Disaster Epidemiology: Methods and Applications

Disaster Epidemiology

Methods and Applications

Editor

Jennifer A. Horney

Table of Contents

Cover image

Title page

Copyright

Dedication

List of Contributors

Acknowledgments

Introduction to Disaster Epidemiology

Chapter 1. History of Disaster Epidemiology: 1960–2015

Background

1960s–1980s

1990s

2000s

Chapter 2. Methods: Surveillance

The History of Public Health Surveillance

Defining Surveillance

Types of Surveillance

Using Public Health Surveillance Data During a Disaster

Conclusions

Vignette: Veterans Health Affairs, Veterans, and Disasters

Introduction

Veterans Affairs' Role in Emergency Preparedness and Response

Veterans Health Administration Disaster Responses in Recent Years

Summary and Conclusions

Chapter 3. Applications: Using Information Systems to Improve Surveillance During Disasters

Background

Development and Use of the Georgia State Electronic Notifiable Disease Surveillance System

Building Infrastructure

Chapter 4. Applications: Shelter Surveillance

Introduction

Why Conduct Shelter Surveillance?

Data Collection

Data Aggregation

Vignette: Postdisaster Carbon Monoxide Surveillance

Carbon Monoxide Poisoning in the Aftermath of Hurricane Sandy

What is Carbon Monoxide Poisoning?

Why is Carbon Monoxide Poisoning a Public Health Concern?

Establishing Cases of Carbon Monoxide Exposure

The Epidemiology of Carbon Monoxide Poisoning After a Disaster

How to Prepare?

Chapter 5. Applications: Disaster-Related Mortality Surveillance: Challenges and Considerations for Local and State Health Departments

Background

Challenges and Considerations

Surveillance Case Studies

Chapter 6. Methods: Study Designs in Disaster Epidemiology

Introduction

Methods and Study Designs

Examples of Disaster Epidemiology Studies

The World Trade Center, September 11, 2001

Hurricane Katrina and Superstorm Sandy

Deepwater Horizon Oil Spill

Typhoon Haiyan, Philippines

Haiti Earthquake, 2010

Conclusion

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

Introduction

Background and History

Sampling Frame and Methodology

Questionnaire and Field Interviews

Data Analysis and Reporting

CASPER Example

Conclusion

Chapter 8. Applications: Assessment of Chemical Exposures: Epidemiologic Investigations After Large-Scale Chemical Releases

Background

Assessment of Chemical Exposures Resources

Outcomes of Assessment of Chemical Exposures Investigations

Conclusion

Vignette: Geothermal Venting and Emergency Preparedness—Lake County, California

Vignette: CASPER in Response to a Slow-Moving Disaster—The California Drought

Chapter 9. Methods: Questionnaire Development and Interviewing Techniques

Introduction

Questionnaire Development

Interview Techniques

Conclusion

Vignette: Investigating Foodborne Outbreaks

Chapter 10. Applications: Social Vulnerability to Disaster (Hampton and Hertford Counties—Isabel)

Introduction

Physical and Social Vulnerability in Hertford County

Physical and Social Vulnerability in the City of Hampton

Emergency Preparedness Demonstration Project and the Data Collection Process

Data Collection, Analysis, and Findings for Hertford County

Data Collection, Analysis, and Findings for City of Hampton

Conclusion

Chapter 11. Applications: Emergency Responder Health Monitoring and Surveillance: Successful Application

Background

Emergency Responder Health Monitoring and Surveillance

Getting Started

Successful Application

Summary

Vignette: Experiences Working With Ebola Virus Disease and Pregnancy in Sierra Leone, 2014

Activity 1. Improving Screening Criteria for Ebola Virus Disease Among Pregnant Women

Activity 2. Addressing Barriers to Care Among Pregnant Women During an EVD Outbreak

Chapter 12. Methods: Data Analysis for Disaster Epidemiology

Data Analysis for Disaster Epidemiology

Conclusion

Chapter 13. Applications: Biosurveillance, Biodefense, and Biotechnology

Prevention and Preparedness—Concepts in Biosurveillance

Surveillance Systems

Biodefense and Outbreak Response

Summary: Prospective Biosurveillance

Vignette: Climate Change Effects on Flooding During Hurricane Sandy (2012)

Vignette: Disasters and Chronic Medical Conditions

Introduction

Action Steps

Summary

Chapter 14. Applications: Disaster Communication and Community Engagement

Introduction

Fundamental Concepts

Risk Communication Plans

Collaborations

Barriers and Challenges to Risk Communications

Conclusions

Vignette From Recent Responses: Roseburg, Oregon Mass Shooting

Chapter 15. What Can Disaster Epidemiology Contribute to Building Resilient Communities?

