Deaths From Hypothermia-Reply

In Reply.—  The concern expressed by Drs Zumwalt and Kicklighter that death certificates may not reflect the true incidence of hypothermia-associated deaths is also applicable to other causes of death. Death certificates have long been used as a surveillance tool in epidemiology, and their limitations are well known. These limitations, however, affected neither our objectives nor the conclusions we reached. Any adjustment for underascertainment of cases increases rather than decreases the importance of this public health problem, and we welcome any suggestions for improving the accuracy of effect estimates for mortality statistics, especially for hypothermia.We agree that bias may be expected among mortality statistics, but we disagree with several conclusions in their letter. On the basis of pathological considerations, they contend that hypothermia is a mechanism and not a legitimate cause of death. Protocols for completing and coding death certificates, however, do identify hypothermia as a cause of death