Whoa, Charley! (and Frances and Ivan and Jeanne): Epidemiologic Response to Hurricanes in Florida, 2004

Transcription

1 Centers for Disease Control and Prevention Case Studies in Applied Epidemiology No. 053-X07 Whoa, Charley! (and Frances and Ivan and Jeanne): Epidemiologic Response to Hurricanes in Florida, 2004 Student's Guide Learning Objectives After completing this case study, the student should be able to: List the common health problems that occur after a natural disaster such as a hurricane; Describe Incident Command Structure and the roles of various agencies involved in emergency response; Describe the key elements of the design of a rapid needs assessment; Describe the key elements of the design of a post-disaster surveillance system. This case study is based on the public health actions and epidemiologic activities initiated in response to Hurricanes Charley, Frances, Ivan, and Jeanne by the Florida Department of Health and many other agencies in This case study was developed by Richard Dicker. Daniel Chertow (EIS 04) and Joann Schulte provided much of the information used in the case study. Comments, suggestions and additional information were provided by members of NCEH/HSB s Disaster Epidemiology and Assessment Team (particularly Dahna Batts and Josephine Mallilay). Review and suggestions were also provided by the 2005 EIS Summer Course instructors. The current version was revised in October U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service

2 CDC/EIS: Hurricanes in Florida (053-X07r) Student s Guide 2/21 Part I On August 13, 2004, Hurricane Charley made landfall on the west coast of Florida as a fastmoving Category 4 storm with sustained winds of 145 mph and 7-foot storm surge (increase in sea level). It resulted in 33 deaths, 1.4 million people evacuated from their homes, 760,000 customers without electrical power, and extensive property damage in Charlotte, DeSoto, and Hardee Counties. Over the next few weeks, Hurricanes Frances (Category 2), Ivan (Category 3), and Jeanne (Category 3) caused additional deaths, displacement, and destruction throughout Florida, as shown in Table 1. Table 1. Hurricanes Affecting Florida, August September 2004 Category Landfall Landfall Primary Cause Hurricane (Winds in mph) Location Date of Damage Deaths Charley 4 ( ) mid-west coast August 13 wind effects 33 Frances 2 (96 110) mid-east coast Sept. 8 flooding 35 Ivan 3 ( ) Alabama coast Sept. 16 tornadoes 24 Jeanne 3 ( ) mid-east coast Sept. 25 winds & flooding 10 Question 1a: What are the factors that influence the health conditions that commonly affect persons in the area of impact of a natural disaster such as a hurricane?

3 CDC/EIS: Hurricanes in Florida (053-X07r) Student s Guide 3/21 Question 1b: Which health conditions most commonly affect persons in the area of impact of a hurricane? Florida officials have considerable experience planning for and responding to hurricanes. As the first hurricane (Hurricane Charley) approached, officials activated their Emergency Operations Center. Question 2: What is an Emergency Operations Center? What agencies might be involved? What is an Incidence Command System?

4 CDC/EIS: Hurricanes in Florida (053-X07r) Student s Guide 4/21 Staff from the state and county health departments were represented at the Emergency Operations Center. Plans were in place for activities that the epidemiologists at both levels would carry out after the hurricane hit. Question 3: What is the appropriate role of epidemiologists after a natural disaster such as this hurricane? Question 4: After the hurricane has hit, what data might the epidemiologists want to gather to assess the situation?

5 CDC/EIS: Hurricanes in Florida (053-X07r) Student s Guide 5/21 Question 5: How might you collect the data you listed in Question 4? Authorities decided to conduct a rapid needs assessment and to implement a supplemental surveillance system of the 3 most affected counties. Because older adults constituted both a vulnerable group and a substantial proportion of the population in those counties, the Florida Department of Health focused the rapid needs assessment on persons aged 60 years and older. The objectives of this assessment were 1) to characterize post-hurricane living conditions, 2) identify and evaluate immediate needs (e.g., access to basic services and health care), and 3) provide recommendations for managing emergency response and recovery. Separate assessments were conducted in each county because they differed in population size, demographics, and socioeconomic status. The sampling strategy and data collection instrument (questionnaire) focused on households with at least one 60 year-old rather than on individuals. Question 6: Design a data collection instrument for this needs assessment.

