保健医療科学

2018 Vol.67 No.1 p.123－132

Topics: Lessons learned on public health from the Fukushima Daiichi Nuclear Power Plant accident＜ Review ＞
Disaster epidemiology: Assessing the health impactsof environmental public health disasters
Erik R. Svendsen
Department of Public Health Sciences, Medical University of South Carolina

Abstract
Introduction: Although disaster epidemiology is essentially recognized as the use of epidemiology
in disaster settings, it now has unique methods and tools applicable only within public health disastersettings. Herein I will briefly describe the history and development of disaster epidemiology, its uniquecharacteristics, and illustrate its potential to both respond to and learn from public health disasters within
the current literature.
Methods: This literature review was used to motivate the potential application of disaster epidemiology
more extensively in the on-going disaster-related public health recovery and research within Fukushima
after the 2011 radiological disaster, and preparedness activities to mitigate any such future event. The
PubMed electronic database for medical journals was used exclusively to identify literature suitable forinclusion in the literature review paper using the following search terms anywhere in the article: disasterand epidemiology; “disaster epidemiology”.
Results: Disaster epidemiology can be used to understand the frequency and severity of disasters, torapidly learn about the needs of the disaster population and intervene in those needs, and to learn how tominimize the public health impacts of future disasters: tracking, mitigating, and researching, accordingly. To
date, the majority of journal articles have been focused on mitigating disasters (10 of the 19 papers).
Discussion: There was a consistent recognition of the applicability of epidemiology within disasters, as
was evident in the large number of journal articles which included both the terms “epidemiology” and“disaster”. However, that did not translate over to an understanding of “disaster epidemiology” as a subdiscipline because only 19 articles were focused on that concept. Within those there was variability in how
the term was being used. More work is needed to better educate the scientific and public health community
about the unique niche which disaster epidemiology plays within public health disaster management andpreparedness.
Conclusions: Disaster epidemiology is a unique sub-discipline which can help advance the tracking,mitigation, and research of public health disasters. Further training and development of this sub-discipline
within epidemiology training programs could help reduce the burden of disasters on public health andadvance our understanding of unique environmental exposures within disaster settings.
keywords: disaster, epidemiology, public health, environmental(accepted for publication, 26th December 2017)

Corresponding author: Erik R. Svendsen
E-mail: svendsendsee@musc.edu

J. Natl. Inst. Public Health, 67 (1) : 2018123

Erik R. Svendsen

I．Introduction
A disaster is in essence any natural or technologicalevent which causes exposures, illnesses, injuries, anddeaths while overwhelming the capacity of the existing
public health infrastructure[1-3]. The prevalence of large
natural disasters has been increasing over the past several
decades[4]. Similarly, technology disasters, or disasters
associated with a human breakdown in a technologicalsystem, such as a large industrial explosion, have been
increasing in both frequency and severity over the past few
decades. As our human population and population density
continue to increase so does the probability that large
populations will be increasingly impacted by various typesof disasters. Therefore, the public health community needs
to be prepared for such disasters, and have establishedtools in place to help manage public health disasters. But
research is needed in disasters, also; often disasters canprovide unique settings for human health research whichcannot be done in experimentally. Dominici, et al. [5],clarify this common view in their statement “as perverse
as it might sound, epidemiologists must view disasters
as important opportunities to learn about the etiology of
disease”. In 2013 a high-profile editorial was published in
the New England Journal of Medicine calling for researchwithin public health disasters [6]. One of the tools which
can both assist with the management of and research withinpublic health disasters is disaster epidemiology.
There has always been a recognition that epidemiology
has a place in modern public health disasters, yet not sofor it as a sub-discipline within epidemiology. The use of
epidemiological methods within disasters has evolved overthe past 70 years such that it is now a distinct sub-discipline
within epidemiology. Although disaster epidemiology isessentially recognized as the use of epidemiology in disastersettings [7], it now has unique methods and tools applicable
only within public health disaster settings. Herein I will
briefly describe the history and development of disasterepidemiology, its unique characteristics, and illustrate its
potential to both respond to and learn from public healthdisasters within the current literature. This literature
review will be used to motivate the potential applicationof disaster epidemiology more extensively in the on-goingdisaster-related public health recovery and research within
Fukushima after the 2011 radiological disaster [8], andpreparedness activities to mitigate any future event such as
that.

II．Methods
The PubMed electronic database for medical journals[9] was used exclusively to identify literature suitablefor inclusion in the literature review paper. I used thefollowing search terms anywhere in the article: disasterand epidemiology; “disaster epidemiology”. The literature
was last accessed in mid-November, 2017. Only Englishlanguage journal articles were considered.

