International Journal ofEnvironmental Researchand Public Health

ReviewPrevention of Hypothermia in the Aftermath of Natural
Disasters in Areas at Risk of Avalanches, Earthquakes,
Tsunamis and Floods
Kazue Oshiro 1, * , Yuichiro Tanioka 2 , Jürg Schweizer 3 , Ken Zafren 4,5 , Hermann Brugger 6Peter Paal 7
1

2

3
4

5
6

7

*

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Citation: Oshiro, K.; Tanioka, Y.;
Schweizer, J.; Zafren, K.; Brugger, H.;
Paal, P. Prevention of Hypothermia in
the Aftermath of Natural Disasters in
Areas at Risk of Avalanches,
Earthquakes, Tsunamis and Floods.

andDepartment of Cardiovascular Medicine and Mountain Medicine, Research, and Survey Division, Hokkaido
Ohno Memorial Hospital, Sapporo 063-0052, Japan
Faculty of Science, Institute of Seismology and Volcanology, Hokkaido University, Sapporo 060-0810, Japan;
tanioka@sci.hokudai.ac.jp
WSL Institute for Snow and Avalanche Research SLF, 7260 Davos, Switzerland; schweizer@slf.ch
Department of Emergency Medicine, Stanford University Medical Center, Stanford, CA 94304, USA;zafren@stanford.edu
Alaska Native Medical Center, Anchorage, AK 99508, USA
Institute of Mountain Emergency Medicine, Eurac Research, 39100 Bolzano, Italy;
hermann.brugger@eurac.edu
Department of Anesthesiology and Intensive Care Medicine, St. John of God Hospital, Paracelsus Medical
University, 5020 Salzburg, Austria; peter.paal@icloud.com
Correspondence: kazooshiro@gmail.com

Abstract: Throughout history, accidental hypothermia has accompanied natural disasters in cold,
temperate, and even subtropical regions. We conducted a non-systematic review of the causes
and means of preventing accidental hypothermia after natural disasters caused by avalanches,
earthquakes, tsunamis, and floods. Before a disaster occurs, preventive measures are required, suchas accurate disaster risk analysis for given areas, hazard mapping and warning, protecting existing
structures within hazard zones to the greatest extent possible, building structures outside hazard
zones, and organising rapid and effective rescue. After the event, post hoc analyses of failures, andimplementation of corrective actions will reduce the risk of accidental hypothermia in future disasters.

Int. J. Environ. Res. Public Health 2022,
19, 1098. https://doi.org/10.3390/
ijerph19031098

Keywords: hypothermia; accidental; avalanche; earthquake; flooding; mountain; ocean; prevention;
rescue; tsunami

Academic Editor: Paul B.
Tchounwou
Received: 6 December 2021
Accepted: 14 January 2022
Published: 19 January 2022
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with regard to jurisdictional claims inpublished maps and institutional affiliations.

Copyright: © 2022 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms andconditions of the Creative Commons
Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).

1. Introduction‘Only human beings can recognize catastrophes, provided they survive them;nature recognizes no catastrophes.’ Max Frisch, Man in the Holocene. 1979.
Natural disasters have plagued humankind since the beginning of our species. Sincemodern humans spread out of Africa 60,000–70,000 years ago, they had to protect against
cold with shelter, clothing, and fire. Natural disasters can destroy all personal belongings
and infrastructure and can deprive humans of the possibility of protecting themselvesfrom harsh environments. One consequence may be death from accidental hypothermia.
This article gives an overview of the history, epidemiology, mechanisms, pathophysiology,
rescue, and treatment of accidental hypothermia caused by natural disasters such asavalanches, earthquakes, tsunamis, and floods. We provide an approach to the preventionof accidental hypothermia. We also discuss the management of multiple casualties, which
is often necessary after natural disasters. A multi-casualty incident is an event in which thenumber of victims exceeds or substantially stretches the technical and medical resources ofthe local rescue system [1]. We conducted a non-systematic review of the causes and meansof preventing accidental hypothermia after natural disasters from avalanches, earthquakes,
tsunamis, and floods.

