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PubMed2006

Caring for non-combatants, refugees, and detainees.

The recently reported abuses at Abu Ghraib prison have brought the issue of medical care for displaced persons (DPs) to greater prominence. Natural disasters in the United States (eg, Hurricane Katrina) and elsewhere also require significant medical resources in situations that lack basic infrastructure. Intimate knowledge of the basic tenets of international law is crucial to the care of DPsin any capacity. This article provides an introduction to the Geneva Conventions and the medical and administrative issues that form a framework on which to base DP care.

Codes of Ethics↗
PubMed2006

Peacekeeping and stability operations: a military surgeon's perspective.

Military surgeons serve a unique role in peacekeeping and stability operations and in response to natural disasters. Military medical units are the best medical resource to respond early in times of cri-sis but are often less equipped for prolonged missions and subsequent management of the chronic health care needs of the masses. Because endemic and host-nation diseases often add complexity to the management of these cases, military surgeons must perform operations outside the scope of their usual civilian practice. The primary medical mission is to treat the peacekeeping force, but the reality lies in eventually treating the refugees and victims of hostile conflict, including women, small children, and the elderly. This article explores the unique features of a surgeon's role in the support of these missions.

Disasters↗
PubMed1999

Disparate effects of the 1989 Loma Prieta and 1994 Northridge earthquakes on hospital admissions for acute myocardial infarction: importance of superimposition of triggers.

BACKGROUND: Most occurrences of presumed triggers of acute myocardial infarction (AMI) do not actually trigger an AMI. The relation between vulnerability to development of AMI and timing of triggers of AMI is poorly understood. The 1989 Loma Prieta earthquake struck the San Francisco Bay Area at 5:04 PM during a period of relatively reduced circadian vulnerability to AMI. The 1994 Northridge earthquake awakened citizens of Los Angeles at 4:31 AM, also during a period of otherwise reduced vulnerability to AMI, but superimposed the stress of the earthquake upon the known stress of awakening. Study of times of onset of natural disasters and their effect on precipitation of AMI may provide insight into the physiology of triggering. This study was designed to compare the triggering ability of 2 similarly intense earthquakes that occurred singly or superimposed upon another trigger. METHODS AND RESULTS: California discharge records were analyzed from the week before, the day of, and the 6 days after the Loma Prieta and Northridge earthquakes and the same dates of control years for total admissions, AMI admissions, and congestive heart failure admissions. There was no statistically significant increase in AMI admissions in the San Francisco Bay Area on the day of the Loma Prieta earthquake compared with the days before or after the earthquake or compared with the same day in 1990. In contrast, there was a 110% increase in admission rate for AMI in Los Angeles County on the day of the Northridge earthquake compared with the average of the 7 days before the earthquake (z = 4.349, P <.001). Similarly, there was a >80% increased risk of admission for AMI on the day of the Northridge earthquake in 1994 compared with the same date in 1995 (relative risk 1.828, 95% confidence intervals 1.289 to 2.592). CONCLUSIONS: Extreme emotional stress superimposed on the stress of awakening results in enhanced triggering of AMI. When emotional stress occurs at less vulnerable periods, there is no significant increase in incidence of AMI.

California↗
PubMed2003

The concept of allostasis in biology and biomedicine.

