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Extreme Heat Events Guidelines: Technical Guide for Health Care Workers Blank Page Extreme Heat Events Guidelines: Technical Guide for Health Care Workers Prepared by: Water, Air and Climate Change Bureau Healthy Environments and Consumer Safety Branch Health Canada is the federal department responsible for helping the people of Canada maintain and improve their health. We assess the safety of drugs and many consumer products, help improve the safety of food, and provide information to Canadians to help them make healthy decisions. We provide health services to First Na- tions people and to Inuit communities. We work with the provinces to ensure our health care system serves the needs of Canadians. Published by authority of the Minister of Health. Extreme Heat Events Guidelines: Technical Guide for Health Care Workers is available on Internet at the following address: www.healthcanada.gc.ca Également disponible en français sous le titre : Lignes directrices à l’intention des travailleurs de la santé pendant les périodes de chaleur accablante : Un guide technique This publication can be made available in a variety of formats. For further information or to obtain additional copies, please contact: Publications Health Canada Ottawa, Ontario K1A 0K9 Tel.: 613-954-5995 Fax: 613-941-5366 Email: [email protected] © Her Majesty the Queen in Right of Canada, represented by the Minister of Health, 2011 This publication may be reproduced without permission provided the source is fully acknowledged. HC Pub.: 110055 Cat.: H128-1/11-642E ISBN: 978-1-100-18172-1 Acknowledgements Health Canada gratefully acknowledges the contribution of the following people in reviewing chapters. Health Canada recognizes the particular efforts of Jean-Christophe Blachère PhD and Pierre Gosselin MD from the Institut national de santé publique du Québec (INSPQ) in contributing to the writing of Chapter 4 Heat Risk Factors Associated with Medications. Health Professionals Information and Training Heat Alert and Response Systems Pilot Advisory Committee Reviewers • Geoffrey Dover PhD • Ada Bennett MD • Paul Eagan MD • Neil Gamey RN, PCP • Richard Gould MD • Stephan Hamel MSc • Joan Hayes RPh, BScPharm • Lori Jones RN, BScN • Glen P. Kenny PhD • Tom P. McCormack • Kieran Moore MD • Robert Munro • David Mowat MD • Toni Morris-Oswald PhD, BSW, MNRM • Sonya Nobbe ND • Karina Richters • Lori Payne • Adrian Robertson MD • Pammla Petrucka RN, PhD • Brent Roussin MD, LLB, MPH(C), CCFP • Sally Shurvell External Reviewers • Sheri Armstrong RN, BScN, MS Heat Alert and Response Systems Advisory • Sandra Brioux RN, BA Committee • Janet Chee RN, BScN, MN • Quentin Chiotti PhD • Audrey Danaher RN, MSc • Patty Gorr • Katie Dilworth MHSc, RN, CCHN(C) • Jane MacDonald RN, MHSc • James Ducharme MD, CM, FRCP(C), DABEM • Franziska Matthies PhD • Doris Grinspun RN, MSN, PhD, O.ONT. • Bettina Menne MD, PhD • Stephanie Gower PhD • Scott Sheridan PhD • Laura Hanson RN, BN, MN • Kathryn Hardill BScN, RN(EC) • Brenda Jacklitsh MS • Carol Mee RN, BScN, MEd • Robert Milling LLB, LLM • Lynn Anne Mulrooney RN, MPH, PhD • Daniel Rainham PhD • Brent Ruddock RPh, BScPharm • Howard Shapiro MD MSc FRCP(C) • Carol M. Stephenson PhD • Althea Stewart-Pyne RN, BN, MHSc • Jill Skinner • Tim Takaro MD, MPH, MS • Pamela VanBelle, RN, BScN, MN Extreme Heat Events Guidelines: Technical Guide for Health Care Workers i Citation Health Canada. (2011). Extreme Heat Events Guidelines: Technical Guide for Health Care Workers. Water, Air and Climate Change Bureau, Healthy Environments and Consumer Safety Branch, Health Canada. Ottawa, Ontario, 149. (Catalogue No. H128-1/11-642E) Any questions or comments on this document may be directed to: Climate Change and Health Office Water, Air and Climate Change Bureau Healthy Environments and Consumer Safety Branch Health Canada 269 Laurier Avenue West Ottawa, Ontario Canada K1A 0K9 Telephone: 613-954-1656 Facsimile: 613-952-1880 Email: [email protected] ii Extreme Heat Events Guidelines: Technical Guide for Health Care Workers Table of Contents of Table Table of Contents Executive Summary 1 1. Introduction 4 1.1 Heat Illnesses in Canada 4 1.2 Extreme Heat Events in Canada 5 1.3 Projected Increase in Extreme Heat Events in Canada 8 2. Physiology and Pathology of Heat Illness 9 2.1 Temperature Regulation 9 2.2 Environmental Parameters Affecting Heat Balance 12 2.3 General Physiological Changes 14 2.5 Physiological Challenges in At-Risk Populations 19 3. Risk Factors Associated with Heat-Related Illness and Death 26 3.1 Risk Factors Associated with Mortality During Extreme Heat Events 26 3.2 Factors Associated with Heat Morbidity 35 3.3 Protective Factors 37 4. Heat Risk Factors Associated with Medications 39 4.1 Drug Use and Heat 39 4.2 Effects of Drugs on Body Thermal Regulation 40 4.3 Polypharmacy Case Studies 40 4.4 Drugs Implicated in Heat-Related Illnesses 41 4.5 Conclusions 46 5. Heat-Related Illnesses 47 5.1 Heat-Related Illnesses 47 5.2 Heat Illnesses 48 5.3 Differences in Mental Status for Heat Stroke and Heat Exhaustion 60 Extreme Heat Events