Data for Decision Making in Disasters: Advances and Controversies Prevention of Disaster Threats Workshop Kaunas, Lithuania 08 August, 2005 Eric K. Noji, M.D., M.P.H. Centers for Disease Control Washington, DC

"The reason for collecting, analyzing and disseminating information on a disease is to control that disease. Collection and analysis should not be allowed to consume resources if action does not follow." William H. Foege, M.D. International Journal of Epidemiology 1976; 5:29-37

Uses of Data in Disasters Assessment and Surveillance Injury and disease profiles Research methodologies Disaster management Vulnerability and hazard assessment

Public Health Actions in Emergencies Before the disaster During the disaster After the disaster

Data Needs Before the Disaster Hazard Analysis Vulnerability Analysis Training and Education

Increasing disaster risk Increasing population density Increased settlement in high-risks areas Increased technological hazards and dependency Increased terrorism: biological, chemical, nuclear? Aging population in industrialized countries Emerging infectious diseases (AMR) International travel (global village)

While knowing the threat agent is important, understanding how each threat expresses its toll on the health and well being of communities, in both the near term and the long run, is crucial to our preparedness and response.

IMMEDIATE RELIEF

Next Steps Rapid needs assessment Disease Surveillance Public health interventions

Rapid Needs Assessment The collection of subjective and objective information, limited in time, performed in acute situations, which requires immediate action to be taken to respond to the basic requirements of the affected population

Objectives of Health Information Systems in Emergency Populations Establish health care priorities Establish health care priorities Follow trends and reassess priorities Follow trends and reassess priorities Detect and respond to epidemics Detect and respond to epidemics Evaluate program effectiveness Evaluate program effectiveness Ensure targeting of resources Ensure targeting of resources Evaluate quality of health care Evaluate quality of health care

Goal of CMR in Emergency Populations For < 5 years of age: Less than 2.0 per 10,000 per day For < 5 years of age: Less than 2.0 per 10,000 per day For > 5 years of age: Less than 1.0 per 10,000 per day For > 5 years of age: Less than 1.0 per 10,000 per day

Morbidity Assessment Necessary Information Diseases of public health importance Diseases of public health importance Measles Measles Diarrhea Diarrhea Acute Respiratory infections Acute Respiratory infections Injuries Injuries Malnutrition Malnutrition

Diseases of epidemic potential Diseases of epidemic potential Cholera Cholera Dysentery Dysentery Meningitis Meningitis Yellow fever Yellow fever

Program or process indicators Immunization coverage Immunization coverage Supplementary feeding attendance Supplementary feeding attendance Antenatal and postnatal clinic coverage Antenatal and postnatal clinic coverage ORS distribution ORS distribution Water consumation Water consumation Caloric intake Caloric intake Latrine coverage Latrine coverage

The Assessment Process Identify information needs and resources Identify information needs and resources Collect data Collect data Analyze and interpret Analyze and interpret Report conclusions Report conclusions Design/modify disaster response Design/modify disaster response Back to the beginning of assessment Back to the beginning of assessment Identify information needs and resources Identify information needs and resources

After the Disaster Lessons learned Lessons learned Improving future disaster response Improving future disaster response Preventing or mitigating loss of life, severe illness and injuries Preventing or mitigating loss of life, severe illness and injuries

Epidemiologic Methods in Disasters After a disaster (Reconstruction Phase): Conducting post-disaster epidemiologic follow-up studies Identifying risk factors for death & injury Planning strategies to reduce impact-related morbidity & mortality Source: EK Noji, The Public Health Consequences of Disaster

Epidemiologic Methods in Disasters After a disaster (Reconstruction Phase): Developing specific interventions Evaluating effectiveness of interventions Conducting descriptive & analytical studies Planning medical & public health response to future disasters Conducting long-term follow-up of rehabilitation/reconstruction activities Source: EK Noji, The Public Health Consequences of Disaster

