Jennifer A. Horney

Individual actual or perceived property flood risk: did it predict evacuation from Hurricane Isabel in North Carolina, 2003?

Individual perception of risk has consistently been considered an important determinant of hurricane evacuation in published studies and reviews. Adequate risk assessment is informed by environmental and social cues, as well as evacuation intentions and past disaster experience. This cross-sectional study measured perceived flood risk of 570 residents of three coastal North Carolina counties, compared their perception with actual risk determined by updated flood plain maps, and determined if either was associated with evacuation from Hurricane Isabel in 2003. Census blocks were stratified by flood zone and 30 census blocks were randomly selected from each flood zone. Seven interviews were conducted at random locations within selected blocks. Bivariate and multivariable analyses were conducted to produce crude and adjusted risk differences. Neither the designated flood zone of the parcel where the home was located nor the residents perceived flood risk was associated with evacuation from Hurricane Isabel in the bivariate analysis. In the multivariable analysis, intention to evacuate and home type were important confounders of the association between actual risk and evacuation. The belief that one is at high risk of property damage or injury is important in evacuation decision making. However, in this study, while coastal residents perceived risk of flooding was correlated with their actual flood risk, neither was associated with evacuation. These findings provide important opportunities for education and intervention by policymakers and authorities to improve hurricane evacuation rates and raise flood risk awareness.

Intent to Receive Pandemic Influenza A (H1N1) Vaccine, Compliance with Social Distancing and Sources of Information in NC, 2009

Background Public adherence to influenza vaccination recommendations has been low, particularly among younger adults and children under 2, despite the availability of safe and effective seasonal vaccine. Intention to receive 2009 pandemic influenza A (H1N1) vaccine has been estimated to be 50% in select populations. This report measures knowledge of and intention to receive pandemic vaccine in a population-based setting, including target groups for seasonal and H1N1 influenza. Methodology and Principal Findings On August 28–29, 2009, we conducted a population-based survey in 2 counties in North Carolina. The survey used the 30×7 two-stage cluster sampling methodology to identify 210 target households. Prevalence ratios (PR) and 95% confidence intervals (CI) were estimated. Knowledge of pandemic influenza A (H1N1) vaccine was high, with 165 (80%) aware that a vaccine was being prepared. A total of 133 (64%) respondents intended to receive pandemic vaccine, 134 (64%) intended to receive seasonal vaccine, and 109 (53%) intended to receive both. Reporting great concern about H1N1 infection (PR 1.55; 95%CI: 1.30, 1.85), receiving seasonal influenza vaccine in 2008–09 (PR 1.47; 95%CI: 1.18, 1.82), and intending to receive seasonal influenza vaccine in 2009–10 (PR 1.27; 95%CI: 1.14, 1.42) were associated with intention to receive pandemic vaccine. Not associated were knowledge of vaccine, employment, having children under age 18, gender, race/ethnicity and age. Reasons cited for not intending to get vaccinated include not being at risk for infection, concerns about vaccine side effects and belief that illness caused by pandemic H1N1 would be mild. Forty-five percent of households with children under 18 and 65% of working adults reported ability to comply with self-isolation at home for 7–10 days if recommended by authorities. Conclusions and Significance This is the first report of a population based rapid assessment used to assess knowledge and intent to receive pandemic vaccine in a community sample. Intention to receive pandemic and seasonal vaccines was higher than previously published reports. To reach persons not intending to receive pandemic vaccine, public health communications should focus on the perceived risk of infection and concerns about vaccine safety.

Post-Disaster Reproductive Health Outcomes

We examined methodological issues in studies of disaster-related effects on reproductive health outcomes and fertility among women of reproductive age and infants in the United States (US). We conducted a systematic literature review of 1,635 articles and reports published in peer-reviewed journals or by the government from January 1981 through December 2010. We classified the studies using three exposure types: (1) physical exposure to toxicants; (2) psychological trauma; and (3) general exposure to disaster. Fifteen articles met our inclusion criteria concerning research focus and design. Overall studies pertained to eight different disasters, with most (nxa0=xa06) focused on the World Trade Center attack. Only one study examined pregnancy loss, i.e., occurrence of spontaneous abortions post-disaster. Most studies focused on associations between disaster and adverse birth outcomes, but two studies pertained only to post-disaster fertility while another two examined it in addition to adverse birth outcomes. In most studies disaster-affected populations were assumed to have experienced psychological trauma, but exposure to trauma was measured in only four studies. Furthermore, effects of both physical exposure to toxicants and psychological trauma on disaster-affected populations were examined in only one study. Effects on birth outcomes were not consistently demonstrated, and study methodologies varied widely. Even so, these studies suggest an association between disasters and reproductive health and highlight the need for further studies to clarify associations. We postulate that post-disaster surveillance among pregnant women could improve our understanding of effects of disaster on the reproductive health of US pregnant women.

