Amy H. Schnall

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.

Community Assessment for Public Health Emergency Response (CASPER) one year following the Gulf Coast oil spill: Alabama and Mississippi, 2011.

BACKGROUND On April 20, 2010, the Deepwater Horizon drilling unit exploded off the coast of Louisiana, resulting in 11 deaths and the largest marine petroleum release in history. Previous oil spill disasters have been associated with negative mental health outcomes in affected communities. In response to requests from Mississippi and Alabama, potential mental health issues resulting from this event were identified by implementing a novel use of a Community Assessment for Public Health Emergency Response (CASPER) in the months immediately following the Gulf Coast oil spill. PURPOSE This assessment was repeated one year later to determine long-term mental health needs and changes. METHODS A two-stage sampling method was used to select households, and a questionnaire including the Centers for Disease Control and Preventions Behavioral Risk Factor Surveillance System (BRFSS) questions was administered. Weighted cluster analysis was conducted, and BRFSS questions were compared to the most recent BRFSS reports and the 2010 results. RESULTS In 2011, 8.8%-15.1% of individuals reported depressive symptoms compared to 15.4%-24.5% of individuals in 2010, with 13.2%-20.3% reporting symptoms consistent with an anxiety disorder compared to 21.4%-31.5% of individuals in 2010. Respondents reporting decreased income following the oil spill were more likely to report mental health symptoms compared to respondents reporting no change in income. CONCLUSIONS Overall, mental health symptoms were higher in the three assessment areas compared to BRFSS reports, but lower than 2010 surveys. These results suggest that mental health services are still needed, particularly in households experiencing decreased income since the oil spill.

Disaster-related injuries and illnesses treated by american red cross disaster health services during hurricanes Gustav and Ike

ObjectiveTo 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. MethodsFrom 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. ResultsA 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. ConclusionsDuring 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.

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 decedents 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.

Evaluation of a Standardized Morbidity Surveillance Form for Use during Disasters Caused by Natural Hazards

INTRODUCTION Surveillance for health outcomes is critical for rapid responses and timely prevention of disaster-related illnesses and injuries after a disaster-causing event. The Disaster Surveillance Workgroup (DSWG) of the US Centers for Disease Control and Prevention developed a standardized, single-page, morbidity surveillance form, called the Natural Disaster Morbidity Surveillance Individual Form (Morbidity Surveillance Form), to describe the distribution of injuries and illnesses, detect outbreaks, and guide timely interventions during a disaster. PROBLEM Traditional data sources can be used during a disaster; however, supplemental active surveillance may be required because traditional systems often are disrupted, and many persons will seek care outside of typical acute care settings. Generally, these alternative settings lack health surveillance and reporting protocols. The need for standardized data collection was demonstrated during Hurricane Katrina, as the multiple surveillance instruments that were developed and deployed led to varied and uncoordinated data collection methods, analyses, and morbidity data reporting. Active, post-event surveillance of affected populations is critical for rapid responses to minimize and prevent morbidity and mortality, allocate resources, and target public health messaging. METHODS The CDC and the Georgia Department of Public Health (GDPH) conducted a study to evaluate a Morbidity Surveillance Form to determine its ability to capture clinical presentations. The form was completed for each patient evaluated in an emergency department (ED) during triage from 01 August, 2007 through 07 August, 2007. Data from the form were compared with the ED discharge diagnoses from electronic medical records, and kappa statistics were calculated to assess agreement. RESULTS Nine hundred forty-nine patients were evaluated, 41% were male and 57% were Caucasian. According to the forms, the most common reasons for seeking treatment were acute illness, other (29%); pain (12%); and gastrointestinal illness (8%). The frequency of agreement between discharge diagnoses and the form ranged from 3 to 100%. Kappa values ranged from 0.23-1.0, with nine of the 12 categories having very good or good agreement. CONCLUSION With modifications to increase sensitivity for capturing certain clinical presentations, the Morbidity Surveillance Form can be a useful tool for capturing data needed to guide public health interventions during a disaster. A validated collection instrument for a post-disaster event facilitates rapid and standardized comparison and aggregation of data across multiple jurisdictions, thus, improving the coordination, timeliness, and accuracy of public health responses. The DSWG revised the Morbidity Surveillance Form based on information from this study.

