Hypothermia-Related Deaths Suffolk County, New York, January 1999

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medical history included dementia, to a makeshift bed in a wooded camp- Hypothermia-Related multiple transient ischemic attacks site with his shirt partly covered with (TIAs), hypertension, and chronic atrial snow. The temperature that day ranged Deaths—Suffolk fibrillation. Her medications included from 24°F-41°F (−4.4°C-4°C). He was County, New York, digoxin, furosemide, aspirin, colchi- fully clothed, including hat and gloves, cine, and sertraline hydrochloride. On and was lying partially in a sleeping bag January 1999– December 21, she developed adult res- on top of a canvass pool cover. The de- March 2000, and piratory distress syndrome; she died on cedent had a history of alcohol and drug January 10, 1999. The death certifi- abuse, but no drugs or alcohol were United States, cate listed the cause of death as com- found in his blood. He had been living 1979-1998 plications of environmental exposure in the woods for several years and was with aspiration. Hypertension, arterio- last seen several weeks before his death. MMWR. 2000;50:53-57 sclerotic cardiovascular disease, and de- The death certificate listed the cause of mentia were contributory. death as probable hypothermia attrib- 2 figures omitted Case 2. In January 2000, a 51-year- uted to environmental exposure with old man wearing a rain-soaked sweater, chronic alcoholism contributing. HYPOTHERMIA IS THE UNINTENTIONAL pants, and work boots was found dead lowering of core body temperature to behind a dumpster. On the day he was New York Ͻ95°F (Ͻ35°C).1 Core body tempera- found, the temperature ranged from During 1979-1998, the age-adjusted ture normally is maintained at 97.7°F 25°F-49°F (−3.9°C-9.4°C); the day be- death rate for hypothermia was 0.2 per (36.5°C).2 Most hypothermia-related fore, it had been raining with tempera- 100,000 population (International Clas- deaths occur during the winter in states tures in the 50s. Drug paraphernalia was sification of Diseases, Ninth Revision that have moderate to severe cold tem- found in his pockets and needle track [ICD-9], codes E901.0, E901.8, and peratures (e.g., Alaska, Illinois, New marks were observed on his arms. Ac- E901.9; excludes man-made cold York, and Pennsylvania).3 During 1979- cording to the police report, the dece- [E901.1]),* compared with the me- 1998, New York had the second high- dent had a history of illegal drug use. dian of 0.4 for the United States. Suf- est number of hypothermia-related Toxicology showed 0.10% ethanol, folk County ranked fifth among New deaths in the United States. This re- morphine, codeine, and methadone in York’s 62 counties in number of hypo- port presents case reports of four hy- his body. The death certificate listed the thermia-related deaths for persons of all pothermia-related deaths during Janu- cause of death as complications of acute ages. Age-specific death rates in Suf- ary 1999-March 2000 in Suffolk County and chronic drug abuse and environ- folk County and New York increased (1999 population: 1,383,847), the larg- mental hypothermia. with age . Of all hypothermia-related est county in New York excluding New Case 3. In January 2000, a 79-year- deaths in New York and Suffolk York City, and summarizes hypother- old woman who resided in an adult County, 386 (53%; 95% confidence in- mia-related deaths in the United States home facility had been missing for 40 terval [CI]=±3.6%) and 25 (58%; 95% during 1979-1998. Such deaths can be minutes. She was found outside, unre- CI=±14.8%), respectively, occurred prevented by educating health-care pro- sponsive, wearing a blouse, sweat- among persons aged Ն65 years. In Suf- viders and the public to identify per- shirt, and sweatpants. The tempera- folk County, age-adjusted death rates sons at risk for hypothermia. ture that day ranged from 26°F-32°F were three times higher for men than (−3.3°C-0°C). At a hospital, her rectal women. Case Reports temperature was 81°F (27°C). She was Case 1. On December 15, 1998, an