disasters: the public health impact. mortality & morbidity disasters cause deaths, injuries, and...

Disasters: Disasters: The Public Health The Public Health

ImpactImpact

Disasters: The Public Health ImpactDisasters: The Public Health Impact

Mortality & MorbidityMortality & MorbidityDisasters cause deaths, injuries, and illnessesDisasters cause deaths, injuries, and illnesses

Disasters may overwhelm medical resources Disasters may overwhelm medical resources and health servicesand health services

Sources: CDC & EK Noji, Sources: CDC & EK Noji, The Public Health Consequences of The Public Health Consequences of DisasterDisaster


Health Care InfrastructureHealth Care InfrastructureDisasters may destroy hospitals Disasters may destroy hospitals

Disasters may disrupt routine health servicesDisasters may disrupt routine health services

Disasters may disrupt preventive activitiesDisasters may disrupt preventive activities

Consequence: long-term increases in Consequence: long-term increases in morbidity and mortalitymorbidity and mortality

Sources: CDC & EK Noji, Sources: CDC & EK Noji, The Public Health The Public Health Consequences of DisasterConsequences of Disaster


Environment & PopulationEnvironment & PopulationDisasters may increase potential for Disasters may increase potential for

communicable diseasescommunicable diseases

Disasters may exacerbate environmental Disasters may exacerbate environmental hazardshazards

Consequences: increases in morbidity and Consequences: increases in morbidity and premature death, decreased quality of lifepremature death, decreased quality of life



Psychological and Social BehaviorPsychological and Social BehaviorDisasters may cause generalized panic or Disasters may cause generalized panic or

paralyzing traumaparalyzing trauma

Disasters may provoke increases in anxiety, Disasters may provoke increases in anxiety, depression and neurosesdepression and neuroses

Disasters may lead to post-traumatic stress Disasters may lead to post-traumatic stress disorder (PTSD) at epidemic levelsdisorder (PTSD) at epidemic levels



Food SupplyFood SupplyDisasters may disrupt the food supplyDisasters may disrupt the food supply

Disasters leading to food shortages may cause Disasters leading to food shortages may cause specific micronutrient deficiencies specific micronutrient deficiencies

Disasters may provoke severe nutritional Disasters may provoke severe nutritional consequences including famine and consequences including famine and starvationstarvation

Sources: CDC & EK Noji, Sources: CDC & EK Noji, The Public Health Consequences The Public Health Consequences of Disasterof Disaster

Disasters: The Public Health ImpactDisasters: The Public Health ImpactPopulation DisplacementPopulation Displacement

Disasters may cause large spontaneous or organized Disasters may cause large spontaneous or organized population movementspopulation movements

Population movement may increase morbidity and Population movement may increase morbidity and mortalitymortality

Population movement may precipitate epidemics of Population movement may precipitate epidemics of communicable diseases in both displaced and host communicable diseases in both displaced and host communitiescommunities

Crowding of populations and overlay of refugee and Crowding of populations and overlay of refugee and host populations may lead to injuries and violencehost populations may lead to injuries and violence

Sources: CDC & EK Noji, Sources: CDC & EK Noji, The Public Health Consequences of DisasterThe Public Health Consequences of Disaster

Epidemiologic Epidemiologic Methods in DisastersMethods in Disasters

Epidemiologic Methods in DisastersEpidemiologic Methods in DisastersBefore a disaster (Interdisaster Phase):Before a disaster (Interdisaster Phase):Conducting hazards & vulnerability analyses of Conducting hazards & vulnerability analyses of

the populationthe populationModeling/simulating disaster scenariosModeling/simulating disaster scenariosConducting drillsConducting drillsDesigning emergency protocolsDesigning emergency protocolsAssessing level of emergency preparednessAssessing level of emergency preparednessAssessing flexibility of surveillance systemsAssessing flexibility of surveillance systemsTraining health and safety personnelTraining health and safety personnelSource: EK Noji, Source: EK Noji, The Public Health Consequences of DisasterThe Public Health Consequences of Disaster

