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Ayoub A, Wainwright HM, Sansavini G, Gauntt R, Saito K. Resilient design in nuclear energy: Critical lessons from a cross-disciplinary analysis of the Fukushima Dai-ichi nuclear accident. iScience 2024; 27:109485. [PMID: 38571761 PMCID: PMC10987892 DOI: 10.1016/j.isci.2024.109485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 01/21/2024] [Accepted: 03/08/2024] [Indexed: 04/05/2024] Open
Abstract
This paper presents a multidisciplinary analysis of the Fukushima Dai-ichi Nuclear Power Plant accident. Along with the latest observations and simulation studies, we synthesize the time-series and event progressions during the accident across multiple disciplines, including in-plant physics and engineering systems, operators' actions, emergency responses, meteorology, radionuclide release and transport, land contamination, and health impacts. We identify three key factors that exacerbated the consequences of the accident: (1) the failure of Unit 2 containment venting, (2) the insufficient integration of radiation measurements and meteorology data in the evacuation strategy, and (3) the limited risk assessment and emergency preparedness. We conclude with new research and development directions to improve the resilience of nuclear energy systems and communities, including (1) meteorology-informed proactive venting, (2) machine learning-enabled adaptive evacuation zones, and (3) comprehensive risk-informed emergency planning while leveraging the experience from responses to other disasters.
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Affiliation(s)
- Ali Ayoub
- Department of Nuclear Science and Engineering, Massachusetts Institute of Technology (MIT), Cambridge, MA, USA
| | - Haruko M. Wainwright
- Department of Nuclear Science and Engineering, Massachusetts Institute of Technology (MIT), Cambridge, MA, USA
| | - Giovanni Sansavini
- Department of Mechanical and Process Engineering, ETH Zurich, Zurich, Switzerland
| | - Randall Gauntt
- Severe Accident Analysis Department, Sandia National Laboratories, Albuquerque, NM, USA
| | - Kimiaki Saito
- Fukushima Environmental Safety Center, Japan Atomic Energy Agency, Fukushima, Japan
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Yasuda H. Implications of the evacuation of hospitalized patients in a nuclear emergency. Front Public Health 2023; 11:1217118. [PMID: 37554727 PMCID: PMC10404715 DOI: 10.3389/fpubh.2023.1217118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 06/26/2023] [Indexed: 08/10/2023] Open
Abstract
In the accident at the Fukushima Daiichi nuclear power station following the Great East Japan Earthquake and tsunami, more than 50 hospital patients died during or soon after evacuation, primarily owing to the interruption of necessary medical care. To prevent the occurrence of such losses in the future, the focus of evacuation decisions should be on the health status of individual patients and not on currently evaluated non-human aspects such as the geophysical conditions and the status of the accident facility. This brief research report provides a conceptual basis considering the principle of justification for making more appropriate decisions on the evacuation of hospitalized patients by balancing radiological risks and evacuation-induced health risks. This research report is expected to foster discussions among stakeholders on how to protect vulnerable people more appropriately in nuclear emergencies.
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Affiliation(s)
- Hiroshi Yasuda
- Research Institute for Radiation Biology and Medicine, Hiroshima University, Minami-ku, Hiroshima, Japan
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Miyamori D, Yoshida S, Kashima S, Koike S, Ishii S, Okazaki Y, Ikeda K, Matsumoto M. How the 2018 Japan Floods Impacted Nursing Home Admissions for Older Persons: A Longitudinal Study Using the Long-Term Care Insurance Comprehensive Database. J Am Med Dir Assoc 2023; 24:368-375.e1. [PMID: 36587929 DOI: 10.1016/j.jamda.2022.11.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 11/28/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVES As disasters become more frequent because of global warming, countries across the world are seeking ways to protect vulnerable older populations. Although these conditions may increase nursing home admission (NHA) rates for older persons, we know of no studies that have directly tested this hypothesis. DESIGN This was a retrospective cohort study. SETTING AND PARTICIPANTS We analyzed data from long-term care insurance (LTCI) users in 3 Japanese prefectures that incurred heavy damage from the 2018 Japan Floods, which is the largest recorded flooding disaster in national history. Specifically, we extracted NHA data from the LTCI comprehensive database, both for disaster-affected and unaffected individuals. METHODS We employed the Cox proportional hazards model to calculate multivariate-adjusted hazard ratios (HRs) for NHAs within a 6-month period following the 2018 Japan Floods, with adjustments for potential confounding factors. RESULTS Of the 187,861 individuals who used LTCI services during the investigated period, we identified 2156 (1.1%) as disaster affected. The HR for NHA was significantly higher for disaster-affected (vs unaffected) individuals (adjusted HR 3.23: 95% CI 2.88‒3.64), and also higher than the HRs for older age (90-94 years vs 65-69 years: 2.29, CI 1.93‒2.70), cognitive impairment (severe impairment vs normal: 1.40, CI 1.25‒1.57), and physical function (bedridden vs independent: 2.27, CI 1.83‒2.70). According to our subgroup analyses, the adjusted HR for disaster-affected individuals unable to feed themselves was 6.00 (CI 3.68‒9.79), with a significant interaction between the 2 variables (P = .01). CONCLUSIONS AND IMPLICATIONS Natural disasters increase the risk of NHA for older persons, especially those who are unable to feed themselves. Health care providers and policymakers should understand and prepare for this emerging risk factor.
