Public health issues in disasters

Eric K. Noji, MD, MPH

T hroughout history, natural di-sasters have exacted a heavy tollof death and suffering (1). Mostrecently, the Bam earthquake in

Iran resulted in thousands of deaths, inju-ries, and homelessness (2) (Table 1). Theproblem has not improved much despitemuch attention by the international scien-tific community (3). Global climate changebrings the potential for severe weatherevents and flooding, and the introductionof tropical vector-borne diseases into moretemperate regions (4, 5). Increasing popu-lation density near coasts, in floodplains,and in regions of high points to the prob-ability of future catastrophic natural disas-ters with millions of casualties.

Disasters affect a community in numer-ous ways. Roads, telephone lines, and othertransportation and communication linksare often destroyed (6). Public utilities andenergy supplies may be disrupted (7). Sub-stantial numbers of victims may be ren-dered homeless (8). Portions of the com-munity’s industrial or economic base maybe destroyed or damaged. Casualties mayrequire medical care, and damage to foodsources and utilities may create publichealth threats (9, 10). The more remote thearea, the longer it takes for external assis-tance to arrive, and the more the commu-nity will have to rely on its own resources,at least for the first several hours, if not

days (11). Good disaster management re-quires accurate information and must linkdata collection and analysis to an immedi-ate decision-making process (12). The over-all objective of disaster management from apublic health perspective is to assess theneeds of disaster-affected populations (13,14), match available resources to thoseneeds, prevent further adverse health ef-fects, implement disease control strategiesfor well-defined problems, evaluate the ef-fectiveness of disaster relief programs (15),and improve contingency plans for varioustypes of future disasters (16). Common pat-terns of morbidity and mortality after cer-tain disasters can be identified (17) (Table2). Effective emergency medical responsedepends on anticipating these differentmedical and health problems before theyarise (18) and on delivering the appropriateinterventions (relief supplies, equipment,and personnel) at the precise times andplaces where they are needed most (19).

CRITICAL PUBLIC HEALTHINTERVENTIONS AFTERDISASTERS

Critical public health interventions af-ter disasters focus on the following areas.

Environmental Health: Water,Sanitation, Hygiene, and VectorManagement

General Issues. Overcrowding and re-sulting poor water supplies and inade-quate hygiene and sanitation are well-known factors that are known to increase

the incidence of diarrhea, respiratory in-fections, and other communicable dis-eases. A good system of water supply andexcreta disposal must be put into placequickly (20). No amount of curativehealth measures can offset the detrimen-tal effects of poor environmental healthplanning (21). Important postdisaster en-vironmental interventions include accessto adequate sources of potable water; andthe collection, disposal, and treatment ofexcreta and other liquid and solid wastes(22). This is achieved through installa-tion of an appropriate number of suitablylocated excreta disposal facilities such astoilets, latrines, or defecation fields; solidwaste pickup points; water distributionpoints; and availability of bathing andwashing facilities and of soap togetherwith effective health education. The con-trol of disease vectors such as mosqui-toes, flies, rats, and fleas is an importantpart of an environmental health approachto protecting community members fromdisease (23).

Water and Excreta Disposal. Adequatequantities of relatively clean water arepreferable to small amounts of high-quality water. Each person must receive aminimum of 15 to 20 L of clean water perday for their domestic needs (24). Unfor-tunately, it is frequently difficult to pro-vide even these minimum quantities ofwater to disaster-affected populations(25). During this early acute phase, la-trine construction begins, but initial san-itation measures may be nothing morethan simply designating an area for def-ecation, hopefully segregated from the

From the Centers for Disease Control and Preven-tion, Atlanta, GA.

Copyright © 2005 by the Society of Critical CareMedicine and Lippincott Williams & Wilkins

DOI: 10.1097/01.CCM.0000151064.98207.9C

Objective: This article outlines a number of important areas inwhich public health can contribute to making overall disastermanagement more effective. This article discusses health effectsof some of the more important sudden impact natural disastersand potential future threats (e.g., intentional or deliberately re-leased biologic agents) and outlines the requirements for effectiveemergency medical and public health response to these events.

