Rapid Community Health and Needs Assessments After Hurricanes Isabel and Charley --- North Carolina, 2003--2004
On September 18, 2003, Hurricane Isabel, a Category 2 hurricane, made landfall on the Outer Banks of North Carolina (NC). The storm, moving to the northeast with winds exceeding 100 mph, caused extensive power outages and structural damage in northeastern NC and southern Virginia. In NC, approximately 762,000 residents lost power during the storm, and the shelter population peaked at an estimated 16,600 persons. Six storm-related fatalities were reported, and 26 eastern NC counties were included in a federal disaster area declaration (1). The North Carolina Division of Public Health (NCDPH) activated the Office of Public Health Preparedness and Response (PHPR) and seven Public Health Regional Surveillance Teams (PHRSTs) to conduct a rapid community health and needs assessment for the affected population. CDC deployed staff to provide technical support to NCDPH. The assessment determined that the majority of public health emergencies resulted from electric power outages, which affected access to food, water, and medical care. Data and recommendations were provided immediately to local and state emergency responders, who used the information to direct Hurricane Isabel recovery efforts and also to improve the assessment, which was next deployed in August 2004 with Hurricane Charley.
Two days after Hurricane Isabel struck, PHPR obtained information about storm damage from field assessments conducted by PHRSTs, reports from local health directors, damage reports from local emergency management offices, and aerial surveillance by the North Carolina Division of Emergency Management. This information was used to select a sample of 14 counties* in the most severely affected area of the state. The Outer Banks barrier islands were excluded from the sample because the majority of residents left the islands before storm landfall, and travel to the islands was restricted after the hurricane.
NCDPH and CDC developed a modified cluster-sampling method for population-based sampling in post-disaster needs assessments (2,3). Census blocks within the affected area were assembled into clusters of five blocks. In sparsely populated areas, blocks were combined to compensate for the low number of households in individual census blocks. Thirty census clusters were then selected with the probability of selection proportionate to the number of occupied housing units in the cluster. Occupied housing unit estimates were based on data from the 2000 U.S. Census. Assessment teams were composed of PHRST staff, with the assistance of students from the University of North Carolina School of Public Health and volunteers from other state agencies. Spanish-speaking interviewers were placed on teams assigned to census groups with large Hispanic populations. Language barriers did not prevent communication or completion of any interviews.
From a central area of the assigned cluster, teams moved sequentially along roadways to collect interviews at seven households in each cluster. In multiple-family dwellings (e.g., apartment buildings), one household was chosen randomly from each building. On Sunday, September 21, the teams collected 210 interviews. NCDPH and CDC staff entered data and conducted weighted cluster analysis by using EpiInfo. Data were analyzed to report the estimated proportion and projected number of households with a specific need or condition with a 95% confidence interval. On September 22, the report was submitted electronically to the Public Health Command Center in Raleigh, 4 days after the hurricane had struck.
The survey population was representative of the 93,738 occupied housing units identified by the 2000 U.S. Census; response rate was 62.3%, with 210 interviews completed. Households in the 14-county sample had an average of 2.7 persons before and after the hurricane. Children aged <2 years represented 4% of the sampled population, and adults aged >65 years represented 19%. Of the 210 households, 162 (77%) were in permanently anchored single-family structures, 44 (21%) were in mobile homes, and four (2%) were in multiple-family dwellings (e.g., apartment buildings).
A total of 137 (65%) households sampled were without electricity on the date of the survey (Table). Portable electrical generators were used after the hurricane in 64 (30%) homes. Other basic service interruptions included 50 (24%) households without running water, 44 (21%) without working cellular or landline telephone service, and 48 (23%) without a battery-operated radio. A total of 90 (43%) households were using bottled water, and 26 (12%) did not have a 3-day supply of food; 68 (32%) households had more than minimal damage but were habitable, and five (2%) were reported uninhabitable.
Few hurricane-related injuries or illnesses were reported. Two (1%) households had a member who experienced injury as a result of the hurricane, and 10 (5%) had a member who experienced hurricane-related illness. A total of 17 (8%) households reported a member who required medical care.
NCDPH and CDC provided assessment results to local health departments, local emergency operations centers, and the NC emergency operations center. Data from the report were used to direct resources, including feeding stations and allocation of bottled water, to affected communities. Information about the risks of using portable electrical generators was provided to local health departments.
Reported by: J Morrow, MD, Pitt County Health Dept; E Norman, MPH, North Carolina Dept of Environmental and Natural Resources; R Dickens, DVM, North Carolina Dept of Agriculture; H Garrison, MD, T Morris, MD, K Henderson, MD, H Swygard, MD, S Ramsey, M Salyers, MD, B Worsham, North Carolina Public Health Regional Surveillance Teams 1--7; S Cline, DDS, J Kirkpatrick, MD, J Engel, MD, G Ghneim, DVM, M Davies, MD, K Sanford, MPH, W Service, MSPH, North Carolina Div of Public Health. WR Daley, DVM, S Young, MPH, Div of Environmental Hazards and Health Effects, National Center for Environmental Health, CDC.
These findings indicated that the hurricane strike produced an emergency involving widespread electric power outages. The outages contributed to problems with access to medical care, access to food and water, and use of portable generators with subsequent risk for fire, electrocution, and exposure to carbon monoxide. Anecdotal reports from survey teams suggested that lower-income persons were more likely to report problems with access to food, water, and medical care and that questions about the socioeconomic status of survey respondents should be considered in future assessments.
Community needs assessments similar to this one have been employed after natural disasters, including hurricanes (4,5), floods (6), and ice storms (7). These assessments, which include estimates of the numbers of households with specific needs, can be used to identify unanticipated needs or effects (e.g., limited access to medical care) and provide valuable information to guide disaster response and recovery efforts.
This post-disaster assessment was the first of its kind in NC. Emergency response and public health officials were not always aware of the assessment and did not always have adequate time or information to use the data to shape recovery efforts. Responders should be provided with information about these assessments before a disaster so they can gauge the strengths, limitations, and potential uses of the data and recommendations provided.
NCDPH used experience gained during Hurricane Isabel to 1) develop the ability to conduct rapid community health and needs assessments by using in-state resources and 2) enhance logistic operations and methods for data collection. On August 17, 2004, NCDPH reported the results of its latest community health and needs assessment <72 hours after Hurricane Charley crossed through the state.
The Hurricane Charley assessment suggested that the storm did not have widespread public health impact in NC. However, NCDPH demonstrated new assessment capabilities with the use of geographic information systems technology and handheld computers. The state team used mapping software to generate and map seven random points in each of the census block groups, and interview teams navigated to the random points in their assigned census blocks by using handheld computers equipped with global positioning system plotters. Interview data were collected on the handheld computers from the household closest to the random point in the census block. These modifications simplified the mapping process and introduced a new method for randomization in the selection of households within the census block group. NC has used its experience with Hurricanes Isabel and Charley to incorporate community health and needs assessments into its public health response to all natural disasters and other public health emergencies.
* Bertie, Camden, Chowan, Currituck, Dare, Gates, Hertford, Hyde, Martin, Northampton, Pasquotank, Perquimans, Tyrell, and Washington counties.
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