13th National Rural Health Conference

Darwin, Australia – May 24-27 2015

Benjamin Ryan MPH, BscEH

PhD Candidate, James Cook University, AustraliaDisaster Coordinator, Cairns and Hinterland Hospital and Health Service, Queensland Health

Director, Disaster Risk Reduction, International Federation of Environmental Health

Acknowledgements Primary supervisor

A/Prof Richard Franklin, James Cook University, Australia

Supervisors A/Prof Kerrianne Watt, James Cook University, Australia

Dr Erin Smith, Senior Lecturer, Edith Cowan University, Australia

Technical advisors Professor Frederick M. Burkle, Senior Fellow and Scientist,

Harvard School of Public Health, Cambridge, MA, USA

A/Prof Peter Aitken, James Cook University, Australia

Professor Peter Leggat, James Cook University, Australia

OverviewDisaster trends

Significance of non‐communicable diseases (NCD)

Disasters and NCDs

Research in rural and remote areas of Queensland

Risk reduction concepts

Conceptual framework – resilience focus

Reflection – Nepal Earthquake 25 April (7.9) and 15 May (7.3)

Killed more than 8,000 people Over 16,000 people injured 2.8 million displaced 5.6 million affected (WHO, 2015)

Source: Time (2015)

Disasters are increasing worldwide…

…due to increasing vulnerability of populations at risk.

Interventions must therefore address the causes of vulnerability not merely the response (CRED, 2015; Keim, 2014)

People Affected/Killed by DisastersAlmost 250,000 deaths

Almost 200 million affected

Impact of Modern Disasters (cont)

Source: UN (2010)

Australian Disaster Related Deaths

Bushfire deaths since 1850 – 700 (12%)

Floods from since 1790 – 2,300 (39%)

Tropical cyclones since 1839 – 2,100 (36%)

Severe storms from since 1824 – 770 (13%)

88% of deaths from floods, cyclones or severe storms

Source: Blong (2015)

Disaster Type by Cost in Australia

9Please note: Every dollar invested in disaster preparedness prevents seven dollars’ worth of disaster-related economic losses (WMO 2012)

Source: Blong (2015)

Public health consequences of disasters

Death Injuries Loss of clean water Loss of shelter Major population movements

Loss of sanitation Loss of routine hygiene Disruption of solid waste management

Public concern for safety Increased pests & vectors Damage to health care system Worsening of non‐communicable diseases

Loss of electricity Toxic exposure Loss of food supply

10

Source: Keim (2014)

Burden of NCDs

Source: WHO (2003)

Millions

0

10

20

30

40

50

60

2008 2019 2030

Non‐Communicable Disease

Other causes

36 million (63%)

52 million (78%)

21 million (37%)

14 million (22%)

Significance of NCDsProjected Trends – Global Deaths

However, don’t people have to die of something?Yes but 42% of NCD deaths occur among people under 60 years

Source: UN (2011)

Traditionally a focus on communicable diseases. Actual risk is low, particularly in developed countries (Watson, 2007).

47% increase in mortality and morbidity one year after Hurricane Katrina (Burkle, 2010).

33% of people exhibited symptoms of NCD exacerbation when arriving at a shelter after Hurricane Katrina (Evans, 2010).

19% increase in cancer related deaths: in the12 months after Hurricane Iniki,1992 (Hendrickson, 1997).

during the weeks after four Hurricane’s in Florida during 2004 (McKinney, 2011).

One year after Hurricane Katrina (2005), there was a 33% reduction in cancer treatment services (Brown, 2008).

Disasters and NCDs

Disasters and NCDs (cont.) Diabetes related deaths accounted for 5% of excess deaths

after the four hurricanes impacting Florida in 2004 (Brown, 2008). Increased risk for people reliant on insulin (Ng, 2011).

Asthma admissions were three times higher in the two weeks after Hurricane Iniki, 1992 (Hendrickson, 1997).

Increased cardiac incidents: In the 30 days Hurricane Sandy, incidence increased by 22% and

mortality by 31% (Swerdel, 2014).

After four hurricanes in Florida during 2004, accounted for 34% of excess deaths (Brown, 2008).

Three-fold increase for six years after Hurricane Katrina (Guatum, 2009).