6 CDC/EIS: Hurricanes in Florida (053-X07r) Student s Guide 6/21 For a sampling strategy, authorities decided to use a modification of the World Health Organization s Expanded Programme on Immunization (WHO-EPI) cluster-sampling method, sometimes known as the 30-by-7 sampling method. With this method, the probability that a geographic area will be included is proportional to the size of its population ( probability proportional to size ). Question 7: What is the WHO-EPI cluster-sampling method? Why do you think authorities decided to use this method?

7 CDC/EIS: Hurricanes in Florida (053-X07r) Student s Guide 7/21 Selected results from the rapid needs assessment are displayed in Table 2. Table 2. Percentage of households with at least one person aged > 60 years reporting changes in status after Hurricane Charley, by selected characteristics Charlotte, DeSoto, and Hardee counties, Florida, August 27 31, 2004 Charlotte County DeSoto County Hardee County % of No. of % of No. of % of No. of house- house- house- house- house- households holds holds holds holds holds Characteristic (n=198) projected (n=192) projected (n=205) projected) Population > 60 years of age 43* 38,301 24* 4,909 18* 3,134 Damage to home Damaged, inhabitable 82 31, , ,490 Damaged, uninhabitable 11 4, Household structure type Mobile home 3 1, , ,425 Single family house 94 36, , ,668 Household utilities No running water 12 4, No electricity 19 7, No functioning indoor toilet 11 4, No working telephone 18 6, No regular garbage pickup 24 9, , No radio 12 4, Food and water Using well water Using public water 10 3, Using bottled water 89 34, , ,054 Without money for Immediate needs 4 1, Health care and social support No access to prescription meds 6 2, Healthcare service interrupted by hurricane 17 6, Social support networks interrupted by hurricane 32 12, Adult with preexisting medical condition 94 35, , ,756 Of those, hurricane exacerbated medical condition 32 12, , Of those, hurricane prevented access to normal care 28 10, , * % of population rather than % of households

8 CDC/EIS: Hurricanes in Florida (053-X07r) Student s Guide 8/21 Question 8: Describe these results. Question 9: What recommendations might you make?

9 CDC/EIS: Hurricanes in Florida (053-X07r) Student s Guide 9/21 As noted earlier, public health authorities decided to develop an ad hoc supplemental surveillance system to 1) augment regular disease reporting, 2) identify outbreaks promptly, 3) describe distributions of illness, 4) respond to public and media concerns, and 5) monitor the health of special populations, particularly the elderly. Question 10: In designing and implementing this surveillance system, list some of the decisions that need to be made.

10 CDC/EIS: Hurricanes in Florida (053-X07r) Student s Guide 10/21 Part II The Hurricane Charley supplemental surveillance system was initiated on August 13, the day the hurricane came ashore. The state s epidemiology response team, comprised of staff and epidemiology trainees from state and country health departments, and CDC staff, set up shop at the Sarasota County Health Department. They recruited hospitals, clinics, and Disaster Medical Assistance Teams (DMATs) to participate in the surveillance system. All major medical facilities in the 3 most affected counties (Charlotte, DeSoto, and Hardee) plus single hospitals from the neighboring Sarasota and Lee Counties agreed to participate. Infection control practitioners or their equivalent were responsible for completing a daily line listing of all visits to their healthcare facility. They assigned one illness/injury category to each presenting illness using a consistent coding scheme. An example of the line-listing format is shown in Table 3. These line listings were sent by fax, , or handdelivery on a daily basis to an epidemiology response team in Sarasota County. One hospital, part of an extensive hospital system with hospitals throughout the state, transmitted data electronically. The CDC EIS Officer assigned to Florida reviewed each record with presenting illness classified as Other and recategorized them as appropriate. Data were input into Epi Info, aggregated, and analyzed nightly. Table 3. Line listing, Hurricane Charley supplemental surveillance system Charlotte, DeSoto, and Hardee Counties, Florida, August 13 31, 2004 Medical Record Number Town and County of Residence Age (years) Sex (M/F) Race, Ethnicity Classification* Disaster- Related Activity* Presenting Illness* Outcome* * Codes for Classification, Disaster-Related Activity, Presenting Illness, and Outcome Classification Disaster-Related Activity R = Resident 1 = Direct impact T = Tourist 2 = Evacuation M = Migrant worker 3 = Clean-up N = Non-resident 4 = Rescue relief worker 5 = Recreation O = Other 6 = Other U = Unknown 7 = Not disaster-related Presenting Illness 1 = Exacerbation of chronic illness 2 = Chest pain 3 = GI illness 4 = Respiratory illness (not pre-existing) 5 = Febrile illness 6 = Skin condition / rash 7 = Injury 8 = Poisoning 9 = Dehydration 10 = Heat illness 11 = Anxiety/stress 12 = Other (specify) Outcome 1 = Discharged 2 = Hospitalized 3 = Died 4 = Transferred to other facility 5 = Other

