In the immediate aftermath of a disaster, household members may experience lack of support services and isolation from one another. To address this, a common recommendation is to promote preparedness through the preparation of an emergency supply kit (ESK). The goal was to characterize ESK possession on a national level to help the Centers for Disease Control and Prevention (CDC) guide next steps to better prepare for and respond to disasters and emergencies at the community level.

The authors analyzed data collected through Porter Novelli’s ConsumerStyles surveys in fall 2020 (n = 3625) and spring 2021 (n = 6455).

ESK ownership is lacking. Overall, while most respondents believed that an ESK would help their chance of survival, only a third have one. Age, gender, education level, and region of the country were significant predictors of kit ownership in a multivariate model. In addition, there was a significant association between level of preparedness and ESK ownership.

These data are an essential starting point in characterizing ESK ownership and can be used to help tailor public messaging, inform work with partners to increase ESK ownership, and guide future research.

Hurricane Harvey left a path of destruction in its wake, resulting in over 100 deaths and damaging critical infrastructure. During a disaster, public health surveillance is necessary to track emerging illnesses and injuries, identify at-risk populations, and assess the effectiveness of response efforts. The Centers for Disease Control and Prevention (CDC) and American Red Cross collaborate on shelter surveillance to monitor the health of the sheltered population and help guide response efforts.

We analyzed data collected from 24 Red Cross shelters between August 25, 2017, and September 14, 2017. We described the aggregate morbidity data collected during Harvey compared with previous hurricanes (Gustav, Ike, and Sandy).

Over one-third (38%) of reasons for visit were for health care maintenance; 33% for acute illnesses, which includes respiratory conditions, gastrointestinal symptoms, and pain; 19% for exacerbation of chronic disease; 7% for mental health; and 4% for injury. The Red Cross treated 41% of clients within the shelters; however, reporting of disposition was often missed. These results are comparable to previous hurricanes.

The capacity of Red Cross shelter staff to address the acute health needs of shelter residents is a critical resource for local public health agencies overwhelmed by the disaster. However, there remains room for improvement because reporting remained inconsistent.

Official counts of deaths attributed to disasters are often under-reported, thus adversely affecting public health messaging designed to prevent further mortality. During the Oklahoma (USA) May 2013 tornadoes, Oklahoma State Health Department Division of Vital Records (VR; Oklahoma City, Oklahoma USA) piloted a flagging procedure to track tornado-attributed deaths within its Electronic Death Registration System (EDRS). To determine if the EDRS was capturing all tornado-attributed deaths, the Centers for Disease Control and Prevention (CDC; Atlanta, Georgia USA) evaluated three event fatality markers (EFM), which are used to collate information about deaths for immediate response and retrospective research efforts.

Oklahoma identified 48 tornado-attributed deaths through a retrospective review of hospital morbidity and mortality records. The Centers for Disease Control and Prevention (CDC; Atlanta, Georgia USA) analyzed the sensitivity, timeliness, and validity for three EFMs, which included: (1) a tornado-specific flag on the death record; (2) a tornado-related term in the death certificate; and (3) X37, the International Classification of Diseases, 10th Revision (ICD-10) code in the death record for Victim of a Cataclysmic Storm, which includes tornadoes.

The flag was the most sensitive EFM (89.6%; 43/48), followed by the tornado term (75.0%; 36/48), and the X37 code (56.2%; 27/48). The most-timely EFM was the flag, which took 2.0 median days to report (range 0-10 days), followed by the tornado term (median 3.5 days; range 1-21), and the X37 code (median >10 days; range 2-122). Over one-half (52.1%; 25/48) of the tornado-attributed deaths were missing at least one EFM. Twenty-six percent (11/43) of flagged records had no tornado term, and 44.1% (19/43) had no X37 code. Eleven percent (4/36) of records with a tornado term did not have a flag.

The tornado-specific flag was the most sensitive and timely EFM. Using the flag to collate death records and identify additional deaths without the tornado term and X37 code may improve immediate response and retrospective investigations. Moreover, each of the EFMs can serve as quality controls for the others to maximize capture of all disaster-attributed deaths from vital statistics records in the EDRS.

