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1.  Heat Stress Illness Emergency Department Visits in National Environmental Public Health Tracking States, 2005–2010 
Journal of community health  2016;41(1):57-69.
Variability of heat stress illness (HSI) by urbanicity and climate region has rarely been considered in previous HSI studies. We investigated temporal and geographic trends in HSI emergency department (ED) visits in CDC Environmental Public Health Tracking Network (Tracking) states for 2005–2010. We obtained county-level HSI ED visit data for 14 Tracking states. We used the National Center for Health Statistics Urban-Rural Classification Scheme to categorize counties by urbanicity as 1) large central metropolitan (LCM), 2) large fringe metropolitan (LFM), 3) small–medium metropolitan (SMM), or 4) nonmetropolitan (NM). We also assigned counties to one of six US climate regions. Negative binomial regression was used to examine trends in HSI ED visits over time across all counties and by urbanicity for each climate region, adjusting for pertinent variables. During 2005–2010, there were 98,462 HSI ED visits in the 14 states. ED visits for HSI decreased 3.0 % (p < 0.01) per year. Age-adjusted incidence rates of HSI ED visits increased from most urban to most rural. Overall, ED visits were significantly higher for NM areas (IRR = 1.41, p < 0.01) than for LCM areas. The same pattern was observed in all six climate regions; compared with LCM, NM areas had from 14 % to 90 % more ED visits for HSI. These findings of significantly increased HSI ED visit rates in more rural settings suggest a need to consider HSI ED visit variability by county urbanicity and climate region when designing and implementing local HSI preventive measures and interventions.
PMCID: PMC4715715  PMID: 26205070
Heat illness; Emergency department; Urbanization; Metropolitan; Nonmetropolitan; Time trend
2.  Exertional Heat-Related Illnesses at the Grand Canyon National Park, 2004–2009 
The Grand Canyon National Park has approximately 4 million visitors between April and September each year. During this period, outdoor activity such as hiking is potentially hazardous owing to extreme heat, limited shade, and steep, long ascents. Given the high visitation and the public health interest in the effects of extreme heat, this study calculated morbidity rates and described heat-related illness (HRI) among visitors.
We conducted a retrospective cross-sectional study from April 1 through September 30, during 2004–2009. From a review of Ranger Emergency Medical Services (EMS) incident report files, we extracted information on those that met the case definition of greater than 1 hour of outdoor heat exposure with an HRI assessment or diagnosis, HRI self-report, or signs or symptoms of HRI without another etiology noted. Visitor and temperature data were obtained from respective official sources.
Grand Canyon EMS responded to 474 nonfatal and 6 fatal HRI cases, with the majority (84%) being US residents, 29% from Western states. Of the nonfatal cases, 51% were women, the median age was 43 years (range, 11–83 years), and 18% reported a cardiovascular condition. Clinical HRI assessments included dehydration (25%), heat exhaustion (23%), and suspected hyponatremia (19%). Almost all (90%) were hiking; 40% required helicopter evacuation. The highest HRI rates were seen in May.
HRI remains a public health concern at the Grand Canyon. High-risk evacuations and life-threatening conditions were found. Majority were hikers, middle-aged adults, and US residents. These findings support the park’s hiker HRI prevention efforts and use of park EMS data to measure HRI.
PMCID: PMC4910089  PMID: 24119571
heat illness; hiking; National Park; Grand Canyon; wilderness; emergency medical services
3.  Public Health Needs Assessments of Tutuila Island, American Samoa, After the 2009 Tsunami 
An 8.3 magnitude earthquake followed by tsunami waves devastated American Samoa on September 29, 2009, resulting in widespread loss of property and public services. An initial and a follow-up Community Needs Assessment for Public Health Emergency Response (CASPER) objectively quantified disaster-affected population needs.
Using a 2-stage cluster sampling method of CASPER, a household questionnaire eliciting information about medical and basic needs, illnesses, and injuries was administered. To assess response efforts, percent changes in basic and medical needs, illnesses, and injuries between the initial and follow-up CASPER were calculated.
During the initial CASPER (N=212 households), 47.6% and 51.6% of households reported needing a tarpaulin and having no electricity, respectively. The self-reported greatest needs were water (27.8%) and financial help with cleanup (25.5%). The follow-up CASPER (N=207 households) identified increased vector problems compared to pre-tsunami, and food (26%) was identified as the self-reported greatest need. As compared to the initial CASPER, the follow-up CASPER observed decreases in electricity (−78.3%), drinking water (−44.4%), and clothing (−26.6%).
