Assessing disaster-attributed mortality: development and application of a definition and classification matrix.

BACKGROUND: A useful step in developing and implementing sound policies to prevent disaster-attributed mortality is to classify the relationship between disasters and mortality. While there are classification methods for specific health outcomes, there is no standard method that includes all potential outcomes from exposure to a natural disaster. Without standards, our ability to assess health effects from disasters and implement prevention programmes is limited. METHODS: We present a method for ascertaining and classifying disaster-attributed mortality which includes a case definition, flow chart, and matrix. The matrix is used for coding, reporting, and evaluating information about manner, cause, and circumstance of disaster-attributed deaths and geographical location and time of the disaster. To illustrate its use, two readers determine and classify deaths attributed to Hurricane Andrew (1992, USA). RESULTS: Of 322 deaths investigated by the Dade County Medical Examiner's Office, our readers showed 97% (313/322) agreement on case status and 83% (35/42) agreement on case classification. CONCLUSIONS: Our definition allows for a liberal interpretation of what constitutes disaster-related circumstances and the conditions or diseases that might arise from these circumstances. The inclusion of the flow chart and matrix provides a framework for consistent case classification and reporting. It also provides information about relationships between exposures and health effects, thereby identifying prevention policy needs.

The World Trade Center bombing: injury prevention strategies for high-rise building fires.

The WTC disaster provided an opportunity to look for ways to prevent morbidity among occupants of high-rise buildings during fires. This paper first describes the overall morbidity resulting from the explosion and fire, and second, presents the results of a case-control study carried out to identify risk factors for smoke-related morbidity. The main ones include: increased age, presence of a pre-existing cardio-pulmonary condition, entrapment in a lift and prolonged evacuation time. Study results point to the importance of the following safety systems during high-rise building fires: smoke-control systems with separate emergency power sources; lift-cars, lift-car position-monitoring systems, and lift-car communication systems with separate emergency power sources; two-way emergency communication systems on all floors and in stairwells; stairwells with emergency lighting and designed for the rapid egress of crowds; evacuation systems/equipment to assist in the evacuation of vulnerable people (elderly, infirm). Also important are evacuation plans that include regularly scheduled safety training and evacuation drills.

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.

Use of a modified cluster sampling method to perform rapid needs assessment after Hurricane Andrew.

STUDY OBJECTIVE: To rapidly obtain population-based estimates of needs in the early aftermath of Hurricane Andrew in South Florida. METHODS: We used a modified cluster-sampling method (the Expanded Programme on Immunization [EPI] method) for three surveys. We selected a systematic sample of 30 quarter-mile square clusters for each survey and, beginning from a random start, interviewed members of seven consecutive occupied households in each cluster. Two surveys were of the most affected area (1990 population, 32,672) at three and ten days after the hurricane struck; one survey was of a less affected area (1990 population, 15,576) seven days after the hurricane struck. MEASUREMENTS AND MAIN RESULTS: Results were available within 24 hours of beginning each survey. Initial findings emphasized the need for restoring utilities and sanitation and helped to focus medical relief on primary care and preventive services. The second survey of the most affected area showed improvement in the availability of food, water, electricity, and sanitation (P < or = .05). There was no evidence of disease outbreaks. CONCLUSION: For the first time, the EPI method provided population-based information to guide and evaluate relief operations after a sudden-impact natural disaster. An improvement over previous approaches, the EPI method warrants further evaluation as a needs assessment tool in acute disasters.

Active morbidity surveillance after Hurricane Andrew--Florida, 1992.

OBJECTIVE: To describe the health status of and to detect disease outbreaks in the population affected by Hurricane Andrew in south Dade County, Florida. DESIGN: The Florida Department of Health and Rehabilitative Services and the US Army conducted active surveillance for gastrointestinal illness, respiratory illness, injury, and other index conditions by monitoring civilian and service member visits to care sites (civilian and military free care sites and hospital emergency departments) from August 30 (1 week after the hurricane's landfall) through September 30, 1992. SETTING: South Dade County, Florida. MAIN OUTCOME MEASURES: Proportional morbidity: the number of daily visits for each index condition divided by the total number of visits, expressed as a percentage. Morbidity rate: the total number of daily visits by service members divided by the total number of service members, expressed as a percentage. RESULTS: Six index conditions accounted for 41.3% of visits to civilian free care sites: diarrhea (4.7%), cough (4.7%), other infection (9.6%), rash (5.4%), animal bite (1.2%), and injury (15.7%). At military free care sites, five index conditions accounted for 75.7% of civilian visits: injury (23.7%), dermatologic illness (12.4%), respiratory illness (9.9%), gastrointestinal illness (5.3%), and other medical conditions (24.4%). Two index conditions accounted for 54.1% of service member visits: injury (36.2%) and dermatologic illness (17.9%). During the 5 weeks after the hurricane, proportional morbidity from injury decreased; proportional morbidity from respiratory illness increased; and proportional morbidity from diarrhea was stable. No infectious disease outbreaks occurred. CONCLUSIONS: Injuries were an important source of morbidity throughout the surveillance period, especially among service members. Enteric and respiratory agents did not cause disease outbreaks, despite alarming rumors to the contrary.

Mortality rates in displaced and resident populations of central Somalia during 1992 famine.

Famine and civil war have resulted in high mortality rates and large population displacements in Somalia. To assess mortality rates and risk factors for mortality, we carried out surveys in the central Somali towns of Afgoi and Baidoa in November and December, 1992. In Baidoa we surveyed displaced persons living in camps; the average daily crude mortality rate was 16.8 (95% CI 14.6-19.1) per 10,000 population during the 232 days before the survey. An estimated 74% of children under 5 years living in displaced persons camps died during this period. In Afgoi, where both displaced and resident populations were surveyed, the crude mortality rate was 4.7 (3.9-5.5) deaths per 10,000 per day. Although mortality rates for all displaced persons were high, people living in temporary camps were at highest risk of death. As in other famine-related disasters, preventable infectious diseases such as measles and diarrhoea were the primary causes of death in both towns. These mortality rates are among the highest documented for a civilian population over a long period. Community-based public health interventions to prevent and control common infectious diseases are needed to reduce these exceptionally high mortality rates in Somalia.