Association between social vulnerability factors and homicide and suicide rates - United States, 2016 - 2020.

BACKGROUND: Differences in social and environmental factors contribute to disparities in fatal injury rates. This study assessed the relationship between social vulnerability and homicide and suicide rates across United States counties. METHODS: County-level age-adjusted homicide and suicide rates for 2016-2020 were linked with data from the Centers for Disease Control and Prevention's 2020 Social Vulnerability Index (SVI), a dataset identifying socially vulnerable communities. We conducted negative binomial regressions to examine the association between SVI and homicide and suicide rates, overall and by Census region/division. We mapped county-level data for SVI and homicide and suicide rates in bivariate choropleth maps. RESULTS: Overall SVI was associated with homicide rates across U.S. counties. While no association was found for overall SVI and suicide rates, Socioeconomic Status and Racial & Ethnic Minority Status domains were associated. The geographic distribution of SVI and homicide and suicide rates varied spatially; notably, counties in the South had the greatest levels of social vulnerability and greatest homicide rates. CONCLUSIONS: Our findings demonstrate county-level social vulnerability is associated with homicide rates but may be more nuanced for suicide rates. A modified SVI for injury should include additional social and structural determinants and exclude variables not applicable to injuries. PRACTICAL APPLICATIONS: This study combines the SVI with homicide and suicide data, enabling researchers to examine related social and environmental factors. Modifying the SVI to include relevant predictors could improve injury prevention strategies by prioritizing efforts in areas with high social vulnerability.

Association between social vulnerability factors and unintentional fatal injury rates - United States, 2015-2019.

BACKGROUND: Differences in social and environmental factors can contribute to disparities in fatal injury rates. The purpose of this study was to examine the relationship between social and environmental factors and unintentional fatal injury across counties in the United States and how this relationship varies by geography. METHODS: County-level vital statistics on age-adjusted unintentional fatal injury rates for 2015-2019 were linked with county-level data from the 2018 Social Vulnerability Index (SVI), a dataset identifying socially vulnerable communities. We conducted linear regression to examine the association between SVI and unintentional fatal injury, overall and by Census region/division. We mapped county-level data for SVI and unintentional fatal injury rates in bivariate choropleth maps using quartiles. RESULTS: SVI was positively associated with unintentional fatal injury (ß = 18.29, p < 0.001) across U.S. counties. The geographic distribution of SVI and unintentional fatal injury rates varied spatially and substantially for U.S. counties, with counties in the South and West regions having the greatest levels of SVI and rates of unintentional fatal injury. CONCLUSIONS: Our findings demonstrate that the social vulnerability of counties is associated with unintentional fatal injury rates. Modification of the SVI for injury research could include additional social determinants and exclude variables not applicable to injuries. A modified SVI could inform unintentional injury prevention strategies by prioritizing efforts in areas with high levels of social vulnerability. PRACTICAL APPLICATIONS: This study is the first step in combining the SVI and injury mortality data to provide researchers with an index to investigate upstream factors related to injury.

Addressing health disparities using multiply imputed injury surveillance data.

BACKGROUND: Assessing disparities in injury is crucial for injury prevention and for evaluating injury prevention strategies, but efforts have been hampered by missing data. This study aimed to show the utility and reliability of the injury surveillance system as a trustworthy resource for examining disparities by generating multiple imputed companion datasets. METHODS: We employed data from the National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP) for the period 2014-2018. A comprehensive simulation study was conducted to identify the appropriate strategy for addressing missing data limitations in NEISS-AIP. To evaluate the imputation performance more quantitatively, a new method based on Brier Skill Score (BSS) was developed to assess the accuracy of predictions by different approaches. We selected the multiple imputations by fully conditional specification (FCS MI) to generate the imputed companion data to NEISS-AIP 2014-2018. We further assessed health disparities systematically in nonfatal assault injuries treated in U.S. hospital emergency departments (EDs) by race and ethnicity, location of injury and sex. RESULTS: We found for the first time that significantly higher age-adjusted nonfatal assault injury rates for ED visits per 100,000 population occurred among non-Hispanic Black persons (1306.8, 95% Confidence Interval [CI]: 660.1 - 1953.5), in public settings (286.3, 95% CI: 183.2 - 389.4) and for males (603.5, 95% CI: 409.4 - 797.5). We also observed similar trends in age-adjusted rates (AARs) by different subgroups for non-Hispanic Black persons, injuries occurring in public settings, and for males: AARs of nonfatal assault injury increased significantly from 2014 through 2017, then declined significantly in 2018. CONCLUSIONS: Nonfatal assault injury imposes significant health care costs and productivity losses for millions of people each year. This study is the first to specifically look at health disparities in nonfatal assault injuries using multiply imputed companion data. Understanding how disparities differ by various groups may lead to the development of more effective initiatives to prevent such injury.

