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Humans are warm-blooded, that is, we have the physiological ability to regulate our
bodys internal temperature, which is kept at 37C 2C. If the bodys core temperature either
rises or falls beyond this, then serious illness or even death may result (Pits, 2004). Operations
involving high air temperatures, radiant heat sources, high humidity, direct physical contact
with hot objects, or strenuous physical activities have a high potential for inducing heat stress
in employees engaged in such operations including iron and steel foundries, nonferrous
foundries, brick-firing and ceramic plants, glass products facilities, rubber products factories,
electrical utilities (particularly boiler rooms), bakeries, confectioneries, commercial kitchens,
laundries, food canneries, chemical plants, mining sites, smelters, and steam tunnels. Outdoor
operations conducted in hot weather, such as construction, refining, asbestos removal, and
hazardous waste site activities, especially those that require workers to wear semipermeable or
impermeable protective clothing, are also likely to cause heat stress among exposed workers
(Zens, 2005).
Age, weight, degree of physical fitness, degree of acclimatization, metabolism, use of
alcohol or drugs, and a variety of medical conditions such as hypertension all affect a person's
sensitivity to heat. Individual behaviour also plays a role in regulating body temperature. For
example, an individual can remain in a warm area on a cold day, or seek out shade on a hot day
also can decide either to wear heavyweight or lightweight clothing, depending on the weather
conditions. It is difficult to predict just who will be affected and when, because individual
susceptibility varies. In addition, environmental factors include more than the ambient air
temperature (Pearson, 2007). Radiant heat, air movement, conduction, and relative humidity
all affect an individual's response to heat.

In the work situation, employers have a legal obligation under the Health and Safety in
Employment Act 1992. The Act requires employers to have a safe place of work, and to identify
and control hazards (OSHA ACT, 1992).


a) Modes Of Body Heat Transfer
The main source of heat in normal conditions is the body's own internal heat. Called
metabolic heat, it is generated within the body by the biochemical processes that keep us alive
and by the energy we use in physical activity. The body exchanges heat with its surroundings
mainly through radiation, convection, and evaporation of sweat (Mutchler, 2001).
Radiation is the process by which the body gains heat from surrounding hot objects,
such as hot metal, furnaces or steam pipes, and loses heat to cold objects, such as chilled
metallic surfaces, without contact with them. No radiant heat gain or loss occurs when the
temperature of surrounding objects is the same as the skin temperature (about 35C).
Convection is the process by which the body exchanges heat with the surrounding air.
The body gains heat from hot air and loses heat to cold air which comes in contact with the
skin. Convective heat exchange increases with increasing air speed and increased differences
between air and skin temperature.
Evaporation of sweat from the skin cools the body. Evaporation occurs more quickly
and the cooling effect is more noticeable with high wind speeds and low relative humidity. In
hot and humid workplaces, the cooling of the body due to sweat evaporation is limited because
the air cannot accept more moisture. In hot and dry workplaces, the cooling due to sweat
evaporation is limited by the amount of sweat produced by the body.

The body also exchanges small amounts of heat by Conduction and breathing. By
conduction, the body gains or loses heat when it comes into direct contact with hot or cold
objects. Breathing exchanges heat because the respiratory system warms the inhaled air. When
exhaled, this warmed air carries away some of the body's heat. However, the amount of heat
exchanged through conduction and breathing is normally small enough to be ignored in
assessing the heat load on the body.

b) Body Temperature Regulations

Although human are able to control internal temperature, the human body does not
maintain the same temperature throughout. The temperature of the body at the skin may be a
few degrees different from the internal temperature (Pearson, 2007). The body does, however,
maintain a constant temperature at its centre, that is, in the interior of the brain, the heart and
abdominal organs (Zane, 2006). This constant temperature is known as the core temperature,
and fluctuates very slightly at around 37C. Maintaining this core temperature is necessary for
the normal function of important vital organs. The body has a number of means to raise or
lower the core temperature. The main are (Mutchler, 2001):
Sweating to lower the core temperature. Loss of heat occurs from the evaporation of
sweat on the skin.
Shivering to raise the core temperature. Shivering is an involuntary muscle activity that
increases metabolic heat production.
Increasing or reducing the blood flow to the skin. In a hot thermal environment, a
persons blood flow to the skin will increase, aiding heat transfer and loss. In a cold
thermal environment, the blood flow to the skin is reduced. While this prevents heat
loss and maintains the bodys core temperature around the vital organs, it does make a
person more susceptible to cold injuries such as frostbite.

