Heat-Related Deaths — United States, 2004–2018

Deaths attributable to natural heat exposure, although generally considered preventable (1), represent a continuing public health concern in the United States. During 2004–2018, an average of 702 heat-related deaths occurred in the United States annually. To study patterns in heat-related deaths by age group, sex, race/ethnicity, and level of urbanization, and to explore comorbid conditions associated with deaths resulting from heat exposure, CDC analyzed nationally comprehensive mortality data from the National Vital Statistics System (NVSS).* The rate of heat-related mortality tended to be higher among males, persons aged ≥65 years, non-Hispanic American Indian/Alaska Natives, and persons living in noncore nonmetropolitan and large central metropolitan counties. Natural heat exposure was a contributing cause of deaths attributed to certain chronic medical conditions and other external causes. Preparedness and response initiatives directed toward extreme heat events, currently underway at local, state, and national levels, can contribute to reducing morbidity and mortality associated with natural heat exposure. Successful public health interventions^† to mitigate heat-related deaths include conducting outreach to vulnerable communities to increase awareness of heat-related symptoms and provide guidance for staying cool and hydrated, particularly for susceptible groups at risk such as young athletes and persons who are older or socially isolated (2). Improved coordination across various health care sectors could inform local activities to protect health during periods of high heat. For instance, jurisdictions can monitor weather conditions and syndromic surveillance data to guide timing of risk communication and other measures (e.g., developing and implementing heat response plans, facilitating communication and education activities) to prevent heat-related mortality in the United States. CDC also recommends that federal, state, local, and tribal jurisdictions open cooling centers or provide access to public locations with air conditioning for persons in need of a safe, cool, environment during hot weather conditions. In light of the coronavirus disease 2019 (COVID-19) pandemic, CDC updated its guidance on the use of cooling centers to provide best practices (e.g., potential changes to staffing procedures, separate areas for persons with symptoms of COVID-19, and physical distancing) to reduce the risk for introducing and transmitting SARS COV-2, the virus that causes COVID-19, into cooling centers.^§

Heat-related deaths among U.S. residents were identified using International Classification of Diseases, Tenth Revision (ICD-10)^¶ codes included in the NVSS multiple-cause-of-death mortality data. Selected heat-related case records included those listing ICD-10 codes X30 (exposure to excessive natural heat), P81.0 (environmental hyperthermia of newborn), or T67 (effects of heat and light) as the underlying cause of death,** or as one of the contributing causes.^†† Records with ICD-10 code W92 (exposure to excessive heat of man-made origin) listed anywhere on the death certificate were excluded to restrict the selection to deaths resulting from natural heat exposure. For case records listing heat-related codes for natural heat exposure occurring only as contributing causes, comorbid conditions recorded as the underlying cause of death were further evaluated for the following categories^§§: major cardiovascular diseases (I00–I78) (2); external causes of morbidity and mortality (V01–Y98 and U01–U03); mental and behavioral disorders (F00–F99); diseases of the respiratory system (J00–J99); endocrine, nutritional and metabolic disorders (E00–E90); diseases of the digestive system (K00–K93); genitourinary disorders (N00–N98); musculoskeletal disorders (M00–M99); and other diseases. Deaths were stratified by age group, sex, race/ethnicity, and level of urbanization and combined with U.S. Census Bureau population estimates for calculating crude rates. Crude rate estimates based on fewer than 20 deaths were deemed unreliable and not reported. Analyses were performed using SAS statistical software (version 9.4; SAS Institute).

During 2004–2018, a total of 10,527 deaths resulting from exposure to heat-related conditions were identified. Approximately 90% (9,757) of these deaths occurred during May–September. The crude rate of heat-related deaths varied from year to year, with highest rates observed over the 15-year period during 2006, 2011, and 2018. Although Arizona, California, and Texas account for only approximately 23% of the U.S. population,^¶¶ these three states accounted for approximately one third (3,852; 37%) of heat-related deaths among U.S. residents. Overall, approximately two thirds (70%) of all heat-related deaths occurred in males, and deaths among males outnumbered those among females in all age groups except infants aged <1 year (Table 1). Among the 10,470 decedents for whom age information was available, 748 (7%) were aged <15 years, 2,010 (19%) were aged 15–44 years, 3,693 (35%) were aged 45–64 years, and 4,019 (39%) were aged ≥65 years; the rate of heat-related deaths among persons aged ≥65 years was 0.7 per 100,000 population, the highest across all age groups. For the period 2004–2018, among all race/ethnicity groups, non-Hispanic whites had the highest number of heat-related deaths (6,602); however, non-Hispanic American Indian/Alaska Natives had the highest rate of heat-related deaths (0.6 per 100,000 population) (Table 2). Non-Hispanic blacks had the second highest number of heat-related deaths (1,965) and rate ( 0.3 per 100,000 population). Across various levels of urbanization,*** the highest heat-related mortality rates were observed among persons living in noncore nonmetropolitan (0.3 per 100,000 population) and large central metropolitan counties (0.3 per 100,000 population) (Table 2).

