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The Use of Cooling Centers to Prevent Heat-Related Illness:Summary of Evidence and Strategies for ImplementationClimate and Health Technical Report SeriesClimate and Health Program,Centers for Disease Control and PreventionStasia Widerynski,1 Paul Schramm,1 Kathryn Conlon,1 Rebecca Noe,2 Elena Grossman,3Michelle Hawkins,4 Seema Nayak,5 Matthew Roach,6 Asante Shipp Hilts51Climate and Health Program, Division of Environmental Hazards and Health Efects (DEHHE),National Center for Environmental Health (NCEH), Centers for Disease Control and Prevention (CDC)Health Studies Branch, Division of Environmental Hazards and Health Efects (DEHHE),National Center for Environmental Health (NCEH), Centers for Disease Control and Prevention (CDC)2University of Illinois at Chicago3NOAA National Weather Service4New York State Department of Health, Center for Environmental Health5Arizona Department of Health Services6The fndings and conclusions in this report are those of the author(s)and do not necessarily represent the ofcial position of the Centers for Disease Control and Prevention.The authors would like to acknowledge Dana Hyland, Marcus Sarofm, Emma Zinsmeister,and Joanna Taliano for their contributions to this documentNational Center for Environmental HealthDivision of Environmental Hazards and Health EffectsCS280845-A

iiThe Use of Cooling Centers to Prevent Heat-Related Illness: Summary of Evidence and Strategies for Implementation

ContentsExecutive Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1Background. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Literature Summary: Effectiveness of Cooling Centers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Climate Change and Energy Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Implementation of Cooling Centers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Research Gaps. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27Appendix. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31The Use of Cooling Centers to Prevent Heat-Related Illness: Summary of Evidence and Strategies for Implementationiii

The Use of Cooling Centers to Prevent Heat-Related Illness: Summary of Evidence and Strategies for Implementation

Executive SummaryExtreme heat is a major public health concern in the United States. The trend ofincreasing frequency and duration of heat events (“heat waves”) is expected tocontinue in the future. Exposure to extreme heat can cause a variety of health problems,including heat stroke and even death. Public health departments, their partners, andother government organizations have undertaken a variety of strategies to protectthe public from high temperatures. The use of cooling centers, a cool site, or airconditioned building designated as a safe location during extreme heat, is a commonstrategy. This document is intended to give a summary of the efectiveness of coolingcenters, with a focus on highly relevant peer-reviewed literature. It also provides anoverview of steps for the implementation of cooling centers.The Use of Cooling Centers to Prevent Heat-Related Illness: Summary of Evidence and Strategies for Implementation1

BackgroundAs the most recent US Global Change Research Program report notes, changingclimate conditions are a threat to human health, with negative impacts expected toincrease in the future.1 Heat-related illness is one health impact that will be afectedby climate change. Temperatures have already increased across much of the UnitedStates, with an average increase of 1.3 F to 1.9 F since record keeping began in1895.2 The most recent decade was the warmest on record, and globally 2016 was thewarmest single year since modern record keeping began.3 This temperature increaseis projected to continue, with longer, more severe, and more frequent heat wavesexpected.1Heat endangers human health in many ways, under many diferent scenarios.Long term temperature increases, extreme heat events, heat-related drought, highnighttime temperatures, and urban heat islands all impact health. Heat-relatedillness is one health impact that will be directly afected by climate change. Healthefects include heat cramps, heat exhaustion, heat stroke, and death.4,5 Extremeheat events can be characterized by temperatures that are much warmer than theseasonal average. Exposure to several days of extreme heat, sometimes calledheatwaves, have a potential to cause a large number of deaths in a short time period.The 1995 Chicago heat wave resulted in over 700 deaths and thousands of cases ofheat-related emergency room visits.6 In some years, heatwaves cause more deathsin the United States than any other weather-related disaster, including hurricanesand tornadoes.7,8 The exact number of deaths is difcult to quantify as heat is oftennot mentioned as a specifc cause of death on death certifcates, potentially leadingto an underestimation of the health impacts of heat.9 Outside workers, older adults,children, communities of color, the homeless, individuals with a mental healthdisability, individuals with chronic medical conditions, individuals without access toair-conditioning, and low-income communities are particularly vulnerable to heatrelated illness.10Heat-related illness is largely preventable, and health departments, federal agencies,state and local governments, and others are taking steps to prepare for warmertemperatures in a changing climate. Some health departments are utilizing TheCenters for Disease Control and Prevention’s (CDC) Building Resilience AgainstClimate Efects (BRACE) framework to help prepare and implement adaptations toprotect health.11 During step three of BRACE, “assessing public health interventions,”health departments may choose to examine the usefulness of various heatadaptations in their jurisdiction.There are many tools and programs that can be used to protect the public fromextreme heat, including adoption of a heat-alert system, use of real-time data andsurveillance to monitor health outcomes during heat events, built environmentstrategies (e.g., tree-planting, cool roofs), zoning regulations, heat safety educationcampaigns, wellness checks, and hydration stations. A health department may nothave the authority, resources, or expectation to implement most interventions, butcan be an important leader and partner.2The Use of Cooling Centers to Prevent Heat-Related Illness: Summary of Evidence and Strategies for Implementation

