Deaths Related to Hurricane Irma - Florida, Georgia, and North Carolina, September 4-October 10, 2017

NPCC4: Climate change, energy, and energy insecurity in New York City

This chapter of the New York City Panel on Climate Change 4 (NPCC4) report provides an overview of energy trends in New York City and the State of New York, as well as accompanying challenges and barriers to the energy transition-with implications for human health and wellbeing. The link between energy trends and their impact on health and wellbeing is brought to the fore by the concept of "energy insecurity," an important addition to the NPCC4 assessment.

Climate Change and Children's Health: Building a Healthy Future for Every Child

Observed changes in temperature, precipitation patterns, sea level, and extreme weather are destabilizing major determinants of human health. Children are at higher risk of climate-related health burdens than adults because of their unique behavior patterns; developing organ systems and physiology; greater exposure to air, food, and water contaminants per unit of body weight; and dependence on caregivers. Climate change harms children through numerous pathways, including air pollution, heat exposure, floods and hurricanes, food insecurity and nutrition, changing epidemiology of infections, and mental health harms. As the planet continues to warm, climate change's impacts will worsen, threatening to define the health and welfare of children at every stage of their lives. Children who already bear higher burden of disease because of living in low-wealth households and communities, lack of access to high quality education, and experiencing racism and other forms of unjust discrimination bear greater risk of suffering from climate change hazards. Climate change solutions, advanced through collaborative work of pediatricians, health systems, communities, corporations, and governments lead to immediate gains in child health and equity and build a foundation for generations of children to thrive. This technical report reviews the nature of climate change and its associated child health effects and supports the recommendations in the accompanying policy statement on climate change and children's health.

Mass fatality and disaster response preparedness across medical examiner and coroner offices in the United States

With the rise of mass fatalities and disasters, access to mass fatality and disaster planning trainings and resources available to medical examiners and coroners (MECs) in the United States should be reviewed. This paper provides a necessary update on the extent of access to these resources by analyzing data from the 2018 Census for Medical Examiner and Coroner Offices (CMEC). Results show that a high percentage of respondents have access to mass fatality and disaster planning trainings/resources; however, the access is disproportionate. Respondents in the Midwest and South-and those with smaller populations-have less access to resources, while agencies with larger budgets and more full-time staff have more access to resources. This paper discusses potential contributing factors for these disparities, but the data only begin to elucidate gaps in access to mass fatality and disaster planning trainings/resources for MECs and where further research should be conducted.

Disasters and kidney care: pitfalls and solutions

Patients with kidney disease, especially those with kidney failure, are particularly susceptible to the adverse effects of disasters because their survival depends on functional infrastructure, advanced technology, the availability of specific drugs and well-trained medical personnel. The risk of poor outcomes across the entire spectrum of patients with kidney diseases (acute kidney injury, chronic kidney disease and kidney failure on dialysis or with a functioning transplant) increases as a result of disaster-related logistical challenges. Patients who are displaced face even more complex problems owing to additional threats that arise during travel and after reaching their new location. Overall, risks may be mitigated by pre-disaster preparedness and training. Emergency kidney disaster responses depend on the type and severity of the disaster and include medical and/or surgical treatment of injuries, treatment of mental health conditions, appropriate diet and logistical interventions. After a disaster, patients should be evaluated for problems that were not detected during the event, including those that may have developed as a result of the disaster. A retrospective review of the disaster response is vital to prevent future mistakes. Important ethical concerns include fair distribution of limited resources and limiting harm. Patients with kidney disease, their care-givers, health-care providers and authorities should be trained to respond to the medical and logistical problems that occur during disasters to improve outcomes.

Total Excess Mortality Surveillance for Real-Time Decision-Making in Disasters and Crises

Crises such as Hurricane Maria and the coronavirus disease 2019 (COVID-19) pandemic have revealed that untimely reporting of the death toll results in inadequate interventions, impacts communication, and fuels distrust on response agencies. Delays in establishing mortality are due to the contested definition of deaths attributable to a disaster and lack of rapid collection of vital statistics data from inadequate health system infrastructure. Readily available death counts, combined with geographic, demographic, and socioeconomic data, can serve as a baseline to build a continuous mortality surveillance system. In an emergency setting, real-time Total, All-cause, Excess Mortality (TEM) can be a critical tool, granting authorities timely information ensuring a targeted response and reduce disaster impact. TEM measurement can identify spikes in mortality, including geographic disparities and disproportionate deaths in vulnerable populations. This study recommends that measuring total, all-cause, excess mortality as a first line of response should become the global standard for measuring disaster impact.

