Cold, health, admissions and winter mortality' Briefing

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Cold, health, admissions and winter
mortality.Briefing

• Greg Fell, NW Leeds PCT
• Greg.fell_at_leedsnorthwest-pct.nhs.uk
• 0113 3057 548

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Purpose of this presentation

• Support to a Winter 06 project to reduce cold
  related admissions and death.
• Overview of effects of cold on health, morbidity,
  mortality and quality of life
• Overview of key interventions to address, both
  warmth and clinical.
• Overview of what is being done in W Yorks in
  Winter 2005 / 2006

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Context

• Most people and many doctors have difficulty in
  recognising the importance of cold. As a nation
  we are poorly educated about the effects of cold
  and how to deal with it.
• This probably contributes to the poor record of
  our high extra winter mortality and this may be
  exacerbated by the run of recent mild winters
• Nationally we have a tendency for warmer winters
  than elsewhere in Northern Europe.
• But.
• The quality (primarily insulation and thermal
  efficiency) of the UK housing stock is well below
  that in Northern Europe.
• Therefore we live in colder homes. When we go
  outside, we are less likely to wrap up.

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Effects of Cold on Health

• Excess Winter Mortality primarily
  cardiovascular and respiratory
• Admission
• respiratory illness / hypothermia /
  cardiovascular illness following a cold snap.
• Consultation particularly GPs
• approximately 8 householders (Leeds City Council
  data) feel their health has been affected by cold
  in their home. A likely under estimate
• Quality of life
• there is consistent anecdotal evidence re
  families sleeping and living on one room in
  winter due to inability to heat house
• Educational attainment
• there are many local examples of children not
  doing homework due to living in cold conditions.
  Longer term impact on health poor educational
  attainment leads to lower adult income.

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1 Excess Winter Mortality (EWM)
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Excess Winter Mortality (EWM) key facts (1)

• EWM compares the 4 months of Dec to Mar with the
  preceding and following 4 month periods.
• There is a 40 difference between the peak death
  rate in Winter with the lowest death rate in
  Summer.
• There is a linear relationship of temperature and
  mortality (a 1.4 increase in mortality for every
  1C fall in temperature from 18C.)
• This means that all winter days not just the
  coldest that create some excess mortality.
• There are approximately 810 Excess Winter Deaths
  in W Yorkshire per year (ONS EWM for 2002 / 03)
• For every 1 degree fall in the winter average air
  temperature, there is an approximate one fifth
  increase in excess winter deaths 5,000 deaths
  nationally, 162 deaths in West Yorkshire.
• It has been consistently suggested that cold, and
  particularly cold damp homes, are a major
  contributory factor to 80 of excess winter
  deaths.

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EWM key facts (2)

• The UK has one of the largest increases in
  mortality during cold weather compared to other
  countries in Europe. This is due to the fact
  that during cold weather people
• dont maintain their body temperature since they
  dont wear enough clothing, especially when
  outdoors
• are less active
• live in colder houses - living rooms in the UK
  are colder, bedrooms are less likely to be heated
  
• compared to their counterparts in colder
  countries.
• The Eurowinter study demonstrated that a mild
  climate was no protection to extra winter deaths.
  London has double the excess winter mortality
  compared to colder countries.
• Also see Pattenden S. JECH, 2003. comparison of
  EWM between Sophia and London. Higher increas in
  EWM in response to cold temperatue in London
  compared to the conditions in Sophia
• In the coldest countries, at 7C people were more
  likely to wear anoraks hats and gloves and were
  more active compared to London at the same
  temperature.
• thought that indoor temperature (rather than
  outdoor) is key factor affecting physiology
• much colder countries have lower rates of excess
  winter mortality than the UK.