Int. J. Environ. Res. Public Health 2022, 19, 1098. https://doi.org/10.3390/ijerph19031098

https://www.mdpi.com/journal/ijerph

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2. Hypothermia Caused by Avalanches
Avalanches are one of the greatest natural threats to humans living in mountain areas.
Avalanches have repeatedly caused disasters claiming multiple victims [2]. An avalanche
can cause hypothermia by direct contact of a buried victim with snow or by exposure to
the cold environment if a victim remains unburied or is trapped in a destroyed structure or
vehicle with inadequate shelter and delayed rescue.
2.1. History and Epidemiology
Avalanches have claimed many lives, especially in mountain warfare. In 216 BC,
Hannibal lost up to 20,000 soldiers to avalanches and cold when he crossed the Alps [3].
During World War I, in the Italian Dolomites, the death toll from avalanches amounted toseveral thousand soldiers [4].
During severe winter storms, widespread avalanche cycles have claimed many lives
among residents of mountain settlements. For instance, in 1951, during the most disastrous
winter in the twentieth century in the European Alps, avalanches destroyed 900 buildings
and killed 256 people [5]. In 1962, in Peru, an ice avalanche from the Nevados Huascaran
killed about 4000 people in the city of Ranrahirca [6]. In 1979, in India, a series of avalanches
in the Lahaul Valley killed 200 people [3]. In 1991, an avalanche hit several villages in Bingol,
Turkey, killing at least 255 people [7]. In 1999, catastrophic avalanches claimed 38 lives
in the Austrian villages of Galtür and Valzur [8]. In 2012 and 2015, a series of avalanches
destroyed several villages and killed approximately 400 people in Afghanistan [9,10]. In
2017, an avalanche killed 29 people in a hotel near Farindola, Italy [11]. In 2014, an ice
avalanche hit the Khumbu Icefall in Nepal on the climbing route of Mt. Everest, killing
16 people [12].
2.2. Mechanisms of Avalanche Burial
Over the last several decades in Europe, the number of avalanche fatalities on roads
and in villages has steadily declined because of preventive measures. Currently, about
90% of the avalanches affecting humans in Europe or North America are triggered byrecreationists [13–15]. The number of people venturing into avalanche terrain is unknown
even in Europe and North America. Between 1983 and 2015, avalanches claimed over
5000 lives in Europe and North America, with an average annual toll of about 130 in Europe
and 36 in North America [16]. Recreationists account for more than 90% of avalanche
fatalities in the European Alps [17] and in North America [18–20].
Worldwide, outside North America and Europe, mortality statistics are only roughestimates. Avalanche fatalities are not systematically reported in the highest mountainregions, including the Andes, the Karakoram, and the Himalayas, where even densely
populated valleys and villages are not protected from avalanches. Occasionally, avalanche
disasters claim many lives. With global warming, the risk of heavy, often wet, snowfall
events, and consequently severe avalanche cycles, may increase in some mountain ranges.
Safety precautions may have to be re-evaluated and increased [21]. Mixed avalanches, withsnow, ice, and rock, may occur more frequently, sometimes causing glacial lake outburst
floods (GLOFs) or forming dams that block rivers. These cascading hazards can lead toflooding, with far-reaching effects downstream [22].
2.3. Prevention and Mitigation of Avalanche Burial
Avalanche disasters during World War I contributed to the founding of the first Commission for Snow and Avalanche Research in Switzerland in 1931. In 1942, the Institute for
Snow and Avalanche Research was established in Davos, Switzerland. Three years later,
the first civil avalanche warning service in the world became operational. Other warning
services were established over time in several other European countries [23]. Especiallyafter 1951, public funds were invested in engineering works, such as for supporting structures above villages, snow sheds, and dams, and for planting protective forests. TheseInt. J. Environ. Res. Public Health 2022, 19, 1098

