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2019
Green, H, Bailey J, Schwarz L, Vanos J, Ebi K, Benmarhnia T.  2019.  Impact of heat on mortality and morbidity in low and middle income countries: A review of the epidemiological evidence and considerations for future research. Environmental Research. 171:80-91.   10.1016/j.envres.2019.01.010   AbstractWebsite

Heat waves and high air temperature are associated with increased morbidity and mortality. However, the majority of research conducted on this topic is focused on high income areas of the world. Although heat waves have the most severe impacts on vulnerable populations, relatively few studies have studied their impacts in low and middle income countries (LMICs). The aim of this paper is to review the existing evidence in the literature on the impact of heat on human health in LMICs. We identified peer-reviewed epidemiologic studies published in English between January 1980 and August 2018 investigating potential associations between high ambient temperature or heat waves and mortality or morbidity. We selected studies according to the following criteria: quantitative studies that used primary and/or secondary data and report effect estimates where ambient temperature or heat waves are the main exposure of interest in relation to human morbidity or mortality within LMICs. Of the total 146 studies selected, eighty-two were conducted in China, nine in other countries of East Asia and the Pacific, twelve in South Asia, ten in Sub-Saharan Africa, eight in the Middle East and North Africa, and seven in each of Latin America and Europe. The majority of studies (92.9%) found positive associations between heat and human morbidity/mortality. Additionally, while outcome variables and study design differed greatly, most utilized a time-series study design and examined overall heath related morbidity/mortality impacts in an entire population, although it is notable that the selected studies generally found that the elderly, women, and individuals within the low socioeconomic brackets were the most vulnerable to the effects of high temperature. By highlighting the existing evidence on the impact of extreme heat on health in LMICs, we hope to determine data needs and help direct future studies in addressing this knowledge gap. The focus on LMICs is justified by the lack of studies and data studying the health burden of higher temperatures in these regions even though LMICs have a lower capacity to adapt to high temperatures and thus an increased risk.

Hosokawa, Y, Casa DJ, Trtanj JM, Belval LN, Deuster PA, Giltz SM, Grundstein AJ, Hawkins MD, Huggins RA, Jacklitsch B, Jardine JF, Jones H, Kazman JB, Reynolds ME, Stearns RL, Vanos JK, Williams AL, Williams WJ.  2019.  Activity modification in heat: critical assessment of guidelines across athletic, occupational, and military settings in the USA. International Journal of Biometeorology. 63:405-427.   10.1007/s00484-019-01673-6   AbstractWebsite

Exertional heat illness (EHI) risk is a serious concern among athletes, laborers, and warfighters. US Governing organizations have established various activity modification guidelines (AMGs) and other risk mitigation plans to help ensure the health and safety of their workers. The extent of metabolic heat production and heat gain that ensue from their work are the core reasons for EHI in the aforementioned population. Therefore, the major focus of AMGs in all settings is to modulate the work intensity and duration with additional modification in adjustable extrinsic risk factors (e.g., clothing, equipment) and intrinsic risk factors (e.g., heat acclimatization, fitness, hydration status). Future studies should continue to integrate more physiological (e.g., valid body fluid balance, internal body temperature) and biometeorological factors (e.g., cumulative heat stress) to the existing heat risk assessment models to reduce the assumptions and limitations in them. Future interagency collaboration to advance heat mitigation plans among physically active population is desired to maximize the existing resources and data to facilitate advancement in AMGs for environmental heat.

2018
McGregor, GR, Vanos JK.  2018.  Heat: a primer for public health researchers. Public Health. 161:138-146.   10.1016/j.puhe.2017.11.005   AbstractWebsite

Objectives: To provide a primer on the physical characteristics of heat from a biometeorological perspective for those interested in the epidemiology of extreme heat. Study design: A literature search design was used. Methods: A review of the concepts of heat, heat stress and human heat balance was conducted using Web of Sciences, Scopus and PubMed. Results: Heat, as recognised in the field of human biometeorology, is a complex phenomenon resulting from the synergistic effects of air temperature, humidity and ventilation levels, radiation loads and metabolic activity. Heat should therefore not be conflated with high temperatures. A range of empirical, direct and rational heat stress indices have been developed to assess heat stress. Conclusion: The conceptualisation of heat stress is best described with reference to the human heat balance which describes the various avenues for heat gain to and heat loss from the body. Air temperature alone is seldom the reason for heat stress and thus heat-related health effects. (c) 2017 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.

Herdt, AJ, Brown RD, Scott-Fleming I, Cao GF, Macdonald M, Henderson D, Vanos JK.  2018.  Outdoor thermal comfort during anomalous heat at the 2015 Pan American Games in Toronto, Canada. Atmosphere. 9   10.3390/atmos9080321   AbstractWebsite

Mass sporting events in the summertime are influenced by underlying weather patterns, with high temperatures posing a risk for spectators and athletes alike. To better understand weather variations in the Greater Toronto Area (GTA) during the Pan American Games in 2015 (PA15 Games), Environment and Climate Change Canada deployed a mesoscale monitoring network system of 53 weather stations. Spatial maps across the GTA demonstrate large variations by heat metric (e.g., maximum temperature, humidex, and wet bulb globe temperature), identifying Hamilton, Ontario as an area of elevated heat and humidity, and hence risk for heat-related illness. A case study of the Hamilton Soccer Center examined on-site thermal comfort during a heat event and PA15 Soccer Games, demonstrating that athletes and spectators were faced with thermal discomfort and a heightened risk of heat-related illness. Results are corroborated by First Aid and emergency response data during the events, as well as insight from personal experiences and Twitter feed. Integrating these results provides new information on potential benefits to society from utilizing mesonet systems during large-scale sporting events. Results further improve our understanding of intra-urban heat variability and heat-health burden. The benefits of utilizing more comprehensive modeling approaches for human heat stress that coincide with fine-scale weather information are discussed.

