Surveillance for Injuries and Illnesses and Rapid Health-Needs Assessment Following Hurricanes Marilyn and Opal, September-October 1995

Hurricanes rated a category three or greater (on a scale of one to five) strike the United States or its territories approximately once every 1.5 years (1). In 1995, both a category two and category three hurricane struck the United States within 18 days, causing approximately 40 deaths (2). This report summarizes the surveillance for injuries and illnesses and a rapid health-needs assessment conducted after the storms.

MORBIDITY SURVEILLANCE

Hurricane Marilyn, September 1995

During September 15-16, Hurricane Marilyn struck the U.S. Virgin Islands (USVI), passing over St. Croix (1990 population: 50,139) on September 15, with sustained winds of 80 mph, and over St. Thomas (1990 population: 48,166) on September 15-16, with sustained winds of 100 mph and gusts of 125 mph. On St. Thomas, 92% of houses were damaged (habitable) or destroyed (uninhabitable); on St. Croix and St. John (1990 population: 3504), 71% and 76%, respectively, of housing units were affected.

On September 16, the USVI Department of Social and Health Services, in collaboration with CDC and the Preventive Medicine Task Force of the Public Health Service National Disaster Medical System, inititated public health surveillance to 1) maintain daily contact with primary health-care facilities, including deployed Disaster Medical Assistance Teams (DMATs); 2) characterize adverse health events during the early post-hurricane phase; 3) coordinate disease outbreak investigations; 4) provide reliable information to health planners for determining priorities; and 5) recommend public health interventions.

Because of the disruption of health-care systems, active posthurricane surveillance was initiated on St. Thomas. Independent surveillance systems were established on each of the three islands. Daily patient summaries were obtained from the Governor Juan F. Luis Hospital and Medical Center, three outpatient treatment clinics, two smaller clinic sites that provided summary information only, and DMATs deployed to provide supplemental health care. Patient logs were abstracted into 20 diagnostic surveillance categories.

During September 16-30, a total of 3265 patient visits were recorded at the four primary medical treatment sites (i.e., the hospital and three DMAT sites). Of the 3265 visits, 1084 (33%) were storm-associated injuries involving minor wounds (i.e., abrasions, lacerations, punctures, and foreign-body removal) or trauma to the musculoskeletal system (i.e., fractures, sprains, strains, and dislocations). In addition, eight persons sustained burns while operating or refueling portable power generators. Other problems reported included upper and lower respiratory tract illnesses (383 {12%}) (e.g., sore throat, cough, pneumonia, and asthma) and dermatologic disorders (199 {6%}) (e.g., rashes, sores, and infections). Of the 167 visits for gastrointestinal disorders, 77 were for diarrheal illness (2.4% of total patient visits). The second largest category of visits (23.5%) was grouped as miscellaneous and was for problems unrelated to the storm (e.g., blood pressure and blood glucose screening, prescription refills, vaccinations, and other health-care services).

Hurricane Opal, October 1995

On October 4, Hurricane Opal made landfall at Navarre, Florida, approximately 20 miles east of Pensacola, with sustained winds of 115 mph. The storm caused extensive damage along the 100 miles of coastline from Navarre east to Mexico Beach. Efforts to evaluate the impact of the hurricane on the health of residents in the affected area included review of records of emergency department (ED) visits to the two hospitals serving one of the most severely affected counties. The frequencies of 20 conditions were determined for the 6 days after the hurricane (i.e., posthurricane) (October 4-9) and were compared with those observed for the 6 days before the storm (i.e., prehurricane) (September 27-October 3) (Table_1).

EDs treated 996 patients during the prehurricane period and 1135 during the post-hurricane period. For both periods, the proportion of ED visits were similar for lacerations, puncture wounds, musculoskeletal injuries, rashes, and gastrointestinal or respiratory illnesses. During the posthurricane period, the proportion of visits for insect bites increased from 0.2% to 1.7% (p less than 0.05). These findings were shared with local health officials and emergency management officials coordinating disaster relief.

