1) Public health issues are important in disaster management. Natural disasters can cause deaths, injuries, homelessness and damage infrastructure like roads and utilities. They can also increase risks of communicable diseases by disrupting sanitation and increasing population density. 2) Critical public health interventions after disasters focus on environmental health like ensuring clean water, sanitation and hygiene to prevent disease outbreaks. They also involve providing shelter, controlling disease, and addressing nutrition issues. 3) While disasters do not usually cause disease outbreaks, risks can increase under conditions of overcrowding and sanitation breakdowns, as seen in refugee camps. Diseases spread through water and respiratory routes. Mass immunization is usually not effective or needed

1. Public health issues in disasters
Eric K. Noji, MD, MPH
Objective: This article outlines a number of important areas in grounds. Some similarities exist, however, among the health effects
which public health can contribute to making overall disaster of different natural disasters, which if recognized, can ensure that
management more effective. This article discusses health effects health and emergency medical relief and limited resources are well
of some of the more important sudden impact natural disasters managed. (Crit Care Med 2005; 33[Suppl.]:S29 –S33)
and potential future threats (e.g., intentional or deliberately re- KEY WORDS: disasters, natural, earthquake, flood, volcano, tor-
leased biologic agents) and outlines the requirements for effective nado, hurricane, typhoon, cyclones; disaster epidemiology; disas-
emergency medical and public health response to these events. ter medicine; emergency; mass casualty incident; homeland
Conclusion: All natural disasters are unique in that each affected security
region of the world has different social, economic, and health back-
T hroughout history, natural di- days (11). Good disaster management re- the incidence of diarrhea, respiratory in-
sasters have exacted a heavy toll quires accurate information and must link fections, and other communicable dis-
of death and suffering (1). Most data collection and analysis to an immedi- eases. A good system of water supply and
recently, the Bam earthquake in ate decision-making process (12). The over- excreta disposal must be put into place
Iran resulted in thousands of deaths, inju- all objective of disaster management from a quickly (20). No amount of curative
ries, and homelessness (2) (Table 1). The public health perspective is to assess the health measures can offset the detrimen-
problem has not improved much despite needs of disaster-affected populations (13, tal effects of poor environmental health
much attention by the international scien- 14), match available resources to those planning (21). Important postdisaster en-
tific community (3). Global climate change needs, prevent further adverse health ef- vironmental interventions include access
brings the potential for severe weather fects, implement disease control strategies to adequate sources of potable water; and
events and flooding, and the introduction for well-defined problems, evaluate the ef- the collection, disposal, and treatment of
of tropical vector-borne diseases into more fectiveness of disaster relief programs (15), excreta and other liquid and solid wastes
temperate regions (4, 5). Increasing popu- and improve contingency plans for various (22). This is achieved through installa-
lation density near coasts, in floodplains, types of future disasters (16). Common pat- tion of an appropriate number of suitably
and in regions of high points to the prob- terns of morbidity and mortality after cer- located excreta disposal facilities such as
ability of future catastrophic natural disas- tain disasters can be identified (17) (Table toilets, latrines, or defecation fields; solid
ters with millions of casualties. 2). Effective emergency medical response waste pickup points; water distribution
Disasters affect a community in numer- depends on anticipating these different points; and availability of bathing and
ous ways. Roads, telephone lines, and other medical and health problems before they washing facilities and of soap together
transportation and communication links arise (18) and on delivering the appropriate with effective health education. The con-
are often destroyed (6). Public utilities and interventions (relief supplies, equipment, trol of disease vectors such as mosqui-
energy supplies may be disrupted (7). Sub- and personnel) at the precise times and toes, flies, rats, and fleas is an important
stantial numbers of victims may be ren- places where they are needed most (19). part of an environmental health approach
dered homeless (8). Portions of the com- to protecting community members from
munity’s industrial or economic base may
CRITICAL PUBLIC HEALTH disease (23).
