Epidemiology of Exertional Heat Illness Among

U.S. High School Athletes

Zachary Y. Kerr, MPH, MA, Douglas J. Casa, PhD, ATC,
Stephen W. Marshall, PhD, R. Dawn Comstock, PhD

Background: It is estimated that more than 9000 high school athletes are treated for exertional heat
illness annually. Risk factors include being obese and beginning practice during hot and humid
weather, when athletes are not yet acclimated to physical exertion in heat.
Purpose: To describe the epidemiology of exertional heat illness in high school athletes.
Methods: National High School Sports–Related Injury Surveillance System data (2005/2006–2010/2011)
were analyzed in 2012 to calculate rates and describe circumstances of exertional heat illness.

Results: Exertional heat illness occurred at a rate of 1.20 per 100,000 athlete exposures (95%
CI⫽1.12, 1.28). Exertional heat illnesses were widely distributed geographically, and most occurred
in August (60.3%). Of the exertional heat illnesses reported during practice, almost one third (32.0%)
occurred more than 2 hours into the practice session. The exertional heat illness rate in football (4.42
per 100,000 athlete exposures) was 11.4 times that in all other sports combined (95% CI⫽8.3, 15.5,
p⬍0.001). In addition, approximately one third (33.6%) of exertional heat illnesses occurred when a
medical professional was not onsite at the time of onset.

Conclusions: Although most exertional heat illnesses occurred in football, athletes in all sports and
all geographic areas are at risk. Because exertional heat illness frequently occurs when medical
professionals are not present, it is imperative that high school athletes, coaches, administrators, and
parents are trained to identify and respond to it. Implementing effective preventive measures
depends on increasing awareness of exertional heat illness and relevant preventive and therapeutic
countermeasures.
(Am J Prev Med 2013;44(1):8 –14) © 2013 American Journal of Preventive Medicine

Background thermal stress, which is typically 30 – 60 minutes from the

critical threshold for cell damage.2

V
arious types of exertional heat illness (EHI),
The majority of sports-related, heat-related deaths in
such as heat cramps, heat syncope, heat exhaus-
U.S. children and adolescents occur during participation
tion, and exertional heat stroke (EHS) are
in football, wrestling, and cross-country/track.3,4 It is es-
sources of concern for both athletes and medical staff.1
timated that more than 9000 high school athletes are
EHS, the most serious of these EHI events, can cause
treated for EHI annually, principally during August, at
death or permanent disability if the length of time of
the beginning of the Fall sports season, when athletes are
hyperthermia exceeds the ability of the cells to tolerate the
not yet acclimated to physical exertion in the heat.5 The
estimated incidence rate of nonfatal EHI for high school
From the Department of Epidemiology (Kerr, Marshall), Injury Prevention
Research Center (Marshall), the Department of Exercise and Sport Science
sports is 1.6 per 100,000 athlete exposures (defıned as one
(Marshall), University of North Carolina, Chapel Hill, North Carolina; athlete participating in one athletic practice or competi-
Korey Stringer Institute, Department of Kinesiology (Casa), University of tion),5 with rates highest in football.5,6 Between 1995 and
Connecticut, Storrs, Connecticut; College of Public Health, Division of
2010, a total of 35 football players died from EHS,7 an
Epidemiology (Comstock), College of Medicine, Department of Pediatrics,
The Ohio State University (Comstock), The Research Institute at Nation- average of two annually. In Summer 2011, six high school
wide Children’s Hospital, Center for Injury Research and Policy (Com- football players died due to high temperatures and lack of
stock), Columbus, Ohio rehydration.8 In the 5-year block from 2005 to 2009, more
Address correspondence to: R. Dawn Comstock, PhD, The Research Insti-
tute at Nationwide Children’s Hospital, Center for Injury Research and Policy, EHS deaths occurred in organized sports than in any
700 Children’s Drive, Columbus OH 43205. E-mail: dawn.comstock@ other 5-year period over the past 35 years.8
nationwidechildrens.org.
0749-3797/$36.00 Adolescents are considered to be at an increased risk for EHI
http://dx.doi.org/10.1016/j.amepre.2012.09.058 relative to adults due to both physiologic differences and the