Issa AN, Baker K, Pate D, Law R, Bayleyegn T, Noe RS. Evaluation of Oklahoma’s Electronic Death Registration System and event fatality markers for disaster-related mortality surveillance – Oklahoma USA, May 2013. Prehosp Disaster Med. 2019;34(2):125–131

The Flint Community Resilience Group (Flint, Michigan USA) and the Centers for Disease Control and Prevention (CDC; Atlanta, Georgia USA) assessed behavioral health concerns among community members to determine the impact of lead contamination of the Flint, Michigan water supply.

A Community Assessment for Public Health Emergency Response (CASPER) was conducted from May 17 through May 19, 2016 using a multi-stage cluster sampling design to select households and individuals to interview.

One-half of households felt overlooked by decision makers. The majority of households self-reported that at least one member experienced more behavioral health concerns than usual. The prevalence of negative quality of life indicators and financial concerns in Flint was higher than previously reported in the Michigan 2012 and 2014 Behavioral Risk Factor Surveillance System (BRFSS) survey.

The following can be considered to guide recovery efforts in Flint: identifying additional resources for behavioral health interventions and conducting follow-up behavioral health assessments to evaluate changes in behavioral health concerns over time; considering the impact of household economic factors when implementing behavioral health interventions; and ensuring community involvement and engagement in recovery efforts to ease community stress and anxiety.

FortenberryGZ, ReynoldsP, BurrerSL, Johnson-LawrenceV, WangA, SchnallA, PullinsP, KieszakS, BayleyegnT, WolkinA. Assessment of Behavioral Health Concerns in the Community Affected by the Flint Water Crisis — Michigan (USA) 2016. Prehosp Disaster Med. 2018;33(3):256–265.

Carbon monoxide (CO) is an odorless, colorless gas produced by fossil fuel combustion. On October 29, 2012, Hurricane Sandy moved ashore near Atlantic City, New Jersey, causing widespread morbidity and mortality, $30 to $50 billion in economic damage, and 8.5 million households to be without power. The combination of power outages and unusually low temperatures led people to use alternate power sources, placing many at risk for CO exposure.

We examined Hurricane Sandy–related CO exposures from multiple perspectives to help identify risk factors and develop strategies to prevent future exposures. This report combined data from 3 separate sources (health departments, poison centers via the National Poison Data System, and state and local public information officers).

Results indicated that the number of CO exposures in the wake of Hurricane Sandy was significantly greater than in previous years. The persons affected were mostly females and those in younger age categories and, despite messaging, most CO exposures occurred from improper generator use.

Our findings emphasize the continued importance of CO-related communication and ongoing surveillance of CO exposures to support public health response and prevention during and after disasters. Additionally, regional poison centers can be a critical resource for potential on-site management, public health promotion, and disaster-related CO exposure surveillance. (Disaster Med Public Health Preparedness. 2017;11:562–567)

We evaluated the usefulness and accuracy of media-reported data for active disaster-related mortality surveillance.

From October 29 through November 5, 2012, epidemiologists from the Centers for Disease Control and Prevention (CDC) tracked online media reports for Hurricane Sandy–related deaths by use of a keyword search. To evaluate the media-reported data, vital statistics records of Sandy-related deaths were compared to corresponding media-reported deaths and assessed for percentage match. Sensitivity, positive predictive value (PPV), and timeliness of the media reports for detecting Sandy-related deaths were calculated.

Ninety-nine media-reported deaths were identified and compared with the 90 vital statistics death records sent to the CDC by New York City (NYC) and the 5 states that agreed to participate in this study. Seventy-five (76%) of the media reports matched with vital statistics records. Only NYC was able to actively track Sandy-related deaths during the event. Moderate sensitivity (83%) and PPV (83%) were calculated for the matching media-reported deaths for NYC.

During Hurricane Sandy, the media-reported information was moderately sensitive, and percentage match with vital statistics records was also moderate. The results indicate that online media-reported deaths can be useful as a supplemental source of information for situational awareness and immediate public health decision-making during the initial response stage of a disaster. (Disaster Med Public Health Preparedness. 2017;11:460–466)

For the past decade, emergency preparedness campaigns have encouraged households to meet preparedness metrics, such as having a household evacuation plan and emergency supplies of food, water, and medication. To estimate current household preparedness levels and to enhance disaster response planning, the Virginia Department of Health with remote technical assistance from the Centers for Disease Control and Prevention conducted a community health assessment in 2013 in Portsmouth, Virginia.

