Nephrology 20 (2015) 873–880
Natural disasters and dialysis care in the Asia-Paciﬁc NICHOLAS A GRAY,1,2 MARTIN WOLLEY,3,4 ADRIAN LIEW5 and MASAAKI NAKAYAMA6 1 Department of Renal Medicine and 2The University of Queensland, Sunshine Coast Clinical School, Nambour General Hospital, Nambour, 3Department of Renal Medicine, Royal Brisbane and Women’s Hospital, 4School of Medicine, The University of Queensland, Brisbane, Queensland, Australia; 5Department of Renal Medicine, Tan Tock Seng Hospital, Singapore; and 6Department of Nephrology and Hypertension, Fukushima Medical University School of Medicine, Fukushima, Japan
KEY WORDS: Asia, dialysis, disaster, earthquake, review. Correspondence: A/Prof Nicholas Gray, Renal Unit, Nambour General Hospital, PO Box 547, Nambour, Qld. 4560, Australia. Email: [email protected]
Accepted for publication 22 May 2015. Accepted manuscript online 29 May 2015. doi:10.1111/nep.12522
SUMMARY AT A GLANCE This paper is a timely review of natural disasters in the Asia-Paciﬁc and the provision of urgent dialysis care, including local experience and impact on patients and staff.
ABSTRACT The impact of natural disasters on the provision of dialysis services has received increased attention in the last decade following Hurricane Katrina devastating New Orleans in 2005. The Asia-Pacific is particularly vulnerable to earthquakes, tsunami, typhoons (also known as cyclones and hurricanes) or storms and flooding. These events can seriously interrupt provision of haemodialysis with adverse effects for patients including missed dialysis, increased hospitalization and post-traumatic stress disorder. Furthermore, haemodialysis patients may need to relocate and experience prolonged periods of displacement from family and social supports. In contrast to haemodialysis, most literature suggests peritoneal dialysis in a disaster situation is more easily managed and supported. It has become apparent that dialysis units and patients should be prepared for a disaster event and that appropriate planning will result in reduced confusion and adverse outcomes should a disaster occur. Numerous resources are now available to guide dialysis units, patients and staff in preparation for a possible disaster. This article will examine the disaster experiences of dialysis units in the Asia-Pacific, the impact on patients and staff, methods employed to manage during the disaster and suggested plans for reducing the impact of future disasters.
NATURAL DISASTERS AND THE ASIA-PACIFIC In the period 2003–2012, Asia suffered more natural disasters, with more victims (81.5% of the global total), and greater damages, than any other region in the world1 (Table 1). China, Indonesia, the Philippines and India were among the top five countries to experience natural disasters in the aforementioned decade.1 The growing urbanized population in Asia will result in disasters affecting more people and causing more damage in future. The impact of climate change on the South Asian summer monsoon2 and tropical cyclone intensity3 remains uncertain, although some predict increased frequency and severity of events in the East Asia region.3 However, even without climate change, future increases in income will double tropical cyclone damage.3 Disasters have serious consequences for the delivery of dialysis to people with end-stage kidney disease. The impact of disasters will grow due to increasing uptake of dialysis, a © 2015 Asian Paciﬁc Society of Nephrology
growing and aging population and possibly increased storm frequency and severity. It is therefore essential that dialysis units prepare for a disaster event.
EARTHQUAKES Earthquakes cause immediate deaths, but also complex medical and surgical emergencies in the aftermath, typically when infrastructure such as hospitals and transport routes are destroyed or damaged. Furthermore, earthquakes occur without warning limiting last minute preparation.4 Earthquakes may result in two separate patient populations for renal services to manage – those with crush injury and acute kidney injury (AKI) and those already undergoing chronic dialysis impacted by personal injury or damaged infrastructure. Examples of the impact on dialysis provision in the Asia-Pacific region include the Taiwan Chi-Chi earthquake in 1999,5,6 the Kashmir earthquake in Pakistan in 1995,7 the Hanshin (Kobe) earthquake in 1995,8–11 the Great 873
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Table 1 Natural disaster occurrence and impacts (2003–2012 average): Asia and rest of the world (adapted from Guha-Sapir et al.1) Number of natural disasters
Climatological Geophysical Hydrological Meteorological Total
Damages (2013 US$ billion)
Rest of world
Rest of world
Rest of world
12 21 83 39 155
48 13 111 61 233
40.18 7.19 100.17 28.07 175.61
28.57 1.11 7.55 2.65 39.88
3.59 39.67 18.45 9.55 71.26
8.88 9.78 9.48 57.31 85.45
Climatological includes extreme temperature, drought and ﬁre; geophysical includes earthquake, tsunami, volcano and dry mass movement; hydrological includes ﬂood and wet mass movement; meteorological includes typhoon/cyclone and storm.