Coping with oil spills: oil exposure and anxiety among residents of Gulf Coast states after the Deepwater Horizon Oil Spill.

In April 2010, a fatal explosion on the Deepwater Horizon drilling rig in the Gulf of Mexico resulted in the largest marine oil spill in history. This research describes the association of oil exposure with anxiety after the Deepwater Horizon Oil Spill and evaluates effect modification by self-mastery, emotional support and cleanup participation. To assess the impacts of the Deepwater Horizon Oil Spill, the Centers for Disease Control and Prevention (CDC) conducted the Gulf States Population Survey (GSPS), a random-digit-dial telephone cross-sectional survey completed between December 2010 and December 2011 with 38,361 responses in four different Gulf Coast states: Louisiana, Florida, Alabama and Mississippi. Anxiety severity was measured using the Generalised Anxiety Disorder (GAD) symptom inventory. We used Tobit regression to model underlying anxiety as a function of oil exposure and hypothesised effect modifiers, adjusting for socio-demographics. Latent anxiety was higher among those with direct contact with oil than among those who did not have direct contact with oil in confounder-adjusted models [ß = 2.84, 95% confidence interval (CI): 0.78, 4.91]. Among individuals with direct contact with oil, there was no significant interaction between participating in cleanup activities and emotional support for anxiety (p = 0.20). However, among those with direct contact with oil, in confounder-adjusted models, participation in oil spill cleanup activities was associated with lower latent anxiety (ß = -3.55, 95% CI: -6.15, -0.95). Oil contact was associated with greater anxiety, but this association appeared to be mitigated by cleanup participation.

Assessing Female Suicide From a Health Equity Viewpoint, U.S. 2004-2018.

INTRODUCTION: Geographic and urbanization differences in female suicide trends across the U.S. necessitates suicide prevention efforts on the basis of geographic variations. The purpose of this study was to assess female suicide rates by mechanism within Census divisions and by urbanicity to help inform geographically tailored approaches for suicide prevention strategies. METHODS: Data from 2004 to 2018 were obtained from the National Vital Statistics System (analyzed in 2021). Annual counts of female suicides were tabulated for firearm, suffocation, and drug poisoning and stratified by the U.S. Census division and urbanicity. Age-adjusted rates were calculated to describe female suicide incidence by geographic areas and urbanicity. Data were analyzed annually and by 5-year timeframes. Trends in annual female suicide rates by mechanism for 3 urbanization levels were identified using Joinpoint Regression. Annual percent change estimates were calculated for age-adjusted female suicide rates between 2004 and 2018. RESULTS: Female suicide rates by mechanism were not homogeneous within Census divisions or by urbanization levels. Suicide rates by mechanism across Census divisions within the same urbanization level varied (range=3.38-11.15 [per 100,000 person per year]). From 2014 to 2018 in large metropolitan areas in the northern divisions, rates for suffocation were higher than for firearms and drug poisoning. During the same period, in all urbanization levels in southern divisions, rates for firearms were higher than for suffocation and drug poisoning. CONCLUSIONS: Female suicide mechanisms vary by urbanization level, and this variation differs by region. These results could inform female suicide prevention strategies on the basis of mechanism, urbanization, and geographic region.

Injury-Related Emergency Department Visits During the COVID-19 Pandemic.

