2012, the Department of Epidemiology of the Lazio Region is currently also a key coordinator for the national forecasting and prevention plan against heatwaves.
Lessons learned
Although this practice has proved to be successful to prevent and address heat-
related impacts on the health of the most vulnerable by decreasing the mortality
rate, this doesn’t mean that the situation is fully under control. Impact assessment studies continue to be rare in Italy (both at the local and the national level) as well as abroad. But given the connection of the Lazio Region operational plan to the national forecasting and prevention plan, it could be helpful to focus on the overall evaluation provided by Annamaria de Martino in 2016, as officer at the General Directorate of Health Prevention of the Health Ministry. She affirmed that by comparing the mortality rate of Summer 2003 with other similar Summers such as in 2012, the plan has somehow helped to contain heat-related deceases. Yet, Summer 2015 was marked by a peak of deaths, which suggests that even more efforts should be made to reinforce the intervention system already implemented. The progressively ageing population in Italy, that will see an expansion of the population layer aged 85 and more, is a warning that that the number of vulnerable people is increasing and the impact of heatwaves on their health could be stronger.
Sustainability
As for the institutional sustainability of the practice, it needs to focus on functionality of the services it intends to provide, based on the actual needs of the users of such services. In this case the Regional Plan offers a detailed overview on the aspects that need to be considered to adapt living environments, medical treatments and lifestyles to heatwaves. In order to be more socially sustainable, the competent authorities should increase their efforts in providing periodical and updated impact assessment studies to get an overall understanding of the results of the practice, something that is missing everywhere. The yearly review and entry into force of the practice suggests that it works but access to data should be made more transparent. Finally, as regards environmental sustainability, the practice as it was implemented in the Lazio Region has enhanced the use of various digital tools to keep track of
monitoring visits and collect useful data. Besides, monitoring visits themselves are only in part provided in presence, because telemedicine practices and phone
consultations are equally made available and used.
Replicability and/or up-scaling
The good practice presents great possibilities of being extended in other regional realities, despite some corrective actions might be applied to the complex hierarchical intervention structure, based on the existence of other governance systems. The indicator on the impact effect on deaths can be easily replicated elsewhere, since in all places there is a registry office, that can provide relevant data to identify local vulnerable groups and classify them.
Contact details
Department of Epidemiology of the Regional Social Services of the Lazio Region
+39 06 99722161/1621
Related Web site(s)
https://www.deplazio.net/it/temi/151-piano-di-prevenzione-e-sistema-di-allarme-
ondate-di-calore?jjj=1676894863191
https://www.aslroma6.it/-/ondate-di-calore-piano-operativo-regionale-
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