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measures have resulted in the almost complete elimination of avalanche disasters in theEuropean Alps.
In general, strategies for dealing with avalanche hazards include preventing the releaseof avalanches, influencing their paths, and avoiding hazardous areas [24]. Accidents canbe prevented by controlling avalanches, by regulating human presence, and by placing
structures outside avalanche paths. These measures require avalanche forecasting, public
warnings, and hazard mapping for land use planning. These are relatively inexpensivemeans of mitigation. On the other hand, engineering works are expensive and requiresignificant resources [25]. If avalanche hazards are evaluated daily, temporary road closuresand evacuation of buildings can also be effective mitigation measures. The duration ofthese disruptions can be limited by intentionally triggering avalanches using explosives.
In the mountain areas where residents and recreationists are threatened by avalanches
and where avalanche mitigation is still in its infancy, the first step should be to establish
weather forecast and avalanche warning services. Weather forecasts, as well as current
avalanche warnings, should be publicly available and widely distributed. In populated areas with a high risk of avalanches, emergency response and evacuation plans are necessary.
Local authorities should be specifically trained in avalanche risk management [26].
For recreationists, who account for most avalanche victims in Europe and North
America, training in avalanche risk assessment is critical. Proper trip planning, adequate
rescue equipment, and safe travel habits complement avalanche prevention during winterbackcountry activities in avalanche terrain [27].
2.4. Pathophysiology of Avalanche Burial with a Focus on Accidental Hypothermia
A detailed description of the pathophysiology of avalanche burial and discussionof the avalanche survival curve are beyond the scope of this article. They can be foundelsewhere [28,29]. Although avalanche injuries may not be severe enough to cause death,the depressed level of consciousness caused by trauma may decrease the probabilityof survival by predisposing to asphyxiation, limiting shivering, and accelerating cooling.
Relatively mild maritime climates with high snow density are associated with a significantly
earlier decrease in survival compared to continental climates, with low snow density andcold temperatures [28]. The longest survival of a completely buried avalanche victim in the
open was 44 h [30]. The longest survival in a structure was 37 days [31]. Survival longer
than 35 min has been reported in up to 25% of completely buried avalanche victims who
were able to breathe under snow. The term ‘triple H syndrome’, referring to the combined
effects of hypoxia, hypercapnia, and hypothermia, was coined in 2003 [32]. Avalanche
victims breathing into an air pocket in low-density avalanche debris or into a large oropen air pocket may be able to survive for hours [33,34]. Accidental hypothermia has
been reported as the sole cause of death in only about 1% of completely buried avalanche
victims. Trauma can increase the risk of hypothermia. A higher injury severity score isassociated with a higher incidence and severity of hypothermia [35,36]. Hypothermia
should be suspected in an avalanche victim presenting with an open (not obstructed)
airway at extrication after burial for >60 min [37,38]. Individual cooling rates during snow
burial vary widely, from 0.1 ◦ C/h [39] to 9 ◦ C/h [40,41]. It usually takes at least 1 h after
avalanche burial for a victim to reach a core temperature < 30 ◦ C [38]. During rescue
operations there is an additional risk of post-extrication cooling when avalanche victims
are exposed to cold air on the snow surface after being buried in snow. Post-extrication
cooling can be more rapid than cooling in the snow because of wind and lower ambient
temperatures [41]. Moving air on the skin causes more rapid cooling than still air [42].
Cooling rates have not been reported for people buried in houses or vehicles. Anecdotal
and statistical evidence suggests that survivors in structures tend to survive longer thanburied subjects in open terrain, at least partly because they are not in constant, directcontact with snow (Figure 1) [31,43].

Int. J. Environ. Res. Public Health 2022, 19, 1098

4 of 14evidence suggests that survivors in structures tend to survive longer than buried subjects
in openterrain, at least partly because they are not in constant, direct contact with snow
Int. J. Environ. Res. Public Health 2022,
19, 1098
4 of 13(Figure 1) [31,43].

FigureSurvival
probability
foravalanche
avalanchevictims
victimscompletely
completelyburied
buriedunder
under thethe snow
snow inFigure1. 1.
Survival
probability
forin Switzerland
Switzerfrom
1981
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1998
(n
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735)
in
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victimsburiedinopen(blackland from 1981 to 1998 (n = 735) in relation to time (minutes), comparing victims buried areas
in opencurve,
n = curve,638) withburiedin buildings
vehicles or(grey
curve,(greyn = 97).
Medianextrication
areas(blackn = victims
638) withvictimsburied inorbuildings
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n = 97)[43].
Mediantimes
wereareas
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and56 min frombuildings
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ial,withcompared
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The
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33% in buildings and on roads (p = 0.008; Pearson’s chi-square). The dotted curve represents
represents the survival function for completely buried avalanche victims in open areas (n = 422)
the survival function for completely buried avalanche victims in open areas (n = 422) based on thebased on the Swiss data for 1981 to 1991, calculated by Falk et al. [44].
Swiss data for 1981 to 1991, Reprinted with permission form ref. [43,44]. Copyright 2022 Copyright
Clearance Center.

