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Good basic personal hygiene and handwashing are critical to help prevent the spread of illness
and disease. Clean, safe running water is essential for proper hygiene and handwashing.
Hygiene is especially important in an emergency such as a flood, hurricane, or earthquake, but
finding clean, safe running water can sometimes be difficult. The following information will help to
ensure good hygiene and handwashing in the event of an emergency.

Disaster Supplies Kit (Hygiene Supplies)

Before an emergency, make sure you have created a Disaster Supplies Kit.

Handwashing
Keeping hands clean during an emergency helps prevent the spread of germs. If your tap water
is not safe to use, wash your hands with soap and water that has been boiled or disinfected.
Follow these steps to make sure you wash your hands properly:

Wet your hands with clean, running water (warm or cold) and apply soap.

Rub your hands together to make a lather and scrub them well; be sure to scrub the backs
of your hands, between your fingers, and under your nails.

Continue rubbing your hands for at least 20 seconds. Need a timer? Hum the "Happy
Birthday" song from beginning to end twice.

Rinse your hands well under running water.

Dry your hands using a clean towel or air dry them.

A temporary hand washing station can be created by using a large water jug that contains clean
water (for example, boiled or disinfected).
Washing hands with soap and water is the best way to reduce the number of germs on them. If
soap and water are not available, use an alcohol-based hand sanitizer that contains at least 60%
alcohol. Alcohol-based hand sanitizers can quickly reduce the number of germs on hands in
some situations, but sanitizers do not eliminate all types of germs.
Hand sanitizers are not effective when hands are visibly dirty.
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When to Wash Hands

Wash hands with soap and clean, running water (if available):

Before, during, and after preparing food

Before eating food

After using the toilet

After changing diapers or cleaning up a child who has used the toilet

Before and after caring for someone who is sick

After blowing your nose, coughing, or sneezing

After touching an animal or animal waste

After touching garbage

Before and after treating a cut or wound

Other Hand Hygiene Resources

Food and Water Safety and Hand Hygiene Resources

Handwashing: Clean Hands Save Lives

Do not use contaminated water to wash dishes, brush your teeth, wash and prepare food,
or make ice.
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Bathing
Bathing after a water-related emergency should only be done with clean, safe water. Listen to
local authorities for further instructions. Sometimes water that is not safe to drink can be used for
bathing.

Dental Hygiene

Brushing your teeth after a water-related emergency should only be done with clean, safe
water. Listen to local authorities to find out if tap water is safe to use.

Visit the Safe Drinking Water for Personal Use page for more information about making
your water safe for brushing your teeth.

You may visit CDC's Oral Health Web site for complete dental hygiene information.

Wound Care
Keeping wounds clean and covered is crucial during an emergency. If you have open cuts or
sores, keep them as clean as possible by washing well with soap and clean, safe water to control
infection. If a wound develops redness, swelling, or drainage, seek immediate medical attention.
When providing first aid for a wound, clean hands can help prevent infection (see Handwashing
on this page). Visit Emergency Wound Care After a Natural Disaster to find complete information
on caring for wounds.
Healthcare professionals should visit Emergency Wound Management for Healthcare
Professionals and Management of Vibrio vulnificus Wound Infections After a Disaster.
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Additional Hygiene Information

Cleaning and Sanitizing With Bleach after an Emergency

Flood Water After a Disaster or Emergency

Guidelines for the Management of Acute Diarrhea After a Disaster

Water-Related Emergencies & Outbreaks

Guidance on Microbial Contamination in Previously Flooded Outdoor Areas

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Emergency Disinfection of Bored or Dug Wells

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EPA: Private Drinking Water Wells: What to Do After the Flood

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Emergency Disinfection of Cisterns and other Rain-Catchment Systems

WHO: Cleaning and Disinfecting Water Storage Tanks and Tankers

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Personal Hygiene and Handwashing After a Disaster or Emergency

HomePublicationsArticle

Preventing and controlling infectious diseases

after natural disasters
Health, Risk & Vulnerabilities, Water

ARTICLE
RELATED FILES

20120313

Kouadio Koffi Isidore, Syed Aljunid, Taro Kamigaki, Karen Hammad and Hitoshi
Oshitani

Flooding in Nowshera, Pakistan. Photo: UN Photo/WFP/Amjad Jamal

Beyond damaging and destroying physical infrastructure, natural disasters can lead to outbreaks of
infectious disease. In this article, two UNU-IIGH researchers and colleagues review risk factors and
potential infectious diseases resulting from the secondary effects of major natural disasters that occurred
from 2000 to 2011, classify possible diseases, and give recommendations on prevention, control measures
and primary healthcare delivery improvements.

Over the past few decades, the incidence and magnitude of natural disasters has grown, resulting in
substantial economic damages and affecting or killing millions of people. Recent disasters have shown that
even the most developed countries are vulnerable to natural disasters, such as Hurricane Katrina in the
United States in 2005 and the Great Eastern Japan Earthquake and tsunami in 2011. Global population
growth, poverty, land shortages and urbanization in many countries have increased the number of people
living in areas prone to natural disasters and multiplied the public health impacts.
Natural disasters can be split in three categories: hydro-meteorological disasters, geophysical disasters and
geomorphologic disasters.
Hydro-meteorological disasters, like floods, are the most common (40 percent) natural disasters worldwide
and are widely documented. The public health consequences of flooding are disease outbreaks mostly
resulting from the displacement of people into overcrowded camps and cross-contamination of water
sources with faecal material and toxic chemicals. Flooding also is usually followed by the proliferation of
mosquitoes, resulting in an upsurgence of mosquito-borne diseases such as malaria. Documentation of
disease outbreaks and the public health after-effects of tropical cyclones (hurricanes and typhoons) and
tornadoes, however, is lacking.
Geophysical disasters are the second-most reported type of natural disaster, and earthquakes are the
majority of disasters in this category. Outbreaks of infectious diseases may be reported when earthquake
disasters result in substantial population displacement into unplanned and overcrowded shelters, with

limited access to food and safe water. Disease outbreaks may also result from the destruction of
water/sanitation systems and the degradation of sanitary conditions directly caused by the earthquake.
Tsunamis are commonly associated with earthquakes, but can also be caused by powerful volcanic
eruptions or underwater landslides. Although classified as geophysical disasters, they have a similar
clinical and threat profile (water-related consequences) to that of tropical cyclones (e.g., typhoon or
hurricane).
Geomorphologic disasters, such as avalanches and landslides, also are associated with infectious disease
transmissions and outbreaks, but documentation is generally lacking.

After a natural disaster

The overwhelming majority of deaths immediately after a natural disaster are directly associated with
blunt trauma, crush-related injuries and burn injuries. The risk of infectious disease outbreaks in the
aftermath of natural disasters has usually been overemphasized by health officials and the media, leading
to panic, confusion and sometimes to unnecessary public health activities.
The prolonged health impact of natural disasters on a community may be the consequence of the collapse
of health facilities and healthcare systems, the disruption of surveillance and health programmes
(immunization and vector control programmes), the limitation or destruction of farming activities (scarcity
of food/food insecurity), or the interruption of ongoing treatments and use of unprescribed medications.
The risk factors for increased infectious diseases transmission and outbreaks are mainly associated with
the after-effects of the disasters rather than to the primary disaster itself or to the corpses of those killed.
These after-effects include displacement of populations (internally displaced persons and refugees),
environmental changes and increased vector breeding sites. Unplanned and overcrowded shelters, poor
water and sanitation conditions, poor nutritional status or insufficient personal hygiene are often the case.
Consequently, there are low levels of immunity to vaccine-preventable diseases, or insufficient vaccination
coverage and limited access to health care services.

Phases of outbreak and classification of infectious disease

Infectious disease transmission or outbreaks may be seen days, weeks or even months after the onset of the
disaster. Three clinical phases of natural disasters summarize the chronological public health effects on
injured people and survivors:

Phase (1), the impact phase (lasting up to to 4 days), is usually the period when victims are
extricated and initial treatment of disaster-related injuries is provided.

Phase (2), the post-impact phase (4 days to 4 weeks), is the period when the first waves of
infectious diseases (air-borne, food-borne, and/or water-borne infections) might emerge.

