Seventy-five years of searching for a heat index

A century of exercise physiology: concepts that ignited the study of human thermoregulation. Part 3: Heat and cold tolerance during exercise

In this third installment of our four-part historical series, we evaluate contributions that shaped our understanding of heat and cold stress during occupational and athletic pursuits. Our first topic concerns how we tolerate, and sometimes fail to tolerate, exercise-heat stress. By 1900, physical activity with clothing- and climate-induced evaporative impediments led to an extraordinarily high incidence of heat stroke within the military. Fortunately, deep-body temperatures > 40 °C were not always fatal. Thirty years later, water immersion and patient treatments mimicking sweat evaporation were found to be effective, with the adage of cool first, transport later being adopted. We gradually acquired an understanding of thermoeffector function during heat storage, and learned about challenges to other regulatory mechanisms. In our second topic, we explore cold tolerance and intolerance. By the 1930s, hypothermia was known to reduce cutaneous circulation, particularly at the extremities, conserving body heat. Cold-induced vasodilatation hindered heat conservation, but it was protective. Increased metabolic heat production followed, driven by shivering and non-shivering thermogenesis, even during exercise and work. Physical endurance and shivering could both be compromised by hypoglycaemia. Later, treatments for hypothermia and cold injuries were refined, and the thermal after-drop was explained. In our final topic, we critique the numerous indices developed in attempts to numerically rate hot and cold stresses. The criteria for an effective thermal stress index were established by the 1930s. However, few indices satisfied those requirements, either then or now, and the surviving indices, including the unvalidated Wet-Bulb Globe-Thermometer index, do not fully predict thermal strain.

Physiological interactions with personal-protective clothing, physically demanding work and global warming: An Asia-Pacific perspective

The Asia-Pacific contains over half of the world's population, 21 countries have a Gross Domestic Product <25% of the world's largest economy, many countries have tropical climates and all suffer the impact of global warming. That 'perfect storm' exacerbates the risk of occupational heat illness, yet first responders must perform physically demanding work wearing personal-protective clothing and equipment. Unfortunately, the Eurocentric emphasis of past research has sometimes reduced its applicability to other ethnic groups. To redress that imbalance, relevant contemporary research has been reviewed, to which has been added information applicable to people of Asian, Melanesian and Polynesian ancestry. An epidemiological triad is used to identify the causal agents and host factors of work intolerance within hot-humid climates, commencing with the size dependency of resting metabolism and heat production accompanying load carriage, followed by a progression from the impact of single-layered clothing through to encapsulating ensembles. A morphological hypothesis is presented to account for inter-individual differences in heat production and heat loss, which seems to explain apparent ethnic- and gender-related differences in thermoregulation, at least within thermally compensable states. The mechanisms underlying work intolerance, cardiovascular insufficiency and heat illness are reviewed, along with epidemiological data from the Asia-Pacific. Finally, evidence-based preventative and treatment strategies are presented and updated concerning moisture-management fabrics and barriers, dehydration, pre- and post-exercise cooling, and heat adaptation. An extensive reference list is provided, with >25 recommendations enabling physiologists, occupational health specialists, policy makers, purchasing officers and manufacturers to rapidly extract interpretative outcomes pertinent to the Asia-Pacific.

Investigation of outdoor thermal sensation and comfort evaluation methods in severe cold area

Comfortable outdoor environment benefits the health of citizens and reduces energy consumption and pollution. This study discusses different outdoor thermal sensation and comfort evaluation methods in severe cold area. The database was from a year-long outdoor thermal comfort survey conducted in Harbin, China. Thermal sensation evaluation was developed using meteorological parameters and three popular thermal comfort indices including Standard Effective Temperature (SET*), Physiologically Equivalent Temperature (PET) and Universal Thermal Climate Index (UTCI). Thermal comfort prediction was developed by the three thermal comfort indices and acceptability. Original thermal sensation scales of SET* and PET were less applicable to predict thermal sensation vote (TSV). Calibrated scales of the three indices were obtained based on linear regression results and probit analysis. The accuracies of calibrated scales of thermal sensation were all below 32.8%. The comfortable thermal sensation range in severe cold area varied from "slightly cool" to "hot". This calibrated range improved accuracies of thermal comfort predicting by around 20%. The unacceptability appropriate to define comfortable range was 9% on the cold thermal sensation side and 26% on the hot side. Adaptation and local exposure also acted on thermal sensation and comfort apart from factors included in thermal comfort indices. Our results provide practical thermal sensation and thermal comfort scales for severe cold area. The discussions indicate the significance of considering adaptation and local exposure for further improving thermal sensation and comfort predicting.

