AIM: The aim of this systematic literature review was to identify the extent and implications of medication loss and the burden of prescription refill on medical relief teams following extreme weather events and other natural hazards.

METHOD: The search strategy followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Key health journal databases (Medline, Embase, PsycINFO, Maternity and Infant Care, and Health Management Information Consortium (HMIC)) were searched via the OvidSP search engine. Search terms were identified by consulting MeSH terms. The inclusion criteria comprised articles published from January 2003 to August 2013, written in English and containing an abstract. The exclusion criteria included abstracts for conferences or dissertations, book chapters and articles written in a language other than English. A total of 70 articles which fulfilled the inclusion criteria were included in this systematic review.

RESULTS: All relevant information was collated regarding medication loss, prescription loss and refills, and medical aids loss which indicated a significant burden on the medical relief teams. Data also showed the difficulty in filling prescriptions due to lack of information from the evacuees. People with chronic conditions are most at risk when their medication is not available. This systematic review also showed that medical aids such as eye glasses, hearing aids as well as dental treatment are a high necessity among evacuees.

DISCUSSION: This systematic review revealed that a considerable number of patients lose their medication during evacuation, many lose essential medical aids such as insulin pens and many do not bring prescriptions with them when evacuated.. Since medication loss is partly a responsibility of evacuees, understanding the impact of medication loss may lead to raising awareness and better preparations among the patients and health care professionals. People who are not prepared could have worse outcomes and many risk dying when their medication is not available.

Background: Decades of civil conflict compound the challenges of food insecurity in South Sudan and contribute to persistent, high levels of child malnutrition. As efforts to prevent child malnutrition continue, there is a critical need for strategies that effectively supplement the diets of pregnant women and young children in transitional, highly food insecure settings like South Sudan.

Methods: This mixed-methods case study of four communities in South Sudan reports on the diets of children under 2 years of age and explores household-level factors including household size, intrahousehold food allocation practices, and responses to scarcity that may have significant impact on the effectiveness of strategies relying on household ration distribution to supplement the diets of pregnant women and children under 2 years of age.

Results: Participants reported experiencing increased scarcity as a result of prolonged drought and household sizes enlarged by the high volume of returning refugees. Although communities were receiving monthly household rations through a non-emergency food assistance program, most households had exhausted rations less than 30 days after receipt. Results showed that more than one half of children 12-17 months and one third of children 18-23 months consumed diets consisting of fewer than 4 food groups in the last week. Intrahousehold food allocation patterns give children first priority at meal times even in times of scarcity, yet adult women, including pregnant women, have last priority.

Discussion: These findings suggest that distribution of supplementary household rations will likely be insufficient to effectively supplement the diets of young children and pregnant women in particular. In light of the multiple contextual challenges experienced by households in transitional, food-insecure settings, these findings support recommendations to take a context-specific approach to food assistance programming, in which considerations of intrahousehold food allocation patterns and broader cultural and environmental factors inform program design. Incorporating assessments of intrahousehold food allocation patterns as part of needs assessments for food assistance and voucher or cash transfer programs may contribute to more effective, context specific programming.

Introduction
While many of the acute risks posed by flooding and other disasters are well characterised, the burden of carbon monoxide (CO) poisoning and the wide range of ways in which this avoidable poisoning can occur around flooding episodes is poorly understood, particularly in Europe. The risk to health from CO may continue over extended periods of time after flooding and different stages of disaster impact and recovery are associated with different hazards.

Methods
A review of the literature was undertaken to describe the changing risk of CO poisoning throughout flooding/disaster situations. The key objectives were to identify published reports of flood-related carbon monoxide incidents that have resulted in a public health impact and to categorise these according to Noji’s Framework of Disaster Phases (Noji 1997); to summarise and review carbon monoxide incidents in Europe associated with flooding in order to understand the burden of CO poisoning associated with flooding and power outages; and to summarise those strategies in Europe which aim to prevent CO poisoning that have been published and/or evaluated.
The review identified 23 papers which met its criteria. The team also reviewed and discussed relevant government and non-government guidance documents. This paper presents a summary of the outcomes and recommendations from this review of the literature.