III．Results
There were 13,453 journal articles for the terms“disaster” and “epidemiology”. When searching for thestring of words “disaster epidemiology” there were much
fewer: 3,646 anywhere, 52 in the title, and only 19 withdisaster epidemiology as the focus. All 19 articles wereaccessed and reviewed in addition to select articles fromthe broader literature search.
Disaster epidemiology can really be classified into threeclasses: the epidemiology used to track the incidence ofdisasters, epidemiology used to mitigate the consequencesof disasters, and epidemiology to perform etiologicalresearch within disasters (Table 1). In other words disasterepidemiology can be used to understand the frequency
and severity of disasters, to rapidly learn about the needsof the disaster population and intervene in those needs,
and to learn how to minimize the public health impactsof future disasters. To simplify these classes, I will callthem tracking, mitigating, and researching, accordingly. To
date, the majority of journal articles have been focused on
mitigating disasters (10 of the 19 papers).
The first use of the term “disaster epidemiology” within
the title of a journal article was in 1975 [10-12]. However,disaster epidemiology goes back much further than that, toeven the structured tracking of death, disease, and injuries
from wars, epidemics, and natural disasters in the 19th andearly 20th centuries [13]. Some long-term assessments

Table 1 Classes and tools within Disaster Epidemiology

Tool

124

Class
Tracking
Mitigating
Event surveillance
Rapid Needs Assessment
Descriptive studies
Cluster Analyses
Ecological studies
Outbreak Assessment
Case studies
Event registries
Public Health PracticeResearching
Cohort studies
Case‐control studies
Intervention studies
Quasi‐experimental studies
Human Subjects Research

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Disaster epidemiology: Assessing the health impacts of environmental public health disasters
of soldiers exposed to war gases during World War I were
performed [14], but not using structured epidemiologicalmethods [14]. Modern designs were first incorporated into
researching epidemiology within disasters in the massive
Lifespan cohort study of the survivors from Hiroshima andNagasaki [15]. But such early adaptations of epidemiologic
methods to disaster settings were not classified as disasterepidemiology, rather just epidemiology within a disaster
population. Disaster epidemiology was incubated througha series of humanitarian disasters and wars in the 1950s
and 1960s such that by the mid-1970s there were new
epidemiological methods which were well-suited for
mitigating the impacts of disasters and humanitarian crises
on human health [16-19], most notably the rapid needs
assessment survey [20-22]. However, these methods
were very slowly adopted across the disaster management
community within the 1980s [21,23-25]. On the researchingside of disaster epidemiology, epidemiology began to be
used as a powerful research tool in the Bhopal disaster[26,27], Mt. St. Helens eruption [28-30], and multiple
natural disasters throughout the 1980s and 1990s. Larger
disasters in the early 2000s helped to further develop thedisaster epidemiology sub-discipline, especially the 9-1-1
and Hurricane Katrina disasters in the USA [31,32]. Yet theneeds to balance researching, mitigating, and tracking publichealth within disasters had been identified as a significant
gap in our international disaster management processes
even just five years ago [6]. Since then new developments
have been made to support the researching class within
disaster epidemiology [4], and new funding mechanisms
and associated survey tools are available for many to do
expedited research following disasters, including a rapid
human subjects review process [4].
Now there are multiple methods which are available toepidemiologists for tracking, mitigating, and researching
public health impacts within disaster populations. The
full spectrum of epidemiology designs can be used, fromdescriptive (e.g. cluster analysis), observational (e.g. casecontrol), quasi-experimental (e.g. interrupted time series),
to experimental (e.g. intervention study). These can beapplied within the public health practice or human subjects
research context. But it is important to understand theethics behind these activities. In public health practice thefocus is on what you can give to the disaster population
through rapid assessment of disease, injury, deaths, andresource needs such that the impact of the disaster is
mitigated. In essence the patient is the disaster population,and disaster epidemiology is used to treat the ʻpatientʼ.
In human subjects research you are trying to understandwhat lessons can be taken away from this event and used
to better prepare for the next disaster. So it is important toremember that disaster populations have already had muchtaken away from them, and they should first be treated as adisaster patient and not a research subject. Delicate balanceis needed to navigate the needs for both learning from adisaster and helping those within the disaster population[33]. The disaster epidemiology focus must always beon what should be done, not simply what could be done.
There are always many studies which could be done indisaster populations. But which studies would best help thedisaster populations while advancing improved scientificunderstanding? Those are the studies which should be
done.
The 19 journal articles purely focused on “disasterepidemiology” within their title were regarding disasters
worldwide [5,10-12,24,34-47]. The last article to really
discuss disaster epidemiology as a sub-discipline within
epidemiology was in 2005 [5,40]. Disaster epidemiology
was not brought into prominence until the 1990 editorial
in the Lancet [47]. Much of that was due to the progressthat had been made in addressing the problems withdisaster management highlighted in previous articles in
the 1970s [39]. The problems with disaster management
and the insufficient use of disaster epidemiology methods
were collectively a significant impetus behind the World
Health Organization selecting the 1990s as the decadeduring which it was hoped that we would collectively
reduce the frequency and severity of disasters, especiallyin the developing world [47]. So it is not a surprise that the
number of disaster epidemiology articles increased in the
1990s. Those were predominantly focused on international
crises within resource-poor nations. But natural disasters
hit more economically developed countries within the
1990s, also, both challenging and refining the newly
developed disaster epidemiology mitigation methods[37,44,48-53]. But disaster epidemiology was first applied toterrorism in the 1990s, also, and later refined in the 2000s
after the World Trade Center attacks [31,54-57]. With theWorld Trade Center disaster of 2001 came a renaissancein researching disaster populations which has continued tothis day with dozens of studies having been published fromresearch within that disaster population. Yet there has beena notable gap in the literature since then of any articles
explicitly focused on disaster epidemiology within their title
and content. Yes, many disaster epidemiology cases havebeen described and research studies performed since then.
But no article systematically discussed the sub-discipline ofdisaster epidemiology in an engaging way. Regardless, muchhas been learned since that first ʻcall to armsʼ paper in 1975,
and many methods developed for the tracking, mitigating,and researching applications of disaster epidemiology.
Tracking large disasters has become implicitly easier in

