SEARCH

SEARCH BY CITATION

Keywords:

  • aspiration;
  • disaster;
  • infection;
  • inhalation;
  • pulmonary

ABSTRACT

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. THE DIRECT EFFECTS OF NATURAL DISASTERS ON THE LUNG
  5. THE INDIRECT EFFECTS OF NATURAL DISASTERS ON THE LUNG
  6. CONCLUSION
  7. REFERENCES

As the world population expands, an increasing number of people are living in areas which may be threatened by natural disasters. Most of these major natural disasters occur in the Asian region. Pulmonary complications are common following natural disasters and can result from direct insults to the lung or may be indirect, secondary to overcrowding and the collapse in infrastructure and health-care systems which often occur in the aftermath of a disaster. Delivery of health care in disaster situations is challenging and anticipation of the types of clinical and public health problems faced in disaster situations is crucial when preparing disaster responses. In this article we review the pulmonary effects of natural disasters in the immediate setting and in the post-disaster aftermath and we discuss how this could inform planning for future disasters.


INTRODUCTION

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. THE DIRECT EFFECTS OF NATURAL DISASTERS ON THE LUNG
  5. THE INDIRECT EFFECTS OF NATURAL DISASTERS ON THE LUNG
  6. CONCLUSION
  7. REFERENCES

Barely a year passes without a major natural disaster occurring. Some recent examples of such damaging events include the 2004 Indian Ocean tsunami and the 2009 Sumatran and 2010 Haitian earthquakes (Fig. 1). Asia is particularly susceptible to the effects of natural disasters because of its geology, especially in relation to earthquakes, volcanoes and tsunamis, and its high population density. The victims of such disasters are not just those killed and injured but those displaced by the disaster and those whose access to health care is vastly compromised. All survivors of disasters are at increased risk of pulmonary disease. Such lung problems may occur as a direct result of the disaster itself, such as inhalation of tsunami water or volcanic dust, or may occur as a result of the post-disaster situation, for example, overcrowding leading to respiratory infections. This review discusses the range of these pulmonary problems with a view to informing and assisting those responding to disasters to better plan their responses. Although some major disasters are man-made, such as terrorist bombs, this review focuses only on natural disasters. The personal experience of the authors includes established leadership roles in training programmes for disaster preparedness and response plus service in Aceh and the Maldives following the 2004 Indian Ocean tsunami, Jogjakarta after the 2006 earthquake, Padang after the 2009 earthquake and Haiti after the 2010 earthquake, which cumulatively killed over half a million people and left many millions more displaced.

image

Figure 1. The effects of natural disasters on communities. The devastating effects of major natural disasters such as the 2004 Indian Ocean tsunami (a) or the 2009 Padang and 2010 Haitian earthquakes (b and c) on communities increase the risk of lung diseases via direct pulmonary injury or by increasing the risk of new/exacerbated pulmonary illnesses, particularly infections.

Download figure to PowerPoint

THE DIRECT EFFECTS OF NATURAL DISASTERS ON THE LUNG

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. THE DIRECT EFFECTS OF NATURAL DISASTERS ON THE LUNG
  5. THE INDIRECT EFFECTS OF NATURAL DISASTERS ON THE LUNG
  6. CONCLUSION
  7. REFERENCES

Many pulmonary complications that occur following natural disasters are a direct result of the disaster itself. The mechanism of insult to the lung as a consequence of a natural disaster will vary depending on the nature of events, but in broad terms can be considered under the following categories

  • • 
    Inhalation of respirable particles, smoke or other toxic gases
  • • 
    Aspiration of water and water borne pathogens
  • • 
    Direct trauma to the chest
  • • 
    Psychological effects causing respiratory symptoms

Inhalation

Fire

Smoke inhalation is common due to increased population exposure to wild fires.1 In addition, fire can be a major cause of morbidity and mortality in other natural disasters, accounting for almost 10% of deaths following the Hanshin-Awaji earthquake in 1995.2

Inhalational lung injury occurs in a round one-fifth of all burns victims; however, this number rises to around two-thirds if central facial burns are present.3 Lung injury accounts for the majority of fire-related deaths and the mortality in burns cases increases from 4% to around 30% if inhalation injury is present.4,5

Direct thermal injury to the upper airways is common but thermal injury to the lower airways is rare.6 As well as carbonaceous particulates (soot), wood smoke contains a diverse variety of respiratory irritants, including sulphur oxides, nitrogen oxides, phenols, formaldehyde and gaseous acids and alkalis,7 which cause mucosal inflammation and acute lung injury. Poorly water-soluble substances may cause delayed injury up to 48 h after exposure.3 In addition, absorption of systemic toxins such as carbon monoxide and hydrogen cyanide, generated through incomplete combustion, can result in impairment of oxygen delivery and cellular respiration.3,8

The manifestations of an acute smoke inhalational injury may not occur immediately, and can take several hours to develop.3 The CXR is an insensitive early indicator of smoke inhalation injury9 and serial X-rays may be required to detect the development of pulmonary oedema/ARDS. In intubated patients, direct inspection of the airways by bronchoscopy if available, allows visualization and assessment of the degree of mucosal injury.8

Early intubation should be considered for any patient where a significant inhalational injury is suspected and as such it is important that personnel with appropriate airway management skills are involved at an early stage.3,6 Nebulization of adrenaline and corticosteroids has been used to try and minimize airway oedema although there is no conclusive evidence of efficacy.3