Living organisms have regular patterns and routines that involve obtaining food and carrying out life history stages such as breeding, migrating, molting, and hibernating. The acquisition, utilization, and storage of energy reserves (and other resources) are critical to lifetime reproductive success. There are also responses to predictable changes, e.g., seasonal, and unpredictable challenges, i.e., storms and natural disasters. Social organization in many populations provides advantages through cooperation in providing basic necessities and beneficial social support. But there are disadvantages owing to conflict in social hierarchies and competition for resources. Here we discuss the concept of allostasis, maintaining stability through change, as a fundamental process through which organisms actively adjust to both predictable and unpredictable events. Allostatic load refers to the cumulative cost to the body of allostasis, with allostatic overload being a state in which serious pathophysiology can occur. Using the balance between energy input and expenditure as the basis for applying the concept of allostasis, we propose two types of allostatic overload. Type 1 allostatic overload occurs when energy demand exceeds supply, resulting in activation of the emergency life history stage. This serves to direct the animal away from normal life history stages into a survival mode that decreases allostatic load and regains positive energy balance. The normal life cycle can be resumed when the perturbation passes. Type 2 allostatic overload begins when there is sufficient or even excess energy consumption accompanied by social conflict and other types of social dysfunction. The latter is the case in human society and certain situations affecting animals in captivity. In all cases, secretion of glucocorticosteroids and activity of other mediators of allostasis such as the autonomic nervous system, CNS neurotransmitters, and inflammatory cytokines wax and wane with allostatic load. If allostatic load is chronically high, then pathologies develop. Type 2 allostatic overload does not trigger an escape response, and can only be counteracted through learning and changes in the social structure.

Adaptation, Physiological↗
PubMed2002

Investing in safety an analytical precautionary principle.

PROBLEM: Governments and businesses must respond to increasing safety requirements and balance the associated costs with productivity and competing pressures. METHOD: A real options approach has been introduced for decision making in the private sector; this approach is adapted for regulatory decisions that can involve irreversible and uncertain safety impacts, social costs that differ from private costs, and differences in perception among the stakeholders. RESULT AND IMPACT ON INDUSTRY AND GOVERNMENT: The outcome is an economic decision gage that determines if it is optimal to invest in safety even if the estimated costs significantly exceed the estimated benefits. Applications potentially include safety decisions related to aviation, ground transportation, pipelines, nuclear facilities, natural disaster planning, and terrorism, among others.

Cost-Benefit Analysis↗
PubMedDate not supplied

Methodological problems and amendments to demonstrate effects of temperature on the epidemiology of malaria. A new perspective on the highland epidemics in Madagascar, 1972-89.

There is a growing consensus that changes in climate will have major consequences for human health through a reduction in the availability of food and an increasing frequency of natural disasters. However, the contribution of higher temperatures to vector-borne diseases, particularly malaria, remains controversial despite the known biological dependence of both vector and pathogen on climate. Misconceptions and inappropriate use of variables and methods have contributed to the controversy. At present there appears to be more support for non-climatic explanations to account for the resurgence of malaria in the African highlands, e.g. the deterioration of malaria control and the development of drug resistance. An attempt is made here to show that dismissing temperature as a driving force in the case of malaria is premature. Using a de-trended time-series of malaria incidence in Madagascar between 1972 and 1989 indicated that a minimum temperature during 2 months at the start of the transmission season can account for most of the variability between years (r2 = 0.66). These months correspond with the months when the human-vector (Anopheles gambiae sensu lato) contact is greatest. The relationship between El Niño Southern Oscillation (ENSO) and temperature (r = 0.79), and ENSO and malaria (r = 0.64), suggests that there might be an increased epidemic risk during post-Niño years in the Madagascar highlands and therefore warrants increased vigilance and extended control efforts in the first half of 2003. This review suggests that the rejection of climate-disease associations in studies so far published may not have used biologically relevant climate parameters. It highlights the importance of identifying more relevant parameters during critical periods of the transmission season in order to aid epidemic forecasting and to assess the potential impact of global warming.

Altitude↗
PubMed2003

El Niño and health.

El Niño Southern Oscillation (ENSO) is a climate event that originates in the Pacific Ocean but has wide-ranging consequences for weather around the world, and is especially associated with droughts and floods. The irregular occurrence of El Niño and La Niña events has implications for public health. On a global scale, the human effect of natural disasters increases during El Niño. The effect of ENSO on cholera risk in Bangladesh, and malaria epidemics in parts of South Asia and South America has been well established. The strongest evidence for an association between ENSO and disease is provided by time-series analysis with data series that include more than one event. Evidence for ENSO's effect on other mosquito-borne and rodent-borne diseases is weaker than that for malaria and cholera. Health planners are used to dealing with spatial risk concepts but have little experience with temporal risk management. ENSO and seasonal climate forecasts might offer the opportunity to target scarce resources for epidemic control and disaster preparedness.