INTRODUCTION: On March 13, 2020, the U.S. declared COVID-19 to be a national emergency. As communities adopted mitigation strategies, there were potential changes in the trends of injuries treated in emergency department. This study provides national estimates of injury-related emergency department visits in the U.S. before and during the pandemic. METHODS: A secondary retrospective cohort study was conducted using trained, on-site hospital coders collecting data for injury-related emergency department cases from medical records from a nationally representative sample of 66 U.S. hospital emergency departments. Injury emergency department visit estimates in the year before the pandemic (January 1, 2019-December 31, 2019) were compared with estimates of the year of pandemic declaration (January 1, 2020-December 31, 2020) for overall nonfatal injury-related emergency department visits, motor vehicle, falls-related, self-harm-, assault-related, and poisoning-related emergency department visits. RESULTS: There was an estimated 1.7 million (25%) decrease in nonfatal injury-related emergency department visits during April through June 2020 compared with those of the same timeframe in 2019. Similar decreases were observed for emergency department visits because of motor vehicle‒related injuries (199,329; 23.3%) and falls-related injuries (497,971; 25.1%). Monthly 2020 estimates remained relatively in line with 2019 estimates for self-harm‒, assault-, and poisoning-related emergency department visits. CONCLUSIONS: These findings provide updates for clinical and public health practitioners on the changing profile of injury-related emergency department visits during the COVID-19 pandemic. Understanding the short- and long-term impacts of the pandemic is important to preventing future injuries.

The Epidemiology and Geographic Patterns of Natural Disaster and Extreme Weather Mortality by Race and Ethnicity, United States, 1999-2018.

OBJECTIVES: The adverse effects that racial and ethnic minority groups experience before, during, and after disaster events are of public health concern. The objective of this study was to examine disparities in the epidemiologic and geographic patterns of natural disaster and extreme weather mortality by race and ethnicity. METHODS: We used mortality data from the Centers for Disease Control and Prevention from January 1, 1999, through December 31, 2018. We defined natural disaster and extreme weather mortality based on International Classification of Diseases, 10th Revision codes X30-X39. We calculated age-adjusted mortality rates by race, ethnicity, and hazard type, and we calculated age-adjusted mortality rate ratios by race, ethnicity, and state. We used geographic mapping to examine age-adjusted mortality rate ratios by race, ethnicity, and state. RESULTS: Natural disasters and extreme weather caused 27 335 deaths in the United States during 1999-2018. Although non-Hispanic White people represented 68% of total natural disaster and extreme weather mortality, the mortality rate per 100 000 population among non-Hispanic Black people was 1.87 times higher (0.71) and among non-Hispanic American Indian/Alaska Native people was 7.34 times higher (2.79) than among non-Hispanic White people (0.38). For all racial and ethnic groups, exposure to extreme heat and cold were the 2 greatest causes of natural disaster and extreme weather mortality. Racial and ethnic disparities in natural disaster and extreme weather mortality were highest in the South, Southwest, Mountain West, and Upper Midwest. CONCLUSIONS: Racial and ethnic minority populations have a greater likelihood of mortality from natural disaster or extreme weather events than non-Hispanic White people. Our study strengthens the current knowledge base on these disparities and may inform and improve disaster preparedness and response efforts.

Mechanisms of resiliency against depression following the Deepwater Horizon Oil Spill.

Prior studies of oil spills have reported adverse impacts on mental health, but have not examined some potentially important moderators. In this cross-sectional analysis of n=38,361 responses to the 2010-2011 Gulf States Population Survey, we assessed the association of direct oil contact with depression severity following the Deepwater Horizon oil spill, and modification by self-mastery, emotional support, and cleanup participation using Tobit regression models accounting for the complex survey design. Oil contact was associated with increased depression severity. Among respondents with oil contact, depression was more severe for those reporting lower self-mastery. However, respondents with oil contact had lower depression severity if they participated in cleanup efforts, compared to exposed individuals who did not participate. This potential protective effect was larger for respondents with lower self-mastery. Our results are consistent with the notion that participation in recovery efforts may reduce depressive symptoms following oil spills among impacted individuals.

Getting the Message Out: Social Media and Word-of-Mouth as Effective Communication Methods during Emergencies.