Haze/smog

Natural wildfires are associated with deteriorations in air quality and elevated levels of atmospheric particulates, carbon monoxide and carbon dioxide.10 Although some have reported little or no impact of bushfires on daily mortality,11,12 or on presentation to hospital,13 other studies have shown that increases in levels of respirable particulates (<10 µm in diameter—PM10) following bushfires have been associated with increased respiratory symptoms, respiratory-related emergency department attendances or hospital admissions, particularly for those with asthma and COPD.10,14–18 The 1997 haze disaster in Indonesia caused by forest fires led to over 500 haze-related deaths in a 3-month period, with around 300 000 episodes of asthma, 50 000 cases of bronchitis and 1.5 million respiratory infections reported during this time.10,18 Furthermore, increases in PM10 levels in Malaysian cities during this period were associated with an increased risk of cardiovascular and respiratory deaths, especially in the elderly.19

Volcanic emissions

Post-mortem studies on victims killed by the 1982 St Helens volcanic eruption demonstrated that over 80% died as a result of asphyxiation due to bronchial obstruction following ash inhalation.20,21 Three patients caught in the periphery of the pyroclastic flow were treated in hospital for severe thermal and inhalational injuries, with ARDS developing as a fatal complication in two.22

Toxic volcanic gases, including carbon dioxide, sulphur dioxide, acid aerosols and hydrogen sulphide, can be released during eruptions and during non eruptive periods and it estimated they account for up to 4% of volcano-related deaths.23 Although observational studies have reported increased respiratory morbidity as a result of exposure to volcanic sulphur dioxide and acid aerosols,23,24 the highly heterogenous nature of these studies means that conclusions about the precise nature of the dose–response relationship are difficult to draw.23

In addition to gaseous emissions, volcanic eruptions release vast quantities of particulates into the atmosphere with consequent effects on air quality. Heavy ash falls occurred over 100 km from the Mt Helena eruption site with concentrations of respirable particulates in places reaching in excess of 30 times the level normally associated with significant harm21. Transient increases in emergency department attendances and respiratory admissions in those areas with heaviest ashfall were observed,21 and a past history of asthma or chronic bronchitis was the main risk factor for developing respiratory symptoms.25 Overall, despite the high concentrations of particulates measured in this instance, the health effects of the volcanic ash cloud appeared to be relatively minor.26 In other populations exposed to much lower levels of volcano derived airborne particulates, no significant excess of respiratory complaints was observed.27

Dust/building collapse

Although particles larger than 10 µm are usually filtered by the upper airways, particles above this size have been detected in the lungs of New York City firefighters exposed to the dust cloud after collapse of the World Trade Centre.28 This may in part be due to the extremely high density of exposure to these particles in this cohort, but may also reflect the fact that during exertion, mouth breathing is likely to occur, bypassing the filtering system of the nasal airways.29 Studies on rescue workers exposed to World Trade Centre dust have shown that intense exposures of a relatively short duration may cause both acute and chronic health effects. This group have developed high levels of chronic rhinosinusitus, chronic cough, persistent bronchial hyperreactivity and persistent declines in FEV1.29–31 The applicability of these findings to other instances of building collapse is unclear, although acute bronchospasm necessitating hospital admission following dust inhalation after an earthquake has been observed.32

Aspiration/near drowning

A sudden rise in water levels, such as during a tsunami, hurricane or a flash flood, is more likely to directly lead to drowning, aspiration and traumatic injury than a more gradual or predictable rise.33 Both occurrences can, however, cause massive disruption of infrastructure, sanitation and population displacement, with attendant health consequences in the medium to longer term.

Aspiration of water into the lung can lead to the introduction of infection, loss of alveolar surfactant, pulmonary oedema and ARDS.34 Pulmonary oedema is more common in salt water immersion than fresh water.35 In addition, vomiting of swallowed water can lead to the aspiration of gastric contents, especially if consciousness and airway protective reflexes are impaired. Signs of significant aspiration are usually detectable clinically, such that those with no signs of aspiration on presentation—no coughing, normal examination, normal blood gases and normal CXR—have a very low likelihood of developing pulmonary oedema or pneumonia and are unlikely to require further medical intervention.35

Following the 2004 tsunami, near drownings and trauma constituted most of the immediate post-disaster morbidity.36 One medical team reported on 37 patients who had aspirated soil-contaminated salt water.37 Around half of these developed aspiration pneumonia and eight patients developed ARDS (Fig. 2a). Pneumothorax (19%) and pneumomediastinum (8%) also occurred as a later complication in those receiving ventilatory support.37,38

image

Figure 2. Direct effects of disasters on lungs. Direct effects of disasters on the lung can include aspiration pneumonia, for example, following inhalation of contaminated tsunami water ((a) CXR of a patient with necrotizing pneumonia due to aspiration of tsunami water—‘tsunami lung’; image reproduced from Med. J. Aust. 2005; 182: 364, with permission.) or direct chest trauma, for example, following collapse of buildings during earthquakes ((b) rescuers resuscitate a women pulled from a collapsed building in Haiti).

Download figure to PowerPoint

The infective sequelae of near drowning reflect the microbial flora of the aspirated water. Different organisms may predominate in freshwater and saltwater aspirations, but aerobic Gram-negative bacteria, including pseudomonas and pseudomonas-like species, are often reported.34,39 In addition, colonizers of the oropharynx, such as streptococcus pneumoniae, staphylococcus aureus and anaerobes, may translocate to the lung during aspiration and cause infection. In one series, the majority of organisms isolated from blood or sputum culture of victims of the 2004 tsunami were Gram-negative bacteria, and included cases of Burkholderia pseudomallei, which causes melioidosis and is endemic in South-East Asia.37 As such, antibiotic therapy may need to include agents active against pseudomonas and any locally prevalent organisms. Antibiotics should be instituted in patients with fever, pulmonary infiltrates and/or signs of systemic toxicity.39 Although these signs can develop post aspiration in the absence of pneumonia,35 a conservative approach is warranted given the high morbidity associated with this complication and the likelihood of aspiration of contaminated water in most disaster settings. Fungal infection can also complicate near drowning and should be considered in patients not responding to antibacterial therapy, in those who develop pneumonia some time after the acute aspiration and in those who develop brain abscess or meningitis.39 Both pseudallescheria boydii and aspergillus species have been reported in this situation.39–41