8 Am J Prev Med 2013;44(1):8 –14 © 2013 American Journal of Preventive Medicine • Published by Elsevier Inc.
 Kerr et al / Am J Prev Med 2013;44(1):8 –14
simple fact that adolescents are more likely to engage in vigor-
ous physical exercise during summer months.9 Unfortunately,
many adolescent athletes, and their parents, are unaware of the
symptoms of EHI and its potentially catastrophic outcomes.
Increased awareness and preventive measures are needed,10,11
especially given the fact that sports-related, heat-related deaths
are completely preventable.2
Guidelines for the prevention and management of
EHI10 –17 support a wide range of prevention strategies.
Unfortunately, development of more-aggressive preven-
tion campaigns is hampered by a lack of basic descriptive
data on EHI incidence and circumstances. A 2010 report5
on EHI was limited in that it included only nine sports
and did not examine athlete characteristics (e.g., BMI) or
the availability of medical professionals at onset. The
current study updates the epidemiology of EHI among
high school athletes participating collectively in 20 sports
during 2005/2006 –2010/2011. These epidemiologic data
can assist public health professionals in the development
and distribution of EHI interventions.
Methods
Data Collection
Data were obtained from the National High School Sports-Related
Injury Surveillance System, High School RIO™ (Reporting Infor-
mation Online), an Internet-based sports injury surveillance sys-
tem, which has been described previously.18,19 High schools with
one or more National Athletic Trainers’ Association–affıliated cer-
tifıed athletic trainers with valid e-mail addresses were invited to
participate. Responding high schools were categorized into eight
strata based on school population (two categories of enrollment:
ⱕ1000 and ⬎1000) and the four U.S. Census geographic regions.20
ThehighschoolRIOsystemhastwopanelsfordatacollection.Thefırst
is a stratifıed random sample of high schools, originally established in
2005/2006 with nine sports to provide national estimates. A second con-
venience sample of high schools with 11 additional sports was added in
2008/2009, in order to enable comparison of injury rates, risks, and cir-
cumstances but without generating national estimates.
For the nine sports included in the study since 2005/2006 (foot-
ball, girls’ and boys’ soccer, girls’ volleyball, girls’ and boys’ basket-
ball, boys’ wrestling, boys’ baseball, and girls’ softball), 100 high
schools were randomly chosen to participate (12 or 13 from each of
the eight strata). If a school dropped out of the study, a replacement
from the same stratum was randomly selected to maintain the
annual 100-school study population. Athletic trainers from partic-
ipating high schools logged onto the study website weekly through-
out the academic year to report injury incidence and exposure
information. In addition to injuries, the surveillance system cap-
tured other sports-related adverse health events such as EHI,
asthma attacks, and skin infections.
For the 11 sports added to the study in 2008/2009 (girls’ fıeld
hockey, girls’ gymnastics, boys’ ice hockey, girls’ and boys’ lacrosse,
girls’ and boys’ track and fıeld, girls’ and boys’ swimming and
diving, boys’ volleyball, and girls’ cheerleading), not enough
schools from the eight strata volunteered to report for all sports,
making it impossible to produce a randomly selected sample. Thus,
January 2013
9
exposure and injury data for these sports were collected from a
convenience sample of schools. If a trainer from a convenience-
sample school also reported information for athletes in one of the
original nine sports, these data were included in the overall conve-
nience sample data but not in weighted national estimates.
Definition of Exertional Heat Illness, Injuries/
Adverse Health Events, and Exposure
Exertional heat illness includes a range of conditions that are re-
lated to physical exertion and typically occur in hot or humid
conditions, including heat cramps, heat syncope, heat exhaustion,
heat stroke, and exertional hyponatremia.17 The operational defı-
nition of EHI for the current study was all events reported to the
high school RIO system that (1) were classifıed by the reporting
athletic trainer as heat-related and/or dehydration-induced;
(2) occurred as a result of participation in a school-sanctioned
practice or competition; (3) required medical attention by an ath-
letic trainer or physician; and (4) resulted in a restriction of the
athlete’s participation for at least 1 day beyond the date of injury.
The universe of injuries and adverse health events addressed by
the high school RIO system is all injuries/adverse health events
that: (1) result from participation in a school-sanctioned practice
or competition; (2) require medical attention by a trainer or phy-
sician; and (3) result in a restriction of the athlete’s participation for
at least 1 day beyond the date of injury. In addition, any fracture,
concussion, or dental injury is reportable, regardless of whether it
resulted in a restriction of the student’s participation. For each
event, the athletic trainer completes a detailed event report on the
athlete (e.g., age, height, weight); injury or condition (e.g., site,
diagnosis, severity); and the circumstances (e.g., activity, mecha-
nism). Data reporters were able to view and update previously
submitted information as needed during the course of a season.
Body Mass Index Categorization
Calculation of BMI was made using athletic trainer-reported weight and
height. Age- and gender-specifıc percentiles were assigned to classify ath-
letes as underweight (⬍5th age-specifıc U.S. percentile); normal weight
(ⱖ5th to ⬍85th percentile); overweight (ⱖ85th to ⬍95th percentile); or
obese (ⱖ95th percentile), per CDC guidelines.21
Data Analysis
Data from 2005/2006 to 2010/2011 were analyzed in 2012 using
SPSS 19.0. EHI rates were calculated as the number of heat illness
events per 100,000 athlete exposures. Statistical analyses included
calculation of rate ratios (RRs); injury proportion ratios (IPRs); and
Fisher’s exact tests. Example RR and IPR calculations (where
AEs⫽athlete exposures):
共# competition exertional heat illnesses兲/共# competition AEs兲
RR ⫽
(# practice exertional heat illnesses/共# practice AEs兲
共# exertional heat illnesses in football兲 ⁄
共# total injuries and adverse events in football兲
IPR ⫽
共# exertional heat illnesses in all other sports兲 ⁄
(# total injuries and adverse events in all other sports)
This study was approved by The University of North Carolina at
Chapel Hill.
10 Kerr et al / Am J Prev Med 2013;44(1):8 –14

