1 figure omitted
During the summer of 1999, a heat wave* occurred in the midwestern and
eastern United States. This period of hot and humid weather persisted from
July 12 through August 1, 1999, and caused or contributed to 22 deaths among
persons residing in Cincinnati (18 deaths) and Dayton (four deaths). A CDC
survey of 24 U.S. metropolitan areas indicated that Ohio recorded some of
the highest rates for heat-related deaths during the 1999 heat wave, with
Cincinnati reporting 21 per million and Dayton reporting seven per million
(CDC, unpublished data, 1999). This report describes four heat-related deaths
representative of those that occurred in Cincinnati or Dayton during the 1999
heat wave, summarizes heat-related deaths in the United States during 1979-1997,
describes risk factors associated with heat-related illness and death, and
recommends preventive measures.
Case 1. In July 1999, a 34-year-old woman with schizophrenia was found dead
in a group home in Cincinnati at 9 a.m. A caretaker discovered the decedent
lying on the couch of a second-floor living room; two windows were open and
fans were blowing. The decedent was last seen alive around noon the previous
day. She had a medical history of hypertensive heart disease, asthma, and
swelling of the ankles for which she had been taking a diuretic, furosemide.
The temperature inside the home at the time of her death was unknown; however,
the ambient temperature was 92.1 F (33.4 C) when the decedent was found. Her
liver core temperature was 106.2 F (41.2 C). The Hamilton County Coroner's
Office attributed the death to heatstroke.
Case 2. In July 1999, an 84-year-old man was found dead in his Dayton residence.
He lived alone and was found lying in bed, supine and nude. The doors to his
home were locked and all the windows were shut. When the body was discovered,
the temperature inside the home was approximately 86 F (30 C). A fan was blowing
air toward the ceiling, an air conditioner was present but not running, and
the thermostat was set in the heat mode. The temperature in Dayton that day
reached greater than 90 F (greater than 32 C) with high humidity. An autopsy
report indicated the decedent suffered from arteriosclerosis and hypertensive
cardiovascular disease. The Montgomery County Coroner's Office attributed
the death to exposure to excessive environmental heat.
Case 3. In July 1999, a 65-year-old man was found in his residence by a neighbor,
unresponsive and having seizures. Following transport to the emergency department
of a local hospital by the Cincinnati Fire Division, the patient had a rectal
temperature of 108 F (42.2 C) and subsequently died. The decedent had a history
of chronic alcoholism and hypertensive cardiovascular disease. He lived alone
in an attic apartment without air conditioning. The Hamilton County Coroner's
Office attributed the death to hypoxic encephalopathy following resuscitation
Case 4. In August 1999, a 24-year-old man was found lying face down on the living
room floor of his Dayton apartment in an early stage of decomposition. The
room temperature was 99 F (37.2 C), and the apartment had no air conditioning.
The decedent lived alone and was last seen alive 3 days earlier at his home
by a neighbor. The decedent had a history of mental illness and depression
and had been taking benztropine. The Montgomery County Coroner's report listed
the probable cause of death as cardiac arrhythmia caused by hyperthermia resulting
from exposure to high environmental temperature.
During 1979-1997, the most recent years for which data are available,
an annual average of 371 deaths in the United States1
were attributable to "excessive heat exposure"† (median: 249; range:
148 in 1979 to 1700 in 1980).5 This translates
into a mean annual death rate of 1.5 per million and a median annual death
rate of one per million. Because of a record heat wave, the heat-related death
rate for 1980 was more than three times higher than that for any other year
during the 19-year period. The median annual death rate for hyperthermia in
persons aged greater than or equal to 65 years was three per million. During
1979-1997, 7046 deaths were attributable to excessive heat exposure: 3010
(43%) were "due to weather conditions," 351 (5%) to heat "of manmade origin,"
and 3683 (52%) "of unspecified origin." Of the 2954 persons whose deaths were
caused by weather conditions and for whom age data were available, persons
aged greater than or equal to 65 years accounted for 1783 (44%) deaths, and
persons aged less than or equal to 14 years accounted for 127 (4%) deaths.