Phase (3), the recovery phase (after 4 weeks), is the period when symptoms of victims who have
contracted infections with long incubation periods or those with latent-type infections may become
clinically apparent. During this period, infectious diseases that are already endemic in the area, as
well as newly imported ones among the affected community, may grow into an epidemic.

It is common to see the international community, NGOs, volunteers, experts and the media leaving a
disaster-affected zone usually within three months, when in reality basic sanitation facilities and access to
basic hygiene may still be unavailable or worsen due to the economic burden of the disasters.
Although it is not possible to predict with accuracy which diseases will occur following certain types of
disasters, diseases can be distinguished as either water-borne, air-borne/droplet or vector-borne diseases,
and contamination from wounded injuries.

Diarrhoeal diseases
The most documented and commonly occurring diseases are water-borne diseases (diarrhoeal diseases and
Leptospirosis). Diarrhoeal diseases cause over 40 percent of the deaths in disaster and refugee camp
settings. Epidemics among victims are commonly related to polluted water sources (faecal contamination),
or contamination of water during transportation and storage. Outbreaks have also been related to shared
water containers and cooking pots, scarcity of soap and contaminated food, as well as pre-existing poor
sanitary infrastructures, water supply and sewerage systems.
Diarrhoeal epidemics are frequently reported following natural disasters in developing countries. Floods
are recurrent in many African countries, such as Mozambique, and usually lead to a significant increase in
diarrhoeal disease incidences.
Following the 2005 earthquake in Pakistan, an estimated 42 percent increase in diarrhoeal infections was
reported. In Iran, 1.6 percent of the 75,586 persons displaced by the Bam earthquake in 2003 were infected
with diarrhoeal diseases. A rapid assessment conducted in Indonesia after the 2004 tsunami showed that 85
percent of the survivors in the town of Calang experienced diarrhoeal illness after drinking from
contaminated wells. In Thailand, the 2004 Indian tsunami also contributed to a significant increase in
diarrhoeal disease incidences.
An investigation conducted in 100 households after the 2001 earthquake in El Salvador showed that 137
persons out of 594 (22 percent) experienced diarrhoeal infections. An evolving cholera epidemic was
reported 9 months after the earthquake in Haiti, with a high fatality rate of 6.4 percent among the victims
(of the 4,722 documented affected, 303 died).
Only a small cluster of Norovirus cases was reported in evacuation centres some weeks after the Great
Eastern Japanese Earthquake and tsunami, while various pathogens were confirmed among the populations
displaced by Hurricanes Allison (2001) and Katrina in the US.
Leptospirosis, the other frequently occurring water-borne disease, can be transmitted through contact with
contaminated water or food, or with soil containing contaminated urine (Leptospires) from infected
animals (e.g., rodents). Floods facilitate the proliferation of rodents and the spread of Leptospires in a
human community. Investigations conducted in populations affected by flood disasters in 2000 in India
and Thailand reported Leptospirosis epidemics. Increased risk factors and outbreaks were also reported
after Typhoon Nali in China and Taiwan in 2001.

The following table shows a breakdown of the occurrence of communicable diseases. (This is described in
detail in the original paper, which is available for downloading in the the right sidebar.)

On the topic of outbreak and classification, one final note regarding the myth of infectious disease
transmission from dead bodies: Still controversial and frequently overstated is the assumption that dead
bodies pose a significant risk for the transmission of infectious diseases after a natural disaster. Despite the
vast number of deaths resulting from major disasters, no outbreaks resulting from corpses have been

documented. The environment in which pathogens live in a dead body can no longer sustain them, since
the microorganisms involved in putrefaction (decay processes) are not disease causing. There are a few
situations, such as deaths from cholera or hemorrhagic fever epidemics, that require specific precautions,
but families should not be deprived of appropriate identification and burial ceremonies for their dead
relatives from disasters. Survivors of disaster present a much more substantial reservoir for potential
infectious diseases.

Prevention and control measures

We recommend re-establishing and improving the delivery of primary health care. Medical supply should
be provided, and training of healthcare workers and medical personnel on appropriate case management
should be conducted. Public health responders should set up a rapid disease risk assessment within the first
week of the disaster in order to identify disaster impacts and health needs. Practically, prompt and
adequate prevention and control measures, and appropriate case management and surveillance systems are
essential for minimizing infectious disease burdens. The prevention and control checklist provided in our
paper shows the measures to be undertaken in order to avoid infectious diseases following natural
disasters.
Natural disasters and infectious disease outbreaks represent global challenges towards the achievement of
the Millennium Development Goals. It is important for the public, policymakers and health officials to
understand the concept that disaster does not transmit infectious diseases; that the primary cause of death
in the aftermath of a disaster is non-infectious; that dead bodies (from disasters) are not a source of
epidemic; and that infectious disease outbreaks result secondarily from exacerbation of disease risk
factors.
National surveillance systems and the establishment of continual practices of protocol for health
information management have to be strengthened. In disasters, education on hygiene and hand washing,
and provision of an adequate quantity of safe water, sanitation facilities and appropriate shelter are very
important for prevention of infectious diseases. The assessment and response activities described above
should be properly coordinated.

Personal Hygiene After a Flood or Storm

Natural Disasters and Severe Weather Currently selected

Maintaining Health During Bushfires
Maintaining Health During and After Floods and Storms
Water Quality
Treat all floodwater as potentially contaminated with sewage
Keep children away from flood-affected areas and avoid unnecessary contact with mud and floodwaters. Ensure feet are
covered if they are likely to come into contact with mud and always wear gloves when handling flood-affected items or
mud.
Always wash your hands thoroughly with soap and clean water or with an alcohol-based hand cleanser:

after handling flood-affected items;

when participating in flood clean-up activities;
immediately after going to the toilet; and
before handling or eating food.

Only use clean eating utensils, toothbrushes, towels or handkerchiefs.

All cuts and abrasions should be cleaned, treated with antiseptic and covered
immediately. Seek immediate medical attention if you have deep or puncture wounds, or if
any wounds develop redness or swelling. Check whether you are up-to-date with your
tetanus vaccinations.

To avoid being bitten by mosquitoes, use an insect repellent on exposed skin areas
and reapply every two hours. Cover up as much as possible with light-coloured loose-fitting
clothing.

Epidemics after Natural Disasters

John T. Watson,

Michelle Gayer,* and Maire A. Connolly*

Author information Copyright and License information

This article has been cited by other articles in PMC.

Abstract
Natural disasters are catastrophic events with atmospheric, geologic, and hydrologic origins.
Disasters include earthquakes, volcanic eruptions, landslides, tsunamis, floods, and drought.
Natural disasters can have rapid or slow onset, with serious health, social, and economic
consequences. During the past 2 decades, natural disasters have killed millions of people,
adversely affected the lives of at least 1 billion more people, and resulted in substantial
economic damages (1). Developing countries are disproportionately affected because they
lack resources, infrastructure, and disaster-preparedness systems.
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.
Go to:

Dead Bodies and Disease

The sudden presence of large numbers of dead bodies in the disaster-affected area may
heighten concerns of disease outbreaks (2), despite the absence of evidence that dead bodies
pose a risk for epidemics after natural disasters (3). When death is directly due to the natural

disaster, human remains do not pose a risk for outbreaks (4). Dead bodies only pose health
risks in a few situations that require specific precautions, such as deaths from cholera (5) or
hemorrhagic fevers (6). Recommendations for management of dead bodies are summarized in
the Table.

