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Ambient Outdoor Heat and Heat-Related Illness in Florida

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Ambient Outdoor Heat and Heat-Related Illness in Florida AMBIENT OUTDOOR HEAT AND HEAT-RELATED ILLNESS IN FLORIDA Laurel Harduar Morano A dissertation submitted to the faculty at the University of North Carolina at Chapel Hill in partial fulfillment of the requirements for the degree of Doctor of Philosophy in the Department of Epidemiology in the Gillings School of Global Public Health. Chapel Hill 2016 Approved by: Steve Wing David Richardson Eric Whitsel Charles Konrad Sharon Watkins © 2016 Laurel Harduar Morano ALL RIGHTS RESERVED ii ABSTRACT Laurel Harduar Morano: Ambient Outdoor Heat and Heat-related Illness in Florida (Under the direction of Steve Wing) Environmental heat stress results in adverse health outcomes and lasting physiological damage. These outcomes are highly preventable via behavioral modification and community-level adaption. For prevention, a full understanding of the relationship between heat and heat-related outcomes is necessary. The study goals were to highlight the burden of heat-related illness (HRI) within Florida, model the relationship between outdoor heat and HRI morbidity/mortality, and to identify community-level factors which may increase a population’s vulnerability to increasing heat. The heat-HRI relationship was examined from three perspectives: daily outdoor heat, heat waves, and assessment of the additional impact of heat waves after accounting for daily outdoor heat. The study was conducted among all Florida residents for May-October, 2005–2012. The exposures of interest were maximum daily heat index and temperature from Florida weather stations. The outcome was work-related and non-work-related HRI emergency department visits, hospitalizations, and deaths. A generalized linear model (GLM) with an overdispersed Poisson distribution was used. GLMs were run for each sub-region within Florida and statewide estimates were obtained via random effects meta-regression. The results of the burden analysis indicated that the rates of HRI varied by geography, data source, and work-related status. The sub-groups with the highest relative rates were for males and rural residents. HRI rates increased with increasing heat index/temperature. The strongest effect was associated with the current day’s heat index/temperature. As heat index/temperature increased, at higher heat index/temperature values, there appeared to be some heat adaptation. For a Florida specific heat wave definition, duration should be two days or more above an intensity threshold which is defined by a constant value for heat index or an area varying relative value. Focus on heat waves is not appropriate for Florida. Community-level factors which may iii identify vulnerable Florida populations include populations with a high proportion of: impervious surfaces, renters, or individuals reporting Black race alone. This is the first study to explore the heat- HRI relationship stratified by work-related status and is the first to fully evaluate the heat-HRI relationship in Florida. This study highlights the importance of studying and mitigating the effects of heat in a humid sub-tropical climate. iv To all the pray warriors in my life whose prayers have protected me, sustained me, and guided my path. And to my grandmothers, Leceta Pryce, Octavia Richardson, and Muriel Carpenter; your prayers, hard work, sacrifice, and unconditional love are the foundations of my success. v ACKNOWLEDGEMENTS This work would not have been possible without the collaboration of my many colleagues at the Florida Department of Health, especially Meredith Jagger and Kristina Kintziger. I would like to thank Melissa Griffin who provided meteorological data and answered all of my Florida specific metrological questions. I would like to thank my committee members for their guidance and all their wonderful feedback. I would especially like to thank Steve Wing who has been my advisor throughout my doctoral program. He has always asked the right question at the right time and his philosophy of epidemiology, research, and the spoken word has been has been invaluable to me. I feel blessed to have had the chance to work with him. I am ever grateful to Sharon Watkins who has been my mentor for almost a decade, who encouraged me to start this process, and who has provided me much needed prospective throughout the program. To Jessica Rinsky who was my dissertation partner even after she graduated, I am grateful for her support, wordsmithing, and being an amazing sounding board. To all my friends and classmates who read, edited, and provided feedback on this document – thank you. I would like to acknowledge my family who has always supported me and expected the best of me. Finally, I am forever grateful to my husband, Aaron Morano, who joined me on this roller coaster of ups and downs that is a PhD program. His support and unfailing confidence in me is amazing. vi TABLE OF CONTENTS LIST OF TABLES ................................................................................................................................. xiii LIST OF FIGURES ............................................................................................................................... xv LIST OF EQUATIONS .......................................................................................................................... xix LIST OF ABBREVIATIONS .................................................................................................................. xx CHAPTER 1. INTRODUCTION ............................................................................................................ 1 CHAPTER 2. REVIEW OF THE LITERATURE ................................................................................... 3 Historical Background ......................................................................................................................... 3 Physiology .......................................................................................................................................... 6 Mechanisms of Heat Dissipation .................................................................................................... 7 Body Temperature Regulation ....................................................................................................... 9 Acclimatization .............................................................................................................................. 10 Biological Factors Affecting Thermoregulation ............................................................................. 10 Disease: Heat-Related Illness .......................................................................................................... 11 Pathophysiology ........................................................................................................................... 11 Diagnosis ...................................................................................................................................... 12 Other Potential Heat-Outcomes ....................................................................................................... 14 Diseases of the Circulatory System ............................................................................................. 16 Diseases of the Respiratory System ............................................................................................ 18 Other Diseases ............................................................................................................................. 18 Environmental Parameters ............................................................................................................... 19 Parameters Affecting Response to Heat ...................................................................................... 19 vii Proxies for Heat Exposure............................................................................................................ 21 Collection of the Basic Environmental Parameters ...................................................................... 25 Air Pollution .................................................................................................................................. 26 Epidemiology .................................................................................................................................... 27 Epidemiology of HRI in the General Population ........................................................................... 29 Occupational HRI Epidemiology ................................................................................................... 32 Potential Susceptibility Factors ......................................................................................................... 35 Age ............................................................................................................................................... 35 Gender .......................................................................................................................................... 36 Race/Ethnicity ............................................................................................................................... 37 Socio-economic Status ................................................................................................................. 39 Medical Factors ............................................................................................................................ 40 Air-Conditioning ...........................................................................................................................
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