Considerations in the epidemiology of earthquake injuries

4.
Considerations in the Epidemiology
of Earthquake Injuries

Nicholas P. Jones, M.EERl, Frederick Krimgold, M.EERl, Eric K. Noji, M.EERl, and
Gordon S. Smith, M.EERl

In July, 1989, a workshop entitled "Earthquake Injury Epidemiology for
Mitigation and Response" was held at The Johns Hopkins University in
Baltimore, Maryland, U.S.A. The aim of the wo rkshop. was to gather a
group of interested professionals, all directly or peripherally interested in
the research, planning, mitigation, and response aspects associated with
earthquake-induced injuries and deaths, to lay the foundations and begin
to develop a research agenda for this emerging field. This was achieved
by a combination of presentation of summary papers , discussions in small,
multidisciplinary working groups, and plenary wrap-up and discussion ses
sions. The papers and transcriptions are available from the authors. The
following paper presents a condensation and summary of the workshop ,
its discussions, and its important conclusions . References are cited where
appropriate; much of the content reflects a condensation of the discussions.

Introduction

Significant resources in research support and effort have been expended on the
problem of earthquake hazard mitigation over the past twenty years. Most of this
research effort has been directed toward questions of geophysical research and struc
tural engineering. While this expenditure of effort has been appropriate in terms
of advancing scientific understanding of the underlying phenomena responsible for
earthquake losses, the principal threat of earthquakes is loss of human life. Material
loss is for the most part replaceable or subject to compensation. The tragic fact is
(NPJ) Dept. Civ, Engrg., The Johns Hopkins Univ ., Baltimore, Md 21218-2699
(FK) College Arch. & Urb. Studies, Virginia Polytech. Inst. & State Univ., Alex.,
Va 22314.
(EKN) Dept. Emerg. Med., The Johns Hopkins Univ., Baltimore, Md 21205
(GSS) Injury Prevo Ctr., The Johns Hopkins Univ., Baltimore, Md 21205
507
'1:Earthquake Spectra. Vol. 6. No.3. 1990

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508 N. P. Jones, F. Krimgold, E. K. Noji, and G. S. Smith Considerations in

that earthquakes continue to consume human beings. The specific mechanisms of • To review
death and injury in earthquakes have not yet been the subject of extensive study. This inch;
Early work by epidemiologists suggests, however, that efforts to reduce earthquake injury pat
related fatality and injury may benefit from more disciplined study (1-4,8,9,11,14,15).
Subsequent work by architects and engineers has pointed to the possibility of more • To define
the scope
rigorous data gathering in the aftermath of major earthquakes (12,13).
the establ.
Until recently, there has been no effective or coordinated program of research
into earthquake injury epidemiology. While there have been a few preliminary stud • To identif
ies from individual researchers in several disciplines, this topic has suffered the fate made, or 1
of many trans disciplinary problems. It has been dealt with peripherally by several
disciplines, but not accepted as the central responsibility of any particular research • To identif
group. The topic is difficult to approach from any narrow disciplinary background,
• To introdi
as it requires the collaboration of several disciplines. First, it is necessary to un municatio
derstand the mechanisms of physical failure in earthquakes. This requires structural ing, earth
engineering and architectural competence. Secondly, it is necessary to understand and rescue
the process of human injury in earthquake-induced building failure. The implications
of building/occupant interaction are the critical issue in prevention of life loss and • To enhanc
injury. Understanding these medical aspects, as well as the behaviors influencing the practition.
outcomes requires both physicians and social scientists. Thirdly, it is necessary to
• To formulr
develop an analytical framework for the analysis of injury patterns and the relation
ship between specific causative agents and their negative consequences (15-20). The
involvement of epidemiologists, particularly those familiar with injuries, is essential.
This epidemiological dimension has only recently begun to be explored. In a major The workshc
earthquake, such as the 1985 Mexican or 1988 Armenian events, intensive ground to developing th
shaking near populated areas can result in the severe damage and even collapse of
• The works
inadequately-constructed buildings. The potential for loss of life in such a collapse is
appropriat
high, in addition to the economic loss associated with the structure and its contents.
Preliminary results are now becoming available from these events. Partial results • The subje
have been collected from Chile (1985) (20), the Southern Italian earthquake (1980) injury epic
(2,3) and Tangshan (1976) (10). There is now enough data available to initiate serious aspects?
discussion and to raise serious methodological issues.
• Presentati
In response to this need, an international workshop on the epidemiology of injuries
necessary.
in natural disasters, specifically earthquakes, was organized by the authors of this
paper and held at The Johns Hopkins University in Baltimore, Maryland, U.S.A. in Presented bl
July, 1989. during the discu
The basic objectives of the workshop were the following: are available (J(

[i, and G. S. Smith Considerations in the Epidemiology of Earthquake Injuries 509

: mechanisms of • To review the state of the art in the rather diversefieldof disaster epidemiology.
extensive study. This included reviews of data collected in past events of causes of death and
uce earthquake injury patterns.
-4,8,9,11,14,15 ).
ssibility of more • -To define the field of ea rthquake injury epidemiology. This included defining
the scope of the problem area, identifying the applications for the research, and
the establishment of a research agenda.

• To identify relevant expertise. Who are the individuals/organizations who have
made, or have the potential for making, significantcontributions in the area?

• To identify and unify relevant sources of data.

• To introduce the problem area to related research communities and begin com
munication between relevant groups, including architecture, structural engineer
ing, earthquake engineering, emergency medicine, injury epidemiology, search
and rescue (SAR), occupant safety, and occupant behavior .

• To enhance communication between the research community and the user or
practitioner community concerned with life safety in buildings.

