Satchit Balsari

Mortality in Puerto Rico after Hurricane Maria

BACKGROUND Quantifying the effect of natural disasters on society is critical for recovery of public health services and infrastructure. The death toll can be difficult to assess in the aftermath of a major disaster. In September 2017, Hurricane Maria caused massive infrastructural damage to Puerto Rico, but its effect on mortality remains contentious. The official death count is 64. METHODS Using a representative, stratified sample, we surveyed 3299 randomly chosen households across Puerto Rico to produce an independent estimate of all‐cause mortality after the hurricane. Respondents were asked about displacement, infrastructure loss, and causes of death. We calculated excess deaths by comparing our estimated post‐hurricane mortality rate with official rates for the same period in 2016. RESULTS From the survey data, we estimated a mortality rate of 14.3 deaths (95% confidence interval [CI], 9.8 to 18.9) per 1000 persons from September 20 through December 31, 2017. This rate yielded a total of 4645 excess deaths during this period (95% CI, 793 to 8498), equivalent to a 62% increase in the mortality rate as compared with the same period in 2016. However, this number is likely to be an underestimate because of survivor bias. The mortality rate remained high through the end of December 2017, and one third of the deaths were attributed to delayed or interrupted health care. Hurricane‐related migration was substantial. CONCLUSIONS This household‐based survey suggests that the number of excess deaths related to Hurricane Maria in Puerto Rico is more than 70 times the official estimate. (Funded by the Harvard T.H. Chan School of Public Health and others.)

Perspective: Environment, Biodiversity, and the Education of the Physician of the Future

Ours is an age of unprecedented levels of environmental alteration and biodiversity loss. Beyond the exposure to environmental hazards, conditions such as environmental degradation, biotic impoverishment, climate change, and the loss of ecosystem services create important health threats by changing the ecology of many pathogens and increasing the incidence and/or severity of certain noncommunicable conditions. They also threaten health in the future by weakening the Earths life support systems.Although physicians remain one of the most often accessed and most trusted sources of information about the environment, there is currently little emphasis on educating medical professionals about these environmental issues. This lack of training reduces the ability of most physicians to be efficient science-public interfaces and makes them ineffective at contributing to address the fundamental causes of environmental problems or participate in substantive environmental policy discussions. This is an important challenge facing medical education today.To turn medical students into effective physician-citizens, an already-overwhelmed medical school curriculum must make way for a thoughtful exploration of environmental stressors and their impacts on human health. The overarching question before medical educators is how to develop the competencies, standards, and curricula for this educational endeavor. To this end, the authors highlight some of the critical linkages between health and the environment and suggest a subset of key practical issues that need to be addressed in order to create environmental education standards for the physician of the future.

Water, Sanitation, and Hygiene at the World’s Largest Mass Gathering

The 2013 Kumbh Mela, a Hindu religious festival and the largest human gathering on earth, drew an estimated 120 million pilgrims to bathe at the holy confluence of the Ganga (Ganges) and Yamuna rivers. To accommodate the massive numbers, the Indian government constructed a temporary city on the flood plains of the two rivers and provided it with roads, electricity, water and sanitation facilities, police stations, and a tiered healthcare system. This phenomenal operation and its impacts have gone largely undocumented. To address this gap, the authors undertook an evaluation and systematic monitoring initiative to study preparedness and response to public health emergencies at the event. This paper describes the water, sanitation, and hygiene components, with particular emphasis on preventive and mitigation strategies; the capacity for surveillance and response to diarrheal disease outbreaks; and the implications of lessons learned for other mass gatherings.

