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Public health issues in disasters


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Objective: This article outlines a number of important areas in which public health can contribute to making overall disaster management more effective. This article discusses health effects of some of the more important sudden impact natural disasters and potential future threats (e.g., intentional or deliberately released biologic agents) and outlines the requirements for effective emergency medical and public health response to these events. Conclusion: All natural disasters are unique in that each affected region of the world has different social, economic, and health backgrounds. Some similarities exist, however, among the health effects of different natural disasters, which if recognized, can ensure that health and emergency medical relief and limited resources are well managed.

Public health issues in disasters

  1. 1. Public health issues in disastersEric K. Noji, MD, MPH Objective: This article outlines a number of important areas in grounds. Some similarities exist, however, among the health effectswhich public health can contribute to making overall disaster of different natural disasters, which if recognized, can ensure thatmanagement more effective. This article discusses health effects health and emergency medical relief and limited resources are wellof some of the more important sudden impact natural disasters managed. (Crit Care Med 2005; 33[Suppl.]:S29 –S33)and potential future threats (e.g., intentional or deliberately re- KEY WORDS: disasters, natural, earthquake, flood, volcano, tor-leased biologic agents) and outlines the requirements for effective nado, hurricane, typhoon, cyclones; disaster epidemiology; disas-emergency medical and public health response to these events. ter medicine; emergency; mass casualty incident; homeland Conclusion: All natural disasters are unique in that each affected securityregion of the world has different social, economic, and health back-T hroughout history, natural di- days (11). Good disaster management re- the incidence of diarrhea, respiratory in- sasters have exacted a heavy toll quires accurate information and must link fections, and other communicable dis- of death and suffering (1). Most data collection and analysis to an immedi- eases. A good system of water supply and recently, the Bam earthquake in ate decision-making process (12). The over- excreta disposal must be put into placeIran resulted in thousands of deaths, inju- all objective of disaster management from a quickly (20). No amount of curativeries, and homelessness (2) (Table 1). The public health perspective is to assess the health measures can offset the detrimen-problem has not improved much despite needs of disaster-affected populations (13, tal effects of poor environmental healthmuch attention by the international scien- 14), match available resources to those planning (21). Important postdisaster en-tific community (3). Global climate change needs, prevent further adverse health ef- vironmental interventions include accessbrings the potential for severe weather fects, implement disease control strategies to adequate sources of potable water; andevents and flooding, and the introduction for well-defined problems, evaluate the ef- the collection, disposal, and treatment ofof tropical vector-borne diseases into more fectiveness of disaster relief programs (15), excreta and other liquid and solid wastestemperate regions (4, 5). Increasing popu- and improve contingency plans for various (22). This is achieved through installa-lation density near coasts, in floodplains, types of future disasters (16). Common pat- tion of an appropriate number of suitablyand in regions of high points to the prob- terns of morbidity and mortality after cer- located excreta disposal facilities such asability of future catastrophic natural disas- tain disasters can be identified (17) (Table toilets, latrines, or defecation fields; solidters with millions of casualties. 2). Effective emergency medical response waste pickup points; water distribution Disasters affect a community in numer- depends on anticipating these different points; and availability of bathing andous ways. Roads, telephone lines, and other medical and health problems before they washing facilities and of soap togethertransportation and communication links arise (18) and on delivering the appropriate with effective health education. The con-are often destroyed (6). Public utilities and interventions (relief supplies, equipment, trol of disease vectors such as mosqui-energy supplies may be disrupted (7). Sub- and personnel) at the precise times and toes, flies, rats, and fleas is an importantstantial numbers of victims may be ren- places where they are needed most (19). part of an environmental health approachdered homeless (8). Portions of the com- to protecting community members frommunity’s industrial or economic base may CRITICAL PUBLIC HEALTH disease (23).be destroyed or damaged. Casualties may INTERVENTIONS AFTER Water and Excreta Disposal. Adequaterequire medical care, and damage to food DISASTERS quantities of relatively clean water aresources and utilities may create public preferable to small amounts of high-health threats (9, 10). The more remote the Critical public health interventions af- quality water. Each person must receive aarea, the longer it takes for external assis- ter disasters focus on the following