Hot Weather Response Plan

The Board of Health recommends:

(1)the adoption of the report dated July 22, 1999, from the Medical Officer of Health;

(2)that the Public Health Unit, in seeking to establish Hot Weather Alert indices, incorporate air quality (smog) criteria as well as appropriate Humidex and heat stress criteria, to together form a Toronto Heat and Smog Index appropriate to the City's local conditions; and

(3)that every Councillor be requested to identify in their wards potential cooling sites, both public and private, and areas where there are large numbers of seniors.

The Board of Health reports, for the information of Council, having forwarded the Medical Officer of Health's interim report on the Hot Weather Response Plan to the Seniors' Task Force and the Advisory Committee on Homeless and Socially Isolated Persons for their information and comment.

The Board of Health submits the following report (July 22, 1999) from the Medical Officer of Health:

Purpose:

To outline for the Board of Health and City Council an interim plan to lessen the impact of hot weather on at-risk populations in Toronto. The interim plan applies to the remainder of 1999 and is accompanied by longer term recommendations for 2000 and beyond.

Financial Implications and Source of Funds:

For 1999, up to $150,000.00 be set aside within the Community and Neighbourhood Services Department through internal reallocations from Toronto Public Health and the Shelter, Housing and Support Division. These funds will be used to cover the following expenses:

(1)distribution of TTC tokens to homeless and low-income persons who are at risk of heat stress;

(2)additional staffing to provide extended hours of service in libraries, community centres, drop-in centres, and recreation facilities that are designated as places for people to cool off;

(3)a purchase of service agreement with Environment Canada for ongoing predictions and timely notification of Humidex levels in Toronto;

(4)first aid training by the Canadian Red Cross of designated staff from the City of Toronto and community organizations to enable them to detect and respond appropriately to heat-related illness;

(5)extended operating hours of Anishnawbe Health Toronto's Street Patrol;

(6)co-ordination and communication activities to ensure effective implementation of weather-related advisories; and

(7)further research on the feasibility of developing Toronto-specific temperature and humidity thresholds for the Hot Weather Response Plan.

The financial implications arising from the annualized implementation of the Hot Weather Response Plan and the remaining longer term recommendations will be submitted by Toronto Public Health and respective departments involved to City Council, through the Board of Health and the applicable standing committees, during the 2000 budget process.

Recommendations:

(1) That the Board of Health recommend that City Council adopt the interim Hot Weather Response Plan as outlined in Appendix A;

(2)that up to $150,000.00 be set aside within the Community and Neighbourhood Services Department through internal reallocations from Toronto Public Health and the Shelter, Housing and Support Division to cover the expenses in 1999 of the Hot Weather Response Plan;

(3)that the Medical Officer of Health (MOH) continue to consult with other city agencies, volunteer organizations and community groups to determine how they can best contribute to the Plan;

(4) that Toronto Public Health contract with Environment Canada to provide ongoing forecast and timely notifications of Humidex levels for Toronto;

(5)that the MOH co-ordinate the development of a comprehensive, city-wide response and its potential costs for consideration during the 2000 budget process. This comprehensive plan may include specific actions by other city agencies, volunteer groups and community organizations co-ordinated by Toronto Public Health and an evaluation component to ensure that the goals of the Plan are being met;

(6)that the MOH expand the yearly public health education campaign directed towards hot weather to increase the public's knowledge of the appropriate responses. This should include an emphasis, where possible, on community development strategies including the creation of neighbourhood partner programs for vulnerable residents, along with the provision of information to organizations that serve members of vulnerable populations;

(7)that the Commissioner of Economic Development, Culture and Tourism be requested to improve access to permanent sources of potable water (e.g., drinking fountains) along with bathing and washroom facilities in drop-in centres and community centres, in consultation with local businesses and community organizations that serve Toronto's homeless and underhoused populations;

(8)that the Commissioner of Community and Neighbourhood Services and the Commissioner of Economic Development, Culture and Tourism assess the present state of community centres, drop-in centres and other publicly owned/operated gathering places that could be used as places for people to cool off and as places to bathe. The response should identify resources needed to up-grade and expand these facilities, including installing air conditioning and bathing/washroom facilities where necessary and extending their hours of operation;

(9) that the Toronto Housing Company, as part of its Tenant Support Program, develop responses for when a heat warning is issued by the summer of 2000;

