Excessive Heat
Events Guidebook
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EPA 430-B-06-005 | June 2006
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CDC
United States Environmental Protection Agency
FEJ\1 A Office of Atmospheric Programs (6207J)
1 200 Pennsylvania Avenue NW, Washington, DC 20460
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How to obtain copies
You can electronically download this
document from EPA's Heat Island Site at
http://www.epa.gov/heatisland/about/
heatresponseprograms.html. To request
free copies of this report, call the National
Service Center for Environmental
Publications (NSCEP) at 1-800-490-9198.
For further information
For further information, contact Jason
Samenow, 202-343-9327, samenow.jason@
epa.gov, U.S. Environmental Protection
Agency.
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Excessive Heat
Events Guidebook
EPA 430-B-06-005 June 2006
United States Environmental Protection Agency
Office of Atmospheric Programs (6207J)
1 200 Pennsylvania Avenue NW, Washington, DC 20460
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Table of Contents
Acknowledgments.. 1
List of Acronyms and Abbreviations 3
Summary 5
Chapter 1 Overview 7
1.1 Why Care about EHEs? 7
1.2 Guidebook Goals 7
1.3 Guidebook Development 8
Chapter 2 EHE Health Impacts and Risk Sources. 9
2.1 Defining an EHE 9
2.2 Health Risks Attributable to EHE Conditions 10
2.3 Quantifying the Health Impacts of EHEs 11
2.3.1 EHEs and U.S. mortality 12
2.3.2 EHEs and U.S. morbidity 14
2.4 Identifying Characteristics that Affect EHE Health Risks 16
2.4.1 Meteorological conditions 16
2.4.2 Demographic sensitivities 17
2.4.3 Behavioral choices 17
2.4.4 Regional factors 18
Chapter 3 Summary of Current EHE Notification and Response Programs 21
3.1 Elements in Select EHE Programs 21
3.1.1 EHE prediction 23
3.1.2 EHE risk assessment 23
3.1.3 EHE notification and response 24
3.1.4 EHE mitigation 26
3.2 Case Studies in the Development and Implementation of EHE Programs 26
3.2.1 Philadelphia 26
3.2.2 Toronto 30
3.2.3 Phoenix 32
3.3 Evidence on the Performance of EHE Programs 33
Excessive Heat Events Guidebook
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Chapter 4 Recommendations for EHE Notification and Response Programs 35
4.1 EHE Definition and Forecasting 35
4.1.1 EHE criteria must reflect local conditions 35
4.1.2 Ensure access to timely meteorological forecasts 36
4.2 Public Education and Awareness of EHE Risk Factors and Health Impacts 36
4.2.1 Increase and improve EHE notification and public education 36
4.2.2 Provide information on proper use of portable electric fans
during EHEs 37
4.3 EHE Response Preparation 38
4.3.1 Develop a clear plan of action identifying roles and responsibilities 38
4.3.2 Develop long-term urban planning programs to minimize heat
island formation 39
4.4 EHE Response Actions 39
4.5 Review EHE Programs to Address Changing Needs, Opportunities,
and Constraints 41
References 43
Appendix A: Excessive Heat Event Resources Available on the Internet 47
Appendix B: Use of Portable Electric Fans during Excessive Heat Events 49
Appendix C: Excessive Heat Events Guidebook in Brief 51
Table of Contents
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Excessive Heat Events Guidebook
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Acknowledgments
The primary agencies that partnered to support this guidebook's development are
the U.S. Environmental Protection Agency (EPA), the Centers for Disease Control and
Prevention (CDC), the National Oceanic and Atmospheric Administration's (NOAA's)
National Weather Service (NWS), and the U.S. Department of Homeland Security (DHS).
This guidebook reflects the commitment of individuals who contributed their time and
expertise to guide its development while evaluating a wide range of information. The
key contacts at each of the partnering agencies were instrumental in the guidebook's
development. Alan Perrin and Jason Samenow of EPA served as the guidebook's
day-to-day project managers from its conceptualization through production. Jannie
Ferrell and Mark Tew of NOAA's NWS, George Luber and Mike McGeehin of CDC,
and Carl Adrianopoli of DHS similarly served as the principal guidebook contacts
at their respective agencies, facilitating access to the respective staff and resources of
those agencies. David Mills of Stratus Consulting managed the guidebook's technical
development as the primary EPA consultant. He was greatly assisted in this work by
Dr. Laurence Kalkstein of Applied Climatologists Inc. and the University of Delaware
Center for Climatic Research. Dr. Kalkstein helped pioneer, and continues to lead, the
development of integrated meteorological and human health models for forecasting
excessive heat event (EHE) conditions. He also contributed a wealth of background
information in the form of published articles about and insight into forecasting EHEs,
quantifying their health impacts, and coordinating the development of EHE watch/
warning systems.
Ultimately, though, this guidebook could not have been developed without the
involvement of the members of the Technical Working Group (TWG) that was assembled
to help identify and summarize essential information and to comment on drafts of the
guidebook. Their collective experience designing, implementing, supporting, operating,
and evaluating EHE notification and response programs throughout the United States and
Canada was an invaluable resource. The members of the TWG are as follows:
>• Nancy Day and Marco Vittiglio, Toronto Public Health
*• Timothy Burroughs, Nikolaas Dietsch, Anne Grambsch, and Kathy Sykes, EPA
» Tony Haffer, Melinda Hinojosa, and Paul Trotter, NOAA/NWS
*• Jerry Libby (retired) and Lawrence Robinson, City of Philadelphia Department of
Public Health
>• Christopher Payne, Cincinnati Health Commissioner's Office
>- Liz Robinson, Energy Coordinating Agency of Philadelphia.
The TWG's guidance and perspective make this guidebook such a potentially useful
resource. The members' enthusiasm and commitment of time to the guidebook's
development are deeply appreciated by the partnering agencies and those involved with
the guidebook's technical development.
Acknowledgments
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Finally, extremely helpful comments were received on a final draft of the guidebook from
colleagues and researchers contacted by members of the TWG. In addition to staff at the
partnering agencies, these reviewers included:
Pamela Blixt, City of Minneapolis Emergency Preparedness Coordinator; Robert Davis and
Chip Knappenberger, New Hope Environmental Services; Kristie Ebi, Exponent Inc.;
Pat Finnegan, Metropolitan Chicago Healthcare Council; Robert French and Warren Leek,
Maricopa County; Stephen Keach, Perrin Quarles Associates; Sari Kovats, London School of
Hygiene and Tropical Medicine; Marc Rosenthal, Yale University; Jonathan Skindlov,
Salt River Project Water Resource Operations; Steven Wallace, University of California,
Los Angeles Center for Health Policy Research; and Scott Wright, University of Utah.
Excessive Heat Events Guidebook
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List of Acronyms and Abbreviations
CDC
CSA
DHS
EHE
EMS
EPA
NOAA
NWS
PGA
SMSA
SSC
TWG
UL
Centers for Disease Control and Prevention
Canadian Standards Approved
U.S. Department of Homeland Security
excessive heat event
emergency medical service
U.S. Environmental Protection Agency
National Oceanic and Atmospheric Administration
National Weather Service
Philadelphia Corporation for Aging
standard metropolitan statistical area
spatial synoptic classification
Technical Working Group
Underwriter Laboratories
Acronyms and Abbreviations
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Excessive Heat Events Guidebook
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Introduction
Excessive heat events (EHEs) are and will continue to be a fact of life in the United States.
These events are a public health threat because they often increase the number of daily
deaths (mortality) and other nonfatal adverse health outcomes (morbidity) in affected
populations. Distinct groups within the population, generally those who are older, very
young, or poor, or have physical challenges or mental impairments, are at elevated risk for
experiencing EHE-attributable health problems. However, because EHEs can be accurately
forecasted and a number of low cost but effective responses are well understood, future
health impacts of EHEs could be reduced. This guidebook provides critical information
that local public health officials and others need to begin assessing their EHE vulnerability
and developing and implementing EHE notification and response programs.
Health impacts of EHEs
EHE conditions are defined by summertime weather that is substantially hotter and/or
more humid than average for a location at that time of year. EHE conditions can increase
the incidence of mortality and morbidity in affected populations. Recent examples of
EHE health impacts include:
*• More than 15,000 deaths in France alone (all of western Europe was affected)
attributed to EHE conditions in August 2003
More than 700 deaths attributed to EHE conditions in Cook County, Illinois, in July
1995
^ Roughly 120 deaths attributed to EHE conditions in Philadelphia, Pennsylvania, in
July 1993.
Concern over the potential future health impacts of EHEs follows research conclusions
that EHEs may become more frequent, more severe, or both in the United States.
Responding to EHE conditions
The potential for reducing future health impacts of EHEs in the United States is
significant for several reasons.
First, meteorologists can accurately forecast EHE development and the severity of the
associated conditions with several days of lead time. This provides an opportunity to
activate established EHE notification and response plans or to implement short-term
emergency response actions absent an existing plan.
Second, specific high-risk groups typically experience a disproportionate number of
health impacts from EHE conditions. The populations that have physical, social, and
economic factors and the specific actions that make them at high risk include:
*• Older persons (age > 65)
>• Infants (age < i)
>• The homeless
>• The poor
>- People who are socially isolated
Summary
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>• People with mobility restrictions or mental impairments
»• People taking certain medications (e.g., for high blood pressure, depression,
insomnia)
>• People engaged in vigorous outdoor exercise or work or those under the influence of
drugs or alcohol.
Identifying these high-risk groups in given locations allows public health officials to
develop and implement targeted EHE notification and response actions that focus
surveillance and relief efforts on those at greatest risk.
Third, broad consensus exists on the types of actions that will provide relief to those at
risk during EHEs and help minimize associated health impacts. These actions include:
*• Establishing and facilitating access to air-conditioned public shelters
*- Ensuring real-time public access to information on the risks of the EHE conditions
and appropriate responses through broadcast media, web sites, toll-free phone lines,
and other means
+• Establishing systems to alert public health officials about high-risk individuals or
those in distress during an EHE (e.g., phone hotlines, high-risk lists)
*• Directly assessing and, if needed, intervening on behalf of those at greatest risk (e.g.,
the homeless, older people, those with known medical conditions).
Experience in several North American cities has demonstrated that comprehensive and
effective EHE notification and response programs can be developed and implemented at
relatively low cost. These programs generally use available resources instead of creating
EHE-specific institutions. This approach recognizes that short-term resource reallocations
for EHEs are justified by the severity of their public health risks, the limited duration and
frequency of the events, and the cost-effectiveness of the reallocations.
Guidebook goals and next steps
This guidebook provides interested public health officials with enough background
information on EHE risks and impacts to roughly assess potential local health risks from
EHEs. In addition, it provides a menu of notification and response actions to consider
when developing or enhancing a local EHE program.
The 2005 U.S. hurricane season was a stark reminder that inadequate public and private
preparation and response to well-forecasted and well-understood extreme meteorological
phenomena can have severe public health consequences.
The remaining public health challenge for EHEs is to develop and implement meaningful
EHE notification and response programs that increase public awareness and lessen future
adverse health impacts.
Excessive Heat Events Guidebook
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Overview
EHEs can increase the number of deaths (mortality) and nonfatal outcomes (morbidity)
in vulnerable populations, including older people, the very young, the homeless, and
people with cognitive and physical impairments (NOAA, 1995; American Medical
Association Council on Scientific Affairs, 1997; Semenza et al, 1999). Climate research
suggests that future health risks of EHEs could increase with an increase in EHE frequency
and severity (Meehl and Tebaldi, 2004). At the same time, demographic patterns including
increasing urbanization will increase the size and percentage of the vulnerable U.S.
population. To develop appropriate EHE responses, local officials need to understand the
risks that these events pose to their populations and their response options. The intent of
this guidebook is to address both needs.
1.1 Why Care about EHEs?
Studies estimate that the combined EHE-attributable summertime mortality for several
vulnerable U.S. metropolitan areas is well above 1,000 deaths per year (Kalkstein, 1997;
Davis et al, 2003a). Although similar research to quantify EHE-attributable mortality in
rural areas has not been completed, recent research (Sheridan and Dolney, 2003) found
evidence of such an impact.
Despite the history of adverse health impacts, there is consensus that most of these
outcomes are preventable (CDC, 2004a). Lessening future adverse health outcomes from
EHEs will require improving the awareness of public health officials and the general
public about the health risks of EHEs while continuing to develop and implement
effective EHE notification and response programs.
1.2 Guidebook Goals
This guidebook has two basic goals: first, to provide local health and public safety officials
with the information they need to develop EHE criteria and evaluate the potential health
impacts of EHEs, and second, to offer a menu of EHE notification and response actions to
be considered.