Case studies: Recent Disasters in Queensland

Cyclone Larry 2005 – category 4

Cyclone Yasi 2011 – category 5

Cyclone Ita 2014 – category 4 (expected category 5)

Innisfail Hospital closed. Drinking water unsafe. Power outage. All generators in Australia

exhausted. Waste issues. Food supply concerns.

Cyclone Larry – March 20, 2005

Cyclone Ita – 2014Initial forecast Event – minimal damage

Water contaminated in northern areas. Dialysis issues. Oxygen patients. Access to medication affected.

Cyclone Yasi – February 3, 2011    Cairns Hospital evacuated. Temporary emergency medical

centre. Asbestos exposure. Dialysis issues. Diabetes concerns. Access to medication affected.

Ryan (2014). Analyzing the impact of severe tropical Cyclone Yasi on public health infrastructure and the management of noncommunicable diseases. Prehospital and disaster medicine: 1-10.

Sendai Framework for Disaster Risk Reduction – 2015‐2030 18 March 2015, a new global agreement on disaster

risk reduction

Included chronic diseases (NCDs):

30 (k) People with life threatening and chronic disease, due to their particular needs, should be included in the design of policies and plans to manage their risks before, during and after disasters, including having access to life-saving services.

Research into disasters and NCDsAim: Investigate the impact of cyclone, storm and flood disasters on public health infrastructure and NCDs.

Methodology: Focus groups and interviews

People who have NCDs – cancer, cardiovascular, diabetes, respiratory and renal conditions

Disaster responders, health specialists and government officials across Queensland, Australia.

Explored the impact of disasters on NCDs, resilience concepts and implementation strategies.

Data was analysed following qualitative principles. Ethics approval from James Cook University (H4871) and

Queensland Health (HREC/13/QTHS/251).

Preliminary results• Six focus groups and 32 interviews, 96 participants.

• Five focus groups with public health professionals.

• One focus group with disaster management stakeholders.

• Nine interviews with people who had a NCD.

• 23 interviews with disaster responders, providers and government officials.

Results 30 descriptions of how disasters can impact on

the health of people with NCDs.

123 descriptions of PHI, categorised into 13 themes.

10 descriptions of how PHI and NCDs are related.

24 risk reduction concepts identified.

Disaster impact on NCDs30 descriptions, examples include: Home dialysis patients reliant on safe water

If special diets are not followed, there may be an exacerbation of NCDs

Mold can trigger respiratory diseases

Immune compromised people are susceptible to infections

Fuel supply for generators can run out, which can limit home based treatment

Cyclone's Larry and Yasi, oxygen and drug supplies were almost non-existent.

Description of Public Health Infrastructure123 descriptions of public health infrastructure13 themes identified and since prioritised:

1. Workforce2. Water 3. Sanitation 4. Equipment5. Communication6. Physical structure

7. Power8. Governance9. Prevention10. Supplies11. Service12. Transport13. Surveillance

Source: Ryan (2015)

Public Health Infrastructure and NCDsTen descriptions provided. Examples include: NCDs are generally managed outside of the acute setting

in the community Immune compromised person eating spoiled food If transport, power, medication, food, water and

communication is removed, the ability to manage NCDs rapidly declines

Safe water is required for compounding pharmacies and IV fluids

Transport is important for the chronically ill Water quality and treatment for renal patients.

Risk reduction concepts24 concepts were discussed. Examples include: Educating people to take care of themselves Ensuring good communication (phones, television,

media, SMS and newspaper) Health is involved in evacuation centre processes Exercise disaster plans Partnerships between governments, NGO's and

business Register of certain chronic diseases Data on treatment plans and requirements.

Conceptual Framework

Resilient Public Health Infrastructure

DisasterExcess illness

and deaths

1. Workforce2. Water3. Sanitation4. Equipment5. Communication6. Physical structure7. Power8. Governance9. Prevention10. Supplies11. Services12. Transport13. Surveillance

CancerCardiovascular diseaseChronic respiratory diseasesDiabetes Renal diseases

Weak Public Health Infrastructure

Minimal damage to treatment, care and services

Treatment, care and services interrupted

Minimal impact

Impact influenced by disaster preparedness

Health security

Funding/support

Australian Centre for Health Services Innovation

Toowoomba Hospital Foundation and Cunningham Centre

Cairns and Hinterland Hospital and Health Service, Queensland Health

James Cook University

Thank you – Questions?

