Heat Waves and Rising Temperatures: Human Health Impacts and the Determinants of Vulnerability

  • Helene G. MargolisEmail author
Part of the Respiratory Medicine book series (RM, volume 7)


Globally, heat waves account for dramatic increases in mortality and morbidity; however, there is increasing awareness that day-to-day increases in temperature contribute to a significant risk of heat-related morbidity and mortality (HRMM) that over one or more warm seasons may exceed the public health burden of heat waves. Climate change has already and will continue to increase both average ambient temperatures and the frequency and intensity of excursions above those averages (i.e., heat waves or extreme heat events) and will thereby lead directly and indirectly to amplification of the risk of HRMM. This chapter provides a brief synopsis of our current knowledge about thermoregulation, thermotolerance and the pathophysiology of heat stroke, and the multiple determinants of health and illness that influence the risk of HRMM and that collectively define vulnerability. A particular focus is on two vulnerable populations, older adults and children. An Environmental Health Multiple-Determinant Model of Vulnerability is presented as a conceptual framework to integrate that knowledge, with the intent of providing a tool that can facilitate compilation and translation of the information to interventions and adaptation strategies relevant at the individual level and/or subpopulation and population levels and at one or more geopolitical scales in developing and/or developed nations. Three overarching strategies for HRMM risk reduction are discussed, including Extreme Heat Event and Warm Season Heat Preparedness and Response Action Plans, Promote Good Health and Access to Quality Healthcare (reduces risk and increases resiliency), and Reduce/Manage Potential Exposure(s) (individual, community) to Ambient Heat and Other Physical Environmental Stressors. A key focus of this chapter is on integration and translation of knowledge.


Heat waves and climate change Climate change and heat waves Rising temperatures in climate change Heat-related morbidity and mortality Public health burden of heat waves Heat stroke 


  1. 1.
    Sawka MN, et al. Human adaptations to heat and cold stress. In: RTO HFM symposium on “Blowing hot and cold: protecting against climatic extremes”. Dresden, Germany: RTO-MP; 2001. p. KN4-1–15.Google Scholar
  2. 2.
    Hanna JM, Brown DE. Human heat tolerance: an anthropological perspective. Annu Rev Anthropol. 1983;12:259–84.Google Scholar
  3. 3.
    Bouchama A, Knochel JP. Heat stroke. N Engl J Med. 2002;346(25):1978–88.Google Scholar
  4. 4.
    Wenger, C.B. (2002) Human Adaptation to Hot Environments. In: Pandolf, K.B. and Burr, RE (Eds) Medical Aspects of Harsh Environments. Washington, DC: Office of The Surgeon General Department of the Army, United States of America. p. 51–86.Google Scholar
  5. 5.
    Meehl G, Tebaldi C. More intense, more frequent, and longer lasting heat waves in the 21st century. Science. 2004;305:994–7.PubMedGoogle Scholar
  6. 6.
    IPCC. Intergovernmental panel on climate change, climate change 2007: synthesis report. Contribution of Working Group I to the Fourth Assessment Report of the Intergovernmental Panel on Climate Change. 2007. p. 103.Google Scholar
  7. 7.
    Robine JM, et al. Death toll exceeded 70,000 in Europe during the summer of 2003. C R Biol. 2008;331(2):171–8.PubMedGoogle Scholar
  8. 8.
    Fouillet A, et al. Excess mortality related to the August 2003 heat wave in France. Int Arch Occup Environ Health. 2006;80(1):16–24.PubMedGoogle Scholar
  9. 9.
    Luber G, McGeehin M. Climate change and extreme heat events. Am J Prev Med. 2008;35(5):429–35.PubMedGoogle Scholar
  10. 10.
    Gershunov A, Cayan D, Iacobellis S. The great 2006 California heat wave: signal of an increasing trend. J Climate. 2009;22:6181–203.Google Scholar
  11. 11.
    Kozlowski DR, Edwards LM. An analysis and summary of the July 2006 record-breaking heat wave across the state of California. NOAA Western Regional Tech Attach, No. 07–05 (Feb 27, 2007). Salt Lake City, UT: NOAA; 2007.Google Scholar
  12. 12.
