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Addressing the National Challenges of Extreme Heat by Modernizing Preparedness Approaches at Administration for Strategic Preparedness and Response

04.01.24 | 8 min read | Text by Nathaniel Matthews-Trigg

In the United States, almost one in four Americans are vulnerable to the growing threat of extreme heat. In fact, extreme heat kills more people on average every year than any other extreme weather event. Yet scientists believe these numbers still largely underestimate the true number of heat-related deaths by up to 50-fold, suggesting tens of thousands of Americans could be dying each year from heat-related exposure. Climate change further drives the risk of extreme heat, with a hundred million Americans exposed to dangerous temperatures each summer and projections showing these numbers to further increase.

The Administration for Strategic Preparedness and Response (ASPR) within the Department of Health and Human Services (HHS) can and should play a leadership role in supporting State, Local, Tribal, and Territorial (SLTT) preparedness and response to extreme heat. Just as ASPR serves as the Sector Risk Management Agency for healthcare and Public Health (HPH) cybersecurity, ASPR is uniquely positioned to lead the federal response to extreme heat due to the distinct and disproportionate impacts of extreme heat on the medical and public health sector. As leader, ASPR would support the integration of extreme heat into healthcare preparedness and response programs, participate in an interagency workgroup to develop critical healthcare impact-based forecasts, and implement lessons learned from similar efforts to develop effective hurricane responses. This is critical for ASPR to meet its mandate in a rapidly warming world, will save thousands of American lives, and stand as a testament to U.S. innovation and resolve.

Challenge and Opportunity

Across the U.S., more communities are facing the deadly impacts of extreme heat. Local responses are often disorganized and reactive, resulting in excessive preventable injuries and deaths. Hospitals are overwhelmed, emergency services are stretched thin, and the most vulnerable suffer. Combined with potential power outages, heat waves could create catastrophic impacts, including unparalleled patient surge and mass casualty crises that would overwhelm local and state resources. Unlike other extreme weather hazards, the impacts of extreme heat are disproportionately felt by HPH organizations and agencies, a clear indicator that ASPR should play a leadership role in supporting SLTTs to ensure regional healthcare readiness, sharing of critical impact-forecast data, and effective response coordination.

On June 23, 2021, the Seattle-based National Weather Service (NWS) office alerted Washington State response agencies about a large record-breaking heat dome forecasted to impact the region. With three days until the start of the heat dome and five days until its peak, there was ample time to prepare. However, with Washington being largely unaccustomed to extreme heat —and lacking plans, an understanding of the potential impacts, and technical assistance or resource support from the federal government — SLTTs were left to fend for themselves. The results were catastrophic: more lives were lost than any other extreme weather event in the state’s history.

ASPR, with minimal additional funding from Congress, should act to better support SLTT-level healthcare and public health organizations and agencies by supporting the development of data-driven decision-making tools, heat-integrated preparedness programs, and response systems ready to pre-deploy when extreme heat threatens to overwhelm SLTT HPH resources.

Heat Impact Forecasts and Response Triggers

A major operational barrier to extreme heat response planning is a lack of data-driven decision-making resources, such as impact-based forecasts. Traditional forecasts for heat waves often focus on temperature and humidity, but do little to provide necessary information for SLTTs and national agencies to understand community risk and anticipated impacts on the HPH sectors.

Similar to ongoing efforts to move beyond traditional hurricane forecasts (wind speed, pressure, location) and toward impact-based warnings for jurisdictions and communities, the Centers for Disease Control and Prevention (CDC) and the NWS collaboratively developed the HeatRisk prototype to provide risk-focused information. Even with the tool still in the development phase and only providing forecasts for half of the continental United States, HeatRisk has already been integrated into SLTT response plans. This demonstrates a significant need to complete and expand this tool to support SLTT and federal response decision-making.

ASPR is uniquely positioned to advance this initiative by integrating healthcare data to develop impact-based forecasts that provide anticipated public health and healthcare surge information. Instead of only forecasting the level of risk posed to the public, a HeatRisk HPH platform could provide critical estimates of healthcare service demand due the extreme heat. This information would be vital to identify evidence-based thresholds that could trigger pre-event coordination, technical assistance, and activation of federal resources from ASPR and FEMA. 

Heat-Prepared Medical and Public Health Response System

Extreme temperature exposure can take just hours to days to be deadly, while federal responses often take days to weeks to organize and deploy, so saving lives during an extreme heat event that overwhelms local and state HPH resources requires rapid pre-deployment of federal assets based on extreme heat forecast data. To date, there is no plan for or example of this occurring, even when thousands of Americans are dying each year from extreme heat.