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Trends in excess winter death

• Rate has fallen continually since 1950s. Still a
  significant number of deaths.
• Approx 23,000 in 2003 / 4

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Seasonal pattern and spikes in EWM W Yorkshire
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Time lag and EWM (and Admission)

• It is possible to predict with a high degree of
  accuracy the time lag between a cold snap and
  admissions / excess winter deaths.
• After a cold snap
• 2 to 5 days peak in EWM and admission for
  Cardiovascular
• Heart Attack - 2 days
• Stroke - 5 days
• 10 12 days - peak in EWM and admission for
  Respiratory
• This relationship is consistent in other
  temperate countries. The three and twelve day
  lags mark the peak death days, surrounded by a
  relatively normal distribution.

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Age Distribution of EWM

• Particularly an issue for over 65s.
• 43 of excess winter deaths occurring in the 85
  population, who make up approx 2 of the
  population.
• This is in contrast to 8.5 of excess winter
  deaths occurred in the 0-64 population who make
  up 95 of the total population.

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Causes of EWM

• 810 deaths in W Yorks
• Approximately 80 are strongly influenced or
  possibly caused by cold, particularly living in a
  cold, damp home.
• Of the COLD RELATED EWM
• Cardiovascular disease accounts for approx 62 of
  the cold related excess winter deaths
• Heart attack accounts for 47 - deaths .
  generally occurring 2 days after a cold snap
• Stroke accounts for 15 - deaths - generally
  occurring 5 days (for stroke) after a cold snap.
• Respiratory disease - accounts for approx 37 of
  the cold related excess winter deaths
• Influenza (non epidemic years) 17
• Other (including COPD) remainder
• Hypothermia - accounts for 2 of excess winter
  deaths

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2 Morbidity and Admission
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Morbidity and Excess Winter Admission (1)

• There are strong associations between cold or
  damp living conditions and worsening illness.
• Admission data clearly shows that there are peaks
  in admissions, particularly for respiratory /
  cardiovascular / hypothermia, following a cold
  snap.
• Approximately 8, or 5000 householders feel
  their, or a member of their families, health has
  been affected by cold conditions in the home
• This is most often for those living in private
  rented sector homes where energy efficiency is
  often poor.
• Twice as many residents of private rented
  (compared to owner occupied) reported their
  families health had been affected by cold
  conditions in their home

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Excess Winter Admissions W YorkshirePeaks in
winter
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W Yorkshire HA Analysis of Excess Winter Admission
Over whole winter period (4 months). 5719 Excess
Winter Admissions per year. Averaged over last 3
years.
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8 of householders feel their health has been
affected by cold conditions
LCC Data
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Morbidity, and admission(2)

• Cold, damp living conditions does have a
  significant impact on illness, admission, and
  poor quality of life. The effect of cold homes on
  risk of illness and quality of life are reviewed
  below

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3 GP Consultation
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GP consultations

• Association between low temperature and LRTI
  consultations.
• Particularly 65 population
• For every 1oc drop in mean temperature below
  threshold of 5oc a 19 increase in LRTI
  consults.
• 0 20 day time lag between drop in temp below
  threshold and consult.
• Weaker association between URTI consultations and
  drop in temperature
• North / South Divide. Larger effect in Northern
  England
• Hajat Shakoor et al. Int J Epid, 2004, 19 (10)
  p959
• Strong association between temperature 15 days
  previously and increase in consultations.
  Particularly as temperature falls below 5oc
• For every 1oc drop in temp below 5oc - consults
  for all respiratory problems increased by 10
  (95 CI 7.6 13.4)
• No apparent relationship between falling temp and
  cardiovascular consults. ? More likely acute
  admission
• Hajat S, Haines A. Int J Epid, 2002, 31 (4) p 825
  

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Physiology, temperature (indoor and out), key
population groups
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Physiology

• Cold
• causes blood pressure, red blood cells, platelets
  and fibrinogen to increase
• predispose to formation of clots heart attack
  and stroke.
• The elderly most at risk of thermoregulatory
  problems
• Damp much less clear
• Allergies to mould - rhinitis, alveolitis,
  itching, sneezing, wheezing, conjunctivitis,
  fever, coughing, fibrosis, cardiovascular disease
• Infections - flu-like symptoms to irreversible
  lung damage

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Outdoor and indoor temperature what is the
difference. Which is important?

