Josephine Malilay

Climate Change: The Public Health Response

There is scientific consensus that the global climate is changing, with rising surface temperatures, melting ice and snow, rising sea levels, and increasing climate variability. These changes are expected to have substantial impacts on human health. There are known, effective public health responses for many of these impacts, but the scope, timeline, and complexity of climate change are unprecedented. We propose a public health approach to climate change, based on the essential public health services, that extends to both clinical and population health services and emphasizes the coordination of government agencies (federal, state, and local), academia, the private sector, and nongovernmental organizations.

Natural and technologic hazardous material releases during and after natural disasters: a review

Natural disasters may be powerful and prominent mechanisms of direct and indirect hazardous material (hazmat) releases. Hazardous materials that are released as the result of a technologic malfunction precipitated by a natural event are referred to as natural-technologic or na-tech events. Na-tech events pose unique environmental and human hazards. Disaster-associated hazardous material releases are of concern, given increases in population density and accelerating industrial development in areas subject to natural disasters. These trends increase the probability of catastrophic future disasters and the potential for mass human exposure to hazardous materials released during disasters. This systematic review summarizes direct and indirect disaster-associated releases, as well as environmental contamination and adverse human health effects that have resulted from natural disaster-related hazmat incidents. Thorough examination of historic disaster-related hazmat releases can be used to identify future threats and improve mitigation and prevention efforts.

Assessment of a severe-weather warning system and disaster preparedness, Calhoun County, Alabama, 1994

Tornado preparedness warning system effectiveness, and shelter-seeking behavior were examined in two Alabama areas after tornado warnings. In the area without sirens, only 28.9% of 194 respondents heard a tornado warning of these, 73.2% first received the warning from radios or television. In the area with sirens, 88.1% of 193 respondents heard a warning, and 61.8% first received the warning from a siren. Knowledge of warnings, access to shelter, and education were key predictors for seeking shelter. Our findings indicate that installing sirens, providing access to shelter, and teaching appropriate responses to warnings are important elements of an effective disaster prevention system.

An outbreak of carbon monoxide poisoning after a major ice storm in Maine

Unintentional carbon monoxide (CO) exposure kills over 500 people in the U.S. annually. Outbreaks of CO poisoning have occurred after winter storms. The objective of this study was to describe clinical features and identify important risk factors of a CO poisoning outbreak occurring after a major ice storm. The study design included a case series of CO poisoning patients, a telephone survey of the general community, and a case-controlled study of households using specific CO sources. The setting was the primary service area of four hospital emergency departments located in the heavily storm-impacted interior region of Maine. Participants included all patients with a laboratory-confirmed diagnosis of CO poisoning during the 2 weeks after the storm onset, and a population-based comparison group of 522 households selected by random digit dialing. There were 100 cases identified, involving 42 common-source exposure incidents, most of them during the first week. Though classic CO symptoms of headache, dizziness, and nausea predominated, 9 patients presented with chest pain and 10 were asymptomatic. One patient died and 5 were transferred for hyperbaric oxygen therapy. Gasoline-powered electric generators were a CO source in 30 incidents, kerosene heaters in 8, and propane heaters in 4. In the community, 31.4% of households used a generator after the ice storm. The strongest risk factor for poisoning was locating a generator in a basement or an attached structure such as a garage. Cases of CO poisoning with various presentations can be expected in the early aftermath of a severe ice storm. Generators are a major CO source and generator location an important risk factor for such disasters.

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.

Public Health Assessments in Disaster Settings: Recommendations for a Multidisciplinary Approach

