Heat-Associated Deaths in Maricopa County, AZ Final Report for 2020 Photograph by Dan Sorensen: http://www.dansorensenphotography.com/ Heat Death Report | 2020 ACKNOWLEDGEMENTS...................................................................................................... 2 INTRODUCTION .................................................................................................................. 3 RESULTS ................................................................................................................................ 4 Heat-Associated Deaths by Year................................................................................................................... 4 Heat-Associated Deaths by Month................................................................................................................ 5 Heat-Associated Deaths and Temperatures. .............................................................................................. 6 Heat-Associated Deaths by Residency ........................................................................................................ 7 Demographic Characteristics of Heat-Associated Deaths ...................................................................... 9 Heat-Associated Death Rates....................................................................................................................... 11 Heat-Associated Deaths by Place of Injury ............................................................................................... 13 Air Conditioning Use for Indoor Injuries ....................................................................................................... 21 Substance Use among Heat-Associated Deaths ...................................................................................... 22 Living Situation among Heat-Associated Deaths...................................................................................... 25 Education and Heat-Associated Deaths .................................................................................................... 26 Time of Day and Heat-Associated Deaths ................................................................................................. 27 Air Quality Index and Heat-Associated Deaths ........................................................................................ 28 COVID-19 Heat-Associated Deaths ............................................................................................................ 30 CONCLUSIONS ................................................................................................................. 32 APPENDICES ........................................................................................................................ 34 Appendix 1 - Background and Methodology ........................................................................................................ 34 Appendix 2 – Tables ............................................................................................................................................. 38 Appendix 3 – Profiles ........................................................................................................................................... 50 1 Heat Death Report | 2020 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 Tony Bishop: Tony.bishop@maricopa.gov Jessica Whitney: Jessica.whitney@maricopa.gov Primary Author: Olivia Stratford, Epidemiology Climate and Health Intern 2 Heat Death Report | 2020 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 heatassociated 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 events causing deaths. Heat-related deaths are those in which environmental heat contributed to the deaths but was not in the sequence of events causing these deaths. For more information on how heat-associated deaths are classified, see the definitions in Appendix. For more information on MCDPH’s surveillance system, see Background and Methodology. 