11 CDC/EIS: Hurricanes in Florida (053-X07r) Student s Guide 11/21 The following are descriptions of three patients captured by the surveillance system. Patient 1 was a 48-year-old male from Town A in Desoto County who presented to the hospital on 8/15/04 by ambulance with complaints of abdominal pain and a broken arm following a fall from heights. He had been cutting limbs from trees around his house following Hurricane Charley. He required abdominal surgery and splenectomy but survived. Patient 2 was a 65-year-old male from Town B in Hardee County with a history of coronary artery disease who presented to the hospital on 8/16/04 with complaints of chest tightness. He had been working in his yard with a chainsaw in extreme heat when the symptoms began. He died in the coronary care unit. Patient 3 was a previously healthy 30 year-old female from Town C Osceola County presented to the hospital by ambulance on 8/13/04 with multiple blunt trauma and near drowning following an MVA. The woman had been driving down a flooded highway and turned into a lake instead of a roadway. She was hospitalized but survived. Question 11: Complete the line listing for these patients described above. Only one code is allowed for Disaster-related Activity and for Presenting Illness. Question 12: How might you analyze and/or present the data? (Basically, create table shells and figure shells.)

12 Illness/Injury Categories CDC/EIS: Hurricanes in Florida (053-X07r) Student s Guide 12/21 Part III The following data were collected between August 13 and August 31. Table 4. Demographic findings, Hurricane Charley supplemental surveillance system Charlotte, DeSoto, and Hardee Counties, Florida, August 13 31, 2004 Total hospital visits 13,465 Age (mean) 47 year (range) <1-101years Sex (% female) 53% Race (% white) 78% Ethnicity (% Hispanic) 14% Figure 1. Percent distribution of illness and injury categories, Hurricane Charley supplemental surveillance system Charlotte, DeSoto, and Hardee Counties, Florida, August 13 31, 2004 Injury 23 Resp GI 7 7 Chronic Skin/Rash 6 6 Chest Pain 5 Fever 3 Heat Illness 2 Poisoning Dehydration Stress Other Percent distribution (%)

13 Percent distribution (%) CDC/EIS: Hurricanes in Florida (053-X07r) Student s Guide 13/21 Table 5. Distribution of injuries by disaster-related activity, Hurricane Charley supplemental surveillance system Charlotte, DeSoto, and Hardee Counties, Florida, August 13 31, 2004 Activity Number Percent Clean-up 1,286 41% Direct storm impact 130 4% Recreation 57 2% Evacuation 13 <1% Rescue 13 <1% Other % Not disaster-related % Missing % Total 3, % Figure 2. Percent distribution of selected conditions by date, Hurricane Charley supplemental surveillance system Charlotte, DeSoto, and Hardee Counties, Florida, August 13 31, /13 8/15 8/17 8/19 8/21 8/23 8/25 8/27 8/29 8/31 Date of Healthcare Visit GI Resp. Poisoning GI Trend Respiratory Trend

14 CDC/EIS: Hurricanes in Florida (053-X07r) Student s Guide 14/21 Question 13: What do you conclude from these data? The Hurricane Charley surveillance system was intended to operate for 4 6 weeks, but was shut down after only 2½ weeks, on August 31. This decision was made because Hurricane Frances was threatening the more populous east coast of Florida, and resources and peopled needed to be relocated. The team that was deployed to Palm Beach County to enroll healthcare facilities into a Hurricane Frances surveillance system encountered considerable resistance from hospital administrators and their legal staff. Question 14: Would you attempt to implement the same system on the east coast with fewer hospitals, or try a different design for the Hurricane Frances surveillance system? The epidemiology team contacted the parent hospital system of the hospital that had provided electronic data during the Hurricane Charley surveillance system. That hospital system agreed to provide electronic data from all of its hospitals throughout the state. However, several individual hospital administrators expressed concern to the epidemiology team about HIPAA Privacy Rule restrictions on providing data.