be destroyed or damaged. Casualties may
INTERVENTIONS AFTER Water and Excreta Disposal. Adequate
require medical care, and damage to food
DISASTERS quantities of relatively clean water are
sources and utilities may create public
preferable to small amounts of high-
health threats (9, 10). The more remote the Critical public health interventions af- quality water. Each person must receive a
area, the longer it takes for external assis- ter disasters focus on the following areas. minimum of 15 to 20 L of clean water per
tance to arrive, and the more the commu-
day for their domestic needs (24). Unfor-
nity will have to rely on its own resources,
Environmental Health: Water, tunately, it is frequently difficult to pro-
at least for the first several hours, if not
Sanitation, Hygiene, and Vector vide even these minimum quantities of
water to disaster-affected populations
Management
(25). During this early acute phase, la-
From the Centers for Disease Control and Preven-
tion, Atlanta, GA. General Issues. Overcrowding and re- trine construction begins, but initial san-
Copyright © 2005 by the Society of Critical Care sulting poor water supplies and inade- itation measures may be nothing more
Medicine and Lippincott Williams & Wilkins quate hygiene and sanitation are well- than simply designating an area for def-
DOI: 10.1097/01.CCM.0000151064.98207.9C known factors that are known to increase ecation, hopefully segregated from the
Crit Care Med 2005 Vol. 33, No. 1 (Suppl.) S29

2. community’s source of potable water. friends; 5% to 10% were living in parks, damaged housing is to diminish as much
Construction of one latrine for every 20 city squares, and vacant lots; and the re- as possible the penetration of wind and
persons is recommended but is rarely mainder were living in schools and other rain into the structure. In these situa-
achieved in camp settings (24). public buildings (26). Regarding tempo- tions, plastic sheeting for roof and win-
Shelter. Surveys of settlements and rary living space allocations, 3.5 square dow repairs along with the required ma-
towns around Managua, Nicaragua, after meters is the absolute minimum floor terials for attaching them to the damaged
the December 1972 earthquake indicated space per person in emergency shelters structures are often provided by relief or-
that 80% to 90% of the 200,000 displaced (24). The first priority in areas where ganizations. Most people who lose their
persons were living with relatives and large numbers of people are living in homes will initially be able to take shelter
with friends and relatives (27). Only when
housing losses reach more than approxi-
Table 1. Selected natural disasters 1970 –2004 mately 25% will there be a need to find
other forms of shelter (26).
Approximate The decision to provide shelter at all
Year Event Location Death Toll can have significant long-term conse-
quences, especially in poor communities.
1970 Earthquake/landslide Peru 70,000
1970 Tropical cyclone Bangladesh 300,000
For example, simple shelters provided on
1971 Tropical cyclone India 25,000 an emergency basis may unintentionally
1972 Earthquake Nicaragua 6,000 evolve into permanent shantytowns or
1976 Earthquake China 250,000 squatter settlements and end up attract-
1976 Earthquake Guatemala 24,000 ing many more homeless people to the
1976 Earthquake Italy 900
1977 Tropical cyclone India 20,000 site.
1978 Earthquake Iran 25,000
1980 Earthquake Italy 1,300
1982 Volcanic eruption Mexico 1,700
COMMUNICABLE DISEASE
1985 Tropical cyclone Bangladesh 10,000 CONTROL AND EPIDEMIC
1985 Earthquake Mexico 10,000 MANAGEMENT
1985 Volcanic eruption Columbia 22,000
1988 Hurricane Gilbert Caribbean 343
1988 Earthquake Armenia SSR 25,000 Epidemics
1989 Hurricane Hugo Caribbean 56
1990 Earthquake Iran 40,000 Natural disasters are often followed by
1990 Earthquake Philippines 2,000 rampant rumors of epidemics (such as
