Monitoring Water From Space: An Illustration in Death Valley, California
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We conducted a historical cohort study of mortality among 195 astronauts who were exposed to space and medical sources of radiation between 1959 and 1991. Cumulative occupational and medical radiation exposures were obtained from the astronaut radiation exposure history data base. Causes of death were obtained from obligatory death certificates and autopsy reports that were on file in the medical records. A total of 18 deaths occurred during the 32-year follow-up period for which the all-cause standardized mortality ratio (SMR) was 142 (95 percent confidence interval 84 225). There was one cancer death in the buccal cavity and pharynegeal ICD-9 rubric whose occurrence was significantly beyond expectation. Mortality for coronary disease was 59 percent lower than expected (2 deaths; SMR = 41; 95 percent confidence limit 5 147). The crude death rate for 10 occupationally related accidents was 400 deaths per 100,000 person-years, which is an order of magnitude greater than accidental death rates in mining industries. The SMR of 1027 for fatal accidents was significantly beyond expectation (14 deaths; 95 percent confidence limit 561 1723) and was similar to SMRs for accidents among aerial pesticide applications. The 10-year cumulative risk of occupational fatalities based on the exponential, Weibull, Gompertz, and linear-exponential distributions was 10 percent. Mortality from motor vehicle accidents was slightly higher than expected but was not significant (1 death; SMR = 145; 95 percent confidence limit 2 808). Radiation exposures from medical procedures accounted for a majority of cumulative dose when compared with space radiation exposures. The results of the study do not confirm the impression that astronauts are at increased risk of cancer, but this does not obviate the need for further study. Overall, it was found that astronauts are at a health disadvantage as a result of catastrophic accidents.
This study summarizes the results from fitting a Bayesian hierarchical spatiotemporal model to coronavirus disease 2019 (COVID-19) cases and deaths at the county level in the United States for the year 2020. Two models were created, one for cases and one for deaths, utilizing a scaled Besag, York, Mollié model with Type I spatial-temporal interaction. Each model accounts for 16 social vulnerability and 7 environmental variables as fixed effects. The spatial pattern between COVID-19 cases and deaths is significantly different in many ways. The spatiotemporal trend of the pandemic in the United States illustrates a shift out of many of the major metropolitan areas into the United States Southeast and Southwest during the summer months and into the upper Midwest beginning in autumn. Analysis of the major social vulnerability predictors of COVID-19 infection and death found that counties with higher percentages of those not having a high school diploma, having non-White status and being Age 65 and over to be significant. Among the environmental variables, above ground level temperature had the strongest effect on relative risk to both cases and deaths. Hot and cold spots, areas of statistically significant high and low COVID-19 cases and deaths respectively, derived from the convolutional spatial effect show that areas with a high probability of above average relative risk have significantly higher Social Vulnerability Index composite scores. The same analysis utilizing the spatiotemporal interaction term exemplifies a more complex relationship between social vulnerability, environmental measurements, COVID-19 cases, and COVID-19 deaths.
This study quantifies global premature deaths attributable to long-term exposure of ambient PM 2.5 , or PM 2.5 -attributable mortality, by dust and pollution sources. We used NASA’s Modern-Era Retrospective Analysis for Research and Applications, Version 2 (MERRA-2) aerosol reanalysis product for PM 2.5 and the cause-specific relative risk (RR) from the integrated exposure-response (IER) model to estimate global PM2.5-attributable mortality for five causes of deaths, namely ischaemic heart disease (IHD), cerebrovascular disease (CEV) or stroke, lung cancer (LC), chronic obstructive pulmonary disease (COPD), and acute lower respiratory infection (ALRI). The estimated yearly global PM 2.5 -attributable mortality in 2019 amounts to 2.89 (1.38–4.48) millions, which is composed of 1.19 (0.73–1.84) million from IHD, 1.01 (0.35–1.55) million from CEV, 0.29 (0.11–0.48) million from COPD, 0.23 (0.14–0.33) million from ALRI, and 0.17 (0.04–0.28) million from LC (the numbers in parentheses represent the estimated mortality range due corresponding to RR spread at the 95% confidence interval). The mortality counts vary with geopolitical regions substantially, with the highest number of deaths occurring in Asia. China and India account for 40% and 23% of the global PM 2.5 -attributable deaths, respectively. In terms of sources of PM 2.5 , about 22% of the global all-cause PM 2.5 -attributable deaths are caused by desert dust. The largest dust attribution is 37% for ALRI. The relative contributions of dust and pollution sources vary with the causes of deaths and geographical regions. Enforcing air pollution regulations to transfer areas from PM 2.5 nonattainment to PM2.5 attainment can have great health benefits. Being attainable with the United States air quality standard (AQS) of 15 μg/m 3 globally would have avoided nearly 40% or 1.2 million premature deaths. The most recent update of PM 2.5 guideline from 10 to 5 μg/m 3 by the World Health Organization (WHO) would potentially save additional one million lives. Our study highlights the importance of distinguishing aerodynamic size from geometric size in accurately assessing the global health burden of PM 2.5 and particularly for dust. A use of geometric size in diagnosing dust PM 2.5 from the model simulation, a common approach in current health burden assessment, could overestimate the PM 2.5 level in the dust belt by 40–170%, leading to an overestimate of global all-cause mortality by 1 million or 32%.