To meet these goals, this guidebook is organized as follows.
Chapter 2 provides information on EHE-attributable health impacts and sources of risk
that affect the vulnerability of individuals and communities to EHEs. Specific information
provided in the chapter includes:
*• A general EHE definition
*• Guidance on criteria for EHE forecasting and identifying EHE conditions
>• Estimates of the number and rate of EHE-attributable summertime deaths for select
U.S. metropolitan areas
>• A review of the meteorological, demographic, behavioral, and regional characteristics
that increase health risks from EHEs.
I
o
Overview
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Chapters gives the menu of notification and response options that local officials can use
^ as a starting point when considering whether to develop or enhance an EHE program.
a This menu consists of the following information:
.c
>• The components of current EHE notification and response programs
*• Case studies of specific EHE response programs to understand their development and
lessons learned
A review of the efficacy of EHE response programs.
Chapter 4 provides recommendations that should be considered when developing an
EHE notification and response program. Specifically, this chapter contains:
»• Guidance on specific actions to consider when planning to develop or enhance an
EHE program
^ Recommendations for coordinating EHE programs with other public health
programs (e.g., ozone alert programs).
In addition, the guidebook includes a series of appendices with information that officials
may want to incorporate in other materials or make available independent of the
guidebook. This information includes:
^ A partial list of resources for additional information on EHE-attributable health risks
and impacts and details on EHE programs fAppendixAj
>- Guidance on the personal use of portable electric fans during EHEs fAppendix BJ
A summary of specific actions people and communities can take in response to
forecast EHE conditions to reduce the risk of experiencing heat-attributable health
problems fAppendix CJ.
1.3 Guidebook Development
Other documents have summarized the health risks of EHEs, described the factors that
increase an individual's health risk during these conditions, and recommended elements
for EHE notification and response programs (e.g., Basu and Samet, 2002; Bernard and
McGeehin, 2004; CDC, 2004a,c; FEMA, 2005b; U.S. EPA, 2005).
This guidebook, however, is unique because it was developed as a collaborative effort
among several of the principal federal agencies responsible for addressing EHEs: the
Centers for Disease Control and Prevention (CDC), the National Oceanic and Atmospheric
Administration's (NOAA's) National Weather Service (NWS), the U.S. Department of
Homeland Security (DHS), and the U.S. Environmental Protection Agency (EPA) along with
three other institutions with extensive experience developing and operating recognized
EHE programs in the United States and abroad: the Philadelphia Health Department,
Toronto Public Health, and the University of Delaware Center for Climatic Research.
Summarizing the collective insight and experience of the individuals from these
organizations was facilitated through the participation of their staff in a Technical
Working Group (TWG). The TWG helped shape the guidebook's content through regular
group discussions and review of draft versions of the guidebook.
Excessive Heat Events Guidebook
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EHE Health Impacts and Risk Sources
This chapter first defines an EHE and reviews possible criteria for identifying EHE
conditions, followed by a discussion of the range of EHE-attributable medical conditions,
adverse health outcomes, and mortality estimates for several U.S. metropolitan areas. It
also reviews the characteristics that can affect an individual's health risk and the incidence
of adverse health outcomes in a population.
2.1 Defining an EHE
EHE conditions are defined by summertime weather that is substantially hotter and/or
more humid than average for a location at that time of year. Because how hot it feels
depends on the interaction of multiple meteorological variables (e.g., temperature,
humidity, cloud cover), EHE criteria typically shift by location and time of year. In other
words, Boston, Philadelphia, Miami, Dallas, Chicago, San Diego, and Seattle are likely to
have different EHE criteria at any point in the summer to reflect different local standards
for unusually hot summertime weather. In addition, these criteria are likely to change for
each city over the summer. As a result, reliable fixed absolute criteria, e.g., a summer day
with a maximum temperature of at least 9O°F, are unlikely to be specified.
There are different ways to identify EHE conditions. Some locations evaluate current and
forecast weather to identify EHE conditions with site-specific, weather-based mortality
algorithms. Other locations identify and forecast EHE conditions based on statistical
comparisons to historical meteorological baselines. For example, the criterion for EHE
conditions could be an actual or forecast daily high temperature that is equal to or exceeds
the 95iH percentile value from a historical distribution for a defined time period (e.g., the
summer or a month-long window centered on the date).
Figure 2.1 presents a hypothetical example that shows the difference in defining
EHE conditions when using a seasonally adjusted relative temperature versus a fixed
temperature criterion.
Figure 2.1. An example illustrating the difference between a seasonally adjusted relative
temperature threshold and a fixed absolute temperature threshold for defining EHE
conditions. Source: Personal communication, B. Davis, New Hope Environmental Services, August 2005.
110
a.
as
Max.
Temp °F
June
August
September
EHE Health Impacts and Risk Sources
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ft
CO
.c
O
Representations of actual EHEs can help illustrate these conditions. During the summer
of 2003, Western Europe experienced EHE conditions of unprecedented severity. Figure
2.2 presents the June through August 2003 daily maximum temperature readings in Paris
with the corresponding average daily maximum temperature from the historical record.
Although the June and July temperatures in Figure 2.2 may not seem exceptional,
the extent to which they generally exceeded the long-term average shows why Paris
experienced EHE conditions. The period from August 3 to August 17, however, is notable
for its absolute temperatures and its tremendous deviation from typical conditions.
Reflecting the significant health risks of EHE conditions, France experienced roughly
15,000 heat-related deaths during this period (Koppe et al, 2004).
Figure 2.2. Actual (red line) vs. average (black line) daily maximum temperatures
Paris, France - Summer 2003
Temp
August
2.2 Health Risks Attributable to EHE Conditions
Maintaining a consistent internal body temperature, generally 98.6°F, is essential to
normal physical functioning (American Medical Association Council on Scientific Affairs,
1997). EHE conditions stress the body's ability to maintain this ideal internal temperature.
If individuals fail or are unable to take steps to remain cool and begin to experience
increasing internal temperatures, they increase their risk of experiencing a range of
potential adverse health outcomes.
Table 2.1 lists some of the medical conditions directly attributable to excessive heat
exposure, along with recommended responses.
EHE conditions can result in increases in the number of cases of other health problems
as well. For example, EHEs can increase the number of patients experiencing circulatory
system conditions. These additional problems come from the added strain on the heart,
increasing circulation to regulate internal temperatures, or to overcome the effects of
dehydration, which thickens the blood, making it harder for the heart to pump.
10
Excessive Heat Events Guidebook
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Table 2.1. Medical conditions directly attributable to excessive heat exposure
Medical Condition Symptoms Responses
Heat cramps
Painful muscle cramps and
spasms, usually in muscles
of legs and abdomen.
Heavy sweating.
Apply firm pressure on cramping muscles
or gently massage to relieve spasm.
Give sips of water; if nausea occurs,
discontinue water intake. Consult with a
clinician or physician if individual has fluid
restrictions (e.g., dialysis patients).
Heat exhaustion
Heavy sweating, weakness,
cool skin, pale, and clammy.
Weak pulse. Normal
temperature possible.
Possible muscle cramps,
dizziness, fainting, nausea,
and vomiting.
Move individual out of sun, lay him or her
down, and loosen clothing. Apply cool,
wet cloths. Fan or move individual to air-
conditioned room. Give sips of water; if
nausea occurs, discontinue water intake.
If vomiting continues, seek immediate
medical attention. Consult with a clinician
or physician if individual has fluid
restrictions (e.g., dialysis patients).
Heat stroke Altered mental state.
(sunstroke) Possible throbbing
headache, confusion,
nausea, and dizziness.
High body temperature
(106°F or higher). Rapid
and strong pulse. Possible
unconsciousness. Skin
may be hot and dry, or
patient may be sweating.
Sweating likely especially
if patient was previously
involved in vigorous activity.
Heat stroke is a severe medical
emergency. Summon emergency medical
assistance or get the individual to a
hospital immediately. Delay can be fatal.
Move individual to a cooler, preferably
air-conditioned, environment. Reduce
body temperature with a water mister
and fan or sponging. Use air conditioners.
Use fans if heat index temperatures are
below the high 90s. Use extreme caution.
Remove clothing. If temperature rises
again, repeat process. Do not give fluids.
Sources: CDC, 2004a; Kunihim and Foster, 2004; NWS, 2004.
2.3 Quantifying the Health Impacts of EHEs
Quantifying the health impacts of EHEs is complicated by the differences in
quantification methods and a lack of accurate data.
The most conservative quantification method counts only outcomes on EHE days where
the attribution information (e.g., primary diagnosis, cause of death) lists excessive
weather-related heat exposure or a condition unequivocally associated with excessive
heat exposure, such as heat stroke. This approach underestimates the health impacts of
EHEs because not all the heat-related cases will include an attribution that recognizes
this impact. More inclusive methods quantify EHE health impacts based on increases in
outcomes during EHE periods compared to long-term averages. But such approaches
can be absolute and attribute all observed increases in outcomes to EHEs, overestimating
the heat-related mortality. Alternatively, the approach can be partial and attribute only a
portion of the observed increase in outcomes to EHEs based on professional judgment or
the results of additional analyses such as regression.
a.
oj
EHE Health Impacts and Risk Sources
11
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2.3.1 EHEs and U.S. mortality
There are a number of methods for estimating the public health threat and impact of
EHEs. Since these methods can have a significant impact on the resulting estimate, it
is important to recognize their differences when reviewing information describing the
public health burden of EHEs.
The most conservative estimate of EHE mortality counts only cases in which exposure to
excessive heat is reported on a death certificate as a primary or contributing factor. Using
this approach, it was estimated that extreme heat from weather conditions is, on average,
responsible annually for 182 deaths in the United States (CDC, 2002).
<* The conservative nature of this estimate due to the narrow criteria is recognized in the
study itself (CDC, 2002). The accuracy of this estimate would improve with widespread
g adoption of revised criteria for attributing a death to excessive heat exposure. Typically,
medical examiners list heat exposure as a primary or contributing cause of death only
if the core body temperature exceeds io5°F. In the revised criteria, a death also can be
classified as heat-related if the person is "found in an enclosed environment with a high
ambient temperature without adequate cooling devices and the individual had been
known to be alive at the onset of the heat wave" (Donoghue et al, 1997). Importantly, the
National Association of Medical Examiners supports using these broader criteria, and
medical examiners in several large cities (e.g., Philadelphia) have adopted them.
Alternative EHE mortality estimates come from analyses of daily urban summertime
mortality patterns in the United States (Kalkstein and Greene, 1997; Davis et al, 2003a).
These studies first defined EHE conditions and then calculated the number of EHE-
attributable deaths based on differences in daily deaths on EHE days compared to longer-
term averages. Although differences in the time series, definitions of urban populations,
and other analytical methods prevent an exact comparison of results from Kalkstein and
Greene (1997) and Davis et al. (2003a), their findings correspond closely [for details of the
studies' methods and the comparison of results see accompanying background technical
report (Mills, 2005)]. Table 2.2 presents the estimates of heat-attributable excess deaths
and mortality rates from these studies.
The results in Table 2.2 are notable for several reasons. First, despite differences in
methods and the locations evaluated, the studies' results fall in a narrow range of roughly
1,700-1,800 total heat-attributable deaths per summer. These estimates are roughly an
order of magnitude greater than the comprehensive national annual average of 182
deaths with a listed cause of death of "excessive heat due to weather conditions" (CDC,
2002). This difference highlights the importance of the method (i.e., excess incidence
or attributed outcomes) used to quantify EHEs' health impacts. Although summing the
results across different groups of locations minimizes some of the initial distinctions
in the studies, some of the location-specific results in Table 2.2 show that significant
differences can result from applying different methods to essentially the same mortality
and meteorological data.
Second, both studies' results show significant regional variation: EHEs have the greatest
impact in the Northeast and Midwest and the least impact in the South and Southwest.
This result is consistent with hypotheses that populations in the most vulnerable areas are
not as acclimatized to elevated temperatures and that structures in less susceptible areas
12 Excessive Heat Events Guidebook
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Table 2.2 Estimates of heat-attributable deaths per summer and mortality rates in
select U.S. metropolitan areas
Standard
Metropolitan
Statistical
Area (SMSA)
Birmingham
Providence
Hartford
St. Louis
Kansas City
Buffalo
Indianapolis
Memphis
Columbus
Minneapolis
Chicago
Philadelphia
Denver
Detroit
Greensboro
Nassau, New
York Cify, Newark
Louisville
Boston
Pittsburgh
New Orleans
Tampa
Baltimore;
Washington, D.C.
