ISSN 1464-0325

www.rsc.org/jem

Cutting-Edge Research on Environmental Processes & Impacts

Volume 10 | Number 2 | February 2008 | Pages 149–272

Journal of Environmental Monitoring

Volum

e 10 | Num

ber 2 | 2008 Journal of Environm

ental Monitoring

Pages 149–272

10th Anniversary Review Cook et al.Natural disasters and their long-term impacts on the health of communities

EditorialEduardo de MulderInternational Year of Planet Earth

Celebrating

10 years

1464-0325(2008)10:2;1-B

ISSN 1754-5692

www.rsc.org/ees Volume 1 | Number 1 | Summer 2008 | Pages 001–200

Energy&Environmental Science

A new journal linking all aspects of the chemical sciences relating to energy conversion and storage, alternative fuel technologies and environmental science.

As well as research articles, Energy & Environmental Science will also publish communications and reviews. It will be supported by an international Editorial Board, chaired by Professor Nathan Lewis of Caltech.

Contact the Editor, Philip Earis, at ees@rsc.org or visit the website for more details.

1107

47

Energy & Environmental Science

A new journal from RSC PublishingLaunching summer 2008

The current issue of Energy & Environmental Sciencewill be freely available to all. Free access to all 2008 and 2009 content of the journal will be available following registration.

www.rsc.org/eesRegistered Charity Number 207890

Dow

nloa

ded

by U

nive

rsity

of

Sout

h C

arol

ina

Lib

rari

es o

n 18

/04/

2013

06:

26:0

8.

Publ

ishe

d on

09

Janu

ary

2008

on

http

://pu

bs.r

sc.o

rg |

doi:1

0.10

39/B

7132

56P

View Article Online / Journal Homepage / Table of Contents for this issue

10th Anniversary Review: Natural disasters and their long-term impacts

on the health of communities

Angus Cook,a Jill Watson,b Paul van Buynder,ac Andrew Robertsonc and

Phil Weinsteina

Received 28th August 2007, Accepted 17th December 2007

First published as an Advance Article on the web 9th January 2008

DOI: 10.1039/b713256p

Long-term health impacts in communities that have experienced natural disasters are often

overlooked. Recovery from natural disasters is often a long, drawn-out process. Recovery plans

need to address these interruptions in the return to pre-disaster functioning and make provisions

for addressing ongoing health problems. The following review will examine illness patterns that

may arise, directly or indirectly, in the months and years following a disaster event. The

objectives of the review are: (i) to identify the burden of long-term community ill-health following

natural disaster events; (ii) to evaluate current gaps in the ongoing process of health monitoring

for populations affected by disaster; (iii) to review approaches that would provide ongoing

surveillance of physical and psychosocial ill-health.

Introduction

Natural disasters are extreme environmental events that may

cause substantial morbidity and mortality in the population.1

Some disasters are discrete, relatively infrequent events (such

as earthquakes), whereas others may follow an intermittent or

cyclical pattern, including monsoonal floods, bushfires, and

cyclones. The Southeast Asian tsunami in 2004 was particu-

larly devastating—more than 200 000 were killed worldwide-

and its impacts were largely unpredictable. At the other

extreme, disasters may occur as a long-term and ongoing

process: it may be argued that climate change increasingly

falls into this category, and that this global phenomenon

drives the frequency and intensity of other disaster events

(such as prolonged drought, heatwaves and extreme weather).

Although each of these natural disasters may produce

serious health consequences for victims, it is often the identi-

fication and management of short-term ill-health that captures

most of the attention and resources. In contrast, long-term

health impacts in communities that have experienced natural

disasters are often overlooked. Recovery from natural disas-

ters may be a drawn-out process that does not follow a

predictable path. Ongoing assistance is often required for

long-term physical needs, and adverse impacts on psycho-

social well-being can be protracted. In addition to defined

clinical entities such as post-traumatic stress disorders

(PTSD), many families suffer considerable financial hardship

and social displacement following a disaster event. Recovery

plans need to address these interruptions in the return to pre-

disaster functioning and make provisions for addressing con-

comitant mental health problems. The following review will

examine health issues that may arise, directly or indirectly, in

the months and years following a disaster event. The objectives

of the review are: (i) to identify the burden of long-term

community ill-health following natural disaster events; (ii) to

evaluate current gaps in ongoing health monitoring of popula-

tions affected by disasters; (iii) to review approaches that

would provide surveillance of chronic physical and psychoso-

cial ill-health in these populations.

Long-term health outcomes following natural

disasters

The disease burden following major disaster events ranges

from psychopathology (e.g. depression and generalized anxi-

ety; substance use) to physical injury and systemic illness. The

pathways to such disease events may be direct or indirect, as

will be described in subsequent sections. As Galea (2007)

notes, such illness may become apparent across a spectrum

of community members following a catastrophic event, in-

cluding: people injured during the mass trauma; rescuers;

Dr Angus Cook was born inNew Zealand in 1968. Hereceived his medical degreein 1993 (MBChB, Auckland,New Zealand) and a PhD inpublic heath/epidemiologyfrom Otago University (NZ)in 2007. Currently he is aResearch Fellow at the Schoolof Population Health, TheUniversity of Western Aus-tralia, Perth, Australia. Hiscurrent research interestsencompass environmental

health, spatial modelling of health outcomes, and chronic diseaseepidemiology.

a School of Population Health, University of Western Australia, 35Stirling Highway, Crawley, WA 6009 Australia

bWestern Australian Department of Health, 189 Royal Street, EastPerth, WA 6004 Australia

cHealth Protection Group, Western Australian Department of Health,189 Royal Street, East Perth, WA 6004 Australia

This journal is �c The Royal Society of Chemistry 2008 J. Environ. Monit., 2008, 10, 167–175 | 167

CRITICAL REVIEW www.rsc.org/jem | Journal of Environmental Monitoring

Dow

nloa

ded

by U

nive

rsity

of

Sout

h C

arol

ina

Lib

rari

es o

n 18

/04/

2013

06:

26:0

8.

Publ

ishe

d on

09

Janu

ary

2008

on

http

://pu

bs.r

sc.o

rg |

doi:1

0.10

39/B

7132

56P

View Article Online

people who have lost property, belongings or capacity to

sustain a livelihood; families of those injured; and the more

general population who may lie outside the ‘disaster zone’ but

are nonetheless affected in indirect ways by the event.2 The

principal health outcomes, as well as possible pathways to

community health impact and morbidity measures that could

potentially be used to evaluate such endpoints, are summar-

ized in Table 1. These classifications are discussed more fully

in this section, including references to recent reports and

analyses of post-disaster events.