Results Table 1. Exertional heat illness ratesa (95% CIs) among U.S. high school athletes,
2005/2006 –2010/2011
Original Randomly
Selected Sample Sportb Competition Practice Total
During the 2005/2006– Boys’ football 5.11 (4.20, 0.03) 4.18 (3.81, 4.56) 4.42 (4.07, 4.78)
2010/2011 academic years, c
athletic trainers reported Girls’ field hockey 0.00 2.74 (1.62, 3.85) 1.88 (1.11, 2.64)
165 EHI events represent- Girls’ lacrosse b
0.00 c
1.18 (0.35, 2.01) 0.82 (0.24, 1.40)
ing0.6%ofallreportedinju- Girls’ volleyball 0.25 (0.00, 0.51) 0.91 (0.57, 1.26) 0.69 (0.45, 0.93)
ries and adverse health
events. Of these, 124 EHI Boys’ wrestling 0.95 (0.40, 1.49) 0.44 (0.22, 0.66) 0.57 (0.36, 0.79)
events (75.2%) occurred Boys’ baseball 0.00 c
0.62 (0.34, 0.90) 0.57 (0.35, 0.78)
during practice, and 39 dur- Boys’ soccer 0.49 (0.14, 0.83) 0.52 (0.29, 0.76) 0.51 (0.32, 0.71)
ing competition (23.6%). c
An additional two (1.2%) Girls’ soccer 1.40 (0.77, 2.03) 0.00 0.43 (0.24, 0.62)
occurred during condition- Boys’ swimming and 0.00 c
0.45 (0.00, 0.90) 0.36 (0.00, 0.73)
ing sessions held outside divingb
regular practices; however, Girls’ swimming and 1.63 (0.00, 3.26) 0.00c 0.32 (0.00, 0.64)
b
these were excluded from diving
rate calculations as there Boys’ lacrosseb 0.96 (0.00, 1.92) 0.00c 0.29 (0.00, 0.59)
was no athlete exposure
Boys’ track and fieldb 0.00 c
0.32 (0.09, 0.54) 0.26 (0.08, 0.44)
data available for nonprac-
c c
tice and noncompetition Girls’ cheerleading 0.00 0.37 (0.00, 0.74) 0.27 (0.00, 0.54)
exposures. The remaining Girls’ basketball 0.76 (0.32, 1.20) 0.00c 0.23 (0.10, 0.36)
163 EHI events occurred
Boys’ basketball 0.00c 0.18 (0.05, 0.30) 0.12 (0.04, 0.21)
during 11,268,426 athlete
d
exposures, for a rate of 1.45 Boys’ sports 0.18 (0.08, 0.29) 0.38 (0.28, 0.47) 0.35 (0.28, 0.43)
per 100,000 exposures Girls’ sportsd 0.61 (0.40, 0.81) 0.05 (0.01, 0.08) 0.37 (0.29, 0.46)
(competition⫽1.27 per
Total 1.05 (0.89, 1.20) 1.26 (1.16, 1.36) 1.20 (1.12, 1.28)
100,000 exposures; prac-
tice⫽1.51 per 100,000 ex- a
Rates per 100,000 athlete exposures
b
posures). An estimated Data for the sport were not collected for the entire study period.
c
A rate of 0.00 indicates no exertional heat illness events during the study period; 95% CIs are not
51,943 EHI events oc-
computed for such rates. Sports not included in table (i.e., boys’ ice hockey, boys’ volleyball, girls’
curred nationally in the softball, girls’ gymnastics, girls’ track and field) had 0 exertional heat illnesses reported throughout the
nine original sports. study period.
d
A comparison of EHI Only includes sports in which both genders participated (i.e., soccer, volleyball, basketball, baseball/
softball, lacrosse, swimming and diving, track and field)
rates for the nine sports in
the original randomly se-
lected sample of schools and the combined original and conve- 17,172,376 athlete exposures, for a rate of 1.20 (competi-
niencesamplesshowednodifference,forcompetition,practice, tion⫽1.05; practice⫽1.26) per 100,000 exposures; Table 1).
oroverall.Thus,onlydatafromthecombinedconvenienceand Overall, the rate of EHI among high school athletes in the 20
original samples are discussed hereafter. sports studied decreased over time (Figure 1).
Most EHI events occurred in boy’s football (74.4%),
which had the highest EHI rate (4.42 per 100,000 ath-
Combined Convenience and Original Samples
lete exposures). The football EHI rate was 11.4 times
In the combined convenience and original samples, ath-
that of all other sports combined (95% CI⫽8.3, 15.5,
letic trainers reported the occurrence of 211 EHI events
p⬍0.001). EHI events in football were distributed over
during 2005/2006 –2010/2011 in the 20 sports studied. A
total of 159 EHI events (75.4%) occurred during practice; many states (Figure 2). The highest football EHI rates
47 occurred during competition (22.3%). An additional (per 100,000 athlete exposures) were reported in Flor-
fıve (2.4%) occurred during conditioning sessions held ida (21.60); Alabama (17.92); Arizona (13.63); and
outside regular practices; however, these were excluded Kentucky (13.08). Among football players, EHI occurred
from rate calculations as there were no athlete exposure most frequently among offensive linemen (35.7%); defen-
data available for nonpractice and noncompetition sive linemen (16.9%); and linebackers (9.7%). More than
exposures. The remaining 206 EHI events occurred during one third (35.7%) of football players sustaining EHI were

