Child Health During War and Disasters: Building Resilience.

Children face unique risks resulting from disasters and conflicts. Broadly, complex emergencies create new and augment existing health risks to children. Direct, conflict-related injuries and deaths - such as those resulting from exposure to chemical weapons and blast injuries - not only have immediate impact but also have long-term impacts on the health and wellbeing of children. Lapses in vaccination coverage, changes in vector patterns, and widespread malnutrition, contribute to new and re-emerging infectious diseases among children. Understanding risks resulting from disasters and conflicts is critical for implementing timely and appropriate public health programs to reduce the negative health effects on children.

Global population profile of tropical cyclone exposure from 2002 to 2019.

Tropical cyclones have far-reaching impacts on livelihoods and population health that often persist years after the event1-4. Characterizing the demographic and socioeconomic profile and the vulnerabilities of exposed populations is essential to assess health and other risks associated with future tropical cyclone events5. Estimates of exposure to tropical cyclones are often regional rather than global6 and do not consider population vulnerabilities7. Here we combine spatially resolved annual demographic estimates with tropical cyclone wind fields estimates to construct a global profile of the populations exposed to tropical cyclones between 2002 and 2019. We find that approximately 560 million people are exposed yearly and that the number of people exposed has increased across all cyclone intensities over the study period. The age distribution of those exposed has shifted away from children (less than 5 years old) and towards older people (more than 60 years old) in recent years compared with the early 2000s. Populations exposed to tropical cyclones are more socioeconomically deprived than those unexposed within the same country, and this relationship is more pronounced for people exposed to higher-intensity storms. By characterizing the patterns and vulnerabilities of exposed populations, our results can help identify mitigation strategies and assess the global burden and future risks of tropical cyclones.

Chickenpox Outbreaks in Three Refugee Camps on Mainland Greece, 2016-2017: A Retrospective Study.

INTRODUCTION: Displaced populations face disproportionately high risk of communicable disease outbreaks given the strains of travel, health care circumstances in their country of origin, and limited access to health care in receiving countries. STUDY OBJECTIVE: Understanding the role of demographic characteristics in outbreaks is important for timely and efficient control measures. Accordingly, this study assesses chickenpox outbreaks in three large refugee camps on mainland Greece from 2016 - 2017, using clinical line-list data from Médecins du Monde (MdM) clinics. METHODS: Clinical line-list data from MdM clinics operating in Elliniko, Malakasa, and Raidestos camps in mainland Greece were used to characterize chickenpox outbreaks in these camps. Logistic regression was used to compare the odds of chickenpox by sex, camp, and yearly increase in age. Incidences were calculated for age categories and for sex for each camp outbreak. RESULTS: Across camps, the median age was 19 years (IQR: 7.00 - 30.00 years) for all individuals and five years (IQR: 2.00 - 8.00 years) for cases. Males were 55.94% of the total population and 51.32% of all cases. There were four outbreaks of chickenpox across Elliniko (n = 1), Malakasa (n = 2), and Raidestos (n = 1) camps. The odds of chickenpox when controlling for age and sex was lower for Malakasa (OR = 0.46; 95% CI, 0.38 - 0.78) and Raidestos (OR = 0.36; 95% CI, 0.24 - 0.56) when compared Elliniko. Odds of chickenpox were comparable between Malakasa and Raidestos (OR = 1.49; 95% CI, 0.92 - 2.42). Across all camps, the highest incidence was among children zero-to-five years of age. The sex-specific incidence chickenpox was higher for males than females in Elliniko and Malakasa, while the incidence was higher among females in Raidestos. CONCLUSION: As expected, individuals five years of age and under made up the majority of chickenpox cases. However, 12% of cases were teenagers or older, highlighting the need to consider atypical age groups in vaccination strategies and control measures. To support both host and displaced populations, it is important to consider risk-reduction needs for both groups. Including host communities in vaccination campaigns and activities can help reduce the population burden of disease for both communities.