Defining Community Resilience

Challenges to Collecting and Using Epidemiologic Data After a Disaster

The Importance of Community Engagement

Next Steps

Appendix: Disaster Resources

Index

Copyright

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Notices

Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary.

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Dedication

To my husband, Michael, and my children, Ian and Lila. In memory of my beloved father, Joseph Horney, who was resolute in his support for all my pursuits, both personal and professional.

List of Contributors

Koya C. Allen,     US Department of Defense, Stuttgart, Germany

Latasha A. Allen,     Office of the Assistant Secretary for Preparedness and Response (ASPR), Office of Emergency Management (OEM), Washington, DC, United States

Pamela Allweiss,     Centers for Disease Control and Prevention, Atlanta, GA, United States

Tracy Barreau,     California Department of Public Health, Richmond, CA, United States

Tesfaye M. Bayleyegn,     Centers for Disease Control and Prevention, Atlanta, GA, United States

Jennifer C. Beggs,     Michigan Department of Health and Human Services, Lansing, MI, United States

Venessa Cantu,     Texas Department of State Health Services, Austin, TX, United States

Karen Chu,     VA Greater Los Angeles Healthcare System, Sepulveda, CA, United States

Ashley Conley,     St. Joseph Hospital, Nashua, NH, United States

Joel C. Dietrich,     NC State University, Raleigh, NC, United States

Hope Dishman,     Georgia Department of Public Health, Atlanta, GA, United States

Aram Dobalian

University of California, Los Angeles, CA, United States

VA Greater Los Angeles Healthcare System, Sepulveda, CA, United States

Mary Anne Duncan†,     Agency for Toxic Substances and Disease Registry, Atlanta, GA, United States

Michelle Dynes

Centers for Disease Control and Prevention, Atlanta, GA, United States

US Public Health Service Commissioned Corps, Rockville, MD, United States

Laura Edison

Georgia Department of Public Health, Atlanta, GA, United States

Centers for Disease Control and Prevention, Atlanta, GA, United States

Marilyn Felkner,     Texas Department of State Health Services, Austin, TX, United States

Renée H. Funk,     Centers for Disease Control and Prevention, Atlanta, GA, United States

Rebecca J. Heick,     Augustana College, Rock Island, IL, United States

Jennifer A. Horney,     Texas A&M University, College Station, TX, United States

Josephine Malilay,     Centers for Disease Control and Prevention, Atlanta, GA, United States

Kevin McClaran,     Texas Department of State Health Services, Austin, TX, United States

Jonetta Johnson Mpofu

Centers for Disease Control and Prevention, Atlanta, GA, United States

US Public Health Service Commissioned Corps, Rockville, MD, United States

Nicole Nakata,     Centers for Disease Control and Prevention, Atlanta, GA, United States

Rebecca S. Noe,     Centers for Disease Control and Prevention, Atlanta, GA, United States

Maureen F. Orr,     Agency for Toxic Substances and Disease Registry, Atlanta, GA, United States

Tiffany Radcliff

Texas A&M University, College Station, TX, United States

VA Greater Los Angeles Healthcare System, Sepulveda, CA, United States

Akiko M. Saito,     Oregon Health Authority – Public Health Division, Portland, OR, United States

Amy H. Schnall,     Centers for Disease Control and Prevention, Atlanta, GA, United States

Suzanne Shurtz,     Texas A&M University, College Station, TX, United States

Kanta Sircar,     Centers for Disease Control and Prevention, Chamblee, GA, Unites States

Svetlana Smorodinsky,     California Department of Public Health, Richmond, CA, United States

Karl Soetebier,     Georgia Department of Public Health, Atlanta, GA, United States

Danielle Spurlock,     University of North Carolina, Chapel Hill, NC, United States