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Affiliation(s)
- Daisuke Miyamori
- Department of General Internal Medicine, Hiroshima University Hospital, Hiroshima, Japan; Department of Community-Based Medical System, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan.
| | - Shuhei Yoshida
- Department of General Internal Medicine, Hiroshima University Hospital, Hiroshima, Japan; Department of Community-Based Medical System, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Saori Kashima
- Environmental Health Sciences Laboratory, Graduate School of Advanced Science and Engineering, Hiroshima University, Hiroshima, Japan
| | - Soichi Koike
- Division of Health Policy and Management, Center for Community Medicine, Jichi Medical University, Tochigi, Japan
| | - Shinya Ishii
- Department of Medicine for Integrated Approach to Social Inclusion, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yuji Okazaki
- Department of General Internal Medicine, Hiroshima University Hospital, Hiroshima, Japan; Department of Emergency Medicine, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
| | - Kotaro Ikeda
- Department of General Internal Medicine, Hiroshima University Hospital, Hiroshima, Japan; Department of Community-Based Medical System, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Masatoshi Matsumoto
- Department of Community-Based Medical System, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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Terui T, Kunii Y, Hoshino H, Kakamu T, Hidaka T, Fukushima T, Anzai N, Gotoh D, Miura I, Yabe H. Post-evacuation return of psychiatric hospital inpatients evacuated to hospitals outside the Fukushima prefecture after the nuclear accident: A Retrospective Cohort Study. Int J Soc Psychiatry 2022:207640221141019. [PMID: 36464861 DOI: 10.1177/00207640221141019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Post-evacuation return after mandatory hospital evacuation due to complicated disasters is often overlooked and not well-discussed. AIMS In this study, we explored the factors which are related to the ease or difficulty of the post-evacuation return to Fukushima prefecture of psychiatric inpatients who had been evacuated to hospitals outside the prefecture because of the Great East Japan Earthquake (GEJE) and subsequent Fukushima Daiichi Nuclear Power Plant (FDNPP) accident. METHOD This retrospective cohort study included evacuated psychiatric hospital inpatients who were registered in the Matching Project for Community Transition (MPCT) and had been traced until July 31, 2019. A total of 531 patients were included for the analyses. Univariable and multivariable analysis were conducted to detect the patients' traits including their psychiatric/physical backgrounds which were associated with their outcome - the time from GEJE to the date of return to Fukushima. RESULTS Over half of the patients returned to Fukushima. In the multivariable analysis, the patients' gender (male), age (older), and psychiatric diagnoses of schizophrenia, schizotypal and delusional disorders (ICD-10, F20-29) showed lower hazard ratio (HR) and statistically significant association with the difficulties of post-evacuation return. Meanwhile, disorders of psychological development (F80-89), diseases of the nervous (G00-99, except G40-41) and genitourinary (N00-99) systems showed higher HR and statistically significant association with the ease of return. CONCLUSIONS The specific characteristics of the psychiatric inpatients including their psychiatric and physical status are associated with their post-evacuation return to their hometown. These results indicated that the evacuated hospitals' practitioners and staffs from the MPCT understood the necessity of the earlier return of inpatients to their hometown. Moreover, clinicians should pay more attention to some symptoms unique to psychiatric patients which contributed to their difficulties in returning safely or expressing their hope to return.
