Deliverable 4.1.5 Relevant Scientific Paper for Health ... - HWG paper by UKL-HD.pdf · Bidada...

Deliverable 4.1.5

Relevant Scientific Paper for Health Impacts of Disasters

Draft document with unpublished data.

UniversitätsKlinikum Heidelberg

Abt. Tropenhygiene und Öffentliches GesundheitswesenIm Neuenheimer Feld 324, D- 69120 Heidelberg, Germany.Tel. +49-6221-56 5040, Fax +49-6221-56 5051(www.heidelberg-university-hospital.com/)

Revati Phalkey Draft document_12/1/2009

Injuries reported at a rural hospital after the Gujarat, IndiaEarthquake of 2001 – A call for standardization of earthquakeinjury data recording and reporting.

Phalkey, R* and Marx, M. *

* Department of Tropical Hygiene and Public Health, University of Heidelberg, Heidelberg, Germany.

Abstract

The paper presents a retrospective analysis of injuries treated at a secondary rural hospital inthe Kutch district, Gujarat, India following the January 26, 2001 earthquake. Discharge reportsof patients admitted to the hospital over 10 weeks from January 26, 2001 to April 1, 2001 wereanalyzed for earthquake related injury data. Orthopedic injuries, (particularly fractures of thelower limbs) were predominant and serious injuries like head, chest, abdominal, and crushsyndrome were minimal. The most frequently performed surgical procedures were openreduction with internal fixations, and cleaning and debridement of contaminated wounds. Foursecondary deaths and 102 transfers to tertiary care are reported.

A review of 29 published studies reporting earthquake injuries (1976-2007) rendered data thatwas incomparable due to non-standardized assessment and reporting procedures used. Despite ahigh mortality to injury ratio of 1:3, no international disaster database to date maintainsepidemiological records of earthquake injuries. Given that early effective response strategiesform the mainstay of earthquake impact reduction, standardization of recording and reportingearthquake injuries is urgently mandated. Homogeny is essential to ensure data comparabilityand to guide evidence-based preparedness and response. The authors recommend a uniforminjury case reporting form as a first step towards data standardization.

Key words: disaster, earthquake, injury-epidemiology, data- standardization

Introduction

Over 281 earthquakes occurred in 58 countries between 1996-2005, causing more

than 162,986 deaths and affecting over 39 million people (CRED, 2006). The number

of injured far exceeds those dead and the average injury to mortality ratio in

earthquakes has been marked at 3:1 (C. De Ville de Goyet and M.F Lechat, 1976).

Immediate effective medical response significantly influences injury outcome and

hence the overall health impact of earthquakes. Inadequate or mismanagement of

injuries may lead to disabilities and additionally contribute to the disability burden of

the population thus creating future vulnerabilities. This has important ramifications in


developing countries especially in Asia where most earthquakes strike in densely

populated areas (Guha-Sapir, 1986).

Lack of precise data from immediate aftermath is seen as a remarkably weak point in

overall disaster epidemiology (Guha-Sapir, 2006; Lechat, 1979). Compiling injury

data in very early stages of an earthquake is rather unwelcome as the focus, and

rightly so, is upon saving lives and up-scaling infrastructure to surge capacity for

adequate response.

Given that earthquakes are difficult to predict with a narrow pre warning period the

two points of entry for mitigating their health impacts include anti seismic building

and effective early rescue and first aid (Lechat 1989). The prohibitive costs of seismic

hazard proof construction compromises the adherence to and the implementation of

anti-seismic building codes in most developing countries. The information on injury

patterns from previous earthquakes then becomes crucial in guiding effective

preparedness and successful response programs in resource poor settings. However,

to date few studies have been completed at a population level in detail. An analysis of

existing studies revealed sparse, incomplete, inconsistent, non-standardized and often

missing data.

The rational of the paper is to further the knowledge of the injury epidemiology after

earthquakes to ensure appropriate timely response and help reduce and prevent

disabilities arising from mismanagement of injuries. The authors see the study as a

reasonable contribution for missing population-based non-fatal earthquake injury


epidemiology information and aim to understand the issues in quality and quantity of

injury data reporting and recording.

The last earthquake with its epicenter in India was the Kutch district, Gujarat

earthquake that struck on January 26, 2001 at 08.46 hrs at a magnitude of 6.9. The

epicenter was located in North-East of Bhuj city and the quake lasted 80-150 seconds

affecting over 8792 villages, in 171 Talukas (Governmental administrative units) of

the 21 districts in Gujarat (GOG, 2007b; IMD, NA). The worst affected regions

included predominantly rural areas of Bhuj, Anjar, Rapar, and Bachau. Significant

damage was reported from the urban areas of Ahmedabad, Gandhidham, Rajkot,

Jamnagar, Surat, Surendranagar and Morbi (GOG, 2007b). Human impact of the

earthquake included 20,000 deaths and over 1.6 million (including 20,717 serious)

injuries (Roy et al., 2002). The district of Kutch accounted for more than 92% of the

deaths and 82% of the total injuries reported (Benedick et al., 2001).

Primary failure of the health care facilities in the district due to structural damage

delayed much required early response. The G.K General civil hospital a 44 -year-old

structure (with 250- beds), a crucial secondary referral centre in Bhuj was completely

damaged and collapsed killing 150 patients, 7 nurses and 4 employees (Sharma,

2001). Three other main hospitals in Bhuj city, the Jubilee hospital, the Mental

hospital, and the Branch hospital also collapsed. Almost all of the hospital facilities in

Kutch at Bhuj, Anjar, Bachau and Gandhidham were destroyed including 2 hospitals,

8 community health centers, 42 primary health care centers, 37 dispensaries and 227

sub-centers (Bremer, 2003; Vatsa, 2001).


