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      Association Between Exposure to Hurricane Irma and Mortality and Hospitalization in Florida Nursing Home Residents


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          Key Points


          Was exposure to Hurricane Irma associated with an increased risk of hospitalization and mortality among nursing home residents in the 30 and 90 days after the storm compared with a control group?


          In this cohort study of 61 564 nursing home residents exposed to Hurricane Irma and a control group of 61 813 nonexposed residents, the odds of a first hospitalization and mortality increased significantly at 30 and 90 days for those exposed. A long nursing home stay was associated with a greater risk for mortality compared with a short stay.


          Findings suggest that prioritizing heightened emergency preparedness in disaster situations for nursing home residents is warranted.



          Nursing home residents are at heightened risk for morbidity and mortality following an exposure to a disaster such as a hurricane or the COVID19 pandemic. Previous research has shown that nursing home resident mortality related to disasters is frequently underreported. There is a need to better understand the consequences of disasters on nursing home residents and to differentiate vulnerability based on patient characteristics.


          To evaluate mortality and morbidity associated with exposure to Hurricane Irma, a Category 4 storm that made landfall on September 10, 2017, in Cudjoe Key, Florida, among short-stay (<90-day residence) and long-stay (≥90-day residence) residents of nursing homes.

          Design, Setting, and Participants

          Cohort study of Florida nursing home residents comparing residents exposed to Hurricane Irma in September 2017 to a control group of residents residing at the same nursing homes over the same time period in calendar year 2015. Data were analyzed from August 28, 2019, to July 22, 2020.


          Residents who experienced Hurricane Irma were considered exposed; those who did not were considered unexposed.

          Main Outcome and Measures

          Outcome variables included 30-day and 90-day mortality and first hospitalizations after the storm in both the short term and the long term.


          A total of 61 564 residents who were present in 640 Florida nursing home facilities on September 7, 2017, were identified. A comparison cohort of 61 813 residents was evaluated in 2015. Both cohorts were mostly female (2015, 68%; 2017, 67%), mostly White (2015, 79%; 2017, 78%), and approximately 40% of the residents in each group were over the age of 85 years. Compared with the control group in 2015, an additional 262 more nursing home deaths were identified at 30 days and 433 more deaths at 90 days. The odds of a first hospitalization for those exposed (vs nonexposed) were 1.09 (95% CI, 1.05-1.13) within the first 30 days after the storm and 1.05 (95% CI, 1.02-1.08) at 90 days; the odds of mortality were 1.12 (95% CI, 1.05-1.18) at 30 days and 1.07 (95% CI, 1.03-1.11) at 90 days. Among long-stay residents, the odds of mortality for those exposed to Hurricane Irma were 1.18 (95% CI, 1.08-1.29) times those unexposed and the odds of hospitalization were 1.11 (95% CI, 1.04-1.18) times those unexposed in the post 30-day period.

          Conclusions and Relevance

          The findings of this study suggest that nursing home residents are at considerable risk to the consequences of disasters. These risks may be underreported by state and federal agencies. Long-stay residents, those who have resided in a nursing home for 90 days or more, may be most vulnerable to the consequences of hurricane disasters.


          This cohort study assess the association between exposure to Hurricane Irma and 30- and 90-day mortality and morbidity among short- and long-term residents of nursing homes in Florida.

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          Most cited references26

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          Heat-related deaths during the July 1995 heat wave in Chicago.

          During a record-setting heat wave in Chicago in July 1995, there were at least 700 excess deaths, most of which were classified as heat-related. We sought to determine who was at greatest risk for heat-related death. We conducted a case-control study in Chicago to identify risk factors associated with heat-related death and death from cardiovascular causes from July 14 through July 17, 1995. Beginning on July 21, we interviewed 339 relatives, neighbors, or friends of those who died and 339 controls matched to the case subjects according to neighborhood and age. The risk of heat-related death was increased for people with known medical problems who were confined to bed (odds ratio as compared with those who were not confined to bed, 5.5) or who were unable to care for themselves (odds ratio, 4.1). Also at increased risk were those who did not leave home each day (odds ratio, 6.7), who lived alone (odds ratio, 2.3), or who lived on the top floor of a building (odds ratio, 4.7). Having social contacts such as group activities or friends in the area was protective. In a multivariate analysis, the strongest risk factors for heat-related death were being confined to bed (odds ratio, 8.2) and living alone (odds ratio, 2.3); the risk of death was reduced for people with working air conditioners (odds ratio, 0.3) and those with access to transportation (odds ratio, 0.3). Deaths classified as due to cardiovascular causes had risk factors similar to those for heat-related death. In this study of the 1995 Chicago heat wave, those at greatest risk of dying from the heat were people with medical illnesses who were socially isolated and did not have access to air conditioning. In future heat emergencies, interventions directed to such persons should reduce deaths related to the heat.
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            Excess mortality related to the August 2003 heat wave in France.

            From August 1st to 20th, 2003, the mean maximum temperature in France exceeded the seasonal norm by 11-12 degrees C on nine consecutive days. A major increase in mortality was then observed, which main epidemiological features are described herein. The number of deaths observed from August to November 2003 in France was compared to those expected on the basis of the mortality rates observed from 2000 to 2002 and the 2003 population estimates. From August 1st to 20th, 2003, 15,000 excess deaths were observed. From 35 years age, the excess mortality was marked and increased with age. It was 15% higher in women than in men of comparable age as of age 45 years. Excess mortality at home and in retirement institutions was greater than that in hospitals. The mortality of widowed, single and divorced subjects was greater than that of married people. Deaths directly related to heat, heatstroke, hyperthermia and dehydration increased massively. Cardiovascular diseases, ill-defined morbid disorders, respiratory diseases and nervous system diseases also markedly contributed to the excess mortality. The geographic variations in mortality showed a clear age-dependent relationship with the number of very hot days. No harvesting effect was observed. Heat waves must be considered as a threat to European populations living in climates that are currently temperate. While the elderly and people living alone are particularly vulnerable to heat waves, no segment of the population may be considered protected from the risks associated with heat waves.
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              Prognostic factors in heat wave related deaths: a meta-analysis.