Importance of continuing health care before emergency hospital evacuation: a fatal case of a hospitalized patient in a hospital within 5 km radius of Fukushima Daiichi Nuclear Power Plant: a case report

BACKGROUND

After a disaster, it is essential to maintain the health care supply levels to minimize the health impact on vulnerable populations. During the 2011 Fukushima Daiichi Nuclear Power Plant accident, hospitals within a 20 km radius were forced to make an immediate evacuation, causing a wide range of short- and long-term health problems. However, there is limited information on how the disaster disrupted the continuity of health care for hospitalized patients in the acute phase of the disaster.

CASE PRESENTATION

An 86-year-old Japanese man who needed central venous nutrition, oxygen administration, care to prevent pressure ulcers, skin and suctioning care of the trachea, and full assistance in the basic activities of daily living had been admitted to a hospital within 5 km radius of Fukushima Daiichi Nuclear Power Plant and experienced Fukushima Daiichi Nuclear Power Plant accident. After the accident, the hospital faced a manpower shortage associated with hospital evacuation, environmental changes caused by infrastructure and medical supply disruptions, and the difficulty of evacuating seriously ill patients. As a result, antibiotics and suction care for aspiration pneumonia could not be appropriately provided to the patient due to lack of caregivers and infrastructure shortages. The patient died before his evacuation was initiated, in the process of hospital evacuation.

CONCLUSIONS

This case illustrates that decline in health care supply levels to hospitalized patients before evacuation during the acute phase of a radiation-released disaster may lead to patient fatalities. It is important to maintain the health care supply level even in such situations as the radiation-released disaster; otherwise, patients may experience negative health effects.

Official sources, news outlets, or search engines? Rumour validation on social media during Hurricanes Harvey and Irma

This study, based on data collected from a representative sample of adults in the United States, explores the social cognitive variables that motivated Americans to validate rumours on social media about Hurricanes Harvey and Irma, both of which struck in August/September 2017. The results indicate that risk perception and negative emotions are positively related to systematic processing of relevant risk information, and that systematic processing is significantly related to rumour validation through search engines such as Google. In contrast, trust in information about the hurricane is significantly related to validation through official sources, such as FEMA (Federal Emergency Management Agency), and major news outlets such as The New York Times. Trust in information is also significantly related to systematic processing of risk information. The findings of this study suggest that ordinary citizens may be motivated to validate rumours on social media, which is an increasingly important issue in contemporary societies.

Projecting the Impacts of a Changing Climate: Tropical Cyclones and Flooding

PURPOSE OF REVIEW

There is clear evidence that the earth's climate is changing, largely from anthropogenic causes. Flooding and tropical cyclones have clear impacts on human health in the United States at present, and projections of their health impacts in the future will help inform climate policy, yet to date there have been few quantitative climate health impact projections.

RECENT FINDINGS

Despite a wealth of studies characterizing health impacts of floods and tropical cyclones, many are better suited for qualitative, rather than quantitative, projections of climate change health impacts. However, a growing number have features that will facilitate their use in quantitative projections, features we highlight here. Further, while it can be difficult to project how exposures to flood and tropical cyclone hazards will change in the future, climate science continues to advance in its capabilities to capture changes in these exposures, including capturing regional variation. Developments in climate epidemiology and climate science are opening new possibilities in projecting the health impacts of floods and tropical cyclones under a changing climate.

Community Assessment for Public Health Emergency Response (CASPER) Following Hurricane Michael, Bay and Gulf Counties, Florida, 2019

CONTEXT

On October 10, 2018, Hurricane Michael made landfall near Mexico Beach, Florida, as one of the strongest storms on record to hit the US mainland. Hurricane Michael brought strong winds, heavy rain, and life-threatening storm surge, causing extensive damage across the Florida Panhandle.

OBJECTIVES

To assess community preparedness and effects experienced by Panhandle residents, including structural and economic losses, injury and illness, health care access, and suicide risk and ideation in the counties most severely impacted by Hurricane Michael.