Using the Community Assessment for Public Health Emergency Response (CASPER) methodology with 2-stage cluster sampling, we randomly selected 210 households for in-person interviews. Households were questioned about emergency planning and supplies, information sources during emergencies, and chronic health conditions.

Interview teams completed 180 interviews (86%). Interviews revealed that 70% of households had an emergency evacuation plan, 67% had a 3-day supply of water for each member, and 77% had a first aid kit. Most households (65%) reported that the television was the primary source of information during an emergency. Heart disease (54%) and obesity (40%) were the most frequently reported chronic conditions.

The Virginia Department of Health identified important gaps in local household preparedness. Data from the assessment have been used to inform community health partners, enhance disaster response planning, set community health priorities, and influence Portsmouth’s Community Health Improvement Plan. (Disaster Med Public Health Preparedness. 2016;10:193–198)

Community Assessment for Public Health Emergency Response (CASPER) is an epidemiologic technique designed to provide quick, inexpensive, accurate, and reliable household-based public health information about a community’s emergency response needs. The Health Studies Branch at the Centers for Disease Control and Prevention (CDC) provides in-field assistance and technical support to state, local, tribal, and territorial (SLTT) health departments in conducting CASPERs during a disaster response and in non-emergency settings. Data from CASPERs conducted from 2003 through 2012 were reviewed to describe uses of CASPER, ascertain strengths of the CASPER methodology, and highlight significant findings.

Through an assessment of the CDC’s CASPER metadatabase, all CASPERs that involved CDC support performed in US states and territories from 2003 through 2012 were reviewed and compared descriptively for differences in geographic distribution, sampling methodology, mapping tool, assessment settings, and result and action taken by decision makers.

For the study period, 53 CASPERs were conducted in 13 states and one US territory. Among the 53 CASPERS, 38 (71.6%) used the traditional 2-stage cluster sampling methodology, 10 (18.8%) used a 3-stage cluster sampling, and two (3.7%) used a simple random sampling methodology. Among the CASPERs, 37 (69.9%) were conducted in response to specific natural or human-induced disasters, including 14 (37.8%) for hurricanes. The remaining 16 (30.1%) CASPERS were conducted in non-disaster settings to assess household preparedness levels or potential effects of a proposed plan or program. The most common recommendations resulting from a disaster-related CASPER were to educate the community on available resources (27; 72.9%) and provide services (18; 48.6%) such as debris removals and refills of medications. In preparedness CASPERs, the most common recommendations were to educate the community in disaster preparedness (5; 31.2%) and to revise or improve preparedness plans (5; 31.2%). Twenty-five (47.1%) CASPERs documented on the report or publications the public health action has taken based on the result or recommendations. Findings from 27 (50.9%) of the CASPERs conducted with CDC assistance were published in peer-reviewed journals or elsewhere.

The number of CASPERs conducted with CDC assistance has increased and diversified over the past decade. The CASPERs’ results and recommendations supported the public health decisions that benefitted the community. Overall, the findings suggest that the CASPER is a useful tool for collecting household-level disaster preparedness and response data and generating information to support public health action.

BayleyegnTM, SchnallAH, BallouSG, ZaneDF, BurrerSL, NoeRS, WolkinAF. Use of Community Assessments for Public Health Emergency Response (CASPERs) to Rapidly Assess Public Health Issues — United States, 2003-2012. Prehosp Disaster Med. 2015;30(4):1-8.

Approximately 1.2 million persons in Oakland County, Michigan (USA) reside less than 50 miles from the Fermi Nuclear Power Plant, Unit 2, but information is limited regarding how residents might react during a radiation emergency. Community Assessment for Public Health Emergency Response (CASPER) survey methodology has been used in disaster and nondisaster settings to collect reliable and accurate population-based public health information, but it has not been used to assess household-level emergency preparedness for a radiation emergency. To improve emergency preparedness plans in Oakland County, including how residents might respond during a radiation emergency, Oakland County Health Division (OCHD), with assistance from the Centers for Disease Control and Prevention (CDC) and the Michigan Department of Community Health (MDCH), conducted a CASPER survey.