Effective communication is a critical part of managing an emergency. During an emergency, the ways in which health agencies normally communicate warnings may not reach all of the intended audience. Not all communities are the same, and households within communities are diverse. Because different communities prefer different communication methods, community leaders and emergency planners need to know their communities' preferred methods for seeking information about an emergency. This descriptive report explores findings from previous community assessments that have collected information on communication preferences, including television (TV), social media, and word-of-mouth (WoM) delivery methods. Data were analyzed from 12 Community Assessments for Public Health Emergency Response (CASPERs) conducted from 2014-2017 that included questions regarding primary and trusted communication sources. A CASPER is a rapid needs assessment designed to gather household-based information from a community. In 75.0% of the CASPERs, households reported TV as their primary source of information for specific emergency events (range = 24.0%-83.1%). Households reporting social media as their primary source of information differed widely across CASPERs (3.2%-41.8%). In five of the CASPERs, nearly one-half of households reported WoM as their primary source of information. These CASPERs were conducted in response to a specific emergency (ie, chemical spill, harmful algal bloom, hurricane, and flood). The CASPERs conducted as part of a preparedness activity had lower percentages of households reporting WoM as their primary source of information (8.3%-10.4%). The findings in this report demonstrate the need for emergency plans to include hybrid communication models, combining traditional methods with newer technologies to reach the broadest audience. Although TV was the most commonly reported preferred source of information, segments of the population relied on social media and WoM messaging. By using multiple methods for risk communication, emergency planners are more likely to reach the whole community and engage vulnerable populations that might not have access to, trust in, or understanding of traditional news sources. Multiple communication channels that include user-generated content, such as social media and WoM, can increase the timeliness of messaging and provide community members with message confirmation from sources they trust encouraging them to take protective public health actions.WolkinAF, SchnallAH, NakataNK, EllisEM. Getting the message out: social media and word-of-mouth as effective communication methods during emergencies. Prehosp Disaster Med. 2019;34(1):89-94.

Evaluation of Real-Time Mortality Surveillance Based on Media Reports.

OBJECTIVE: We evaluated the usefulness and accuracy of media-reported data for active disaster-related mortality surveillance. METHODS: From October 29 through November 5, 2012, epidemiologists from the Centers for Disease Control and Prevention (CDC) tracked online media reports for Hurricane Sandy-related deaths by use of a keyword search. To evaluate the media-reported data, vital statistics records of Sandy-related deaths were compared to corresponding media-reported deaths and assessed for percentage match. Sensitivity, positive predictive value (PPV), and timeliness of the media reports for detecting Sandy-related deaths were calculated. RESULTS: Ninety-nine media-reported deaths were identified and compared with the 90 vital statistics death records sent to the CDC by New York City (NYC) and the 5 states that agreed to participate in this study. Seventy-five (76%) of the media reports matched with vital statistics records. Only NYC was able to actively track Sandy-related deaths during the event. Moderate sensitivity (83%) and PPV (83%) were calculated for the matching media-reported deaths for NYC. CONCLUSIONS: During Hurricane Sandy, the media-reported information was moderately sensitive, and percentage match with vital statistics records was also moderate. The results indicate that online media-reported deaths can be useful as a supplemental source of information for situational awareness and immediate public health decision-making during the initial response stage of a disaster. (Disaster Med Public Health Preparedness. 2017;11:460-466).

Effectiveness of Using Cellular Phones to Transmit Real-Time Shelter Morbidity Surveillance Data After Hurricane Sandy, New Jersey, October to November, 2012.

Timely morbidity surveillance of sheltered populations is crucial for identifying and addressing their immediate needs, and accurate surveillance allows us to better prepare for future disasters. However, disasters often create travel and communication challenges that complicate the collection and transmission of surveillance data. We describe a surveillance project conducted in New Jersey shelters after Hurricane Sandy, which occurred in November 2012, that successfully used cellular phones for remote real-time reporting. This project demonstrated that, when supported with just-in-time morbidity surveillance training, cellular phone reporting was a successful, sustainable, and less labor-intensive methodology than in-person shelter visits to capture morbidity data from multiple locations and opened a two-way communication channel with shelters. (Disaster Med Public Health Preparedness. 2015;10:525-528).