1991 Tropical cyclone Bangladesh 140,000 typhoid or rabies) or unusual conditions
1991 Volcanic eruption Philippines 800
1991 Typhoon/Xood Philippines 6,000 such as increased snakebites and dog
1991 Flood China 1,500 bites. Such unsubstantiated reports gain
1992 Hurricane Andrew USA 52 great public credibility when printed as
1993 Earthquake India 10,000 facts in newspapers or reported on tele-
1995 Earthquake Japan 6,000
1998 Hurricane Mitch Central America 10,000
vision or radio (28). For example, after
1999 Earthquake Turkey 18,000 disasters in developing countries, any dis-
1999 Earthquake Taiwan 1,000 ruption of the water supply or sewage
2001 Earthquake India 20,000 treatment facilities has usually been ac-
2003 Earthquake Algeria 3,000 companied by rumors of outbreaks of
2004 Earthquake Iran 25,000
cholera or typhoid (29). Such rumors
Data from Office of U.S. Foreign Disaster Assistance: Disaster history: Significant data on major may well have reflected psychologic fears
disasters worldwide, 1900 –Present. Washington, DC, Agency for International Development, 2004; and and anxieties about a disastrous event
National Geographic Society: Nature on the rampage, our violent earth. Washington, DC, National rather than the true perception of an
Geographic Society, 1987. imminent problem. However, informa-
Table 2. Short-term effects of major natural disasters
High Winds
Effects Earthquakes (Without Flooding) Tsunamis Floods/Flash Floods
Deaths Many Few Many Few
Severe injuries requiring extensive care Overwhelming Moderate Few Few
Increased risk of communicable Potential (but small) risk following all major disasters (probability rises as overcrowding diseases
increases and sanitation deteriorates)
Food scarcity Rare Rare Common Common
(May occur because of factors other than food shortage)
Major population movements Rare Rare Common Common
(May occur in heavily damaged urban areas)
Modified from Office of Emergency Preparedness and Disaster Relief Coordination: Emergency Health Management After Natural Disaster. Washington,
DC, Pan American Health Organization, 2002.
S30 Crit Care Med 2005 Vol. 33, No. 1 (Suppl.)

3. tion on disease incidence in most devel- Unjustified worries about the infec- measles in refugee camp outbreaks and are
oping countries is poor, and some out- tiousness of bodies can lead to the rapid, at greater risk of dying as a result of im-
breaks may have been missed entirely by unplanned disposal of the dead, some- paired nutrition, it is recommended that
public health authorities. times before proper identification of the measles immunization programs along
Although natural disasters do not usu- victim has been made, as well as to taking with vitamin A supplements in emergency
ally result in outbreaks of infectious dis- needless “precautions” such as mass cre- settings target all children from the ages of
ease, under certain circumstances, disas- mation, burying the deceased in common 6 mos through 5 yrs (some would recom-
ters may increase disease transmission. graves, and adding chlorinated lime as a mend as old as 12–14). Ideally, one should
The risk of epidemic outbreaks of com- “disinfectant.” Despite the negligible strive for measles immunization coverage
municable diseases is proportional to health risk, dead bodies represent a deli- in refugee camp settings of better than 80%
population density and displacement. cate social problem. Disposal of bodies (24).
These conditions increase the pressure should respect local custom and practice
on water and food supplies and the risk of when possible. When there are large
Nutrition
contamination (like in refugee camps), numbers of victims, burial is likely to be
the disruption of preexisting sanitation the most appropriate method of disposal. Food shortages in the immediate after-
services such as piped water and sewage, There is little evidence that proper burial math of a disaster may arise in two ways.