Disease burden among refugees in camps on mainland Greece, 2016-2017: a retrospective cross-sectional study.

BACKGROUND: Despite the importance of baseline health data for evidence-informed decision-making, these data are rarely available for displaced populations. At the height of the European refugee crisis, most of those seeking asylum in Europe were from regions with high prevalences of communicable and non-communicable diseases. To create an epidemiologic profile for refugees in camps on mainland Greece, this study assessed the prevalence of 11 communicable and non-communicable diseases among refugees utilizing Médecins du Monde (MdM) in-camp clinics. METHODS: The proportional morbidity of selected diseases among individuals utilizing MdM services were determined from data collected at refugee camp clinics on mainland Greece from April 2016 - July 2017. Overall and age-specific proportional morbidities were reported. Differences in disease burden among refugees from the largest sending countries - Afghanistan and Syria - were compared using proportional morbidity ratios and 95% confidence intervals. Patterns in results were compared with disease burden estimates in sending countries and with findings from comparable settings. RESULTS: Respiratory tract infections (RTIs) were the most prevalent outcome. Among RTIs, upper RTIs were most common, with a proportional morbidity of nearly 40%; throughout the study period, over 46% of children under 18 years had at least one upper RTI consultation. Musculoskeletal conditions (3.64%), were the most prevalent non-communicable outcome, followed by hypertension (2.21%) and asthma (1.28%). Afghans were 31.68% more likely than Syrians to have a consultation for at least one condition (PR: 1.32; 95% CI: 1.25, 1.39). The proportional morbidity of RTIs was comparable to sending countries, but there was a comparatively lower burden of other conditions among refugees than literature estimates from sending countries. CONCLUSION: Refugees utilizing MdM clinics in camps had higher burdens of communicable diseases - predominantly RTIs - relative to non-communicable diseases. Non-communicable disease burdens were comparatively lower than reported prevalences from in-country populations. These findings can be attributed to a range of considerations including differences in demographic profiles between sending countries and refugee populations and missed opportunities for utilizing clinical care. Further investment is needed to capture the health profiles of displaced populations to support evidence-informed decision-making processes in humanitarian emergency responses.

Human and economic impacts of natural disasters: can we trust the global data?

Reliable and complete data held in disaster databases are imperative to inform effective disaster preparedness and mitigation policies. Nonetheless, disaster databases are highly prone to missingness. In this article, we conduct a missing data diagnosis of the widely-cited, global disaster database, the Emergency Events Database (EM-DAT) to identify the extent and potential determinants of missing data within EM-DAT. In addition, through a review of prominent empirical literature, we contextualise how missing data within EM-DAT has been handled previously. A large proportion of missing data was identified for disasters attributed to natural hazards occurring between 1990 and 2020, particularly on the economic losses. The year the disaster occurred, income-classification of the affected country and disaster type were all significant predictors of missingness for key human and economic loss variables. Accordingly, data are unlikely to be missing completely at random. Advanced statistical methods to handle missing data are thus warranted when analysing disaster data to minimise the risk of biasing statistical inferences and to ensure global disaster data can be trusted.

Predictors of exceeding emergency under-five mortality thresholds using small-scale survey data from humanitarian settings (1999 - 2020): considerations for measles vaccination, malnutrition, and displacement status.

