CDC Funded Hurricane Sandy Recovery Research Current Awards

Abstract
Climate change will lead to more extreme weather events such as heat waves and hurricanes, which were found to be associated with increased mortality and morbidity. However, significant gaps remain in our understanding of the impacts from extreme weather event like hurricanes, including the paucity of research on its immediate and long-term health effects, other health outcomes despite mental health, individual and community vulnerabilities, and modified factors. Furthermore, little is known about the health impacts of response and recovery strategies. The proposed study will fill these gaps by evaluating the short- and long- term effects on multiple health outcomes and risk factors in the aftermath of Hurricane Sandy in New York State (NYS). This project will address all four priority areas described under Priority Recovery Research Area B of the RFA-TP13-001 by assessing mortality and multiple relevant morbidity including mental health, injury, respiratory, cardiovascular diseases, CO poisoning, infectious diseases, water-/food-borne diseases, and dialysis (Aim 1). We will further evaluate whether low socio-economic status (SES), environmental factors, community characteristics, and social vulnerability modified the Sandy-health association (Aim 2). Moreover, our study will assess the health effects of different evacuation or displacement strategies and impacts of health care access disruption by Hurricane Sandy (Aim 3). Care pattern change in dialysis patients and consequence of patient transfer will also be evaluated. Finally, we will determine the modifiable risk factors, effective home cleaning strategy and surveillance to reduce health burden. By using multiple NYS datasets, including hospital admission, emergency department visit, clinic visit and prescription billing data, and community surveys, we will recruit all potential mental health and other cases. The two surveys planned among school staff and residents with oil spill homes will collect detailed information on mental health, activity patterns during Sandy, and home cleaning. Each health outcome will be compared between the affected areas (categorized as evacuation zones in the 7 impacted counties) and the control areas (unaffected by Sandy in the same county and similar SES) using unconditional logistic regression analysis in a retrospective cohort study. Trend analysis will also be used to compare pre- and post-Sandy effects using ARIMA, a time-series analysis method. All outcomes will be compared within three time windows, pre-Sandy, 3 months and 1-year after Hurricane Sandy. The proposed study is important as it will not only characterize the impacts of multiple health outcomes after Hurricane Sandy and using different evacuation or recovery strategies, but also identify vulnerabilities and modifiable factors, which will directly contribute to emergency preparedness and responses. The strong state-county-community partnership, unique access to multiple large NYS datasets, and the experienced multidisciplinary research team will assure that the project is feasible and sustainable. PUBLIC HEALTH RELEVANCE: The proposed study will assess multiple health outcomes, individual and community vulnerabilities, and risk factors in the aftermath of Hurricane Sandy in New York State. It will be one of the few studies to assess whether people with certain neighborhood characteristics (poor quality housing, low hospital density), high social vulnerability (> 65 yrs. and living alone, households > 7 residents), or have been relocated for long periods of time are more vulnerable to mental health problems or other adverse health outcomes after Sandy. Findings from this study will help guide the state/ county / community stakeholders to enhance recovery activities in the Sandy-affected areas and to improve public health practice for future emergency preparedness and response.

Abstract
In New York City (NYC), domestic mold contamination has been one of the greatest concerns for public health officials and most common complaints of residents in the aftermath of Hurricane Sandy. Mold problems are common in urban homes in general and disproportionately affect lower-income families who have less control over conditions conducive to mold growth. In urban settings, asthmatic children could be particularly susceptible to adverse health effects related to fungal exposures following catastrophic water damage. A 2004 Institute of Medicine report and several meta-analyses have concluded that mold and home dampness factors are associated with asthma symptoms. However, a majority of this evidence is based on report of dampness or visible mold and not on measured fungal exposure, limiting these studies from demonstrating 1) that fungal exposure was the causative agent, 2) which species of fungi were associated with the health outcomes and 3) whether specific allergic sensitization is an etiological pathway to the asthma-related morbidity. Historically, making these connections was impeded by limitations of traditional methods for assessing domestic mold exposure, including the microscopic identification of morphologically indiscernible spores and species-specific growth conditions required for mold culture and a lack of specificity for mold with bioassays (e.g., ¿-glucans). Recently, advances in polymerase chain reaction methodologies will allow for characterization of fungal profiles associated with water damage, enable monitoring the efficacy of remediation efforts and long-term changes in domestic fungal profiles, and may aid in elucidating the association between fungal exposure and poor respiratory health. This proposal will test the hypotheses that NYC homes with Hurricane Sandy-related water damage will have different fungal species profiles both pre- and post-remediation as compared with NYC homes that were not impacted and that fungal concentrations in homes will be associated with asthma symptoms, airflow obstruction and airway inflammation among asthmatic children. Participants living in NYC homes damaged by Hurricane Sandy will be recruited from a unique public-private partnership that is providing services for free mold remediation for 2,000 houses. An established cohort of seven-eleven year-old asthmatic children living throughout NYC in non-impacted homes will be used to compare exposures and respiratory outcomes with impacted homes and the asthmatics children living in those homes. This proposal will establish collaboration between researchers and public health practitioners at the NYC Department of Health and Mental Hygiene (DOHMH), Columbia University, NIOSH and private industry with complementary expertise and skills to answer important public health research questions in response to this devastating natural disaster. If successful, this proposal will lead to important knowledge about domestic fungal exposure following a natural disaster like Hurricane Sandy in urban communities and the associated increase in asthma morbidity in children. This knowledge will be used by the NYC DOHMH and others to inform the response to future natural disasters, particular to clarify the risks to asthmatic children.