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 Kerr et al / Am J Prev Med 2013;44(1):8 –14
Figure 1. Rates of exertional heat illness among U.S. high
school athletes, by year
Note: Data are from the High School Sports-Related Injury Surveillance System,
U.S., 2005/2006 –2010/2011. AE is defined as one athlete participating in
one athletic practice or competition.
AE, athlete exposure
offensive linemen, even though they comprised only 18.0%
of football players sustaining all other injuries and adverse
health events (IPR 2.0 [95% CI⫽1.6, 2.5], p⬍0.001).
The next-largest numbers of EHI events occurred in girls’
volleyball (4.8%); girls’ soccer (3.0%); and boys’ wrestling
11
(3.0%). No EHI events were reported in boys’ ice hockey, boys’
volleyball, girls’ softball, girls’ gymnastics, or girls’ track and
fıeld. The highest EHI rates (per 100,000 athlete exposures) for
all sports combined except for football were reported in Ala-
bama (3.03), Florida (1.49), and New Hampshire (1.35;
Figure 3).
Most EHI events occurred in the month of August
(60.3%), and among these, most occurred during the pre-
season (90.4%). Varsity athletes were involved in the most
EHI events (58.9%), followed by junior varsity (19.3%), and
freshman (12.2%) athletes. Boys sustained 87.7% of all EHI
events. The proportion of EHI events among all reported
injuries and adverse health events was higher for boys
(0.70%) than for girls overall (0.28%; IPR 2.5 [95% CI⫽1.7,
3.8], p⬍0.001). However, this result is accounted for by
football, which is typically a boys’ sport. Excluding football,
boys accounted for 50.9% of EHI events. In addition, in
gender-comparable sports in which EHI events occurred
(i.e., soccer, basketball, lacrosse, swimming, and diving), the
proportion of EHI events among all injuries and adverse
health events did not differ for girls versus boys.
Availability of Medical Professionals
Athletic trainers reported that all but one of the EHI events
were assessed by at least one sports medicine professional,
with 33.2% assessed by two or more. Most EHI events were
assessed by athletic train-
ers (89.1%), followed by
physicians (35.1%), and
emergency medical tech-
nicians (4.3%). However,
in only 66.4% of EHI
events was a medical pro-
fessional onsite at the start
of an EHI event. The ma-
jority of these were athletic
trainers (95.0% of all med-
ical professionals onsite).