(10)that the Commissioner of Community and Neighbourhood Services conduct research to better quantify the extent to which Toronto residents are at increased risk for heat related illness as a result of poor ventilation, inadequate air conditioning or other conditions in their homes;

(11)that the MOH further investigate the health effects of hot weather and consult with Environment Canada and other agencies to gain a better understanding of the weather systems that have a substantial impact on health;

(12)that the MOH consult with area hospitals, physicians, Toronto Ambulance Services and other interested parties on the feasibility of establishing an active surveillance system focusing on the health impacts of heat stress caused by hot weather, such as emergency room visits and increased mortality;

(13)that Toronto Public Health participate in research into the relationship between hot weather and local health effects using data from the surveillance system and other sources and use the results to establish a scientific basis for heat response thresholds;

(14)that the Toronto Atmospheric Fund be requested to collaborate with Toronto Public Health to develop a workshop in the fall of 1999 on hot weather responses involving experts from Canada and from American cities that have successfully implemented heat emergency plans;

(15)that the Toronto Atmopheric Fund be requested to analyze the Toronto heat island effect and identify methods to mitigate summer heat over the long term, such as enhancing the urban forest, promoting green rooftops and gardens, and encouraging the use of lighter coloured construction material for rooftops that minimize energy use, thereby reducing the impact on air pollution and climate change;

(16)that Toronto Public Health consult with the Toronto Atmospheric Fund on the development of policy options and proposed programs to mitigate the summer heat over the long term from a global warming perspective; and

(17)that City Council authorize and direct the Chief Administrative Officer to incorporate into the City's Emergency Plan a response to extremely hot weather conditions (Humidex over 45 degrees Celsius), should they arise.

Background:

In 1998, the Seniors Task Force and the Advisory Committee on Homeless and Socially Isolated Persons requested the MOH to develop a comprehensive hot weather emergency response plan. This would be based on the health impacts of hot weather on the city's population and include possible responses to mitigate these effects.

This report provides an interim response to these requests. It outlines the current understanding of the relationship between hot weather and health effects, including the increased risk of vulnerable populations and an explanation of some terms that are often used to describe hot weather. It also contains Toronto Public Health's interim recommendations on the magnitude of heat that should prompt a city-wide response and some of the components of that response that will help reduce the likelihood of health consequences from heat exposure.

Comments:

Definitions:

There are a number of terms used to describe summer heat and its impact on people.

"Humidex" is a number that describes how hot the average person feels, or their degree of comfort or discomfort during hot, humid weather. It combines the humidity and temperature to reflect perceived temperature. The term Humidex is used by Environment Canada and thus by all Canadian media and weather reports. It has meaning to the general public.

The "Heat Stress Index" is used to predict/measure the overall physiological effect of excessive heat on the body. This is known as heat stress and is used by the United States National Weather Service. Its calculations involves many factors, such as air temperature, humidity, air movement, radiant heat, and atmospheric pressure. A simpler version using temperature and humidity (similar to Humidex but more complex to calculate) is now being used. Although it may be a better indicator than Humidex as it is more closely correlated with health outcomes, it is not used in Canada and therefore lacks meaning to the public. Also, its interpretation is complex, as is its calculation.

Unfortunately, there is no mathematical relationship between the heat index and Humidex. At different temperatures, the effect of relative humidity is different for the two scales and therefore they can not be used interchangeably. Therefore, simply converting one to the other and using it to initiate a response is not possible. Since the public is familiar with the Humidex scale, it will be used to determine the heat thresholds at which different responses in the Plan will be initiated.

Health Effects of Hot Weather:

All residents feel the health effects of hot weather. They include increased sweating, increased thirst, fatigue and weakness. If a person fails to take adequate precautions such as increasing water intake and seeking shade, these symptoms can worsen and become heat exhaustion. This is characterized by profuse sweating, nausea, dizziness and worsening fatigue.

The most severe health effect of heat is heat stroke, which is defined as a body temperature greater than 40.6 degrees Celsius with lack of sweating and altered consciousness, coma or seizures. Other symptoms of heat stroke include sudden onset, low blood pressure, increased heart rate and increased breathing. Other manifestations include metabolic abnormalities such as changes in blood sugar and chemistry and uncontrolled blood coagulation. Of those presenting to hospital with this diagnosis, approximately 10 percent die even with vigorous treatment.