Except children aged less than or equal to 14 years, the average annual rate
of heat-related deaths increased with each age group, particularly for persons
aged greater than or equal to 65 years. During 1979-1997, among persons of
all ages, the annual death rate "due to weather conditions" was two times
higher for men (0.8 per million) than for women (0.4 per million), and more
than three times higher for blacks (1.6 per million) than for whites (0.5
per million). Arizona and Missouri (four per million) and Arkansas and Kansas
(three per million) had the highest annual age-adjusted rates for heat-related
deaths "due to weather conditions."1
MP Adcock, PhD, City of Cincinnati. WH Bines, MS, Montgomery County;
FW Smith, MD, State Epidemiologist, Ohio Dept of Health. Health Studies Br,
Div of Environmental Hazards and Health Effects, National Center for Environmental
Health; and an EIS Officer, CDC.
Behavioral and environmental precautions are essential to preventing
illness and death‡ associated with heat waves or sustained periods
of hot weather (daytime heat index§ of greater than or equal to 105 F
[greater than or equal to 40.6 C] and a nighttime minimum temperature of 80
F [26.7 C] persisting for at least 48 hours).6
Illnesses associated with high environmental temperatures include heatstroke
(hyperthermia), heat exhaustion, heat syncope, and heat cramps.2
Heatstroke is a medical emergency characterized by the rapid onset and increase
(within minutes) of the core body temperature to greater than or equal to
105 F (greater than or equal to 40.6 C), lethargy, disorientation, delirium,
and coma.2 Heatstroke is often fatal despite
rapidly lowering the body temperature (e.g., ice baths), because frequently
irreparable neurologic damage has occurred.2
Heat exhaustion is characterized by dizziness, weakness, or fatigue often
following several days of sustained exposure to hot temperatures, and results
from dehydration or electrolyte imbalance2;
treatment includes replacing fluids and electrolytes and may require hospitalization.2 Physical exertion during hot weather increases
the likelihood of heat syncope and heat cramps caused by peripheral vasodilation.2 Persons who lose consciousness because of heat
syncope should be placed in a recumbent position with feet elevated and given
fluid and electrolyte replacement.2 For
heat cramps, physical exertion should be discontinued and fluids and electrolytes
All persons are at risk for hyperthermia when exposed to a sustained
period of excessive heat2; however, factors
that increase the risk for hyperthermia and heat-related death include age
(e.g., the elderly), chronic health conditions (e.g., cardiovascular disease
or respiratory diseases), mental illness (e.g., schizophrenia), social circumstances
(e.g., living alone), and other conditions that might interfere with the ability
to care for oneself.2,3
Other risk factors are alcohol consumption, which may cause dehydration, previous
heatstroke, physical exertion in exceptionally hot environments, the use of
medications that interfere with the body's heat regulatory system, such as
neuroleptics (e.g., antipsychotics and major tranquilizers), and medications
with anticholinergic effects (e.g., tricyclic antidepressants, antihistamines,
some antiparkinsonian agents, and some over-the-counter sleep medication).2- 4 Persons working
in hot indoor or outdoor environments should take 10-14 days to acclimate
to high temperatures.
Although adequate salt intake is important, salt tablets are not recommended
and can be hazardous to some persons.2 Although
the use of fans may increase comfort at temperatures less than 90 F (less
than 32.2 C), fans are not protective against heatstroke when temperatures
reach greater than or equal to 90 F (greater than or equal to 32.2 C) and
humidity exceeds 35%.2,4
Measures for preventing heat-related illness and death during a heat
wave include spending time in air conditioned environments, increasing nonalcoholic
fluid intake, exercising only during cooler parts of the day, and taking cool
baths.2 Elderly persons should be encouraged
to take advantage of air conditioned environments (e.g., shopping malls, senior
centers, and public libraries), even for part of the day.2- 4
Public health information about exceptionally high temperatures should be
directed toward persons aged greater than or equal to 65 years and less than
5 years. Parents should be educated about the heat sensitivity of children
aged less than 5 years,2 and should never
leave them unattended, especially in motor vehicles. When a heat wave is predicted,
friends, relatives, neighbors, and caretakers should check frequently on elderly,
disabled, mentally ill, chronically ill, and home-bound persons, and during
periods of high temperatures, prevention messages should be disseminated to
the public as early and often as possible.