2.5. Rescue and Treatment

2.5.InRescue
and Treatment
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fordefining
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defining a
resources.
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of careincidents(MCIs) in mountain
areas
are
multi-casualty
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mayforbe multi-casualty
lower than in an
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becauseof limited
given
in Table
1. principles of care for multi-casualty incidents (MCIs) in mountain areas areresources.
The
given in Table 1.
Table 1.An
Principles
and recommendations
the managementof a multi-casualty
incidentHelicopters(MCI) inavalanche
accident shouldforprompta helicopter
rescue, if possible.
a mountainarea, theadaptedfrom [1].
can decrease
responsetimes of and risks to the rescue teams by transporting rescuers
above potentiallyhazardous terrain.
first’ should be the guiding principle forGeneralsafely
Principles
and Recommendationsin ‘Safety
MCI Management
rescue operations. The risks to rescue teams must be weighed against the potential benefits
Declare an MCI. An MCI should be identified and the appropriate rescue organisations and hospitals should be
for the victims. Avalanche dogs and probing may be valuable tools for timely location
alerted as soon as possible.
of buried subjects [50]. Technical rescue may require heavy machinery and equipment.
Assess safety. Safety of the rescuers is the highest priority. Rescuers should not access an area if the risk to themSpecial precautions may be required when accessing vehicles or entering buried structures.
selves is considered to be too high.
For a mass avalanche incident with insufficient medical resources, a rescue strategy was
Initial response. The initial response
shouldfocus
setting
upmethoda command-and-control
structure, triage, anddevelopedusing
the on
Monte
Carlo
[51].
rapid life- or limb-saving interventions.
Once found, the treatment of victims buried in buildings or vehicles is similar to thatof victims in open terrain. Unfortunately, no data have been published on methods ofaccessing victims buried in buildings or in vehicles. An extrication time of 7 min for the
first vertical meter of snow burial has been reported in an experimental study, but this is
not likely to apply in a real-world situation with hard avalanche debris [52]. The moredeeply a victim is buried, the longer the extrication time, because a larger volume of snow
must be removed.

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Table 1. Principles and recommendations for the management of a multi-casualty incident (MCI) in a
mountain area, Reprinted with permission form ref. [1]. Copyright 2022 Copyright Clearance Center.
General Principles and Recommendations in MCI Management
Declare an MCI. An MCI should be identified and the appropriate rescue organisations and hospitals should be alerted as soon as possible.
Assess safety. Safety of the rescuers is the highest priority. Rescuers should not access an area if the risk to themselves is considered
to be too high.
Initial response. The initial response should focus on setting up a command-and-control structure, triage, and rapid life- or
limb-saving interventions.
Leadership and command. The medical commander should be trained in disaster medicine and in mountain rescue. The medical
commander and leaders of the rescue services should all be at the same location on site to optimise cooperation. All should be
easily identifiable.
Ensuring effective communications. An effective communication structure should be implemented to support command and control.
Triage. Effective triage tools adapted to mountain injuries should be implemented.
Evacuations. Casualties should be evacuated to a safe area, then transferred to medical facilities appropriate to their medical needs.
Identification and tracking. Tools that enable clear identification and tracking of casualties should be available for MCIs in mountains.
Learning from experience. MCIs in mountain areas should be analysed afterwards and necessary improvements in prevention andmanagement should be identified and implemented.
Planning and training. Standard operating procedures should be available, familiar, and implemented with regular training
exercises involving emergency services.
Specific principles and recommendations in MCI management in mountain areas.
Environmental influence. Objective hazards that could affect rescuers and victims, should be constantly monitored and mitigatedto the greatest possible extent.
Use of helicopters. Helicopters with appropriate mountain rescue capabilities are often useful in MCIs. Coordination of helicopterand ground operations is critical.
Communication devices and networks are helpful and should be widely used.
Management of uninjured people. In a mountain environment, uninjured survivors should be considered as victims at risk.
Psychological trauma is often present. Affected survivors should be treated, as necessary.
Specific MCIs in mountain areas.
Avalanches. For a burial time <60 min, extrication is the first priority. Medical care should focus on victims with signs of life until
enough resources are available to treat additional victims in cardiac arrest. For burial time >60 min, cardiopulmonary resuscitation(CPR) should only be started if the airway is patent. The use of a checklist may improve triage and treatment.

