Public Health Impact and Medical Consequences of Earthquakes

Temas de actualidad / Current topics

Worldwide, more than one million earthquakes Public health occur each year, an average of about two every minute (1). Research indicates a 60% probability that impact and medical an earthquake of Richter magnitude 7.5 or greater will occur on the San Andreas fault in southern Cal- consequences ifornia within the next 30 years, and a 50% probability that an earthquake of 7.0 or greater magnitude of earthquakes will occur on the San Andreas or Hayward faults in the San Francisco Bay region within the same time period (2). As previewed by the significant damages M. R. Naghii 1 resulting from the 1989 Loma Prieta earthquake in northern California (magnitude 7.1) and the 1994 Northridge earthquake in southern California (magnitude 6.8), the impact of the predicted higher magnitude earthquakes in California and the central United States could potentially kill and injure thou- sands of people, result in billions of dollars in prop- erty loss, and cause severe disruptions to the United States economy (3). Despite remarkable scientific progress in seismology and earthquake engineering during the past several years, achieving high stan- dards of safety against earthquakes is a goal that has yet to be achieved in many parts of the world. During the past 20 years, earthquakes alone have caused more than a million deaths worldwide (4). Nine countries (Armenia, Chile, China, Guate- mala, Iran, Italy, Japan, Peru, and Turkey) account for more than 80% of all fatalities in this century, and almost half of the total number of earthquake casualties in the world during this period have occurred in China alone (5). Recently, fast urbaniza- tion in other seismically active parts of the world whose population densities reach 20 000 to 60 000 inhabitants per square kilometer makes such areas vulnerable to similarly catastrophic numbers of earthquake-related deaths and injuries. In just the past 10 years, the world has witnessed four catastrophic earthquakes resulting in great loss of life: in Mexico in 1985 (10 000 deaths); in Armenia in 1988 (25 000 deaths); in Iran in 1990 (40 000 deaths); and in India in 1993 (10 000 deaths) (Table 1) (4). The United States has been somewhat fortunate; it has had relatively few earthquake-related casualties so far; only an estimated 1 600 deaths have been attributed to earthquakes since colonial times, with over 60% of these having been recorded in Califor- Key words: earthquake; risk factors; injuries; mor- nia (6). The number of casualties caused by an tality, prevention and control. earthquake will depend on its magnitude, its prox- imity to an urban center, and the degree of earthquake disaster preparedness and mitigation mea- 1 University of Medical Sciences, Tehran, Iran. All correspondence should be sent to this author at: No. 25, Bank Meli Alley, South Mad- sures implemented in the urban center closest to jidieh St., Tehran, Iran. P/C 16336. E-mail: [email protected] where the earthquake takes place.

216 Rev Panam Salud Publica/Pan Am J Public Health 18(3), 2005 Temas de actualidad • Current topics

TABLE 1. Twentieth-century earthquakes that caused more oldest and most widely used is the Richter magni- than 10 000 casualties tude scale, developed by Charles Richter in 1936. Although the scale is open-ended, the strongest a Year Location (Richter magnitude) Deaths earthquake recorded to date has been of Richter 1985 Mexico City, Mexico (8.1 & 7.3) 10 000 magnitude 8.9 (8). 1993 Maharashtra, India (6.4) 10 000 On the other hand, intensity is a measure of 1960 Agadir, Morocco (5.9) 12 000 the felt or perceived effects of an earthquake rather 1968 Dasht-i-Biyaz, Iran (7.3) 12 000 than of the strength of the earthquake itself. It is a 1962 Buyin Zahra, Iran (7.3) 12 000 measure of how severe the tremor was at a particu- 1917 Bali, Indonesia (7.0) 15 000 1978 Tabas, Iran (7.7) 18 000 lar location. Thus, whereas magnitude refers to the 1905 Kangra, India (8.6) 19 000 force of the earthquake as a whole (i.e., an earth- 1948 Ashkabad, USSR (7.3) 19 000 quake can have just one magnitude), intensity refers 1974 Chao-T’Ung, China (6.8) 20 000 to the felt effects of an earthquake at a particular site. 1976 Guatemala City (7.5) 23 000 The intensity is usually strongest close to the epi- 1988 Armenia, USSR (6.9) 25 000 1935 Quetta, Pakistan (7.5) 25 000 center of the earthquake and is weaker as one moves 1923 Concepcion, Chile (8.3) 25 000 away from the epicenter. Intensity is classified on a 1939 Chillan, Chile (8.3) 28 000 scale according to the degree of shaking perceived. 