Tohoku earthquake and tsunami in 2011,12–16 the Tangshan earthquake in 197617 and the Christchurch earthquake in 2011.18 The majority of deaths after an earthquake occur immediately as a result of massive trauma or asphyxiation,4 but entrapment under collapsed buildings leads to the development of crush syndrome and AKI. Following the Kobe earthquake, an estimated 5% of hospital admissions at one centre suffered crush syndrome, whereas nearby dialysis units and emergency aid centres provided acute dialysis to 180 people.8 A survey after the Chi-Chi earthquake reported 95 cases of rhabdomyolysis, of which 52 experienced AKI and 32 (33.7%) required dialysis.5 The management of crush injury is discussed in detail elsewhere19 and includes early aggressive fluid resuscitation and dialysis. The ability to provide haemodialysis to chronic dialysis patients after an earthquake is impacted by damage to infrastructure. The Hanshin earthquake destroyed two dialysis centres, 36 were partly destroyed, 28 lightly damaged and two undamaged.8 Up to 50 facilities were unable to provide haemodialysis following the disaster and around 3000 patients were dialysed at alternative locations.14 The Tohoku earthquake and tsunami of 2011 led to complete destruction of 11 hospitals and caused severe damage to infrastructure.13,14 Three hundred fourteen dialysis facilities were unable to function in the immediate aftermath, comprising 83% of facilities in Miyagi, 66% in Ibaraki, 57% in Fukushima and 36% in Iwate prefectures.14 The most common reason for inability to operate was damage to water and power supplies, with physical damage to buildings and equipment also contributing.14 Hospitals that were still functional were hampered by power blackouts, and limited supplies of gasoline and consumables, necessitating reduced dialysis hours to accommodate all patients. Staff shortages were also a problem, with the Fukushima nuclear accident resulting in evacuation of many people.14,16 In some facilities nursing numbers were reportedly halved. With repair of infrastructure, 68–90% of dialysis units regained function by 10 days after the disaster.14 Following the Chi-Chi earthquake, the most common causes of dialysis facility failure were reverse osmosis system failure, loss of water supply, damage to haemodialysis facil874
ities, power and telecommunication failure.5 Loss of other infrastructure such as gas and transportation makes provision of haemodialysis difficult, if not impossible.8 Displacement of chronic dialysis (especially haemodialysis) patients following an earthquake is common. Following the 2011 Christchurch earthquake, all 42 haemodialysis patients in the city were transferred to other regions.18 After the Great Tohoku earthquake, 10 906 patients were transferred to other areas for dialysis.12,14 Difficulties included securing transportation, identifying where patients and their families could stay and finding dialysis units with the capacity to manage the extra demand. Evacuation typically results in delays to normal dialysis schedules. In one cohort of over 500 haemodialysis patients evacuated after the Tohoku disaster, a median of 3 days (range 1–10) delay before dialysis was reported.12 The period of patient displacement may last weeks18 and possibly patients may not return at all.14 The evolving nuclear disaster in Fukushima caused a long-term reduction of 40% in prevalent haemodialysis patients in some areas, and significant displacement of staff to other regions, many of whom have not returned.16
FLOODS AND STORMS (INCLUDING TYPHOONS, CYCLONES, HURRICANES) Although the Asia Pacific region is regularly exposed to devastating typhoons and flood events such as Typhoon Haiyan in the Philippines in 2013, there are few reports in the literature of their impact on dialysis patients. In Australia, Cyclone Yasi and associated flooding resulted in evacuation of haemodialysis patients and repatriation after a few days.20 Floods in Thailand in 2011 severely impacted the manufacture of peritoneal dialysis (PD) fluids.21 The majority of literature related to meteorological disasters comes from the hurricane experiences in the USA. Hurricane Katrina affected the New Orleans area in 2005, resulting in the evacuation of more than 1 million people. Dialysis facilities cared for almost 6000 people in the region and were poorly prepared for the disaster. Of 26 dialysis services in the New Orleans area, only three remained operational. The characteristics of the operational services © 2015 Asian Paciﬁc Society of Nephrology
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included above ground generators with good supplies of diesel, a water well and water tanks, electronic medical records, point of care testing devices, useable telephone lines within the facility, and data servers switched to a remote location.7 A telephone survey of patients performed a median of 11 months after the storm found 44% missed at least one dialysis session (17% missed 3 or more sessions). Those who missed dialysis sessions were more likely to be living alone, unaware of the dialysis unit disaster plan, did not evacuate early, were evacuated to a shelter or commenced dialysis within 2 years. There was an increased risk of hospitalization among those who missed three or more dialysis sessions.22 An analysis of data from the US Renal Data System showed an increase in all cause hospitalization immediately following the hurricane, mainly because of renal-related admissions.23 Hurricane Katrina did not impact mortality despite 48% of dialysis clinics being closed for 10 or more days.24 The lessons learned from these experiences led to improved preparedness when Hurricane Sandy affected the east coast of the USA in 2012. Nearly 50% of patients received early dialysis prior to the storm, but those affected still experienced increased emergency department visits, hospitalization and 30 day mortality.25