BACKGROUND: Quantifying the effect of measles containing vaccine (MCV) coverage and the prevalence of global acute malnutrition (GAM) on mortality levels in populations of displaced and crisis-affected resident children is important for intervention programming in humanitarian emergencies. METHODS: A total of 1597 surveys containing data on under-five death rate, population status (internally displaced, refugee, or crisis-affected resident), measles containing vaccine coverage, and global acute malnutrition were extracted from the Complex Emergency Database (CE-DAT). Under-five mortality rates were dichotomized to those exceeding critical levels or otherwise. A Bayesian multivariable mixed-effect logistic regression model was used to assess the association between an under-five death rate (U5DR) exceeding this threshold and population status (i.e., internally displaced, refugees or residents), GAM prevalence (proxy for food security), and MCV coverage. RESULTS: The prevalence of GAM, MCV and U5DR were higher in internally displaced children (IDC) with values of 14.6%, 69.9% and 2.07 deaths per 10 000 per day, respectively. Refugee populations had lower average under-five mortality rate (0.89 deaths per 10 000 per day), GAM of 12.0% and the highest measles containing vaccine coverage (80.0%). In crisis-affected residents the prevalence of GAM, MCV and average U5DR are 11.1%, 65.5% and 1.20 deaths per 10 000 per day respectively. In mixed-effect logistic model taking 2 deaths per 10 000 children less than five years old per as emergency threshold (Model III); MCV (AOR = 0.66, 95% Highest Density Interval (HDI): 0.57, 0.78), GAM (AOR = 1.79, 95% HDI: 1.52, 2.12) were associated with a reduction of the odds of U5DR exceeding critical level accounting for country-specific levels of variability. The odds of U5DR exceeding critical level (2/10000/day) in crisis-affected resident children and refugees were 0.36 (95% HDI: 0.22, 0.58) and 0.25(95% HDI: 0.11, 0.55) less than amongst IDP children adjusting for GAM and MCV. In considering country specific yearly median U5DR (model IV) the odds of U5DR exceeding twice the median U5DR were associated with MCV (AOR = 0.72, 95% HDI: 0.64, 0.82), GAM (AOR = 1.53, 95%HDI: 1.34, 1.76). The odds of U5DR exceeding critical level in crisis-affected resident children was 0.30(95% HDI: 0.20, 0.45) less than IDP children, after adjusting for MCV and GAM. We found no difference between the odds of U5DR exceeding twice the country level median U5DR in the refugee population compared to the IDPs. CONCLUSIONS: In this study vaccination coverage and global acute malnutrition (proxy for food security) were associated with U5DR exceeding critical level. The emergency threshold for IDPs and affected residents is significantly different and consistent across the different outcomes, whereas the result is inconsistent for IDPs and refugees. Continued improvement in measles vaccination coverage and reduction of malnutrition in humanitarian emergencies have the potential to minimize the deterioration of mortality level amongst children in emergency settings. To generate a robust understanding of the critical level of child mortality in displaced and affected resident populations, studies accounting for the impact of the duration of displacement, contextual factors in humanitarian settings, and the level of humanitarian assistance provided are needed.

Challenges of Data Availability and Use in Conducting Health-EDRM Research in a Post-COVID-19 World.

Disasters disrupt communication channels, infrastructure, and overburden health systems. This creates unique challenges to the functionality of surveillance tools, data collection systems, and information sharing platforms. The WHO Health Emergency and Disaster Risk Management (Health-EDRM) framework highlights the need for appropriate data collection, data interpretation, and data use from individual, community, and global levels. The COVID-19 crisis has evolved the way hazards and risks are viewed. No longer as a linear event but as a protracted hazard, with cascading and compound risks that affect communities facing complex risks such as climate-related disasters or urban growth. The large-scale disruptions of COVID-19 show that disaster data must evolve beyond mortality and frequency of events, in order to encompass the impact on the livelihood of communities, differentiated between population groups. This includes relative economic losses and psychosocial damage. COVID-19 has created a global opportunity to review how the scientific community classifies data, and how comparable indicators are selected to inform evidence-based resilience building and emergency preparedness. A shift into microlevel data, and regional-level information sharing is necessary to tailor community-level interventions for risk mitigation and disaster preparedness. Real-time data sharing, open governance, cross-organisational, and inter-platform collaboration are necessary not just in Health-EDRM and control of biological hazards, but for all natural hazards and man-made disasters.

Human insecurity and child deaths in conflict: evidence for improved response in Yemen.