This study highlights the use of CASPER during the response and recovery phases following a disaster. The initial CASPER identified basic needs immediately after the earthquake, whereas the follow-up CASPER assessed effectiveness of relief efforts and identified ongoing community needs.
PMCID: PMC4544763  PMID: 23077263
community assessment; disaster; tsunami response; public health assessment; rapid needs assessment
4.  Evaluation of Active Mortality Surveillance System Data for Monitoring Hurricane-Related Deaths—Texas, 2008 
Prehospital and disaster medicine  2012;27(4):392-397.
The Texas Department of State Health Services (DSHS) implemented an active mortality surveillance system to enumerate and characterize hurricane-related deaths during Hurricane Ike in 2008. This surveillance system used established guidelines and case definitions to categorize deaths as directly, indirectly, and possibly related to Hurricane Ike.
The objective of this study was to evaluate Texas DSHS’ active mortality surveillance system using US Centers for Disease Control and Prevention’s (CDC) surveillance system evaluation guidelines.
Using CDC’s Updated Guidelines for Surveillance System Evaluation, the active mortality surveillance system of the Texas DSHS was evaluated. Data from the active mortality surveillance system were compared with Texas vital statistics data for the same time period to estimate the completeness of reported disaster-related deaths.
From September 8 through October 13, 2008, medical examiners (MEs) and Justices of the Peace (JPs) in 44 affected counties reported deaths daily by using a one-page, standardized mortality form. The active mortality surveillance system identified 74 hurricane-related deaths, whereas a review of vital statistics data revealed only four deaths that were hurricane-related. The average time of reporting a death by active mortality surveillance and vital statistics was 14 days and 16 days, respectively.
Texas’s active mortality surveillance system successfully identified hurricane-related deaths. Evaluation of the active mortality surveillance system suggested that it is necessary to collect detailed and representative mortality data during a hurricane because vital statistics do not capture sufficient information to identify whether deaths are hurricane-related. The results from this evaluation will help improve active mortality surveillance during hurricanes which, in turn, will enhance preparedness and response plans and identify public health interventions to reduce future hurricane-related mortality rates.
PMCID: PMC4541770  PMID: 22800916
hurricane; public health surveillance; surveillance evaluation; disaster-related mortality; natural disaster
5.  Post-disaster Surveillance among State Health Departments in the United States 
PMCID: PMC4050838
Surveillance; Disaster; Disaster epidemiology
6.  The Associations between Area of Residence, Sexual Violence Victimization, and Asthma Episodes among US Adult Women in 14 States and Territories, 2005–2007 
Gaps in understanding of how area-based differences in exposure to violence are associated with asthma prevalence may limit the development of effective prevention programs and the identification of risk for asthma episodes. The current investigation examines the associations between sexual violence victimization and asthma episodes among US adult women across three different metropolitan settings. The association between sexual assault victimizations and asthma attacks in the past year was examined using data from the 2005, 2006, and 2007 Behavioral Risk Factor Surveillance System surveys. Cross-sectional analyses were based on adult women with current asthma (n = 4,099). Multivariate logistic regression models were used to identify associations between four categories of sexual violence victimization and asthma episodes across three categories of metropolitan and non-metropolitan settings. Our findings show that unwanted touching, attempted unwanted intercourse, forced unwanted intercourse, and any sexual violence victimization (touching, attempted intercourse, or forced intercourse) were significantly associated with asthma episodes (ORadj. = 3.67, 95% CI, 1.76–7.69; ORadj. = 1.77, 95% CI, 1.32–2.37; ORadj. = 2.24, 95% CI, 1.64–3.05, and ORadj. = 1.93, 95% CI, 1.47–2.53, respectively). While no significant differences in the associations between asthma episodes and metropolitan status were found, a significant interaction between non-metropolitan areas and attempted sexual intercourse was identified (ORadj = 0.53, 95% CI, 0.29–0.96). Sexual victimization appears to be an important, but understudied, correlate of asthma morbidity among adult women in the USA, suggesting that additional research is needed to better understand the associations between sexual violence, psychological distress, and asthma.
PMCID: PMC2648886  PMID: 19096937
Metropolitan; Sexual violence; Asthma; Prevention

Results 1-6 (6)