Use of Community Assessments for Public Health Emergency Response (CASPERs) to Rapidly Assess Public Health Issues - United States, 2003-2012.

INTRODUCTION: Community Assessment for Public Health Emergency Response (CASPER) is an epidemiologic technique designed to provide quick, inexpensive, accurate, and reliable household-based public health information about a community's emergency response needs. The Health Studies Branch at the Centers for Disease Control and Prevention (CDC) provides in-field assistance and technical support to state, local, tribal, and territorial (SLTT) health departments in conducting CASPERs during a disaster response and in non-emergency settings. Data from CASPERs conducted from 2003 through 2012 were reviewed to describe uses of CASPER, ascertain strengths of the CASPER methodology, and highlight significant findings. METHODS: Through an assessment of the CDC's CASPER metadatabase, all CASPERs that involved CDC support performed in US states and territories from 2003 through 2012 were reviewed and compared descriptively for differences in geographic distribution, sampling methodology, mapping tool, assessment settings, and result and action taken by decision makers. RESULTS: For the study period, 53 CASPERs were conducted in 13 states and one US territory. Among the 53 CASPERS, 38 (71.6%) used the traditional 2-stage cluster sampling methodology, 10 (18.8%) used a 3-stage cluster sampling, and two (3.7%) used a simple random sampling methodology. Among the CASPERs, 37 (69.9%) were conducted in response to specific natural or human-induced disasters, including 14 (37.8%) for hurricanes. The remaining 16 (30.1%) CASPERS were conducted in non-disaster settings to assess household preparedness levels or potential effects of a proposed plan or program. The most common recommendations resulting from a disaster-related CASPER were to educate the community on available resources (27; 72.9%) and provide services (18; 48.6%) such as debris removals and refills of medications. In preparedness CASPERs, the most common recommendations were to educate the community in disaster preparedness (5; 31.2%) and to revise or improve preparedness plans (5; 31.2%). Twenty-five (47.1%) CASPERs documented on the report or publications the public health action has taken based on the result or recommendations. Findings from 27 (50.9%) of the CASPERs conducted with CDC assistance were published in peer-reviewed journals or elsewhere. CONCLUSION: The number of CASPERs conducted with CDC assistance has increased and diversified over the past decade. The CASPERs' results and recommendations supported the public health decisions that benefitted the community. Overall, the findings suggest that the CASPER is a useful tool for collecting household-level disaster preparedness and response data and generating information to support public health action.

The role of applied epidemiology methods in the disaster management cycle.

Disaster epidemiology (i.e., applied epidemiology in disaster settings) presents a source of reliable and actionable information for decision-makers and stakeholders in the disaster management cycle. However, epidemiological methods have yet to be routinely integrated into disaster response and fully communicated to response leaders. We present a framework consisting of rapid needs assessments, health surveillance, tracking and registries, and epidemiological investigations, including risk factor and health outcome studies and evaluation of interventions, which can be practiced throughout the cycle. Applying each method can result in actionable information for planners and decision-makers responsible for preparedness, response, and recovery. Disaster epidemiology, once integrated into the disaster management cycle, can provide the evidence base to inform and enhance response capability within the public health infrastructure.

Assessing radiation emergency preparedness planning by using community assessment for public health emergency response (CASPER) methodology.

