Immediate Injury Deaths Related to the Remnants From Hurricane Ida in New York City, September 1-2, 2021.

The remnants from Hurricane Ida in September 2021 caused unprecedented rainfall and inland flooding in New York City (NYC) and resulted in many immediate deaths. We reviewed death records (electronic death certificates and medical examiner reports) to systematically document the circumstances of death and demographics of decedents to inform injury prevention and climate adaptation actions for future extreme precipitation events. There were 14 Ida-related injury deaths in NYC, of which 13 (93%) were directly caused by Ida, and 1 (7%) was indirectly related. Most decedents were Asian (71%) and foreign-born (71%). The most common circumstance of death was drowning in unregulated basement apartments (71%). Themes that emerged from the death records review included the suddenness of flooding, inadequate exits, nighttime risks, and multiple household members were sometimes affected. These deaths reflect interacting housing and climate crises, and their disproportionate impact on disadvantaged populations needing safe and affordable housing. Climate adaptation actions, such as improving stormwater management infrastructure, informing residents about flood risk, implementing Federal Emergency Management Agency recommendations to make basements safer, and expanding emergency notification measures can mitigate risk. As climate change increases extreme precipitation events, multi-layered efforts are needed to keep residents safe.

Energy Insecurity Indicators Associated With Increased Odds Of Respiratory, Mental Health, And Cardiovascular Conditions.

Energy insecurity, defined as the inability to meet household energy needs, has multiple economic, physical, and coping dimensions that affect health. We conducted the first citywide representative survey of energy insecurity and health in a sample of 1,950 New York City residents in 2022. We compiled ten indicators that characterize energy insecurity as experienced in New York City housing settings and then examined associations between number and types of indicators and health conditions. Nearly 30 percent of residents experienced three or more indicators, with significantly higher levels among Black non-Latino/a and Latino/a residents compared with White non-Latino/a residents, renters compared with owners, recent immigrants compared with those living in the United States for longer, and those in households with children compared with those with no children. Residents with three or more indicators of energy insecurity had higher odds of respiratory, mental health, and cardiovascular conditions and electric medical device dependence than residents with no indicators. Our study demonstrates that broadening the understanding of energy insecurity with context-specific metrics can help guide interventions and policies that address disparities relevant to health and energy equity.

Extreme Heat and COVID-19 in New York City: An Evaluation of a Large Air Conditioner Distribution Program to Address Compounded Public Health Risks in Summer 2020.

In summer 2020, New York City (NYC) implemented a free air conditioner (AC) distribution program in response to the threats of extreme heat and COVID-19. The program distributed and installed ACs in the homes of nearly 73,000 older, low-income residents of public and private housing. To evaluate the program's impact, survey data were collected from October 2020 to February 2021 via mail and online from 1447 program participants and 902 non-participating low-income NYC adults without AC as a comparison group. Data were examined by calculating frequencies, proportions, and logistic regression models. Participants were 3 times more likely to report staying home during hot weather in summer 2020 compared to non-participants (adjusted odds ratio [AOR] = 3.0, 95% confidence interval [CI] = 2.2, 4.1), with no difference between groups in summer 2019 (AOR = 1.0, CI = 0.8, 1.3). Participants were less likely to report that 2020 hot weather made them feel sick in their homes compared to non-participants (AOR = 0.2, CI = 0.2, 0.3). The program helped participants-low-income residents and primarily people of color-stay home safely during hot weather. These results are relevant for climate change health-adaptation efforts and heat-health interventions.

Evaluation of Data Sources for Carbon Monoxide Poisoning Surveillance in New York City.

