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Health risk assessments for extreme heat and the design of corresponding interventions can be enhancedwithmore information regarding causal drivers of year-to-year variability in adverse outcomes. Summer 2016was a record-setting year in terms of summer heat and its impacts on health inMaricopaCounty, Arizona, USA. Themonth of Junewas thewarmest observed in the county and the six-monthwarm season spanningMay throughOctoberwas the fourthwarmest. In the same year, a record number of heat-associated deaths was reported by the heat surveillance program run by the county health department.We analyzed the time series of heat-associated deaths to quantify the extent towhich the unprecedented death count in 2016was driven by anomalousweather.Wefirst estimated the historical association between temperature and heat-associated deaths for the time period 2006–2015 using a time series regressionmodel. Subsequently, we used themodel to generate predictions of daily heat-associated deaths in 2016 based on the observedweather.We found no evidence that the unusually high number of heat-associated deaths observed inMaricopaCounty in 2016was related to observedmeteorological conditions. Regardless of the exposure variable ormodel parameterization chosen, the prediction for 2016 fell near or below the historical average number of heat-associated deaths. If the conventionalmethods for estimating the temperature–mortality association are reasonably approximating a causal relationship, factors other than theweather were mostly responsible for the surge in deaths in 2016. Thesefindings highlight the importance of nonmeteorological factors as drivers of temporal variability in the health burden associatedwith heat, which have generally not been included in quantitative retrospective or prospective studies. Further, they highlight a shortcoming in preparedness and response efforts for heat in the study setting that should be diagnosed and addressed as soon as possible.

It’s not the heat, it’s the vulnerability: attribution of the 2016 spike in heat-associated deaths in Maricopa County, Arizona