Epidemic risk after disasters.

To the Editor: We conduct communicable disease risk assessments after humanitarian emergencies, including natural disasters, and would like to clarify the findings of Floret et al. (1) regarding the risk for epidemics in certain disaster settings. Natural disasters that do not result in population displacement, regardless of type of disaster, are rarely associated with increased risk for epidemics. However, large-scale population displacement, with consequent overcrowding in temporary settlements and disruption of water supply and sanitation, are indeed associated with increased risks for communicable disease transmission. This distinction is well documented (2-4). Increased communicable disease incidence after flooding and cyclones has been particularly well described (5,6). In addition, after a disaster of any type, epidemics may go undetected because of poor surveillance or because baseline surveillance data for diseases (such as dengue fever or malaria) are unavailable.

Although we agree with the authors that media reports are often exaggerated and that the risk for epidemics after certain types of natural disasters (e.g., volcanic eruption) is low, we believe the findings are somewhat misleading. Postdisaster communicable disease incidence is related more closely to the characteristics of the displaced population (size, health status, living conditions) than to the precipitating event.

References

(1.) Floret N, Viel JF, Hoen B, Piarroux R. Negligible risk for epidemics after geophysical disasters. Emerg Infect Dis. 2006; 12:543-8.

(2.) Toole MJ. Communicable diseases and disease control. In: Noji ED, editor. Public health consequences of disasters. Oxford: Oxford University Press; 1997.

(3.) The Sphere project. Humanitarian charter and minimum standards in disaster response. Steering Committee for Humanitarian Response. Oxford: Oxford Publishing; 2004.

(4.) World Health Organization. Flooding and communicable diseases fact sheet: risk assessment and preventive measures. [cited 2006 Jun 15]. http://www.who.int/hac/techguidance/ems/flood_cds/en/

(5.) Ahem M, Kovats RS, Wilkinson P, Few R, Matthies F. Global health impacts of floods: epidemiologic evidence. Epidemiol Rev. 2005;27:36-46.

(6.) Shultz JM, Russell J, Espinel Z. Epidemiology of tropical cyclones: the dynamics of disaster, disease, and development. Epidemiol Rev. 2005;27:21-35.

John Watson, * Michelle Gayer, * and Maire A. Connolly *

* World Health Organization, Geneva, Switzerland

Address for correspondence: John Watson, Communicable Diseases, World Health Organization, 20 Ave Appia, 1211 Geneva, Switzerland; email: [e-mail]

In response: Watson et al. stressed some points that may be important determinants in assessing the risk for epidemics following natural disasters (1). We agree that large-scale population displacement, with overcrowding and water disruption, is clearly a risk factor for disease transmission. This factor was probably the main cause of the measles and diarrhea outbreaks that occurred in the temporary settlements created after the eruption of Mount Pinatubo in the Philippines, as mentioned in our previous article (2). However, by studying >600 geophysical disasters (earthquakes, volcano eruptions, and tsunamis) that occurred in the last 20 years, we found that deleterious conditions such as large-scale population displacement with overcrowding and water disruption were uncommon and that epidemics were the exception, not the rule. We agree that some epidemics, especially if they are limited and develop well after the disaster, may remain undetected, as was discussed in our paper (1).

However, we do not concur with the opinion expressed by Watson et al. that the incidence of postdisaster infectious diseases is more related to the characteristics of the displaced population than to the precipitating event. Our findings are just the opposite. In contrast to the situation seen with flooding and cyclones, which are sometimes followed by outbreaks of waterborne diseases, such as cholera or leptospirosis, and vectorborne diseases (3-6), the study we carried out on geophysical disasters did not detect any notable outbreak except for the above-mentioned measles outbreak. Watson et al. illustrated their statement by referring to outbreaks following floods and hurricanes, and not earthquakes, tsunamis, or volcano eruptions. Further work must be carried out on epidemics after floods provoked by heavy rains and hurricanes.

References

(1.) Watson J, Gayer M, Connolly MA. Epidemic risk after disasters. Emerg Infect Dis. 2006;12:1468.

(2.) Floret N, Viel JF, Mauny F, Hoen B, Piarroux R. Negligible risk of epidemics after geophysical disasters. Emerg Infect Dis. 2006;12:543-7.

(3.) Beach M. China's problems persist after the flood. Lancet. 1998;352:1203.

(4.) Siddique AK, Islam Q, Akram K, Mazumder Y, Mitra A, Eusof A. Cholera epidemic and natural disasters; where is the link. Trop Geogr Med. 1989;41:377-82.

(5.) Sehgal SC, Sugunan AP, Vijayachari P. Outbreak of leptospirosis after the cyclone in Orissa. Natl Med J India. 2002; 15:22-3.

(6.) Githeko AK, Lindsay SW, Confalonieri UE, Patz JA. Climate change and vector-borne diseases: a regional analysis. Bull World Health Organ. 2000;78:1136-47.

Renaud Piarroux, * ([dagger]) Nathalie Floret, * ([dagger]) Jean-Francois Viel, * ([dagger]) Frederic Mauny, * ([dagger]) and Bruno Hoen * ([dagger])

* University Hospital of Besancon, Besangon, France; and ([dagger]) University of Franche-Comte, Besangon, France

Address for correspondence: Renaud Piarroux, Service de Parasitologie, Hopital Jean Minjoz, 25000 Besangon, France; email: [e-mail]