1915 Avezzano, Italy (7.5) 33 000 The intensity in a particular location is determined 1939 Erzincan, Turkey (8.0) 33 000 on the basis of the visible consequences left by the 1990 Manjil, Iran (7.7) 35 000 1927 Tsinghai, China (8.0) 41 000 earthquake, such as the extent of the damage to 1908 Messina, Italy (7.5) 58 000 buildings, monuments, pipelines, railroads, bridges, 1970 Ankash, Peru (8.3) 67 000 etc., and from subjective reports by people who ex- 1923 Kanto, Japan (8.3) 143 000 perience the tremor. The extent of an earthquake is 1920 Kansu, China (8.5) 235 000 more germane to its public health consequences 1976 Tangshan, China (7.8) 243 000 than its magnitude. Intensity scales also allow com- Total: 1 161 000 parison with earthquakes that occurred before the a Rounded off to the nearest thousand. development of seismic monitoring instruments. The destruction that an earthquake causes is a function of its intensity and of the resistance of structures to seismic damage. Four human activities or FACTORS AFFECTING EARTHQUAKE consequences of human activities have been known OCCURRENCE AND SEVERITY to induce earthquakes: (1) the filling of large water impoundments; (2) deep well injection; (3) under- Earthquakes tend to occur in particular zones ground explosions of nuclear devices, and (4) the on the earth’s surface that coincide with the bound- collapse of underground mine workings. Some have aries of the tectonic plates into which the earth’s speculated that nuclear detonation along a fault may crust is divided. As the plates move relative to each release strain in a controlled fashion and prevent a other along the plate boundaries, they tend not to major earthquake, but the potential liability of such slide smoothly but to become interlocked. This in- an experiment gone awry has discouraged even the terlocking causes deformations in the rocks on ei- most intrepid seismic investigators (9). ther side of the plate boundaries, with the result that stresses build up. As the rocks deform on either side of the plate boundary, they store energy in enor- PUBLIC HEALTH IMPACT mous amounts, given the huge volumes of rocks in- AND CLINICAL CONSEQUENCES volved. When the fault ruptures, the energy stored in the rocks is released in a few seconds—partly as In most earthquakes, people are killed by me- heat and partly as shock waves, and it is these chanical energy as a direct result of being crushed waves that constitute the earthquake (7). The resul- by falling building materials. Deaths resulting from tant vibration energy is then transmitted through major earthquakes can be instantaneous, rapid, or the earth and, when it reaches the surface, it may delayed (10). Instantaneous death can be due to se- cause damage to structures and their collapse, vere crushing injuries to the head or chest, exter- which in turn may injure or kill their occupants. nal or internal hemorrhage, or drowning from Magnitude and intensity are two measures of earthquake-induced tidal waves (tsunamis). Rapid the strength of an earthquake that lay people fre- death occurs within minutes or hours and can be quently confuse. The magnitude of an earthquake is due to asphyxia from dust inhalation or chest com- a measure of actual physical energy release at its pression, hypovolemic shock, or environmental ex- source as estimated from instrumental observa- posure (e.g., hypothermia). Delayed death occurs tions. A number of magnitude scales are in use. The within days and can be due to dehydration, hy-

Rev Panam Salud Publica/Pan Am J Public Health 18(3), 2005 217 Temas de actualidad • Current topics pothermia, hyperthermia, crush syndrome, wound putations and chronic sequelae of orthopedic and infections, or postoperative sepsis (11, 12). As with neurologic injuries, especially spinal cord injuries, most natural disasters, the majority of people re- can be expected (21). For example, a rate of 1.5 cases quiring medical assistance following earthquakes of paraplegia per 1 000 persons injured was ob- have minor lacerations and contusions caused by served after the Guatemalan earthquake (22) of 1976, falling elements, like pieces of masonry-roof tiles and more than 2 200 people became paraplegics as a and timber beams (13). The next most frequent rea- result of injuries sustained in the 1976 quake in son for seeking medical attention are simple frac- Tangshan, China (5). Following the Tangshan earth- tures not requiring operative intervention (14). quake, all these chronically disabled people required Such light injuries usually require only outpatient extensive treatment and rehabilitation in long-term- treatment and tend to be much more common than care facilities, resulting in a significantly taxed severe injuries requiring hospitalization. For exam- health care system in the region for years to come. ple, after the 1968 earthquake south of Khorasan, As noted above, trauma caused by the col- Iran, only 368 (3.3%) of 11 254 people injured re- lapse of buildings produces the majority of deaths quired inpatient care (15). A similar pattern of in- and injuries in most earthquakes (4). However, a juries is discussed in reports by Durkin et al., which surprisingly large number of patients require acute indicated that following the 1989 Loma Prieta care for non-surgical problems, such as acute myo- earthquake in California as many as 60% of those cardial infarction, exacerbation of chronic diseases with earthquake-related injuries either treated such as diabetes or hypertension, anxiety and other themselves or received treatment in non-hospital mental health problems such as depression (23, 24), settings (16). These findings suggest that a substan- respiratory