Urban disaster preparedness of Hong Kong residents: A territory-wide survey

Abstract Objective To assess the state of community disaster preparedness of Hong Kong residents and to identify factors associated with adequate preparedness behaviors. Design A cross-sectional survey using random Global Positioning System (GPS) spatial sampling conducted from the 8 August 2015 to 6 September 2015. Participants Hong Kong residents aged 18 years or more. Method A 19-item questionnaire was developed to assess respondents’ preparedness information acquisition, communication plan, evacuation strategies, first-aid and disaster knowledge, financial resilience, and preparedness behaviors. In total, 1023 residents were interviewed at 516 GPS locations. Multiple logistic regression was used to identify factors associated with preparedness behaviors, defined as having an evacuation kit in our study. Results Television remains the key information source, both before and during disaster, with young respondents also favoring social media and the internet and elder residents preferring television and radio. Many respondents did not have adequate first-aid knowledge and few showed correct responses to a typhoon warning signal. Only 39.4% had an evacuation kit. In logistic regression, correct responses to first aid questions and a typhoon warning signal were significantly associated with kit preparation (OR 2.023, 95% CI 1.233−3.318, p=0.005). Residents with elderly household member(s) were significantly less likely to do so (OR 0.554, 95% CI 0.333−0.922, p=0.023). Conclusions Community resilience-building programs should tailor information provision to different age groups with a focus on the family caregivers of elderly residents. There is a need to promulgate first-aid training and disaster education in the community.

Using mobile technology to optimize disease surveillance and healthcare delivery at mass gatherings: a case study from India's Kumbh Mela

Background Planning for mass gatherings often includes temporary healthcare systems to address the needs of attendees. However, paper‐based record keeping has traditionally precluded the timely application of collected clinical data for epidemic surveillance or optimization of healthcare delivery. We evaluated the feasibility of harnessing ubiquitous mobile technologies for conducting disease surveillance and monitoring resource utilization at the Allahabad Kumbh Mela in India, a 55‐day festival attended by over 70 million people. Methods We developed an inexpensive, tablet‐based customized disease surveillance system with real‐time analytic capabilities, and piloted it at five field hospitals. Results The system captured 49 131 outpatient encounters over the 3‐week study period. The most common presenting complaints were musculoskeletal pain (19%), fever (17%), cough (17%), coryza (16%) and diarrhoea (5%). The majority of patients received at least one prescription. The most common prescriptions were for antimicrobials, acetaminophen and non‐steroidal anti‐inflammatory drugs. There was great inter‐site variability in caseload with the busiest hospital seeing 650% more patients than the least busy hospital, despite identical staffing. Conclusions Mobile‐based health information solutions developed with a focus on user‐centred design can be successfully deployed at mass gatherings in resource‐scarce settings to optimize care delivery by providing real‐time access to field data.

How Do Doctors and Nurses in Emergency Departments in Hong Kong View Their Disaster Preparedness? A Cross-Sectional Territory-Wide Online Survey

OBJECTIVES To assess the level of all-hazards disaster preparedness and training needs of emergency department (ED) doctors and nurses in Hong Kong from their perspective, and identify factors associated with high perceived personal preparedness. DESIGN This study was a cross-sectional territory-wide online survey conducted from 9 September to 26 October, 2015.ParticipantsThe participants were doctors from the Hong Kong College of Emergency Medicine and nurses from the Hong Kong College of Emergency Nursing. METHODS We assessed various components of all-hazards preparedness using a 25-item questionnaire. Backward logistic regression was used to identify factors associated with perceived preparedness. RESULTS A total of 107 responses were analyzed. Respondents lacked training in disaster management, emergency communication, psychological first aid, public health interventions, disaster law and ethics, media handling, and humanitarian response in an overseas setting. High perceived workplace preparedness, length of practice, and willingness to respond were associated with high perceived personal preparedness. CONCLUSIONS Given the current gaps in and needs for increased disaster preparedness training, ED doctors and nurses in Hong Kong may benefit from the development of core-competency-based training targeting the under-trained areas, measures to improve staff confidence in their workplaces, and efforts to remove barriers to staff willingness to respond. (Disaster Med Public Health Preparedness. 2018; 12: 329-336).