Guidelines: Technical Guide for Health Care Workers iii Table of Contents of Table 6. Questions and Answers: Preventing Heat-Related Illnesses 61 6.1 Preventing Heat-Related Morbidity and Mortality 61 7. Extreme Heat Summary Advice for Medical Officers of Health and Public Health Staff 74 7.1 Extreme Heat Events and Heat-Related Illnesses 74 7.2 Individual and Community Risk Factors 74 7.3 Effective Prevention Measures to Advise the Public to Adapt to the Heat 77 7.4 Messages Developed for Communication with the Public 78 7.5 Mid- to Long-Term Public Health Planning: Prevention for Municipal Planners 82 8. Disaster Preparedness for Health Care Services 83 8.1 Managing Extreme Heat Events 83 8.2 Heat-Related Death May Occur at Home Alone 84 8.3 Hospitals and Nursing Homes without Air Conditioning 85 8.4 Emergency Preparedness 85 8.5 Long-Term Planning 88 8.6 Conclusion 89 9. Conclusions and Future Directions 90 Glossary 92 Appendix A: Guideline Development Methods 99 Appendix B: Fact Sheets for Health Care Workers 107 Appendix C: Heat Resilient Canadians and Communities 115 Appendix D: Heat-Health Fact Sheets 117 References 127 iv Extreme Heat Events Guidelines: Technical Guide for Health Care Workers List of Abbreviations of List List of Abbreviations ACGIH® American Conference of kcal Kilocalorie Governmental Industrial Hygienists kJ/hr Kilojoules per hour ACh Acetylcholine mEq/L Milliequivalents of solute ADH Antidiuretic Hormone per litre of solution ALT Alanine Aminotransaminase MODS Multi-Organ Dysfunction Syndrome AQI Air Quality Index OR Odds Ratio AQHI Air Quality Health Index PM Particulate Matter AST/SGOT Aspartate Aminotransferase/ Serum Glutamic-Oxaloacetic RR Relative Risk Transaminase RH Relative Humidity ATP Adenosine Tri-Phosphate SRES Special Report on Emissions °C Degree(s) Celsius Scenarios CI95 95% Confidence Interval SSRI Selective Serotonin Re-uptake Inhibitor CNF Canadian Nutrient File SGPT Serum Glutamic-Pyruvic CNS Central Nervous System Transaminase COPD Chronic Obstructive Pulmonary Twb Natural Wet-Bulb Thermometer Disease Tg Globe Thermometer CPK Creatine Phosphokinase Tdb Dry-Bulb Thermometer DIC Disseminated Intravascular Coagulation TLV® Threshold Limit Value EHE Extreme Heat Event UHI Urban Heat Island °F Degree(s) Fahrenheit UV Ultraviolet GHG Greenhouse Gas WBGT Wet-Bulb Globe Temperature HPIT Health Professional Intervention/ WHO World Health Organization Information and Training W Watts HSP Heat Shock Protein VO2 max Maximum Volume of Oxygen ICD International Classification over time of Disease VOC Volatile Organic Compound IPCC Intergovernmental Panel on Climate Change Extreme Heat Events Guidelines: Technical Guide for Health Care Workers v Blank Page Executive Summary Executive Summary Executive Extreme heat events (EHEs), more commonly linkages on common concerns and solutions known as heat waves,a have affected health and regarding extreme heat. The Technical Guide resulted in a significant number of preventable provides current national and international research deaths in recent years. Notably, in the summer of in a format designed to promote translation of 2003, Europe experienced 70,000 deaths as a result global imperatives into evidence-based adaptations. of the extreme heat.1 Experts believe that climate The targeted Fact Sheets are each one double-sided change will significantly impact the frequency, page intended to be both brief and sufficient for duration and intensity of EHEs, resulting in an most busy health care providers. These Fact Sheets increased incidence of heat-related illness and groupings were developed to address the needs fatality in Canada. For example, in the absence of several disciplines within each topic. The of effective mitigation and adaptation measures User Guide was developed as a synthesis of the key in Toronto, Windsor, London and Winnipeg, the actions for organizations and institutions to take number of days with a maximum temperature when promoting adaptation. Together, this suite of 30°C is projected to double by 2021-2040 and of products was developed and designed to meet more than triple by 2081-2100, likely resulting the various needs of health care workers in both in further heat-related mortality.2,3 As a result, addressing and preventing heat illnesses through decision makers need to make a concerted effort to education and health promotion. address and adapt to these increased risks in order to protect populations considered at risk. The goal The target audience for this suite of products is b of the Health Canada Heat Resiliency Project is health care workers including, but not limited to: to facilitate these adaptations in particular at a • medical officers of health local and regional level. The information within • public health practitioners the Guidelines has been written with the goal that medical physicians health care workers can adapt it for the needs of the • populations they serve. • medical helpline workers • nurse practitioners Health care worker involvement is needed at all levels nurses in Canada to make decisions concerning adaptation • and planning for EHEs.