2: Special Issue, November 2005
When Chronic Conditions Become Acute: Prevention and Control of Chronic Diseases and Adverse Health Outcomes During Natural Disasters
Ali H. Mokdad, PhD, George A. Mensah, MD, Samuel F. Posner, PhD, Eddie Reed,
MD, Eduardo J. Simoes, MD, MSc, MPH, Michael M. Engelgau, MD, and the Chronic Diseases and Vulnerable Populations in Natural Disasters Working Group
Suggested citation for this article: Mokdad AH, Mensah GA, Posner SF, Reed E, Simoes EJ, Engelgau MM,
and the Chronic Diseases and Vulnerable Populations in Natural Disasters Working Group. When
chronic conditions become acute: prevention and control of chronic diseases and
adverse health outcomes during natural disasters. Prev Chronic Dis
[serial online] 2005 Nov [date cited]. Available from: URL:
Natural disasters pose major public health challenges. Preparations for these disasters usually focus on how to evacuate people from affected areas; how to provide transportation, shelter, food, and water for the evacuees; and how to prevent injury and infectious diseases that may develop in crowded living situations after disasters (1-3). All of these preparations are important and necessary,
but they are not enough.
Also needed are preparations to care for populations whose health is already
compromised and who are, therefore, more vulnerable than healthy people to the
stresses and disruptions caused by natural disasters. Populations affected by disasters may carry a large and measurable burden of disabilities and chronic diseases, especially heart disease, cancer, stroke, diabetes, and chronic respiratory disorders (4). For example, we can reasonably project that the number of people with cancer who were directly affected by the
Hurricane Katrina evacuation is in the tens of thousands (J. King, written
communication, September 2005). In addition,
data from the 2000 U.S. census long-form survey indicate that 20.2% of the population, roughly 275,000 people, aged 5 years and older in the 10 parishes in the greater New Orleans metropolitan area had a disability of some type (5). Accommodating the needs of this population during evacuation and return is a sizable undertaking.
Chronic illnesses are exacerbated by the conditions caused by a disaster (e.g., lack of food, lack of clean water, extremes of cold or heat, physical and mental stress, injury, exposure to infection). Natural disasters may also put people with limited mobility and women who are pregnant and their unborn fetuses at increased risk for adverse health outcomes. Elderly men and women, many of whom
have multiple chronic conditions and comorbidities being treated with multiple
medications, are particularly at risk (6-9). People of low socioeconomic status,
people without health insurance, and people with mental illness or disabilities
are other vulnerable populations who can experience higher morbidity and
mortality during disasters. Similarly vulnerable are ischemic stroke survivors taking anticoagulants,
people whose diabetes is controlled by insulin, heart attack survivors taking
clot-preventing medications, people with severe lung disease receiving home
oxygen therapy, people with hereditary blood disorders, and patients receiving hemodialysis for kidney failure
Lack of access to routine health care is a leading cause of mortality after disasters (15). In addition, indirect effects (e.g., loss of electricity) can lead to exposure to extreme heat or cold or interruption of supplemental oxygen supplies. Many people living with disabilities rely on routine health care services to maintain their quality of life and live
independently. Without access to these services, they may experience adverse health events. Compared
with other pregnant women, women in the early stages of pregnancy may be at higher risk for adverse pregnancy outcomes because of exposure during organogenesis to toxins or infectious agents. Unfortunately the problems of vulnerable populations who are at risk for adverse health outcomes when routine health care
services are disrupted remain inadequately studied or addressed.
The aftermath of Hurricane Katrina is a reminder of the urgent need for
developing and implementing recommendations for the control of chronic diseases
during disasters. A limited needs assessment among individuals staying in
evacuation centers, conducted in the field and reported to the Centers for
Disease Control and Prevention (CDC), demonstrated that five of the top six
conditions were all chronic diseases and that, other than injuries, the majority
of medical and health visits were for medication refills, oral health issues,
and other chronic health conditions (16). Leading the list of top 10 conditions
were hypertension and cardiovascular diseases, diabetes, and psychiatric
disorders (new and existing) (16). Other surveys of Hurricane Katrina evacuees
show that up to 41% had at least one chronic health condition such as heart
disease, hypertension, diabetes, or asthma (17). The preliminary medical examiner report of mortality associated with
Hurricane Charley in Florida in 2004 showed that the six deaths related to natural causes resulted from exacerbation
of existing cardiac or pulmonary conditions (18). The editorial accompanying the report called for strengthening local disaster plans and public health messages for vulnerable populations who are likely to have chronic medical conditions and are likely to require medical supplies or equipment that depend on electricity to operate (18).