Long term sequelae of heat stroke are just now being investigated. The loss of activities of daily living like bathing and meal preparation that accompany heat stroke can remain for one year or more. Those individuals found to have functional impairments at least one year after suffering from heat related illness are at an increased risk of dying from their illness. Also, the loss of independence that accompanies this functional impairment is usually permanent, increasing their need for community and/or institutional support.

Relationship Between Health Effects and Temperature:

As the temperature increases so does the risk of heat stroke in all residents. However, there is little local information on the exact temperature or Humidex level when the health effects of hot weather, such as death or increased hospital admissions, become evident or above which certain populations become particularly vulnerable. This makes it difficult to establish a level that can be used to initiate the city's response to hot weather. To better quantify the relationship between Humidex and adverse health effects in Toronto, surveillance of health effects of hot weather would be required.

This would need to take the form of an active surveillance system that becomes operative when a heat alert of any type occurs. It would consist of communication between Toronto Public Health, local hospital emergency departments and Toronto Ambulance Services. Information on the number of heat related emergency visits, admissions and deaths would need to be collected to provide Toronto Public Health with data on the impact of hot weather on the health of the city's residents.

Another difficulty in determining when to initiate a heat alert is the difference between temperature and Humidex. While some studies have shown a clear relationship between temperature and health outcomes such as death, little work has been published relating the Humidex to specific health outcomes. This makes it difficult to determine the Humidex level that results in significant health effects. This is further complicated by a lack of clarity in the assignment of cause of death by physicians on death certificates. Using body temperature as the sole method of determining cause of death has been shown to underestimate the number of heat-related deaths. Therefore, physician education will be important during any attempt to collect accurate data on the health impact of hot weather.

Smog is frequently associated with hot weather. Most periods of hot weather in Toronto are due to air masses that have originated in the American mid-west. This same area is also a substantial source of air pollution that arrives in Toronto by long range transport. Therefore, during hot weather there is often poor air quality. Many studies have shown the substantial health effects of smog, including increased deaths, emergency visits and hospital admissions. Also, intense sunlight that increases the temperature also increases air conditioning use in buildings and motor vehicles, thereby creating more smog precursors from coal fired generating stations and vehicle emissions. Therefore, separating the health effects of temperature and smog is difficult and little work has been published on this topic. Toronto often experiences air quality advisories on days when heat alerts are anticipated, making the integration of these two weather based alerts a long-term goal.

The scientific literature does not give a well demarcated Humidex level at which health effects become manifest. Therefore, the selection of a Humidex level that will initiate a public health response to hot weather must balance the health risks of society's most vulnerable against the risk of over taxing those needed to respond to hot weather desensitize the public to hot weather health warnings. If the Humidex chosen to activate a substantial city response to hot weather is set too high, vulnerable residents will be placed at substantial risk prior to the initiation of city's response. Conversely, too low a level of Humidex will lead to frequent initiation of the plan, diluting its uniqueness and increasing the burden on community and city agencies.

As indicated above, local data on the relationship between health impacts on weather is not available. Even if a hot weather surveillance system was in place in Toronto, systems already in place in some American cities have shown a substantial proportion of misclassification of deaths and hospital admissions that fail to mention heat stress. Therefore, even current data likely underestimates the impact of hot weather, though the extent is difficult to quantify. Also, even with reliable information on deaths due to hot weather a decision must then be made on the number of excess deaths that are "acceptable" before city action occurs. In some American cities where this data is available, different levels of excess mortality are used to initiate heat emergencies. Therefore, the Humidex levels selected for the Plan are, of necessity, chosen to balance these competing considerations.

Vulnerable Populations:

While all city residents feel the effects of hot weather, certain groups are at increased risk of the more severe forms of heat related illness, namely heat exhaustion and heat stroke. The very old and young are at particular risk because of their lack of mobility, as are those confined to bed with debilitating illness and dependence on care from others. It is this population that suffered the most severe health effects such as death and hospital admission during the Chicago heat wave in 1995. The homeless are at increased risk particularly if they lack access to cool buildings or potable water. Residents taking a variety of certain medications are at increased risk for heat stroke including many drugs prescribed for mental health problems, movement disorders, depression, heart or circulatory problems. The urban poor seem to be at particularly high risk for severe hot weather related illness because they often lack access to air conditioning and/or live in substandard housing that worsens their exposure to heat. Members of these vulnerable populations are often the first to come to medical attention during hot weather. Outdoor workers who are required to exert considerable effort in hot weather are also at risk. However, their protection falls under the mandate of the Ontario Ministry of Labour.

