2019/2/15

Medical and Public Health Needs in Disaster

Shinichi Egawa, MD, PhD, FACS
IRIDeS, Tohoku University

Division of International Cooperation for Disaster Medicine

Agenda

1. Health in Sendai Framework.
2. Change of Health Risks in disaster.
3. Simulation analysis

12019/2/15

Similarity of disease and disaster

Vulnerability &Capacity

Hazards

Disaster••••

Life, HealthProperties
FamilyCommunity

Division of International Cooperation for Disaster Medicine

Disaster Risk Reduction• Know your risk
• Reduce your risk
• Prepared to act

To reduce the disaster risk,

Risk
Risk

Risk

=

Hazard x Vulnerability
Hazardx Vulnerability

Capacities
Capacities

Division of International Cooperation for Disaster Medicine

2

2019/2/15

Sendai Framework
Four Priorities

Priority 1: Understanding Disaster Risk
Priority 2: Disaster Risk Governance
Priority 3: Investment in Disaster Risk Reduction
Priority 4: Enhance preparedness for effective
response and “Build Back Better” in recovery,
rehabilitation and reconstruction

Seven Global Targets
Outcomes
Implementationsc) direct economic lossd) infrastructureb) affectede) national andlocal strategiesa)mortalityf) International
cooperationg) multi-hazard
EWSProf. Kimio Takeya
JICA and TU

Division of International Cooperation for Disaster Medicine

Health in DRR framework350"health"300

314"disaster"Sendai Framework described for the first
time,

280

250

To reduce “disasters losses with a significant
economic, social, health, cultural andenvironmental impact”

200
153

150
100
50
0

34
0

3

Why?

Yokohama
Hyogo
Sendai
Strategy 1995 Framework for Framework for
Action 2005 Disaster Risk
Reduction
2015

Division of International Cooperation for Disaster Medicine

3

2019/2/15

Health is imperative
Health, which is a state of complete physical, mental and social wellbeing,
and not merely the absence of disease or infirmity, is a fundamental
human right.
Declaration of Alma-Ata 1978
International Conference on Primary Health Care

http://www.who.int/publications/almaata_declaration_en.pdf

https://www.preventionweb.net/
publications/view/38336
Mahatma Gandhi
Division of International Cooperation for Disaster Medicine

Health in SFDRR
Target (d)Substantially reduce disaster damage to critical infrastructure and disruption of basic
services, among them health and educational facilities, including through developing theirresilience by 2030.

Local Level– (i)Enhance the resilience of national health systems, including by integrating
disaster risk management into primary, secondary and tertiary health care, especiallyat the local level; developing the capacity of health workers in understanding disasterrisk and applying and implementing disaster risk reduction approaches in health work;and promoting and enhancing the training capacities in the field of disaster medicine;and supporting and training community health groups in disaster risk reduction
approaches in health programmes, in collaboration with other sectors, as well as in theimplementation of the International Health Regulations (2005) of the World HealthOrganization;

Global and Regional Level– Enhance recovery schemes to provide psychosocial support and mental health services
for all people in need

Division of International Cooperation for Disaster Medicine

42019/2/15

Bangkok Principles

1.
2.
3.
4.
5.
6.
7.

Health to DRR, DRR to health.
Cooperation between health and other stakeholders for DRR
Stimulate people-centered investment in DRR including healthIntegrate DRR into health education and training, health into DRR.
Disaster data and health data into risk assessment.
Advocacy and support by science, information and technology
National policies and strategies for DRR and health

http://www.preventionweb.net/files/47606_bangkokprinciplesfortheimplementati.pdf
Division of International Cooperation for Disaster Medicine

Know your risk

Change of Health Risks in disaster5

2019/2/15

1923 Great Kanto Earthquake
September 1, 1923
11:58:32
M7.9
Cause of Death
Asphyxia
11%

Unknown
2%

Drowning
1%

Fire
86%

The buildings should be fire-resistantEvery Sept. 1 is the Disaster Drill Day

Division of International Cooperation for Disaster Medicine

1995 Great Hanshin Awaji Earthquake
January 17, 1995
05:46
M7.3
Cause of Death
Unknown
4%

Fire
13%

Asphyxia
83%

The buildings should be quake-proof
Japanese Association for Disaster
Medicine was established

Division of International Cooperation for Disaster Medicine

62019/2/15

2011 Great East Japan Earthquake
Mar. 11, 2011, 14:46 M9.0
Fire1%

Asphyxia
4%

Unknown
2%

Drowning
93%2011 White pages,
Japan Gov.