*Three or more consecutive days of air temperatures greater than or
equal to 90 F (greater than or equal to 32.2 C).
†The National Association of Medical Examiners' (NAME) definition
for heat-related death includes exposure to high ambient temperature either
causing the death or as substantially contributing to it, cases where the
body temperature at time of collapse was greater than or equal to 105 F (greater
than or equal to 40.6 C), and a history of exposure to high ambient temperature
and the reasonable exclusion of other causes of hyperthermia.1
Because death rates from other causes (e.g., cardiovascular and respiratory
disease) increase during heat waves2- 4
(defined by the National Weather Service as greater than or equal to 3 consecutive
days of temperature greater than 90 F [greater than or equal to 32.2 C]),
deaths classified as caused by hyperthermia represent only a portion of heat-related
‡Underlying cause of death attributed to "excessive heat exposure,"
classified according to the International Classification of Diseases, Ninth
Revision (ICD-9), code E900.0, "due to weather conditions" (deaths); code
E900.1, "of manmade origin" (deaths); or code E900.9, "of unspecified origin"
(deaths). Data were obtained from the Compressed Mortality File of CDC's National
Center for Health Statistics, which contains information from death certificates
filed in 50 states and the District of Columbia. All rates were age-standardized
to the 1990 U.S. population.
§Heat index is a measure of the effect of combined elements (e.g.,
heat and humidity) on the body.
1 table omitted
Heart disease and stroke, the principal causes of cardiovascular disease
(CVD), are the first and fifth leading causes of death among American Indians
and Alaska Natives (AI/AN).1,2
Risk factors for CVD frequently cluster, which may increase CVD risk multiplicatively.3 To characterize the prevalence of risk factors
for CVD (i.e., hypertension, current cigarette smoking, high cholesterol,
obesity, and diabetes) among AI/AN, CDC analyzed data from the 1997 Behavioral Risk Factor Surveillance
System (BRFSS). This report summarizes the results of that analysis, which
indicated that 63.7% of AI/AN men and 61.4% of AI/AN women who participated
in the survey had one or more CVD risk factors.
BRFSS is an ongoing state-based, random-digit-dialed telephone survey
of the U.S., noninstitutionalized civilian population. Self-reported data
were analyzed for the 1820 AI/AN aged greater than or equal to 18 years who
participated in the 1997 BRFSS in 50 states and the District of Columbia (DC).
Identification of race as AI/AN was based on response to the question, "What
is your race?" Awareness of hypertension, high cholesterol, and diabetes was
determined by the response to, "Have you even been told by a doctor or other
health professional that you have (hypertension, high cholesterol, diabetes)?"
Current smoking status was defined as having smoked at least 100 cigarettes
during one's lifetime and still smoking at the time of the survey. Self-reported
data on height and weight were used to calculate body mass index (BMI). Obesity
was defined as a BMI greater than or equal to 30 kg/m2. Persons
defined as employed were either employed for wages or self-employed, regardless
of the number of hours spent on the job. The 50 states and DC were grouped
into the four geographic regions defined by the U.S. Bureau of the Census.1 Sample estimates were weighted by sex, age, and
race to reflect the state's noninstitutionalized civilian population. To account
for the complex sampling design, SUDAAN was used for data analysis.4
Of the 1820 AI/AN BRFSS participants, 46.3% were women; 63.3% were aged
18-44 years, 25.6% were 45-64 years, and 11.1% were ≥ 65 years (mean: 42.4
years; standard deviation=16.2); 15.9% were college graduates; 60.2% were
employed; and 49.8% ranked their health status as excellent or very good.