Climate↗
PubMed1996

Targeting the vulnerable in emergency situations: who is vulnerable?

BACKGROUND: Emergencies such as wars and natural disasters increase the vulnerability of affected populations and expose these populations to risks such as disease, violence, and hunger. Emergency public health interventions aim to mitigate these effects by providing basic minimum requirements, reducing vulnerability, and reducing exposure to risk. Targeted services are generally aimed at children under 5. Mortality rates among young children are higher than the crude mortality rate (CMR) among the whole population in emergency settings, so attention is focused on this age group. However, even under normal conditions mortality is higher in young children. This analysis compared the relative risk of death for young children with that for older children and adults under normal conditions and in emergency settings. METHODS: Mortality data from refugee camps set up in response to three different emergencies were examined. Baseline mortality rates in the refugees' countries of origin were calculated from published data. Relative risks between normal and emergency conditions were calculated and compared. FINDINGS: Mortality rates were higher among children under 5 than among older children and adults both under normal circumstances and in the emergency setting in camps in Tanzania, Uganda, and Zaire. However, the relative risk for under-5 versus over-5 mortality was smaller under emergency conditions than under normal circumstances. Thus, children over 5 and adults are disproportionately more affected by exposure to emergency risks than are younger children. INTERPRETATION: If the objective of intervention, to reduce mortality, is to be achieved, the population over the age of 5 cannot be ignored. Emergency public health needs to develop specific tools to investigate risk in other age groups (as well as children under 5), to identify causes, and to design programmes to address such needs.

Adolescent↗
PubMed1999

Mortality in North Korean migrant households: a retrospective study.

BACKGROUND: A deteriorating economy, coupled with a series of natural disasters in 1995-97, led to a severe food crisis in North Korea. Although the country has received substantial international aid since 1996, demographic assessments of crisis impact have been limited. We assessed mortality trends in North Korea since 1995. METHODS: At 15 randomly selected sites in China, 440 North Korean adult migrants were interviewed during July-September, 1998. Respondents were asked about births, deaths, and migration patterns in their households between mid-1994 and mid-1998, and about household food sources. The respondents also provided basic demographic information about the households of their relatives. We compared mortality rates from migrant households with data from the 1993 census and with data about households of non-migrant relatives. FINDINGS: Households that included a recent migrant to China showed increasing mortality: crude death rates rose from 28.9 per 1000 in 1995, to 45.6 per 1000 in 1996, and to 56.0 per 1000 in 1997 (p=0.0001), with a 3-year average rate of 42.8 per 1000. The crude 3-year birth rate was 11.0 per 1000. Average household size declined from 4.0 at the beginning of 1995 to 3.4 at the end of 1997 (p=0.0002). Among 259 households of non-migrant relatives, the crude death rate was 43.2 per 1000 and the crude birth rate was 8.8 per 1000. In these households, the 3-year trend of increasing mortality was significant (p=0.001), as was the decline in average household size from 4.3 at the beginning of 1995 to 3.7 at the end of 1997 (p=0.0001). INTERPRETATION: Among North Korean households that include a recent migrant to China, mortality has increased and household size has declined since 1995. This trend raises concern about the state of the general population, at least in the province of North Hamkyong, from where most of the migrants originated.

Adolescent↗
PubMed1999

Derivation of the SPAN, a brief diagnostic screening test for post-traumatic stress disorder.

