Since the beginning of the DANA last Tuesday, October 29, which mainly affected the region of Valencia, more than 200 people have died and dozens are still missing due to severe flooding. In a few hours, the equivalent of a year's worth of rain fell in some areas, causing large floods that swept away entire towns, trapping thousands of people.
This type of environmental disaster can have short- and long-term cascading effects on physical and mental health, and can indirectly affect health and well-being as a result of evacuation, social disruption, financial loss, change in lifestyle, damage to health care facilities, and changes in the broader political and socioeconomic context.
Cascading disasters can be defined as extreme events, where the effects increase in progression over time and generate unexpected secondary events that have a strong impact and tend to contribute substantially to the overall duration of the disaster. A key element is that they have an escalation point, a junction in a chain of reactions that leads to greater effects than the initial disaster would have had.
Cascading disasters are extreme events, in which the cascading effects increase in progression over time and generate unexpected secondary events of strong impact.
The disaster management cycle establishes four stages: prevention, preparedness, response and recovery.
The response phase, in which there is still a certain degree of overlap with the recovery phase, concerns the actions to be taken during the emergency and includes the preferential use of human resources and technical means, the rapid assessment of needs to enable the notification of the specific aid required. It should aim to ensure the functioning of vital systems (drinking water, energy, communications, etc.) and to coordinate external aid, which should in any case be designed to serve as a link with post-disaster activities.
Moreover, at this stage, in terms of public health, the health objectives of disaster management should be to prevent and reduce mortality; care for victims and prevent after-effects; prevent indirect health-related effects; prevent morbidity in the short, medium and long term; and reestablish basic health services.
What is done in public health
The public health response to a disaster has to be tailored to the specific hazards depending on their causes and the specific situation. The United Nations Office for Disaster Risk Reduction defines a disaster as a serious disruption of the functioning of a community or a society on any scale due to hazardous events interacting with conditions of exposure, vulnerability and capacity, leading to one or more of the following: human, material, economic and environmental losses and impacts.
The Spanish Society of Public Health and Health Administration (SESPAS) has prepared two documents in which it shares the recommendations of the Ministry of Health and the surveillance protocol for the early detection of cases of infection associated with the floods caused by the DANA in the Valencian Community. These are a series of recommendations for the consequences for public health after a natural disaster such as the one that occurred, which are varied and may appear in the short and medium term. They contain some basic general measures and other specific ones in relation to dead bodies, water and food, cleaning and disinfection, waste management, prevention of carbon monoxide poisoning (CO) and coordination of volunteer health personnel who offer to collaborate.
Some infectious diseases that may be favored by flooding are: leptospirosis, hepatitis A, tetanus, gastroenteritis and gastrointestinal infections or mosquito-borne diseases.
Likewise, SESPAS highlights the urgency of setting up the State Public Health Agency, an entity that will improve coordination between public health administrations, the sharing and analysis of socio-health information, the communication of this information to professionals and citizens and the evaluation of the health impact of the programs implemented.
One of the most serious dangers in an emergency situation such as the current one is the risk of epidemics and poisoning due to the contamination of drinking water. Flood waters and mud pose a serious health risk because, when in contact with garbage and animal carcasses, they create the ideal breeding ground for microorganisms. Specifically, some of the infectious diseases that can be favored by flooding are: leptospirosis, hepatitis A, tetanus, gastroenteritis and gastrointestinal infections or diseases transmitted by vectors, especially mosquitoes.
Risks from contaminated water
Spain has a very powerful public health and prevention system that allows the control of many diseases, such as those that are waterborne. However, in a circumstance like this, in which sanitation systems and access to drinking water have been affected, there may be a risk of infection associated with the ingestion of contaminated water or food, such as those caused by pathogens like E. coli, Salmonella or Shigella, which can cause gastroenteritis of greater or lesser severity. Therefore, it is very important to maintain and recover as soon as possible the supply of clean and safe water for drinking, cooking, washing, as well as electricity and food supply, in addition to soap and other basic cleaning products.
Therefore, in addition to informing the population about hygiene measures to be implemented during and after the flood, it is important to involve health professionals who have experience in the prevention of epidemics and risks related to water contaminated by pathogenic microbes.