Preparations for the prevention and control of chronic diseases, of secondary
conditions among people with disabilities, and of adverse pregnancy outcomes during disasters must be guided by 1) the predisaster rates of adverse health outcomes and disease burden, 2) awareness of the immediate needs of people with chronic diseases (including
a plan for providing essential medications), 3)
knowledge of the basic and surge capacity of health care delivery systems of the affected and surrounding areas to treat and manage chronic diseases, and 4) the areas’ ability to rebuild the basic infrastructure needed to support care. A comprehensive strategy to address the overall health of disaster survivors must therefore include
not only a plan for evacuation and emergency treatment
but also a strategy to deliver care to vulnerable populations including pregnant women and people with chronic diseases or disabilities.
In accordance with established clinical and preventive services guidelines, disaster preparations must ensure the availability of everything necessary to control chronic diseases, prevent acute events and complications related to chronic diseases, and protect the health and well-being of pregnant women and their fetuses. These guidelines should
address patient triage, clinical evaluation, and
supply of essential medications for care of chronic illnesses (19-21). Support of the emergency medical response system and access to specialty care such as hemodialysis, ventilatory support, and emergency obstetric care must be delineated. A list of essential medications consistent with the predicted burden of chronic diseases should be developed and used in planning for provision of chronic
maintenance medications during disasters.
The CDC, in partnership with the public health community, should consider developing surveillance tools to support disaster planning that adequately addresses the health care needs of the general population and of vulnerable populations, including pregnant women and people living with disabilities. Such a surveillance tool should have at least three components: 1) the ability to establish a
baseline of the size, functional status, and needs of the vulnerable populations in areas susceptible to predictable disasters (such as hurricanes); 2) the ability to assess the needs and levels of actual response during the disasters; and 3) the ability to monitor the long-term effects of the emergency. These components map the surveillance activities into a timeline reflecting the three phases
of the disaster: before, during, and after.
A wide range of professionals, including physicians, nurses, public health professionals, legislators, the aging services network, and national and community organizations must use the data generated from these assessments to guide policy development and to ensure the use of best practices during disasters. Appropriate policies should be established to support the development of training
materials for health professionals so that they can care for vulnerable populations. Similar training materials could be used in medical schools, nursing schools, and public health institutions and as part of emergency relief training. A response to chronic diseases and obstetric health care needs during emergencies based on appropriate policies and best practices should be included in the
emergency response plans of states and municipalities, and the planned response should be evaluated periodically by all the groups, agencies, and institutions involved in disaster planning. Public education materials, including public service announcements in affected areas, should remind people of routine steps needed to ensure that their chronic diseases remain stable and adverse health
outcomes are prevented throughout a disaster. For example, in response to
Hurricane Katrina, the CDC developed materials, including radio and television public service announcements, to deliver public health messages for pregnant women. These messages have been aired in multiple areas with large populations of evacuees. Messages were also developed for topics such as hand washing and
were widely used in evacuee shelters.
Although individual patients and their families need to be well prepared and provided with clear and consistent recommendations to make preparations, many others must help them. To ensure an adequate response, disaster preparation should be coordinated with all partners, roles should be well defined, and procedures should be clearly stated. Responsibilities for each element of the response
should be assigned in advance. An adequate means of communication and standardized health procedures should be available.
The lessons of Hurricane Katrina should stimulate action long overdue to consider the importance of chronic diseases in disaster planning. It is time to carefully reflect on the chronic health needs of all populations and the health conditions that may be exacerbated during natural disasters. Although reducing the potential for infectious disease outbreaks is vital, minimum standards
should be set to prevent and control morbidity and mortality among people with chronic diseases,
people who are pregnant, and people with disabilities whose safety and quality of life may be adversely affected by a stressful interruption in their routine health care. It is time to develop and implement guidelines for both short- and long-term care before, during, and in the immediate aftermath of
Back to top
The following are members of the Chronic Diseases and Vulnerable Populations in Natural Disasters Working Group, Coordinating Center for Health Promotion, CDC, Atlanta, Ga: P Allweiss, L Anderson, L Balluz, G Beckles, A Berkowitz, BP Bernard, B Bowman, D Brantley, V Campbell, JL Collins, J Cordero, WH Dietz, P Eke, MM Engelgau, E Ford, D Galuska, HW Giles, K Greenlund, E Gregg, L
Grummer-Strawn, C Husten, R Jiles, JM Kelly, LK Kann, W Kohn, DL Labarthe, J Lando, M Link, W Maas, R McDonald, GA Mensah, AH Mokdad, MJ Moore, L Pollack, SF Posner, M Pratt, S Rasmussen, E Reed, S Rutledge, P Rzeszotarski, L Schieve, EJ Simoes, F Vinicor, H Wechsler, E Weiss, L Wilcox, P Wingo, and S Zaza.
We are grateful to Helen McClintock and Rick Hull for editorial and technical assistance.
Back to top
Corresponding Author: George A. Mensah, MD, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Mail Stop K-40, 4770 Buford Hwy, NE, Atlanta, GA 30341-3717. Telephone: 770-488-5401. E-mail: email@example.com.