treated with hypothermic blankets but United States 89-year-old woman with a history of died 1 hour later. The decedent had a During 1979-1998, 13,970 persons died wandering was noticed missing from history of senile dementia, syncope, and from hypothermia, an average of 699 the adult home facility where she re- TIAs. Her medications included iron deaths per year (range: 420-1024 sided and was found shivering in 1 foot sulfate and aspirin. The cause of death deaths) , and the age-adjusted death of water at the edge of a pond on the was hypothermia with senile demen- rates for hypothermia decreased property. The temperature that day tia and arteriosclerotic cardiovascular significantly (pϽ0.001). Of all hypo- ranged from 23°F-54°F (−5°C-12.2°C). disease contributing. thermia-related deaths, 6857 (49%; On admission to a hospital, her rectal Case 4. In March 2000, a 45-year- 95% CI=±0.83%) occurred among temperature was 95°F (35°C). Her old homeless man was found dead next persons aged Ն65 years. The age-

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adjusted rate for hypothermia was ap- confusion, memory loss, drowsiness, ex- son’s principles of internal medicine. 14th ed. New York, New York: McGraw-Hill, 1999:210-2. proximately 2.5 times higher for men haustion, fumbling hands, and slurred 9. CDC. Extreme cold: a prevention guide to promote (0.5 per 100,000 population) than speech. Severe hypothermia can result in your personal health and safety. Atlanta, Georgia: US women (0.2) during the same period. loss of consciousness, apparent apnea, or Department of Health and Human Services, CDC, 1996. undetectable pulse. In infants, warning *These data were obtained from the Compressed Mor- Reported by: CV Wetli, MD, Office of the Medical signs of hypothermia include cold, bright tality File (CMF), maintained by CDC’s National Cen- Examiner, Dept of Health Svcs, Suffolk County, Haup- ter for Health Statistics, and have been prepared in pauge; P Smith, MD, State Epidemiologist, New York red skin and lethargy. accordance with the external cause-of-death codes State Dept of Health. Health Studies Br, Div of Envi- Preventive measures include wear- from the ICD-9. The CMF contains information from ronmental Hazards and Health Effects, National Cen- death certificates filed in the 50 states and the Dis- ter for Environmental Health; and an EIS Officer, CDC. ing several layers of loosely fitting cloth- trict of Columbia. ing with a tightly woven, wind- CDC Editorial Note: The findings in this resistant outer layer and wool, silk, or report indicate that hypothermia- polypropylene inner layers to hold body Outbreak of Ebola related deaths in the United States de- heat. In cold and windy climates, per- creased during 1979-1998. In addition, sons should maintain dry clothing; eat Hemorrhagic Fever— in New York and Suffolk County, hypo- well-balanced meals; drink warm, sweet, thermia-related death rates increased by nonalcoholic beverages; and avoid ex- Uganda, August age category and were higher among ertion because excess perspiration can 2000-January 2001 men, similar to trends observed in the cause chilling.9 Persons who partici- United States. All four case-patients in pate in outdoor recreation should take MMWR. 2000;50:73-77 this report had one or more risk factors appropriate precautions, such as wear- 2 figures omitted for hypothermia-related death (e.g., older ing wet suits while participating in water- age [Ն65 years], lack of adequate hous- related activities or carrying emer- ON OCTOBER 8, 2000, AN OUTBREAK OF ing, homelessness, mental impairment, gency shelters and heat-generating an unusual febrile illness with occa- drug overdose, and alcohol ingestion).4 devices for unexpected weather changes sional hemorrhage and significant mor- Contributing factors include malnutri- while hiking or camping. During win- tality was reported to the Ministry of tion, lack of fitness, severe illness, and ter months or in areas with low night- Health (MoH) in Kampala by the su- drug use or abuse.5 time temperatures, blankets or extra