Collectively, the eight Québec HRs affected by the July 2010 heat wave showed significant increases in the crude death and emergency department admission rates in relation to the comparison periods. However, the regional analysis identified important variations. Only three HRs had a significant increase in crude emergency department admission rates, and only the Montréal health region had higher emergency department admission and death rates simultaneously. Finally, no mortality displacement was observed over a 60-day horizon.
Deaths
As elsewhere worldwide, this study shows that heat waves can be fatal weather events [
15‐
18]: the significant increase (33%) in crude rate is comparable to the results reported elsewhere [
16,
19]. However, it is lower than during two similar episodes that occurred in the Montréal HR in 1987 and 1994 when the daily mortality exceeded 100% of the historical average [
20]. At the time of these previous episodes, no public health intervention plan existed and no preventive measures had been implemented. Since 2006, a formal Heat Action Plan [
21] has been implemented at the provincial level for all relevant HRs, promoting a proactive approach. Moreover, the new thresholds proposed [
5,
7], although based on a 60% excess mortality of historical heat wave episodes, were used to establish forecast thresholds for full public health intervention before the heat wave, or at its very beginning. Since we know that heat-related deaths are largely preventable through appropriate communication and prevention [
22], this more organized and proactive approach could partly explain the lower excess mortality, even with an aging population. This situation could also be partly explained by the gradual changes in the population's behaviour during heat waves, notably the increased use of air conditioning systems. Since 1987, for all households in the province of Québec, the ownership of air conditioning systems increased from 15% to 42% in 2010 [
23,
24]. However, the actual use of air conditioning is not measured and will vary significantly according to income, even during heat waves [
25]. Unfortunately, none of this data is available by HR, which could have helped greatly in the interpretation of some of our results.
This study also shows that heat-related mortality increases rapidly from the start of the heat wave [
8‐
11], and some of its health impacts are detectable up to three days after the maximum temperature peak [
12,
26]. Thus, some regional differences in heat exposure (and occurrence/ absence of rain) could explain the regional variability. The HRs of Montréal and Montérégie are the most populous in Québec, and contain significant urban heat island areas which promote an increased exposure of the population to heat [
12,
22,
27,
28]. Also, the characteristics of the heat wave are different from one region to another (Table
1). The highest maximum temperatures (≥ 34°C) involve only three HRs, including those of Outaouais and Montérégie. Otherwise, the highest minimum temperatures (≥ 24°C) involve only three HRs, including those of Montréal and Montérégie. In these highly urbanized regions, the minimum temperature peaks were reached very rapidly, namely 24 hours after the start of the heat wave. It seems that the maximum value of the minimum temperature and the time to reach this peak are important factors in estimating the intensity of a heat wave and the severity of its impacts [
29,
30].
The lack of statistically different impacts in the HRs other than Montréal, Outaouais and Montérégie could also be due to the small numbers of health events in the less populated regions and to the related low power of detection, or even to differences related to certain individual parameters such as age [
16,
19,
22] or health status [
12,
31‐
34], but we have no evidence to this effect. Other studies would be needed to clarify these aspects.
The graph (Figure
1) of the daily variations (2010 vs. 2005–2009) of the all-cause deaths between July 1 and 31, 2010, suggests that this indicator has several qualities that make it useful in watching for and monitoring heat waves. In fact, there is a short period (a few hours) between the start of the heat wave and the increase in deaths, and deaths increase right from the first day. The all-cause death indicator seems to be sufficiently sensitive and specific to exceedences of the temperature thresholds, because the daily variations in deaths clearly reflect the fluctuations in temperatures during the heat wave. In this case, analysis of mortality over a 60-day horizon after the heat wave does not show any significant lower mortality, contrary to some other studies [
35‐
38]. For some heat waves, a decrease in mortality was observed during the weeks after the wave. This short-term forward shift in mortality is also referred to as mortality displacement, or harvesting effect. This reduction in mortality usually suggests that the heat wave particularly affected individuals whose health is already so compromised that they would have died in the short term anyway [
39]. Hence, in the absence of mortality displacement, it seems that the deaths measured in this study were primarily due to the July 2010 heat wave, and not to the early mortality of weakened individuals. On the other hand, we may not have detected lower forward mortality because of our methodology (e.g., periods chosen for studying the delayed effects) or the characteristics of our studied populations compared to other studies [
40].
Finally, our results do not reveal a greater increase in deaths in the elderly (75 years of age and older) compared to the 0–64 year group as in other studies [
22,
30,
41‐
43]. The Québec population may have various strategies for adapting to heat, independent of their age (e.g., heat wave warnings issued in the regions involved, and action plans targeting the elderly). Nonetheless, it is also possible that this absence of a greater increase in deaths in the elderly could be explained by the coarse nature of the variable (in the Québec daily death record, age is classified according to three strata only: < 65, 65–74, and > 74).
Emergency department admissions
In this study, the significant increase in emergency department admissions (4%) for all of the HRs affected by the July 2010 heat wave is similar to the increase recently observed in a California study (3%) [
3]. In addition, there are some rate variations across the HRs that could be explained by local factors, but we do not have enough information to reach any conclusion about the reasons for these variations. Furthermore, the graph (Figure
1) of the daily variations in emergency department admissions (2010 vs. 2005–2009) indicates that they are modest and do not reflect the fluctuations in temperature. Such modest variations in the impact of a heat wave on these daily variations were also reported in a French study in 2005 [
44]. Based on this information, the usefulness of this indicator for monitoring the health impact of a heat wave is not as clear as in the case of deaths. Nevertheless, this indicator remains useful for hospital management in such a context.
Limitations
Our study is based on the analysis of a single heat episode, which limits the generalization of results. The study is also affected by the difficulty in characterizing exposure in ecological studies. As well, the temperature values come from a single reference weather station per HR, even though each HR generally includes several cities. However, even if there could be some variation in temperatures in different parts of a region, the reference station reflects well the temperatures of the most populated areas, and thus provides valid temperatures for most of the population, according to the definition of a reference station by Environment Canada. Additionally, the presence of heat islands (and associated risk) is also greater in the more urbanized areas.
It should be mentioned that the temporary death file contains only coarse information about age and no information about the diagnosis, which limits further data interpretation. Finally, the analysis did not take atmospheric pollutants into account. This could have explained some regional differences regarding the impact on mortality, but this remains a hypothesis since the effect of atmospheric pollution on the temperature-mortality relationship remains highly controversial [
15,
27,
40,
45].