Conclusion: All natural disasters are unique in that each affectedregion of the world has different social, economic, and health back-

grounds. Some similarities exist, however, among the health effectsof different natural disasters, which if recognized, can ensure thathealth and emergency medical relief and limited resources are wellmanaged. (Crit Care Med 2005; 33[Suppl.]:S29–S33)

KEY WORDS: disasters, natural, earthquake, flood, volcano, tor-nado, hurricane, typhoon, cyclones; disaster epidemiology; disas-ter medicine; emergency; mass casualty incident; homelandsecurity

S29Crit Care Med 2005 Vol. 33, No. 1 (Suppl.)

community’s source of potable water.Construction of one latrine for every 20persons is recommended but is rarelyachieved in camp settings (24).

Shelter. Surveys of settlements andtowns around Managua, Nicaragua, afterthe December 1972 earthquake indicatedthat 80% to 90% of the 200,000 displacedpersons were living with relatives and

friends; 5% to 10% were living in parks,city squares, and vacant lots; and the re-mainder were living in schools and otherpublic buildings (26). Regarding tempo-rary living space allocations, 3.5 squaremeters is the absolute minimum floorspace per person in emergency shelters(24). The first priority in areas wherelarge numbers of people are living in

damaged housing is to diminish as muchas possible the penetration of wind andrain into the structure. In these situa-tions, plastic sheeting for roof and win-dow repairs along with the required ma-terials for attaching them to the damagedstructures are often provided by relief or-ganizations. Most people who lose theirhomes will initially be able to take shelterwith friends and relatives (27). Only whenhousing losses reach more than approxi-mately 25% will there be a need to findother forms of shelter (26).

The decision to provide shelter at allcan have significant long-term conse-quences, especially in poor communities.For example, simple shelters provided onan emergency basis may unintentionallyevolve into permanent shantytowns orsquatter settlements and end up attract-ing many more homeless people to thesite.

COMMUNICABLE DISEASECONTROL AND EPIDEMICMANAGEMENT

Epidemics

Natural disasters are often followed byrampant rumors of epidemics (such astyphoid or rabies) or unusual conditionssuch as increased snakebites and dogbites. Such unsubstantiated reports gaingreat public credibility when printed asfacts in newspapers or reported on tele-vision or radio (28). For example, afterdisasters in developing countries, any dis-ruption of the water supply or sewagetreatment facilities has usually been ac-companied by rumors of outbreaks ofcholera or typhoid (29). Such rumorsmay well have reflected psychologic fearsand anxieties about a disastrous eventrather than the true perception of animminent problem. However, informa-

Table 1. Selected natural disasters 1970–2004

Year Event LocationApproximateDeath Toll

1970 Earthquake/landslide Peru 70,0001970 Tropical cyclone Bangladesh 300,0001971 Tropical cyclone India 25,0001972 Earthquake Nicaragua 6,0001976 Earthquake China 250,0001976 Earthquake Guatemala 24,0001976 Earthquake Italy 9001977 Tropical cyclone India 20,0001978 Earthquake Iran 25,0001980 Earthquake Italy 1,3001982 Volcanic eruption Mexico 1,7001985 Tropical cyclone Bangladesh 10,0001985 Earthquake Mexico 10,0001985 Volcanic eruption Columbia 22,0001988 Hurricane Gilbert Caribbean 3431988 Earthquake Armenia SSR 25,0001989 Hurricane Hugo Caribbean 561990 Earthquake Iran 40,0001990 Earthquake Philippines 2,0001991 Tropical cyclone Bangladesh 140,0001991 Volcanic eruption Philippines 8001991 Typhoon/Xood Philippines 6,0001991 Flood China 1,5001992 Hurricane Andrew USA 521993 Earthquake India 10,0001995 Earthquake Japan 6,0001998 Hurricane Mitch Central America 10,0001999 Earthquake Turkey 18,0001999 Earthquake Taiwan 1,0002001 Earthquake India 20,0002003 Earthquake Algeria 3,0002004 Earthquake Iran 25,000

Data from Office of U.S. Foreign Disaster Assistance: Disaster history: Significant data on majordisasters worldwide, 1900–Present. Washington, DC, Agency for International Development, 2004; andNational Geographic Society: Nature on the rampage, our violent earth. Washington, DC, NationalGeographic Society, 1987.