Results
Papers describing poisonings can be considered in terms of the appliance/source of CO or the circumstances leading to poisoning.The specific circumstances identified which lead to CO poisoning during flooding and other disasters vary according to disaster phase. Three key situations were identified in which flooding can lead to CO poisoning; pre-disaster, emergency/recovery phase and post-recovery/delayed phase. These circumstances are described in detail with case studies.
This classification of situations is important as different public health messages are more appropriate at different phases of a disaster. The burden of disease from poisoning caused by each potential source and at each phase of a disaster is different. CO poisoning is not compulsory and deaths associated with a flood but delayed for a period of months, for example due to a damaged boiler, may never be attributed to the flood as surveillance often ends once the floodwaters recede. The problem of under–reporting is crucial to our understanding of flooding-related poisoning.
The indoor use of portable generators, cooking and heating appliances designed for use outdoors during periods of loss of mains power or gas is a particular problem. In the recovery phase, equipment for pumping, dehumidifying and drying out of properties poses a new risk. In the long term, mortality and morbidity associated with the renewed use of boilers which may have suffered covert damage in flooding is recognised but very difficult to quantify.
Papers evaluating interventions were not found and where literature exists on prevention of CO poisoning in disaster situations, it is from the USA.

Conclusions
This paper for the first time describes the different risks of CO poisoning posed by the different phases of a disaster. There is a specific need to recognise that any room in a building can harbour a CO emitting appliance in flooding; wood burners and rarely used chimney flues may become particularly problematic following a flood.

Recommendations
1) Public health workers and policy makers should consider establishing toolkits using the CDC toolkit approach; the acceptability of any intervention must be evaluated further to guide informed policy.

2) CO poisoning must form part of syndromic and event based surveillance systems for flooding and should be included in measures of the health impact of flooding.

3) CO monitors in the domestic environment should be sited not only in proximity to known CO emitters but also in locations where mobile or short term CO emitting appliances may be placed, including woodburners and infrequently used fireplaces.

Background: International humanitarian assistance is essential for disaster-affected populations, particularly in resource scarce settings. To target such assistance, needs assessments are required. According to internationally endorsed principles, donor governments should provide funding for humanitarian assistance based on need.

Aim: The aim of this study is to explore a major donor’s use of needs assessment data in decision-making for allocations of funds for health-related humanitarian assistance contributions.

Setting: This is a case study of the Swedish International Development Cooperation Agency (Sida), a major and respected international donor of humanitarian assistance.

Methods: To explore Sida’s use of needs assessment data in practice for needs-based allocations, we reviewed all decision documents and assessment memoranda for humanitarian assistance contributions for 2012 using content analysis; this was followed by interviews with key personnel at Sida.

Results: Our document analysis found that needs assessment data was not systematically included in Sida’s assessment memoranda and decision documents. In the interviews, we observed various descriptions of the concept of needs assessments, the importance of contextual influences as well as previous collaborations with implementing humanitarian assistance organizations. Our findings indicate that policies guiding funding decisions on humanitarian assistance need to be matched with available needs assessment data and that terminologies and concepts have to be clearly defined.

Conclusion: Based on the document analysis and the interviews, it is unclear how well Sida used needs assessment data for decisions to allocate funds. However, although our observations show that needs assessments are seldom used in decision making, Sida’s use of needs assessments has improved compared to a previous study. To improve project funds allocations based on needs assessment data, it will be critical to develop distinct frameworks for allocation distributions based on needs assessment and clear definitions, measurements and interpretations of needs.

Key words: Needs assessment, humanitarian assistance, disasters, donor decision-making

Aim – To explore the challenges for general practitioners (GPs) following the 2010/2011 Canterbury earthquakes and describe how these were met.
Methods – Qualitative study using semi-structured interviews with eight GPs from the Christchurch area exploring their experiences.
Results – The interviews revealed that the GPs faced a range of challenges both in the immediate aftermath of the earthquakes and in the following months. These included dealing with an increased and changed workload, and managing personal concerns. The GPs reflected on their coping behaviour and how their professional practice had changed as a result.
Conclusions – All GPs reported significant increases in workload raising questions about the need for coordination of locum support. GPs often found themselves working outside their area of accustomed expertise especially in relation to patients needing financial aid. GPs identified a number of coping behaviours though some only in hindsight. Greater awareness of self-care strategies would benefit GPs responding to disasters.

Background: Natural and man-made disasters are prevailing in Ethiopia mainly due to drought, floods, landslides, earthquake, volcanic eruptions, and disease epidemics. Few studies so far have critically reviewed about medical responses to disasters and little information exists pertaining to the initiatives being undertaken by health sector from the perspective of basic disaster management cycle. This article aimed to review emergency health responses to disasters and other related interventions which have been undertaken in the health sector.

