Heat-Associated Deaths in Maricopa County, AZ Final Report for 2019 Photograph by Dan Sorensen: http://www.dansorensenphotography.com/ Heat Death Report | 2019 ACKNOWLEDGEMENTS .......................................................................................................... 2 INTRODUCTION ..................................................................................................................... 3 RESULTS ................................................................................................................................ 4 Heat-Associated Deaths by Year ............................................................................................................................ 4 Heat-Associated Deaths and Temperatures ........................................................................................................... 6 Heat-Associated Deaths by Residency ................................................................................................................... 7 Heat-Associated Deaths by Time Residing in Arizona* ........................................................................................... 8 DEMOGRAPHIC CHARACTERISTICS OF HEAT-ASSOCIATED DEATHS ......................................... 8 Heat-Associated Death Rates* ............................................................................................................................. 10 Heat-Associated Deaths by Place of Injury ........................................................................................................... 12 Air Conditioning Use for Indoor Deaths* .............................................................................................................. 15 Substance Use among Heat-Associated Deaths ................................................................................................... 16 Living Situation among Heat-Associated Deaths .................................................................................................. 17 CONCLUSIONS ..................................................................................................................... 19 APPENDIX............................................................................................................................ 20 Background.......................................................................................................................................................... 20 Methodology ....................................................................................................................................................... 20 1 Heat Death Report | 2019 Acknowledgements The Maricopa County Department of Public Health (MCDPH), Office of Epidemiology would like to thank the following agencies for their contributions to this report: ➢ Maricopa County Office of the Medical Examiner (OME) ➢ Maricopa County Office of Vital Registration (OVR) ➢ Arizona Department of Health Services (ADHS), Office of Vital Registration ➢ National Weather Service (NWS) ➢ Maricopa Association of Governments (MAG) ➢ Local hospitals (infection preventionists, emergency departments, social worker staff) ➢ City of Phoenix Heat Relief Network To receive additional data, please submit a data request form through the Maricopa County Public Health website here. A staff member from the Climate and Health team will contact you to discuss your request. You may also contact the Climate and Health Team through email: Vjollca Berisha: Vjollca.berisha@maricopa.gov Aaron Gettel: Aaron.gettel@maricopa.gov Adriana Holmes: Adriana.holmes@maricopa.gov 2 Heat Death Report | 2019 Introduction Mortality from environmental heat is a significant public health problem in Maricopa County, especially because it is largely preventable. Maricopa County has conducted heat surveillance since 2006. Each year, the enhanced heat surveillance season usually begins in May and ends in October. The main goals of heat surveillance are to identify the demographic characteristics of heat-associated deaths (e.g., age and gender) and the risk factors for mortality (e.g., homelessness). Sharing this information helps community stakeholders to design interventions to prevent heat-associated deaths among vulnerable populations. The two main sources of data for heat surveillance are: preliminary reports of death (PRODs) from the Office of the Medical Examiner (OME) and death certificates from the MCDPH Office of Vital Registration. Heat-associated deaths are classified as heat caused or heat related. Heat caused deaths are those in which environmental heat was directly involved in the sequence of conditions causing deaths. Heat related deaths are those in which environmental heat contributed to the deaths but was not in the sequence of conditions causing these deaths. For more information on how heatassociated deaths are classified, see the definitions in Appendix. For more information on MCDPH’s surveillance system, see Background and Methodology. 