Learning from Katrina: environmental health observations from the SWCPHP response team in Houston.

Introduction

On August 29, 2005, Hurricane Katrina made landfall in the coastal areas of Alabama, Florida, Louisiana, and Mississippi. Katrina was a catastrophe and has been called the "most devastating natural environmental calamity in U.S. history" (Manuel, 2006). The impact of Katrina on individuals and communities was overwhelming and displaced approximately 400,000 residents (U.S. Department of Homeland Security, Federal Emergency Management Agency, 2005; Centers for Disease Control and Prevention [CDC], 2006), resulting in significant and widespread public health challenges due to the demand for long-term shelters in 18 states (CDC, 2005a). The aftermath of the storm emphasized the limitations of current federal, state, and local capacity in responding to catastrophic natural events. While some perceived health threats were overblown and some were understated, the environmental health implications were both acute and chronic (Manuel). Katrina also provided vital lessons about identifying and learning to emphasize critical effective response measures (Puckett, 2006). Standards for meeting the public health needs of displaced populations had been well described; however, a major challenge was ensuring that performance standards would be met without exposing volunteers to harmful health conditions.

The devastation in New Orleans created a near total disruption of both public health and medical care infrastructure (Falk & Baldwin, 2006). The critical issues raised by Katrina's destruction were among the most basic and essential public environmental health tenets: safe water, food protection, extended-stay shelter, sanitation, hygiene, and infection control. Traditionally, infectious-disease management is a key focus in work with displaced populations because of the conditions that naturally arise from the establishment of temporary disaster housing and shelters. During Katrina and afterward, the lack of adequate supplies and distribution methods for potable water, general unsanitary conditions, and a lack of basic knowledge of the risks associated with airborne and waterborne diseases were compounded by the stress already evident in families. It was virtually impossible to maintain personal hygiene as large populations were collected into crowded venues, some of which were not designed or intended to be housing facilities.

During the week following Katrina, an estimated 240,000 persons were evacuated to Houston, Texas (CDC, 2005b). On August 31, 2005, approximately 24,000 evacuees were housed at facilities in Reliant Park that included the Reliant Astrodome, the Reliant Center, and the Reliant Arena. By September 2, 2005, staff from the Harris County Public Health and Environmental Services noted a considerable number of adults and children with diarrhea, vomiting, or both at the on-site medical clinics supported by the Harris County Hospital District (CDC, 2005b). Enhanced surveillance for identification and investigation of outbreaks involved the Center for Biosecurity and Public Health Preparedness (CBPHP) at University of Texas School of Public Health. CBPHP coordinated interactions with city and county health authorities, the Red Cross, and other organizations and universities, including the Southwest Center for Public Health Preparedness (SWCPHP) of the College of Public Health, the University of Oklahoma Health Sciences Center. CBPHP's primary charges were to conduct rapid health assessments of the evacuees using ongoing and systematic data collection to monitor illness trends. During this time public health professionals made a number of observations that contributed to the lessons learned from one of the worst natural disasters in U.S. history.

It is important to note that the SWCPHP team arrived seven days after the shelters were established at the Reliant Center, by which time the shelters were stabilized and evacuees were receiving health care as needed and surveillance was being implemented to identify potential disease transmission. Evacuees had faced numerous physical, mental, and social challenges in the course of their journey to Reliant Park, challenges that continued while they were housed there. It was during the rapid-health-assessment process that the reported observations were made. The following remarks summarize the observations made by the SWCPHP team during the events in Houston. A large percentage of these remarks pertain to the volunteers and staff who were assisting with the needs of the thousands of evacuees.

Observations

A significant number of observations made by the SWCPHP team subsequent to arriving and throughout the time team members were in place were considered noteworthy from a preparedness and response perspective. These firsthand observations support many of the recommendations made in the Federal Response to Hurricane Katrina: Lessons Learned report issued in February 2006 (Hurricane Katrina Lessons Learned Staff, 2006) and provide a contextual backdrop for improvement in the areas of volunteer and citizen preparedness training and education.

Overcrowding and Noise

On first exposure to the Astrodome environment, the SWCPHP team recognized that the evacuees were being housed in a facility that inherently presented significant public health issues. Cots, each of which occupied a space 2 feet by 6 feet, lined the floor and the hallways of the Astrodome and Reliant Center. Although aisles were provided between the hundreds of rows of cots, individual spacing of cots was severely limited. Each person was allotted space for one or two cots and allowed to store personal belongings under and around the cot space. The arrangement met the needs of keeping families together but created conditions of crowding for people with diverse ethnic, social, and cultural backgrounds. Overcrowding has been identified as a fundamental and significant factor in promoting and sustaining epidemic levels of outbreaks. In this instance, unless an individual had active symptoms upon arrival, little medical screening took place. Additional logistical and psychological issues associated with overcrowding are known to contribute to the spread of disease and lead to significantly enhanced levels of mental anguish and increased stress.