EMcounter-charting the epidemiology of medical emergencies in India: a status report

BackgroundIn the last decade, the specialty of Emergency Medicine has gained tremendous interest in low and middle income countries, with a demand for new training programs, pre-hospital systems, emergency department expansions and policy change. Yet, little is known about the actual distribution of medical emergencies in these settings.AimProject EMcounter proposes the implementation of this much needed, uniform, multi-center epidemiologic survey of emergencies in India to provide sound scientific data upon which new training programs, infrastructural expansions, and legislative change can be built.MethodologyA standardized, web-based, user-friendly data entry tool, EMcounter, forms the backbone of this project. The tool is currently piloted at a tertiary center in Chennai, India. The project is aimed at capturing the geographic and temporal variations in over 20 participating centers across the private and public sector in rural and urban India. The uniform use of the web-based tool ensures standardization in data collection across the centers. Our pilot project logs patient demographics, pre-hospital transportation, chief complaints, vitals, interventions, disposition and diagnoses. The volume of data thus collected is large and is currently saved in a spread sheet format.ObservationsThe first quarter has already begun to highlight the epidemiologic differences between a local hospital in Chennai and national averages in the US. The pilot phase has been critical in gauging the robustness of the tool before its expansion to multiple centers and has proved to be invaluable in identifying potential flaws.ConclusionThe early pilot phase has demonstrated that combining the multiple parameters available through the EMcounter database will allow the study of demographics and existing practice algorithms. Expansion of the project to multiple centers will shed objective light on the gaps in health-care provision at various levels and help design triage and transfer guidelines based on these data. This epidemiologic knowledge can potentially have significant influence in shaping the inventories and designs of emergency departments, and identifying staff needs and skill requirements. The project aims to seek and analyze data that will make the development of emergency medicine in India locally relevant.

Reimagining Health Data Exchange: An Application Programming Interface–Enabled Roadmap for India

In February 2018, the Government of India announced a massive public health insurance scheme extending coverage to 500 million citizens, in effect making it the world’s largest insurance program. To meet this target, the government will rely on technology to effectively scale services, monitor quality, and ensure accountability. While India has seen great strides in informational technology development and outsourcing, cellular phone penetration, cloud computing, and financial technology, the digital health ecosystem is in its nascent stages and has been waiting for a catalyst to seed the system. This National Health Protection Scheme is expected to provide just this impetus for widespread adoption. However, health data in India are mostly not digitized. In the few instances that they are, the data are not standardized, not interoperable, and not readily accessible to clinicians, researchers, or policymakers. While such barriers to easy health information exchange are hardly unique to India, the greenfield nature of India’s digital health infrastructure presents an excellent opportunity to avoid the pitfalls of complex, restrictive, digital health systems that have evolved elsewhere. We propose here a federated, patient-centric, application programming interface (API)–enabled health information ecosystem that leverages India’s near-universal mobile phone penetration, universal availability of unique ID systems, and evolving privacy and data protection laws. It builds on global best practices and promotes the adoption of human-centered design principles, data minimization, and open standard APIs. The recommendations are the result of 18 months of deliberations with multiple stakeholders in India and the United States, including from academia, industry, and government.

A retrospective analysis of hypertension screening at a mass gathering in India: Implications for non-communicable disease control strategies

Cardiovascular disease is the leading case of mortality from non-communicable diseases (NCD) in India. The government’s National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke seeks to increase capacity building, screening, referral and management of NCDs across India, and includes community-based outreach and screening programmes. The government in India routinely provides basic care at religious mass gatherings. However, in 2015, at the Kumbh Mela in Nashik and Trimbakeshwar, the state government extended its services to include a hypertension screening programme. We examine here the value and implications of such opportunistic screening at mass gatherings. At the Kumbh, 5760 persons voluntarily opted for hypertension screening, and received a single blood pressure measurement. In all, 1783 (33.6%) screened positive, of whom, 1580 were previously unaware of their diagnosis. Of the 303 that had previously known hypertension, 240 (79%) were prescribed medications, and 160 were compliant (that is, 52.8% under treatment). Fifty-five (18%) had normal blood pressure readings (BP under control). The data also demonstrated higher prevalence (39%) of hypertension among tobacco users compared to non-users (28%) (P<0.001). Poor recording of phone numbers (0.01%) precluded any phone-based follow-up. The low rates of hypertension awareness, treatment and control underscore the ongoing challenge of both hypertension screening and management in India.