CONTEXT: Carbon monoxide (CO) exposure can be life-threatening. Suspected and confirmed cases of CO poisoning warranting health care in New York City (NYC) are reportable to the NYC Poison Control Center (PCC). OBJECTIVES: We evaluated 4 hospital-based sources of CO surveillance data to identify ways to improve data capture and reporting. DESIGN: Suspected and confirmed CO poisoning records from October 2015 through December 2016 were collected from the NYC emergency department (ED) syndromic surveillance system, New York State Statewide Planning and Research Cooperative System (SPARCS) ED billing data, NYC PCC calls made from hospitals, and the Electronic Clinical Laboratory Reporting System (ECLRS). Syndromic and SPARCS records were person- and visit-matched. SPARCS and ECLRS records were also matched to PCC records on combinations of name, demographic characteristics, and visit information. SETTING: Hospitals in NYC. PARTICIPANTS: Individuals who visited NYC hospitals for CO-related health effects. MAIN OUTCOME MEASURES: We assessed the validity of syndromic data, with SPARCS records as the gold standard. We matched SPARCS and ECLRS records to PCC records to analyze reporting rates by case characteristics. RESULTS: The sensitivity of syndromic surveillance was 60% (225 true-positives detected among 372 visit-matched SPARCS cases), and positive predictive value was 46%. Syndromic records often missed CO flags because of a nonspecific or absent International Classification of Diseases code in the diagnosis field. Only 15% of 428 SPARCS records (total includes 56 records not visit-matched to syndromic) and 16% of 199 ECLRS records were reported to PCC, with male sex and younger age associated with higher reporting. CONCLUSIONS: Mandatory reporting makes PCC useful for tracking CO poisoning in NYC, but incomplete reporting and challenges in distinguishing between confirmed and suspected cases limit its utility. Simultaneous tracking of the systems we evaluated can best reveal surveillance patterns.

Applying an Innovative Model of Disaster Resilience at the Neighborhood Level : The COPEWELL New York City Experience.

Community resilience is a community's ability to maintain functioning (ie, delivery of services) during and after a disaster event. The Composite of Post-Event Well-Being (COPEWELL) is a system dynamics model of community resilience that predicts a community's disaster-specific functioning over time. We explored COPEWELL's usefulness as a practice-based tool for understanding community resilience and to engage partners in identifying resilience-strengthening strategies. In 2014, along with academic partners, the New York City Department of Health and Mental Hygiene organized an interdisciplinary work group that used COPEWELL to advance cross-sector engagement, design approaches to understand and strengthen community resilience, and identify local data to explore COPEWELL implementation at neighborhood levels. The authors conducted participant interviews and collected shared experiences to capture information on lessons learned. The COPEWELL model led to an improved understanding of community resilience among agency members and community partners. Integration and enhanced alignment of efforts among preparedness, disaster resilience, and community development emerged. The work group identified strategies to strengthen resilience. Searches of neighborhood-level data sets and mapping helped prioritize communities that are vulnerable to disasters (eg, medically vulnerable, socially isolated, low income). These actions increased understanding of available data, identified data gaps, and generated ideas for future data collection. The COPEWELL model can be used to drive an understanding of resilience, identify key geographic areas at risk during and after a disaster, spur efforts to build on local metrics, and result in innovative interventions that integrate and align efforts among emergency preparedness, community development, and broader public health initiatives.

Use of 5-Aminolevulinic Acid and Daylight Photodynamic Therapy for the Treatment of Actinic Keratoses.

BACKGROUND: Photodynamic therapy (PDT) is an effective modality for the treatment of actinic keratoses (AKs). The use of methyl aminolevulinate with daylight PDT (D-PDT) has quickly gained popularity internationally because of its tolerability and high levels of safety and efficacy. However, there is a paucity of studies on the use of D-PDT with 5-aminolevulinic acid (ALA). OBJECTIVE: To study the safety and efficacy of D-PDT in treating AKs on the face and scalp using ALA. MATERIALS AND METHODS: Thirty patients were recruited for this prospective, uncontrolled study. Patients were treated with topical ALA on either the scalp or face, incubated for 30 minutes, and then sat at home in a shady area for 2 hours. Weather conditions, lux measurements, and AK counts at 3 and 6 months were measured. RESULTS: Daylight PDT led to a median of 75% reduction in AK count at 6 months, with no significant adverse effects. Ninety-six percentage of patients were either moderately or very satisfied with the treatment, and the median peak pain score during treatment was 1. There was no correlation between weather or average lux received during treatment and 6-month outcomes. CONCLUSION: Daylight PDT with ALA is a safe and effective treatment modality for AKs on the head.