3 Heat Death Report | 2020 Results Heat-Associated Deaths by Year Graph 1. There were 323 heat-associated deaths reported in 2020, a 62.3% increase from 2019, and 15 times the amount from 2001. 323 179 182 199 154 106 75 21 38 85 51 49 42 49 74 110 75 61 84 82 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Graph 2. Sixty-one percent of heat-associated deaths since 2006 have been classified as heat caused. 34% 43% 32% 46% 50% 35% 66% 43% 36% 41% 68% 25% 75% 35% 65% 64% 59% 54% 57% 2006 2007 2008 2009 2010 2011 2012 44% 46% 46% 56% 54% 54% 2013 2014 2015 Heat-Caused 31% 57% 50% 2016 2017 65% 2018 69% 2019 2020 Heat Related *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 | 2020 5 Heat-Associated Deaths by Month ➢ The months with the greatest number of deaths have been migrating to later in the year over time. June and July had been the months with the greatest number of deaths in 2013, while July and August are more prominent in 2020. Graph 3. Eighty-seven percent of all heat associated deaths occurred in the months of July, August, and September (N=323). 48% 33% 7% 3% 1% April May 6% June July August 1% September October Graph 4. Heat associated deaths have been migrating, occurring more often in the second half of the year. 44% 31% 35% 30% 21% 10% 21% Jan Feb March 2006-2008 April May 2009-2011 June July 2012-2014 15% 8% August Sept 2015-2017 1% 2% October November December 2018-2020 Heat Death Report| 2020 6 Heat-Associated Deaths and Temperatures. ➢ In 2020, the National Weather Service issued twelve excessive heat warnings for a total of 48 days. The average number of heat warnings for the past 5 years (2015-2019) is 5 lasting for a total of 17 days. ➢ The highest daily temperature this year (2020) occurred on July 30th and was 118°F, 2 deaths occurred on this day. The average highest daily temperature for the past 5 years (2015-2019) is 117°F. The highest daily temperatures ranged from 115°F to 119°F. ➢ For the past 5 years (2015-2019), an average of 23% of heat-associated deaths occurred on days for which an excessive heat warning had been issued. Last year (2019), 34% of heat-associated deaths occurred on days for which an excessive heat warning had been issued. Graph 5. Fifty-two percent of heat-associated deaths occurred on days for which an excessive heat warning has been issued. (N=167). 16 120°F 14 100°F 12 10 60°F 8 6 40°F 4 20°F 0°F 4/26/2020 2 0 5/26/2020 Excessive Heat Warning 6/26/2020 7/26/2020 Heat Associated Deaths 8/26/2020 Daily Minimum Temperature 9/26/2020 10/26/2020 Daily Maximum Temperature Number of Deaths 80°F Heat Death Report | 2020 Heat-Associated Deaths by Residency Graph 6. Maricopa County residents accounted for 86% of all heat-associated deaths among cases with known county of residence. 86% 8% 5% Maricopa County Resident Non-Maricopa County Arizona Resident† Non-Arizona Resident‡ † Non-Maricopa County Arizona Resident cases include residents from Apache, Coconino, Gila, Graham, Mohave, Navajo, Pima, Pinal, Yavapai, and Yuma Counties and cases of unknown county residency in Arizona. ‡ Non-Arizona Resident cases include residents of Alaska, California, Louisiana, Maryland, Michigan, Missouri, Nayarit, New Mexico, Ohio, Oregon, Pennsylvania, Texas, and Utah. * 16 cases have an unknown residency state or county. Heat Death Report| 2020 Graph 7. Sixty-three percent of heat-associated deaths with Arizona residency history had lived in Arizona for 20 or more years at time of death. 16% 63% 13% 7% <3 Years 3-9 Years 10-19 Years 20+ Years *Seventy-two cases for which time spent in Arizona was unknown were excluded from analysis. 8 Heat Death Report| 2020 Demographic Characteristics of Heat-Associated Deaths Graph 8. Males made up 81% of all heat associated deaths. 19% Male Female 81% Graph 9. Males saw the highest number of heat associated deaths across all age groups, except children ages 0-4. 