BACKGROUND: Since the beginning of the ongoing conflict in Yemen, >23 000 air strikes and >100 000 fatalities have been recorded. Data from Yemen Data Project linked >1300 child fatalities and >900 child injuries to air raids. However, there is little literature on the effect of the protracted armed conflict on the pattern of child mortality using data from small-scale surveys. We aimed to identify the pattern of the death rate for children aged <5 years ('under-5') and its relationship with human insecurity in Yemen. METHODS: We created a human insecurity index (i.e. severely insecure vs insecure) for the 22 governorates in Yemen from 2015 to 2019, using data from the Armed Conflict Location and Event Database. We matched this insecurity index with the corresponding under-5 mortality data from the Complex Emergency Database. We analysed the relationship between the under-5 death rate (U5DR) and the insecurity level using a Bayesian finite mixture model in order to account for unobserved heterogeneity in clustered finite subsets of a population. RESULTS: We extracted 72 surveys and 77.8% (n = 56) were included in this study. The mean of the recall period for mortality was 106 days with a standard deviation of 93 days. We identified two subpopulations: Subpopulation I-high average number of child deaths and Subpopulation II-low average number of child deaths. The log posterior mean of the U5DR is 1.10 (95% credible intervals: 0.36, 1.82) in the severely insecure group in Subpopulation I and 3-fold the estimate in Subpopulation II. However, in Subpopulation II, we found no association between the insecurity level and the U5DR. CONCLUSION: The pattern of child deaths is crucial in understanding the relationship between human insecurity and the U5DR.

Changes in the incidence and prevalence of ischemic stroke and associations with natural disasters: an ecological study in 193 countries.

Epidemiological studies have indicated that natural disasters have important impacts on ischemic stroke. This study determined the associations between natural disasters and the incidence and prevalence of ischemic stroke at the global level. A 28-year ecological trend study was performed to estimate worldwide changes in the incidence and prevalence of ischemic stroke and their associations with natural disasters by analyzing data from 193 countries. Quantum geographic information system-based visualization and multivariable linear regression were used. Changes in the incidence and prevalence of ischemic stroke, as well as disaster occurrence, varied among the different regions over the past 28 years (p < 0.001). Multiple linear regression revealed an independent and positive association between disaster occurrence and the incidence of ischemic stroke in males, females and both sexes combined (standardized coefficients = 0.515, 0.470 and 0.483, p < 0.001); similar associations were found for the prevalence of ischemic stroke (standardized coefficients = 0.471, 0.417 and 0.438, p < 0.001). The incidence and prevalence of ischemic stroke changed significantly at the global level and were independently associated with natural disasters. Both males and females show common but different vulnerabilities to natural disasters. This evidence supports policy making and resource allocation for disaster response and disease burden reduction.

Civil war and death in Yemen: Analysis of SMART survey and ACLED data, 2012-2019.

Conflict in Yemen has displaced millions and destroyed health infrastructure, resulting in the world's largest humanitarian disaster. The objective of this paper is to examine mortality in Yemen to determine whether it has increased significantly since the conflict began in 2015 compared to the preceding period. We analysed 91 household surveys using the Standardized Monitoring and Assessment of Relief and Transitions methodology, covering 2,864 clusters undertaken from 2012-2019, and deaths from Armed Conflict Location & Event Data Project database covering the conflict period 2015-2019. We used a Poisson-Gamma model to estimate pre-conflict (µp, baseline value) and conflict period (µc) mean death rates using household survey data from 2012-2019. To analyse changes in the distribution of deaths and estimate nationwide excess deaths, we applied pre- and post-conflict death rates to total population numbers. Further, we tested for association between excess death and security levels by governorate. The national estimated crude death rate/10,000 in the conflict period was 0.20 (95% CI: 0.17, 0.24), which is meaningfully higher than the estimated baseline rate of 0.19 (95% CI: 0.17, 0.22). Applying the conflict period rate to the Yemeni population, we estimated 168,212 excess deaths that occurred between 2015 and 2019. There was an 17.8% increase in overall deaths above the baseline during the conflict period. A large share (67.2%) of the excess deaths were due to combat-related violence. At the governorate level, posterior crude death rate varied across the country, ranging from 0.03 to 0.63 per 10,000 per day. Hajjah, Ibb, and Al Jawf governorates presented the highest total excess deaths. Insecurity level was not statistically associated with excess deaths. The health situation in Yemen was poor before the crisis in 2015. During the conflict, intentional violence from air and ground strikes were responsible for more deaths than indirect or non-violent causes. The provision of humanitarian aid by foreign agencies may have helped contain increases in indirect deaths from the conflict.

