Eric K. Noji

The public health consequences of disasters.

Although disasters have exacted a heavy toll of death and suffering, the future seems more frightening. Good disaster management must link data collection and analysis to the decision-making process. The overall objectives of disaster management from the viewpoint of public health are: 1) needs assessments; 2) matching available resources with defined needs; 3) prevention of further adverse health effects; 4) implementation of disease-control strategies; 5) evaluation of the effectiveness of the application of these strategies; and 6) improvement in contingency planning for future disasters. The effects of sudden-onset, natural disasters on humans are quantifiable. Knowledge of the epidemiology of deaths, injuries, and illnesses is essential to determine effective responses; provide public education; establish priorities, planning, and training. In addition, the temporal patterns for the medical care required must be established so that the needs in future disasters can be anticipated. This article discusses: 1) the nature of disasters due to sudden-onset, natural events; 2) the medical and health needs associated with such events and disasters; 3) practical issues of disaster responses; and 4) the advance organization and management of disasters. The discussion also includes: 1) discussions of past problems in disaster management including non-congruence between available supplies and the actual needs of the affected population; 2) information management; 3) needs assessments; 4) public health surveillance; and 5) linking information with decision-making. This discussion is followed by an analysis of what currently is known about the health-care needs during some specific types of sudden-onset, natural disasters: 1) floods; 2) tropical cyclones; 3) tornadoes; 4) volcanic eruptions; and 5) earthquakes. The article concludes with descriptions of some specific public-health problems associated with disasters including epidemics and disposition of corpses. All natural disasters are unique in that the regions affected have different social, economic, and health backgrounds. But, many similarities exist, and knowledge about these can ensure that the health and emergency medical relief and limited resources are well-managed.

Gunshot and Explosion Injuries: Characteristics, Outcomes, and Implications for Care of Terror-Related Injuries in Israel

Context:An increase of terror-related activities may necessitate treatment of mass casualty incidents, requiring a broadening of existing skills and knowledge of various injury mechanisms. Objective:To characterize and compare injuries from gunshot and explosion caused by terrorist acts. Methods:A retrospective cohort study of patients recorded in the Israeli National Trauma Registry (ITR), all due to terror-related injuries, between October 1, 2000, to June 30, 2002. The ITR records all casualty admissions to hospitals, in-hospital deaths, and transfers at 9 of the 23 trauma centers in Israel. All 6 level I trauma centers and 3 of the largest regional trauma centers in the country are included. The registry includes the majority of severe terror-related injuries. Injury diagnoses, severity scores, hospital resource utilization parameters, length of stay (LOS), survival, and disposition. Results:A total of 1155 terror-related injuries: 54% by explosion, 36% gunshot wounds (GSW), and 10% by other means. This paper focused on the 2 larger patient subsets: 1033 patients injured by terror-related explosion or GSW. Seventy-one percent of the patients were male, 84% in the GSW group and 63% in the explosion group. More than half (53%) of the patients were 15 to 29 years old, 59% in the GSW group and 48% in the explosion group. GSW patients suffered higher proportions of open wounds (63% versus 53%) and fractures (42% versus 31%). Multiple body-regions injured in a single patient occurred in 62% of explosion victims versus 47% in GSW patients. GSW patients had double the proportion of moderate injuries than explosion victims. Explosion victims have a larger proportion of minor injuries on one hand and critical to fatal injuries on the other. LOS was longer than 2 weeks for 20% (22% in explosion, 18% in GSW). Fifty-one percent of the patients underwent a surgical procedure, 58% in the GSW group and 46% in explosion group. Inpatient death rate was 6.3% (65 patients), 7.8% in the GSW group compared with 5.3% in the explosion group. A larger proportion of gunshot victims died during the first day (97% versus 58%). Conclusions:GSW and injuries from explosions differ in the body region of injury, distribution of severity, LOS, intensive care unit (ICU) stay, and time of inpatient death. These findings have implications for treatment and for preparedness of hospital resources to treat patients after a terrorist attack in any region of the world. Tailored protocol for patient evaluation and initial treatment should differ between GSW and explosion victims. Hospital organization toward treating and admitting these patients should take into account the different arrival and injury patterns.

The 1988 earthquake in Soviet Armenia: A case study

A major earthquake devastated the Armenian Republic of the Soviet Union on December 7, 1988, resulting in thousands of deaths and injuries. In a postearthquake investigation of three towns seriously affected by the earthquake, we studied earthquake-related injury patterns, made observations on rescue and medical efforts, and postulated certain factors associated with increased morbidity and mortality. Information was obtained from official Soviet documents, interviews with survivors of the earthquake, and interviews with local, regional, and national government officials. Figures were based on assessments made by these officials in the field in the immediate postearthquake period. Out of a population of 8,500, there were 4,202 (49.4%) deaths and 1,244 (14.6%) injured (casualty rate, 64.0%). Deaths and injuries were 67 and 11 times higher, respectively, among trapped than nontrapped victims. Being outside at the time of the earthquake or having escaped to the outside from the collapsing structure was crucial for survival. Among persons found alive, 89% were rescued during the first 24 hours, mostly without the use of heavy equipment. This observation underscores the importance of swift rescuer response. As with all field surveys after disasters, there were methodological limitations to this study due to chaotic postearthquake conditions. Accordingly, results must be approached with caution. Nonetheless, these preliminary observations are striking and have generated several new hypotheses for further investigations using more sophisticated analytic methods.