Analysis of Hygrothermal Microclimatic (HTM) Parameters in Specific Food Storage Environments in Slovakia

The quality of work environment, temperature changes and humidity must be controlled in every production process and in the locations where employees are present. The aim of this paper is to objectively assess the exposure of employees to microclimatic factors of the workplace environment: the warehouse, changing rooms, office and cold room refrigerator. Data were obtained in real working conditions. The heat stress due to cold and heat exposure in the individual locations was evaluated using the WBGT (wet bulb globe temperature) indicator. The parameters of the hygrothermal microclimate (HTM) were objectified by a QUES Temp 44/46 T spherical thermometer. The measurements were performed both in cold and hot periods of the year. The measurements confirmed standard temperatures for individual types of interiors in the winter period, but in the summer period there was a variability of results, leading to the thermal discomfort of employees. The assessment of the WBGT index revealed that nearly 80% of employees are susceptible to hypothermia as a result of thermal stress conditions. It was proven that the temperatures measured by a spherical thermometer in the hottest room were 8.62% higher than the calculated operating temperature, while the difference in the cold room refrigerator was only 1.28% higher.

Prediction models, assessment methodologies and biotechnological tools to quantify heat stress response in ruminant livestock

Livestock industries have an important role in ensuring global food security. This review discusses the importance of quantifying the heat stress response of ruminants, with an emphasis on identifying thermo-tolerant breeds. There are numerous heat stress prediction models that have attempted to quantify the response of ruminant livestock to hot climatic conditions. This review highlights the importance of investigating prediction models beyond the temperature-humidity index (THI). Furthermore, this review highlights the importance of incorporating other climatic variables when developing prediction indices to ensure the accurate prediction of heat stress in ruminants. Prediction models, particularly the heat load index (HLI) were developed to overcome the limitations of the THI by incorporating ambient temperature (AT), relative humidity (RH), solar radiation (SR) and wind speed (WS). Furthermore refinements to existing prediction models have been undertaken to account for the interactions between climatic variables and physiological traits of livestock. Specifically, studies have investigated the relationships between coat characteristics, respiration rate (RR), body temperature (BT), sweating rate, vasodilation, body weight (BW), body condition score (BCS), fatness and feed intake with climatic conditions. While advancements in prediction models have been occurring, there has also been substantial advancement in the methodologies used to quantify animal responses to heat stress. The most recent development in this field is the application of radio frequency identification (RFID) technology to record animal behaviour and various physiological responses. Rumen temperature measurements using rumen boluses and skin temperature recording using infrared thermography (IRT) are making inroads to redefine the quantification of the heat stress response of ruminants. Further, this review describes several advanced biotechnological tools that can be used to identify climate resilient breeds of ruminant livestock.

Case-study of a user-driven prosthetic arm design: bionic hand versus customized body-powered technology in a highly demanding work environment

BACKGROUND

Prosthetic arm research predominantly focuses on "bionic" but not body-powered arms. However, any research orientation along user needs requires sufficiently precise workplace specifications and sufficiently hard testing. Forensic medicine is a demanding environment, also physically, also for non-disabled people, on several dimensions (e.g., distances, weights, size, temperature, time).

METHODS

As unilateral below elbow amputee user, the first author is in a unique position to provide direct comparison of a "bionic" myoelectric iLimb Revolution (Touch Bionics) and a customized body-powered arm which contains a number of new developments initiated or developed by the user: (1) quick lock steel wrist unit; (2) cable mount modification; (3) cast shape modeled shoulder anchor; (4) suspension with a soft double layer liner (Ohio Willowwood) and tube gauze (Molnlycke) combination. The iLimb is mounted on an epoxy socket; a lanyard fixed liner (Ohio Willowwood) contains magnetic electrodes (Liberating Technologies). An on the job usage of five years was supplemented with dedicated and focused intensive two-week use tests at work for both systems.

RESULTS

The side-by-side comparison showed that the customized body-powered arm provides reliable, comfortable, effective, powerful as well as subtle service with minimal maintenance; most notably, grip reliability, grip force regulation, grip performance, center of balance, component wear down, sweat/temperature independence and skin state are good whereas the iLimb system exhibited a number of relevant serious constraints.

CONCLUSIONS

Research and development of functional prostheses may want to focus on body-powered technology as it already performs on manually demanding and heavy jobs whereas eliminating myoelectric technology's constraints seems out of reach. Relevant testing could be developed to help expediting this. This is relevant as Swiss disability insurance specifically supports prostheses that enable actual work integration. Myoelectric and cosmetic arm improvement may benefit from a less forgiving focus on perfecting anthropomorphic appearance.