28% 75+ 10% 65-74 10% 11% 31% 50-64 38% Female 23% 35-49 20-34 5% 5-19 0% 0-4 2% 30% 11% *See Appendix 3 for more detailed information on youth heat-associated deaths Male 9 Heat Death Report| 2020 Graph 10. Sixty-one percent of heat-associated deaths were among those 50 and older. 37% 29% 11% 10% 20-34 35-49 50-64 65-74 13% 75+ AGE RANGE * The ages for one case was unknown. ** Children ages 0-19 made up <%1 of the total data and were excluded from this graph. ***See Appendix 3 for more detailed information on youth heat-associated deaths Graph 11. Blacks and American Indians are disproportionately represented among heat-associated deaths. White 60% Hispanic 20% African American 15% American Indian Asian/Pacific Islander 4% 1% *Six cases for which race, and ethnicity was unknown were excluded from analysis **See Appendix 3 for more detailed information on African American, Hispanic, and American Indian heatassociated deaths 10 Heat Death Report| 2020 Heat-Associated Death Rates • Death rate graphs below include rates per 100,000 residents. Rates calculated using census population estimates for 2019. Graph 12. The heat-associated death rate for males was more than three times greater than the rate for females. 9.8 2.5 Males Females Graph 13. For males, the heat-associated death rate was highest in the 5064 age group. For females, the heat-associated death rate was highest in the 75+ year age group. 22.1 17.8 13.8 Male 12.4 Female 9.7 5.1 4.7 2.8 2.5 0.0 0.7 0-4 0.2 0.0 5-19 0.6 20-34 35-49 50-64 65-74 75+ 11 Heat Death Report| 2020 Graph 14. Those aged 50-64 and 75+ had the highest rates of heatassociated death. 13.3 13.1 8.2 7.2 2.9 0.4 0.1 0-4 5-19 20-34 35-49 50-64 65-74 75+ Age Group Graph 15. African Americans and American Indians had the highest rates of heat-associated deaths per 100,000 residents. Black/African American 15.71 American Indian 9.15 White Non-Hispanic 6.77 Hispanic Asian/Pacific Islander 3.76 2.03 *See Appendix 3 for more detailed information on African American, Hispanic, and American Indian heatassociated deaths. 12 Heat Death Report| 2020 Heat-Associated Deaths by Place of Injury Table 1. Top 3 cities in Maricopa County with the highest number of deaths City Number of Deaths Rate per 100,000 Phoenix 191 12 Tempe 17 9 Mesa 26 5 *Rates based on US Census Bureau 2019 Population Rate by City Graph 16. Of the deaths where the ZIP code for place of injury is known (N=305), the ZIP codes 85034, 85337, 85004, 85007, and 85320 had the highest rates of heat-associated deaths per 100,000 residents. 287 179 85034 85337 101 100 85004 85007 84 85320 13 Heat Death Report| 2020 Table 2. Top 5 ZIP codes in Maricopa County with the highest rates of deaths Zip Code 85034 (Phoenix) 85377 (Carefree) 85004 (Phoenix) 85007 (Phoenix) 85320 (Aguila) Number of Deaths Rate per 100,000 16 287 5 179 1 101 5 100 14 84 Graph 17. A greater proportion of injuries that lead to deaths occurred outdoors than in previous years. 2011 46% 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% 2020 85% Outdoor 15% Indoor 14 Heat Death Report| 2020 Graph 18. A higher proportion of male injuries than female injuries occurred outdoors. 10% 34% Indoor Outdoor 66% 90% Males Females *See appendix 3 for more detailed information on male/female indoor and male outdoor heat-associated deaths. Graph 19. Fifty percent of indoor deaths were found during a welfare check compared to five percent of outdoor deaths. Outdoor Deaths Indoor Deaths 5% 95% 50% Welfare Check 50% No Welfare Check 15 Heat Death Report| 2020 Outdoor Deaths Graph 20. Sixty-one percent of outdoor injuries with a known location of injury occurred in an urban area. Other 1% Unknown 2% Urban Area/Park 61% Residence 19% Desert Area/Hiking Trail 14% Car 3% *9 total cases have an unknown indoor/outdoor place of injury ** See appendix 3 for more detailed information on heat-associated car deaths. Graph 21. The greatest number of outdoor deaths happened in the 2nd week of July. 04/26-05/02 05/10-05/16 05/24-05/30 1% 1% 0% 1% 0% 4% 06/07-06/13 1% 1% 1% 06/21-06/27 3% 07/05-07/11 10% 19% 07/19-07/25 9% 13% 08/02-08/08 7% 6% 08/16-08/22 8% 5% 08/30-09/05 09/13-09/19 09/27-10/03 10/11-10/17 10/25-10/31 6% 1% 0% 0% 1% 1% 0% 16 Heat Death Report| 2020 Graph 22. Outdoor heat associated deaths occurred most often in July. 49% 31% 8% 1% April 7% 3% 1% May June July August September October Graph 23. The average high air temperature for outdoor heat associated deaths was 108 degrees. 