Table
Principles for management of dead bodies*

Despite these facts, the risk for outbreaks after disasters is frequently exaggerated by both
health officials and the media. Imminent threats of epidemics remain a recurring theme of
media reports from areas recently affected by disasters, regardless of attempts to dispel these
myths (2,3,7).
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Displacement: Primary Concern

The risk for communicable disease transmission after disasters is associated primarily with
the size and characteristics of the population displaced, specifically the proximity of safe
water and functioning latrines, the nutritional status of the displaced population, the level of
immunity to vaccine-preventable diseases such as measles, and the access to healthcare
services (8). Outbreaks are less frequently reported in disaster-affected populations than in
conflict-affected populations, where two thirds of deaths may be from communicable
diseases (9). Malnutrition increases the risk for death from communicable diseases and is
more common in conflict-affected populations, particularly if their displacement is related to
long-term conflict (10).
Although outbreaks after flooding (11) have been better documented than those after
earthquakes, volcanic eruptions, or tsunamis (12), natural disasters (regardless of type) that
do not result in population displacement are rarely associated with outbreaks (8). Historically,
the large-scale displacement of populations as a result of natural disasters is not common (8),
which likely contributes to the low risk for outbreaks overall and to the variability in risk
among disasters of different types.
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Risk Factors for Communicable Disease Transmission

Responding effectively to the needs of the disaster-affected population requires an accurate
communicable disease risk assessment. The efficient use of humanitarian funds depends on
implementing priority interventions on the basis of this risk assessment.
A systematic and comprehensive evaluation should identify 1) endemic and epidemic
diseases that are common in the affected area; 2) living conditions of the affected population,
including number, size, location, and density of settlements; 3) availability of safe water and
adequate sanitation facilities; 4) underlying nutritional status and immunization coverage
among the population; and 5) degree of access to healthcare and to effective case
management.
Go to:

Communicable Diseases Associated with Natural Disasters

The following types of communicable diseases have been associated with populations
displaced by natural disasters. These diseases should be considered when postdisaster risk
assessments are performed.
Water-related Communicable Diseases

Access to safe water can be jeopardized by a natural disaster. Diarrheal disease outbreaks can
occur after drinking water has been contaminated and have been reported after flooding and
related displacement. An outbreak of diarrheal disease after flooding in Bangladesh in 2004
involved >17,000 cases; Vibrio cholerae(O1 Ogawa and O1 Inaba) and
enterotoxigenic Escherichia coli were isolated (13). A large (>16,000 cases) cholera
epidemic (O1 Ogawa) in West Bengal in 1998 was attributed to preceding floods (14), and
floods in Mozambique in JanuaryMarch 2000 led to an increase in the incidence of diarrhea
(15).
In a large study undertaken in Indonesia in 19921993, flooding was identified as a
significant risk factor for diarrheal illnesses caused by Salmonella enterica serotype
Paratyphi A (paratyphoid fever) (16). In a separate evaluation of risk factors for infection
with Cryptosporidium parvum in Indonesia in 20012003, case-patients were >4 more
likely than controls to have been exposed to flooding (17).
The risk for diarrheal disease outbreaks following natural disasters is higher in developing
countries than in industrialized countries (8,11). In Aceh Province, Indonesia, a rapid health
assessment in the town of Calang 2 weeks after the December 2004 tsunami found that 100%
of the survivors drank from unprotected wells and that 85% of residents reported diarrhea in
the previous 2 weeks (18). In Muzaffarabad, Pakistan, an outbreak of acute watery diarrhea
occurred in an unplanned, poorly equipped camp of 1,800 persons after the 2005 earthquake.
The outbreak involved >750 cases, mostly in adults, and was controlled after adequate water
and sanitation facilities were provided (19). In the United States, diarrheal illness was noted

after Hurricanes Allison (20) and Katrina (2123), and norovirus, Salmonella, and toxigenic
and nontoxigenic V. cholerae were confirmed among Katrina evacuees.
Hepatitis A and E are also transmitted by the fecal-oral route, in association with lack of
access to safe water and sanitation. Hepatitis A is endemic in most developing countries, and
most children are exposed and develop immunity at an early age. As a result, the risk for
large outbreaks is usually low in these settings. In hepatitis Eendemic areas, outbreaks
frequently follow heavy rains and floods; the illness is generally mild and self-limited, but in
pregnant women case-fatality rates can reach 25% (24). After the 2005 earthquake in
Pakistan, sporadic hepatitis E cases and clusters were common in areas with poor access to
safe water. Over 1,200 cases of acute jaundice, many confirmed as hepatitis E, occurred
among the displaced (25). Clusters of both hepatitis A and hepatitis E were noted in Aceh
after the December 2004 tsunami (26).
Leptospirosis is an epidemic-prone zoonotic bacterial disease that can be transmitted by
direct contact with contaminated water. Rodents shed large amounts of leptospires in their
urine, and transmission occurs through contact of the skin and mucous membranes with
water, damp soil or vegetation (such as sugar cane), or mud contaminated with rodent urine.
Flooding facilitates spread of the organism because of the proliferation of rodents and the
proximity of rodents to humans on shared high ground. Outbreaks of leptospirosis occurred in
Taiwan, Republic of China, associated with Typhoon Nali in 2001 (27); in Mumbai, India,
after flooding in 2000 (28); in Argentina after flooding in 1998 (29); and in the Krasnodar
region of the Russian Federation in 1997 (30). After a flooding-related outbreak of
leptospirosis in Brazil in 1996, spatial analysis indicated that incidence rates of leptospirosis
doubled inside the flood-prone areas of Rio de Janeiro (31).
Diseases Associated with Crowding

Crowding is common in populations displaced by natural disasters and can facilitate the
transmission of communicable diseases. Measles and the risk for transmission after a natural
disaster are dependent on baseline immunization coverage among the affected population,
and in particular among children <15 years of age. Crowded living conditions facilitate
measles transmission and necessitate even higher immunization coverage levels to prevent
outbreaks (32). A measles outbreak in the Philippines in 1991 among persons displaced by
the eruption of Mt. Pinatubo involved >18,000 cases (33). After the tsunami in Aceh, a
cluster of measles involving 35 cases occurred in Aceh Utara district, and continuing sporadic
cases and clusters were common despite mass vaccination campaigns (26). In Pakistan, after
the 2005 South Asia earthquake, sporadic cases and clusters of measles (>400 clinical cases
in the 6 months after the earthquake) also occurred (25).
Neisseria meningitidis meningitis is transmitted from person to person, particularly in
situations of crowding. Cases and deaths from meningitis among those displaced in Aceh and
Pakistan have been documented (25,26). Prompt response with antimicrobial prophylaxis, as
occurred in Aceh and Pakistan, can interrupt transmission. Large outbreaks have not been

recently reported in disaster-affected populations but are well-documented in populations

displaced by conflict (34).
Acute respiratory infections (ARI) are a major cause of illness and death among displaced
populations, particularly in children <5 years of age. Lack of access to health services and to
antimicrobial agents for treatment further increases the risk for death from ARI. Risk factors
among displaced persons include crowding, exposure to indoor cooking using open flame,
and poor nutrition. The reported incidence of ARI increased 4-fold in Nicaragua in the 30
days after Hurricane Mitch in 1998 (35), and ARI accounted for the highest number of cases
and deaths among those displaced by the tsunami in Aceh in 2004 (26) and by the 2005
earthquake in Pakistan (25).
Vectorborne Diseases

Natural disasters, particularly meteorologic events such as cyclones, hurricanes, and flooding,
can affect vector-breeding sites and vectorborne disease transmission. While initial flooding
may wash away existing mosquito-breeding sites, standing water caused by heavy rainfall or
overflow of rivers can create new breeding sites. This situation can result (with typically
some weeks delay) in an increase of the vector population and potential for disease
transmission, depending on the local mosquito vector species and its preferred habitat. The
crowding of infected and susceptible hosts, a weakened public health infrastructure, and
interruptions of ongoing control programs are all risk factors for vectorborne disease
transmission (36).
Malaria outbreaks in the wake of flooding are a well-known phenomenon. An earthquake in
Costa Ricas Atlantic Region in 1991 was associated with changes in habitat that were
beneficial for breeding and preceded an extreme rise in malaria cases (37). Additionally,
periodic flooding linked to El NioSouthern Oscillation has been associated with malaria
epidemics in the dry coastal region of northern Peru (38).
Dengue transmission is influenced by meteorologic conditions, including rainfall and
humidity, and often exhibits strong seasonality. However, transmission is not directly
associated with flooding. Such events may coincide with periods of high risk for transmission
and may be exacerbated by increased availability of the vectors breeding sites (mostly
artificial containers) caused by disruption of basic water supply and solid waste disposal
services. The risk for outbreaks can be influenced by other complicating factors, such as
changes in human behavior (increased exposure to mosquitoes while sleeping outside,
movement from dengue-nonendemic to -endemic areas, a pause in disease control activities,
overcrowding) or changes in the habitat that promote mosquito breeding (landslide,
deforestation, river damming, and rerouting of water).
Other Diseases Associated with Natural Disasters