DESIGN

The Florida Department of Health conducted a Community Assessment for Public Health Emergency Response (CASPER) in October and November 2019, a year after Hurricane Michael made landfall. CASPER is a 2-stage cluster sampling method designed to provide household-level information about a community's needs in a timely, inexpensive, and representative manner.

SETTING

A total of 30 clusters were randomly selected from Bay and Gulf Counties, Florida.

PARTICIPANTS

In total, 178 face-to-face interviews were completed with adult residents 18 years or older.

MAIN OUTCOME MEASURES

Hurricane-related impacts, including structural and economic losses, injury and illness, health care access; and mental health.

RESULTS

Almost half of respondents did not evacuate despite mandatory evacuation orders. Most houses (78.1%) received some damage, with more than half still not repaired 1 year later. Access to emergency supply kits, water, nonperishable foods, medications, and health care was common, though many reported needing supplies not included in their kit. Less than half reported having working household carbon monoxide detectors. Injuries and illnesses associated with the hurricane were uncommon; however, anxiety, depression, and insomnia were reported as occurring or worsening by more than one-third of respondents posthurricane.

CONCLUSIONS

Increased education and communication regarding hurricane preparedness and recovery, which include clearer messaging on evacuation, improving emergency supply kits, importance of carbon monoxide detectors, and proper generator use, could enhance the safety of the community.

Exposure Assessment for Tropical Cyclone Epidemiology

PURPOSE OF REVIEW

Tropical cyclones impact human health, sometimes catastrophically. Epidemiological research characterizes these health impacts and uncovers pathways between storm hazards and health, helping to mitigate the health impacts of future storms. These studies, however, require researchers to identify people and areas exposed to tropical cyclones, which is often challenging. Here we review approaches, tools, and data products that can be useful in this exposure assessment.

RECENT FINDINGS

Epidemiological studies have used various operational measures to characterize exposure to tropical cyclones, including measures of physical hazards (e.g., wind, rain, flooding), measures related to human impacts (e.g., damage, stressors from the storm), and proxy measures of distance from the storm's central track. The choice of metric depends on the research question asked by the study, but there are numerous resources available that can help in capturing any of these metrics of exposure. Each has strengths and weaknesses that may influence their utility for a specific study. Here we have highlighted key tools and data products that can be useful for exposure assessment for tropical cyclone epidemiology. These results can guide epidemiologists as they design studies to explore how tropical cyclones influence human health.

Association of Power Outage With Mortality and Hospitalizations Among Florida Nursing Home Residents After Hurricane Irma

Importance

Exposure to hurricanes is associated with increased mortality and morbidity in nursing home (NH) residents, but the factors contributing to these outcomes are less understood. One hypothesized pathway could be power outages from hurricanes that expose NH residents to excess ambient heat.

Objective

To determine the association of power loss from Hurricane Irma with hospitalization and mortality in NH residents in Florida.

Design Setting and Participants

This retrospective cohort study of NH residents residing in Florida when Hurricane Irma landed on September 10, 2017, assessed mortality at 7 and 30 days after the storm and hospitalization at 30 days after the storm. The analysis was conducted from May 2, 2021, to June 28, 2021. All NH residents residing in Florida at landfall were eligible (N = 67 273). We excluded those younger than 65 years, missing power status information, or who were evacuated (13 178 [19.6%]).

Exposure

We used state-administered surveys to determine NH power outage status. Exposed residents experienced a power outage poststorm, whereas unexposed residents did not experience a power outage poststorm.

Main Outcomes and Measures

We used Medicare claims to assess mortality and hospitalization after Hurricane Irma landfall using generalized linear models with robust standard errors.

Results

In the aftermath of Hurricane Irma, 27 892 residents (18 510 women [66.4%]; 3906 [14.0%] Black, 1651 [5.9%] Hispanic, and 21 756 [78.0%] White individuals) in 299 NHs were exposed to power loss and 26 203 residents (17 620 women [67.2%]; 4175 [15.9%] Black, 1030 [3.9%] Hispanic, and 20 477 [78.1%] White individuals) in 292 NHs were unexposed. Nursing homes that lost power were similar in size, quality star rating, and type of ownership compared with NHs that did not lose power. Power loss was associated with an increased adjusted odds of mortality among all residents within 7 days (odds ratio [OR],1.25; 95% CI,1.05-1.48) and 30 days (OR, 1.12; 95% CI,1.02-1.23) poststorm and hospitalization within 30 days, although only among residents aged 65 to 74 years (OR, 1.16; 95% CI, 1.03-1.33).

