The public health consequences of disasters.

Although disasters have exacted a heavy toll of death and suffering, the future seems more frightening. Good disaster management must link data collection and analysis to the decision-making process. The overall objectives of disaster management from the viewpoint of public health are: 1) needs assessments; 2) matching available resources with defined needs; 3) prevention of further adverse health effects; 4) implementation of disease-control strategies; 5) evaluation of the effectiveness of the application of these strategies; and 6) improvement in contingency planning for future disasters. The effects of sudden-onset, natural disasters on humans are quantifiable. Knowledge of the epidemiology of deaths, injuries, and illnesses is essential to determine effective responses; provide public education; establish priorities, planning, and training. In addition, the temporal patterns for the medical care required must be established so that the needs in future disasters can be anticipated. This article discusses: 1) the nature of disasters due to sudden-onset, natural events; 2) the medical and health needs associated with such events and disasters; 3) practical issues of disaster responses; and 4) the advance organization and management of disasters. The discussion also includes: 1) discussions of past problems in disaster management including non-congruence between available supplies and the actual needs of the affected population; 2) information management; 3) needs assessments; 4) public health surveillance; and 5) linking information with decision-making. This discussion is followed by an analysis of what currently is known about the health-care needs during some specific types of sudden-onset, natural disasters: 1) floods; 2) tropical cyclones; 3) tornadoes; 4) volcanic eruptions; and 5) earthquakes. The article concludes with descriptions of some specific public-health problems associated with disasters including epidemics and disposition of corpses. All natural disasters are unique in that the regions affected have different social, economic, and health backgrounds. But, many similarities exist, and knowledge about these can ensure that the health and emergency medical relief and limited resources are well-managed.

Deaths and injuries due to the earthquake in Armenia: a cohort approach.

BACKGROUND: This is the first population-based study of earthquake injuries and deaths that uses a cohort approach to identify factors of high risk. As part of a special project that collected data about the population in the aftermath of the earthquake that hit Northern Armenia on 7 December 1988, employees of the Ministry of Health working in the earthquake zone on 7 December 1988, and their families, were studied as a cohort to assess the short and long term impact of the disaster. The current analysis assesses short term outcomes of injuries and deaths as a direct result of the earthquake. METHODS: From an unduplicated list of 9017 employees, it was possible to contact and interview 7016 employees or their families over a period extending from April 1990 to December 1992. The current analysis presents the determinants of 831 deaths and 1454 injuries that resulted directly from the earthquake in our study population of 32,743 people (employees and their families). RESULTS: Geographical location, being inside a building during the earthquake, height of the building, and location within the upper floors of the building were risk factors for injury and death in the univariate analyses. However, multivariate analyses, using different models, revealed that being in the Spitak region (odds ratio [OR] = 80.9, 95% confidence interval [CI]: 55.5-118.1) and in the city of Gumri (OR = 30.7, 95% CI: 21.4-44.2) and inside a building at the moment of the earthquake (OR = 10.1, 95% CI: 6.5-15.9) were the strongest predictors for death. Although of smaller magnitude, the same factors had significant OR for injuries. Building height was more important as a factor in predicting death than the location of the individual on various floors of the building except for being on the ground floor of the building which was protective. CONCLUSIONS: Considering that most of the high rise buildings destroyed in this earthquake were built using standard techniques, the most effective preventive effort for this disaster would have been appropriate structural approaches prior to the earthquake.

The historical development of public health responses to disaster.

The first of a of series state-of-the-art reviews commissioned to mark Disasters' 21st anniversary, this paper considers key publications on public health aspects of natural disasters, refugee emergencies and complex humanitarian disasters over the past twenty-odd years. The literature is reviewed and important signposts highlighted showing how the field has developed. This expanding body of epidemiological research has provided a basis for increasingly effective prevention and intervention strategies.

The World Trade Center bombing: injury prevention strategies for high-rise building fires.

The WTC disaster provided an opportunity to look for ways to prevent morbidity among occupants of high-rise buildings during fires. This paper first describes the overall morbidity resulting from the explosion and fire, and second, presents the results of a case-control study carried out to identify risk factors for smoke-related morbidity. The main ones include: increased age, presence of a pre-existing cardio-pulmonary condition, entrapment in a lift and prolonged evacuation time. Study results point to the importance of the following safety systems during high-rise building fires: smoke-control systems with separate emergency power sources; lift-cars, lift-car position-monitoring systems, and lift-car communication systems with separate emergency power sources; two-way emergency communication systems on all floors and in stairwells; stairwells with emergency lighting and designed for the rapid egress of crowds; evacuation systems/equipment to assist in the evacuation of vulnerable people (elderly, infirm). Also important are evacuation plans that include regularly scheduled safety training and evacuation drills.

Disaster epidemiology.

Sound epidemiologic knowledge of the morbidity and mortality caused by disasters is essential when determining what relief supplies, equipment, and personnel are needed to respond effectively in emergency situations. All disasters are unique because each affected region of the world has different social, economic, and baseline health conditions. Some similarities exist, however, among the health effects of different types of disasters, that if recognized, can ensure that the limited health and medical resources of the affected community are well managed.

Disaster epidemiology and disease monitoring.

Better epidemiologic knowledge of the mechanisms of death and of the types of injuries and illnesses caused by disasters is clearly essential to determining the appropriate relief medications, supplies, equipment, and personnel needed to effectively respond to such emergencies. The overall objective of disaster epidemiology is to measure scientifically and describe the health effects of disasters and the factors contributing to these effects. The results of such investigations allow disaster epidemiologists to assess the needs of disaster-affected populations, efficiently match resources to needs, prevent further adverse health effects, evaluate relief effectiveness, and plan for future disasters.