Natural heat exposure–related codes were recorded as the underlying cause in 6,220 (59%) heat-related deaths, with one heat-related death attributed to environmental hyperthermia of a newborn, and the remainder from exposure to excessive natural heat (6,219; 59%) as the underlying cause. For the remaining 4,307 (41%) heat-related deaths, exposure to excessive natural heat, environmental hyperthermia of a newborn, or effects of heat and light were recorded as a contributing cause of death. When heat-related conditions were a contributing factor, as opposed to the underlying cause of death, major cardiovascular diseases (2,112; 49%) or external causes (1,543; 36%) were most often listed as the underlying cause, collectively accounting for approximately 85% of such deaths (Table 3). More specifically, natural heat exposure contributed to 1,463 (34%) deaths from ischemic heart diseases, 438 (10%) deaths from hypertension, and 773 (18%) deaths from alcohol poisoning and drug overdoses.

Acknowledgments

Hatice S. Zahran, MD, Arthur Chang, MD, Division of Environmental Health Science and Practice, National Center for Environmental Health, CDC; Scott R. Kegler, PhD, Division of Injury Prevention, National Center for Injury Prevention and Control, CDC; National Environmental Public Health Tracking Program, CDC.

Corresponding author: Ambarish Vaidyanathan, [email protected], 770-488-3997.

¹Division of Environmental Health Science and Practice, National Center for Environmental Health, CDC.

References

1. Taylor EV, Vaidyanathan A, Flanders WD, Murphy M, Spencer M, Noe RS. Differences in heat-related mortality by citizenship status: United States, 2005–2014. Am J Public Health 2018;108(S2):S131–6. CrossRef PubMed
2. Ni H, Xu J. Recent trends in heart failure-related mortality: United States, 2000–2014. NCHS data brief 2015;231:1–8. PubMed
3. Gronlund CJet al. Racial and socioeconomic disparities in heat-related health effects and their mechanisms: a review. Curr Epidemiol Rep 2014;1:165–73. CrossRef PubMed
4. Oudin Åström D, Schifano P, Asta F, et al. The effect of heat waves on mortality in susceptible groups: a cohort study of a Mediterranean and a northern European City. Environ Health 2015;14:30. CrossRef PubMed
5. Epstein Y, Yanovich R. Heatstroke. N Engl J Med 2019;380:2449–59. CrossRef PubMed
6. Iyoho AE, Ng LJ, MacFadden L. Modeling of gender differences in thermoregulation. Mil Med 2017;182(Suppl 2):S295–303. CrossRef PubMed
7. Gubernot DM, Anderson GB, Hunting KL. Characterizing occupational heat-related mortality in the United States, 2000–2010: an analysis using the Census of Fatal Occupational Injuries database. Am J Ind Med 2015;58:203–11. CrossRef PubMed
8. Basu R. High ambient temperature and mortality: a review of epidemiologic studies from 2001 to 2008. Environ Health 2009;8:40. CrossRef PubMed
9. Marzuk PM, Tardiff K, Leon AC, et al. Ambient temperature and mortality from unintentional cocaine overdose. JAMA 1998;279:1795–800. CrossRef PubMed
10. Cusack L, de Crespigny C, Athanasos P. Heatwaves and their impact on people with alcohol, drug and mental health conditions: a discussion paper on clinical practice considerations. J Adv Nurs 2011;67:915–22. CrossRef PubMed