perintendent of St. Mary’s Hospital in Data in this report are limited by the clothing should be kept in vehicles when Lacor, and the District Director of underreporting of hypothermia in medi- driving. Measures to prevent hypother- Health Services in the Gulu District. A cal records and death certificates.5 Hypo- mia-related deaths include educating the preliminary assessment conducted by thermia-related deaths may be underre- public and health-care providers (e.g., MoH found additional cases in Gulu ported because (1) physical signs of emergency department, adult home fa- District and in Gulu Hospital, the re- hypothermia may not be recognized; (2) cility, and social services staff) to iden- gional referral hospital. On October 15, hospitals may not use low-temperature tify persons at risk and establishing out- suspicion of Ebola hemorrhagic fever thermometers; (3) medical personnel reach programs that provide warm (EHF) was confirmed when the Na- may be unaware of hypothermia’s sig- shelter and adequate clothing. tional Institute of Virology (NIV), Jo- nificance; and (4) an autopsy cannot hannesburg, South Africa, identified prove hypothermia as an underlying REFERENCES Ebola virus infection among speci- cause of death.6 In addition, vital record 1. Petersdorf RG. Hypothermia and hyperthermia. In: mens from patients, including health- data on hypothermia may not code hypo- Wilson JD, Braunwald E, Isselbacher KJ, et al, eds. Har- care workers at St. Mary’s Hospital. This rison’s principles of internal medicine. 12th ed. New thermia as the underlying cause of death. York, New York: McGraw-Hill, 1991:2198-200. report describes surveillance and con- Mortality estimates are 75%-90% for 2. Yoder E. Disorders due to heat and cold. In: Ben- trol activities related to the EHF out- net JC, Plum F, eds. Cecil textbook of medicine. Phila- persons with hypothermia and under- delphia, Pennsylvania: WB Saunders Company, 1996: break and presents preliminary clini- lying disease, compared with Յ10% for 501-3. cal and epidemiologic findings. 7 3. CDC. Hypothermia-related deaths—Georgia, Janu- those with hypothermia alone. Dis- ary 1996-December 1997, and United States, 1979- Control activities were organized eases such as hypoglycemia, hypothy- 1995. MMWR 1998;47:1037-40. around surveillance and epidemiol- 4. Abramowicz M, ed. Treatment of hypothermia. In: roidism, sepsis, and cirrhosis, or drug use The Medical Letter on Drugs and Therapeutics. New ogy, clinical case management, social (e.g., alcohol, phenothiazines, opiates, Rochelle, New York: The Medical Letter on Drugs and education and mobilization, and coor- clonidine, lithium, barbiturates, and ben- Therapeutics, December 1994. dination and logistic support. An ac- 5. Hector MG. Treatment of accidental hypother- zodiazepenes) can result in decreased mia. Am Fam Physician 1992;45:785-92. tive EHF surveillance system was ini- heat production.8 Alcohol use results in 6. CDC. Hypothermia—United States. MMWR 1983; tiated to determine the extent and 32:46-8. central nervous system depression, va- 7. Vassallo SU, Delaney KA. Thermoregulatory prin- magnitude of the outbreak, identify foci sodilation, and blunting behavioral ciples. In: Goldfrank LR, Flomenbau NE, eds. Gold- of disease activity, and detect cases frank’s toxicologic emergencies. 6th ed. Stamford, Con- responses to cold. Signs of hypother- necticut: Appleton and Lange, 1998:285-95. early. Ill persons were encouraged to be mia include uncontrollable shivering, 8. Fauci AS, Isselbacher KJ, Wilson JD, eds. Harri- assessed at a hospital and, if indicated,

