Mortality Burden Attributed to the Synergy Between Human Bio-Climate and Air Quality Extremes in a Climate Change Hotspot

The Eastern Mediterranean is a rapidly warming climate-change hotspot where heat and air pollution increasingly interact to affect human health. This study quantifies the mortality burden attributed to the synergistic effects of thermal stress and air pollution in Thessaloniki, Greece. Daily mortality data (2001–2019) were analyzed together with pollutant concentrations (PM10, NO₂, O₃) and the modified Physiologically Equivalent Temperature (mPET) using a hierarchical Generalized Additive Model with Distributed Lag Non-Linear terms to capture combined, lagged, and age-specific responses. A re-fined, count-independent definition of the Attributable Fraction (AF) was introduced to improve stability in small strata. Results show that heat and pollution act synergistically, explaining on average 20–30% of daily mortality during severe co-occurrence events. Seniors were most affected during hot, polluted summers (AF ≈ 27%), while adults showed higher burdens during cold, polluted winters (AF ≈ 30%). Intra-urban analyses revealed stronger compound effects in the western, more industrial districts, reflecting combined environmental and socioeconomic vulnerability. The findings demonstrate that temperature extremes amplify pollution-related mortality and underline the need to integrate air-quality and bioclimatic indicators into early-warning and adaptation systems in Eastern Mediterranean cities.