Perceived exertion is as effective as the perceptual strain index in predicting physiological strain when wearing personal protective clothing

OBJECTIVE

The perceptual strain index (PeSI) has been shown to overcome the limitations associated with the assessment of the physiological strain index (PSI), primarily the need to obtain a core body temperature measurement. The PeSI uses the subjective scales of thermal sensation and perceived exertion (RPE) to provide surrogate measures of core temperature and heart rate, respectively. Unfortunately, thermal sensation has shown large variability in providing an estimation of core body temperature. Therefore, the primary aim of this study was to determine if thermal comfort improved the ability of the PeSI to predict the PSI during exertional-heat stress.

METHODS

Eighteen healthy males (age: 23.5years; body mass: 79.4kg; maximal aerobic capacity: 57.2ml·kg^-1·min^-1) wore four different chemical/biological protective garments while walking on treadmill at a low (<325W) or moderate (326-499W) metabolic workload in environmental conditions equivalent to wet bulb globe temperatures 21, 30 or 37°C. Trials were terminated when heart rate exceeded 90% of maximum, when core body temperature reached 39°C, at 120min or due to volitional fatigue. Core body temperature, heart rate, thermal sensation, thermal comfort and RPE were recorded at 15min intervals and at termination. Multiple statistical methods were used to determine the most accurate perceptual predictor.

RESULTS

Significant moderate relationships were observed between the PeSI (r=0.74; p<0.001), the modified PeSI (r=0.73; p<0.001) and unexpectedly RPE (r=0.71; p<0.001) with the PSI, respectively. The PeSI (mean bias: -0.8±1.5 based on a 0-10 scale; area under the curve: 0.887), modified PeSI (mean bias: -0.5±1.4 based on 0-10 scale; area under the curve: 0.886) and RPE (mean bias: -0.7±1.4 based on a 0-10 scale; area under the curve: 0.883) displayed similar predictive performance when participants experienced high-to-very high levels of physiological strain.

CONCLUSIONS

Modifying the PeSI did not improve the subjective prediction of physiological strain. However, RPE provided an equally accurate prediction of physiological strain, particularly when high-to-very high levels of strain were observed. Therefore, given its predictive performance and user-friendliness, the evidence suggests that RPE in isolation is a practical and cost-effective tool able to estimate physiological strain during exertional-heat stress under these work conditions.

From built environment to health inequalities: An explanatory framework based on evidence

OBJECTIVE

The Health in All Policies strategy aims to engage every policy domain in health promotion. The more socially disadvantaged groups are usually more affected by potential negative impacts of policies if they are not health oriented. The built environment represents an important policy domain and, apart from its housing component, its impact on health inequalities is seldom assessed.

METHODS

A scoping review of evidence on the built environment and its health equity impact was carried out, searching both urban and medical literature since 2000 analysing socio-economic inequalities in relation to different components of the built environment.

RESULTS

The proposed explanatory framework assumes that key features of built environment (identified as density, functional mix and public spaces and services), may influence individual health through their impact on both natural environment and social context, as well as behaviours, and that these effects may be unequally distributed according to the social position of individuals.

CONCLUSION

In general, the expected links proposed by the framework are well documented in the literature; however, evidence of their impact on health inequalities remains uncertain due to confounding factors, heterogeneity in study design, and difficulty to generalize evidence that is still very embedded to local contexts.

A comprehensive catalogue and classification of human thermal climate indices

The very large number of human thermal climate indices that have been proposed over the past 100 years or so is a manifestation of the perceived importance within the scientific community of the thermal environment and the desire to quantify it. Schemes used differ in approach according to the number of variables taken into account, the rationale employed, the relative sophistication of the underlying body-atmosphere heat exchange theory and the particular design for application. They also vary considerably in type and quality, as well as in several other aspects. Reviews appear in the literature, but they cover a limited number of indices. A project that produces a comprehensive documentation, classification and overall evaluation of the full range of existing human thermal climate indices has never been attempted. This paper deals with documentation and classification. A subsequent report will focus on evaluation. Here a comprehensive register of 162 thermal indices is assembled and a sorting scheme devised that groups them according to eight primary classification classes. It is the first stage in a project to organise and evaluate the full range of all human thermal climate indices. The work, when completed, will make it easier for users to reflect on the merits of all available thermal indices. It will be simpler to locate and compare indices and decide which is most appropriate for a particular application or investigation.

WBGT index revisited after 60 years of use

The Wet Bulb Globe Temperature (WBGT) seems to be still used world widely for the evaluation of heat stress conditions and it is recommended by ISO and American Conference of Governmental Industrial Hygienists as a screening method. Unfortunately, many occupational health practitioners and users appear to be unaware of its limitations. As the ISO 7243 Standard, based on WBGT, is presently under revision, it is an appropriate time to review the validity and applicability of this empirical approach to evaluate heat stress. This article underlines the main issues about the WBGT index from a rational perspective.