Improvements to water purification and sanitation infrastructure may reduce the diarrheal burden in a marginalized and flood prone population in remote Nicaragua.

BackgroundThe isolated northern region of Nicaragua has one of the highest rates of diarrheal disease in Central America. Political and environmental hardships faced by inhabitants of this region are contributing factors to this health inequity. The aim of this study was to assess the relationship between water and latrine infrastructure and the prevalence of diarrhea in this region.MethodsA population-based, cross-sectional survey of women of reproductive age was conducted in the Sahsa region of northern Nicaragua in July, 2009. Households were selected by two stage cluster sampling methodology. A questionnaire was administered in Spanish and Miskito with assessment of household and socioeconomic conditions, sanitation practices, and health care access. Diarrhea prevalence differences at the household level over a two week reporting period were estimated with a standardized instrument which included assessment of water treatment and latrine use and maintenance.ResultsThere were 189 women enrolled in the current study. The use of water purification methods, such as chlorine and filters, and latrine ownership were not associated with reduced prevalence of household diarrhea in the two week reporting period. Latrine overflow, however, was associated with an increased prevalence of diarrhea during the same two week period [adjusted prevalence difference and 95% CI: 0.19 (0.03, 0.36)].ConclusionsSimple, low cost interventions that improve water and latrine infrastructure may reduce the prevalence of diarrheal disease in the isolated regions of Nicaragua and Central America.

Linking public health agencies and hospitals for improved emergency preparedness: North Carolina's public health epidemiologist program.

BackgroundIn 2003, 11 public health epidemiologists were placed in North Carolinas largest hospitals to enhance communication between public health agencies and healthcare systems for improved emergency preparedness. We describe the specific services public health epidemiologists provide to local health departments, the North Carolina Division of Public Health, and the hospitals in which they are based, and assess the value of these services to stakeholders.MethodsWe surveyed and/or interviewed public health epidemiologists, communicable disease nurses based at local health departments, North Carolina Division of Public Health staff, and public health epidemiologists hospital supervisors to 1) elicit the services provided by public health epidemiologists in daily practice and during emergencies and 2) examine the value of these services. Interviews were transcribed and imported into ATLAS.ti for coding and analysis. Descriptive analyses were performed on quantitative survey data.ResultsPublic health epidemiologists conduct syndromic surveillance of community-acquired infections and potential bioterrorism events, assist local health departments and the North Carolina Division of Public Health with public health investigations, educate clinicians on diseases of public health importance, and enhance communication between hospitals and public health agencies. Stakeholders place on a high value on the unique services provided by public health epidemiologists.ConclusionsPublic health epidemiologists effectively link public health agencies and hospitals to enhance syndromic surveillance, communicable disease management, and public health emergency preparedness and response. This comprehensive description of the program and its value to stakeholders, both in routine daily practice and in responding to a major public health emergency, can inform other states that may wish to establish a similar program as part of their larger public health emergency preparedness and response system.

User patterns and satisfaction with on-line trainings completed on the North Carolina Center for Public Health Preparedness Training Web Site.

Short online training modules have been developed by the North Carolina Center for Public Health Preparedness (NCCPHP) and provided to registered users for free on its Training Web Site. Use of these modules can improve the knowledge, skills, and awareness of public health professionals in topics related to public health preparedness. According to the results of a survey implemented in October 2004, the NCCPHP Training Web Site is effectively reaching its target audience of local and state public health workers. The utilization of distance learning technology allows for broad distribution of training materials, with registered users in all 50 US states and 122 foreign countries. In addition, the NCCPHP Training Web Site is providing training materials in topics most requested by the public health workforce. According to the findings of this survey, online training in public health preparedness and response is an efficient way to improve the knowledge and skills of our public health workforce to increase competency.