These vulnerable populations are often difficult to quantify. The census reveals that Toronto had over 300,000 residents who were 65 years and older and 65,000 babies one year old or less in 1996. The Golden Report suggested that over 3,000 people use shelters on any night and a substantial proportion of these are mentally ill. However, these may not reflect those residents at increased risk of heat illness.

Many elderly live in newer seniors' buildings with air-conditioning and good ventilation, making them far less vulnerable to the effects of hot weather. Likewise, many individuals taking medications that put them at increased risk for heat stress heed the warnings of their physician and take precautions to avoid heat related illness. However, a large proportion of these populations live in substandard housing or are unable to take precautions while taking their medication because they are homeless. Therefore, determining the number of individuals actually at increased risk for heat related illness is difficult, making the planning of any response to hot weather more challenging.

Those residents already at increased medical risk for heat related illnesses are placed at added hazard if they also experience inadequate housing, lack of air-conditioning or proper ventilation. Research needs to be done to assess the type and prevalence of conditions in the residential sector which create added, severe health risks for people during hot weather. This information is not currently available, making it difficult to accurately determine the number of residents in need of an alternative place to cool off.

Initiating a City-Wide Response to Hot Weather:

Experience in American Cities:

In 1995, Chicago experienced a sustained heat wave of eight days during which the daily temperature ranged from 33.9 to 40.0 degrees Celsius and the heat index (note, not humidex) peaked at 48.3 degrees Celsius. During this time the city experienced over 600 excess deaths and over 3,300 emergency room visits due to heat related illness. After this event Chicago established a heat emergency protocol that is used to co-ordinate the city's response to hot weather. It includes the establishment of cooling centres in city controlled buildings, increased surveillance of heat-related illness by emergency health services and expansion of hours at recreation facilities.

Several other cities in the United States have also developed well-defined protocols that they use in response to hot weather. Washington, St. Louis and other cities have two and three stage programs based on the Heat Index issued by the U.S. National Weather Service that provide for gradually increasing resources to help vulnerable populations in these cities. Philadelphia, with the help of one of the foremost experts on hot weather, has developed its own city-specific system that identifies "oppressive" air masses based on historical correlations between weather conditions and increased deaths.

There is great variation among these cities' hot weather protocols. They begin to open cooling centres at different levels of heat index and even use different heat indices to initiate different levels of their protocols. Some cities have found it difficult to garner co-operation from other city departments while others use the power of the mayor's office to ensure city-wide compliance.

The unique circumstances of each city make it difficult for Toronto to simply adopt a protocol from one of these American cities. Also, all of the protocols in use in the United States are based on the Heat Stress Index which is difficult to translate into Humidex. To introduce another measure of heat such as the "heat index" or "heat stress index" would create confusion. Therefore, Toronto Public Health consulted with various city and community organizations to create a local plan for hot weather.

Toronto's Proposed Hot Weather Response Plan:

Introduction to Summer:

In the spring of each year, Toronto Public Health will collect and disseminate information on the health effects of hot weather and on strategies to decrease the risk of heat related illness. This information will be widely distributed to organizations dealing with vulnerable populations such as the homeless and seniors and to pharmacies and health care organizations to alert them to the interaction between some medications and hot weather. It will also be sent to city agencies involved in the implementation of the Plan. The media will be notified so they can help to increase the public's awareness of the danger of hot weather. Information will also be available through the City's web site. Fact sheets have been developed and widely distributed this summer (see Appendix B).

Partnership:

Preliminary discussions with the Toronto Atmospheric Fund have indicated interest in collaborating with Toronto Public Health in further development of the Hot Weather Response Plan. Other city agencies that have many locations engaged in front line service delivery such as libraries and community centres will be important locations for people to cool off should they become needed. Agencies with many vulnerable clients such as the Community Care Access Centre are also important to provide increased surveillance for their clients during hot weather. Other professional organizations such as pharmacies are necessary to remind their patients that certain medications make people vulnerable to heat- related illness. Physician organizations will also be important points of information dissemination. Toronto Public Health will also investigate the potential for added participation by other community agencies, such as the Salvation Army and the area utilities (e.g., to not disconnect power due to failure to meet payments).