Category A: Chronic disability/pain following physical injury

Natural disasters may result in severe injury. During cyclonic

events, for example, individuals are at risk both from the

destructive winds, which can destroy shelters and leave them

exposed to flying debris, and from storm surges, which have

the potential to raise coastal waters many meters above

normal tide level. Associated heavy rainfall also poses an

immediate threat from flooding. The principal injuries re-

ported after such events include lacerations, blunt trauma,

and puncture wounds, often in the feet and lower extremities.3

Ahern’s 2005 review of flood-related conditions reported

sprains/strains (34%), lacerations (24%), ‘‘other injuries’’

(11%), and abrasions/contusions (11%).4 A follow-up analysis

after Hurricane Iniki in 1992 reported that a total of 1584

injuries were treated compared with 231 injuries treated in the

pre-Iniki period (relative risk = 6.86, 95% CI 5.98–7.87); of

the disaster-related injuries, over half were open wounds.5,6

Similar patterns of injury were observed after the 2004 South

Asia tsunami, with many patients requiring amputation be-

cause of surgical irreparability, delays in care or trauma-

related complications.7 Major head and chest injuries, usually

fatal, crush injuries and peripheral limb injuries are character-

istic of major earthquakes, such as the 2003 Bam and 2005

Kashmir events.8–10

Although many of these injuries are limited and non-dis-

abling, the pathway to recovery may not be complete for many

individuals. Brain injury, amputation or paralysis may require

prolonged rehabilitation and institutional care.11 Orthopedic

services are often limited in less industrialized nations, as are

options for post-surgical management, such as fitting of pros-

theses, physical and occupational therapies, and other pathways

for remobilization and return to work-related activities.8,12 One

year after the Gujarat earthquake of 2001, which killed 13 805

people and left 166 000 injured, many thousands still required

assistance for paraplegia, poorly healed fractures, amputations

and other mobility problems.13 Organ damage may also require

long-term management, such as dialysis after renal crush in-

juries. Following the devastating Armenian earthquake in 1988,

the medical needs of 600 cases of acute renal failure—of which at

least 225 victims required dialysis—created a second catastrophe

described as the ‘‘renal disaster.’’14

Category B: Infectious disease risk

There is ample evidence that natural disasters are linked to

increased rates of infectious disease. However, this is not an

Table 1 Summary and review of post-disaster community health indicatorsa

Pathways to community health impact Measures of community morbidity

Category A: Chronic Initiation of injuries and their sequelae attributable Injury rates attributable to the disaster eventdisability/pain following to disaster event (directly or indirectly e.g. from Use of rehabilitation servicesphysical injury road accidents from infrastructure damage), both Delayed admission for complications of injury or

in the general population and vulnerable groups chronic pain management

Category B: Infectious Delayed biological contamination of water or Cause-specific incidence and mortality ratesdisease risk food sources including vaccine preventable diseases

Rodent, arthropod or other vector proliferation of Notification and admission rates for water- anddisease-causing organisms or disease vectors in food-borne infectious diseasedisrupted environments Notification and admission rates forCollapse of public health services, including mosquito-borne/rodent-borne diseaseimmunization programs

Category C: Chronic Exacerbation of pre-existing chronic disease Cause-specific mortality ratessystemic illness Cardiorespiratory sequelae to psychological Rates of admissions with cardiorespiratory illness

illness (e.g. depression/PTSD) (e.g. COPD and asthma exacerbations;Chronic exposure to toxic agents (e.g. air-borne IHD) and other chronic diseasesparticulates/air toxic/release of material from Rates of admissions with severe reactions orcontaminated sites) poisoning from toxicant exposureCollapse of public health services Other health system utilization data e.g.

prescriptions; family doctor contacts

Category D: Effects of Contamination or loss of food sources Morbidity data, particularly in children andmalnutrition Modification of dietary practice the elderlyand trace element toxicity Suboptimal micronutrient intake, especially in Nutritional surveys

vulnerable populations

Category E: Mental health PTSD/depression/anxiety from psychological or Contacts with mental health servicesoutcomes physical trauma/regional economic Admission for self-injury, depression, anxiety

insecurity/decline in social capital Suicide ratesExacerbation of pre-existing mental health illness Morbidity data for mental health illness

a PTSD = post-traumatic stress disorder; COPD = chronic obstructive pulmonary disease; IHD = ischemic heart disease.

168 | J. Environ. Monit., 2008, 10, 167–175 This journal is �c The Royal Society of Chemistry 2008

Dow

nloa

ded

by U

nive

rsity

of

Sout

h C

arol

ina

Lib

rari

es o

n 18

/04/

2013

06:

26:0

8.

Publ

ishe

d on

09

Janu

ary

2008

on

http

://pu

bs.r

sc.o

rg |

doi:1

0.10

39/B

7132

56P

View Article Online

inevitable consequence, and the risk of epidemics after geo-

physical incidents may often be relatively low. The majority of

infections of concern occur during or shortly after the acute

disaster phase. Post-injury complications are an immediate

concern: after the 2004 tsunami, for example, polymicrobial

wound infections were common and contained pathogens

from sea-water, freshwater and soil.15 Injuries with secondary

Gram-negative bacilli and anaerobic infections have been

noted from flying debris arising with tornados and other

high-velocity winds. Tetanus is an associated risk; 106 cases

(including 20 deaths) were described in the early weeks in Aceh

after the Asian tsunami.16

Following cyclonic events and flooding, infections trans-

mitted by the fecal-oral route are a risk in the short-to

intermediate term. For example, Hurricane Mitch in 1998

caused a documented increase in the frequency of acute

diarrheas in the post-disaster population of Nicaragua.17

The 2004 floods in Bangladesh resulted in more than

17 000 confirmed cases of enterotoxigenic Escherichia coli,

Vibrio cholerae, Shigella spp and other enteric pathogens

in one treatment centre,18 with those affected by milder

diarrhea in the overall population estimated to be far greater.

Other fecally transmitted pathogens, such as hepatitis A and

E, Salmonella typhi and Salmonella enterica serotype Para-

typhi A (typhoid and paratyphoid fever, as occurred in

Mauritius in 1980 and in Indonesia in 1992, respectively)