The rapid implementation of a statewide emergency health information system during the 1993 Iowa flood.

In the face of disastrous flooding, the Iowa Department of Public Health established the statewide Emergency Computer Communications Network to establish rapid electronic reporting of disaster-related health data, provide e-mail communications among all county health departments, monitor the long-range public health effects of the disaster, and institute a general purpose public health information system in Iowa. Based on software (CDC WONDER/PC) provided by the Centers for Disease Control and Prevention and using standard personal computers and modems, this system has resulted in a 10- to 20-fold increase in surveillance efficiency at the health department, not including time saved by county network participants. It provides a critical disaster assessment capability to the health department but also facilitates the general practice of public health.

Tornado injuries related to housing in the Plainfield tornado.

BACKGROUND: On 28 August 1990, a tornado in Will County, Illinois, caused 29 deaths and more than US $200 million in damage. Risk factors for impact-related morbidity and mortality were studied. METHODS: A case-control study was conducted of 26 people hospitalized or killed, and 116 injured, randomly selected people who were in houses damaged by the tornado. To obtain information on study subjects, telephone interviews were conducted, and hospital records, coroners' reports, and American Red Cross records were abstracted. Structural details on houses were collected from tax assessor records. RESULTS: Cases were more likely than controls to have been in multistorey houses than in single-storey houses (OR = 3.9; 95% CI: 1.2-13.2). The risk associated with houses built after 1972 (OR = 7.9) and those built from 1962 to 1972 (OR = 2.2) was greater than for those built before 1962 (OR = 1.0; chi 2 for trend = 12.1; P < 0.01). Being in the basement when the tornado hit was protective (OR = 0.1; 95% CI: 0.0-0.4). CONCLUSIONS: One-storey houses were safer than multistorey houses, and basements were safer than other rooms. The association of risk with the construction date of the house is a new finding and should be examined in further studies.

Evaluating a fluorosis hazard after a volcanic eruption.

The August, 1991 eruption of Mt. Hudson (Chile) deposited ash across southern Argentina and contributed to the deaths of thousands of grazing sheep. Early ash analysis revealed high levels of fluoride, a potential ash constituent toxic to humans and animals. In order to evaluate fluorosis as the cause of sheep deaths and to examine the possibility that similar ash and airborne toxins could also have an effect on the human population, we conducted an investigation that included health provider interviews, hospital record review, physical examination of sheep, determination of sheep urine fluoride levels, and complete constituent analysis of ash samples collected at proscribed distances from the volcano. Ash deposited farthest from the volcano had highest fluoride levels; all fluoride measurements were normal after rainfall. There were no signs or symptoms of fluorosis observed in sheep or humans. Sheep deaths resulted from physical, rather than chemical properties of the ash.

Use of a modified cluster sampling method to perform rapid needs assessment after Hurricane Andrew.

STUDY OBJECTIVE: To rapidly obtain population-based estimates of needs in the early aftermath of Hurricane Andrew in South Florida. METHODS: We used a modified cluster-sampling method (the Expanded Programme on Immunization [EPI] method) for three surveys. We selected a systematic sample of 30 quarter-mile square clusters for each survey and, beginning from a random start, interviewed members of seven consecutive occupied households in each cluster. Two surveys were of the most affected area (1990 population, 32,672) at three and ten days after the hurricane struck; one survey was of a less affected area (1990 population, 15,576) seven days after the hurricane struck. MEASUREMENTS AND MAIN RESULTS: Results were available within 24 hours of beginning each survey. Initial findings emphasized the need for restoring utilities and sanitation and helped to focus medical relief on primary care and preventive services. The second survey of the most affected area showed improvement in the availability of food, water, electricity, and sanitation (P < or = .05). There was no evidence of disease outbreaks. CONCLUSION: For the first time, the EPI method provided population-based information to guide and evaluate relief operations after a sudden-impact natural disaster. An improvement over previous approaches, the EPI method warrants further evaluation as a needs assessment tool in acute disasters.

Disaster medical assistance teams: providing health care to a community struck by Hurricane Iniki.

STUDY OBJECTIVE: To describe the type of medical care that disaster medical assistance teams (DMATs) provided to a community struck by a major hurricane. STUDY DESIGN: A prospective study describing the use of DMAT field clinics by a population affected by a major hurricane. Data regarding the type of medical care provided to disaster victims and the acuity of each patient's medical condition were abstracted from medical charts at each field clinic. SETTING: Three DMAT field clinics that provided medical care to residents of Kauai, Hawaii, after Hurricane Iniki struck the island on September 11, 1992. RESULTS: From September 16 to 19, 1992, three DMATs provided medical care to 614 people. The patients' average age was 34 years, and 60% were male. The largest treatment categories were injury (40.4%), illness (38.6%), and preventive services (9.0%). Most illnesses and injuries were minor, and 99% of the patients were ambulatory. Only 33 patients (5.4%) were referred to another medical provider. Referrals were generally for procedures not available in DMAT field clinics rather than for life-threatening conditions. CONCLUSION: DMATs sent to assist with the medical needs of a US community struck by a major hurricane should be prepared to deliver basic medical services and primary health care. The need for these medical services will continue beyond the impact phase of a hurricane disaster.