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Environ Health Perspect. 2019 Apr;127(4):47003. doi: 10.1289/EHP4163.

The Association between Mandated Preseason Heat Acclimatization Guidelines and Exertional Heat Illness during Preseason High School American Football Practices.

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1 Department of Exercise and Sport Science, University of North Carolina at Chapel Hill , Chapel Hill, North Carolina, USA.
2 Department of Exercise and Nutrition Sciences, University at Buffalo, State University of New York , Buffalo, New York, USA.
3 Department of Epidemiology, University of Colorado Anschutz , Aurora, Colorado, USA.
4 Korey Stringer Institute, Department of Kinesiology, University of Connecticut , Storrs, Connecticut, USA.
5 Department of Kinesiology, University of North Carolina at Greensboro , Greensboro, North Carolina, USA.
6 Department of Epidemiology, University of North Carolina at Chapel Hill , Chapel Hill, North Carolina, USA.



The risk of heat-related illness and death may continue to increase in many locations as a consequence of climate change, but information on the effectiveness of policies to protect populations from the adverse effects of excessive heat is limited. In 2009, the National Athletic Trainers' Association Inter-Association Task Force (NATA-IATF) released guidelines to reduce exertional heat illness (EHI) among U.S. high school athletes participating in preseason sports activities, including preseason practice sessions for American football. A subset of state high school athletic associations have implemented state-mandated guidelines consistent with the 2009 NATA-IATF recommendations, but their effectiveness for reducing preseason EHI is unknown.


This study examines the association between the enactment of state high school athletic association-mandated NATA-IATF guidelines and the rate of EHI among high school students during preseason American football practice sessions.


We performed a quasi-experimental interrupted time-series study of EHI during high school American football practices in the 2005/2006-2016/2017 school years. We estimated state-level EHI rates using High School Reporting Information Online injury and athlete-exposure data, and used generalized estimating equations Poisson regression models to estimate incidence rate ratios (IRRs) and 95% confidence intervals (CIs) comparing state-years with and without mandated NATA-IATF guidelines. State-level covariates included state-year-specific average August temperatures, yearly deviations from each state's August average temperature across the study period, and school year.


Data were available for 455 state-years from 48 states, including 32 state-years (7.0%) from 8 states when mandated guidelines consistent with the NATA-IATF recommendations were implemented. During an estimated 2,697,089 athlete-exposures, 190 EHIs were reported. Estimated preseason EHI rates were lower during state-years with versus without mandated guidelines (adjusted [Formula: see text], 95% CI: 0.23, 0.87).


Our findings suggest that high school athletes would benefit from enactment of the 2009 NATA-IATF guidelines. Similar analyses of the effectiveness of other public health policies to reduce adverse health effects from ambient heat are warranted.

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