Bidada Sarvodaya hospital was an intact health care facility 60 kilometers from the

epicenter. This trust run, private, charitable, hospital organizes an annual health camp

(in January) for the Kutch district population for the last 20 years covering operative,

boarding, lodging and travel costs. Funded by Indian Diaspora mainly in the United

States many of them super-specialty consultants with medical students and

professionals from the larger cities in Gujarat join to assist with primary as well as

super-specialty care. Since the January 26, 2001 earthquake closely followed the

completion of the annual camp, the voluntary network was immediately activated.

Figure 1: The study site.

Materials and Methods

The study is a retrospective cross sectional analysis of secondary data obtained from the

Bidada Sarvodaya hospital, Kutch, Gujarat, India completed in August 2007. Approval

for the site visit was obtained from the Director, Bidada Rehabilitation Centre and the


Chairman of the hospital. Access to these data resulted from the author’s own work in the

Bidada hospital during the earthquake in 2001 within a relief and rehabilitation project.

Patients treated for earthquake related injuries and illnesses in the hospital over the ten-

week post quake period (January 26, 2001 to April 4, 2001) were included in the study.

Earthquake injuries were defined as those for which health care was sought, had resulted

from the January 26, 2001 earthquake, and did not result in death. In the authors opinion

the use of standard protocols Abbreviated Injury Severity (AIS) or the Injury Severity

Score (ISS) to code the injuries would defeat the precise purpose of the study to segregate

the injury types by distribution frequency and were hence not applied.

Data on the variables were extracted from the actual patient discharge case report forms.

A total of 1248 report series were reviewed by hand and analyzed for sex, age, village for

geographic origin, date of admission, date of discharge, diagnosis, injury types

(compound/ crush/ multiple/ soft tissue), anatomical side of injury, anatomical site of

injury, level and type of fractures, presence of infection, treatment imparted, hospital

procedure performed and outcome of treatment (including transfer to tertiary care). The

data obtained was entered in Microsoft™ Excel: Mac® for a descriptive analysis. All of

the 1248 discharge reports were included in the analysis for geographical origin and the

demographic data of age and sex. Of these 852 (68.2%) case reports were missing or

incomplete and hence were separated out. A total of 396 (31.7%) reports were

individually verified by the author. Although also incomplete, a careful crosschecking by

name, age, sex and origin of the patient and matched serial number to the corresponding

discharge case reports, sufficient details of additional 179 patients were recovered from

computerized information of earthquake related admissions. Thus a total of 575 (46.0%)


patient reports were analyzable for distribution of injury by frequency and 673 (53.9%)

case reports were excluded from the analysis due to insufficient data on the study

variables. The structure of the database is described in Figure 2.

Figure 2: Structure of the database.

Further, a bibliographic review of articles was performed. PubMed, Lexis Nexis, Medline,

Blackwell Synergy and Science Direct databases were used to search for the following

N - 1248

Verified 396

Non Verified852

Computerized data179 (21%)

Sufficient variabledata not available

673 (79%)

575 (396 +179) Analyzedfor distributionof injury type

673 excludedfrom injurydistribution

analysis 673

Analyzed forDemographic

data andGeographic

origin1248

N = 1248n = 575

31.7% 68.2%

100%

53.9%46.0%%


key words: earthquake, trauma, injury, epidemiology, seismology, field hospital, Gujarat,

musculoskeletal, disasters response and natural disasters. A total of 29 studies were

identified for review that reported earthquake morbidity data. These studies published

between 1976-2007 covered 18 locations in 13 countries and reported earthquakes

between 1976-2005 (See Annex II).

Results

Descriptive analysis of the dataset

Of the 1248 case reports 100 (8.0%) had missing information for the village of origin.

The hospital received patients from almost all of the affected Talukas (Government

administrative units). Over half of the patients (51%) came from the epicenter city of

Bhuj reason being the collapsed civil hospital (G.K General Hospital) in Bhuj.

Date of admission was available for 397 of the 575 patients (Figure 3). The maximum

admissions were reported on the second day after the earthquake.

The first admission was reported on January 26, 2001 and the last on 01.04.2001. The

first discharge was reported on January 27, 2001 and the last on April 15, 2001. A

total of 185 admissions (highest for a week) and 86 discharges were recorded in the

first week. From week two to ten they were uniformly balanced. On the day of the

earthquake only 6 admissions were recorded. There was an initial lag period before

the number of discharged per day increased. It peaked on day 5 (31.01.2001) after the

earthquake, which coincided with the admissions returning to baseline (day 6). There

was a classic second wave of admissions that peaked (15 admissions) on 4th of

February, day 9 after the earthquake. The number of discharges increased in the last


week (26.03.2001- 31.03.2001). No new admissions were recorded during this

period.

Figure 3: Admissions and discharge per day in the week following the

earthquake.

The date of admission (DOA) was missing in 33 reports and was assumed to be

26.01.2001 and these reports were included in the final analysis. The date of

discharge (DOD) was missing in 10 case report forms. These cases were excluded

from the analysis of duration of hospital stay. Thus a total of 420 patients were

analyzed for the duration of hospital stay, which ranged from 0 to 64 days. 35.3%

patients were hospitalized for less than a week and a majority of them (25.3%) stayed

between 2 to 4 days. The highest number of patients 45 (10.7%) stayed for a period of

three days followed by 40 (9.5%) who stayed for two days.