INTRODUCTION Rapid assessments of needs and health status have been conducted by the U.S. Centers for Disease Control and Prevention (CDC) in natural disaster settings for gathering information about the status of affected populations during emergencies. A review of eight such assessments (6 from hurricanes, 1 from an ice storm, and 1 from an earthquake) examines current methods and applications, and describes the use of results by policy makers so assessments in post-disaster settings can be improved. OBJECTIVE Because the results of assessments greatly influence the nature of relief activities, a review can: 1) ascertain strengths and limitations; 2) examine the methods; and 3) ascertain the utility of results and their use by policy makers. This review compares assessments for similarities and differences: 1) across disaster types; 2) within similar disasters; 3) by timing when the assessments are conducted; and 4) in domestic and international settings. The review also identifies decision-making actions that result from the assessments, and suggests direction for future applications. METHODS Assessments reported in CDCs Morbidity and Mortality Weekly Report from 1980 through 1999 were reviewed because they applied a systematic methodology in data collection. They were compared descriptively for study characteristics and content areas. RESULTS Of 13 assessments identified from six reports, eight were reviewed because they focused on initial assessments, rather than on repeated studies. Of the eight, six pertained to hurricanes; one to an ice storm; and one to an earthquake. Seven (88%) were performed during or after the third day post-impact (range: 1-70 days, median: 7 days). All eight addressed demographics, morbidity, and water availability; seven concerned food, sanitation, and transportation; and six queried access to medical care and electricity. Of the three assessments conducted more than 10 days post-event, two addressed vulnerable children, the elderly, pregnant and lactating women, and migrant workers; two singled storm preparation and evacuation behavior; and one concerned mental health, preventive health care, and social programs. Only one, after an earthquake, asked about disaster-related deaths in household members. Two were international assessments and both were performed at least 60 days post-event. All eight provided estimates of proportions of needs based on survey respondents; none, however, extrapolated the proportions to estimate the magnitude of needs for populations at risk. Of the eight, five confirmed a policy decision, such as accelerating delivery of food supplies. CONCLUSION Assessments typically were conducted within 1 week after the precipitating event occurred. Most, performed within 3-10 days, focused on demographics, health status, food and water, and restoration of utilities. Three assessments, conducted > 1 month later, concerned long-term planning. Only one was performed < 72 hours post-event. Five assessments resulted in policy actions to guide relief activities. Increasing application of health assessments provides: 1) impetus for improving current methodologies; 2) standardizing collection instruments; 3) involving other sectors in emergency relief; and 4) ensuring useful information for decision makers.

Environmental pesticide exposure in Honduras following hurricane Mitch.

OBJECTIVE To investigate whether environmental contamination occurred in the wake of hurricane Mitch (30-31 October 1998), we conducted a population-based cross-sectional household survey in the barrio of Istoca, Department of Choluteca, Honduras. The goals were to evaluate chemical contamination of potable water and the extent of human exposure to chemicals as a result of extensive flooding. METHODS The survey consisted of an environmental exposure assessment, which included assaying water and soil samples for contaminants, and taking blood and urine samples from 45 adolescents aged 15-18 years. We also made a subjective questionnaire assessment of 155 households. FINDINGS There was significant contamination of the soil in Istoca, but no water contamination in the aftermath of hurricane Mitch. The soil levels of chlopyrifos and parathion were 30- and 1000-times higher, respectively, than the Environmental Data Quality Level. However, the most striking finding was the detection of elevated levels of chlorinated and organophosphate pesticides in adolescents. Toxicological analyses of serum specimens showed that 51% of the samples had elevated levels of 1,1-dichloro-2,2-bis-(p-chlorophenyl) ethylene (p,p-DDE) (range, 1.16-96.9 ng/ml) (US reference mean = 3.5 ng/ml) in adults). Dieldrin levels > 0.2 ng/ml were also present in 23% of the serum specimens (serum levels of this analyte in US adolescents are < 0.2 ng/ml). Of 43 urine samples analysed for organophosphate metabolites, 18.6% contained diethyl phosphate (DEP) at levels which were greater that the reference mean of 6.45 micrograms/g creatinine. We also detected elevated levels of p-nitrophenol (p-NP) and of 3,5,6-trichloro-2-pyridinol (3,5,6-TCPY) in 91% and 42% of the samples, respectively. CONCLUSIONS The elevated levels of chlorinated pesticides were surprising, since although these substances were banned in Honduras 15 years ago it appears that they are still being used in the country. Moreover, elevated levels of organophosphates were detected in the study adolescents even three weeks after the hurricane. Since these chemicals are usually cleared from the body quickly, our data suggest that the adolescents face an ongoing threat from pesticide exposure.