Tetanus is not transmitted person to person but is caused by a toxin released by the anaerobic
tetanus bacillus Clostridium tetani. Contaminated wounds, particularly in populations where

vaccination coverage levels are low, are associated with illness and death from tetanus. A
cluster of 106 cases of tetanus, including 20 deaths, occurred in Aceh and peaked 2-1/2
weeks after the tsunami (26). Cases were also reported in Pakistan following the 2005
earthquake (25).
An unusual outbreak of coccidiomycosis occurred after the January 1994 Southern California
earthquake. The infection is not transmitted person to person and is caused by the
fungus Coccidioides immitis, which is found in soil in certain semiarid areas of North and
South America. This outbreak was associated with exposure to increased levels of airborne
dust subsequent to landslides in the aftermath of the earthquake (39).
Disaster-Related Interruption of Services

Power cuts related to disasters may disrupt water treatment and supply plants, thereby
increasing the risk for waterborne diseases. Lack of power may also affect proper functioning
of health facilities, including preservation of the vaccine cold chain. An increase in diarrheal
illness in New York City followed a massive power outage in 2003. The blackout left 9
million people in the area without power for several hours to 2 days. Diarrhea cases were
widely dispersed and detected by using nontraditional surveillance techniques. A case-control
study performed as part of the outbreak investigation linked diarrheal illness with the
consumption of meat and seafood after the onset of the power outage, when refrigeration
facilities were widely interrupted (40).
Go to:

Discussion
Historically, fears of major disease outbreaks in the aftermath of natural disasters have
shaped the perceptions of the public and policymakers. These expectations, misinformed by
associations of disease with dead bodies, can create fear and panic in the affected population
and lead to confusion in the media and elsewhere.
The risk for outbreaks after natural disasters is low, particularly when the disaster does not
result in substantial population displacement. Communicable diseases are common in
displaced populations that have poor access to basic needs such as safe water and sanitation,
adequate shelter, and primary healthcare services. These conditions, many favorable for
disease transmission, must be addressed immediately with the rapid reinstatement of basic
services. Assuring access to safe water and primary healthcare services is crucial, as are
surveillance and early warning to detect epidemic-prone diseases known to occur in the
disaster-affected area. A comprehensive communicable disease risk assessment can
determine priority diseases for inclusion in the surveillance system and prioritize the need for
immunization and vector-control campaigns. Five basic steps that can reduce the risk for
communicable disease transmission in populations affected by natural disasters are
summarized in an (Appendix Table).

Disaster-related deaths are overwhelmingly caused by the initial traumatic impact of the
event. Disaster-preparedness plans, appropriately focused on trauma and mass casualty
management, should also take into account the health needs of the surviving disaster-affected
populations. The health effects associated with the sudden crowding of large numbers of
survivors, often with inadequate access to safe water and sanitation facilities, will require
planning for both therapeutic and preventive interventions, such as the rapid delivery of safe
water and the provision of rehydration materials, antimicrobial agents, and measles
vaccination materials.
Surveillance in areas affected by disasters is fundamental to understanding the impact of
natural disasters on communicable disease illness and death. Obtaining relevant surveillance
information in these contexts, however, is frequently challenging. The destruction of the
preexisting public health infrastructure can aggravate (or eliminate) what may have been
weak predisaster systems of surveillance and response. Surveillance officers and public
health workers may be killed or missing, as in Aceh in 2004. Population displacement can
distort census information, which makes the calculation of rates for comparison difficult.
Healthcare during the emergency phase is often delivered by a wide range of national and
international actors, which creates coordination challenges. Also, a lack of predisaster
baseline surveillance information can lead to difficulties in accurately differentiating
epidemic from background endemic disease transmission.
Although postdisaster surveillance systems are designed to rapidly detect cases of epidemicprone diseases, interpreting this information can be hampered by the absence of baseline
surveillance data and accurate denominator values. Detecting cases of diseases that occur
endemically may be interpreted (because of absence of background data) as an early
epidemic. The priority in these settings, however, is rapid implementation of control
measures when cases of epidemic-prone diseases are detected. Despite these challenges,
continued detection of and response to communicable diseases are essential to monitor the
incidence of diseases, to document their effect, to respond with control measures when
needed, and to better quantify the risk for outbreaks after disasters.

Long-term Health Problems After

Natural Disasters Strike

Health obstacles plague communities long after a natural disaster.

By Katherine BeardJan. 6, 2014 | 7:00 a.m. EST+ More

It's been nearly two months since the strongest storm ever recorded slammed the Philippines
and the U.S. alone has contributed more than $37 million to relief efforts in the devastated
country according to Time Magazine. Other countries and international organizations like the
U.N. have donated just as much to help decimated communities in the badly damaged province
of Leyte return to some sense of normalcy as they begin to rebuild their lives.
Whether it's Louisiana hit by Hurricane Katrina in 2005, or Indonesia struck by the tsunami in
2004, communities that suffer from natural disasters also suffer from the side effects of the
disaster long after the cameras have stopped rolling and the aid comes to a halt. Some of the
greatest challenges these people undergo is not the natural disaster itself but the residual
problems stemming from the disaster, namely the long-term health problems kindled from the
calamity.
Courtland Robinson, a professor at the Center for Refugee and Disaster Response at the Johns
Hopkins Bloomberg School of Public Health, says that when communities deal with natural
disasters they deal with the emergency phase first. These are typically the images flashed across
the TV screen immediately after a natural disaster has taken place.
This phase is all about rescue and recovery Robinson explained. Doctors and aid workers
"stabilize the health of the population with emergency interventions," he says.

"You need people who have acute trauma care skills to come in, find and rescue those people
who are able to be saved," says Robinson. "It's really kind of a triage operation in many cases."
Like doctors do in triage, first responders must decide who to save first based on their condition
and the resources the relief teams have to help the individuals.
The emergency phase requires "providing things for the community that are realities like clean
water, food, temporary shelter, immediately followed by health services," says Ron Waldman,
professor of global health at George Washington University and board president of the nongovernmental organization Doctors of the World.
[READ: Aid Workers Settle In for Long Haul After Haiyan]
Peace Corps Response Volunteer Christy Grimsley assisted the Red Cross in Sri Lanka after an
earthquake in southeastern Asia triggered the 2004 Boxing Day tsunami, which is known as one
of the deadliest natural disasters in history, when more than 230,000 people died. Grimsley says
the redevelopment phase follows the emergency phase. While the emergency phase "is the big
splash with all the aid and assistance coming in, the development phase is how the communities
then put themselves together," she said. This phase is where the less immediate health
conditions begin to be addressed.
The long-term health conditions typically addressed during the redevelopment phase include
mental and psychological issues, vaccinating and eliminating the outbreak of communicable
diseases like cholera, malaria, and measles and reinstating the infrastructure of the health
services system.
Mental Health
Mental health problems have proven to be some of the most common side effects of natural
disasters. The great loss and devastation disasters incur makes mental health problems like
post-traumatic stress disorder and depression, rampant among survivors of these horrific acts of
nature.
"Disasters cause a significant amount of stress; the death of loved ones can be particularly
traumatic but also the loss of jobs, material goods and livelihoods," Amanda McClelland, senior
officer of Emergency Health at the International Federation of Red Cross wrote in an email.
But mental health problems rarely manifest themselves in the early stages of the emergency.
"Mental health and psycho social issues become more apparent as time goes on and can be
overlooked in emergencies," McClelland explained.
One reason these mental problems are not examined till later is because in fact the majority of
the population will suffer from grief and shock following the event. "That's really normal,"
Robinson said. "You almost hope to see it," he continued.
But then you hope and expect to see people returning to some kind of normalcy; picking up and
trying to dig out and get themselves into their houses and back to school or back to work. And
when that doesn't happen then that's a sign the individual is beginning to experience posttraumatic stress disorder, maybe depression, or maybe anxiety."