During September 2012, a 2-stage cluster sampling design was used to select 210 representative households in Oakland County. By using in-person surveys, the proportion of households with essential needs and supplies, how residents might respond to public health authorities’ instructions, and their main source for obtaining information during a radiation emergency were assessed. Data were weighted to account for the complex sampling design.

Of the goal of 210 households, 192 (91.4%) surveys were completed: 64.7% and 85.4% of respondents indicated having 3-day supplies of water and of nonperishable food, respectively; 62.8% had a 7-day supply of prescription medication for each person who needed it. Additionally, 64.2% had a working carbon monoxide detector; 67.1% had a first-aid kit; and 52% had an alternative heat source. In response to instructions from public health officials during a radiation emergency, 93.3% of all respondents would report to a radiation screening center; 96% would evacuate; and 91.8% would shelter-in-place. During a radiation emergency, 55.8% of respondents indicated their main information source would be television, 18.4% radio, and 13.6% the Internet. The most trusted source for information would be the local public health department (36.5%), local news (23%), a physician (11.2%), and family members (11.1%). Including completed and incomplete interviews, refusals, and nonrespondents, 517 total households were contacted.

CASPER data regarding how residents might react during a radiation emergency provided objective and quantifiable information that will be used to develop Oakland County's radiation emergency preparedness plans. Survey information demonstrates the feasibility and usefulness of CASPER methodology for radiation emergency preparedness planning.

NyakuMK, WolkinAF, McFaddenJ, CollinsJ, MurtiM, SchnallA, BiesS, StanburyM, BeggsJ, BayleyegnTM. Assessing Radiation Emergency Preparedness Planning by Using Community Assessment for Public Health Emergency Response (CASPER) Methodology. Prehosp Disaster Med. 2014;29(3):1-9.

We examined the association between housing type and household emergency preparedness among households in Oakland County, Michigan.

We used interview data on household emergency preparedness from a cluster design survey in Oakland County, Michigan, in 2012. We compared survey-weighted frequencies of household demographics, medical conditions, and preparedness measures in single-detached homes versus multi-unit dwellings, and determined the unadjusted odds ratios (OR) and the income-level adjusted OR for each preparedness measure.

Households had similar demographics and medical conditions between housing types. Unadjusted ORs were statistically significant for single detached homes having a generator (11.1), back-up heat source (10.9), way to cook without utilities (5.8), carbon monoxide (CO) detector (3.8), copies of important documents (3.4), evacuation routes (3.1), and 3-day supply of water (2.5). Income level adjusted ORs remained statistically significant except for owning a CO detector.

Households in multi-unit dwellings were less likely to have certain recommended emergency plans and supplies compared to those in single detached homes. Further research is required to explore the feasibility, barriers, and alternatives for households in multi-unit dwellings in terms of complying with these measures. (Disaster Med Public Preparedness. 2014;0:1–8)

Rapid mental health surveillance during the acute phase of a disaster response can inform the allocation of limited clinical resources and provide essential household-level risk estimates for recovery planning.

To describe the use of the PsySTART Rapid Mental Health Triage and Incident Management System for individual-level clinical triage and traumatic exposure assessment in the aftermath of a large-scale disaster.

We conducted a cross-sectional, comparative review of mental health triage data collected with the PsySTART system from survivors of the September 2009 earthquake-tsunami in American Samoa. Data were obtained from two sources—secondary triage of patients and a standardized community assessment survey—and analyzed descriptively. The main outcome measures were survivor-reported traumatic experiences and exposures—called triage factors—associated with risk for developing severe distress and new mental health disorders following disasters.

The most common triage factors reported by survivors referred for mental health services were “felt extreme panic/fear” (93%) and “felt direct threat to life” (93%). The most common factor reported by persons in tsunami-affected communities was “felt extreme panic or fear” (75%). Proportions of severe triage factors reported by persons living in the community were consistently lower than those reported by patients referred for mental health services.

The combination of evidence-based mental health triage and community assessment gave hospital-based providers, local public health officials, and federal response teams a strategy to match limited clinical resources with survivors at greatest risk. Also, it produced a common operating picture of acute and chronic mental health needs among disaster systems of care operating in American Samoa.(Disaster Med Public Health Preparedness. 2013;7:327-331)

To evaluate key attributes, strengths, and limitations of the American Red Cross (ARC) disaster-related mortality surveillance system implemented during Hurricane Ike in Texas 2008, and to provide recommendations for system improvement.

