A Framework for Assessing Mortality and Morbidity After Large-Scale Disasters (2020) / Chapter Skim
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1 Introduction
1 Introduction
Pages 23-48
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This report describes the importance of accurately assessing mortality and morbidity data and the diverse uses of these data. In addition to reviewing the current landscape 23
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These include an explanation of the term "significant morbidity," per the language used in the Statement of Task, as well as a discussion of the vocabulary used for the attribution of both mortality and morbidity to a disaster, among others. 1 The Stafford Act declaration in response to the ongoing coronavirus pandemic resulted in the inclusion of the pandemic in the committee's deliberation and report.
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Specifically, the committee will: • Describe the importance of mortality and significant morbidity data after disaster impact, their use, and the organizations that capture these data or could benefit from use of the data. • Describe the current architecture, methodologies, and information sys tems currently in use or available to SLTT public health agencies for the sharing and reporting of these data, highlighting the diversity of processes and identifying potential best practices.
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, or, regardless of cause, any fire, flood, or explosion, in any part of the United States, which in the determination of the President causes damage of suf ficient severity and magnitude to warrant major disaster assistance under this Act to supplement the efforts and available resources of States, local governments, and disaster relief organizations in alleviating the damage, loss, hardship, or suffering caused thereby. "Emergency" means any occasion or instance for which, in the determina tion of the President, Federal assistance is needed to supplement State and local efforts and capabilities to save lives and to protect property and public health and safety, or to lessen or avert the threat of a catastrophe in any part of the United States.
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was determined to be outside the scope of this study. For this reason, this report does not provide a detailed analysis of these issues or dedicated recommendations on strategies for integrating social determinants of health information into mortality and morbidity data systems or how these data, once collected, could inform the actions of the disaster management enterprise.
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The committee deliberated from May 2019 to June 2020 and during this time the committee held five in-person meetings. Committee's Approach Regarding the committee's approach, this study was brought before the committee due the extreme discrepancies in mortality estimates following Hurricane Maria in Puerto Rico in 2017.
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Therefore, while the report's recommendations are focused directly on major disasters as defined in the Stafford Act and are referred to in this report as "large-scale disasters," the report's conclusions and recommendations can be read and adopted more broadly. Chapter 5 includes further discussion on the broader applicability of the committee's recommendations.
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to provide additional supporting material for the report. Guiding Precepts for an Effective Data System for Assessing Mortality and Morbidity After reviewing the current landscape of practices for assessing mortality and morbidity following large-scale disasters, the committee established a set of guiding precepts to aid in developing its recommendations.
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Efforts to improve the timeliness and accuracy of mortality and morbidity data should be underpinned by the broader ethos of saving lives, protecting health, and preparing for future disasters. Incorporate both individual counts and population estimates to better understand a disaster's true effect The two primary approaches for assessing disaster-related mortality and morbidity, individual counts and population estimates, have important and complementary values.
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An enterprise approach across the disaster management enterprise would unite stakeholders under common goals and mitigate the complexity of operationalizing improved practices and methods. Support the resilience and strength of historically disadvantaged populations by using data to understand, mitigate, and eliminate inequalities in disaster impacts Mortality and morbidity data can offer valuable contextual information about population-specific vulnerabilities and provide evidence for targeted mitigation and preparedness efforts to protect and improve the resilience of these populations.
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FIGURE 1-1 Changing uses of mortality and morbidity data over a disaster lifecycle.
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These different approaches -- individual counts and population estimates -- used for estimating disaster-related mortality and morbidity as well as the practical uses for these data and relevant barriers will be discussed in greater detail in Chapters 3 and 4. CURRENT ISSUES IN MORTALITY AND MORBIDITY ASSESSMENT Despite the importance of mortality and morbidity data in protecting human life, the nation lacks the capacity to assess disaster-related mortality and morbidity in a standardized way across states, tribal nations, territories, and localities.
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. Obvious mismatches between mortality as presented by individual counts versus population estimates can ignite controversy and confusion -- as was most recently seen following Hurricane Maria in Puerto Rico in 2017 (see Box 1-3)
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. Hurricane Maria serves as an example of challenges in measuring the true effect of a major disaster and the value that population estimation methods can provide in the absence of robust individual counts.