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Erik R. Svendsen
the modern age of the internet and electronic disease andmedical record systems. Likewise, mitigating disasters
through the effective use of disaster epidemiology has
become easier. Several new methods have helped toassist with that process. These include improvements incluster analyses [58-62], other spatial models [58,59,6365], syndromic surveillance [66-69], and community
needs assessments [70-75]. However, while the methods
available for mitigating disasters through epidemiology
have improved significantly, disaster epidemiology researchmethods have developed exponentially.
Epidemiological research studies of environmental
disasters are uniquely poised to accomplish novel etiologic
research [5], especially when a longitudinal cohort design
is used [76]. However, such designs usually require large
sample sizes. A more innovative and powerful design isthe natural experiment [77,78], which can be used even insmaller disaster populations. Such a quasi-experimental
design can provide results comparable to an experimentand may be the strongest study design available when an
experiment is unethical. Other quasi-experimental methods
are quite robust, also [79-83]. But disaster epidemiology
research has its challenges.
Disaster effects are wide-ranging and can go beyond
the individual [28-30,84-92]. Environmental disasters,
like Fukushima, usually involve a breakdown in manmade systems [87,93,94], which may result in community
mistrust [87]. Such mistrust can result in selection biases
due to poor participation [95], high attrition, volunteer
bias, and loss to follow-up from emigration [76,96-101]. On
the contrary, communities may be resilient [93]. Recovery
efforts have proven more effective when the community
is engaged [93,102-104]; then science can follow [86,105,106]. Community-based participatory research (CBPR)
can do that [94,107]. Disaster communities are oftensocio-economically disadvantaged [108]. Therefore, it isimperative to fully engage the study community within
the scientific approach, building trust, and establishing
local credibility prior to initiating any studies [109]. Thisapproach was chosen by Japanese scientists in Hiroshima
and Nagasaki a priori to focus on the public health needs
first and the science second before any study was evereven started with the USA, now resulting in the longest
prospective cohort study in history [110]. CBPR has be used
when studying a smaller disaster community, also [111-119].
Therefore, CBPR should be used when studying a disastercommunity [111,112,114,116,117,119-122]. Collectively,
disaster epidemiology tracking, mitigating, and researchmethods have improved significantly since 1975. Most
recently, there are now established templates and tools for

126

performing public health service-based assessments tomitigate and track disasters [67,68,71,72,123-127], and evento study unique risk factors within them [4,128].