We evaluated key attributes of the ARC mortality surveillance system. Evaluation included interviews with stakeholders and linking ARC data with the Texas Department of State Health Services’ (DSHS) system for comparison.

During September 11 through October 6, 2008, the ARC identified 38 deaths, whereas DSHS identified 74 deaths related to Hurricane Ike (sensitivity = 47%; positive predictive value = 92%). The ARC had complete data on 61% to 92% of deaths, and an 83% to 97% concordance was observed between the 2 systems for key variables.

The ARC surveillance system is simple, flexible, and stable. We recommend establishing written guidelines to improve data quality and representativeness. As an important supporting agency in disaster situations and the sole source of data regarding disaster-related mortality in multiple states, improvement of the ARC system will benefit stakeholders and promote dissemination of useful information for preventing future deaths. (Disaster Med Public Health Preparedness. 2013;7:13-19)

On April 20, 2010, the Deepwater Horizon drilling unit exploded off the coast of Louisiana, resulting in 11 deaths and the largest marine petroleum release in history. Previous oil spill disasters have been associated with negative mental health outcomes in affected communities. In response to requests from Mississippi and Alabama, potential mental health issues resulting from this event were identified by implementing a novel use of a Community Assessment for Public Health Emergency Response (CASPER) in the months immediately following the Gulf Coast oil spill.

This assessment was repeated one year later to determine long-term mental health needs and changes.

A two-stage sampling method was used to select households, and a questionnaire including the Centers for Disease Control and Prevention's Behavioral Risk Factor Surveillance System (BRFSS) questions was administered. Weighted cluster analysis was conducted, and BRFSS questions were compared to the most recent BRFSS reports and the 2010 results.

In 2011, 8.8%-15.1% of individuals reported depressive symptoms compared to 15.4%–24.5% of individuals in 2010, with 13.2%-20.3% reporting symptoms consistent with an anxiety disorder compared to 21.4%-31.5% of individuals in 2010. Respondents reporting decreased income following the oil spill were more likely to report mental health symptoms compared to respondents reporting no change in income.

Overall, mental health symptoms were higher in the three assessment areas compared to BRFSS reports, but lower than 2010 surveys. These results suggest that mental health services are still needed, particularly in households experiencing decreased income since the oil spill.

ButtkeD, VagiS, SchnallA, BayleyegnT, MorrisonM, AllenM, WolkinA. Community Assessment for Public Health Emergency Response (CASPER) One Year Following the Gulf Coast Oil Spill: Alabama and Mississippi, 2011. Prehosp Disaster Med. 2012;27(6):1-7.

Previous oil spills and disasters from other human-made events have shown that mental health effects to the affected population are widespread and can be significant.

There has been concern regarding the likelihood that existing public health surveillance was not capturing the mental health effects to the population affected by the Gulf Coast oil spill. The objectives of this study were to assess the mental health needs of coastal communities in the states of Alabama and Mississippi following the Deepwater Horizon oil spill.

A cluster sampling methodology was used to assess the mental health status of coastal residents in three counties in Alabama four months following the 2010 Deepwater Horizon oil spill, and in the Gulf Coast counties in Mississippi 5.5 months after the oil spill.

A total of 469 residents of the selected areas were interviewed. Between 15.4 and 24.5% of the respondents reported depressive symptoms, with 21.4-31.5% reporting symptoms consistent with an anxiety disorder, and 16.3-22.8% reporting ≥14 mentally unhealthy days within the past 30 days. Overall, there were more negative quality of life indicators and negative social context outcomes than in the state's Behavioral Risk Factor Surveillance System (BRFSS) survey. Between 32.1% and 35.7% of all households reported decreased income since the oil spill, and 35.5-38.2% of all households reported having been exposed to oil.

The proportion of respondents reporting negative mental health parameters in the affected Alabama and Mississippi coastal communities is higher than the proportion reported in the 2008 and 2009 BRFSS state reports, suggesting that the public health response to the Deepwater Horizon oil spill should focus on mental health services in these communities.

