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2 Value and Use of Mortality and Morbidity Data
Pages 49-78

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From page 49...
... The second part of the chapter discusses the value and meaningful use of mortality and morbidity data by various stakeholders across the disaster lifecycle and provides examples of how these data are currently used or could be used. Chapters 3 and 4 will focus on the analytical and operational challenges and practices related to the collection, reporting, and recording of individual counts and population estimates of mortality and morbidity.
From page 50...
... A uniform approach could also support: • More consistent assessment of the human impact of disasters across all jurisdictions; • Delivery of adequate resources for recovery; • Forecasting of needs for similar incidents in the future; • Identification of behavioral contributors to disaster-related mor tality and morbidity to inform interventions to modify future behavior; • Exploration of population impacts to promote health and offer relevant services and support for prevention and recovery; and • Identification of vulnerable populations and their specific needs to improve services and reduce additional morbidity, injury, and death. To address the need for a uniform approach for conceptualizing and assessing mortality and mortality data following large-scale disasters, the committee developed a framework that can be adopted across all systems and jurisdictions (see Table 2-1)
From page 51...
... existing cardiovascular disease; death due to suicide following or during a disaster in a patient with pre-existing mental illness Total mortality and morbidity derived from population estimates: Population estimates are point-in-time estimates of the impact of a disaster at a population level derived using various statistical methods and tools, including sampling. Examples: Increase in all-cause mortality in the 4 weeks after a hurricane derived from excess mortality data; increase in myocardial infarctions in the 6 months following a disaster derived from claims data; estimation of population infection rates using serological prevalence studies; increase in asthma exacerbation episodes in the wake of a large wildfire using data from electronic health records.
From page 52...
... . As discussed below, the committee's case definition for a direct death will capture only unnatural disaster-related deaths, while the case definitions for indirect deaths and partially attributable deaths can capture both natural and unnatural deaths.
From page 53...
... For example, Florida's statewide reporting system centralizes the counting of all deaths at the state level, with individual counties not tasked with counting and reporting their deaths independently. This approach allows initial counts of disaster-related deaths to be communicated to the public by a single source with access to all mortality data from across the state, in addition to ensuring consistency and timeliness of data.
From page 54...
... When applied appropriately, the two approaches can help answer different questions, elucidate different sets of risk factors, and uncover different potential points of intervention. Therefore, both individual counts and population estimates contribute to a comprehensive picture of a disaster's health impacts, which can be used to inform response and recovery and to prepare for future events.
From page 55...
... Unlike individual counts, population estimates of total disaster-related mortality and morbidity are derived by estimating the number of mortalities and morbidities using statistical means, such as representative and complex sampling, survey-based methods or using a variety of excess mortality and morbidity methods (e.g., comparing deaths or illness rates in the disasteraffected population to rates observed in the same population during the previous year or during a relevant time period)
From page 56...
... It is critical to recognize that individual counts are not always superior to population estimates based on samples or vice versa. For some audiences, the term "count" might imply greater precision than the term "estimate," but this assumption is incorrect and both approaches can produce valuable estimates of the true effect of a disaster, which are useful for different purposes.
From page 57...
... Accuracy of Individual Counts and Degree of Attribution The precision of estimates of disaster-related mortality and morbidity made using individual counts depends on the accuracy of decisions that are made about the strength of association of an individual outcome to a disaster. In the case of mortality, medical examiners, coroners, or other medical certifiers1 must consider for each individual death (1)
From page 58...
... As discussed above, a person who dies as a direct consequence of a disaster should always be considered a direct death or morbidity, even if the death occurs many years later. Box 2-2 provides an overview of data sources for individual counts of disaster-related deaths and morbidity.
From page 59...
... . Access to death certificate information may be delayed during recovery operations, but a number of alternative sources of mortality data exist, including funeral home records, emergency medical services scene transport records, hospital medical records, media reports and memorial websites, the Red Cross disaster-related mortality report form, and the Federal Emergency Management Agency's records of individual funeral benefits distributed (Horney, 2017)
From page 60...
... Importantly, this category is not static, and partially attributable deaths or morbidities can be reclassified as indirect deaths or morbidities as more evidence of causation becomes available. Population Estimation Methods Population estimates quantify mortality and morbidity related to a disaster at a population level through statistical analyses and epidemiological approaches to assess the size and characteristics of the population affected.