Organization of the Workshop

The workshop was held over a three-day period. Careful consideration was given
to developing the structure and organization of the workshop for several reasons :

• The workshop was multidi.!ciplinary. Care was taken to ensure adequate and
appropriate mixing of participants from the variousprofessionsdiscussed above.

• The subject was relatively poorly defined i.e., what, precisely, is earthquake
injury epidemiology,and how does it interface with the mitigation and response
aspects? .

logy of injuries • Presentation of past research from the perspective of the various disciplineswas
Luthors of this necessary.
and, U.S.A. in Presented below 15 a summary of the discussions and important points raised
during the discussions. These are presented in summary form; detailed ·transcriptions
are available (Jones et al. 1989).

510 N. P. Jones, E Krimgold, E. K. Noji, and G. S. Smith Considerationsir

Summary of Discussions of epidemiologi
used to effect cr
The most fundamental question raised was what is the precise purpose and def response. In pe
inition of earthquake injury epidemiology? What information is needed, for what significant effec
application will it be used, and can it be gathered in a quantitative, rather than Consider th
qualitative way? Can it be used to help mitigate future impacts? The associated to on-site medi
methodological question is: What are the ques tions that need to be asked and meth ate, post-hospi
ods used to obtain this information? Can epidemiologic methods be used to study process", e.g., '
this problem, and the various processes involved, in such a way as to provide insights clear that the t
into the answers to some of the above questions? ent levels of de
The purpose of earthquake injury epidemiology is to determine the distribution of Whether inforn
death and injury in earthquakes, and in particular to consider the causal mechanism block, developr:
of the fatal or nonfatal injury. The causal mechanism is difficult to define precisely, as lection method,
are the appropriate variables and indicators describing it. It is necessary to consider The medical re
hazard exposure, construction types and their performance during earthquakes, in operation. It is
fluence of nonstructural components and building contents, occupancy and occupant erational struct
bese
these in future

interaction of several disciplines.
For the above components, there are large differences from country to country; The inform
international interaction is also needed. Standardization of terminology and method not been coUec
ologies must therefore transcend cultural as well as disciplinary boundaries. Whether difficult to colle
such a multidisciplinary and multinational approach is feasible is open to some ques from the rescu
tion. lacking; there 1:
Unfortunately, it is not clear from the relatively sketchy data that are available restrictions oft
from past earthquakes exactly where the efforts and finances should be focused. If emergency int.
it is found, for example, that most severe injuries or deaths are resulting from inap those who can
propriate responses on the part of the victims , then education should be targeted as improved metl:
a priority item. If a large number of people are dying because they are not being
extricated quickly enough, then extrication or rescue equipment needs improvement .
If a large number of people are dying after extrication then it is necessary to improve The usefuh
emergency treatment procedures. Unfortunately, the above scenarios are specula the methodolo
tive: detailed epidemiologic studies of injuries in past events have not, in general, is often no di:
occurred. The information required to make the type of decision exemplified above hospital admis
is not available. earthquake-rei
The purpose of disaster epidemiology, as suggested b y the workshop title and of severity (4)
echoed repeatedly by workshop participants is mitigation and response: The results there is a reasc

and G. S. Smith Considerations in the Epidemiology of Earthquake Injuries 511

of epidemiologic studies of injuries in disasters, in this case earthquakes, are to be
used to effect casualty reduction by improving both mitigation, or preparedness, and
.rpose and def
response. In particular, the behavior of victims during the impact phase may have
eded, for what
significant effect on their outcomes.
e, rather than
Consider the medical aspect of the relief phase. This aspect can be broken down
The associated
to on-site medical assistance, transportation, hospital treatment and, if appropri
.ked and rneth-
ate, post-hospital care. At this scale, identification of a weak link in the "medical
used to study
process", e.g., transportation delays, can be important to enhancing survival. It is
'rovide insights
clear that the types of information needed at this stage in the process require differ
ent levels of detail, and are required by different personnel in different time frames.
distribution of
Whether information is needed at the level corresponding to a particular structure,
sal mechanism
block, development, town, city or country has a profound influence on the data col
ne precisely, as
lection methodology implemented and on the types of questions which must be asked.
ary to consider
The medical response must also then be somehowaggregated into the total response
lrthquakes, in
operation. It is important to identify where problems may have occurred in this op
. and occupant
erational structure in the past, and efforts made to establish procedures to minimize
ovided. These
these in future events.
but require the
Data Needs and Collection Methodology
ry to country; The information that is needed in the immediate response phase has generally
y and method
not been collected in the past. There are a number of reasons for this: the data are
aries, Whether
difficult to collect; time spent collecting this information is often viewed as detracting
to some ques- from the rescue effort; the exact definition of what data to collect has generally been
lacking; there has been no person with the soleresponsibility for data collection; access
.t are available restrictions often hamper the data collection effort. The primary focus of immediate
be focused. If emergency intervention in the response phase is to reduce human losses: to save
ing from inap those who can be saved. Unfortunately, due to the paucity of data, development of
be targeted as
improved methods has been limited.
are not being
improvement. Data Sources from Past Events
ary to improve The usefulness of past data is difficult to assess in general terms, and depends on
-s are specula the methodology used and questions asked in the collection. As an example, there
ot , in general, is often no distinction made in the time period following an earthquake whether
nplified above hospital admissions are earthquake-related or not: they are often just assumed to be
earthquake-related. Often the definition of injury is unclear and gives no indication
shop title and of severity (4). Discrimination requires a detailed follow-up study. In most cases,
re: The resuIts there is a reasonable amount of data available as regards structural performance, but

