The City of Milwaukee Health Department (MHD) convened a county-wide Heat Task Force in 1996 to reduce morbidity and mortality during extreme heat events. Epidemiologically-identified target populations included the elderly, very young, mentally-ill, cognitively-impaired, anticholinergic drug consumers, severely obese and those with cardiovascular or pulmonary disease.
The annually-updated plan specifies communications and client support roles for over 20 agencies before and during heat waves, triggered by specific weather criteria. MHD faxes and emails Heat Health Action Notices to partners and the media. Response is intensified as needed, based on MHD active surveillance of heat illness and deaths. Twenty-four hour hotlines and web information help the public and providers access information and services. Forty-nine percent to 83% reductions in heat-adjusted morbidity and mortality between 1995 (before) and 1999 (after) heat waves were observed. The plan and related resources are available at www.milwaukee.gov/health/heat.
Heat waves are responsible for more deaths than hurricanes, tornadoes, floods, lightning strikes and earthquakes combined. MHD formed the Heat Task Force in direct response to an excessive heat event in July of 1995 in which 91 people in Milwaukee County died from heat-related illness. The task force unites a diverse group of over 20 state, county and local agencies, community-based organizations, health care providers, utilities and the media to prepare for and respond to excessive heat events in Milwaukee. Triggers for action and the roles of taskforce members are specified in an Extreme Heat Plan which is updated annually based on experience and changes in organizational capacity. Because the plan is very simple, based on trigger levels and roles, it is easily updated each year and can be adapted easily by other communities.
The MHD role in the task force includes:
Bringing the members together for at least one meeting per year;
Seeking member input for annual plan evaluation and revision;
Maintaining and testing current member database to ensure timely communications particularly during heat events;
Providing relevant information for member agencies and their clients prior to and during heat events;
Managing public risk communications during heat events; and
Conducting active surveillance to compile and analyze data relative to climate, morbidity and mortality.
Until 2001 MHD fully operated the Extreme Heat Hotline for the public; then, a county-wide “211” all-human-services hotline agreed to receive calls from the general public, permitting health department staff to focus on calls from healthcare providers.
Task force members include the National Weather Service, the American Lung Association, the Red Cross, the Salvation Army, Goodwill Industries, the Milwaukee County Medical Examiner, the Wisconsin Department of Health and Family Services, other City Departments including Police, Fire and Schools, Medical Society of Milwaukee County, County Human Services Departments serving at-risk populations, community-based agencies serving at-risk populations as well as local hospital emergency departments and other local public health departments in Milwaukee County. Taskforce members are recruited and assume different roles based on their client populations and usual services offered.
The plan lays out interventions by taskforce member based on specific triggers including four escalating Heat Health Action Levels based on NWS weather alerts, and annual springtime community preparation. Given the still-uncertain relationship between NWS alerts and health outcomes, the Heat Health Action Levels may be escalated on the basis of observed heat morbidity as well as weather reports. Collaboration is fostered by steady flow of information and allowing member agencies to interact and participate in decision-making at an annual planning meeting.
The taskforce and plan were created using MHD staff time with assistance from other taskforce organization representatives. Apart from the time applied to initial discussion and authoring of the plan, maintenance costs are minimal. Plan maintenance (annual taskforce meeting and plan revisions, maintaining taskforce database, communications tests, website maintenance, creation of educational materials) and health department heat wave response roles have consumed 0.1 or less full-time-equivalent (FTE) of an environmental hygienist or epidemiologist. Other local public health agencies could adapt an existing plan like Milwaukee’s with their own taskforce at minimal cost.
Each spring response issues and heat morbidity and mortality during the previous year's heat events are reviewed by the taskforce. Process improvements are identified for incorporation into the plan for the upcoming summer.
A severe heat wave in 1999 provided an opportunity for outcome evaluation. Several different published models of interaction between heat index, time, heat morbidity and heat mortality were applied to Milwaukee data from 1995 (pre-plan) and 1999 (post-plan) heat waves. Adjusted by these models, observed 1999 heat morbidity (emergency medical service runs) and mortality fell to between .17 to .51 of 1995 levels, with 95% confidence intervals below identity in 11 of 12 model-outcome combinations.
Logistical challenge: Current member database has 92 individuals (many represent two and three deep contacts at the same agency for redundancy). Originally, heat notifications and other messages were sent via fax machine, however, as the database grew hand faxing became an impractical method. MHD moved to using a web-based fax that allows near simultaneous broadcast of fax notifications to all members. For 2003 email is also usedl for communications during heat events. Power blackouts that sometimes accompany heat waves would adversely impact communications.
Resource challenge: Very few of the member agencies providing direct service to at-risk populations operate on a 24-7 schedule, sometimes slowing communication with or response of that agency. Milwaukee County now has a 24-hour “211” community information and referral line. Staff members at the hotline are trained to give accurate heat health information and can access appropriate resources in urgent situations.
Capacity challenge: A task force subcommittee was formed to investigate the possibility of providing air-conditioners to individuals most at-risk. The main focus was people with asthma and other breathing difficulties who would benefit from air-conditioning throughout the summer, not just during excessive heat events. One agency had previously operated an air-conditioner program but found that the number of requests and the labor-intensive screening process quickly overwhelmed their staff. Other difficulties reported included client inability to install the units, inadequate wiring in homes, transient clients who left air-conditioners behind in moves, difficulty in developing a consistent and workable screening tool. Previously, practical advice for those lacking air-conditioning has included relocating, moving to cool basement or air-conditioned common rooms, and using cool showers or baths.
Key program elements include:
Assembling and meeting with the relevant community partners,
Creating a simple written plan based on objective triggers, and
Creating capacity to be alerted to extreme heat forecasts and to notify partner agencies.
Maintaining resources on the internet helps all participants, including the public, understand their roles and responsibilities and access needed resources.