areas. minimum of 15 to 20 L of clean water pertance to arrive, and the more the commu- day for their domestic needs (24). Unfor-nity will have to rely on its own resources, Environmental Health: Water, tunately, it is frequently difficult to pro-at least for the first several hours, if not Sanitation, Hygiene, and Vector vide even these minimum quantities of water to disaster-affected populations Management (25). During this early acute phase, la- From the Centers for Disease Control and Preven-tion, Atlanta, GA. General Issues. Overcrowding and re- trine construction begins, but initial san- Copyright © 2005 by the Society of Critical Care sulting poor water supplies and inade- itation measures may be nothing moreMedicine and Lippincott Williams & Wilkins quate hygiene and sanitation are well- than simply designating an area for def- DOI: 10.1097/01.CCM.0000151064.98207.9C known factors that are known to increase ecation, hopefully segregated from theCrit Care Med 2005 Vol. 33, No. 1 (Suppl.) S29
  2. 2. community’s source of potable water. friends; 5% to 10% were living in parks, damaged housing is to diminish as muchConstruction of one latrine for every 20 city squares, and vacant lots; and the re- as possible the penetration of wind andpersons is recommended but is rarely mainder were living in schools and other rain into the structure. In these situa-achieved in camp settings (24). public buildings (26). Regarding tempo- tions, plastic sheeting for roof and win- Shelter. Surveys of settlements and rary living space allocations, 3.5 square dow repairs along with the required ma-towns around Managua, Nicaragua, after meters is the absolute minimum floor terials for attaching them to the damagedthe December 1972 earthquake indicated space per person in emergency shelters structures are often provided by relief or-that 80% to 90% of the 200,000 displaced (24). The first priority in areas where ganizations. Most people who lose theirpersons were living with relatives and large numbers of people are living in homes will initially be able to take shelter with friends and relatives (27). Only when housing losses reach more than approxi-Table 1. Selected natural disasters 1970 –2004 mately 25% will there be a need to find other forms of shelter (26). Approximate The decision to provide shelter at allYear Event Location Death Toll can have significant long-term conse- quences, especially in poor communities.1970 Earthquake/landslide Peru 70,0001970 Tropical cyclone Bangladesh 300,000 For example, simple shelters provided on1971 Tropical cyclone India 25,000 an emergency basis may unintentionally1972 Earthquake Nicaragua 6,000 evolve into permanent shantytowns or1976 Earthquake China 250,000 squatter settlements and end up attract-1976 Earthquake Guatemala 24,000 ing many more homeless people to the1976 Earthquake Italy 9001977 Tropical cyclone India 20,000 site.1978 Earthquake Iran 25,0001980 Earthquake Italy 1,3001982 Volcanic eruption Mexico 1,700 COMMUNICABLE DISEASE1985 Tropical cyclone Bangladesh 10,000 CONTROL AND EPIDEMIC1985 Earthquake Mexico 10,000 MANAGEMENT1985 Volcanic eruption Columbia 22,0001988 Hurricane Gilbert Caribbean 3431988 Earthquake Armenia SSR 25,000 Epidemics1989 Hurricane Hugo Caribbean 561990 Earthquake Iran 40,000 Natural disasters are often followed by1990 Earthquake Philippines 2,000 rampant rumors of epidemics (such as1991 Tropical cyclone Bangladesh 140,000 typhoid or rabies) or unusual conditions1991 Volcanic eruption Philippines 8001991 Typhoon/Xood Philippines 6,000 such as increased snakebites and dog1991 Flood China 1,500 bites. Such unsubstantiated reports gain1992 Hurricane Andrew USA 52 great public credibility when printed as1993 Earthquake India 10,000 facts in newspapers or reported on tele-1995 Earthquake Japan 6,0001998 Hurricane Mitch Central America 10,000 vision or radio (28). For example, after1999 Earthquake Turkey 18,000 disasters in developing countries, any dis-1999 Earthquake Taiwan 1,000 ruption of the water supply or sewage2001 Earthquake India 20,000 treatment facilities has usually been ac-2003 Earthquake Algeria 3,000 companied by rumors of outbreaks of2004 Earthquake Iran 25,000 cholera or typhoid (29). Such rumors Data from Office of U.S. Foreign Disaster Assistance: Disaster history: Significant data on major may well have reflected psychologic fearsdisasters worldwide, 1900 –Present. Washington, DC, Agency for International Development, 2004; and and anxieties about a disastrous eventNational Geographic Society: Nature on the rampage, our violent earth. Washington, DC, National rather than the true perception of anGeographic Society, 1987. imminent problem. However, informa-Table 2. Short-term effects of major natural disasters High Winds Effects Earthquakes (Without Flooding) Tsunamis Floods/Flash FloodsDeaths Many Few Many FewSevere injuries requiring extensive care Overwhelming Moderate Few FewIncreased risk of communicable Potential (but small) risk following all major disasters (probability rises as overcrowding diseases increases and sanitation deteriorates)Food scarcity Rare Rare Common Common (May occur because of factors other than food shortage)Major population movements Rare Rare Common Common (May occur in heavily damaged urban areas) Modified from Office of Emergency Preparedness and Disaster Relief Coordination: Emergency Health Management After Natural Disaster. Washington,DC, Pan American Health Organization, 2002.S30 Crit Care Med 2005 Vol. 33, No. 1 (Suppl.)