The Davidson Trauma Scale (DTS) is a validated 17-item self-rating scale used in the diagnosis of post-traumatic stress disorder (PTSD), which is sensitive to the effects of treatment. It was felt that a shorter version of the scale might provide a better diagnostic screening tool. Subjects were drawn from a sample of 243 patients obtained from multiple cohorts that included a group of survivors of various forms of trauma, including natural disaster, rape and combat. All subjects had diagnostic assessments for PTSD with a clinical interview and completed the DTS. The data were randomly divided between two subsamples, and frequency and severity scores were calculated for the DTS. A four-item scale, the SPAN (named for its top four items: Startle, Physiological arousal, Anger, and Numbness), was developed. It demonstrated an efficiency of 0.88, sensitivity of 0.84, specificity of 0.91 and positive likelihood ratio of 9.1. In a replication sample, values were slightly lower but still acceptable (efficiency = 0.80). A subgroup of PTSD patients received either fluoxetine or placebo in a clinical trial, and a significant SPAN score improvement was observed on fluoxetine. The SPAN, which correlated significantly with the Impact of Events Scale, the Sheehan Disability Scale, and the Structured Interview of PTSD, was found to have a diagnostic accuracy of 88%.

Adult↗
PubMed1997

Influences of The Great Hanshin-Awaji Earthquake on glycemic control in diabetic patients.

We investigated influences on glycemic control in 177 diabetic patients after The Great Hanshin-Awaji Earthquake which occurred on January 17, 1995. Changes in serum HbA(1c) level were studied according to the worsen rate of dietary and living conditions. A significant temporary increase in the mean value of HbA(1c) level was found after the earthquake (8.34 +/- 2.07% in March, 1995 vs. 7.74 +/- 1.82% in December, 1994, P < 0.01). Ninety nine of them showed more than 0.5% in the rate of increase. Multiple regression analysis was applied to the following factors: inappropriate diet, discontinuation of drug uptake, reduction of exercise, destruction of house, long stay at shelter, sex, age, and pre-earthquake therapy. Among them, inappropriate diet demonstrated the highest partial regression coefficient to raise the mean value of the HbA(1c) level. The increased level of HbA(1c) declined gradually to the pre-earthquake level in September, 1995. This study emphasizes the importance of appropriate diet for diabetic patients during a natural disaster. To fulfil it, medical staff have to educate diabetic patients of their disorders tediously in ordinary time. In addition, it seems quite useful to supply a medical information card and a small medical bag containing essential drugs to each patient.

Adult↗
PubMed1994

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.

Adult↗
PubMed2001

Vaccination against hepatitis viruses in Poland.

At present, two etiologic varieties of viral hepatitis (VH) can be directly vaccine-preventable: VH type A and VH type B. In addition, VH type D can be prevented indirectly through vaccination against VH-B. The first commercially available vaccine against VH-B appeared in 1981 and was human plasma-derived. After several years, it has generally been replaced by a recombinant type of vaccines. The obvious benefits of vaccination against VH-B prompted its introduction into the national immunization program in Poland in 1989. At that time, vaccination was offered free of charge to high-risk groups: newborns of HBsAg-carrier mothers, health-care workers, students: at medical schools, nursing schools, medical technology schools, and caretakers at institutions for mentally retarded persons. However, similarly to the experiences of other countries, observations in Poland indicated that such a targeted strategy fails to induce major epidemiological changes. In 1989 and in 1993, the incidence of VH-B per 100000 was 40.3 and 34.6, respectively. In addition, during these years, the incidence of V-B per 100000 children aged 0-4 years was 20.0 and 38.4, respectively. It has been decided that vaccination against VH-B will be obligatory for all newborns beginning from 1993. Due to financial constraints, it has been introduced in three phases, and since 1996, all newborns in Poland have been vaccinated. Already in 1993, three additional risk groups have been offered vaccination: patients with chronic diseases, patients awaiting planned surgery, and persons coming into close contact with acute VH-B or chronically HBV-infected individuals. In 1999, the incidence of VH-B per 100000 was 9.1/100000, and it may be assumed that vaccination helped to decrease the incidence of VH-B in Poland. The country experience with vaccination against VH-A is still limited. At present, it is recommended for children and adolescents and people dealing with food distribution, as well as for several other groups of people, such as travellers or long-term visitors (soldiers, missionaries, diplomats) to the endemic regions of the world. It has also been recommended in connection with natural disasters such as floods occurring in a large area of Poland in 1997.