Methods: Relevant documents were identified by searches in the websites of different sectors in Ethiopian and international non-governmental organizations and United Nations agencies. Using selected keywords, articles were also searched in the data bases of Medline, CINAHL, Scopus, and Google Scholar. In addition, pertinent articles from non-indexed journals were referred to.

Results: Disaster management system in Ethiopia focused on response, recovery, and rehabilitation from 1974 to 1988; while the period between 1988 and 1993 marked the transition phase towards a more comprehensive approach. Theoretically, from 1993 onwards, the disaster management system has fully integrated the mitigation, prevention, and preparedness phases into already existing response and recovery approach, particularly for drought. This policy has changed the emergency response practices and the health sector has taken some initiatives in the area of emergency health care. Hence, drought early warning system, therapeutic feeding program in hospitals, health centers and posts in drought prone areas to manage promptly acute malnutrition cases have all been put in place. In addition, public health disease emergencies have been responded to at all levels of health care system.

Conclusions: Emergency health responses to drought and its ramifications such as acute malnutrition and epidemics have become more comprehensive in the context of basic disaster management phases; and impacts of drought and epidemics seem to be declining. However, the remaining challenge is to address disasters arising from other hazards such as flooding in terms of mitigation, prevention, preparedness and integrating them in the health care system.

Key Words: Disaster, Emergency Health, Health System, Ethiopia

Background: Although natural disasters have caused considerable damages around the world, and gender analysis can improve community disaster preparedness or mitigation, there is little research about the gendered analytical tools and methods in communities exposed to natural disasters and hazards. These tools evaluate gender vulnerability and capacity in pre-disaster and post-disaster phases of the disaster management cycle.

Objectives: Identifying the analytical gender tools and the strengths and limitations of them as well as determining gender analysis studies which had emphasized on the importance of using gender analysis in disasters.

Methods: The literature search was conducted in June 2013 using PubMed, Web of Sciences, ProQuest Research Library, World Health Organization Library, Gender and Disaster Network (GDN) archive. All articles, guidelines, fact sheets and other materials that provided an analytical framework for a gender analysis approach in disasters were included and the non-English documents as well as gender studies of non-disasters area were excluded. Analysis of the included studies was done separately by descriptive and thematic analyses.

Results: A total of 207 documents were retrieved, of which only nine references were included. Of these, 45% were in form of checklist, 33% case study report, and the remaining 22% were article. All selected papers were published within the period 1994-2012.

Conclusions: A focus on women’s vulnerability in the related research and the lack of valid and reliable gender analysis tools were considerable issues identified by the literature review. Although non-English literatures with English abstract were included in the study, the possible exclusion of non-English ones was found as the limitation of this study.

Importance: Refugees and internally displaced persons are highly vulnerable to sexual violence during conflict and subsequent displacement. However, accurate estimates of the prevalence of sexual violence among in these populations remain uncertain.

Objective: Our objective was to estimate the prevalence of sexual violence among refugees and displaced persons in complex humanitarian emergencies.

Data Source: We conducted systematic review of relevant literature in multiple databases (EMBASE, CINAHL, and MEDLINE) through February 2013 to identify studies. We also reviewed reference lists of included articles to identify any missing sources.

Study Selection: Inclusion criteria required identification of sexual violence among refugees and internally displaced persons or those displaced by conflict in complex humanitarian settings. Studies were excluded if they did not provide female sexual violence prevalence, or that included only single case reports, anecdotes, and those that focused on displacement associated with natural disasters. After a review of 1175 citations 19 unique studies were selected.

Data Extraction: Two reviewers worked independently to identify final selection and a third reviewer adjudicated any differences. Descriptive and quantitative information was extracted; prevalence estimates were synthesized. Heterogeneity was assessed using I2.

Main Outcomes: The main outcome of interest was sexual violence among female refugees and internally displaced persons in complex humanitarian settings.

Results: The prevalence of sexual violence was estimated at 21.4% (95% CI, 14.9-28.7; I2=98.3%), using a random effects model. Statistical heterogeneity was noted with studies using probability sampling designs reporting lower prevalence of sexual violence (21.0%, 95% CI, 13.2-30.1; I2=98.6%), compared to lower quality studies (21.7%, 95% CI, 11.5-34.2; I2=97.4%). We could not rule out the presence of publication bias.

Conclusions: The findings suggest that approximately one in five refugees or displaced women in complex humanitarian settings experienced sexual violence. However, this is likely an underestimation of the true prevalence given the multiple existing barriers associated with disclosure. The long-term health and social consequences of sexual violence for women and their families necessitate strategies to improve identification of survivors of sexual violence and increase prevention and response interventions in these complex settings.