Notes on the implementation of the IREQ model for the assessment of extreme cold environments

This paper has been devoted to the difficulties that practitioners, skilled ergonomists or occupational health experts could find in the assessment of cold environments by means of (insulation required) IREQ model at the base of the (International Standardization Organization) ISO 11079 Standard. The in-depth analysis discussed here has underlined several difficulties about: (a) the graphical calculation of the predicted limit exposures; (b) some differences in both IREQ and (duration limit exposure) DLE values reported in ISO 11079; and (c) some errors and incongruities in the program available online for the assessment of DLEs. These occurrences lead to the systematic overestimation of the DLE that exceed up to 4 h, those obtained by means of the figures reported in the Standard with the consequent unreliable assessment. Such matters justify the need to promote, in the whole scientific community involved in the ergonomics of the thermal environment, an in-depth discussion on the best practice to be followed for the assessment of extreme cold environments by means of IREQ model.

PRACTITIONER SUMMARY

Incongruities in IREQ model and errors in the code suggested by ISO 11079 Standard prevent a reliable assessment of cold environments with DLE systematically overestimated. Therefore IREQ model has been theoretically investigated trying to help both neophytes and skilled ergonomists on the best practice to be followed.

Electric fans for reducing adverse health impacts in heatwaves

BACKGROUND

Heatwaves are hot weather events, which breach regional or national thresholds, that last for several days. They are likely to occur with increasing frequency in some parts of the world. The potential consequences were illustrated in Europe in August 2003 when there were an estimated 30,000 excess deaths due to a heatwave. Electric fans might be used with the intention of reducing the adverse health effects of a heatwave. Fans do not cool the ambient air but can be used to draw in cooler air from outside when placed at an open window. The aim of the fans would be to increase heat loss by increasing the efficiency of all normal methods of heat loss, but particularly by evaporation and convection methods. However, it should be noted that increased sweating can lead to dehydration and electrolyte imbalances if these fluids and electrolytes are not replaced quickly enough. Research has also identified important gaps in knowledge about the use of fans, which might lead to their inappropriate use.

OBJECTIVES

To determine whether the use of electric fans contributes to, or impedes, heat loss at high ambient temperatures during a heatwave, and to contribute to the evidence base for the public health impacts of heatwaves.

SEARCH METHODS

We sought unpublished and published studies that had been published in any language. The review team were able to assess studies reported in English, Chinese, Dutch, French and German; and reports in other languages would have been translated into English as necessary. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, the Indian biomedical literature (IndMED and MedIND) and databases of Chinese literature (Chinese Journal Net and Digital Periodical of WanFang Data). The most recent electronic searches were done in April 2012. We also checked the reference lists of relevant articles and the websites of relevant national and international organisations, and consulted with researchers and policy makers with experience in strategies to manage heatwaves to identify additional studies. The titles and abstracts from each search were checked independently by two review authors. The full text articles that we retrieved were checked independently by at least two authors for their relevance and for references to potentially eligible studies.

SELECTION CRITERIA

Randomised trials and other experimental designs, such as interrupted time series and controlled before-and-after studies, comparing the use of electric fans with no fans during a heatwave were eligible for this review. The electric fans could be hand-held (battery operated), portable or mounted on the wall or ceiling, or in a window. We sought interventions delivered to anyone for whom a heatwave was likely to have serious adverse health impacts. This would include people of all ages but with a particular focus on some groups (for example older people). Populations from high-, middle- and low-income countries were eligible for the review.

DATA COLLECTION AND ANALYSIS

If we had identified eligible studies, they would have been assessed independently by at least two review authors and data would have been extracted on the characteristics of the study, its participants and interventions, as well as the effects on health outcomes. The primary outcomes were mortality, hospital admission and other contacts with healthcare services.

MAIN RESULTS

We did not identify any eligible studies despite the extensive searching and correspondence with several experts in this topic area. We identified retrospective, observational studies, usually with a case-control design, that investigated the association between the use of electric fans and health outcomes, including death. The results of these studies were mixed. Some studies found that the use of fans was associated with better health outcomes, others found the reverse.

AUTHORS' CONCLUSIONS

The evidence we identified does not resolve uncertainties about the health effects of electric fans during heatwaves. Therefore, this review does not support or refute the use of electric fans during a heatwave. People making decisions about electric fans should consider the current state of the evidence base, and they might also wish to make themselves aware of local policy or guidelines when making a choice about whether or not to use or supply electric fans. The main implication of this review is that high quality research is needed to resolve the long standing and ongoing uncertainty about the benefits and harms of using electric fans during a heatwave, for example randomised trials comparing the health effects in people with electric fans to those in people without them.