and the failure to maintain or restore of bodies poses a threat to groundwater Food stock destruction within the disaster
normal public health programs in the that serves as a source of drinking water area may reduce the absolute amount of
immediate postdisaster period. The most (32). food available, or disruption of distribution
frequently observed increases in commu- systems may curtail access to food, even if
nicable disease are caused by fecal con- Immunization there is no absolute shortage. Generalized
tamination of water and by respiratory food shortages severe enough to cause nu-
spread (for example, flu in evacuation Mass immunization during situations
tritional problems usually do not occur af-
camps) (30). In the longer term, an in- of natural disasters is usually counterpro-
ter natural disasters. Flooding and sea
crease in vector-borne diseases occurs in ductive and diverts limited human re-
surges can damage household food stocks
some areas because of disruption of vec- sources and materials from other more
and crops, disrupt distribution, and cause
tor control efforts, particularly after effective and urgent measures. Immuni-
major local shortages. Food distribution, at
heavy rains and floods. Residual insecti- zation campaigns can give a false sense of
least in the short term, is often a major and
cides may be washed away from build- security, leading to the neglect of basic
urgent need, but large-scale importation/
measures of hygiene and sanitation,
ings, and the number of mosquito breed- donation of food is not usually necessary
which are more important during the
ing sites may increase. Moreover, (34). In extended droughts such as those
emergency. Mass vaccination would be
displacement of wild or domesticated an- occurring in Africa, or in complex disasters,
justified only when the recommended
imals near human settlements brings ad- the homeless and refugees may be com-
sanitary measures do not have an effect
ditional risk of zoonotic infection. pletely dependent on outside sources for
and if there is evidence of the progressive
food supplies for varying periods of time
increase in the number of cases with the
(35). Depending on the nutritional condi-
Disposition of Dead Bodies risk of an epidemic. A vaccine with the
tion of these populations, especially of
following characteristics could be consid-
more vulnerable groups such as pregnant
The public and government authori- ered useful in this situation:
or lactating women, children, and the el-
ties are usually greatly concerned about
● A vaccine of proven efficacy, high derly, it may be necessary to institute emer-
the danger of disease transmission from
safety, and low reactogenicity; gency feeding programs (36). The highest
decaying corpses. Responsible health au-
● A vaccine that is easy to apply (single- nutritional priority in the postdisaster set-
thorities should recognize, however, that
dose); ting is the timely and adequate provision of
health hazards such as epidemics associ-
● A vaccine that confers rapid and long- food rations containing at least 2,100 calo-
ated with unburied bodies are minimal,
lasting protection for people of all ages; ries and that includes sufficient protein, fat,
particularly if death resulted from
● Sufficient quantities of vaccine should and micronutrients (24).
trauma. It is far more likely that survi-
be available to guarantee the supply for
vors will be a source of disease outbreaks.
the entire population at risk; and
Although the risks for rescue workers MYTHS AND REALITIES OF
● Low-cost vaccines.
who handle dead bodies are higher than NATURAL DISASTERS
for the survivors of a disaster, those risks For example, immunization of children
can be limited through a set of simple against measles is one of the most impor- Many mistaken assumptions are asso-
measures. Appropriate precautions in- tant (and cost-effective) preventive mea- ciated with the impact of disasters on
clude training military personnel and sures in emergency-affected populations, public health. Disaster planners and
others who might have to provide assis- particularly those housed in camps. Immu- managers should be familiar with the fol-
tance after a disaster, vaccinating those nization of refugee children against mea- lowing myths and realities (37):
persons against hepatitis B and tubercu- sles in Thailand in 1979 clearly saved many
losis, using body bags and disposable lives. Although measles was an early prob- Myth: volunteers with any kind of med-
gloves, washing hands after handling ca- lem in Somalia, immunization of the refu- ical background are needed.
davers, and disinfecting stretchers and gee population was effective in preventing Reality: the local population almost al-
vehicles that have been used to transport outbreaks after 1981 (33). Because infants ways covers immediate lifesaving
bodies (31). as young as 6 mos of age may contract needs. Only medical personnel with
Crit Care Med 2005 Vol. 33, No. 1 (Suppl.) S31

4. skills that are not available in the af- ries and illnesses caused by disasters is 14. Liang NJ, Shih YT, Shih FY, et al: Disaster
fected community may be needed. clearly essential when determining what epidemiology and medical response in the
relief supplies, equipment, and personnel Chi-Chi earthquake in Taiwan. Ann Emerg
Myth: any kind of assistance is needed, Med 2001; 38:549 –555
and it is needed immediately! are needed to respond effectively in emer-
15. WADEM Task Force on Quality Control of
gency situations (42). The overall objec-
Reality: a hasty response that is not Disaster Management: Health disaster man-
tive of disaster management is to assess
based on an impartial evaluation only agement: Guidelines for evaluation and re-
the needs of disaster-affected popula- search in the Utstein Style, vol I. Conceptual
contributes to the chaos. It is better to
tions, to match resources to needs effi- framework of disasters. Prehospital Disaster
wait until genuine needs have been as-
ciently, to prevent further adverse health Med 2003; 17(Suppl 3):1–177
sessed. In fact, most needs are met by
effects, to evaluate relief program effec- 16. Noji EK: Progress in disaster management.