Abstract
This proposed project will explore the challenges and difficulties that arose for two local public health agencies (Nassau and Westchester Counties) in preparing for Hurricane Sandy and after the storm hit the New York City region. The study’s goals are to: (1) conduct a case study of how Hurricane Sandy affected these two organizations and use those as tools to elucidate how complex organizations function during times of extreme duress; (2) determine how public health workers can improve upon their disaster response and recovery strategies, particularly when working on new disaster-related job tasks; and (3) identify and deliver new remedial trainings in various modalities. The project is a collaboration of the National Center for Disaster Preparedness (NCDP), a unit of Columbia University’s Earth Institute and the two subject health departments, each of which will appoint an assistant/deputy-commissioner level staff member as a Co-Investigator. Other senior NCDP researchers also will be co-investigators. Over the 2-year term of this project, the investigators will (a) Analyze the communications among the health departments and other response organizations during Hurricane Sandy, as recorded in the Crisis Management Information Systems utilized by the Nassau and Westchester County Emergency Operations Centers, in order to inform development of the structured guides for interviews and focus groups; (b) Interview 10 senior leadership staff in each health department who participated in making critical decisions in preparation for and during Sandy; (c) Conduct focus groups at each agency involving at least 30 line staff in order to (along with the interviews) elicit information on any gaps in communication, coordination, preparation, logistics, staff availability, competencies, and leadership that came into play during the Sandy preparation and response; (d) Analyze the transcripts of the interviews and focus groups to identify barriers and obstacles that need to be addressed in order to improve these (and possibly other) health departments’ ongoing Sandy recovery efforts; (e) Develop and offer two customized face-to-face trainings for each health department in order to provide hands-on practice and support in relation to the identified barriers; (f) Develop (in collaboration with NACCHO) four Columbia-hosted distance learning offerings based upon the preceding analysis and face-to-face training experiences; and (g) Evaluate all of the above training offerings to document learning outcomes and address whether learners have used what they’ve learned to enhance their functional role. Each health department Co-Investigator will obtain transcripts of the county’s Crisis Management Information System for the NCDP researchers, serve as liaison with the respective department for organizing key informant interviews and focus groups, and develop proposals for NCDP-provided face-to-face and online training for departmental staff. PUBLIC HEALTH RELEVANCE: This project will create a case study of how two suburban health departments in the New York City region prepared for and then responded to Hurricane Sandy in the fourteen months after the storm, relying upon an examination of the crisis period Emergency Operations Center communications recorded in the two counties’ crisis management information systems, insights from interviews with agency leaders and focus groups with line staff, and an evaluation of new training offerings. The case studies will identify challenges and obstacles these departments encountered in fulfilling their emergency response and recovery functions, related to planning, coordination, capabilities, resource allocation, logistics, and communications-problems that if addressed through education, training and other types of remediation can make these agencies (and others like them) more effective in supporting the ongoing long-term recovery from Hurricane Sandy. The project will generate and deliver four new face-to-face training programs and four new online training products that will help these and other public health department’s kick-start necessary improvements