Abbreviation: N/A = not applicable.
* Heat-related deaths are identified using International Classification of Diseases, Tenth Revision cause-of-death codes X30 (exposure to excessive natural heat), P81.0 (environmental hyperthermia of newborn), and T67 (effects of heat and light) listed as the underlying cause or as one of the contributing causes in death records. Records with code W92 (exposure to excessive heat of man-made origin) listed anywhere on the death certificate were excluded from this selection.
^† Based on multiple-cause-of-death data from the National Center for Health Statistics (NCHS) Vital Statistics System (https://www.cdc.gov/nchs/nvss/deaths.htm) and NCHS Bridged-Race Population data (https://www.cdc.gov/nchs/nvss/bridged_race.htm). This information is available from https://wonder.cdc.gov.
^§ Crude rate per 100,000 population.
^¶ Rate estimates based on fewer than 20 deaths were deemed unreliable and not reported.
** Rate estimates were not calculated because a population denominator was unavailable.

Abbreviation: N/A = not applicable.
* Heat-related deaths are identified using International Classification of Diseases, Tenth Revision cause-of-death codes X30 (exposure to excessive natural heat), P81.0 (environmental hyperthermia of newborn), and T67 (effects of heat and light) listed as the underlying cause or as one of the contributing causes in death records. Records with code W92 (exposure to excessive heat of man-made origin) listed anywhere on the death certificate were excluded from this selection.
^† Based on multiple-cause-of-death data from the National Center for Health Statistics (NCHS) Vital Statistics System (https://www.cdc.gov/nchs/nvss/deaths.htm) and NCHS Bridged-Race Population data (https://www.cdc.gov/nchs/nvss/bridged_race.htm). This information is available from https://wonder.cdc.gov.
^§ Crude rate per 100,000 population.
^¶ American Indian/Alaska Native, Asian/Pacific Islander, black, and white decedents were non-Hispanic; Hispanic decedents could have been of any race.
** Rate estimates were not calculated because a population denominator was unavailable.
^†† https://www.cdc.gov/nchs/data/series/sr_02/sr02_166.pdf.

* The underlying cause of death was defined as the disease or injury that initiated the chain of events that led directly and inevitably to death. https://icd.who.int/browse10/Content/statichtml/ICD10Volume2_en_2010.pdf.
^† Contributing conditions, or factors, were defined as diseases, injuries, or complications that contributed to the death and were a result of the underlying cause. https://icd.who.int/browse10/Content/statichtml/ICD10Volume2_en_2010.pdf.
^§ Based on multiple-cause-of-death data from the National Center for Health Statistics Vital Statistics System (https://www.cdc.gov/nchs/nvss/deaths.htm). This information is available from https://wonder.cdc.gov.
^¶ Deaths were classified using International Classification of Diseases, Tenth Revision codes.
** Major cardiovascular diseases were identified using underlying cause-of-death codes I00–I78. Hypertensive diseases and ischemic heart diseases were identified using underlying cause-of-death codes I10–I15 and I20–I25.
^†† External causes of mortality were identified using underlying cause-of-death codes V01–Y98 and U01–U03. Alcohol poisoning deaths were identified using underlying cause-of-death codes X45, X65, and Y15. Drug overdose deaths were identified using underlying cause-of-death codes X40–X44, X60–X64, X85, and Y10–Y14.
^§§ Mental and behavioral disorders were identified using underlying cause-of-death codes F00–F99. Mental and behavioral disorders attributed to psychoactive substance use were identified using underlying cause-of-death codes F10–F19.
^¶¶ Diseases of the respiratory system were identified using underlying cause-of-death codes J00–J99. Chronic lower respiratory diseases were identified using underlying cause-of-death codes J40–J47.
*** Endocrine, nutritional and metabolic disorders were identified using underlying cause-of-death codes E00–E90. Diabetes mellitus diseases were identified using underlying cause-of-death codes E10–E14.
^††† Diseases of the digestive system were identified using underlying cause-of-death codes K00–K93. Diseases of the liver were identified using underlying cause-of-death codes K70–K77.
^§§§ Genitourinary disorders were identified using underlying cause-of-death codes N00–N98.
^¶¶¶ Musculoskeletal disorders were identified using underlying cause-of-death codes M00–M99.
**** Heat-related conditions were identified using cause-of-death codes X30 (exposure to excessive natural heat), P81.0 (environmental hyperthermia of newborn), and T67 (effects of heat and light). Records with code W92 (exposure to excessive heat of man-made origin) listed anywhere on the death certificate were excluded from this selection.