Respiratory infections, alongside enteric infections, also predominate in the weeks following a flood or tsunami,42–44 reflecting a number of factors in addition to direct water borne carriage of pathogens, including population displacement, overcrowding and poor nutritional status. In addition, moulds may contaminate wet buildings following hurricane or flood damage, causing respiratory illness in susceptible individuals.45

Trauma

Trauma is a major cause of morbidity and mortality in a number of different disaster scenarios but it is the predominant mechanism of injury following earthquakes46,47 and constitutes the majority of earthquake-related hospital admissions in the first 24 h.46 The very young and the very old have the highest risk of mortality from an earthquake.48,49 Chest trauma is present in around 10% of earthquake casualties who present to hospital32,50,51 and management may be complicated by delays of several hours or even days in extricating some of those trapped under the rubble.32,51 (Fig. 2b) Chest injury is often accompanied by injuries to other organ systems and multiple injuries are associated with increased mortality.50

Excluding superficial abrasions to the chest, the spectrum of injuries seen in those with chest trauma following earthquakes includes: rib fracture (17–50%), which may be complicated by flail chest, pneumothorax (6–52%), haemothorax/haemopneumothorax (11–19%), subcutaneous emphysema (10%), pulmonary contusion; rupture of cardiovascular system and diaphragmatic rupture.32,50,51 In addition, pulmonary embolism and pneumonia may complicate chest trauma, and ARDS and renal failure can develop in those with severe polytrauma or crush injuries.

Management of the trauma patient should follow in accordance with the advanced trauma life support (ATLS) guidelines and is beyond the scope of this review.52 In addition to immediate airway management and cardiovascular support, tube thoracostomy is one of the most important thoracic interventions in the acute setting.47 Tube thoracostomy was the second most common procedure (behind fasciotomy) performed in one hospital following the 1999 earthquake in Turkey, occurring in 34/263 (13%) of patients.46

Psychological

Natural disasters are times of immense psychological stress. Acute psychological reactions are ubiquitous following a natural disaster and may develop into symptoms resembling post-traumatic stress disorder (PTSD) and depression within days of the acute event.53 Physical manifestations of these disorders can occur and respiratory symptoms attributable to stress ranging from relatively simple anxiety syndromes through to PTSD can occur in victims, survivors and, importantly, in rescue and aid workers. For example, one-third of firefighters have been described as developing PTSD-like features following a bushfire disaster.54

THE INDIRECT EFFECTS OF NATURAL DISASTERS ON THE LUNG

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. THE DIRECT EFFECTS OF NATURAL DISASTERS ON THE LUNG
  5. THE INDIRECT EFFECTS OF NATURAL DISASTERS ON THE LUNG
  6. CONCLUSION
  7. REFERENCES

Communicable respiratory diseases

Communicable diseases, including those of the lung, commonly emerge following disasters. This occurs due to population displacement, poor availability of safe water and sanitation facilities, overcrowding and the non-functional state of health-care services in affected areas. These are often compounded by a poor underlying health and low vaccination status of the affected population55

Overcrowding is a common problem in populations displaced by natural disaster and may facilitate the transmission of communicable diseases, particularly respiratory and gastrointestinal diseases. Loss of housing forces people into emergency shelters, tents, community building with limited daily living support. The World Health Organization recommends 30 m2 living place per person-plus the necessary land for communal activities, agriculture and livestock-as a minimum overall figure for planning a camp layout. Of this total living space, 3.5 m2 is the absolute minimum floor space per person in emergency shelters.56 Beds and mats should be separated for a minimum distance of 0.75 m.57,58 These requirements unfortunately cannot be fulfilled when the disaster affects developing countries with limited capacity to respond, leading to increased frequency of respiratory infections. In addition, these infections are often severe as lack of access to health services and to antimicrobial agents for treatment increases the risk for death from acute respiratory infection (ARI) following disasters.

Acute respiratory infections are a major cause of illness and death among displaced populations and often occur in the first 3–5 days following the emergency.59 Cumulative data from Aceh following the 2004 Indian Ocean tsunami showed that by week 12, 62% of the 184 864 documented consultations were for cases of respiratory infections. Children are often affected in these situations—6599 cases from the above dataset were children less than 5 years of age and 18 613 were children over 5 years of age. A similar situation was recorded in Sri Lanka following the tsunami.60,61

The ARI due to viral diseases in crowded refugee/displaced population settings spreads quickly. Overcrowding is an important pulmonary risk for healthy displaced survivors (Fig. 3a), especially children (Fig. 3b,c) and also for those injured and for those caring for them in makeshift hospitals because of the ease of spread of organisms (Fig. 3d). This can be prevented by reducing the concentration of infectious respiratory aerosols in the air and by reducing the presence of contaminated surfaces and items with the following methods:62

image

Figure 3. Indirect effects of disasters—infection/overcrowding. Disasters typically increase the risk of transmissible respiratory infections amongst healthy survivors because of the need to provide urgent but overcrowded temporary housing ((a) tent city following the Haiti earthquake). Children are particularly at risk of severe pulmonary infections ((b) Haitian orphan with respiratory infection and (c) child with severe lobar pneumonia following the Indian Ocean tsunami). This increased risk of transmissible pulmonary infection also applies in the crowded temporary medical facilities established ((d) temporary tent hospital following the Padang earthquake).

