David Sugerman, MD MPH FACEP Health Systems Team Lead Division of Unintentional Injury Prevention CSTE Workgroup May 9, 2013 Improving Post-disaster Injury Morbidity and Mortality Surveillance National Center for Injury Prevention and Control Division of Unintentional Injury Prevention

Background “Deaths associated with natural disasters, particularly rapid-onset disasters, are overwhelmingly due to blunt trauma, crush-related injuries, or drowning. Deaths from communicable diseases after natural disasters are less common.” Watson JT, Gayer M, Connolly MA. Epidemics after natural disasters. Emerg Infect Dis. Jan, 2007

Background  Provision of emergency trauma care is the immediate need following a disaster  Search and rescue  Triage  Emergency medicine care and surgery  High injury events  Earthquakes/Tornados (crush syndrome, traumatic amputations, fractures)  Floods (drownings)  Tsunamis/Hurricanes (mixed events)

Current Surveillance Systems for PH Emergencies  Death certificate-based databases  County/state hospital discharge databases  National discharge databases (HCUP, NHAMCS)  ED-based syndromic surveillance (ID focused)  Biosense  ESSENCE  SendSS (State Electronic Notifiable Disease Surveillance System)  Poison control center based databases for toxic chemical and nuclear exposures  NPDS (National Poison Data System)  Toxic Exposure Surveillance System (TESS)  State Trauma Registries

Active Case Finding  Retrospective  Hospital chart review  Hospital EHR review  State/local Hospital Associations (de-identified counts)  Ideal if injuries made notifiable by HD

Finding Population Controls  Reflect background exposure frequency  Sampling options  Community cluster sample  Shelter lists American Red Cross (ARC)  Individual assistance lists FEMA / ARC  Random digit dialing  Friend / Associate/ Relatives Respondent driven sampling (RDS)

FEMA Individual Assistance List

Map of Hospitals Contacted Declined (n=7) Participated (n=39)

Recruitment of Cases for Survey  Patient data abstracted from hospital charts  14 hospitals  408 case contacts  Invitation letter sent by hospital  4 hospitals  4 case contacts  Declined patient contact  21 hospitals

Neighborhood Controls

Field Limitations

Phone interviews  Ensure mental health referral services  Landline limitations Cell phone only homes (25-50%) Unlisted numbers (young women > others) Home destroyed without call forwarding  Responder bias

Injury Center Work in Post-earthquake Haiti  Haiti National Sentinel Site Surveillance System  Collaboration with NCEH/HSB and CGH/DGDDER on injury  51 sites selected from 99 PEPFAR facilities  January 25-April 24, 2010  5,065 injuries (12% total)  University of Miami / Project Medishare Field Hospital  Data sharing agreement  Paper records abstracted 6 months after earthquake  January 13- May 28,2010  1,369 admissions / 581 injuries (162 earthquake related) Centers for Disease Control and Prevention (CDC). Launching a National Surveillance System after an earthquake --- Haiti, MMWR Morb Mortal Wkly Rep Aug 6;59(30): Erratum in: MMWR Morb Mortal Wkly Rep Aug 13;59(31):993 Centers for Disease Control and Prevention (CDC). Post-earthquake injuries treated at a field hospital --- Haiti, MMWR Morb Mortal Wkly Rep Jan 7;59(51):

NSSS and Medishare Field Hospital Nature of injury and treatment National Sentinel Site Surveillance (1/25-4/24/2010) Project Medishare Field Hospital (1/13-5/28/2010) 51 sites1 site Fracture(s) Concussion Laceration from weapon11130 Amputation1445 Burns14925 Wounds (infected)3, Crush injury syndrome8850 Surgical procedures Final disposition Total5,065581

Surgical Response Evaluation — Handicap International / DFID  Background / Methods  274 organizations provided healthcare, ?# provided surgical care  Qualitative (patient interviews)  Quantitative (8 surgical providers contacted, 4 participated)  Results  Amputation rates (1% to 45%)  Lowest among orthopedic and plastic surgery combined teams  Primary treatment for complex severe wounds and fractures in salvageable limb  Secondary treatment for infected wounds and compart. syndrome  Many Guillotine amputations that required complex repair Knowlton LM, Gosney JE, Chackungal, et al. Consensus statements regarding the multidisciplinary care of limb amputation patients in Disasters. Prehosp and Dis Med. Dec 2011.

For more information please contact Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA Telephone, CDC-INFO ( )/TTY: Web: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Thank you National Center for Injury Prevention and Control Place Descriptor Here David Sugerman