140 14 120 12 100 10 80 8 60 6 40 4 20 2 0 0 4/26/2020 5/26/2020 6/26/2020 Number of Outdoor Deaths 7/26/2020 8/26/2020 Daily Maximum Temperature 9/26/2020 10/26/2020 Daily Minimum Temperature 17 Heat Death Report| 2020 Male Outdoor Death Demographics Graph 24. Sixty-three percent of outdoor male deaths occurred in an urban area. 63% 16% 16% 2% Car      2% 1% Desert Area Other Residence Unknown Urban Areas Eighty-five percent of outdoor deaths were male. Sixty-seven percent of male outdoor deaths were homeless. Seventy-five percent of homeless males died in an urban area. Thirty-seven percent of all male outdoor deaths were aged 50-64. Fifty-six percent of all male outdoor deaths identified as White/Non-Hispanic. Indoor Deaths Graph 25. Twenty-eight percent of indoor heat-associated deaths occurred in a trailer/RV. Condo Apartment 2% 9% House 54% Trailer/RV Unknown Type of Residence 28% 7% *9 total cases have an unknown indoor/outdoor place of injury **Unknown Type of Residence is defined as an unspecified living space. ***See Appendix 3 for more detailed information on mobile home heat-associated deaths. 18 Heat Death Report| 2020 19 Graph 26. The majority (92%) of indoor heat deaths occurred during the months of July and August. 26% 20% 15% 11% 2% 2% 2% 0% 2% 7% 4% 0% 2% 0% Graph 27. Indoor heat associated deaths occur from May to September. 50% 39% 4% 4% May June 2% July August 7% September Heat Death Report| 2020 Graph 28. Indoor heat-associated deaths can occur at temperatures as low as 87 degrees. 49% 39% 10% 2.4% 87-89 90-99 100-109 110+ *See appendix 3 for more detailed information on male/female indoor and male outdoor heat-associated deaths. 20 Heat Death Report| 2020 Air Conditioning Use for Indoor Injuries *Evaporative coolers were not considered as A/C units as their ability to cool becomes inadequate in extreme Maricopa County temperatures. Graph 29. Eighty-two percent of indoor deaths had an air conditioning unit present at time of death. 18% A/C Present A/C Not Present 82% *1 unknown case Graph 30. Among deaths where an A/C unit was present, a non-functioning A/C unit was the most common reason for not having a cooled environment at the time of death. Non-Functioning 31% 69% Functioning but Not In Use *In past years there has been a category for individuals who did not have electricity as a reason for having no air conditioning. No individuals fall into this category for 2020, possibly due to the Electric Utility Relief Package put in place during the COVID-19 pandemic. 21 Heat Death Report| 2020 Substance Use among Heat-Associated Deaths Graph 31. Fifty-eight percent of all cases involved substance use as a cause of death or a contributing factor. 42% Substance Use 58% No Substance Use *See Appendix 3 for more detailed information on substance use heat-associated deaths. Graph 32. In eighty-five percent of cases that involved substance use, drug use was listed as either a cause of death or a contributing factor. 85% 10% Drugs only Alcohol only 5% Drugs and alcohol *Types of drugs included in multiple drug toxicity cases include: Methamphetamine, Oxycodone, Fentanyl, Citalopram, Opioids, Benzodiazepines, Lorazepam, Morphine, Hydroxyzine, Aripiprazole, Oxymorphone, Gabapentin, Cyclobenzaprine, Diphenhydramine, and Carisoprodol. 22 Heat Death Report| 2020 Graph 33. Of the heat related deaths where drugs were involved (N=158), 71% involved methamphetamine toxicity. 1% 27% 71% Multiple Methamphetamine Cocaine Fentanyl Graph 34. The proportion of heat-associated deaths involving drug use increased by seven percent from the previous year.