The mean age of the patients treated at the hospital was 30.7 years (± 20.87) with a

range of 0 to 90 years (See Figure 4). A total of 314 (25.1%) individuals were18

First Week185 Admissions

86 Discharge

02

5

15

8

32

17

76

32

65

46

12

75

12

0

10

20

30

40

50

60

70

26.01.2001 27.01.2001 28.01.2001 29.01.2001 30.01.2001 31.01.2001 01.02.2001 02.02.2001

Date

Nu

mbe

r of

Pat

ien

ts

Discharge

Admissions


years old or younger and 136 (13.0%) were 60 years or older. The data showed a

predominance of middle-aged males. The gender distribution of the study group was

uniform with 621 (49.7%) males and 551 (44.1%) females. Information pertaining to

the gender of the patient was missing in 76 (6.0%) reports and that pertaining to the

age was missing in 91 (7.2%) reports.

Figure 4: Demographic information of those treated.

N=1248

0

50

100

150

200

250

-99 0-4 05-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85-94

Age in years

Freq

uenc

y

U

M

F

-99 = Age Data not Available


Clinical analysis of the injuries

The injuries sustained to the left (173, 39%) were marginally higher than the right

side (154, 35%) in the 441 reports that identified the anatomical side of injury. The

incidence of axial and bilateral injuries was 67 (15%) and 47 (11%) respectively. A

total of 136 patients reported multiple injuries and compound injuries were reported

in 76 out of 575 patients.

Figure 5: Anatomical site of the injury

Of the 575 patients, extremity injuries (260, 46%) predominated followed by soft

tissue injuries that mainly included cuts, bruises, contusions and lacerations (119,

20%). Two cases of abdominal injury were of burst abdomen type. Head injury (12,

2%) included minor conditions mainly fractures of the mandible. Chest injuries (11,

2%) included multiple fractures of the ribs and three cases required inter-costal drain

tube insertion for restoring respiratory function. Spinal cord injuries were low(12,

SPINE12 (2%)

TRUNK 24 (4%)

NERVE INJURIES6 (1%)

SOFT TISSUE INJURIES 119 (20%)

MULTIPLE INJURIES 136(23%)

HEAD12 (2%)

ABDOMEN 2 (0%)

CHEST11(2%)

EXTREMITIES 260 (46%)

N=575


2%) and two cases of paraplegia reported. Nerve injuries included Brachial Plexus

Injury (3), Radial nerve (2) and Radio-Ulnar nerve (1) injuries respectively.

31 cases (5.3%) of crush injury were reported mainly of the hand and foot. The

distribution of the incidence of crush injury across the age groups was uniform with

no significant differences.

Figure 6: Frequency of fractures by fracture type.

A total of 293 cases of fractures were recorded. Lower extremity particularly Tibia-

Fibular (38.5%) and Femur (22.1%) fractures were most common followed by

Radius-Ulna fractures (9.5%). Ankle fractures (8.8%) were more common compared

to wrist (1.0%) fractures. Pelvic girdle fractures (6.8%) mainly included Acetabular

and Pubic-rami fractures. Spinal fractures (4.0%) were of burst vertebral nature.

WRIST3 (1%)

FEMUR65 (22%)

TIBIA FIBULA113 (38%)

RADIUS ULNA28 (10%)

ANKLE26 (9%)

HUMERUS21 (7%)

PELVIC GIRDLE20 (7%)

SPINAL12 (4%)

CLAVICLE5 (2%)

N= 293


Upper extremity fractures were less frequent at 48 (16.3%) than lower extremity

fractures 203 (69.2%) amongst the 293 reported fractures. 9 patients (3.0%) reported

fractures of both upper as well as lower extremities. Dislocations (13) were less

frequent than fractures including ankle dislocations (4, 31%) followed by hip (3,

23%), radius-ulna (2, 15%) and shoulder joint (2, 15%). Wrist and elbow dislocations

were reported one each (1, 8%).

In the treatment front operative treatment was more frequent than conservative.

Plaster of Paris (POP) cast for closed fractures (17%) was most common conservative

procedure. Open Reduction and Internal Fixation (17%) was the most common

surgical procedure followed closely by cleaning and debridement of wounds (15%).

This correlates to the finding that fractures and soft tissue injuries were the two major

types of injuries sustained. Ten percent of the cases required split thickness skin

grafting.

A total of 38 amputations were recorded. Below-ankle amputations involving the foot

(36%) were most frequent followed by below-knee amputations (26%). This was in

accordance to the crush injuries, which were more common in the foot and the most

common Tibia-Fibular fractures. The level of amputation was unknown in 3 (8%)

cases.


Figure 7: Treatment procedures performed at the hospital.

The most common general surgery procedure reported was Hernioplasty (10, 13.3%).

A total of 72 (12.1%) cases were considered unrelated directly to the earthquake by

the author. Of these conditions the single most common complaint was Hernia

followed by 9 (12.5%) cases of COPD, 4 (5.5%) cases of Tuberculosis, 4 (5.5%) of

Ischaemic Heart Disease, and 6 (8.3%) cases of diabetic complications. The operative

procedures in the general surgery domain and the general medical conditions were

reflective of baseline conditions requiring attention as a result of the destroyed health

care system.