and Cryptosporidium parvum have all been documented in

the wake of natural disasters.19,20 Slightly delayed clinical

problems may arise because of indirect or unanticipated

transmission pathways. A typhoon in the Truk territories in

the Pacific in 1971 compromised the usual groundwater

sources, and alternate sources used were contaminated by

pig feces leading to an outbreak of balantidiasis.21 Disease

transmission through airborne mobilization of pathogens has

also been reported, such as inhalation of fungal spores leading

to outbreaks of coccidioidomycosis following earthquakes.22

Long-range transport of microorganisms and fungal spores

has also been reported following major dust storms23 and in

smoke from wildfires.24

Although most of these events are relatively short-lived, the

potential for a more protracted risk of communicable disease

may arise if these post-disaster problems are not resolved. In

general, the main risks arise as a result of population displace-

ment,20 which creates situations in which poor sanitation,

overcrowding and contamination of food or water sources

arise. Full-scale epidemics are more likely in communities

experiencing associated conflict, poor underlying health status

(including immunity to vaccine preventable diseases), and

limited availability of health care.25,26 If the disaster is suffi-

ciently severe, community destruction and dislocation may

force populations to remain in camp accommodation for

months or years. Communicable diseases usually present at

lower levels in the community may display epidemicity in the

disrupted setting after a disaster. Delayed increases in a

number of infectious diseases, including typhoid and paraty-

phoid fever, infectious hepatitis, gastroenteritis, and measles,

was reported five months after Hurricanes David and Fredrick

in the Dominican Republic in 1979. These deferred outbreaks

were attributed to extended residence in crowded shelters

coupled with insufficient sanitary facilities, disruption and

contamination of food and water supplies, and suboptimal

immunization rates.3 Clusters of Neisseria meningitidis infec-

tion have been described post disaster where access to health

care and antibiotics are suboptimal. Measles is a well-recog-

nized cause of child mortality in such contexts.27 After the Mt

Pinatubo eruption in the Philippines, 18 000 cases of measles

were described in vulnerable non-immunized populations in

resettlement camps.28 An earthquake in Colombia in January

1999 destroyed most of the houses in Armenia city,

and transitory housing camps still remained until two years

after the disaster. Parasitological studies found that the popu-

lation in these camps were vulnerable to chronic infections,

including giardiasis.29 Displacement may also favor malaria

transmission. Nonimmune refugees may contract the

disease by passing through or settling in high-risk areas,

or—conversely—infectious cases may disseminate disease to

other areas.30

Environmental changes caused by a major catastrophe may

act as an ongoing driver of infectious disease. Inundation or

disruption of water services, such as damaged or overwhelmed

sewerage or drainage systems, provide ideal conditions for

proliferation of disease vectors. In particular, ecological dis-

turbances that contribute to the collection of stagnant or slow-

moving water tend to favor mosquito breeding.4 As Gubler

(2001) notes: ‘‘Climate-related natural disasters may change

the dynamics of human–mosquito contact; floods may create

conditions that allow mosquito proliferation and enhance

mosquito–human contact.’’31 Following the Mozambique

floods of 2000, the number of malaria cases within the

displaced population increased by a factor of 1.5 to two times

compared with previous levels.32 Saenz (1995) reported an

increase in malaria rates in the months after the 1991 Limon

earthquake and subsequent floods in Costa Rica, and attrib-

uted this increased disease burden to habitat changes that

expanded available mosquito breeding sites (landslide defor-

estation, river damming, and rerouting) in combination with

disruptions in malaria control activities.33 In the aftermath of

giant waves and local subsidence following the massive 2004

South Asian earthquake, the problem of saltwater intrusion

became more acute for the Andaman Islands.34 Paddy fields

and fallow land which once contained mainly freshwater

turned increasingly brackish, resulting in profuse breeding of

a salt-tolerant malaria vector, Anopheles sundaicus. The

authors note that vector abundance and increased malaria

transmission is likely to be a permanent feature of the islands,

given the extent of the tsunami-created breeding grounds and

their continued flooding from land subsidence. The increase in

water availability and disrupted flow also raise the likelihood

of arboviral epidemics following natural disasters. Heavy rains

and flooding have been have been associated with elevated

dengue rates in Thailand, Indonesia, Venezuela, and Brazil,

although the longer-term disease risks from flood-related

modification of these environments is less certain.18 In the

US, vector species for a number of arboviruses—including

West Nile virus (WNV), eastern equine encephalomyelitis

(EEE), western equine encephalomyelitis (WEE), and St.

Louis encephalitis (SLE)—have the potential to increase sig-

nificantly in response to heavy rainfall or flooding.35 Similarly,

This journal is �c The Royal Society of Chemistry 2008 J. Environ. Monit., 2008, 10, 167–175 | 169

Dow

nloa

ded

by U

nive

rsity

of

Sout

h C

arol

ina

Lib

rari

es o

n 18

/04/

2013

06:

26:0

8.

Publ

ishe

d on

09

Janu

ary

2008

on

http

://pu

bs.r

sc.o

rg |

doi:1

0.10

39/B

7132

56P

View Article Online

heavy rains in Europe led to the re-emergence of West Nile

Fever in Romania in 1996, the Czech Republic in 1997 and

Italy in 1998.36

Relevant disease vectors of course do not only include

arthropods: vertebrate populations may also dramatically

increase in the period after disaster events.37 Ivers (2006) notes

the potential risks of infection from the proliferation of rodent

populations—including carriage of leptospirosis, hantavirus

and plague—although it is uncertain how long these popula-

tion explosions are maintained in the post-disaster period.15

Dog bites increased after the Guatemala earthquake in 1976,

raising the risk of rabies.11 Leptospirosis may also occur from

contact with infected water and a number of outbreaks have

been described in the aftermath of floods in Portugal (1967),

Brazil (1978), in Taiwan after Typhoon Nali in 2001, and in

the Krasnodar region of Russia in 1997.38

Finally, Noji (2005) makes the important point that the

threat posed by sexually transmitted infections, including

HIV, can be exacerbated by disasters. The author noted that:

‘‘HIV spreads fastest during emergencies, when conditions

such as poverty, powerlessness, social instability, and violence

against women are most extreme.’’39 Other public health

initiatives, including immunization and tuberculosis control

programs, may also suffer as a consequence of the disruption

in services, staff availability and access to communities follow-

ing a disaster event.15,37

Category C: Chronic systemic illness

Following a disaster, chronic physical illnesses in the inter-

mediate- to long-term often arise because of the disruptions in

medical care and management. The increased strain on, or

collapse of, existing medical facilities following such events

may destabilize normal patterns of care. As Greenough noted

in wake of Hurricane Katrina: ‘‘[t]he biggest health is-

sue. . .was and will continue to be the inability of the displaced

population to manage their chronic diseases.’’40 The failure of

the health infrastructure to care for displaced (and often

impoverished) people has profound implications for those

who require medications, ongoing procedures (for example,

dialysis; pain management), or a high level of care (including

those with diabetes, epilepsy, heart disease and respiratory

illnesses; those with disabilities; the elderly). In the weeks and

months following Hurricane Iniki in 1992, Hendrickson (1996;

1997) identified a significantly higher incidence of injuries,

asthma and cardiovascular disease in the population of

Kauai.5,6 However, the authors concluded that the increased

asthma and cardiovascular rates were not representative of

acute exacerbations per se, but instead were attributable to the

need to replace medications or to power outages that disrupted

use of home nebulizers for patients with respiratory illness.