Benjamin Ryan MPH, BscPhD Candidate, James Cook University

Disaster Coordinator, Cairns and Hinterland Hospital and Health Service, Queensland HealthDirector, Disaster Risk Reduction, International Federation of Environmental Health

Email: benjamin.ryan@my.jcu.edu.au or ben.ryan@health.qld.gov.auPh: 0448 257 912

Blong, R. (2005). Natural hazards risk assessment: An Australian perspective. Issues in risk science series, Benfield Hazard Research Centre, London.Brown, D. W., Young, S. L., Engelgau, M. M., & Mensah, G. A. (2008). Evidence-based approach for disaster preparedness authorities to inform the contents of repositories for prescription medications for chronic disease management and control. Prehospital and Disaster Medicine, 23(05), 447-457. Burkle, F. (2010). Complex Public Health Emergencies. In Koenig KL, Schultz CH (eds): Disaster Medicine: Comprehensive Principles and Practices. Cambridge University Press, New York, NY, pp 361–376Center for Research on the Epidemiology of Disasters (2015) : URL:http://www.unisdr.org/we/inform/disaster-statistics Evans, J. R. N. B. N. P. M. (2010). Mapping the vulnerability of older persons to disasters. International Journal of Older People Nursing, 5(1), 63-70.Gautam, S., Menachem, J., Srivastav, S. K., Delafontaine, P., & Irimpen, A. (2009). Effect of Hurricane Katrina on the incidence of acute coronary syndrome at a primary angioplasty center in New Orleans. Disaster Medicine and Public Health Preparedness, 3(3), 144-150. Hendrickson LA, Vogt RL, Goebert D, Pon E (1997). Morbidity on Kauai before and after Hurricane Iniki. Preventive Medicine. 26(5 part 1):711-716.Hendrickson, L. A., & Vogt, R. L. (1996). Mortality of Kauai residents in the 12-month period following Hurricane Iniki. American journal of epidemiology, 144(2), 188-191. Keim, M. (2014). Preventing Disasters: Disaster Risk Reduction as a Sustainable Adaptation to Climate Change. Centers for Disease Control and Prevention. Presentation at National Environmental Health Association National Conference. McKinney, N., Houser, C., & Meyer-Arendt, K. (2011). Direct and indirect mortality in Florida during the 2004 hurricane season. International journal of biometeorology, 55(4), 533-546. Ng, J., et al. (2011), The effect of extensive flooding in Hull on the glycaemic control of patients with diabetes. Diabetic Medicine. 28(5): p. 519-524.Ryan BJ, Franklin RC, Burkle FM, Watt K, Aitken P, Smith EC, et al (2015) Defining, describing and categorizing public healthinfrastructure priorities for cyclone, flood and storm related disasters. Disaster Medicine and Public Health Preparedness(submitted).

References

Swerdel, J.N., et al. (2014). The Effect of Hurricane Sandy on Cardiovascular Events in New Jersey. Journal of the American Heart Association. 3(6): p. e001354.Time (2015). 101-Year-Old Nepalese Man Found Alive in Rubble a Week After Quake. Accessed 21 May 2015 –http://time.com/3844669/nepal-earthquake-101-year-old-survivor/United Nations (2011). Prevention and control of non-communicable diseases - Report of the Secretary-General. United Nations General Assembly; Accessed 29 December 2014; Available at: http://www.ghd-net.org/sites/default/files/UN%20Secretary-General's%20Report%20on%20NCDs.pdfUnited Nations and World Bank (2010). Natural Hazards, UnNatural Disasters – The Economics of Effective Prevention. The International Bank for Reconstruction and Development, Washington DC, USAWatson, J. T., M. Gayer, et al. (2007). "Epidemics after natural disasters." Emerging Infectious Diseases 13(1): 1.WHO (2015). Situation Report #17 – Nepal Earthquake 2015. Accessed 21 May 2015 -http://reliefweb.int/sites/reliefweb.int/files/resources/who-sitrep17-19-may-2015.pdfWorld Health Organization (2003), Projections of Mortality and Burden of Disease, 2004-2030. Available at: http://www.who.int/healthinfo/global_burden_disease/projections/en/index.htmlWorld Meteorological Organization (2012). Natural Hazards. Accessed 13 October 2014 - http://www.wmo.int/pages/prog/drr/

References (cont.)