BACKGROUND: Preliminary data suggest that the analysis of R-R interval variability by fractal analysis methods may provide clinically useful information on patients with heart failure. The purpose of this study was to compare the prognostic power of new fractal and traditional measures of R-R interval variability as predictors of death after acute myocardial infarction. METHODS AND RESULTS: Time and frequency domain heart rate (HR) variability measures, along with short- and long-term correlation (fractal) properties of R-R intervals (exponents alpha(1) and alpha(2)) and power-law scaling of the power spectra (exponent beta), were assessed from 24-hour Holter recordings in 446 survivors of acute myocardial infarction with a depressed left ventricular function (ejection fraction </=35%). During a mean+/-SD follow-up period of 685+/-360 days, 114 patients died (25.6%), with 75 deaths classified as arrhythmic (17.0%) and 28 as nonarrhythmic (6.3%) cardiac deaths. Several traditional and fractal measures of R-R interval variability were significant univariate predictors of all-cause mortality. Reduced short-term scaling exponent alpha(1) was the most powerful R-R interval variability measure as a predictor of all-cause mortality (alpha(1) <0.75, relative risk 3.0, 95% confidence interval 2.5 to 4.2, P<0.001). It remained an independent predictor of death (P<0.001) after adjustment for other postinfarction risk markers, such as age, ejection fraction, NYHA class, and medication. Reduced alpha(1) predicted both arrhythmic death (P<0.001) and nonarrhythmic cardiac death (P<0.001). CONCLUSIONS: Analysis of the fractal characteristics of short-term R-R interval dynamics yields more powerful prognostic information than the traditional measures of HR variability among patients with depressed left ventricular function after an acute myocardial infarction.
BACKGROUND. The purposes of the present study were (1) to establish normal values for the regression of log(power) on log(frequency) for, RR-interval fluctuations in healthy middle-aged persons, (2) to determine the effects of myocardial infarction on the regression of log(power) on log(frequency), (3) to determine the effect of cardiac denervation on the regression of log(power) on log(frequency), and (4) to assess the ability of power law regression parameters to predict death after myocardial infarction. METHODS AND RESULTS. We studied three groups: (1) 715 patients with recent myocardial infarction; (2) 274 healthy persons age and sex matched to the infarct sample; and (3) 19 patients with heart transplants. Twenty-four-hour RR-interval power spectra were computed using fast Fourier transforms and log(power) was regressed on log(frequency) between 10(-4) and 10(-2) Hz. There was a power law relation between log(power) and log(frequency). That is, the function described a descending straight line that had a slope of approximately -1 in healthy subjects. For the myocardial infarction group, the regression line for log(power) on log(frequency) was shifted downward and had a steeper negative slope (-1.15). The transplant (denervated) group showed a larger downward shift in the regression line and a much steeper negative slope (-2.08). The correlation between traditional power spectral bands and slope was weak, and that with log(power) at 10(-4) Hz was only moderate. Slope and log(power) at 10(-4) Hz were used to predict mortality and were compared with the predictive value of traditional power spectral bands. Slope and log(power) at 10(-4) Hz were excellent predictors of all-cause mortality or arrhythmic death. To optimize the prediction of death, we calculated a log(power) intercept that was uncorrelated with the slope of the power law regression line. We found that the combination of slope and zero-correlation log(power) was an outstanding predictor, with a relative risk of > 10, and was better than any combination of the traditional power spectral bands. The combination of slope and log(power) at 10(-4) Hz also was an excellent predictor of death after myocardial infarction. CONCLUSIONS. Myocardial infarction or denervation of the heart causes a steeper slope and decreased height of the power law regression relation between log(power) and log(frequency) of RR-interval fluctuations. Individually and, especially, combined, the power law regression parameters are excellent predictors of death of any cause or arrhythmic death and predict these outcomes better than the traditional power spectral bands.