DRESSING29 (5%)

OR EXTERNAL FIXATION5 (1%)

MEDICATIONS71 (13%)

SKIN GRAFTING55 (10%)

AMPUTATION38 (7%)

SUTURING12 (2%)

CONSERVATIVE16 (3%)

INTERCOSTAL DRAINAGE

3 (1%)

OPEN REDUCTION12 (2%)

INCISION AND DRAINAGE 18 (3%)

EXPLORATORY LAPRATOMY

24 (4%)

CLEANING AND DEBRIDEMENT

87 (15%)

POP CAST100 (17%)

OR INTERNAL FIXATION 94 (17%)

N= 575


Table 1: General Medical conditions treated at the hospital during 10-weekperiodGeneral medical conditionsCondition Frequency Condition FrequencyAbdominal pain 1 (1.3%) Hernia 10 (13.8%)Adenoma 2 (2.7%) Hydrocoele 2 (2.7%)Appendicitis 3(4.1%) C a r d i o V a s c u l a r

Disease4 (5.5%)

Acute Renal Failure (Diabetic) 1(1.3%) Infection 2 (2.7%)Burst Abdomen 1(1.3%) Lipoma 2 (2.7%)Carcinoma 1(1.3%) Low Back Pain 1 (1.3%)COPD 9(12.5%) Muscular pain 5 (6.9%)CTEV 2(2.7%) Neoplastic Growth 1 (1.3%)Cyst 1(1.3%) Rheumatoid Arthritis 1 (1.3%)Diabetes 6(8.3%) Syndactaly 1 (1.3%)Diarrhea 2(2.7%) Tuberculosis 4 (5.5%)Fever 3(4.1%) Torticollis 1 (1.3%)Fistula 1(1.3%) Urethral Stricture 2 (2.7%)Hemi-paresis 2(2.7%) Vaginal Tear 1 (1.3%)Total 72

A total of 78 of the 575 patients (13.5%) reported infected wounds at the time of

admission. A look at corresponding dates of admission revealed 41 (52.5%) cases in

the first week. Day three (29.01.2001) following the earthquake recorded the highest

number of admissions with infected wounds at 13 (16.6%). The distribution of wound

infections was substantially low for a disaster situation. The cases were uniformly

distributed over the 10-week period despite the increase in the number of admissions

in week 4, 7 and 8 respectively.


Figure 8: Reported wound infection including those at the time of admission ona weekly basis.

Analysis of patient outcome

A large majority of the patients (42%) underwent operative procedures. The

definitive outcomes are as described in Figure 9. The cause of death in these patients

was not ascertained as the case reports were sent to the coroners. The date of death

was known for three of the four patients and was 30.01.2001 (45 yrs, female, crush

injury), 01.02.2001(22 yrs, male) and 08.02.2001(70 yrs, female) respectively. The

fourth patient was 17-year-old male. A total of 102 patients were transferred for

tertiary care. Seventy-eight patients were transferred in the descending order of

frequency to Mandvi, Mumbai, Bhojay, Ahmedabad, Anand and Jamnagar cities.

Details for the destination of transfer for 24 cases (23%) was not available.

173

64

16

30 28

17

31 31

61

41

16

4 6 3 3 1 3 1 00

20

40

60

80

100

120

140

160

180

200

Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Week 9 Week 10

Weeks

Freq

uen

cy

Number ofAdmissonsInfection

DOA known= 397 Infections reported= 78


Figure 9: Definitive outcomes in the patient treatment.

Discussion

We report orthopaedic injuries particularly extremity fractures (78.0%) of the lower

limbs (tibia-fibula, femur, radius-ulna and humerus in this order of frequency) as the

most common injuries. Head, spine, and chest injuries were low at 2% each

respectively. The findings of the study are in accordance with the 29 published

studies reporting earthquake injury data (1976-2007) accessible for review.

We report the predominance of young males (25- 45 yrs) compared to other studies

from Gujarat. This anomaly is difficult to explain sufficiently. However, two of the

four studies from Gujarat reported more female patients than males, 1 study did not

mention this information and one found no gender difference. Similar inconsistencies

are reported in other studies that report gender as a vulnerability factor for injuries

EXPIRED4 (1%)

TRANSFERRED78 (14%)

ABSCONDED1 (0%) CONSERVATIVE

94 (16%)

CLOSED REDUCTION22 (4%)

OPERATIVE244 (42%)

DISCHARGED 132 (23%)

N= 575


which was not statistically correlated. Nearly half (15, 51.7%) of the 29 studies we

reviewed did not report gender differences in the patients. The number of female

patients was higher than the males in 5 and lower in 4 of the 29 studies. These data

were not mentioned in 6 of the studies. Independent age and gender associated risk

factors may explain increased injuries in females or children and elderly. (Shoaf et

al., 1998, Peek-Asa et al., 2003) A further investigation about the social structure and

gender equation of the society and its influence in health seeking behavior alongside a

thorough statistical analysis of injury data may provide useful information in

resolving these anomalies.

The mechanism of injury may explain some of the vulnerabilities. Our study could

not record the mechanism of injury due to absent data. This is a major drawback and

further research is required for formulating building codes and infrastructure

construction. Limited studies (17, 58.6%) correlate the cause and mechanisms of

injury to the nature of injury sustained. The most common causes of injury were

identified as ‘being trapped’ by 6, ‘falls’ by 3, and ‘being hit by falling debris or

objects’ by 6 of the 29 studies. (add references) Only one of the study investigated

human and environmental factors for causing injuries (Peek-Asa, 2003). However,

none of the studies provide concrete statistical evidence to assist in identifying

vulnerabilities. Three studies of the four from Gujarat attributed ‘being trapped’ and

‘falling debris’ as the main cause of injury. (reference)


The time of strike is associated with the vulnerability to injuries principally due to

level of alertness and body position at strike (C. de Ville De Goyet 1976). However,

even though the time of strike in 14 of the 29 (48.2%) studies was between midnight

and 06.00 am the nature of injuries reported were largely similar to the 9 other studies

reporting earthquakes occurring in later part of the day. Six studies did not report the

time of the earthquake in the publications. The Gujarat earthquake occurred at 08.46

am and the injury epidemiology we report is in general agreement with most studies.