Awareness, Risk Perception, and Protective Behaviors for Extreme Heat and Climate Change in New York City.

Preventing heat-related illness and death requires an understanding of who is at risk and why, and options for intervention. We sought to understand the drivers of socioeconomic disparities in heat-related vulnerability in New York City (NYC), the perceived risk of heat exposure and climate change, and barriers to protective behaviors. A random digit dial telephone survey of 801 NYC adults aged 18 and older was conducted from 22 September⁻1 October, 2015. Thirteen percent of the population did not possess an air conditioner (AC), and another 15% used AC never/infrequently. In adjusted models, odds of not possessing AC were greater for non-Hispanic blacks compared with other races/ethnicities, odds ratio (OR) = 2.0 (95% CI: 1.1, 3.5), and for those with low annual household income, OR = 3.1 (95% CI: 1.8, 5.5). Only 12% reported going to a public place with AC if they could not keep cool at home. While low-income individuals were less likely to be aware of heat warnings, they were more likely to be concerned that heat could make them ill and that climate change would affect their health than participants with a higher household income, OR = 1.6 (95% CI: 1.0, 2.3). In NYC, lack of access to AC partially explains disparities in heat-related health outcomes. Our results point to opportunities for knowledge building and engagement on heat-health awareness and climate change adaptation that can be applied in NYC and other metropolitan areas to improve and target public health prevention efforts.

Power Outage Preparedness and Concern among Vulnerable New York City Residents.

Power outages can impact health, and certain populations may be more at risk. Personal preparedness may reduce impacts, but information on power outage preparedness and risk perception among vulnerable populations is limited. We examined power outage preparedness and concern among New York City residents, including vulnerable populations defined as older adults (≥ 65 years), and respondents with household members who require assistance with daily activities or depend on electric medical devices. A random sample telephone survey was conducted during November-December 2016. Preparedness was defined as having a three-day supply of drinking water, non-perishable food, and a working flashlight. Among all respondents (n = 887), 58% were prepared and 46% expressed concern about health. Respondents with electric-dependent household members (9% of all respondents) tended to have higher preparedness (70 vs. 56% of respondents without electric-dependent household members). Among this group, only 40% reported being registered with a utility company to receive early notification of outages. While the subgroup sample was small, respondents with registered electric-dependent household members had lower preparedness than those with non-registered users (59 vs. 76%). Respondents with household members who needed assistance had comparable levels of preparedness to respondents without someone who needed assistance (59 vs. 57%). Older adults had greater preparedness than younger adults (65 vs. 56%). Health concerns were greater among all vulnerable groups than the general population. Levels of preparedness varied among vulnerable respondents, and awareness of power outage notification programs was low. Our findings highlight the need to increase awareness and preparedness among at-risk people.

Health Impacts of Citywide and Localized Power Outages in New York City.

BACKGROUND: Previous studies investigated potential health effects of large-scale power outages, including the massive power failure that affected the northeastern United States and Ontario, Canada, in August 2003, and outages associated with major storms. However, information on localized outages is limited. OBJECTIVE: The study sought to examine potential health impacts of citywide and localized outages in New York City (NYC). METHODS: Along with the citywide 2003 outage, localized outages in July 1999 and July 2006 were identified. We additionally investigated localized, warm- and cold-weather outages that occurred in any of 66 NYC electric-grid networks during 2002­2014 using New York State Public Service Commission data. Mortality and hospitalizations were geocoded and linked to the networks. Associations were estimated using Poisson time-series regression, including examining distributed lags and adjusting for temperature and temporal trends. Network-specific estimates were pooled by season. RESULTS: Respiratory disease hospitalizations were associated with the 2006 localized outage [cumulative relative risk [CRR] over 0­1 lag day, lag01=2.26 (95% confidence interval [CI]: 1.08, 4.74)] and the 2003 citywide outage, but not with other localized, warm-weather outages. Renal disease hospitalizations were associated with the 2003 citywide outage, and with localized, warm-weather outages, pooled across networks [RR at lag3=1.16 (95% CI: 1.00, 1.34)], but not the 2006 localized outage. All-cause mortality was positively associated with the 1999, 2003, and 2006 outages (significant for the 2003 outage only), but not with other localized, warm-weather outages. Localized, cold-weather outages were associated with all-cause mortality [lag01 CRR=1.06 (95% CI: 1.01, 1.12)] and cardiovascular disease hospitalizations [lag01 CRR=1.14 (95% CI: 1.03, 1.26)], and fewer respiratory disease hospitalizations [lag03 CRR=0.77 (95% CI: 0.61, 0.97)]. CONCLUSIONS: Localized outages may affect health. This information can inform preparedness efforts and underscores the public health importance of ensuring electric grid resiliency to climate change. https://doi.org/10.1289/EHP2154.