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The COVID-19 pandemic has demonstrated how the availability of multiple methods for assessing mortality and morbidity can create confusion and make these numbers susceptible to manipulation or the appearance thereof. Defining which morbidity data are of value to the disaster management enterprise and developing standards for the data systems that generate these data are critical first steps to building the capability to collect and use these data effectively (see Chapters 3 and 4)
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The guide is based on CDC's uniform disaster mortality case definitions and offers a flow chart for making determinations about attribution; it also includes examples of common causes of direct disaster-related death and common circumstances leading to indirect disaster-related deaths. To address challenges in gathering deathscene data, CDC's Death Scene Investigation After Natural Disaster or Other Weather-Related Events toolkit supports investigators by providing a common framework for collecting and documenting consistent disasterrelated death-scene information (CDC, 2017)
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The CDC tools mentioned above have now been included in the updated CDC Public Health Emergency Preparedness and Response Capabilities of the PHEP cooperative agreement (CDC, 2018, 2020)
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Other important stakeholders are hospital and health BOX 1-5 Stakeholder Involvement Federal Assistant Secretary for Preparedness and Response Census Bureau Centers for Disease Control and Prevention Centers for Medicare & Medicaid Services Department of Defense Department of Homeland Security Department of Veterans Affairs Federal Emergency Management Agency Federal Interagency Council on Statistical Policy Government Accountability Office National Center for Health Statistics National Institutes of Health National Weather Service/National Oceanic and Atmospheric Administration Office of Management and Budget State, Tribal, and Territorial Association of State and Territorial Health Officials Council of State and Territorial Epidemiologists Medical examiners and coroners (state-specific) State health departments State vital records offices County and Localities County health departments Medical examiners and coroners National Association of County & City Health Officials School systems Vital records
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Other Academic schools of public health American Academy of Forensic Sciences American Board of Medicolegal Death Investigators American Public Health Association American Statistical Association Association of Schools and Programs of Public Health Community-based organizations and research partners Emergency medical services Environmental health groups Faith-based organizations International Association of Coroners & Medical Examiners International Association of Emergency Managers Health and other insurance companies Health information exchanges Health information systems Homeless shelters and outreach organizations Hospitals and health systems Law enforcement (criminologists, forensics) National Association for Public Health Statistics and Information Systems National Association of Medical Examiners Nongovernmental organizations Nursing home and home-health trade organizations Organizations that support institutionalized and incarcerated populations Organizations that support people with disabilities and lived experience populations Organizations that support undocumented immigrants Public health institutes Red Cross Social media (Facebook, Twitter, Google)
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First, the terms individual count (i.e., estimates derived from individual death records) and population estimate (i.e., estimates derived from population-based estimation methods)
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Estimates of total mortality and morbidity -- both individual counts and population estimates -- are not static and can change over time as additional data are gathered or updated, as additional mortality or morbidity occurs, or as the assumptions for characterizing the estimate evolve. The third concept is that each approach is valuable and imprecise in different ways and has different appropriate uses.
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The daily number of deaths, therefore, is a seriously lagging indicator of the efficacy of control efforts, and thus a poor guide for deciding whether, say, social distancing measures can be relaxed. Defining Significant Morbidity The qualification of significant morbidity, rather than all degrees and types of disaster-related morbidity, was specifically noted in the committee's Statement of Task, but the term was not explicitly defined by the study sponsor.
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See Chapter 3 for a discussion of potential key morbidities that could be targeted by data collection efforts and how these individual counts could be used by SLTT entities and Chapter 4 for information about survey methods for collecting these data and analytical approaches for developing population estimates of morbidity. ORGANIZATION OF THIS REPORT This report seeks to provide federal and SLTT stakeholders with actionable guidance for improving the assessment of mortality and significant morbidity of disasters.
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2017. Stafford Act declarations 1953–2016: Trends, analyses, and implications for Congress.
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2005. When chronic conditions become acute: Prevention and control of chronic diseases and adverse health outcomes during natural disasters.
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Presentation at the August 29, 2019, public meeting of the National Academies of Sciences, Engineering, and Medicine's Committee on Best Practices for Assessing Mortality and Significant Morbidity Following Large Scale Disasters, Washington, DC. Ragan, P., J
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