the victims themselves and their local
tiveness, and to plan for future disasters Lancet 1994; 343:1239 –1240
government and agencies, not by ex-
(43, 44). 17. Noji EK: The Public Health Consequences of
ternal relief agencies (38). Disasters. New York, Oxford University Press,
Myth: epidemics and plagues are inev- REFERENCES 1997
itable after every disaster. 18. Noji EK: Disaster epidemiology: Challenges
1. Office of US Foreign Disaster Assistance: A for public health action. An update. Ann Ig
Reality: epidemics do not spontane-
Disaster History: Significant Data on Major 2002; 14(Suppl 1):97–102
ously occur after a disaster, and dead Disasters Worldwide, 1900 –Present. Wash- 19. Noji EK, Toole MJ: Public health and disas-
bodies will not lead to catastrophic ington, DC, Agency for International Devel- ters: The historical development of public
outbreaks of exotic diseases. The key to opment, 2004 health responses to disasters. Disasters 1997;
preventing disease is to improve sani- 2. Schnitzer JJ, Briggs SM: Earthquake relief— 21:369 –379
tary conditions and educate the public The US medical response in Bam, Iran. 20. Lillibridge SR, Noji EK (Eds): Water, sanita-
(39). N Engl J Med 2004; 350:1174 –1176 tion and excreta. The Public Health Conse-
3. IDNDR Secretariat: The International De- quences of Disasters. New York, Oxford Uni-
Myth: disasters bring out the worst in
cade for Natural Disaster Reduction: Action versity Press, 1997
human behavior (e.g., looting, rioting). Plan for 1998 –1999. Geneva, UN Office for 21. Wisner B, Adams J (Eds): Environmental
Reality: although isolated cases of an- the Coordination of Humanitarian Assis- Health in Emergencies and Disasters. Ge-
tisocial behavior exist, most people re- tance, 1998, pp 1–2 neva, World Health Organization, 2003
spond spontaneously and generously 4. Greenough G: The potential impacts of cli- 22. Mong Y, Kaiser R, Ibrahim D, et al: Impact of
(40). mate variability and change on health im- the safe water system on water quality in
pacts on extreme weather events in the cyclone-affected communities in Madagas-
Myth: the affected population is too United States. Environ Health Perspect 2001; car. Am J Public Health 2001; 91:1577–1579
shocked and helpless to take responsi- 109(suppl 2):191–198 23. Nasci RS, Moore CG: Vector-borne disease
bility for their own survival. 5. Senior CA, Jones RG, Lowe JA, et al: Predic-
surveillance and natural disasters. Emerg In-
Reality: on the contrary, many find tions of extreme precipitation and sea-level
fect Dis 1998; 4:333–334
rise under climate change. Philos Transact
new strength during an emergency, as 24. Sphere Project: Humanitarian Charter and
Ser A Math Phys Eng Sci 2002; 360:
evidenced by the thousands of volun- Minimum Standards in Disaster Response.
1301–1311
teers who spontaneously united to sift 6. Carby BE, Ahmad R: Vulnerability of roads
London, Oxfam Publishing, 2004
through the rubble in search of victims 25. Levy BS, Sidel VW (Eds): War and Public
and water systems to hydro-geological haz-
after the 1985 Mexico City earthquake. Health. Washington, DC, APHA, 2000, pp
ards in Jamaica. Built Environment 2003;
1– 417
Myth: disasters are random killers. 145–153
26. University of Wisconsin Disaster Manage-
7. Kunii O, Akagi M, Kita E: Health conse-
Reality: disasters strike hardest at the quences and medical and public health re-
ment Center: First International Emergency
most vulnerable groups such as the sponse to the great HanshinAwaji earthquake
Settlement Conference: New Approaches to
poor, especially women, children, and in Japan: A case study in disaster planning. New Realities. April 15–19, 1996. Madison,
the elderly. Medicine and Global Survival 1995; 2:32– 45 WI, University of Wisconsin Disaster Man-
8. Najarian LM, Goenjian AK, Pelcovitz D, et al: agement Center, 1996
Myth: locating disaster victims in tem- 27. Landesman LY: Public Health Management