It is for this reason health professionals urge people in natural disaster ridden communities to
return to their daily routines as soon as possible.
[ALSO: A Year After Sandy, Research Focuses on the Social Impact of Disasters]
"Getting people back to work is really vital and is really a part of human dignity," says Waldman .
"If these needs are not re-established soon there's bound to be an onset of depression that can
have a negative impact on individuals and the community," he said.
Communicable Diseases
Communities reeling from natural disasters also tend to become breeding grounds for outbreaks
of communicable diseases, which are defined as diseases that easily transfer from person to
person or animal to person. "Continuing problems with hygiene and diseases related to hygiene
are common in refugee camps," Grimsley says. "Maintaining hygiene levels in these camps is
critical to full recovery."
Prevention methods like washing hands and vaccinations are the key to combating these deadly,
yet preventable outbreaks.
"Disasters change the environment, so they can also change the population [through
displacement], as well as the agents that create disease," McClelland said.
Creating new breeding environments can sometimes even mean new diseases are introduced to
populations that have not suffered from those diseases in the past.
"Disease that was present before the disaster can increase, and disease previously under control
can become problematic," she said.
Though public health officials used to live by the rule that if a disease wasn't in a community
before the disaster it wouldn't be there after, they have come to find that like every rule, there are
exceptions. "Following this rule without consideration can have dire consequences," McClelland
explained, noting that Haiti was one of those exceptions. Haiti suffered from a 7.0 earthquake in
January 2010. This catastrophic event destroyed what little structures and infrastructures that
existed in the Western Hemisphere's poorest country. When CNN returned to Haiti in the
summer of 2010 to check up on the relief efforts, reporter Ivan Watson wrote in an article "Six
months later, not much appears to have changed. It still looks like a bomb just dropped on this
city." In fact, the U.N. estimated 1.5 million individuals were homeless and living in the refugee
camps. Many criticized the relief organizations who were assisting with Haiti's recovery efforts
and their lack of organization and effectiveness. Then in October 2010 a cholera epidemic broke
out. Later it was discovered the disease was brought over by foreign aid workers. The lack of
sanitation and cleanliness that are typical when large populations of people live in close quarters
only cultivated the epidemic in the already sub-par health conditions. "In Haiti, where they had
not had cholera in 100 years, new imported cases caused an outbreak," McClelland said.
Though the number of displaced Haitians has decreased to about 350,000 as of 2013, Haiti's
progress is still few and far between, Time Magazine reported.
Health Service System
"The real damage in the long run is done to the health service infrastructure," Waldman says.

On top of the physical damage done to the hospitals and health buildings, the loss of medical
equipment and medicines, "there's the issue of the dysfunction of health facilities."
Haiti is an example of where an already poor health infrastructure system was destroyed and has
yet to be rebuilt and improved. Waldman points out that the initial cholera epidemic that struck
Haiti following the earthquake actually had nothing to do with the actual earthquake and
everything to do with the health care system, more precisely the lack of an efficient one.
"Cholera will continue to outbreak because the infrastructure remains inadequate," Waldman
said.
The mass exodus of residents from the epicenter of any emergency is a common problem for
communities working to recover and rebuild. This exodus also contributes greatly to the lack of
health services that communities recovering from disasters tend to deal with.
"A lot of people leave and that means there are fewer resources available to help address these
long term problems," Waldman says. He used Hurricane Sandy and the communities hit in New
York and New Jersey as an example of an area that has experienced a lag in restoration on
account of this routine migration away from the initial point of the disaster, causing a scarcity of
health services.
[MORE: Cholera in Haiti Far Worse Than Predicted]
"If you look at places that were affected by Hurricane Sandy from a health point of view, a lot of
doctors left the area," Waldman said. "So though much concern was expressed early on [the
communities affected by Hurricane Sandy] still haven't recovered because the doctors left, so
there are fewer facilities and resources available to the residents of the affected areas more than
a year a later."
This trend was evident in October as newspapers marked the first anniversary since Hurricane
Sandy killed an estimated 160 people, and destroyed massive amounts of property as it tore
through communities in New Jersey and New York. NBC News reported a community that had
lost nearly 350 residents' homes, yet only 40 homes were being rebuilt.
Natural disasters are fleeting. Earthquakes tremor to stillness, tsunamis subside, and flood
waters recede. But the effects ripple long after the actual event. Robinson refers to these as
"chronic emergencies."
"It seems like a contradiction of terms," he says. "You have acute things and then you have
chronic things. But in fact a lot of these emergencies have these long tails where people aren't
back home again, their lives aren't normal again and the lot of the relief aid that comes in for 60,
90, 120 days maybe up to year, go away as we move onto the next emergency."

Grimsley applauded the Red Cross' pledge to stay in Indonesia's tsunami impacted areas six
years after it displaced more than 1.5 million people in Southeastern Asia. She says this
commitment is what has helped it not only recover but thrive. The World Bank says thanks to
nearly $7 billion in contributions and exceptional disaster response and reconstruction Aceh, the
capital of the Indonesian province which was destroyed in the tsunami, has been transformed to
a robust city. In fact, the approaches initiated in response to Indonesia's tsunami are beginning to
be replicated in other emergency response areas. The World Bank is encouraging disaster
response organizations to use Aceh as a model for future communities devastated by calamity.
She says if there is any hope to see these communities repair and recuperate, governments,
international agencies and non-governmental organizations must maintain their commitment to
recovery.
"It's really important for government and international agencies to maintain their commitment and
not just move on to the next big disaster," Grimsley says.

atural Disasters & Environmental Hazards

Josephine Malilay, Dahna Batts, Armin Ansari, Charles W. Miller, Clive M. Brown

NATURAL DISASTERS
Travelers should be aware of the potential for natural phenomena such as hurricanes, floods,
tsunamis, tornadoes, or earthquakes. Natural disasters can contribute to the transmission of some
diseases, especially since water supplies and sewage systems may be disrupted; sanitation and
hygiene may be compromised by population displacement and overcrowding; and normal public
health services may be interrupted.
When arriving at a destination, travelers should be familiar with local risks for seismic, floodrelated, landslide-related, tsunami-related, and other hazards, as well as warning systems,
evacuation routes, and shelters in areas of high risk.

Disease Risks
The risk for infectious diseases among travelers to affected areas is minimal unless a disease is
endemic in an area before the disaster, because transmission cannot take place unless the
causative agent is present. Although typhoid can be endemic in developing countries, natural
disasters have seldom led to epidemic levels of disease. Floods have been known to prompt

outbreaks of leptospirosis and cholera in areas where the organism is found in water sources (see
theLeptospirosis and Cholera sections in Chapter 3).
When water and sewage systems have been disrupted, safe water and food supplies are of great
importance in preventing enteric disease transmission. If contamination is suspected, water should
be boiled or disinfected (see the Water Disinfection for Travelers section earlier in this chapter).
Travelers who are injured during a natural disaster should have a medical evaluation to determine
what additional care may be required for wounds potentially contaminated with feces, soil, or
saliva, or that have been exposed to fresh or sea water that may contain parasites or bacteria.
Tetanus booster status should always be kept current.
Various vaccine-preventable diseases have been eliminated or are near elimination in some
developing countries. However, if someone who has the disease travels to the country, the disease
could be reintroduced, leading to an outbreak. Therefore, it is very important that people traveling
to offer relief or other services in countries affected by natural disasters be protected against such
diseases or not be sick when entering a country.

Injuries
After a natural disaster, deaths are rarely due to infectious diseases. Rather they are most often
due to blunt trauma, crush-related injuries, or drowning. Therefore, travelers should be aware of
the risks for injury during and after a natural disaster. In floods, people should avoid driving
through swiftly moving water. Travelers should exercise caution during clean-up, particularly when
encountering downed power lines, water-affected electrical outlets, interrupted gas lines, and stray
or frightened animals. During natural disasters, technological malfunctions may release hazardous
materials (such as release of toxic chemicals from a point source displaced by strong winds,
seismic motion, or rapidly moving water).

Environmental Risks
Natural disasters often lead to wide-ranging air pollution in large cities. For example, uncontrolled
forest fires have caused widespread pollution over vast expanses. Natural or manmade disasters
resulting in massive structural collapse or dust clouds can cause the release of chemical or biologic
contaminants (such as asbestos or the arthrospores that lead to coccidioidomycosis). Health risks
associated with these environmental occurrences have not been fully studied. Travelers with
chronic pulmonary disease or who are immunocompromised may be more susceptible to adverse
effects from these types of exposures.

Event-Specific Information
Typically, after natural disasters of a magnitude that may affect travelers, current information
about the disaster, as well as travel health information specific to those needing to travel to the
affected area, is provided on the CDC website (www.cdc.gov/travel). Recommendations may
include specific immunizations or cautions about unique hazards in the affected area.