Ambient air pollution from ground-level ozone and fine particulate matter (PM(sub 2.5)) is associated with premature mortality. Future concentrations of these air pollutants will be driven by natural and anthropogenic emissions and by climate change. Using anthropogenic and biomass burning emissions projected in the four Representative Concentration Pathway scenarios (RCPs), the ACCMIP ensemble of chemistry climate models simulated future concentrations of ozone and PM(sub 2.5) at selected decades between 2000 and 2100. We use output from the ACCMIP ensemble, together with projections of future population and baseline mortality rates, to quantify the human premature mortality impacts of future ambient air pollution. Future air-pollution-related premature mortality in 2030, 2050 and 2100 is estimated for each scenario and for each model using a health impact function based on changes in concentrations of ozone and PM(sub 2.5) relative to 2000 and projected future population and baseline mortality rates. Additionally, the global mortality burden of ozone and PM(sub 2.5) in 2000 and each future period is estimated relative to 1850 concentrations, using present-day and future population and baseline mortality rates. The change in future ozone concentrations relative to 2000 is associated with excess global premature mortality in some scenarios/periods, particularly in RCP8.5 in 2100 (316 thousand deaths per year), likely driven by the large increase in methane emissions and by the net effect of climate change projected in this scenario, but it leads to considerable avoided premature mortality for the three other RCPs. However, the global mortality burden of ozone markedly increases from 382000 (121000 to 728000) deaths per year in 2000 to between 1.09 and 2.36 million deaths per year in 2100, across RCPs, mostly due to the effect of increases in population and baseline mortality rates. PM(sub 2.5) concentrations decrease relative to 2000 in all scenarios, due to projected reductions in emissions, and are associated with avoided premature mortality, particularly in 2100: between 2.39 and 1.31 million deaths per year for the four RCPs. The global mortality burden of PM(sub 2.5) is estimated to decrease from 1.70 (1.30 to 2.10) million deaths per year in 2000 to between 0.95 and 1.55 million deaths per year in 2100 for the four RCPs due to the combined effect of decreases in PM(sub 2.5) concentrations and changes in population and baseline mortality rates. Trends in future air-pollution-related mortality vary regionally across scenarios, reflecting assumptions for economic growth and air pollution control specific to each RCP and region. Mortality estimates differ among chemistry climate models due to differences in simulated pollutant concentrations, which is the greatest contributor to overall mortality uncertainty for most cases assessed here, supporting the use of model ensembles to characterize uncertainty. Increases in exposed population and baseline mortality rates of respiratory diseases magnify the impact on premature mortality of changes in future air pollutant concentrations and explain why the future global mortality burden of air pollution can exceed the current burden, even where air pollutant concentrations decrease.
We used the EVAv6.0 system to estimate the present (2015) and future (2015–2050) global PM 2.5 and O 3 -related premature mortalities, using simulated surface concentrations from the GISS-E2.1-G Earth system model. The PM 2.5 -related global premature mortality is estimated to be 4.3 and 4.4 million by the non-linear and linear models, respectively. Ischemic heart diseases are found to be the leading cause of PM 2.5 -related premature deaths, contributing by 35% globally. Both long-term and short-term O 3 -related premature deaths are estimated to be around 1 million, globally. Overall, PM 2.5 and O 3 -related premature mortality leads to 5.3–5.4 million premature deaths, globally. The global burden of premature deaths is mainly driven by the Asian region, which in 2015 contributes by 75% of the total global premature deaths. An increase from 6.2% to 8% in the PM 2.5 relative risk as recommended by the WHO leads to an increase of PM 2.5 -related premature mortality by 28%, to 5.7 million. Finally, bias correcting the simulated PM 2.5 concentrations in 2015 leads to an increase of up to 73% in the global PM 2.5 -related premature mortality, leading to a total number of global premature deaths of up to 7.7 million, implying the necessity of bias correction to get more robust health burden estimates. PM 2.5 and O 3 -related premature mortality in 2050 decreases by up to 57% and 18%, respectively, due to emission reductions alone. However, the projected increase and aging of the population leads to increases of premature mortality by up to a factor of 2, showing that the population exposed to air pollution is more important than the level of air pollutants, highlighting that the population dynamics should be considered when setting up health assessment systems.