ButtkeD, VagiS, BayleyegnT, SircarK, StrineT, MorrisonM, AllenM, WolkinA. Mental Health Needs Assessment After the Gulf Coast Oil Spill—Alabama and Mississippi, 2010. Prehosp Disaster Med.2012;27(5):1-8.

The Texas Department of State Health Services (DSHS) implemented an active mortality surveillance system to enumerate and characterize hurricane-related deaths during Hurricane Ike in 2008. This surveillance system used established guidelines and case definitions to categorize deaths as directly, indirectly, and possibly related to Hurricane Ike.

The objective of this study was to evaluate Texas DSHS' active mortality surveillance system using US Centers for Disease Control and Prevention's (CDC) surveillance system evaluation guidelines.

Using CDC's Updated Guidelines for Surveillance System Evaluation, the active mortality surveillance system of the Texas DSHS was evaluated. Data from the active mortality surveillance system were compared with Texas vital statistics data for the same time period to estimate the completeness of reported disaster-related deaths.

From September 8 through October 13, 2008, medical examiners (MEs) and Justices of the Peace (JPs) in 44 affected counties reported deaths daily by using a one-page, standardized mortality form. The active mortality surveillance system identified 74 hurricane-related deaths, whereas a review of vital statistics data revealed only four deaths that were hurricane-related. The average time of reporting a death by active mortality surveillance and vital statistics was 14 days and 16 days, respectively.

Texas's active mortality surveillance system successfully identified hurricane-related deaths. Evaluation of the active mortality surveillance system suggested that it is necessary to collect detailed and representative mortality data during a hurricane because vital statistics do not capture sufficient information to identify whether deaths are hurricane-related. The results from this evaluation will help improve active mortality surveillance during hurricanes which, in turn, will enhance preparedness and response plans and identify public health interventions to reduce future hurricane-related mortality rates.

Choudhary E, Zane DF, Beasley C, Jones R, Rey A, Noe RS, Martin C, Wolkin AF, Bayleyegn TM. Evaluation of active mortality surveillance system data for monitoring hurricane-related deaths, Texas, 2008. Prehosp Disaster Med. 2012;27(4):1-6.

On 13 September 2008, Hurricane Ike made landfall near Galveston, Texas, resulting in an estimated 74 deaths statewide and extensive damage in many counties. The Texas Department of State Health Services, US Public Health Service, and the Centers for Disease Control and Prevention conducted assessments beginning 12 days following hurricane landfall to identify the public health needs of three affected communities. The results of the assessment are presented, and an example of a type of public health epidemiological response to a disaster due to a natural hazard is provided.

A one-page questionnaire that focused on household public health characteristics was developed. Using a two-stage cluster sampling methodology, 30 census blocks were selected randomly in three communities (Galveston, Liberty, and Manvel, Texas). Seven households were selected randomly from each block to interview.

The assessments were conducted on 25, 26, and 30 September 2008. At the time of the interview, 45% percent of the households in Galveston had no electricity, and 26% had no regular garbage collection. Forty-six percent reported feeling that their residence was unsafe to inhabit due to mold, roof, and/or structural damage, and lack of electricity. Sixteen percent of households reported at least one member of the household had an injury since the hurricane. In Liberty, only 7% of the household members interviewed had no access to food, 4% had no working toilet, 2% had no running water, and 2% had no electricity. In Manvel, only 5% of the households did not have access to food, 3% had no running water, 2% had no regular garbage collection, and 3% had no electricity.

Post-Ike household-level surveys conducted identified the immediate needs and associated risks of the affected communities. Despite the response efforts, a high proportion of households in Galveston still were reportedly lacking electricity and regular garbage pickup 17 days post-storm. The proportion of households with self-reported injury in Galveston suggested the need to enhance public education on how to prevent injuries during hurricane cleanup. Galveston public health officials used the assessment to educate local emergency and elected officials of the health hazards related to lack of basic utilities and medical care in the community. This resulted in the provision of an extensive public health outreach education program throughout the island. The Liberty and Manvel assessment findings suggest that most households in both communities were receiving the basic utilities and that the residents felt “safe”. The assessments reassured local health officials that there were no substantial acute public health needs and provided objective information that services were being restored.