Conclusions and Relevance

In this cohort study, power loss was associated with higher odds of mortality in all affected NH residents and hospitalization in some residents. The benefits and costs of policies that require NHs to have emergency alternate power sources should be assessed.

Altered hippocampal microstructure and function in children who experienced Hurricane Irma

Hurricane Irma was the most powerful Atlantic hurricane in recorded history, displacing 6 million and killing over 120 people in the state of Florida alone. Unpredictable disasters like Irma are associated with poor cognitive and health outcomes that can disproportionately impact children. This study examined the effects of Hurricane Irma on the hippocampus and memory processes previously related to unpredictable stress. We used an innovative application of an advanced diffusion-weighted imaging technique, restriction spectrum imaging (RSI), to characterize hippocampal microstructure (i.e., cell density) in 9- to 10-year-old children who were exposed to Hurricane Irma relative to a non-exposed control group (i.e., assessed the year before Hurricane Irma). We tested the hypotheses that the experience of Hurricane Irma would be associated with decreases in: (a) hippocampal cellularity (e.g., neurogenesis), based on known associations between unpredictable stress and hippocampal alterations; and (b) hippocampal-related memory function as indexed by delayed recall. We show an association between decreased hippocampal cellularity and delayed recall memory in children who experienced Hurricane Irma relative to those who did not. These findings suggest an important role of RSI for assessing subtle microstructural changes related to functionally significant changes in the developing brain in response to environmental events.

[Knowledge gained from a 31-h power outage in Berlin Köpenick-medical problems and challenges]

On 19 February 2019 the severance of a 110kW cable caused an extensive electrical power cut in the Treptow-Köpenick district of Berlin. Subsequently, ca. 30,000 households were without electricity and ca. 70,000 people were affected. The power cut lasted more than 24h and all those involved were faced with a multitude of challenges. An operational command post was set up in which medical problems had to be continuously identified and re-evaluated. These included the identification of patients particularly at risk, such as home-ventilated patients and patients with artificial hearts. Furthermore, individual nursing homes had to be evacuated. During the procedure it was necessary to evacuate an intensive care ward or intermediate care ward with 23 patients due to the loss of power supply in the affected area. Hospitals must be prepared for such scenarios within the framework of preliminary planning. Furthermore, preliminary planning containing the special needs of vulnerable groups must be carried out on the part of the responsible authorities.

Wind disasters adaptation in cities in a changing climate: A systematic review

Wind-related disasters will bring more devastating consequences to cities in the future with a changing climate, but relevant studies have so far provided insufficient information to guide adaptation actions. This study aims to provide an in-depth elaboration of the contents discussed in open access literature regarding wind disaster adaptation in cities. We used the Latent Dirichlet Allocation (LDA) to refine topics and main contents based on 232 publications (1900 to 2019) extracted from Web of Science and Scopus. We conducted a full-text analysis to filter out focal cities along with their adaptation measures. The results show that wind disaster adaptation research in cities has formed a systematic framework in four aspects: 1) vulnerability and resilience of cities, 2) damage evaluation, 3) response and recovery, and 4) health impacts of wind disaster. Climate change is the background for many articles discussing vulnerability and adaptation in coastal areas. It is also embedded in damage evaluation since it has the potential to exacerbate disaster consequences. The literature is strongly inclined towards more developed cities such as New York City and New Orleans, among which New York City associated with Hurricane Sandy ranks first (38/232). Studies on New York City cover all the aspects, including the health impacts of wind disasters which are significantly less studied now. Distinct differences do exist in the number of measures regarding the adaptation categories and their subcategories. We also find that hard adaptation measures (i.e., structural and physical measures) are far more popular than soft adaptation measures (i.e., social and institutional measures). Our findings suggest that policymakers should pay more attention to cities that have experienced major wind disasters other than New York. They should embrace the up-to-date climate change study to defend short-term disasters and take precautions against long-term changes. They should also develop hard-soft hybrid adaptation measures, with special attention on the soft side, and enhance the health impact study of wind-related disasters.