    Hoshiko S, et al. A simple method for estimating excess mortality due to heat waves, as applied to the 2006 California heat wave. Int J Public Health. 2010;55(2):133–7.PubMedGoogle Scholar
  13. 13.
    Ostro BD, et al. Estimating the mortality effect of the July 2006 California heat wave. Environ Res. 2009;109(5):614–9.PubMedGoogle Scholar
  14. 14.
    Knowlton K, et al. The 2006 California heat wave: impacts on hospitalizations and emergency department visits. Environ Health Perspect. 2009;117(1):61–7.PubMedGoogle Scholar
  15. 15.
    Knowlton K, et al. Six climate change-related events in the United States accounted for about $14 billion in lost lives and health costs. Health Aff (Millwood). 2011;30(11):2167–76.Google Scholar
  16. 16.
    Hajat S, et al. Impact of high temperatures on mortality: is there an added heat wave effect? Epidemiology. 2006;17(6):632–8.PubMedGoogle Scholar
  17. 17.
    Hajat S, Kosatky T. Heat-related mortality: a review and exploration of heterogeneity. J Epidemiol Community Health. 2010;64(9):753–60.PubMedGoogle Scholar
  18. 18.
    Ye X, et al. Ambient temperature and morbidity: a review of epidemiological evidence. Environ Health Perspect. 2012;120(1):19–28.PubMedGoogle Scholar
  19. 19.
    Zanobetti A, et al. Summer temperature variability and long-term survival among elderly people with chronic disease. Proc Natl Acad Sci USA. 2012;109(17):6608–13.PubMedGoogle Scholar
  20. 20.
    McMichael AJ, et al. International study of temperature, heat and urban mortality: the ‘ISOTHURM’ project. Int J Epidemiol. 2008;37(5):1121–31.PubMedGoogle Scholar
  21. 21.
    McMichael AJ, Woodruff RE, Hales S. Climate change and human health: present and future risks. Lancet. 2006;367(9513):859–69.PubMedGoogle Scholar
  22. 22.
    Chestnut LG, et al. Analysis of differences in hot-weather-related mortality across 44 US metropolitan areas. Environ Sci Technol. 1998;1:59–70.Google Scholar
  23. 23.
    Haines A, et al. Climate change and human health: impacts, vulnerability and public health. Public Health. 2006;120(7):585–96.PubMedGoogle Scholar
  24. 24.
    Haines A, Patz JA. Health effects of climate change. JAMA. 2004;291(1):99–103.PubMedGoogle Scholar
  25. 25.
    Kalkstein LS, Greene JS. An evaluation of climate/mortality relationships in large U.S. cities and the possible impacts of a climate change. Environ Health Perspect. 1997;105(1):84–93.PubMedGoogle Scholar
  26. 26.
    Ebi KL, et al. Weather changes associated with hospitalizations for cardiovascular diseases and stroke in California, 1983–1998. Int J Biometeorol. 2004;49(1):48–58.PubMedGoogle Scholar
  27. 27.
    Anderson BG, Bell ML. Weather-related mortality: how heat, cold, and heat waves affect mortality in the United States. Epidemiology. 2009;20(2):205–13.PubMedGoogle Scholar
  28. 28.
    Roberts EM, et al. Personal communication. 2012.Google Scholar
  29. 29.
    Durand-Lasserve A, Clerc V. Regularization and integration of irregular settlements: lessons from experience (Working Paper No. 6) (Urban Management and Land); 1996.Google Scholar
  30. 30.
    Adachi M, et al. Oxidative stress impairs the heat stress response and delays unfolded protein recovery. PLoS One. 2009;4(11):e7719.PubMedGoogle Scholar
  31. 31.
    Leon LR, Helwig BG. Heat stroke: role of the systemic inflammatory response. J Appl Physiol. 2010;109(6):1980–8.PubMedGoogle Scholar
  32. 32.
    Horowitz M, Robinson SD. Heat shock proteins and the heat shock response during hyperthermia and its modulation by altered physiological conditions. Prog Brain Res. 2007;162:433–46.PubMedGoogle Scholar
  33. 33.
    Smith T, Zaitchik B, Gohlke J. Heat waves in the United States: definitions, patterns and trends. Clim Change. 2013;118:811–25.PubMedGoogle Scholar
  34. 34.