One potentially efective and widely used adaptation option is the implementationof cooling centers.5,12 Access to air conditioning can prevent heat-related morbidityand mortality.13 Low-income populations may have limited access to air conditioning12or may be hesitant to operate air conditioning and cooling units due to potentiallyhigh electricity costs during peak heat hours. Cooling centers can provide a coolenvironment for these individuals. Although there is currently limited direct evidenceof the direct health impacts of cooling centers in the peer-reviewed literature, coolingcenters are commonly used across the US.14 They are a relatively low-cost strategy thatcan utilize existing infrastructure and personnel and be relatively easily implementedby a variety of stakeholders. Their use has a high biological plausibility for reducingheat-related illness and death. Heat is a well-known health threat, and it is logical thata relatively cool environment reduces heat exposure and prevents negative healthoutcomes. However, the best strategies for efective implementation of cooling centersare unclear. Figure 1 outlines the simple pathway by which implementation of coolingcenters protects health.Cooling Center Analytic FrameworkFigure 1: Simple framework demonstrating the causal pathway for cooling centerspreventing heat-related illnessThe Use of Cooling Centers to Prevent Heat-Related Illness: Summary of Evidence and Strategies for Implementation3

What is a Cooling Center?A cooling center (or “cooling shelter”) is a location, typically an air-conditioned or cooledbuilding that has been designated as a site to provide respite and safety during extremeheat. This may be a government-owned building such as a library or school, an existingcommunity center, religious center, recreation center, or a private business such as acoffee shop, shopping mall, or movie theatre. Some counties have set up cooling sitesoutdoors in spray parks, community pools, and public parks. Sometimes temporary coolspaces are constructed for events such as a marathon or outdoor concert.Signs for free water at a cooling center in Maricopa County, Arizona.Photo credit: Travis L Williams Family Service Center.No one group or agency is responsible for the implementation of cooling centers.They may be operated by a health department, city government, non-proft groups,or a combination of agencies and/or partners.This document highlights the existing scientifc evidence for use of cooling centers,describes known best practices and considerations for implementation, and outlinesresearch gaps that could be addressed.4The Use of Cooling Centers to Prevent Heat-Related Illness: Summary of Evidence and Strategies for Implementation