Epidemiologic Methods in DisastersEpidemiologic Methods in Disasters

During a disaster (Emergency Phase):During a disaster (Emergency Phase):Conducting disaster damage assessmentConducting disaster damage assessmentConducting rapid field investigationsConducting rapid field investigationsIdentifying urgent needs & matching Identifying urgent needs & matching

resourcesresourcesPrioritizing relief effortsPrioritizing relief effortsConducting disaster surveillanceConducting disaster surveillanceConducting epidemic investigationsConducting epidemic investigationsSource: EK Noji, Source: EK Noji, The Public Health Consequences of DisasterThe Public Health Consequences of Disaster


After a disaster (Reconstruction Phase):After a disaster (Reconstruction Phase):

Conducting post-disaster epidemiologic Conducting post-disaster epidemiologic follow-up studiesfollow-up studies

Identifying risk factors for death & injuryIdentifying risk factors for death & injury

Planning strategies to reduce impact-Planning strategies to reduce impact-related morbidity & mortalityrelated morbidity & mortality

Source: EK Noji, Source: EK Noji, The Public Health Consequences of The Public Health Consequences of DisasterDisaster


After a disaster (Reconstruction Phase):After a disaster (Reconstruction Phase):Developing specific interventionsDeveloping specific interventionsEvaluating effectiveness of interventionsEvaluating effectiveness of interventionsConducting descriptive & analytical studiesConducting descriptive & analytical studiesPlanning medical & public health response Planning medical & public health response

to future disastersto future disastersConducting long-term follow-up of Conducting long-term follow-up of

rehabilitation/reconstruction activitiesrehabilitation/reconstruction activitiesSource: EK Noji, Source: EK Noji, The Public Health Consequences of The Public Health Consequences of

DisasterDisaster

Epidemiologic Methods in DisastersEpidemiologic Methods in DisastersChallenges for EpidemiologistsChallenges for EpidemiologistsApplying epidemiologic methods in the context of:Applying epidemiologic methods in the context of:Physical destructionPhysical destructionPublic fearPublic fearSocial disruptionSocial disruptionLack of infrastructure for data collectionLack of infrastructure for data collectionTime urgencyTime urgencyMovement of populationsMovement of populationsLack of local support and expertiseLack of local support and expertiseSource: EK Noji, Source: EK Noji, The Public Health Consequences of DisasterThe Public Health Consequences of Disaster

Epidemiologic Methods in DisastersEpidemiologic Methods in DisastersChallenges for EpidemiologistsChallenges for EpidemiologistsSelecting study designs:Selecting study designs:Cross-sectional:Cross-sectional:

Studies of frequencies of deaths, illnesses, injuries, Studies of frequencies of deaths, illnesses, injuries, adverse health affectsadverse health affectsLimited by absence of population countsLimited by absence of population counts

Case-control:Case-control:Best study to determine risk factors, eliminate Best study to determine risk factors, eliminate confounding, study interactions among multiple confounding, study interactions among multiple factorsfactorsLimited by definition of specific outcomes, issues of Limited by definition of specific outcomes, issues of selection of cases & controlsselection of cases & controls

Source: EK Noji, Source: EK Noji, The Public Health Consequences of DisasterThe Public Health Consequences of Disaster


Challenges for EpidemiologistsChallenges for Epidemiologists

Selecting study designs:Selecting study designs: Longitudinal:Longitudinal:

Studies document incidence and estimate Studies document incidence and estimate magnitude of riskmagnitude of riskLimited by logistics of mounting a study Limited by logistics of mounting a study in a post-disaster environment and in a post-disaster environment and subject follow-upsubject follow-up

Source: EK Noji, Source: EK Noji, The Public Health Consequences of The Public Health Consequences of DisasterDisaster