ENVIRONMENTAL HAZARDS
Air

Air pollution may be found in large cities throughout the world; its sources are often attributed to
automobile exhaust and industrial emissions and may be aggravated by climate and geography.
Specifically, particulate matter (PM), or particle pollution, consisting of fine particles 2.5 m or
smaller in diameter, may enter the lungs and cause serious health problems. Travelers should be
aware that global long-term average PM2.5 concentrations have been estimated to exceed the
World Health Organizations Air Quality PM2.5 Interim Target-1 (35 g/m3 annual average) in
eastern and central Asia and North Africa.
Although the harmful effects of air pollution are difficult to avoid when visiting some cities, limiting
strenuous activity and not smoking can help. Any risk to healthy short-term travelers to such
areas is probably small, but people with preexisting health conditions (such as asthma, chronic
obstructive pulmonary disease, or heart disease) could be more susceptible. Avoiding dust clouds
and areas of heavy dust or haze is wise.

Water
Rivers, lakes, and oceans may be contaminated with organic or inorganic chemical compounds
(such as heavy metals or other toxins); harmful algal blooms (cyanobacteria) that can be toxic
both to fish and to people who eat the fish, or who swim or bathe in the water; and pathogens
from human and animal waste that may cause disease in swimmers. Such hazards may not be
immediately apparent in a body of water. Available drinking water may also be contaminated; see
the Water Disinfection for Travelers section earlier in this chapter for guidance on ensuring water
is safe to drink.
Extensive water damage after major hurricanes and floods increases the likelihood of mold
contamination in buildings. Travelers may visit flooded areas overseas as part of emergency,
medical, or humanitarian missions. Mold is a more serious hazard for people with conditions such
as impaired host defenses or mold allergies. To prevent exposure that could result in adverse
health effects from disturbed mold, people should adhere to the following recommendations:

Avoid areas where mold contamination is obvious.

Use personal protective equipment (PPE), such as gloves, goggles, and a tight-fitting
approved N-95 respirator. Travelers should take sufficient PPE with them, as these may be
scarce in the countries visited.

Keep hands, skin, and clothing clean and free from mold-contaminated dust.

Review the CDC guidance, Mold Prevention Strategies and Possible Health Effects in the
Aftermath of Hurricanes and Major Floods
(www.cdc.gov/mmwr/preview/mmwrhtml/rr5508a1.htm), which provides recommendations
for dealing with mold in these settings.

Radiation
Natural background radiation levels can vary substantially from region to region, but these natural
variations are not a health concern for either the traveler or resident population. Travelers should
be aware of regions known to have been contaminated with radioactive materials, such as the

areas surrounding the Chernobyl nuclear power plant in Ukraine and the Fukushima Daiichi nuclear
power plant in Japan.
The Chernobyl plant is located 100 km (62 miles) northwest of Kiev. This 1986 accident
contaminated regions in 3 republicsUkraine, Belarus, and Russiawith the highest radioactive
ground contamination within 30 km (19 miles) of Chernobyl.
The Fukushima Daiichi plant is located 240 km (150 miles) north of Tokyo. The area within a 20km (32-mile) radius of the plant is restricted, and Japanese authorities also advised evacuation
from locations farther away to the northwest of the plant. This incident occurred in 2011, and as
Japanese authorities continue to clean the affected areas and monitor the situation, travel
advisories may change. US travelers are advised to check the website of the US embassy in Tokyo
for up-to-date information. There are no travel advisories for Tokyo or any city or region south of
Tokyo. Travelers who choose to reside for >1 year within 80 km of the Fukushima Daiichi nuclear
plant should consult with local authorities to receive guidance on expected levels of radiation and
recommendations for reducing exposure to radiation. In addition, pregnant women, children, and
the elderly should avoid residing within 30 km of the Fukushima Daiichi Nuclear Plant.
More than 450,000 travelers to the United States originate from Japan each month. During the
height of the Fukushima releases, there was some concern about those travelers bringing
contamination into the United States with them. Based on radiologic contamination screening at
points of entry into the United States, 3 travelers arriving from Japan after the incident had low
levels of contamination and were not considered to pose a health hazard to themselves or others.
In most countries, known areas of radioactive contamination are fenced or marked with signs.
These areas should not be trespassed. Any traveler seeking long-term (more than a few months)
residence near a known or suspected contaminated area should consult with staff of the nearest
US embassy and inquire about any applicable advisories in that area regarding drinking water
quality or purchase of meat, fruit, and vegetables from local farmers. Radiation emergencies are
rare events. In case of such an emergency, however, travelers should follow instructions provided
by local emergency and public health authorities. If such information is not forthcoming, US
travelers should immediately seek advice from the nearest US embassy.
Natural disasters (such as floods) may also displace industrial or clinical radioactive sources. In all
circumstances, travelers should exercise caution when they encounter unknown objects or
equipment, especially if they bear the radioactive symbol. Travelers who encounter a questionable
object should notify authorities.

The Devastating Impact of

Natural Disasters

Children observe destroyed homes in Guatemala, which suffered a massive earthquake in November
2012.

Millions of people are affected by natural disasters every

year, and the impact can be calamitous. From the
destruction of buildings to the spread of disease, natural
disasters can devastate entire countries overnight.
Tsunamis, earthquakes and typhoons do not just wreak
havoc on land; they also disrupt people's lives, especially
for those living in remote regions.

Displaced Populations
One of the most immediate effects of natural disasters is population
displacement. When countries are ravaged by earthquakes and other
powerful forces of nature, many people have to abandon their homes and
seek shelter in other regions. A large influx of refugees can disrupt
everything from accessibility of health care and education to food supplies
and basic hygiene. Large-scale evacuations are common in light of the
power of tsunamis and other natural disasters, and those fortunate
enough to survive face a range of challenges following widespread
destruction.

Health Risks

Aside from the obvious danger that natural disasters present, the
secondary effects can be just as damaging. Typhoons, hurricanes and
tsunamis often cause severe flooding, which can result in the spread of
waterborne bacteria and malaria. As a result, health complications can be
prevalent among survivors of natural disasters, and without the help of
international relief organizations, death tolls can rise even after the
immediate danger has passed.

Food Scarcity
After natural disasters, food can become scarce. Thousands of people
around the world go hungry as a result of destroyed crops and a loss of
agricultural supplies. The impacts of hunger following an earthquake,
typhoon or hurricane can be tremendous, but fortunately, there are ways
you can help. ChildFund's Child Alert Emergency Fundprovides people
affected by natural disasters with the food and nutritional support they
need. Your donation of $25, $50 or $100 will be used to fulfill immediate
needs on the ground.

Emotional Aftershocks
Natural disasters can be particularly traumatic for young children.
Confronted with scenes of destruction and the deaths of friends and loved
ones, many children develop post-traumatic stress disorder (PTSD), a
serious psychological condition resulting from extreme trauma. Left
untreated, children suffering from PTSD can be prone to lasting
psychological damage and emotional distress. ChildFund works in
countries around the world affected by natural disasters to help
children receive the psychosocial care they need following these traumatic
events.
Although nobody can prevent natural disasters, we can help people in
need in their wake. By making a donation to ChildFund's Child Alert
Emergency Fund, you can help us provide food, clean water, health care
and emotional support to children and communities displaced by natural
disasters.

The Impact of Disasters on Public Health

Disasters change the landscape in numerous ways, and only a portion of the
changes are immediately evident. Thats especially so when it comes to public
health. Public health encompasses efforts to protect and improve the health of
communities as a whole, including the promotion of healthy lifestyles, research
into the prevention of injury and disease, and education. The healthier the
community and the more resources it has before disaster strikes, the greater
resilience that community will show.