Author Affiliations: Ali H. Mokdad, PhD, Chief, Behavioral Surveillance
Branch, Division of Adult and Community Health, National Center for Chronic
Disease Prevention and Health Promotion (NCCDPHP), Coordinating Center for
Health Promotion (CoCHP), Centers for Disease Control
and Prevention (CDC), Atlanta, Ga; Samuel F. Posner, PhD, Associate Director for
Science, Division of Reproductive Health, NCCDPHP, CoCHP, CDC, Atlanta, Ga; Eddie Reed, MD, Director,
Division of Cancer Prevention and Control, NCCDPHP, CoCHP, CDC, Atlanta, Ga; Eduardo J. Simoes, MD, MSC, MPH,
Research Centers, NCCDPHP, CoCHP, CDC, Atlanta, Ga; Michael M. Engelgau, MD, Division
of Diabetes Translation, NCCDPHP, CoCHP, CDC, Atlanta, Ga.
Back to top
Hurricane Katrina response and guidance for health-care providers, relief workers, and shelter operators. MMWR
Morb Mortal Wkly Rep 2005;54(35):877.
- Toole MJ, Waldman RJ.
The public health aspects of complex emergencies and refugee situations. Annu Rev Public Health 1997;18:283-312.
Famine-affected, refugee, and displaced populations: recommendations for public health issues. MMWR Recomm
- National Center for Health Statistics. Health, United States, 2004. Chartbook on trends in the health of Americans. Hyattsville (MD): Centers for Disease Control and Prevention; 2004.
- U.S. Census Bureau. Census 2000, summary file 3 [Internet]. Washington
(DC): U.S. Department of Commerce [cited 2005 Sep 25]. Available from:
- Bierman AS, Clancy CM.
Health disparities among older women: identifying opportunities to improve quality of care and functional health outcomes. J Am Med Womens Assoc 2001;56(4):155-9, 188.
- Menotti A, Mulder I, Nissinen A, Giampaoli S, Feskens EJ, Kromhout D.
Prevalence of morbidity and multimorbidity in elderly male populations and their impact on 10-year all-cause mortality: The FINE study (Finland, Italy, Netherlands, Elderly). J Clin Epidemiol 2001;54(7):680-6.
- Mudur G.
Aid agencies ignored special needs of elderly people after tsunami. BMJ 2005;331(7514):422.
- Fernandez LS, Byard D, Lin CC, Benson S, Barbera JA.
Frail elderly as disaster victims: emergency management strategies. Prehospital Disaster Med 2002;17(2):67-74.
- Morrow BH.
Identifying and mapping community vulnerability. Disasters 1999;23(1):1-18.
Epidemiologic assessment of the impact of four hurricanes — Florida, 2004. MMWR
Morb Mortal Wkly Rep 2005;54(28):693-7.
Rapid assessment of the needs and health status of older adults after Hurricane Charley
— Charlotte, DeSoto, and Hardee Counties, Florida, August 27-31, 2004. MMWR
Morb Mortal Wkly Rep 2004;53(36):837-40.
- Cordero JF.
The epidemiology of disasters and adverse reproductive outcomes: lessons learned. Environ Health Perspect 1993;101 Suppl 2:131-6.
- The Sphere Project. Humanitarian charter and minimum standards in disaster
response [Internet]. Geneva (Switzerland): The Sphere Project; 2005.
Available from: URL: http://www.sphereproject.org*.
- Spiegel P, Sheik M, Gotway-Crawford C, Salama P.
Health programmes and policies associated with decreased mortality in displaced people in postemergency phase camps: a retrospective study. Lancet 2002;360(9349):1927-34.
- Centers for Disease Control and Prevention. Update on CDC's response to
Hurricane Katrina [Internet]. Atlanta (GA): Centers for Disease Control
and Prevention; 2005 Sep 19. Available from: URL: http://www.cdc.gov/od/katrina/09-19-05.htm.
- The Henry J. Kaiser Family Foundation. Survey of Hurricane Katrina evacuees [press release].
Washington (DC: The Henry J. Kaiser Family Foundation; 2005 Sep 16.
Available from: URL: http://www.kff.org/newsmedia/upload/7401.pdf*.
Preliminary medical examiner reports of mortality associated with Hurricane Charley--Florida, 2004. MMWR
Morb Mortal Wkly Rep 2004;53(36):835-7.
- Quick JD, Hogerzeil HV, Velasquez G, Rago L.
Twenty-five years of essential medicines. Bull World Health Organ 2002;80(11):913-4.
- Chitwood M, Lewis C, Harle C.
Preparing for natural disasters: a survival plan for persons with diabetes. Diabetes Educ 1992 May;18(3):246-7, 250.
The selection and use of essential medicines. Report of the WHO Expert
Committee, 2002 (including the 12th Model list of essential medicines).
World Health Organ Tech Rep Ser 2003;914:i-vi, 1-126.
Back to top
*URLs for nonfederal organizations are provided solely as a
service to our users. URLs do not constitute an endorsement of any organization
by CDC or the federal government, and none should be inferred. CDC is
not responsible for the content of Web pages found at these URLs.