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Medical Examiner Summer Mortality
Surveillance -- United States, 1979-1981
Sustained increases in summer temperature and humidity (heat
waves) have been associated with extensive morbidity and mortality
in
the United States (1-4). Identification of high-risk groups and
effective prevention measures for certain heat-related illnesses
have
allowed development of prevention programs (2,5-13). A pilot study
designed to explore the utility and feasibility of using summer
mortality statistics from medical examiners as a basis for indirect
surveillance of heat-related illness was initiated in June 1981.
The
medical examiners of 16 major metropolitan areas, the National
Climatic Center, and the National Weather Service provided CDC with
the number of deaths each day and meteorologic measurements for the
period June 1 - August 31, 1979-1981.
Average July temperatures were within 4F (2.2C) of normal at
all
surveillance sites in 1979 and 1981, but were as high as 8F (4.4C)
above normal in 1980 at several surveillance sites due to a severe
and
widespread heat wave in July 1980. Deaths reported by medical
examiners rose in mid-July 1980 in areas in which other health
effects
related to heat were severe (Figure 2). The proportionate increase
in
deaths in July 1980 over those reported in July 1979 correlated
poorly
with the average maximum temperature for July 1980, even after
adjustment for the effect of humidity, but correlated well with the
upward departure from the normal July temperature for each
surveillance site.
The striking increase in deaths recorded by medical examiners
and
noted in several cities in association with the onset of unusually
high temperatures suggests that these mortality data are useful in
the
prompt detection of outbreaks of heat-related illness. Further
work
is required to quantify the specificity and sensitivity of this
method. Data collection will continue during the summer of 1982.
Reported by LE Norton, MD, Office of the Jefferson County Medical
Examiner, W Birch, DVM, State Epidemiologist, Alabama State Dept of
Health; HH Karnitschnig, MD, Office of the Maricopa County Medical
Examiner, JJ Sacks, MD, Acting State Epidemiologist, Arizona State
Dept of Health Svcs; TT Noguchi, MD, Office of the Medical
Examiner,
Los Angeles, J Chin, MD, State Epidemiologist, California Dept of
Health Svcs; RR Stivers, MD, Office of the Fulton County Medical
Examiner, RK Sikes, DVM, State Epidemiologist, Georgia Dept of
Human
Resources; P Lipkovic, MD, Office of the Medical Examiner,
Jacksonville, RA Gunn, MD, State Epidemiologist, Florida State Dept
of
Health; F Finger, National Weather Service, Camp Springs, Maryland;
WU
Spitz, MD, Office of the Medical Examiner, Detroit, NS Hayner, MD,
State Epidemiologist, Michigan State Dept of Health; B Peterson,
MD,
Office of the Jackson County Medical Examiner, GE Gantner, MD, ME
Case, MD, Office of the Medical Examiner, St. Louis, HD Donnell Jr,
MD, State Epidemiologist, Missouri State Dept of Social Svcs; GS
Green, MD, Office of the Clark County Coroner, WE Edwards, MD,
State
Epidemiologist, Nevada State Dept of Human Resources; E Gross, MD,
Office of the Medical Examiner, D Sencer, MD, New York City Dept of
Health, R Rothenberg, MD, State Epidemiologist, New York State Dept
of
Public Health; ML Nicodemus, National Climatic Center, Asheville,
HR
Wood, MD, Office of the Mecklenburg County Medical Examiner, MP
Hines,
DVM, North Carolina State Dept of Human Resources; FB Jordan, MD,
Office of the Medical Examiner, Oklahoma City, MA Roberts, PhD,
State
Epidemiologist, Oklahoma State Dept of Health; LV Lewman, MD,
Office
of the Multnomah County Medical Examiner, JA Googins, MD, State
Epidemiologist, Oregon State Dept of Human Resources; RL Catherman,
MD, Office of the Medical Examiner, Philadelphia, EJ Witte, VMD,
State
Epidemiologist, Pennsylvania State Dept of Health; JT Francisco,
MD,
Office of the Medical Examiner, Memphis, RH Hutcheson Jr, MD, State
Epidemiologist, Tennessee State Dept of Public Health; CS Petty,
MD,
Dallas County Institute of Forensic Science, CR Webb Jr, MD, State
Epidemiologist, Texas State Dept of Health; Special Studies Br,
Chronic Disease Div, Center for Environmental Health, CDC. Editorial Note
Editorial Note: Large increases in numbers of deaths from stroke
and
ischemic heart disease as well as deaths from more obviously
heat-related illness (e.g., heatstroke) have been reported in
association with heat waves (14). Deaths caused by these
conditions
are often sudden, unlikely to be witnessed by a physician, and
therefore likely to be investigated by a medical examiner. A
population-based study of heat-related morbidity and mortality in 2
midwestern cities in 1980 showed that numbers of cases reported to
medical examiners increased to a proportionately greater extent
than
did other indirect measures of impact on community health, e.g.,
total
mortality, emergency room visits, and hospital admissions (2).
