Analysis of Heat Illness using Michigan Emergency Department Syndromic Surveillance

Objective

The purpose of this work was to conduct an enhanced analysis of heat illness during a heat wave using Michigan’s Emergency Department Syndromic Surveillance System (MSSS) that could be provided to Public Health and Preparedness Stakeholders for situational awareness.

Introduction

The MSSS, described elsewhere (1), has been in use since 2003 and records Emergency Department (ED) chief complaint data along with the patient’s age, gender and zip code in real time. There were 85/139 hospital EDs enrolled in MSSS as of June 2012, capturing 77% of the annual hospital ED visits in Michigan. The MSSS is used routinely during the influenza season for situational awareness and is monitored throughout the year for aberrations that may indicate an outbreak, emerging disease or act of bioterrorism. The system has also been used to identify heat-related illnesses during periods of extreme heat. Very young children, the elderly, and people with mental illness and chronic diseases are at the highest risk of preventable heat-related illnesses including sunburn, heat exhaustion, heat stroke and/or death (2). During a heat wave in the summer of 2012, data was reviewed on an ad hoc basis to monitor potential increases in heat-related ED visits.

Methods

MSSS ED visits were queried to identify those with the primary complaints of: “heat”, “sun”, or “dehydration” including word derivatives and misspellings. The query excluded terms and misspellings such as “Sunday”, “heater”, and “heatlh”. Daily maximum temperatures for four major cities in Michigan were tracked using measures from the National Oceanic and Atmospheric Administration’s National Weather Service (3). Multiple analyses were performed. For this abstract, ED data from a 10-day period of sustained above normal temperatures are presented with data from the prior 10-day period used as reference.Visits were categorized into 1 of 3 syndromes based on the chief complaint: sun-associated, heat-associated, and dehydration. Gender, age group, and syndrome for the period of interest were compared to the reference period. Heat-related visits during the period of extreme heat were also analyzed by Michigan Public Health Preparedness Region.

Results

During the period of June 28–July 7, 2012 the South and Central regions of Michigan sustained maximum daily temperatures surpassing 90°F with maximum temperatures at or above 100°F on at least 2 days. Among the cities reviewed, a total of 9 high temperature records were set or tied during that period. The number of heat-related ED visits reported into MSSS increased compared to the previous period of June 18–June 27, 2012. Heat-associated ED visits such as heat exhaustion and heat stroke were more frequent than the reference period, 30.0% vs. 13.7% (p<0.0001). Sun-associated ED visits such as sunburn were lower compared to the reference period, 17.3% vs. 23.8% (p=0.01). Dehydration complaints were elevated among those 20-29 years of age, 17.7% vs. 10.0% (p=0.01). While the proportion of ED visits due to heat-related complaints was highest in the Central and Northwestern areas of the state, increases were observed in all regions of Michigan.On July 6, 2012 an initial analysis summary was issued via the Michigan Health Alert Network (MIHAN) to provide situational awareness related to a concurrent heat advisory for much of the state. By July 23, 2012 MDCH issued a media release reporting this increase in heat-related ED visits.

Conclusions

Although cases used in the analysis may not represent all potential cases of heat-related illness and also may represent non-heat-related illnesses, ED data are useful in describing trends in illness presentations over time. As the MSSS covers a large proportion of Michigan’s population, the data from the MSSS can be stratified by type of heat-related injury, age group, and region, providing detailed situational awareness to public health stakeholders. This type of in-depth analysis further contributes to our knowledge of heat events and allows public health to relay important information regarding the severity of the situation and information about groups at risk for illness.     

The burden of psychological symptoms in UK Armed Forces

OBJECTIVE: To assess the prevalence of psychological symptoms during periods of relatively low deployment activity and the factors associated with each psychological health outcome. METHODS: A survey of 4500 randomly selected UK service personnel was carried out in 2002. The questionnaire included the General Health Questionnaire (GHQ-12), the post-traumatic stress disorder checklist (PCL), 15 symptoms and an assessment of alcohol intake. RESULTS: A total of 20% were above cut-offs for GHQ-12, 15% for symptoms, 12% for alcohol intake and 2% for PCL. Gender, age, excessive drinking and smoking were independently associated with most outcomes of interest. Number of deployments was independently associated with multiple symptoms and excessive drinking. High post-traumatic stress disorder score was more frequent in the Army and in lower ranks. CONCLUSIONS: Psychological symptoms are highly prevalent in UK Armed Forces. Many risk factors are associated with measures of psychological ill-health.     