injury caused by exposure to dust and tial number of earthquake-related injuries are asbestos fiber from rubble, and near drowning treated outside the formal health care system. caused by flooding from broken dams. An example Major injuries requiring hospitalization in- of the adverse health effects of an earthquake was clude skull fractures with intracranial hemorrhage observed in 1981 after a magnitude 6.7 earthquake (e.g., subdural hematoma); cervical spine injuries in Athens, Greece. A 50% increase in deaths due to with neurologic impairment; and damage to in- myocardial infarction was documented during the trathoracic, intraabdominal, and intrapelvic organs, first three days after the earthquake, with the death including pneumothorax, liver lacerations, and rup- rate peaking on the third day (25, 26). There may be tured spleen. Most seriously injured people will sus- a plausible biological mechanism for increased risk tain combination injuries, such as pneumothorax in of cardiac problems after a natural disaster: emo- addition to an extremity fracture. More detailed in- tional stress and physical activity cause increased patient information is available from data collected levels of catecholamines, vasoconstriction, and in- on 4 832 patients admitted to hospitals following the creased coagulability of the blood (27). If stress has 1988 earthquake in Armenia. Consistent with find- such an acute physiological effect, then the propor- ings from other major earthquakes, these data show tion of sudden deaths might be expected to in- that combination injuries constituted 39.7% of the crease. On September 19, 1985, the date of a strong cases. Superficial trauma such as lacerations and Mexico City earthquake, the number of abortions, contusions were the injuries most frequently ob- premature births, and normal deliveries in chronic served (24.9%), followed by head injuries (22%), care facilities rose and together constituted the pri- lower extremity injuries (19%), crush syndrome mary cause of all admissions seen on that day (14, (11%), and upper extremity trauma (10%) (17). Hy- 28). Even more admissions for these causes oc- pothermia, secondary wound infections, gangrene curred four days later, again probably because of requiring amputation, sepsis, adult respiratory dis- the effects of stress related to the disaster (28). tress syndrome (ARDS), multiple organ failure, and Huge amounts of dust are generated when a crush syndrome have been identified as major med- building is damaged or collapses, and dust clogging ical complications in past earthquakes. Crush syn- the air passages and filling the lungs is a major cause drome results from prolonged pressure on limbs of death for many building-collapse victims (5, 29, causing disintegration of muscle tissue (rhabdomy- 30). Fulminant pulmonary edema from dust inhala- olysis) and release of myoglobin, potassium, and tion may also be a delayed cause of death (31). Dust phosphate into the circulation (18). Systemic effects has hampered rescue and clean-up operations by include hypovolemic shock, hyperkalemia, renal causing eye and respiratory-tract irritation. Burns failure, and fatal cardiac arrhythmias. Patients with and smoke inhalation from fires used to be major crush syndrome may develop kidney failure and re- hazards after an earthquake. For example, follow- quire dialysis (19). Following the 1988 earthquake in ing the 1923 earthquake in Tokyo, Japan, more than Armenia, more than 1 000 victims trapped in col- 140 000 people perished, principally because of fires lapsed buildings developed crush syndrome as a re- that broke out in a city where most buildings were sult of limb compression; 323 developed secondary constructed from highly flammable paper (shoji) and acute renal failure requiring renal dialysis (20). Am- wood material. Since 1950, however, the incidence of

218 Rev Panam Salud Publica/Pan Am J Public Health 18(3), 2005 Temas de actualidad • Current topics burns in the aftermath of earthquakes has decreased probability of finding live victims diminishes very considerably (4) largely because of engineering inter- rapidly with time, entrapped people have survived ventions, improved standard construction practices, for many days. People have been rescued alive 5, 10, and the use of safer building materials. and even 14 days after an earthquake (35), and these Most earthquakes are followed by many af- “miracle rescues” are often the result of exceptional tershocks, some of which may be as strong as the circumstances. For example, someone with very main shock itself. Many fatalities and serious in- light injuries could be trapped in a void deep in the juries occurred from a strong aftershock that fol- rubble with air and possibly water available. lowed two days after the 1985 Mexico City earthquake that killed an estimated 10 000 people (28). In some cases landslides may be triggered by an after- PREVENTION AND CONTROL MEASURES shock, after having been primed by the main shock. Some major debris flows start slowly with a minor Prevention and control efforts need to be mul- trickle and then are triggered in waves. In these tidisciplinary