From page 61...
... .2 For example, research following Hurricane Katrina found that the interruption of health maintenance activities was an indicator for additional future morbidity since up to one-half of evacuees seeking shelter in the Astrodome and Red Cross facilities lacked access to their prescription medications (Brodie et al., 2006; Greenough et al., 2008)
From page 62...
... 62 MORTALITY AND MORBIDITY AFTER LARGE-SCALE DISASTERS TABLE 2-3  Selected Research on Physical and Psychological Morbidities Associated with Disaster Exposure Morbidity Type Disaster Type Major Findings Carbon monoxide poisoning Hurricane Number of cases, associated (Bourque et al., 2009) with improper use of generators, peaked within 3 days of hurricane landfall.
From page 63...
... . More discussion about gaps and potential opportunities for collecting, recording, and using morbidity data for individual counts can be found in Chapter 3.
From page 64...
... Overall, the disaster management enterprise remains underinvested in understanding morbidity and how using morbidity data can contribute to saving lives, protecting health, and improving health equity, as will be discussed in Chapters 3 and 4.
From page 65...
... This requires determining the types of data with the most value in ensuring people's well-being at each phase of the disaster management cycle. In terms of their functional value, mortality and morbidity data enable the Federal Emergency Management Agency (FEMA)
From page 66...
... -- Public Health and Medical Services -- offers federal support to strengthen SLTT-level disaster response capabilities. Under ESF8, the National Disaster Medical System can respond to spikes in mortality and morbidity to provide human resources in settings where health system capacity and infrastructure have been compromised by a disaster.
From page 67...
... Mortality data in particular have major financial implications for individuals and families seeking funeral assistance from FEMA, because one of the eligibility requirements for this support is documentation that the death occurred either directly or indirectly as a result of the disaster impact (NCHS, 2017) .3 If a death was not attributed as such by the medical examiner, coroner, or other medical certifier, then the death may be ruled ineligible for funeral assistance, or assistance may be delayed (Bowden, 2018)
From page 68...
... , better data on health effects and interactions might not only mitigate disaster impacts but even help to prevent future disasters. Building Health System Capacity To support health systems in building response capacity, mortality and morbidity data can be used to predict demands on health care delivery
From page 69...
... Furthermore, comparing actual morbidity and mortality data following a disaster to historical data for similar prior disasters can feed back into continuous improvement of preparedness policies and activities (Schnall et al., 2017)
From page 70...
... . Socially vulnerable groups include people in financially precarious situations who become homeless and unemployed, leading to indirect deaths by overdose or suicide, as well as local homeless populations.
From page 71...
... The contextualization of morbidity and mortality using SDOH data adds additional value and evidence to foster a stronger and more responsive disaster management enterprise that prioritizes community resilience. The contributory role of SDOH on vulnerability should not be deemphasized.
From page 72...
... Fundamentally, the lack of a consistently used framework for attributing mortality and morbidity results in the inconsistent collection and reporting of data on the scope and causes of mortality and morbidity over time and across disasters. The committee's framework responds to this critical gap and is unique in that it balances the value of both individual count and population estimation methods for developing quantitative indicators of total mortality or morbidity and provides updated individual count case definitions to characterize the level of attribution for all deaths related to disasters of all types.
From page 73...
... Timely guidance should be disseminated to SLTT entities regarding the proper certification of individual deaths with provision for direct, indi rect, and partially attributable deaths following a large-scale disaster. The following terminology and approaches for defining mortal ity and morbidity following large-scale disasters should be adopted immediately: • Total reported mortality and morbidity estimation using indi vidual counts: Individual counts are point-in-time estimates of disaster-related mortality and morbidity derived from reported cases.
From page 74...
... Individual count data should be referred to as reported cases or reported deaths and should not be referred to as reflecting total mortality or a death toll. Total mortality estimates should be derived from population estimation methods, which provide a more complete assessment of overall impacts of large-scale disasters.
From page 75...
... :153–186. FEMA (Federal Emergency Management Agency)
From page 76...
... 2019. Challenges with disaster mortality data and measuring progress towards the implementation of the Sendai Framework.
From page 77...
... 2018. Differential and persistent risk of excess mortality from Hurricane Maria in Puerto Rico: A time-series analysis.
From page 78...
... . Washoe County Regional Medical Examiner's Office.


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