After extrication, a victim should be insulated from cold using available materials,
such as parkas, wind shells, hats, gloves, bivouac sacks, and sleeping bags, and with vapour
barriers such as aluminium blankets. Medical treatment is beyond the scope of this article
and is discussed in detail elsewhere [16,38,53].
2.6. Outcome
In avalanche disasters affecting structures and vehicles, the rate of long-term survival
may be higher than in avalanches in open areas, partly because air pockets in structures arelikely to be larger than air pockets in the open (Figure 1) [31,43]. The extrication times may
be substantially longer in avalanches affecting structures and vehicles.
3. Hypothermia Caused by Earthquakes and Tsunamis
3.1. Key Challenges of Large Earthquakes
Earthquakes with associated tsunamis have killed more people than all other disasters
combined. Millions of earthquakes occur every year [54]. Most are small and cause
no damage. Over 80% of the fatalities from earthquakes have been in China, Japan,
Pakistan, Turkey, countries of the former USSR, Peru, Chile, and Italy. Earthquakes andtsunamis are rapid-onset disasters. From 1994 to 2013, earthquakes were responsible for an
estimated 1.35 million deaths and displacement of an estimated 218 million people [55].
In addition to tsunamis, earthquakes can cause snow or ice avalanches, as well as GLOFs.
All these disasters have the potential to cause accidental hypothermia in the people who
initially survive an earthquake. Most people who suffer from hypothermia in earthquakes
associated with tsunamis become hypothermic by being caught in the tsunami. Data
regarding hypothermia caused by earthquakes and associated disasters are very limited.

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6 of 133.1.1. Irpinia Earthquake 1980
One report of accidental hypothermia after an earthquake concerned the 1980 Irpinia
earthquake in southern Italy [56]. On 23 November 1980, this magnitude 6.9 earthquake
killed almost 2500 people, injured at least 7700, and left 250,000 people homeless. Nine
children were buried for 7 to 27 h before being rescued alive. All were wearing light pyjamas
or flannels. The lowest temperature overnight was 7.7 ◦ C. Seven of the nine children wereburied and immobilised for longer than 12 h and were mildly hypothermic on arrival tothe hospital. All were rewarmed without incident using radiant infant warmers.
3.1.2. Kashmir Earthquake 2005
The magnitude 9.0 South Asian earthquake struck Kashmir on 8 October 2005. The
official death toll was over 73,000 in the part of Kashmir administered by Pakistan andalmost 1400 in the part administered by India [57]. An estimated 3.3 million people were left
homeless. Three months after the quake, most of the people left homeless were still living
in tents. Night-time temperatures were below freezing. In mountain villages, temperatures
fell to as low as −13 ◦ C. Few of the tents were winterised or designed for arctic-type cold.
Relief efforts were thwarted by landslides caused by heavy snow and rain. Supplies andpersonnel could not be airlifted because of fog. Although there was enough food, there
was a shortage of warm clothing and blankets. Many tents collapsed under snow. A news
report on 28 November 2005 estimated that more than 100 people had been brought tohospitals with hypothermia and respiratory diseases.
3.1.3. Great East Japan Earthquake 2011
Probably the best studied tsunami followed the Great East Japan earthquake on 11
March 2011. There were about 16,000 fatalities. Over 90% were caused by drowning [58].
The ratio of tsunami-related deaths to earthquake-related deaths was 9:1. The ratio of
injuries to deaths was 1:3.9. If missing persons are included, the ratio was 1:3.3. This
contrasts with a ratio of 1:0.15 injuries to deaths after the Great Hanshin earthquake of1995 [59]. The occurrence of a tsunami increased the number of fatalities. Causes ofdeath were not investigated in any detail. Autopsies were not conducted. As with mostnatural disasters, corpses were examined primarily to identify the victims. Interviews withmedical examiners suggested that diagnoses of ‘death by drowning’ may have included
cases of death by hypothermia and cases in which victims developed hypothermia before
drowning [60]. Hypothermia accounted for 0.2% of deaths reported in the three hardest hit
prefectures [61].
Victims of hypothermia caused by earthquakes and tsunamis can be broadly divided
into those who developed hypothermia after gradual exposure to cold, as a result of
their homes collapsing or damage to infrastructure, and those who were caught in thetsunami. The average temperature during the 24 h after the earthquake was 0.8 ◦ C. The
lowest temperature was −1.3 ◦ C. The average wind speed was 5.8 m/s, with a maximum
wind speed of 9.7 m/s. During early March, the sea surface temperature is typicallybetween 5.4 ◦ C and 8.3 ◦ C [62]. The likelihood that hypothermia will develop increases asambient temperature decreases and is increased by convective heat loss caused by windand evaporative heat loss from wet clothing [63]. The risk of hypothermia increases during
immersion in water colder than 18 ◦ C [64,65]. According to a survey of 134 patients in
the hardest hit prefecture who received medical care at a hospital within 72 h after theearthquake, hypothermia caused by the tsunami accounted for about three-fourths (45 of59) of all admissions. Most patients arrived at the hospital within 24 h [66]. The numberof hypothermia cases occurring indoors increased with time, especially in victims with
underlying conditions and in victims requiring assistance for activities of daily living
who were living in their own homes or in shelters after evacuating their homes [66].
Seventy-seven of 91 (85%) patients were cold stressed at presentation (core temperature
35–35.9 ◦ C—32 of 91) or mildly hypothermic (core temperature 32–35 ◦ C—45 of 91) [66].
The predominance of patients with cold stress or mild hypothermia likely reflects theInt. J. Environ. Res. Public Health 2022, 19, 1098