• Indoor temperature is clearly linked to outdoor
  air temperature, however the ability to heat a
  home is modified by housing condition (thermal
  and energy efficiency), fuel prices and household
  income all modifiable.
• There is a strong link between older houses (more
  difficult to keep warm) and excess winter death.
• There is a 20 difference in excess winter death
  between people living in the most and least
  thermally efficient homes
• Excess winter deaths are significantly more
  likely in people living in old houses they are
  harder to heat to a decent standard.
• Compared with other countries living rooms in
  the UK are colder, bedrooms are less likely to be
  heated and when we do go outside in cold
  temperatures, we are less likely to wear warm
  clothing

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Risk Temperatures - EWM

• Linear relationship between decreasing temp and
  EWM (a 1.4 increase in mortality for every 1c
  fall in temperature from 18C.).
• This means that all winter days not just the
  coldest that create some excess mortality.
• Nahya S. Int J Circumpolar H. 2002
• EWM Cardiovascular and respiratory
• Strongest association between falling temperature
  and respiratory mortality.
• Still mainly linear relationship
• Rate of increase (of EWM) steepen below 11oc
• For temp below 11oc, a 1oc fall in daytime mean
  temperature was associated with an increase in
  mortality of
• 2.9 (95 CI 2.5 3.4) all cause
• 3.4 (95 2.6 4.1) cardiovascular
• 4.8 (95 3.5 6.2) respiratory
• 1.7 (95 10. 2.4) other cause
• Over the following month.
• Wind chill does not have significant impat. Dry
  bulb temp seems to be the key factor.
• Carder M et al. Occup Env Med, 2005

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Indoor thermal comfort

• Indoor temp risk markers are set
• gt 18c - Adequate warmth. No risk to sedentary,
  but otherwise healthy individuals
• lt 18c discomfort
• lt 15c increased risk of respiratory infection
  reduced resistance to infection
• lt 12c increased risk of heart attack / stroke
  increase in blood viscosity
• lt 9c reduced core temp. risk of hypothermia

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Indoor temperatures recommended for thermal
comfort
(see Health and Safety Rating System for home
hazard assessment)
Consider these temperature risk markers when in a
patients home.
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Vulnerable Groups

• Older people 65 especially
• Young children and babies
• People with respiratory illnesses
• People with established cardiovascular disease
• People with established long term condition /
  chronic illnesses
• People with disabilities
• People with mobility difficulties
• People without access to advice information
• Patients leaving hospital particularly from
  above groups
• Asylum Seekers more likely to have poor
  accommodation?

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Interventions
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Key interventions

• Keep Warm / Keep Well
• Cover for wide range of winter warmth
  interventions, e.g.
• Keeping the house warm
• Cold outdoor temperatures. Wrapping up!
• Early reporting of symptoms.
• Available medication ensuring there is some
• Physical activity / Diet / hot drinks etc.
• Social Support
• Flu jab
• Stop smoking
• Home energy efficiency / thermal comfort
• See http//www.dh.gov.uk/PolicyAndGuidance/HealthA
  ndSocialCareTopics/HealthAndSocialCareArticle/fs/e
  n?CONTENT_ID4076849chkN3IuFO

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Clinical advice?