Cleveland
Dallas
Atlanta
Cincinnati
Portland
Los Angeles
and Riverside
San Francisco
San Antonio
Houston
Seattle
Jacksonville
Miami, Fort
Lauderdale
Phoenix
Salt Lake City
San Diego
Norfolk
Charlotte
Total
Deaths1
(Estimated average
from 1990 population)
42
47
38
79
49
33
36
25
33
59
191
129
42
110
22
362
17
96
39
20
28
84
29
36
25
14
9
72
28
4
7
5
0
0
0
0
0
N/A
N/A
1,810
Deaths2
(Estimated average
summertime heat-
attributable deaths
from 1990 population)
N/A
N/A
N/A
0
0
19
N/A
N/A
N/A
0
193
71
22
124
0
552
N/A
56
40
30
0
40
23
0
75
0
32
216
138
N/A
0
96
N/A
0
6
N/A
N/A
0
0
1,733
Mortality Rate1
(Estimated heat-
attributable deaths
per 100,000,
1990s baseline)
5.00
4.14
3.28
3.17
3.10
2.78
2.61
2.48
2.45
2.32
2.32
2.19
2.12
2.12
2.10
1.85
1.79
1.76
1.63
1.56
1.35
1.25
1.01
0.89
0.84
0.77
0.50
0.50
0.45
0.30
0.19
0.17
0.00
0.00
0.00
0.00
0.00
N/A
N/A
Mortality Rate2
(Estimated heat-
attributable deaths
per 100,000,
1990s baseline)
N/A
N/A
N/A
0.00
0.00
1.63
N/A
N/A
N/A
0.00
2.34
1.21
1.09
2.39
0.00
2.82
N/A
1.03
1.69
2.31
0.00
0.59
0.80
0.00
2.51
0.00
1.76
1.50
2.21
N/A
0.00
3.27
N/A
0.00
0.30
N/A
N/A
0.00
0.00
a.
as
Note: N/A, not applicable, refers to a metropolitan area not examined in one of the studies.
1. Ka/kstein and Greene, 1997.
2. Davis et a/., 2003a.
EHE Health Impacts and Risk Sources
13
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ft
CO
.c
O
are better designed to accommodate elevated temperatures. However, fewer locations were
evaluated in the South and Southwest because of the studies' population selection criteria,
so support for these hypotheses remains qualified. This regional result is more evident in
Figure 2.3, which presents the Kalkstein and Greene (1997) results along with a similar
result for Toronto (N. Day, personal communication, Toronto Public Health, 2005).
EHE-attributable mortality estimates from specific EHEs are also available:
>• Chicago, 1995, mid-July EHE: The county coroner certified 465 heat-related deaths
in Chicago (Cook County, Illinois) from July n to July 27,1995 (CDC, 1995). More
than 700 deaths in Chicago were eventually attributed to this EHE (e.g., Palecki et
al, 2001). The difference reflects deaths directly attributed to heat by the medical
examiner (CDC, 1995) and estimates of the total excess mortality attributable to the
EHE based on studies of daily mortality patterns (Palecki et al, 2001).
Philadelphia, 1993, early-July EHE: The county coroner certified 118 heat-related
deaths in Philadelphia from July 6 to July 14,1993 (CDC, 1994).
These estimates demonstrate that an EHE in the United States can easily be responsible
for hundreds of deaths in a large metropolitan area.
2.3.2 EHEs and U.S. morbidity
EHE morbidity studies are relatively rare because of a lack of suitable daily time-series
data. Further, when such studies are attempted, only the most severe morbidity outcomes
(emergency room visits and hospitalizations) tend to be evaluated because of the limited
number of locations where patients can be seen and be treated.
One of the few U.S. EHE morbidity studies examined Chicago hospital admissions during
the July 1995 EHE. Semenza et al. (1999) calculated that this EHE was responsible for
more than 1,000 hospital admissions, and anecdotal evidence strongly suggests that this
EHE increased the incidence of Chicago emergency room visits. Specifically, the Natural
Disaster Survey Report: July 1995 Heat Wave (NOAA, 1995) reported that on the second
day of the EHE, only a few Chicago emergency rooms were directing ambulances to other
facilities because of crowding (i.e., operating in bypass status), but by the fourth day, 18
city emergency rooms were doing so.
14
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Figure 2.3. Estimated EHE-attributable mortality rates.
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In summary, available evidence suggests that EHEs increase morbidity incidence.
More complete assessments of EHE impacts, including evaluations of EHE impacts on
less severe outcomes, may require carefully designed retrospective surveys in affected
populations.
2.4 Identifying Characteristics that Affect EHE Health Risks
Several factors can increase health risks during an EHE: the EHE's meteorological
conditions, demographic characteristics, personal behavioral choices, and regional
characteristics.
2.4.1 Meteorological conditions
When the weather gets hotter, the risk of losing control of one's internal temperature
increases. Heat index tables such as the one in Table 2.3 are commonly used to capture
interactions among several meteorological variables to provide a measure of how hot it
feels. Even heat index table results are sensitive, however, to the particular meteorological
variables measured. For example, heat index results, including those in Table 2.3, often
assume measurements are taken in a shaded location with light wind. As a result, most
heat index tables also note that exposure to direct sunlight can increase heat index values
by up to i5°F. These table notes may also state that exposure to hot dry winds can further
increase health risks by promoting rapid dehydration, although a quantitative measure of
these conditions' impact is not provided (NWS Forecast Office, Pueblo, Colorado, 2004).
Ultimately, a change in any meteorological variable that increases heat index values or
promotes dehydration will increase the individual's health risk.
EHE conditions represent a "shock" that can overwhelm typical responses to elevated
temperatures. All else being equal, the shock value and the health risks increase the earlier
in the summer the EHE occurs (Kalkstein and Davis, 1989; Sheridan and Kalkstein, 1998)
because residents adapt, to some degree, to warmer summer conditions over the season.
Similarly, health risks increase with the duration of the EHE measured as the number of
consecutive EHE days (Greene and Kalkstein, 1996) and the amount of time spent above
minimum temperature thresholds (Kalkstein and Davis, 1989).
Table 2.3. Heat index values
Temperature
3. Heat index values were not given for the temperature and relative humidity combinations that have blank
cells.
4. Heat index values can be up to 15°F higher with exposure to direct sunlight. Heat index values assume
calm wind conditions; hot dry winds can a/so increase heat index values.
Source: NWS Forecast Office, Pueblo, Colorado, 2004.
16
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2.4.2 Demographic sensitivities
Individuals possessing any combination of the following characteristics or conditions are
at greater risk for experiencing an EHE-attributable adverse health outcome:
>- Physical constraints: It is difficult for some people to increase their circulation
and perspiration during an EHE to help them remain cool. This at-risk group
includes infants, older people (age 65 and older, who may also be less likely to
recognize symptoms of excessive heat exposure), the obese, the bedridden, those with
underlying medical conditions (e.g., heart disease, diabetes), those taking certain
medications (e.g., for high blood pressure, depression, insomnia), and individuals
under the influence of drugs or alcohol.
>- Mobility constraints: People with mobility constraints are at higher risk during EHEs
if the constraints limit their ability to access appropriately cooled locations. This
group includes the very young and the bedridden.
>• Cognitive impairments: People with mental illnesses, with cognitive disorders, or
under the influence of drugs or alcohol maybe unable to make rational decisions
that would help limit their exposure to excessive heat or to recognize symptoms of
excessive heat exposure.
** Economic constraints: The poor may be disproportionately at risk during
EHEs if their homes lack air conditioning or they are less likely to use available
air conditioning because of the cost (NWS, 2004). In addition, if the poor
disproportionately reside in high crime areas, fear of crime can increase their risks
by hindering their willingness to take appropriate responses [e.g., opening doors
and windows for circulation, visiting cooling shelters (American Medical Association
Council on Scientific Affairs, 1997)].
>• Social isolation: Socially isolated individuals are less likely to recognize symptoms
of excessive heat exposure. This can delay or prevent treatment and result in more
serious health outcomes. Members of this group, which include the homeless and
those living alone, may also be less willing or able to reach out to others for help.
2.4.3 Behavioral choices
In addition to demographic characteristics, the choices individuals make during an EHE
can have a profound effect on the health risks they face. Examples of personal choices that
can increase an individual's health risks during an EHE include the following (American
Medical Association Council on Scientific Affairs, 1997; CDC2004a,c; NWS, 2004):
>• Wearing inappropriate clothing: Heavy, dark clothing can keep the body hot and
limit cooling from evaporation of perspiration. Clothing that exposes skin to the sun
increases the risk of sunburn, which limits the potential for evaporative cooling.
*• Failing to stay adequately hydrated: During EHE conditions, we rely heavily on
perspiration to regulate our body temperature. Without enough water consumption,
perspiration will be inadequate or even cease and body temperature will rise.
a.
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EHE Health Impacts and Risk Sources
17
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*• Consuming alcohol: Alcohol is a diuretic and thus limits perspiration. It can also
impair judgment and result in excessive exposure to the elevated temperatures.
>• Engaging in outdoor activities: Any activities that increase exposure to the sun or
generate additional body heat (e.g., attending outdoor events, exercising, outdoor
labor) increase the amount of body heat that must be dissipated.
*• Eating inappropriate meals: Eating hot and heavy (e.g., high-protein) foods will
increase the metabolic rate and increase the amount of body heat that must be
dissipated.
2.4.4 Regional factors
Finally, regional characteristics can help determine an individual's health risks during
EHEs. These characteristics include:
Geographic location: Climate variability is largely a function of location, and
increased variability has been associated with elevated heat-attributable mortality
rates (Chestnut et al, 1998).
*- Urbanization and urban design: As buildings, especially those with dark roofs, and
dark paving materials replace vegetation in urban areas, the heat absorbed during
the day increases and cooling from shade and evaporation of water from soil and
leaves is lost. Urban areas can also have reduced air flow because of tall buildings,
and increased amounts of waste heat generated from vehicles, factories, and air
conditioners. These factors can contribute to the development of an urban heat
island, which has higher daytime maximum temperatures and less nighttime cooling
than surrounding rural areas (see Figure 2.4). Urban heat islands can increase health
risks during EHEs by increasing the potential maximum temperature residents are
exposed to and the length of time that they are exposed to elevated temperatures.
Residential location: Residents on the upper floors of buildings will feel the effects
of rising heat. This can elevate room temperatures and make it more difficult to
maintain a consistent internal temperature if air conditioning is not available or is not
used, or if ventilation is restricted.
Urban Heat Island Profile
Rural
Commercial
Suburban
Residential
Urban
Residential
Suburban
Residential
Downtown
Park
Figure 2.4. Impact
of the urban heat
island on ambient
temperatures.
Source: US. EPA,
2006.
18
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Table 2.4 summarizes the factors that increase the risk of an individual getting sick or
dying from an EHE.
Table 2.4. Factors that increase an individual's risk of experiencing an EHE-attributable
adverse health outcome
Meteorological Characteristics
Increased temperature
Increased relative humidity
Dry, hot winds
Demographic Characteristics
Physical constraints (including underlying medical conditions)
Mobility constraints
Cognitive impairments
Economic constraints
Social isolation
a.
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Wearing inappropriate clothing
• Failing to stay adequately hydrated
Consuming alcohol
• Engaging in outdoor activities
• Eating heavy and/or hot foods
Regional Characteristics
Living in an area with a variable climate
Living in an urban area
Living on the upper floors of buildings
EHE Health Impacts and Risk Sources
19
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Summary of Current
EHE Notification & Response Programs
Effective EHE notification and response programs draw on available local resources and
recognize local constraints to minimize increases in morbidity and mortality during
EHEs. As a result, effective EHE notification and response programs can vary.
This chapter summarizes the current range of observed response actions to EHE
conditions. Not all of these actions will be feasible or appropriate for every location.
This summary is intended to provide parties wanting to develop or enhance an EHE
notification and response program with a "menu" of possible actions to consider.
This summary has a number of caveats. First, the reviewed EHE programs were selected to
provide an illustrative rather than all-inclusive set of notification and response actions. As
a result, specific actions that are important components of other effective EHE programs
may have been omitted. Second, our exclusion of specific actions in this summary is not
a judgment on their potential benefit. In fact, developing and evaluating notification and
response actions in response to local conditions is strongly encouraged.
This chapter first summarizes actions incorporated in the EHE programs we reviewed.
This is followed by narratives that offer insight into how and why the reviewed programs
were developed, and summarize critical lessons their administrators have learned over
time. The chapter also describes several short-term responses that the city of Phoenix,
Arizona, implemented during the EHE in the southwestern and central United States
in July 2005. These Phoenix responses are included to highlight actions that can be
taken with relatively short notice to address exceptional EHEs even if a formal EHE
program has not been developed. Finally, the chapter reviews evidence from studies
that have attempted to quantify the impact of EHE notification and response programs.