Background and objective: Iran’s hospitals have been considerably affected by disasters during last decade. To address this, health system of I.R.Iran has taken an initiative to assess disaster safety of the hospitals using an adopted version of Hospital Safety Index (HSI). This article presents the results of disaster safety assessment in 224 Iran’s hospitals.

Methods: A self-assessment approach was applied to assess the disaster safety in 145 items categorized in 3 components including structural, non-structural and functional capacity. For each item, safety level was categorized to 3 levels: not safe (0), average safe (1) and high safe (2). A raw score was tallied for each safety component and its elements by a simple sum of all the corresponding scores. All scores were normalized on a 100 point scale. Hospitals were classified to three safety classes according to their normalized total score: low (≤34.0), average (34.01-66.0) and high (>66.0).

Results: The average score of all safety components were 32.4 out of 100 (± 12.7 SD). 122 hospitals (54.5%) were classified as low safe and 102 hospitals (45.5%) were classified as average safe. No hospital was placed in the high safe category. Average safety scores out of 100 were 27.3 (±14.2 SD) for functional capacity, 36.0 (±13.9 SD) for non-structural component and 36.0 (±19.0 SD) for structural component. Neither the safety classes nor the scores of safety components were significantly associated with types of hospitals in terms of affiliation, function and size (P>0.05).

Conclusions: To enhance the hospitals safety for disaster in Iran, we recommend: 1) establishment of a national committee for hospital safety in disasters; 2) supervision on implementation of the safety standards in construction of new hospitals; 3) enhancement of functional readiness and safety of non-structural components while structural retrofitting of the existing hospitals is being taken into consideration, whenever is cost-effective; 4) considering the disaster safety status as the criteria for licensing and accreditation of the hospitals.

Key words: Hospital, safety, disaster, emergency, Iran

Correspondence to: Ali Ardalan MD, PhD. Tehran University of Medical Sciences, Harvard Humanitarian Initiative, Email: [email protected], [email protected]

Portable generators are commonly used during electrical service interruptions that occur following large storms such as hurricanes. Nearly all portable generators use carbon based fuels and produce deadly carbon monoxide gas. Despite universal warnings to operate these generators outside only, the improper placement of generators makes these devices the leading cause of engine related carbon monoxide deaths in the United States. The medical literature reports many cases of Carbon Monoxide (CO) toxicity associated with generator use following hurricanes and other weather events.

This paper describes how Howard County, Maryland Fire and Rescue (HCFR) Services implemented a public education program that focused on prevention of Carbon Monoxide poisoning from portable generator use in the wake of events where electrical service interruptions occurred or had the potential to occur. A major challenge faced was communication with those members of the population who were almost completely dependent upon electronic and wireless technologies and were without redundancies. HCFR utilized several tactics to overcome this challenge including helicopter based surveillance and the use of geocoded information from the electrical service provider to identify outage areas. Once outage areas were identified, HCFR personnel conducted a door-to-door canvasing of effected communities, assessing for hazards and distributing information flyers about the dangers of generator use.

This effort represents one of the first reported examples of a community-based endeavor by a fire department to provide proactive interventions designed to prevent carbon monoxide illness.

Objective: To create a framework and methodology for organizing relevant disaster epidemiology literature. The target audience for the framework is local public health practitioners conducting emergency surveillance in the setting of preparedness or response to natural disasters.
Methods: The approach to developing the framework involved utilizing the public health and emergency management literature. It was created along four axes. The first was the type of natural disaster; second was according to phase of disaster cycle; third was the impact of the disaster (health, infrastructure, economic); and fourth was related to the main outcome of the study (ie. injuries or infectious diseases). A literature review was conducted and subsequently the current literature was utilized to perform a reliability test of the established framework, using two independent reviewers.
Results: Using existing disaster classification systems and risk analysis tools, a framework was developed along the four axes. The final literature search resulted in 85 articles on surveillance in natural disaster settings. The majority of studies are on the subject of hurricanes with a catastrophic impact rating. The phase of testing reliability of the framework resulted in percent agreement of 74%.
Conclusions: A reliable framework was developed that enables local public health practitioners to easily access appropriate and previously utilized surveillance methods for a natural disaster emergency. This framework contributes to an evidence-informed approach to surveillance in natural disasters with public health impacts.