Literature Summary:Effectiveness of Cooling CentersCooling Centers: A Review of the LiteratureThe literature search methodology is described in the appendix. The initial searchstrategies resulted in more than 600 references, including peer-reviewed literature,grey literature and reports (documents that are not peer-reviewed but are producedby experts or relevant practitioners), and newspaper articles. Expert opinion wassought to identify any other key resources on cooling centers, especially additionalgrey literature. 17 highly relevant peer-reviewed articles and 3 relevant grey literaturesources were identifed. The major fndings of these resources are described in thefollowing section and summarized in Figure 2 below.KEY RELEVANT FINDINGOR OUTCOME(S)AUTHOR (YEAR)TITLEMETHODSPalecki, et al. (2001)15The Nature and Impactsof the July 1999 HeatWave in the MidwesternUnited States: LearningFrom the Lessons of1995Comparative andanalytical review of heatwaves that occurred inthe Midwest focusing onChicago and St. Louis.The Chicago 1999 heat wave had80% less mortality than 1995.Some newspapers reported thatretail activity was actually upslightly; people went to shoppingmalls, and movie theaters hadabove average attendance aspeople tried to escape the heatin air conditioned facilities. Heatplans were implemented in thewake of the 1995 heat wave. Aheat warning system and coolingcenters were opened prior to the1999 heat wave. These actionsresulted in a decrease in deathsfor Chicago in the 1999 heatwave as compared to the 1995heat wave.Kovats, et al (2006)16Heatwaves and PublicHealth in EuropeReview of public healthaspects of heat wavesand evaluation of theeffectiveness of publichealth responses inEurope.Evidence shows that coolingcenters are used by more lowrisk individuals compared tohigh risk individuals. Identifeda need to encourage at riskindividuals to visit cool areas.Vandentorren, et al(2006)17August 2003 Heat Wavein France: Risk Factorsfor Death of Elder PeopleLiving at HomeInterview of familymembers of thedeceased from 2003French heat wave.Calculated odds-ratios.Utilization of a cool spaceresulted in reduced mortalityduring the 2003 Europeanheatwave.Bouchama, et al(2007)18Prognostic Factors inLiterature review: metaHeat Wave Relatedanalysis. CalculatedDeaths: A Meta-Analysis. odds-ratios.Meta-analysis of fve studiesfound that utilization of a“cool environment” resulted inreduced mortality.The Use of Cooling Centers to Prevent Heat-Related Illness: Summary of Evidence and Strategies for Implementation5

AUTHOR (YEAR)METHODSSheridan (2007)19A Survey of PublicPerception and Responseto Heat Warnings acrossFour North AmericanCities: an Evaluation ofMunicipal EffectivenessTelephone interview ofresidents of four cities(Philadelphia, Phoenix,Dayton, and Toronto) todetermine their behaviorduring a heat wave.Less than half of respondentsmodifed their behavior duringa heat wave. Few opted for coolspaces, but those that did wentto malls.Bedsworth (2009)20Preparing for ClimateChange: A Perspectivefrom Local Public HealthOffcers in CaliforniaInterviews of localpublic health offcers inCalifornia.Almost all (30/34) jurisdictionshad a heat emergency plan inplace. All plans include coolingcenters but very few providedtransportation and even fewerprovided fnancial assistanceto low income residents to helpwith additional cooling costs.Interviews of Montrealresidents with chronicdiseases.When 238 elderly patientsin Quebec, Canada wereinterviewed about their heatwave habits, 25% of themstated that they would refuseto be sheltered in the event of aprolonged heat wave due to theidea of sleeping in a dormitoryor not seeing themselves as illenough to need it.Kosatsky, et al (2009)21 Heat Awareness andResponse amongMontreal Residents withChronic Cardiac andPulmonary Disease6KEY RELEVANT FINDINGOR OUTCOME(S)TITLEAlberini, et al (2011)22Individual and PublicProgram Adaptation:Coping with Heat Wavesin Five Cities in CanadaInterviews fromMore than half of respondentsresidents from 5 cities in didn’t know about coolingCanada.centers. Knowledge of coolingcenters varied by location.Cusack, et al (2012)23Extreme Weather-Related Interviews withHealth Needs of Peoplevulnerable populationsWho are Homelessin Adelaide, Australia.Found that it was diffcult forhomeless individuals to utilize apublic cool space. The authorssuggested longer cooling hoursfor homeless services or coolingcenters.Sampson, et al(2013)24Staying Cool in aChanging Climate:Reaching VulnerablePopulations During HeatEventsInterviews withvulnerable populationsin four U.S cities(Detroit, Phoenix,New York City andPhiladelphia).Many respondents did not seethemselves as vulnerable toheat. Others were hesitant to goto cooling centers because theyare unsure of what they provideand don’t want to sit in a roomwith nothing to do.Lane, et al (2013)25Extreme Heat Awareness Interviews withand Protective Behaviors vulnerable populationsin New York City.in New York City.Many of the vulnerableindividuals interviewed didn’tfeel they were vulnerable, didn’twant to be surrounded by “oldpeople,” or feared leaving theirhouse unoccupied for longperiods of time.The Use of Cooling Centers to Prevent Heat-Related Illness: Summary of Evidence and Strategies for Implementation