Disaster assessment: The emergency health evaluation of a population affected by a disaster

In the past decade, interest in the operational and epidemiologic aspects of disaster medicine has grown dramatically. State, local, and federal organizations have created vast emergency response networks capable of responding to disasters, while hospitals have developed extensive disaster plans to address mass casualty situations. Increasingly, the US armed forces have used both their ability to mobilize quickly and their medical expertise to provide humanitarian assistance rapidly during natural and man-made disasters. However, the critical component of any disaster response is the early conduct of a proper assessment to identify urgent needs and to determine relief priorities for an affected population. Unfortunately, because this component of disaster management has not kept pace with other developments in emergency response and technology, relief efforts often are inappropriate, delayed, or ineffective, thus contributing to increased morbidity and mortality. Therefore, improvements in disaster assessment remain the most pressing need in the field of disaster medicine.

Evaluating a Fluorosis Hazard after a Volcanic Eruption

The August, 1991 eruption of Mt. Hudson (Chile) deposited ash across southern Argentina and contributed to the deaths of thousands of grazing sheep. Early ash analysis revealed high levels of fluoride, a potential ash constituent toxic to humans and animals. In order to evaluate fluorosis as the cause of sheep deaths and to examine the possibility that similar ash and airborne toxins could also have an effect on the human population, we conducted an investigation that included health provider interviews, hospital record review, physical examination of sheep, determination of sheep urine fluoride levels, and complete constituent analysis of ash samples collected at proscribed distances from the volcano. Ash deposited farthest from the volcano had highest fluoride levels; all fluoride measurements were normal after rainfall. There were no signs or symptoms of fluorosis observed in sheep or humans. Sheep deaths resulted from physical, rather than chemical properties of the ash.

Disaster Medicine: Challenges for Today

Abstract [Waeckerle JF, Lillibridge SR, Noji EK: Burkle FM, Disaster medicine: Challenges for today. Ann Emerg Med April 1994;23:715-718.]

Fatality management in mass casualty incidents

Medical involvement in mass casualty incidents requires proper planning and preparedness. In disaster situations, legal aspects concerning the dead add to the general problem of a lack of time, place and resources to maintain routine working conditions, and demand authority and competence. The aspects of planning the recovery of the dead, transportation and morgue facilities, establishment of cause of death, identification, and the final disposition of the dead are discussed. The implementation of forensic mass fatality teams is felt to be the right answer for a better planning and coordination.

Acute Renal Failure in Natural Disasters

Sudden-impact natural disasters such as earthquakes present a serious challenge to medical personnel in both developed and less developed countries. Crush syndrome with acute renal failure has been identified as a major medical complication that occurs among people whose limbs are trapped by heavy objects during natural disasters such as earthquakes or volcanic eruptions. Rescue and field medical teams should be trained to recognize and promptly treat the problems associated with prolonged limb compression and should carry the appropriate fluids and medications to treat the complications of traumatic rhabdomyolysis. Early, aggressive volume replacement followed by forced solute-alkaline diuresis therapy may protect the kidney against acute renal failure. Better epidemiologic knowledge of the specific disaster conditions that predispose traumatic rhabdomyolysis to develop is clearly essential for those who must determine when emergency dialysis services are required in response to injuries sustained during natural disasters. Disaster health care personnel involved with providing emergency acute renal care should have a basic familiarity with disaster epidemiology in order to determine whether a given event requires their intervention. This paper includes recommendations for improving medical planning, preparedness, and response to natural disasters that cause acute renal failure.

Estimating population size in emergencies.

One of the first challenges in a natural disaster or humanitarian emergency is to obtain accurate estimates of affected populations (1). In the aftermath of rapid-onset disasters such as the recent tsunami disaster in south Asia, there is frequently an absence of adequate baseline data against which to measure the impact of the disaster. Available population data vary widely in quality, and the movement of persons can result in inaccurate estimates. The population may be widely dispersed, highly mobile, or in refugee camps. Uncertainty over population figures and demographic information constitutes one of the main barriers to accurate needs assessment.A basic problem faced by all humanitarian relief agencies in an emer-gency is that of counting the numbers of displaced persons and assessing their general well-being. The various methods of estimating population size in disasters have their advantages and disadvantages, and demographic techniques are con-tinually being updated and improved.Social scientists, epidemiologists and statisticians alike are familiar with the principles of sampling: selecting a subset of the population of interest in order to gain information about the entire population. A global positioning system (GPS — a system of satellites that provide precise location informa-tion that can be accessed using hand-held electronic units) is increasingly used to identify a sampling frame in the conflict setting. Alternatively, satellite imagery can be used to estimate popula-tion density and select a geographical area for sampling. Different tech-niques and types of samples need to be considered in crisis situations, so it is important to understand the limitations and potential weaknesses of the various methodologies.Cluster sampling consists of assign-ing each member of the population to a group (cluster); clusters are randomly selected and all members of selected clusters are included in the sample (2). Spatial sampling — which is a variant of cluster sampling and is also known

Health and politics in the 2003 war with Iraq: lessons learned

1Military involvement is often essential for the provision of intelligence, security, and logistical support to international relief organisations (in this article: UN Agencies, non-governmental organisations [NGOs], the International Committee of the Red Cross, and the International Federation of Red Cross and Red Crescent societies). In these situations, however, such organisations have retained overall leadership and control, which is essential for maintaining neutrality of relief workers. However, since the Balkan wars, the US armed forces have increased engagement in humanitarian projects, such as community health and food programmes. Relief organisations believe that this engagement contributes to insecurity by blurring the lines between civilian and military function, and falsely associates them with the military forces. 1,2