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to be hospitalized to reduce further positive for Ebola virus antigen or Ebola ritual contact with the deceased oc- community transmission. Targeted pre- IgG antibody. curred, and intrafamilial or nosoco- vention activities included follow-up of During October 5–November 27, mial transmission. Fourteen (64%) of contacts of identified cases for 21 days; among 62 persons with laboratory- 22 health-care workers in Gulu were in- establishment of trained burial teams confirmed EHF admitted to Gulu Hos- fected after establishing the isolation for all potential and confirmed EHF pital, symptoms included diarrhea wards; these incidenses led to the re- deaths; community education; cessa- (66%), asthenia (64%), anorexia (61%), inforcement of infection-control mea- tion of traditional healing and burial headache (63%), nausea and vomiting sures. Two distant focal outbreaks were practices; cessation of large public gath- (60%), abdominal pain (55%), and initiated by movement of infected erings; and updates of hospital infec- chest pain (48%). Patients presented for contacts of EHF cases from Gulu to tion-control measures, including iso- care a mean of 8 days (range: 2-20 days) Mbarara and Masindi districts. Na- lation wards. Laboratory testing was after symptom onset. Bleeding oc- tional notification and surveillance ef- performed at a field laboratory estab- curred in 12 (20%) patients and pri- forts led to the rapid identification of lished at St. Mary’s Hospital by CDC marily involved the gastrointestinal these foci and effective containment. and supplemented by additional test- tract. Among the 62 confirmed case- Reported by: Ministry of Health: T Oyok, DTC&E, C ing at CDC and NIV. Sequence analy- patients, 36 (58%) died; among pa- Odonga, MBChB, E Mulwani, MBChB, J Abur, F Ka- sis revealed that the virus associated tients aged Ͻ15 years, four of five died ducu, MBChB, Gulu Hospital; M Akech, J Olango, DNA, P Onek, MSc, Gulu District; J Turyanika, Kiryandongo with this outbreak was Ebola-Sudan and (case fatality: 80%). Spontaneous abor- Hospital; I Mutyaba, Masindi Hospital, Masindi Dis- differed at the nucleotide sequence level tions were reported among pregnant trict; HRS Luwaga, MA, G Bisoborwa, MPH, Masindi from earlier Ebola-Sudan isolates by women infected with EHF. Patients District, A Kaguna, MPH, Mbarara District; FG Omaswa, FRCS, S Zaramba, S Okware, A Opio, PhD, J Aman- 3.3% and 4.2% in the polymerase (362 who died usually exhibited a rapid pro- dua, MmedPH, J Kamugisha, MPH, E Mukoyo, MSc, J nucleotides sequenced) and nucleo- gression of shock, increasing coagu- Wanyana, MmedPH, C Mugero, MSc, M Lamunu, MPH, GW Ongwen, Dip EH, M Mugaga, Bstat, C Ki- capsid (146 nucleotides sequenced) lopathy, and loss of consciousness. yonga, MBChB, Ministry of Health, Kampala, Uganda. protein encoding genes, respectively. As of January 23, 2001, 425 pre- Other National Team Members: Z Yoti, MBChB, A * Olwa, MBChB, M deSanto, M Lukwiya, MD, St. Mary’s During the third week of October, sumptive case-patients with 224 (53%) Hospital, Lacor, Gulu District; P Bitek, Uganda Red Cross active surveillance was established and deaths attributed to EHF were re- Society, Gulu District Br; P Louart, C Maillard, A Del- forge, C Levenby, International Committee of the Red included three case notification catego- corded from three districts in Uganda: Cross, Gulu District Br; E Munaaba, MBChB, African ries: alert, suspect, and probable. The 393 (93%) from Gulu, 27 (6%) from Medical Relief Foundation, Gulu District; Rwaguma, Msc alert category comprised persons with Masindi, and five (1%) from Mbarara. Vet Med, J Lutwama, PhD, Uganda Virus Research In- stitute, Entebbe; S Banonya, MPH, Z Akol, MmedPH, sudden onset of high fever, sudden death, The combined area comprises approxi- L Lukwago, MPH, E Tanga, MPH, L Kiryabwire, or hemorrhage, and was used by com- mately 11,700 square miles (31,000 MmedPH, Institute of Public Health-Makerere Univ, Ka- mpala, Uganda. International Organizations: Re- munity members to alert health-care per- square kilometers; 2000 combined gional Office for Africa, Harare, Zimbabwe. Country sonnel. The suspect category com- population: 1.8 million) .1 Although the Office, Kampala, Uganda. World Health Organiza- tion, Geneva, Switzerland. Emergency Dept, Italian Co- prised persons with fever and contact cluster of cases in early October trig- operation, Kampala, Uganda. Epicentre, Paris, France. with a potential case-patient; persons gered identification of the