Understanding human vulnerability to climate change: A global perspective on index validation for adaptation planning.

Climate change is a severe global threat. Research on climate change and vulnerability to natural hazards has made significant progress over the last decades. Most of the research has been devoted to improving the quality of climate information and hazard data, including exposure to specific phenomena, such as flooding or sea-level rise. Less attention has been given to the assessment of vulnerability and embedded social, economic and historical conditions that foster vulnerability of societies. A number of global vulnerability assessments based on indicators have been developed over the past years. Yet an essential question remains how to validate those assessments at the global scale. This paper examines different options to validate global vulnerability assessments in terms of their internal and external validity, focusing on two global vulnerability indicator systems used in the WorldRiskIndex and the INFORM index. The paper reviews these global index systems as best practices and at the same time presents new analysis and global results that show linkages between the level of vulnerability and disaster outcomes. Both the review and new analysis support each other and help to communicate the validity and the uncertainty of vulnerability assessments. Next to statistical validation methods, we discuss the importance of the appropriate link between indicators, data and the indicandum. We found that mortality per hazard event from floods, drought and storms is 15 times higher for countries ranked as highly vulnerable compared to those classified as low vulnerable. These findings highlight the different starting points of countries in their move towards climate resilient development. Priority should be given not just to those regions that are likely to face more severe climate hazards in the future but also to those confronted with high vulnerability already.

Measles in conflict-affected northern Syria: results from an ongoing outbreak surveillance program.

BACKGROUND: The Syrian conflict has dramatically changed the public health landscape of Syria since its onset in March of 2011. Depleted resources, fractured health systems, and increased security risks have disrupted many routine services, including vaccinations, across several regions in Syria. Improving our understanding of infectious disease transmission in conflict-affected communities is imperative, particularly in the Syrian conflict. We utilize surveillance data from the Early Warning Alert and Response Network (EWARN) database managed by the Assistance Coordination Unit (ACU) to explore trends in the incidence of measles in conflict-affected northern Syria and analyze two consecutive epidemics in 2017 and 2018. METHODS: We conducted a retrospective time-series analysis of the incidence of clinically suspected cases of measles using EWARN data between January 2015 and June 2019. We compared regional and temporal trends to assess differences between geographic areas and across time. RESULTS: Between January 2015 and June 2019, there were 30,241 clinically suspected cases of measles reported, compared to 3193 cases reported across the whole country in the decade leading up to the conflict. There were 960 regional events that met the measles outbreak threshold and significant differences in the medians of measles incidence across all years (p-value < 0.001) and in each pairwise comparison of years as well as across all geographic regions (p-value < 0.001). Although most governorates faced an elevated burden of cases in every year of the study, the measles epidemics of 2017 and 2018 in the governorates of Ar-Raqqa, Deir-Ez-Zor, and Idlib accounted for over 71% of the total suspected cases over the entire study period. CONCLUSIONS: The 2017 and 2018 measles epidemics were the largest since Syria eliminated the disease in 1999. The regions most affected by these outbreaks were areas of intense conflict and displacement between 2014 and 2018, including districts in Ar-Raqqa, Deir-Ez-Zor, and Idlib. The spread of measles in northern Syria serves as an indicator of low immunization coverage and limited access to care and highlights the Syrian peoples' vulnerability to infectious diseases and vaccine preventable diseases in the setting of the current conflict.

Ensuring Rights while Protecting Health: The Importance of Using a Human Rights Approach in Implementing Public Health Responses to COVID-19.