Epidemiologic Methods in DisastersEpidemiologic Methods in DisastersChallenges for EpidemiologistsChallenges for EpidemiologistsNeed standardized protocols for data collection Need standardized protocols for data collection

immediately following disasterimmediately following disasterNeed standardized terminology, technologies, methods Need standardized terminology, technologies, methods

and proceduresand proceduresNeed operational research to inventory medical Need operational research to inventory medical

supplies and determine 1) actual needs, 2) local supplies and determine 1) actual needs, 2) local capacity, 3) needs met by national/international capacity, 3) needs met by national/international communitiescommunities

Need evaluation studies to determine efficiency and Need evaluation studies to determine efficiency and effectiveness of relief efforts and emergency effectiveness of relief efforts and emergency interventionsinterventions


Epidemiologic Methods in DisastersEpidemiologic Methods in DisastersChallenges for EpidemiologistsChallenges for EpidemiologistsNeed databases for epidemiologic research based on Need databases for epidemiologic research based on

existing disaster information systemsexisting disaster information systemsNeed to identify injury prevention interventionsNeed to identify injury prevention interventionsNeed to improve timely and appropriate medical care Need to improve timely and appropriate medical care

following disaster (search & rescue, emergency following disaster (search & rescue, emergency medical services, importing skilled providers, medical services, importing skilled providers, evacuating the injured)evacuating the injured)

Need measures to quickly reestablish local health care Need measures to quickly reestablish local health care system at full operating capacity soon after disastersystem at full operating capacity soon after disaster



Challenges for EpidemiologistsChallenges for EpidemiologistsNeed uniform disaster-related injury definitions Need uniform disaster-related injury definitions

and classification schemeand classification schemeNeed investigations of disease transmission Need investigations of disease transmission

following disasters and public health measures following disasters and public health measures to mitigate disease riskto mitigate disease risk

Need to study problems associated with massive Need to study problems associated with massive influx of relief supplies and relief personnelinflux of relief supplies and relief personnel

Need cost-benefit and cost-effectiveness analysesNeed cost-benefit and cost-effectiveness analysesSource: EK Noji, Source: EK Noji, The Public Health Consequences of DisasterThe Public Health Consequences of Disaster

The Disaster CycleThe Disaster Cycle

Disaster CycleDisaster CycleSudden impact natural disastersSudden impact natural disasters

can be considered as a continuous time sequencecan be considered as a continuous time sequenceof five phases:of five phases:

InterdisasterInterdisasterPredisasterPredisaster

ImpactImpactEmergencyEmergency

ReconstructionReconstructionSource: EK Noji, Sivertson KT. Injury prevention in natural Source: EK Noji, Sivertson KT. Injury prevention in natural

disasters: a theoretical framework. disasters: a theoretical framework. Disasters Disasters 1987;11:290-296.1987;11:290-296.

Disaster CycleDisaster Cycle

Interdisaster PhaseInterdisaster PhasePlanning disaster Planning disaster

prevention/preparedness/mitigation prevention/preparedness/mitigation Identifying risksIdentifying risksIdentifying vulnerabilitiesIdentifying vulnerabilitiesCreating a resource inventoryCreating a resource inventoryConducting professional trainingConducting professional trainingConducting community educationConducting community education

Synonym: Nondisaster PhaseSynonym: Nondisaster Phase


Predisaster PhasePredisaster PhaseIssuing timely warningsIssuing timely warnings

Implementing protective actionsImplementing protective actions

Undertaking emergency management Undertaking emergency management activitiesactivities

Evacuating population as necessaryEvacuating population as necessary

Synonym: Warning PhaseSynonym: Warning Phase


Impact PhaseImpact PhaseDestructionDestruction

InjuriesInjuries

DeathsDeathsmay occur during impactmay occur during impact

Disaster CycleDisaster CycleEmergency PhaseEmergency Phase

Implementing life-saving actionsImplementing life-saving actions-search and rescue-search and rescue-first aid-first aid-emergency medical assistance-emergency medical assistanceRestoring emergency communicationsRestoring emergency communicationsRestoring emergency transportationRestoring emergency transportationImplementing public health surveillanceImplementing public health surveillanceEvacuating vulnerable areasEvacuating vulnerable areas