Dorothy Stearns,     Centers for Disease Control and Prevention, Chamblee, GA, Unites States

Kahler Stone,     Texas A&M University, College Station, TX, United States

Jason Wilken

California Department of Public Health, Richmond, CA, United States

Centers for Disease Control and Prevention, Atlanta, GA, United States

U.S. Public Health Service Commissioned Corps, Rockville, MD, United States

Amy Wolkin,     Centers for Disease Control and Prevention, Atlanta, GA, United States

† Deceased

Acknowledgments

This book is the result of important contributions by a large number of public health practitioners and academicians, and the resulting combination of both epidemiologic methods and applications has been a critical focus of the book from its inception. For the last decade or more, a dedicated group of experts in epidemiology and environmental health have led the charge to recognize the importance of disaster epidemiology within the fields of public health and epidemiology, as well as within the phases of the disaster management cycle. This book would not have been possible without the work of many people who are not listed as authors, including members of the Center for Disease Control and Prevention's Disaster Epidemiology Community of Practice (DECoP), formerly known as the Disaster Surveillance Workgroup, the Council of State and Territorial Epidemiologists' Disaster Epidemiology Subcommittee, and attendees at the annual National Disaster Epidemiology Workshop. I would particularly like to acknowledge the many applied public health practitioners at the federal, state, and local levels who have shared their time and their real-world expertise with me and given me an opportunity to learn what cannot be taught in a classroom. Most importantly, these practitioners have been generous with my students, building on what I can teach them, and helping them become the next generation of disaster epidemiologists.

Introduction to Disaster Epidemiology

Josephine Malilay¹, and Jennifer A. Horney²,     ¹Centers for Disease Control and Prevention, Atlanta, GA, United States,     ²Texas A&M University, College Station, TX, United States

Introduction

Despite efforts to control, prevent, and mitigate public health consequences of natural disasters and complex emergencies in recent decades, these events continue to affect increased numbers of people worldwide and lead to a significant number of deaths, injuries, diseases, and disabilities (Leaning & Guha Sapir, 2013). The study of the health impacts of disasters and emergencies has led to an expanding use of methods borrowed from epidemiology, the science that studies the causes and determinants of diseases in populations (Last, 1988). The use of epidemiologic methods and study designs in postdisaster settings can aid in identifying vulnerable populations, quantifying disaster-related morbidity and mortality, determining effects of a disaster event on predisaster health status, and informing decision-making for appropriate interventions and allocation of resources for relief, recovery, and resilience building programs.

The application of epidemiologic methods in the disaster setting has led to the emergence of disaster epidemiology, which began with the study of health risks after environmental disasters and is now widely regarded as a subset of environmental epidemiology (Lauriola & Leonardi, 2016). Beginning with descriptive techniques, one of the earliest disaster epidemiology applications was an evaluation of health status after a cyclone struck East Bengal, Bangladesh in 1970. Two postdisaster assessments identified young children, elderly, and females as vulnerable subgroups of a densely populated and impoverished region and provided reasonably accurate estimates of disaster relief requirements so that the region could recover agricultural self-sufficiency (Sommer & Mosley, 1972). Since then, other public health pioneers with years of field experience have pointed out the utility of epidemiologic methods in addressing the health effects of disasters (Lechat, 1976; Seaman, 1984) and described the role of the epidemiologist in natural disasters (Binder & Sanderson, 1987). In 2014, after numerous applications of the use of epidemiologic methods including rapid needs assessments in diverse field settings, the United States–based Council for State and Territorial Epidemiologists (CSTE) and the US Centers for Disease Control and Prevention (CDC) published a conceptual framework describing the role of disaster epidemiology and outlining specific epidemiologic activities that could be conducted during different phases of the disaster management cycle (Malilay et al., 2014). The framework provides guidance for using epidemiologic methods in investigations and studies during preparedness, response, recovery, and mitigation. However, the process during the preceding four and half decades deserves mention.