The development of a health policy for the Army

This paper describes the development of the Army Health Policy (AHP), which is a key component of the Army Human Resources Strategy (AHRS). The work on the AHP provided an opportunity for a fundamental review of the delivery of health support to the Army. The AHP will provide the strategic framework by which the Army will ensure the health of its workforce and, where appropriate, their dependents. The methodology used for this work may be a useful model for the development of a health policy for occupational populations.     

Environmental factors and heatstroke

The objective of this study was to determine the extent of the influence of temperature and humidity on the number of heatstroke presentations. Three hundred and forty-five labourers presented to the Accident and Emergency Hospital in Abu Dhabi with heatstroke during a 3 month summer period. There was no significant predictive association between the maximum daily temperature and/or humidity and the presentation of heatstroke. There was no significant association with the maximum temperature on the previous day, day of the week or temperature trend. The largest statistical correlation was between the maximum temperature and humidity and the log of the number of cases. It is possible that there are other significant explanatory variables that we have not included in the model.     

Heat exposure in the Canadian workplace

Exposure to excessive heat is a physical hazard that threatens Canadian workers. As patterns of global climate change suggest an increased frequency of heat waves, the potential impact of these extreme climate events on the health and well‐being of the Canadian workforce is a new and growing challenge. Increasingly, industries rely on available technology and information to ensure the safety of their workers. Current Canadian labor codes in all provinces employ the guidelines recommended by the American Conference of Governmental Industrial Hygienists (ACGIH) that are Threshold Limit Values (TLVs) based upon Wet Bulb Globe Temperature (WBGT). The TLVs are set so that core body temperature of the workers supposedly does not exceed 38.0°C. Legislation in most Canadian provinces also requires employers to install engineering and administrative controls to reduce the heat stress risk of their working environment should it exceed the levels permissible under the WBGT system. There are however severe limitations using the WGBT system because it only directly evaluates the environmental parameters and merely incorporates personal factors such as clothing insulation and metabolic heat production through simple correction factors for broadly generalized groups. An improved awareness of the strengths and limitations of TLVs and the WGBT index can minimize preventable measurement errors and improve their utilization in workplaces. Work is on‐going, particularly in the European Union to develop an improved individualized heat stress risk assessment tool. More work is required to improve the predictive capacity of these indices. Am. J. Ind. Med. 53:842–853, 2010. © 2010 Wiley‐Liss, Inc.     

武警部队医院健康教育现状分析及对策

目的　了解武警部队医院健康教育的现状 ,发现不足 ,并提出问题的解决方法。方法　对全国 51所武装警察医院负责健康教育的专职行政人员进行无记名问卷调查 ,部分项目进行现场观察。结果　 2 9 4 %的医院健康教育工作开展较为规范 ;35 3%医院配备有专职健康教育人员 ;2 1 6 %的医院有健康教育网络或类似组织机构 ;2 1 6 %的医院门诊大厅中有大屏幕播放卫生科普知识 ,52 9%的医院设立了健康教育咨询台 ,74 5%的医院住院部科室内有宣传栏或黑板报 ;6 5 2 %的医院没有对医务人员进行健康教育专业培训 ;2 1 6 %的医院将健康教育列入各科室业务考评范围。结论　武警部队医院健康教育工作发展不平衡 ,大多数医院尚未开展此项工作或不规范 ,有待于在组织、制度、实施、管理、评价等方面进一步完善     

Smoking and injury in Royal Marines' training

BACKGROUND: Training for the Royal Marines (RMs) is considered to be one of the most arduous military training regimes in the world. Approximately 16% of the annual intake of recruits suffer an injury. Smoking has been found to be a predisposition to injury. OBJECTIVE: To examine the relationship between recruits' smoking status on entry to training and subsequent incidence of injury. METHOD: Retrospective, longitudinal analysis of 1 year's intake of RM recruits at Commando Training Centre Royal Marines. RESULTS: A significantly greater proportion of RM recruits who were smokers on entry to training experienced a physical injury during the course than their non-smoking counterparts (chi-square = 8.15, P < 0.01). A recruit who smoked on entry to training was almost twice as likely to acquire an injury during training [relative risk = 1.7 (95% CI = 1.2-2.8)]. CONCLUSION: Smoking status of RM recruits in training was significantly associated with injury.     

The impact of quality on the demand for outpatient services in Cyprus

Health policy reforms in a number of countries seek to improve provider quality by sharpening the incentives they face, for example by exposing them to greater competition. For this to succeed, patients must be responsive to quality in their choice of provider. This paper uses data from Cyprus to estimate the effect of quality on patients' choice between public and private outpatient care. It improves on the existing literature by using a more comprehensive set of quality attributes which allows the dimensions of quality that have the largest effect on patient choice of provider to be identified. We also introduce an innovative way of measuring patients' perceptions of quality in a household survey. We find that patients' choice of provider is sensitive to quality, and that interpersonal quality is more important than either technical quality or system-related factors.     

