June 2023 2022 Heat Deaths Report Maricopa County Department of Public Health Division of Epidemiology and Informatics Table of Contents Acknowledgements 3 Introduction 4 Heat-Associated Deaths Over Time 5 Deaths by Year 5 Deaths by Day and Temperature 6 Demographics Overview 7 Age, Sex, Race, and Ethnicity 7 Sex, Age, and Education 8 Residency 9 Circumstances of Death 10 Location of Injury 10 Place of Injury 11 Living Situation 13 Substance Use 14 2022 Summary 16 Appendices 17 Background 17 Methodology 17 Tables 20 Maricopa County • Department of Public Health • Division of Epidemiology and Informatics • June 2023 2 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: Meaghan Calendo: Meaghan.calendo@maricopa.gov Tony Bishop: Tony.bishop@maricopa.gov Aaron Gettel: Aaron.gettel@maricopa.gov Jackie Ward: Jackie. ward@maricopa.gov Primary Author: Meaghan Calendo, Climate and Health Epidemiologist Maricopa County • Department of Public Health • Division of Epidemiology and Informatics • June 2023 3 Introduction Mortality from environmental heat is a significant public health problem in Maricopa County, especially because it is largely preventable. Sharing this information helps community stakeholders to design interventions to prevent heat-associated deaths among vulnerable populations. TIMELINE OF HEAT SURVEILLANCE IN MARICOPA COUNTY Maricopa County has conducted heat surveillance each year since 2006. The enhanced heat surveillance season usually begins in May and ends in October 2006 Maricopa County began conducting heat surveillance 2012 2023 Maricopa County improved their methodology for heat surveillance by incorporating data on air conditioning and energy use. HEAT DEATHS CLASSIFICATION Heat-associated deaths are classified as heat-caused or heat-related: Maricopa County integrates heat-mortality surveillance into a new Public Health and Climate Program HEAT SURVEILLANCE DATA SOURCES Maricopa County uses two main sources of data for heat surveillance: HEAT SURVEILLANCE OBJECTIVES 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 or lack of air conditioning). 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. Maricopa County • Department of Public Health • Division of Epidemiology and Informatics • June 2023 4 Heat-Associated Deaths Over Time Deaths by Year Maricopa County identified a total of 425 heat-associated deaths occurring in 2022. This represents a twenty-five percent increase from last year +25% 323 154 110 76 2012 2013 61 2014 179 182 2017 2018 425 339 199 84 2015 2016 2019 2020 2021 2022 In recent years, most deaths have been classified as heat-caused. This year, environmental heat was directly involved in the sequence of events causing death in more than half of all heat-associated death cases. 56% Heat Caused 57% 66% 57% 57% 2012 57% 2013 54% 2014 50% 65% 69% Heat Related 54% 2015 2016 2017 2018 2019 2020 2021 2022 Maricopa County • Department of Public Health • Division of Epidemiology and Informatics • June 2023 5 Deaths by Day and Temperature In 2022, more than half of all heat-associated deaths occurred during the month of July. Compared with previous years, a higher proportion of deaths occurred in July (58%) and fewer deaths occurred in August (11%). In 2022, 107 heat-associated deaths occurred on days with an excessive heat warning. Excessive Heat Warning In 2022, the National Weather Service issued seven excessive heat warnings for a total of 17 days. Over the past 5 years, an average of 34% of deaths occurred on days with an excessive heat warning. 18 High Temperature The daily high peaked at 115°F on July 11, with 10 deaths occurring on this day alone. 