A thorough investigation is required to identify vulnerability associated with the time

of strike and the nature of injury sustained.

The nature and seriousness of injuries sustained along with other vulnerabilities

determine mortality rate. A study of injury patterns amongst survivors only, needs to

be approached with great caution since most primary mortality (impact deaths) is

caused by serious injuries (Guha-Sapir, 1993). Given that earthquakes cause high

number of impact deaths/ primary mortality a study of the actual cause of death in

those found dead at rescue could yield substantial information about the serious

injuries sustained after an earthquake. Although the autopsies were not completed in

the Northridge earthquake, common injuries seen in those dead were head (48.5%),

thoracic (42.4%) followed by abdominal and lower extremity injuries (Peek-Asa et

al., 1998). However, autopsies are a rare possibility in the emergency phase

particularly in developing countries given that mass management of dead bodies is a

challenge in itself. Besides the emotional aspects and the logistical capacities

involved in conducting autopsies are resource consuming. (reference)


The number of non fatal serious injuries like chest and head injuries were limited to a

mere 2% in our study and only 2 abdominal burst injuries were reported. Other

important serious injuries of specific concern following earthquakes are Crush

Injuries and Crush Syndrome. Crush Injury (CI) occurs when a body part is subjected

to a high degree of force or pressure that leads to bleeding, bruising, increased

pressure in the compartment, fracture and lacerations (Medline Plus, NS-a). Thirty-

one (5.39%) cases of crush injuries were observed in our study. Children are more

prone to crush syndrome following crush injuries and also develop acute renal failure

at a higher rate. Since they are more difficult to diagnose both clinically and

diagnostically close monitoring of children is solicited to detect early signs (Iskit et

al., 2001). However, the age distribution for crush injuries was uniform in our study

with no significant increase in the pediatric or geriatric age group. The other aspect

with crush injuries is the secondary complications with infection, gangrene, and

amputation of the affected limb(s).i Crush injuries of the foot were more common in

our study and correspondingly 14 below ankle amputation (36%) were reported.

“Crush syndrome (CS) is the systemic manifestation of Rhabdomyolysis caused by

prolonged continuous pressure on muscle tissue. It is characterized by hypovolaemic

shock, hyperkalemia, acute renal failure and muscle necrosis (Dönmez et al., 2001).

Crush Syndrome is more common in concrete multi-story building collapse as seen in

the earthquakes in Japan and Armenia. In the study of morbidity after the Hanshin-

Awaji Earthquake of 1995, 262 cases of crush syndrome (of which 202 developed


acute renal failure requiring dialysis) were reported. The Armenian earthquake of

1988 reported 385 cases of Crush syndrome (Tanaka et al., 1999). Far lower numbers

were reported in Nicaragua, Guatemala and Iran due to the mud and adobe

construction and due to poor rescue operations. Reference Secondary deaths due to

crush syndrome are associated with lack of dialysis infrastructure to cope with the

mass casualties (Vanholder et al., 2007). This problem is however pertinent only

when the search and rescue level is effective enough to retrieve these patients alive in

large numbers, which was not the case in the Gujarat earthquake (Roy et al., 2002).

Less than two percent cases of crush syndrome were reported in Gujarat (Cooper,

2006). No cases of crush syndrome were recorded in our study. One case of diabetes

related Acute Renal Failure (ARF) was reported. This could be first due to the poor

rescue time after the Gujarat earthquake, second that CS is related to the building

design and most of the region affected was predominantly rural with mixed

construction designs and third that often first responders, rescue workers, paramedics,

and even untrained nephrologists are unfamiliar with recognizing early symptoms

(Dhar et al., 2007).

Secondary deaths (deaths after rescue) are relatively low following earthquakes and

have been associated with the efficiency of the search and rescue performance (De

Bruycker et al., 1983). If a greater number of serious injuries are rescued alive, then

the secondary mortality may rise proportionately and was seen where the total

percentage of head, abdominal and thoracic injuries constituted less than 7.5% of the

total injured but the secondary mortality in this group was the highest (Tanaka et al.,


1999). Our study reported four secondary deaths. The cause of death could not be

ascertained due to missing files and so the actual diagnosis and the clinical condition

for these patients remained unknown. The low mortality in our study can be

explained by the low number of serious injuries treated and the transfer of more

serious cases for tertiary care to Mumbai and Ahmedabad (102 transfers reported in

our study, see Figure 9).

Moderate and serious injuries requiring admission are better reported than minor soft

tissue injuries that are often treated at site or on an outpatient basis. Soft tissue

injuries are wounds which may be torn (lacerations), injury without laceration

(contusion), an injury transmitted through unbroken skin to underlying tissue, causing

rupture of small blood vessels and escape of blood into the tissue with resulting

discoloration (bruise) or a combination of these (Medline Plus, NA-b). These can be

effectively managed on site by simple first aid techniques to prevent unnecessary

overcrowding and overburdening of hospitals and to allow effective use of available

scarce resources. This leads to unintentional selective exclusion of minor injuries

being reported. This is critical given that most earthquake injuries are soft tissue

injuries resulting from falling objects or debris. (reference)

We reported single hospital inpatient data a criticism we raise for the Fifteen (51.7%)

of the 29 studies other studies that reported analysis of inpatient data and 19 (65.5%)

of them reporting single hospital data. However, we report 119 (20%) of the 575

cases with soft tissue injuries in our study. 15% of the fractures sustained were


compound injuries -open wounds with fractures. Proportionately, 15% of the surgical

operation theatre procedures were of cleaning and debridement of contaminated

wounds (see Figure 7). The reasons for high number of admissions for minor soft

tissue injuries at our hospital were, first the individual delay in seeking health care

that led to complications, second the long commuting distances which made travel for

most patients both logistically and monetarily less feasible for daily dressings and

third, more relevant that Bidada has a long-standing history of charity. People with

lost homes preferred to stay in the hospital tents where free food and accommodation

was provided free of cost for accompanying family members as well.