512 · P. Jones, F. Krimgold, E. K. oji, and G. S. Smith Considerationsin

data on injury which are any more than anecdotal are scarce. Even fewer cases exist The 1987WI
where specific injury-structure interaction data are avai lable. rian Hospital ap
studies have alsr
The 1988 A
amounts of dat
techniques such as record searching or questionnaire distribution require much effort. views, to captui
It is considered that sufficient data exist on past events that comparative studies may due to the exter
now begin to be made. tion of the even
A number of
quakes were me
of quantitative:
for the Peruvia
of questionable
Other types of "disasters" may provide useful information relevant to the earth may also be avt
quake injury problem. For example, the Kansas City Hyatt skywalk collapse, the General SOt
Bridgeport L'Ambience Plaza collapse, tornado, hurricane, fire, terrorist bombing, records, and .tl
and mine-related collapses all potentially present mass casualty situations. While Office of U.S. F
the specific details of the collapse or mechanisms of injury may vary, parallels may and other disas
provide insight. these sources c:
As an example of the possible use of past earthquakes as sources of data, some While even
discussion at the workshop focused on the significant effort that has been made re existing data sc
cently to compile data from the 1906 San Francisco earthquake, using newspaper limitations of t
accounts, letters, coroner's records and U.S . Army archives (6). Building information
is also available. While incomplete, it may be possible to generate some structural
performance-morbidity /mortality correlations. Data are likely to exist on the Vet It was clea;
eran's Administration hospital collapse in the 1971 San Fernando earthquake with mechanism of i
the L.A. Fire Department or the V.A. itself. The Ministry of Health in San Sal It is import
vador has some information on the Ruben Dario collapse, and some injury-structure are identified,
studies were performe~. The Romanian earthquake (1976) is considered a source of scope of data
behavioral and structural data as related to injuries. questions askec
Some opportunities appear to remain from the 1985 Mexicoearthquake . A database repetitive data
on the organizational aspects exists at the Disaster Research Center at the Univer The types
sity of Delaware. Injury data is apparently available at the Juarez Hospital and the the data into E
General Hospital, and there is some structural data available also . Surprisingly, the
engineering data available on collapsed structures in Mexico is rather scarce, as these 1. Earthqu;
buildings were cleared away as soon as possible after the earthquake. location

i, and G. S. Smith Considerationsin the Epidemiology Earthquake
of Injuries 513

ewer cases exist The 1987 Whittier Narrows earthquake is a possible source for data. The Presbyte
rian Hospital apparently has information on 250-300 people injured. Some behavioral
studies have also been done, and structural information is sure to be a vailable.
.s, and assist in The 1988 Armenian event presents a rather unique possibility to collect large
labor intensive: amounts of data. Projects are currently underway, making particular use of inter
ire much effort. views, to capture as much information as possible. It has been speculated, however,
ive studies may due to the extent of the catastrophe, that many records were lost , making reconstruc
tion of the event difficult.
affecting urban A number of other potential sources were discussed . "Ancient" or historical earth
environments is quakes were mentioned. It is unlikely that such events would yield much in the way
from the Glass of quantitative injury-structure data, or even injury data. Selected data are available
. (5) to planning for the Peruvian and Chilean earthquakes related to injuries, but the latter may be
of questionable validity. Archival data on Italian, Iranian and Japanese earthquakes
:1tto the earth may also be available, but again the data are considered poor.
lk collapse, the General sources of information were mentioned such as hospital and doctor 's
rorist bombing, records, and the journals and archives of historical and geological societies. The
uations. While Office of U.S. Foreign Disaster Assistance maintains a database on past earthquakes
r, parallels may and other disasters, but not in a detailed form. While not all necessarily complete,
these sources can serve to provide as complete a picture as possible of past events .
s of data, some While even the above list is incomplete, it was deemed important to investigate
: been made re existing data sources for as much useful information as possible, keeping in mind the
sing newspaper limitations of the data, and inherent uncertainties and lack of reliability.
ing information
some structural Identification of Critical Variables
:ist on the Vet
It was clear that a better database of statistical information relating injuries to
arthquake with
mechanism of injury is required.
lth in San Sal
It is important that the appropriate variables or indicators, and their interactions
injury-structure are identified, in the generation of a multivariate model of outcome. The type and
ered a source of
scope of data required must be defined based on the focus of the study, and the
questions asked must reflect what weknow already, to avoid collection of unnecessaril y
lake. A database
repetitive data and improve the level of detail and quality.
. at the Univer
The types of data to be collected will vary, as stated. It is convenient to group
.ospital and the
the data into several categories, and give examples:
iurprisingly, the
scarce, as these Earthquake Information such as time of day , magnitude and local intensity, and
location of epicenter relative to site of interest.


2. Demographic Data reflecting spatial variations in population dens ity, urban/rural for classifying t.
distinctions, the economic and cultural characteristics of the region, etc . comprehensive s
sets of question:
3. Building Characteristics such as construction type, materials, occupancy, "strength"
facilitated.
on an appropriate scale, collapse or damage characteristics, nonstructural ele
The questior
ment performance, evidence of fire, and so on.
pline and organ
4. Me<ll!=MTreatment _Chcy:acteristi~including nature and severity of injury, treat etc.) The consi
ment received, cause of death, times of discovery, extrication and hospitaliza tional dimensio
tion, hospital treatment received, final outcome. etc. It is also essential to zational level a:
collect detailed data on the precise mechanism of injury . In addition, special country.
ized data may be needed, e.g., to evaluate the incidence of earthquake-induced What quest
heart attacks in victims. information nee
The timing.
5. S.ARJnformation such as method and time of extrication, arrival time of SAR
five phases of d
equipment, effectiveness of SAR response both technically and operationally.
1. Retrosper
6. Behavioral Factors including occupant behavior before, during and after the
may influ
impact, reaction to warnings, etc. are important influences in determining
current" d
injury severity or death.
health cal
The above list is by no means comprehensive. Coupled with the identification of
2. Data coll
the variables or indicators is the methodology used to collect them. Methodological
effectiven
issues are discussed in detail in the following section. This includes consideration of
the perishability of the data, the sources of the data, and the means used to record 3. Impact p
them. Because·
this pote.
Data Collection Methodology
this phas
Perhaps one of the most important issues discussed at the workshop was the
4. Response
preparedness aspect as it relates to data collection, and methodological issues. Specif
as the or
ically, the definition and organization of the questions to be asked, when to ask them,
in the re
of whom, and by whom all need to be addressed before the fact. The following rec
collectior
ommendations and observations were made with regard to data collection methods.
health ai
It is clear from past events that the existence of a defined set of focused yet
injury de
comprehensive questions is critical. To effectively improve preparedness and response
capability at all levels, the "right" questions must be asked, and in a timely manner. 5. Follow-u
The questions must serve to test particular hypotheses. and address operational plete the
issues. Each discipline should develop its own questions, perhaps using appropriate The souret
quantitative scales such as the injury severity score (14) and a corresponding scale and ultimate,