Cross Infection↗
PubMed2003

Inequalities in child mortality in Mozambique: differentials by parental socio-economic position.

This study investigates the relation between socio-economic parental position (education and occupation) and child death in Mozambique using data from the Mozambican Demographic and Health Survey carried out between March and July 1997. The analysis included 9142 children born within 10 years before the survey. In spite of the Western system of classification used in the study, the results partly showed a parental socio-economic gradient of infant and child mortality in Mozambique. Father's education seemed to reflect the family's social standing in the Mozambique context, showing a strong statistical association with postneonatal and child mortality. However, maternal education as a measure of socio-economic position was not statistically significantly associated with child mortality. This finding may partly be explained by the extreme hardships experienced by the country (civil war and natural disasters) and the implementation of the Economic Structural Adjustment Programme that have also affected the health of women and their children during the years covered by this study. Other measures of socio-economic position applicable to the rural African setting should be investigated.

Adolescent↗
PubMed2002

Emergency mental health management in bioterrorism events.

The United States has not suffered significant psychosocial or medical consequences from the use of biological weapons within its territories. This has contributed to a "natural" state of denial at the community level. This denial could amplify the sense of crisis, anxiety, fear, chaos, and disorder that would accompany such a bioterrorist event. A key part of primary prevention involves counteracting this possibility before an incident occurs. Doing so will require realistic information regarding the bioterrorism threat followed by the development of a planned response and regular practice of that response. Unlike in natural disasters or other situations resulting in mass casualties, emergency department physicians or nurses and primary care physicians (working in concert with epidemiologic agencies), rather than police, firemen, or ambulance personnel, will be most likely to first identify the unfolding disaster associated with a biological attack. Like community leaders, this group of medical responders must be aware of its own susceptibility to mental health sequelae and performance decrement as the increasing demands of disaster response outpace the availability of necessary resources. A bioterrorist attack will necessitate treatment of casualties who experience neuropsychiatric symptoms and syndromes. Although symptoms may result from exposure to infection with specific biological agents, similar symptoms may result from the mere perception of exposure or arousal precipitated by fear of infection, disease, suffering, and death. Conservative use of psychotropic medications may reduce symptoms in exposed and uninfected individuals, as may cognitive-behavioral interventions. Clear, consistent, accessible, reliable, and redundant information (received from trusted sources) will diminish public uncertainty about the cause of symptoms that might otherwise prompt persons to seek unnecessary treatment. Training and preparation for contingencies experienced in an attack have the potential to enhance delivery of care. Initiating supportive social, psychotherapeutic, and psychopharmacologic treatments judiciously for symptoms and syndromes known to accompany the traumatic stress response can aid the efficient treatment of some patients and reduce long-term morbidity in affected individuals. Preventive strategies and planning must take into account the idea that specific groups within the population are at higher risk for psychiatric morbidity. First responders comprise one group at psychologic risk in this situation, and healthcare providers comprise another. These and other high-risk groups will benefit from the same supportive interventions developed for the community as a whole.

Bioterrorism↗
PubMed1997

Population-based analysis of the effect of the Northridge Earthquake on cardiac death in Los Angeles County, California.