Download figure to PowerPoint

  • 1
    Adequate ventilation to ensure good air flow and prevent increased concentrations of respiratory particles.
  • 2
    Separating infected patients from other patients to reduce the risk of transmission of infection from the source patient to others by reducing direct or indirect contact transmission.
  • 3
    Limiting contact between infected and uninfected people, such as nonessential health-care workers and visitors, which reduces the risk of transmission to susceptible individuals.
  • 4
    Spatial separation (>1 m) between patients including head-to-toe positioning of patient beds if space is limited.
  • 5
    Cleaning and disinfection of contaminated surfaces and items.

Rescuers and health workers may also be at increased risk of ARI. For example, after the 2008 Wenchuan, China earthquake, victims and rescuers lived in close proximity in temporary shelters with crowded conditions with poor ventilation. The rate of ARI among the victims and rescuers that lived in these shelters was very high, particularly acute upper respiratory infections.63

Transmission of pulmonary tuberculosis (TB) is also increased in displaced populations following natural disasters. The transmission of TB is facilitated by recirculation of exhaled air, closeness and duration of contact to persons with TB, low exposure to ultraviolet light and poor nutritional status. This is especially so in children, in whom risk of TB is usually followed by exposure to adult TB64.

Transmission rates can also increase following disasters because victims default from TB treatment programmes, particularly if they are part of a mobile refugee population.65 Thus, it is important to maintain adequate antituberculosis treatment programmes following disasters. Acquired TB drug resistance can also occur post disasters due to poor adherence to treatment, inappropriate prescription, irregular drug supply and poor drug quality. A cluster of four cases of multi-drug-resistant TB in Austria between June 2005 and April 2006 was identified as the transmission arose from single primary case, a 36-year-old Chechen who immigrated illegally to Austria and was relocated in a hostel and had no clinical follow-up visit and no controls of drug intake.66 The lessons learned from Hurricane Katrina, New Orleans 2005 provides an example of how to minimize the risk of transmission of TB—the strategic elements included: (i) supplying 2 weeks or 30 days of medicine to each patient who was likely to relocate; (ii) providing each patient with a personal card listing contact numbers of the TB programme personnel; (iii) sending a list of patient names to the National Tuberculosis Control Association for sharing with programme officials in other states; and (iv) establishing a referral centre.67

Measles can have a major impact on health following disasters, especially those that involve massive population displacements. It is spread by respiratory contact with fluids from an infected person's nose and mouth. The World Health Organization recognizes refugees as one of the highest-risk groups for measles outbreaks. Several outbreaks have been reported among refugees and other emergency settings due to their characteristic massive population displacements, overcrowding, high population densities and low vaccination coverage.60 Other factors include the continuous arrival of new displaced persons, poor vaccination status in the surrounding community, narrow target age group for vaccination campaign, primary vaccination failure due to vaccination in lower age group, lower vaccination coverage in high-risk group, one time measles vaccination strategy, frequent visit of displaced persons between camps, frequent movement of refugees in the neighbouring community and in other camps, malnutrition and famine, insecurity and inability to target zones, no or limited surveillance system, lack of laboratory confirmation of suspect cases and association with other diseases. Following the eruption of Mount Pinatubo in the Philippines in 1991, measles accounted for 25% of the morbidity and 22% of the mortality among the more than 100 000 people displaced. As expected, the high morbidity and mortality rates in that group were attributed to crowding and very low immunization coverage plus cultural barriers to care.68 The experience amongst displaced persons in Sudan is similar, with measles accounting for 53% of deaths, with the highest proportion occurring in children. Because international agencies are now implementing measles vaccine campaigns in emergency settings and camps, measles outbreaks have been less frequently reported since 1990.69 Kouadio et al. suggest that control of measles in displaced population settings can be achieved by a vaccination campaign based on a combination of local epidemiological factors, targeting the priority age group of 6 months to 5 years, extending then to 15 years and older only if the budget allows it. They also suggest giving measles vaccine together with vitamin A supplements to malnourished children (100 000 UI on day 1 and day 2 for children aged 6 months to 12 years and 200 000 UI on day 1 and day 2 for those aged >12 years), vaccinating refugees immediately upon arrival in camps, promoting simultaneous vaccination campaigns within all refugee populations in neighbouring camps plus the surrounding host community population, as well active case detection to supplement passive surveillance for early case detection for rapid response and appropriate treatment for infectious complications (pneumonia, severe diarrhoea, encephalitis and severe malnutrition).70

Collapse of health systems following natural disasters

Local health-care provision is often compromised following disasters (Fig. 4). This might be because of destruction of the health facilities, death or injury of staff, destruction of supplies of medications and equipment and loss of power and water supply. Following the 2004 tsunami, 53 of 244 health facilities in Aceh province were destroyed or severely incapacitated and 42 of 481 health professionals died.60 Furthermore, other facilities were rendered non-functional for weeks because of the mud and debris that filled them. In addition, health-care staff were often understandably ‘distracted’ by the need to find and care for their own families. Thus it was difficult to provide the population with medical services in hospitals and in primary health cares. In Sri Lanka, 92 health facilities, including 35 hospitals, were destroyed by that tsunami and in the Maldives, one regular hospital, two atoll hospitals and 20 health centres were destroyed.59,71 In 2007, an earthquake off the coast of Peru caused significant damage to 24 (60%) of the regional health facilities with 10% completely destroyed, 13% with significant damage (defined as repairable, but with at least partial collapse of walls or roof) and 38% intact with some structural damage (defined as having cracks or shifts in the walls or foundation). However, as was learnt in Haiti following the 2009 earthquake, cracks in health facilities can appear benign but may actually render the building vulnerable to collapse in subsequent tremors, that is, health-care delivery remains delayed until structural inspections by experts can be completed and support provided where needed.72

image

Figure 4. Collapse of health infrastructure. Not only are individuals at increased risk of pulmonary disease following disasters, but the health infrastructure required to manage these illnesses is often unserviceable. Shown is an emergency clinic being conducted outside a collapsed community health clinic north of Padang following the 2009 earthquake.