Disasters also have the capacity to exert ongoing health

effects by dispersal of toxic agents—including petrochemicals,

human and agricultural wastes, and asbestos—into the envir-

onment. The disease process, and the risks posed by such

hazards, may not be apparent until many years after the event,

and are likely to be subsumed by more immediate concerns in

the immediate disaster aftermath. Young (2004) identifies a

number of pathways by which high levels of anthropogenic

contaminants may be released, including through the action of

floodwaters, seismic activity or extreme winds damaging sto-

rage sites, pipelines, and sewage disposal systems.41 Analysis

of contaminant levels after the floods of 2002–2003 in the UK

indicated that dioxin residues accumulated in rivers, canals,

storm water and sewage drains, and were likely to have been

deposited in publicly accessible areas, including household

gardens.42 A combined flood and fire at a Gloucestershire

waste management site in 2000 liberated 160 tonnes of hazar-

dous waste containing a wide range of chemicals including

cyanide, pesticides, solvents, low-level radiation waste and

asbestos, some of which entered and prompted evacuation

from surrounding homes.42 Following the earthquake in

Kobe, rescue and demolition workers were exposed to asbes-

tos (crocidolite) dusts exceeding international occupational

exposure limits.41

Considerable concern has been expressed about the poten-

tial toxicity of the floodwaters in post-Katrina New Orleans.43

A systematic study indicated that levels of lead, arsenic, and

chromium exceeded drinking water standards. Although con-

tamination levels were not notably high, the extent of their

dispersal and the potential population affected was consider-

able.44 The receding waters also left sediments at risk of

eventually becoming desiccated and windborne. These dusts,

which are potentially respirable and contain toxicants such

petrochemical residues and asbestos, may continue to pose a

hazard for many years into the future. This process of dust

mobilization is occurring in combination with a serious mold

hazard:45 a study of water-damaged homes in New Orleans

and surrounding parishes estimated that 63% of homes are

experiencing mold contamination. It has recently been hy-

pothesized that the combination of exposure to mold and the

contaminated dusts is likely to result in increased susceptibility

to allergies and respiratory illness in New Orleans residents

who are trying to return to their lives and businesses.46

Mobilization of previously stabilized or inaccessible materi-

als may also occur through the action of wildfires, which are

increasing in scale and frequency with growing aridity in many

continents. In 1992, wildfires in Belarus entered the zone

around the Chernobyl Power Plant and resuspended 137-

cesium radionuclides contained in the forest litter, leading to

a 10-fold increase in atmospheric cesium levels. The burning

vegetative matter in wildfires also liberates organochlorines

and volatile organic compounds, both of which pose long-term

health hazards.41

Toxicants may also be directly expelled from natural pro-

cesses. Volcanic fog (so-called ‘vog’) from Kilauea volcano in

Hawaii contains a complex mixture of respiratory irritants,

such as sulfur compounds (SO2, SO3 and sulfate aerosols) and

toxic metals (particularly mercury).47 Degassing of the Ma-

saya volcano in Nicaragua throughout much the 1990s pro-

duced continuous emissions of SO2 at rates increasing from

600 metric tons (t) day�1 (7.0 kg s�1) in 1995 to 1800 t day�1

(21.0 kg s�1) in 1999; atmospheric hydrofluoric acid at high

levels has also been detected around this site.48 Such irritants

have been linked to ongoing respiratory health effects in the

surrounding communities (fully reviewed by Weinstein and

Cook49). The eruption of Mount St Helens in 1980 initiated a

series of studies on the potential health hazards of airborne

170 | J. Environ. Monit., 2008, 10, 167–175 This journal is �c The Royal Society of Chemistry 2008

Dow

nloa

ded

by U

nive

rsity

of

Sout

h C

arol

ina

Lib

rari

es o

n 18

/04/

2013

06:

26:0

8.

Publ

ishe

d on

09

Janu

ary

2008

on

http

://pu

bs.r

sc.o

rg |

doi:1

0.10

39/B

7132

56P

View Article Online

volcanic ash. Ash from volcanic eruptions contains a high

proportion of crystalline silica, thereby potentially raising the

long term risk of silicosis and chronic obstructive pulmonary

disease (COPD) in surrounding communities. As outlined in

Hansell’s recent review,50 follow-up of those with pre-existing

lung conditions and occupationally exposed loggers reported

increases in respiratory symptoms that persisted in some

individuals for months, probably due to resuspension of loose

ash deposits on the ground. The Caribbean island of Mont-

serrat has been subject to many years of sustained volcanic

fallout from the mid-1990s, and a large proportion of the land

area is coated with varying levels of ash. In the areas most

frequently affected by ash falls, a risk assessment conducted in

2003 for the UK Department for International Development

suggested that the risk of developing early radiological

changes of silicosis was highest amongst gardeners and other

outdoor workers, with increased risks up to 10% if their

cumulative exposure over 20 years was at the extreme end of

the likely range. An analysis by Forbes (2003) of children on

Montserrat reported a greater prevalence of wheeze in those

heavily or moderately exposed to volcanic ash compared with

the group exposed to low levels (wheeze in last 12 months:

odds ratio (OR) 4.30; wheeze ever: OR 3.45).51

The link between physical illness outcomes and post-disaster

psychosocial factors is also well-established. Research con-

ducted after the 1988 earthquake in Armenia found an asso-

ciation between heart disease in the 6 months after the event

and those who experienced elevated levels of loss of material

possessions and family members (up to an odds ratios of 2.6

for those with the highest ‘‘loss scores’’). There are also

relationships between the intensity of exposure to disaster-

related losses and elevated rates of newly reported hyperten-

sion, diabetes mellitus, and arthritis.52

Category D: Effects of malnutrition and trace element toxicity

The spectrum of malnutrition in the wake of a disaster

is highly variable, and may occur as a consequence of

general calorie- or protein-deficiencies, inadequate intake of

micronutrients, or excessive ingestion of trace elements.

Impaired nutritional intake is also a risk factor for

mortality from infectious diseases, such as gastroenteritis

and measles, which are often also more common in the

post-disaster phase. Noji (2005) discusses a range of nutri-

tion-mediated outcomes, including the relationship between

vitamin deficiencies and increased childhood mortality in

refugee populations.39

Most dramatically, disasters can directly decrease the quan-

tity of food supplies (such as crop yields; fish stocks) or access

to such supplies. Populations already vulnerable to poverty

and food insecurity, such as Sub-Saharan Africa, are particu-

larly likely to succumb to superimposed crises.53 Droughts

over many years are associated with increased risk of disease

and malnutrition, and are likely to become more prolonged

and widespread if climate change predictions are correct.54,55

Monsoonal floods in Bangladesh have resulted in adverse long

term outcomes for a range of developmental and nutritional

indicators.56 Ongoing issues of food supplies were particularly

apparent for many months after the 2005 Pakistan earth-

quake. A total of 2.3 million people experienced insecure

access to food, a problem which persisted due to logistical

difficulties in providing relief and the inaccessibility of the

affected areas.57

Volcanic hazards may destroy croplands, poison livestock

and contaminate available water supplies. This geophysical

activity may continue for many years, sometimes requiring

complete relocation away from non-viable land.58 The poten-

tial for excessive nutritional intake of trace elements also

arises. Drinking water may become contaminated by fluorine

from tephra, although subsequent fluorosis in human popula-

tions following disasters is not well documented.50 Outflows

from volcanic lakes may also result in destruction of food

sources or heavy metal contamination, as illustrated by the

highly acidic Kawah Ijen crater lake in East Java, which

carries a very high load of SO4, NH4, F, Fe, Cu, Pb, Zn, Al

and other potentially toxic elements to irrigated croplands

downstream.59

Category E: Mental health outcomes

Mental health issues following natural disasters are well

documented, and it is common for individuals to experience

acute distress in the face of such overwhelming events.

Although the majority do not continue to be adversely affected

in the long-term, a significant proportion of disaster victims

experience persistent mental ill-health, including PTSD, major

depression, or other psychiatric outcomes.60 Galea61 contrasts

the early-onset post-traumatic stress disorder that resolves

quickly versus those who experience it over a longer term.

Some analyses have suggested that post-disaster PTSD may

persist in more than one third of the initial cases for more than

a decade.61 Suicide and child abuse are other reported con-

sequences of disasters.3 In children, Ahern4 reviewed the

evidence of mental illness after flooding, and noted evidence

for long-term increases in PTSD, depression, and dissatisfac-

tion with life. Children may be particularly traumatized by the

loss of one or both parents.26

This prolonged clinical trajectory in the post-disaster phase

is supported by numerous findings. A longitudinal study in a

post-earthquake communities in Northern China reported a

higher prevalence of psychopathology at nine months than at

three months post-event.62 A surveillance study of displaced

and nondisplaced participants was conducted in Thailand

following the 2004 tsunami: this event affected all 6 south-

western provinces of Thailand, in which 5395 individuals died,

2991 were unaccounted for, and 8457 were injured. The loss of

livelihood as a result of the tsunami in southern Thailand was

profound, with major disruption of fishing and tourist indus-

tries. At nine months after the event, prevalence rates of

symptoms of PTSD, anxiety, and depression among displaced

persons were 7%, 24.8%, and 16.7%, respectively, compared

to rates in the non-displaced of 2.3%, 25.9%, and 14.3%,

respectively.63 Staff who have been at the centre of emergency

management and subsequent care of the victims (e.g. health

workers) are also vulnerable to burn-out because of enormous

pressure placed upon them.64 A cohort study of firefighters

conducted after the 1983 Australian bushfires revealed that

psychological symptoms fluctuated considerably over time,

This journal is �c The Royal Society of Chemistry 2008 J. Environ. Monit., 2008, 10, 167–175 | 171

Dow

nloa

ded

by U

nive

rsity

of

Sout

h C

arol

ina

Lib

rari

es o

n 18

/04/

2013

06:

26:0

8.