* 49% 42% 37% 32% 24% 19% 16% 13% 14% 16% 9% 10% 6% 8% 23% 23% 21% 18% 13% 17% 16% 9% 11% 16% 16% 10% 13% 12% 9% 6% 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Alcohol Drugs *Cases involving both drug and alcohol use are represented uniquely on each line. 23 Heat Death Report| 2020 Graph 35. Of the heat related deaths where drugs were involved (N=158), 79% of the time drugs were a primary cause of death. 21% Cause of Death Related to Death 79% 24 Heat Death Report| 2020 Living Situation among Heat-Associated Deaths Graph 36. Fifty-three percent of cases were homeless at time of death. Homeless 53% Living Independently 21% Co-Habitating/Roommate 13% Unknown (Non-Homeless) 2% Unknown 11% Graph 37. The number of heat associated deaths among the homeless population more than doubled from 2019 to 2020. 116 53 32 45 6 46 * 2006 2007 2008 53 21 60 22 86 20 90 20 55 20 2009 2010 2011 2012 2013 100 122 121 133 54 7 76 8 54 57 61 66 172 2014 2015 2016 2017 2018 2019 2020 Homeless Non-Homeless *34 cases where living situation was unknown were excluded from graph. **5 homeless heat-associated deaths had an unknown county of residence. ***See Appendix 3 for more detailed information on homeless heat-associated deaths. 25 Heat Death Report| 2020 Homeless Outdoor Death Demographics Graph 38. Seventy-seven percent of homeless outdoor deaths occurred in an urban area. 77%       2% 5% Car Residential Area 14% Desert Area Urban Area Sixty-two percent of outdoor deaths were homeless. Ninety-seven percent of homeless deaths occurred outdoors. Seventy-seven percent of homeless outdoor deaths died in an urban area. Ninety-two percent of homeless outdoor deaths were male. Forty percent of homeless outdoor deaths were among 50-64 year olds. Fifty-six percent of homeless outdoor deaths were among White Non-Hispanics; 20% were among Hispanics; and 17% were among Blacks. Education and Heat-Associated Deaths *83 cases have an unknown level of education **Only adults aged ≥20 were included in these results. Graph 39. Heat-associated deaths occur in individuals with all levels of education. 44% 19% 15% 8% 8% 3% 8th Grade or 9th-12th (No High School Some College less Diploma) Associate Bachelors 2% 1% Masters PhD 26 Heat Death Report| 2020 Time of Day and Heat-Associated Deaths *Day time is considered after sunrise (5:30a) and before sunset (7:30p) *Nighttime is considered after sunset and before sunrise Graph 40. Eighty percent of all heat associated deaths occured during daytime hours. 20% Daytime Nightime 80% Graph 41. The number of deaths during day time hours is highest from 4p to 7:30p. Dawn (5:30a-8a) Early Morning (8-10a) 9% 10% Late Morning (10a-12p) Early Afternoon (12-2p) Mid Afternoon (2-4p) Dusk (4-7:30p) 19% 14% 19% 29% 27 Heat Death Report| 2020 Air Quality Index and Heat-Associated Deaths There was a total of 150 Moderate Air Quality days and 40 Exceedance Air Quality days. *Moderate Air Quality – Ozone (O3) has reached or exceeded 55 part per billion *Exceedance Air Quality - Ozone (O3) has reached or exceeded 71 part per billion Figure 1. Seventy-five percent of deaths that occurred on an air quality exceedance day also occurred on an excessive heat warning day. Graph 42. Of the 167 deaths that occured on heat advisory days, one third of them also occured on an AQI exceedance day. 4/26/2020 5/26/2020 6/26/2020 Excessive Heat Warning 7/26/2020 AQ Advisory 8/26/2020 Heat Associated Deaths 9/26/2020 28 Heat Death Report| 2020 Graph 43. Of the total number of outdoor deaths, 25% (67) of them occured on Air Quality Advisory days. 75% Outdoor Deaths 25% Outdoor Deaths Deaths on Air Quality Advisory Days Pollution ratings found on Arizona Department of Environmental Quality 29 Heat Death Report| 2020 COVID-19 Heat-Associated Deaths  Cases were verified for COVID-19 using MEDSIS, Arizona’s Medical Electronic Disease Surveillance Intelligence System. Graph 44. Four percent (11) of the total heat-associated deaths in 2020 had been positive for COVID-19 at time of death. 