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limited number of victims taken to hospitals during the early phase of the disaster. Landapproaches were blocked when roads collapsed and were submerged. Air rescue was
the primary means of reaching survivors. Air rescue was limited during the night. In alarge-scale disaster, there is very little chance that hypothermic victims without vital signs
will be resuscitated or transferred to a hospital [30,38]. When it is unclear if the cause of
cardiac arrest is drowning or hypothermia, it is difficult to identify victims who might becandidates for extracorporeal life support (ECLS) rewarming [67]. Even if hypothermic
victims are transferred, ECLS treatment may be impossible because of power outages. In
the Great East Japan earthquake, about 80% of hospitals and 30% of clinics were damaged.
Almost all medical facilities in coastal areas had limited capabilities. Water and power
outages, including interruptions of natural gas pipelines, were widespread. It took several
days before most medical facilities were able to operate normally.
Only 4 of 91 (4%) hypothermic patients arriving at hospital within 72 h of the earthquake died. The low mortality likely reflects the high proportion of cold stressed andmildly hypothermic patients. Patients without vital signs were not transferred to hospitals
and were not represented in this in-hospital study [66]. Hospital treatment is limited
when infrastructure is compromised because of limited rewarming capabilities, problems
in identifying patients with underlying conditions and injuries, and the difficulties ofallocating available resources. Most medical facilities also had little experience treating
hypothermic patients.
The situation is different during a small-scale disaster with few casualties, in which
the response capabilities of the area are not overwhelmed. A wider range of victims canaccess medical resources. Victims in hypothermic cardiac arrest might receive medical
treatment with ECLS rewarming. The allocation of ECLS rewarming should be guided byoutcome stratification using a validated tool, such as the Hypothermia Outcome Prediction
after Extracorporeal Life Support (HOPE) score [68].
4. Hypothermia Caused by Flooding
Worldwide, floods are the most common disasters. Climate change increases the riskof floods by increasing precipitation [69]. Areas at special risk are low-lying areas nearoceans or below sea level, such as parts of Bangladesh and the Netherlands, along rivers,
and in or below mountain ranges in places where water can accumulate. The Netherlands
is one of the countries with the highest risk of floods, because almost one-third of thecountry is below sea level. The Netherlands are protected by a sophisticated system ofdams and water management [70].
In Europe, floods are the most common natural disasters. The most severe European flood of the last 100 years was the 1953 North Sea flood, caused by a combinationof wind, high tides, and low atmospheric pressure. It flooded land up to 5.6 m above
mean sea level. In the Netherlands, the 1953 North Sea flood claimed 2551 lives, flooded
9% of the Dutch farmland, drowned 30,000 animals, damaged 47,300 structures, and destroyed 10,000 buildings. There were 28 fatalities in Belgium, 307 in England, and 19 in
Scotland [71–73]. Another 230 people died on boats. In the aftermath, England and theNetherlands reinforced their coastal defences with storm surge barriers. England built
the Thames and Humber Estuaries. The Netherlands developed the Delta Works. In Italy,
68% of municipalities are at high risk of hydrological disasters. In 2021, heavy rainfall in
Belgium, Germany, and the Netherlands again caused severe destruction and disruption.
North American and Asian countries have been struck by floods, often when dams
were breached after hurricanes or typhoons. Hurricane Katrina claimed 1464 lives anddestroyed vast low-lying sections of New Orleans [74]. The immediate health impacts offloods include drowning and other injuries, heart attacks, and accidental hypothermia.
Indirect and delayed effects include displacement, starvation, unemployment, mental
health problems (including post-traumatic stress disorder), respiratory diseases, allergic
reactions, and water-borne infectious diseases [69].