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Affiliation(s)
- Toshihiro Terui
- Department of Neuropsychiatry, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Yasuto Kunii
- Department of Disaster Psychiatry, International Research Institute of Disaster Science, Tohoku University, Aoba-ku, Sendai, Japan
| | - Hiroshi Hoshino
- Department of Neuropsychiatry, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Takeyasu Kakamu
- Department of Hygiene and Preventive Medicine, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Tomoo Hidaka
- Department of Hygiene and Preventive Medicine, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Tetsuhito Fukushima
- Department of Hygiene and Preventive Medicine, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Nobuo Anzai
- Graduate School of Clinical Psychology, Teikyo Heisei University, Toshima-Ku, Tokyo, Japan
| | - Daisuke Gotoh
- Department of Neuropsychiatry, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Itaru Miura
- Department of Neuropsychiatry, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Hirooki Yabe
- Department of Neuropsychiatry, Fukushima Medical University School of Medicine, Fukushima, Japan
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Miyamori D, Yoshida S, Kashima S, Koike S, Ishii S, Matsumoto M. Discontinuation of long-term care among persons affected by the 2018 Japan Floods: a longitudinal study using the Long-term Care Insurance Comprehensive Database. BMC Geriatr 2022; 22:168. [PMID: 35232379 PMCID: PMC8886770 DOI: 10.1186/s12877-022-02864-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 02/22/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Most older people with disabilities or illnesses continue to use long-term care (LTC) services for the rest of their lives. However, disasters can cause a discontinuation of LTC services, which usually means tragic outcomes of affected persons. In view of the recent progression of population aging and the increase in natural disasters, this study focuses on the impact of disasters on older people's discontinuation of LTC services, and those more risk of such discontinuation than others. However, current evidence is scarce. METHODS We conducted a retrospective cohort study with 259,081 subjects, 2,762 of whom had been affected by disaster and 256,319 who had not been affected during the 2018 Japan Floods. The sample in the three most disaster-affected prefectures was drawn from the Long-term Care Insurance Comprehensive Database and included older people certified with care-need level. The observation period was two months before the disaster and five months after it. We calculated the hazard ratio (HR) of municipality-certified subjects affected by the disaster versus those who were not. Subgroup analyses were conducted for categories of individual-, facility- and region-associated factors. RESULTS Affected persons were twice as likely to discontinue LTC services than those who were not affected (adjusted HR, 2.06 95% CI, 1.91-2.23). 34% of affected persons whose facilities were closed discontinued their LTC services at five months after the disaster. A subgroup analysis showed that the risk of discontinuing LTC services for affected persons compared to those who were not affected in the relatively younger subgroup (age < 80: adjusted HR, 2.55; 95% CI, 2.20-2.96 vs. age ≥ 80 : 1.91; 1.75-2.10), and the subgroup requiring a lower level of care (low: 3.16; 2.74-3.66 vs. high: 1.71; 1.50-1.96) were more likely to discontinue than the older and higher care level subgroups. CONCLUSIONS A natural disaster has a significant effect on the older people's discontinuation of LTC services. The discontinuations are supposedly caused by affected persons' death, hospitalization, forced relocation of individuals, or the service provider's incapacity. Accordingly, it is important to recognize the risk of disasters and take measures to avoid discontinuation to protect older persons' quality of life.
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Affiliation(s)
- Daisuke Miyamori
- Department of General Internal Medicine, Hiroshima University Hospital, Hiroshima, Japan. .,Department of Community-Based Medical System, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan.