Synonyms: Relief Phase, Isolation PhaseSynonyms: Relief Phase, Isolation Phase


Emergency PhaseEmergency PhaseNote: The immediate postimpact period is Note: The immediate postimpact period is

the isolation phase where most urgent the isolation phase where most urgent rescue tasks are accomplished by the rescue tasks are accomplished by the survivors using local resourcessurvivors using local resources

Synonyms: Relief Phase, Isolation PhaseSynonyms: Relief Phase, Isolation Phase


Reconstruction PhaseReconstruction PhaseRestoring predisaster conditionsRestoring predisaster conditions

Reestablishing health servicesReestablishing health services

Reconstructing & repairing damaged facilitiesReconstructing & repairing damaged facilities

Reflecting and debriefing on lessons learnedReflecting and debriefing on lessons learned

Synonym: Rehabilitation PhaseSynonym: Rehabilitation Phase

Disaster SeverityDisaster Severity


A Decade of Natural DisastersA Decade of Natural Disasters1 million thunderstorms1 million thunderstorms

100,000 floods100,000 floods

Tens of thousands of landslides, earthquakes, Tens of thousands of landslides, earthquakes, wildfires & tornadoeswildfires & tornadoes

Several thousand hurricanes, tropical cyclones, Several thousand hurricanes, tropical cyclones, tsunamis & volcanoestsunamis & volcanoes



A Decade of Natural Disasters (1980s)A Decade of Natural Disasters (1980s)FloodsFloods 39,000 deaths 39,000 deathsTropical cyclonesTropical cyclones 14,000 deaths 14,000 deathsHurricanesHurricanes 1,000 deaths 1,000 deathsEarthquakesEarthquakes 54,000 deaths 54,000 deathsOther disastersOther disasters 1,012,000 deaths1,012,000 deathsTOTALTOTAL 1,120,000 deaths1,120,000 deaths



Factors Contributing to Disaster Factors Contributing to Disaster SeveritySeverity

-Human vulnerability due to poverty & -Human vulnerability due to poverty & social inequalitysocial inequality

-Environmental degradation-Environmental degradation-Rapid population growth especially among -Rapid population growth especially among

the poorthe poor


Disaster SeverityDisaster SeverityInfluence of PovertyInfluence of Poverty

Persons in poverty:Persons in poverty:--Live in poor housing unable to withstand seismic activityLive in poor housing unable to withstand seismic activity-Live in poor housing susceptible to landslides-Live in poor housing susceptible to landslides-Inhabit coastal areas and flood plains vulnerable to -Inhabit coastal areas and flood plains vulnerable to

hurricanes, storm surges, flooding, and tidal waveshurricanes, storm surges, flooding, and tidal waves-Live near hazardous industrial sites-Live near hazardous industrial sites-Do not receive education on life-saving actions during -Do not receive education on life-saving actions during

disastersdisasters-Do not receive warning of impending disasters-Do not receive warning of impending disastersSources: CDC & EK Noji, Sources: CDC & EK Noji, The Public Health Consequences of DisasterThe Public Health Consequences of Disaster


Influence of PovertyInfluence of Poverty-Low-income countries:-Low-income countries:

3,000 deaths per disaster3,000 deaths per disaster

-High-income countries:-High-income countries:500 deaths per disaster500 deaths per disaster



Influence of Population GrowthInfluence of Population Growth- Urban dwellers:- Urban dwellers:

1920: 100 million1920: 100 million1980: 1 billion1980: 1 billion2000: 2 billion2000: 2 billion

- 2000: 20 cities with >10 million people- 2000: 20 cities with >10 million people



