Background

• Disasters, such as hurricanes, floods, earthquakes, power outages, terrorism, wars, and tornadoes, frequently occur without warning and can seriously threaten lives, especially those with chronic illnesses such as diabetes.
• Survivors are often without: electricity, refrigeration, means of communication, or transportation, and there are shortages of food, clothing, and shelter.
• Access to medical facilities, providers, medical records, and medications may be limited. [13]
• When the healthcare system is damaged, it may be harder for people with diabetes and other chronic conditions to get the ongoing care and treatment they need. [13]
• Early planning may increase the resiliency of people with diabetes before, during, and after disasters.

Impact of disasters on glycemic control

• Glycemic control often deteriorates after disasters.[13]
• There is an increased risk for morbidity and mortality due to diabetic complications during disasters such as infections and diabetic ketoacidosis.
• Often, there are an increased number of Emergency Department visits among people with diabetes for various reasons such as medication refills or poor glycemic control.[13]
• Increased stress may also contribute to deterioration of glycemic control. Other factors that contribute include lack of access to healthcare, medication, healthy food choices, clean water and sanitation, as well as possible exposure to infections.

Shelters:[11]

• A study of shelter evacuees revealed that 23% of those sheltered had some identifiable preexisting health problems such as cardiovascular problems (28.7%), or diabetes (16.9%).

• Shelter conditions can worsen chronic medical conditions such as diabetes because of shortages of healthy food choices, personal hygiene items, sleeping space, and prescription medications.

Historical perspectives on diabetes and disasters: Examples of published studies

• The effect of the Gulf War on glycemic control.
  • The study found that hemoglobin A1c increased from 10.1% to 10.9% in people with type 2 diabetes and from 9.6% to 10.2% in people with type 1 diabetes.
  • Weight also increased on average by 1.4 kg in people with type 2 diabetes and by 1.5 kg in people with type 1 diabetes.
  • Both measurements returned to baseline after the war.[10]
• The effect of the Kobe Earthquake on stress and glycemic control in patients with diabetes.
  • Patients with diabetes in Kobe (the site of the earthquake) were compared to age-matched controls with diabetes in Osaka (an area not affected by the earthquake).
  • Hemoglobin A1c levels were significantly higher in the patients from Kobe compared to Osaka following the earthquake.
  • GHQ (General Health Questionnaire) scores were used to evaluate stress and values were higher in patients from Kobe compared to Osaka.[8]
• Glycemic control in people with diabetes after the Great Hanshin-Awaji Earthquake.
  • There was a significant temporary increase in mean hemoglobin A1c values after the earthquake, from 7.74% to 8.34%.
  • Based on multiple regression analysis, inappropriate diet appeared to be the main cause of the increased hemoglobin A1c level.[9]
• Impact of Hurricane Katrina on people with chronic medical conditions.
  • Medical assessments of people affected by Hurricane Katrina showed that the leading chronic conditions were cardiovascular diseases, hypertension, diabetes, and psychiatric disorders.[6]
  • After Hurricane Katrina, an assessment was done to look at the relationship between the medication needs of the 18,000 evacuees relocated to San Antonio vs. the actual pharmaceutical relief supplies available.
  • Medical relief supplies did not reflect the demands of the evacuees.
  • Federal disaster relief teams supplied only 9% of all chronic care medicines and retail pharmacies were needed to meet the demand.[3]

Examples of lessons learned from past disasters

• After Hurricane Katrina, a qualitative study identified the most pressing issues in providing care for people with chronic diseases after a natural disaster:
  • Availability of medications for patients
  • Patient preparedness and self awareness of medical information
  • Ability to access medical information
  • Coordination of aid efforts
  • Communication and collaboration among private and public aid institutions.[2]
• After Hurricane Charley in 2004, a rapid needs assessments was done 10 days after the event to evaluate the health status and immediate needs of communities affected by disasters.
  • Older adult residents experienced disruptions in medical care for preexisting conditions (cardiovascular disease, diabetes, and physical disabilities).
  • In Charlotte County, Florida, one third of households had at least one older adult’s medical condition worsen because of the hurricane and one quarter of households reported at least one older adult was prevented from receiving routine care for a preexisting condition.
  • In Hardee County, Florida, 9% of households reported at least one older adult did not have access to prescription medications.
  • The report concluded that earlier assessments (e.g., 3-5 days instead of 10-14 days after the hurricane) might have been useful in guiding decisions about the deployment of appropriate medical responders and medications. [7]
• A surveillance system such as the BRFSS (Behavioral Risk Factor Surveillance System) can be used to provide estimates of the numbers of people with chronic diseases. This information can help the medical and public health community in assessing the needs for emergency treatment for people with chronic disease and in planning relief efforts after disasters.[5]
• Other recommendations to help strengthen prescription drug continuity in disasters include:
  • Create flexible drug-dispensing policies to help patients build reserves
  • Training professions to inform patients about disaster planning
  • Building collaborative partnerships among system stakeholders.[1]