Download figure to PowerPoint

Natural disasters may also impact on pre-existing respiratory diseases by disrupting the treatment of chronic respiratory problems, for example, via loss of power for those requiring oxygen or nebulizations, by destroying health services and infrastructural and by removing access hospitals and clinics, for example, for physiotherapy and early intervention for disease exacerbation.71

Disaster preparedness and respiratory disease

Although respiratory conditions are common post disaster, the treatment required to manage them is often absent. A necessary part of an effective response to any natural disaster is having the required equipment and pharmaceuticals that are needed to manage and treat the resulting conditions that will predictably occur. This is difficult in developed countries, where health-care logistic systems have moved to ‘just-in-time’ supply, which, while both efficient and fiscally responsibly in normal operations, leaves little redundancy.73 Having medical caches within hospitals are both burdensome and difficult to maintain. National stockpiles can take up to 36 h to be delivered, as demonstrated during Hurricane Katrina in 2005.74

In respiratory disease in disasters, there is a requirement for supplies of equipment and medications for both acute and chronic disease. The exact requirements will vary, depending on the type of disaster, the climatic conditions, the vaccination status and the general health of the population. Respiratory drugs were the most commonly used drugs post the 2003 Bam earthquake in Iran, albeit in a cold and poor sheltered environment,75 while acute respiratory diseases made up between 13 and 25% of all consultations in the first 5 weeks post the 2004 Asian tsunami.76

The types of medications and equipment required to be stockpiled for a natural disaster is less clear, but are often focused on ARI. Various reviews have highlighted that the medications required should be a mix of pharmaceutical agents designed to treat both the acute repiratory infections, which are common after many types of disasters, and exacerbations of chronic repiratory diseases.77 Following Hurricane Andrew in 1992, field hospitals were reporting depletion of all their antibiotics within 24 h.78 Drugs for more chronic respiratory diseases, including asthma and chronic obstructive pulmonary disease, become increasingly important, particularly as the ARI recede. Following the eruption of Mt Pinatubo in the Phillipines, the majority of medications dispensed to the 20 000 evacuees were for chronic medical conditions.79

The research on what medications should be stockpiled is less clear. Apart from basic antibiotics the stockpiles may need to include a range of antibiotics, such as imipenem, ciprofloxacin, azithromycin and vancomycin, to treat unusual pathogens seen in near drownings from tsunami and floods.76 Bronchodilators may be required acutely for exacerbations of asthma or isolated cases of bronchospasm, which may be related to smoke inhalation from bushfires.80 A review of data from the 2004 National Hospital Ambulatory Medical Care Survey in the USA identified that the most likely chronic respiratory disease requirements for a disaster were bronchodilators, oral steroids and antibiotics.81

Given the critical care demands, the stockpiling of ventilators, particularly for traumatic injury post disaster, is certainly recommended, although little is known about the success of such stockpiling.82 Given that there will be a number of roles for these ventilators, including movement from the scene, movement between hospitals and in-hospital care, any stockpile should have a mix of both transport and critical care ventilators.82 Other equipment is more readily available in the hospitals, but stockpiles of thoracostomy trays, for tube or needle thoracostomy procedures, for thorax injuries in earthquakes particularly, may be useful.47

Transport of respiratory patients after disasters

Transport of any respiratory patients post disaster will depend on the various modalities of transport and the priority of the patients. In large countries like Australia, where the event has occurred outside a major urban centre, this transport will principally be by aeromedical evacuation. This may be by rotary wing aircraft, if the disaster is relatively close to a city, or by fixed wing aircraft, if it is more remote. Apart from military aircraft, most medical evacuation aircraft are small, only usually able to take a maximum of two critically ill patients. Military aircraft, such as the C-17 or C-130, while able to carry many more patients, are a limited resource. In addition to limited availability, they are often limited as to what airstrips they can land at and the availability of critical care staff.83

In many developed countries, there are well-established protocols for activating and using military aeromedical evacuation teams in mass casualty incidents. These teams need to be activated early, are highly trained and are generally equipped to the level of a mobile critical care facility.84 Their focus is on advanced airways management and respiratory support, including oxygen and mechanical ventilation, as well as haemorrhage control and careful monitoring.84 Such transport, while important for patient care, may have a significant associated risks, with up to 34% of patients reported having an adverse event.85 The transport of critically ill mechanically ventilated patients by helicopter, however, is rarely associated with major adverse events, although there may be a greater risk of minor adverse events on longer fixed-wing flights.86

There are significant challenges, particularly with respiratory patients, on longer flights. Oxygen supplies are limited and patient management must include planning for expected consumption and patient deterioriation.87 Electrical power is often restricted, including battery life, which may impact on the monitoring of a patient in a noisy environment and the availability of diagnostic tests, and the physiological impacts of the decrease in ambient pressure (usually equivalent to 2000 to 2500 m a.s.l.), low humidity and the acceleration and deceleration of the aircraft need to be factored into the management of the patient, even when ventilated.88 With good planning and proper management, however, most respiratory patients, including acute respiratory distress syndrome patients, can be adequately ventilated and oxygenated, even on long flights.88

CONCLUSION

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. THE DIRECT EFFECTS OF NATURAL DISASTERS ON THE LUNG
  5. THE INDIRECT EFFECTS OF NATURAL DISASTERS ON THE LUNG
  6. CONCLUSION
  7. REFERENCES

In conclusion, pulmonary problems are major causes of morbidity and mortality following natural disasters. It is therefore vital that disaster preparedness and response teams are aware of these problems. Pulmonologists are well placed to provide advice and training to such teams. Such training programmes, which are usually administered by professional medical societies, government bodies or non-government organizations, typically welcome the assistance of pulmonologists in informing disaster response teams of the range and management of the pulmonary diseases listed above and, where feasible and appropriate, helping serve on such teams.