HEALTH NEEDS ASSESSMENT

Population-based surveys were conducted on St. Thomas on September 23, 1 week after Hurricane Marilyn. Based on maps and population data, the island was divided into four population zones, which then were subdivided into clusters. In each of the 30 clusters, a survey team interviewed an adult member of selected households. Respondents were asked about the number and age of residents, number of sick and injured persons, supply of food and water, water purification and access to sanitary toilets, extent of damage to housing, access to telephone and electricity, availability of transportation, and monitoring of local radio broadcasts. One week after the initial survey, the process was repeated. A similar clustering technique was used on St. Croix and St. John and on the Florida panhandle following Hurricane Opal.

For Hurricane Marilyn, most (93%-99%) respondents reported having drinking water that had been purified, access to a motor vehicle (77%-89%), and having listened to a local radio station (79%-99%) (Table_2). For Hurricane Opal, most persons reported having access to electricity (89%), running water (96%), medical care (91%), and transportation (99%).

Reported by: N George-McDowell, MD, AB Hendry, LB SewerBridges-Williams, MSW, K Nickel, St. Thomas; J Heyliger, N Michael, PhD, St. Croix; A Wade, St. John, US Virgin Islands. J Stringer, C Reedy, Winston-Salem, North Carolina; L McDaniel, Pensacola, Florida; C Budd, Toledo, Ohio; A Wallace, MD, T Walton, Tulsa, Oklahoma; D McClure, C Perry, Ft. Thomas, Kentucky; L Patton, Fort Wayne, Indiana; S Briggs, MD, Boston, Massachusetts; K Yeskey, MD, Rockville/Bethesda, Maryland; L Stringer, MD, Disaster Medical Assistance Teams, Emergency Support Function No. 8. M Moore, Bay Medical Center, D Abbot, HCA Gulf Coast Medical Center, M Pettis, District 2, P Sylvester, MD, Bay County Health Dept, Panama City, Florida; G Hlady, MD, R Hopkins, MD, State Epidemiologist, Florida Dept of Health and Rehabilitative Svcs. S Bright, K Lawton, Office of Disaster Medical Svc, Dept of Veterans Affairs. F Young, MD, National Disaster Medical System, Office of Emergency Preparedness, Public Health Svc. Special Pathogens Br, Div of Viral and Rickettsial Diseases, National Center for Infectious Diseases; Program Operations Br, National Immunization Program; Div of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion; Div of Birth Defects and Developmental Disabilities, and Emergency Response Coordination Group, Disaster Assessment and Epidemiology Section, Health Studies Br, Div of Environmental Hazards and Health Effects, National Center for Environmental Health; Div of Field Epidemiology, Epidemiology Program Office, CDC.

Editorial Note

Editorial Note: Rapid assessment of health needs in populations affected by disasters is an important first step in guiding relief efforts (3). The cluster sampling survey method used for hurricanes Marilyn and Opal were based on methods used after Hurricane Andrew in 1992 (4) and provided some of the earliest objective data describing the status of affected populations after the storm. Similarly, after hurricanes Marilyn and Opal, the rapid collection of morbidity data from permanent and temporary facilities provided timely and reliable data for assessing the health impact of the disasters.

Increased frequencies of injuries such as those observed after Hurricane Marilyn and illnesses such as skin rashes and heat stress have been documented after recent storms (5-7). Most of the injuries reported after Hurricane Marilyn were associated with clean-up and restoration activities, including several burns associated with the use of portable gasoline generators. These findings underscore the need for public awareness campaigns that address the risks related to specific activities, including the use and maintenance of emergency power sources and general safety precautions in the immediate recovery phase.

The objective estimates from the surveys of health needs and from morbidity surveillance enabled conservation of medical and monetary resources. For example, based on survey findings, officials in the USVI decided not to provide door-to-door community outreach health care because a high proportion of the affected population had access to relief information through radio reports and transportation to a central relief location. In addition, following both storms, expensive interventions (e.g., mass aerial spraying for disease vectors and nuisance insects) were determined to be unnecessary.