Emergency Health Surveillance After Severe Flooding in Louisiana, 1995

INTRODUCTION In disaster situations, timely surveillance systems that provide illness, injury, and mortality information to public health officials and hospitals are essential for planning and evaluating interventions. OBJECTIVES To describe flood surveillance methodology, the impact of the event on hospitals, and the number of daily patient visits due to selected illnesses and injuries before, during, and after severe flooding in southeastern Louisiana in May 1995. METHODS Survey of disaster-area hospitals regarding flood impact. Emergency department surveillance of injuries and illnesses for the week before, the two days during, and the week after the flood. RESULTS There occurred an increase in the number of persons who drowned or were injured that presented to the moderately affected hospitals during the storm, but there was no increase in visits for gastroenteritis to any group of hospitals. Services were disrupted in more than half of hospitals. The severely affected hospitals had the least variation in the average number of daily visits. None of the drownings were reported by those hospitals that reported severe service disruption. CONCLUSIONS Data should be collected from all hospitals in or near disaster areas, even if they were not directly affected by the disaster. Public education about the danger of drowning during flash flooding must be improved. The Louisiana experience emphasizes the need for a disaster-preparedness plan for rapid surveillance of illnesses and injuries.

Mortality and Morbidity Patterns Associated with the October 12, 1992 Egypt Earthquake

On October 12, 1992, the metropolitan area of Cairo, Egypt and surrounding villages in the Nile Valley sustained the effects of a moderate earthquake of magnitude M B 5.9 (M S 5.2). To identify mortality- or injury-prevention strategies for communities at risk, we investigated deaths and injuries that were associated with the event and modeled the time that patients spent in the hospital because of earthquake-related injuries. Populations in areas closest to the epicenter experienced increased death and injury rates (4.6 deaths per 100,000 and 80.6 injuries per 100,000) compared to those located further from the epicenter (0.8 deaths per 100,000 and 23.7 injuries per 100,000). The distribution of earthquake-related admissions in one hospital peaked within 36 hours after the earthquake. A general linear model predicted that older people were hospitalized longer than younger people and people with fractures to the trunk were hospitalized longer than those with injuries at other anatomical sites (p = 0.008). While recognizing that other characteristics are also important, we recommend that emergency managers consider proximity to the epicenter when planning response operations, and that health officials focus on ensuring appropriate medical care for older people and for people who have suffered severe injuries to the trunk.

Vigilancia de la salud pública después de una erupción volcánica: lecciones aprendidas en Cerro Negro, Nicaragua, 1992

La erupcion del volcan Cerro Negro cerca de Leon, Nicaragua, el 9 de abril de 1992 lanzo alrededor de 1,7 millones de toneladas de ceniza en una zona de 200 km². Se efectuo una evaluacion inicial de los efectos en la salud de cerca de 300 000 residentes, con los datos normalmente obtenidos mediante el sistema nacional de vigilancia epidemiologica. Se determino que el numero de consultas a los establecimientos de atencion de salud por diarrea e infecciones respiratorias agudas (IRA) aumento en las dos comunidades estudiadas, una dentro de la zona del desastre y otra en sus cercanias. En particular, las consultas por diarrea aguda fueron casi 6,0 veces mas numerosas que antes de la erupcion en ambas comunidades y las consultas por IRA, 3,6 veces mas frecuentes en Malpaisillo (la comunidad cercana a la zona del desastre) y 6,0 veces mas frecuentes en Telica (la comunidad situada dentro de esa zona). Casi todas fueron consultas por enfermedad en lactantes y ninos menores de 5 anos. El aumento de la tasa de morbilidad por diarrea, que frecuentemente se produce despues de las erupciones volcanicas, exige que se investiguen detalladamente el tipo y la calidad del abastecimiento de agua despues de una acumulacion cuantiosa de ceniza. Es preciso examinar con mayor detenimiento los problemas respiratorios asociados con la ceniza para determinar el espectro de esas enfermedades y el momento en que se presentan en lactantes y otros subgrupos especiales de la poblacion. Los datos acopiados por medio de la vigilancia pasiva sobre las condiciones de salud antes y despues de una erupcion pueden emplearse para detectar la morbilidad relacionada con la erupcion. Los sistemas que ya estan establecidos, como el sistema nacional de vigilancia epidemiologica de Nicaragua, se pueden modificar o ampliar para mejorar su sensibilidad a nuevos casos y, por ende, su capacidad de ofrecer servicios de notificacion apropiados a los organismos de socorro medico.