Surveillance of mortality data from medical examiners is
simple,
timely, and relatively inexpensive. Information that reflects the
health of an entire city is rapidly available from a single source.
Even the time required for post-mortem diagnosis does not delay
collection of data.
Groups at high risk of having heatstroke are the elderly,
infants
1 year of age, military recruits, persons exposed to high
temperatures in the work place, the chronically ill or bedfast, the
mentally ill, those taking antipsychotic or anticholinergic drugs,
and
alcoholics (2,5-7,9-12). Low socioeconomic status and residence in
an
urban area have also been associated with high risk of heatstroke
(2,9). Studies of race and sex as predisposing factors for
heatstroke
have yielded inconsistent results (4,8,9). Deaths from heatstroke
reflect 10%-50% of the increase in mortality associated with
unusually
high temperatures (2,14). Less is known about the risk factors for
deaths not associated with heatstroke during a heat wave.
During a heat wave, prevention programs are best targeted
toward
persons at high risk of having heatstroke. Having home air
conditioning and spending increased time in air-conditoned places
have
been associated with decreased risk, suggesting that
air-conditioned
heat wave shelters are of benefit. Reducing physical activity
during
hot weather has also been associated with decreased risk (5).
Adequate fluid intake is important in reducing the risk of
having
heatstroke (5,13). Although adequate salt intake with meals is
important, salt tablets are of doubtful benefit and should not be
taken unless prescribed by a physician (13). Alcohol consumption
should be reduced or eliminated during very hot weather.
References
Environmental Data and Information Service. Impact assessment:
U.S. social and economic effects of the great 1980 heat wave
and
drought. Washington, DC. National Oceanic and Atmospheric
Administration, US Dept of Commerce 1980:12.
Jones TS, Liang AP, Kilbourne EM, et al. Morbidity and
mortality
associated with the July 1980 heat wave in St. Louis and Kansas
City, Mo. JAMA 1982;247:3327-31.
CDC. Heatstroke--United States, 1980. MMWR 1981;30:277-9.
Henschel A, Burton LL, Margolies L, Smith JE. An analysis of
the
heat deaths in St. Louis during July, 1966. Amer J Public
Health
1969;59:2232-42.
Kilbourne EM, Choi K, Jones TS, Thacker SB, and The Field
Investigation Team. Risk factors for heatstroke: a
case-control
study. JAMA 1982;247:3332-36.
Danks DM, Webb DW, Allen J. Heat illness in infants and young
children. A study of 47 cases. Brit Med J 1962;2:287-93.
Occupational Safety and Health Administration. Hot
environments.
Cincinnati: National Institute for Ocupational Safety and
Health.
(NIOSH publication no. 80-132). 1980.
Schuman SH. Patterns of urban heat-wave deaths and implications
for prevention: data from New York and St. Louis during July,
1966. Environ Res 1972;5:59-75.
Ferris EB, Blankenhorn MA, Robinson HW, Cullen GE. Heat stroke:
clinical and chemical observations on 44 cases. J Clin
Investigation 1938;17:249-62.
Zelman S, Guillan R. Heat stroke in phenothiazine-treated
patients: a report of three fatalities. Amer J Psychiat
1970;126:1787-90.
Wise TN. Heatstroke in three chronic schizophrenics: case
reports
and clinical considerations. Compr Psychiatry 1973;14:263-7.
Adams BE, Manoguerra AS, Lilja GP, Long RS, Ruiz E. Heat stroke
associated with medications having anticholinergic effects.
Minn
Med 1977;60:103-6.
Pitts GC. Johnson RE, Consolazio FC. Work in heat as affected
by
intake of water, salt, and glucose. Am J Physiol 1944;
142:253-9.
Ellis FP. Heat illness. Trans Roy Soc Trop Med Hyg
1977;70:402-28.
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