AUTHOR (YEAR)White-Newsome, et al(2014)26TITLEStrategies to Reducethe Harmful Effects ofExtreme Heat Events: AFour-City Study.METHODSKEY RELEVANT FINDINGOR OUTCOME(S)Interview data fromcounties on how theyprepare for heat eventsin four cities in the U.S.Each city had a differentheat action plan in place.Respondents reported that theonly people that use coolingcenters are “old people” andthey are “not for me.”Bradford, et al (2015)27 A Heat VulnerabilityIndex and AdaptationSolutions for Pittsburgh,PennsylvaniaCalculated a heatvulnerability index (HVI)for use in choosingoptimal cooling centerlocations in Pittsburgh,Pennsylvania.Describes how to use GIS tolocate the most vulnerable areasand situate additional coolingcenters.Uebelherr, et al(2015)28Innovative ParticipatoryAgent Based ModelingUsing a ComplexityGovernance PerspectiveUsed participatorymodeling and complexitygovernance to createa heat relief network.Review and lessonslearned in MaricopaCounty, ArizonaReviews how a county createda heat relief network (includingplanning for cooling centers)using stakeholder engagement.Nayak, et al (2016)29Surveying Local HealthDepartments and CountyEmergency ManagementOffces on CoolingCenters as a HeatAdaptationCooling centerevaluation of localhealth departments inNew York State.Only 29% of counties hadcooling centers implemented intheir area. Some counties saidthey have no plans to set upcooling centers due to the lackof need, limited resources, or lowattendance in the past. Somecounties reported that outdoorcooling sites such as publicpools and parks were usedmore often than indoor coolingcenters.Fechter-Leggett, et al(2016)30Heat Stress IllnessEmergency DepartmentVisits in NationalEnvironmental PublicHealth Tracking States,2005–2010Quantitative data.Analyzed heat stressillness emergencydepartment visit counts2005–2010 in 14 states.Higher rate of heat stress illnessemergency department visitswere seen in rural areas. Thereare many reasons this couldbe the case, one being thatthere are fewer designated coolspaces.Berisha, et al (2016)31Assessing AdaptationStrategies for ExtremeHeat: A Public HealthEvaluation of CoolingCenters in MaricopaCounty, ArizonaCooling centerevaluation describedvisitor demographics,facility descriptions, andmanagement practicesof the centers inMaricopa County, AZ.Cooling centers in MaricopaCounty mainly were found withincommunity, senior, or religiouscenters, discovered by wordof mouth or by having seenthe cooling center’s location.Many visitors self-reported asunemployed or homeless.Figure 2: Findings from Key Relevant Peer-reviewed ArticlesThe Use of Cooling Centers to Prevent Heat-Related Illness: Summary of Evidence and Strategies for Implementation7