    Basu R. High ambient temperature and mortality: a review of epidemiologic studies from 2001 to 2008. Environ Health. 2009;8:40.PubMedGoogle Scholar
  35. 35.
    Trent RB, et al. Review of July 2006 heat wave related fatalities in California. Sacramento, CA: California Department of Public Health; 2008.
  36. 36.
    Bouchama A, et al. Prognostic factors in heat wave related deaths: a meta-analysis. Arch Intern Med. 2007;167(20):2170–6.PubMedGoogle Scholar
  37. 37.
    CDC. Heat-related deaths—Los Angeles County, California, 1999–2000, and United States, 1979–1998. MMWR Morb Mortal Wkly Rep. 2001;50(29):623–6.Google Scholar
  38. 38.
    Medina-Ramon M, et al. Extreme temperatures and mortality: assessing effect modification by personal characteristics and specific cause of death in a multi-city case-only analysis. Environ Health Perspect. 2006;114(9):1331-6. doi: 10.1289/ehp.9074 (
  39. 39.
    Naughton GA, Carlson JS. Reducing the risk of heat-related decrements to physical activity in young people. J Sci Med Sport. 2008;11(1):58–65.PubMedGoogle Scholar
  40. 40.
    Naughton MP, et al. Heat-related mortality during a 1999 heat wave in Chicago. Am J Prev Med. 2002;22(4):221–7.PubMedGoogle Scholar
  41. 41.
    Kovats RS, Hajat S. Heat stress and public health: a critical review. Annu Rev Public Health. 2008;29:41–55.PubMedGoogle Scholar
  42. 42.
    Belmin J, et al. Level of dependency: a simple marker associated with mortality during the 2003 heatwave among French dependent elderly people living in the community or in institutions. Age Ageing. 2007;36(3):298–303.PubMedGoogle Scholar
  43. 43.
    Stollberger C, Lutz W, Finsterer J. Heat-related side-effects of neurological and non-neurological medication may increase heatwave fatalities. Eur J Neurol. 2009;16(7):879–82.PubMedGoogle Scholar
  44. 44.
    Fouillet A, et al. Has the impact of heat waves on mortality changed in France since the European heat wave of summer 2003? A study of the 2006 heat wave. Int J Epidemiol. 2008;37(2):309–17.PubMedGoogle Scholar
  45. 45.
    Gehlert S, et al. Targeting health disparities: a model linking upstream determinants to downstream interventions: knowing about the interactions of societal factors and disease can enable targeted interventions to reduce health disparities. Health Aff (Millwood). 2008;27(2):339–49.Google Scholar
  46. 46.
    Liburd LC, Sniezek JE. Changing times: new possibilities for community health and well-being. Prev Chronic Dis. 2007. . Accessed July 2007.
  47. 47.
    Blum LN, Bresolin LB, Williams MA. From the AMA Council on Scientific Affairs Heat-related illness during extreme weather emergencies. JAMA. 1998;279(19):1514.PubMedGoogle Scholar
  48. 48.
    Allen AJ, Segal-Gidan F. Heat-related illness in the elderly. Clin Geriatr. 2007;15(7):37–45.Google Scholar
  49. 49.
    Kenney WL, Munce TA. Invited review: aging and human temperature regulation. J Appl Physiol. 2003;95(6):2598–603.PubMedGoogle Scholar
  50. 50.
    Worfolk JB. Heat waves: their impact on the health of elders. Geriatr Nurs. 2000;21(2):70–7.PubMedGoogle Scholar
  51. 51.
    Jardine DS. Heat illness and heat stroke. Pediatr Rev. 2007;28(7):249–58.PubMedGoogle Scholar
  52. 52.
    Falk B, Dotan R. Children’s thermoregulation during exercise in the heat: a revisit. Appl Physiol Nutr Metab. 2008;33(2):420–7.PubMedGoogle Scholar
  53. 53.
    Bytomski JR, Squire DL. Heat illness in children. Curr Sports Med Rep. 2003;2(6):320–4.PubMedGoogle Scholar
  54. 54.
    Howe AS, Boden BP. Heat-related illness in athletes. Am J Sports Med. 2007;35(8):1384–95.PubMedGoogle Scholar
  55. 55.