Heat centre controls

Heat transported by the blood

Secretion of sweat

Production of heat by shivering

Figure 1: Schematic Diagram of the Human Temperature Regulation System Control
Mechanism (Grandjean, 1986).
However, it is possible for the bodys core temperature control mechanisms to fail. For
example, if a person is working in an extreme hot environment, their core temperature may
start to rise. They will start to sweat to cool down. If the fluid lost in sweat is not replaced, the
person will eventually dehydrate and be unable to produce further sweat (Grandjen, 2006). The
body has then lost the ability to control its core temperature. Serious heat problems may then

c) Factor Influences on Body Temperature

There are six (6) main factors that may impact on a person to determine how they feel
either hot or cold. These are (Helman, 2015):

Air temperature, it will have a direct warming or cooling effect on a person.

In situations with a high radiant heat level, air temperature alone is not a good indicator of the
thermal environment.

Humidity is the moisture content of the air. Relative humidity is the moisture

content expressed as a percentage, with 100% being total saturation for that temperature. The
warmer the air, the more moisture is able to be carried in the air. High humidity tends to make

people feel hotter than low humidity. This is because although a person will sweat, sweat will
not evaporate and cool the person if the air is already moisture saturated. Cold air has a lower
moisture content, so humidity is not a factor in cold environments, except that mist, rain or wet
clothing can cause a decrease in insulating characteristics.

Radiant heat is emitted from anything that is hot. Radiant heat will in time heat

the air, but people will absorb heat far more quickly. Radiant heat will affect people anywhere
there is direct sunlight, or where a person is close to a process that emits heat.

Air movement in most situations will cool a person. This will provide some

relief to people in a hot situation, but extra chill to people in a cold situation. In hot
environments increasing the air speed can be used as a control measure. In cold environments,
a wind chill factor can make a person considerably colder than if there was no wind.

Physical activity will increase the generation of heat in the body. In a cold

environment, physical activity can help to warm a person. In a warm or hot environment,
physical activity can increase the load of heat on a person. A high level of physical activity on
a hot day can place a worker at risk of heat strain, where the heat of the day alone would not
cause a problem.

Clothing aids or prevents heat transfer from our bodies to the surrounding

environment. In a cold environment, a person should wear clothing that will prevent as much
heat transfer as possible. Ideal clothing in a hot environment will allow a worker to freely
dissipate heat. Clothing can also be used to shield a person from factors such as radiant heat or
a high wind speed.
Besides to these six factors that affect everyone, there are personal factors that affect
individuals. These include (Helman, 2015):

Overweight people are more at risk of harm in both hot and cold environments.

This is due to an imbalance in heat transfer.

Health condition, there are a number of medical conditions that increase the

risk of harm to people working in an extreme hot or cold environment such as Diabetes and

Level of fitness, physically fit person will acclimatise better and generally cope

with heat or cold stress better than an unfit person.

Age, as a person reaches middle age (45+), lifestyle health issues can start to

emerge. These can make people more susceptible to harm caused by extreme hot or cold

Use of prescribed/non-prescribed substances, such as alcohol or cannabis

will adversely affect people working in extreme hot or cold environments.

All the influences factor on an individual must be taken into consideration for effective
health management in the workplace since it can promote to the development of Heat Stress or
Heat Strain condition where harmful to a person as a result of working.
A) Definitions
Heat stress is the net heat load on the body with contributions from both metabolic
heat production, and external environmental factors including temperature, relative humidity,
radiant heat transfer and air movement, as they are affected by clothing (Grogan, 2002).
Heat strain refers to the acute (short-term) or chronic (long-term) consequences of
exposure to environmental heat stress on a persons physical and mental states (Grogan, 2002).
Heat strain is the term used to describe the effects that occur in the body as a result of heat
stress. The physical effects of heat strain can vary from less serious disorders such as skin
rashes and fainting, to serious life-threatening situations where sweating stops and heat stroke
develops (Parson, 2007).