Descriptive Studies

Initially, disaster epidemiology studies were conducted after certain events, often as a result of the intervention of outside agencies or groups due to the magnitude of disaster. Occasionally, natural experiments took place in areas where ongoing predisaster studies allowed for timely response by seamless allocation of resources and staff to postdisaster studies. Many descriptive studies described mortality and morbidity related to the event. For instance, counts of fatalities are summarized in the literature for specific events including earthquakes, volcanic eruptions, hurricanes, tornadoes, and floods (Baxter et al., 1981; Brenner & Noji, 1992; CDC, 1985, 1989, 1990, 1993a,b,c, 1994; Glass et al., 1980; Peek-Asa et al., 1998; Rosenfield, McQueen, & Lucas, 1994). Fatalities and injuries were largely attributed to trauma and traumatic rhabdomyolysis from crush injuries in earthquakes (CDC, 1990; Peek-Asa et al., 1998), described by their location on the body (e.g., head, clavicle, extremities) in tornadic events (Brenner & Noji, 1992; Brown, Archer, Kruger, & Mallonee, 2002; Glass et al., 1980; Rosenfield et al., 1994), or explained by individual activity during preparation or cleanup (e.g., electrocution while securing outside electrical items or in postflood cleanup work) (CDC, 1993b, 1994). In some volcanic disasters, a variety of health outcomes were observed, ranging from respiratory conditions from ashfall-related hazards to burns from tephra associated with explosive eruptions (Baxter, Bernstein, Falk, French, & Ing, 1982). In hydrometeorological events such as hurricanes and flash flooding, fatalities tend to be mostly related to drowning, and in particular, drowning among occupants of motor vehicles where drivers attempted to drive through flood waters of unknown depth (CDC, 1993a, 1993b, 1994). In tornadoes, fatalities were mainly attributed to trauma (Brenner & Noji, 1992; Brown et al., 2002; Edison, Lybarger, Parsons, Maccormack, & Freeman, 1990; Glass et al., 1980; Rosenfield et al., 1994), while the health impacts from major winter storms included carbon monoxide poisoning due to the inappropriate use of generators (Daley et al., 2005).

Issues Related to Methods

The use of descriptive techniques prompted questions of whether a fatality, injury, or other health outcome could be causally attributed to a disaster event, and more specifically, directly or indirectly related to the mechanical forces of the disaster event, considered to be the exposure. Efforts were made to involve stakeholders such as the National Oceanic and Atmospheric Administration (NOAA) and the National Association of Medical Examiners in establishing causal distinctions and a working matrix was proposed (Combs, Quenemoen, Parrish, & Davis, 1999). Today, as mentioned previously, collaborative work to facilitate the distinction is led by the CSTE and CDC. Other methodological advances include the development of a new reporting form to identify disaster-related deaths proposed by the National Center for Health Statistics (National Center for Health Statistics, 2016). By using these and other tools, commonalities and differences among similar disaster types are now observed, setting the stage for the application of analytic techniques to ascertain risks for individual behaviors and other pertinent factors in various postdisaster events.

Risk Investigations and Studies

Characterization of the risks in some types of disaster events has developed. For example, in a classic study of earthquake impacts in Guatemala in 1976, Glass et al. (1977) examined structural characteristics, as well as individual characteristics and behaviors among occupants of earthquake impacted structures. Subsequent studies in postearthquake settings examined these issues and sought to identify floors within multistoried structures with the greatest chance of survival (Armenian, Noji, & Oganesian, 1992; Peek-Asa et al., 1998; Roces, White, Dayrit, & Durkin, 1992). Results suggested areas where search and rescue teams could prioritize a search as the top, middle, or bottom of rubble. In other postdisaster settings, risks for carbon monoxide poisoning after a major ice storm pointed to improper use of fuel-powered generators when electrical power was out (Daley, Smith, Paz-Argandona, Malilay, & McGeehin, 2000; Lutterloh et al., 2011). Other analytic studies in tornado, tropical cyclone, and landslide settings addressed the utility of forecasting and warning systems, access and use of NOAA weather radios and receipt of messages, and occupant behavior on hearing of a rapidly moving weather event, such as a tornado (Brown et al., 2002; Daley et al., 2005; Hammer & Schmidlin, 2002; Hayden et al., 2007; Paul, Stimers, & Caldas, 2015; Perreault, Houston, & Wilkins, 2014). Results from each of these studies add to a growing body of knowledge related to the appropriate actions to take for shelter seeking in a tornado event.