    Bates G, Gazey C, Cena K. Factors affecting heat illness when working in conditions of thermal stress. J Hum Ergol (Tokyo). 1996;25(1):13–20.Google Scholar
  56. 56.
    Jay O, Kenny GP. Heat exposure in the Canadian workplace. Am J Ind Med. 2010;53(8):842–53.PubMedGoogle Scholar
  57. 57.
    Rodahl K. Occupational health conditions in extreme environments. Ann Occup Hyg. 2003;47(3):241–52.PubMedGoogle Scholar
  58. 58.
    Parsons KC. International standards for the assessment of the risk of thermal strain on clothed workers in hot environments. Ann Occup Hyg. 1999;43(5):297–308.PubMedGoogle Scholar
  59. 59.
    Cusack L, de Crespigny C, Athanasos P. Heatwaves and their impact on people with alcohol, drug and mental health conditions: a discussion paper on clinical practice considerations. J Adv Nurs. 2011;67(4):915–22.PubMedGoogle Scholar
  60. 60.
    Kaciuba-Uscilko H, Grucza R. Gender differences in thermoregulation. Curr Opin Clin Nutr Metab Care. 2001;4(6):533–6.PubMedGoogle Scholar
  61. 61.
    Epstein Y, Moran DS. Thermal comfort and the heat stress indices. Ind Health. 2006;44(3):388–98.PubMedGoogle Scholar
  62. 62.
    McLellan TM. The importance of aerobic fitness in determining tolerance to uncompensable heat stress. Comp Biochem Physiol A Mol Integr Physiol. 2001;128(4):691–700.PubMedGoogle Scholar
  63. 63.
    Selkirk GA, McLellan TM. Influence of aerobic fitness and body fatness on tolerance to uncompensable heat stress. J Appl Physiol. 2001;91(5):2055–63.PubMedGoogle Scholar
  64. 64.
    Gagnon D, et al. Cold-water immersion and the treatment of hyperthermia: using 38.6 degrees C as a safe rectal temperature cooling limit. J Athl Train. 2010;45(5):439–44.PubMedGoogle Scholar
  65. 65.
    Hales JRS, Hubbard RW, Gaffin SL. Limitation of heat tolerance, In: Fregly MJ, Blatteis CM, editors. Handbook of physiology, environmental physiology, Suppl 14. New York: Wiley; 1996.Google Scholar
  66. 66.
    Weller AS, et al. Quantification of the decay and re-induction of heat acclimation in dry-heat following 12 and 26 days without exposure to heat stress. Eur J Appl Physiol. 2007;102(1):57–66.PubMedGoogle Scholar
  67. 67.
    Moseley PL. Heat shock proteins and heat adaptation of the whole organism. J Appl Physiol. 1997;83(5):1413–7.PubMedGoogle Scholar
  68. 68.
    Kuennen M, et al. Thermotolerance and heat acclimation may share a common mechanism in humans. Am J Physiol Regul Integr Comp Physiol. 2011;301(2):R524–33.PubMedGoogle Scholar
  69. 69.
    Moseley P. Stress proteins and the immune response. Immunopharmacology. 2000;48(3):299–302.PubMedGoogle Scholar
  70. 70.
    Fleming PJ, et al. Thermal balance and metabolic rate during upper respiratory tract infection in infants. Arch Dis Child. 1994;70(3):187–91.PubMedGoogle Scholar
  71. 71.
    Dematte JE, et al. Near-fatal heat stroke during the 1995 heat wave in Chicago. Ann Intern Med. 1998;129(3):173–81.PubMedGoogle Scholar
  72. 72.
    Finkel T, Holbrook NJ. Oxidants, oxidative stress and the biology of ageing. Nature. 2000;408(6809):239–47.PubMedGoogle Scholar
  73. 73.
    Lee IT, Yang CM. Role of NADPH oxidase/ROS in pro-inflammatory mediators-induced airway and pulmonary diseases. Biochem Pharmacol. 2012;84(5):581–90.PubMedGoogle Scholar
  74. 74.
    Libby P. Inflammation in atherosclerosis. Nature. 2002;420(6917):868–74.PubMedGoogle Scholar
  75. 75.
