Perspectives in Disease Prevention and Health Promotion Exposure-Related Hypothermia Deaths -- District of Columbia, 1972-1982

During the ten cold-weather seasons of 1972-1973 through 1981-1982, 63 exposure-related hypothermia deaths (ERHD)* were recorded on death certificates within the District of Columbia (DC). Two additional ERHD cases have been recorded through December 20 of the current winter season. Most deaths occurred in December and January, particularly around Christmas. Inadequate housing and prior ethanol ingestion contributed to ERHD.

All were investigated (including autopsy) by the Office of the Chief Medical Examiner. Complete data were available on the 57 ERHD that occurred before January 1982. Fifty-four victims were DC residents, for an overall ERHD rate of 0.88 resident deaths/100,000 person years.** Resident ERHD rates/100,000 person years among black males (n = 42), white males (n = 7), black females (n = 4), and white females (n = 1) were 1.91, 1.01, 0.17, and 0.12, respectively. Corresponding relative risks were 15.9, 8.4, 1.4, and 1.0. Median age was 50 years. The highest age-specific death rate occurred in the 50-54-year range (n = 10; 3.0 deaths/100,000 person years). Seven victims (13.0%) were 65 years of age or older; one was less than 32 years old. *ERHD cases were defined as deaths occurring in appropriate environmental circumstances of persons without trauma or apparent natural disease sufficient to cause death. Body temperature was less than 35 C (95 F) for all hospitalized ERHD victims for whom data were available. **Population estimates from Office of Planning and Development, DC Government.

ERHD ranged from two to 12 per season and were noted in all months from October through April (Figure 1). Thirty-nine (72%) of the 54 resident ERHD occurred in December or January during these 9 years; 22 (56%) of these 39 occurred in the 6 coldest of these 18 months (p 0.005). Eleven (20%) ERHD victims were found during Christmas weeks (Dec 24-30). Thirteen others (24%) were found during the subsequent two-week periods. Only 10 (19%) of the 54 DC resident ERHD victims survived long enough to reach hospitals. At least 15 (33%) of 46 victims had been undernourished ( 5th percentile of weight for height) (1). Pre-existing disease (convulsive disorders, diabetes, uremia) was a possible contributing factor in at least seven (13%) of these cases and trauma or accident in an additional four (7%). Twenty-seven victims (50%) had inadequate housing. Two of these were found dead in unheated apartments; for the remaining 25, no fixed address, other than abandoned buildings or vehicles, could be established despite extensive investigation. Fifteen others (28%) lived alone. Twenty-one (40%) of 52 resident ERHD victims for whom data were available were found in census tracts where the mean family income was less than $10,000. These census tracts contain only 13% of the total DC population (p 0.0001). Blood ethanol levels were measured in 52 ERHD victims. Twenty-five (48%) of these victims had blood ethanol levels greater than 0.15 g/dl, a level felt to be associated with loss of central thermoregulatory ability (2). Eleven others (21%) had lower levels of ethanol in their blood. Victims with inadequate housing were less likely to have blood ethanol levels less than 0.15 g/dl (eight of 26) than were victims with adequate housing (17 of 26, p = 0.010, Fisher exact test). Twenty (37%) of the 54 were found partially or completely undressed. No victims were found with hats. Because their confused mental states were believed due to ethanol intoxication, several ERHD victims were taken to detoxification centers before their hypothermia was recognized. Only nine (17%) of these 54 victims had been reported missing. Investigators' reports indicated, however, that a substantial number had had contact with a community agency (hospital, police department, social agency) within hours to days before death. Reported by JL Luke, MD, ME Levy, MD, District Epidemiologist, Washington DC Dept of Human Svcs; Field Svcs Div, Epidemiology Program Office, CDC.