• Over and above the standard Keep Warm message, it
  is difficult to be precise with regard to
  clinical advice given to patients with specific
  conditions.
• Clinical judgment is necessary but consider how
  will, or could, cold affect this patient.
• With knowledge of physiology, ability to get out
  to a pharmacy or GP,
• What support is available to the patient
  family, friends, carers, neighbours to look in
• Does the patient have the ability to deal
  adequately with an exacerbation of their
  condition? Will they know what to do? Is their
  carer aware?
• Has the patient been through a self management
  course? Consider their ability to self manage
• Is there a formal self management plan in place
• Encourage early reporting of symptoms ie dont
  wait until it is an emergency!
• Keep active
• Consider the value of having a reserve of any
  medications eg for COPD patients keep a
  reserve of antibiotics and steroids (data
  indicates that 60 will be receptive to this)

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Impact of interventions

• Flu immunisation - very good evidence of effect
• Smoking cessation as above
• Fuel poverty eradication - the evaluation of
  'Warm Front', soon to be published, shows
  insulation and central heating installation in
  eligible households to be cost effective,
  particularly in relation to morbidity and
  wellbeing, but also in relation to CV mortality
• Behavioural - good evidence from a range of
  studies that wrapping up, keeping moving outside,
  sleeping in an adequately heated bedroom (ie
  with the window shut!) all make a difference.

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Local Systems
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What is being done in W Yorks?

• Agreement to trial an early warning system with
  regard to cold conditions. Based on some work
  done by Met Office
• Twice weekly review of meteorological information
  and risk management by Leeds North West PCT
  Public Health staff
• Twice weekly 'cold alert' bulletin when
  appropriate by e-mail to key PCT contacts (Winter
  Planning Lead and/or LA contact, and/or
  providers)
• Onward urgent alert by PCT lead to relevant staff
  e.g., Community Matrons, Care Support Workers
  etc.,
• "Keep Warm, Keep Well", simple message emphasised
  to relevant identified patients
• Active identification of high risk of admission
  patients consideration of usefulness of calling
  them to emphasise Keep Warm Keep Well and key
  clinical advice pertinent to cold conditions.
• Passive dissemination of message to wide variety
  of health, social care and other agencies
  cascade onto their patients / clients / users as
  possible and appropriate
• Use of media particularly local weather
  bulletins.
• Ongoing media support through Winter period.

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Materials to support

• A 2-side fact sheet will be prepared for
  clinicians. Weekly temperature predictions. Key
  messages for KW KW.
• DH Keep Warm Keep Well fact sheets particularly
  those translated into community languages.
• 1 side simple prompt sheet for patients eg
  distribution through pharmacies (with scripts) /
  libraries / other. Top Tips for keeping warm in
  winter.
• Media bulletins and editorial to support press
  release etc etc.

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What will this add

• Systematic means of delivering the Keep Warm Keep
  Well message to key population groups / those
  most at risk.
• Means of combining clinical advice with more
  generic health promotion advice
• Means of starting to address one of the key
  infrastructure issues housing thermal
  efficiency
• getting people into systems (generally falling
  under Local Authority Fuel Poverty) to improve
  energy efficiency and therefore contribute to
  significant reduction in EWM and Admissions.

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Summary
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Summary

• Well documented effect of cold temperature on
• Mortality
• Admission
• Quality of life
• GP consultation
• Linear relationship between cold and the above
  effects
• However, evidence suggests that temperatures of
  11oc and 5oc are key points.
• Significant incidence of Excess Winter Mortality
  and Admission
• 80 cold related.
• This is useful for predicting emergency
  admissions. However there is v limited capacity
  in the secondary care system to respond.

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Summary (2)

• Good evidence underpinning the Keep Warm Keep
  Well message (flu jab, smoking, wrap up warm,
  turn heating up)
• W Yorkshire agreed to trial more systematic
  delivery of a real time process for delivery of
  this message to at risk an vulnerable groups
  aim is to prevent admissions / improve health.
• Real time temperature forecasts will be
  disseminated to wide spectrum of professional
  groups (within and outside NHS) agencies and the
  public.
• Passive dissemination to most.
• It is proposed that active dissemination to those
  on Community Matron caseloads (in theory most
  vulnerable and at risk of admission) though
  telephone calls.
• Wide range of materials to support.
• System will only have impact if acted upon by
  both professionals and the public.
• Careful monitoring will attempt to establish the
  reach.
• Attributing any impact to the intervention will
  be very difficult.