Exposure Type
Of the EHI events re-
ported during practice,
32.0% occurred more
than 2 hours into the
practice session. How-
ever, this fınding was
again accounted for by
boys’ football. The pro-
portion of practice EHI
events occurring more
Figure 2. Rates of exertional heat illness among U.S. high school football athletes, by than 2 hours into the
state
Note: Data are from the National High School Sports-Related Injury Surveillance System, U.S., 2005/2006 –2010/2011. practice session in foot-
*Football data were not collected from this state. ball (36.7%) was 2.4

January 2013
12 Kerr et al / Am J Prev Med 2013;44(1):8 –14
times that in all other
sports (15.2% [95%
CI⫽1.0, 5.6], p⫽0.03).
Among boys that did not
play football and girls, re-
spectively, 22.2% and
6.7% of practice EHI
events occurred more
than 2 hours into the
practice session.

Body Mass Index

Overall, the majority of
the students who sus-
tained EHI were obese
(37.1%), followed by
normal weight (33.4%),
and overweight (27.4%).
There were no data on
the distribution of BMI
in the underlying athlete
population. However,
among student-athletes
sustaining all other inju- Figure 3. Rates of exertional heat illness among U.S. high school athletes in sports other
ries and adverse health than football, by state
Note: Data are from the National High School Sports-Related Injury Surveillance System, U.S., 2005/2006 –2010/2011.
events, only 15.5% were *Data were not collected in this state.
obese and 22.0% were
overweight. Within foot-
ball, BMI was a factor in the onset of EHI. The proportion and competitions for one high school. Therefore, edu-
of football players sustaining EHI that were obese (47.1%) cation of sports administrators, coaches, athletes, and
was 1.7 times the proportion of football players sustain- parents about the prevention, identifıcation, and man-
ing other injuries and adverse health events that were agement of EHI is critically important.
obese (27.5% [95% CI⫽1.4, 2.1], p⬍0.001). The fındings were largely consistent with previous
fındings from the high school RIO system data regard-
Discussion ing U.S. high school EHI events in nine sports.5,6 In
The current fındings highlight the fact that EHI events oc- addition, the fındings demonstrate that the EHI rate
curred across the U.S., not only in hot or humid areas. Most has decreased over the past 6 years. Although it ap-
EHI events occurred in football; however, athletes in 14 pears that there was an increase in the EHI rate from
additional sports were involved in EHI events, demonstrat- 2005/2006 to 2006/2007, the lower rate in 2005/2006
ing that athletes in many sports are at risk. EHI is an uncom- was likely attributable to the learning curve associated
mon outcome of high school sports participation, represent- with athletic trainers beginning to use the high school
ing 0.6% of all reported injuries and adverse health events RIO system.
from 2005/2006 to 2010/2011. However, its potential sever- It is also possible that increased attention and pre-
ity, coupled with the number of recent EHI-related vention education regarding EHI contributed to de-
7,8 creasing its incidence and severity among high school
deaths, make further examination warranted, in order to
aid the development, distribution, and adoption of EHI pre- athletes. A large proportion of EHI events occurred
vention interventions. during practice, particularly 2 hours after practice ses-
Although almost all EHI events were assessed by a sions began. Adhering to preseason heat-acclimatization
trained professional (e.g., athletic trainer, physician), guidelines that limit practice session durations to
approximately one third occurred when a clinician was 2 hours,11,15 and providing frequent water breaks, is
not available onsite at the time of onset. Although all recommended. Research is needed to better under-
schools in the study sample had an athletic trainer, one stand barriers and facilitators of adherence to the pre-
athletic trainer cannot be present at all sports practices season heat-acclimatization guidelines.