3 Heat Death Report | 2019 Results Note: Values of ≤ 5 or a value that would facilitate calculation of a suppressed value are not included in graphs. To receive additional data, please submit a data request form through the Maricopa County Public Health website here. A staff member from the Climate and Health team will contact you to discuss your request. Heat-Associated Deaths by Year Graph 1. There were 197 heat-associated deaths reported in 2019. 197* 179 182 154 106 85 74 75 38 49 51 42 82 110 75 84 61 49 21 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 *3 cases pending Data Sources: Maricopa County, Office of Vital Registration and Office of Medical Examiner; Arizona Department of Health Services, Office of Vital Registration ➢ See Methodology in the Appendix for more information about the number of confirmed, ruled-out, and pending cases by year. 4 Heat Death Report | 2019 Heat-Associated Deaths by Month Graph 2. Sixty percent of heat-associated deaths since 2006 have been classified as heat-caused. Heat-Caused Heat-Related 60 63 89 66 47 49 27 34 27 13 58 2006 32 2007 2008 119 28 17 38 137 39 33 48 2009 2010 90 2016 2017 63 57 47 88 42 2011 2012 2013 33 2014 45 2015 2018 2019 Graph 3. Eighty-three percent of all heat-associated deaths occurred in the months of July, August, and September (N=163). 55 39 24 0 * April 15 * * May 21 * 8 June July Heat-Related (N=60) * Indicates suppressed value of ≤ 5. 20 August September Heat-Caused (N=137) * * October * 0 November 5 Heat Death Report| 2019 6 Heat-Associated Deaths and Temperatures ➢ The National Weather Service issued 10 excessive heat warnings for a total of twenty-five days in 2019. ➢ The highest daily maximum temperature in 2019 was 115°F and occurred on July 16th and August 5th. Graph 4. Thirty-four percent of heat-associated deaths occurred on days for which an excessive heat warning has been issued. (N=67) 12 120°F 10 100°F 60°F 6 40°F 4 20°F 2 0°F 0 Excessive Heat Warning Heat-Associated Deaths High Temperature Low Temperature Number of Deaths 8 80°F Heat Death Report | 2019 Heat-Associated Deaths by Residency Graph 5. Maricopa County residents accounted for eighty-seven percent of all heat-associated deaths with known county of residence (N=195)* 170 16 Maricopa County Resident Non-Maricopa County Arizona Resident† 9 Non-Arizona Resident‡ † Non-Maricopa County Arizona Resident cases include residents from Apache, Gila, La Paz, Pima, Pinal, Yavapai, and Yuma Counties and one case with unknown county of residency. ‡ Non-Arizona Resident cases include residents of California, Illinois, Minnesota, North Carolina, Oklahoma, Texas, Utah, and Washington. * 2 cases have an unknown residency Heat Death Report| 2019 Heat-Associated Deaths by Time Residing in Arizona* Graph 6. Fivty-eight percent of heat-associated deaths with known residency history had lived in Arizona for 20 or more years at time of death. 22 73 19 12 <3 Years 3-9 Years 10-19 Years 20+ Years *Seventy-one cases for which time spent in Arizona was unknown were excluded from analysis. Demographic Characteristics of Heat-Associated Deaths Graph 7. The majority of heat-associated deaths occurred among males. Female 24% Male 76% 8 Heat Death Report| 2019 Graph 8. Most female deaths (46%) occur among those 65+ years and older, while most male deaths (34%) occur among those 50-64 years old. Male Female 0-4 0% 5-19 0% 20-34 8% 35-49 50-64 6% 8% 26% 10% 34% 29% 65-74 15% 75+ 15% 21% 25% . Graph 9. Sixty-eight percent of heat-associated deaths were among those 50 and older. (N=194)* 33.5% 22.2% 16.5% 18.0% 8.2% 1.5% 0-4 0.0% 5-19 20-34 35-49 Age Range * The ages for three cases were unknown. 50-64 65-74 75+ 9 Heat Death Report| 2019 Graph 10. Sixty-three percent of heat-associated deaths for which race and ethnicity are known occurred among whites. (N=178)* 3% 3% 11% Asian/Pacific Islander Native American African American 20% Hispanic White 63% *Nineteen cases for which race and ethnicity was unknown were excluded from analysis Heat-Associated Death Rates* *Death rate graphs below include rates per 100,000 residents. Rates calculated using census population estimates for 2018. Graph 11. The heat-associated death rate for males was more than three times greater than the rate for females. 5.7 1.8 Males Females 10 Heat Death Report| 2019 Graph 12. While most deaths among females occur for those aged 65 years or older, more deaths among males occur in those 50-64 years old than 65-74 years old. 11.9 Female rates per 100,000 Male 15.5 11.2 7.6 7.5 4.3 2.2 0.0 1.7 0.0 0.0 0-4 5-19 2.7 0.7 0.7 20-34 35-49 50-64 65-74 75+ Age Group Graph 13. The heat-associated death rate increases with age. rates per 100,000 11.0 7.2 7.5 50-64 65-74 4.1 1.2 1.1 0.0 0-4 5-19 20-34 35-49 Age Group 75+ 11 Heat Death Report| 2019 Graph 14. African Americans and Native Americans had the highest rates of heat-associated deaths per 100,000 residents. 6.59 4.37 2.86 2.56 2.43 Asian/Pacific Islander Native American African American Hispanic Heat-Associated Deaths by Place of Injury Graph 15. A lower proportion of deaths occurred indoors than in previous years. 2011 Outdoor, 46% Indoor, 54% 2012 58% 42% 2013 59% 41% 2014 72% 28% 2015 61% 39% 2016 61% 39% 2017 60% 40% 2018 72% 28% 2019 76% 24% Outdoor Indoor White 12 Heat Death Report| 2019 Graph 16. A higher proportion of male deaths than female deaths occurred outdoors. Indoor 16% Indoor 8% Outdoor 16% Outdoor 60% Males Females Graph 17. Fifty-four percent of outdoor deaths with a known location of injury occurred in an urban area. Yard * Business * Car Desert Area/Hiking Trail Residence 12 21 23 Urban Area/Park * Indicates suppressed value of ≤ 5. 