and should include public education cases there may be sufficient warning to allow a programs, as well as better building design and im- community that is aware of this hazard to evacuate proved quality of construction in those areas most in time. Local weather conditions, which are known likely to suffer an earthquake (36). The problem of to affect survival time among people trapped in col- “earthquake casualties” involves questions of seis- lapsed buildings after an earthquake, have a major mology, with careful delineation of areas having a influence on the percentage of those injured who high seismic risk; the engineering of the built envi- subsequently die before they can be rescued. ronment; the nature of both the physical and the so- Our modern industrial cities are laden with ciological environments; aspects of personal and chemical and petroleum products that could con- group psychology and behavior; short- and long- tribute substantially to the generation of toxic sub- term economic issues, as well as many planning and stances following an earthquake (32). Industrial preparedness aspects. Public-health and disaster- storage facilities for hazardous materials might ex- response officials need to work together in the effort plode or leak, and damage to a nuclear power plant to develop and maintain effective seismic safety could lead to widespread contamination by radio- planning and earthquake mitigation programs (37). active materials. In a major earthquake, pipelines Avoiding unnecessary residential and com- carrying natural gas, water, and sewage can be ex- mercial construction on or near active faults and in pected to be disrupted. Following the Loma Prieta areas subject to tsunamis or landslide slope failures, earthquake, about 20% of post-earthquake injuries soil liquefaction, and rock falls is technically a sec- were caused by toxic materials (16). Thus, rescue ondary prevention measure for earthquakes, but it personnel must constantly observe all safety pre- is a primary prevention measure for earthquake- cautions to protect themselves from injury (33). related injuries (38). Disaster response to earth- In earthquakes, people over 60 years of age quakes is more akin to medical treatment than to are at increased risk for death and injury and can prevention, but some aspects of the response may have a death rate five times higher than that of the be likened to tertiary prevention in that those re- rest of the population. Children between 5 and 9 sponding seek to limit further injury and to con- years of age, women, and the chronically ill also trol the secondary effects of the earthquake (36). seem to be at an elevated risk for injury and death Prompt rescue should improve the outcome of vic- (34). Lack of mobility to flee collapsing structures, tims, and early medical treatment should lessen the inability to withstand trauma, and exacerbation of sequelae of the primary injuries (e.g., wound com- underlying disease are factors that may contribute plications, chronic neurological disabilities). Provi- to the vulnerability of these groups. Mortality dis- sion of adequate food, water, and shelter should es- tribution by age will also be affected to a certain de- pecially help people in vulnerable age groups and gree by the social attitudes and habits of different those with pre-existing diseases. Effective environ- communities. For example, in some societies young mental control measures should prevent secondary children sleep close to their mothers and may be environmental health problems, such as gas leaks, more easily protected by them. As might be ex- fallen or loose wires, damaged appliances and pipe- pected, entrapment appears to be the single most lines, sewage backup, and water contamination. significant factor associated with death or injury. In Identification and control of long-term hazards (e.g., the 1988 Armenia earthquake, death rates were 67 asbestos in rubble) should reduce chronic health ef- times higher and injury rates more than 11 times fects. Because rapid rescue of trapped victims and higher for people who were trapped than for those prompt treatment of those with life-threatening in- who were not. In general, the morbidity and mor- juries can improve their outcome, early rapid as- tality rates are significantly greater among people sessment of the extent of damage and injuries is who are indoors than among those who are out- needed to help mobilize resources and direct them doors when the tremor begins (29). Although the to where they are most needed (39). Unfortunately,