This paper analyses the perceptions of disaster risk reduction (DRR) practitioners concerning the on-going integration of climate change adaptation (CCA) into their practices in urban contexts in Nicaragua. Understanding their perceptions is important as this will provide information on how this integration can be improved. Exploring the perceptions of practitioners in Nicaragua is important as the country has a long history of disasters, and practitioners have been developing the current DRR planning framework for more than a decade. The analysis is based on semi-structured interviews designed to collect information about practitioners’ understanding of: (a) CCA, (b) the current level of integration of CCA into DRR and urban planning, (c) the opportunities and constraints of this integration, and (d) the potential to adapt cities to climate change. The results revealed that practitioners’ perception is that the integration of CCA into their practice is at an early stage, and that they need to improve their understanding of CCA in terms of a development issue. Three main constraints on improved integration were identified: (a) a recognized lack of understanding of CCA, (b) insufficient guidance on how to integrate it, and (c) the limited opportunities to integrate it into urban planning due to a lack of instruments and capacity in this field. Three opportunities were also identified: (a) practitioners’ awareness of the need to integrate CCA into their practices, (b) the robust structure of the DRR planning framework in the country, which provides a suitable channel for facilitating integration, and (c) the fact that CCA is receiving more attention and financial and technical support from the international community.

Background: The adverse effects of heatwaves on mortality are well recognised. Heatwaves are predicted to become more frequent and severe in coming decades. England’s National Heatwave Plan (NHP) aims to prepare the country for periods of extreme heat and thereby limit adverse health effects. The central aim of this study is to understand how effectively the NHP is disseminated within an acute hospital and to identify any barriers to its use.

Methods: Qualitative data was collected through semi-structured interviews and focus groups with key hospital managers, nurses and healthcare assistants. All participants were recruited from a single hospital in the South East of England. Data were analysed using Framework Analysis.

Results: We conducted two focus groups with frontline clinical staff and five interviews with senior managers, all of whom deemed the NHP a low priority. Hospital managers showed good awareness of the plan, which was lacking amongst frontline staff. Nevertheless front line staff were familiar with the dangers of excess heat and felt that they individualised care accordingly. Communication of information between managers and frontline staff was highlighted as a problem during heatwaves. Additionally, issues with inadequate building stock and equipment limited effective implementation of the plan. Participants were able to suggest novel improvements to the plan.

Conclusions: Increased awareness and improved communication could help better integrate the NHP into the clinical practice of English hospital-based healthcare professionals. Further evaluation of the NHP in acute care trusts and other health care settings is warranted to expand upon these initial findings.

In January 12, 2010, a 7.0 magnitude earthquake shook Port-au-Prince, Haiti. The massive disaster made it difficult for local Haitian community officials to respond immediately, leaving the country reliant on foreign aid and international and non-governmental relief organizations. This study explores the effectiveness of various supports that were made available to health and social service providers in Haiti, by focusing on their lived experiences pre-deployment, on-site and post-deployment. The paper provides a qualitative exploration of participant perceptions with respect to the success of their performance in response, and relevant literature describing the various supports provided to health and social service providers responding to disasters. Methods: A single, semi-structured interview was conducted with Canadian health professionals (n=21) who deployed to Haiti during the time of, or after, the 2010 earthquake. The study uses Strauss and Corbin’s structured approach to grounded theory to identify main themes and relationships in the interviews. Results: The interviews indicate that training, and psychological and emotional supports for health and social service providers require improvement to enhance the experience and effectiveness of their work. Conclusions: Findings indicate that supports are most effective when they are tailored to the volunteers. The paper highlights future research stemming from the grounded theory findings.

Background
Extreme events (e.g. flooding) threaten critical infrastructure including power supplies. Many interlinked systems in the modern world depend on a reliable power supply to function effectively. The health sector is no exception, but the impact of power outages on health is poorly understood. Greater understanding is essential so that adverse health impacts can be prevented and/or mitigated.

Methods
We searched Medline, CINAHL and Scopus for papers about the health impacts of power outages during extreme events published in 2011-2012. A thematic analysis was undertaken on the extracted information. The Public Health England Extreme Events Bulletins between 01/01/2013 – 31/03/2013 were used to identify extreme events that led to power outages during this three-month period.

Results
We identified 20 relevant articles. Power outages were found to impact health at many levels within diverse settings. Recurrent themes included the difficulties of accessing healthcare, maintaining frontline services and the challenges of community healthcare. We identified 52 power outages in 19 countries that were the direct consequence of extreme events during the first three months of 2013.

Conclusions
To our knowledge, this is the first review of the health impacts of power outages. We found the current evidence and knowledge base to be poor. With scientific consensus predicting an increase in the frequency and magnitude of extreme events due to climate change, the gaps in knowledge need to be addressed in order to mitigate the impact of power outages on global health.