Soft tissue injuries are more prone to primary and secondary infections. Most injuries

after earthquakes were either contaminated and or infected due to delay in arrival to

health care. The potential of tetanus with open contaminated wounds particularly in

disasters is a concern (Waring and Brown, 2005). However, none of the 29 studies

reviewed mentioned risks of tetanus. Furthermore, limited information is available

about the hospital-acquired secondary infections after disasters particularly despite

that adequate hygiene in mass casualty situations is problematic (Öncul et al., 2002).

In Gujarat, generally low rates of secondary post-operative infections were reported.

Partly due to the high sensitivity of the rural population to antibiotics that were

largely unused in these areas (Roy et al., 2005). This finding was similar in our study.

Over the 10 weeks, the infection rates remained low probably also indicating

appropriate postoperative care. Most crush injuries in our study were managed


conservatively. However cases with gangrene (death of tissue due to inadequate

blood supply and superadded infections) required elective amputation (surgical

removal or loss of a body part). Amputations of the foot, below the ankle were

reported in 36% cases and Below Knee (BK) in 25% cases in our study. This is

explained by the common injuries sustained.

Amputations and traumatic paraplegia (paralysis of both lower limbs usually a result

of spinal fractures involving damage to the spinal nerves) are the most common

secondary outcomes after earthquake injuries. As per Government records over 268

amputees, about 500 spinal cord injuries which recovered completely and 104 cases

of complete spinal paraplegia were reported in Gujarat. There were several deaths in

the last seven years amongst the paraplegics and currently as per the Government

pension scheme records a total of 94 paraplegics were receiving stipend from the

pension scheme. We report 2 cases of spinal cord injury patients who later developed

paraplegia. Peripheral Nerve Injuries (PNI) leading to distal paralysis accounts for

significant disability. Nerve injuries reported in our study included Brachial Plexus

Injury (3), Radial nerve (2) and Radio-Ulnar nerve (1) respectively. Brachial Plexus

Injuries result mainly from traction injuries to the Axilla commonly seen during

rescue activities, when holding the arms one pulls up the body weight.

Physical disability is an enormous psychological and financial burden on the

population in terms of resources. Activities of daily living and more importantly,

income generation are greatly affected besides contributing to future vulnerabilities.


A study in Japan showed that individuals with physical disabilities were 5.6 times

more vulnerable to earthquake impacts (Osaki and Minowa, 2001). However,

disabilities both partial and permanent are often neglected after earthquakes.ii Since

orthopaedic trauma constitute the bulk of the injuries after earthquakes, non-union

and mal-union are a concern.

In post disaster conditions, physical disabilities often result from unintentional

negligence, inadequate or mismanaged injuries due to lack of infrastructure

availability at a mass scale. A study conducted two years after the Gujarat earthquake

reported 10% of the injuries (mainly spinal in multiple injury and double fractures)

were missed during diagnosis and over 30.5% patients underwent re-surgeries, 23%

had non-union and 12% experienced joint range of motion (ROM) restriction.

Another hospital experienced a 100% surgery failure rate in the 30 spinal cord injury

patients operated reasons for which are beyond the current scope. Reassessment and

review of all patients before discharge is necessary to detect missed injuries and more

importantly training in mass casualty management for surgeons and medical staff

should be mandatory (Emami et al., 2005).

In Gujarat, aggressive orthopedics especially with respect to implant operations was

observed along with serious compromises in implant type (Roy et al., 2005).

Symbolically, 76 of the 575 cases in our study (13%) were open compound fractures.

Ideally, external fixators are mandated in open contaminated fractures. However, The

number of external fixations in our study were 5 (1%) and in contrast internal


fixations were comparatively high at 94 (17%). A common problem faced by the

Bidada hospital was lack of continuous competent manpower. Postoperative

management was occasionally compromised due to the short-term commitments

offered by these volunteers. The surgeons often operated and left within a week or

visited in rotations. Often the coordination amongst the therapeutic plans of one

surgeon and the next one was difficult.

Inadequate fixation materials besides inexperienced surgeons (mainly registrars from

city teaching hospitals with short time commitments in Gujarat) may have

compromised treatment resulting in high number of re-surgeries. This explains the

presence of surgical cases at Bidada hospital; long after the initial phase was over. In

parts of Gujarat, external devices (new to local specialists) were used which were

initially effective. However, led to Osteomyelities (death of bone and muscle tissue

due to infections), due to delayed removal (Jain et al., 2003). The competence of local

orthopedic surgeons is critical when deciding complex therapies that achieve near

similar results to standard local practices. However, it may be incorrect to judge the

surgical decisions in disaster situations retrospectively. Especially in view of the

availability of fixation instruments at a specific time and the need for clinical

accuracy.

The preparedness and functional surge capacity of the health care system is crucial

and determines local response capacity. The ability to cope with the transient excess

need alongside baseline function is demanding. Time is an important factor as health


care needs are dynamic in nature and evolve (Figure 10). Most often the baseline

diseases and routine chronic conditions present at health care facilities throughout all

the emergency phases. The most common complaint not directly related to the

earthquake impact in our study was Chronic Obstructive Pulmonary Disease (COPD).