It was also noted that individuals who would not routinely associate with the elderly or with children were now living with many elderly individuals and children of all ages, including infants. In some instances, evacuees were continuously confronted with chronically or acutely ill people in addition to people with physical or mental disabilities. Throughout the days on site, elements of gang activity were noted, and while the most obvious examples occurred on the grounds outside the housing areas, some shelter residents who were interviewed noted concern, and some degree of personal intimidation was observed inside the centers as well.

The combination of overcrowding, live acoustical surfaces, children playing, loudspeaker announcements, equipment and materials being moved, thousands of people conversing, and the many other factors associated with a population equivalent in numbers to a small city produced levels of noise that went beyond distracting to being at some times almost deafening. Given the size of the facilities over which the team operated, cell phones were necessary. Ambient-noise levels were routinely so elevated that communication by that mode was sometimes almost impossible. Many residents who were interviewed complained of sleep deprivation resulting from the stress of having to flee homes and property combined with the noise. When sleep disruption becomes chronic, adverse health effects are soon noted or become exacerbated (Fay, 1991). Studies have linked noise exposure with enhanced anxiety and, according to Fay, noise can be a significant source of annoyance that can make people tense, angry, and stressed, and make them show increased aggression. The exposure to noise within the shelters further intensified the distress of a population already at risk for anxiety and adverse health effects.

Lighting inside the facilities also contributed to sleep deprivation. Residents complained that it was never dark, or that the lighting was never sufficiently lowered to allow comfortable sleeping conditions. Center management cited security and facility management issues that required 24-hour lighting at an appropriate level. Although both perspectives were relevant, the fact that many occupants could not sleep led to a series of related mental and physical concerns.

Reluctance to Seek Care

An interesting observation was a reluctance of evacuees to seek available health care. Recurrent visits to evacuees revealed that health care was not sought because of the fear of losing personal belongings or the fear of missing an opportunity to meet or communicate with one of the placement agencies, the Federal Emergency Management Agency (FEMA), or other government agencies providing service and support. While some evacuees demonstrated symptoms of needing immediate care and nevertheless refused to seek care, many did respond when the seriousness of their individual or family situation was adequately explained. Direct communication was one of the benefits of having public health and medical professionals assisting with the rapid health assessments. It was also noted that many of the evacuees who exhibited chronic-health conditions were not taking their medications out of fear of running out. Reluctance to take medication was also observed if a prescription had been filled and the medication was of a different size, shape, or color than the individual was used to.

Special Populations

It was quickly noted that a number of "special populations" existed within the Houston housing facilities. Some of those populations consisted of hearing- or speech-impaired people, blind people, people for whom English was not a first language, mentally challenged people, people with limited ambulatory abilities, parentless children, and separated families. A very poignant note was the number of older people with grandchildren trying to cope in the absence of one or both biological parents. Assistance for the hearing- and speech-impaired was limited, although often, if a hearing family member was present, that person would assist with communication. Non-English-language translators were scarce.

Professionals were available to assist individuals with known mental health problems and to intervene when symptoms were recognized by the health assessment team members. Medications that were needed by patients with mental health histories were made available after professional assessments were completed.

Infectious Diseases 

Diseases commonly related to crowded conditions include diarrhea, colds, influenza, and tuberculosis. All were of concern at Reliant Park as well as at the other shelters set up across the country. On September 2, 2005, the physicians and staff manning Reliant Park noticed a substantial number of adults and children with diarrhea, vomiting, or both (CDC, 2005b). Between September 2 and September 12, approximately 6,500 evacuees visited the provided medical clinic, and 18 percent (1, 169) of these had acute gastroenteritis (CDC, 2005b). Medical staff, disaster relief personnel, volunteers, and evacuees were alerted to the increased need for use of proper handwashing techniques. Posted and hand-distributed fliers and electronic postings were used to remind everyone to wash their hands frequently. Gel hand sanitizers were made available to everyone. The outbreak continued for almost two weeks, but a decline was reported before evacuees left Reliant Park near the end of the September (CDC, 2005b).