Peer-reviewed literature summaryThis section summarizes the key fndings in scientifc peer-reviewed literature related tothe implementation and usage of cooling centers, and the context in which theyare used.Impact of cool environmentsStudies indicate that spending even a few hours in a cool environment, or with a workingair conditioner or cooling unit, reduces vulnerable populations’ risk to heat exposure.5,12,18Those who adjust their behavior to include spending time in a cool place during aheat wave are less likely to sufer from heat wave mortality.17 An analysis of the 2003European heat wave surveyed family members of the deceased individuals to determinebehavior factors that infuenced mortality. The study found that spending time in acooler environment during a heat event was associated with a lower risk of death.17 Ameta-analysis on the risks and protective factors associated with heat-related mortalityidentifed that the act of visiting an air-conditioned space (not necessarily a coolingcenter) reduced risk of mortality by roughly 66% compared to those who did not visit airconditioned spaces.18Cooling centers as part of a larger strategy:heat health warning systemsCooling centers are a commonly used intervention, typically implemented as partof a larger heat health warning system (HHWS).20,31 A HHWS can consist of myriadactivities such as early alerts, advisories and emergency measures that are often tailoredto a specifc locale.32 Studies have shown that HHWS have reduced mortality duringheat events.33,34 HHWS are also colloquially referred to as “heat action plans” or “heatwarning systems”. HHWS and simultaneous public health response plans have grownincreasingly popular after several prominent extreme heat events caused wide spreadmortality. The City of Chicago and the Government of France created thorough publicresponse plans after their deadly heat wave events in 1995 and 2003 respectively. Bothplans included cooling centers as “boots on the ground” interventions. While coolingcenters can serve as a means to provide shelter to larger groups of people, O’Neill et alnoted that this protective strategy assumes that those who may need to use the centersmost are aware that they’re at risk to extreme heat and have adequate transportation tothe centers.35Interventions for heat wave events, such as establishing cooling centers, are difcultto evaluate because no two heat wave events, and the populations that are afected, areexactly alike. Case studies can help to draw comparisons between the efectiveness ofimplemented interventions during comparable heat waves. For instance, Palecki, et al15compared the heatwave that struck Chicago in 1995 with the July 1999 heatwave thatheavily impacted St. Louis and Chicago. The meteorological intensity of the two eventswas comparable, though the 1995 event began and ended more abruptly. Unfortunately,the 1995 heat wave was responsible for nearly 700 deaths.36 Soon after, the City ofChicago began planning a HHWS. The HHWS included interventions such as coolingcenters, heat health hot lines, and enhanced warning communication and emergencycommunication with the National Weather Service (NWS).378The Use of Cooling Centers to Prevent Heat-Related Illness: Summary of Evidence and Strategies for Implementation

While the individual contribution of cooling centers wasn’t assessed during the 1999event, cooling centers were integral to the heat adaptation strategy and warning system.Chicago opened 34 cooling centers, provided free bus service to anyone needing toreach a center, and opened 31 schools to provide more cooling spaces. In addition tothese formal city-operated cooling centers, newspapers at this time reported an increasein retail activity, “people went to shopping malls, and movie theaters had above averageattendance as people tried to escape the heat in air conditioned facilities.”15 On the ffthhot day, the city advised residents to visit cooling centers after fnding low attendanceduring the previous days. It was reported that many individuals were afraid to leavetheir homes because they feared their houses being robbed. Over 1,200 people werebrought to cooling centers in Chicago during the heat wave.Because heat waves were common in the Midwest during the 1980s, St. Louis wasprepared for heat events. During the 1995 heat wave, a heat alert was issued jointlyby the St. Louis Department of Health and the St. Louis County Health Department.38There were 27 heat-related deaths reported. The 1999 heat wave was longer in durationcompared to the 1995 event. The city identifed 36 heat-related deaths. The heat planin place included designating cooling centers and employing city workers to performwellness visits on elderly individuals. Although there was an increase in mortalityduring the 1999 heat wave in St. Louis as compared to the 1995 event, Palecki et alpostulate that without a cohesive heat plan in place it would have undoubtedly killedmore.15 The region reported nearly a quarter the number of heat-related deaths duringthe 1999 heat wave compared to the 1995 event, suggesting that these interventionsefectively decreased mortality associated with extreme heat.15The role of health departments and local governments: summaryof surveys on local needs and the implementation and use ofcooling centersOngoing work in Maricopa County, Arizona, has contributed to knowledge onutilization of cooling centers. The Maricopa County Department of Public Health,Arizona Department of Health Services, and Arizona State University evaluated coolingcenters and the services that they provided to visitors.31 The evaluation encompassedthree surveys taken by 658 visitors, 52 facility managers, and an observational sitesurvey. The project was undertaken to gain an understanding regarding the capacity ofthe centers to provide relief during extreme heat events. The facility manager surveywas an in-person interview created to collect information on the facility, capacity,utilization and types of services and supplies ofered. The cooling centers are locatedin many diferent facility types, the most common is in a community center (n 16, 31%)or senior center (n 16, 31%), followed by religious facility (n 7, 13%), and other (n 13,25%) (e.g., rehab/recovery, parks and recreation, homeless shelter, government ofcebuilding).31,39 Facilities were open mainly Monday through Friday (90%) 6 am to 6 pm(54%).40 Facility staf indicated that although visitors came at all times of the day noonto 4 pm had the most amount of visitors (61%) on average. Those that responded hadthe most amount of visitors in July and August and the lowest amount of visitors inSeptember. Facilities mainly communicate their cooling center and services by wordof mouth (54%) and print materials (33%). 71% provided food and snacks, while 27%provided entertainment. All provide free water, 50% go through one case (i.e. 24 bottles)The Use of Cooling Centers to Prevent Heat-Related Illness: Summary of Evidence and Strategies for Implementation9