outbreak and Medecins sans Frontieres, Holland and Belgium. Health with unexplained bleeding; persons with response measures, investigations (i.e., Canada, Ottawa, Canada. International Committee of the Red Cross, Geneva, Switzerland. Catholic Relief Svcs, fever and three or more specified symp- case-record review and interviews with Gulu District. Office of US Foreign Disaster Assis- toms (i.e., headache, vomiting, anorexia, surviving patients or their surrogates) tance, US Agency for International Development, Wash- ington, DC International Rescue Committee, New York, diarrhea, weakness or severe fatigue, identified cases occurring in the com- New York. Italian Institute of Health, Rome, Italy. In- abdominal pain, body aches or joint munity and patients hospitalized sev- stitute for Tropical Medicine, Antwerp, Belgium. Nagoya City Univ Medical School, Nagoya; Institute of Medi- pains, difficulty swallowing, difficulty eral weeks earlier. The onset of illness cal Science, Univ of Tokyo; National Institute of Infec- breathing, and hiccups), and all unex- of the earliest presumptive case was Au- tious Diseases; Kansai Airport Quarantine Station; Sen- dai Quarantine Station; Ministry of Health, Labor, and plained deaths. The suspect category was gust 30, 2000, and onset of the last pre- Welfare, Tokyo, Japan. National Health Svc, Public used by mobile surveillance teams to sumptive case was January 9, 2001. The Health Laboratory Svcs, London, England. National In- determine whether a patient required ages of presumptive case-patients stitute of Virology, Johannesburg, South Africa. Tropi- cal Medicine Institute, Hamburg, Germany. National transport to an isolation ward. The prob- ranged from 3 days-72 years (median: Center for Infectious Diseases; and EIS officers, CDC. able category included persons who met 28 years); 269 (63%) were women. these criteria and were assessed and Mean time from symptom onset to CDC Editorial Note: EHF is caused by reported by a physician. Laboratory tests death was 8 days (95% confidence in- infection with viruses of the genus Ebo- included virus antigen detection and terval=±5days); 218 (51%) presump- lavirus in the family Filoviridae.2 The antibody ELISA tests and reverse tran- tive cases were laboratory confirmed. zoonotic reservoir for the viruses is un- scriptase polymerase chain reaction. Epidemiologic investigations iden- known; however, outbreaks of EHF are Laboratory-confirmed case-patients were tified the three most important means associated most often with the intro- defined as patients who met the surveil- of transmission as attending funerals of duction of the virus into the commu- lance case definitions and were either presumptive EHF case-patients where nity by one infected person followed by

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dissemination by person-to-person contacts in Gulu District were under sur- ment of Health-Related Quality of Life,” transmission, often within medical fa- veillance for 21 days by approximately the first comprehensive report to de- cilities. This is the largest reported EHF 150 trained volunteers. The goal of on- scribe the validity and use of a set of sur- outbreak and the third known Ebola- going prevention efforts is to identify spe- vey measures developed by CDC and Sudan virus-associated outbreak.3,4 The cific risk factors for disease acquisition partners to track population health sta- first occurred in 1976 in the southern in the community and hospitals, exam- tus and health-related quality of life Sudan towns of Nzara and Maridi and ine virologic and clinical parameters of (HRQOL) in states and communities.1 was concurrent with an Ebola-Zaire infection, and increase the reporting of The report is intended for public health outbreak in Zaire (Democratic Repub- potentially epidemic diseases into a na- professionals involved or interested in lic of the Congo). The second Ebola- tional surveillance system. HRQOL surveillance or measure- Sudan outbreak occurred in 1979 in the ment. The report identifies the policy same locations. Similar to the 1976 and REFERENCES and conceptual origins of a brief set of 1979 outbreaks, the 2000 outbreak had 1. Rwabwoogo MO, ed. In: Uganda districts infor- healthy days HRQOL measures devel- mation handbook. 