Effects of heat wave on body temperature and blood pressure in the poor and elderly

OBJECTIVES

We aimed to investigate the acute effects of heat stress on body temperature and blood pressure of elderly individuals living in poor housing conditions.

METHODS

Repeated measurements of the indoor temperature, relative humidity, body temperature, and blood pressure were conducted for 20 elderly individuals living in low-cost dosshouses in Seoul during hot summer days in 2010. Changes in the body temperature, systolic blood pressure (SBP) and diastolic blood pressure (DBP) according to variations in the indoor and outdoor temperature and humidity were analyzed using a repeated-measures ANOVA controlling for age, sex, alcohol, and smoking.

RESULTS

Average indoor and outdoor temperatures were 31.47℃ (standard deviation [SD], 0.97℃) and 28.15℃ (SD, 2.03℃), respectively. Body temperature increased by 0.21℃ (95% confidence interval [CI], 0.16 to 0.26℃) and 0.07℃ (95% CI, 0.04 to 0.10℃) with an increase in the indoor and outdoor temperature of 1℃. DBP decreased by 2.05 mmHg (95% CI, 0.05 to 4.05 mmHg), showing a statistical significance, as the indoor temperature increased by 1℃, while it increased by 0.20 mmHg (95% CI, -0.83 to 1.22 mmHg) as outdoor temperature increased by 1℃. SBP decreased by 1.75 mmHg (95% CI, -1.11 to 4.61 mmHg) and 0.35 mmHg (95% CI, -1.04 to 1.73 mmHg), as the indoor and outdoor temperature increased by 1℃, respectively. The effects of relative humidity on SBP and DBP were not statistically significant for both indoor and outdoor.

CONCLUSIONS

The poor and elderly are directly exposed to heat waves, while their vital signs respond sensitively to increase in temperature. Careful adaptation strategies to climate change considering socioeconomic status are therefore necessary.

Climate change and occupational heat stress: methods for assessment

Background

Presumed effects of global warming on occupational heat stress aggravate conditions in many parts of the world, in particular in developing countries. In order to assess and evaluate conditions, heat stress must be described and measured correctly.

Objective

Assessment of heat stress using internationally recognized methods.

Design

Two such methods are wet bulb globe temperature (WBGT; ISO 7243) and predicted heat strain (PHS; ISO 7933). Both methods measure relevant climatic factors and provide recommendations for limit values in terms of time when heat stress becomes imminent. The WBGT as a heat stress index is empirical and widely recognized. It requires, however, special sensors for the climatic factors that can introduce significant measurement errors if prescriptions in ISO 7243 are not followed. The PHS (ISO 7933) is based on climatic factors that can easily be measured with traditional instruments. It evaluates the conditions for heat balance in a more rational way and it applies equally to all combinations of climates.

Results

Analyzing similar climatic conditions with WBGT and PHS indicates that WBGT provides a more conservative assessment philosophy that allows much shorter working time than predicted with PHS.

Conclusions

PHS prediction of physiological strain appears to fit better with published data from warm countries. Both methods should be used and validated more extensively worldwide in order to give reliable and accurate information about the actual heat stress.

Thermal environment assessment reliability using temperature--humidity indices

A reliable assessment of the thermal environment should take into account the whole of the six parameters affecting the thermal sensation (air temperature, air velocity, humidity, mean radiant temperature, metabolic rate and thermo-physical properties of clothing). Anyway, the need of a quick evaluation based on few measurements and calculations has leaded to like best temperature-humidity indices instead of rational methods based on the heat balance on the human body. Among these, Canadian Humidex, preliminarily used only for weather forecasts, is becoming more and more widespread for a generalized assessment of both outdoor and indoor thermal environments. This custom arouses great controversies since using an index validated in outdoor conditions does not assure its indoor reliability. Moreover is it really possible to carry out the thermal environment assessment ignoring some of variables involved in the physiological response of the human body? Aiming to give a clear answer to these questions, this paper deals with a comparison between the assessment carried out according to the rational methods suggested by International Standards in force and the Humidex index. This combined analysis under hot stress situations (indoor and outdoor) has been preliminarily carried out; in a second phase the study deals with the indoor comfort prediction. Obtained results show that Humidex index very often leads to the underestimation of the workplace dangerousness and a poor reliability of comfort prediction when it is used in indoor situations.

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 degrees 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.

A vulnerability study of the low-income elderly in the context of high temperature and mortality in Seoul, Korea

INTRODUCTION

We investigated the impact of environmental high temperature on mortality in Seoul, Korea, and the consequences of high temperature-induced mortality with a focus on the low-income elderly.