In response to the COVID-19 pandemic, governments around the world have implemented public health policies that limit individual freedoms in order to control disease transmission. While such limitations on liberties are sometimes necessary for pandemic control, many of these policies have been overly broad or have neglected to consider the costs for populations already susceptible to human rights violations. Furthermore, the pandemic has exacerbated preexisting inequities based on health care access, poverty, racial injustice, refugee crises, and lack of education. The worsening of such human rights violations increases the need to utilize a human rights approach in the response to COVID-19. This paper provides a global overview of COVID-19 public health policy interventions implemented from January 1 to June 30, 2020, and identifies their impacts on the human rights of marginalized populations. We find that over 70% of these public health policies negatively affect human rights in at least one way or for at least one population. We recommend that policy makers take a human rights approach to COVID-19 pandemic control by designing public health policies focused on the most marginalized groups in society. Doing so would allow for a more equitable, realistic, and sustainable pandemic response that is centered on the needs of those at highest risk of COVID-19 and human rights violations.

Evaluation of Early Warning, Alert and Response System for Ebola Virus Disease, Democratic Republic of the Congo, 2018-2020.

The 10th and largest Ebola virus disease epidemic in the Democratic Republic of the Congo (DRC) was declared in North Kivu Province in August 2018 and ended in June 2020. We describe and evaluate an Early Warning, Alert and Response System (EWARS) implemented in the Beni health zone of DRC during August 5, 2018-June 30, 2020. During this period, 194,768 alerts were received, of which 30,728 (15.8%) were validated as suspected cases. From these, 801 confirmed and 3 probable cases were detected. EWARS showed an overall good performance: sensitivity and specificity >80%, nearly all (97%) of alerts investigated within 2 hours of notification, and good demographic representativeness. The average cost of the system was US $438/case detected and US $1.8/alert received. The system was stable, despite occasional disruptions caused by political insecurity. Our results demonstrate that EWARS was a cost-effective component of the Ebola surveillance strategy in this setting.

Does Ethnic Diversity Impact on Risk Perceptions, Preparedness, and Management of Heat Waves?

Detrimental health impacts of heatwaves, including excess mortality, are increasing worldwide. To assess risk perceptions, protective knowledge and behaviors concerning heatwaves in Israel, a study was initiated, comparing attitudes of majority (Jewish) and minority (Arab) populations. A quantitative survey was disseminated through an internet panel, to a representative sample of 556 individuals (79% Jews; 21% Arabs). Overall, 74% consider heatwaves a problem, 93% believe that heatwaves' frequencies will increase, 27% are very concerned about the effects of heatwaves. Higher levels of awareness to heatwaves were found among Jewish compared to Arab respondents; 90 vs. 77% (respectively) could name heatwaves' symptoms (p < 0.001); 81 vs. 56% (respectively) reported knowing how to protect themselves (p < 0.001); 74 vs. 47% (respectively) reported knowing what to do when someone suffers from heat stroke (p < 0.001). Arab compared to Jewish respondents presented higher levels of concern about heatwaves' effects (3.22 vs. 3.09 respectively; t -2.25, p = 0.03), while knowledge of protective measures was higher among Jews compared to Arabs (3.67 vs. 3.56 t = 2.13 p = 0.04). A crucial component of enhancing preparedness to heatwaves is empowerment of minority as well as majority groups, to strengthen their capacity to implement protective behavior and elevate their self-belief in their individual ability and fortitude.

Changes in ischemic heart disease mortality at the global level and their associations with natural disasters: A 28-year ecological trend study in 193 countries.