  3. 3. tion on disease incidence in most devel- Unjustified worries about the infec- measles in refugee camp outbreaks and areoping countries is poor, and some out- tiousness of bodies can lead to the rapid, at greater risk of dying as a result of im-breaks may have been missed entirely by unplanned disposal of the dead, some- paired nutrition, it is recommended thatpublic health authorities. times before proper identification of the measles immunization programs along Although natural disasters do not usu- victim has been made, as well as to taking with vitamin A supplements in emergencyally result in outbreaks of infectious dis- needless “precautions” such as mass cre- settings target all children from the ages ofease, under certain circumstances, disas- mation, burying the deceased in common 6 mos through 5 yrs (some would recom-ters may increase disease transmission. graves, and adding chlorinated lime as a mend as old as 12–14). Ideally, one shouldThe risk of epidemic outbreaks of com- “disinfectant.” Despite the negligible strive for measles immunization coveragemunicable diseases is proportional to health risk, dead bodies represent a deli- in refugee camp settings of better than 80%population density and displacement. cate social problem. Disposal of bodies (24).These conditions increase the pressure should respect local custom and practiceon water and food supplies and the risk of when possible. When there are large Nutritioncontamination (like in refugee camps), numbers of victims, burial is likely to bethe disruption of preexisting sanitation the most appropriate method of disposal. Food shortages in the immediate after-services such as piped water and sewage, There is little evidence that proper burial math of a disaster may arise in two ways.and the failure to maintain or restore of bodies poses a threat to groundwater Food stock destruction within the disasternormal public health programs in the that serves as a source of drinking water area may reduce the absolute amount ofimmediate postdisaster period. The most (32). food available, or disruption of distributionfrequently observed increases in commu- systems may curtail access to food, even ifnicable disease are caused by fecal con- Immunization there is no absolute shortage. Generalizedtamination of water and by respiratory food shortages severe enough to cause nu-spread (for example, flu in evacuation Mass immunization during situations tritional problems usually do not occur af-camps) (30). In the longer term, an in- of natural disasters is usually counterpro- ter natural disasters. Flooding and seacrease in vector-borne diseases occurs in ductive and diverts limited human re- surges can damage household food stockssome areas because of disruption of vec- sources and materials from other more and crops, disrupt distribution, and causetor control efforts, particularly after effective and urgent measures. Immuni- major local shortages. Food distribution, atheavy rains and floods. Residual insecti- zation campaigns can give a false sense of least in the short term, is often a major andcides may be washed away from build- security, leading to the neglect of basic urgent need, but large-scale importation/ measures of hygiene and sanitation,ings, and the number of mosquito breed- donation of food is not usually necessary which are more important during theing sites may increase. Moreover, (34). In extended droughts such as those emergency. Mass vaccination would bedisplacement of wild or domesticated an- occurring in Africa, or in complex disasters, justified only when the recommendedimals near human settlements brings ad- the homeless and refugees may be com- sanitary measures do not have an effectditional risk of zoonotic infection. pletely dependent on outside sources for and if there is evidence of the progressive food supplies for varying periods of time increase in the number of cases with the (35). Depending on the nutritional condi-Disposition of Dead Bodies risk of an epidemic. A vaccine with the tion of these populations, especially of following characteristics could be consid- more vulnerable groups such as pregnant The public and government authori- ered useful in this situation: or lactating women, children, and the el-ties are usually greatly concerned about ● A vaccine of proven efficacy, high derly, it may be necessary to institute emer-the danger of disease transmission from safety, and low reactogenicity; gency feeding programs (36). The highestdecaying corpses. Responsible health au- ● A vaccine that is easy to apply (single- nutritional priority in the postdisaster set-thorities should recognize, however, that dose); ting is the timely and adequate provision ofhealth hazards such as epidemics associ- ● A vaccine that confers rapid and long- food rations containing at least 2,100 calo-ated with unburied bodies are minimal, lasting protection for people of all ages; ries and that includes sufficient protein, fat,particularly if death resulted from ● Sufficient quantities of vaccine should and micronutrients (24).trauma. It is far more likely that survi- be available to guarantee the supply forvors will be a source of disease outbreaks. the entire population at risk; andAlthough the risks for rescue workers MYTHS AND REALITIES OF ● Low-cost vaccines.who handle dead bodies are higher than NATURAL DISASTERSfor the survivors of a disaster, those risks For example, immunization of childrencan be limited through a set of simple against measles is one of the most impor- Many mistaken assumptions are asso-measures. Appropriate precautions in- tant (and cost-effective) preventive mea- ciated with the impact of disasters onclude training military personnel and sures in emergency-affected populations, public health. Disaster planners andothers who might have to provide assis- particularly those housed in camps. Immu- managers should be familiar with the fol-tance after a disaster, vaccinating those nization of refugee children against mea- lowing myths and realities (37):persons against hepatitis B and tubercu- sles in Thailand in 1979 clearly saved manylosis, using body bags and disposable lives. Although measles was an early prob- Myth: volunteers with any kind of med-gloves, washing hands after handling ca- lem in Somalia, immunization of the refu- ical background are needed.davers, and disinfecting stretchers and gee population was effective in preventing Reality: the local population almost al-vehicles that have been used to transport outbreaks after 1981 (33). Because infants ways covers immediate lifesavingbodies (31). as young as 6 mos of age may contract needs. Only medical personnel withCrit Care Med 2005 Vol. 33, No. 1 (Suppl.) S31
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