Community Needs Assessment and Morbidity Surveillance Following an Ice Storm -- Maine, January 1998

On January 7, 1998, an ice storm struck the northeastern United States and southeastern Canada. In Maine, 3 consecutive days of rain combined with ground temperatures consistently below freezing resulted in heavy accumulations of ice on trees and electric power lines. Falling trees and branches and breaking utility poles resulted in the loss of electrical power to an estimated 600,000 persons. Although the rain had stopped by January 11, temperatures declined to less than 10 F (less than -12 C) over most of the state, exacerbating the danger. On January 16, an estimated 50,000 households, primarily in the interior portion of the state, remained without power. This report summarizes a community needs assessment and a study of emergency department (ED) visits conducted during the aftermath of this storm.

Community Needs Assessment

The Maine Bureau of Health (MBH) and CDC developed a community needs survey to assess the continuing needs of and potential health hazards to residents of the state who remained without power. This assessment was conducted on January 17 in the minor civil division of Norway (1995 population: 4738), which was chosen because 1) it was in the interior region of the state, which received the greatest damage to electrical supply lines; 2) it reportedly contained many homes that remained without power; and 3) it contained a representative mixture of town and rural residential tracts. Maps with 1990 census data were used to randomly select 30 census tracts from the 285 within Norway, with the probability of a tract being selected proportional to the number of residential structures contained within it. Road segments were then mapped to the selected census tracts. These segments were assigned to survey teams who attempted to interview residents from four households residing within each of 30 selected census tracts; some teams were unable to contact four households within their census tract.

On January 17, residents from 111 households were interviewed. Electrical power had been restored to 75 (68%) of these households, 20 (18%) were using gasoline-powered generators to supply electricity, and 16 (14%) had no source of electricity. All but one of the surveyed households without restored power were in rural tracts. In all households, drinking water was available from municipal service, private wells, or water-distribution points. All but one of the 111 households had water to flush toilets and access to transportation. Telephone service remained unrestored in 14 (13%) homes. Residents were listening to a radio or television in 103 (93%) households and, therefore, had access to public service broadcasts.

An average of three persons resided in each surveyed household (range: one to nine persons). Of these, 3% were aged less than 2 years, and 15% were aged greater than or equal to 65 years. In homes without any source of electricity, 15% of residents were aged greater than or equal to 65 years, and none were aged less than 2 years. The following number of households had at least one resident who had experienced the following adverse health events since the ice storm: vomiting or diarrhea (nine {8%}), cough with fever (five {5%}), severe headache with dizziness (four {4%}), burns (four {4%}), severe cuts (two {2%}), and fractures (one {1%}).

Potentially hazardous sources of carbon monoxide (CO) were present in many homes. Among the 36 households without restored electrical power, eight (22%) used a propane heater, and five (14%) used a kerosene heater. Where a gasoline generator was used for electricity, four (20%) households placed it in an open porch or garage and three (15%) households placed it in an enclosed porch or garage. All other generators were placed outside the residential structure. Of households without restored electrical power, three (8%) reported having a working CO detector.

Morbidity Surveillance

To determine the early health impact of the ice storm, MBH and CDC surveyed the EDs of Stephens Memorial Hospital in Norway and Central Maine Medical Center and St. Mary's Regional Medical Center in Lewiston. These EDs were selected because they were in the region of the state most heavily affected by the storm. ED logs were reviewed for January 7- January 18, 1998 (January 17 at St. Mary's). This review also was conducted for January 8-January 19, 1997 (January 18 at St. Mary's), to provide a reference. On the basis of early reports and previous disaster experience, 14 diagnostic categories were selected for tabulation.

The three EDs treated 1758 patients during the 1997 reference period and 2586 during the post-storm period, a 47% increase. The absolute number of visits for each selected diagnostic category and the proportion of the total visits represented by each category were compared between periods (Table_1). Presumptive CO poisonings increased from zero to 101 cases. Most of the injury categories showed absolute increases, but proportional increases occurred only with cold exposure (0-0.3%) and burns (0.4%-0.7%). Visits for lower respiratory tract disease (6.3%-7.4%), and cardiac complaints (4.2%-4.6%) were also proportionally higher during the post-storm period.

The results of these two surveys were reported to MBH. Recommendations included continuation of public education about the hazards of CO and further study into the immediate health effects of the ice storm and subsequent power outage. Community outreach activities by local fire departments, which included CO monitoring, were continued in Norway and other areas of the state. CO warnings also were broadcast over the radio. An investigation into the factors involved with the epidemic of CO poisoning began immediately following the survey. Post-storm surveillance, using final physician diagnosis, has been instituted over a wider geographic area to provide more precise estimates of the storm's health impact.

Reported by: D Holt, Town Office, Norway; J Even, Stephens Memorial Hospital, Norway; WW Young, Jr, PE Chalke, D Stuchner, MD, L Covey, S King, MA Johnson, M Twomey, Central Maine Medical Center; S Steinkeler, MD, P Pelletier, P Boucher, St. Mary's Regional Medical Center, Lewiston; D Mills, MD, G Becket, A Hawkes, MD, D Shields, N Sonnenfeld, PhD, R Wolman, MD, A Smith, ScD, L Crinion, C Sloat, J Sherman, P Pabst, M Bouchard, J Matthews, J Hardacker, D Smith, A Drake, K Gensheimer, MD, State Epidemiologist, Bur of Health, Maine Dept of Human Svcs. Environmental Hazards Epidemiology Section, Health Studies Br, Div of Environmental Hazards and Health Effects, National Center for Environmental Health; Div of Field Epidemiology, Epidemiology Program Office; and EIS officers, CDC.