42% of the 72 patients with non-earthquake related health issues were operated for

Hernia and 13% for acute appendicitis. Besides these, Tuberculosis (TB), Diabetes

and Cardio Vascular cases.

0-3 days 3-10 days 10-14 days

EARTHQUAKE TIME

Irrespective of time after the earthquake

Figure 10: Dynamics of health needs following earthquakes.

Strengthening reporting of morbidity following earthquakes is therefore crucial to

improve preparedness. Injury epidemiology is especially critical to reduce impact and

to prevent mismanagement of injuries leading to disabilities. Although most studies

Follow-up careand surgicalcomplications

Return tobaselinefunction

Routine emergency cases including Accidents, Obstetrics andPediatric emergencies, acute exacerbations of routineconditions

Immediate medical care,maximal need Orthopedictrauma and soft tissueinjuries


including ours have small sample size (11 to 3619 cases) compared to actual numbers

of injured in the earthquakes, they contribute to current understanding of the field.

Methodological issues identified with recording and reporting patient data

Some of the methodological issues identified with reporting and recording patient

information are one, that majority of the studies (19, 65.5%) report single hospital

data. Drawing generalizations based on single hospital data may leave some aspects

un-addressed. Although, it is reassuring that the pattern of injuries we observed is

representative in general of earthquake injuries, large multi hospital studies should be

initiated to arrive at adequate statistical evidence base for policy decisions.

Two, studies reflect the findings in the individuals who actively seek medical care,

largely excluding those were unable to reach the facility. The proportion of cases

actively seeking medical care is greatly influenced by factors such as population

density, the time of strike, successful rescue, survival of the injured, availability of

transport facilities, distance to the nearest functional health facility and most

importantly availability of an intact operational health care facility with access. In a

rural setting especially as in Kutch, there is a strong possibility that access could have

been a challenge.


Three, often it is unclear if the studies reviewed the injuries in each patient or the total

number of injuries sustained. This is relevant as multiple injuries in single patients are

common.

Four, the correlation between mechanism of injury and injury severity and the

relationship between nature of severity and patient outcome is not sufficiently

reported.

Five, the sources of bias in recording injury data are high and more varied than those

known to affect normal medical records since wide variety of professionals from

different training schools complete patient reports in disasters (Sanchez-Carriallo,

1989).

Six, emerging concern about the close interactions between psychological symptoms

and physical manifestations is inadequately addressed. Seven of the 29 (24.1%)

studies reported the importance of considering it. Four studies reported the recorded

incidence in patients. One of four studies on Gujarat mentions psychological trauma.

Professional management of psychological stress is necessary to mitigate long-term

effects. Our study did not ascertain this aspect due to data in-availability.

Seven, disaster data has inherent “incomplete” nature. Table 2 represents the

percentage of missing data on variables in our study dataset. Further assessment is

mandated to detect under or over reporting of injury data.


Table 2: Missing data by dataset variable (N=1248)

Variable Dataavailable

Percentagemissing

Analysis of Injury Epidemiology 575/1248 53.9%Geographical origin 1148/1248 8.0%Date of Admission 397/1248 68.1%Date of Discharge 420/1248 66.3%Sex 1172/1248 6.0%Age 1157/1248 7.2%Anatomical site of Injury 575/1248 53.9%Anatomical side of Injury 441/575 23.3%Mortality cause 0/4 100%Outcome in transferred patients 78/102 23.5%Level of Amputation 35/38 7.8%

Eight, health outcome in the patients is insufficiently addressed. About half (51.7%)

of the studies discussed patient outcome and none discussed disability as an outcome

in treated patients. In our study data of those transferred to tertiary care after initial

care was not recorded. A total of 102 patients were transferred and the location of

transfer was missing in 24 patients. The case papers were missing and so the reason,

date and treatment imparted before transfer could not be assessed. This calls for

ensuring that a double copy of inpatient and outpatient records is maintained to

improve hospital records for future retrospective studies.

Nine, follow up time in the studies is inconsistent. Pre-morbid and chronic diseases in

patients with earthquake injuries is under reported.


Current challenges

There are general discrepancies in definitions, classification, and reporting of disaster

data internationally (Tschoegl et al., 2006). In the wake of increase in the frequency

of natural disasters and their human impacts a consensus is urgent on these

fundamental issues especially for earthquake morbidity data. International databases

report number of injuries collectively. None of them reported injury epidemiology.

Although a large number of scattered databases exist, currently no national disaster

database is active in India. As per Emergency Events Database (EM-DAT) at Center

for Research on the Epidemiology of Disasters (CRED), Brussels, the pilot project

“Indis Data” was launched in 2002 and expanded to 4 other states in 2005. However,

to date no standard guidelines exist for effective injury database management. Most

of the published studies report haphazard, patchy, inadequate, selective data and none

report disability burden resulting from injuries sustained from earthquakes. There is

no agreement on standardized methodology to assess or report the injuries. This

makes comparability of data across earthquakes within the country as well as

internationally difficult.

Evidence based response programmes need statistically significant data. Given the

challenges of non-standardized data reported from the past earthquakes in India as

well as internationally, the authors proposes a simple Patient Case Reporting Form

for earthquake injury data reporting in the early phases of the earthquakes.

Information provided in the basic form may assist in acquiring an overview of the

types, nature, mechanism and frequency of injuries sustained. A registry may be


maintained for the outpatient departments recording the same information. A state or

national level database should be maintained and regularly updated. Efforts in this

direction are underway in India with the National Disasters Management Authority,

Delhi. Incidentally, not all studies reporting injury data were publicly accessible.