Abstract
On October 28th Hurricane Sandy hit the East Coast of the US, affecting the lives and wellbeing of more than 50 million people. The greater New York City area was heavily struck by the hurricane. The psychological devastation of the hurricane, along with the mental health consequences of being displaced, major loss of property, flooding, mold, prolonged lack of heat, water and power, are unknown. Estimates can be drawn from anecdotal reports from health providers, first responders, hospitals and shelters, however, reliable data is lacking in terms of the prevalence of psychological health effects. The current study aims to understand the psychological impact of this hurricane in an effort to inform current intervention and future prevention efforts. This application represents a partnership between a large hospital system, the North Shore-LIJ Health System (NSLIJHS), and the Nassau County Department of Human Services which is the agency that oversees all mental health agencies in the county. NSLIJHS consists of 16 hospitals spanning across Nassau County, Suffolk County, Queens, Manhattan and Staten Island, encompassing areas most affected by Hurricane Sandy.

The goals of the current project include establishing associations between exposure to the hurricane and various mental health symptoms and diagnoses while also defining subgroups of individuals who were most vulnerable to mental health effects due to the hurricane. We will accomplish this using multiple methodologies including survey data from a cohort of at least 500 individuals who reside in Nassau, Suffolk, Queens or Richmond (Staten Island) counties as well as using Emergency Department (ED) data from the 14 EDs that are part of the NSLIJHS. Further, we will also investigate the impact of various displacement strategies on the mental health of residents using the survey data and we will examine the psychological impact of the hurricane on those who indicate that they are first responders. Ultimately, our research will result in two significant products. The first is a vulnerability profile of those most affected by Hurricane Sandy in terms of psychological health and wellbeing. This profile will be accompanied by tables and other user-friendly charts and diagrams for local government agencies, mental health agencies, emergency preparedness agencies, health care workers, and the NSLIJHS (among others) to use in order to continue to target current intervention strategies for those highly affected by the hurricane and most vulnerable to its effects as well as to inform emergency preparedness efforts by indicating areas and groups to prioritize in terms of mental health intervention during future natural disasters. Second, our work will produce a Hurricane Sandy cohort and database that can be tracked and followed over time. The database will be available to researchers and other key stakeholders in order to examine the long-term impact of hurricane exposure, to continue to provide important information as to emergency preparedness for future hurricanes and other natural disasters, as well as for community groups and those in the scientific emergency preparedness community to leverage additional funding for future research and intervention endeavors. Ultimately, we see this work as an integral first step toward the development of a NSLIJHS ED syndromic surveillance system as well as a first step towards the development of an Emergency Preparedness Research Center that will provide important and timely information to community groups and health care providers throughout the region.

The goals of this proposal are feasible and reasonable because of the strong community linkages that already exist by all members of the research and Project Advisory Board team. We consulted with many community groups including members of government agencies, hospital administrators, community coalitions and network members among many others in the development of this project. Further, we have already confirmed its feasibility in the community given the successful pilot study that was conducted with 107 participants. We plan to work collaboratively with key stakeholders including our community partners during each step of the project from implementation through dissemination and translation. Our community partners are key to the efficacy of the project especially in terms of the dissemination of our research findings, vulnerability profile and cohort database. We will use multiple methods and media to effectively disseminate to key groups on both local and national levels. Further, given that one of the co-PIs is the Commissioner of the Department of Human Services and has strong connections to government agencies including emergency preparedness groups, mental health agencies and first responders throughout the affected region, we will easily be able to translate our findings into public health practice.