Information on how people with diabetes can prepare for disasters

• During a disaster, the American Diabetes Association (ADA) has been a leading source of information for people with diabetes, caregivers, and media. The ADA has developed guidelines to help people with diabetes prepare for disasters.
• ADA Statement of Disaster Preparedness:[4]

1. Obtain good diabetes education that emphasizes self-management skills and stresses management.

2. Be up to date with all immunizations, including tetanus.

3. Keep a waterproof and insulated disaster kit ready with:

• List of items to pack during an evacuation:
  • Glucose test strips
  • Lancets
  • Glucometer
  • Medications including insulin
  • Syringes
  • Glucose tabs or gels
  • Antibiotic ointments/creams
  • Glucagon emergency kits
  • Prepackaged snacks
• List of contacts for national organizations, such as ADA, through their help lines or online.
• Photocopies of relevant medical information, particularly recent lab tests/procedures, if available.
• Up-to-date information on all oral medication and insulin, regarding formulation and dosing. If possible, have the prescription number available. Many chain pharmacies throughout the country may be able to refill based on the prescription number alone. This should be reviewed and updated at least twice yearly.

4. Evacuate early, if possible, taking the items listed above with you. Other emergency preparedness considerations:

• Wear protective clothing and sturdy shoes.
• Check your feet daily for any irritation, infection, open sores, or blisters. Never go without shoes.
• Stay well hydrated and avoid excessive outdoor activity in the heat.
• Seek emergency treatment if you experience fatigue, weakness, abdominal cramps, decreased urination, fever, or confusion.
• Increase food and water intake during periods of increased exertion or physical activity
• Avoid periods of hunger and overindulgence
• Know nutrition options that will be useful in a disaster. Examples include:
  • Large box of unopened crackers
  • One jar of peanut butter
  • One small box of powdered milk
  • One gallon of water per day
  • Two packages of cheese and crackers or one jar of soft cheese
  • One package dry unsweetened cereal or single serving boxes
  • Six cans of sugar-free soda
  • Six pack of canned fruit juice or sports drink
  • Cans of tuna, salmon, chicken and nuts
  • Can opener
• Insulin Storage and Switching:[14]
• In disasters, insulin storage can become challenging.
• Insulin that is not currently in use is recommended to be stored in a refrigerator at approximately 36^o F – 46^o F. If unopened and stored in this manner, insulin may be used until the expiration date.
• Insulin products in vials or cartridges (opened or unopened) may be left unrefrigerated at a temperature between 59^oF – 86^o F for up to 28 days. However if the insulin has been altered (diluted or removed from original vial) it should be discarded within 2 weeks.
• Insulin pens that are not in use and are refrigerated can be used until their expiration date.
• Insulin pens that are in use should not be refrigerated. General guidelines for use are as follows:
  • Short-acting insulin pens are good for 28 days
  • NPH pens are good for 14 days
  • NPH combination premixed pens are good for 10 days.
  • Detemir pens are good for 42 days.
  • Glargine pens are good for 28 days.
  • There may be variations based on the formulation so it is important to check to confirm how many days the pens can be used once in use.[15]
• Switching insulin should always be done in consultation with a physician but if this is not possible in an emergency situation, the following website may be referenced: http://www.fda.gov/Drugs/EmergencyPreparedness/ucm085213.htm

Public Health Implications

• Public health preparedness strategies need to address short and long term needs of people with diabetes.
• Healthcare professionals and organizations should be educated about these needs.
• Objectives of disaster management from the viewpoint of public health:[12]
  • Needs Assessments
  • Matching available resources with defined needs
  • Prevention of further adverse health effects
  • Implementation of disease-control strategies
  • Evaluation of the effectiveness of the application of these strategies
  • Improvement in contingency planning for future disasters

Information Resources

• American Association of Clinical Endocrinologists: http://www.empoweryourhealth.org/diabetes-emergency-plan
• American Diabetes Association (ADA): www.diabetes/org/living-with-diabetes/treatment-and-care/medication/tips-for-emergency-preparedness
• Centers for Disease Control and Prevention Clinician Outreach and Communication Activity (COCA): http://emergency.cdc.gov/coca/
• Centers for Disease Control and Prevention Coping with Disaster or Traumatic Event Web page: www.bt.cdc.gov/disasters
• American Diabetes Association Diabetes Forecast February 2006: www.diabetes.orghttp://www.diabetes.org/for-parents-and-kids/living-with-diabetes/emergency- preparedness.jsp