    Agarwal SK, et al. Airflow obstruction, lung function, and risk of incident heart failure: the Atherosclerosis Risk in Communities (ARIC) study. Eur J Heart Fail. 2012;14(4):414–22.PubMedGoogle Scholar
  76. 76.
    Park HS, Kim SR, Lee YC. Impact of oxidative stress on lung diseases. Respirology. 2009;14(1):27–38.PubMedGoogle Scholar
  77. 77.
    Emanuela F, et al. Inflammation as a link between obesity and metabolic syndrome. J Nutr Metab. 2012;2012:476380.PubMedGoogle Scholar
  78. 78.
    Whitham M, Febbraio MA. HSP and diabetes. In: Asea AAA, Pederson BK, editors. Heat shock proteins and whole body physiology. New York: Springer; 2010. p. 3–18.Google Scholar
  79. 79.
    Plummer LE, Smiley-Jewell S, Pinkerton KE. Impact of air pollution on lung inflammation and the roll of toll-like receptors. Int J Infereron Cytokine Mediator Res. 2012;4:43–57.Google Scholar
  80. 80.
    Breton CV, et al. Genetic variation in the glutathione synthesis pathway, air pollution, and children’s lung function growth. Am J Respir Crit Care Med. 2011;183(2):243–8.PubMedGoogle Scholar
  81. 81.
    Islam T, et al. Glutathione-S-transferase (GST) P1, GSTM1, exercise, ozone and asthma incidence in school children. Thorax. 2009;64(3):197–202.PubMedGoogle Scholar
  82. 82.
    Gilliland FD, et al. A theoretical basis for investigating ambient air pollution and children’s respiratory health. Environ Health Perspect. 1999;107 Suppl 3:403–7.PubMedGoogle Scholar
  83. 83.
    Franchini M, et al. Air pollution, vascular disease and thrombosis: linking clinical data and pathogenic mechanisms. J Thromb Haemost. 2012;10(12):2438–51.PubMedGoogle Scholar
  84. 84.
    Miller MR, Shaw CA, Langrish JP. From particles to patients: oxidative stress and the cardiovascular effects of air pollution. Future Cardiol. 2012;8(4):577–602.PubMedGoogle Scholar
  85. 85.
    Basu R, Ostro BD. A multicounty analysis identifying the populations vulnerable to mortality associated with high ambient temperature in California. Am J Epidemiol. 2008;168(6):632–7.PubMedGoogle Scholar
  86. 86.
    Coris EE, Ramirez AM, Van Durme DJ. Heat illness in athletes: the dangerous combination of heat, humidity and exercise. Sports Med. 2004;34(1):9–16.PubMedGoogle Scholar
  87. 87.
    Fleming PJ, Azaz Y, Wigfield R. Development of thermoregulation in infancy: possible implications for SIDS. J Clin Pathol. 1992;45(11 Suppl):17–9.PubMedGoogle Scholar
  88. 88.
    Falk B. Effects of thermal stress during rest and exercise in the paediatric population. Sports Med. 1998;25(4):221–40.PubMedGoogle Scholar
  89. 89.
    Bergeron MF, Devore C, Rice SG. Policy statement—climatic heat stress and exercising children and adolescents. Pediatrics. 2011;128(3):e741–7.PubMedGoogle Scholar
  90. 90.
    Prentice AM. The emerging epidemic of obesity in developing countries. Int J Epidemiol. 2006;35(1):93–9.PubMedGoogle Scholar
  91. 91.
    McConnell R, et al. Asthma in exercising children exposed to ozone: a cohort study. Lancet. 2002;359(9304):386–91.PubMedGoogle Scholar
  92. 92.
    Delfino RJ, et al. Association of asthma symptoms with peak particulate air pollution and effect modification by anti-inflammatory medication use. Environ Health Perspect. 2002;110(10):A607–17.PubMedGoogle Scholar
  93. 93.
    Moreno-Macias H, et al. Ozone exposure, vitamin C intake, and genetic susceptibility of asthmatic children in Mexico City: a cohort study. Respir Res. 2013;14(1):14.PubMedGoogle Scholar
  94. 94.
    Romieu I, et al. Genetic polymorphism of GSTM1 and antioxidant supplementation influence lung function in relation to ozone exposure in asthmatic children in Mexico City. Thorax. 2004;59(1):8–10.PubMedGoogle Scholar
  95. 95.