Symptoms of Heat Strain:


Headaches are usually the earliest of all warning symptoms of heat strain, a warning
sign that is often missed if the person has received no training in managing heat stress.


Muscle cramps.

iii. Changes in breathing patterns and pulse rates.

iv. Weakness.

Heavy perspiration.

vi. Prickly heat.

vii. Dizziness or faintness.
viii. Reduced performance.
ix. An initially strong rapid pulse, then changing to a weak rapid pulse.


xi. Cold clammy skin changing to hot dry skin.

xii. Cessation of perspiration.

B) Health Effects from Exposure to Hot Environments

Work in heat can result in both mental and physical effects on a person. These include:
Initial Mental Responses which will increased irritation, anger, aggression, mood
changes and depression.
Physical Responses which will increased heart activity, sweating, an imbalance of water
and salt levels in the body, and changes in the skin blood flow.
Combined Mental and Physical Responses which will shows lack of efficiency in
performing heavy tasks, people performing skilled tasks less well, accelerated onset of
fatigue, and lack of concentration resulting in higher error rates (MOH, 2016).

Besides, exposure to a hot environment can also result in acclimatisation.

Acclimatisation is best described as the processes (physiological changes) by which a person
adapts themselves to be able to safely and comfortably work in a hot environment. Depending
on the factors of fitness, age, physique, gender and race, the time needed to acclimatise can
take 7-15 days. The steps involved in acclimatisation are:

A gradual increase in perspiration, which means more and more heat loss.


The sweat becomes less salty as the sweat glands learn to conserve salts. This

prevents a salt deficiency in the body which, if it did occur, could lead to muscular cramps.

There is a loss of weight which helps heat loss by reducing the amount of

insulating fat and reduces energy consumption.


As the change proceeds, the worker drinks more to replace the fluid lost by

sweating. After a person becomes acclimatised, they feel thirst whenever their body needs more
fluid, and will therefore drink more.
Acclimatisation should be carried out where it is known that the job will take a period
of time. It is should be a managed process. People working in hot environments should not be
allowed to suffer heat strain as part of the process. Acclimatisation will gradually decline after
exposure to a hot environment ceases. Unless a person moves from one hot job to another, it
should never be assumed they are acclimatised.
Any worker who stops sweating is at extreme risk of suffering serious harm. When
sweating ceases, the bodys core temperature will rise very rapidly. If the core temperature
reaches 41C or higher, the condition commonly known as heat stroke can occur.
Sweat is one of the bodys main means of controlling the core temperature. As a person
works in a hot environment, the body produces sweat in an effort to cool itself, which occurs

as the sweat evaporates. Dangerous levels of dehydration is greater than 10% of body weight
can occur rapidly when working in extremes of temperature. A moderate degree of dehydration,
example 5% reduction in body weight, is usually accompanied by a sensation of thirst.
Although thirst is not a reliable indicator of the degree of dehydration, it gets worse as
dehydration progresses, and the person complains of fatigue, irritability, headaches, nausea,
and giddiness.
The main clinical signs of dehydration are not passing urine and changes to a persons
mental state and personality. When dehydrated, urine will be dark yellow to orange in colour
and there will be far less of it (Azen, 2002). It is therefore vital that any person replace water
and salt that is lost through sweat. Human body can lose up to 5 or 6 litres of fluid in an 8-hour
shift. While working, drink about 250 ml (1 cup) of water every 15-20 minutes. Workers should
be well hydrated before work in the heat begins. A person working in a hot environment loses
water and salt through sweat.
On average, about one litre of water each hour must be drunk to replace lost fluid.
Workers in hot environments should be encouraged to drink water even if they do not feel
thirsty. A person is adequately hydrated when the person has to urinate slightly more often than
usual. Make sure plenty of cool (10-15C) or room temperature (20C) drinking water is
available at the worksite (ACGIH, 2002).
An acclimatized worker loses relatively little salt in their sweat and, therefore, salt in
the normal diet is usually enough to maintain the electrolyte balance in body fluids. For
unacclimatized workers who may sweat continuously and repeatedly, additional salt in the food
may be used. In most cases, people will eat enough salt to maintain their electrolyte balance.
Salt tablets are not recommended because the salt does not enter the body system as fast as
water or other fluids. Too much salt can cause higher body temperatures, increased thirst and
nausea. Workers on salt-restricted diets should discuss their job tasks and the need for

supplementary salt with their doctor.