Table 2. Short-term effects of major natural disasters

Effects EarthquakesHigh Winds

(Without Flooding) Tsunamis Floods/Flash Floods

Deaths Many Few Many FewSevere injuries requiring extensive care Overwhelming Moderate Few FewIncreased risk of communicable Potential (but small) risk following all major disasters (probability rises as overcrowding diseases

increases and sanitation deteriorates)Food scarcity Rare Rare Common Common

(May occur because of factors other than food shortage)Major population movements Rare Rare Common Common

(May occur in heavily damaged urban areas)

Modified from Office of Emergency Preparedness and Disaster Relief Coordination: Emergency Health Management After Natural Disaster. Washington,DC, Pan American Health Organization, 2002.

S30 Crit Care Med 2005 Vol. 33, No. 1 (Suppl.)

tion on disease incidence in most devel-oping countries is poor, and some out-breaks may have been missed entirely bypublic health authorities.

Although natural disasters do not usu-ally result in outbreaks of infectious dis-ease, under certain circumstances, disas-ters may increase disease transmission.The risk of epidemic outbreaks of com-municable diseases is proportional topopulation density and displacement.These conditions increase the pressureon water and food supplies and the risk ofcontamination (like in refugee camps),the disruption of preexisting sanitationservices such as piped water and sewage,and the failure to maintain or restorenormal public health programs in theimmediate postdisaster period. The mostfrequently observed increases in commu-nicable disease are caused by fecal con-tamination of water and by respiratoryspread (for example, flu in evacuationcamps) (30). In the longer term, an in-crease in vector-borne diseases occurs insome areas because of disruption of vec-tor control efforts, particularly afterheavy rains and floods. Residual insecti-cides may be washed away from build-ings, and the number of mosquito breed-ing sites may increase. Moreover,displacement of wild or domesticated an-imals near human settlements brings ad-ditional risk of zoonotic infection.

Disposition of Dead Bodies

The public and government authori-ties are usually greatly concerned aboutthe danger of disease transmission fromdecaying corpses. Responsible health au-thorities should recognize, however, thathealth hazards such as epidemics associ-ated with unburied bodies are minimal,particularly if death resulted fromtrauma. It is far more likely that survi-vors will be a source of disease outbreaks.Although the risks for rescue workerswho handle dead bodies are higher thanfor the survivors of a disaster, those riskscan be limited through a set of simplemeasures. Appropriate precautions in-clude training military personnel andothers who might have to provide assis-tance after a disaster, vaccinating thosepersons against hepatitis B and tubercu-losis, using body bags and disposablegloves, washing hands after handling ca-davers, and disinfecting stretchers andvehicles that have been used to transportbodies (31).

Unjustified worries about the infec-tiousness of bodies can lead to the rapid,unplanned disposal of the dead, some-times before proper identification of thevictim has been made, as well as to takingneedless “precautions” such as mass cre-mation, burying the deceased in commongraves, and adding chlorinated lime as a“disinfectant.” Despite the negligiblehealth risk, dead bodies represent a deli-cate social problem. Disposal of bodiesshould respect local custom and practicewhen possible. When there are largenumbers of victims, burial is likely to bethe most appropriate method of disposal.There is little evidence that proper burialof bodies poses a threat to groundwaterthat serves as a source of drinking water(32).

Immunization

Mass immunization during situationsof natural disasters is usually counterpro-ductive and diverts limited human re-sources and materials from other moreeffective and urgent measures. Immuni-zation campaigns can give a false sense ofsecurity, leading to the neglect of basicmeasures of hygiene and sanitation,which are more important during theemergency. Mass vaccination would bejustified only when the recommendedsanitary measures do not have an effectand if there is evidence of the progressiveincrease in the number of cases with therisk of an epidemic. A vaccine with thefollowing characteristics could be consid-ered useful in this situation:

● A vaccine of proven efficacy, highsafety, and low reactogenicity;

● A vaccine that is easy to apply (single-dose);

● A vaccine that confers rapid and long-lasting protection for people of all ages;

● Sufficient quantities of vaccine shouldbe available to guarantee the supply forthe entire population at risk; and

● Low-cost vaccines.