The members of the team from SWCPHP were able to identify and assist a number of evacuees who reported vomiting, diarrhea, or bloody diarrhea. The Rapid Assessment Tally Form (available at http://www.swcphp.ouhsc.edu/pdf/RapAsmntTallyForm.pdf used for the health assessments specifically asked for symptoms related to gastroenteritis. The form was created by CBPHP after the center was asked to assist in the investigation of the outbreak. Other infectious-disease symptoms included on the form were cough, runny nose, rash, and wound or skin infections. It was known throughout the complex that if one reported having gastrointestinal distress, one was likely to be placed in an isolation area for a period of a few days. As a result, some of the evacuees with gastroenteritis were reluctant to seek health care for fear of becoming hospitalized and possibly losing belongings or missing appointments.

The aforementioned conditions of overcrowding played an important role in the management of infectious diseases. Close contact with numerous individuals on a continual basis provided ample opportunity for person-to-person transmission of disease. It was also observed that other potential sources of disease spread were fomites such as soiled cots, soiled bedding, and soiled clothing.

Hygienic Practice

While the facilities at Reliant Park did provide bathrooms with running water, toilets, and showers, the sheer number of evacuees attempting to use the facilities overwhelmed the available resources. It should be stated that none of the Reliant housing centers were designed for or possessed the volume of plumbing facilities needed to provide toilets, sinks, showers, and so forth that would be adequate for the large numbers present for an extended period of time. Many of the bathrooms on the upper floors had only cold running water or no running water in the sinks, which tended to limit or negate their use for handwashing. On the main floor of the Astrodome, it was observed that one of the largest and most frequented bathrooms had been commandeered as a barber-shop/hair-salon/massage area for the evacuees. This circumstance resulted in massive queuing and the inability of some individuals, especially the elderly, to access the bathroom. Shared notations of SWCPHP personnel revealed that operations to address waste disposal issues were insufficient. This concern was especially applicable to chronically ill evacuees who were unable or unwilling to leave their cots. Also, open bins of dirty, soiled linens were kept on the floor proximate to the living quarters, providing ample opportunity for children and adults to contact contaminated items.

With respect to food and water safety, there was no separation of food and water from the immediate living quarters, and poor hygienic practices were noted by the team as many families consumed food from soiled cots, the floor, or next to an ill person.

The SWCPHP team observed volunteers assisting and providing care who did not themselves practice good hygiene. A lack of volunteers practicing handwashing was noted, and self-contamination after care of an evacuee was observed. On multiple occasions, volunteers were observed assisting ill individuals then performing simple acts such as rubbing their own eyes, scratching their nose, wiping their hands on their clothing, or moving on to the next person for hands-on transmission to that individual.

ICS 

There was a general lack of knowledge and understanding of the incident command system (ICS) among the volunteers. A good understanding of incident command is necessary for an effective response (Federal Emergency Management Agency, 2006) by all those at a site such as this one. While agencies and organizations do modify ICS to fit specific needs, it is absolutely critical to practice basic management concepts in order to address problems and conflicts that may arise. Of special concern to the SWCPHP team was the inability of volunteers to identify shelter leaders or individuals in authority for the purposes of making decisions. It was never clear what person, agency, or office should be notified about concerns or observed problems.

Security Concerns

Since evacuees were not restricted to the housing facilities, large numbers left the structures and walked in a 2-to-3-mile radius around the Reliant compound. Many individuals interviewed reported that boredom and the need to "get away" from the monotony of shelter life were primary reasons for walking out. Many more were unaccustomed to constant air conditioning and left to simply warm themselves outside. A very limited number of evacuees showed signs of confrontational behavior and actions considered unacceptable. These observations were not unexpected given the duress and uncertainty with which the shelter residents were existing. The SWCPHP team employed an access and egress personnel check, with two males accompanying each female in the areas where assigned health care assessments occurred.

Limitations

The numerous lessons learned during the SWCPHP response effort came from direct observations secondary to the purpose for which the team was on site. No on-site data collection methodology was in place for comparison and contrast between observations made by the team's members or between observations made by the SWCPHP team and those made by other teams assisting at the site. From the observations and collective assessments, several key lessons were learned that could be translated into improved preparedness and better emergency responsiveness.

Lessons Learned

While the overall response to Katrina repeatedly demonstrated the good intentions of volunteers, public health professionals, and health care professionals across the country, it also provided an opportunity to keenly observe public health in a highly stressed practice setting and to identify the basic tenets of public health with which all individuals responding to an event should be familiar (Table 1). The experiences of the SWCPHP team suggested the following lessons:

1. All individuals with a desire to respond and assist the community in times of disaster or crisis should be familiar with the fundamental personal steps that can reduce personal and family risk of exposure to infectious diseases and other threats.

