Part 5: The methodological lessons from Bam earthquake Disaster Epidemiology Lessons From Bam Earthquake Dec 26, 2003 Iran Part 5: The methodological lessons from Bam earthquake Ali Ardalan MD, MPH, PhD student in Epidemiology 1

To understand some applications and Learning objectives: To understand some applications and limitations of epidemiologic studies in earthquakes To understand the application and methodology of Rapid Health Assessment in Bam. To learn about the application of Geographic- based sampling method in Bam. To learn about important points of ethical issues of research in disasters 2

Challenges and problems facing Epidemiologists following the disasters Political environment Changing social conditions and demographics Difficulty in applying standard epidemiologic techniques in the context of great destruction Lack of time for organizing epidemiologic investigation Absence of well defined population counts Lack of active collaboration between scientists from different disciplines Source: http://www.pitt.edu/~super1/lecture/lec11311/013.htm As Dr. Noji has mentioned, Epidemiologists face numerous complex problems in disaster situations. I had the opportunity to visit Bam about 2 weeks after the earthquake, which was my first experience in a real disaster field. My first objective was to find out what can an epidemiologist do in such disaster-stricken situation. Just after a few hours, I felt that this slide of Dr. Noji's lecture on Supercourse has been prepared based on Bam experience. Actually, all items were the same in Bam. In this part of the lecture, I am trying to share with you some points on methodology of epidemiologic investigations, which I experienced or were interesting for me and drew my attention. 3

Rapid Health Assessment after the earthquake Objectives: To identify, define and prioritize potential impacts in disaster situations To help mobilize resources and direct them to where they are most needed. What drew my attention, was that in the aftermath of the earthquake when conducting classic epidemiologic studies seems rather impossible due to critical situation, hence RHA is a good alternative solution. In an RHA, data gather and analyze in the following areas: · The general content of the disaster · Disaster related factors, which may have an immediate impact · Possible immediate environmental impacts of disaster · Unmet basic needs of disaster survivors · Potential negative environmental consequences of relief operation 4

Rapid Health Assessment The principles of methodology: Simple consensus-based qualitative assessment process Not replace the quantitative studies, but fills a gap until such studies are appropriate. Can be used from the time disaster happens till some month later, or for any major stage-change in an extended crisis. 5

Rapid Health Assessment Source of information: Direct observation of the field Reviewing of the pre-disaster records Reviewing of community profiles in the news and on the Internet, and diverse reports. Interviewing with local and national authorities Interviewing with affected people 6

Rapid Health Assessment in the Bam Earthquake As part of a joint mission of the World Health organization (WHO) with the Iranian Ministry of Health (MoH), a rapid assessment was conducted on the health status of the affected population and health activities in Bam on Dec 27, 2003. You can find a good report of RHA at: "www.who.int/disasters/repo/11635.pdf". Please notice the structure of report, the date of assessment, the addressed area and source of information. 7

Survey Methodology-Phase 1: Feasibility study Interviews with local disaster managers Direct observation of the field Before going to Bam, I was blamed because some people believed that the people were so needy and the situation was so catastrophic that conducting a study seemed a little unethical. But soon after going there, I happened to know that the major problem of the people was lack of evidence-based information of decision-makers. I conducted 2 surveys there, on the needs of survivors and rescue teams. Also, some other points were addressed, which you will see later. Herein I’d like to discuss with you some methodological points, which I have learned and used and may be applied in the same situations. During the first day visit of Bam the following assessments were done. First, a feasibility study including: 1) Interviews with local disaster managers to assess their knowledge and attitude toward the necessity of research activities after an earthquake and to estimate their level of supports and possible limitations 2) To estimate the available facilities for data collection such as transportation and basic needs of interviewers consisting of tents, food, water and latrines. 3) Assessment of population-based design requirement, including living status of people by direct observation and asking for available information of geographical distribution of population and the map of city. Second, some interviews were done. 1) Ten in-depth interviews with people from different corners of the city to assess their needs, living status and their cooperation. 2) Three interviews with rescue teams about their needs and health problems. Assessment of population-based design requirements 8

Volunteer students of School of Public Health Research at KUMS, before leaving for Bam. To assemble a data gathering team, I had to return to Kerman which was about 3 hours drive and stay there for 2 nights. That was a time taking process. But fortunately, Dean of School of Public Health at KUMS had announced for volunteer students and I could train them, and also edit and copy the questionnaires. This is a picture of them. This was a rewarding experience, which brought up the idea that such team could be formed and trained in advance, in almost all provinces of the country, in order to assist research activities in such situations. These teams can provide necessary just in time information for disaster managers. That is worthwhile, especially when all people are too busy in the earthquake-stricken area! 9