Background: Hurricane Isaac made landfall in southeastern Louisiana in late August 2012, resulting in extensive storm surge and inland flooding. As the lead federal agency responsible for medical and public health response and recovery coordination, the Department of Health and Human Services (HHS) must have situational awareness to prepare for and address state and local requests for assistance following hurricanes. Both traditional and non-traditional data have been used to improve situational awareness in fields like disease surveillance and seismology. This study investigated whether non-traditional data (i.e., tweets and news reports) fill a void in traditional data reporting during hurricane response, as well as whether non-traditional data improve the timeliness for reporting identified HHS Essential Elements of Information (EEI).

Methods: HHS EEIs provided the information collection guidance, and when the information indicated there was a potential public health threat, an event was identified and categorized within the larger scope of overall Hurricane Issac situational awareness. Tweets, news reports, press releases, and federal situation reports during Hurricane Isaac response were analyzed for information about EEIs. Data that pertained to the same EEI were linked together and given a unique event identification number to enable more detailed analysis of source content. Reports of sixteen unique events were examined for types of data sources reporting on the event and timeliness of the reports.

Results: Of these sixteen unique events identified, six were reported by only a single data source, four were reported by two data sources, four were reported by three data sources, and two were reported by four or more data sources. For five of the events where news tweets were one of multiple sources of information about an event, the tweet occurred prior to the news report, press release, local government\emergency management tweet, and federal situation report. In all circumstances where citizens were reporting along with other sources, the citizen tweet was the earliest notification of the event.

Conclusion: Critical information is being shared by citizens, news organizations, and local government representatives. To have situational awareness for providing timely, life-saving public health and medical response following a hurricane, this study shows that non-traditional data sources should augment traditional data sources and can fill some of the gaps in traditional reporting. During a hurricane response where early event detection can save lives and reduce morbidity, tweets can provide a source of information for early warning. In times of limited budgets, investing technical and personnel resources to efficiently and effectively gather, curate, and analyze non-traditional data for improved situational awareness can yield a high return on investment.

Background: Children are a special population, particularly susceptible to injury. Registries for various injury types in the pediatric population are important, not only for epidemiological purposes but also for their implications on intervention programs. Although injury registries already exist, there is no uniform injury classification system for traumatic mass casualty events such as earthquakes.
Objective: To systematically review peer-reviewed literature on the patterns of earthquake-related injuries in the pediatric population.
Methods: On May 14, 2012, the authors performed a systematic review of literature from 1950 to 2012 indexed in Pubmed, EMBASE, Scopus, Web of Science, and Cochrane Library. Articles written in English, providing a quantitative description of pediatric injuries were included. Articles focusing on other types of disasters, geological, surgical, conceptual, psychological, indirect injuries, injury complications such as wound infections and acute kidney injury, case reports, reviews, and non-English articles were excluded.
Results: A total of 2037 articles were retrieved, of which only 10 contained quantitative earthquake-related pediatric injury data. All studies were retrospective, had different age categorization, and reported injuries heterogeneously. Only 2 studies reported patterns of injury for all pediatric patients, including patients admitted and discharged. Seven articles described injuries by anatomic location, 5 articles described injuries by type, and 2 articles described injuries using both systems.
Conclusions: Differences in age categorization of pediatric patients, and in the injury classification system make quantifying the burden of earthquake-related injuries in the pediatric population difficult. A uniform age categorization and injury classification system are paramount for drawing broader conclusions, enhancing disaster preparation for future disasters, and decreasing morbidity and mortality.

Background: Two separate but complementary epidemiologic surveillance methods for human stampedes have emerged since the publication of the topic in 2009. The objective of this study is to estimate the degree of underreporting in India.

Method: The Ngai Search Method was compared to the Roy Search Method for human stampede events occurring in India between 2001 and 2010.

Results: A total of 40 stampedes were identified by both search methods. Using the Ngai method, 34 human stampedes were identified. Using a previously defined stampede scale: 2 events were class I, 21 events were class II, 8 events were class III, and 3 events were class IV. The median deaths were 5.5 per event and median injuries were 13.5 per event. Using the Roy method, 27 events were identified, including 9 events that were not identified by the Ngai method. After excluding events based on exclusion criteria, six additional events identified by the Roy’s method had a median of 4 deaths and 30 injuries. In multivariate analysis using the Ngai method, religious (6.52, 95%CI 1.73-24.66, p=0.006) and political (277.09, 95%CI 5.12-15,001.96, p=0.006) events had higher relative number of deaths.