Hot Weather Impacts on New York City Restaurant Food Safety Violations and Operations.

Previous studies have shown that higher ambient air temperature is associated with increased incidence of gastrointestinal illnesses, possibly as a result of leaving potentially hazardous food in the temperature danger zone for too long. However, little is known about the effect of hot weather on restaurant practices to maintain safe food temperatures. We examined hot weather impacts on restaurant food safety violations and operations in New York City using quantitative and qualitative methods. We used data from 64,661 inspections conducted among 29,614 restaurants during May to September, 2011 to 2015. We used Poisson time-series regression to estimate the cumulative relative risk (CRR) of temperature-related food safety violations across a range of daily maximum temperature (13 to 40°C [56 to 104°F]) over a lag of 0 to 3 days. We present CRRs for an increase in daily maximum temperature from the median (28°C [82°F]) to the 95th percentile (34°C [93°F]) values. Maximum temperature increased the risk of violations for cold food holding above 5°C (41°F) (CRR, 1.19; 95% CI, 1.14, 1.25) and insufficient refrigerated or hot holding equipment (CRR, 2.37; 95% CI, 2.02, 2.79). We also conducted focus groups among restaurant owners and managers to aid interpretation of findings and identify challenges or knowledge gaps that prevent hot weather preparedness. Focus group participants cited refrigeration issues as a common problem during hot weather. Participants expressed the need for more guidance on hot weather and power outages to be delivered concisely. Our findings suggest that hotter temperatures may compromise cold and hot food holding, possibly by straining refrigeration or other equipment. The findings have public health implications because holding potentially hazardous foods in the temperature danger zone allows foodborne pathogens to proliferate and increases risk for foodborne illness. Distribution of simple guidelines that can be easily accessed during emergencies could help restaurants respond better.

Burden and Risk Factors for Cold-Related Illness and Death in New York City.

Exposure to cold weather can cause cold-related illness and death, which are preventable. To understand the current burden, risk factors, and circumstances of exposure for illness and death directly attributed to cold, we examined hospital discharge, death certificate, and medical examiner data during the cold season from 2005 to 2014 in New York City (NYC), the largest city in the United States. On average each year, there were 180 treat-and-release emergency department visits (average annual rate of 21.6 per million) and 240 hospital admissions (29.6 per million) for cold-related illness, and 15 cold-related deaths (1.8 per million). Seventy-five percent of decedents were exposed outdoors. About half of those exposed outdoors were homeless or suspected to be homeless. Of the 25% of decedents exposed indoors, none had home heat and nearly all were living in single-family or row homes. The majority of deaths and illnesses occurred outside of periods of extreme cold. Unsheltered homeless individuals, people who use substances and become incapacitated outdoors, and older adults with medical and psychiatric conditions without home heat are most at risk. This information can inform public health prevention strategies and interventions.

Real-time surveillance of heat-related morbidity: Relation to excess mortality associated with extreme heat.