The largest percentage of AI/AN participants in the BRFSS lived in the West
(47.4%), followed by the South (25.9%), the Midwest (17.4%) and the Northeast
Approximately 22% of participants reported being told by a health professional
that they had hypertension (women=23.0%, men=21.0%). Thirty-one percent reported
they were current smokers (men=32.8%; women=28.8%). Approximately 16% were
told by a health professional that they had high cholesterol, and 7% were
told they had diabetes. Awareness of high cholesterol and diabetes was higher
among women (17.6% and 9.1%, respectively) than men (13.8% and 5.5%, respectively).
Nearly one fourth (23.6%) of men and nearly one fifth (19.1%) of women were
categorized as obese (21.5% of all AI/AN).
Among AI/AN men, 36.3% reported having none of the selected CVD risk
factors, 41.4% reported having one risk factor, and 22.3% reported having ≥
2 risk factors. Among AI/AN women, 38.6% reported having no CVD risk factors,
37.7% reported having one risk factor, and 23.7% reported having ≥ 2 risk
The prevalence of having one or more CVD risk factors increased with
increasing age. The prevalence of having ≥ 2 risk factors was highest among
respondents aged ≥ 65 years. The prevalence of having ≥ 2 CVD risk factors
varied inversely with level of education. Approximately 25% of AI/AN men with
less than a high school education reported having ≥ 2 CVD risk factors,
compared with approximately 15% of AI/AN men who were college graduates. AI/AN
women with less than a high school education were almost three times more
likely to report having ≥ 2 risk factors than were AI/AN women who had
graduated from college. The percentage of having ≥ 2 risk factors was almost
three times higher among unemployed women than employed women.
Half of the respondents who reported their health status as fair or
poor reported having ≥ 2 CVD risk factors (women=51.8%; men=50.0%) compared
with approximately one eighth of respondents who reported their health status
as excellent or very good (women=13.3%; men=13.2%).
The number of reported CVD risk factors varied by geographic region.
For men, the prevalence of having ≥ 2 risk factors was highest in the Midwest
(26.1%) and lowest in the Northeast (13.8%). Less geographic variation was
observed among women. The prevalence of having ≥ 2 risk factors was highest
in the Northeast (28.0%) and lowest in the West (20.0%).
The following BRFSS coordinators: S Reese, MPH, Alabama; P Owen, Alaska;
B Bender, MBA, Arizona; G Potts, MBA, Arkansas; B Davis, PhD, California;
M Leff, MSPH, Colorado; M Adams, MPH, Connecticut; F Breukelman, Delaware;
I Bullo, District of Columbia;'s Hoecherl, Florida; L Martin, MS, Georgia;
F Reyes-Salvail, MS, Hawaii; J Aydelotte, MA, Idaho; B Steiner, MS, Illinois;
L Stemnock, Indiana; K MacIntyre, Iowa; C Hunt, Kansas; T Sparks, Kentucky;
B Bates, MSPH, Louisiana; D Maines, Maine; A Weinstein, MA, Maryland; D Brooks,
MPH, Massachusetts; H McGee, MPH, Michigan; N Salem, PhD, Minnesota; D Johnson,
MS, Mississippi; J Jackson-Thompson, PhD, Missouri; P Feigley, PhD, Montana;
L Andelt, PhD, Nebraska; E DeJan, MPH, Nevada; L Powers, MA, New Hampshire;
G Boeselager, MS, New Jersey; W Honey, MPH, New Mexico; C Baker, New York;
P Buescher, PhD, North Carolina; L Shireley, MPH, North Dakota; P Pullen,
Ohio; K Baker, MPH, Oklahoma; J Grant-Worley, MS, Oregon; L Mann, Pennsylvania;
J Hesser, PhD, Rhode Island; M Wu, MD, South Carolina; M Gildemaster, South
Dakota; D Ridings, Tennessee; K Condon, Texas; K Marti, Utah; C Roe, MS, Vermont;
K Carswell, MPH, Virginia; K Wynkoop Simmons, PhD, Washington; F King, West
Virginia; P Imm, MS, Wisconsin; M Futa, MA, Wyoming. Div of Applied Public
Health Training, Epidemiology Program Office; Cardiovascular Health Br, Div
of Adult and Community Health, National Center for Chronic Disease Prevention
and Health Promotion; and an EIS Officer, CDC.