Publ

ishe

d on

09

Janu

ary

2008

on

http

://pu

bs.r

sc.o

rg |

doi:1

0.10

39/B

7132

56P

View Article Online

and that 21% of the firefighters were documented to have

persistent PTSD over a 2 year period.65

The role of the social and economic consequences of

disasters in shaping long-term health should not be under-

estimated.64,66 The immediate impact of the 2004 tsunami

provides a recent example of profound social disruption: in

the three Sumatran coastal communities of Calang, Rigah and

Sayeung, almost 100% of structures were destroyed and an

estimated 64% of the total population was classified as killed

or missing. Almost two-thirds of households in Calang re-

ported the death of at least one immediate family member

directly attributable to the tsunami impact.57,67 Hurricane

Katrina caused population displacement of hundreds of thou-

sands of Gulf Coast residents to at least 18 different states.68

As Wilson (2006) notes: ‘‘Because of stress and disenchant-

ment, evacuees are at increased risk for depression and post-

traumatic stress disorder, domestic violence, and domestic

abuse.’’46

Carr (1995) reported that ongoing disruption and other life

events were significant predictors of chronic morbidity follow-

ing a major earthquake in Newcastle, Australia.69 In particu-

lar, disaster-related job loss and unemployment have been

consistently identified as risk factors for long-term psycho-

pathology.70 Following a disaster, many families suffer con-

siderable financial hardship and may become temporarily

displaced or permanently relocated, thereby interrupting es-

tablished community, cultural and social ties.71 The impacts

are usually greatest in lower income households, who because

of limited resources, often take longer to pass through the

transition to recovery. Indeed, many are forced to remain in

‘‘temporary’’ living arrangements long after other sections of

the community have re-established their pre-disaster status.72

Fernandez (2002) notes the particular difficulties experienced

by the elderly in relation to financial recovery, noting that

younger age groups are better able to return to their pre-

disaster standard of living.73

Prolonged disasters may also take a more widespread

economic toll, escalating the health effects from socioeconomic

deprivation. Ongoing drought is particularly damaging in its

contribution to loss of livelihood, incurred debts, and closure

of essential services. In Australia, the 2002–2003 drought is

estimated to have cost 1.6% of GDP and about 70 000 jobs,

with an on-going Federal Government commitment of

$AUS740 million in drought relief between 2002 and

2005.1,74 In industrialized countries, creation of regional pov-

erty is the process by which drought is most likely to lead to

adverse health consequences, as opposed to the malnutrition-

related effects described in the previous section.

Optimizing disease surveillance and management in

the post-disaster period

Specific emergency response measures vary from hazard to

hazard; however, the broad management approach remains

the same. Quarentelli (1997) states that ‘‘agent-generated

needs vary depending upon the disaster impact and the specific

nature of the agent, [but] response-generated demands, such as

coordination, mobilization of personnel and resources, and

proper delegation of tasks are common to all disasters.’’75 The

four main elements to the approach may be defined by the

quartet of ‘‘Prevention; Preparedness; Response; Recovery’’.

Considerable advances have been made in recent years in

relation to prevention, preparedness and response planning,

and most industrialized countries and States have detailed

support plans and procedures for disasters. However, few

authorities outline the requirements for maintaining commu-

nity health beyond the acute disaster phase. In 1975, Michel

Lechat, a prominent disaster epidemiologist, described con-

temporary disaster relief as ‘‘crisis dominated’’:19 even today,

this often remains the case. Although the community health

effects have become better recognized, most forms of illness in

the post-disaster phase remain under-researched.76 In order to

adequately protect the health of the population, these require-

ments need to be more clearly defined during reconstruction

and beyond, including a commitment to minimizing disease in

neighborhoods already at high risk (for example, for socio-

economic reasons).77 Many authors have questioned the

capacity of relief agencies to transfer from the acute disaster

phase into longer-term management of disease.78 Unfortu-

nately, many organizations responsible for disasters lack an

adequate process or authority structure to coordinate hazard

assessment and population health surveillance in the weeks,

months and years following a disaster.79 As VanRooyen

observed: ‘‘Relief organizations still have much to learn about

shifting from short-term medical-aid efforts to productive,

sustainable interventions that promote the development of a

local health care system’’: it may be argued that the ongoing

capacity to monitor disease outcomes should be included as an

integral component in the provision of ‘‘local health care’’.80

The final section of this review will focus on one particular

aspect on post-disaster management: the enhancement of

long-term health surveillance. An effective public health res-

ponse to any emergency places a priority the collection,

collation, interpretation and dissemination of accurate infor-

mation to allow for the proper management of the disease

burden.57,67,81,82 Given the range of disease outcomes identi-

fied above, it is apparent that this surveillance and response

approach should be extended to communities in the post-

disaster phase. The persistence of physical and psychological

symptoms during the period after a disaster has implications

for health care providers and funding agencies, and accurate

information relating to these outcomes is a necessary prere-

quisite for health planning.2 It has also been acknowledged

that longitudinal analyses of health effects are required to

capture the scale of the true disease burden following a

disaster.40,83 As noted above, Table 1 outlines a list of poten-

tial health indicators that could be used to extend epidemio-

logical capacity. Although options are limited by the pre-

existing extent of the region’s health information systems,

data collection procedures in communities impacted by emer-

gency events might encompass cause-specific mortality rates,

hospitalization events, emergency room consultations, sentinel

general practice consultations and mental health contacts.

Enhanced surveillance data would allow robust epidemiologi-

cal risk analyses to be conducted, comparing the health effects

(attributable disease burden) associated with different predic-

tors of disaster events, including severity and the scale of

response/outcome. Advanced temporo-spatial techniques,

172 | J. Environ. Monit., 2008, 10, 167–175 This journal is �c The Royal Society of Chemistry 2008

Dow

nloa

ded

by U

nive

rsity

of

Sout

h C

arol

ina

Lib

rari

es o

n 18

/04/

2013

06:

26:0

8.

Publ

ishe

d on

09

Janu

ary

2008

on

http

://pu

bs.r

sc.o

rg |

doi:1

0.10

39/B

7132

56P

View Article Online

such as disease mapping and time series analysis of the

datasets at both aggregate and case-level, may be used to

elucidate the relationships between emergency events and

health outcomes. GIS technology can help with the assessment

of disaster-affected areas,84,85 and may eventually play a role

in long-term surveillance of health events and in planning

services for high-risk communities.

Record-based epidemiological summaries do not, however,

necessarily address all the information-gathering require-

ments. Indirect pathways to disease are not well captured by

simple frequency-based analyses. Many chronic outcomes,

particularly those related to psychological illness or illness

due to social factors, may not be formally evaluated or

included in such disease estimates. Diminishing community

income following a disaster may result in indebtedness, bank-

ruptcies, job losses, strained family relationships and marriage

breakdowns leading to chronic depression and other mental

illnesses: exploring such complexity is better suited to other

techniques, including qualitative and sociological methods.