Perspectives on the Health Effects of Hurricanes: A Review and Challenges

Hurricanes are devastating natural disasters which dramatically modify the physical landscape and alter the socio-physical and biochemical characteristics of the environment, thus exposing the affected communities to new environmental stressors, which persist for weeks to months after the hurricane. This paper has three aims. First, it conceptualizes potential direct and indirect health effects of hurricanes and provides an overview of factors that exacerbate the health effects of hurricanes. Second, it summarizes the literature on the health impact of hurricanes. Finally, it examines the time lag between the hurricane (landfall) and the occurrence of diseases. Two major findings emerge from this paper. Hurricanes are shown to cause and exacerbate multiple diseases, and most adverse health impacts peak within six months following hurricanes. However, chronic diseases, including cardiovascular disease and mental disorders, continue to occur for years following the hurricane impact.

Governors' Use of Executive Orders and Proclamations in Hurricane Response, 2006-2018

Hurricanes can destroy or overwhelm communities and cause or exacerbate health conditions. Legal mechanisms and practices may aid or impede hurricane response. In the United States, where states have primary public health responsibility, state governors possess legal powers to address hurricanes. They often exercise these powers using executive orders and proclamations-legal mechanisms that direct public and private parties. Although executive orders and proclamations are critical for hurricane preparedness and response, how governors use them to respond to hurricanes is not fully understood. Using legal epidemiology, we systematically identified and analyzed hurricane-related executive orders and proclamations issued in the United States from January 1, 2006, through December 31, 2018. We found 468 relevant executive orders and proclamations, 14% of which were issued, at least in part, to benefit a jurisdiction other than the issuer's state. We observed variations in when and where such orders and proclamations were issued. Executive orders and proclamations were most commonly used to direct government response or recovery (32%), handle and administer government resources (31%), and suspend legal requirements perceived to inhibit response (27%). Fewer orders and proclamations regulated private parties (10%). Understanding how governors use executive orders and proclamations to respond to hurricanes can bolster future preparedness and response efforts.

Management Of Chronic Noncommunicable Diseases After Natural Disasters In The Caribbean: A Scoping Review

Extreme weather events in the Caribbean region are becoming increasingly severe because of climate change. The region also has high rates of poorly controlled chronic noncommunicable diseases (NCDs), which were responsible for at least 30 percent of deaths after two recent hurricanes. We conducted a scoping review of literature published between 1974 and 2020 to understand the burden and management of chronic NCDs in the Caribbean after natural disasters. Of the twenty-nine articles included in this review, most described experiences related to Hurricanes Dorian (2019) and Irma and Maria (2017) and the Haiti earthquake (2010). Challenges included access to medication, acute care services, and appropriate food, as well as communication difficulties and reliance on ad hoc volunteers and outside aid. Mitigating these challenges requires different approaches, including makeshift points of medication dispensing, disease surveillance systems, and chronic disease self-management education programs. Evidence is needed to inform policies to build resilient health systems and integrate NCD management into regional and national disaster preparedness and response plans.

Association Between Exposure to Hurricane Irma and Mortality and Hospitalization in Florida Nursing Home Residents

IMPORTANCE

Nursing home residents are at heightened risk for morbidity and mortality following an exposure to a disaster such as a hurricane or the COVID19 pandemic. Previous research has shown that nursing home resident mortality related to disasters is frequently underreported. There is a need to better understand the consequences of disasters on nursing home residents and to differentiate vulnerability based on patient characteristics.

OBJECTIVE

To evaluate mortality and morbidity associated with exposure to Hurricane Irma, a Category 4 storm that made landfall on September 10, 2017, in Cudjoe Key, Florida, among short-stay (<90-day residence) and long-stay (≥90-day residence) residents of nursing homes.

DESIGN, SETTING, AND PARTICIPANTS

Cohort study of Florida nursing home residents comparing residents exposed to Hurricane Irma in September 2017 to a control group of residents residing at the same nursing homes over the same time period in calendar year 2015. Data were analyzed from August 28, 2019, to July 22, 2020.

EXPOSURE

Residents who experienced Hurricane Irma were considered exposed; those who did not were considered unexposed.

MAIN OUTCOME AND MEASURES

Outcome variables included 30-day and 90-day mortality and first hospitalizations after the storm in both the short term and the long term.