Sport drinks, fruit juice and others similar group drinks specially designed to replace
body fluids and electrolytes may be taken but for most people, they should be used in
moderation. They may be of benefit for workers who have very physically active occupations
but keep in mind they may add unnecessary sugar or salt to your diet. Fruit juice or sport and
electrolyte drinks, diluted to half the strength with water, is an option. Drinks with alcohol or
caffeine should never be taken, as they dehydrate the body. For most people water is the most
efficient fluid for re-hydration (Azen, 2002).
Besides dehydration others factor can lead to heat stress are lack of airflow by working
in hot, poorly ventilated or confined areas, prolonged sun exposure especially on hot days,
between 11am and 3pm. Hot and crowded conditions when people attending large events
(concerts, dance parties or sporting events) in hot or crowded conditions may also experience
heat stress that can result in illness. Bushfires, exposure to radiant heat from bushfires can cause
rapid dehydration and heat-related illness. Bushfires usually occur when the temperature is
high, which adds to the risk. Some drugs, such as ecstasy and speed, also raise the bodys
temperature, which can lead to heat stress
Heat edema is swelling which generally occurs among people who are not acclimatized
to working in hot conditions. Swelling is often most noticeable in the ankles. Recovery occurs
after a day or two in a cool environment.
Heat rashes are tiny red spots on the skin which cause a prickling sensation during heat
exposure. The spots are the result of inflammation caused when the ducts of sweat glands
become plugged.
Heat cramps are sharp pains in the muscles that may occur alone or be combined with


one of the other heat stress disorders. The cause is salt imbalance resulting from the failure to
replace salt lost with sweat. Cramps most often occur when people drink large amounts of
water without sufficient salt (electrolyte) replacement. Heat cramps are spasms in the voluntary
muscles that occur following a reduction in the concentration of sodium chloride in the blood
below a certain critical level. A negative salt balance in hot conditions usually arises in the
unacclimatised person with a naturally high salt content in sweat, when sweat salt losses but
are not replaced by additional dietary salt during the first few days of work in the heat.
Heat exhaustion is caused by loss of body water and salt through excessive sweating.
Signs and symptoms of heat exhaustion include heavy sweating, weakness, dizziness, visual
disturbances, intense thirst, nausea, headache, vomiting, diarrhea, muscle cramps,
breathlessness, palpitations, tingling and numbness of the hands and feet. Recovery occurs after
resting in a cool area and consuming cool drinks example water, clear juice, or a sports drink.
Heat syncope is heat-induced dizziness and fainting induced by temporarily
insufficient flow of blood to the brain while a person is standing. It occurs mostly among
unacclimatized people. It is caused by the loss of body fluids through sweating, and by lowered
blood pressure due to pooling of blood in the legs. Recovery is rapid after rest in a cool area.
Heat stroke is the most serious type of heat illness. Signs of heat stroke include body
temperature often greater than 41C, and complete or partial loss of consciousness. Sweating
is not a good sign of heat stress as there are two types of heat stroke; (i) "classical" where there
is little or no sweating usually occurs in children, persons who are chronically ill, and the
elderly and (ii) "exertional" where body temperature rises because of strenuous exercise or
work and sweating is usually present.


The Wet Bulb Globe Temperature (WBGT) Index is a model for assessing the heat

stress on a person in a hot environment. It takes into account the main factors that influence
how people feel heat, by directly reading air temperature and radiant heat, and indirectly
measuring humidity and air speed. Factors such as the level of physical activity and the clothing
being worn are also considered. It assumes that the workers are healthy and physically fit for
the work being done. WBGT readings are taken using a globe thermometer, a natural wet bulb
thermometer, and a dry bulb thermometer. All of these can be combined on an area heat stress
Disadvantages of the WBGT Index are a few critical areas where WBGT readings will
not predict the likely effect of heat on employees. These include (i) Where the WBGT
temperature measured is hotter than the index allows for, and where it is not possible to
eliminate or significantly reduce the heat the worker is exposed to, (ii) Where workers are
exposed to extremely hot temperatures for short periods of time, (iii) Where protective clothing
is required to be worn and it cannot be determined what effect the clothing is having on a
person, (iv) Where a cooling device such as an air vest is being worn, and it cannot be
determined what effect it is having on a person. In these situations other means of measurement,
such as core temperature or heart rate, are necessary.