4% COVID(+) COVID(-) 96% Graph 45. American Indians and African Americans were disproportionately represented among COVID-19 heatassociated deaths. 36% 27% 18% 9% American Indian African American 9% Hispanic Unknown White 30 Heat Death Report| 2020 Graph 46. Forty-five percent of all COVID-19 heat-associated deaths were among those aged 50-64. 45% 18% 18% 20-34 35-49 18% 50-64 75+ Graph 47. Twenty-seven percent of cases that were COVID-19 positive had COVID-19 listed as a cause of or relation to death. 73% Cause of Death Related to Death Not Listed 18% 9% * Cause of death and related to death indicates that COVID-19 was either directly involved in the sequence of conditions causing death or contributed to the death as indicated on the death certificate. ** Not listed means the individual was COVID-19 positive but COVID-19 was not directly involved in the sequence of conditions causing death or contributing to the death. 31 Heat Death Report| 2020 Conclusions  There was an 62.3% increase in heat-associated deaths between 2019 and 2020.  Twelve excessive heat warnings were issued in 2020 for a total of 48 days. On those days, 52% of all heat-associated deaths occurred. The average number of heat warnings for the past 5 years (2015-2019) is 5 lasting for a total of 17 days.  This year had the earliest excessive heat warning on record on April 26th, 2020.  The majority of Arizona residents who died from heat-associated deaths lived here for greater than 20 years.  Males, African Americans, American Indians, and those ages 75+ have the highest rates of heat-associated death.  Sixty-six percent of all heat-associated deaths occurred in those aged 3564.  Males had a 4x higher death rate than females per 100,000.  The proportion of outdoor deaths compared to indoor deaths in 2020 is the highest it’s been since 2011. Eighty-five percent of deaths in 2020 occurred outdoors.  Phoenix had the highest number of heat-associated deaths compared to all other cities in Maricopa county.  Sixty-one percent of heat-related injuries that happened outdoors occurred in an urban area.  Sixty-nine percent of people who had A/C at the time of death reported having non-functioning A/C.  Substance use was directly correlated with 58% of all heat deaths, 85% of which involved drugs only. 32 Heat Death Report| 2020  Methamphetamine was a contributing factor or main cause of death in 35% of all heat-associated deaths.  Fifty-three percent of heat-associated deaths occurred among the homeless population, nearly double the proportion in 2019.  Eighty-one percent of all deaths occurred during daytime hours, most commonly during dusk.  One quarter of all outdoor heat-associated deaths occurred on days that had an AQI advisory warning issued.  Four percent (11) of all heat-associated deaths in 2020 tested positive for COVID-19.  People aged 50-64 made up 45% of all COVID-19 positive heat-associated deaths. 33 Heat Death Report| 2020 Appendices Appendix 1 - Background and Methodology 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 heat-associated 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 heat-related 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 ICD 10 Code HEAT EXPOSURE X30 ENVIRON T67.X EXHAUSTION P810 Corresponding Definition Exposure to excessive natural heat Effects of heat and light Environmental hyperthermia of newborn 34 Heat Death Report| 2020 SUN HEAT STRESS HEAT STROKE HYPERTHERMIA 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 manmade 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, 35 Heat Death Report| 2020 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: nonfunctioning, 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. 