Abstract
The New York State Department of Health is leading a collaborative effort to evaluate the public health system in its preparation, response, and recovery from Hurricane Sandy, and to research modifications needed to improve future response and recovery. Nine NYS counties and New York City (NYC) were declared as disaster areas after Sandy. The Long Island counties of Nassau and Suffolk suffered direct hits, as well as Westchester north of NYC. Collectively, the health departments in these three counties serve almost three million residents, with an additional million residents served by another six affected counties. Many local health department offices and public health service providers were closed due to power outages or hurricane damage. NYSDOH was required to assume surveillance, investigation, and control activities for notifiable diseases in Nassau County. Two large drinking water systems received infrastructure damage sufficient to interrupt their ability to deliver water to customers. Aim 1 will focus on evaluating the public health system, addressing business processes in Objective 1.1, critical information needs in Objective 1.2, and public health system integration in Objective 1.3. Aim 2 will evaluate the impact on select community service providers, including public drinking water suppliers in Objective 2.1, HIV/STD community service providers in Objective 2.2, and WIC providers in Objective 2.3. Each objective has two parts. The outcome for part (a) is a research report evaluating the Sandy impact, and the outcome for part (b) is the research summary of needed modifications to build resiliency for future disasters. NYSDOH will analyze pre-existing data sources such as after action reports and Integrated Health Alerting and Notification System records using content analyses. Executive orders and regulation waivers (federal and state) will be reviewed. Primary data collection will include qualitative research using confidential one-on-one telephone interviews with key informants and meetings with focus groups, prioritizing counties with greatest impact. Primary data collection through quantitative surveys will also be extended to all counties in the disaster area. State and local health and emergency management departments will be included in the assessments. Seventeen key staff roles in health departments and four key staff roles in emergency management departments have been identified for participation. All scientific research and data collection, management, and analysis will be conducted as approved by the NYSDOH Institutional Review Board to assure informed consent and confidentiality. All research activities will be overseen by a Guidance Team with academic, local, and state representatives. PUBLIC HEALTH RELEVANCE: The application proposes a collaborative effort to evaluate the public health system in its preparation, response, and recovery from Hurricane Sandy and to research modifications needed to improve future response and recovery. Each aim is designed to produce two relevant public health outcomes. Outcome part a) is a research report evaluating the impact of Sandy, and the outcome for part (b) is the research summary of needed modifications to build resiliency for future disasters.

Abstract
Local public health agencies (LPHAs) are at the heart of the public health emergency preparedness system, and their workers play critical roles in all disaster phases – including recovery. Despite this, LPHA workers’ perceptions of efficacy toward disaster recovery challenges remain poorly understood. Of note, a substantial body of research has found perceived efficacy to be determinative of positively adaptive individual and collective behaviors in the face of challenges. It is therefore essential to understand LPHA workers’ efficacy perceptions toward disaster recovery public health challenges, to identify relevant deficits in their perceived recovery-phase efficacy, and to develop evidence-based curricular approaches to address these deficits. Our proposed mixed-methods study will accomplish these goals in the context of Hurricane Sandy recovery, from the critical perspectives of LPHA workers whose jurisdictions were impacted by this disaster. Consonant with this goal, our aims are to: 1) Characterize the nature of operational challenges that LPHA workers face in Hurricane Sandy recovery efforts by investigating potential barriers to communicating and receiving needed information in recovery activities; impediments to recovery surveillance efforts, and how these impediments differ by types of surveillance activities; and hurdles to effective integration and coordination of recovery efforts between LPHAs and other organizations across the public health emergency preparedness system; 2) Apply a threat- and efficacy-based model to assess LPHA workers’ perceptions and related beliefs toward Hurricane Sandy recovery operational challenges identified in Specific Aim 1, including: whether and how LPHA workers’ perceived levels of efficacy toward Hurricane Sandy recovery activities differ by recovery phases per the National Disaster Recovery Framework; the roles, if any, that jurisdictional- and agency-level policies, legal authorities, and personal and household preparedness play in modifying LPHA workers’ perceptions of threat and efficacy toward Hurricane Sandy recovery efforts; and whether LPHA workers perceive that their individual participation in Hurricane Sandy recovery activities meaningfully impacts their agencies’ success in disaster recovery efforts; and 3) Gauge the effectiveness of a novel curricular intervention for boosting LPHA workers’ efficacy perceptions toward the identified recovery challenges and for enhancing their motivation toward ongoing preparedness efforts. The value of this project to the public health emergency preparedness system is both practical and substantial, as it will provide much- needed data-driven insights and novel evidence-based approaches to optimize LPHA recovery and ongoing public health preparedness in the wake of Hurricane Sandy. PUBLIC HEALTH RELEVANCE: The proposed research is directly relevant to public health recovery in the aftermath of Hurricane Sandy, and its novel focus on local public health agency (LPHA) workers’ perceptions toward disaster recovery will shed critical new light on leading public health recovery phase challenges from the perspectives of those on the front lines. These insights will, in turn, inform a first-of-its-kind curricular intervention to address identified deficits in LPHA workers’ recovery-phase efficacy – thus benefiting population health and welfare in the wake of this disaster. This study will yield generalizable knowledge to not only address post-Hurricane Sandy public health recovery challenges, but also to enhance public health preparedness and recovery for future disasters.