16 120°F 100°F 14 12 80°F 10 60°F 8 Low Temperature 6 The highest overnight temperature was 95°F on July 22. Heat-Associated Deaths 4 40°F 20°F 2 Maricopa County • Department of Public Health • Division of Epidemiology and Informatics • June 2023 0 3/13/2022 6 0°F 4/13/2022 5/13/2022 6/13/2022 7/13/2022 8/13/2022 9/13/2022 10/13/2022 Demographics Overview Age, Sex, Race, and Ethnicity 81% 19% Males accounted for more than 80% of heat-associated deaths in 2022. Nearly two-thirds of all heat-associated deaths occurred among individuals aged 50 years or older. 31.9% 24.8% 15.8% 13.2% 0.0% 0.5% 0-4 5-19 20-34 35-49 50-64 65-74 13.7% 75+ Nearly 60% of heat-associated deaths occurred among non-Hispanic White individuals. Compared to the proportion in which they make up Maricopa County’s population, African Americans (7.4%) and American Indians (3.6%) are overrepresented among heat deaths. 58.8% White 19.5% Hispanic or Latino 11.3% Black or African American 8.0% American Indian or Alaska Native Asian or Pacific Islander 1.9% Not Specified 0.5% * Percentages exclude 1 case where sex is unknown and 2 cases where age is unknown. Maricopa County • Department of Public Health • Division of Epidemiology and Informatics • June 2023 7 Sex, Age, and Education The median age of heat-associated deaths was younger among males than females in 2022. Male Heat Deaths Female Heat Deaths 69 median age 52 More than two-thirds of adult decedents did not attend any post-secondary schooling, among all heat-associated deaths with known educational background. 47% 21% 12% 5% 8th grade or Some High High School less School Diploma or GED Some College 5% 6% Associates Bachelors 3% Masters or higher * Percentages exclude 2 cases where age is unknown and 78 cases where education is unknown. Maricopa County • Department of Public Health • Division of Epidemiology and Informatics • June 2023 8 Residency Resident Death Rates Local residents account for the majority of heat-associated deaths in Maricopa County. 7.1% 10.1% 77.2% • 77.2% Maricopa County Residents • 7.1% In-State Residents Includes residents of nine other Arizona counties. • 5.6% Out-of-State Residents Includes residents of 18 other states. • 10.1% Residency Unknown Includes 43 cases where residency state, county, or both are unknown. Among local residents for whom length of residency is known, three-fourths had lived in Maricopa County for twenty years or more. 4% 11% 9% 75% *Includes 53 residents where time spent in AZ is known. > 3 Years 3-9 Years 10-19 Years 20+ Years The percentage of heat-associated deaths that are Maricopa County residents has decreased in recent years, despite an increase in overall heat-associated deaths. NonResidents 85% 88% 92% 77% 92% 96% 76% 83% 85% 81% 77% Maricopa Residents 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 Maricopa County • Department of Public Health • Division of Epidemiology and Informatics • June 2023 9 Circumstances of Death Location of Injury Cities with less than 5 heat-associated deaths have been excluded from the table. PLACE OF INJURY CITY HEAT DEATHS Phoenix 245 Mesa 36 Glendale 22 Scottsdale 10 Tempe 10 Avondale 8 Peoria 8 Chandler 7 Gilbert 6 To view an interactive map of 2022 heat-associated deaths in Maricopa County, click the QR code on the map or scan it with your smartphone camera. Maricopa County • Department of Public Health • Division of Epidemiology and Informatics • June 2023 10 Place of Injury Deaths in outdoor settings have driven the increase in total number of heatassociated deaths in recent years 80% 75% Outdoor 85% 61% 58% 2012 61% 2013 72% 2014 60% 72% 76% 61% 2015 Indoor 2016 2017 2018 2019 2020 2021 2022 Welfare Check  None Indoor 56% Outdoor More than half of all indoor deaths were found during a welfare check. Welfare checks identified less than three percent of outdoor deaths. 