Assessment of the potential effects of population changes in attitudes, awareness and beliefs on self-reporting of occupational ill-health

BACKGROUND: It is important to take account of the effects of population changes in attitudes, awareness and beliefs when interpreting temporal trends in self-reported occupational ill-health. Aim To assess how changes in population attitudes, awareness and beliefs have influenced trends in the self-reporting of occupational and other types of ill-health. METHOD: A review of relevant literature was carried out. The criterion for inclusion was that papers must be based on empirical evidence; theoretical discussion papers were included only where empirical examples were included. RESULTS: Several examples were identified where raised awareness of a health problem following intended or unintended publicity was followed by an increase in self-reports of this problem. The magnitude of the increase varied widely according to the situation. One example was identified where self-reports decreased following a publicity programme designed to prevent the occurrence and worsening of the problem in the population. Potential mechanisms identified as influencing changes in self-reporting of ill-health following raised awareness included changes in symptom/illness management, perception of symptoms, tolerance of symptoms, recognition and diagnosis of illness, attribution of illness; social desirability and legitimacy and recall. CONCLUSION: The effects of changes in population attitudes, awareness and beliefs on trends in self-reports of occupational and other illness are difficult to predict for any given situation.     

Minor Psychiatric Morbidity, Its Prevalence and Outcome in a Cohort of Civil Servants A Seven-year Follow-up Study

During the years 1979–1986, a cohort of direct entrantexecutive officers in the Civil Service were followed up toexamine the prevalence and outcome of minor psychiatric morbidityin an occupational setting. All studies using epidemiologicalstandardized research methods agree, that prevalence rates arehigh in occupational settings. As in primary care settings,half of the illness episodes followed a chronic course, whichemphasizes the need for early detection and prompt managementof these conditions, and for evaluative studies of interventionstrategies.     

Use of prescribed medication at work in employees with chronic illness

BACKGROUND: This study examined factors associated with the use of prescribed medication at work. METHODS: Questionnaire survey of employees with diagnosed chronic illnesses from four UK organizations. Data were collected on type of chronic illness, health status, health beliefs, work limitations, occupational health support, general practitioner (GP) and line manager support. Data were analysed using univariate logistic regression. RESULTS: A total of 1474 employees with chronic illness participated. Medication use at work (yes versus no) was predicted by age, pain, diagnosis of heart disease, medication use at home, benefit of prescribed medication to health, ease of using medication at work, practical support from families and practical and emotional support from GP and line manager. In a multivariate logistic regression model, medication use at work was predicted by medication use at home and ease of using medication at work only. CONCLUSIONS: The ease of taking medication at work was found to be a key predictor of medication use at work, suggesting occupational health may play a vital role in finding ways to support employees in their usage of medication. This may be for example by providing help and guidance in storing medication at work and encouraging employees to disclose medication use to employers and managers where necessary. Occupational health services can help create a workplace culture that places a high value on health, educating staff on the value of looking after their health and the benefits of following advice.     

The 2019 introduction of the new National Healthcare System in Cyprus

In 2019, Cyprus launched its new National Healthcare System (NHS) as one of the major structural reforms required by the bail-out agreement with the International Monetary Fund, the European Commission and the European Central Bank (known as the Troika) which averted Cyprus bankruptcy in 2011. This paper presents the key features of the new NHS: A National Health Insurance Fund operated by the Health Insurance Organisation pays for services provided by a mix of public and private providers. A prerequisite for the establishment of this new quasi-market was the transfer of public hospitals from the Ministry of Health to the new State Health Services Organisation, thus establishing a purchaser-provider and regulator split. The first implementation phase started in June 2019 and introduced coverage of outpatient healthcare services for the entire population, providing access – with relatively small user charges – to family physicians, outpatient specialists, pharmaceuticals and laboratories. The second implementation phase began in June 2020 with the inclusion of hospital care, followed by the inclusion of specialty pharmaceuticals in September and was completed in December 2020. The reform is a vital achievement as it is a major step towards the goal of universal health coverage, reducing the excessive reliance on out-of-pocket payment and glaring inequities in access to care.     