For example, immunization of childrenagainst measles is one of the most impor-tant (and cost-effective) preventive mea-sures in emergency-affected populations,particularly those housed in camps. Immu-nization of refugee children against mea-sles in Thailand in 1979 clearly saved manylives. Although measles was an early prob-lem in Somalia, immunization of the refu-gee population was effective in preventingoutbreaks after 1981 (33). Because infantsas young as 6 mos of age may contract

measles in refugee camp outbreaks and areat greater risk of dying as a result of im-paired nutrition, it is recommended thatmeasles immunization programs alongwith vitamin A supplements in emergencysettings target all children from the ages of6 mos through 5 yrs (some would recom-mend as old as 12–14). Ideally, one shouldstrive for measles immunization coveragein refugee camp settings of better than 80%(24).

Nutrition

Food shortages in the immediate after-math of a disaster may arise in two ways.Food stock destruction within the disasterarea may reduce the absolute amount offood available, or disruption of distributionsystems may curtail access to food, even ifthere is no absolute shortage. Generalizedfood shortages severe enough to cause nu-tritional problems usually do not occur af-ter natural disasters. Flooding and seasurges can damage household food stocksand crops, disrupt distribution, and causemajor local shortages. Food distribution, atleast in the short term, is often a major andurgent need, but large-scale importation/donation of food is not usually necessary(34). In extended droughts such as thoseoccurring in Africa, or in complex disasters,the homeless and refugees may be com-pletely dependent on outside sources forfood supplies for varying periods of time(35). Depending on the nutritional condi-tion of these populations, especially ofmore vulnerable groups such as pregnantor lactating women, children, and the el-derly, it may be necessary to institute emer-gency feeding programs (36). The highestnutritional priority in the postdisaster set-ting is the timely and adequate provision offood rations containing at least 2,100 calo-ries and that includes sufficient protein, fat,and micronutrients (24).

MYTHS AND REALITIES OFNATURAL DISASTERS

Many mistaken assumptions are asso-ciated with the impact of disasters onpublic health. Disaster planners andmanagers should be familiar with the fol-lowing myths and realities (37):

Myth: volunteers with any kind of med-ical background are needed.

Reality: the local population almost al-ways covers immediate lifesavingneeds. Only medical personnel with

S31Crit Care Med 2005 Vol. 33, No. 1 (Suppl.)

skills that are not available in the af-fected community may be needed.

Myth: any kind of assistance is needed,and it is needed immediately!

Reality: a hasty response that is notbased on an impartial evaluation onlycontributes to the chaos. It is better towait until genuine needs have been as-sessed. In fact, most needs are met bythe victims themselves and their localgovernment and agencies, not by ex-ternal relief agencies (38).

Myth: epidemics and plagues are inev-itable after every disaster.

Reality: epidemics do not spontane-ously occur after a disaster, and deadbodies will not lead to catastrophicoutbreaks of exotic diseases. The key topreventing disease is to improve sani-tary conditions and educate the public(39).

Myth: disasters bring out the worst inhuman behavior (e.g., looting, rioting).

Reality: although isolated cases of an-tisocial behavior exist, most people re-spond spontaneously and generously(40).

Myth: the affected population is tooshocked and helpless to take responsi-bility for their own survival.

Reality: on the contrary, many findnew strength during an emergency, asevidenced by the thousands of volun-teers who spontaneously united to siftthrough the rubble in search of victimsafter the 1985 Mexico City earthquake.

Myth: disasters are random killers.

Reality: disasters strike hardest at themost vulnerable groups such as thepoor, especially women, children, andthe elderly.

Myth: locating disaster victims in tem-porary settlements is the best alterna-tive.