METHODS

Changes in the risk of death by age and income were estimated by a 1 degrees C increase in temperature using a generalized additive model adjusting for non-temperature related factors: time trends, seasonality, and air pollution. The study covered the years of 2000, 2001, and 2002.

RESULTS

We found that income and age were potential factors in high-temperature-induced excess mortality. Evidences to support these results are as follows: first, regarding the effect of an economic factor in the association between mortality and high temperature, the study shows that the mortality rate of the low-income group is higher, by as much as 1.3- to 1.7-fold, than that of the general population. Second, taking age into consideration, the mortality of low-income elderly people is 1.5-fold higher than that of the whole low-income group. The combined effect of income and age on mortality is estimated as 2.3-fold higher than that of the general population. But the results of the low-income and elderly group were not statistically significant due to wide standard deviation.

CONCLUSIONS

The relationship between high-temperature-induced excess mortality, income, and age suggests the need for a public health message, yet many results were not statistically significant: preventive and health care interventions need to be administered to the elderly and low-income group during periods of high temperature.

Epidemiologic study of mortality during the Summer 2003 heat wave in Italy

INTRODUCTION

It is widely recognized that extreme climatic conditions during summer months may constitute a major public health threat. Owing to what is called the "urban heat island effect," as well as to the consequences of heat waves on health, individuals living in cities have an elevated risk of death when temperature and humidity are high compared to those living in suburban and rural areas. Studies on heat wave-related mortality have further demonstrated that the greatest increases in mortality occur in the elderly. Following the unusually hot summer of 2003 and the dramatic news from neighboring countries such as France, the Italian Minister of Health requested the Istituto Superiore di Sanita-Bureau of Statistics to undertake an epidemiologic study of mortality in Italy during Summer 2003 to investigate whether there had been an excess of deaths, with a particular focus on the elderly population.

MATERIALS AND METHODS

Communal offices, which maintain vital statistics, were asked for the individual records of death of residents registered daily during the period 1 June-31 August 2003 and during the same period of 2002 for each of the 21 capitals of the Italian regions. As it was necessary to obtain mortality data quickly from many municipalities and to make the analysis as soon as possible, the method adopted was comparison of mortality counts during the heat wave with figures observed during the same period of the previous year.

RESULTS

Compared with 2002, between 1 June and 31 August 2003, there was an overall increase in mortality of 3134 (from 20,564 to 23,698). The greatest increase was among the elderly; 2876 deaths (92%) occurred among people aged 75 years and older, a more than one-fifth increase (21.3%, from 13.517 to 16.393%). The highest increases were observed in the northwestern cities, which are generally characterized by cold weather, and in individuals 75 years and older: Turin (44.9%), Trento (35.2%), Milan (30.6%), and Genoa (22.2%). Of note are also the increases observed in two southern cities, L'Aquila (24.7%) and Potenza (25.4%), which are located, respectively, at 700 and 800 m above see level. For Bari and Campobasso, both in the South, with a typically hot summer climate, the increase during the last 15 days of August was 186.2 and 450%, respectively.

CONCLUSIONS

The relationship between mortality and discomfort due to climatic conditions as well as the short lag time give a clear public health message: preventive, social, and health care actions must be administered to the elderly and the frail to avoid excess deaths during heat waves.

Perceptual versus physiological heat strain during exercise-heat stress

PURPOSE

The physiological strain index (PSI) has been proposed as a universally applicable measure of exercise-heat strain. Unknown is whether this index, based on normalized increases in core temperature and heart rate, is matched by its perceptual analog.

METHODS

By using a similar mathematical construct to the PSI, the perceptions of thermal sensation and perceived exertion were combined, and the resultant index, PeSI, was compared with its physiological counterpart, denoted as PhSI, for the exercise-heat stress specific to this study. Twenty-six young and healthy subjects wore semi-impermeable clothing and walked (3.5 km.h(-1)) under hot conditions (40 degrees C and 30% RH) until exhaustion or when their core temperature reached 39.5 degrees C. Subjects were divided into two fitness groups [endurance trained (T) and untrained (U)] comprised of 10 men and 3 women each. U subjects had a higher level of body fatness (mean +/- SD 18.1 +/- 5.3 vs 12.6 +/- 4.5%; P=0.010) and a lower level of aerobic fitness ((.)VO(2max)= 43.6 +/- 3.8 +/- vs 59.0 +/- 6.2 mL.min(-1).kg(-1); P<0.001).