RESULTS

A total of 61 564 residents who were present in 640 Florida nursing home facilities on September 7, 2017, were identified. A comparison cohort of 61 813 residents was evaluated in 2015. Both cohorts were mostly female (2015, 68%; 2017, 67%), mostly White (2015, 79%; 2017, 78%), and approximately 40% of the residents in each group were over the age of 85 years. Compared with the control group in 2015, an additional 262 more nursing home deaths were identified at 30 days and 433 more deaths at 90 days. The odds of a first hospitalization for those exposed (vs nonexposed) were 1.09 (95% CI, 1.05-1.13) within the first 30 days after the storm and 1.05 (95% CI, 1.02-1.08) at 90 days; the odds of mortality were 1.12 (95% CI, 1.05-1.18) at 30 days and 1.07 (95% CI, 1.03-1.11) at 90 days. Among long-stay residents, the odds of mortality for those exposed to Hurricane Irma were 1.18 (95% CI, 1.08-1.29) times those unexposed and the odds of hospitalization were 1.11 (95% CI, 1.04-1.18) times those unexposed in the post 30-day period.

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that nursing home residents are at considerable risk to the consequences of disasters. These risks may be underreported by state and federal agencies. Long-stay residents, those who have resided in a nursing home for 90 days or more, may be most vulnerable to the consequences of hurricane disasters.

Hurricane Shutter-Related Injuries Treated in Emergency Departments

OBJECTIVES

Injuries may occur when putting up and taking down hurricane (storm) shutters. This study described hurricane shutter-related injuries managed at emergency departments (EDs).

METHODS

Hurricane shutter-related injuries were identified through the National Electronic Injury Surveillance System (NEISS), a database of consumer product-related injuries collected from the EDs of approximately 100 United States hospitals.

RESULTS

There were 329 hurricane shutter-related injuries during 2001-2017. Thirty-six injuries were reported during October 2005 (Hurricane Wilma), 30 during August 2008 (Tropical Storm Fay), and 103 during September 2017 (Hurricane Irma). Patients were 20 years or older in 90.6% of the cases; 76.3% of the patients were male. The most frequently reported injuries were laceration (48.9%), sprain or strain (15.2%), and fracture (9.4%). Lower extremities (34.0%) were the most commonly affected body part followed by upper extremities (29.5%) and head or neck (17.0%). The patient was treated or examined at the ED and released in 86.6% of the cases.

CONCLUSIONS

Over half of the hurricane shutter-related injuries appeared to occur in association with hurricanes and tropical storms. The most frequently reported injuries were laceration followed by sprain or strain and fracture. The majority of patients were treated or examined at the ED and released.

The Short- and Long-Term Impacts of Hurricane Irma on Florida Agricultural Leaders as Early Emergency Responders: The Importance of Workplace Stability

The impacts of hurricane-related disasters in agricultural communities include extensive losses of fields, orchards, and livestock, the recovery of which could span many years. Agricultural Extension Agents (EAs) try to manage and mitigate these losses, while simultaneously overseeing emergency shelter operations. These non-professional emergency responders face numerous potential stressors, the outcomes of which are minimally known. This study examined the short- and long-term medical and behavioral outcome of 36 University of Florida Agricultural Extension Agents within two months and one year after Hurricane Irma, Florida, USA, taking into consideration personal/home and work-related hurricane impacts. Regression analyses indicated that combined home and work hurricane impacts were associated with greater anxiety, depression, and medical symptoms controlling for age and number of prior hurricane experiences within two months of landfall. One year later, depression symptoms increased as well as the use of negative disengagement coping strategies for which stability of the work environment was protective. The findings suggest that advanced training in emergency response, organization and time management skills, time off and temporary replacement for personally impacted EAs, and workplace stability, including enhanced continuity of operations plans, represent critical elements of health prevention and early intervention for this occupational group.

How community vulnerability factors jointly affect multiple health outcomes after catastrophic storms

BACKGROUND

While previous studies uncovered individual vulnerabilities to health risks during catastrophic storms, few evaluated the population vulnerability which is more important for identifying areas in greatest need of intervention.

OBJECTIVES

We assessed the association between community factors and multiple health outcomes, and developed a community vulnerability index.