85 **3 cases have an unknown place of injury 13 Heat Death Report| 2019 Graph 18. Sixty-three percent of indoor deaths occurred in a house or apartment. Shed * Group Home * Apartment * Trailer/RV 19 Residence 23 * Indicates suppressed value of ≤ 5. **1 case has an unknown place of injury Graph 19. Fouty-three percent of indoor deaths were discovered during a welfare check, compared to just seven percent of outdoor deaths. 20 10 Indoor Deaths Outdoor Deaths 14 Heat Death Report| 2019 Air Conditioning Use for Indoor Deaths* *Evaporative coolers were not considered as A/C units as their ability to cool becomes inadequate in extreme Maricopa County temperatures. Graph 20. Ninety-one percent of indoor deaths had an air conditioning unit present at time of death. (N=43) A/C Not Present 9% A/C Present 91% Graph 21. Among deaths where an A/C unit was present, a nonfunctioning A/C unit was the most common reason for not having a cooled environment at the time of death. 5% 8% Non-Functioning Functioning but Not In Use No Electricity 87% 15 Heat Death Report| 2019 Substance Use among Heat-Associated Deaths Graph 22. Fourty-seven percent of all cases involved substance use as a cause of death or a contributing factor. (N=93) No Substance Use 53% Substance Use 47% Graph 23. In thirty-five percent of cases, drug use was listed as either a cause of death or a contributing factor. (N=68) 68 19 6 Drugs only Alcohol only Drugs and alcohol 16 Heat Death Report| 2019 Graph 24. The proportion of heat-associated deaths involving drug use increased by six percent from the previous year.* 50% Drugs 40% 30% 20% 10% Alcohol 0% 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 *Cases involving both drug and alcohol use are represented uniquely on each line. Living Situation among Heat-Associated Deaths Graph 25. Thirty-seven percent of cases were homeless at time of death. Homeless 67 Living Independently Co-Habitating/Roommate Unknown 50 36 43 17 Heat Death Report| 2019 Graph 26. More heat-associated deaths occurred among homeless individuals than any previous year on record. Homeless Non-Homeless 158 122 121 57 61 100 86 53 53 45 46 6 * 32 90 60 55 76 54 21 22 20 20 20 7 54 67 8 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 * Indicates suppressed value of ≤ 5. 18 Heat Death Report| 2019 Conclusions  There was an 8.2% increase in heat-associated deaths between 2018 and 2019.  Ten excessive heat warnings were issued in 2019 and ranged in average of 3 days. On those days, 34% of all heat-associated deaths occurred.  For the second consecutive year, more heat deaths occurred in September than in June.  There were more heat-caused deaths than heat-related deaths.  Most cases were residents of Maricopa County. Furthermore, most cases had lived in Arizona for 20 years or more.  Among Maricopa County residents, the rate of heat-associated deaths was the highest for males, African Americans, Native Americans, and those 65 years of age or older.  Most cases were injured outdoors. The most common place of injury for outdoor deaths was an urban area. The most common place of injury for indoor deaths was at a private residence.  While 83% of indoor deaths had an A/C unit present at the time of death, in all cases the environment was not being adequately cooled. Reasons for lack of cooling in the presence of an A/C unit include a malfunctioning unit, a lack of electricity, the unit being turned off due to cost, forgetfulness, or other reasons, and the unit being set to a high temperature. A total of 9% of indoor cases did not have an A/C unit present.  Drugs or alcohol were mentioned on the death certificate in half of all cases.  Individuals experiencing homelessness accounted for 37% of heat-associated deaths. 19 Heat Death Report| 2019 Appendix Background In July 2005, Maricopa County (MC) experienced exceptionally high temperatures that contributed to 45 deaths, of which 35 occurred over nine consecutive days. Temperatures reached 116°_F and three excessive heat warnings were issued during this month. After this event, the Maricopa County Department of Public Health (MCDPH) created a novel and effective approach for surveillance of heatassociated deaths in 2006 and has continued to use this system annually. Methodology Surveillance data is obtained from the following sources: 1. The Maricopa County Office of the Medical Examiner (OME) forwards suspected heatrelated deaths to MCDPH and provides data including demographics, preliminary information regarding how the death occurred, and the circumstances of death. In the past, this information came solely as a weekly line list with limited information for each case. However, in February of 2012, MCDPH started receiving all preliminary reports of death (PRODs) from the OME. These reports provide expanded information daily and have changed the screening methods used by MCDPH staff to ensure that all potential heat-related deaths are documented. 