In October 2010, ten months after the devastating earthquake rocked Haiti,
a cholera outbreak was identified; it went on to sicken 470,000 Haitians
and nearly 7,000 died. Cholera typically spreads in places with deficient
water treatment, inadequate hygiene, and poor waste management, and the
event only magnified a precarious situation. Some might believe the
outbreak was a direct result of the earthquake, but others consider the
timing more coincidental. Its estimated that just half of the nations
population had access to clean drinking water before the earthquake
occurred, and less than one quarter had sufficient access to sanitation, like
latrines.
In 2005, when Hurricane Katrina hit New Orleans, La., the complication
was not cholera. But prior public health concerns played a role here, too.
Before the storm, a quarter of the population lived below poverty levels
and one in five was uninsured, resulting in an overwhelming load on an
already overburdened health delivery system. And almost all of the deaths
were among the already vulnerable elderly and/or African American
populations.
The impact a disaster has on an affected populations health is far from
predictable. A variety of factors influence the spread of disease and other
health-related issues following an event, and many can be mitigated with
thoughtful planning.
Disaster preparedness efforts that consider, for example, health facility
capabilities, reproductive health, mental health, and water, sanitation, and
hygiene greatly lessen the toll of sickness on compromised populations.
The field is rife with opportunities for further study, investment, and
improvement across the disaster life cycle, from risk reduction through

long-term recovery, including the preparedness and resources of affected

and at-risk populations.
Key Facts

Disaster-related health needs typically do not show up

immediately. Some health concerns will not appear until much later,
especially in terms of mental health. Consider the challenges of
survival after livelihoods have been lost, such as the loss of
livestock, which represents years of accumulated family wealth.
Also of concern: ongoing issues following the death of the head of a
household.
Damage to health care facilitiesand diagnostic equipment
can have long-reaching consequences. So, too, can damage to
infrastructure such as roads and bridges, keeping people from being
able to connect to services they need. In addition, losses that affect
the personal lives of healthcare workers also affect the ability of
health facilities to provide services.
Water, sanitation, and hygiene conditions before and after a
disaster can greatly affect the level of impact on a communitys
health. Drinking water supply and waste management are especially
important factors in controlling disease, as is the management of
toxic substances released by the disaster.
Often, post-disaster outbreaks of disease are associated with
population displacement. Widespread disasters such as hurricanes,
famine, or floods can result in large groups of people being
evacuated. But disease tends to spread in overcrowded areas without
proper access to healthcare services. In resource-poor areas, already
decreased nutritional status and lack of vaccinations can contribute
to the problem. Sometimes this can mean outbreaks of diarrhea, but
other times, it could be respiratory infections or conjunctivitis with
so many in close quarters.
Disasters can exacerbate reproductive health needs. Along with
damage to facilities, equipment, medications, and other
infrastructure, access to services could decrease. Other concerns can
take higher priority. In addition, periods of high stress, overcrowding
in temporary relief situations, and challenges related to hygiene
could increase the chance of sexually transmitted diseases and
gender-based violence. And yet, pregnancies and deliveries

continue, even with diminished facilities and a decrease in the

number of skilled healthcare workers.
There is no health without mental health. The Center for Disaster
Philanthropy has prepared an issue insight on Mental Health Needs
During and After Disaster.

How You Can Help

Opportunities for reducing the health impact of disasters abound.
Interested donors could:

Support local efforts to bolster critical services and build

community resilience. On a larger scale, strengthen water treatment
and sewer facilities to better withstand disasters. On a smaller but
equally as important scale, fund efforts to improve healthcare
equipment, support hygiene programs, and ensure plans for mental
health access are in place.
Fund efforts to ensure post-disaster reproductive care and
access. Consider both immediate needs and long-term concerns,
including birth control, pregnancy, sexually transmitted diseases,
and efforts to reduce gender-based violence in overcrowded
displaced populations.
Fund risk reduction activities such as vulnerability assessments
for potentially disaster-prone areas and impact mitigation. Fund
the creation of rapid needs assessments to collect reliable data about
the needs of affected communities after disasters occur. In addition,
identify marginalized and vulnerable populations that suffer the most
in disasters, assessing their unique needs. In terms of mitigating
impact, include the creation of public health communications that
are reliable, consistent, and culturally relevant.
Fund training for healthcare providers to identify and
strengthen the most vulnerable populations. Recognize that
different populations may be more vulnerable to different disasters.
Support programs that assist care givers in disaster-affected
areas. They may be coping with their own grief while assisting
others.
Fund the transfer to electronic medical records in higher-income
areas. These are less easily lost following a disaster.
Support research into the ongoing effects of disasters on
populations, as well as effective ways to build coping capacities
among individuals and communities. Also worth study: methods

of promoting early recovery and mitigation of the impact of future

disasters.
- See more at: http://disasterphilanthropy.org/the-impact-of-disasters-onpublic-health/#sthash.Oe9bjZqU.dpuf

EMOTIONAL EFFECTS OF
NATURAL DISASTERS
By NADINE BROZAN
Published: June 27, 1983

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REPRINTS

Natural disasters strike suddenly and leave behind lives shattered by

physical injury or the loss of home and job. At the time that flood
waters rise over riverbanks, as they have done recently in several
Western states, or when an earthquake shatters a community, as one
did last month in Coalinga, Calif., there is little time at first to pay
attention to the survivors' feelings. Emotional pain is usually hidden
at the outset, but it often lingers, to emerge long after the debris has
been cleared away.
The psychological upset caused by disaster is increasingly attracting
the attention of Federal and state officials, socialservice professionals
and scholars. One indication of the seriousness with which it is being
taken is the establishment last month of the Center for Mental Health
Studies of Emergencies in the National Institute of Mental Health.
Planning Preventive Strategies

The center will fund research and provide crisis-counseling grants

when the President declares a disaster area, as has been done 11 times
this year. It will also plan preventive mental-health strategies.
According to Dr. Mary Lystad, its chief, its mission is clear-cut: ''We
simply don't know enough about responses to emergencies and the
kind of services people need.''
Experts who have worked with survivors of disasters ranging from the
Boston blizzard of 1978 to the eruption of Mount St. Helens in 1980
agreed that reactions fall into an almost predictable sequence. The
initial shock - a stunning sense of astonishment and terror -is followed
by euphoria at having survived. The Rev. Frank Reuter, pastor of the
First Southern Baptist Church in Coalinga, Calif., site of the
devastating earthquake last month, recalled: ''Three hours after it
happened I saw people throwing Frisbees and setting up tents and
campers.'' Then the elation dissolves rapidly in the face of reality and
depression, ranging from mild to extreme, sets in. Finally
recuperation begins.
According to Dr. Lystad, ''There are six typical initial responses: fear,
numbness and shock, confusion and difficulty in making decisions,
desire for information, seeking help for oneself and family, and
helpfulness to others.''
Delayed responses, which can surface months later, include, she said,
changes in appetite, headaches, inability to sleep, anger, suspicion,
apathy, depression, withdrawal from family and friends,
disillusionment with official help, and guilt at not having been able to
prevent or avoid the emergency.
The pain can be particularly profound when friends or neighbors are
lost or social support is unavailable or when a home is destroyed.
''Losing a home is like losing a limb,'' said Bill O'Callahan, assistant
director of emergency services for the Golden Gate Chapter of the
American Red Cross, who arrived in Coalinga three hours after the
quake on May 2 and remained for a month. ''You may have worked on
that house for 20 years, you may still be paying off the mortgage, you
may never have the opportunity to own another home, especially if
you're older. And later on, moving into a new home, it's not the same
as an old home.''

