Acute effects

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Do curso por The University of Tokyo

Global Health Policy

66 classificações

The University of Tokyo

Global Health Policy

66 classificações

In this course, learners will become familiar with principles and theories of global health problems, and major challenges and controversies in improving global population health as well as practical applications of quantitative methods to analyze and interpret issues and challenges for policy. Topics will include health and foreign policy, health governance, acute disease surveillance, non-communicable diseases, burden of disease, universal health coverage, health systems strengthening, health financing, and human resources for health and ageing.

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Pandemics and Health Security Responses

In this module, we will explore the relationship between universal health coverage, disasters and pandemics. We will learn how to measure and understand the spread of infectious diseases, and how to respond to them. We will also consider the conditions necessary to ensure an effective and timely response to both infectious disease emergencies and disasters, and identify the common role that universal health coverage plays in preparing societies for these unexpected threats to human well-being.

Acute disaster response in an aging society7:59

Acute effects8:20

Long-term health effects10:39

Conheça os instrutores

Hiroshi Nishiura
(Former Affiliation) Associate Professor, Graduate School of Medicine, The University of Tokyo
(Current Affiliation) Professor, Graduate School of Medicine, Hokkaido University
Stuart Gilmour
Associate Professor
Department of Global Health Policy, Graduate School of Medicine
Kenji Shibuya
Professor and Chair
Department of Global Health Policy, Graduate School of Medicine

Okay, we have seen now the context in which the Great East Japan earthquake,

tsunami, and nuclear accident happened in Japan.

So now I'm going to talk a little bit about the acute effects of that accident

and their implications for human security.

So, the first thing I'm going to talk about is the problem of

evacuating elderly people from the town.

And one of the first things that we identified when we started working in

Minamisoma was that there was a great deal of concern about what happened to elderly

people living in care homes in Minamisoma immediately after the earthquake and

the nuclear accident.

So, everyone was evacuating from the town.

But some people, the elderly people in the town, were living in care homes,

where they couldn't actually evacuate themselves.

And their family were not necessarily present, so,

we ran a study about those care homes.

The results, of which, I'm going to present to you today.

So first, I'd like to give three quotes from people who worked in the care homes

about their experience at the time.

The first quote, by a person at one care home, they say,

looking back now, I think evacuation was not necessary, but

we were in a panicked condition due to fear of radiation and starvation.

Evacuation was unavoidable at that time.

Another person in a different facility said,

every day, facility staff told me with tears that they decided to evacuate.

One or two people a day.

I believe that it was a very hard decision to evacuate for

them after consulting with their families.

So, this facility member wanted to keep running the facility in the affected area,

but every day, was losing staff,

who had to concern themselves with their own families and children.

Another person said, after the accident, some families told me on the phone

that they would leave all care of their father or mother to us, and

then, they evacuated and left their parents behind.

Then some of us came to wonder why we had to take care of the residents whom their

family abandoned.

So here we begin to see immediately the breakdown of the kind of standard

public order that we expect in an ordinary society due to an earthquake and tsunami.

So, once we began our field work in Minamisoma, we realized that this had been

a big concern for many of the elderly care homes in the town.

We conducted a research project to understand exactly what happened.

So, we analyzed the evacuation and

mortality records from five of the eight elderly care homes in Minamisoma.

All of these homes evacuated after the Fukushima dai-ichi nuclear accident, but

they evacuated at different times and in different ways.

Our objective was to estimate the change in mortality due to evacuation

after the earthquake and nuclear accident, and also to try and

identify some facility-specific factors affecting mortality.

And this work was published in PLOS ONE in 2013.

So for this study, we collected facility entry, exit, and mortality records for all

of the five facilities from the period of 11th of March, 2006 to 10th of March 2011.

After the earthquake and the nuclear accident,

all of these facilities evacuated.

And they kept evacuation records.

So they kept records on where they went, when they went, and

the mortality of their residents during the period that they were evacuating.

So we collected those evacuation mortality records from the 11th of March 2011

to the 10th of March 2012.

Some facilities had shorter follow-up, but we used a method called Cox proportional

hazards regression to understand the mortality rates in this period of time.

This enabled us to compare pre- and post-earthquake time periods, and also to

incorporate the length of time that people were at risk of death due to evacuation.

So this slide shows the basic results from that analysis.

The green band shows the hazard ratio of death that is the increased risk of

death in facility number one, after the earthquake.

And then beneath that green line,

there are additional effects in all of the other facilities of the earthquake.

We can combine these effects together using a linear combination method,

which to give us the facility specific hazard ratio, that is the rate of death

after the earthquake compared to before, in each facility.

And that's what the black arrow points to.

So for example, in facility one,

the death rate increased by a factor of 2.9 after the earthquake,

compared to the same death rate in the facility before the earthquake.

In contrast, in facility three, the death rate increased by a factor of 1.4,

but this was effectively no different from the pre-earthquake death rate

in that facility after we adjust for our uncertainty about the path of mortality.

So you can see, facilities one, two, and four had significantly

higher rates of mortality, and facilities three and five did not.

We can see this effect, graphically, in this slide.

This slide shows a survival chart for the five facilities after the earthquake.

The x-axis in this chart is the survival time in days.

So we have created a record of all the deaths and

non-deaths in each facility in the time after the earthquake, and

we can plot them as survival curves on this chart.

The y-axis is the probability of survival at each time point.

Each downward step in this chart, in one particular line, represents a death or

deaths occurring in that particular time.

As you can see, for example, in facility one, there was a staircase of

deaths in the first 30 days with many rapid downward steps in the curve.

That indicates rapid mortality in the first 30 days.

You can see that facility three and facility five, the green and gold bar,

near the top of the graph, are the ones where the deaths occurred slowest, so

they're the ones with the lowest death rate.

And you can see, especially, facility one and facility four had very rapid declines

in survival in the first one to three months after the earthquake.

This represents the specific higher mortality in those two facilities.

So, in conclusion, the evacuation in these facilities, in some of these facilities,

significantly increased mortality.

And this post-evacuation mortality varied widely between the facilities.

This variation in mortality was due to the particular conditions in the particular

facilities.

So for example, one facility had no preparation for evacuation at all, and

they did not have a place to evacuate to, so they had to prepare a place rapidly,

in a hurry, after the earthquake, and that place was in Yokohama.

So they had to evacuate from Minamisoma to Yokohama,

which is a 14-hour drive by bus, with elderly and frail people in the bus.

Another facility had arranged a prior agreement with a facility in Niigata.

They were able to wait a couple of days and

then leave in a more orderly fashion, on a two-hour journey to Niigata.

So, different facilities had different ability to evacuate and

different levels of order about the way that they evacuated.

An alternative strategy, however, which would have worked for all facilities,

would have been to shelter-in-place, that is to stay in Minamisoma, look after

the elderly people in the care homes in the town, and wait for the crisis to pass.

However, this was impossible because of the loss of services and support.

Staff were leaving, as I described in the first slide of this lecture, and

also people were not entering the evacuation area

to bring supplies to the facilities because of a fear of radiation.

What this means is that if they had wanted to stay in place, or indeed,

if they had wanted to evacuate in a more orderly way, they would have needed

the support of the government to help organize supplies to the area or

to organize a more orderly and sophisticated evacuation process.

And that shows us that even in a developed nation with a well-functioning disaster

response and a well-functioning health system, such as Japan,

human security is essential for a safe disaster response.

And this human security need exists even where you have a wealthy population of

elderly people living in a society with a well-functioning disaster response.

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