The acute radiation syndrome in man is clinically bounded by death at high dose levels and by the prodromal syndrome of untoward physiological effects at minimal levels of clinically effective exposure. As in lower animals, man experiences principally three acute modes of death from radiation exposure (Bond et al., 1965). These are known collectively as the lethal radiation syndromes: central nervous system death, gastrointestinal death, and hematopoietic death. The effect of multiple exposure on lethality, the effect of multiple exposure on hematopoietic recovery, and quantitative aspects of cell and tissue repair are discussed.
Since the beginning of manned spaceflight, NASA has recognized the potential risk of cardiovascular decrements due to stressors in the space environment. Of particular concern is the effect of space radiation on cardiovascular disease since astronauts will be exposed to higher levels of galactic cosmic rays outside the Earth's protective magnetosphere. To date, only a few studies have examined the effects of heavy ion radiation on cardiovascular disease, and at lower, space-relevant doses, the association between radiation exposure and cardiovascular pathology is more varied and unclear. Furthermore, other spaceflight conditions such as microgravity, circadian shifts, and confinement stress pose unique challenges in estimating the health risks that can be attributed to exposure to ionizing radiations. In this work, we review age, cause of mortality, and radiation exposure amongst early NASA astronauts in selection groups and discuss the limitations of assessing such a cohort when attempting to characterize the risk of space flight, including stressors such as space radiation and microgravity exposure, on cardiovascular health. METHODS: NASA astronauts in selection groups 1-7 were chosen and the comparison population was white men of the same birth cohort as drawn from data from the CDC Wonder Database and CDC National Center for Health Statistics Life Tables. Cause of death information was obtained from the Lifetime Surveillance of Astronaut Health program and deceased astronauts were classified based on ICD-10 codes: ischemic heart disease (IHD), stroke, cancer, acute occupational events, non-NASA accidents, and other/unknown. Expected years of life left and expected age at death were calculated for the cohort. RESULTS AND CONCLUSIONS: There were 32 deaths in this early astronaut population, 12 of which were due to accidents or acute occupational events that impacted lifespan considerably. The average age at death from these causes is 30 years lower than the average expected ~70 years of age in the general population. Remarkably, all 41 living early astronauts outlived our calculated expected age at death for members of their birth cohort; furthermore, 13 of the 20 deceased astronauts who did not die in NASA/non-NASA accidents exceeded this age. There was no difference in IHD between the astronaut cohort and the comparison population; therefore, it is not possible to associate IHD mortality with radiation in that astronaut cohort. As NASA looks toward future exploration-class missions, early astronaut cohorts provide a convenient option for assessing these risks and for developing mitigation strategies. However, many challenges still exist when assessing such limited evidence, including small cohort size, health and lifestyle confounders (such as smoking and drinking), the high accident mortality rate, and the fact that many of these astronauts are still alive, outliving many of their birth-cohort peers. Future analysis should include a longitudinal study, monitoring cases as they occur in the cohort. As this cohort is currently followed-up over time, and as more IHD cases are anticipated in a population of this age, this type of study is not as resource-intensive as would normally be the case.