The impact of heat on mortality is well documented but deaths tend to occur after (or lag) extreme heat events, and mortality data is generally not available for timely surveillance during extreme heat events. Recently, systems for near-real time surveillance of heat illness have been reported but have not been validated as predictors of non-external cause of deaths associated with extreme heat events. We analyzed associations between daily weather conditions, emergency medical system (EMS) calls flagged as heat-related by EMS dispatchers, emergency department (ED) visits classified as heat-related based on chief complaint text, and excess non-external cause mortality in New York City. EMS and ED data were obtained from data reported daily to the city health department for syndromic surveillance. We fit generalized linear models to assess the relationships of daily counts of heat related EMS and ED visits to non-external cause deaths after adjustment for weather conditions during the months of May-September between 1999 and 2013. Controlling for temporal trends, a 7% (95% confidence interval (CI): 2-12) and 6% (95% CI: 3-10) increase in non-external cause mortality was associated with an increase from the 50th percentile to 99th percentile of same-day and one-day lagged heat-related EMS calls and ED visits, respectively. After controlling for both temporal trends and weather, we observed a 7% (95% CI: 3-12) increase in non-external cause mortality associated with one-day lagged heat-related EMS calls and a 5% mortality increase with one-day lagged ED visits (95% CI: 2-8). Heat-related illness can be tracked during extreme heat events using EMS and ED data which are indicators of heat associated excess non-external cause mortality during the warm weather season.

Evaluation of a Novel Syndromic Surveillance Query for Heat-Related Illness Using Hospital Data From Maricopa County, Arizona, 2015.

OBJECTIVES: We evaluated a novel syndromic surveillance query, developed by the Council of State and Territorial Epidemiologists (CSTE) Heat Syndrome Workgroup, for identifying heat-related illness cases in near real time, using emergency department and inpatient hospital data from Maricopa County, Arizona, in 2015. METHODS: The Maricopa County Department of Public Health applied 2 queries for heat-related illness to area hospital data transmitted to the National Syndromic Surveillance Program BioSense Platform: the BioSense "heat, excessive" query and the novel CSTE query. We reviewed the line lists generated by each query and used the diagnosis code and chief complaint text fields to find probable cases of heat-related illness. For each query, we calculated positive predictive values (PPVs) for heat-related illness. RESULTS: The CSTE query identified 674 records, of which 591 were categorized as probable heat-related illness, demonstrating a PPV of 88% for heat-related illness. The BioSense query identified 791 patient records, of which 589 were probable heat-related illness, demonstrating a PPV of 74% for heat-related illness. The PPV was substantially higher for the CSTE novel and BioSense queries during the heat season (May 1 to September 30; 92% and 85%, respectively) than during the cooler seasons (55% and 29%, respectively). CONCLUSION: A novel query for heat-related illness that combined diagnosis codes, chief complaint text terms, and exclusion criteria had a high PPV for heat-related illness, particularly during the heat season. Public health departments can use this query to meet local needs; however, use of this novel query to substantially improve public health heat-related illness prevention remains to be seen.

Excess Mortality Attributable to Extreme Heat in New York City, 1997-2013.

Extreme heat event excess mortality has been estimated statistically to assess impacts, evaluate heat emergency response, and project climate change risks. We estimated annual excess non-external-cause deaths associated with extreme heat events in New York City (NYC). Extreme heat events were defined as days meeting current National Weather Service forecast criteria for issuing heat advisories in NYC based on observed maximum daily heat index values from LaGuardia Airport. Outcomes were daily non-external-cause death counts for NYC residents from May through September from 1997 to 2013 (n = 337,162). The cumulative relative risk (CRR) of death associated with extreme heat events was estimated in a Poisson time-series model for each year using an unconstrained distributed lag for days 0-3 accommodating over dispersion, and adjusting for within-season trends and day of week. Attributable death counts were computed by year based on individual year CRRs. The pooled CRR per extreme heat event day was 1.11 (95%CI 1.08-1.14). The estimated annual excess non-external-cause deaths attributable to heat waves ranged from -14 to 358, with a median of 121. Point estimates of heat wave-attributable deaths were greater than 0 in all years but one and were correlated with the number of heat wave days (r = 0.81). Average excess non-external-cause deaths associated with extreme heat events were nearly 11-fold greater than hyperthermia deaths. Estimated extreme heat event-associated excess deaths may be a useful indicator of the impact of extreme heat events, but single-year estimates are currently too imprecise to identify short-term changes in risk.

Daylight photodynamic therapy: the Southern California experience.