Although limited, such studies provide some perspective on the potential benefits of EHE
notification and response programs.
3.1 Elements in Select EHE Programs
On the following page, Table 3.1 summarizes the actions Philadelphia and Toronto
incorporated in their EHE notification and response programs. These programs were
selected because they are widely recognized as benchmarks for those considering
developing a comprehensive EHE program.
Following Table 3.1, the individual elements are described in greater detail.
a.
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Summary of Current EHE Notification and Response Programs
21
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Table 3.1. Summary of confirmed EHE program elements in Philadelphia and Toronto
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Program elements
Prediction see 3.1.1, p. 23 ^
Ensure access to weather forecasts capable of predicting
EHE conditions 1-5 days in advance
Philadelphia5 Toronto6
Risk assessment see 3.1.2, p. 23 ^
Coordinate transfer and evaluation of weather forecasts by
EHE program personnel
Develop quantitative estimates of the EHE's potential
health impact
Use the broader criteria to identify heat-attributable deaths
Develop information on high-risk individuals
Develop an accessible record on facilities and locations
with concentrations of high-risk individuals
Notification and response see 3.1.3, p. 24 ^
Coordinate public broadcasts of information about the
anticipated timing, severity, and duration of EHE conditions
and availability and hours of any public cooling centers
Coordinate public distribution and broadcast of heat
exposure symptoms and tips on how to stay cool during
an EHE
Operate informational phone lines that can be used to
report heat-related health concerns
Designate public buildings or specific private buildings
with air conditioning as public cooling shelters and
provide transportation
Extend hours of operation at community centers with air
conditioning
Arrange for extra staffing of emergency support services
Directly contact and evaluate the environmental conditions
and health status of known high-risk individuals and
locations likely to have concentrations of these individuals
Increase outreach efforts to the homeless and establish
provisions for their protective removal to cooling shelters
Suspend utility shutoffs
Reschedule public events to avoid large outdoor
gatherings when possible
Mitigation see 3.1.4, p. 26 ^
Develop and promote actions to reduce effects of urban
heat islands
y
y
S
S
s
s
s
s
s
s
s
s
Not evaluated
5. NOAA, 1995; Kalkste/n, 2002.
6. Ka/kstein, 2002; personal communications, M. Vittig/io and N. Day, Toronto Public Health, 2005.
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3.1.1 EHE prediction
' Ensure access to weather forecasts capable of predicting EHE conditions
1-5 days in advance
Forecasting the development and characteristics of an EHE is a critical element of
both EHE risk assessment and notification and response activities. In the United
States, NWS forecasts provide national coverage, so any location could incorporate
this element into an EHE program. Toronto and Philadelphia both use a sophisticated,
air mass-based heat health system developed by the Center for Climatic Research at
the University of Delaware to evaluate meteorological forecast data in terms of the
potential to increase the number of daily deaths above average levels (Sheridan and
Kalkstein, 2004).
3.1.2 EHE risk assessment
^- Coordinate transfer and evaluation of weather forecasts by EHE program
personnel
In some locations, EHE program personnel may need to review forecast data to
determine whether location-specific criteria for EHE conditions are satisfied and,
potentially, how the forecast conditions match with any established EHE severity
criteria. Establishing forecast transfer and evaluation protocols involves specifying to
under what conditions forecasters (e.g., the NWS) forward information to local
officials (and confirm receipt) and identifying who within the EHE program reviews
and evaluates the information. Alternatively, electronic systems can be established
to retrieve and review forecast data from meteorologists and notify EHE program
personnel if certain criteria are satisfied.
^ Develop quantitative estimates of the EHE's potential health impacts
Several locations with EHE notification and response programs, including
Philadelphia and Toronto, have integrated heat health watch/warning systems that use
meteorological forecast data as inputs to health impact models, which identify when
forecast conditions could result in excess mortality and then estimate the potential
number or probability of heat-attributable deaths (Sheridan and Kalkstein, 2004).
These quantitative health impact estimates are then used in both cities to determine if
and what type of heat emergency is declared. These determinations affect the type and
scope of notification and response activities that will be implemented.
^ Use the broader criteria to identify heat-attributable deaths
Medical examiners can use the criteria in Donoghue et al. (1997) to define heat-
attributable deaths and to provide the public with more accurate reporting of an EHE's
health impacts. This information can increase public awareness and appreciation of
the health risks of the conditions, which may improve compliance with recommended
actions.
^- Develop information on high-risk individuals
Recognizing that some individuals have an elevated risk facilitates notifying and
responding to these individuals (e.g., older individuals, the homeless) to achieve
the greatest public health benefit for a given resource commitment. Easily accessible
contact information for these individuals during an EHE can help the program
Summary of Current EHE Notification and Response Programs 23
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prioritize assessment and intervention efforts. In some locations such as Chicago,
the development of information on high-risk individuals has been expanded beyond
persons known to public agencies. It includes people and organizations who can
identify high-risk individuals so they can be a part of any active assessment and
intervention program efforts.
^ Develop an accessible record of facilities and locations with concentrations
of high-risk individuals
A database or list of high-risk facilities and locations would complement a list of high-
risk individuals. This list could help prioritize active assessment efforts during an EHE
(e.g., visiting retirement homes) to coordinate EHE notification activities through
combinations of fax, email, or telephone contact trees. For example, in Toronto, more
than 800 community agencies are notified of EHE conditions through a fax/call-out
tree.
3.1.3 EHE notification and response
Coordinate public broadcasts of information about the anticipated timing, severity, and
duration of EHE conditions, and availability and hours of any public cooling centers
Effective public notification of forecast EHE conditions helps eliminate the risk of an
EHE taking a population by surprise. More specifically, notifying the public of anticipated
EHE conditions will enable many residents to prepare and will enable public assessment
and intervention actions to concentrate on known high-risk individuals and locations.
Likewise, advance public notification about the availability of cooling centers will increase
the likelihood that at-risk individuals can take advantage of these services.
>• Coordinate public distribution and broadcast of heat exposure symptoms
and tips on how to stay cool during EHEs
Publicly broadcasting cooling tips and symptoms of excessive heat exposure will
complement similar broadcasts about forecast EHE conditions and help residents
develop appropriate EHE responses (e.g., seek air-conditioned locations, minimize
direct sun exposure, reschedule outdoor gatherings). When possible, this action would
include providing this information before and throughout the summer to public
meeting areas (e.g., churches, recreation centers, libraries, schools), arranging periodic
broadcasts through available media, and developing EHE Internet sites.
^- Operate informational phone lines that can be used to report heat-related
health concerns
Telephone help lines give real-time advice and information that can help people stay
safe and avoid serious outcomes. This phone system either can be activated when
an EHE is forecast (e.g., Philadelphia's or Toronto's Heat Lines), or can be a more
general, full-time system (e.g., a 311 line) staffed during EHEs by personnel with
the information and ability to access and direct other intervention resources (e.g.,
emergency medical staff) as needed.
24
Excessive Heat Events Guidebook
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Designate public buildings or specific private buildings with air conditioning
(e.g., shopping malls, movie theaters) as public cooling shelters and provide
transportation if necessary
Spending time in an air-conditioned environment during an EHE is one of the most
effective means of reducing one's risk of overheating. By designating specific public
buildings with air conditioning as cooling shelters, and by providing information on
large private buildings with air conditioning where the public can freely congregate
(e.g., shopping malls and movie theaters), local officials can increase the awareness
and use of these resources to minimize an EHE's health impacts. Providing free public
transportation to those locations during an EHE also recognizes that many with the
greatest need for the shelters may have limited access to personal transportation and
limited financial resources.
Extend hours of operation at community centers with air conditioning
Many of those at greatest risk during an EHE may already frequently visit specific air-
conditioned public locations (e.g., child care and senior centers). Extending the hours
of operation at these and other public locations with air conditioning during EHEs
increases the opportunity for high-risk individuals to spend time in an air-conditioned
environment.
CO
Arrange for extra staffing of emergency support services
EHEs will place additional burdens on emergency medical and social support services
through increased activity focused on preventing adverse health outcomes and
increased need for medical services. Increasing the staffing of emergency medical and
social support services in response to an EHE forecast increases the opportunity to
avert some outcomes with intervention and assessment activities or at least have them
addressed at an earlier and less severe stage by preventing the emergency medical
system from becoming overwhelmed.
Directly contact and evaluate the environmental conditions and health status
of known high-risk individuals and locations likely to have concentrations of
these individuals
High-risk individuals need to be contacted directly and, preferably, observed several times
a day during EHEs to ensure that cooling tips are being followed (e.g., fluids are being
consumed, appropriate clothing is being worn) and that any symptoms of overexposure
are recognized and alleviated as early as possible. This labor-intensive action is offset by
a reduction in the number and severity of adverse health outcomes among the high-
risk population. The individuals to be contacted and locations to be visited would be
identified in the risk assessment component of the EHE program (see Section 3.1.2).
Increase outreach efforts to the homeless and establish provisions for their
protective removal to cooling shelters
The homeless are vulnerable during EHEs, so additional effort must be devoted to
homeless outreach and evaluation during an EHE, especially during the day. This
increased outreach effort should be supported by authorization for officials to move
individuals believed to be experiencing medical difficulties or at extreme risk to cooling
shelters for observation and treatment.
Summary of Current EHE Notification and Response Programs 25
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^ Suspend utility shutoffs
Suspending utility service during an EHE could significantly increase the risk of
exposure to elevated temperatures. As a result, many local governments require local
utilities to suspend shutoffs during EHEs if they do not already have their own shutoff
suspension guidelines. However, suspending utility shutoffs during an EHE does not
ensure that at-risk individuals with access to air conditioning will use it.
^ Reschedule public events to avoid large outdoor gatherings, when possible
When an EHE is forecast, there are likely to be previously scheduled outdoor activities
involving large gatherings of individuals (e.g., youth league games, outdoor camps,
concerts). If these activities take place as scheduled, many people may experience
significant heat exposure. To the extent that local officials have control over how these
events proceed (e.g., through permits or use of facilities), efforts should be made to
reschedule the event or, when rescheduling is not feasible, require more medical staff
and "cool zones" for attendees.
3.1.4 EHE mitigation
> Develop and promote actions to reduce effects of urban heat islands
Urban heat islands can increase daytime temperatures and limit nighttime cooling.
This can increase the severity and duration of urban residents' exposure to high-heat
conditions and increase their risk for experiencing a heat-attributable adverse health
o outcome. Programs and actions that increase urban vegetation and the reflectiveness of
urban surfaces help address this problem.
3.2 Case Studies in the Development and Implementation
of EHE Programs
This section uses case studies from Philadelphia, Toronto, and Phoenix to show how
different forces can drive the development and implementation of EHE notification and
response programs and summarizes the lessons learned over time in these locations. These
insights are especially useful because these programs cover a broad geographic spectrum
and reflect varying degrees of active program coordination.
3.2.1 Philadelphia
Overview
Philadelphia's EHE notification and response program is often viewed as a benchmark for
integrated, urban EHE programs. Philadelphia has a long history of EHE impacts, with
references to heat-attributable deaths recorded since colonial times. The development
of this program demonstrates how an exceptional meteorological event can combine
with seemingly minor bureaucratic adjustments to create significant public interest and
support for an EHE notification and response program.
This EHE program's development also demonstrates the importance of institutional
support and shows how response actions can be matched to program partners based on
their areas of expertise. Finally, the program highlights the benefits of incorporating a
system for active program review and adjustment to respond to needs, constraints, and
opportunities as they arise.
26 Excessive Heat Events Guidebook
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Development of Philadelphia's EHE program
Philadelphia's EHE notification and response program is a direct response to observable
public health impacts from specific EHEs combined with the public recognition of these
risks and institutional support to develop an effective response to avoid similar outcomes
in the future.
In the summer of 1991, more than 20 deaths in Philadelphia were attributed to excessive
heat exposure. In response, the city established and began to convene meetings of a Heat
Task Force under the direction of Health Department staff. The Health Department
identified original task force participants by informally assessing public and private
organizations that served at-risk individuals during an EHE or provided Philadelphia with
critical infrastructure and medical services (e.g., electric and water utilities and emergency
medical service providers).
The Heat Task Force continued to meet through the spring of 1993, but had made little
progress in developing what would be recognized as an EHE notification and response
program. Then, from July 4 to July 14,1993, Philadelphia experienced EHE conditions
characterized by minimum daily high temperatures of at least 9O°F. By July 6, the risks
were apparent and publicly recognized as the city health commissioner announced that
people were dying because of EHE conditions.
CO
At the same time, informal discussions between Health Department staff and o
Southeastern Pennsylvania Red Cross board members led to the establishment of the
Heatline, a telephone hotline, to handle calls from residents with heat-related questions
and concerns. The Heatline, which represented the extent of the city's direct response
actions to the EHE, operated for five days, and its number was widely reported by local
media.