Community Development:

Toronto Public Health's response to hot weather will also include community development strategies. Many American cities have successfully created neighbourhood partner programs that stimulate people in the community to 'look in' on nearby residents who are at increased risk of heat related illness because of pre-existing medical conditions or a lack of air conditioning. With the large and uncertain number of vulnerable people in Toronto, this would be a very effective way of preventing severe heat illness such as heat stroke in those unwilling or unable to move to a cooler place. Community agencies that already visit these vulnerable people would be an obvious ally in this program.

Hot Weather Response Plan:

Environment Canada uses the Humidex ranges in the following table to describe the degree of comfort in summer and to inform the public when conditions of heat and humidity are potentially uncomfortable or dangerous. In Toronto, Humidex levels are available on a day-to-day basis but are generally not predicted more than half a day in advance due to uncertainty surrounding the relative humidity. The notice period can be increased at Toronto's request through a purchase of service agreement with Environment Canada. At Humidex of 40 degrees Celsius (and temperature of at least 30 degrees Celsius), Environment Canada issues a Humidex advisory.

 When Environment Canada predicts that the Humidex will reach between 40 and 45 degrees Celsius, the Medical Officer of Health will issue a heat warning and the protocol as outlined in Appendix A will be activated.

Humidex 45 degrees Celsius and Over: Heat Emergency:

When the Humidex is predicted to be above 45 degrees Celsius or actually exceeds 45 degrees Celsius (i.e., is considered "dangerous" by Environment Canada), a city-wide emergency response strategy is needed. Only once since 1953 (in 1995) has the Humidex peaked above 45 degrees Celsius. During the next year, the Chief Administrative Officer should consult with Toronto Public Health and other city agencies and develop a response to be implemented if this Humidex level is reached and build this response into the city's emergency plan.

Conclusion:

This report outlines an interim hot weather response plan for the balance of 1999 that can be funded through internal reallocations within the Community and Neighbourhood Services Department. The Plan will include the use of local community centres and libraries as places for people to cool off, increased access to public pools, and additional outreach and support for vulnerable populations including seniors and the homeless and underhoused. The Plan will be implemented if the Humidex is predicted to be 40 degrees Celsius to 45 degrees Celsius, beyond which a declared emergency is recommended.

The proposed Plan will complement the basic public education program being instituted by Toronto Public Health at the start of each summer. It should also be accompanied by longer term measures to increase public access to drinking water and bathing facilities, environmentally sustainable measures to mitigate summer heat over the long term, and further research to assess the magnitude of weather-related health risks.

The financial implications arising from the annualized implementation of the proposed Plan and the longer term recommendations will be submitted by Toronto Public Health and respective departments involved to City Council, through the Board of Health and the applicable standing committees, as part of the 2000 budget process.

Contact Name:

Liz Janzen

Regional Director

Tel: (416) 392-7458; Fax: (416) 392-0713

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Appendix A

Hot Weather Response Plan

Humidex 40 to 45 degrees Celsius: Heat Warning:

Environment Canada will notify Toronto Public Health in the morning of its predicted Humidex levels for that day and the following day. If the Humidex is predicted to reach between 40 degrees Celsius and 45 degrees Celsius, the Medical Officer of Health will declare a Heat Warning and activate the following protocol.

(1)Using phone, fax or other communication modalities, area drop-in centres, seniors' agencies (such as community care access centre) and other community groups working with vulnerable populations will be advised of the heat warning. Information will include ways of avoiding heat, the increased vulnerability of elderly populations especially those who rarely go out and are reliant on outside agencies for support, and the increased risk of heat stress faced by people taking certain medications.

(2)Media releases will be used to encourage residents to call or visit friends, relatives, and/or neighbours who are at increased risk of suffering health consequences of hot weather. This includes seniors in poorly ventilated buildings or those lacking air conditioning.

(3)City-wide communication organizations such as Community Information Toronto and its Street Help Line will be available to provide a source of information for residents to call and determine what services are available.

(4)Toronto Public Health nursing staff will contact those clients who may be at high risk of severe health impacts due to the hot weather.

(5)Agencies that regularly visit frail seniors or other populations at increased risk of heat related illness (e.g., Community Care Access Centres) will be encouraged to look in on or call their clients during the hot weather, even those that they would normally not visit that day.