4th ed. Kampala, Uganda: Foun- a case fatality of approximately 50%. tain Publishers Ltd, 1997. oped for use as public health outcome Also similar to the earlier outbreaks, the 2. Peters CJ, LeDuc JW. An introduction to Ebola: the measures and summarizes the results 2000 outbreak seemed to have begun virus and the disease. J Infect Dis 1999;179(suppl): of studies to test the measures’ accu- ix-xvi. with the introduction of the virus into 3. World Health Organization International Study racy and consistency. Gulu District followed by transmis- Team. Ebola hemorrhagic fever in Sudan, 1976. Bull During January 1993–December World Health Organ 1978;56:247-70. sion into the community and health- 4. Baron RC, McCormick JB, Zubier OA. Ebola virus 2000, approximately 1 million U.S. care facilities. However, the first cases disease in southern Sudan: hospital dissemination and adults were asked Behavioral Risk Fac- intra familial spread. Bull World Health Organ 1983; associated with this EHF outbreak re- 61:997-1003. tor Surveillance System questions on main obscure, which has limited the 5. CDC and World Health Organization. Infection con- self-rated health, recent physical and trol for viral hemorrhagic fevers in the African health ability to investigate possible reser- care setting. Atlanta, Georgia: US Department of Health mental health, and activity limita- voirs of the virus. and Human Services, CDC, 1998. tions. State and local health officials can

Community transmission was elimi- *Persons initially identified by the mobile teams or as- use the measures and data to help nated by recognition of the outbreak, ini- sessed by a health-care worker (suspect and prob- achieve the two major goals of the na- tiation of case finding, case isolation and able cases using the notification scheme) who were tional health objectives for 2010: im- not laboratory negative and met the following case other infection-control practices, and definition: (a) unexplained bleeding; or (b) fever and prove the quality and years of healthy hospitalization of identified case- three or more specified symptoms (i.e., headache, vom- life and eliminate health disparities. iting, anorexia, diarrhea, weakness or severe fatigue, patients in medical facilities where bar- abdominal pain, body aches or joint pains, difficulty States and communities are encour- rier nursing (e.g., wearing personal pro- in swallowing, difficulty in breathing, and hiccups); or aged to use the measures to identify (c) unexplained deaths. All laboratory-confirmed cases tective clothing) and other infection- also were included. subgroups of persons with poor per- control procedures were implemented.5 ceived health and to use that informa- Decreased transmission also was the re- tion to identify population health trends sult of community education about the Publication of Report and disparities, define disease burden, dangers of contact with symptomatic and allocate resources based on unmet deceased EHF patients, the establish- on Validation and needs, and evaluate disease preven- ment of specialized burial teams, and Use of Measures of tion efforts. The report is available on heightened awareness of the disease the World-Wide Web, http://www.cdc among health-care staff. Although trans- Health-Related .gov/nccdphp/hrqol. mission to health-care workers occurred during this outbreak, the use of Quality of Life isolation facilities remains the most ef- REFERENCE MMWR. 2000;50:61-62 fective means of controlling EHF out- 1. CDC. Measuring healthy days: population assess- 5 ment of health-related quality of life. Atlanta, Geor- breaks. During the 4-month outbreak CDC RECENTLY PUBLISHED “MEASUR- gia: US Department of Health and Human Services, and response period, approximately 5600 ing Healthy Days: Population Assess- CDC, November 2000.

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