97% Indoor In 2022, 42% of indoor deaths were among females, despite females comprising less than 20% of the overall heat deaths for the year. 42% Female Outdoor 87% Male * Percentages exclude 3 cases with unknown injury location and 1 with unknown sex Maricopa County • Department of Public Health • Division of Epidemiology and Informatics • June 2023 11 The majority of outdoor heat-associated deaths occurred in an Urban Area in 2022. Nearly 70% of outdoor heat deaths and over half of all overall heat-associated deaths occurred in an Urban Area within Maricopa County throughout the year. Outdoor Heat Injury Sites Indoor Heat Injury Sites House 41 Urban Area 228 Apartment/Condo 14 Desert Area 41 RV/Trailer 12 Residence 30 Mobile 10 Other/Unknown 24 Townhouse 5 Car 21 Shed 4 All indoor heat-associated deaths in 2022 occurred in uncooled environments. In most indoor death cases, an air conditioning (AC) unit was present on-site. Among indoor deaths where an AC unit was present, the unit was non-functioning in 78% of cases. Indoor Deaths: 86 AC Present: 65 AC Not Functioning: 51 AC Not Present: 15 Unknown: 6 AC Not in Use: 10 No Electricity: 3 Unknown: 1 Maricopa County • Department of Public Health • Division of Epidemiology and Informatics • June 2023 12 Living Situation Individuals experiencing homelessness make up the largest proportion of heatassociated deaths in 2022. 178 Homeless 105 Unknown Living Independently 76 61 Co-habitating Unknown (Non-Homeless) 5 Among deaths where the living situation is known, people experiencing homelessness have accounted for an increasingly large share of all heatassociated deaths in recent years. 60% 35% 18% 2012 28% 2013 11% 2014 32% 34% 2017 2018 56% 42% 33% 10% 2015 2016 2019 2020 2021 2022 * Percentages exclude cases where living situation is unknown * According to the Maricopa Association of Governments Point-in-Time Count, there was a 36% increase in homeless individuals overall in Maricopa County from 2019-2022. Maricopa County • Department of Public Health • Division of Epidemiology and Informatics • June 2023 13 Substance Use Maricopa County identified 283 deaths involving substance use, representing over two-thirds of all heat-associated deaths recorded in 2022. Substance use includes use of drugs and/or alcohol. 67% Involved Substance Use Over half of all heat-associated deaths involved drug use. The proportion of deaths involving drug use has increased in recent years. 11% 15% 2012 16% 16% 2013 23% 24% 10% 11% 2014 2015 21% 15% 2016 34% 39% 49% 13% 10% 6% 2018 2019 31% 9% 2017 2020 46% Both 54% Drugs 10% 9% Alcohol 2021 2022 Among heat-associated deaths involving substance use, more than four-in-five deaths involved drug use alone in 2022. 80.9% Drugs only 14.1% Alcohol only 4.9% Both Drugs and Alcohol Maricopa County • Department of Public Health • Division of Epidemiology and Informatics • June 2023 14 In 2022, 54% of heat-associated deaths involving substance use were among individuals experiencing homelessness. Homeless  Not Homeless Involved Substances 154 Involved None Drug Caused 86.8% 38 24 104 * Excludes cases with unknown living situations Drug use was a primary cause of death in more than 80% of heat-associated deaths involving drug use. When drug use was involved in heat-associated deaths, drugs were more likely to be identified as a cause of death than merely a factor related to death. Drug Related 13.2% Methamphetamine was involved in 90% of heat-associated deaths involving drug use. Methamphetamine was a contributing factor or main cause of death in 53% of all heat-associated deaths. Methamphetamine 93.0% Fentanyl 44.4% Polysubstance 25.9% *These are the three most common substances involved in the cause of death found within the death certificates of heatassociated deaths. This is not an all-inclusive list of substances involved. Maricopa County • Department of Public Health • Division of Epidemiology and Informatics • June 2023 15 2022 Summary +25% 425 heat-associated deaths occurred in Maricopa 425 339 323 County during 2022. 