METHODS

We retained emergency department visits for several health conditions from the 2005-2014 New York Statewide Planning and Research Cooperative System. We developed distributed lag nonlinear models at each spatial cluster across eight counties in downstate New York to evaluate the health risk associated with Superstorm Sandy (10/28/2012-11/9/2012) compared to the same period in other years, then defined census tracts in clusters with an elevated risk as "risk-elevated communities", and all others as "unelevated". We used machine-learning techniques to regress the risk elevation status against community factors to determine the contribution of each factor on population vulnerability, and developed a community vulnerability index (CVI).

RESULTS

Overall, community factors had positive contributions to increased community vulnerabilities to Sandy-related substance abuse (91.35%), injuries (70.51%), cardiovascular diseases (8.01%), and mental disorders (2.71%) but reversely contributed to respiratory diseases (-34.73%). The contribution of low per capita income (max: 22.08%), the percentage of residents living in group quarters (max: 31.39%), the percentage of areas prone to flooding (max: 38.45%), and the percentage of green coverage (max: 29.73%) tended to be larger than other factors. The CVI based on these factors achieved an accuracy of 0.73-0.90 across outcomes.

CONCLUSIONS

Our findings suggested that substance abuse was the most sensitive disease susceptible to less optimal community indicators, whereas respiratory diseases were higher in communities with better social environment. The percentage of residents in group quarters and areas prone to flooding were among dominant predictors for community vulnerabilities. The CVI based on these factors has an appropriate predictive performance.

Environmental health effects attributed to toxic and infectious agents following hurricanes, cyclones, flash floods and major hydrometeorological events

Extreme hydrometeorological events such as hurricanes and cyclones are increasing in frequency and intensity due to climate change and often associated with flash floods in coastal, urbanized and industrial areas. Preparedness and response measures need to concentrate on toxicological and infectious hazards, the potential impact on environmental health, and threat to human lives. The recognition of the danger of flood water after hurricanes is critical. Effective health management needs to consider the likelihood and specific risks of toxic agents present in waters contaminated by chemical spills, bio-toxins, waste, sewage, and water-borne pathogens. Despite significant progress in the ability to rapidly detect and test water for a wide range of chemicals and pathogens, there has been a lack of implementation to adapt toxicity measurements in the context of flash and hurricane-induced flooding. The aim of this review was to highlight the need to collect and analyze data on toxicity of flood waters to understand the risks and prepare vulnerable communities and first responders. It is proposed that new and routinely used technologies be employed during disaster response to rapidly assess toxicity and infectious disease threats, and subsequently take necessary remedial actions.

Pedestrian hit by a car impacted metal pole: reconstructing the head load

Fatal head injuries are frequently seen in pedestrians hit by motorized vehicles. In our case, the pedestrian sustained a devastating head injury with skull splitting in the mediosagittal plane. A car collided with a traffic sign causing a bending of the pole. The metal pole hit a man standing close beside it; the man had a head injury severity that is more commonly due to falling objects than due to traffic accidents. Assuming a head mass of 5 kg, simplified calculations yield maximum contact forces of ca. 36 kN exceeding mean parietal fracture forces which are in the order of magnitude of 12.5 kN. The influences of the effective body mass and the horizontal distance between the pole and the pedestrian on maximum contact forces are investigated. High contact forces in our case can be mainly explained by the comparably high impact velocity and by a partial mass transfer of the total car mass to the pole.

Perceived Importance of Climate Change Adaptation and Mitigation According to Social and Medical Factors Among Residents of Impacted Communities in the United States

Purpose: To determine whether perceived importance of local climate change adaptation and mitigation efforts differs according to social or medical factors among residents of impacted communities.

Methods: An online survey was conducted among residents of California (Los Angeles/Orange), Florida (Miami-Dade/Broward), and Arizona (Maricopa) counties in July 2018 (n=605). Multivariable ordered logistic regression measured associations between the perceived importance of adaptation/mitigation approaches and income, race/ethnicity, and health conditions, controlling for age, political party, and county.

Results: Lower income was associated with higher perceived importance of improved emergency alerts, government-subsidized costs of household air conditioners and energy-efficient appliances, strengthening buildings against extreme weather, regulation of greenhouse gas emissions, urban planning using “cooling” technologies, and expanding community gardens/local agriculture. Black respondents perceived evacuation services for those with financial barriers during extreme weather, government-subsidized costs of energy-efficient appliances, and communication from government agencies about local climate impacts and mitigation as significantly more important compared to non-Black, non-Hispanic respondents. Hispanic respondents perceived significantly greater importance of improved emergency alerts and health care access during extreme weather, evacuation services for residents without transportation, government-subsidized costs of energy-efficient appliances, regulation of greenhouse gas emissions, communication from government agencies about local climate impacts and mitigation efforts, and intergovernmental cooperation on mitigation compared to non-Hispanic respondents.