Mortality data from experiments conducted at the Argonne National Laboratory (ANL) on the long-term effects of external whole-body irradiation on B6CF(1) mice were used to investigate radiation-induced effects at intermediate doses of (60)Co gamma rays or fission-spectrum neutrons either delivered as a single exposure or protracted over 60 once-weekly exposures. Kaplan-Meier analyses were used to identify the lowest dose in the ANL data (within radiation quality, pattern of exposure, and sex) at which radiation-induced mortality caused by primary tumors could be detected (approximately 1-2 Gy for gamma rays and 10-15 cGy for neutrons). Doses at and below these levels were then examined for radiation-induced shifts in the spectrum of pathology detected at death. To do this, specific pathology events were pooled into larger assemblages based on whether they were cancer, cardiovascular disease or non-neoplastic diseases detected within the lungs and pleura, liver and biliary tract, reproductive organs, or urinary tract. Cancer and cardiovascular disease were further subdivided into categories based on whether they caused death, contributed to death, or were simply observed at death. Counts of how often events falling within each of these combined pathology categories occurred within a mouse were then used as predictor variables in logistic regression to determine whether irradiated mice could be distinguished from control mice. Increased pathology burdens were detected in irradiated mice at doses lower than those causing detectable shifts in mortality-22 cGy for gamma rays and 2 cGy for neutrons. These findings suggest that (1) models based on mortality data alone may underestimate radiation effects, (2) radiation may have adverse health consequences (i.e. elevated health risks) even when mortality risks are not detected, and (3) radiation-induced pathologies other than cancer do occur, and they involve multiple organ systems.
Simulated microgravity within the NASA High Aspect Rotating-Wall Vessel (HARV) provides a quiescent environment to culture fragile insect cells. In this vessel, the duration of stationary and death phase for cultures of Spodoptera frugiperda cells was greatly extended over that achieved in shaker-flask controls. For both HARV and control cultures, S. frugiperda cells grew to concentrations in excess of 1 x 10(7) viable cells ml-1 with viabilities greater than 90%. In the HARV, stationary phase was maintained 9-15 days in contrast to 4-5 days in the shaker flask. Furthermore, the rate of cell death was reduced in the HARV by a factor of 20-90 relative to the control culture and was characterized with a death rate constant of 0.01-0.02 day-1. Beginning in the stationary phase and continuing in the death phase, there was a significant decrease in population size in the HARV versus an increase in the shaker flask. This phenomenon could represent cell adaptation to simulated microgravity and/or a change in the ratio of apoptotic to necrotic cells. Differences observed in this research between the HARV and its control were attributed to a reduction in hydrodynamic forces in the microgravity vessel.
The net growth rate of bovine embryonic kidney cells in microcarrier bioreactor is the result of a variable death rate imposed on a cell culture trying to grow at a constant intrinsic growth rate. The death rate is a function of the agitation conditions in the system, and increases at higher agitation because of increasingly energetic interactions of the cell covered microcarriers with turbulent eddies in the fluid. At very low agitation rates bead-bead bridging becomes important; the large clumps formed by bridging can interact with larger eddies than single beads, leading to a higher death rate at low agitation. The growth and death rate were correlated with a dimensionless eddy number which compares eddy forces to the buoyant force on the bead.
Mass accumulations of fossilized large terrestrial vertebrate skeletons (bone beds: BB) provide a test for K-T catastrophic extinction hypotheses. The two major factors contributing to BB formation are mode of death and sedimentation rate. Catastrophic mass mortality (CMM) is the sudden death of numerous individuals where species, age, health, gender, or social ranking offer no survivorship advantage. Noncatastrophic mass mortality (NCMM) occurs over time and is strongly influenced by species, age, or gender. In addition to cause of death, sedimentation rate is also important in BB formation. Models of BBs can be made. The CMM drops all individuals in their tracks, therefore, the BB should reflect the living population with respect to species, age, or gender. The NCMM results in monospecific BBs skewed in the direction of the less fit, usually the very young or very old, or towards a specific gender. The NCMM and AM BBs may become more similar the more spread out over time NCMM deaths occur because carcasses are widely scattered requiring hydraulic accumulation, and the greater time allows for more disarticulation and weathering. The CMM and NCMM BB appear to be dominated by social animals. Applying this and the characteristics of mortality patterns to the uppermost Cretaceous Hell Creek Formation indicates that only NCMM and AM BB occur. Furthermore, NCMM BB are rare in the upper third of the Hell Creek. Near the K-T boundary, only AM BB are known. The absence of CMM and NCMM BB appears to be real reflecting a decrease in population levels of some dinosaurs prior to the K-T event. The absence of CMM suggests that the K-T event did not lead to an instantaneous extinction of dinosaurs. Nor was there a protracted die-off due to an asteroid impact winter, because no NCMM BB are known at or near the K-T boundary.