Conclusion: Many causes accounting for the global increase in human stampede events can only be elucidated through systematic epidemiological investigation. Focusing on a country with a high recurrence of human stampedes, we compare two independent methods of data abstraction in an effort to improve the existing database and to identify pertinent risk factors. We concluded that our previous publication underestimated stampede events in India by approximately 18% and an international standardized database to systematically record occurrence of human stampedes is needed to facilitate understanding of the epidemiology of human stampedes.

Background
Severe limb trauma is common in earthquake survivors. Overall medium term outcomes and patient-perceived outcomes are poorly documented.

Methods and Findings
The prospective study SuTra2 assessed the functional and socio-economic status of a cohort of patients undergoing surgery for limb injury resulting in amputation (A) or limb preservation (LP) one year and two years after the 2010 Haiti earthquake.
305 patients [A: n=199 (65%), LP: n=106 (35%)] were evaluated. Their characteristics were: 57% female; mean age 31 years; 74% of principal injuries involved the lower limb; 46% of patients had an additional severe injury; 60% had fractures, of which two-thirds were compound or associated with severe soft tissue damage; 15% of amputations were traumatic. At 2 years, 51% of patients were satisfied with the functional outcome (A: 52%, LP: 49%, ns). Comparison with the 1-year status indicates a worsening of the perceived functional status, significantly more pronounced in amputees, and an increase in pain complaints, mainly in amputees (62% and 80% of pain in overall population at 1- and 2-year respectively). Twenty eight percent (28%) of LP and 66% of A considered themselves as “cured”. 100% of LP and 79% of A would have chosen a conservative approach if an amputation was medically avoidable. Two years after the earthquake, 23·5 % of patients were still living in a tent, 30% were working, and 25·5% needed ongoing surgical management.

Conclusions
Only half the patients with severe limb injuries, whether managed with amputation or limb preservation, deemed their functional status satisfactory at 2 years. The patients’ perspective, clearly favors limb conservative management whenever possible. Prolonged care and rehabilitation are needed to optimize the outcome for earthquake survivors with limb injuries. Humanitarian respondents to catastrophes have professional and ethical obligations to provide optimal immediate care and ensure scrupulous attention to long-term management.

Keywords
Haiti earthquake, limb injury, two-year outcome, patients’ perspective, amputation, limb salvage

Public health facilities in Iran are exposed to a wide range of natural hazards. This article presents the first survey of the impacts of such natural hazards on primary health care (PHC) centers in Iran from 2001 to 2011. A retrospective survey was conducted in 25 out of 30 provinces of Iran. Archival reports at provincial public health departments were cross-referenced with key informant interviews. During a 10-year period, 119 natural hazard events were recorded that led to physical damage and/or functional failure in 1,401 health centers, 127 deaths and injury or illness in 644 health staff. Earthquakes accounted for the most physical damage and all health-worker deaths. However, there was an increasing trend of impacts due to hydro-meteorological hazards. Iran’s health system needs to establish a registry to track the impact of natural hazards on health facilities, conduct regular hazard and vulnerability assessments and increase mitigation and preparedness measures.

Keywords: Disaster, primary health care, facility, Iran, natural hazard

Corresponding author: Ali Ardalan MD, PhD. Iran’s National Institute of Health Research, Tehran University of Medical Sciences. Harvard Humanitarian Initiative. Email: [email protected]

Currently there is no consensus on how to identify pregnant women as acutely malnourished and when to enroll them in nutritional programmes. Médecins Sans Frontières Switzerland undertook a literature review with the purpose of determining values of anthropometric indicators for acute malnutrition that are associated with adverse birth outcomes (such as low birth weight (LBW)), pre-term birth and intra-uterine growth retardation (IUGR). A literature search in PUBMED was done covering 1 January 1995 to 12 September 2012 with the key terms maternal anthropometry and pregnancy. The review focused on the humanitarian context. Mid-upper-arm circumference (MUAC) was identified as the preferential indicator of choice because of its relatively strong association with LBW, narrow range of cut-off values, simplicity of measurement (important in humanitarian settings) and it does not require prior knowledge of gestational age. The MUAC values below which most adverse effects were identified were <22 and <23 cm. A conservative cut-off of <23 cm is recommended to include most pregnant women at risk of LBW for their infants in the African and Asian contexts.