Predictors of disease may also be inferred from other con-

textual measures, such as those which capture ecological

change. For example, it may be appropriate to conduct an

analysis of post-disaster environmental modifications which

facilitate mosquito proliferation, including an evaluation of

changes in vector species abundance.

Globally, the impact of extreme weather events increasingly

needs to be anticipated, given the likelihood that climate

change may alter the frequency, severity or complexity of

many natural disasters.55 The health impacts of weather-

related disasters (including floods, landslides, and windstorms)

have been well-documented, and encompass direct (deaths and

injuries) and indirect effects (infectious disease, long-term

psychological morbidity).86 Many of these problems will also

have implications for the development of long-term health

sequelae.40,83 As we move into an era of climatic unpredict-

ability and instability, it is timely to recall that recovery from

disasters is protracted and not inevitable. Climate modeling

may help identify vulnerable regions and population groups

and could provide guidance for long-term public health

surveillance priorities.87,88

Conclusion

Natural disasters have serious consequences for human well-

being in ways that are not always readily apparent or pre-

dictable in the intermediate- and long-term. This review has

indicated that the capacity of health services to monitor and

address delayed or indirect disease outcomes remains ques-

tionable, even though it is these factors that often predict

community recovery in the wake of a disaster. Most epide-

miological evidence following such events is derived from

cross-sectional studies or studies with short-term follow-up;

we therefore have relatively little information about the long-

er-term trajectory of disaster victims. It is apparent that

national and local health services must be equipped not only

to handle the increase in demand during the immediate

emergency, but also to provide health surveillance systems in

subsequent weeks, months and years. Some groups within the

population are likely to be particularly vulnerable to cata-

strophic events, including the elderly, children, or those with

limited resources for recovery for socioeconomic reasons.

Emergencies place communities at risk of numerous hazards,

and it is important to remember that not all health problems

recede with the floodwaters.

References

1 J. N. Logue, Disasters, the environment, and public health:improving our response, Am. J. Public Health, 1996, 86(9),1207–1210.

2 S. Galea, The long-term health consequences of disasters and masstraumas.[comment], Can. Med. Assoc. J., 2007, 176(9), 1293–1294.

3 J. M. Shultz, J. Russell and Z. Espinel, Epidemiology of tropicalcyclones: the dynamics of disaster, disease, and development,Epidemiol. Rev., 2005, 27, 21–35.

4 M. Ahern, R. S. Kovats, P. Wilkinson, R. Few and F. Matthies,Global health impacts of floods: epidemiologic evidence, Epide-miol. Rev., 2005, 27, 36–46.

5 L. A. Hendrickson and R. L. Vogt, Mortality of Kauai residents inthe 12-month period following Hurricane Iniki, Am. J. Epidemiol.,1996, 144(2), 188–191.

6 L. A. Hendrickson, R. L. Vogt, D. Goebert and E. Pon, Morbidityon Kauai before and after Hurricane Iniki, Prev. Med., 1997,26(5 Pt 1), 711–716.

7 A. J. Chambers, M. J. Campion, B. G. Courtenay, J. A. Crozierand C. H. New, Operation Sumatra Assist: surgery for survivors ofthe tsunami disaster in Indonesia, ANZ J. Surg., 2006, 76(1–2),39–42.

8 S. A. Dhar, M. A. Halwai, M. R. Mir, Z. A. Wani, M. F. Butt, M.I. Bhat and A. Hamid, The Kashmir Earthquake Experience, Eur.J. Trauma Emerg. Surg., 2007, 33(1), 74–80.

9 A. D. Redmond, Natural disasters, Br. Med. J., 2005, 330(7502),1259–1261.

10 J. J. Schnitzer and S. M. Briggs, Earthquake relief—-the USmedical response in Bam, Iran, N. Engl. J. Med., 2004, 350(12),1174–1176.

11 Pan American Health Organization. and Pan American SanitaryBureau, Natural disasters: protecting the public’s health. 2000,Washington, DC, Pan American Health Organization, Pan Amer-ican Sanitary Bureau, Regional Office of the World HealthOrganization, xi, 119 pp.

12 J. Calder and S. Mannion, Orthopaedics in Sri Lanka post-tsunami, J. Bone Jt. Surg., Br. Vol., 2005, 87(6), 759–761.

13 P. Chatterjee, One year after the Gujarat earthquake, Lancet, 2002,359(9303), 327.

14 M. S. Sever, R. Vanholder and N. Lameire, Management of crush-related injuries after disasters, N. Engl. J. Med., 2006, 354(10),1052–1063.

15 L. C. Ivers and E. T. Ryan, Infectious diseases of severe weather-related and flood-related natural disasters, Curr. Opin. Infect. Dis.,2006, 19(5), 408–414.

16 S. A. Brenner and E. K. Noji, Wound infections after tornadoes, J.Trauma: Injury Infection and Critical Care, 1992, 33(4), 643.

17 N. Campanella, Infectious diseases and natural disasters: theeffects of Hurricane Mitch over Villanueva municipal area, Nicar-agua, Public Health Rev., 1999, 27(4), 311–319.

18 S. C. Waring and B. J. Brown, The threat of communicablediseases following natural disasters: a public health response,Disaster Manage. Response, 2005, 3(2), 41–47.

19 L. Beinin, Medical consequences of natural disasters, SpringerVerlag, Berlin, New York, 1985, xi, p. 160.

20 J. T. Watson, M. Gayer and M. A. Connolly, Epidemics afternatural disasters, Emerging Infect. Dis., 2007, 13(1), 1–5.

21 P. D. Walzer, F. N. Judson, K. B. Murphy, G. R. Healy, D. K.English and M. G. Schultz, Balantidiasis outbreak in Truk, Am. J.Trop. Med. Hyg., 1973, 22(1), 33–41.

22 E. Schneider, R. A. Hajjeh, R. A. Spiegel, R. W. Jibson, E. L.Harp, G. A. Marshall, R. A. Gunn, M. M. McNeil, R. W. Pinner,R. C. Baron, R. C. Burger, L. C. Hutwagner, C. Crump, L.Kaufman, S. E. Reef, G. M. Feldman, D. Pappagianis and S. B.Werner, A coccidioidomycosis outbreak following the Northridge,Calif, earthquake, J. Am. Med. Assoc., 1997, 277(11), 904–908.

This journal is �c The Royal Society of Chemistry 2008 J. Environ. Monit., 2008, 10, 167–175 | 173

Dow

nloa

ded

by U

nive

rsity

of

Sout

h C

arol

ina

Lib

rari

es o

n 18

/04/

2013

06:

26:0

8.

Publ

ishe

d on

09

Janu

ary

2008

on

http

://pu

bs.r

sc.o

rg |

doi:1

0.10

39/B

7132

56P

View Article Online

23 D. W. Griffin, Atmospheric movement of microorganisms inclouds of desert dust and implications for human health, Clin.Microbiol. Rev., 2007, 20(3), 459–477.

24 S. A. Mims and F. M. Mims, Fungal spores are transported longdistances in smoke from biomass fires, Atmos. Environ., 2004,38(5), 651–655.