2. The role of schools of public health can include direct-response capacity and the ability to contribute effectively during public health disasters.

3. Personal and organizational preparedness must include fundamental training in the recognition of and appropriate lay response to psychological aspects of disaster response.

4. Public health preparedness should be included as a key curricular element in the education and training of all health-related professions.

The SWCPHP team's experiences highlight and demonstrate the need to rapidly implement the recommendations of the Federal Response to Hurricane Katrina: Lessons Learned report. The role of volunteers and the level of citizen preparedness figure significantly both in our observations and in the lessons learned presented in the federal report. Although a short (~15-minute) "dos-and-don'ts" briefing was given to volunteers on site, it paled in comparison with what was truly needed. A significant concern was preventing volunteers from becoming victims by identifying what they could contribute without becoming part of a problem. It was evident that volunteers were potentially being exposed to illnesses in the evacuee population (hepatitis, tuberculosis, etc.) and that a volunteer could become a vector for a transmissible disease either to others in the evacuee population, to the volunteer's family, or to the community at large.

Katrina presented evacuees and volunteers in shelters with an array of environmental hazards, most unrecognized, but some of which could be controlled. If priority is given to education focused on safety and preventive measures related to the environment, public health workers, volunteers, and evacuees can become better prepared to respond to the hazards inherently associated with catastrophic events. In situations of extreme overcrowding, noise, sleep deprivation, and constant light will be inherent in emergency shelters. A recognition that these circumstances contribute to poor health, poor sanitation, and increased stress provides insight into the care that can be provided and offered to evacuees and responders. It is important for all responders to understand that evacuees who have suffered from disruptions in medical care, loss of relatives and friends, ad hoc living arrangements, and separation from familiar surroundings will exhibit increased anguish, and they should be prepared to recognize associated symptoms and able to direct individuals to receive proper care. All volunteers and responders should receive some training relative to the social issues and mental health of displaced populations.

To prepare the public health workforce and volunteers who respond to disasters, it is imperative that standardized training be provided, not only so that the response effort is efficacious, but also so that the responders protect themselves as well as those they are assisting. The observations of the SWCPHP team indicate that standardized training should provide a good understanding of ICS, basic hygiene, and transmission of disease, as well as of food and water safety principles. As the team witnessed, there is a pressing need for all essential personnel to have a working knowledge of ICS before being deployed to a disaster site. Volunteers also need a basic understanding of ICS in order to be fully effective in a disaster response. As the federal report states--and as supported by direct observation--there is a need to organize, train, equip, register, and pre-configure deployable teams that include medical professionals, public health officials, and volunteers.

The environmental factors that create confusion and psychological stress in a shelter the size of the Reliant Center are compounded by the unclear process of obtaining essential human services. As was seen in Houston and as the Katrina report highlights, there is a pressing need to simplify, organize, and efficiently administer human services at a disaster site. We make the following recommendations:

* A response should provide personnel adequate to serve special populations, and those personnel should be on site as soon as possible. The development and deployment of interagency human-services teams, incorporating faith-based and nongovernment organizations (NGOs), is greatly needed.

* Management of waste and soiled linens should be a priority, especially in any situation in which overcrowding is expected.

* Understanding the impact of mixing populations unfamiliar to each other may prevent a considerable amount of stress and anxiety in an already burdened population.

* A third management criteria would be ensuring that facilities within a shelter are accessible and used for their intended purpose, and that the facilities support the sheer numbers present.

* Security may always be an issue in the response to any disaster; however, when thousands of people are forced to live together in unfamiliar surroundings, security should be strictly enforced.

Conclusions

As the lessons from Katrina continue to be assessed, the knowledge gained from the tragedy should be integrated into future disaster-response-planning efforts. Natural disasters cannot be controlled or in most instances predicted, and certainly the same is true for technological catastrophes and terrorist attacks; however, preparedness can be enhanced so that impacts are significantly reduced and mitigated.

During a disaster, the key community partners tasked with professional response missions as a function of organizational responsibilities are rapidly supplemented by ranks of volunteers who come with a keen desire to assist but frequently lack the specific knowledge, skills, and abilities requisite to being genuinely helpful without creating a higher order of threat in an already risk-rich environment. Federal Response to Hurricane Katrina: Lessons Learned (2006) highlights the need for a more robust interface between the professional response community and volunteer organizations. The SWCPHP team's experience also indicates a pressing need for more integrated coordination between these two communities. As we witnessed and the report highlights, there is clearly a need for better communication between responders and volunteers. Volunteers need training in the areas of ICS, basic hygiene, transmission of disease, and food and water safety principles. Pre-identifying and cataloguing volunteer resources and capabilities would be an improvement, and SWCPHP agrees with the report's recommendation that the Department of Homeland Security should establish a vehicle for integrating and coordinating volunteer agencies, establishing credentialing for volunteers, assimilating volunteers into disaster exercises and drills, and establishing best practices. In addition, there is a clear need to better prepare citizens and communities for disaster.