There is no diagnostic test for heat strain. Diagnostic studies are for detection of end
organ damage secondary to the metabolic derangement and ruling out other differential
diagnosis of hyperthermia and CNS dysfunction (Ministry of Health Malaysia, 2016).
a) Laboratory Investigation;

Arterial Blood Gases, to detect hypoxaemia that can occur in patient with continuous
seizure or inadequate respiration secondary to brain injury. Metabolic acidosis can


occur secondary to acute renal impairment.


Glucose / random blood sugar, exclude diagnosis of hypoglycaemia in unconscious

patient and also hyperglycaemia in patient with underlying diabetes or undiagnosed

iii. Electrolytes
a) Sodium, detection of hypernatremia or hyponatremia due to reduced intake fluid
and dehydration and guide the choice of fluid for resuscitation.
b) Potassium, to detect hypokalemia or hyperkalemia that can occurs in early phases
of heat stroke and muscle damages and during treatment.
c) Calcium, Hypocalcaemia occur due to binding of calcium to damage muscles.
iv. Liver Function Test (LFT), Hepatic transaminases (ALT) usually elevated in heat
stroke patient due to centrilobular necrosis of the liver.

Coagulation studies, direct thermal injury also leads to denaturation of proteins

exhibited by dysfunctional enzymes. Any derangement of coagulation is a sign of poor

vi. Full Blood Count, thermal injury to vascular endothelium causes platelet aggregation
and deactivation of protein plasma leading to platelet aggregation and decrease clotting
factor. Total white cell may be elevated due of infection and thrombocytopenia.
vii. Renal Function Test, Acute kidney injury due to inadequacy of volume, dehydration
and may also due to rhadomyolysis, or direct thermal injury to renal parenchyma.
viii. Urine analysis for protein, cast and myoglobin.
b) Electrocardiography (ECG);
Arrhythmias is one of the complications of heat stroke and ruling out underlying cardiac
disease / myocardial injury.


c) Imaging studies

Chest X ray carried out to detect presence atelectasis, pneumonia, pulmonary infarction
and pulmonary oedema complementing clinical examination.


CT scan can be performed once patient is hemodynamically stable and helpful to rule
out intracranial bleeding for patient who did not show improvement in neurological


Prompt diagnosis based on focus history (heat exposure or heat exertion) and clinical
assessment is vital in ensuring improved clinical outcome. Then followed by effective cooling
measures, avoiding a series of metabolic event that may progress into irreversible injury and
death (Ministry of Health Malaysia, 2016).
a) Health Clinic or At Scene of Incident
The goal of therapy at health clinic is to detect the clinical syndrome of heat
exhaustion/heat stroke and initiate effective cooling measures immediately, subsequently
transfer to nearest appropriate hospital for definitive treatment.
The following is the recommended management workflow of suspected heat stroke victims
that present at the health clinic or found at scene.


(Guidelines on Management of Heat Related Illness at Health Clinic and Emergency and Trauma Department, Mac 2016)


(Guidelines on Management of Heat Related Illness at Health Clinic and Emergency and Trauma Department, Mac 2016)


(Guidelines on Management of Heat Related Illness at Health Clinic and Emergency and Trauma Department, Mac 2016)


b) The Emergency and Trauma Department

The goal of therapy for a heat stroke patient is to prevent further metabolic derangement
(rhabdomyolysis, coagulopathy, leading to liver and acute kidney injury) due to thermal injury
and institute effective cooling measures, to lower the core body temperature to below 39C.
Initial management of the heat stroke patients is as following:

(Guidelines on Management of Heat Related Illness at Health Clinic and Emergency and Trauma Department, Mac 2016)