15 CDC/EIS: Hurricanes in Florida (053-X07r) Student s Guide 15/21 Question 15: What is HIPAA? What is the Privacy Rule? How would you address these concerns? Public health authorities discussed disseminating information on a regular basis to the stakeholders and to others. Question 16: Who needs to know? How might you communicate these findings?

16 CDC/EIS: Hurricanes in Florida (053-X07r) Student s Guide 16/21 Conclusion The second surveillance system collected electronic data from 9 hospitals located throughout the state. Aberration detection software ( EARS the Early Aberration Reporting System) was used to analyze the electronic data. EARS compares daily counts or rates of disease to 7 9 days of baseline counts or rates to detect statistically significant aberrations. These aberrations, or flags, must be reviewed by public health officials to determine whether they represent true outbreaks. Although numerous flags were generated, no true outbreaks were detected. Surveillance was discontinued after October 15, about 3 weeks after the last hurricane hit. However, the Florida Department of Health planned to set up a similar system for surveillance for the Superbowl festivities scheduled for Jacksonville, Florida in February References Disaster Management / Response Landesman LY. Public Health Management of Disasters: The Practical Guide. Washington, DC: American Public Health Association, 2001 Waldman R, Noji EK. Field Investigations of Natural Disasters and Complex Emergencies. In: Gregg MB, ed. Field Epidemiology, 3 rd ed. New York: Oxford University Press, 2008 Rapid Needs Assessments Mallilay J, Flanders WD, Brogan D. A modified cluster sampling method for post-disaster rapid needs assessment. Bull WHO 1996;74(4): CDC. Rapid assessment of the needs and health status of older adults after Hurricane Charley Charlotte, DeSoto, and Hardee Counties, Florida, August 27 31, MMWR 2004;53(36): WHO-EPI 30x7 Cluster Sampling Henderson RH, Sundaresan T. Cluster sampling to assess immunization coverage: a review of experience with a simplified sampling method. Bull World Health Organ 1982; 60: Lemeshow S, Robinson D. Surveys to measure programme coverage and impact: a review of the methodology used by the Expanded Programme on Immunization. World Health Stat Q 1985;38: Syndromic Surveillance Reingold A. If syndromic surveillance is the answer, what is the question? Biosecurity and Bioterrorism: Biodefense Strategy, Science, and Practice 2003, 1:1-5.

17 CDC/EIS: Hurricanes in Florida (053-X07r) Student s Guide 17/21 Hurricanes Saffir-Simpson Scale Category Wind Speed (mph) Storm surge (ft) >155 >18

18 CDC/EIS: Hurricanes in Florida (053-X07r) Student s Guide 18/21 The National Response Plan s 12 Emergency Support Functions Emergency Support Function Responsibility Lead Agency ESF 1: Providing civilian and military Dept. of Transportation Transportation transportation ESF 2: Communications Providing telecommunications support National Communications System ESF 3: Public Works and Engineering Restoring essential public health services US Army Corps of Engineers, Dept. of Defense ESF 4: Fire Fighting Detecting and suppressing wilderness, rural, and urban fires US Forest Service, Dept. of Agriculture ESF 5: Information and Planning Collecting, analyzing, and disseminating critical information to facilitate the overall federal Federal Emergency Management Agency ESF 6: Mass Care ESF 7: Resource Support ESF 8: Health and Medical Services ESF 9: Urban Search and Rescue ESF 10: Hazardous Materials ESF 11: Service, Food ESF 12: Energy response and recovery operations Managing and coordinating food, shelter, and first aid for victims; providing bulk distribution of relief supplies; operating a system to reunite families Providing equipment, materials, supplies and personnel to federal entities during response operations Providing assistance for public health and medical care needs Locating, extricating, and providing initial medical treatment to victims Supporting federal response to actual or potential releases of oil and hazardous materials Identifying food needs; ensuring that food gets to areas affected by disaster Restoring power systems and fuel supplies American Red Cross General Services Administration U.S. Public Health Service, Dept. of Health and Human Services Federal Emergency Management Agency Environmental Protection Agency Food and Nutrition, US Dept. of Agriculture US Dept of Energy