Lesser losses can be devastating, too. ''The items that cause the most
grief are photographs,'' Mr. O'Callahan said. ''People lose their history
when photos are lost.''
The speed of recuperation varies from one person to another. ''It is
impossible to say, 'You will heal in six weeks or three months,' '' said
Wilma O'Callaghan, chief of the special programs unit for the
California Department of Mental Health. ''We usually expect things to
begin to settle down after six months, and then there is an upsurge of
stress symptoms at the annniversary of the event as well as on
important holidays and birthdays.''
Little research has been done on long-term disturbances, but Dr.
Raquel Cohen, professor of psychiatry at the University of Miami
Medical School and co-author of ''Handbook of Mental Health Care of
Disaster Victims,'' said, ''We believe that 10 percent of the affected
population will have some associated problems for two to four years.''
Another difficulty is predicting who will make healthy adjustments
and who will not. The victim's situation at the time - someone who has
recently undergone surgery is likely to experience more emotional
turmoil than one who has not, for instance - along with the availability
of support systems appear to be among the factors that make a big
difference.
Other variables play a role. Dr. Michael A. Crabbs, assistant professor
of professional education at the University of Houston at Clear Lake,
who worked with tornado survivors in Nebraska and flood survivors in
Texas, said: ''I could not look at five individuals and predict which
ones would be hardest hit. But there are special highrisk groups:
children, the elderly, the poor and victims of previous disasters.'' Dr.
Crabbs conducted workshops in Omaha after a tornado there in 1973
because he found that parents were so involved with reparations that
they were oblivious to their children's needs.
Dr. Cohen commented: ''Children regress to previous levels. If they
have recently become independent, then they become frightened to
leave home or to sleep without a light at night.''
Similarly, a marriage can be tightened or eroded by a disaster. ''A
marriage will often be better off, strengthened by extraordinary

events,'' Mr. O'Callahan said. ''Some families rediscover themselves

and their real values.'' On the other hand, couples can undergo severe
strain if they are unable to comfort each other or if they were already
having difficulties. Indeed, the consequences can drastically alter the
way partners view each other. ''In traditional familes,'' Mr. O'Callahan
said, ''the husband is supposed to save the wife. Then all of a sudden
the house may be destroyed, he may be out of work, so in this type of
relationship he is no longer considered to be fulfilling his role. It is not
uncommon to see six months later a rise in child abuse, spouse abuse,
alcoholism and suicide among people who simply cannnot manage.''
'Affected Everybody's Lives'
Even those who successfully put the disaster in the past do not live in
quite the same way. Arthur Lehman, water-sewer superintendent for
Centralia, Wash., which is 35 miles north of Mount St. Helens, said:
''It affected everybody's lives, so we're always watching it. We don't
really think that it's gone back to sleep for another 200 years.''
In Connecticut, where a storm killed 12 people and damaged 17,000
dwellings in June 1982, Dr. Joseph M. Torres, a state official who
coordinated mental-health services during the disaster, looked back a
year later and commented: ''Of course people make adjustments, but
for some it will never be the same. They will never again have what
they had, not the same neighborhood, not the same friends.''

Lesson

Health Problems Common to All Natural Disasters

Social Reactions
After a major natural disaster, behavior only rarely reaches generalized panic or stunned
waiting. Spontaneous yet highly organized individual action accrues as survivors rapidly
recover from their initial shock and set about purposefully to achieve clear personal ends.

Earthquake survivors often begin search and rescue activities minutes after an impact and
within hours may have organized themselves into groups to transport the injured to medical
posts. Actively antisocial behavior such as widespread looting occurs only in exceptional
circumstances.
Although everyone thinks his or her spontaneous reactions are entirely rational, they may be
detrimental to the communitys higher interests. A persons conflicting roles as family head
and health official, for instance, have in some instances resulted in key relief personnel not
reporting to duty until their relatives and property are safe.
Rumors abound, particularly of epidemics. As a result, considerable pressure may be put on
the authorities to undertake emergency humanitarian work such as mass vaccinations
against typhoid or cholera, without sound medical justification. In addition, people may be
reluctant to submit to measures that the authorities think necessary. During warning periods,
or after the occurrence of natural disasters, people are reluctant to evacuate, even if their
homes are likely to be or have been destroyed.
These patterns of behavior have two major implications for those making decisions about
humanitarian programs. First, patterns of behavior and demands for emergency assistance
can be limited and modified by keeping the population informed and by obtaining necessary
information before embarking on extended relief programs. Second, the population itself will
provide most rescue and first aid, take the injured to hospitals if they are accessible, build
temporary shelters, and carry out other essential tasks. Additional resources should,
therefore, be directed toward meeting the needs that survivors themselves cannot meet on
their own.
Communicable Diseases
Natural disasters do not usually result in massive outbreaks of infectious disease, although
in certain circumstances they do increase the potential for disease transmission. In the shortterm, the most frequently observed increases in disease incidence are caused by fecal
contamination of water and food; hence, such diseases are mainly enteric.
The risk of epidemic outbreaks of communicable diseases is proportional to population
density and displacement. These conditions increase the pressure on water and food
supplies and the risk of contamination (as in refugee camps), the disruption of preexisting
sanitation services such as piped water and sewage, and the failure to maintain or restore
normal public health programs in the immediate post-disaster period.
In the longer term, an increase in vector-borne diseases occurs in some areas because of
disruption of vector control efforts, particularly following heavy rains and floods. Residual
insecticides may be washed away from buildings and the number of mosquito breeding sites
may increase. Moreover, displacement of wild or domesticated animals near human
settlements brings additional risk of zoonotic infections.
In complex disasters where malnutrition, overcrowding, and lack of the most basic sanitation
are common, catastrophic outbreaks of gastroenteritis (caused by cholera or other diseases)
have occurred, as in Rwanda/Zaire in 1994.
Population Displacements
When large, spontaneous or organized population movements occur, an urgent need to
provide humanitarian assistance is created. People may move to urban areas where public
services cannot cope, and the result may be an increase in morbidity and mortality. If much

of the housing has been destroyed, large population movements may occur within urban
areas as people seek shelter with relatives and friends. Surveys of settlements and towns
around Managua, Nicaragua, following the December 1972 earthquake indicated that 80%
to 90% of the 200,000 displaced persons were living with relatives and friends; 5% to 10%
were living in parks, city squares, and vacant lots; and the remainder were living in schools
and other public buildings. Following the earthquake that struck Mexico City in September
1985, 72% of the 33,000 homeless found shelter in areas close to their destroyed dwellings.
In internal conflicts, such as occurred in Central America (1980s) or Colombia (1990s),
refugees and internally displaced populations are likely to persist.
Climatic Exposure
The health hazards of exposure to the elements are not great, even after disasters in
temperate climates. As long as the population is dry, reasonably well clothed, and able to
find windbreaks, death from exposure does not appear to be a major risk in Latin America
and the Caribbean. The need to provide emergency shelter therefore varies greatly with
local conditions.
Food and Nutrition
Food shortages in the immediate aftermath may arise in two ways. Food stock destruction
within the disaster area may reduce the absolute amount of food available, or disruption of
distribution systems may curtail access to food, even if there is no absolute shortage.
Generalized food shortages severe enough to cause nutritional problems do not occur after
earthquakes.
Flooding and sea surges often damage household food stocks and crops, disrupt
distribution, and cause major local shortages. Food distribution, at least in the short term, is
often a major and urgent need, but large-scale importation/donation of food is not usually
necessary.
In extended droughts, such as those occurring in Africa, or in complex disasters, the
homeless and refugees may be completely dependent on outside sources for food supplies
for varying periods of time. Depending on the nutritional condition of these populations,
especially of more vulnerable groups such as pregnant or lactating women, children, and the
elderly, it may be necessary to institute emergency feeding programs.
Water Supply and Sanitation
Drinking water supply and sewerage systems are particularly vulnerable to natural hazards,
and the disruptions that occur in them pose a serious health risk. The systems are extensive,
often in disrepair, and are exposed to a variety of hazards. Deficiencies in established
amounts and quality of potable water and difficulties in the disposal of excreta and other
wastes result in the deterioration of sanitation, contributing to conditions favorable to the
spread of enteric and other diseases.
Mental Health
Anxiety, neuroses, and depression are not major, acute public health problems immediately
following disasters, and family and neighbors in rural or traditional societies can deal with
them temporarily. A group at high risk, however, seems to be the humanitarian volunteers or
workers themselves. Wherever possible, efforts should be made to preserve family and

community social structures. The indiscriminate use of sedatives and tranquilizers during the
emergency relief phase is strongly discouraged. In industrialized or metropolitan areas in
developing countries, mental health problems are reported to be significant during long-term
rehabilitation and reconstruction and need to be dealt with during that phase.
Damage to the Health Infrastructure
Natural disasters can cause serious damage to health facilities and water supply and
sewage systems, having a direct impact on the health of the population dependent on these
services. In the case of structurally unsafe hospitals and health centers, natural disasters
jeopardize the lives of occupants of the buildings, and limit the capacity to provide health
services to disaster victims. The earthquake that struck Mexico City in 1985 resulted in the
collapse of 13 hospitals. In just three of those buildings, 866 people died, 100 of whom were
health personnel. Nearly 6,000 hospital beds were lost in the metropolitan facilities. As a
result of Hurricane Mitch in 1998, the water supply systems of 23 hospitals in Honduras were
damaged or destroyed, and 123 health centers were affected. Peru reported t