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Spatial variability in temperature exists within metropolitan areas but very few studies have investigated intra-urban differentiation in the temperature-mortality effects. We investigated whether local characteristics of 42 Municipalities within the Greater Athens Area lead to modified temperature effects on mortality and if effect modifiers can be identified. Generalized Estimating Equations models were used to assess the effect of high ambient temperature on the total and cause-specific daily number of deaths and meta-regression to investigate effect modification. We found significant effects of daily temperature increases on all-cause, cardiovascular, and respiratory mortality (e.g., for all ages 4.16% (95% CI: 3.73,4.60%) per 1 °C increase in daily temperature (lags 0-3). Heterogeneity in the effect estimates between Municipalities was observed in several outcomes and environmental and socio-economic effect modifying variables were identified, such as % area coverage of buildings, length of roads/km 2 , population density, % unemployed, % born outside the EU countries and mean daily temperature. To further examine the role of temperature, we alternatively used modelled temperature per Municipality and calculated the effects. We found that heterogeneity was reduced but not eliminated. It appears that there are socioeconomic status and environmental determinants of the magnitude of heat-related effects on mortality, which are detected with some consistency and should be further investigated.

Spatial Variability in the Effect of High Ambient Temperature on Mortality: An Analysis at Municipality Level within the Greater Athens Area