Rev Panam Salud Publica/Pan Am J Public Health 18(3), 2005 219 Temas de actualidad • Current topics the very factors likely to cause large numbers of in- tained from different disciplines should be inte- juries are also likely to disrupt communications and grated. Most earthquake casualty studies have transportation and to damage medical-care facili- addressed the problem from the point of view of ties. Public health officials need to establish in ad- a single discipline, either that of engineers or that vance how the affected areas will be surveyed. Just of health researchers. This lack of active collabora- as speed is required for effective search and extri- tion between workers from different disciplines cation, it is also essential for effective emergency has been a major shortcoming of past research into medical services, since the greatest demand occurs the health effects of disasters. Successful epidemi- within the first 24 hours (29). ologic studies will require close interdisciplinary Unconscious patients with either upper air- collaboration among structural engineers, physi- way obstruction or inhalation injury or any patients cians, and epidemiologists. Again, it is important with correctable hypovolemia resulting from hem- to recognize that earthquakes will recur and that orrhage or burns would be especially likely to ben- lessons learned during the surveillance effort fol- efit from early medical intervention. Safar, studying lowing a particular earthquake can help save lives the 1980 earthquake in southern Italy, concluded during subsequent earthquakes. that 25% to 50% of victims who were injured and died slowly could have been saved if life-saving first aid had been rendered immediately (40). In- jured people usually sought emergency medical SINOPSIS attention only during the first three to five days following the earthquake, after which hospital case- Impacto sanitario y consecuencias médicas mix patterns returned almost to normal. From the de los terremotos sixth day onward, the need for emergency medical Un terremoto de gran magnitud en una zona urbana es uno attention declined rapidly and the majority of the de los peores desastres naturales que pueden ocurrir en ciertas wounded required only ambulatory medical atten- partes del mundo. La mayor parte de las medidas aplicables tion, so that specialized field hospitals arriving one para mitigar los traumatismos tienen que implantarse antes week or more after an earthquake are generally too de que el desastre ocurra. Los investigadores han identificado late to help during the emergency phase. algunos factores de riesgo importantes en relación con las he- The medical and public health impacts of a se- ridas que se asocian, de un modo directo o indirecto, con los vere earthquake may well be compounded by sig- terremotos. Como el colapso estructural es el factor de riesgo nificant damage to medical facilities, hospitals, clin- individual más importante, la seguridad antisísmica debe ocu- ics, and supply stores within the affected area (41). par un lugar priotario en el uso del terreno y en el diseño y construcción de edificios seguros. In the worst-case scenario, a hospital building may Para poder entender mejor los tipos de traumatismos oca- itself be damaged by the earthquake, and the hos- sionados por los terremotos, es indispensable que se integren pital staff may have to continue emergency treat- los estudios epidemiológicos con los de otras disciplinas, tales ment without using the buildings (42). Hospital como la ingeniería, la arquitectura, las ciencias sociales y la emergency plans in earthquake areas should pro- medicina. Es esencial, además, tener un mejor conocimiento vide for the contingency of evacuating patients epidemiológico de los factores de riesgo de morir o de sufrir from the wards; safely removing critical equipment distintos tipos de heridas y enfermedades como consecuencia from operating theaters, radiology departments, de los terremotos a fin de poder determinar qué materiales, and other parts of the hospital; and re-establishing instrumental y personal se necesitan para responder de ma- routine patient-care services (43). nera eficaz. En zonas propensas a los desastres, el adiestra- miento y la educación en primerios auxilios y métodos de res- cate debe ser parte integral de todo programa comunitario de respuesta a emergencias y desastres. Lamentablemente, entre CONCLUSION terremotos de gran magnitud transcurren períodos relativa- mente largos, con el resultado de que las autoridades sanita- Few earthquakes have been adequately stud- rias se enfrentan al reto especial de tener que comunicarle efi- ied epidemiologically. Thus, it is vital that plans for cazmente al público los peligros planteados por los terremotos follow-up epidemiologic study be developed be- y la necesidad de planificar acciones y emprenderlas antes de fore an earthquake occurs so that initial surveil- que ocurra el siniestro. lance data collected will allow proper follow-up Pese a los grandes adelantos científicos que se han produ- (44). Disaster-response officials must be convinced cido en seismología e ingeniería antisísmica en años recientes, lograr que se adopten normas estrictas de seguridad antisís- to invest time and resources in the initial surveil- mica es una meta que aún no se ha alcanzado en muchas par- lance effort, even though their attention is likely tes del mundo. to be focused on emergency medical services and disaster relief. Without this investment, the oppor- Palabras clave: Terremoto, factores de riesgo, trauma- tunity to learn many lessons useful for future tismos,mortalidad, prevención y control earthquakes may be lost (45, 46). Knowledge ob-

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