INTRODUCTION: Approximately 1.2 million persons in Oakland County, Michigan (USA) reside less than 50 miles from the Fermi Nuclear Power Plant, Unit 2, but information is limited regarding how residents might react during a radiation emergency. Community Assessment for Public Health Emergency Response (CASPER) survey methodology has been used in disaster and non disaster settings to collect reliable and accurate population-based public health information, but it has not been used to assess household-level emergency preparedness for a radiation emergency. To improve emergency preparedness plans in Oakland County, including how residents might respond during a radiation emergency, Oakland County Health Division (OCHD), with assistance from the Centers for Disease Control and Prevention (CDC) and the Michigan Department of Community Health (MDCH), conducted a CASPER survey. METHODS: During September 2012, a 2-stage cluster sampling design was used to select 210 representative households in Oakland County. By using in-person surveys, the proportion of households with essential needs and supplies, how residents might respond to public health authorities' instructions, and their main source for obtaining information during a radiation emergency were assessed. Data were weighted to account for the complex sampling design. RESULTS: Of the goal of 210 households, 192 (91.4%) surveys were completed: 64.7% and 85.4% of respondents indicated having 3-day supplies of water and of non perishable food, respectively; 62.8% had a 7-day supply of prescription medication for each person who needed it. Additionally, 64.2% had a working carbon monoxide detector; 67.1% had a first-aid kit; and 52% had an alternative heat source. In response to instructions from public health officials during a radiation emergency, 93.3% of all respondents would report to a radiation screening center; 96% would evacuate; and 91.8% would shelter-in-place. During a radiation emergency, 55.8% of respondents indicated their main information source would be television, 18.4% radio, and 13.6% the Internet. The most trusted source for information would be the local public health department (36.5%), local news (23%), a physician (11.2%), and family members (11.1%). Including completed and incomplete interviews, refusals, and non respondents, 517 total households were contacted. CONCLUSIONS: CASPER data regarding how residents might react during a radiation emergency provided objective and quantifiable information that will be used to develop Oakland County's radiation emergency preparedness plans. Survey information demonstrates the feasibility and usefulness of CASPER methodology for radiation emergency preparedness planning.

Heat illness: predictors of hospital admissions among emergency department visits-Georgia, 2002-2008.

Heat-related illnesses (HRI) are the most frequent cause of environmental exposure-related injury treated in US emergency departments (ED). While most individuals with HRI evaluated in EDs are discharged to home, understanding predictors of individuals hospitalized with HRI may help public health practitioners and medical providers identify high risk groups who would benefit from educational outreach. We analyzed data collected by the Georgia Department of Public Health, Office of Health Indicators for Planning, regarding ED and hospital discharges for HRI, as identified by ICD-9 codes, between 2002 and 2008 to determine characteristics of individuals receiving care in EDs. Temperature data from CDC's Environmental Public Health Tracking Network were linked to the dataset to determine if ED visits occurred during an extreme heat event (EHE). A multivariable logistic regression model was developed to determine characteristics predicting hospitalization versus ED discharge using demographic characteristics, comorbid conditions, socioeconomic status, the public health district of residence, and the presence of an EHE. Men represented the majority of ED visits (75 %) and hospitalizations (78 %). In the multivariable model, the odds of admission versus ED discharge with an associated HRI increased with age among both men and women, and odds were higher among residents of specific public health districts, particularly in the southern part of the state. Educational efforts targeting the specific risk groups identified by this study may help reduce the burden of hospitalization due to HRI in the state of Georgia.

Evaluation of the National Weather Service Extreme Cold Warning Experiment in North Dakota.

Dangerously cold weather threatens life and property. During periods of extreme cold due to wind chill, the National Weather Service (NWS) issues wind chill warnings to prompt the public to take action to mitigate risks. Wind chill warnings are based on ambient temperatures and wind speeds. Since 2010, NWS has piloted a new extreme cold warning issued for cold temperatures in wind and nonwind conditions. The North Dakota Department of Health, NWS, and the Centers for Disease Control and Prevention collaborated in conducting household surveys in Burleigh County, North Dakota, to evaluate this new warning. The objectives of the evaluation were to assess whether residents heard the new warning and to determine if protective behaviors were prompted by the warning. This was a cross-sectional survey design using the Community Assessment for Public Health Emergency Response (CASPER) methodology to select a statistically representative sample of households from Burleigh County. From 10 to 11 April 2012, 188 door-to-door household interviews were completed. The CASPER methodology uses probability sampling with weighted analysis to estimate the number and percentage of households with a specific response within Burleigh County. The majority of households reported having heard both the extreme cold and wind chill warnings, and both warnings prompted protective behaviors. These results suggest this community heard the new warning and took protective actions after hearing the warning.

Exertional heat-related illnesses at the Grand Canyon National Park, 2004-2009.