Perhaps the most critical aspect of the July EHE, in terms of its contribution to the
development of the current EHE program, was that the city medical examiner broke from
requiring a core body temperature in excess of io5°F for listing a death as heat related.
Instead, deaths were listed as heat related if the core temperature criterion was satisfied
or if a body was "found in an enclosed environment with a high ambient temperature
without adequate cooling devices and the individual had been known to be alive at the
onset of the heat wave" (Donoghue et al, 1997).
This change resulted in the medical examiner classifying 105 deaths during the July 1993
EHE as heat related. In contrast, for all of July, New York City and Washington, D.C.,
which had experienced similar meteorological conditions, reported three and two heat-
related deaths, respectively, using solely the core temperature criterion.
This finding and its public reporting made the impact of excessive heat in Philadelphia
a topic of considerable local and national media interest, including references to
Philadelphia as the "Heat Death capital of the world." In addition, the contrast between
the number of heat-related deaths reported in Philadelphia and the totals from
surrounding counties and other urban centers led to a request by state and other officials
for a CDC investigation into the appropriateness of the coding criterion the Philadelphia
medical examiner used. The resulting investigation ultimately concluded that the criterion
was appropriate and the associated estimates of heat-attributable mortality were accurate.
Summary of Current EHE Notification and Response Programs 27
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Following the CDC investigation, and with increased public attention on the health risks
of EHE conditions, staff at Philadelphia's Health Department became aware of work
under the direction of Dr. Laurence Kalkstein of the University of Delaware to develop
a system that would identify weather conditions expected to increase daily mortality.
Ultimately, this interest led to the development by the summer of 1995 of a computerized
system capable of forecasting EHE conditions up to two days in advance.
Over this period, spurred by the events of 1993, the Philadelphia Heat Task Force began
preparing EHE response plans that identified lead agencies, secured formal commitments
of support from relevant departments, and worked on developing a system for integrated
communications between program participants.
As the July 1995 EHE developed in the Midwest and the scope of its health impact began
to emerge (eventually more than 700 deaths in Chicago would be classified as heat
related), the Philadelphia Hot Weather-Health Watch/Warning System was announced at a
meeting with EPA and Philadelphia Health Department officials. This system was initially
implemented as the EHE moved eastward into Philadelphia.
Philadelphia's Hot Weather-Health Watch/Warning System response actions
Philadelphia's initial EHE program implemented combinations of the following actions
to depending on the predicted severity of the EHE (NOAA, 1995; Kalkstein et al, 1996):
Media announcements: Local news media were notified of any EHE notification
o
a
as
o made by the health commissioner. Media were also given background information on
how to minimize exposure to heat during the event and encouraged to broadcast it as
part of any heat-related stories.
>• Buddy system advocacy: Media messages included recommendations for friends,
relatives, neighbors, and block captains (see discussion below) to check on local high-
risk residents (e.g., sick and older individuals) throughout the day during the event.
*- Heatline activation: The same phone system staffed by the Red Cross that was
developed for the 1993 EHE was part of the formal program rollout.
+• Home visits by Health Department staff (currently a county sanitarian and nurse
make up each field team): Individuals were identified from calls received on the
Heatline.
* Halt to service shutoffs: Agreements were reached with the respective utilities that
electrical and water service would not be shut off for nonpayment during periods for
which the Health Department issued a high heat warning.
>• Increased emergency medical service staffing: Increased numbers of staff with
the city's Fire Department and Emergency Medical Services were on duty for the
duration of the high heat period.
Increased outreach to the homeless: Activities that involved identifying homeless
individuals and providing shelter were extended to daytime hours to minimize their
exposure to the most severe conditions.
28 Excessive Heat Events Guidebook
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;• Cooling shelters/senior refuge: Hours of operation at air-conditioned senior
centers were extended to provide a refuge for those otherwise lacking access to air
conditioning.
>• Outreach: The Heatline phone number was displayed on the Crown Lights display in
downtown Philadelphia (an electronic billboard on top of the Philadelphia Electric
Company building that is visible over a large area).
Two notable aspects of the Philadelphia Watch/Warning System that warrant additional
discussion are its use of block captains and its use of field assessment teams from the
Health Department to evaluate high-risk individuals during EHEs.
Philadelphia's block captains are a critical point of interaction between the public and
the Health Department during EHEs. Block captains are volunteers elected by residents
of their block to help coordinate neighborhood improvement projects with the city.
Philadelphia currently has about 5,000 block captains. They can both identify and evaluate
the health status of high-risk and hard-to-reach individuals in their residential area during
an EHE. Although block captains are not required to contact specific individuals during a
declared EHE, anecdotal evidence suggests that many do. Their actions most likely benefit
others and, during declared heat events, news crews frequently record and broadcast
block captains checking on the status of high-risk individuals in their area, spreading the
message to check on those at risk.
The second notable aspect of Philadelphia's program is its coordinated use of field teams
composed of city Health Department staff in follow-up visits to at-risk individuals
identified from Heatline calls. Teams assembled during a declared heat event currently
consist of a sanitarian and a nurse who have been temporarily reassigned from their
typical duties. This reallocation of staff reflects a belief that a more immediate and more
significant public health risk is being addressed.
Adjustments and lessons learned
Since 1995, a number of relatively minor changes have been made in the response elements
of Philadelphia's EHE program, including the following:
>- Transferring the Heatline's operation from the Red Cross to the Philadelphia
Corporation for Aging (PGA) and using the PCA's Senior Line number to double
as the Heatline. When EHEs are announced, the hours of operation for the Senior
Line/Heatline are expanded from between 8 A.M. and 5 P.M. to between 8 A.M. and
midnight.
>- Adding nurses to the on-call Heatline staff to handle calls with specific medical
questions.
+• Mailing heat information to block captains to distribute in their areas.
*• Increasing the forecast period for the spatial synoptic classification (SSC)-based Heat
Health Watch Warning System from 2.5 days (60 hours) to 5.0 days (120 hours).
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Philadelphia's experience demonstrates the importance of public recognition of EHE
health risks and of continued support from upper levels of government for developing
an EHE notification and response program. The city's program also shows that matching
responsibilities of program elements with program partners who already perform similar
tasks is critical for achieving a wide range of response actions. Specific examples of this
matching in the Philadelphia program include shifting the Heatline from the Red Cross to
the PCA, staffing field teams with temporarily reassigned Health Department personnel,
and incorporating the city's existing block captain program to create a community-based
buddy system capable of evaluating the status of high-risk individuals.
3.2.2 Toronto
Overview
Toronto is one of several North American locations with an EHE notification and
response program that is driven by calculations of potential excess mortality or mortality
probability based on forecast meteorological conditions. Toronto Public Health's EHE
program uses these results to determine when heat warnings should be issued and what
type of message to communicate.
Toronto's EHE program is of special interest because it evolved primarily as a proactive,
precautionary response to a perceived public health risk by local politicians. This is in
contrast to most of the other highly active and integrated programs, which typically
originated as responses to EHEs that triggered recognizable increases in daily mortality
and morbidity. In addition, Toronto's program is an example of how an effective
program can be developed by drawing general lessons from other locations and tailoring
implementation to respond to local opportunities and challenges. Finally, the routine,
structured process of performance review, needs assessment, and adjustment of the
Toronto EHE program is noteworthy.
Development of the Toronto EHE program
The origins of Toronto's EHE program can be traced to 1998 and the Mayor's Task Force
on Homelessness. This effort established a lead role for Toronto Public Health to identify
and develop responses to the health issues faced by the city's homeless. In the spring of
1999, the Task Group asked Toronto Public Health to establish temperature thresholds that
would be used to initiate health alerts and trigger additional homeless interventions (e.g.,
increasing daytime staff and efforts to get the homeless indoors).
To address this task, Toronto Public Health staff reviewed information from several
EHE programs in the United States, including those in Philadelphia and Chicago.
This review increased awareness of the demographic and physical characteristics that
increase EHE vulnerability and highlighted the potential for an effective EHE program.
Most importantly, this review increased awareness among officials that, although the
homeless were especially vulnerable to EHE conditions, the presence of other high-risk
subpopulations meant that EHEs should be recognized as a much larger threat to public
health.
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Development of an EHE prediction system similar to the one used in Philadelphia and
several other U.S. cities began in 2000. The Toronto prediction system was completed and
became active on June 18,2001, in time to assist in forecasting the EHE that occurred in
August of that year. Initial program elements focused on issuing a media release any time
EHE conditions were forecast that contained information about the health risks of the
conditions and appropriate responses. These announcements were also used to trigger
increased intervention activities directed at the homeless population.
With the program's development, Toronto Public Health also established a Hot Weather
Response Committee to develop, monitor, and update its Hot Weather Response Plan. The
committee is a partnership of representatives from various city departments and agencies
working with potentially vulnerable populations. Every year, before the hot season, the
committee discusses and finalizes the contributions and roles each agency will assume
during the coming summer. Using a call-out tree, Toronto Public Health coordinates the
plan and notifies the committee and a list of more than 800 agencies of an EHE. Each
agency and city department implements its part of the plan.
Adjustments and lessons learned
In the fall of each year, the Hot Weather Response Committee meets to assess the
performance of the system and program. The focus of this meeting is on identifying areas
and items that could be added or improved to enhance the program's performance. This
active review process has resulted in these changes to the program:
>- Having the Red Cross operate an informational heat-health telephone line during
declared heat advisories
>• Coordinating the city's emergency medical service (EMS) with the health line to
address specific medical questions, conduct follow-up visits with all callers to evaluate
conditions in their residences, and to take individuals to cooling centers when needed
>• Providing functional drinking water fountains in city parks
>• Extending the hours of operation of city pools
>- Providing transit tokens to those who have been evaluated by street patrol teams and
are found to be in need of a cooling center.
Less formal program adjustments over time have included coordinating with other
city officials to evaluate and, when necessary, relax enforcement of certain ordinances
to allow compliance with cooling tips provided during EHEs. For example, the city
relaxes enforcement of late-night park closure rules, because many residents who lack air
conditioning visit Toronto's parks at night during EHE conditions.
Finally, a critical component of the Toronto EHE program has involved working to
increase public education and awareness of EHEs and their health risks. To this end,
Toronto Public Health holds an annual media event in mid-May at which Health
Department, Red Cross, and EMS staff members are available to answer EHE questions
from the media.
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3.2.3 Phoenix
Summer in Phoenix is, by any measure, hot. Daily high temperatures above IOO°F are
routine, temperatures up to HO°F are common, and temperatures above i2o°F are possible.
Although residents over time physically adapt to some extent to Phoenix's high heat,
summer conditions can still be quite variable. Despite Phoenix routinely experiencing
life-threatening summertime temperatures, studies of excess heat mortality there have
consistently found little evidence of any major heat-attributable excess mortality impacts
(e.g., Kalkstein and Greene, 1997; Davis et al, 2003a,b)J
Although definitive explanations for this result cannot yet be offered, it seems likely
that this can be attributed to significant local experience in responding to elevated
temperatures, relatively low humidity, extensive access to air conditioning, widespread
public recognition of the health risks during EHE conditions, and a willingness to
make appropriate adjustments to minimize heat exposure. These findings suggest the
importance of having a public that understands the health risks inherent in EHEs and
knows how to minimize their health impacts.
Still, in mid-July 2005, much of the southwestern and central United States experienced
consecutive days of hot weather that broke all-time high temperature records in many
locations. During this period, Phoenix was a focus of media attention because of the
duration of the conditions (all but 3 days in the 2-week period through July 21 reached
HO°F) and because several deaths were attributed to the heat (Associated Press, 2005).
o Extreme high temperatures like those experienced in July 2005, however, create potentially
life-threatening conditions for anyone experiencing unmitigated exposure, regardless
of adaptation. As a result, it is not surprising that the majority of deaths in Phoenix
attributed to the heat were of homeless individuals. Phoenix's sudden increase in heat-
attributable deaths in July 2005 should be viewed as a reflection of how an exceptionally
severe and long-lasting EHE can overwhelm even highly adapted populations.
Before the 2005 summer, Phoenix's EHE program consisted mainly of relying on the local
NWS forecast office to predict dangerous conditions and the local media to broadcast
warnings and advice for limiting heat exposure. Although Phoenix is covered by an
operating SSC-based EHE prediction system, developed with funding by NOAA's NWS
and the local electrical utility to help guide utility shutoff decisions, there was minimal
interest in incorporating this available information into a broader EHE notification and
response program.