154 110 2012 179 182 2017 2018 199 84 76 61 2013 2014 2015 2016 2019 2020 2021 2022 4/5 heat-associated deaths were among males in 2022. 3/5 were among non-Hispanic white individuals. 2/3 were among people aged 50 or older or people who did not attend any post secondary schooling. Males Females 80% Outdoor 87% Male Most heat-associated deaths occurred outdoors in recent years. Nearly half of all 42% Female indoor deaths occurred among females. 20% Indoor 81% 67% of heat-associated deaths involved substance use. Among those, 81% involved drugs only. 14% drugs alcohol 5% both Unknown 178 heatassociated Homeless deaths were 42% among people experiencing homelessness Not Homeless 54% of heat-associated deaths involving substance use were among individual's experiencing homelessness. 53% of all heat-associated deaths involved methamphetamine. Maricopa County • Department of Public Health • Division of Epidemiology and Informatics • June 2023 16 Appendices 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 heatrelated 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 • • • • • • • 3. Heat exposure Environ Exhaustion Sun Heat Stress Heat Stroke Hyperthermia ICD-10 Codes • X30 – Exposure to excessive natural heat • T67.X – Effects of heat and light • P810 – Environmental hyperthermia of newborn Hospital and media reports can sometimes initiate a heat death investigation, for example, if a child is reportedly left in a hot car. Maricopa County • Department of Public Health • Division of Epidemiology and Informatics • June 2023 17 Once data are received, analysis of the information is required to identify only those deaths related to or caused by 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 counts, 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: 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 indicates that the unit worked properly but 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 nonfunctioning, were counted in the “no electricity” category. Maricopa County • Department of Public Health • Division of Epidemiology and Informatics • June 2023 18 Homelessness is defined as having an address on the death certificate that matches a homeless shelter, government agency, business, or 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. The medical examiner learns if someone if homeless by speaking to next of kin, law enforcement, and reviewing medical records. 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: www.heataz.org. 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: Meaghan Calendo: Meaghan.calendo@maricopa.gov Tony Bishop: Tony.bishop@maricopa.gov Aaron Gettel: Aaron.gettel@maricopa.gov Jackie Ward: Jackie.ward@maricopa.gov Maricopa County • Department of Public Health • Division of Epidemiology and Informatics • June 2023 19 Tables: Resident Death Rates Rates per 100,000 residents calculated using surveillance data for 425 heatassociated deaths among confirmed Maricopa County residents and 2020 US Census Bureau population estimates. Table 1. Heat-associated death rates per 100,000 residents by age group group AGE GROUP RATE PER 100,000 0 to 4 0.0 5 to 19 0.1 20 to 34 4.0 35 to 49 9.1 50 to 64 12.1 65 to 74 13.8 75+ 16.8 ALL AGES 7.2 Residents aged 50 years and older are disproportionately impacted by heatassociated death in Maricopa County Table 2. Heat-associated death rates per 100,000 residents by sex Males had a 3x SEX RATE PER 100,000 higher death rate Female 3.1 than females per Male 11.3 100,000 in 2022. Table 3. Heat-associated death rates per 100,000 residents by race RACE RATE PER 100,000 Black or African American 13.0 American Indian or Alaska Native 8.9 White Non-Hispanic 7.7 Hispanic or Latino 5.3 Asian or Pacific Islander 1.6 African Americans