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In the US, between 2006 and 2010, 2000 US residents died because of weather events.
Six percent of deaths were attributed to floods, storms, and lightning [75,76]. In the present
climate crisis, rising seawater levels and a higher incidence of extreme precipitation are
increasing the likelihood of floods along coastlines and riverbeds [77].
5. Treatment of Hypothermia after a Natural Disaster
Treatment strategies should be established with the assumption that infrastructure
will be partly or completely disrupted over a large area. Precautions should be taken sothat as few victims as possible become cold stressed or hypothermic. In the Great East
Japan earthquake, 500,000 blankets were distributed [78]. Patients with cold stress ormild hypothermia were passively rewarmed with blankets in hospitals. Hospital treatment
should be limited initially to hypothermic patients with underlying conditions or associatedinjuries and to victims with moderate or severe hypothermia. Medical professionals
experienced in treating hypothermia should be deployed to evacuation shelters to help
victims with mild symptoms self-treat and to identify victims requiring care at medical
facilities. Wet clothing should be removed as soon as possible. If a change of clothing
is not available [30,38], victims should be insulated with blankets [30]. Heating systems
will likely not be available at evacuation shelters. Without electricity, forced air warming
devices will not function. Chemical or battery-powered heat packs that do not require an
external source of electricity or hot water bottles should be stockpiled for active external
rewarming. A review of the diagnosis and treatment of accidental hypothermia can befound in this special issue [79].
6. Prevention and Mitigation
6.1. Earthquakes
There is usually little or no warning before an earthquake. Earthquakes, tsunamis, andfloods that occur at night when people are indoors and sleeping usually cause more injuries
and deaths than disasters that occur during the day. The Great Earthquake in Nepal on
25 April 2015 took place at about noon on a Saturday, the one day of the week when schools
and businesses are closed in Nepal. Children were not in school. Most people in rural areas
were outdoors, working in the fields. About 8000 people died. The toll would have been far
higher if the earthquake had occurred on a normal working day or at night. Earthquakes
also tend to have a higher mortality in winter, because more people are indoors during
the day.
Earthquake early warning systems typically give less than a minute notice of animpending earthquake, but have saved many lives. Education about safety during an earthquake and about avoiding tsunamis is critical to preventing injuries and deaths (Table 2).
Table 2. Strategies to prevent and mitigate hypothermia after natural disasters.
Areas Susceptible to Tsunamis Should Be Identified.
Future housing and critical infrastructure should be built in safe places. Existing structures inareas at risk should be moved or protected.
Early warning and protection systems should cover areas at risk.
Adequate engineering of buildings, roads, and embankments is required.
Education about safety and how to avoid natural disasters should be implemented for citizens inareas at risk.
Temporary shelters and sanitation should be established on elevated land with adequate food andwater and should be supplied with rewarming equipment.
Essential non-food items, e.g., clothing and blankets, should be stockpiled.
Global positioning system (GPS)-capable communication systems should be available.

Int. J. Environ. Res. Public Health 2022, 19, 1098

9 of 13

Damage to buildings is a major cause of injuries and deaths. Adequate engineering ofbuildings, roads, and embankments can prevent injuries and deaths. Needs in humanitariancrises, such as earthquakes and tsunamis, include shelter and security, food and water,and sanitation. To prevent hypothermia, adequate shelter should be prepared in advance.
Food and essential non-food items should be stockpiled. Essential non-food items include
clothing, bedding, cookware, plates, utensils, and soap. Sanitation is important to prevent
diseases that could contribute to hypothermia as well as morbidity or mortality.
6.2. Tsunamis
To prevent hypothermia caused by tsunamis, susceptible areas should be identified.
Tsunamis are rare events, occurring about once in a hundred years at any given location.
Areas along the Pacific coasts of Canada, Alaska, Russia, and northern Japan, and along
Int. J. Environ. Res. Public Health 2022, 19, 1098
the coast of the Japan Sea, including areas of Japan, Russia, and Korea, have conditions in 10 of 14
which hypothermia could occur after tsunamis (Figure 2).