Adjustments and lessons learned
Phoenix's public response to the July 2005 EHE conditions largely focused on opening
homeless shelters during daytime hours, bringing homeless individuals to these and other
locations with air conditioning, and providing donated bottled water. Given the general
prevalence of air conditioning in Phoenix, this targeted action may be the most effective
approach for limiting the health risks and impacts of an especially severe EHE.
7 A lack of evidence of a heat-mortality relationship in these studies does not mean that excessive heat is
not reported as a contributing factor in deaths in Phoenix during the summer; in fact, heat-related deaths
are routinely reported. This finding simply means there has not previously been a measurable increase in
all-cause mortality rates in Phoenix when the heat reaches exceptional levels.
32 Excessive Heat Events Guidebook
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This action also demonstrates how a location that generally lacks a formal EHE program
can take immediate steps to reduce the risks and health impacts of an especially severe
EHE.
In addition, the July 2005 EHE in Phoenix triggered a review of the county's response
plans to EHE warnings issued by the local NWS office. Although this review is ongoing,
the revised plan is expected to clearly define a set of actions the county will take after an
NWS announcement.
3.3 Evidence on the Performance of EHE Programs
Few studies have evaluated the efficacy of EHE notification and response programs.
This reflects the difficulty of developing these studies (e.g., issues in identifying case and
control locations and accounting for variation in populations and EHE conditions) and,
in many cases, the brevity of existing operating EHE programs.
One study in Philadelphia (Ebi et al, 2004) used regression analysis to quantify the impact
of publicly announcing forecast EHE conditions on EHE-attributable excess mortality
from 1995 to 1998. This study was possible largely because, at the time, the city and the
regional NWS forecast office independently evaluated forecast data for anticipated EHE
conditions. As a result, during this period there were days when the city's criteria called
for an EHE warning but the NWS would not issue one, days when the city's system would
suggest a warning be issued and the NWS would issue one, and days when the NWS
would issue a warning when the city's system did not call for a warning.
Ebi et al. (2004) found that for each day Philadelphia issued an EHE warning based on the
SSC system recommendation, expected mortality was reduced by roughly 2.6 lives per day
and this mortality reduction was experienced for the 3 days following the last issued heat
warning. This result was statistically significant at the 8% level, which the authors note is
equivalent to saying there was a 92% chance that the system saved at least one life during
this period. It is estimated that the system saved 117 lives during the study period. To place
this result in a cost-benefit framework, the authors report an estimated cost, primarily
for wages of extra emergency medical staff, of $10,000 for each day a heat advisory is
issued. In contrast, EPA routinely assumed a value per avoided statistical life year lost of $6
million in regulatory impact assessments at the time of the study.
The other formal study that examined the effectiveness of EHE programs, Palecki et al.
(2001), compared the health impacts of EHEs in 1995 and 1999 in Chicago and St. Louis.
The basis for evaluating the effectiveness of EHE programs in this study is provided
mainly by the contrast of the impacts of the events in Chicago, which lacked an EHE
notification and response program in 1995 but then developed one, which became active
in 1999. The authors take care to note that there were differences in the duration, intensity,
and meteorological conditions preceding the two EHEs, but they focus primarily on the
fact that 700 deaths were attributed to the 1995 EHE in Chicago compared to roughly 100
deaths from the 1999 event. The authors then argue that much of this sharp reduction in
mortality can be attributed to the effectiveness of Chicago's EHE program, which, among
other actions, included reminding the public of the toll the 1995 EHE had taken to convey
the risks of the 1999 conditions.
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Additional anecdotal evidence from Philadelphia supports the contention that the city's
EHE program has had a beneficial public health impact. Specifically, although more than
100 deaths in Philadelphia were attributed to the July 1993 EHE, the 1995 EHE experienced
in the city resulted in only 60-70 heat-attributable deaths after the city's EHE program
was implemented that summer [personal communication, Jerry Libby, Philadelphia Health
Promotion Department (retired), September 27, 2005]. This reduced mortality is even more
notable given the higher temperatures and longer duration of the 1995 event.
These results provide limited quantitative evidence that EHE notification and response
programs can demonstrably improve public health.
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Summary Recommendations for
EHE Notification & Response Programs
A central theme of this guidebook is the importance of accounting for local conditions
and populations when defining EHE conditions and developing and implementing EHE
notification and response programs. Despite the recognized difficulty of addressing
all combinations of program needs, opportunities, and constraints that users of this
guidebook may encounter, general recommendations that draw on available data, research
results, and experience with EHE programs can be made.
The foundation for these recommendations is the recognition that EHEs are but one of
a much larger group of extreme meteorological events (e.g., blizzards, floods, hurricanes,
tornadoes) and anthropogenic conditions (i.e., urban smog) that can adversely affect
public health. These recommendations are organized according to data needs and actions
that we believe an EHE notification and response program must address to provide public
health benefits. Specifically, the recommendations are organized into the following general
areas: EHE definition and forecasting, public education and awareness of EHE risk factors
and health impacts, EHE response preparation, EHE response actions, and EHE program
review and evolution.
Each area has two categories of recommendations. Strongly recommended actions address
information or actions we believe an EHE notification and response program must
address to help minimize heat-attributable public health impacts. The second category
of recommendations offers guidance on additional actions or data development that
could enhance the public health effectiveness of an EHE program once the program has
addressed the strongly recommended actions.
4.1 EHE Definition and Forecasting
As with notification and response programs for other extreme meteorological events, the
effectiveness of an EHE notification and response program will initially be constrained
by its ability to define and accurately forecast the relevant meteorological conditions. The
recommendations in this section are intended to ensure timely access to locally relevant
EHE forecast information.
4.1.1 EHE criteria must reflect local conditions
Many established meteorological criteria are used to determine whether forecast or
existing conditions can be labeled as a certain type of extreme meteorological event
(e.g., using maximum sustained wind speeds to identify and categorize hurricane
conditions). A distinguishing feature for most of these criteria is that they do not vary by
location.
In contrast, this guidebook's Technical Working Group (TWG) strongly recommends
that EHE criteria be defined based on a review of local meteorological data. For example,
a criterion that defines anticipated EHE conditions on all days with a forecast maximum
temperature of IOO°F or greater would not be useful in locations where this temperature
has never been observed or in areas where such temperatures are common. In contrast,
a criterion that announces anticipated EHE conditions any time the forecast daily
maximum temperature is greater than the 95™ percentile value for that day from the past
30 years would allow for variation by location.
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Incorporating evidence of heat-attributable adverse health impacts from analyses
of health outcomes and weather conditions can enhance EHE criteria development.
Thus analyses of historical meteorological conditions should incorporate available
health outcome data (e.g., regression-based analyses of daily mortality as a function of
meteorological variables or air masses). Adding additional control variables that have
been identified as affecting the number of heat-attributable health outcomes (e.g., time
of season, prior EHEs in the season) would enhance the results of these analyses. Further,
the results of any enhanced weather-health outcome analyses could be used in a predictive
fashion to calculate the potential health impact of forecast conditions. These predictive
models could then provide a basis for defining EHE conditions based on predicted
changes in health outcomes.
4.1.2 Ensure access to timely meteorological forecasts
An effective EHE notification and response program requires access to reliable
meteorological forecasts to provide lead time for implementing program elements.
To forecast EHEs, we strongly recommend that local officials in the United States use and
evaluate the meteorological data in the NWS' 5-day regional forecasts.
To enhance EHE forecasting, we recommend developing systems that electronically
retrieve and evaluate revised NWS forecast data as they become available. For example,
the University of Delaware's Center for Climatic Research has developed automated
computer systems for existing EHE notification and response programs that retrieve NWS
forecasts as they are updated, assess the forecast data against EHE criteria over the 5-day
forecast period, and notify EHE program managers when EHE criteria are satisfied.
The TWG also recommends that cities not use surveillance-based systems as the primary
means for identifying EHE conditions. Specifically, systems that rely on observable
increases in the demand for medical services such as ambulance calls or demand for
emergency room services to identify EHE conditions are not recommended. Although
$ such systems may have a role in determining appropriate resource allocation during an
EHE, they are of little value as a forecast tool because they do not provide the necessary
lead time for implementing EHE responses.
4.2 Public Education and Awareness of EHE Risk Factors and
Health Impacts
A significant source of the public health impacts of EHEs is that individuals either
fail to adequately recognize the danger associated with EHE conditions or make poor
response choices during EHEs. This is tragically reflected by conclusions that most EHE-
attributable deaths are preventable (CDC, 2004a,c). This conclusion also suggests that
there is a significant need for continued and enhanced public education about the EHE-
attributable risks and health impacts.
4.2.1 Increase and improve EHE notification and public education
The TWG strongly recommends there be a formal system for notifying the public
when EHE conditions are forecast. At a minimum, announcements made using this
system should include information on the anticipated arrival, duration, and severity of
the forecast EHE. In addition, these announcements need to provide the public with
information about critical EHE risk factors (e.g., being very young or old, using certain
36 Excessive Heat Events Guidebook
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medications, having physical or mental impairments that restrict mobility, or lacking the
ability to respond to environmental changes), the symptoms of excessive heat exposure,
and recommended response actions (e.g., seek air-conditioned locations, stay hydrated).
These announcements can be conveyed to the public through usual methods such as
television, radio, and newspapers, and by using established health alert networks such
as those operated by some state health departments (e.g., Minnesota). EHE information
could also be periodically distributed through other avenues such as fliers in newspapers,
local magazines, and church and civic group literature at the start of and periodically
throughout the EHE season. Announcements should describe basic precautionary steps
individuals can take to limit the health risks: stay hydrated; spend time in air-conditioned
environments; wear loose-fitting, light-colored clothing; check on individuals with high-
risk characteristics [see Rudnick (2002) and U.S. EPA Aging Initiative (2004) for more
detailed information]. The announcements should also suggest appropriate responses
when symptoms of excessive heat exposure are observed.
One way to enhance the public education program for EHE risks, impacts, and personal
response strategies is to repeatedly present a clear and consistent message to varied
audiences. An example of such an effort is Toronto Public Health's hosting of an EHE
media day each May before the start of the summer heat season. During this event,
Toronto Public Health provides the media with information about the city's EHE
notification and response program and answers questions about the health risks and
impacts of EHEs. This event maintains media interest in the program and generally results
in reporting that keeps EHEs in the public's eye.
An example of another broad-based educational activity that could be pursued is EHE
education programs for schools. These programs would help inform a vulnerable
segment of the population about risks and appropriate responses and could potentially
provide an effective means of having central messages repeated and adopted by a range of
households.
t
EHE education should also be specifically directed at first responders and local emergency
Q.
management personnel as well as to those who care for older individuals, the very young, J2
the homeless, and the physically and mentally challenged. This targeted education would
inform critical response personnel and caregivers about the health risks EHEs pose to
members of the vulnerable groups they look after and emphasize the need for active
assessment and intervention to prevent adverse health outcomes.
4.2.2 Provide information on proper use of portable electric fans during EHEs
The TWG also strongly recommends that, as part of a public education program, cities
emphasize that portable electric fans are not the simple cooling solution they appear to
be. Because of the limits of conduction and convection, using a portable electric fan alone
when heat index temperatures exceed 99°F actually increases the heat stress the body must
respond to by blowing air that is warmer than the ideal body temperature over the skin
surface (American Medical Association Council on Scientific Affairs, 1997; CDC, 2004c). In
these conditions, portable electric fans provide a cooling effect by evaporating sweat. The
increased circulation of hot air and increased sweat evaporation can, however, speed the
onset of heat-attributable conditions (e.g., heat exhaustion).
Recommendations for EHE Notification and Response Programs 37
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Thus, portable electric fans need to be used with caution and under specific circumstances
during an EHE, such as exhausting hot air from a room or drawing in cooler air through
an open window. Generally, portable electric fans may not be a practical and safe cooling
mechanism during an EHE in homes that are already hot and are not air-conditioned;
their use should be discouraged unless the fans are bringing in significantly cooler air
from outside the dwelling. If a resident must stay in these dwellings, and if they are unable
to access an air-conditioned environment, safer cooling approaches would include taking
frequent cool showers and drinking cool, nonalcoholic fluids (e.g., ice water). Because of
the importance of this issue, and the contradictory messages people may have received
about using portable electric fans during EHEs, Appendix B provides a series of guidelines
for fan use during EHEs.
Finally, public officials should review the various educational messages about EHEs
for consistency with other messages and information on other issues. For example,
recommendations against letting cars idle to control ozone concentrations would be
inconsistent with EHE recommendations to stay in air-conditioned environments
whenever possible. Public officials can recognize any potentially conflicting messages and
then make clear statements about which message should take precedence during an EHE.