BACKGROUND: Photodynamic therapy (PDT) is a safe and effective treatment for actinic keratoses (AKs) and photoactinic damage. Three elements are needed for PDT: a photosensitizer, oxygen, and a light source. Conventional PDT is performed with a variety of different laser and light sources including blue, yellow and red in addition to filtered intense pulsed lights (IPL). Daylight PDT, using ambient visible light has been reported as safe, time- and cost-efficient, and more comfortable than with other light sources. We report our experience with daylight PDT in 80 patients. MATERIAL AND METHODS: Eighty patients with multiple actinic keratoses related to chronic photodamage underwent one or two sessions with daylight PDT. Anatomic locations treated included face, chest, arms, and legs. Aminolevulinic acid (ALA, Levulan, Kerastick Dusa USA) was applied one hour prior to light exposure. Thick actinic keratoses were gently curetted prior to ALA application. A chemical sunscreen was applied thirty minutes into the incubation and subsequently patients sat outside in the shade for 2.5 hours. The following day, patients applied a chemical sunscreen and went into either shaded or direct sunlight for 15-30 extra minutes depending on sensitivity. Significant pain associated with this second day exposure was an indication to return indoors immediately. After the second exposure they were instructed to stay inside for the remainder of the 48 hour post treatment period. RESULTS: All patients tolerated the procedure well. Patients denied any pain during the first two and half hour exposure. The second day exposure elicited a mild burning sensation that patients rated as a 2-3/10 though some patients elected to go outside protocol and 'tough it out' despite more significant discomfort. Patients and physicians noted significant reduction in photoactinic damage and actinic keratoses. Patients appreciated the convenience of the treatment. There were no significant adverse events, and no patients reported scarring. CONCLUSION: In this case series, daylight PDT achieved obvious improvement in photodamage, specifically precancerous lesions, and in photoaging with a reduction in lentigenes and other signs of aging. Patients reported significantly less pain than with conventional PDT and enjoyed the convenience of treatment generally in their backyard. It was noted to be a safe procedure with no significant adverse events such as scarring. Additionally, the cost of the procedure was significantly reduced, with ALA and its application being the only expenses.

Extreme heat awareness and protective behaviors in New York City.

Heat waves can be lethal and routinely prompt public warnings about the dangers of heat. With climate change, extreme heat events will become more frequent and intense. However, little is known about public awareness of heat warnings or behaviors during hot weather. Awareness of heat warnings, prevention behaviors, and air conditioning (AC) prevalence and use in New York City were assessed using quantitative and qualitative methods. A random sample telephone survey was conducted in September 2011 among 719 adults and follow-up focus groups were held in winter 2012 among seniors and potential senior caregivers. During summer 2011, 79 % of adults heard or saw a heat warning. Of the 24 % who were seniors or in fair or poor health, 34 % did not own AC or never/rarely used it on hot days. Of this subgroup, 30 % were unaware of warnings, and 49 % stay home during hot weather. Reasons for not using AC during hot weather include disliking AC (29 %), not feeling hot (19 %), and a preference for fans (18 %). Seniors in the focus groups did not perceive themselves to be at risk, and often did not identify AC as an important health protection strategy. While heat warnings are received by most New Yorkers, AC cost, risk perception problems, and a preference for staying home leave many at risk during heat waves. Improving AC access and risk communications will help better protect the most vulnerable during heat waves.

Health effects of coastal storms and flooding in urban areas: a review and vulnerability assessment.

Coastal storms can take a devastating toll on the public's health. Urban areas like New York City (NYC) may be particularly at risk, given their dense population, reliance on transportation, energy infrastructure that is vulnerable to flood damage, and high-rise residential housing, which may be hard-hit by power and utility outages. Climate change will exacerbate these risks in the coming decades. Sea levels are rising due to global warming, which will intensify storm surge. These projections make preparing for the health impacts of storms even more important. We conducted a broad review of the health impacts of US coastal storms to inform climate adaptation planning efforts, with a focus on outcomes relevant to NYC and urban coastal areas, and incorporated some lessons learned from recent experience with Superstorm Sandy. Based on the literature, indicators of health vulnerability were selected and mapped within NYC neighborhoods. Preparing for the broad range of anticipated effects of coastal storms and floods may help reduce the public health burden from these events.