Mental health
Another major challenge to be addressed during an environmental catastrophe such as the TLD is that of mental health, both of those affected and of the health workers themselves. In the case of people directly affected by the tragedy, such as those who have lost people in their environment or material belongings, there is a risk that in some cases the trauma may result in long-term psychological suffering. In particular, depression and post-traumatic stress disorder are the two main disorders from which survivors may suffer. Early intervention by psychologists specialized in emergencies is essential for the emotional recovery of those affected and to prevent long-term psychological problems.
Post-traumatic stress will affect three groups: those who have seen dead bodies, those who feel intense guilt for having survived or for not having been able to help more, and those who were previously in treatment or had experienced similar situations.
It is estimated that 20-25% of the population of the destroyed ground zero will suffer different forms of post-traumatic stress. A community approach minimizes the impact by proactively meeting the needs of each affected person. Above all, it will affect three groups: those who have seen dead bodies, those who feel intense guilt for having survived or for not having been able to help more, and those who were previously in treatment or had experienced similar situations, such as the 1957 floods. In these three groups, the probability of suffering post-traumatic stress rises to 70 to 80%.
Vaccines, pharmacies and chronically ill patients
Regarding vaccination, a mass vaccination campaign is not considered necessary at this time. The availability of vaccines in health centers has been reinforced, especially those that could be necessary in the event of an increase in demand (tetanus, diphtheria) or possible outbreaks (hepatitis A), systematic vaccination and seasonal vaccination campaigns (influenza, covid-19, RSV in children) are also being maintained, and health professionals are recommended to check the vaccination status of the people who come for consultation, taking every opportunity to complete the vaccination schedule.
We cannot forget that the DANA also affected more than a hundred pharmacy offices in the most devastated areas. One week later, 56 of them had not recovered their activity, according to the monitoring being done by the College of Pharmacists of Valencia, which ensures that the supply is guaranteed for the entire population and that, in the event that the establishment is far away or there are no means to reach it, a service has been provided with volunteers and ambulances; or a collection point for drugs in operational health centers.
In most cases, cancer treatments can be delayed for a few days without jeopardizing their efficacy.
There is also concern for chronic patients whose treatments may have been interrupted. The Spanish Society of Medical Oncology (SEOM) has sent a message of reassurance in this respect, since in most cases treatments can be delayed for a few days without jeopardizing their efficacy, and has asked that no trips be made for this reason that could endanger the integrity of the patients.
The destruction of communication and transport infrastructures also hinders the distribution of food, cleaning products and medicines. It is important to recover these supplies as soon as possible. However, there are infrastructures that have been badly damaged and the return to normality may take a long time.
Coordinated health groups for each health challenge
In relation to addressing the consequences of the consequences of the DANA, a coordinated response health group has been created by the Ministry of Health and the Generalitat Valenciana. Its objective is to work in a joint, coordinated and consensual manner to assess and address risks to public health. This group, called the Coordination Group for the Public Health Response to the Floods Caused by the DANA, is coordinated from the Coordination Center for Health Alerts and Emergencies (CCAES) of the Ministry of Health, together with the General Directorate of Public Health of the Generalitat Valenciana, which meets twice daily, and has generated five specific working subgroups: Vector-Related Risks and Control Measures subgroup, Epidemiological Surveillance subgroup, Measures in Relation to Immunopreventable Diseases subgroup, Epidemiological Surveillance subgroup and, finally, the Environmental Health subgroup.
All countries need clear policies, strategies and programs aimed at minimizing health risks and their health consequences.
Finally, managing the risk of such public health disasters requires the active participation of a wide range of sectors and stakeholders at all levels of society and, although emergencies affect everyone, the most vulnerable are disproportionately affected.
No country, regardless of its level of economic and social development, is immune to the severity of particular environmental disasters. All countries need clear policies, strategies and programs aimed at minimizing health risks and their health and other consequences. These policies and strategies should be multidisciplinary and cross-sectoral and apply comprehensive risk management approaches that cover all hazards. While public health emergency and disaster risk management requires multidimensional strategies and specific measures to manage the wide range of emergency risks, the overall strengthening of a country's health system is also critical.