4.3 EHE Response Preparation
Preparations for an EHE can be distinguished according to when they are initiated relative
to the development of the EHE. Long-term preparations address actions that need to be
initiated well before an EHE is forecast because of the time needed to reach necessary
agreements, develop systems, or secure supplies and personnel. Short-term preparations
are actions that need to be taken when a multiday forecast anticipates EHE conditions.
This section focuses on long-term preparations; Section 4.4 covers short-term preparation
actions.
4.3.1 Develop a clear plan of action identifying roles and responsibilities
^
$ Defining the structure, relationships, and responsibilities for those supporting an EHE
notification and response program (e.g., health departments, utilities, homeless advocates)
is an essential long-term action. More generally, this action requires establishing a means
for planning and communication among the program supporters so that available
resources are used most efficiently and potentially conflicting messages from program
participants are clarified.
To achieve this coordination, the TWG strongly recommends establishing periodic
meetings among program participants, distributing materials electronically, and
designating points of contact for each participating group or agency. Variations across
locations in the structure and expertise of agencies and the presence of different
private organizations make it problematic to offer specific recommendations about
recommended organizational structures for an EHE program. However, because EHEs are
a threat to public health, relevant public health agencies can and should play a significant,
but not necessarily the lead, role in developing and managing an EHE program. In
addition, local emergency management agencies, street and sanitation departments,
and health code enforcement staff typically have significant contact with the public. As
a result, their information distribution networks and staffs could, depending on local
conditions, be a valuable resource to consider in EHE response planning.
38 Excessive Heat Events Guidebook
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Finally, nonprofits such as the Red Cross, homeless outreach programs, area agencies on
aging, and senior centers should be actively recruited to become EHE program partners to
incorporate their expertise in identifying, communicating with, and providing services to
populations that are at high risk during EHEs.
When developing a plan of action, we also strongly recommend EHE program partners
pay particular attention to the potential for public recommendations that could
conflict during an EHE and provide clear guidance regarding priorities. For example,
environmental organizations may generally recommend against idling cars for extended
periods of time to improve air quality. This message could be modified to note that
if idling is necessary to stay in an air-conditioned environment during an EHE, it is
acceptable and preferable to exposing the occupants to the heat.
4.3.2 Develop long-term urban planning programs to minimize
heat island formation
Although not the focus of this guidebook, the TWG strongly recommends urban design
and development programs be reviewed with a goal of promoting actions that will
help control the development of urban heat islands. The longer timeframes envisioned
for implementing any actions result in these actions being viewed as part of the EHE
preparation actions. However, effective implementation of specific actions designed to
mitigate urban heat islands, such as programs to increase the reflectiveness of urban
surfaces, increase urban vegetation, and modify behavior, is likely to require a significant
public education component.
4.4 EHE Response Actions
This section covers activities that should be initiated after meteorological forecasts
identify an impending EHE or EHE conditions have been announced. Four essential
recommendations involve these short-term EHE response actions:
*• The public should be encouraged to spend time in available air-conditioned buildings ^.
(e.g., shopping centers, movie theaters, senior centers, libraries). To the extent
Q.
these types of buildings have air conditioning, they are also generally capable of J2
accommodating sudden increases in public use for short periods of time (e.g., a few
days) without significant difficulty.
*• EHE program partners should reallocate resources to address critical short-term
needs of the EHE that are likely to provide a significant public health benefit. For
example, this could involve shifting some public health inspectors from inspecting
dining facilities to visiting nursing homes or supporting home environment
assessments for individuals who may call available non-gn help lines. Other examples
could include having homeless agencies emphasize providing daytime services and
interventions during the EHE instead of nighttime services when conditions will
generally be cooler.
>- Once a forecast for EHE conditions has been aired, the locality should prohibit the
suspension of electric and water services. For this reason, all meetings related to the
EHE program should include representatives from local utility companies who have
been solicited as program partners.
Recommendations for EHE Notification and Response Programs 39
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>• Local medical examiners should be directed to use the guidelines set forth by
Donoghue et al. (1997) for classifying heat-related deaths. Although statistical
analyses of total daily mortality can and should be used to identify and quantify
increases in mortality attributable to the EHE, using the Donoghue et al. guidelines
will improve the accuracy of estimates of heat-attributable deaths for those who base
these estimates solely on the information from death certificates.
Additional recommendations for response actions that could provide additional public
health benefits include:
*• Conducting direct assessments of high-risk individuals during EHEs to check for
signs of excessive heat exposure
>• Increasing the extent and duration of public access to air-conditioned settings
>- Increasing the capacity of the emergency medical system to respond to increased
surveillance and treatment demands.
Each of these additional recommendations for enhancing short-term responses is
discussed below.
EHE health risks are not equally distributed among the population. Therefore, the TWG
recommends that enhanced program responses include direct assessments of the health
and environments of those at greatest risk during the EHE. Increasing home visits, using
telephone check-in systems, and operating toll-free lines to provide advice or receive
reports of concerns can alert EHE program staff to individuals who may be at the greatest
risk or experiencing health problems during the EHE and help avoid more serious health
outcomes.
Spending time in an air-conditioned environment has long been recognized and
advocated as the most effective means of preventing heat-attributable health impacts
during an EHE. To increase the potential time spent in air-conditioned locations, we also
recommend the hours of operation and number of air-conditioned locations (e.g., senior
centers, libraries) made publicly available be increased during an EHE. Providing free
transportation to these locations could also increase their use.
Finally, regardless of the extent of preparations and response implemented for an EHE,
it is likely that the onset of EHE conditions will result in an increase in the demand for
emergency medical services in the form of 911 calls, visits to emergency room facilities,
and increased volume and need for medical examiner staff and services. The TWG
therefore recommends additional staffing of emergency medical personnel to increase the
number of people who can receive treatment at any given time, reduce waiting times for
treatment, or both. Existing local and state mutual aid agreements and state emergency
medical assistance compacts as well as the resources of state and local emergency
management agencies, the Federal Emergency Management Agency, the Medical Reserve
Corps, and the National Disaster Medical System may be available to help meet some of
these needs. The applicability and availability of these resources need to be evaluated,
however, and contacts must be established before the onset of EHE conditions.
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Appendix C provides one-page summaries of the critical actions individuals and EHE
program partners can and should take once EHE conditions are forecast or are being
experienced.
4.5 Review EHE Programs to Address Changing Needs,
Opportunities, and Constraints
Over time, the constraints and opportunities faced by an EHE notification and response
program will shift and experience will be gained in developing working relationships
between program partners and in responding to different types of meteorological
conditions. Finally, the relative importance of EHEs as a public health threat could change
over time.
As a result, the TWG strongly recommends establishing a regular and formal review of the
program's performance. For example, in the fall, when the risk of an EHE has diminished,
program partners should evaluate past performance and make recommendations to
improve the notification and response program. Alternatively, hypothetical "table-top"
exercises could be conducted that allow program partners to work through how they
would respond to alternative EHE scenarios in order to identify problems with current
preparation and response activities and develop solutions.
o
a.
Recommendations for EHE Notification and Response Programs
41
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AMA. 2005. Heat- Related Illness During Extreme Weather Emergencies, http://www.ama-
assn.org/ama/pub/category/13637.html.
American Medical Association Council on Scientific Affairs. 1997. Heat- Related Illness
During Extreme Weather Emergencies. Report 10 of the Council on Scientific Affairs (A-
97). Presented at the 1997 AMA Annual Meeting.
American Red Cross. 2005. Heat Waves, http://www.redcross.org/services/
disaster/0, 1082,0_586_,00.html.
Associated Press. 2005. Weather: Homeless Hit Hard by Heat, http://www.cnn.com/2005/
WEATHER/07/22/heat.deaths.ap/index.html. Accessed July 22, 2005.
Basu, R. and J.M. Samet. 2002. Relation between elevated ambient temperature and
mortality: A review of the epidemiologic evidence. Epidemiologic Reviews 24(2):i9o-2O2.
Bernard, S.M. and M.A. McGeehin. 2004. Municipal heat wave response plans. American
Journal of Public Health 94(9):i52o-i522.
CDC. 1994. Heat-related deaths - Philadelphia and United States, 1993-1994. Centers for
Disease Control. Morbidity and Mortality Weekly Report
CDC. 1995. Heat- related mortality- Chicago, July 1995. Centers for Disease Control.
Morbidity and Mortality Weekly Report 44(3i):577-579-
CDC. 1996. Heat-wave-related mortality - Milwaukee, Wisconsin, July 1995. Morbidity
and Mortality Weekly Report
CDC. 1997. Heat- related-deaths - Dallas, Wichita, and Cooke counties, Texas, and United
States, 1996. Morbidity and Mortality Weekly Report 46(23):528-53o.
CDC. 1998. Heat-related mortality - United States, 1997. Morbidity and Mortality Weekly
Report 47(23):473-476.
CDC. 1999. Heat-related-deaths - Missouri, 1998, and United States, 1979-1996. Morbidity
and Mortality Weekly Report 48(22):469-472.
CDC. 2000. Heat-related illnesses, deaths, and risk factors - Cincinnati and Dayton, Ohio,
1999, and United States, 1979-1997. Morbidity and Mortality Weekly Report 49(2i):47o-473.
CDC. 2001. Heat-related-deaths - Los Angeles County, California, 1999-2000, and United
States, 1979-1998. Morbidity and Mortality Weekly Report 5o(29):623-626.
CDC. 2002. Heat-related deaths - four states, July- August 2001, and United States, 1979-
1999. Morbidity and Mortality Weekly Report 5i(26):567-57o.
CDC. 2004A. Extreme Heat: A Prevention Guide to Promote Your Personal Health and
Safety, http://www.bt.cdc. gov/disasters/extremeheat/heat_guide. asp. Accessed January 24,
2005.
I
References
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CDC. 20048. Extreme Heat Bibliography, http://www.bt.cdc.gov/disasters/extremeheat/
bibliography.asp.
CDC. 20040. Extreme Heat: Tips for Preventing Heat-Related Illness, http://www.bt.cdc.
gov/disasters/extremeheat/heattips.asp. Accessed January 24,2005.
Chestnut, L.G., W.S. Breffle, J.B. Smith, and L.S. Kalkstein. 1998. Analysis of differences in
hot-weather-related mortality across 44 U.S. metropolitan areas. Environmental Science
and Policy i(i):59-/o.
Davis, R.E., PC. Knappenberger, PJ. Michaels, and W.M. Novicoff. 2OO3A. Changing heat-
related mortality in the United States. Environmental Health Perspectives Hi(i4):i7i2-i7i8.
Davis, R.E., PC. Knappenberger, W.M. Novicoff, and PJ. Michaels. 20038. Decadal changes
in summer mortality in U.S. cities. International Journal of Biometeorology 47(33:166-175.
Donoghue, E.R., M.A. Graham, J. Jentzen, B.D. Lifschultz, J.L. Luke, and H.G.
Mirchandani. 1997. Criteria for the diagnosis of heat-related deaths: National Association
of Medical Examiners: Position paper. American Journal of Forensic Medicine and
Pathology i8(i):n-i4.
Ebi, K.L., T.J. Teisberg, L.S. Kalkstein, L. Robinson, and R.E Weiher. 2004. Heat watch/
warning systems save lives. Bulletin of the American Meteorological Society 85(8):io67-
1073-
FEMA. 2005A. Extreme Heat: Are You Ready? http://www.fema.gov/areyouready/heat.
shtm.
FEMA. 20058. Hazards Backgrounder: Extreme Heat, http://www.fema.gov/hazards/
extremeheat/heat.shtm. Accessed February 8, 2005.
Greene, J.S. and L.S. Kalkstein. 1996. Quantitative analysis of summer air masses in the
eastern United States and an application to human mortality. Climate Research 7:43-53.
Kalkstein, L.S. 1997. Climate and human mortality: Relationship and mitigating measures.
Advances in Bioclimatology 5:161-177.
Kalkstein, L. 2002. Description of our Heat/Health Watch-Warning Systems: Their Nature
Extent, and Required Resources. Prepared for Stratus Consulting, Boulder, CO.
o Kalkstein, L.S. and R.E. Davis. 1989. Weather and human mortality: An evaluation of
demographic and interregional responses in the United States. Annals of the Association
of American Geographers 79(i):44-64.
Oi
Kalkstein, L.S. and J.S. Greene. 1997. An evaluation of climate/mortality relationships
in large U.S. cities and the possible impacts of a climate change. Environmental Health
Perspectives io5(i):84-93.
Kalkstein, L.S., PR Jamason, J.S. Greene, J. Libby, and L. Robinson. 1996. The Philadelphia
Hot Weather-Health Watch/Warning System: Development and application: Summer
1995. Bulletin of the American Meteorological Society 77(7):i5i9-i528.
44 Excessive Heat Events Guidebook
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Koppe, C., S. Kovats, G. Jendritzky, and B. Menne. 2004. Heat-Waves: Risks and Responses.