2. The MCDPH Office of Vital Registration registers all Maricopa County death certificates in the Arizona Department of Health Services vital records database. The MCDPH Office of Epidemiology searches this database looking for causes of death associated with environmental heat. A Statistical Analysis Software (SAS) program looks for the key phrases and International Classification of Disease-10 (ICD-10) codes listed below. Key Phrases HEAT EXPOSURE ENVIRON ICD 10 Code X30 T67.X EXHAUSTION P810 SUN HEAT STRESS HEAT STROKE HYPERTHERMIA Corresponding Definition Exposure to excessive natural heat Effects of heat and light Environmental hyperthermia of newborn 20 Heat Death Report| 2019 3. Hospital and media reports can sometimes initiate a heat death investigation, for example, if a child is reportedly left in a hot car. Once data are received, analysis of the information is required to identify only those deaths caused as a result of environmental heat. Environmental heat is heat generated by the climate (sun, humidity, etc.) rather than heat from man-made sources such as ovens or manufacturing equipment. Heat-associated deaths are categorized based on the classification criteria listed below: Heat-caused (HC) deaths are those in which environmental heat was directly involved in the sequence of conditions causing deaths. These are deaths where environmental heat terms were indicated in Part I1 of the death certificate causes of death (diseases or conditions in the direct sequence causing death), for cause of death variables (cod_a, cod_b, cod_c, or cod_d). County of death: Maricopa. Heat-related (HR) deaths are those in which environmental heat contributed to the deaths but was not in the sequence of conditions causing these deaths. These are cases where environmental heat terms were mentioned in Part II2 of the death certificate causes of death (diseases and conditions contributing but not directly resulting in the death sequence), but not in any of the Part I death variables (cod_a, cod_b, cod_c, or cod_d). County of death: Maricopa. For the purposes of this report, heat-caused and heat-related deaths are combined and referred to as “heat-associated deaths.” Please note that most jurisdictions report only heat-caused deaths. This should be considered when comparing Maricopa County data with data from other locations. Death certificate data, in combination with the OME notes, are used to produce the information that is contained in this report. Total case count, demographics, residency, drug/alcohol use, and years lived in Arizona are directly retrieved from death certificate data. Place of death location, indoor/outdoor occurrence, air conditioning use, and homelessness are retrieved based on explicit notations made in the death certificate and/or OME notes. For the purposes of this report, reasons for not having a cooled environment at the time of death in indoor cases where an A/C unit was present were grouped into three categories: non-functioning, functioning but turned off, and no electricity. “Non-functioning” is defined as an A/C unit that was not operating properly, was broken, or could not be turned on despite the presence of electricity. Cases categorized as having a “functioning but turned off” A/C unit indicate that the unit worked properly but was the A/C was turned off for some reason at the time of the OME scene inspection. In cases where the unit could not be turned on due to a lack of electricity, regardless of whether it was functioning or non-functioning, were counted in the “no electricity” category. 21 Heat Death Report| 2019 Homelessness is defined as having an address on the death certificate that matches a homeless shelter, government agency, business, or an intersection. Cases are also classified as homeless if there is an indication on the death certificate. If the address is listed as unknown on the death certificate then an examination of the medical examiner’s notes is made to determine if there is a reference to an address - if none, then the person is classified as homeless. If the address is listed as out of jurisdiction then time spent in Arizona, as provided by the death certificate, is taken into consideration. Once classification is completed, the data are summarized for the production and dissemination of reports. Reports are generated weekly during the season and posted to the MCDPH website which can be found at: http://www.maricopa.gov/publichealth/Services/EPI/Reports/heat.aspx 1 Part I of the death certificate: cod a – is the immediate cause (final disease or condition resulting in death) cod b, cod c, cod d – are sequentially listed conditions leading to the cause listed on cod a. 2 Part II of the death certificate: Other significant conditions contributing to death but not resulting in the underlying cause given in Part I. To receive additional data, please submit a data request form through the Maricopa County Public Health website here. A staff member from the Climate and Health team will contact you to discuss your request. You may also contact the Climate and Health Team through email: Vjollca Berisha: Vjollca.berisha@maricopa.gov Aaron Gettel: Aaron.gettel@maricopa.gov Adriana Holmes: Adriana.holmes@maricopa.gov 22