PREPARATION FOR A DISASTER Preparation for a disaster and development of a disaster plan needs to be well in advance and give consideration to potential types of disaster that may impact a region. The Centre for Research on the Epidemiology of Disasters1 provides historic
data on types and frequency of disaster by country. Although this provides a guide, dialysis units need to consider their local situation to further clarify their risk. This will require consultation with government agencies and review of local data such as geological fault lines, flood zones and risk of inundation from ocean storm surges or tsunami. The resources devoted to disaster preparation will need to be proportionate to the local risk assessment. The Kidney Community Emergency Response Coalition was formed in 2006 and has produced recommendations for disaster preparedness summarized in Table 2. There are numerous resources to guide planning for a disaster7,18,20,26–30 and a selection of online resources for both patients and providers are shown in Table 3. Detailed planning for a disaster will involve local government and hospital administration. This will aid preparation for the common causes of haemodialysis unit failure as well as synchronization with government disaster planning. Details to understand include: awareness of the severity of earthquake that the dialysis unit building can withstand, understanding of water and power supplies both to and within the building (including backup options available), development of emergency transportation plans and access to back up reverse osmosis machines. Table 4 provides practical recommendations for dialysis unit disaster mitigation and planning that can be addressed depending on each individual dialysis unit’s risk assessment. In the case of a typhoon or flood (as opposed to an earthquake), last-minute preparation is possible when the disaster is imminent. For example, the effectiveness of a just-in-time training programme designed to educate non-dialysis staff to
Table 2 Recommendations for disaster preparedness for people with kidney disease (adapted from the Kidney Community Emergency Response Coalition26) Federal, state and local emergency responders Consider needs of renal patients in planning
Nephrology providers Identify a leader
Patients with kidney failure Personal information
• • • •
Prioritize dialysis units for emergency services (e.g. generators and fuel) and restoration of utilities Establish clear contacts with nephrology staff
Facilitate delivery of dialysis
• • •
delivery of supplies
An emergency plan for each individual patient
access for staff and patients
provide alternate sites for treatment Shelters
• • •
Plan to secure equipment, supplies and medical records Contact list for staff and patients
Screen for people with kidney disease
Report the dialysis facilities status immediately after a disaster
medications allergies dialysis facility name and contact details
medical history Emergency supply kit and diet Evacuation
• • •
early if possible
• • •
know the local dialysis facility emergency plan
identify other dialysis facilities in the region Liaise with your dialysis facility notify contact details for family away from the area
follow advice Try to avoid missing haemodialysis sessions
Provide appropriate diet Group dialysis patients together and near a functional dialysis facility
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Table 3 Selected resources for dialysis units and patients Organization Renal Disaster Relief Taskforce (RDRTF) of International Society of Nephrology27 Kidney Community Emergency Response Coalition (KCER)26
‘Task description for volunteers’ ‘Crush syndrome following disasters’ ‘RDRTF crush patients clinical follow-up chart’
‘Preparing for emergencies: a guide for people on dialysis’ ‘GET READY! Handout for patients’ ‘Emergency checklist’ ‘Emergency contacts form’ ‘Preparedness for kidney transplant patients’ ‘Disaster preparedness: a guide for chronic dialysis facilities – second edition’ ‘Restarting dialysis after a disaster presentation’ ‘Technical considerations when bringing haemodialysis facilities’ water systems back on line after Hurricane Katrina’ ‘Planning for emergencies. A guide for people with chronic kidney disease’ ‘Patient information cards’ ‘Nutrition planning for a disaster when you have CKD’ ‘Infection control for peritoneal dialysis (PD) patients after a disaster’
National Kidney Foundation28
Centers for Disease Control and Prevention31
support dialysis staff in a disaster has been demonstrated.32 Other strategies include shortening dialysis hours to provide last-minute haemodialysis to as many patients as possible, moving equipment, supplies and medical records to a safe location, redirecting staff to areas of need,20 contacting all patients and revising their disaster plan, pre-emptive evacuation or identifying evacuation options after the storm, upload electronic medical records to a central database, ensure 2 weeks of supplies are available, and securing the dialysis facility just prior to the disaster.29 Despite Hurricane Katrina highlighting the need for preparation, a survey performed in 2009 in North Carolina found most dialysis patients remained poorly prepared for a disaster.33 This highlights the need for ongoing review and rehearsal of disaster plans.