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 36 Heat Death Report| 2020 Tony Bishop: Tony.bishop@maricopa.gov Jessica Whitney: Jessica.whitney@maricopa.gov 37 Heat Death Report| 2020 Appendix 2 – Tables Table 1. Heat-Associated Deaths by Year Year Number of deaths 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Under Investigation 21 38 49 42 75 85 51 49 74 82 106 110 75 61 84 154 179 182 199 323 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 38 Heat Death Report| 2020 39 Table 2. Heat-Associated Deaths by Year Year Heat-Caused Heat-Related Total 2006 58 27 85 2007 38 13 51 2008 32 17 49 2009 47 27 74 2010 48 34 82 2011 57 49 106 2012 63 47 110 2013 42 33 75 2014 33 28 61 2015 45 39 84 2016 88 66 154 2017 90 89 179 2018 119 63 182 2019 138 61 199 2020 213 110 323 TOTAL 1111 703 1814 Table 3. Heat-Associated Deaths by Month and Classification, Maricopa County, 2020 March April May June July August September October November December Total Heat-Related 0 * 7 7 53 35 * * 0 0 110 Heat-Caused 0 * * 17 102 73 14 * 0 0 213 Total 0 * 11 24 155 108 19 * 0 0 323 Heat Death Report| 2020 40 Table 4. Heat Associated Deaths by Year and Month Years Jan Feb March April May June July August Sept October November December Total 2006-2008 3 39 104 28 8 3 185 262 20091 2011 2012-2014 1 2 7 37 118 67 27 2 1 1 6 47 97 65 20 5 4 2015-2017 5 4 11 127 148 86 26 5 4 4 24 63 312 221 69 10 1 2018-2020 Table 5. Heat Associated Deaths by Residency Maricopa NonNonCounty Maricopa Arizona Resident County Resident Total Unknown Total (N=323) 273 26 17 % of Cases 86% 8% 5% 316 7 246 1 417 704 Heat Death Report| 2020 41 Table 6. Heat-Associated Deaths by Time Residing in Arizona* Years in Arizona Number of Deaths % Deaths <3 Years 3-9 Years 10-19 Years 20+ Years Total 13 29 24 112 178 7% 16% 13% 63% 100% Unknown 72 29% Heat Associated deaths by Demographic Table 7. Total Deaths By Gender Gender Male Female N % 262 61 81% 19% Table 8. Total Deaths by Gender and Age Group Age Group Female Male Total Percent 0-4 * * * 0.3% 5-19 20-34 35-49 50-64 65-74 75+ Unknown Total * * 14 19 6 17 * 61 * 29 79 99 28 26 * 262 * 32 93 118 34 43 * 323 0.3% 9.9% 28.8% 36.5% 10.5% 13.3% 0% Heat Death Report| 2020 Table 9. Total Deaths By Race Race Asian/Pacific Islander American Indian African American Hispanic White Total Unknown Heat-Associated Deaths All Deaths (Incl Non-MC Res) 1% * 4% 13 15% 48 20% 62 60% 190 100% 317 6 Heat Associated Death Rates All populations based on US Census Bureau 2019 population counts. Table 10. Death Rates by Gender and Age Gender Male Female Age Deaths Population Rate Deaths Population Rate Group 0-4 * 140990 0.0 * 135129 0.7 5-19 * 456832 0.2 * 438712 0.0 20-34 25 487518 5.1 * 467839 0.6 35-49 60 433254 13.8 11 435891 2.5 50-64 85 384623 22.1 19 408159 4.7 65-74 23 185041 12.4 6 217273 2.8 75+ 23 128858 17.8 16 165295 9.7 TOTAL 217 2217116 9.8 56 2268298 2.5 42 Heat Death Report| 2020 Table 11. Deaths Rate by Race Race % of all HeatRate per Population All MCR Deaths Associated 100,000 MC Deaths residents Asian/Pacific 1% 2.03 196,671 * Islander American 3% 9.15 76,504 7 Indian African 14% 15.71 248,228 39 American Hispanic 20% 3.76 1,408,855 53 White 60% Total 100% Unknown 6.77 2,437,462 165 4,485,414 268 0% Heat Associated Deaths By Place of Injury Table 12. Gender and Place of Injury POI Male Male N Female Female N Total Indoor 10% 25 34.4% 21 46 Outdoor 90% 231 65.6% 40 271 Unknown 6 0 6 Total 256 61 323 *Unknowns not included in % calculations. Table 13. Place of Injury by Year Year Outdoor Indoor Outdoor Indoor 2020 85% 15% 271 46 2019 76% 24% 152 47 2018 72% 28% 128 51 2017 60% 40% 108 71 2016 61% 39% 93 59 2015 61% 39% 51 33 2014 72% 28% 42 16 2013 59% 41% 44 30 2012 58% 42% 62 45 2011 46% 54% 47 56 * 43 Heat Death Report| 2020 Table 14. Outdoor Place of Injury Place of Injury (Outdoor) N % Car 8 3% Desert Area/Hiking Trail Residence 39 14% 51 19% Urban Area/Park 166 61% * 2% * 271 1% 100% Unknown Other Total Table 15. Indoor Place of Injury Place of Injury (Indoor) N % Residence * Trailer/RV 13 House Apartment Condo Total 25 * * 46 7% 28% 54% 9% 2% 100% Table 16. Welfare Check Yes No Total Welfare Check No