Cluster Sampling with Referral to Improve the Efficiency of Estimating Unmet Needs among Pregnant and Postpartum Women after Disasters

INTRODUCTION AND BACKGROUNDnWomen of reproductive age, in particular women who are pregnant or fewer than 6 months postpartum, are uniquely vulnerable to the effects of natural disasters, which may create stressors for caregivers, limit access to prenatal/postpartum care, or interrupt contraception. Traditional approaches (e.g., newborn records, community surveys) to survey women of reproductive age about unmet needs may not be practical after disasters. Finding pregnant or postpartum women is especially challenging because fewer than 5% of women of reproductive age are pregnant or postpartum at any time.nnnMETHODSnFrom 2009 to 2011, we conducted three pilots of a sampling strategy that aimed to increase the proportion of pregnant and postpartum women of reproductive age who were included in postdisaster reproductive health assessments in Johnston County, North Carolina, after tornadoes, Cobb/Douglas Counties, Georgia, after flooding, and Bertie County, North Carolina, after hurricane-related flooding.nnnRESULTSnUsing this method, the percentage of pregnant and postpartum women interviewed in each pilot increased from 0.06% to 21%, 8% to 19%, and 9% to 17%, respectively.nnnCONCLUSION AND DISCUSSIONnTwo-stage cluster sampling with referral can be used to increase the proportion of pregnant and postpartum women included in a postdisaster assessment. This strategy may be a promising way to assess unmet needs of pregnant and postpartum women in disaster-affected communities.

An Evaluation of Community Assessment for Public Health Emergency Response (CASPER) in North Carolina, 2003-2010

INTRODUCTIONnCommunity Assessment for Public Health Emergency Response (CASPER) is a group of tools and methods designed by the US Centers for Disease Control and Prevention (CDC) to provide rapid, reliable, and accurate population-based public health information. Since 2003, North Carolina public health professionals have used CASPERs to facilitate public health emergency responses and gather information on other topics including routine community health assessments.nnnPROBLEMnTo date, there has been no evaluation of CASPER use by public health agencies at the state or local level in the US.nnnMETHODSnLocal health departments of North Carolina reported when and how CASPERs were used during the period 2003 to 2010 via an online survey. Data on barriers and future plans for using CASPERs also were collected.nnnRESULTSnFifty-two of North Carolinas 85 local health departments (61%) completed the survey. Twenty-eight departments reported 46 instances of CASPER use during 2003 to 2010. The majority of CASPERs were performed for community health assessments (n = 20, 43%) or exercises (n = 11, 24%). Fifty-six percent of respondents indicated they were likely or very likely to use CASPERs in the future; those who had prior experience with CASPERs were significantly more likely (P = .02) to report planned future use of CASPERs compared to those without prior experience with the tool. Lack of training, equipment, and time were the most frequently reported barriers to using CASPERs.nnnCONCLUSIONSnLocal public health agencies with clear objectives and goals can effectively use CASPERs in both routine public health practice and disaster settings.

Characterizing the Impact of Extreme Heat on Mortality, Karachi, Pakistan, June 2015

UNLABELLEDnIntroduction Karachi, Pakistan was affected by a heat wave in June 2015 during the Muslim holy month of Ramadan. Many media reports attributed the excess deaths in part to the practice of daylight fasting during Ramadan. As much of the published research reports on heat-related mortality in Europe and the United States, an exploration of the effects of extreme heat on residents of a South Asian mega-city address a gap in current disaster research. Hypothesis/Problem This report investigated potential risk factors for excess mortality associated with the June 2015 heat wave in Karachi, Pakistan.nnnMETHODSnData were obtained through manual review of death certificates at public hospitals and private clinics in Karachi, Pakistan, conducted from July 1 through July 31, 2015 by a trained physician. Demographic data for any deaths with a primary cause of death of heat-related illness were recorded in Microsoft Excel (Microsoft Corp.; Redmond, Washington USA). EpiSheet (2012; Rothman. Modern Epidemiology. Lippincott Williams & Wilkins; Philadelphia, Pennsylvania USA) was used to calculate risk differences (RD), rate ratios (RR), and 95% confidence intervals (95% CI).nnnRESULTSnOverall, residents of Karachi were approximately 17 times as likely to die of a heat-related cause of death during June 2015 (RR=17.68; 95% CI, 13.87-22.53) when compared with the reference period of June 2014. Residents with a monthly income lower than 20,000 Pakistani Rupees (US

Evaluation of the implementation of the H1N1 pandemic influenza vaccine in local health departments (LHDs) in North Carolina

196; RD=0.03; 95% CI, 0.01-0.05) and those with less than a fifth grade education (RD=0.03; 95% CI, 0.00-0.05) were at significantly higher risk of death during the 2015 heat wave compared to the reference period.nnnCONCLUSIONnFasting during Ramadan was not a significant risk factor for mortality from heat-related causes during the Karachi heat wave of June 2015. A large number of excess deaths were reported across all demographic groups, which due to the burden of record keeping in an under-resourced health system during a public health emergency, are almost certainly an underestimate. Ghumman U , Horney J . Characterizing the impact of extreme heat on mortality, Karachi, Pakistan, June 2015. Prehosp Disaster Med. 2016;31(3):263-266.