i, and G. S. Smith Considerationsin the Epidemiology
ofEarthquakeInjuries 515

rsity, urban/rural for classifying the collapsed state of a structure, and then incorporate these into a
.gion, etc. comprehensive survey instrument. If consensus can be reached on these questions , or
:cupancy, "strength" sets of questions, comparative studies of the effects of different earthquakes will be
mstructural ele- facilitated.
The questions should fit into a hierarchical model, with dimensions of time, disci
pline and organizational level (e.g., on-site, local hospital, public health department,
y of injury, treat etc.) The consideration of a four-dimensional matrix was suggested, with the addi
and hospitaliza tional dimension of function, although in some cases, this may overlap the organi
also essential to zationallevel axis. It should be noted that the organizational structure varies with
ddition, special country.
;hquake-induced What questions are to be asked is a function of time. It is apparent that the
information needs vary dramatically from one phase to the next.
The timing of data collection may be divided into five phases, connected to the
val time of SAR
five phases of disaster, all of which are important in the overall process :
operationally.
1. Retrospective collection from past events, to whatever extent possible, which
19 and after the
may influence preparedness and planning activities. In addition, collection of
in determining
current data, as regards assessments (e.g., structural), preparedness (e .g., of
health care system, SAR capability), etc. would be carried out in this phase .
identification of
2. Data collection in the pre-disaster phase, as related to response to warnings ,
~ethodological
effectiveness of preparedness plans, etc.
consideration of
s used to record 3. Impact phase: In most cases this is the most critical yet difficult data to obtain .
Because of the initial chaotic state, it is generally extremely difficult to collect
this potentially most perishable data. Raw video footage is of potential use in
this phase.
rrkshop was the
4. Response phase collection is similar to the impact phase in many cases, although
cal issues. Specif
as the organized response begins to take over, collection is possible if included
hen to ask them,
in the response plan. Collaboration with local teams may be important in this
he following rec
collection phase. During this time it is essential to make contact with local
ection methods.
health authorities to ensure that collection of appropriate hospital and other
t of focused yet
injury data is possible.
ess and response
L timely manner. 5. Follow-up, detailed data collection, using interviews and questionnaires, to com
.ress operational plete the process begun in 3 and 4 . above.
sing appropriate
The source of the information in many cases will determine the level of de tail
responding scale and ultimate application of the data. For example , in the impact or response phases ,

516 N, p, Jones, F. KrimgoJd, E. K,Noji, and G. S. Smith Considerationsin th,

with regard to emergency medical response, questions asked concerning "needs" will with building dan
certainly obtain different responses if health departments, hospital administrators, The National
individual physicians and rescue or EMT's are asked. Each group has its own view routinely conduct
and assessment of the situation. quite different fro
The priorities for data collection must be established a priori. In the impact and be of use for guid
response phases, for example, data collection personnel must not be burdened with Data collectiO!
requirements to collect what may be termed archival information: records, reports being there to th
or data which are not immediately available, at the expense of perishable data which and even between
may be available only in the context of the impact phase, or data which are critical tion processes, ar
in terms of mobilization of response. The definition of data as perishable or archival prepared to relea
depends crucially on the application, and such identification must be made in advance. to the media, ar
Development of data-collection instruments for the impact and response phases can result in lOSE
must reflect the difficult situation which exists at such times. Questionnaires or forms before organized
should allow for the collection of detailed and anecdotal information as it is available. by untrained, loc
Terminology must be standardized across disciplines. Computers were suggested as fected populatior
potentially useful. in preparing date'
Development of a trial form for use in future incidents was considered a high An important
priority. This could be circulated for review by each of the disciplines involved, and connaissance tee.
tested in future events. A strategy for deployment of the form must also be developed. collection methoc
It was considered extremely important that response teams include personnel tivities.
whose function is to collect data. Assessment teams, appropriately deployed, should
be responsible for gathering not only data which will be used in long-term analysis
and research tasks, but also "intelligence" information which can be used to guide
Loss estimat.
SAR and medical personnel. Recorders of data and their sources must be identified.
preparedness ac:
The multidisciplinary nature of the data required must be captured in the collection
casualties. One (
instrument, yet reflect the fact that the collector will most likely not be an expert
epidemiologic stt
in more than one or two areas. Composition of assessment teams should reflect this
developed or ref
difficulty.
Exactly wha
Tracking victims through the response system was considered an important con
carefully defined
sideration. In this way, outcomes can be related to circumstances of injury, on-site
lacerations, cont
treatment, extrication, transportation, and hospital treatment, and the timing of
so-called to distr
each.
Does the model
Carefully designed, comprehensive follow-up, sample surveys of building occu
At the natio
pants should be conducted. Data should be collected on all occupants of damaged
injured. This in
structures, whether injured or not, and case studies conducted where possible. Data
and for respons
on the uninjured is potentially of great use in understanding interaction of occupants
to the planning