Miliaria rubra of the lower limbs in underground miners

This report documents a case series of miliaria rubra of the lower limbs in miners at a deep underground metalliferous mine in tropical arid Australia. During the summer months of February and March 1999, all cases of miliaria rubra of the lower limbs in underground miners seen at the mine's medical centre were clinically examined and administered a questionnaire. Twenty-five patients were seen, an incidence of 56.4 cases per million man-hours. Miliaria rubra was most often located between the ankle and knee (88% of cases). Twenty-four percent had concurrent folliculitis and 20% had concurrent tinea. Thirty-two percent had a personal history of asthma. Walking through ground-water and splashing of the legs was common. Three to 4 weeks of sedentary duties in air conditioning was generally required to achieve resolution of miliaria rubra. The incidence of miliaria rubra of the lower limbs is 38% of the incidence of heat exhaustion at the same mine. The length of disablement is greater, however. Atopics may be at increased risk of miliaria rubra. Control measures are discussed.     

The risk of heat exhaustion at a deep underground metalliferous mine in relation to body-mass index and predicted VO2max

The risk of heat exhaustion at a deep underground metalliferous mine was assessed in relation to the body-mass index (BMI) and predicted maximal oxygen uptake (VO2max) of miners, using case-control methodology. Sixty-five cases of acute heat exhaustion and 119 controls were studied. Heat exhaustion cases had a significantly higher BMI than controls (P = 0.006). The odds ratios increased with BMI. For a BMI of 32.00-36.99, compared to a BMI of less than 27.00 the odds ratio was 3.63 (95% confidence interval, 1.42-9.36). VO2max was not significantly lower in cases than controls. The odds ratios for heat exhaustion increased with decreasing VO2max, but not significantly. The sample size provided 80% power of detecting an odds ratio of 2.5 or greater. Deep underground miners should be advised to maintain a BMI of 24-27. Selection of miners on the basis of BMI should not be used as an alternative to satisfactory engineering controls such as ventilation and refrigeration.     

Cyprus in crisis: Recent changes in the pharmaceutical market and options for further reforms without sacrificing access to or quality of treatment

The pharmaceutical market in Cyprus has been characterised by high volume and a steep increase in per-capita expenditure over the past decade. Most importantly, the market is fragmented due to the absence of universal health insurance, and the uninsured have to rely exclusively on the private market. The objective of this study is to examine the weaknesses of the Cypriot pharmaceutical market before the financial crisis; to discuss the measures recently introduced after recommendations by the Troika; and to propose interventions that can improve access to pharmaceuticals and efficiency without compromising health outcomes. Apart from the introduction of new pharmaceutical policies, we also recommend the swift implementation of universal health insurance.     

An exploratory workplace study to investigate the perceived value of continuous low-level heatwrap therapy in manual workers

BACKGROUND: Between 60 and 80% of the population in industrialized countries experience low back pain at some time in their lives. The physical demands of work, i.e. manual handling, lifting, bending, twisting, awkward postures and whole body vibration are associated with low back symptoms. This study was undertaken to investigate the benefits of a new form of continuous low-level heatwrap therapy available for the symptomatic relief of acute low back pain in the workplace. METHODS: The subjects were recruited to the study upon their visit to the occupational health doctor after being diagnosed with acute low back pain. RESULTS: The study results show that use of the heatwrap therapy significantly reduced pain intensity and impact of pain on everyday activities. The results of the study were further extrapolated to show potential cost reduction benefits of using this heatwrap therapy in the workplace.     

驻南方部队防治训练中暑对策探析

本文针对南方部队训练中暑发病率高的特点,分析影响因素,探讨救治措施和预防对策,降低中暑发病率,减少非战斗减员,提高部队战斗力。     

A survey of the provision of educational supervision in occupational medicine in the Armed Forces

OBJECTIVE: The aim of this study was to assess whether balanced educational supervision was being provided for occupational medicine (OM) specialist registrars (SpRs) in the Armed Forces and to consider the effectiveness of current supervision. METHODS: Anonymized postal questionnaires, using Likert five-point response scales, were sent to Service OM SpRs and their educational supervisors (Ed Sup) to assess the degree of understanding of the purpose, effectiveness and organization of the educational supervision being provided. RESULTS: Completed questionnaires were returned from 35 (92%) specialists and 14 (61%) SpRs. Less than a third of the specialists were involved as Ed Sup and only three (11%) had undergone any formal medical education training. There was an agreement about the purpose and effectiveness of educational supervision between both the groups, though there appeared to be a bias towards providing supportive functions with patient management and educational components scoring less highly. CONCLUSIONS: A high response rate enabled an accurate assessment of OM supervision practices in the Armed Forces to be made. There was agreement over the relative effectiveness, importance and coverage of educational supervision, though this was being provided by a relatively small group of OM specialists, few of whom had undertaken any formal medical education training. The supervision provided also appeared to be biased towards providing supportive functions rather than patient management and educational components of training, which may result in an unbalanced training for the SpRs. Having assessed the relatively close-knit service OM community, there would be value in seeing whether similar patterns prevail in the wider OM community.