Ahmedabad Heat Action Plan: Lessons Learned and Future Challenges

1. Ahmedabad Heat Action Plan: What Worked (and What Didn’t) Jeremy Hess, MD, MPHAssociate ProfessorSchools of Medicine and Public HealthUniversity of Washington

2. 2010 Experience

3. First Steps • Favorable context • Public health lead • Trusted leadership • Risk management • Series of studies to learn more • 2010 heat wave • Health system • Population vulnerability • Worker vulnerability • Heat EWS

4. Epi Research • Tropical climate with hot season and monsoon • Gradually warming • Heat a nuisance until 2010

5. Vulnerability Surveys Workers Slum Households • Construction Workers, Kite Makers, Aggarbatti rollers, Rag Pickers and Street Vendors (368 people) • High prevalence of self-reported heat related symptoms • All worksite temperatures (WBGT) above ACGIH standards • Minimal awareness of heat stress and illnesses • Few to no protections • Frequent hospitalizations • 300 slum households surveyed – info on total of 1,650 individuals • High degree of exposure and limited protective measures • High prevalence of self-reported symptoms of heat illness • Low level of awareness regarding heat as a health hazard • Relatively high media access • Strong family and social networks

6. Health System Preparedness • Focus groups with physicians, public health practitioners, emergency medical service providers • Heat illness known, but often not first thought • Limited diagnostic and therapeutic tools available • Built environment exacerbating the problem In 2010, 24 NICU admissions with high temperatures and no infection compared with 8 and 4 in 2009 and 2011, respectively

7. Multi-year, Multi-faceted Process • 2011-2012 – Vulnerability assessment, information gathering, and systems development • 2013 – HAP “dry run” • 2014 – full implementation • Plan includes: • Nodal officers, steering committee • Public awareness and education • Resilience in health care system, from pre-hospital to clinics to hospitals • Improved surveillance and data collection • Forecast – 7-day, with thresholds and color-coded warning system

8. Organizational Arrangements

9. Thresholds

10. Warning Matrix

11. Administrative Cycle • Biweekly preparation & information sharing meetings with stakeholders. • Public media events to raise awareness about heat-health vulnerability • Weekly Steering Committee meeting • Community, NGOs meet weekly & contact Steering Committee Liaison • Steering Committee members meet daily • Media outreach & public relations • Municipal Departments heat-reduction interventions • Collection and analysis of health data Evaluations of HAP - what worked well, what didn’t • Discuss climate change scenarios, multiple emergencies, resources needed

12. Outcome Evaluation

13. Expected -vs- Observed Temp: 45 Reduction:33.5% Temp: 45 Mortality Reduction:35.0% Temp: 46 Reduction:36.5% • Mortality Reduction = 2,199 [95% CI 351-4,048]

14. Heat Waves of 2010 and 2014: Hospital Case reports of heat stroke and deaths *Cases reported from 5 of Ahmedabad’s municipal hospitals – VS Hospital, LG Hospital, Sola civil hospital, Sardar Patel Hospital and Civil Hospital Asarwa.

15. Heat Stroke Cases & Fatalities 2014 cases

16. Lessons & Remaining Challenges • Partnership and coordination, with one agency taking the lead, were essential • Public engagement and building awareness have been crucial • Scale was manageable and matched with managerial scope • The local emphasis was central to success but presents a challenge for scaling up to other locations • High quality data are very important and, as often is the case, can be elusive • Stakeholders have different motivations and interests and it is important to acknowledge this and work together to achieve desired ends • Celebrate success early and often without resting on laurels • Dialogue and learn from other settings as capacities and risk factors differ and systems fit locales • Remarkable progress and significant impacts in relatively short time, but future progress likely more difficult

17. Journal Publications • Kim Knowlton, Anjali Jaiswal, Gulrez Shah Azhar, Dileep Mavalankar, AmrutaNori-Sarma, Ajit Rajiva, Priya Dutta et al. (2014) Ahmedabad, Gujarat: Development and Implementation of South Asia’s First Heat-Health Action Plan. Int. J. Environ. Res. Public Health, 11: 3473-3492. (IF: 2.197) http://www.mdpi.com/journal/ijerph/special_issues/weather-risks • Gulrez Shah Azhar, Dileep Mavalankar, AmrutaNori-Sarma, Ajit Rajiva, Priya Dutta et al. (2014) Heat-related mortality in India: Excess all-cause mortality associated with the 2010 Ahmedabad heat wave. PLOS ONE 9(3): 1-8. (IF: 3.73) http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0091831 • Khyati Kakkad, Michelle L. Barzaga, Sylvan Wallenstein, Gulrez Shah Azhar, and Perry E. Sheffield (2014) Neonates in Ahmedabad, India, during the 2010 Heat Wave: A Climate Change Adaptation Study. Journal of Environmental and Public Health, Article ID 946875, 1:8. http://www.hindawi.com/journals/jeph/2014/946875/ • Tran, Kathy V., Gulrez S. Azhar, Rajesh Nair, Kim Knowlton, Anjali Jaiswal, Perry Sheffield, Dileep Mavalankar, and Jeremy Hess (2013). A cross-sectional, randomized cluster sample survey of household vulnerability to extreme heat among slum dwellers in Ahmedabad, India." International journal of environmental research and public health 10, no. 6: 2515-2543. http://www.mdpi.com/1660-4601/10/6/2515

18. Questions?