DIALYSIS MODALITY In any disaster, haemodialysis for maintenance dialysis patients may be impacted due to loss of power, inadequate supply of clean water, staff or disposable equipment shortages and disruption of transportation. As a result, some have suggested that PD is a better option in disaster-prone regions. Compared with the literature on haemodialysis in a disaster, references to PD are generally brief.5,8,10,20,30,34–36 At the time of the Chi-Chi earthquake, 401 patients were managed with PD in the central Taiwan region. Patients had several weeks to 1 month of PD dialysate supplies at home and were able to continue to manage their dialysis independently. Patients managed with automated PD (n = 45) switched to manual exchanges due to loss of electricity. Medical companies successfully managed to deliver dialysate supplies in the 876
weeks following the disaster. Two patients developed peritonitis in the month after the earthquake.5 Most English language literature on PD from Japan comes from the Kobe earthquake.8–10 At the time, the Hyogo Prefecture managed 265 PD patients (4% of the total dialysis population).9,10 Patients were surveyed after the event and most managed PD at home, seven continued PD in an evacuation centre, three were hospitalized and one was transferred.9 Medical companies were pro-active, managing to contact all PD patients within 2.7 days on average, inform treating hospitals of patient’s status and deliver necessary PD equipment.8–10 In the Tohoku earthquake and tsunami, 359 PD patients were in the severely affected districts comprising ∼3% of the dialysis population.37 In contrast to haemodialysis patients, only a minority of PD patients were evacuated (∼30 in total), mostly due to destruction of housing.14,15 Most PD patients continued to dialyse at home and most had adequate supplies of consumables with early assistance from medical companies. In one report from Iwaki city in Fukushima, despite large-scale destruction of infrastructure, 40% of PD patients in this unit continued treatment at home, compared with 3% of haemodialysis patients.15 Patients had five or more days supply of PD fluid, and some patients reduced the number of daily exchanges to extend supplies. The resumption of outpatient services was faster with PD patients, with a 60% patient return rate compared with only 11% of haemodialysis patients.15,16 Persistent shortages of haemodialysis facilities and staff since the disaster have resulted in efforts to increase PD uptake in Fukushima.15,16 The experience with PD in typhoons and floods has also been positive, although most reports are from outside © 2015 Asian Paciﬁc Society of Nephrology
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Table 4 Dialysis unit hazard mitigation and preparation for a disaster (adapted from Kopp et al.7,29 and KCERC26) Building
Earthquake retro-ﬁtting (e.g. above ground water pipes, reduce non-secured items like shelves and machines) and/or build new sites able to withstand earthquakes. Typhoon window shutters. Fire-resistant building materials. Shatter-proof glass. Build in low risk areas for ﬂooding, storm surge or tsunami. If a building is ﬂood prone, ensure supplies are above ﬂood levels. Maps of the facility, emergency exits, evacuation locations, emergency shut-off valves and ﬁre extinguishers. Purchase or rent a generator (if patient evacuation is unlikely to be an option) and seek electrician guidance to ensure it is the correct size. Locate the generator above ﬂood level. Ensure adequate fuel supplies and regular testing. During a ‘boil water alert’, provided reverse osmosis (ensure portable machines available if the main system fails) is used the water may be used for haemodialysis. A deionization unit does not remove microbes and a submicron or endotoxin microﬁlter will be needed. During the Hurricane Katrina emergency, dialysis units with access to on site water (via a well) were able to function. Water may be brought by truck or stored in tanks. Communicate with the local water authority to ensure notiﬁcation of any ‘shock’ treatment with high level chlorine. Test water frequently. Identify the leadership team and media spokesperson. Develop a memorandum of understanding with stakeholders and other dialysis units identiﬁed for evacuation. Update contact information for staff, patients and vendors every 3 months. Toll free telephone numbers. Pre-scripted public service announcements for radio and television. Internet and/or social media sites. Satellite telephone services and other satellite-based systems. Ensure batteries in phones are charged. Create an emergency box for irreplaceable