per day, and 25% go through four or more cases per day. 62% report no additionalcosts associated with using their facility as a cooling center, 23% said additional stafhours are an additional cost, and 17% said that bottled water is an additional cost. Theobservational survey was an in-person survey taken by evaluators to gauge coolingcenter facility type, visibility, accessibility, utilization, features and amenities. 67% of thecooling centers in this evaluation did not have clear or visible signs notifying the publicof their existence.39 Of those who did have a sign (n 17) only 7 had the sign in bothEnglish and Spanish, the main languages in Maricopa County. 90% (n 47) were easilyaccessible, 10% (n 5) may not have been easy to enter or use for a disabled person.A survey in New York State also evaluated cooling center utilization and procedures.Nayak, et al29 collected the locations, organization, and information on utilization ofcooling centers. The authors identifed 377 cooling centers in NYS through searchingcounties’ online resources, American Red Cross chapters, and by administering asurvey to local health departments and county emergency management ofces. Thesurvey was answered by 36 local health departments and 26 emergency managementofces, with 62 responses total. Responses came from 56 of the 57 counties surveyed(98% response rate). Only 16 of the 56 (29%) counties surveyed replied that they hadcooling centers as part of their response to heat wave events. Five counties did nothave cooling centers, but provided cool down information to the public. Thirty fvepercent (n 19) of counties said they have no plans to set up cooling centers due tothe lack of need, limited resources, or low attendance in the past. Participants in thisstudy responded that NYS currently has relatively mild summers and many healthdepartments see cooling centers as unnecessary. This study suggests that moreeducation and outreach is needed in those communities to communicate that due toindividual’s low adaptation to heat they may be more afected when heat increases inthe future. Some counties reported that outdoor cooling sites such as public pools andparks were used more often than indoor cooling centers during heat waves. Almost allcooling centers in NYS provide free water and air conditioning. Although a majorityof the cooling centers were accessible by public transportation (76%), few countiesprovided special transportation to the vulnerable (13%). Almost all of the counties(90%) disseminated their information to the public through the radio, followed by socialmedia, then newspapers. Other methods of information dissemination included callinghome care agencies and engaging church groups in the community.A study surveyed California’s county public health departments (n 61) regarding theirpreparedness to deal with climate change events including extreme heat events.20Most county health departments in this study cited heat as the most serious threatto their region’s public health in the future. Out of the 34 responses, 30 had a heataction emergency plan available (88%), all included cooling centers and a process foridentifying vulnerable populations. In many cities the cooling centers are located ingovernment buildings and community centers. In California, lower income householdsare less likely to have air conditioning and may not have access to public transit.Almost all (90%) of the responding county public health departments said they hadprograms that reached out to vulnerable populations in their community. Only 32%reported they provided transportation to cooling centers and 12% provided fnancialassistance to help with additional cooling costs.10The Use of Cooling Centers to Prevent Heat-Related Illness: Summary of Evidence and Strategies for Implementation

In a study by White-Newsome et al,26 the authors conducted qualitative interviews withlocal governments in four U.S cities (Detroit, New York City, Philadelphia, and Phoenix)to understand their public health response plans to extreme heat and their attitudestoward cooling centers as a plausible intervention. This study highlighted someuseful “lessons learned” on promoting and using cooling centers. Detroit providedreal time information of the location of cooling centers but mentioned the challengesthey have with the perception of cooling centers being “just for old people,” thereforelimiting other vulnerable groups from using them. New York City has an establishedand organized command system to create their HHWS. The public health departmentcoordinates with the NWS to create a plan before each heat wave is expected to begin.The health department opens cooling c

warmest single year since modern record keeping began. 3. This temperature increase is projected to continue, with longer, more severe, and more frequent heat waves . coffee shop, shopping mall, or movie theatre. Some counties have set up cooling sites outdoors in