Encouraging residents in high-risk areas to evacuate before a hurricane makes landfall is one of the few ways to reduce hurricane-related morbidity and mortality. However, demographic factors associated with evacuation in at-risk groups have not been consistent across studies. To determine if social factors (social control, social cohesion, and social capital) modified the relationship between demographic groups and failure to evacuate from Hurricane Irene, the authors conducted a cross-sectional stratified two-stage cluster sample among residents of Beaufort County, NC. Of 226 attempted rapid response interviews, 205 were completed (response rate = 90.7%). Data were analyzed using generalized linear modeling, which produced crude risk differences to estimate the association between failure to evacuate from Hurricane Irene and a number of demographic and social factors; effect measure modification (EMM) was assessed on the additive scale through stratified analyses of key social factors. There were no significant associations between demographic or social factors and evacuation in the bivariate analysis. However, EMM was present for households with high social capital or social cohesion among special needs residents, those over age 65, males, and non-whites. In Beaufort County, NC, future hazard mitigation plans should include evacuation messages tailored for households with high social capital or social cohesion.

Introduction.
Climate change projections indicate that droughts will become more intense in the 21 century in some areas of the world. The El Niño Southern Oscillation is associated with drought in some countries, and forecasts can provide advance warning of the increased risk of adverse climate conditions. The most recent available data from EMDAT estimates that over 50 million people globally were affected by drought in 2011. Documentation of the health effects of drought is difficult, given the complexity in assigning a beginning/end and because effects tend to accumulate over time. Most health impacts are indirect because of its link to other mediating circumstances like loss of livelihoods.

Methods.
The following databases were searched: MEDLINE; CINAHL; Embase; PsychINFO, Cochrane Collection. Key references from extracted papers were hand-searched, and advice from experts was sought for further sources of literature. Inclusion criteria for papers summarised in tables include: explicit link made between drought as exposure and human health outcomes; all study designs/methods; all countries/contexts; any year of publication. Exclusion criteria include: drought meaning shortage unrelated to climate; papers not published in English; studies on dry/arid climates unless drought was noted as an abnormal climatological event. No formal quality evaluation was used on papers meeting inclusion criteria.

Results.
87 papers meeting the inclusion criteria are summarised in tables. Additionally, 59 papers not strictly meeting the inclusion criteria are used as supporting text in relevant parts of the results section. Main categories of findings include: nutrition-related effects (including general malnutrition and mortality, micronutrient malnutrition, and anti-nutrient consumption); water-related disease (including E coli, cholera and algal bloom); airborne and dust-related disease (including silo gas exposure and coccidioidomycosis); vector borne disease (including malaria, dengue and West Nile Virus); mental health effects (including distress and other emotional consequences); and other health effects (including wildfire, effects of migration, and damage to infrastructure).

Conclusions.
The probability of drought-related health impacts varies widely and largely depends upon drought severity, baseline population vulnerability, existing health and sanitation infrastructure, and available resources with which to mitigate impacts as they occur. The socio-economic environment in which drought occurs influences the resilience of the affected population. Forecasting can be used to provide advance warning of the increased risk of adverse climate conditions and can support the disaster risk reduction process. Despite the complexities involved in documentation, research should continue and results should be shared widely in an effort to strengthen drought preparedness and response activities.

Objective
To provide an overview of the health needs following the Great East Japan Earthquake Disaster and the lessons identified.

Methods
The relevant of peer review and grey literature articles in English and Japanese, and books in Japanese, published from March 2011 to September 2012 were searched. Medline, Embase, PsycINFO, and HMIC were searched for journal articles in English, CiNii for those in Japanese, and Amazon.co.jp. for books. Descriptions of the health needs at the time of the disaster were identified using search terms and relevant articles were reviewed.

Findings
85 English articles, 246 Japanese articles and 13 books were identified, the majority of which were experience/activity reports. Regarding health care needs, chronic conditions such as hypertension and diabetes were reported to be the greatest burden from the early stages of the disaster. Loss of medication and medical records appeared to worsen the situation. Many sub-acute symptoms were attributed to the contaminated sludge of the tsunamis and the poor living environment at the evacuation centres. Particularly vulnerable groups were identified as the elderly, those with mental health illnesses and the disabled. Although the response of the rescue activities was prompt, it sometimes failed to meet the on-site needs due to the lack of communication and coordination.

Conclusion
The lessons identified from this mega-disaster highlighted the specific health needs of the vulnerable populations, particularly the elderly and those with non-communicable diseases. Further research is needed so that the lessons identified can be incorporated into future contingency plans in Japan and elsewhere.