Ioji, and G. S. Smith Considerationsin the Epidemiology Earthquake
of Injuries 517

·ning "needs" will with building damage.
11 administrators, The National Transportation Safety Board (N.T.S.B), and other organizations
has its own view routinely conduct post-disaster investigations. While in most cases the situations are
quite different from earthquake disasters, protocols have been developed which may
.n the impact and be of use for guiding procedures in the latter event .
be burdened with Data collection is not always simply a matter of having the questions defined, and
: records, reports being there to the collect the data. Political problems, internationally, nationally,
shable data which and even between organizational or responding departments can often hinder collec
which are critical tion processes, and restrict information flow. In many cases, sources are simply not
shable or archival prepared to release, or allow access to, critical data. Researchers, or perceived links
made in advance. to the media, are often particularly suspect. Damage to facilities, e.g., hospitals,
r response phases can result in loss of information. How can data be collected in the critical hours
onnaires or forms before organized rescue teams arrive, when a large numbers of rescues are performed
. as it is available. by untrained, local volunteers. The psychologicaland emotional responses of an af
vere suggested as fected population (e.g., those who are in mourning or shock) need to be considered
in preparing data collection methodologies, particularly interviews.
onsidered a high An important purpose of data collection is that of guiding response . Rapid re
nes involved, and connaissance techniques, facilitated through the development of appropriate data
ilso be developed. collection methodologies, are necessary to guide impact and response-phase SAR ac
nclude personnel tivities.
deployed, should
-ng-term analysis Casualty Estimation Modeling
be used to guide Loss estimation models are frequently used by planners and public officials in
ust be identified. preparedness activities. "Loss" may refer to property and economic losses, or to
in the collection casualties. One of the potential uses for the data collected through earthquake injury
lot be an expert epidemiologic studies is as a database with which casualty estimation models may be
hould reflect this developed or refined. Much discussion at the workshop addressed this issue.
Exactly what a casualty estimation model is designed to accomplish must be
1 important con carefully defined. Are estimates of the breakdown of injuries given, e.g., orthopedic,
of injury, on-site lacerations, contusions, etc.? Does the model predict final outcomes , or the initial or
rd the timing of so-called to distribution of deaths and injury or injury severity before intervention?
Does the model produce aggregate information. or structure-specific informat.ion?
-f building occu At the national level it is important to make reliable estimates of the dead and
ants of damaged injured. This includes, for preparedness and planning purposes, pre -event estimates,
'e possible. Data and for response, impact or response-phase estimates, which represent refinements
.ion of occupants to the planning model based on reconnaissance. The latter are necessary for the

518 N. P. Jones, F. KrimgoJd,E. K. Noji, and G. S. Smith Considerations in the

allocation of resources after the event (28). At the local level, models predicting the The usefulness·
SAR demand for particular structures are essential for effective responses. assessment and res
Is it even possible to develop general models which are based on individual events unlikely that detail
or individual structures or blocks of structures? While this is a difficult task, the or hazardous mate
consensus was that this is necessary. In addition to providing a rational method for Intervention str
casualty estimation, which is essential to planners, such models enable the mechanism For example, what
of injury in earthquakes to be elucidated through identification and observation of rapid and effective
critical variables, and also provide a framework for data collection in future events survival of a very f

(32,33). While the development of comprehensive models was generally considered
important, there were questions raised as to the possibility of achieving a "universal
The abili ty to
model."
but this capability
One of the important features of such a model is the potential for identifying how
of hazardous [pote
the variables interact and how independent risk factors modulate the expected out
mitigation activiti-
comes. Sensitivity of the model to small changes in the variables should be addressed.
Effective chan,
Spatial models would greatly assist in resource allocation planning both before and
component of ear
after an event.
as related to injur
The interactive relationship between modeling and data collection was stressed.
lack of a coherent
Proposed critical indicators, which become collected data (deductive), can be evalu
is scarce, particulr
ated through the framework of a model (inductive), and revised, accepted or rejected
injury is assumed
through retrospective application.
characterization is
There are some serious doubts as to the validity of existing casualty estimation
to the causal mec!
models - both pre-event and post-event. While they often have been instrumental
A number of i
in motivating preparedness activities, their reliability, and thereby usefulness for de
factors on casualt
tailed planning are generally limited. Most are based on engineering models with little
initial usable volt
input from medicine or epidemiology. It is common for post-event damage estimates,
potential. It is a t
and therefore casualty estimates to initially err on the low side. This is perhaps a fault
throughout the st
which lies with the organization and implementation of rapid post-event reconnais
of building collap
sance. The problem is a difficult one: both the Mexico and Lorna Prieta earthquakes
both occupants 0:
exhibited localized areas of intense damage interspersed throughout large, relatively
Are there des
unaffected areas.
collapse and prov
The development of probabilistic models is seen as an important need in this area.
some structures a
Not only should expected numbers of casualties be given, but also the variances of
should the struct
the estimates, and the associated statistical moments for the various variables and
suggested, but it
indicators in the model. In this way, estimates can be improved (i.e., the variance of
for protection of
the estimate reduced) as more data become available. Pre-event predictions can be
The effect of ;
modified quickly after the event by performing reconnaissance activities.
is important, anc

Noji, and G. S. Smith Considerationsin the Epidemiology EarthquakeInjuries
of 519

dels predicting the The usefulness of models for SAR operations remains to be proven . While initial
esponses. assessment and resource allocation issues can be impacted by reliable models, it is
n individual events unlikely that detailed, on-site peculiarities are addressable (e.g., the presence of fire
difficult task, the or hazardous material risks) without first-hand information.
ational method for Intervention strategies will affect outcomes, and models need to address this issue.
rble the mechanism For example, what impact will SAR processes have in improving outcomes? Can a
and observation of rapid and effective response system significantly reduce casualties or only affect the
an in future events survival of a very small proportion of all casualties.
enerally considered Engineering Issues
ieving a "universal
The ability to make assessments about collapse potential of buildings is limited,
but this capability is important for pre-event estimation procedures. Identification
ror identifying how
of hazardous (potentially lethal) buildings in the anticipatory phase is important for
the expected out
mitigation activities. There have been some attempts to study collapse mechanics .
.ould be addressed.
Ig both before and