Kalkstein, AJ, Kalkstein LS, Vanos JK, Eisenman DP, Dixon PG.  2018.  Heat/mortality sensitivities in Los Angeles during winter: a unique phenomenon in the United States. Environmental Health. 17   10.1186/s12940-018-0389-7   AbstractWebsite

Background: Extreme heat is often associated with elevated levels of human mortality, particularly across the mid-latitudes. Los Angeles, CA exhibits a unique, highly variable winter climate, with brief periods of intense heat caused by downsloping winds commonly known as Santa Ana winds. The goal is to determine if Los Angeles County is susceptible to heat-related mortality during the winter season. This is the first study to specifically evaluate heatrelated mortality during the winter for a U.S. city. Methods: Utilizing the Spatial Synoptic Classification system in Los Angeles County from 1979 through 2010, we first relate daily human mortality to synoptic air mass type during the winter season (December, January, February) using Welch's t-tests. However, this methodology is only somewhat effective at controlling for important inter-and intra-annual trends in human mortality unrelated to heat such as influenza outbreaks. As a result, we use distributed lag nonlinear modeling (DLNM) to evaluate if the relative risk of human mortality increases during higher temperatures in Los Angeles, as the DLNM is more effective at controlling for variability at multiple temporal scales within the human mortality dataset. Results: Significantly higher human mortality is uncovered in winter when dry tropical air is present in Los Angeles, particularly among those 65 years and older (p < 0.001). The DLNM reveals the relative risk of human mortality increases when above average temperatures are present. Results are especially pronounced for maximum and mean temperatures, along with total mortality and those 65 +. Conclusions: The discovery of heat-related mortality in winter is a unique finding in the United States, and we recommend stakeholders consider warning and intervention techniques to mitigate the role of winter heat on human health in the County.

Kosaka, E, Iida A, Vanos J, Middel A, Yokohari M, Brown R.  2018.  Microclimate variation and estimated heat stress of runners in the 2020 Tokyo Olympic Marathon. Atmosphere. 9   10.3390/atmos9050192   AbstractWebsite

The Tokyo 2020 Olympic Games will be held in July and August. As these are the hottest months in Tokyo, the risk of heat stress to athletes and spectators in outdoor sporting events is a serious concern. This study focuses on the marathon races, which are held outside for a prolonged time, and evaluates the potential heat stress of marathon runners using the COMFA (COMfort FormulA) Human Heat Balance (HBB) Model. The study applies a four-step procedure: (a) measure the thermal environment along the marathon course; (b) estimate heat stress on runners by applying COMFA; (c) identify locations where runners may be exposed to extreme heat stress; and (d) discuss measures to mitigate the heat stress on runners. On clear sunny days, the entire course is rated as dangerous' or extremely dangerous', and within the latter half of the course, there is a 10-km portion where values continuously exceed the extremely dangerous level. Findings illustrate which stretches have the highest need for mitigation measures, such as starting the race one hour earlier, allowing runners to run in the shade of buildings or making use of urban greenery including expanding the tree canopy.

2017
Vanos, JK, Herdt AJ, Lochbaum MR.  2017.  Effects of physical activity and shade on the heat balance and thermal perceptions of children in a playground microclimate. Building and Environment. 126:119-131.   10.1016/j.buildenv.2017.09.026   AbstractWebsite

Outdoor thermal comfort (TC) is an important parameter in assessing the value and health utility of a recreational space. Given the public health significance of child heat illness, the ability to model children's heat balance and TC during activity has received little attention. The current pilot study tests the performance of an outdoor human heat balance model on children playing in warm/hot outdoor environments in sun and shade. Fourteen children aged 9-13 participated in the 8-day study in Texas in spring 2016, performing physical activity while wearing heartrate monitors and completing thermal perception surveys (e.g., actual thermal sensation (ATS)). Surveys were compared to predicted thermal sensation (PTS) based on principles of human-environment heat exchange using personal data and a suite of on-site microclimate information. Results demonstrate the model to significantly predict ATS votes (Spearman's rho = 0.504). Subjective preferred change was also significantly correlated to modeled PTS (rho = -0.607). Radiation, air temperature, windspeed, and level of tiredness were significant predictors of ATS. Finally, the mean human energy balance was significantly lower in the shade (-168 W m(-2)), thus lowering heat stress potential, with the model predicting ATS with little-to-no error (0.2 and 0.0 scale error units in sun and shade, respectively). This study demonstrates an ability to estimate a child's heat balance while accounting for changes in major heat contributors (e.g., radiation, metabolism), and is the first study to evaluate TC of children during activity in outdoor built environments. New insights of heat perception may aid in recognition of often under-recognized heat stress. (C) 2017 Elsevier Ltd. All rights reserved.

Graham, DA, Vanos JK, Kenny NA, Brown RD.  2017.  Modeling the Effects of Urban Design on Emergency Medical Response Calls during Extreme Heat Events in Toronto, Canada. International Journal of Environmental Research and Public Health. 14   10.3390/ijerph14070778   AbstractWebsite

Urban residents are at risk of health-related illness during extreme heat events but the dangers are not equal in all parts of a city. Previous studies have found a relationship between physical characteristics of neighborhoods and the number of emergency medical response (EMR) calls. We used a human energy budget model to test the effects of landscape modifications that are designed to cool the environment on the expected number of EMR calls in two neighborhoods in Toronto, Canada during extreme heat events. The cooling design strategies reduced the energy overload on people by approximately 20-30 W m(-2), resulting in an estimated 40-50% reduction in heat-related ambulance calls. These findings advance current understanding of the relationship between the urban landscape and human health and suggest straightforward design strategies to positively influence urban heat-health.