and American Indians have the highest rates of heat-associated death. Table 4. Heat-associated death rates per 100,000 residents by age group and sex AGE GROUP MALE RATE PER 100,000 FEMALE RATE PER 100,000 0 to 4 0.0 0.0 5 to 19 0.2 0.0 20 to 34 8.4 0.5 35 to 49 15.4 2.0 50 to 64 21.5 3.1 65 to 74 17.1 11.0 75+ 21.3 13.2 Across all age groups, male residents were more likely than female residents to suffer fatal heat-associated injuries Maricopa County • Department of Public Health • Division of Epidemiology and Informatics • June 2023 20 Tables: Demographics & Details Table 5. Cause of death among heat-associated deaths by year YEAR HEAT CAUSED HEAT RELATED 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 2021 194 145 339 2022 240 185 425 TOTAL 1545 1033 2578 TOTAL Table 7. Heat-associated deaths by race - 2022 RACE Table 6. Heat-associated deaths by sex - 2022 HEAT DEATHS Not Specified 2 Asian or Pacific Islander 8 343 American Indian or Alaska Native 34 Female 81 Black or African American 48 Unknown 1 Hispanic or Latino 83 White 250 SEX HEAT DEATHS Male Table 8. Heat-associated deaths by education level - 2022 EDUCATION LEVEL Table 9. Heat-associated deaths by age group -2022 HEAT DEATHS AGE GROUP HEAT DEATHS 8th Grade or less 18 0-4 0 Some High School High School Diploma or GED Some College 74 163 42 5-19 2 20-34 56 35-49 105 Associates 19 50-64 134 Bachelors 21 65-74 67 Masters or higher 10 75+ 58 Unknown 78 Unknown Maricopa County • Department of Public Health • Division of Epidemiology and Informatics • June 2023 3 21 Tables: Residency & Place of Injury Table 10. Heat-associated deaths among Maricopa residents by year YEAR Table 11. Heat-associated deaths by time in AZ - 2022 MARICOPA RESIDENT HEAT DEATHS 2012 93 2013 67 2014 56 2015 65 2016 141 2017 171 2018 138 2019 165 2020 273 2021 267 2022 328 TIME IN AZ HEAT DEATHS Unknown 275 < 3 Years 4 3-9 Years 8 10-19 Years 12 20+ Years 70 Table 12. Heat-associated deaths by residency status - 2022 TIME IN AZ HEAT DEATHS < 3 Years 2 3-9 Years 6 10-19 Years 5 20+ Years 70 Table 13. Heat-associated deaths by place of injury by year YEAR OUTDOOR INDOOR Table 14. Heat-associated deaths by place of injury and sex - 2022 2012 63 46 2013 46 30 PLACE OF INJURY 2014 44 17 Outdoor 50 36 2015 51 33 Indoor 290 45 2016 93 59 2017 108 71 2018 129 51 2019 152 47 2020 271 46 2021 252 82 2022 336 86 MALE FEMALE Table 15. Heat-associated deaths by place of injury and welfare checks - 2022 PLACE OF INJURY Outdoor Indoor WELFARE NO WELFARE CHECK CHECK 10 326 48 38 Maricopa County • Department of Public Health • Division of Epidemiology and Informatics • June 2023 22 Tables: Substance Use & Living Situation Table 16. Heat-associated deaths and substance involvement by year YEAR ALCOHOL DRUGS + ALCOHOL DRUGS NONE TOTAL 2012 17 3 12 78 110 2013 12 2 12 49 76 2014 6 0 14 41 61 2015 9 2 20 53 84 2016 23 5 32 94 154 2017 16 1 56 106 179 2018 23 7 61 91 182 2019 19 6 77 97 199 2020 19 9 158 137 323 2021 34 13 156 136 339 2022 40 14 229 142 425 Table 17. Heat-associated deaths and substance involvement - 2022 Table 18. Heat-associated deaths and living status by year INVOLVED SUBSTANCE USE YES YEAR NO HEAT DEATHS 283 142 Table 19. Cause of death among heat-associated deaths involving drugs - 2022 CAUSE OF DEATH HEAT DEATHS Drug Caused 211 Drug Related 32 Table 20. Heat-associated deaths and drug type among deaths involving drugs - 2022 DRUG TYPE HOMELESS NON-HOMELESS 2012 20 90 2013 21 55 2014 7 54 2015 8 76 2016 54 100 2017 57 122 2018 61 121 2019 66 133 2020 172 116 2021 130 177 2022 178 142 HEAT DEATHS Methamphetamine 226 Fentanyl 108 Polysubstance 63 Maricopa County • Department of Public Health • Division of Epidemiology and Informatics • June 2023 23 Maricopa County Department of Public Health Division of Epidemiology and Informatics