A case-crossover analysis of indoor heat exposure on mortality and hospitalizations among the elderly in Houston, Texas

Cassandra R. O’lenick, Amir Baniassadi, Ryan Michael, Andrew Monaghan, Jennifer Boehnert, Xiao Yu, Mary H. Hayden, Christine Wiedinmyer, Kai Zhang, Peter J. Crank, Jannik Heusinger, Paige Hoel, David J. Sailor, Olga V. Wilhelmi

Research output: Contribution to journalArticlepeer-review

18 Scopus citations


BACKGROUND: Despite the substantial role indoor exposure has played in heat wave–related mortality, few epidemiological studies have examined the health effects of exposure to indoor heat. As a result, knowledge gaps regarding indoor heat–health thresholds, vulnerability, and adaptive capacity persist. OBJECTIVE: We evaluated the role of indoor heat exposure on mortality and morbidity among the elderly (≥65 years of age) in Houston, Texas. METHODS: Mortality and emergency hospital admission data were obtained through the Texas Department of State Health Services. Summer indoor heat exposure was modeled at the U.S. Census block group (CBG) level using building energy models, outdoor weather data, and building characteristic data. Indoor heat–health associations were examined using time-stratified case-crossover models, controlling for temporal trends and meteorology, and matching on CBG of residence, year, month, and weekday of the adverse health event. Separate models were fitted for three indoor exposure metrics, for individual lag days 0–6, and for 3-d moving averages (lag 0–2). Effect measure modification was explored via stratification on individual-and area-level vulnerability factors. RESULTS: We estimated positive associations between short-term changes in indoor heat exposure and cause-specific mortality and morbidity [e.g., circulatory deaths, odds ratio per 5°C increase = 1:16 (95% CI: 1.03, 1.30)]. Associations were generally positive for earlier lag periods and weaker across later lag periods. Stratified analyses suggest stronger associations between indoor heat and emergency hospital admissions among African Americans compared with Whites. DISCUSSION: Findings suggest excess mortality among certain elderly populations in Houston who are likely exposed to high indoor heat. We developed a novel methodology to estimate indoor heat exposure that can be adapted to other U.S. locations. In locations with high air conditioning prevalence, simplified modeling approaches may adequately account for indoor heat exposure in vulnerable neighborhoods. Accounting for indoor heat exposure may improve the estimation of the total impact of heat on health. https://doi.org/10.1289/EHP6340.

Original languageEnglish (US)
Article number127007
Pages (from-to)1-17
Number of pages17
JournalEnvironmental health perspectives
Issue number12
StatePublished - Dec 1 2020

ASJC Scopus subject areas

  • Public Health, Environmental and Occupational Health
  • Health, Toxicology and Mutagenesis


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