| | - Shuhei Yoshida
- Department of Community-Based Medical System, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Saori Kashima
- Environmental Health Sciences Laboratory, Graduate School of Advanced Science and Engineering, Hiroshima University, 1-5-1 Kagamiyama, Higashi-Hiroshima, Hiroshima, Japan
| | - Soichi Koike
- Division of Health Policy and Management, Center for Community Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, Japan
| | - Shinya Ishii
- Department of Medicine for Integrated Approach to Social Inclusion, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Masatoshi Matsumoto
- Department of Community-Based Medical System, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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The Role of Emergency Medical Services in Earthquake Response: Integrating the ABC Approach of Israel's Magen David Adom. Disaster Med Public Health Prep 2021; 15:770-776. [PMID: 32624082 DOI: 10.1017/dmp.2020.124] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Throughout history, earthquakes have caused devastation and loss of life. Emergency medical services (EMS) plays a vital role in the response to any mass-casualty incident or disaster. Magen David Adom, Israel's premier EMS organization, has a unique strategy known as the ABC approach to earthquake response. It involves thousands of salaried workers and trained volunteers who are prepared to respond to an earthquake based on the extent of the disaster. Depending on the amount of destruction, they will be working locally or available to help in other areas. A Level A earthquake causes local destruction and minimal casualties. Any EMS responders in that area as well as in surrounding areas will be available to help. Furthermore, all responders will need to work automatically and autonomously. A Level B earthquake causes extensive destruction, and all responders in the region will be busy caring for the victims. Anyone available outside of the region will come and help. A Level C earthquake is completely devastating, and all workers nationwide will be involved in responding to the catastrophe. The role of EMS responders using the ABC approach to earthquake response, as described here, may be integrated in part or whole in other EMS systems.
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Ohba T, Tanigawa K, Liutsko L. Evacuation after a nuclear accident: Critical reviews of past nuclear accidents and proposal for future planning. ENVIRONMENT INTERNATIONAL 2021; 148:106379. [PMID: 33453652 DOI: 10.1016/j.envint.2021.106379] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 01/03/2021] [Accepted: 01/04/2021] [Indexed: 06/12/2023]
Abstract
Standards and guidelines for preparedness and response in the case of a nuclear accident cover radiation protection, health management and communication with affected populations. Decision makers use these recommendations to decide on measures that protect people residing around a nuclear power plant that suffers an accident from radiation exposure; for example, sheltering, evacuation and relocation. While technological and radiological criteria exist for these protective measures, studies on past radiological and nuclear emergencies have shown that evacuation and relocation result in serious health effects; this needs to be considered in accident preparedness and responses in the future. Within the framework of the Nuclear Emergency Situations Improvement of Medical and Health Surveillance (SHAMISEN) (Ohba et al., 2020), a critical review of recommendations and experiences of previous major nuclear accidents was conducted, and the current paper focuses on the lessons learned about evacuation and relocation. We reviewed the contents of official documents and literature relating to the evacuation and relocation of residents, and to the evacuation of medical and other facilities in the three largest nuclear accidents to date: the Three Mile Island accident, Chernobyl accident, and Fukushima accident. We developed recommendations classified into the preparedness phase, early and intermediate phases, and recovery phase after an accident. In the cases of Three Mile Island and Fukushima, the evacuation area was set at 8-10 km from the nuclear power plant in the disaster prevention plan, and emergency responses, such as information provision and evacuation, had been developed only in this area. When the Fukushima accident occurred, evacuation beyond this area was urgently planned or instructed, resulting in marked confusion, such as forced multiple evacuations and relocations for long periods. Furthermore, information was lacking, and personal protective measures such as respiratory protection and iodine prophylaxis were not applied to evacuees. In hospital and facility evacuation, it became more difficult to implement evacuation owing to a lack of advance planning and support in the event of the accident. In Fukushima, more than 60 people in hospitals and nursing care facilities died during or soon after evacuation. In long-term relocation, in addition to continuing adverse mental effects, there were health effects relating to relocation, such as lifestyle-related disease. The return of residents to the evacuation area required many issues, such as a delayed recovery of the living environment, to be overcome in addition to measures to reduce the effects of radiation. Recommendations for evacuation in the SHAMISEN framework were developed (SHAMISEN Consortium, 2017; Liutsko et al., 2020) from these lessons of previous accidents.
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Affiliation(s)
- Takashi Ohba
- Fukushima Medical University, 1 Hikarigaoka, 9601295 Fukushima, Japan
| | - Koichi Tanigawa
- Futaba Medical Center, 817-1 Otsuka, Moto-oka, Tomioka Town, Futaba-gun, 9791151 Fukushima, Japan.