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 Kerr et al / Am J Prev Med 2013;44(1):8 –14
Limitations
Limitations of this study include the fact that the sample
was restricted to high schools with athletic trainers. This
may affect generalizability, as only 42% of U.S. high
schools have access to an athletic trainer.22 However, the
event data were all documented by sports medicine pro-
fessionals with training in EHI, which is important to
ensure data quality and consistency.
Additionally, the results should be considered as a lower
bound of the actual burden of EHI, as the defınition of a
reportable EHI was limited to those resulting in at least 1 day
of time lost. For EHI events, the difference between no days
lost and 1 or more days lost likely reflects the speed of
identifıcation of EHI and the type of therapeutic action
taken following detection. Events that were quickly identi-
fıed and treated by athletic trainers, allowing athletes to
return to full participation the next day (and thus not in-
cluded in this study) could have had much more severe
consequences had they been sustained in schools without
medical coverage. Future research efforts should include
data on all EHI events regardless of time lost.
Finally, the EHI data did not include time of day or
ambient environmental conditions (i.e., temperature and
humidity) for EHI events at the time of onset. Conse-
quently, it is unknown if changes in annual EHI rates
were attributable to changes in annual weather patterns.
Despite these limitations, this study remains one of the
largest nationwide epidemiologic evaluations of EHI
events among U.S. high school athletes. Such national
data are essential to inform EHI prevention strategies.
The nationwide distribution of EHI in this study varies
from previous fındings that the greatest number of EHI
events among collegiate athletes occurred in the South
and Southeast (M Ferrara, University of Georgia, unpub-
lished observations, 2012). Such a discrepancy may be due to
reporting variations or population differences associated
with the age of the athletes. This study also had limited
exposure time recorded from states such as Tennessee and
Arkansas, which may explain their low rates of EHI events.
In addition, the distribution of the sampling of sports across
states may have influenced the fındings. As in other injuries
such as concussions,23,24 sampling issues, regional varia-
tions of diagnosis, and athletes’ and coaches’ knowledge and
willingness to address the issue may affect reporting of EHI.
Defınitively diagnosing EHI is diffıcult, given the wide-
spread dependence on external body temperature measure-
ments, which may not be valid.2,25
The BMI of student-athletes sustaining EHI events was
higher than those of student-athletes sustaining all other
injuries and adverse health events. This association be-
tween BMI and EHI is likely influenced by the large
number of EHI events sustained in football, a sport that
tends to have higher-BMI players. This disparity may also
January 2013
13
Table 2. Strategies to improve surveillance of exertional
heat illness in sports
Include exertional heat illness events that are less than
1 day of time lost
Collect data related to:
Time of onset of exertional heat illness event
Ambient environmental conditions (i.e., temperature,
humidity) at onset of exertional heat illness event
Method of temperature measurement (i.e., external,
rectal, internal heat sensors)
BMI of athlete
Types of healthcare professional (if any) that were onsite
at time of onset
Setting (e.g., club, high school, middle school) and
characteristics (athletic trainer staff size, number of
student-athletes)
Consider incorporating data on changes in annual weather
patterns across study period
Ensure athletic training staff are properly trained in utilizing
prevention strategies to reduce incidence and severity
of exertional heat illness, such as monitoring of
temperature and humidity
Track whether proper treatment of exertional heat illness
(i.e., rapid cooling) occurred
Include nationally representative samples of athletes from
multiple sports
Increase education regarding exertional heat illness and
how to prevent it
be attributable to the fact that the high school RIO system
captures data related to only student-athletes who expe-
rience injuries and adverse health events and not their
uninjured teammates. However, this study sample’s pro-
portion of injured student-athletes that were obese was
similar (15.5%) to that of the nationally representative
sample of high school students from the 2011 Youth Risk
Behavior Surveillance System.26
Conclusion
As high school sports participation steadily increases,27
public health practitioners must identify risk factors and
prevention strategies to address EHI events. Continued
surveillance will help to describe the epidemiology of EHI
in football and other sports. Table 2 lists strategies to
improve the surveillance of EHI in sports. At the same
time, coaches and athletic trainers should be prepared to
modify, postpone, or cancel practices and competitions
in accordance with published EHI prevention guide-
lines.28 The Wet Bulb Globe Temperature, which com-
bines ambient temperature and ambient humidity data
into one overall index,10,11,17 should be used. Unfortu-
nately, many high school athletes and coaches lack the
knowledge required to identify and treat EHI.29 In-
creased awareness and preventive measures are needed to
reduce the incidence and severity of this preventable
sports-related adverse health event.
14 Kerr et al / Am J Prev Med 2013;44(1):8 –14
ZYK was funded by The Society for Public Health Education
(SOPHE)/CDC Student 2012 Fellowship in Injury/Violence
Prevention and Control.
The content of this report was also funded in part by the CDC
Grant Nos. R49/CE000674-01 and R49/CE001172-01. The au-
thors also acknowledge the generous research funding contri-
butions of the National Federation of State High School Asso-
ciations, DonJoy Orthotics, and EyeBlack.
No other authors reported fınancial disclosures.
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