With the possibility that another natural or manmade disaster will occur in the not-too-distant future, it is imperative that programs and actions be undertaken to improve the readiness of volunteers and citizens for disaster situations. We concluded that the schools of public health, working in cooperation and concert with key local outreach partners such as community colleges, career technology centers, and public libraries, can begin a process of designing and disseminating personal and organizational public health preparedness education, training, and exercises that will make a demonstrable difference in terms of response outcomes during disasters.

Acknowledgements: The SWCPHP response efforts were funded by Centers for Disease Control and Prevention Project #U90/CCU624260-02. As part of the Centers for Public Health Preparedness, we are appreciative of the efforts and commitment of the agencies, organizations, and volunteers who responded to the disaster.

Corresponding Author: Brenda L. Elledge, Assistant Professor, Occupational & Environmental Health, College of Public Health Delivery and Translational Coordinator, Southwest Center for Public Health Preparedness, 801 NE 13th, CHB Rm. 417, Oklahoma City, OK 73104. E-mail: [e-mail].

REFERENCES

Centers for Disease Control and Prevention. (2005). Infectious disease and dermatologic conditions in evacuees and response workers after hurricane Katrina--multiple states, August-September, 2005. Morbidity and Mortality Weekly Report, 54(38), 961-964.

Centers for Disease Control and Prevention. (2005b). Norovirus outbreak among evacuees from hurricane Katrina--Houston, Texas, September 2005. Morbidity and Mortality Weekly Report, 54(40), 1016-1018.

Centers for Disease Control and Prevention. (2006). Surveillance in hurricane evacuation centers--Louisiana, September-October, 2005. Morbidity and Mortality Weekly Report, 55(2), 32-35.

Falk, H., & Baldwin G. (2006). Environmental health and Hurricane Katrina. Environmental Health Perspectives, 114(1), A12-A13.

Fay, T. H. (1991). League for the hard of hearing noise and health fact sheet. Retrieved April 12, 2006, from http://www.lhh.org/noise/facts/health.html.

Federal Emergency Management Agency. (2006). National incident management system [web site]. Retrieved June 7, 2006, from http://www.fema.gov/emergency/nims/index.shtm.

Hurricane Katrina Lessons Learned Staff. (2006). Federal response to Hurricane Katrina: Lessons learned. Retrieved October 10, 2006, from http://www.whitehouse.gov/reports/katrina-lessons-learned/.

Manuel, J. (2006). In Katrina's wake. Environmental Health Perspectives, 114(1), A32-A39.

Puckett, RP. (2006). Personal and organizational preparedness: The key to surviving a disaster. Health Care Food & Nutrition Focus, 23(1), 3-7.

U.S. Department of Homeland Security, Federal Emergency Management Agency (2006). By the numbers: FEMA recovery update in Louisiana. Retrieved July 15, 2006, from http://www/fema.gov/news/newsrelease.fema?id=22403.

Brenda L. Elledge, Dr.P.H., R.T.

Daniel T. Boatright, Ph.D.

Paul Woodson, Ph.D.

Rodney E. Clinkenbeard, Ph.D.

Michael W. Brand, Ph.D.

TABLE 1 Key Recommendations and Standardized Training

Recommendation         Target Population    Standardized Training

Acquire knowledge to   Responders,          * Basic Hygiene
  reduce personal and  volunteers,          * Transmission of Disease
  family risk of       individuals          * Food and Water Safety
  infectious diseases
Provide education on   Schools of public    ICS/NIMS
  response capacity    health, public
  as a volunteer or    health agencies
  public health
  professional
Provide education on   Individuals, public  Psychological First Aid
  the psychological    health agencies,
  aspects of disaster  responders
  response
Mandate public health  Health-related       * Basic Hygiene
  preparedness         professions          * Transmission of Disease
  curriculum                                * Food and Water Safety
                                            * ICS/NIMS
                                            * Psychological First Aid
Register/pre-          Government/state     * Basic Hygiene
  configure volunteer  agencies, volunteer  * Transmission of Disease
  teams                organizations,       * Food and Water Safety
                       medical              * ICS/NIMS
                       professionals,       * Psychological First Aid
                       public health
                       officials