Figure 2. Areas in Figure
which 2.
victimsmay
be vulnerable
after tsunamis.
circles
arecircles are
Areas inwhich
victims may tobe hypothermia
vulnerable to hypothermia
afterBluetsunamis.
Blue
victimsto
arehypothermia
vulnerable to after
hypothermia
afterwherea tsunami,
whereaveragemonthly average
locations in whichlocations
victims inarewhichvulnerable
a tsunami,
monthlyminimum
temperatures
2020
were
<0 one°C inmonth.
at least Greenone month.
Greenshadedareas are source
minimum temperaturesin 2020
were <0in◦ C
in at
least
shadedareas
are sourceareas of historical earthquakes that caused tsunamis with maximum wave heights >10 m. Green
areas of historical earthquakes that caused tsunamis with maximum wave heights > 10 m. Greenstars are epicentres of the 1983 Japan Sea and the 1993 Hokkaido Nansei-oki earthquakes (maximum
stars are epicentreswaveof the1983 Japan
Hokkaido
heights>10 m).Sea
Redandstarstheare1993
epicentresof theNansei-oki
1896 Sanrikuearthquakes
and the 1946 (maximum
Aleutian earthquakes
wave heights > 10 m).
stars areepicentres
ofheights
the 1896
Sanrikuand the 1946 Aleutian earthquakes
withRedtsunamis(maximum
wave
> 30
m).
with tsunamis (maximum wave heights > 30 m).
6.3. Floods

In the cold areasEarly
thatwarning
are vulnerable
to large
tsunamis, for
temporary
shelters
shouldWarning
systems shouldbe establishedheavy rainfall
and storms.
be established onsystems
elevatedand should
be supplied
rewarming
equipment
andandlandcoastline
protections
have been withinstalled
in many developed
countries,
and,lesser extent
in developing
countries,
such aaslarge
Bangladesh.
Unfortunately,
many earlyadequate food. Ittoisadifficult
to raise
the temperatureinsideevacuation
shelter suchandespeciallycoastline protections
arepeople
rudimentary,
requiring improvements
to save moreas a gymnasium. warning
Evacuees,children andwith underlying
conditions, may
lives. Devastatingin July2021 along
and adjacentshelters
rivers in forwestern
Gernot be able to tolerate
long stays.floods
Evacuees
shouldonly thestayAhrin evacuationa
many
and eastern
Belgium claimed
more than 200 lives
The
floods caused over 7
short period of time
beforebeing transferredto accommodations
with [80].
betterinfrastructure,euros indamages.
ThewhoAhr areRiver
hadpreviously had
severeareflood
in 1910 thatsuch as hotels inbillion
unaffectedareas.
Peoplenotindependent
anda who
livingkilled 200 people. In the future, housing and critical infrastructure should be built on highground well above past flood levels.
7. Conclusions
Throughout history, accidental hypothermia has accompanied natural disasters in

Int. J. Environ. Res. Public Health 2022, 19, 1098

10 of 13in their own homes or in nursing facilities are likely to remain where they live, unless anearthquake makes these structures uninhabitable. Food and water should be stockpiled, asshould equipment to heat surviving structures if electricity and gas lines are disrupted. To
prepare for temporary disruptions to communications, systems, such as global-positioningsystem-enabled mobile phones, should be put in place to help victims summon help.
6.3. Floods
Early warning systems should be established for heavy rainfall and storms. Warning
systems and coastline protections have been installed in many developed countries, and,to a lesser extent in developing countries, such as Bangladesh. Unfortunately, many early
warning and coastline protections are rudimentary, requiring improvements to save more
lives. Devastating floods in July 2021 along the Ahr and adjacent rivers in western Germany
and eastern Belgium claimed more than 200 lives [80]. The floods caused over 7 billion
euros in damages. The Ahr River had previously had a severe flood in 1910 that killed
200 people. In the future, housing and critical infrastructure should be built on high ground
well above past flood levels.
7. Conclusions
Throughout history, accidental hypothermia has accompanied natural disasters in cold,
temperate, and even subtropical regions. We have explored the causes and means of preventing accidental hypothermia after natural disasters caused by avalanches, earthquakes,
tsunamis, and floods. Before a disaster occurs, preventive measures are required, such as
accurate disaster risk analysis for given areas, hazard mapping and warning, protecting
existing structures within hazard zones to the greatest extent possible, building structures
outside hazard zones, and organising rapid and effective rescue. After the event, post
hoc analyses of failures and implementation of corrective actions will reduce the risk ofaccidental hypothermia in future disasters.
Author Contributions: Concept: K.O., Y.T., J.S., K.Z., H.B. and P.P.; methodology and literaturesearch: K.O., Y.T., J.S., K.Z., H.B. and P.P.; writing—original draft preparation: K.O., Y.T., J.S., K.Z.,
H.B. and P.P.; writing—review and editing: K.O., Y.T., J.S., K.Z., H.B. and P.P.; graphics: K.O., Y.T.,
J.S., K.Z., H.B. and P.P.; funding acquisition: K.O. and P.P. All authors have read and agreed to the
published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.
Conflicts of Interest: The authors declare no conflict of interest.

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