First night in a tent at Bam Health Center: After dinner, without having lunch! Text: Since, assembling such a team had not been planned ahead, defective supporting supplies like food and transportation in the field was a serious problem. In addition to that field managers were so concerned about this young team that they even took their presence as an interference and disturbance to the area! So, in order not to cause any disturbance we tried to keep silent and avoid unnecessary commotion even in our staying place. But as luck would have it, the uninvited presences of a centipede in the girls' tent led to burst of deafening screams. It seemed as if that the field managers heard a scream for each step taken by the invader centipede. Specially, when simultaneously there was a power cut! This was not a detective story by Agatta Christy, but just a real disaster field experience that really led to a second disaster for us the day after. 10

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Ethical issues of population-based research in disasters Verbal consent Confidentiality of individual information The most important point, People must be informed that the interviews are unrelated to providing information for personal service deliveries to deal with their needs. 12

Geographic-based sampling design in disasters A very useful tool in Bam, because of lack of a sampling frame of residential tents. Regarding lack of a sampling frame of residential tents, a cluster geographic-based sampling plan was used. In next slides we have a brief review about it. This technique also has applied for a survey on mental health and also interventional studies of mental health. 13

Geographic-based sampling plan Geographic zone Section 1 Main street On the date of survey, the earthquake-stricken area of Bam was divided to 13 zones. The samples were proportionally distributed in 8 zones, based on a rough estimate of the total number of tents. To determine the clusters, with the help of an available map and a native who was well familiar with the city, each zone was divided to some sections by half of required clusters. In each section, the main squares and cross-roads were determined and one of them was selected randomly. Cross-road Section 3 Square Section 2 Selected start point 14

Geographic-based sampling plan Main street Cross-road        500 m Square        Selected start point  Tent From the selected point the survey group started moving northwards to find the first tent in the first cluster in the section. Following that, the group interviewed seven consecutive households living in the tents. Then the group continued their way at least about 500 meters forward and then turned left at the nearest minor street or alley to find the first tent in the second cluster. Again, they interviewed seven consecutive households living in tents. Five hundreds meters was considered in accordance with the limited physical ability and fitness level of group members, especially females, to walk after completing the first cluster. The supporting idea for including the minor streets and alleys residents along with the main streets ones was the possible differences between their accessibility to health care services or opium abuse. Movement direction Minor street, Alley 15

Geographic-based sampling plan Main street Cross-road     500 m Square          Selected start point   Tent If a group did not complete seven interviews because of lack of sufficient visible tents on the moving path; they turned left to find the nearest tent and completed interviewing with 7 households. Movement direction Minor street, Alley 16

Geographic-based sampling plan Square as selected start point Cross-road Square as selected start point Main street     Minor street, Alley If the determined address in a section was a square inside which people were living, the group interviewed them as the first cluster and then moved northwards onto the most northern street and turn left after about 500 meters to find the second cluster in that section. If several households were living in one tent, the group interviewed one of them randomly by the digit of the serial number of a bill (paper money). 500 m     Tent        Movement direction 17

determining the risk factors of Limitation of cross-sectional studies in post-disaster period of Bam earthquake Potential selection bias in determining the risk factors of mortality and injuries and also their incidence estimations This is because of: · Considerable death of population · Movement of some of quake-stricken to other cities around the country · Invasion of people from neighboring areas to Bam In two next slides, you can see some supportive evidences. 18

Population movement After the earthquake Earthquake-stricken area   Zones   Earthquake-stricken area 19

The main construction materials of earthquake-stricken population houses based on a cross-sectional study on 19th and 20th days of post-disaster period in Bam You see here a crystal clear example of selection bias by a cross-sectional study after a devastating earthquake. Every body knows that the main structure of Bam houses were clay and mud-bricks. But in this slide it is machinery bricks, concrete and steel. Clearly, it is related to studying just the households with at least one survivor. 20

Death by cross-sectional study 18 % Total death: 40 % of population A consequence of cross-sectional studies in post-disaster period of Bam Death by cross-sectional study 18 % Selection bias - 45 % You see here another example of selection bias due to a cross-sectional study after the massive earthquake of Bam. The household representatives were asked for number of direct-related death to the earthquake in their family. Total death: 40 % of population 21

Conclusion: Considering the limitations of cross-sectional and case-control studies, it seems a retrospective cohort approach, for instance, based on before-quake list of governmental employees, would be decreases the aforementioned problem. 22