Myths and Realities in Disaster Situations Myth: Foreign medical volunteers with any kind of medical background are needed. Myth: Foreign medical volunteers with any kind of medical background are needed. Reality: The local population almost always covers immediate lifesaving needs. Only medical personnel with skills that are not available in the affected country may be needed. Reality: The local population almost always covers immediate lifesaving needs. Only medical personnel with skills that are not available in the affected country may be needed. Myth: Any kind of international assistance is needed, and it's needed now! Myth: Any kind of international assistance is needed, and it's needed now! Reality: A hasty response that is not based on an impartial evaluation only contributes to the chaos. It is better to wait until genuine needs have been assessed. Reality: A hasty response that is not based on an impartial evaluation only contributes to the chaos. It is better to wait until genuine needs have been assessed. Myth: Epidemics and plagues are inevitable after every disaster. Myth: Epidemics and plagues are inevitable after every disaster. Reality: Epidemics do not spontaneously occur after a disaster and dead bodies will not lead to catastrophic outbreaks of exotic diseases. The key to preventing disease is to improve sanitary conditions and educate the public. Reality: Epidemics do not spontaneously occur after a disaster and dead bodies will not lead to catastrophic outbreaks of exotic diseases. The key to preventing disease is to improve sanitary conditions and educate the public. Myth: Disasters are random killers. Myth: Disasters are random killers. Reality: Disasters strike hardest at the most vulnerable group, the poor -- especially women, children and the elderly. Reality: Disasters strike hardest at the most vulnerable group, the poor -- especially women, children and the elderly. Myth: Locating disaster victims in temporary settlements is the best alternative. Myth: Locating disaster victims in temporary settlements is the best alternative. Reality: It should be the last alternative. Many agencies use funds normally spent for tents to purchase building materials, tools, and other construction-related support in the affected country. Reality: It should be the last alternative. Many agencies use funds normally spent for tents to purchase building materials, tools, and other construction-related support in the affected country.

Epidemiologic Methods in Disasters Challenges for Epidemiologists Applying epidemiologic methods in the context of: Physical destruction Physical destruction Public fear Public fear Social disruption Social disruption Lack of infrastructure for data collection Lack of infrastructure for data collection Time urgency Time urgency Movement of populations Movement of populations Lack of local support and expertise Lack of local support and expertise Source: EK Noji, The Public Health Consequences of Disaster

Epidemiologic Methods in Disasters Challenges for Epidemiologists Selecting study designs: Cross-sectional: Cross-sectional: Studies of frequencies of deaths, illnesses, injuries, adverse health affects Limited by absence of population counts Case-control: Case-control: Best study to determine risk factors, eliminate confounding, study interactions among multiple factors Limited by definition of specific outcomes, issues of selection of cases & controls Source: EK Noji, The Public Health Consequences of Disaster

Epidemiologic Methods in Disasters Challenges for Epidemiologists Selecting study designs: Longitudinal: Longitudinal: Studies document incidence and estimate magnitude of risk Limited by logistics of mounting a study in a post-disaster environment and subject follow-up Source: EK Noji, The Public Health Consequences of Disaster

Epidemiologic Methods in Disasters Challenges for Epidemiologists Need standardized protocols for data collection immediately following disaster Need standardized protocols for data collection immediately following disaster Need standardized terminology, technologies, methods and procedures Need standardized terminology, technologies, methods and procedures Need operational research to inventory medical supplies and determine 1) actual needs, 2) local capacity, 3) needs met by national/international communities Need operational research to inventory medical supplies and determine 1) actual needs, 2) local capacity, 3) needs met by national/international communities Need evaluation studies to determine efficiency and effectiveness of relief efforts and emergency interventions Need evaluation studies to determine efficiency and effectiveness of relief efforts and emergency interventions Source: EK Noji, The Public Health Consequences of Disaster

Epidemiologic Methods in Disasters Challenges for Epidemiologists Need databases for epidemiologic research based on existing disaster information systems Need databases for epidemiologic research based on existing disaster information systems Need to identify injury prevention interventions Need to identify injury prevention interventions Need to improve timely and appropriate medical care following disaster (search & rescue, emergency medical services, importing skilled providers, evacuating the injured) Need to improve timely and appropriate medical care following disaster (search & rescue, emergency medical services, importing skilled providers, evacuating the injured) Need measures to quickly reestablish local health care system at full operating capacity soon after disaster Need measures to quickly reestablish local health care system at full operating capacity soon after disaster Source: EK Noji, The Public Health Consequences of Disaster

Epidemiologic Methods in Disasters Challenges for Epidemiologists Need uniform disaster-related injury definitions and classification scheme Need uniform disaster-related injury definitions and classification scheme Need investigations of disease transmission following disasters and public health measures to mitigate disease risk Need investigations of disease transmission following disasters and public health measures to mitigate disease risk Need to study problems associated with massive influx of relief supplies and relief personnel Need to study problems associated with massive influx of relief supplies and relief personnel Need cost-benefit and cost-effectiveness analyses Need cost-benefit and cost-effectiveness analyses Source: EK Noji, The Public Health Consequences of Disaster