OBJECTIVES: We sought to determine whether a natural disaster affected total cardiovascular mortality and coronary mortality in an entire population. BACKGROUND: The effect of the January 17, 1994 Northridge Earthquake (NEQ) on all deaths and causes of deaths within the entire population of Los Angeles County is unknown. The purposes of our study were to analyze all deaths in this entire population before, during and after the NEQ and to determine whether the NEQ temporally and spatially altered death due to cardiovascular disease. METHODS: We analyzed all death certificate data (n = 19,617) from Los Angeles County during January of 1992, 1993 (control periods) and 1994, using International Classification of Diseases, 9th Revision codes for ischemic heart disease (IHD) and atherosclerotic cardiovascular disease (ASCVD), as well as other causes of death. RESULTS: There was an average of 73 deaths per day due to IHD and ASCVD during January 1 to 16, 1994; this increased to 125 on the day of the NEQ, and then decreased to 57 deaths per day from January 18 to 31 (p < 0.00001, before NEQ vs. day of NEQ; after NEQ vs. day of NEQ; and before NEQ vs. after NEQ). The NEQ was associated with an increase in deaths due to myocardial infarction and trauma but not cardiomyopathy, hypertensive heart disease, valvular heart disease, cerebrovascular disease or noncardiovascular causes. Based on plots of daily deaths due to IHD and ASCVD, the decrease in deaths during the 14 days after the NEQ (-144) overcompensated for the increase on the day of the NEQ (+55). Geographic analysis revealed a redistribution of deaths due to IHD and ASCVD toward the epicenter on the day of the NEQ. CONCLUSIONS: When an entire population simultaneously experiences a major environmental stress, there is an increase in death due to coronary artery disease (but not other cardiac causes), followed by a decrease that overcompensates for the excess of death. The overcompensation may represent a residual population that is more resistant to stress or a possible preconditioning effect of the stress, or both. This study supports the concept that cardiovascular events within an entire population can be triggered by a shared stress.

Aged↗
PubMed1999

An elective rotation in applied epidemiology with the Centers for Disease Control and Prevention (CDC), 1975-1997.

INTRODUCTION: To increase awareness of and interest in public health and epidemiology, CDC initiated an elective in epidemiology and public health for senior medical students in 1975 and for veterinary students in 1982. METHODS: A review of CDC records to describe participation in the elective, to assess whether students subsequently enrolled in another CDC training program, the Epidemic Intelligence Service (EIS), and, if enrolled, employment status following EIS. A review of documentation of board certification in preventive medicine to determine how many participants later chose this specialty, one indicator of public health and prevention as a career choice. RESULTS: From 1975 through 1997, 632 students participated in the elective. Of these, 438 (69%) were assigned to infectious disease areas, 95 (15%) to environmental health, 59 (9%) to chronic disease, and 40 (7%) to other areas. Students participated in at least 278 official investigations of important public health problems including infectious disease outbreaks, natural disasters, chronic disease problems and access to health care. Of 530 students who had completed the elective through June 1995, 91 (17%) were enrolled in EIS by July 1997. Of 83 completing EIS by July 1997, 65 (78%) had continued in public health careers: 35 with CDC; 17 with local or state health departments; 7 with other federal agencies; 4 in academic public health; and 2 in international health. Of those not enrolling in EIS, at least 5% were certified by the American Board of Preventive Medicine, compared with 34% of those completing EIS. CONCLUSION: An elective rotation in public health and applied epidemiology is valuable in introducing future physicians and veterinarians to the practice of public health, and can provide important role models for encouragement to pursue careers in public health.

Adult↗
PubMed2001

[Risk of accidents for a Parisian pedestrian].

The risk of accident for a parisian pedestrian is of reduced frequency and of moderate severity (terrorism and natural disasters not included) according to the statistics of 1999. This is due to security measures and the excellent organisation of assistance to wounded persons. The improvement in protection of pedestrians, even the disabled and elderly persons will soon make Paris the best protected megalopolis of our continent. Pedestrians are involved in 28% of accidents on public streets with a mortality of 1.2%, with serious injuries in 12.6% of the cases. Injuries without collision occur in 57% of the cases. 18% of the wounded older than 75 years with 1.8% of deaths and 66% of severe injury. Accidents related to public transportation represent a very slight risk of 0.00044%. By modification of the concept of transportation and its materials over a five year period there is a decrease in the number of the victims (-3.75%), in spite of the increase of accidents (3.5%). For lone pedestrian being victims of aggression in public places, after a decrease of 10% in 1999, there is in 2001 an increase which raises the question of police proximity again. Over a five year period the RATP (subway authority) has noticed a 14.77% decrease of thefts and a 54.78% decrease in attacks... This makes the Parisian railnet (subway mostly) seven times less dangerous than the streets.

Accidents, Traffic↗