The effect of relocation after a natural disas-
porary settlements is the best alterna- of Disasters: The Practice Guide. Washington
ter. J Trauma Stress 2001; 14:511–526
tive. DC, APHA, 2001, pp 1–250
9. Natural Disasters—Protecting the Public’s
Reality: it should be the last alterna- Health. Washington, DC, Pan American 28. ReliefWeb: Flooding Disaster in Haiti and the
tive. Many agencies use funds normally Health Organization, 2000 Dominican Republic. New York, Office for
spent for tents to purchase building 10. Curry MD, Larsen PG, Mansfield CJ, et al: the Coordination of Humanitarian Assis-
Impacts of a flood disaster on an ambulatory tance, 2004
materials, tools, and other construc-
pediatric clinic population. Clin Pediatr 29. Sharma R: Pneumonia, cholera, and dysen-
tion-related support in the affected
(Phila) 2001; 40:571–574 tery feared after earthquake. BMJ 2001; 322:
community. 317
11. Alexander D: The study of natural disasters,
1977–1997: Some reflection on a changing 30. Vahaboglu H, Gundes S, Karadenizli A, et al:
SUMMARY field of knowledge. Disasters 1997; 21: Transient increase in diarrheal diseases after
284 –304 the devastating earthquake in Kocaeli, Tur-
This article discusses health effects of key: Results of an infectious disease surveil-
12. Noji EK: Field investigations of natural di-
disasters and outlines the requirements sasters. In: Field Epidemiology. Gregg MB lance study. Clin Infect Dis 2000; 31:
for effective emergency medical and pub- (Ed). New York, Oxford University Press, 1386 –1389
lic health response to these events (41). 2002, pp 365–383 31. Veenema TG: Disaster Nursing and Emer-
Sound epidemiologic knowledge of the 13. Rapid Health Assessment Protocols. Geneva, gency Preparedness for Chemical, Biological,
causes of death and of the types of inju- World Health Organization, 1999 Radiological Terrorism and Other Hazards.
S32 Crit Care Med 2005 Vol. 33, No. 1 (Suppl.)

5. New York, Springer Publishing, 2004, pp 36. Proceedings of the African Refugee Nutrition 40. McGlown KJ: Terrorism and Disaster Man-
1– 616 Conference, Machakos, Kenya, December agement: Preparing Healthcare Leaders for
32. Morgan O: Infectious disease risks from dead 1994. Geneva, UN Administrative Committee the New Reality. Chicago, ACHE, 2004, pp
bodies following natural disasters. Rev Pa- on Coordination, Sub-Committee on Nutri- 1–343
nam Salud Publica 2004; 15:307–312 tion, 1995 41. Keim M: Developing a public health emer-
33. Toole MJ, Steketee RW, Waldman RJ, et al: 37. de Ville de Goyet C: Stop propagating disas- gency operations plan: A primer. Pac Health
Measles prevention and control in emer- ter myths. Prehospital Disaster Med 1999; Dialog 2002; 9:124 –129
gency settings. Bull World Health Organ 14:213–214 42. Binder S, Sanderson LM: The role of the
38. Bradt DA, Drummond CM: Rapid epidemio- epidemiologist in natural disasters. Ann
1989; 67:381–388
logical assessment of health status in dis- Emerg Med 1987; 16:1081
34. Hogan DE, Burstein JL: Disaster Medicine.
placed populations—An evolution toward 43. Humanitarian Assistance in Disaster Situa-
Philadelphia, Lippincott Williams & Wilkins,
standardized minimum, essential data sets. tions. A Guide for Effective Aid. Washington,
2002, pp 1– 431
Prehospital Disaster Med 2003; 18:178 –185 DC, PAHO, 2000:1–24
35. Toole MJ, Nieburg P, Waldman RJ: Associa- 39. Keven K, Ates K, Sever MS, et al: Infectious 44. McCaughrin WC, Mattammal M: Perfect
tion between inadequate rations, undernutri- complications after mass disasters: The Mar- storm: Organizational management of pa-
tion prevalence and mortality in refugee mara earthquake experience. Scand J Infect tient care under natural disaster conditions.
camps. J Trop Paed 1990; 34:218 –224 Dis 2003; 35:110 –113 J Healthc Manag 2003; 48:295–308
Crit Care Med 2005 Vol. 33, No. 1 (Suppl.) S33