REFERENCES

  1. Top of page
  2. ABSTRACT
  3. INTRODUCTION
  4. THE DIRECT EFFECTS OF NATURAL DISASTERS ON THE LUNG
  5. THE INDIRECT EFFECTS OF NATURAL DISASTERS ON THE LUNG
  6. CONCLUSION
  7. REFERENCES
  • 1
    Sim M. Bushfires: are we doing enough to reduce the human impact? Occup. Environ. Med. 2002; 59: 2156.
  • 2
    Nakamori Y, Tanaka H, Oda J et al. Burn injuries in the 1995 Hanshin-Awaji earthquake. Burns 1997; 23: 31922.
  • 3
    Toon MH, Maybauer MO, Greenwood JE et al. Management of acute smoke inhalation injury. Crit. Care Resusc. 2010; 12: 5361.
  • 4
    Shirani KZ, Pruitt BA Jr, Mason AD Jr. The influence of inhalation injury and pneumonia on burn mortality. Ann. Surg. 1987; 205: 827.
  • 5
    Smith DL, Cairns BA, Ramadan F et al. Effect of inhalation injury, burn size, and age on mortality: a study of 1447 consecutive burn patients. J. Trauma 1994; 37: 6559.
  • 6
    Marko P, Layon AJ, Caruso L et al. Burn injuries. Curr. Opin. Anaesthesiol. 2003; 16: 18391.
  • 7
    Larson TV, Koenig JQ. Wood smoke: emissions and noncancer respiratory effects. Annu. Rev. Public Health 1994; 15: 13356.
  • 8
    Endorf FW, Gamelli RL. Inhalation injury, pulmonary perturbations, and fluid resuscitation. J. Burn Care Res. 2007; 28: 803.
  • 9
    Lee MJ, O'Connell DJ. The plain chest radiograph after acute smoke inhalation. Clin Radiol. 1988; 39: 337.
  • 10
    Kunii O, Kanagawa S, Yajima I et al. The 1997 haze disaster in Indonesia: its air quality and health effects. Arch. Environ. Health 2002; 57: 1622.
  • 11
    Vedal S, Dutton SJ. Wildfire air pollution and daily mortality in a large urban area. Environ. Res. 2006; 102: 2935.
  • 12
    Emmanuel SC. Impact to lung health of haze from forest fires: the Singapore experience. Respirology 2000; 5: 17582.
  • 13
    Smith MA, Jalaludin B, Byles JE et al. Asthma presentations to emergency departments in western Sydney during the January 1994 Bushfires. Int. J. Epidemiol. 1996; 25: 122736.
  • 14
    Kunzli N, Avol E, Wu J et al. Health effects of the 2003 Southern California wildfires on children. Am. J. Respir. Crit. Care Med. 2006; 174: 12218.
  • 15
    Tham R, Erbas B, Akram M et al. The impact of smoke on respiratory hospital outcomes during the 2002–2003 bushfire season, Victoria, Australia. Respirology 2009; 14: 6975.
  • 16
    Johnston FH, Bailie RS, Pilotto LS et al. Ambient biomass smoke and cardio-respiratory hospital admissions in Darwin, Australia. BMC Public Health 2007; 7.
  • 17
    Chen L, Verrall K, Tong S. Air particulate pollution due to bushfires and respiratory hospital admissions in Brisbane, Australia. Int. J. Environ. Health Res. 2006; 16: 18191.
  • 18
    Aditama TY. Impact of haze from forest fire to respiratory health: Indonesian experience. Respirology 2000; 5: 16974.
  • 19
    Sastry N. Forest fires, air pollution, and mortality in southeast Asia. Demography 2002; 39: 123.
  • 20
    Eisele JW, O'Halloran RL, Reay DT et al. Deaths during the May 18, 1980, eruption of Mount St. Helens. N. Engl. J. Med. 1981; 305: 9316.
  • 21
    Baxter PJ, Ing R, Falk H et al. Mount St Helens eruptions, May 18 to June 12, 1980. An overview of the acute health impact. JAMA 1981; 246: 25859.
  • 22
    Parshley PF, Kiessling PJ, Antonius JA et al. Pyroclastic flow injury. Mount St. Helens, May 18, 1980. Am. J. Surg. 1982; 143: 5658.
  • 23
    Hansell A, Oppenheimer C. Health hazards from volcanic gases: a systematic literature review. Arch. Environ. Health 2004; 59: 62839.
  • 24
    Longo BM, Yang W, Green JB et al. Acute health effects associated with exposure to volcanic air pollution (vog) from increased activity at Kilauea Volcano in 2008. J. Toxicol. Environ. Health A 2010; 73: 137081.
  • 25
    Baxter PJ, Ing R, Falk H et al. Mount St. Helens eruptions: the acute respiratory effects of volcanic ash in a North American community. Arch. Environ. Health 1983; 38: 13843.
  • 26
    Buist AS, Bernstein RS, Johnson LR et al. Evaluation of physical health effects due to volcanic hazards: human studies. Am. J. Public Health 1986; 76: 6675.
  • 27
    Yano E, Yokoyama Y, Higashi H et al. Health effects of volcanic ash: a repeat study. Arch. Environ. Health 1990; 45: 36773.
  • 28
    Fireman EM, Lerman Y, Ganor E et al. Induced sputum assessment in New York City firefighters exposed to World Trade Center dust. Environ. Health Perspect. 2004; 112: 15649.
  • 29
    Prezant DJ, Levin S, Kelly KJ et al. Upper and lower respiratory diseases after occupational and environmental disasters. Mount Sinai. J. Med. 2008; 75: 89100.
  • 30