Clear legal guidelines allow ASPR to pre-deploy response personnel and supplies without a disaster declaration. Section 301, 311, 2812 of the Public Health Services Act authorizes the HHS secretary to provide public health service personnel, equipment, medical supplies, and other assistance to states and local jurisdictions to prevent or respond to any health emergency, with or without a public health emergency declaration. In addition, there are many examples of ASPR pre-deploying assets in anticipation of extreme weather hazards such as Hurricane Ian in 2022, which included the pre-deployment of Health and Medical Task Force teams, Incident Management Teams, and caches of medical supplies. 

ASPR has a mission responsibility to support SLTTs before and during an overwhelming heat emergency with technical assistance and resources – such as personnel and critical medical supplies. This will require modernizing the National Disaster Medical System (NDMS) and U.S. Public Health Service (USPHS) Commissioned Corps to meet the current and future threat landscape of extreme heat, development of heat-specific response standards and training, and integration of forecast-based pre-deployment and technical assistance into regional SLTT preparedness activities. 

Additionally, heat response standards and training could support SLTT Medical Reserve Corps (MRC) volunteer heat-response capabilities through an already existing ASPR and the National Association of County and City Health Officials collaboration, which provides MRC deployment training and readiness guides. This technical support would help meet the growing demand for MRC volunteers in local extreme heat responses.

Heat-Prepared Healthcare Systems

Healthcare systems are often caught off guard by extreme heat events due to a lack of hazard analysis and preparedness. ASPR is critical in supporting healthcare readiness via the Hospital Preparedness Program (HPP), which provides funding through grants and cooperative agreements to support local healthcare capacity, system readiness, and coordination in response to medical surge events.

There is a significant opportunity to integrate heat-specific programmatic requirements into HPP, such as requiring heat-specific hazard and vulnerability analyses and preparedness activities, which would ensure health systems are aware and prepared. Additionally, advancements in medical surge coordination, such as regional and state medical operations coordination cells (MOCC), developed or refined during the pandemic and utilized during periods of extreme heat, should be funded through HPP to ensure patient and resource coordination capabilities are developed, utilized, have appropriate authority, and are financially sustained. 

Heat-Health Response Excellence Centers

ASPR has created and funded several medical-academic centers that provide technical assistance, training, exercises, and assessments specific to unique hazards and demographics. These include two Pediatric Disaster Care Centers of Excellence and the National Emerging Special Pathogens Training & Education Center. With adequate congressional funding, ASPR should establish two national Heat-Health Response Excellence Centers that support SLTTs and ASPR in identifying preparedness and response best practices; developing heat-specific federal response standards and training; understanding regional heat impact characteristics and supporting HeatRisk data integration; connecting HPH response planners with leading national heat research and subject matter experts; and leveraging ASPR TRACIE, ASPR Project ECHO, and the National Integrated Heat Health Information Network (NIHHIS) to capture and disseminate best practices and ongoing engagement.

Plan of Action

To ensure ASPR is able to advance SLTT HPH extreme heat readiness and can effectively support jurisdictions responding to a heat-related health emergencies, the following actions should be taken.

Recommendation 1. Develop heat impact-based forecasts 

  1. ASPR collaborates closely with CDC and NWS to support the expansion of the HeatRisk prototype to include HPH sector risk analysis (using ASPR-controlled healthcare data), and is socialized/integrated in SLTT heat response plans. 
  2. Identify specific NDMS forecast thresholds to trigger support for SLTTs, such as prepositioning of personnel, resources, and provision of technical assistance. 
  3. One-time funds of $10 million to increase HeatRisk scope and impact-based forecast planning that would include:
    1. Staff support to appropriately integrate ASPR healthcare data
    2. Cross-agency integration of HeatRisk data to identify activation thresholds
    3. Outreach and promotion for SLTT awareness and planning
  4. Recurring $3 million to ensure ongoing HeatRisk refinement (incorporating new data), ASPR healthcare data integration, and ongoing assistance to SLTTs to support heat response planning.