Reality: it should be the last alterna-tive. Many agencies use funds normallyspent for tents to purchase buildingmaterials, tools, and other construc-tion-related support in the affectedcommunity.

SUMMARY

This article discusses health effects ofdisasters and outlines the requirementsfor effective emergency medical and pub-lic health response to these events (41).Sound epidemiologic knowledge of thecauses of death and of the types of inju-

ries and illnesses caused by disasters isclearly essential when determining whatrelief supplies, equipment, and personnelare needed to respond effectively in emer-gency situations (42). The overall objec-tive of disaster management is to assessthe needs of disaster-affected popula-tions, to match resources to needs effi-ciently, to prevent further adverse healtheffects, to evaluate relief program effec-tiveness, and to plan for future disasters(43, 44).

REFERENCES

1. Office of US Foreign Disaster Assistance: ADisaster History: Significant Data on MajorDisasters Worldwide, 1900–Present. Wash-ington, DC, Agency for International Devel-opment, 2004

2. Schnitzer JJ, Briggs SM: Earthquake relief—The US medical response in Bam, Iran.N Engl J Med 2004; 350:1174–1176

3. IDNDR Secretariat: The International De-cade for Natural Disaster Reduction: ActionPlan for 1998–1999. Geneva, UN Office forthe Coordination of Humanitarian Assis-tance, 1998, pp 1–2

4. Greenough G: The potential impacts of cli-mate variability and change on health im-pacts on extreme weather events in theUnited States. Environ Health Perspect 2001;109(suppl 2):191–198

5. Senior CA, Jones RG, Lowe JA, et al: Predic-tions of extreme precipitation and sea-levelrise under climate change. Philos TransactSer A Math Phys Eng Sci 2002; 360:1301–1311

6. Carby BE, Ahmad R: Vulnerability of roadsand water systems to hydro-geological haz-ards in Jamaica. Built Environment 2003;145–153

7. Kunii O, Akagi M, Kita E: Health conse-quences and medical and public health re-sponse to the great HanshinAwaji earthquakein Japan: A case study in disaster planning.Medicine and Global Survival 1995; 2:32–45

8. Najarian LM, Goenjian AK, Pelcovitz D, et al:The effect of relocation after a natural disas-ter. J Trauma Stress 2001; 14:511–526

9. Natural Disasters—Protecting the Public’sHealth. Washington, DC, Pan AmericanHealth Organization, 2000

10. Curry MD, Larsen PG, Mansfield CJ, et al:Impacts of a flood disaster on an ambulatorypediatric clinic population. Clin Pediatr(Phila) 2001; 40:571–574

11. Alexander D: The study of natural disasters,1977–1997: Some reflection on a changingfield of knowledge. Disasters 1997; 21:284–304

12. Noji EK: Field investigations of natural di-sasters. In: Field Epidemiology. Gregg MB(Ed). New York, Oxford University Press,2002, pp 365–383

13. Rapid Health Assessment Protocols. Geneva,World Health Organization, 1999

14. Liang NJ, Shih YT, Shih FY, et al: Disasterepidemiology and medical response in theChi-Chi earthquake in Taiwan. Ann EmergMed 2001; 38:549–555

15. WADEM Task Force on Quality Control ofDisaster Management: Health disaster man-agement: Guidelines for evaluation and re-search in the Utstein Style, vol I. Conceptualframework of disasters. Prehospital DisasterMed 2003; 17(Suppl 3):1–177

16. Noji EK: Progress in disaster management.Lancet 1994; 343:1239–1240

17. Noji EK: The Public Health Consequences ofDisasters. New York, Oxford University Press,1997

18. Noji EK: Disaster epidemiology: Challengesfor public health action. An update. Ann Ig2002; 14(Suppl 1):97–102

19. Noji EK, Toole MJ: Public health and disas-ters: The historical development of publichealth responses to disasters. Disasters 1997;21:369–379

20. Lillibridge SR, Noji EK (Eds): Water, sanita-tion and excreta. The Public Health Conse-quences of Disasters. New York, Oxford Uni-versity Press, 1997