Division of International Cooperation for Disaster Medicine

Change of health risks in Great East Japan Earthquake
InjuredDead and lost

Displaced

Hanshin-Awaji
Earthquake 1995

43,800

6,433

307,200

Great EastJapan
Earthquake 2011

5,942

19,582

488,000

•
•
•
•
•
•

Less injuries, but different medical needs lasted longer
Disruption of traffic and communication made health sector paralyzed
Complicated radiological disaster
Mental health of affected people was devastatedHealth facilities were also destroyed by disaster
Education of disaster medicine was not generalized in health professionals

Division of International Cooperation for Disaster Medicine

72019/2/15

Distribution Map for Radiation Dose
http://ramap.jmc.or.jp/map/eng/

As
7,
As of
of Nov.
Nov.29,4, 2014
2015
19,
2013
Mar.
31,
2012
Apr.
18,
2011
2016
3.5
years
later
4.5
2.5
year
later
1
5.5
month
years
later
later

Division of International Cooperation for Disaster Medicine

Number of evacuees after Great East Japan Earthquake
45000040000035000030000025000020000015000010000050000
02011/3/11

2012/3/10

2013/3/10
2014/3/10
2015/3/11
Evacuees in pre-designated EC
From Miyagi to outside
Total

2016/3/10
2017/3/10
2018/3/10
From Fukushima to outside
From Iwate to outside

2019/3/11

Division of International Cooperation for Disaster Medicine

82019/2/15

Disaster related deaths
Ministry of Reconstruction, Mar. 31, 2014
Total 3, 089
Total
Fukushima
Miyagi
Iwate

800
600
400
200
0

Total
Miyagi

Division of International Cooperation for Disaster Medicine

What irradiation exposure will not cause
1.

Immediate death–2.

Immediate burn and physical injury––

3.

One engineer died of acute radiation injury 66.5 h later in 1997
Russian Salov criticality accident
Think of heat material or casualty
Decontamination sometimes cause skin inflammation

Harmful irradiation of care giver–

Less than 1 mSv even the patient had 26,000 cpm contaminationin the upper body

Acute radiation injury occurs when more than 1000 mSv
effective dose was irradiated in a short time.
Division of International Cooperation for Disaster Medicine

92019/2/15

2018 Japan Floods
Jun. 28-Jul. 9, 2018
Flood
L d
Land
SlidesLand
SlidesFlood

Total 222 deaths with unconfirmed missing(Police Department as of Jul. 17, 2018)
Total number of evacuees;
23,000 (Fire Department as of Jul. 8, 2018)

Division of International Cooperation for Disaster Medicine

Reduce your risk

Capacity building of disaster medicine
in Japan

10

2019/2/15

Disaster Base Hospital• 725 DBHs in Japan– 1 National Disaster Medical Center– 788 DMAT providing DBH– 271 Emergency Center– 54 Radiological DBH
Support
HQ

ICU
ER

Water

DMAT
Emergency
infrastructure
O2

Power

Division of International Cooperation for Disaster Medicine

Disaster Base Hospitals in Japan

Division of International Cooperation for Disaster Medicine

112019/2/15

Number of DMAT teams in DBH and access to downtown

Chofu
AirportNaritaAirportDMAT HQ

Gov. HQ

Service Area and Parking Area will serve as
an emergency supply centers

HanedaAirportDivision of International Cooperation for Disaster Medicine

DMAT Teams in DBH

Disaster Medical Assistant Team (DMAT)•••

Number of victims•

More than 1000 teams were trained in Japan after Hanshin Awaji
Earthquake
Arrives in the affected area within 24 hours and save the lives frompreventable death until 72 hours when the local health care recovers.
Consists of a medical doctor, a nurse, a pharmacist and a logistician
with self-standing materials and vehicle.
Specific training for confined space medicine and wide areatransportation.

DMAT

Local Health Care Providers

Division of International Cooperation for Disaster Medicine

122019/2/15

Medical Management System
Ministry of Health, Labor and Welfare

Disaster Base
Hospital

DMAT HQ

DMAT

DMAT

Disaster Base
HospitalDMAT

Emergency Medical Information System (EMIS)

Division of International Cooperation for Disaster Medicine

J-DMAT: Japan Disaster Medical Assistance Team on Training

Staging Care
Unit

Confined SpaceDMAT not only provide medical care, but also
assists the local HQ and Staging Care Unit
(SCU) in medical coordination.