    Banauch GI, Alleyne D, Sanchez R et al. Persistent hyperreactivity and reactive airway dysfunction in firefighters at the World Trade Center. Am. J. Respir. Crit. Care Med. 2003; 168: 5462.
  • 31
    Aldrich TK, Gustave J, Hall CB et al. Lung function in rescue workers at the World Trade Center after 7 years. N. Engl. J. Med. 2010; 362: 126372.
  • 32
    Ozdogan S, Hocaoglu A, Caglayan B et al. Thorax and lung injuries arising from the two earthquakes in Turkey in 1999. Chest 2001; 120: 11636.
  • 33
    Du W, FitzGerald GJ, Clark M et al. Health impacts of floods. Prehospital Disaster Med. 2010; 25: 26572.
  • 34
    Bierens JJ, Knape JT, Gelissen HP. Drowning. Curr. Opin. Crit. Care 2002; 8: 57886.
  • 35
    van Berkel M, Bierens JJ, Lie RL et al. Pulmonary oedema, pneumonia and mortality in submersion victims; a retrospective study in 125 patients. Intensive Care Med. 1996; 22: 1017.
  • 36
    Yamada S, Gunatilake RP, Roytman TM et al. The Sri Lanka tsunami experience. Disaster Manag. Response 2006; 4: 3848.
  • 37
    Kongsaengdao S, Bunnag S, Siriwiwattnakul N. Treatment of survivors after the tsunami. N. Engl. J. Med. 2005; 352: 26545.
  • 38
    Kateruttanakul P, Paovilai W, Kongsaengdao S et al. Respiratory complication of tsunami victims in Phuket and Phang-Nga. J. Med. Assoc. Thai. 2005; 88: 7548.
  • 39
    Ender PT, Dolan MJ. Pneumonia associated with near-drowning. Clin. Infect. Dis. 1997; 25: 896907.
  • 40
    Vieira DF, Van Saene HK, Miranda DR. Invasive pulmonary aspergillosis after near-drowning. Intensive Care Med. 1984; 10: 2034.
  • 41
    Fisher JF, Shadomy S, Teabeaut JR et al. Near-drowning complicated by brain abscess due to Petriellidium boydii. Arch. Neurol. 1982; 39: 5113.
  • 42
    Kondo H, Seo N, Yasuda T et al. Post-flood—infectious diseases in Mozambique. Prehospital Disaster Med. 2002; 17: 12633.
  • 43
    Schwartz D, Goldberg A, Ashkenasi I et al. Prehospital care of tsunami victims in Thailand: description and analysis. Prehospital Disaster Med. 2006; 21: 20410.
  • 44
    Kunii O, Nakamura S, Abdur R et al. The impact on health and risk factors of the diarrhoea epidemics in the 1998 Bangladesh floods. Public Health 2002; 116: 6874.
  • 45
    Brandt M, Brown C, Burkhart J et al. Center for Disease Control and Prevention. Mold prevention strategies and possible health effects in the aftermath of hurricanes and major floods. MMWR 2006; 55.
  • 46
    Bulut M, Fedakar R, Akkose S et al. Medical experience of a university hospital in Turkey after the 1999 Marmara earthquake. Emerg. Med. J. 2005; 22: 4948.
  • 47
    Gautschi OP, Cadosch D, Rajan G et al. Earthquakes and trauma: review of triage and injury-specific, immediate care. Prehospital Disaster Med. 2008; 23: 195201.
  • 48
    Sullivan KM, Hossain SM. Earthquake mortality in Pakistan. Disasters 2010; 34: 17683.
  • 49
    Liang NJ, Shih YT, Shih FY et al. Disaster epidemiology and medical response in the Chi-Chi earthquake in Taiwan. Ann. Emerg. Med. 2001; 38: 54955.
  • 50
    Toker A, Isitmangil T, Erdik O et al. Analysis of chest injuries sustained during the 1999 Marmara earthquake. Surg. Today 2002; 32: 76971.
  • 51
    Yoshimura N, Nakayama S, Nakagiri K et al. Profile of chest injuries arising from the 1995 southern Hyogo Prefecture earthquake. Chest 1996; 110: 75961.
  • 52
    American College of Surgeons Trauma Programs. [Accessed 31 Jan 2011.] Available from URL: http://www.facs.org/trauma/index.html
  • 53
    Davidson JR, McFarlane AC. The extent and impact of mental health problems after disaster. J. Clin. Psychiatry 2006; 67 (Suppl. 2): 914.
  • 54
    McFarlane AC, Atchison M, Rafalowicz E et al. Physical symptoms in post-traumatic stress disorder. J. Psychosom. Res. 1994; 38: 71526.
  • 55
    Watson JT, Gayer M, Connolly MA. Epidemics after natural disasters. Emerg. Infect. Dis. 2007; 13: 15.
  • 56
    Noji EK. Public health in the aftermath of disasters. BMJ 2005; 330: 137981.
  • 57
    Western KA. Epidemiological surveillance after natural disaster. Pan American Health Organisation Scientific Publication. 1982; 420: 48.
  • 58
    Root G. Population density and spatial differentials in child mortality in Zimbabwe. Soc. Sci. Med. 1997; 44: 41321.
  • 59
    Moving beyond the tsunami—the WHO story, Chapter 1: The emergency and its aftermath. pp. 6–39. [Accessed 11 Oct 2010.] Available from URL: http://whqlibdoc.who.int
  • 60
    Epidemic-prone disease surveillance and response after the tsunami in Aceh Province, Indonesia. Wkly Epidemiol. Rec. 2005; 80: 1604.
  • 61
    Lim JH, Yoon D, Jung G et al. Medical needs of tsunami disaster refugee camps. Fam. Med. 2005; 37: 4228.
  • 62