25 E. K. Noji, Public health in the aftermath of disasters, Br. Med. J.,2005, 330(7504), 1379–1381.

26 W. H. Hooke and P. G. Rogers, Institute of Medicine (US)Roundtable on Environmental Health Sciences Research and Med-icine, and National Research Council (US). Disasters Roundtable,Public health risks of disasters: communication, infrastructure, andpreparedness: workshop summary, National Academies Press,Washington DC, 2005, xv, p. 71.

27 G. R. Ciottone, Disaster medicine, Philadelphia, Elsevier/Mosby,3rd edn, 2006, xxxi, p. 952.

28 Anonymous, Disaster epidemiology, Lancet, 1990, 336(8719),845–846.

29 F. Lora-Suarez, C. Marin-Vasquez, N. Loango, M. Gallego, E.Torres, M. M. Gonzalez, J. C. Castano-Osorio and J. E. Gomez-Marin, Giardiasis in children living in post-earthquake camps fromArmenia (Colombia), BMC Public Health, 2002, 2, 5.

30 P. Martens and L. Hall, Malaria on the move: human populationmovement and malaria transmission, Emerging Infect. Dis., 2000,6(2), 103–109.

31 D. J. Gubler, P. Reiter, K. L. Ebi, W. Yap, R. Nasci and J. A. Patz,Climate variability and change in the United States: potentialimpacts on vector- and rodent-borne diseases, Environ. HealthPerspect., 2001, 109(Suppl 2), 223–233.

32 H. Kondo, N. Seo, T. Yasuda, M. Hasizume, Y. Koido,N. Ninomiya and Y. Yamamoto, Post-flood—infectiousdiseases in Mozambique, Prehospital Disaster Med., 2002, 17(3),126–133.

33 R. Saenz, R. A. Bissell and F. Paniagua, Post-disaster malaria inCosta Rica, Prehospital Disaster Med., 1995, 10(3), 154–160.

34 K. Krishnamoorthy, P. Jambulingam, R. Natarajan, A. N.Shriram, P. K. Das and S. C. Sehgal, Altered environment andrisk of malaria outbreak in South Andaman, Andaman &Nicobar Islands, India affected by tsunami disaster, Malaria J.,2005, 4, 32.

35 R. S. Nasci and C. G. Moore, Vector-borne disease surveillanceand natural disasters, Emerging Infect. Dis., 1998, 4(2), 333–334.

36 G. L. Campbell, A. A. Marfin, R. S. Lanciotti and D. J. Gubler,West Nile virus, Lancet Infect. Dis., 2002, 2(9), 519–529.

37 B. L. Ligon, Infectious diseases that pose specific challenges afternatural disasters a review, Semin. Ped. Infect. Dis., 2006, 17(1),36–45.

38 J. Seaman, S. Leivesley and C. Hogg, Epidemiology of naturaldisasters, Contributions to epidemiology and biostatistics, Karger,Basel, New York, 1984, vol. 5, viii, p. 177.

39 E. K. Noji, Public health issues in disasters, Crit. Care Med., 2005,33(1 Suppl), S29–33.

40 P. G. Greenough and T. D. Kirsch, Hurricane Katrina Publichealth response—assessing needs, N. Engl. J. Med., 2005, 353(15),1544–1546.

41 S. Young, L. Balluz and J. Malilay, Natural and technologichazardous material releases during and after natural disasters: areview, Sci. Total Environ., 2004, 322(1–3), 3–20.

42 E. Euripidou and V. Murray, Public health impacts of floods andchemical contamination, J. Public Health, 2004, 26(4), 376–383.

43 G. S. Plumlee, and Geological Survey (US), USGS environmentalcharacterization of flood sediments left in the New Orleans area afterHurricanes Katrina and Rita, 2005 progress report, 2006, cited;1.0.:[p. 74]. Available from: http://purl.access.gpo.gov/GPO/LPS84848.

44 J. H. Pardue, W. M. Moe, D. McInnis, L. J. Thibodeaux, K. T.Valsaraj, E. Maciasz, I. van Heerden, N. Korevec and Q. Z. Yuan,Chemical and microbiological parameters in New Orleans flood-water following Hurricane Katrina, Environ. Sci. Technol., 2005,39(22), 8591–8599.

45 M. Brandt, C. Brown, J. Burkhart, N. Burton, J. Cox-Ganser, S.Damon, H. Falk, S. Fridkin, P. Garbe, M. McGeehin, J. Morgan,E. Page, C. Rao, S. Redd, T. Sinks, D. Trout, K. Wallingford, D.Warnock and D. Weissman, Mold prevention strategies andpossible health effects in the aftermath of hurricanes and major

floods, Morbidity and Mortality Weekly Report, Recommendations& Reports, 2006, 55(RR-8), 1–27.

46 J. F. Wilson, Health and the environment after Hurricane Katrina,Ann. Int. Med., 2006, 144(2), 153–156.

47 J. P. Michaud, D. Krupitsky, J. S. Grove and B. S. Anderson,Volcano related atmospheric toxicants in Hilo and Hawaii Volca-noes National Park: implications for human health, Neurotoxicol-ogy, 2005, 26(4), 555–63.

48 P. Delmelle, J. Stix, P. J. Baxter, J. Garcia-Alvarez andJ. Barquero, Atmospheric dispersion, environmental effects andpotential health hazard associated with the low-altitude gas plumeof Masaya volcano, Nicaragua, Bull. Volcanol., 2002, 64(6),423–434.

49 O. Selinus and B. J. Alloway, Essentials of medical geology: impactsof the natural environment on public health, Elsevier AcademicPress, Amsterdam, Boston, 2005, xiv, p. 812.

50 A. L. Hansell, C. J. Horwell and C. Oppenheimer, The healthhazards of volcanoes and geothermal areas, Occup. Environ. Med.,2006, 63(2), 149–156.

51 L. Forbes, D. Jarvis, J. Potts and P. J. Baxter, Volcanic ash andrespiratory symptoms in children on the island ofMontserrat, British West Indies, Occup. Environ. Med., 2003,60(3), 207–211.

52 H. K. Armenian, A. K. Melkonian and A. P. Hovanesian, Longterm mortality and morbidity related to degree of damage follow-ing the 1998 earthquake in Armenia, Am. J. Epidemiol., 1998,148(11), 1077–84.

53 M. Haile, Weather patterns, food security and humanitarianresponse in sub-Saharan Africa, Philos. Trans. R. Soc. London,Ser. B: Biol. Sci., 2005, 360(1463), 2169–2182.

54 R. Few, Health and climatic hazards: Framing social research onvulnerability response and adaptation, Global Environ. Change,2007, 17(2), 281–295.

55 J. A. Patz, D. Engelberg and J. Last, The effects of changingweather on public health, Annu. Rev. Public Health, 2000, 21,271–307.

56 A. Y. Choudhury and A. Bhuiya, Effects of biosocial variables onchanges in nutritional status of rural Bangladeshi children,pre- and post-monsoon flooding, J. Biosoc. Sci., 1993, 25(3),351–357.

57 R. J. Brennan and R. J. Waldman, The south Asian earthquake sixmonths later—an ongoing crisis, N. Engl. J. Med., 2006, 354(17),1769–1771.

58 G. A. Tobin and L. M. Whiteford, Community resilience andvolcano hazard: the eruption of Tungurahua and evacuation of thefaldas in Ecuador, Disasters, 2002, 26(1), 28–48.