Radio-resistant or recurrent prostate cancer represents a serious health risk for approximately 20%-30% of patients treated with primary radiation therapy for clinically localized prostate cancer. In our current studies, we investigated the expressions of apoptosis related gene expression profile (84 genes) in two distinct prostate cell lines Lncap (P53+ and AR+) and PC3 (P53- and AR-) before and after exposure to X-rays or protons, using cDNA PCR arrays. In Lncap cells, 10Gy X-ray radiation significantly induced the expression of 19 out of 84 genes at 4h after irradiation. The changed genes were mostly in death and death receptor domain families, TNF ligand and receptor families, and apoptotic group of the BCL2 family, especially in P53 related genes, such as FAS, BAX, BAK1 and GADD45A. In PC3, X-rays only induced the expression of 3 genes, including an increased expression of BIRC3. There was no difference of the X-ray mediated cell killing in both cell lines using the cell cycle analysis. However, these X-ray-induced gene expression differences between PC3 and Lncap may explain the phenotype of PC3 cells that shows more tolerant not only to radiation, but also to other apoptosis inducing and sensitizing reagents. To compare the effectiveness of cell killing with X-rays, we also exposed PC3 cells to 10Gy protons at the Bragg peak region. Protons did not induce more apoptosis than X-rays for the same dose. In comparison to X-rays, protons significantly altered expressions of 13 genes in PC3, which included decreased expressions of anti-apoptosis genes (BCL2 and BCL2L2), and increased expressions of death and death receptor domain family genes, TNF ligand and receptor family and several kinases (FAS, DAPK1 and RIPK2). These data suggest that proton treatment is more effective in influencing the apoptosis pathways in PC3 cells than X-rays, thus protons may be more effective in the treatment of specific prostate tumor.
Although it has now been over 50 years since mankind first ventured into space, the long-term health impacts of human space flight remain largely unknown. Identifying factors that affect survival and prognosis among those who participate in space flight is vitally important, as the era of commercial space flight approaches and NASA prepares for missions to Mars. The Longitudinal Study of Astronaut Health is a prospective study designed to examine trends in astronaut morbidity and mortality. The purpose of this analysis was to describe and explore predictors of overall and cause-specific mortality among individuals selected for the U.S. astronaut corps. All U.S. astronauts (n=321), regardless of flight status, were included in this analysis. Death certificate searches were conducted to ascertain vital status and cause of death through April 2009. Data were collected from medical records and lifestyle questionnaires. Multivariable Cox regression modeling was used to calculate the mortality hazard associated with embarking on space flight, adjusted for sex, race, and age at selection. Between 1959 and 2009, there were 39 (12.1%) deaths. Of these deaths, 18 (42.2%) were due to occupational accidents; 7 (17.9%) were due to other accidents; 6 (15.4%) were attributable to cancer; 6 (15.4%) resulted from cardiovascular/circulatory diseases; and 2 (5.1%) were from other causes. Participation in space flight did not significantly increase mortality hazard over time (adjusted hazard ratio=0.57; 95% confidence interval=0.26-1.26. Because our results are based on a small sample size, future research that includes payload specialists, other space flight participants, and international crew members is warranted to maximize statistical power.
Weather and climate profoundly affect human health. Several studies have demonstrated a U-, V-, or J-shaped temperature-mortality relationship with increasing death rates at the lower and particularly upper end of the temperature distribution. The objectives of this study were (1) to analyze the relationship between temperature and mortality in Bangladesh for different subpopulations and (2) to project future heat-related mortality under climate change scenarios. We used (non-)parametric Generalized Additive Models adjusted for trend, season and day of the month to analyze the effect of temperature on daily mortality. We found a decrease in mortality with increasing temperature over a wide range of values; between the 90th and 95th percentile an abrupt increase in mortality was observed which was particularly pronounced for the elderly above the age of 65 years, for males, as well as in urban areas and in areas with a high socio-economic status. Daily historical and future temperature values were obtained from the NASA Earth Exchange Global Daily Downscaled Projections (NEX-GDDP) dataset. This dataset is comprised of downscaled climate scenarios for the globe that are derived from the General Circulation Model (GCM) runs conducted under the Coupled Model Intercomparison Project Phase 5 (CMIP5). The derived dose-response functions were used to estimate the number of heat-related deaths occurring during the 1990s (1980-2005), the 2020s (2011-2040) and the 2050s (2041-2070). We estimated that excess deaths due to heat will triple from the 1990s to the 2050s, with an annual number of 0.5 million excess deaths in 1990 to and expected number of 1.5 millions in 2050.