    Gayer M, Watson J, Legros D. Pandemic influenza preparedness and mitigation in refugee and displaced populations. WHO guidelines for humanitarian agencies. World Health Organisation, 2008.
  • 63
    Kun P, Wang Z, Chen X et al. Public health status and influence factors after 2008 Wenchuan earthquake among survivors in Sichuan province, China: cross-sectional trial. Public Health 2010; 124: 57380.
  • 64
    Lienhardt C, Sillah J, Fielding K et al. Risk factors for tuberculosis infection in children in contact with infectious tuberculosis cases in the Gambia, West Africa. Pediatrics 2003; 111: e60814.
  • 65
    Shears P. Epidemiology and infection in famine and disasters. Epidemiol. Infect. 1991; 107: 24151.
  • 66
    Schmid D, Fretz R, Kuo HW et al. An outbreak of multidrug-resistant tuberculosis among refugees in Austria, 2005–2006. Int. J. Tuberc. Lung Dis. 2008; 12: 11905.
  • 67
    Miner MC, Burns-Grant G, DeGraw C et al. Integrated preparedness for continuity of tuberculosis care after Hurricanes Gustav and Ike: Louisiana and Texas, 2008. Public Health Rep. 2010; 125: 5189.
  • 68
    Surmieda MR, Lopez JM, Abad-Viola G et al. Surveillance in evacuation camps after the eruption of Mt. Pinatubo, Philippines. MMWR CDC Surveill. Summ. 1992; 41: 912.
  • 69
    Connolly MA, Gayer M, Ryan MJ et al. Communicable diseases in complex emergencies: impact and challenges. Lancet 2004; 364: 197483.
  • 70
    Kouadio IK, Kamigaki T, Oshitani H. Measles outbreaks in displaced populations: a review of transmission, morbidity and mortality associated factors. BMC Int. Health Hum. Rights 2010; 10: 5.
  • 71
    Ofrin RH, Nelwan I. Disaster risk reduction through strengthened primary health care. WHO Reg. Health Forum 2009; 13: 2934.
  • 72
    Chapin E, Daniels A, Elias R et al. Impact of the 2007 Ica earthquake on health facilities and health service provision in southern Peru. Prehospital Disaster Med. 2009; 24: 32632.
  • 73
    Kaji A, Koenig KL, Bey T. Surge capacity for healthcare systems: a conceptual framework. Acad. Emerg. Med. 2006; 13: 11579.
  • 74
    Pekareo M, Singh K, Lavin RP et al. Hospital impact: long term issues. In: PowersRB, DailyEK (eds) International Disaster Nursing. Cambridge University Press, Cambridge, 2010; 11938.
  • 75
    Sepehri G, Maimandi MS. The pattern of drug prescription and utilization among Bam residents during the first six months after the 2003 Bam earthquake. Prehospital Disaster Med. 2009; 21: 396402.
  • 76
    Guha-Sapir D, van Panhuis WG. Health impact of the 2004 Andaman Nicobar earthquake and tsunami in Indonesia. Prehospital Disaster Med. 2009; 24: 4939.
  • 77
    Bellos A, Mulholland K, O'Brien KL et al. The burden of acute respiratory infections in crisis-affected populations: a systematic review. Confl. Health 2010; 4: 3.
  • 78
    Lacy E. Pharmaceuticals in disasters. In: HoganDE, BursteinJL (eds) Disaster Medicine. Lippincott Williams & Wilkins, Philadelphia, PA; London, 2002; 3440.
  • 79
    Shalita EA, Samford JE. Pharmaceutical services to evacuated U.S. military dependents. Am. J. Hosp. Pharm. 1992; 49: 24746.
  • 80
    Duclos P, Sanderson LM, Lipsett M. The 1987 forest fire disaster in California: assessment of emergency room visits. Archives Environmental Health. 1990; 45: 538.
  • 81
    Brown DW, Young SL, Engelgau MM et al. Evidence-based approach for disaster preparedness authorities to inform the contents of repositories for prescription medications for chronic disease management and control. Prehospital Disaster Med. 2008; 23: 44757.
  • 82
    Branson RD, Johannigman JA, Daugherty EL et al. Surge capacity mechanical ventilation. Respir Care. 2008; 53: 7888; discussion —90.
  • 83
    Ligthelm TJ. Hospital impact: internal disasters. In: PowersR, DailyEK (eds) International Disaster Nursing. Cambridge University Press, Cambridge, 2010; xxiii, 614 p.
  • 84
    Lavon O, Hershko D, Barenboim E. Large-scale air-medical transport from a peripheral hospital to level-1 trauma centers after remote mass-casualty incidents in Israel. Prehospital Disaster Med. 2009; 24: 54955.
  • 85
    Ligtenberg JJ, Arnold LG, Stienstra Y et al. Quality of interhospital transport of critically ill patients: a prospective audit. Crit. Care 2005; 9: R44651.
  • 86
    Seymour CW, Kahn JM, Schwab CW et al. Adverse events during rotary-wing transport of mechanically ventilated patients: a retrospective cohort study. Crit. Care 2008; 12: R71.
  • 87
    Kashani KB, Farmer JC. The support of severe respiratory failure beyond the hospital and during transportation. Curr. Opin. Crit. Care 2006; 12: 439.
  • 88
    Rice DH, Kotti G, Beninati W. Clinical review: critical care transport and austere critical care. Crit. Care 2008; 12: 207.