Welfare Check Indoor Outdoor Deaths Deaths 23 23 46 50% 14 257 271 5.2% 50% 94.8% 44 Heat Death Report| 2020 Air Conditioning Use for Indoor Injury* Table 17. A/C Status A/C Present (Indoor) Number of Cases A/C Present A/C Not Present Total (not including unknowns) Unknown Percent 37 8 45 * Table 18. A/C Reason Reasons for not having properly running AC* N Non-Functioning Functioning but Not In Use Total Other/Unknown 25 11 36 * Substance Use among Heat-Associated Deaths Table 19. Substance use Substance use status Substance Use No Substance Use N % 186 137 58% 42% Table 20. Substance Type Substance Drugs only Alcohol only Drugs and alcohol TOTAL N % 158 19 9 186 85% 10% 5% 82% 18% 45 Heat Death Report| 2020 Table 21. Type of Drug used (Cause or Related to Death) Drug Name # of Deaths Cause of Death Related to Death Multiple 43 33 10 Methamphetamine 112 89 23 Cocaine * * * Fentanyl * * * Total 158 125 33 Percentages 100% 79% 21% Table 22. Substance Use by Year Year Alcohol Percent Drugs Percent 2006 14 16% 20 24% 2007 7 14% * 6% 2008 * 10% 8 16% 2009 6 8% 7 9% 2010 13 16% 17 21% 2011 14 13% 10 9% 2012 14 13% 12 11% 2013 14 19% 13 17% 2014 6 10% 14 23% 2015 10 12% 15 18% 2016 25 16% 36 23% 2017 17 9% 57 32% 2018 30 16% 68 37% 2019 25 13% 84 42% 2020 19 6% 158 49% 46 Heat Death Report| 2020 47 Living Situation among Heat-Associated Deaths Table 23. Living Situation Type Living Situation Homeless Living Independently Co-Habitating/Roommate Unknown (Non-Homeless) Unknown Total N % 172 68 41 7 35 323 53% 21% 13% 2% 11% 100% Table 24. Living Situation by Year 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Homeless 32 6 * 21 22 20 20 20 7 8 54 57 61 66 172 NonHomeless 53 45 46 53 60 86 90 55 54 76 100 122 121 133 116 Percent Homeless 38% 12% 6% 28% 27% 19% 18% 27% 11% 10% 35% 32% 34% 33% 60% Education Level Among Heat Associated Deaths Table 25. Education Education Level 8th Grade or less 9th-12th (No Diploma) High School Some College Associate Bachelors Masters PhD Total # of % of Total Deaths Deaths 19 44 105 35 7 19 * * 237 8% 19% 44% 15% 3% 8% 2% 1% Heat Death Report| 2020 Heat Associated Deaths by Time Table 26. Time of Day (General) Number of Deaths Daytime Nighttime 260 63 Table 27. Time of Day (Specific) Daytimes Deaths Dawn (5:30a-8a) Early Morning (8-10a) Late Morning (10a-12p) Early Afternoon (12-2p) Mid Afternoon (2-4p) Dusk (4-7:30p) # of Deaths 23 27 49 36 50 75 Heat Associated Deaths and COVID-19 Table 28. Total COVID-19 Deaths COVID(+) COVID(-) Unknown 11 296 * Table 29. COVID-19 and Gender Gender COVID + % Male 10 91% Female * 9% Total 11 100% 48 Heat Death Report| 2020 Table 30. COVID-19 and Race Race COVID + % American * 9% Indian African * 27% American Hispanic * 18% Unknown * 9% White * 36% Total 11 100% Table 31. COVID-19 and Age Age COVID + % 20-34 * 18% 35-49 * 18% 50-64 * 45% 75+ * 18% Total 11 100% Table 32. COVID-19 Cause or Related to Death COD/CDC COVID + % Cause of Death * 9% Related to * 18% Death Not Listed 8 73% 49 Heat Death Report| 2020 Appendix 3 – Profiles *Minority race includes the following races: Hispanic, American Indian, Asian/Pacific Islander, and African American. 50 Heat Death Report| 2020 51 Heat Death Report| 2020 52 Heat Death Report| 2020 53 Heat Death Report| 2020 54 Heat Death Report| 2020 55 Heat Death Report| 2020 56 Heat Death Report| 2020 57 Heat Death Report| 2020 58 Heat Death Report| 2020 *Minority race includes the following races: Hispanic, American Indian, Asian/Pacific Islander, and African American. 59 Heat Death Report| 2020 60 Heat Death Report| 2020 61 Heat Death Report| 2020 62 Heat Death Report| 2020 63 Heat Death Report| 2020 *Minority race includes the following races: Hispanic, American Indian, Asian/Pacific Islander, and African American. 64 Heat Death Report| 2020 65 Heat Death Report| 2020 66 Heat Death Report| 2020 67 Heat Death Report| 2020 68 Heat Death Report| 2020 69 Heat Death Report| 2020 70 Heat Death Report| 2020 71 Heat Death Report| 2020 72