59 A. J. Lohr, T. A. Bogaard, A. Heikens, M. R. Hendriks,S. Sumarti, M. J. Van Bergen, C. A. M. Van Gestel,N. M. Van Straalen, P. Z. Vroon and B. Widianarko,Natural pollution caused by the extremely acidic crater LakeKawah Ijen, East Java, Indonesia, Environ. Sci. Pollut. Res.,2005, 12(2), 89–95.

60 F. H. Norris, J. L. Perilla, J. K. Riad, K. Kaniasty and E. A.Lavizzo, Stability and change in stress, resources, and psychologi-cal distress following natural disaster: Findings from HurricaneAndrew, Anxiety Stress Coping, 1999, 12(4), 363–396.

61 S. Galea, A. Nandi and D. Vlahov, The epidemiology of post-traumatic stress disorder after disasters, Epidemiol. Rev., 2005, 27,78–91.

62 X. Wang, L. Gao, N. Shinfuku, H. Zhang, C. Zhao and Y. Shen,Longitudinal study of earthquake-related PTSD in a randomlyselected community sample in north China, Am. J. Psychiatry,2000, 157(8), 1260–1266.

63 F. van Griensven, M. L. Chakkraband, W. Thienkrua, W.Pengjuntr, B. Lopes Cardozo, P. Tantipiwatanaskul, P. A.Mock, S. Ekassawin, A. Varangrat, C. Gotway, M. Sabin,J. W. Tappero and G. Thailand Post-Tsunami Mental HealthStudy, Mental health problems among adults in tsunami-affectedareas in southern Thailand, J. Am. Med. Assoc., 2006, 296(5),537–548.

64 M. Carballo, B. Heal and M. Hernandez, Psychosocial aspects ofthe Tsunami, J. R. Soc. Med., 2005, 98(9), 396–399.

65 A. C. McFarlane and P. Papay, Multiple diagnoses in post-traumatic stress disorder in the victims of a natural disaster, J.Nervous Mental Dis., 1992, 180(8), 498–504.

174 | J. Environ. Monit., 2008, 10, 167–175 This journal is �c The Royal Society of Chemistry 2008

Dow

nloa

ded

by U

nive

rsity

of

Sout

h C

arol

ina

Lib

rari

es o

n 18

/04/

2013

06:

26:0

8.

Publ

ishe

d on

09

Janu

ary

2008

on

http

://pu

bs.r

sc.o

rg |

doi:1

0.10

39/B

7132

56P

View Article Online

66 M. Carballo, B. Heal and G. Horbaty, Impact of the tsunami onpsychosocial health and well-being, Int. Rev. Psychiatry, 2006,18(3), 217–223.

67 R. J. Brennan and K. Rimba, Rapid health assessment in AcehJaya District, Indonesia, following the December 26 tsunami,Emergency Med. Aust., 2005, 17(4), 341–350.

68 T. S. Ghosh, J. L. Patnaik and R. L. Vogt, Rapid needs assessmentamong Hurricane Katrina evacuees in metro-Denver, J. HealthCare Poor Underserved, 2007, 18(2), 362–368.

69 V. J. Carr, T. J. Lewin, R. A. Webster, P. L. Hazell, J. A. Kenardyand G. L. Carter, Psychosocial Sequelae of the 1989 NewcastleEarthquake. 1. Community Disaster Experiences and Psychologi-cal Morbidity 6 Months Postdisaster, Psychol. Med., 1995, 25(3),539–555.

70 S. Galea, Disasters and the health of urban populations, J. UrbanHealth, 2005, 82(3), 347–349.

71 D. Alexander, The study of natural disasters, 1977–1997: somereflection on a changing field of knowledge, Disasters, 1997, 21(4),284–304.

72 M. K. Lindell and C. S. Prater, Assessing Community Impacts ofNatural Disasters, Nat. Hazards Rev., 2003, 4(4), 176–185.

73 L. S. Fernandez, D. Byard, C. C. Lin, S. Benson and J. A. Barbera,Frail elderly as disaster victims: emergency management strategies,Prehospital Dis. Med., 2002, 17(2), 67–74.

74 K. Hennessy, in EMA Disaster Conference, Canberra, 2003.75 E. L. Quarantelli, Ten criteria for evaluating the management of

community disasters, Disasters, 1997, 21(1), 39–56.76 E. K. Noji, Disasters: introduction and state of the art, Epidemiol.

Rev., 2005, 27, 3–8.77 D. Alexander, Globalization of Disaster: Trends Problems and

Dilemmas, J. Int. Affairs, 2006, 59(2), 1.78 F. Dominici, J. I. Levy and T. A. Louis, Methodological challenges

and contributions in disaster epidemiology, Epidemiol. Rev., 2005,27, 9–12.

79 M. Fenig and D. C. Cone, Advancing disaster epidemiology andresponse: developing a national disaster-victim database, Prehos-pital Emergency Care, 2005, 9(4), 457–467.

80 M. VanRooyen and J. Leaning, After the tsunami—facingthe public health challenges, N. Engl. J. Med., 2005, 352(5), 435–8.

81 D. A. Bradt, K. Abraham and R. Franks, A strategic plan fordisaster medicine in Australasia, Emergency Med., 2003, 15(3),271–282.

82 D. A. Bradt and C. M. Drummond, Rapid epidemiologicalassessment of health status in displaced populations—an evolutiontoward standardized minimum, essential data sets. [republishedfrom Prehospital Disaster Med, 2002 Oct–Dec, 17(4), 178–85;PMID: 12929948], Prehospital Dis. Med., 2003, 18(1), 178–185.

83 G. Greenough, M. McGeehin, S. M. Bernard, J. Trtanj, J. Riadand D. Engelberg, The potential impacts of climate variability andchange on health impacts of extreme weather events in the UnitedStates, Environ. Health Perspect., 2001, 109(Suppl 2), 191–198.

84 S. Waring, A. Zakos-Feliberti, R. Wood, M. Stone, P. Padgett andR. Arafat, The utility of geographic information systems (GIS) inrapid epidemiological assessments following weather-related dis-asters: methodological issues based on the Tropical Storm AllisonExperience, Int. J. Hyg. Environ. Health, 2005, 208(1–2), 109–116.

85 D. Mathew, Information technology and public health manage-ment of disasters—a model for South Asian countries, PrehospitalDis. Med., 2005, 20(1), 54–60.

86 R. S. Kovats, D. Campbell-Lendrum and F. Matthies, Climatechange and human health estimating avoidable deaths and disease,Risk Anal., 2005, 25(6), 1409–1418.

87 F. Thomalla, T. Downing, E. Spanger-Siegfried, G. Han and J.Rockstrom, Reducing hazard vulnerability: towards a commonapproach between disaster risk reduction and climate adaptation,Disasters, 2006, 30(1), 39–48.

88 J. Tibbetts, Driven to extremes health effects of climate change,Environ. Health Perspect., 2007, 115(4), A196–203.

This journal is �c The Royal Society of Chemistry 2008 J. Environ. Monit., 2008, 10, 167–175 | 175

Dow

nloa

ded

by U

nive

rsity

of

Sout

h C

arol

ina

Lib

rari

es o

n 18

/04/

2013

06:

26:0

8.

Publ

ishe

d on

09

Janu

ary

2008

on

http

://pu

bs.r

sc.o

rg |

doi:1

0.10

39/B

7132

56P

View Article Online