Conclusion

Although substantial data on epidemiology of injuries following earthquakes

currently exists, drawing consolidated statistical conclusions is difficult due to non

standardized methodologies and approaches. Coordinated standardization of

recording and reporting earthquake injury data is therefore a pressing need to help

guide preparedness and emergency response programmes globally.


Annex I Variables mentioned in the studiesVariable Number of

studiesreporting

Variable asmostfrequentinjury

Rangeamongstthoseenrolled

4 GujaratEarthquakeStudiesfindings

BidadaHospital studyN=575

PsychologicalTrauma

7 0-32% 1 study Not assessed

Orthopaedicinjuries

8 2 (both inGujarat)

15-45% 42-45% 83.3%

General Surgery 2 6-13% Not reported 4.1%Medicine 6 1 30-79% 29.2% 12.5%Gynaecology 5 5-22 5-22% 0%Paediatric Cases 2 1 23-37% 22.2% 25.1%CardiovascularDisease

3 3-16% 15.7% 5.5%

Fractures 5 1 20-55% 38.7% 50.9%Crush Syndrome 6 1-26% 0-2% 0%Crush Injury 5 5-46% Low incidence 5.3%Acute Rena lFailure

6 2-69% 0% 0.1%

ExtremityInjuries

9 6 19-55% 50.4% 46%

Upper Extremity 10 Humerus 10-30% 11-13% 18.4% (RU)Lower ExtremityInjuries

10 7, Femur 30-54%, 1study 4%, 1study 7%

53-56% 78.0%(TF)

Clavicle 7 0 - 1 % , 1study 11%

Not reported 2%

Spinal 11 4-16% 8-17% 4%Pelvis 6 3-13% 11% 7%Trunk 2 1 6-55% 4%Head 12 0-30% 7% 2%Chest 7 3-19% 2% 2%Abdominal 9 0-15% 2% 0% (2)Burns 5 2-16% 10% 0%CompoundInjuries

2 4-6% Not reported 15%

Multiple Injuries 7 3-50% 43% 23%Infections 6 5-47% 8-19% 13.5%S o f t T i s s u eInjuries

16 6 10-83% 10-42% 20%

Peripheral NerveInjuries

6 1-9% 0 1%

Deaths 8 2-23% 1% 0.6%Amputations 7 1-20% 2-12% 6.6%Transfers 5 0-25% 7% 14%Others 9 3-77% 6% NoneUnknown 1 10% Not reported See Table ?


Annex II: Details of published papers reviewedFirst Author, Year Location Date Time Intensity

de Ville de Goyet, C 1976 Guatemala February 4, 1976 03.02 7.2

De Bruycker, M 1985 Southern Italy November 23, 1980 19.34 NM

Sanchez-Carriallo, C 1989 Mexico City September 19-20, 1985 Not Mentioned 8.1, 6.5

Sapir, DG, 1992 Yunnan Province, China November 6, 1988 21.03, 21.06 7.6, 7.2

Yoshimura, N 1996 Southern Hyogo, Japan, January 17, 1995 05.46 7.2

Tanaka, H 1997 Hanshin Awaji, Japan January 17, 1995 05.46 7.2

Armenian, H 1997 Armenia December 7, 1998 11.41 6.9

Shoaf, K 1998 Whittier Narrow, USA October 1987 Not Mentioned 5.9

Shoaf, K 1998 Loma Preita, USA October 1989 Not Mentioned 7.1

Shoaf, K 1998 Northridge, USA January 17, 1994 04.31 6.7

Peek –Asa, C 1998 Northridge, USA January 17, 1994 04.31 6.7

Mahue-Giangreco, M 2001 Northridge, USA January 17, 1994 04.31 6.7

Yi-Szu, W 2000 Chi Chi Taiwan September 21, 1999 01.47 7.3

Bar-Dayan, Y 2000 Marmara, Turkey August 17, 1999 03.04 7.4

Dönmez, O 2001 Marmara, Turkey August 17, 1999 01.37 7.4

Iskit, S 2001 Marmara, Turkey August 17, 1999 03.02 7.4

Öncül, O 2002 Marmara, Turkey August 17, 1999 03.02 7.4

Sarisözen, B 2003 Marmara, Turkey August 17, 1999 03.01 7.4

Bar-Dayan, Y 2005 Marmara, Turkey November 12, 1999 22.00 7.2

Roschin, G 2002 Kutch, Gujarat, India January 26, 2001 08.46 6.9

Jain, V 2003 Kutch, Gujarat, India January 26, 2001 08.46 6.9

Roy, N 2003 Kutch, Gujarat, India January 26, 2001 08.53 6.9

Roy, N 2005 Kutch, Gujarat, India January 26, 2001 08.46 6.9

Woersching, J.C 2003 El Salvador January -February 2001 Not Mentioned Not Mentioned

Emami, MJ 2005 Bam, Iran December 26, 2003 05.26 6.5

Naghi, TM 2005 Bam, Iran December 26, 2003 05.30 6.8

Dhar, S 2006 Kashmir, Pakistan October 8, 2005 09.20 IST* 7.6

Vanholder, R 2007 Kashmir, Pakistan October 8, 2005 08.50 PST** 7.6

Bozkurt, M 2007 Kashmir, Pakistan October 8, 2005 Not Mentioned 7.6

* Indian Standard Time, ** Pakistan Standard Time


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i This relates to the personal observation of the author during her work in Gujarat,after the earthquake.

ii This relates to the personal observation of the author during her work in Gujarat,after the earthquake.

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