World Health Organization, Rome.
Kunihiro, A. and J. Foster. 2004. Heat Exhaustion and Heatstroke. http://www.emedicine.
com/emerg/topic236.htm. Accessed November 28,2005.
LBNL. 2000. Heat Island Group. http://eetd.lbl.gov/HeatIsland/.
Meehl, G.A. and C. Tebaldi. 2004. More intense, more frequent, and longer lasting heat
waves in the 2isr century. Science 305:994-997.
Mills, D.M. 2005. Excessive Heat Events: A Review of Evidence on Health Risks, Impacts,
and Opportunities for Response. Prepared for U.S. Environmental Protection Agency,
Office of Air and Radiation, Office of Atmospheric Programs, Climate Change Division.
October, 27.
Milwaukee Health Department and Milwaukee Heat Task Force. 2005. Milwaukee Health
Department and Milwaukee Heat Task Force: Plan for Excessive Heat Conditions 2005.
http://www.city.milwaukee.gov/display/displayFile.asp?docid = 2689&filename = /
Groups/healthAuthors/DCP/PDFs/Heat_Plan_2005_-_rev_6-17-05.pdf
NCAR. 2005. Heat Wave Awareness Homepage, http://www.isse.ucar.edu/heat/.
New York City Office of Emergency Management. 2005. Ready New York: Extreme Heat.
http://www.nyc.gOV/html/oem/h tml/readynewyork/hazard_heat.html.
NOAA. 1995. Natural Disaster Survey Report: July 1995 Heat Wave. National Oceanic and
Atmospheric Administration, Silver Spring, MD.
NWS. 2004. Heat Wave: A Major Summer Killer. National Weather Service. http://www.
nws.noaa.gov/om/brochures/heatwave.pdf. Accessed January 13,2005.
NWS. 2005. Natural Hazard Statistics, http://www.nws.noaa.gov/om/hazstats.shtml.
NWS Forecast Office, Pueblo, Colorado. 2004. Heat Index. National Weather Service.
http://www.crh.noaa.gov/pub/heat.htm. Accessed January 13,2005.
Palecki, M.A., S.A. Changnon, and K.E. Kunkel. 2001. The nature and impacts of the
July 1999 heat wave in the midwestern United States: Learning from the lessons of 1995.
Bulletin of the American Meteorological Society 82(7) 11353-1368.
Philadelphia Office of Mental Health & Mental Retardation. 2002. Fan Facts. Philadelphia,
PA.
o
at
Rudnick, A. 2002. Reducing the Risk of Heat Stress Disorders for Consumers of Behavioral
Health Services: Questions and Answers. Philadelphia Office of Mental Health & Mental
Retardation, Philadelphia.
Semenza, J.C., J.E. McCullough, WD. Flanders, M.A. McGeehin, and J.R. Lumpkin. 1999.
Excess hospital admissions during the July 1995 heat wave in Chicago. American Journal of
Preventive Medicine i6(4):269-277.
References 45
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I
ffi
1
Sheridan, S.C. and T.J. Dolney. 2003. Heat, mortality, and level of urbanization: Measuring
vulnerability across Ohio, USA. Climate Research 24:255-266.
Sheridan, S.C. and L.S. Kalkstein. 1998. Heat watch-warning systems in urban areas. World
Resource Review io(3):3/5-383.
Sheridan, S.C. and L.S. Kalkstein. 2004. Progress in heat watch-warning system
technology. Bulletin of the American Meteorological Society 85:1931-1941.
Toronto Public Health. 2002. Summer Safety: Fan Facts. Toronto, Ontario, Canada.
U.S. EPA. 2005. Heat Wave Response Programs. U.S. Environmental Protection Agency.
http://epa.gov/heatisland/about/heatresponseprograms.html. Accessed February 22, 2005.
U.S. EPA. 2006. Heat Island Effect. U.S. Environmental Protection Agency. http://www.
epa.gov/heatisland/about/index.html. Accessed January 5,2006.
U.S. EPA Aging Initiative. 2004. It's Too Darn Hot: Planning for Excessive Heat Events.
September. U.S. Environmental Protection Agency, http://www.epa.gov/aging/resources/
epareports.htm#itstoodarnhot. Available in English, low literacy, Spanish, Chinese,
Vietnamese, Haitian Creole, Russian. Accessed August 3,2005.
46
Excessive Heat Events Guidebook
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Appendix A: Excessive Heat Event
Resources Available on the Internet
Extreme Heat Bibliography
Extreme Heat Bibliography, http://www.bt.cdc.gov/disasters/extremeheat/bibliography.
asp. (CDC, 20048)
Heat Index Summaries
Heat Index, http://www.crh.noaa.gov/pub/heat.htm. (NWS Forecast Office, Pueblo,
Colorado, 2004)
Summaries of the Health Risks and Tips for Minimizing Risk
from Exposure to Elevated Temperatures
Extreme Heat: A Prevention Guide to Promote Your Personal Health and Safety, http://
www.bt.cdc.gov/disasters/extremeheat/heat_guide.asp. (CDC, 2OO4A)
Extreme Heat: Are You Ready? http://www.fema.gov/areyouready/heat.shtm. (FEMA,
2005A)
Extreme Heat: Tips for Preventing Heat-Related Illness, http://www.bt.cdc.gov/disasters/
extremeheat/heattips.asp. (CDC, 20040)
Hazards Backgrounder: Extreme Heat, http://www.fema.gov/hazards/extremeheat/heat.
shtm. (FEMA, 20058)
Heat-Related Illness During Extreme Weather Emergencies, http://www.ama-assn.org/
ama/pub/category/13637.html. (AMA, 2005)
Heat Wave: A Major Summer Killer, http://www.nws.noaa.gov/om/brochures/heatwave.
pdf. (NWS, 2004)
Heat Wave Awareness Homepage, http://www.isse.ucar.edu/heat/. (NCAR, 2005)
Heat Wave Response Programs, http://epa.gov/heatisland/about/heatresponseprograms.
html. (U.S. EPA, 2005)
Heat Waves. http://www.redcross.Org/services/disaster/0,1082,0_586_,00.html. (American
Red Cross, 2005)
Natural Hazard Statistics, http://www.nws.noaa.gov/om/hazstats.shtml. (NWS, 2005)
Extreme Heat: Tips for Preventing Heat-Related Illness, http://www.bt.cdc.gov/disasters/
extremeheat/heattips.asp. (CDC, 20040)
Summaries of Existing EHE Programs
Milwaukee Health Department and Milwaukee Heat Task Force: Plan for Excessive
Heat Conditions 2005. http://www.city.milwaukee.gov/display/displayFile.asp?docid =
2689&filename = /Groups/healthAuthors/DCP/PDFs/Heat_Plan_2005_-_rev_6-17-
05.pdf. (Milwaukee Health Department and Milwaukee Heat Task Force, 2005)
Ready New York: Extreme Heat, http://www.nyc.gov/html/oem/html/readynewyork/
hazard_heat.html. (New York City Office of Emergency Management, 2005)
Appendix A: Excessive Heat Event Resources Available on the Internet
a.
47
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Heat Island Effect: Heat Wave Response Programs, http://epa.gov/heatisland/about/
heatresponseprograms.html. (U.S. EPA, 2005)
Urban Heat Island Overview and Control Measures
Heat Island Effect, http://www.epa.gov/heatisland/. (U.S. EPA, 2006)
Heat Island Group. http://eetd.lbl.gov/HeatIsland/. (LBNL, 2000)
EH E Case Studies
Natural Disaster Survey Report: July 1995 Heat Wave, ftp://ftp.nws.noaa.gov/om/
assessments/heat95.pdf. (NOAA, 1995)
Morbidity and Mortality Weekly Report, http://www.cdc.gov/mmwr/
(CDC). Examples:
Heat-Wave-Related Mortality - Milwaukee, Wisconsin, July 1995. June 21,1996. Vol. 45.
No. 24. (CDC, 1996)
Heat-Related-Deaths - Dallas, Wichita, and Cooke Counties, Texas, and United States,
1996. June 13,1997. Vol. 46. No. 23. (CDC, 1997)
Heat-Related Mortality - United States, 1997. June 19,1998. Vol. 47. No. 23. (CDC, 1998)
Heat-Related Illnesses, Deaths, and Risk Factors - Cincinnati and Dayton, Ohio, 1999, and
United States, 1979-1997. Vol. 49. No. 21. (CDC, 2000)
Heat-Related-Deaths - Four States, July-August 2001, and United States, 1979-1999. July 5,
2002. Vol. 51. No. 26. (CDC, 2002)
Heat-Related-Deaths - Los Angeles County, California, 1999-2000, and United States,
1979-1998. July 27,2001. Vol. 50. No. 29. (CDC, 2001)
Heat-Related-Deaths - Missouri, 1998, and United States, 1979-1996. June n, 1999. Vol. 48.
No. 22. (CDC, 1999)
Q.
48
Excessive Heat Events Guidebook
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Appendix B: Use of Portable Electric
Fans During Excessive Heat Events
The widespread availability and ease of using portable electric fans draw
many people to use them for personal cooling during an EHE. Portable
electric fans can, however, increase the circulation of hot air, which
increases thermal stress and health risks during EHE conditions.
As a result, portable electric fans need to be used with caution and under
specific circumstances during an EHE. Here is a list of Do's and Don't's
for their use:
Do
Use a portable electric fan in or next to an open window so heat can
exhaust to the outside (box fans are best).
>- Use a portable electric fan to bring in cooler air from the outside.
*• Plug your portable electric fan directly into a wall outlet. If you need
an extension cord, check that it is UL (Underwriter Laboratories)
approved in the United States or CSA (Canadian Standards
Approved) approved in Canada.
Don't
Use a portable electric fan in a closed room without windows or
doors open to the outside.
+• Believe that portable electric fans cool air. They don't. They just move
the air around and keep you cool by helping to evaporate your sweat.
+• Use a portable electric fan to blow extremely hot air on yourself. This
can accelerate the risk of heat exhaustion.
Use a fan as a substitute for spending time in an air-conditioned
facility during an EHE.
If you are afraid to open your window to use a portable
electric fan, choose other ways to keep cool (e.g., cool
showers, spend time in an air-conditioned location).
Sources: Philadelphia Office of Mental Health & Mental Retardation, 2002; Toronto Public Health, 2002.
Appendix B: Use of Portable Electric Fans during Excessive Heat Events
CO
X
a.
49
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50
Excessive Heat Events Guidebook
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Appendix C: Excessive Heat Events
Guidebook in Brief
Quick Tips for Responding to
Excessive Heat Events
For the Public
Do
>• Use air conditioners or spend time in air-conditioned locations
such as malls and libraries
>• Use portable electric fans to exhaust hot air from rooms or
draw in cooler air
>- Take a cool bath or shower
» Minimize direct exposure to the sun
^ Stay hydrated - regularly drink water or other nonalcoholic fluids
>• Eat light, cool, easy-to-digest foods such as fruit or salads
>• Wear loose fitting, light-colored clothes
*• Check on older, sick, or frail people who may need help
responding to the heat
* Know the symptoms of excessive heat exposure and the
appropriate responses.
Don't
>• Direct the flow of portable electric fans toward yourself when
room temperature is hotter than 90°F
*- Leave children and pets alone in cars for any amount of time
>• Drink alcohol to try to stay cool
Eat heavy, hot, or hard-to-digest foods
Wear heavy, dark clothing.
O
x
a.
Appendix C: Excessive Heat Events Guidebook in Brief
51
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o
X
a
Useful Community Interventions
For Public Officials
Send a clear public message
*• Communicate that EHEs are dangerous and conditions can be
life-threatening. In the event of conflicting environmental safety
recommendations, emphasize that health protection should be the
first priority.
Inform the public of anticipated EHE conditions
»- When will EHE conditions be dangerous?
+• How long will EHE conditions last?
•» How hot will it FEEL at specific times during the day
(e.g., 8 A.M., 12 P.M., 4 P.M., 8 P.M.)?
Assist those at greatest risk
*• Assess locations with vulnerable populations, such as nursing homes
and public housing
Staff additional emergency medical personnel to address the
anticipated increase in demand
" Shift/expand homeless intervention services to cover daytime hours
*- Open cooling centers to offer relief for people without air
conditioning and urge the public to use them.
Provide access to additional sources of information
>• Provide toll-free numbers and Web site addresses for heat
exposure symptoms and responses
>• Open hotlines to report concerns about individuals who may
be at risk
••• Coordinate broadcasts of EHE response information in newspapers
and on television and radio.
52 Excessive Heat Events Guidebook
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