Abstract:
NJ Department of Health (NJDOH), in conjunction with New Jersey Medical School (NJMS) and NJ Department of Human Services (NJDHS), proposes to enhance the state’s current understanding of and responses to health outcomes associated with Sandy to characterize morbidity and mortality associated with Sandy, utilizing existing data from health care systems, public health surveillance, and mental health programs; and to enhance data collection, surveillance, prevention and interventions statewide, examining how ongoing activities might be modified to mitigate adverse health outcomes in future disaster events. We will characterize hospitalization trends, evaluating changes after Sandy, and examine conditions that in ideal circumstances would have been managed on an outpatient basis. We will evaluate outcomes classified from real-time ED chief complaint data in comparison with uniform billing data on all ED visits. We will use findings to improve current public health syndromic surveillance activities and estimate changes in ED visits for key conditions. Using NJ death certificates data, we will identify causes of death that increased or decreased in the first month and 1-6 and 7-12 month periods after Sandy. We will look at all causes, with particular attention to injuries, carbon monoxide poisonings, cardiovascular events, and suicide. Using NJDHS FEMA Crisis Counseling Program data, we will determine characteristics of persons who used crisis counseling services over time, including frequency of use and outcome, if known. Using NJDHS clinical services data; we will determine characteristics of persons who used clinical services over time. By adding supplemental questions to NJBRFS, a complex sample survey that is on- going in New Jersey, we will determine Sandy-associated exposures and health effects to the NJ population overall. We will characterize access to care and resources reported by individuals in vulnerable populations based on ethnographic interviews. We will summarize results and describe possible risk factors for specific health outcomes. The results in hand, we will obtain feedback from stakeholders, and translate findings for applied public health use which will provide crucial resources in the event of future disasters. Characterization of NJ Poison and Information System (NJPIES) calls contrasted and compared to ED visits and findings from interviews, will focus on how use NJPIES hotline calls for focused public health interventions. PUBLIC HEALTH RELEVANCE: NJ Department of Health (NJDOH), in conjunction with New Jersey Medical School (NJMS) and NJ Department of Human Services (NJDHS), proposes the following goals to enhance the state’s current understanding of and responses to health outcomes associated with Sandy: a. To characterize morbidity and mortality associated with Sandy, utilizing existing data from health care systems, public health surveillance, and mental health programs; and b. To enhance data collection, surveillance, prevention and interventions statewide, examining how ongoing activities might be modified to mitigate adverse health outcomes in future disaster events.

Abstract
Hurricane Sandy was a large-scale natural disaster that had serious impacts on the mental and physical health of New Yorkers. These impacts were wide ranging and unique, in part, due to the effects of the storm on NYC’s built environment including widespread power and heat outages followed by cold weather; large numbers of people sheltering in place in high-rise residential buildings where power outages disabled elevators and running water; transportation shutdowns; emergency healthcare facility evacuations; residential evacuations; and disruptions to healthcare access. Despite the best efforts of many government agencies and other organizations, 43 deaths were directly attributed to Hurricane Sandy in NYC, primarily due to drowning. Additionally, in the 10 days following the hurricane (November 1-10, 2012), death counts were 11% higher than expected compared to the prior two years. Neither the causes of this excess nor the broader impacts of the storm on physical and mental health have been fully characterized. Additionally, many of the populations most affected by the storm and its aftermath were already vulnerable and the storm is likely having long lasting impacts in these groups. This research will use multiple data sources to investigate 1) the increase in overall mortality immediately following Hurricane Sandy including any possible increase due to health care facility and nursing home evacuations and residential flooding and disruption of power and transportation; 2) the full extent of and modifiable community and individual-level risk factors for injury-related morbidity and mortality; and 3) the immediate and long-term impact of Hurricane Sandy, evacuation, displacement, and relocation on the mental health of NYC residents. Data sources will include vital statistics mortality data, medical examiner case investigation files, American Red Cross interview data, emergency department syndromic surveillance, hospital discharge, and a population-based and two special Hurricane Sandy-specific surveys. Several of these datasets will be matched, allowing for the full characterization of the morbidity and mortality impacts of the storm to identify vulnerable populations most in need of government services to aid recovery. The findings will also improve the timeliness of recovery plans in future disasters by establishing a process for combining and analyzing data to support recovery plans.