              Although identifying individuals who are at increased risk of dying during heat waves and instituting protective measures represent an established strategy, the evidence supporting the components of this strategy and their strengths has yet to be evaluated. We conducted a meta-analysis of observational studies on risk and protective factors in heat wave-related deaths. Using the OVID interface, we searched Medline (1966-2006) and CINHAL (1982-2006) databases. The Web sites of the World Health Organization, Institut National de Veille Sanitaire, and Centers for Disease Control and Prevention were also visited. The search terms included heat wave, heat stroke, heatstroke, sunstroke, and heat stress disorders. Eligible studies were case-control or cohort studies. Odds ratios (ORs) and information on study quality were abstracted by 2 investigators independently. Six case-control studies involving 1065 heat wave-related deaths were identified. Being confined to bed (OR, 6.44; 95% confidence interval [CI], 4.5-9.2), not leaving home daily (OR, 3.35; 95% CI, 1.6-6.9), and being unable to care for oneself (OR, 2.97; 95% CI, 1.8-4.8) were associated with the highest risk of death during heat waves. Preexisting psychiatric illness (OR, 3.61; 95% CI, 1.3-9.8) tripled the risk of death, followed by cardiovascular (OR, 2.48; 95% CI, 1.3-4.8) and pulmonary (OR, 1.61; 95% CI, 1.2-2.1) illness. Working home air-conditioning (OR, 0.23; 95% CI, 0.1-0.6), visiting cool environments (OR, 0.34; 95% CI, 0.2-0.5), and increasing social contact (OR, 0.40; 95% CI, 0.2-0.8) were strongly associated with better outcomes. Taking extra showers or baths (OR, 0.32; 95% CI, 0.1-1.1) and using fans (OR, 0.60; 95% CI, 0.4-1.1) were associated with a trend toward lower risk of death. The present study identified several prognostic factors that could help to detect those individuals who are at highest risk during heat waves and to provide a basis for potential risk-reducing interventions in the setting of heat waves.

                Author and article information

                JAMA Netw Open
                JAMA Netw Open
                JAMA Netw Open
                JAMA Network Open
                American Medical Association
                6 October 2020
                October 2020
                6 October 2020
                : 3
                : 10
                [1 ]School of Public Health, Brown University, Providence, Rhode Island
                [2 ]Warren Alpert Medical School, Brown University, Providence, Rhode Island
                [3 ]Providence VAMC, Center of Innovation for Long Term Services and Supports, Providence, Rhode Island
                [4 ]University of South Florida, School of Aging Studies, Tampa
                [5 ]University of South Florida, Department of Industrial and Management Systems Engineering, Tampa
                Author notes
                Article Information
                Accepted for Publication: July 24, 2020.
                Published: October 6, 2020. doi:10.1001/jamanetworkopen.2020.19460
                Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Dosa DM et al. JAMA Network Open.
                Corresponding Author: David M. Dosa, MD, MPH, Center for Gerontology and Healthcare Research, Brown University, 121 S Main St, Box G-121(6), Providence, RI 02912 ( david_dosa@ 123456brown.edu ).
                Author Contributions : Dr Dosa and Ms Skarha had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
                Concept and design: Dosa, Skarha, Peterson, Jester, Thomas, Hyer.
                Acquisition, analysis, or interpretation of data: Dosa, Skarha, Peterson, Jester, Sakib, Ogarek, Thomas, Andel.
                Drafting of the manuscript: Dosa, Skarha, Peterson, Thomas.
                Critical revision of the manuscript for important intellectual content: All authors.
                Statistical analysis: Dosa, Skarha, Jester, Sakib, Ogarek, Andel.
                Obtained funding: Dosa, Hyer.
                Administrative, technical, or material support: Dosa, Thomas, Hyer.
                Supervision: Dosa, Hyer.
                Conflict of Interest Disclosures: Drs Dosa and Hyer have worked as expert witnesses in legal cases related to Hurricane Irma. Dr Dosa reported grants from National Institutes of Aging and grants from Veteran's Administration during the conduct of the study; other from Legal Work outside the submitted work. Dr Jester reported grants from the National Institute on Aging (R01AG060581-01) during the conduct of the study. Dr Sakib reported grants from NIH during the conduct of the study. Dr Ogarek reported grants from NIH during the conduct of the study. Dr Hyer reported grants from National Institute on Aging during the conduct of the study; and personal fees from Rutledge Ecenia (law firm) outside the submitted work. No other disclosures were reported.
                Funding/Support: This work is funded by a grant from the National Institutes of Aging (RO1 AG060581). Drs Dosa and Thomas are also funded by the Veterans Administration Center of Innovation for Long Term Services and Supports.
                Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
                Disclaimer: The contents do not represent the views of the US Department of Veterans Affairs or the US government.
                Copyright 2020 Dosa DM et al. JAMA Network Open.

                This is an open access article distributed under the terms of the CC-BY License.

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