Division of International Cooperation
Medicine for Disaster Medicine

Wide Area
Transportation13

2019/2/15

Medical Management System
Ministry of Health, Labor and Welfare

Disaster Base
Hospital

Disaster Base
Hospital

DMAT HQ

DMAT

DMAT

DMAT

Emergency Medical Information System (EMIS)

Division of International Cooperation for Disaster Medicine

Role of DMAT before 3.11
Wide Area
Transportation

Staging
Care Unit SCU

Distant
DBH

SCU
Affected Area
DBH

Confined Space
Medicine
Damaged
Site

Local Hp

Support of
DBH

NearbyDBH

Division of International Cooperation for Disaster Medicine

142019/2/15

Aircrafts for Wide Area Transportation

C1 (Self Defense Force)

C130 (Self Defense Force)
Capacities
8 Patients with stretchers in C1 and C130
4 Patients with stretchers in CH-47
SCU triages
Multiple injuries, Head injury, Crash syndromes andSevere burns that require intensive care in Life saving
emergency center outside the affected area.

CH-47 (Self Defense Force)

Division of International Cooperation for Disaster Medicine

EMIS Emergency Medical Information System

Division of International Cooperation for Disaster Medicine

152019/2/15

Data entry to EMIS
%
100
90
80
70
60
50
40
30
20
10
0

All
Miyagi
Iwate
Fukushima
IbarakiMar. 11Mar. 12Mar. 13DMAT or personnel in disaster base hospitalshould enter EMIS as soon as possible.

Dr. Koido
Disaster Medical Center

Division of International Cooperation for Disaster Medicine

Further improvement after GEJE
1. Increased assignment of disaster medical and public healthcoordinator
2. Specialized teams to assist mental health, reproductive health,rehabilitation, public health and oral health
1.
2.
3.
4.
5.
6.

DPAT （Disaster Psychiatry Assistance Team)
Mental Care TeamALSO (Advanced Life Support in Obstetrics)
DHEAT (Disaster Health Emergency Assistance Team)JRAT (Japan Rehabilitation Assistance Team)
Disaster oral care coordinator

3. Improved management of evacuation center and welfare
evacuation center4. Collaboration with other sectors.

Division of International Cooperation for Disaster Medicine

162019/2/15

Disaster Psychiatric Assistance Team (DPAT)
•
•
•
•
•
•

Multidisciplinary team managed by prefectures and Ministry of Health
Main psychiatry hospitals has DPAT
Composed of a psychiatrist, a nurse and a logistician
Equipped with self standing materials and vehicles.
Coordinates with DMAT
Disaster Mental Health Information Support System (DMHISS)

Information andassessment
Education

Coordination

DPAT
Mental care of
responders

Support of psychiatricfacilities
Mental care of affected
peopleDivision of International Cooperation for Disaster Medicine

Japan Rehabilitation Assistance Team (JRAT)

Health Cluster Meeting

Kumamoto Earthquake
Apr. 14, 2016, M7.3
Dead 50, Related Death 76
Related Death by Rainfall 5
Injured 2,337 as of Sep 30, 2016
Japan Police

Conversation with
evacuated people

Setting slope andhandrail
JRAT Kumamoto Earthquake Report 2017

TemporarySupporting
DeviceSafety assessment ofmobility

17

2019/2/15

Disaster Medical Coordinator••

First established in Hyogo in 1997
Four out of 47 prefectures （10.6％）had designated medical
coordinators before GEJE.
Miyagi prefecture assigned 6 coordinators, but Iwate and Fukushima
did not.

•

Relief
Aids

Help
Needs

Help
Needs

Relief
Aids

Division of International Cooperation for Disaster Medicine

Implementation of Disaster Medical Coordinator in Japan
As of Aug. 2015
100%
90%

60%
50%
40%

Assigned
Great East Japan Eq

70%

In Prep
Great Hanshin Awaji Eq

80%

30%
20%
10%
0%

More than 80% of the all prefecture will assign Disaster Medical
Coordinator by the end of 2015 (Egawa TJEM 2017)
Division of International Cooperation for Disaster Medicine

18

2019/2/15

R&D

Simulation Analysis
in Disaster Medicine

IRIDeS
Hazard and risk evaluation

Endowedresearch division(Tokio Marine)