BACKGROUND: Natural disasters are believed to be associated with cardiovascular disease. This study aimed to explore the changes in mortality due to ischemic heart disease (IHD) and their associations with natural disasters at the global level. METHODS: Country-specific data on the impact of natural disasters, rates of mortality due to IHD and years of life lost (YLL) and socioeconomic variables were obtained for 193 countries for the period from 1990 to 2017. An ecological trend study was conducted to estimate the changes in the IHD mortality and YLL rates and their associations with natural disasters (occurrence, casualties and total damage). Correlation analyses and multivariate linear regression were used. RESULTS: Significant changes were found in the IHD mortality and YLL rates and the occurrence of disasters between the two equal periods (1990 to 2003 and 2004 to 2017) (p<0.001). The bivariate Pearson correlation test revealed that the trend in the occurrence of natural disasters was positively correlated with trends in the IHD mortality and YLL rates among females and all individuals (p<0.05) and was marginally correlated among males. Multiple linear regression revealed an independent association between the occurrence of natural disasters and the IHD mortality rate among males, females and all individuals (standardized coefficients = 0.163, 0.357 and 0.241, p<0.05), and similar associations were found for the YLL rate (standardized coefficients = 0.194, 0.233 and 0.189, p<0.05). CONCLUSIONS: Our study demonstrated significant changes in the IHD mortality and YLL rates at the global level and their independent associations with natural disasters. Both males and females were vulnerable to natural disasters. These results provide evidence that can be used to support policy making and resource allocation when responding to disasters and developing strategies to reduce the burden of IHD.

Heatwave-protective knowledge and behaviour among urban populations: a multi-country study in Tunisia, Georgia and Israel.

BACKGROUND: There is an expected increase in heatwaves globally. As such, it is imperative to have sufficient levels of heatwave-protective knowledge and behaviour in areas regularly affected by heatwaves. Our study assessed this among urban populations in Tunisia, Georgia and Israel. METHODS: We undertook a cross-sectional population survey in the three countries. The questionnaire focused on obtaining information on respondents' knowledge level regarding 1) symptoms due to overheating, 2) risk groups for heatwaves, 3) actions to take when someone is overheated, and 4) heatwave-protective measures. Furthermore, we asked respondents about protective measures they applied during the last heatwave. We compared the results between the countries. RESULTS: Heatwave-protective knowledge was highest in Israel, and lowest in Georgia, for all indicators except for heatwave-protective measures, for which knowledge was highest in Tunisia. Most respondents who named certain protective measures had also applied these during the last heatwave: more than 90% for all measures except for one in Tunisia and Israel, and more than 80% for all measures in Georgia. CONCLUSION: There is a need to further improve heatwave-protective knowledge in Tunisia, Georgia and Israel. One potential solution to achieve this is by implementing a National Heat Health Action Plan. Improving knowledge is a vital step before adaptive behaviour can take place.

Disability-Adjusted Life Years (DALYs) Due to Ischemic Heart Disease (IHD) Associated with Natural Disasters: A Worldwide Population-Based Ecological Study.

Background: Recent studies have reported an association between natural disasters of various kinds and ischemic heart disease (IHD). We investigated the association between Disability-adjusted life years (DALYs) due to IHD and natural disasters and aimed to assess DALYs as a quantification of the burden of IHD related to natural disasters at the global level. Methods: Country-specific data of natural disaster impacts DALYs due to IHD and socioeconomic variables were obtained from open sources over the period of 1990-2013 and 2014-2017. A population-based trend ecological design was conducted to estimate the association between trends in DALYs and natural disasters (occurrence, casualties and total damage), adjusting for socioeconomic variables. Results: Most countries have experienced increases in natural disaster occurrences and decreases in DALYs during this study period. The unadjusted correlation analysis demonstrated a positive and significant correlation between DALYs and natural disasters for females and for both sexes (R = 0.163 and 0.146, p = 0.024 and 0.043), and a marginally significant correlation for males (R = 0.128, p = 0.076). After adjusting for socioeconomic variables, multiple linear regression demonstrated independent associations between the occurrence and DALYs due to IHD for males, females and both sexes (standardized coefficients = 0.192, 0.23 and 0.187, p = 0.016, 0.004 and 0.022). Conclusions: A weak but significantly positive association between natural disaster and IHD was confirmed and quantified at the global level by this DALY metric analysis. Adaptation strategies for natural disaster responses and IHD disease burden reduction need to be developed.