Scientifically valid information is critical to enable decision making and resource prioritization by health-care providers and emergency management officials during the immediate response phase following disasters. To enhance surveillance in disaster settings, relief officials should 1) refine the statistical methods for estimating the size of affected populations; 2) ensure the availability of trained surveillance workers; 3) establish standardized assessment instruments -- including computerized interviewing instruments -- and use wireless communications technologies; and 4) modify surveillance data collection to indicate whether an illness or injury was "disaster related."

References

1. Herbert P, Taylor G, Case R. Hurricane experience levels of coastal county population -- Texas to Maine. Miami: US Department of Commerce, National Oceanographic and Atmospheric Administration, 1984. (Technical memorandum no. NWS NHC 25).

2. CDC. Deaths associated with hurricanes Marilyn and Opal -- United States, September-October 1995. MMWR 1996;45:32-8.

3. Lillibridge S, Noji E, Burkle F. Disaster assessment: the emergency health evaluation of a population affected by a disaster. Ann Emerg Med 1993;22:1715-20.

4. CDC. Rapid health needs assessment following Hurricane Andrew -- Florida and Louisiana, 1992. MMWR 1992;41:685-8.

5. CDC. Injuries and illnesses related to Hurricane Andrew -- Louisiana, 1992. MMWR 1993;42:242-3,249-51.

6. CDC. Work-related electrocutions associated with Hurricane Hugo -- Puerto Rico. MMWR 1989;38:718-25.

7. Longmire AW, Ten Eyck RP. Morbidity of Hurricane Frederic. Ann Emerg Med 1984;13:334-8.

TABLE 1. Number and percentage of persons reporting injuries or illnesses
before and after Hurricane Opal, by condition and phase of hurricane -- Bay
County, Florida, October 1995
==============================================================================
                                  Prehurricane *       Posthurricane +
                                      (n=996)            (n=1135)
                                  --------------       ---------------
Condition                            No.   (%)           No.   (%)
------------------------------------------------------------------------------
Injury
 Laceration/wound                    80   (8.0)          70   (6.2)
 Sprain/strain/fracture              79   (7.9)          77   (6.8)
 Motor-vehicle--related injury       37   (3.7)          18   (1.6)
 Insect bite                          2   (0.2)          19   (1.7)
 Other                               38   (3.8)          23   (2.0)

Illness
 Gastrointestinal                    44   (4.4)          45   (4.0)
 Respiratory                          3   (0.3)          11   (1.0)
 Skin rash                           19   (1.9)          14   (1.2)
 Psychiatric symptoms                18   (1.8)           5   (0.4)
------------------------------------------------------------------------------
* During the 6 days before the hurricane struck land.
+ During the 6 days after the hurricane struck land.
==============================================================================

Table 2. Percentage of persons reporting selected conditions following Hurricane
Marilyn, by condition and island * --  U.S. Virgin Islands, September 1995 +
=====================================================================================
                                    St. Thomas   St. Thomas
Condition                           (Sept. 23)   (Sept. 30   St. Croix   St. John
-------------------------------------------------------------------------------------
Housing unit completely destroyed        11%         14%         2%        11%
Housing unit damaged but inhabitable     67%         78%        69%        65%
Ill person in household                   5%         10%        14%        19%
Injured person in household               2%          4%         3%         9%
Person lacking prescription drugs
 in household                             3%          6%         3%        27%
Purifying drinking water                 99%         99%        99%        93%
Symptoms of psychological stress         12%         60%        25%        42%
Access to a flushing toilet              99%         99%        98%        99%
Listening to a local radio station       98%         99%        79%        79%
Working telephone (including cellular)   12%          9%        54%        24%
Access to electrical power               52%         65%        NA &       45%
Working motor vehicle                    86%         89%        77%        79%
-------------------------------------------------------------------------------------
* Surveys were conducted on St. Thomas on September 23 and 30, on St. Croix on
  September 28, and on St. John during September 26-28.
+ Because of the hurricane, modification of the sampling frame precluded usual
  variance estimates.
& Not available.
=====================================================================================

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