Community Assessment for Public Health Emergency Response (CASPER): An Innovative Emergency Management Tool in the United States

Objectives To demonstrate how inclusion of the Centers for Disease Control and Preventions Community Assessment for Public Health Emergency Response (CASPER) as a tool in Public Health Preparedness Capabilities: National Standards for State and Local Planning can increase public health capacity for emergency response. Methods We reviewed all domestic CASPER activities (i.e., trainings and assessments) between fiscal years 2012 and 2016. Data from these CASPER activities were compared with respect to differences in geographic distribution, type, actions, efficacy, and usefulness of training. Results During the study period, the Centers for Disease Control and Prevention conducted 24 domestic in-person CASPER trainings for 1057 staff in 38 states. On average, there was a marked increase in knowledge of CASPER. Ninety-nine CASPERs were conducted in the United States, approximately half of which (53.5%) assessed preparedness; the others were categorized as response or recovery (27.2%) or were unrelated to a disaster (19.2%). Conclusions CASPER trainings are successful in increasing disaster epidemiology skills. CASPER can be used by Public Health Emergency Preparedness program awardees to help build and sustain preparedness and response capabilities.

Using Poison Center Data for Postdisaster Surveillance

The role of public health surveillance in disaster response continues to expand as timely, accurate information is needed to mitigate the impact of disasters. Health surveillance after a disaster involves the rapid assessment of the distribution and determinants of disaster-related deaths, illnesses, and injuries in the affected population. Public health disaster surveillance is one mechanism that can provide information to identify health problems faced by the affected population, establish priorities for decision makers, and target interventions to meet specific needs. Public health surveillance traditionally relies on a wide variety of data sources and methods. Poison center (PC) data can serve as data sources of chemical exposures and poisonings during a disaster. In the US, a system of 57 regional PCs serves the entire population. Poison centers respond to poison-related questions from the public, health care professionals, and public health agencies. The Centers for Disease Control and Prevention (CDC) uses PC data during disasters for surveillance of disaster-related toxic exposures and associated illnesses to enhance situational awareness during disaster response and recovery. Poison center data can also be leveraged during a disaster by local and state public health to supplement existing surveillance systems. Augmenting traditional surveillance data (ie, emergency room visits and death records) with other data sources, such as PCs, allows for better characterization of disaster-related morbidity and mortality. Poison center data can be used during a disaster to detect outbreaks, monitor trends, track particular exposures, and characterize the epidemiology of the event. This timely and accurate information can be used to inform public health decision making during a disaster and mitigate future disaster-related morbidity and mortality.

Chapter 7 – Applications: Community Assessment for Public Health Emergency Response

Abstract The Community Assessment for Public Health Emergency Response (CASPER) is an epidemiologic technique designed to provide quickly, and at low cost, household-based information about a communitys needs. Gathering health and basic needs information using valid statistical methods allows public health and emergency managers to make informed decisions. CASPER data are often used to allocate resources, provide valid information to dispel rumors, support funding of projects, and for future planning purposes. CASPER can also be used whenever representative data are needed throughout the disaster life cycle. Preparedness CASPERs may focus on evacuation and household readiness plans as well as communications so that local emergency plans can be tailored to the specific needs of the community. Response CASPERs often focus on the communitys immediate needs and general health status. During the recovery phase, CASPERs assess long-term and ongoing needs and can evaluate response efforts. CASPER has also proven useful for nondisaster purposes.

Chapter 9 – Methods: Questionnaire Development and Interviewing Techniques

Abstract Responding appropriately and effectively to the public health threats of a disaster, whether natural or human-induced, requires timely and accurate information. The questionnaire and interview are essential components of data collection for epidemiologic studies. An effective questionnaire is an objective means of collecting data from people affected by the disaster about their health status, knowledge, beliefs, attitudes, and behaviors. Careful planning is crucial for systematic and thorough data collection. The researcher must know a priori the questions they want answered and must ensure the questionnaire measures what it is intended to measure. The key to successful interviews is standardization. This increases reliability of the data and eliminates a source of bias and error. This is especially important when more than one interviewer is collecting data. This chapter discusses several key steps and tips to developing an effective questionnaire and successfully completing an interview.

Characterization of Carbon Monoxide Exposure During Hurricane Sandy and Subsequent Nor’easter

OBJECTIVE Carbon monoxide (CO) is an odorless, colorless gas produced by fossil fuel combustion. On October 29, 2012, Hurricane Sandy moved ashore near Atlantic City, New Jersey, causing widespread morbidity and mortality,