    Lambert MI, Mann T, Dugas JP. Ethnicity and temperature regulation. Med Sport Sci. 2008;53:104–20.PubMedGoogle Scholar
  96. 96.
    Horowitz M. Heat acclimation and cross-tolerance against novel stressors: genomic-physiological linkage. Prog Brain Res. 2007;162:373–92.PubMedGoogle Scholar
  97. 97.
    Horowitz M, Kodesh E. Molecular signals that shape the integrative responses of the heat-acclimated phenotype. Med Sci Sports Exerc. 2010;42(12):2164–72.PubMedGoogle Scholar
  98. 98.
    Lau WKM, Kim K-M. The 2010 Pakistan flood and Russian heat wave: teleconnections of hydrometeorological extremes. J Hydrometeorol. 2012;13:392–403.Google Scholar
  99. 99.
    Cayan D, et al. Climate scenarios for California. Sacramento, CA: California Energy Commission, California Climate Change Center; 2006. p. 52.Google Scholar
  100. 100.
    CDPH. Heat-related illness and mortality: information for the public health network in California. In: Public health impacts of climate change in California: community vulnerability assessments and adaptation strategies. Sacramento, CA: California Department of Public Health, Public Health Institute; 2007.
  101. 101.
    Stone B, Hess JJ, Frumkin H. Urban form and extreme heat events: are sprawling cities more vulnerable to climate change than compact cities? Environ Health Perspect. 2010;118(10):1425–8.Google Scholar
  102. 102.
    Oke T. The energetic basis of the urban heat island. Q J Roy Meteorol Soc. 1982;108(455):1–24.Google Scholar
  103. 103.
    United Nations. World urbanization prospects: the 2007 revision. New York: United Nations; 2008.Google Scholar
  104. 104.
    UNHabitat. (2011). Cities and climate change global report on human settlements 2011. United Nations Human Settlements Programme. London, UK: Earthscan Ltd; Washington, DC: Earthscan LLC.Google Scholar
  105. 105.
    WHO. World health statistics 2012. Geneva: World Health Organization; 2012.Google Scholar
  106. 106.
    CDC. Infectious disease and dermatologic conditions in evacuees and rescue workers after hurricane Katrina—multiple States, August–September, 2005. MMWR Morb Mortal Wkly Rep. 2005;54(38):961–4.Google Scholar
  107. 107.
    Keatinge WR. Death in heat waves. BMJ. 2003;327(7414):512–3.PubMedGoogle Scholar
  108. 108.
    Semenza JC, et al. Excess hospital admissions during the July 1995 heat wave in Chicago. Am J Prev Med. 1999;16(4):269–77.PubMedGoogle Scholar
  109. 109.
    Dannenberg AL, Frumkin H, Jackson R, editors. Making healthy places: designing and building for health, well-being, and sustainability. Washington, DC: Island Press; 2011.Google Scholar
  110. 110.
    WHO. Heat-health action plans: guidance. Europe, Copenhagen, Denmark: World Health Organization; 2008.Google Scholar
  111. 111.
    Durazo EM, et al. The health status and unique health challenges of rural older adults in California. Los Angeles, CA: University of California, Los Angeles (UCLA) Center for Health Policy research; 2011.Google Scholar
  112. 112.
    CHHSA, Strategic plan for an aging California population: Getting California ready for the “Baby Boomers”. Sacramento, CA: California Health and Human Services Agency, Editor; 2003. p. 258.Google Scholar
  113. 113.
    Bernard SM, McGeehin MA. Municipal heat wave response plans. Am J Public Health. 2004;94(9):1520–2.PubMedGoogle Scholar
  114. 114.
    Diaz J, Linares C, Tobias A. A critical comment on heat wave response plans. Eur J Public Health. 2006;16(6):600.PubMedGoogle Scholar
  115. 115.
    Richard L, Kosatsky T, Renouf A. Correlates of hot day air-conditioning use among middle-aged and older adults with chronic heart and lung diseases: the role of health beliefs and cues to action. Health Educ Res. 2011;26(1):77–88.PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  1. 1.Department of Internal Medicine: General Medicine Center for Healthcare Policy & Research, School of MedicineUniversity of California, DavisSacramentoUSA

Personalised recommendations