(6)Community Health Centres will be encouraged to contact the clients they feel are at risk for heat-related illness.

(7)The Toronto Housing Company will communicate with tenants to ensure that they have access to cool places such as air-conditioned common rooms in facilities where they exist.

(8)Hostel facilities are 80 percent fully or partially air-conditioned. Hostel Services are adding air conditioning in three shelters this summer, and are investigating requirement in the remaining facilities as part of the Division's multi-year business plan to upgrade facilities. Hostel Services will request that four of the shelters, which are normally closed from noon to 5:00 p.m., permit vulnerable clients to occupy air-conditioned space.

(9)Parks and Recreation will extend the operating hours of public pools and encourage people to go to community centres and city pools to cool off or use the shade in parks.

(10)Library branches normally closed during a week day will be opened, and those already opened will extend their hours from at least 12:00 p.m. to 8:00 p.m. Monday to Saturday to be available as places for people to cool off.

(11)The Red Cross will provide volunteers for public facilities that may lack adequate staff during these Heat Warnings. They will help transport those in need of assistance to places for people to cool off and provide these centres with supplies such as water, food etc. These services can be available seven days a week, 24 hours a day.

(12)Street patrol hours will be extended to communicate the danger of heat illness to the homeless, and TTC tokens will be made available for the homeless to go to places for people to cool off.

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Appendix B

Fact Sheet

Summer Safety: How to Beat the Heat

In the summer, the combination of high heat and high humidity can be very dangerous. Those especially at risk during these weather conditions include:

-The elderly.

-People with certain chronic illnesses, such as heart conditions or people unable to move or change position by themselves.

-Infants and preschool children.

-People who exercise vigorously or are involved in strenuous work outdoors for prolonged periods.

-People taking certain medications, for example, for mental health conditions. (Please consult your doctor or pharmacist.)

How to avoid heat-related illness:

-Drink lots of water and natural juices even if you do not feel very thirsty. Avoid alcohol beverages, coffee and cola.

-Avoid going out in the blazing sun or heat when possible. If you must go outside, stay in the shades as much as possible and plan to go out early in the morning or evening when it is cooler and smog levels may not be as high as in the afternoon. Wear a hat.

-Take advantage of air conditioned or cool places such as shopping malls, libraries, community centres or a friend's place.

-If you do not have air conditioning, keep shades or drapes drawn and blinds closed on the sunny side of your home, but keep windows slightly open.

-Keep electric lights off or turned down low.

-Take a cool bath or shower periodically or cool down with cool, wet towels.

-Wear loose fitting, light clothing.

-Avoid heavy meals and using your oven.

-Avoid intense or moderately intense physical activity.

-Never leave a child in a parked car or sleeping outside in direct sunlight.

-Fans alone may not provide enough cooling when the temperature is high.

-Consult your doctor or pharmacist regarding side effects of your medications.

Get help from a friend, relative, or a doctor if you have the following symptoms of heat illness:

-Rapid breathing.

-Weakness or fainting.

-More tiredness than usual.

-Headache.

-Confusion.

Friends are relatives can help someone with heat illness by doing the following:

-Call for help.

-Remove excess clothing from the person.

-Cool the person with lukewarm water, by sponging or bathing.

-Move the person to a cooler location.

-Give the person sips or cool water, not ice cold water.

If you become ill, faint, have difficulty breathing or feel confused

and disoriented, call your doctor.

In an emergency, call 911.

For more information on heat-related illness, call the Toronto Public Health office nearest you:

East Region-East York (416) 397-4777

-Scarborough (416) 396-4228

North Region-North York (416) 395-7600

South Region-Toronto (416) 392-7401

West Region-Etobicoke (416) 394-8302

-York (416) 394-2891

June, 1999

(The development of this fact sheet has been a collaborative effort between Toronto Public Health, the Seniors' Taskforce and the Community Health Network of West Toronto, Seniors Sub-group.)

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Fact Sheet

Medications and Heat-Related Illness

Some medications make it harder for your body to control its temperature. If you are taking any of the medications listed below, you are at higher risk for heat-related illness, especially if you are doing lots of exercise or heavy work and are not drinking enough water. This is even more true if you are on two or more medications.