Editorial Note

Editorial Note: The community needs assessment used in this investigation was a modification of the rapid needs assessment technique (1,2), a methodology that was successfully employed after recent hurricanes (3-5) to guide emergency response efforts. This investigation was the first to use U.S. Census data to guide the assessment. The findings in this report demonstrate that, even after an extended period without power, most residents were able to meet their basic needs for water, food, warmth, and sanitation.

Absolute increases in the number of adverse health events reported from EDs after a disaster must be interpreted with caution. Temporary shifting of patients to hospital-based EDs can occur as independent practitioners encounter difficulties resuming normal operations. Therefore, absolute and proportional changes in reported events should be considered when evaluating this data. Most physician's offices in the interior region of Maine lost power. However, because normal operations resumed relatively rapidly, provider shifting probably occurred less than would be expected after a flood or hurricane.

The findings of this report indicated that CO exposures and poisonings were the most dramatic health concerns in the early aftermath of the ice storm. Although the use of ED logs is an imprecise method of categorizing many diseases, this survey provided timely information that was useful in efforts to quickly focus the public health response. Both the surveillance and community assessment results prompted the state to continue warnings about CO hazards and to investigate the factors involved in instances of CO poisonings.

CO toxicity has been documented as a health concern following winter storms, especially during power outages (6-8). Many of the same mechanisms observed in previous outbreaks of CO poisoning (e.g., improper use of gasoline generators and fuel-powered heaters) may have played a role in Maine. Review of carboxyhemoglobin levels among reported cases and further investigation of the sources of exposure will be needed to completely characterize the Maine outbreak.

Timely, valid information is important in formulating an effective public health response in the aftermath of any disaster. Rapid needs assessment and emergency medical surveillance remain key tools in providing the early estimates needed to guide response efforts. Continued refinements in the methodology of these investigations and dissemination to the local level of the tools and expertise necessary to perform them will contribute to the rapid collection of important information.

References

1. Malilay J, Flanders WD, Brogan D. A modified cluster-sampling method for post-disaster rapid assessment of needs. Bull World Health Organ 1996;74:399-405.

2. Lillibridge SR, Noji EK, Burkle FM Jr. Disaster assessment: the emergency health evaluation of a population affected by a disaster. Ann Emerg Med 1993;22:1715-20.

3. CDC. Rapid health needs assessment following Hurricane Andrew -- Florida and Louisiana, 1992. MMWR 1992;41:685-8.

4. Hlady WG, Quenemoen LE, Armenia-Cope RR, et al. Use of a modified cluster sampling method to perform rapid needs assessment after Hurricane Andrew. Ann Emerg Med 1994;23:719-25.

5. CDC. Surveillance for injuries and illnesses and rapid health-needs assessment following hurricanes Marilyn and Opal, September-October 1995. MMWR 1996;45:81-5.

6. Wrenn K, Conners GP. Carbon monoxide poisoning during ice storms: a tale of two cities. J Emerg Med 1997;15:465-7.

7. CDC. Unintentional carbon monoxide poisoning following a winter storm

• Washington, January 1993. MMWR 1993;42:109-11.

TABLE 1. Number and percentage of emergency department diagnoses of conditions
of patients reported from three hospitals during reference and post-storm periods, by
diagnostic category -- Maine, 1997 and 1998
==============================================================================================
                                           Reference period *     Post-storm period +
                                           ------------------     -------------------
Diagnostic category                          No.       (%)            No.     (%)
-------------------------------------------------------------------------------------
Injury/Environmental exposure
  Fracture/Dislocation (noncranial)           93      ( 5.3)          110    ( 4.3)
  Cranial/Intracranial injury                 23      ( 1.3)           26    ( 1.0)
  Eye injury                                  18      ( 1.0)           19    ( 0.7)
  Laceration/Puncture                        134      ( 7.6)          134    ( 5.2)
  Musculoskeletal injury                     288      (16.4)          328    (12.7)
   (nonfracture)
  Carbon monoxide poisoning                    0      ( 0  )          101    ( 3.9)
  Cold exposure                                0      ( 0  )            8    ( 0.3)
  Electrical exposure                          0      ( 0  )            0    ( 0  )
  Burn                                         7      ( 0.4)           17    ( 0.7)

Illness
  Lower respiratory tract                    110      ( 6.3)          191    ( 7.4)
  Cardiac                                     73      ( 4.2)          118    ( 4.6)
  Acute gastrointestinal                      76      ( 4.3)          107    ( 4.1)
  Alcohol/Substance abuse                     27      ( 1.5)           42    ( 1.6)
  Mental health                               39      ( 2.2)           40    ( 1.5)

Total                                       1758                     2586
-------------------------------------------------------------------------------------
* January 8-19, 1997 (Central Maine Medical Center, Stephens Memorial Hospital), and January
  8-18, 1997 (St. Mary”s Regional Medical Center).
+ January 7-18, 1998 (Central Maine Medical Center, Stephens Memorial Hospital), and January
  7-17, 1998 (St. Mary”s Regional Medical Center).
==============================================================================================

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