21. Wisner B, Adams J (Eds): EnvironmentalHealth in Emergencies and Disasters. Ge-neva, World Health Organization, 2003

22. Mong Y, Kaiser R, Ibrahim D, et al: Impact ofthe safe water system on water quality incyclone-affected communities in Madagas-car. Am J Public Health 2001; 91:1577–1579

23. Nasci RS, Moore CG: Vector-borne diseasesurveillance and natural disasters. Emerg In-fect Dis 1998; 4:333–334

24. Sphere Project: Humanitarian Charter andMinimum Standards in Disaster Response.London, Oxfam Publishing, 2004

25. Levy BS, Sidel VW (Eds): War and PublicHealth. Washington, DC, APHA, 2000, pp1–417

26. University of Wisconsin Disaster Manage-ment Center: First International EmergencySettlement Conference: New Approaches toNew Realities. April 15–19, 1996. Madison,WI, University of Wisconsin Disaster Man-agement Center, 1996

27. Landesman LY: Public Health Managementof Disasters: The Practice Guide. WashingtonDC, APHA, 2001, pp 1–250

28. ReliefWeb: Flooding Disaster in Haiti and theDominican Republic. New York, Office forthe Coordination of Humanitarian Assis-tance, 2004

29. Sharma R: Pneumonia, cholera, and dysen-tery feared after earthquake. BMJ 2001; 322:317

30. Vahaboglu H, Gundes S, Karadenizli A, et al:Transient increase in diarrheal diseases afterthe devastating earthquake in Kocaeli, Tur-key: Results of an infectious disease surveil-lance study. Clin Infect Dis 2000; 31:1386–1389

31. Veenema TG: Disaster Nursing and Emer-gency Preparedness for Chemical, Biological,Radiological Terrorism and Other Hazards.

S32 Crit Care Med 2005 Vol. 33, No. 1 (Suppl.)

New York, Springer Publishing, 2004, pp1–616

32. Morgan O: Infectious disease risks from deadbodies following natural disasters. Rev Pa-nam Salud Publica 2004; 15:307–312

33. Toole MJ, Steketee RW, Waldman RJ, et al:Measles prevention and control in emer-gency settings. Bull World Health Organ1989; 67:381–388

34. Hogan DE, Burstein JL: Disaster Medicine.Philadelphia, Lippincott Williams & Wilkins,2002, pp 1–431

35. Toole MJ, Nieburg P, Waldman RJ: Associa-tion between inadequate rations, undernutri-tion prevalence and mortality in refugeecamps. J Trop Paed 1990; 34:218–224

36. Proceedings of the African Refugee NutritionConference, Machakos, Kenya, December1994. Geneva, UN Administrative Committeeon Coordination, Sub-Committee on Nutri-tion, 1995

37. de Ville de Goyet C: Stop propagating disas-ter myths. Prehospital Disaster Med 1999;14:213–214

38. Bradt DA, Drummond CM: Rapid epidemio-logical assessment of health status in dis-placed populations—An evolution towardstandardized minimum, essential data sets.Prehospital Disaster Med 2003; 18:178–185

39. Keven K, Ates K, Sever MS, et al: Infectiouscomplications after mass disasters: The Mar-mara earthquake experience. Scand J InfectDis 2003; 35:110–113

40. McGlown KJ: Terrorism and Disaster Man-agement: Preparing Healthcare Leaders forthe New Reality. Chicago, ACHE, 2004, pp1–343

41. Keim M: Developing a public health emer-gency operations plan: A primer. Pac HealthDialog 2002; 9:124–129

42. Binder S, Sanderson LM: The role of theepidemiologist in natural disasters. AnnEmerg Med 1987; 16:1081

43. Humanitarian Assistance in Disaster Situa-tions. A Guide for Effective Aid. Washington,DC, PAHO, 2000:1–24

44. McCaughrin WC, Mattammal M: Perfectstorm: Organizational management of pa-tient care under natural disaster conditions.J Healthc Manag 2003; 48:295–308

S33Crit Care Med 2005 Vol. 33, No. 1 (Suppl.)