Recommendation 2. Leverage HPP to advance healthcare readiness

  1. Require HPP recipients to integrate extreme heat in the required coalition-led hazard and vulnerability assessments (HVA). This should include connections with local or regional climate projection subject matter experts.
  2. Require healthcare coalitions to develop a coalition heat response plan, similar to existing requirements for hazard-specific response plans, such as the radiation emergency surge annex requirement.
  3. Require healthcare coalitions to use extreme heat as a Medical Response and Surge Exercise scenario once in each cooperative agreement, or more frequently based on HVA and priorities.
  4. Streamline MOCC-capability funding through HPP, require all HPP recipients to establish patient and resource transfer coordination capabilities, and institute clear transfer authority. 50% increase in annual funding per recipient, or $120 million based on 2023 funding.
    1. Current funding mechanisms for MOCCs are convoluted, tied to expiring COVID funding or reallocating funds from various response funds. A clear, streamlined approach will ensure sustainability and readiness.
    2. MOCC funding should be periodically reassessed based on innovative best practices and changes in the local and national threat landscape. For example, MOCCs may be critical during non-emergency protracted hospital strain and should be funded appropriately.
  5. Ensure healthcare coalitions engage outpatient healthcare, long-term care, and federally qualified health centers and their respective regional or state associations.

Recommendation 3. Establish technical assistance resources

  1. Fund and establish two regional Heat-Health Response Excellence Centers at two academic institutions that will provide technical expertise and guidance to federal agencies and SLTTs on heat preparedness and response best practices, regional heat characteristics, and connect SLTTs with heat subject matter experts.
  2. Develop heat-specific response guidance—examples could include heat-sensitive pharmaceutical guidance, heat-associated mass casualty triage, and critical resources for extreme heat-related patient surges. 
  3. Allocate $6 million in annual funds based on existing ASPR-funded Pediatric Disaster Care Centers of Excellence

Recommendation 4. Modernize NDMS and USPHS for extreme heat

  1. Work with Heat-Health Response Excellence Centers to develop heat-specific response standards and training. Integrate them into current NDMS modernization efforts, starting with Disaster Medical Assistant Teams.
  2. Update NDMS response plans to align with forecast-based response triggers. Integrate these plans into ongoing regional exercises that include HPP recipients. 
  3. One-time funds: $17 million based on 2020 CARES Act for USPHS training.

Cost Estimates

This proposal would require a first-year cost of $153 million and future annual costs of $129 million. The economic justification to fund these efforts is apparent. The sharp increase in billion-dollar extreme weather disasters in the U. S., the growing awareness of the impact of extreme heat on human health (and associated medical expenses), and mitigation research showing that every dollar in prevention saves up to $15 in response and recovery expenses should incentivize Congress to fully fund this proposal. 


Increasing risks associated with extreme heat in the United States signal an urgent need to enhance national preparedness and response strategies. ASPR is ideally suited to lead in supporting SLTTs in their preparedness and response. ASPR can accomplish this through low-cost measures that develop critical decision-making tools and better integrate extreme heat into existing programs, funding mechanisms, and medical and public health deployment systems.

Frequently Asked Questions
Why should ASPR be in a leadership role?

Extreme heat events are unique compared to other extreme weather events. The impacts more closely resemble those of a rapid epidemic, with often geographically dispersed direct impacts to human health resulting in significant surges of patients into emergency departments. While heat-related impacts to infrastructure do occur, and require coordination with local, state, and federal emergency management, ASPR is ideally situated to support the frontlines of a heat emergency with existing programs and response systems, such as HPP, and HPH technical assistance, coordination, and resources.

How are so many people dying of heat with so little public attention?

Sociologist Eric Klinenberg characterizes heat as a “silent and invisible killer of silenced and invisible people,” highlighting the many, often intersecting health inequities that drive heat morbidity and mortality. In the U.S., the socially isolated, elderly, disabled, and unhoused make up the majority of heat-related deaths. Tragically, these deaths rarely garner media attention. Additionally, heat affects the human body in a variety of often under-recognized ways, resulting in underreporting on medical records. Lastly, aggregate surveillance data from heat events is often slow to come out or not analyzed at all. The combination of these factors results in significant undercounting of heat deaths—and a public that largely underestimates their risk to this growing threat.

How does extreme heat impact healthcare and public health?

Direct health impacts (e.g., heat stress, heat stroke, heat-associated cardiac and respiratory events) increase demand for emergency healthcare services, which can result in significant patient surges to emergency departments. This can increase 9-1-1 wait times and pre-hospital wall times. Indirect health impacts, such increases in drownings, auto accidents, burns, domestic violence, and overdoses, further stress an already-overwhelmed healthcare service. High temperatures can affect medical equipment, staff safety, productivity, and burnout. As extreme heat exposure increases in frequency, severity, and duration, the risk of a catastrophic heat event that results in tens of thousands of deaths increases, demanding urgent action.