:tion was stressed.
ive), can be evalu
is scarce, particularly quantitatively. The relationship between building damage and
:cepted or rejected
injury is assumed in a general sense, not established statistically or otherwise. This
characterization is needed to both enable correlation of the type and severity of injury
asualty estimation
to the causal mechanism and to assist in the triage, as described above.
been instrumental
A number of indicators were proposed as indicators for the effect of structural
. usefulness for de
factors on casualty. Volume change, the ratio of the loss in usable volume to the
; models with little
initial usable volume is suggested as a measure of void potential, hence survival
damage estimates,
potential. It is a single-parameter estimate, however, and provides no differentiation
5 is perhaps a fault
throughout the structure, and has other limitations. Scales for quantifying "degrees
.t-event reconnais
of building collapse" are needed. Separation of walls may have significant effects on
:>rietaearthquakes
both occupants or nearby pedestrians; this is difficult to quantify, in the usual sense.
ut large, relatively
Are there design techniques that can be used which address the possibilit y of
collapse and provide for "safe" regions or voids in the collapsed structure? In Texas,
t need in this area.
some structures are designed with a concrete core to afford protection from tornadoes
o the variances of
should the structure otherwise fail. In a similar vein , designing to provide voids was
ious variables and
suggested, but it is unlikely that clients would want to address such issues. Designing
e., the variance of
for protection of escape routes may be more acceptable.
oredictions can be
The effect of nonstructural components and building contents on occupant injury
.is important, and needs further study.


Structural characteristics also relate to behavioral factors. For example, folk wis-. and water leaks:
dom claims such things as: "run outside" or "do not run outside" or "wait three impact phase.
minutes then run outside;" "stand under a door frame;" and so on. The correct One issue rai
action depends on the particular structure. Detailed study should provide the basis other factors in
for valid education to avoid incorrect actions being taken by occupants. Incorrect building should :
extrapolations are often made. While much,
Development and testing of new SAR equipment is an engineering issue. Testing noted that orga
and evaluation of equipment is necessary to determine what is the best to use in sponse. For exa
various applications. Most existing equipment has been adapted from other uses, and which follows a
is not particularly well-suited to the collapsed building environment. For example, needs to be stu:
determination of victim status after detection is important in terms of operational body of research
decisions New specialized technologies potentially will suffer from the fact that they both with regar
will generally not be mass-produced products, and there will be reluctance to pursue research in eartJ
development in industry. Studies and development of SAR equipment should be
pursued in a focused and coordinated manner.
Some discus
Behavioral Issues
injuries" and "«
Behavioral aspects must be considered to produce effective casualty estimation earthquakes. (
models or for SAR operational guidelines. failures, e.g., re
The basic behavioral questions are: What was an occupant doing when the earth classifications 0
quake occurred, what was his or her initial response and what did he or she do after or at least defin
the earthquake? Why were these actions taken? Did they represent a learned re While it was
sponse? Were factors like culture or age a factor? What behavior is appropriate? "requiring medi
What is inappropriate? Can public education programs provide valuable advice that it was noted th
people will use in the impact phase? Clearly, answers to these questions must be ob unreliable. To
tained from post-event interviews in most cases; data collection methodologies which severity is imp
involve interviews should try to address these questions in addition to those relating noted that botl
to structure and injury. It was noted that past studies on occupant behavior do ex personnel need
ist, such as the Imperial County Services Building during the 1979 Imperial Valley needs to be de
earthquake (20). should be made
o epjCLe.mjology and those treat
of severity avai
occupant survival. Assessment
that a more site-specific approach is needed. The question was raised, however, backtracking ir
whether prior training does actually effectively change behavior under stress. More concept of trac
research needs to be done in this area, and in the development of more effective tality, and det
teaching tools. It is likely that it is easier to teach behaviors such as checking for gas intervention st

J'oji,and G. S. Smith Considerationsin the Epidemiology
ofEarthquakeInjuries 521

.xample, folk wis and water leaks after the earthquake than teaching appropriate behaviors during the
e" or "wait three impact phase.
on. The correct One issue raised during the discussions was how does behavior interact with the
provide the basis other factors in influencing survival? For example , the design of escape routes in a
ipants. Incorrect building should reflect behavioral as well as structural considerations .
While much discussion is focussedon individual victim/occupant response, it was
ing issue. Testing noted that organizational response is important , and its linkage to individual re
he best to use in sponse. For example, how are rescue activities affected by the emotional response
m other uses, and which follows a devastating earthquake? The behavior of i~dividual rescuers also
.nt, For example, needs to be studied: what was their response, and was it modified by training? A
ms of operational body of research and experience exists on the mental health consequencesof disasters
.he fact that they both with regard to the the victims and the effect on SAR personnel. More detailed
uctance to pursue research in earthquake situations is needed.
pment should be
Injury Issues
cl::I.ikc:
injuries" and "earthquake deaths." Heart attacks are often claimed as induced by
.sualty estimation earthquakes. On the other hand, it is possible that deaths resulting from power
fa:i 3'j not b rclate:i:l.
g when the earth
he or she do after
sent a learned re While it was suggested that injury could be defined by indicators or signs, such as
Jr is appropriate? "requiring medical care" or "requiring hospital care," rather than by using diagnoses,
luable advice that it was noted that these definitions will vary across cultures, perhaps making them
;tioos must be ob unreliable. To correlate building types with injuries, types of injury, and injury
thodologies which severity is important, as well as the number and distribution of injuries , It was
1 to those relating noted that both types and numbers are important for the estimation of supplies and
it behavior do ex personnel needs. Such a classification system must be field applicable. More work
'9 Imperial Valley needs to be done to develop simple severity measures (14). However, distinctions
should be ~ade between those requiring hospital (or emergency shelter 24-hour care)
jury epidemiology and those treated as outpatients. At present, this represents the best simple indicator
hich may enhance of severity available.
aeral; it is possible Assessment of the number of out-of -hospital deaths is extremely difficult . Also,
; raised, however, backtracking injuries from hospitals to specific buildings poses major problems. The
nder stress. More
of more effective
1S checking for gas


