Effect Modification by Environmental Quality on the Association between Heatwaves and Mortality in Alabama, United States.

: Previous studies have shown that heatwaves are associated with increased mortality. However, it remains unclear whether the associations between heatwaves and mortality are modified by the environmental quality. : We used the United States (US) Environmental Protection Agency's Environmental Quality Index (EQI) and its five domain indices (air, water, land, built, and sociodemographic) to represent the cumulative environmental quality. We applied a time-stratified case-crossover design to analyze the disparities in the association between heatwaves and non-accidental deaths (NAD) among counties with different environmental qualities, in metropolitan areas in Alabama (AL), United States. : We found significant associations between heatwaves and NAD and a significant effect modification of this relationship by EQI. There were higher odds ratios in counties with the worst cumulative environmental qualities compared to counties with the best cumulative environmental qualities. For example, the percent change in odds ratio (mean and (95% CI)) between heatwave days and non-heatwave days was -10.3% (-26.6, 9.6) in counties with an overall EQI of 1 (the best overall environment) and 13.2% (4.9, 22.2) in counties with an overall EQI of 3 (the worst overall environment). Among the five domains, air quality had the strongest effect modification on the association. : Our findings provide evidence that the associations between heatwaves and NAD vary among areas with different environmental qualities. These findings suggest that integration of air quality and heatwave warning systems may provide greater protection to public health.