Capabilities of Developed NationsCapabilities of Developed NationsThat Mitigate Disaster EffectsThat Mitigate Disaster Effects

-Ability to forecast severe storms-Ability to forecast severe storms-Ability to enforce strict building codes-Ability to enforce strict building codes-Ability to use communication networks to -Ability to use communication networks to

broadcast alerts and warningsbroadcast alerts and warnings-Ability to provide emergency medical services-Ability to provide emergency medical services-Ability to engage in contingency planning-Ability to engage in contingency planningSources: CDC & EK Noji, Sources: CDC & EK Noji, The Public Health Consequences of DisasterThe Public Health Consequences of Disaster

Disaster:Disaster: PerspectivesPerspectives

Disaster: PerspectivesDisaster: Perspectives

““A disaster is a result ofA disaster is a result ofa vast ecological breakdowna vast ecological breakdownin the relation betweenin the relation betweenhumans and their environment, humans and their environment, a serious or sudden eventa serious or sudden eventon such a scale that the stricken communityon such a scale that the stricken communityneeds extraordinary effortsneeds extraordinary effortsto cope with it,to cope with it,often with outside help or international aid”often with outside help or international aid”



Public Health ViewPublic Health View

““Disasters are definedDisasters are defined

by what they do to people...”by what they do to people...”



Major Categories of DisastersMajor Categories of Disasters

-Natural Disasters-Natural Disasters

-Human-generated Disasters-Human-generated Disasters



Natural DisastersNatural Disasters-Arise from forces of nature-Arise from forces of nature

-Two subcategories:-Two subcategories:– Sudden impact or acute onsetSudden impact or acute onset– Slow or chronic onsetSlow or chronic onset


Disaster: PerspectivesDisaster: PerspectivesSudden Impact or Acute Onset DisastersSudden Impact or Acute Onset Disasters

Geological or climatic hazardsGeological or climatic hazards Hurricanes/typhoonsHurricanes/typhoons TornadoesTornadoes EarthquakesEarthquakes VolcanoesVolcanoes FloodsFloods TsunamisTsunamis Temperature extremesTemperature extremes WildfiresWildfires LandslidesLandslides AvalanchesAvalanches

EpidemicsEpidemicsFood, water, vector-borne diseasesFood, water, vector-borne diseasesPerson-to-person transmission diseasesPerson-to-person transmission diseases



Slow or Chronic Onset DisastersSlow or Chronic Onset DisastersDroughtDroughtFamineFamineEnvironmental degradationEnvironmental degradationChronic exposure to toxic substancesChronic exposure to toxic substancesDesertificationDesertificationDeforestationDeforestationPest infestationPest infestation



Human-Generated DisastersHuman-Generated DisastersIndustrial/technologicalIndustrial/technological

Transportation (vehicular)Transportation (vehicular)

DeforestationDeforestation

Material shortagesMaterial shortages

Complex emergenciesComplex emergenciesSource: EK Noji, Source: EK Noji, The Public Health Consequences of DisasterThe Public Health Consequences of Disaster


Complex EmergenciesComplex Emergencies-Wars and civil strife-Wars and civil strife-Armed aggression-Armed aggression-Insurgency-Insurgency-Other actions resulting in displaced -Other actions resulting in displaced

persons and refugeespersons and refugees



2002 DEEP Center Classification2002 DEEP Center Classification-Natural disasters-Natural disasters

-Non-intentional human-generated disasters-Non-intentional human-generated disasters

-Terrorist-perpetrated disasters-Terrorist-perpetrated disasters

-Complex disasters-Complex disasters

-Natural-technological disasters (NA-TECHS)-Natural-technological disasters (NA-TECHS)


Terrorist-perpetrated DisastersTerrorist-perpetrated Disasters-Biological-Biological-Nuclear-Nuclear-Incendiary-Incendiary-Chemical-Chemical-Explosive-Explosive

Mnemonic: B-NICEMnemonic: B-NICE

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