The use of injury severity scores as a means of providing detailed quantitative.
injury data was strongly advocated. Two different types of injury may generate iden
The possibili
tical injury severity scores, but the interventions they demand may be quite different.
in structures wa
It was suggested that there needs to be a larger database of detailed descriptive data
potentially fruit
on earthquake injuries. How do victims of collapsed structures differ from standard
in the automob
trauma victims? Can the data used from motor vehicle injury studies be extrapolated
to safer vehicles
to trapped earthquake victims?
While shaking .
Appropriate interventions for various injuries or conditions need more research
frequently usin;
e.g., what are the best treatments for victims of crush syndrome? Do tranquilizers
structural engir
avoid the so-called "rescue death"? Animal models are currently being 'used to study
was noted that
crush and asphyxiation injuries and their treatment. What is the pathophysiology of
While not trad
the dying process? Research in resuscitation methodology (e.g., the role of surgery)
and housing mr
is needed. How can it be determined if amputation is necessary? Laboratory and
clinical studies are needed, as clinical research is difficult to do under pressure of A related is
resuscitation. Development of standards for treatments in disaster situations will ios. These disa
improve aggregate medical response in such events. New specifically-designed EMS exercises, home
equipment must be developed, and widely applicable to enable production. This is ganizational re:
needed for both intensive individual care and standard mass care situations. Progress and have prove
levels of respon
in disaster medicine may also lead to improvements in non-disaster EMS techniques.
and operationa
A somewhat separate, but related, topic is the study of injuries to rescue work
ers, both volunteer and professional. Of particular interest are the mental health
consequences of those involved in the stressful and demanding rescue process .
The genera'
SAR Operational Issues discussed. Inte

Some discussion 'occurred relative to operational organization and the Incident critical phases
Command System (ICS). Past experience with ICS indicated that it worked best gathering and
when applied to situations for which it was designed. It was questionable whether an It was cons
event such as an earthquake affecting a major city fell into this category. Problems eration be give
with ICS have been identified during both disasters and drills . It was suggested that and response.
ICS be thoroughly reviewed to ascertain whether it is adaptable to this context, and shown that mi

if not, develop a more appropriate system. It is noted that a significant strength of must be aware

ICS is planning. Whether development of centralized or decentralized organization or suspected c
in the response phase is desirable and appropriate was debated. Is it better to build immobilized.
on existing emergency resources or to create a specialized disaster response center? Possible av
noted that res!
data discussed

,foji. nd C. S. Si'itilli

ailed quantitative Experimental Issues
lay generate iden
be quite different. The possibility of using experiments to study various aspects of the injury process
d descriptive data in structures was discussed. Full-scale testing and modeling of structures was seen as
Ferfrom standard potentially fruitful. It was noted that this approach has been used with some success
es be extrapolated in the automobile industry, where crash tests, using instrumented dummies, has led
to safer vehicles through improved structure performance and better safety devices.
ed more research While shaking tests using tables and reaction walls with model structures, and less
Do tranquilizers frequently using full-scale buildings, have been performed; their focus has been on
.ing used to study structural engineering. No injury modeling has been performed, except in Japan. It
athophysiology of was noted that studies of this type do not realistically account for behavioral effects.
e role of surgery) While not traditionally considered "engineered structures," experiments on houses,
Laboratory and and housing materials and components are needed to improve life-safety.
lnder pressure of A related issue, which may be considered "experimental" is the use of scenar
er situations will ios. These disaster simulations can be made at various levels (e .g., workshops, field
lly-designed EMS exercises, home safety drills) and can be used to test, in particular, behavior and or
:>duction. This is ganizational responses. These have been used successfully,for example, in California,
uations. Progress and have proven to be powerful tools . In addition to providing exposure to various
EMS techniques. levels of responders to "realistic" disaster situations , studies made of the procedures
s to rescue work and operational effectiveness can augment the databases in this area.
he mental health
General Research Issues
ue process.
The general question of the need for and effectiveness of international help was
discussed. International help must be considered a backup to local response in the
and the Incident critical phases. It was suggested that international responders are a resource for
.t it worked best gathering and dissemination of information .
nable whether an It was considered important, in light of the above comments, that serious consid
tegory. Problems eration be given to training both local responders and communities in preparedness
as suggested that and response. There are difficulties: the numbers of people are large; experience has
this context, and shown that much of the information is not retained. Rescue workers , in particular,
Scant strength of must be aware of the "dos and don 'ts" of light rescue: e.g. , patients with potential
ized organization or suspected cervical spine injuries should be moved only after the neck has been
it better to build immobilized.
esponse center? Possible avenues include the linking of training to the place of employment . It is
noted that rescue work must start immediately , with or without the rapid assessment
data discussed above.