Human andsocial response

Regional and urban
reconstruction
Disaster information
management and public
collaboration

Disaster medical
science

Disaster science

Division of International Cooperation for Disaster Medicine

192019/2/15

Simulation in disaster science••••

Reproducible without actual damage
Controllable parameters
Impact on decision making
Low cost

Simulators in medical education

Simulation software in science

System Dynamics

Agent Based

Division of International Cooperation for Disaster Medicine

Types of Simulation• System Dynamics– Complex phenomenon can be divided into interactive factors– Interactions can be expressed by simple equations– Robust forecasting of the outcome• Agent Based– Agent takes action according to the specified rules– Parameters define the action of each agent– Statistical analysis of actions

Division of International Cooperation for Disaster Medicine

202019/2/15

Ebola Virus Disease (EVD)
Deadly disease: Average case fatality ratio is 50% (WHO).
Symptoms
–
–
–
–
–
–
–

Ebola virus.
Source: CDC

Fever
Vomiting
Diarrhea
Bleeding
Stomach pain
Muscle pain
Symptoms may appear anywhere from 2 to 21 days after exposure to Ebola, but the
average is 8 to 10 days.

Division of International Cooperation for Disaster Medicine

Zoonosis

Division of International Cooperation for Disaster Medicine

21

2019/2/15

Capacity building•

Community engagement is key to successfully controlling outbreaks.
– case management– surveillance and contact tracing– a good laboratory service– safe and dignified burials and social mobilization.

•

What we should know
– EV transmits by contact with body fluids including sweat– EV transmits from bush meats– EV is easily inactivated by disinfection (75-80% alcohol, boilingwater)– Incubation period 2-21 days

Division of International Cooperation for Disaster Medicine

People’s mindset in Ebola Virus Disease Outbreak• Key words– Deadly Disease– Possible Outbreak• Communication of
People and Media– No direct skin contact– Wear PPE– Learning Period– Forgetting Period– Effectiveness– Happy Birthday!

Division of International Cooperation for Disaster Medicine

222019/2/15

State chart of agent “Person”
Healthy“Deadlydisease”“No direct skincontact”

Worriedhealthy

Educated
healthy

Chance ofExposure Learning score“Wear PPE”

Experienced
healthy

Infectedand Wearing PPE
defines possibilityof infection“Take careof me”A person forgets
and return to
Healthy

Symptomatic“Take careof me”

Survived

Dead“Wear PPE”

Division of International Cooperation for Disaster Medicine

What defines the people’s mindset?
Controlled Trial (Experiments)
Positive Control
Negative Control

Division of International Cooperation for Disaster Medicine

23

2019/2/15

Results• Scenario 1: Naïve community– 3, 3, 14, 7, beginning122• Scenario 2: Educated community– 3, 3, 14, 7, pre-messages, after PFP– 3, 3, 14, 7, pre-messages, before PFP

146
77• Scenario 3: Forgetful community– 3, 3, 6, 3, beginning– 3, 3, 6, 3, pre-messages, after PFP

368
329

• Scenario 4: Experienced community– 3, 3, 14, 30, beginning– 3, 3, 14, 30, pre-messages, before PFP

162
<10

Division of International Cooperation for Disaster Medicine

Implications• Sustainable risk perception and education• Role of Media• Role of Academia• DRR at all levels

Division of International Cooperation for Disaster Medicine

242019/2/15

From GEJE to all hazard

Conclusion

Change the concept of Risk Reduction
Needs

Paradigm ShiftTop 3 priorities for communities (UN Survey)
1. A good education
2. Better healthcare
3. An honest and responsive government

Climate Change
Rapid urbanization
PovertyLack of resource
Loss of biodiversity

Change of Risk
Better accessResilientCommunity

Safe Hospital
Safe School
Mental andPhysicalEffective
Response

Qualityof LifeInjuryIllness
disability

Hazard-proof
Structure
Early Warning

Communication Funding andDevelopment

Division of International Cooperation for Disaster Medicine

25

2019/2/15

Human Security in Disaster

Clusters

HealthCare

Protection
Food
Security

Communication

Education
Safe School

Better access(Accessibility)

Mental andPhysical
HealthShelter(Housing)

WASH

Safe Hospital
Early
Warning

Logistics
Funding

Hazard-proof Structure
Effective Response
Early Recovery

People-centered approach is important
Division of International Cooperation for Disaster Medicine

26