The findings in this report document the prevalence of selected CVD
risk factors among AI/AN by sociodemographic characteristics and are consistent
with previous findings that CVD risk factors and death rates are not uniformly
distributed across regions among AI/AN.2,5
Higher CVD death rates have been reported among AI/AN residing in the Midwest2; data from this study indicate that AI/AN men residing
in the Midwest were most likely to report having ≥ 2 CVD risk factors.
Geographic variation in risk factors and death rates may reflect differences
in cultural backgrounds, historical circumstances, and socioeconomic conditions.
Prevalence estimates probably are influenced by sociodemographic factors (i.e.,
age distribution, educational attainment, employment status, and poverty),
lifestyle (i.e., physical inactivity), aspects of the social environment (i.e.,
educational and economic opportunities), and factors affecting the health-care
system (i.e., access to health care, cost, and availability of screening for
diseases and risk factors). Higher prevalences of multiple CVD risk factors
among AI/AN participants who were either unemployed or had completed less
than a high school education corroborate the well-documented influence of
low socioeconomic status on CVD risk factors.
The findings in this report are subject to at least five limitations.
First, estimates of CVD risk factors are based on self-reported data and are
subject to the biases associated with self-reported data. Second, these results
probably underestimate the prevalence of CVD risk factors because the data
are dependent on the respondent being aware of his risk factor profile. Third,
data on physical inactivity, a risk factor for CVD, was not collected in the
1997 BRFSS survey. If data on physical activity levels had been included,
the prevalence of CVD risk factors among AI/AN probably would have been higher.
Fourth, approximately 23% of AI/AN households do not have a telephone6; these findings could underestimate the prevalence
of CVD risk factors among AI/AN because persons without telephones are more
likely to be of lower socioeconomic status and to have higher risk for disease.7 Finally, BRFSS does not collect information on
reservation residency or tribal affiliation. Aggregating the AI/AN participants
into relatively large geographic regions may mask important differences among
The percentages of AI/AN with multiple CVD risk factors highlight the
importance of enhancing primary prevention activities among communities of
AI/AN. Through CDC's Racial and Ethnic Approaches to Community Health (REACH
2010) Project,8 two AI/AN communities are
developing effective and sustainable programs designed to eliminate racial/ethnic
disparities in CVD and diabetes. Another activity is the Inter-Tribal Heart
Project, a collaboration between CDC, the Indian Health Service, and three
tribal communities to determine the prevalence of risk factors for heart disease
and to implement community-based heart disease prevention programs.9 Reducing the prevalence of CVD risk factors among
AI/AN requires an understanding of the diversity of cultural values and practices
among AI/AN, and historical circumstances that contributed to the current
socioeconomic conditions. Therefore, tribal-specific assessments of CVD risk
factor profiles and CVD morbidity and mortality profiles are needed to develop
culturally relevant CVD prevention programs and policies that support heart-healthy
living and working conditions for AI/AN.
*Northeast=Connecticut, Maine, Massachusetts, New Hampshire, New Jersey,
New York, Pennsylvania, Rhode Island, and Vermont; Midwest=Illinois, Indiana,
Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio,
South Dakota, and Wisconsin; South=Alabama, Arkansas, Delaware, District of
Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North
Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia;
and West=Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada,
New Mexico, Oregon, Utah, Washington, and Wyoming.