Conclusions: Perceptions of the importance of specific local climate actions differ according to race/ethnicity and income. Community engagement is recommended to help local decisions reflect priorities of the most affected residents.

Population Health Adaptation Approaches to the Increasing Severity and Frequency of Weather-Related Disasters Resulting From our Changing Climate: A Literature Review and Application to Charleston, South Carolina

PURPOSE OF REVIEW

Recent changes in our planetary climate have and will continue to challenge historical knowledge and risk assumptions for weather-related disasters. While the public health community is rapidly working to develop epidemiological approaches and tools to mitigate and adapt to these weather-related disasters, recent high-profile events have exposed gaps in knowledge and response efforts. Limited work has been done to assess the climate readiness of the local public health and healthcare community as it pertains to local response planning and adaptation measures in the event of a weather-related disaster. The purpose of this paper is to review the existing literature related to climate change, weather-related disasters, and population health approaches to adapt to climate-related changes in weather-related disasters at the local level. We highlight a brief case study to illustrate an example of a local approach to adaptation planning in a coastal community.

RECENT FINDINGS

Few studies have put forth quantitative disaster epidemiology tools to aid public health officials in preparing for and responding to these weather-related disaster events. There is a general lack of understanding within the public health community about the epidemiological tools which are available to assist local communities in their preparation for, response to, and recovery from weather-related disasters. Cities around the nation are already working to assess their vulnerability and resilience to weather-related disasters by including climate change in emergency preparedness plans and developing adaptation strategies, as well as equipping local hospitals, health departments and other critical public health systems with climate information. But more work is needed and public health funding is lagging to support local and state-level efforts in preparing for and adapting to weather-related disasters in the context of a changing climate. Our population health disaster preparedness programs need to be adapted to address the increasing risks to local public health resulting from our changing climate.

Differential and persistent risk of excess mortality from Hurricane Maria in Puerto Rico: a time-series analysis

BACKGROUND

Hurricane Maria struck Puerto Rico on Sept 20, 2017, devastating the island. Controversy surrounded the official death toll, fuelled by estimates of excess mortality from academics and investigative journalists. We analysed all-cause excess mortality following the storm.

METHODS

We did a time-series analysis in Puerto Rico from September, 2017, to February, 2018. Mortality data were from the Puerto Rico Vital Statistics System. We developed two counterfactual scenarios to establish the population at risk. In the first scenario, the island's population was assumed to track the most recent census estimates. In the second scenario, we accounted for the large-scale population displacement. Expected mortality was projected for each scenario through over-dispersed log-linear regression from July, 2010, to August, 2017, taking into account changing distributions of age, sex, and municipal socioeconomic development, as well as both long-term and seasonal trends in mortality. Excess mortality was calculated as the difference between observed and expected deaths.

FINDINGS

Between September, 2017, and February, 2018, we estimated that 1191 excess deaths (95% CI 836-1544) occurred under the census scenario. Under the preferred displacement scenario, we estimated that 2975 excess deaths (95% CI 2658-3290) occurred during the same observation period. The ratio of observed to expected mortality was highest for individuals living in municipalities with the lowest socioeconomic development (1·43, 95% CI 1·39-1·46), and for men aged 65 years or older (1·33, 95% CI 1·30-1·37). Excess risk persisted in these groups throughout the observation period.

INTERPRETATION

Analysis of all-cause mortality with vital registration data allows for unbiased estimation of the impact of disasters associated with natural hazards and is useful for public health surveillance. It does not depend on certified cause of death, the basis for the official death toll in Puerto Rico. Although all sectors of Puerto Rican society were affected, recovery varied by municipal socioeconomic development and age groups. This finding calls for equitable disaster preparedness and response to protect vulnerable populations in disasters.

FUNDING

Forensic Science Bureau, Department of Public Safety, and Milken Institute School of Public Health of The George Washington University (Washington, DC, USA).