BACKGROUND: The Grand Canyon National Park has approximately 4 million visitors between April and September each year. During this period, outdoor activity such as hiking is potentially hazardous owing to extreme heat, limited shade, and steep, long ascents. Given the high visitation and the public health interest in the effects of extreme heat, this study calculated morbidity rates and described heat-related illness (HRI) among visitors. METHODS: We conducted a retrospective cross-sectional study from April 1 through September 30, during 2004-2009. From a review of Ranger Emergency Medical Services (EMS) incident report files, we extracted information on those that met the case definition of greater than 1 hour of outdoor heat exposure with an HRI assessment or diagnosis, HRI self-report, or signs or symptoms of HRI without another etiology noted. Visitor and temperature data were obtained from respective official sources. RESULTS: Grand Canyon EMS responded to 474 nonfatal and 6 fatal HRI cases, with the majority (84%) being US residents, 29% from Western states. Of the nonfatal cases, 51% were women, the median age was 43 years (range, 11-83 years), and 18% reported a cardiovascular condition. Clinical HRI assessments included dehydration (25%), heat exhaustion (23%), and suspected hyponatremia (19%). Almost all (90%) were hiking; 40% required helicopter evacuation. The highest HRI rates were seen in May. CONCLUSIONS: HRI remains a public health concern at the Grand Canyon. High-risk evacuations and life-threatening conditions were found. Majority were hikers, middle-aged adults, and US residents. These findings support the park's hiker HRI prevention efforts and use of park EMS data to measure HRI.

Mortality from a tornado outbreak, Alabama, April 27, 2011.

OBJECTIVES: We describe the demographics of the decedents from the tornado outbreak in Alabama on April 27, 2011; examine the circumstances of death surrounding these fatalities; and identify measures to prevent future tornado-related fatalities. METHODS: We collected information about the decedents from death certificates, disaster-related mortality surveillance, and interview data collected by American Red Cross volunteers from the decedent's families. We describe demographic characteristics, circumstances and causes of death, and sheltering behaviors before death. RESULTS: Of the 247 fatalities, females and older adults were at highest risk for tornado-related deaths. Most deaths were directly related to the tornadoes, on scene, and trauma-related. The majority of the deceased were indoors in single-family homes. Word of mouth was the most common warning mechanism. CONCLUSIONS: This tornado event was the third deadliest in recent US history. Our findings support the need for local community shelters, enhanced messaging to inform the public of shelter locations, and encouragement of word-of-mouth warnings and personal and family preparedness planning, with a special focus on assisting vulnerable individuals in taking shelter.

Disaster-related injuries and illnesses treated by American Red Cross disaster health services during Hurricanes Gustav and Ike.

OBJECTIVE: To describe the injuries and illnesses treated by the American Red Cross (Red Cross) during Hurricanes Gustav and Ike disaster relief operations reported on a new Aggregate Morbidity Report Form. METHODS: From August 28 to October 18, 2008, 119 Red Cross field service locations in Louisiana, Mississippi, Tennessee, and Texas addressed the healthcare needs of people affected by the hurricanes. From these locations, individual client visit data were retrospectively collated per site onto new 24-hour Aggregate Morbidity Report Forms. RESULTS: A total of 3863 clients were treated. Of the clients, 48% were girls and women and 44% were boys and men; 61% were 19 to 64 years old. Ninety-eight percent of the visits occurred in shelters. The reasons for half of the visits were acute illness and symptoms (eg, pain) and 16% were for routine follow-up care. The majority (65%) of the 2516 visits required treatment at a field location, although 34%, or 1296 visits, required a referral, including 543 healthcare facility transfers. CONCLUSIONS: During the hurricanes, a substantial number of displaced evacuees sought care for acute and routine healthcare needs. The capacity of the Red Cross to address the immediate and ongoing health needs of sheltered clients for an extended period of time is a critical resource for local public health agencies, which are often overwhelmed during a disaster. This article highlights the important role that this humanitarian organization fills, to decrease surge to local healthcare systems and to monitor health effects following a disaster. The Aggregate Morbidity Report Form has the potential to assist greatly in this role, and thus its utility for real-time reporting should be evaluated further.