MMWR. 2000;49:305 .
CDC has launched its Spanish language web site, CDC En Espanol, on the
World-Wide Web at http://www.cdc.gov/spanish/. It is also accessible
from the left navigation side bar of the CDC home page.
CDC En Espanol is not a translation of the English language web site
but is a site tailored to Hispanic/Latino populations. It provides health-related
information to the Hispanic/Latino professional and to the Spanish-speaking
community. The site also includes information directed at special groups,
such as adolescents, students, teachers, patients, health-care providers,
women, and men.
Included is information from the CDC and Agency for Toxic Substances
and Disease Registry (ATSDR) centers, institutes, and offices and appropriate
links to other key federal agency web sites that are important to the Hispanic/Latino
community. CDC En Espanol provides an opportunity for CDC/ATSDR and its national
and international partners to access common information and discuss issues.
Questions related to CDC En Espanol can be sent by e-mail to firstname.lastname@example.org.
Current Procedural Terminology (CPT) codes are standardized codes developed
and maintained by the American Medical Association (AMA) for the classification
and reporting of medical services. The Health Care Financing Administration
(HCFA) requires the use of these codes for reporting services to Medicare
and Medicaid for reimbursement. On January 1, 1998, the components of the
test panel for acute viral hepatitis (CPT#80059) were changed to exclude the
tests for IgM antibody to hepatitis A virus (IgM anti-HAV) and IgM antibody
to hepatitis B core antigen (IgM anti-HBc), the tests that specifically identify
recent infection with hepatitis A virus (HAV) and hepatitis B virus (HBV).
Effective January 1, 2000 (CPT 2000), the acute hepatitis panel has
been revised (CPT#80074) to re-include the tests for IgM anti-HAV and IgM
anti-HBc. This revised panel, which also includes tests for hepatitis B surface
antigen (HBsAg) and antibody to hepatitis C virus (anti-HCV), should be used
to diagnose any patient presenting with signs and/or symptoms of acute viral
hepatitis. Additional information on CPT codes is available at
the AMA World-Wide Web site, http://www.ama-assn.org/med-sci/cpt/coding.htm.*
*References to sites of non-CDC organizations on the World-Wide Web
are provided as a service to MMWR readers and do not constitute or imply endorsement
of these organizations or their programs by CDC or the U.S. Department of
Health and Human Services. CDC is not responsible for the content of pages
found at these sites.
On May 15, 2000, CDC posted on its World-Wide Web site an interactive
web-based training program titled "Hepatitis C: What Clinicians and Other
Health Professionals Need to Know." The program is at http://www.cdc.gov/hepatitis.
This program provides users with up-to-date information on the epidemiology,
diagnosis, and management of hepatitis C virus (HCV) infection and HCV-related
chronic disease. Users also can test their knowledge of the material through
study questions at the end of each section and case studies at the end of
the program. Continuing medical and nursing education credits are available
free from CDC on completion of the training. The American Academy of Family
Physicians also will grant the academy's education credits on completion of
training and filing with the academy.
In the article "Cause-Specific Adult Mortality: Evidence From Community-Based
Surveillance-Selected Sites, Tanzania, 1992-1998," the district location of
Dar es Salaam was misidentified. The first sentence of the second paragraph
should read: The AMMP surveillance project was conducted in a low-income and
in a middle-income section of the city of Dar es Salaam, in part of a region
ranked by the Tanzanian government as being among the 50% most deprived in
Tanzania (i.e., Morogoro Rural District in Morogoro Region), and in part of
a region ranked as one of the 15% least deprived (i.e., Hai District in Kilimanjaro
Heat-Related Illnesses, Deaths, and Risk Factors—Cincinnati and Dayton, Ohio, 1999, and United States, 1979-1997. JAMA. 2000;284(1):34-35. doi:10.1001/jama.284.1.34