524 N. P. Jones, F. Krimgold, E. K. Noji, and G. S. Smith Considerations in th.

A large number of rescues are always self-rescues, or are performed by volunteers. the integration of e
Planning for integration of local volunteers into the rescue effort should be taken research is likely t<
seriously. The capacity of such resources should not be underestimated, and in fact It is anticipate
should be considered when evaluating an appropriate response. Information on local also be applied to
EMS resources available is also needed in such an assessment. An important question Principal nee'd
is how is the communication between formal and informal groups established and
1. The develop
how can it be made more effective? Should we, for example, be training formal SAR
on injury, st
personnel in methods of coordinating volunteer teams rather than concentrating on
individual rescues? 2. The study
The SAR issue is a complex one. SAR is not always needed. Nor does it always gathering d
save the most lives. Nor is it necessarily "cost effective" when compared with mitiga
tion measures. Public pressure may demand the implementation of professional SAR 3. The prepa:
efforts, even though few, if any, persons remain alive. It is viewed by the public as a designed st
heroic response, and its presence, whether particularly effective or not, is necessary.
4. The develo
Extrication difficulties with trapped victims still clearly pose a major problem, even
ment.
if the numbers involved are not necessarily large. In terms of resource allocation,
however, an important fundamental question which must be addressed is whether
improved SAR technologies can save significant numbers of lives?
Research in SAR and how to improve its overall effectiveness is therefore necessary. Principal fur
Coordination of SAR resources is often a problem; specialized personnel are needed dation (NSF), s
for heavy SARj can SAR teams be certified? It is noted that resuscitation and life Division of Crit
support should be part of SAR: The process should be designed accordingly. What National Center
can we learn from other SAR situations such as mine rescues? 6010 and 88-401
for Internationa
Conclusions
acknowledged.
The International WorkJhop on Earthquake Injury Epidemiology for Mitigation
and Response held at The Johns Hopkins University in July, 1989 was an important
first step in defining the field of earthquake injury epidemiology, outlining potential
1. Alexande
interventions which cou~dbe based on research findings, and reaching some agreement
- 60.
on data collection needs and methodologies. The workshop, as outlined in the above
paper, did not provide answers to all the important problems associated with the 2. de Bruyc
study of approaches to reduce the health consequences of earthquakes. However, Italy: Re
it has provided a clearer understanding of many of these problems and of possible 1021 - 1C
directions for future research. To effect reductions in earthquake casualties in future
3. de Bruy
events, contributions from many professions must be integrated and implemented
Haly: M
in a rational and consistent manner. Just as epidemiology and other public health
117.
principles have provided important new insights into the study of disease processes, so

l by volunteers. the integration of epidemiologic techniques to other disciplines involved in earthquake
aould be taken research is likely to lead to better methods to reduce casualties in future earthquakes.
ed, and in fact It is anticipated that the lessons learned addressing the earthquake problem may
nation on local also be applied to other natural (and technological) disasters.
ort ant question Principal needs identified during the workshop were:
.stablished and
ng formal SAR 1. The development of standard data collection forms which can incorporate data
'llcentrating on on injury, structural collapse and SAR response.

2. The study of historical events, in particular recent events, with a focus on
does it always
gathering data on the above topics.
ed wi th mi tiga
ofessionalSAR 3. The preparation for data collection in future events and planning for well
the public as a designed studies in anticipation of an event.
t, is necessary.
4. The development of functional models for casualty estimation and needs assess
problem, even
ment.
tree allocation,
sed is whether Acknowledgements

efore necessary. Principal funding for the workshop was provided by the National Science Foun
nel are needed dation (NSF), grant number CES-8815609, through Dr. William A. Anderson of the
.ation and life Division of Critical Engineering Systems. Additional support was provided by the
rdingly. What National Center for Earthquake Engineering Research in Buffalo, grant numbers 88-
6010 and 88-4005, the Office of U.S. Foreign Disaster Assistance of the U.S. Agency
for International Development, and the Hoechst Company. This support is gratefully
acknowledged.
for .Mitigation
; an important References
.ning potential
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- 60.
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526 N. P. Jones, F. Krimgold, E. K. Noji, and G. S. Smith Considerations i

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Appror,
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27. Kunkle, R. "Medical Care of Entrapped Victims in Confined Spaces." P-338 -
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28. Mahoney, L.E. "Public Policy Needs in Earthquake Injury Measurement." P-
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29. Wenger, D. "The Study of Volunteer and Emergent Organizational Response:
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528 N. P Jones, F. Krirngold. E. K. oji, and G. S. Smith

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-
5.
Bvaluatic
Seismic ~
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33. Steinbrugge, K. V. "Reducing Earthquake Casualties: An Overview." P-415
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Intensity." P-420 - P-434. evaluate rr
soils. The
35. Abrams, J "Detection and Extrication in the Armenian Earthquake ." P-435 as propose
- P-451. nia, and la
Gonzalo C
36. Charchoghlian, R., and Sekoyan, R.V. "The Earthquake in Armenia: Conse mended aI
which is ir
quences and Problems." P-452 - P-457.
a research
and his co
37. Comfort, L.K. "Suggested Problems for F ield Research in Earthquake Disaster
based con
Operations." P-458 - P-459.

38. Comfort, L.K. "Reflections on the Armenia Earthquakes." P-460 P-461

39. Pesola, G., Bayshtok, V., and Kvetan, V. "American Critical Care Team at a Ever since
Foreign Disaster Site: The Armenian Experience." P-462 - P-465. and Niigata, Jc
during earthqu
40. Ricci, E.M., Pretto, E., Klain, M., and Safar, P. "Retrospective Disaster Re understanding
animatology Study of the Earthquake in Armenia in December 1988." P-466- Excellent surru
P-493. and state of th
by Yoshimi et
41. Hays, W.W "Data Acquisition for Earthquake Hazard Mitigation." P-494 Research Cow
P-502. As a resu.
February 1971
the Lower San
investigations,
embankment (

(WFM,1'.
Experiment St

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