Editorial Note

Editorial Note: Lack of adequate housing, acute ethanol intoxication, or both were noted in 82% of the ERHD victims in Washington, D.C. over this 10-year period. The higher rates of ERHD found in this study among blacks and among males are consistent with trends in previous death certificate data (3). In addition, ethanol-intoxication association, advanced age, and adverse social and economic circumstances have been described among patients hospitalized with hypothermia in the United Kingdom (4,5) and the United States (6,7). DC data suggest that younger and middle-aged adults, particularly nonwhite males, may comprise a larger proportion of those at risk from fatal hypothermia than previously thought. This difference may in part reflect the hospital-based nature of earlier studies (4-7) in that patients who survive to reach hospitals may represent a different subgroup of those at risk of hypothermia. Alternatively, the difference may represent economic circumstances different from those present in the earlier studies (4-7).

The seemingly irrational undressing noted in many of these ERHD has previously been reported from Scandinavia (8). That report suggested that when core body temperature falls to a critical level, peripheral vasoconstriction fails. The resulting sudden vasodilation could lead to an exaggerated sensation of heat and a consequent attempt by the victim to undress (8).

In addition to ongoing public education efforts (9), public safety personnel (police, ambulance crews) should receive training to recognize hypothermia victims, with particular emphasis on such aspects as confusion and unsteady gait, which are similar to symptoms of ethanol intoxication. Persons taken to detoxification centers during cold weather should have their temperatures taken on admission. Homeless persons found outside or removed from buildings during cold weather should be provided with alternative heated shelters. A clothed person loses the greatest amount of heat through the head, especially when hatless (10). The importance of adequate head covering for all people exposed to cold needs to be brought to public attention.

Although a large body of literature exists on various methods of resuscitation from hypothermia once it is recognized (10,11), one recent study in a northeastern U.S. area found that only 20% of hospital emergency rooms have low temperature thermometers (12). Hospitals should ensure that their emergency room staffs are familiar with symptoms of and initial therapy for hypothermia (10,13) and have access to low temperature thermometers. Based on a finding of hypoglycemia in a high proportion of patients with both ethanol intoxication and hypothermia, intravenous 50% dextrose has recently been recommended for use in resuscitation of hypothermic patients, unless serum glucose is known to be normal or high (11). During cold weather, homeless or intoxicated persons released from hospitals or jails should be sent directly to shelters.

Further studies are needed to more clearly define both the epidemiology and appropriate prevention of ERHD.

References

1. National Center for Health Statistics. Weight by height and age for adults 18-74 years: United States 1971-74. Hyattsville, Md.: National Center for Health Statistics (DHEW Publication No. (PHS) 79-1656), September 1979.

2. Hirvonen J. Systemic and local effects of hypothermia. In: Tedeschi CG, Eckert WG, Tedeschi LG, eds. Forensic medicine: a study in trauma and environmental hazards. Vol 3. Philadelphia: WB Saunders, 1977.

3. National Center for Health Statistics. Vital Statistics of the United States, 1976. Vol II. Mortality, Part A. Hyattsville, Md.: National Center for Health Statistics.

4. Duguid H, Simpson RG, Stowers JM. Accidental hypothermia. Lancet 1961;2:1213-19.

5. Royal College of Physicians of London. Report of the Committee on Accidental Hypothermia. London 1966.

6. Hudson, LD, Conn RD. Accidental hypothermia. Associated diagnoses and prognosis in a common problem. JAMA 1974;227:37-40.

7. Weyman AE, Greenbaum DM, Grace WJ. Accidental hypothermia in an alcoholic population. Am J Med 1974;56:13-21.

8. Wedin B, Vanggaard L, Hirvonen J. "Paradoxical undressing" in fatal hypothermia. J Forensic Sci 1979;24:543-53.

9. National Institutes on Aging. A winter hazard for the old: accidental hypothermia. Bethesda, Md.: National Institutes of Health (NIH Publication, No 81-1464), 1980.

10. Mclean D, Emslie-Smith D. Accidental hypothermia. Oxford: Blackwell Scientific, 1977.

11. Fitzgerald FT. Hypoglycemia and accidental hypothermia in an alcoholic population. West J Med 1980;133:105-7.

12. Sherman FT, Daum M. Hypothermia detection in emergency departments. NY State J Med 1982;82:374-6.

13. Webb P. Disorders due to heat and cold: hypothermia. In: Wyngaarden JB, Smith LH, eds. Textbook of Medicine. 16th ed. Philadelphia: WB Saunders, 1982:2228.

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