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Gotoh D, Kunii Y, Terui T, Hoshino H, Kakamu T, Hidaka T, Fukushima T, Yabe H. Markedly higher mortality among psychiatric inpatients mandatorily evacuated after the Fukushima Daiichi Nuclear Power Plant accident. Psychiatry Clin Neurosci 2021; 75:29-30. [PMID: 32981195 DOI: 10.1111/pcn.13158] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 08/22/2020] [Accepted: 09/23/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Daisuke Gotoh
- Department of Neuropsychiatry, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Yasuto Kunii
- Department of Neuropsychiatry, Fukushima Medical University School of Medicine, Fukushima, Japan.,Department of Disaster Psychiatry, International Research Institute of Disaster Science, Tohoku University, Sendai, Japan
| | - Toshihiro Terui
- Department of Neuropsychiatry, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Hiroshi Hoshino
- Department of Neuropsychiatry, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Takeyasu Kakamu
- Department of Hygiene and Preventive Medicine, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Tomoo Hidaka
- Department of Hygiene and Preventive Medicine, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Tetsuhito Fukushima
- Department of Hygiene and Preventive Medicine, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Hirooki Yabe
- Department of Neuropsychiatry, Fukushima Medical University School of Medicine, Fukushima, Japan
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Sawano T, Nishikawa Y, Ozaki A, Leppold C, Takiguchi M, Saito H, Shimada Y, Morita T, Tsukada M, Ohira H, Tsubokura M. Premature death associated with long-term evacuation among a vulnerable population after the Fukushima nuclear disaster: A case report. Medicine (Baltimore) 2019; 98:e16162. [PMID: 31277119 PMCID: PMC6635282 DOI: 10.1097/md.0000000000016162] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE The health vulnerability of certain populations such as children, the elderly and individuals with illnesses or physical disability can become significant in disasters. After the 2011 Fukushima Daiichi Nuclear Power Plant (FDNPP) accident, significant health impacts on vulnerable populations were observed during early or mid-term phase of the disaster, presumably associated with the evacuation. However, there is limited information available on the health impacts owing to long-term evacuation after disaster among them. PATIENT CONCERNS A 56-year-old physically challenged male with arteriovenous malformation on his right lower limb, diagnosed when he was 2 years' old, lived near the FDNPP. He and his family were forced to evacuate immediately after the accident. DIAGNOSIS Three months after evacuation following the FDNPP accident, he developed a refractory foot ulcer associated with atrial fibrillation and congestive cardiac failure because of deterioration of arteriovenous malformation, presumably led by repeated evacuations. INTERVENTION Although anticoagulation therapy and diuretic therapy improved his cardiac failure in the initial admission, he decided to only be treated with supportive care after revelation that his arteriovenous malformation was no longer eligible for aggressive intervention. OUTCOME Three years after the long-term evacuation in temporary houses, the patient died of bleeding and infection of the ulcer. LESSONS This case suggests that long-term evacuation for individuals with physical disability may lead to significant health impacts, and even premature death, through the deterioration of daily life activities due to physical and psychological burdens. This case presents a need for further research on ways that disasters impact the health of individuals with physical disabilities, and greater disaster preparation for the needs of populations with physical disabilities.
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Affiliation(s)
- Toyoaki Sawano
- Department of Surgery, Minamisoma Municipal General Hospital
- Department of Public Health, Fukushima Medical University School of Medicine
| | - Yoshitaka Nishikawa
- Department of Internal Medicine, Soma Central Hospital, Fukushima
- Department of Health Informatics, School of Public Health, Kyoto University, Kyoto
| | - Akihiko Ozaki
- Department of Breast Surgery, Jyoban Hospital of Tokiwa Foundation
- Research Center for Community Health, Minamisoma Municipal General Hospital, Fukushima, Japan
| | - Claire Leppold
- Global Public Health Unit, School of Social and Political Science, University of Edinburgh, Edinburgh, UK
| | - Mai Takiguchi
- Department of Cardiology, Sukagawa Hospital, Fukushima
| | - Hiroaki Saito
- Department of Gastroenterology, Sendai Kousei Hospital, Miyagi
| | - Yuki Shimada
- Department of Neurosurgery, Minamisoma Municipal General Hospital, Fukushima, Japan
| | - Tomohiro Morita
- Department of Internal Medicine, Soma Central Hospital, Fukushima
| | - Manabu Tsukada
- Department of Surgery, Minamisoma Municipal General Hospital
| | - Hiromichi Ohira
- Department of Surgery, Minamisoma Municipal General Hospital
| | - Masaharu Tsubokura
- Department of Public Health, Fukushima Medical University School of Medicine
- Research Center for Community Health, Minamisoma Municipal General Hospital, Fukushima, Japan
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