IV．Discussion
There was a consistent recognition of the applicabilityof epidemiology within disasters, as was evident in thelarge number of journal articles which included boththe terms “epidemiology” and “disaster”. However, that
did not translate over to an understanding of “disasterepidemiology” as a sub-discipline because only 19 articles
were focused on that concept. Within those there wasvariability in how the term was being used. Some wereusing it clearly under the “tracking” class of definitions,others mitigating, while others were using for researching
within disasters. More work is needed to better educate
the scientific and public health community about the unique
niche which disaster epidemiology plays within publichealth disaster management and preparedness.
However, this literature review has limitations. Only one
electronic library database was reviewed (PubMed), and in
only one language (English). This may have underestimatedthe number and types of journal articles which describeddisaster epidemiology. Further literature review isneeded within other languages which use other electronic
library databases to accomplish a more comprehensive
assessment of the use of disaster epidemiology withinpublic health and medicine. In the USA, disasters may
or may not be officially declared major disasters by the
US President [129]. If not, none of the provisions in the
US federal disaster management regulations [130,131]
are enacted and the affected US disaster population
is to be served by other local/state resources. Hence,
any support or study of the affected population mustbe funded through non-federal disaster appropriation
mechanisms. Therefore, disasters which do not reach thethreshold of a major disaster declaration within the USA
may not receive sufficient support to sustain disasterepidemiology activities. Such disasters may, therefore,
have an underestimation of their public health impacts
and use of disaster epidemiology in the USA. Similarfederal funding protocols can be found in other countries
and may have similar effects on underreporting the use of
and results from disaster epidemiology elsewhere. Lastly,
many disaster epidemiology activities do not produce peerreviewed publications in any language or reports which
are archived within electronic library databases. Often
disaster epidemiologists are so busy tracking, mitigating,and researching best practices for the disasters in which
they are responsible for assisting that their work may not

J. Natl. Inst. Public Health, 67 (1) : 2018

Disaster epidemiology: Assessing the health impacts of environmental public health disasters
be sufficiently recorded in archives which are available tothe broader scientific and public health audience. Therefore,
the results reported herein may vastly underestimate theapplication of disaster epidemiology within public healthdisasters worldwide.

[7]
[8]

V．Conclusion
Disaster epidemiology is a unique sub-discipline which
can help advance the tracking, mitigation, and research of
public health disasters. Further training and development of
this sub-discipline within epidemiology training programs
could help reduce the burden of disasters on public healthand advance our understanding of unique environmental
exposures within disaster settings. Expanding the current
use of disaster epidemiology methods within the Fukushimadisaster research and recovery efforts may be useful.

[9]
[10]
[11]
[12]
[13]

Conflict of Interest[14]
The author has no affiliations with or involvement inany organization or entity with any financial interest, or
non-financial interest in the subject matter or materials
discussed in this article.
[15]

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災害疫学―環境に影響を与える災害における公衆衛生の視点での健康影響の評価法―

エリック・スベンソン
サウスカロライナ医科大学公衆衛生科学部環境保健分野

抄録
導入：「災害疫学」は，災害時に利用される疫学だと基本的には認識されている．しかし，公衆衛生上の問題をもたらす災害時に適用することから，他の疫学的な手法とは異なる特性を持つようになった．そこで，「災害疫学」の歴史を振りかえりその発展の経緯や災害疫学が持つ特性を概説する．また，関連する文献をレビューすることで，「災害疫学」が情報の集約によりいざという時の対応の効率化に役立つだけでなく，災害がもたらす影響をより深く学ぶことで次の事態によりよく備えられるようになる二つの側面の特徴を示す．
方法：2011年の東京電力福島第一原子力発電所災害に対する現在進行中の公衆衛生面での復興活動やそれを支える研究に対して，「災害疫学」をより広範に適用させることや将来新たな災害が発生した
場合の対応措置の準備に役立たせることを意図して文献をレビューした．
結果：「災害疫学」は，追跡調査，影響緩和措置，調査といった手法等を介して，災害を定量的な面からその重大性を理解し，災害に見舞われた人々のニーズを迅速に把握し，そのニーズに対応するだ
けでなく，将来の災害による公衆衛生上の影響を最小限に抑える方法を学ぶために用いることができる．これまで，学術雑誌に掲載されたこの分野の論文の大部分は災害がもたらす影響の緩和に焦点を当てていた（19本中10本で）．
考察：「疫学」と「災害」の両方のキーワードを含む数多くの論文では，災害の中での疫学の適用性についての一貫した認識があった．しかし，19の論文のみがその概念に焦点を当てていたことは，「災害疫学」が疫学のサブカテゴリーとして認識されていないことを示している．しかも，これらの文献
では，用語の使い方にばらつきがあった．災害対応での公衆衛生上の課題やそれへの備えの観点から，本来，対応が求められるものの見過ごされがちな分野について，「災害疫学」の意義に関して科学や公衆衛生コミュニティの理解を深めるためには，さらにその学問体系について概念整理を深める必要がある．
結論：「災害疫学」は，疫学の中で特徴のあるサブカテゴリーで，災害時の公衆衛生対応として，追跡的な調査，被害軽減，研究を進める上で役立つ概念である．疫学の重要なサブカテゴリーである「災害疫学」についても教育や手法開発を進めることは災害時における公衆衛生上の課題を軽減し，災害での対応で課題にもなる環境中の有害物質への災害時の曝露の理解を促進するのにも役立つ．
キーワード：災害，疫学，公衆衛生，環境

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