19 CDC/EIS: Hurricanes in Florida (053-X07r) Student s Guide 19/21 Community Health & Needs Assessment, Hurricane Charley Florida (August, 2004) Please circle or check appropriate responses. Date: County: Cluster: Blocks: Interviewer Team: Lat/Long: Questionnaire conducted in: English Spanish Language barrier, not conducted Type of Structure (pre-hurricane): Mobile home Single family house, non-mobile 2-5 family unit 6 units Migrant camp Damage to Structure: None Damaged/habitable Damaged/uninhabitable/repairable Damaged/uninhabitable/destroyed Household Services/Utilities Do you have running water? YES NO DK What is your primary source of drinking water? Well Bottled Public None Do you have electricity? YES NO DK Have you used a generator at any time since the hurricane?... YES NO DK If yes, where is it located? Indoor Garage/Shed Outside Carport Other Do you have functional CO detector or alarm? YES NO DK Does the indoor toilet work? YES NO DK If no, do you have access to a functioning toilet?... YES NO DK Do you have a working telephone (cell or regular)? YES NO DK Do you have you access to working motorized transportation (e.g., car, bus, scooter, bike pedal, golf cart)? YES NO DK Do you have a functioning radio? YES NO DK Do you have regular garbage pick-up now? YES NO DK How many people lived in this house before the hurricane? How many people slept here last night? If none, Where did you stay? Shelter Special Needs Shelter Hotel/Motel Neighbor s home Other If 1 or more, How many pregnant females: How many <2 years old: How many 65: Women Men If >0 Go to back If at least 1 person is 60, continue with questions on back of form. If no one 60, then STOP.

20 CDC/EIS: Hurricanes in Florida (053-X07r) Student s Guide 20/21 Continue with the questions below only if at least 1 person is 60 The rest of the questions I m going to ask you are about those people in the home who are 60 or older Are you/they a year-round resident? YES NO DK Health Services Was anyone in your household injured because of the hurricane? YES NO DK If yes, were they able to get the medical care they needed? YES NO DK Has anyone been ill (other than injury) since the hurricane? YES NO DK If yes, were they able to get the medical care they needed? YES NO DK Does anyone in the home now require medical care because of the hurricane? YES NO DK If yes, do they have access to the medical care they need? YES NO DK Is anyone in the home taking any prescription medication(s)? YES NO DK If yes, do they have access to their prescription medications? YES NO DK Hurricane impact on Pre-existing Health Conditions Are there any health care services you normally have that have been interrupted by the hurricane such as meals-on-wheels; home-based care; dressing changes; or delivery of supplied such as oxygen? YES NO DK Have any of the social support networks (e.g., adult day care, church activities, regular) that you had before the hurricane been interrupted by the hurricane? YES NO DK Do you have access to enough food for everyone in the residence for the next 3 days? Do you have access to money for immediate daily needs (e.g., groceries, medicine or doctors visits)? In the past 48 hours have you received disaster relief such as food, water, ice, or shelter from disaster relief stations (e.g., FEMA, ARC, etc.)?... YES NO DK YES NO DK YES NO DK If no, why? Didn t need relief Couldn t get there Didn t know about them Other Has a doctor ever told you that you have: Physical disability YES NO DK Hearing impairment YES NO DK Visual impairment/legally blind YES NO DK GI illness YES NO DK Heart/Cardiac/HBP YES NO DK Respiratory YES NO DK Renal YES NO DK Neuro: Stoke, Seizures, TIAs YES NO DK Dementia/Alzheimer s YES NO DK Arthropathy (arthritis, any joint pain) YES NO DK Diabetes YES NO DK Cancer YES NO DK Anemia YES NO DK Psychiatric YES NO DK Other YES NO DK If yes, did the hurricane make any of these worse? YES NO DK If yes, has the hurricane prevented you from getting the care you would normally receive for these conditions (e.g., missing doctors appointments or treatments)? YES NO DK What is your greatest need at the moment?

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