RESULTS

During the first hour of exposure, there was no group difference in PhSI, yet T perceived their physiological strain (PeSI) lower than U (P=0.002). Further, the indices were not different for U whereas PhSI was higher than PeSI for T (P=0.008). At the end of the exposure, T had a higher value of PhSI than U (8.23 +/- 0.72 vs 6.74 +/- 1.47; = 0.002), but there was no group difference in PeSI. Although the indices were again not different for U, PhSI at the end was higher than PeSI for T (6.14 +/- 1.68; P<0.001).

CONCLUSION

T underestimated and U consistently perceived their physiological strain, as defined by PhSI, in accordance with the measured increases in core temperature and heart rate throughout an exposure to uncompensable exercise-heat stress.

Aging and assessment of physiological strain during exercise-heat stress

The purpose of this study was to evaluate the physiological strain index (PSI) for different age groups during exercise-heat stress (EHS). PSI was applied to three different databases. First, from young and middle-age men (21 +/- 2 and 46 +/- 5 yr, respectively) matched (n = 9 each, P > 0.05) for maximal aerobic power. Subjects were heat acclimated by daily treadmill walking for two 50-min bouts separated by 10-min rest for 10 days in a hot-dry environment [49 degrees C, 20% relative humidity (RH)]. The second database involved a group (n = 8) of young (YA) and a group (n = 7) of older (OA) men (26 +/- 1 and 69 +/- 1 yr, respectively) who underwent 16 wk of aerobic training and two control groups (n = 7 each) who were matched for age to YA and OA. These four groups performed EHS at 36 degrees C, 40% RH on a cycle ergometer for 60 min at 60% maximal aerobic power before and after training. The third database was obtained from three groups of postmenopausal women and a group of 10 men. Two groups of women (n = 8 each) were undergoing hormone replacement therapy, estrogen or estrogen plus progesterone, and the third group (n = 9) received no hormone replacement. Subjects were over 50 yr and performed the same EHS: exercising at 36 degrees C, 40% RH on a cycle ergometer for 60 min. PSI assessed the strain for all three databases and reported differences were significant at P < 0.05. This index rated the strain in rank order, whereas the postacclimation and posttraining groups were assessed as having less strain than the preacclimation and pretraining groups. Furthermore, middle-aged women on estrogen replacement therapy had less strain than estrogen + progesterone and no hormone therapy. PSI evaluation was extended for men and women of different ages (50-70 yr) during acute EHS, heat acclimation, after aerobic training, and inclusive of women undergoing hormone replacement therapy.

Stress evaluation by the physiological strain index (PSI)

A physiological strain index (PSI) based on rectal temperature (Tre) and heart rate was recently suggested to evaluate exercise/heat stress. This review summarizes the development of PSI which was evaluated from seven different databases during the last three years. PSI was developed from data obtained from man performing exercise in the heat and from a separate database of man wearing protective clothing and exercising in hot-dry and hot-wet environmental conditions. This index was also evaluated for heat strain associated with hypohydration and for exercise/heat stress and gender. In addition, PSI was adjusted for values in rats, and could be used to assess the individual roles played by heat acclimation and exercise training in rats. This simple to use index scales strain to a range of 0-10, can be used on-line or during data analysis, and includes the ability to depict rest and recovery periods. The PSI has the potential to be widely accepted and to serve universally.

The evaluation of workplaces subjected to heat stress: can ISO 7933 (1989) adequately describe heat strain in industrial workplaces?

The International Standard ISO 7933 (1989) Hot environments--Analytical determination and interpretation of thermal stress using calculation of required sweat rate has been proposed for the evaluation of climatic stress within the European system of CEN standards. Comparison of results of studies performed in climatic chambers and those in the field with the predictions of ISO 7933 show that there are considerable problems in using this index in practice. In its present state of development, ISO 7933 seems to be rather a step towards a useable index for evaluating climatic conditions rather than an established climatic index which is applicable in practice. Within the CEN standards, the deficiencies of ISO 7933 are reflected mainly by a restriction of the limits of application within EN 12 515 (1997) which is based on ISO 7933.