The most effective prevention techniques are by reduce the workers contact with the
hazard, or soften the effect of the hazard. The least effective are those that shield the worker
from the hazard, such as use of personal protective clothing. A high level of physical fitness
and regular intake of water are essential personal factors in preventing heat strain. Prevention
control for minimising are includes:
a) Environment Controls
Provide ventilation, to give a significant air current. This will have the effect of both
removing hot air away from the employee, and increasing the air velocity over the
worker. An increased air velocity aids evaporation of sweat and cools the worker.
Provide air conditioning, either by reducing humidity or providing cooling.
Shield the work environment from any radiant heat sources such as sunlight, or
insulating pipes or other hot objects.
b) Process Modification
Modify the process so that less heat is needed to carry out the task required.
Reduce the heat created in carrying out a process to the lowest possible level to still get
the job done.
c) Administrative Controls
Have only the workers necessary to do the work in any area where heat is a problem.
Other workers who do not have to be exposed to heat as a part of their job should be
situated elsewhere.
Pre-plan jobs so workers have the right tools and only have to enter the hot environment
once, minimising exposure to the heat and enabling the job to be completed quickly and


Perform non-essential work at times when heat is lowest.

Perform all maintenance during a specified shutdown period, and do it well so
breakdowns are minimised.
Ensure workers are properly trained to work in a hot environment, so that they
understand potential problems.
Provide first aid training to those working in hot environments to enable them to
recognise and treat any heat-related disorders. See Appendix D.
Rotate jobs, or have more workers to do a job in a hot environment than would do a
similar job in a normal environment. This means the activity level is lowered, and
workers can get into a cycle of one working while the other rests. It also means that
workers can observe each other for early signs of heat strain.
Reduce the amount of physical work a person has to do in a hot situation, example using
a power tool instead of a hand tool will reduce the amount of heat produced from within
the body.
Provide clothing that will allow workers to sweat freely, and will not stick to the skin.
Provide protective clothing where necessary. See Section 3 Clothing and Personal
Protective Equipment for more details.
Introduce a work/rest regime for workers in hot environments. The WBGT Index
schedules rests depending on the WBGT measured. In lower heat, the work rest ratio is
more work than rest per hour. As heat in the environment increases, the ratio may be
equal, or have more rest than work per hour.
Allow people to acclimatise to a hot environment. If possible, leave heavier tasks for
fully acclimatised workers, or do them in a later stage of project work when
acclimatisation has occurred.


d) Medical Controls
Regular rehydration People working in hot environments should drink 100-150 ml
every 15-20 minutes as a minimum guideline. Fluids must be freely available at the
work site. Plain water or a mixture of 50/50 water/fruit juice are adequate. These are
best at room temperature. These fluids are in addition to routine cups of tea and coffee.
It is best to over-hydrate (drink plenty) before commencing work in a hot environment.
As a guideline, people should drink enough fluids so that they need to urinate slightly more
often than usual. Employers must ensure that fluids are available, and that the workers drink
Maintain fitness during and between periods of work in hot environments.
Eat healthily Fatty food intake should be reduced. Most people do not need to add extra
salt to their diet. The normal intake of salt in their food is usually sufficient.
Additional salt is only justified for unacclimatised workers, and is best taken in the form
of a salty liquid such as beef soup or similar. It is not necessary for short exposure times.
Salt tablets are not recommended, as it is possible to over-compensate for lost salt.
If a person is on a salt-reduced or salt-free diet, they will need to either add salt to their
food for the period of hot work, or have some other means to replace lost salt. If this
situation arises, you should seek medical advice.
Pre-employment medical examinations must be done to ensure that all who are going
to be on the job are sufficiently fit, and have no precluding medical conditions.
Regular medical assessments of workers who spend a lot of time in hot environments
should be undertaken.
Personal hygiene is most important, especially to reduce the risk of prickly heat. A
shower and fresh clothing is advisable as soon as work has finished in the hot


Heatstroke is a life-threatening emergency that can be avoided by following simple
prevention measures. Older people, young children, pregnant or breastfeeding women, and
people with heart disease, high blood pressure or lung disease are most at risk. During hot
weather, drink plenty of water, stay cool indoors or in the shade, and restrict activity, especially
exercise, renovating and gardening.

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