The list below is based in part on information from the Office of the Chief Coroner. Please note it is not complete. Also, some drugs have different brand names, so check with your doctor, nurse or pharmacist to be sure:

Psychiatric drugs such as:

-chlorpromazine (Thorazine, Largactil) ***

-thioridazine (Mellaril) ***

-perphenazine (Trilafon) ***

-fluphenazine (Modecate, Moditen) ***

-thiothixene (Navane) ***

-trifluoperanize (Stelazine)

-prochloperazine (Stemetil)

-haloperidol (Haldol)

-clozapine (Clozaril)

-risperidone (Risperdal)

-loxapine (Loxapac, Loxitane)

-fluspirilene (IMAP)

-pimozide (Orap)

-olanzapine

-flupenthixol (Fluanxol)

-zuclopenthixol (Clopixol)

-reserpine (Serpasil, Serpalan)

-Lithium - heavy exercise in hot weather may also lower lithium levels, so that it will not work as well.

*** The medicines starred there may make it easier for your skin to burn. Many other medicines may also cause your skin to burn more easily. To be sure, ask your doctor, nurse or pharmacist. Try to stay out of the sun. If you cannot try to get sunscreen and wear a hat and long sleeves.

Antiparkinson Drugs such as:

-benztropine (Cogentin)

-biperiden (Akineton)

-ethopropazine (Parsitan, Parsidol)

-procyclidine (Kemardrin, Procyclid)

-trihexyphenidyl (Artane, Trihexane)

-levodopa (Dopar)

-selegiline (Elderpryl)

-amantadine (Symmetrel, Symadine)

Antidepressants such as:

-amitriptyline (Elavil)

-doxepine (Sinequan)

-clomipramine (Anafranil)

-protriptyline (Vivactil)

-imipramine (Tofranil)

-desipramine (Norpramin)

-nortriptyline (Pamelor)

-fluoxetine (Prozac)

-fluvoxetine (Luvox)

-sertraline (Zoloft)

-paroxetine (Paxil)

If you also take the medicines below, you further increase your risk for heat illness:

-some antihistamines (e.g., Benadryl, Chlortripolon)

-over-the-counter sleeping pills (e.g., Nytol)

-anti-diarrhea pills (e.g., Lomotil)

If you are taking any medications regularly, ask you doctor, nurse or pharmacist if you need to be extra careful during hot weather.

July, 1999

(The development of this fact sheet has been a collaborative effort between Toronto Public Health and Regent Park Community Health Centre.)

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Fact Sheet

Summer Safety: Heat, Drugs and Alcohol

In the summer, the combination of high heat, high humidity and smog can be very dangerous. You need to be extra careful if you:

-Drink heavily

-Use illicit drugs

-Take medications for mental health problems

-Are elderly

-Have heart or lung problems

Some medications make it harder for your body to control its temperature. If you are on two or more medications, you may be at even greater risk for heat-related illness. (See "Medications and Heat-Related Illness" Fact Sheet).

Here are some things you can do to keep from getting sick:

-Drink lots of water and juice, even if you do not feel thirsty.

-Try to stay out of the sun, especially in the middle of the day. If you have to be outside, stay in the shades as much as possible.

-If you can get a hat, wear it.

-Wear loose fitting, light clothing.

-Try to take it easy, and rest as much as possible.

-If you have to walk a long way, try to do it in the early morning or evening.

-Try to spend time in cool places with air conditioning like drop-ins and community centres.

-Take a cool shower from time to time. Some drops-ins and recreation centres have public showers.

-Try to spend some time near the lake or waterfront where it is cooler.

-If you sleep outside during the day, try to sleep in the shade. Remember the sun moves, so try to sleep in a spot that will be shady for a few hours.

Get help from a friend or a doctor if you have the following signs of heat illness:

-Rapid breathing.

-Weakness or fainting.

-More tiredness than usual.

-Headache.

-Confusion.

You can help someone with heat illness by doing these things:

-Call for help.

-Take extra clothing off the person.

-Cool the person with lukewarm water, by sponging or bathing.

-Move the person to a cooler place.

-Give the person sips of cool water, not ice cold water.

If you become ill, faint, have trouble breathing or feel confused,

call 911 or go to your doctor or nearest hospital right away.

July, 1999

(The development of this fact sheet has been a collaborative effort between Toronto Public Health and Regent Park Community Health Centre.)

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Dr. Sheela V. Basrur, Medical Officer of Health, gave a presentation to the Board of Health in connection with the foregoing matter.