The physiological strain index applied to heat-stressed rats

A physiological strain index (PSI) based on heart rate (HR) and rectal temperature (Tre) was recently suggested to evaluate exercise-heat stress in humans. The purpose of this study was to adjust PSI for rats and to evaluate this index at different levels of heat acclimation and training. The corrections of HR and Tre to modify the index for rats are as follows: PSI = 5 (Tre t - Tre 0). (41.5 - Tre 0)-1 + 5 (HRt - HR0). (550 - HR0)-1, where HRt and Tre t are simultaneous measurements taken at any time during the exposure and HR0 and Tre 0 are the initial measurements. The adjusted PSI was applied to five groups (n = 11-14 per group) of acclimated rats (control and 2, 5, 10, and 30 days) exposed for 70 min to a hot climate [40 degrees C, 20% relative humidity (RH)]. A separate database representing two groups of acclimated or trained rats was also used and involved 20 min of low-intensity exercise (O2 consumption approximately 50 ml. min-1. kg-1) at three different climates: normothermic (24 degrees C, 40% RH), hot-wet (35 degrees C, 70% RH), and hot-dry (40 degrees C, 20% RH). In normothermia, rats also performed moderate exercise (O2 consumption approximately 60 ml. min-1. kg-1). The adjusted PSI differentiated among acclimation levels and significantly discriminated among all exposures during low-intensity exercise (P < 0.05). Furthermore, this index was able to assess the individual roles played by heat acclimation and exercise training.

Evaluation of different levels of hydration using a new physiological strain index

A physiological strain index (PSI), based on rectal temperature (Tre) and heart rate (HR), was recently suggested for evaluating heat stress. The purpose of this study was to evaluate the PSI for different combinations of hydration level and exercise intensity. This index was applied to two databases. The first database was obtained from eight endurance-trained men dehydrated to four different levels (1.1, 2.3, 3.4, and 4.2% of body wt) during 120 min of cycling at a power output of 62-67% maximum O2 consumption (VO2 max) in the heat [33 degrees C and 50% relative humidity (RH)]. The second database was obtained from nine men performing exercise in the heat (30 degrees C and 50% RH) for 50 min. These subjects completed a matrix of nine trials of exercise on a treadmill at three exercise intensities (25, 45, and 65% VO2 max) and three hydration levels (euhydration and hypohydration at 3 and 5% of body wt). Tre, HR, esophageal temperature (Tes), and local sweating rate were measured. PSI (obtained from either Tre or Tes) significantly (P < 0.05) differentiated among all exposures in both databases categorized by exercise intensity and hydration level, and we assessed the strain on a scale ranging from 0 to 10. Therefore, PSI applicability was extended for heat strain associated with hypohydration and continues to provide the potential to be universally accepted.

A physiological strain index to evaluate heat stress

A physiological strain index (PSI), based on rectal temperature (Tre) and heart rate (HR), capable of indicating heat strain online and analyzing existing databases, has been developed. The index rates the physiological strain on a universal scale of 0-10. It was assumed that the maximal Tre and HR rise during exposure to exercise heat stress from normothermia to hyperthermia was 3 degrees C (36.5-39.5 degrees C) and 120 beats/min (60-180 beats/min), respectively. Tre and HR were assigned the same weight functions as follows: PSI = 5(Tret - Tre0) . (39.5 - Tre0)-1 + 5(HRt - HR0) . (180 - HR0)-1, where Tret and HRt are simultaneous measurements taken at any time during the exposure and Tre0 and HR0 are the initial measurements. PSI was applied to data obtained from 100 men performing exercise in the heat (40 degrees C, 40% relative humidity; 1.34 m/s at a 2% grade) for 120 min. A separate database representing seven men wearing protective clothing and exercising in hot-dry and hot-wet environmental conditions was applied to test the validity of the present index. PSI differentiated significantly (P < 0.05) between the two climates. This index has the potential to be widely accepted and to serve universally after extending its validity to women and other age groups.

Protective clothing and heat stress

The high level of protection required by protective clothing (PPC) severely impedes heat exchange by sweat evaporation. As a result work associated with wearing PPC, particularly in hot environments, implies considerable physiological strain and may render workers exhausted in a short time. Current methods of describing evaporative heat exchange with PPC are insufficient, will overestimate evaporative heat loss and should not be recommended. More reliable measures of the resistance to evaporative heat transfer by PPC should be developed and standardized. Direct measurements of evaporative resistance of PPC may be carried. However, a more promising method appears to be the definition of evaporative resistance on the basis of the icl-index for the fabric layers. The icl-index is a permeation efficiency ratio, which in combination with clothing insulation determines the evaporative heat transfer. Current methods should be further developed to account for effects of moisture condensation and microclimate ventilation.

Solar heat load on man. Review of different methods of estimation

Different methods have been compared for the estimation of solar heat load on man. The comparison comprised several methods based on the calculation of absorbed solar radiation and one method for calculation of mean radiant temperature (Mrt). Regression analysis was carried out for predicted values and values calculated for a vertical cylinder, assumed as an analog model of a standing man. Regression of mean skin temperature, measured in 10 subjects exposed to solar radiation under a variety of climatic conditions, on predicted radiant heat load was also analysed. Mean skin temperature correlated best with Mrt, accounting for more than 50% of the variance. The results indicated that three methods provide a realistic estimation of the radiation heat load, whereas some methods show deviations of several hundred per cent.