Although the current literature continues to grow, much is yet to be done in terms of gathering baseline data for comparison. For example, case-control studies document appropriate behaviors for shelter seeking in high-rise structures during seismic events but are not typically generalizable for earthquake-prone regions outside of the study area (Armenian et al., 1992; Roces et al., 1992). Results from tornado studies indicate that risks for injury and death are greater when attempting to outrun a tornado in a vehicle or remaining in a vehicle (Glass et al., 1980); however, attempting to outrun a tornado also has been shown to be protective (CDC, 1988; Daley et al., 2005). Additional studies of risk and protective factors with appropriate considerations for related infrastructure characteristics, evacuation behaviors, and potential confounders are needed to build the evidence for formulating guidelines and recommendations.

Rapid Needs Assessments

An almost immediate response activity is the requirement to determine health-related needs in disaster-affected populations. Although a number of approaches have been developed to address this challenge, one method that has gained wide acceptance in the state and local governments in the United States is the Community Assessment for Public Health Emergency Response, known as CASPER. First developed in the 1960s by the World Health Organization to estimate immunization coverage in an unknown population, this rapid and cost-effective technique has evolved to become a useful tool to estimate population needs in affected communities (CDC, 2012). The method now employs population data from the U.S. Census and geographic information systems such as the ArcGIS platform (ESRI, Redlands, California) to select clusters and households for the survey. The rapid availability of results from CASPER has encouraged further application in nondisaster settings, such as use of health services and vaccine coverage in a given population (Bayleyegn et al., 2015; Horney, Davis, Davis, & Fleischauer, 2013; Horney, Moore, Davis, & MacDonald, 2010). Also, repeated application of the method can allow emergency officials to observe any trends or changes over time (Kirsch et al., 2016).

Surveillance

Surveillance systems and techniques have also been developed or adapted for use as disaster epidemiology tools in various settings. For example, to quell rumors of epidemics of infectious disease and transmission by cadavers (PAHO, 1994; Morgan, 2004), surveillance systems were instituted to provide information about the health status of displaced populations, populations remaining in the given area, and workers assisting in the relief efforts. A characterization of death and injuries or selected diseases and disabilities over a time period of interest can be presented using epidemic curves. Baseline or comparative information may be obtained by extracting similar data for the same time period from previous years; differences and similarities for the disaster study period are compared with baseline values for a given area. In some events, proportionate morbidity techniques are applied to compare prevalence of one disease with another. Active and passive systems using various sources of data such as hospitals and health-care facilities can be established postdisaster. Surveillance in shelters for evacuees or camps for displaced people can be established. For example, postdisaster surveillance identified an increase in the number of cases of coccidioidomycosis related to fungus-contaminated dust storms from the Northridge earthquake in California (Schneider et al., 1997), gastrointestinal illness associated with the Midwestern floods (Wade et al., 2004), norovirus in shelters after Hurricane Katrina (CDC, 2005), and cholera several months after a devastating earthquake in Haiti (Barzilay et al., 2013). Clearly, the need to monitor health conditions through surveillance systems remains a requisite epidemiologic response activity.

Registries and Accountability Studies

While still relatively new, the use of registries, particularly for long-term studies to address potential chronic health effects of disasters, allows for a more careful long-term follow-up of people affected by a disaster event. A registry instituted after the World Trade Center disaster in 2001 led to the identification of cancers from exposures to ignited chemicals and material among firefighters and emergency responders (Li et al., 2012). The National Institute for Environmental Health Sciences (NIEHS) initiated a similar registry in the aftermath of the 2010 Deepwater Horizon oil spill to ascertain the health outcomes of exposed individuals involved in cleanup and remediation activities (Kwok et al., 2017). Accountability studies, also called evaluation studies, assess the efficacy of interventions such as relief programs. In one study, an evaluation of the effectiveness of mental health outreach teams after Hurricane Andrew in Florida found that the teams had no significant impact on mental distress or the use of mental health services (McDonnell et al., 1995).

Summary and Conclusions

At this juncture, we may ask What are the next steps for disaster epidemiology? To summarize, we have seen the evolution of community-based rapid needs assessments, the development and implementation of surveillance systems capturing infectious diseases and chronic health conditions, the conduct of descriptive and analytic studies addressing risk and protective factors for preventing and controlling adverse health outcomes, as well as applications of registries and accountability studies. New