documents including patient medical histories and prescriptions, presence of multi-resistant organisms or infection, advance health directives, contact details for staff, patients and vendors and spare batteries. Store copies and electronic record back-ups off site. Education and training including facility layout, evacuation plans, use of ﬁre extinguishers, staying calm in a disaster, assuming control, emergency telephone numbers, instruction in ‘clamp and cap’, ﬁrst aid, cardiopulmonary resuscitation and managing hazardous materials. Regular updates and training. Mock disaster drill. Staff to have personal plans in place for family, friends and pets. Staff to carry identiﬁcation in event of a disaster. Be aware of the facility disaster plan, including communications. Emergency haemodialysis disconnect procedures and an emergency disconnect pack beside each dialysis machine. Self protection instructions. Instructions for those at home when a disaster occurs. Identify alternate dialysis facilities and accommodation or disaster shelters. Medical alert bracelet or identiﬁer. Communicate with dialysis facility or emergency response personnel their whereabouts to enable patient tracking. Ensure a 2 week supply of medication. Copy of medical records, dialysis prescription. Follow an emergency renal diet (low in potassium, salt and ﬂuid) and ensure supplies are available and not beyond their ‘use by’ date. Have potassium binding resins available. Create a stockpile of supplies. Develop electronic medical records that can be accessed outside the disaster area. Point of care testing devices. Develop a security strategy. Identify alternate dialysis facilities. Identify transportation options in event of infrastructure damage.
Asia.20,30,34,35 Following flooding in India,36 PD allowed flexibility and the ability to provide acute dialysis when haemodialysis was not an option. Box 1 details an example of improvisation with PD. PD is recommended as a preferred treatment modality in disaster-prone areas9,20,30,34 because patients can manage independently with adequate supplies, treatment is flexible © 2015 Asian Paciﬁc Society of Nephrology
and mobile, power and water are not needed and medical companies have historically been supportive. Special care needs to be taken to prevent exit site infections and peritonitis after a disaster, and guidelines are available.38 In addition to expanding the update of PD, some have suggested the use of less water-dependent forms of haemodialysis including sorbent-based machines, sterile 877
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Box 1 Acute peritoneal dialysis in the absence of any dialysis facilities – a case report During the period of United Nations Transitional Administration in East Timor in 2002, an indigenous East Timorese male presented with acute falciparum malaria, complicated by ‘blackwater fever’ and AKI. While receiving treatment with intravenous quinine, the uraemia worsened. In the absence of any haemodialysis facility in the new country, a decision was made to institute acute peritoneal dialysis using the limited resources available. Peritoneal access was achieved using a Foley urinary catheter through a small sub-umbilical incision performed under local anaesthesia, and anchored to the skin via a purse-string suture. A 2 litre peritoneal dialysate solution was made using 1 litre of 5% dextrose and 1 litre of normal saline. Electrolytes were constituted using 5 mL of 10% calcium chloride, 80 mL of 8.4% sodium bicarbonate and 50 mL of 3% sodium chloride solution. The patient underwent four exchanges daily, with a fill volume of 2 litres, for a period of 9 days, following which renal function recovered. He was discharged back to the community after a 3 week hospital stay.
haemodialysis solutions and closed-loop machines.29 However, the limitations with these technologies has restricted widespread uptake.
MANAGEMENT DURING A DISASTER The first priority following a disaster is to ensure staff, patient and facility safety. In the event of a disaster striking while patients are undergoing haemodialysis, initially assess the situation and call for emergency assistance. Protect those in danger and initiate a ‘clamp and cap’ procedure to remove patients from haemodialysis (cutting lines or catheters is not recommended).26 If there is no immediate danger, and power is lost, hand crank the blood pump and then clamp and cap lines. Evacuation to a designated safe area should follow facility guidelines and be followed by a head count.26 Staff should not re-enter a damaged building until it is assessed as structurally sound and clear of hazards. The ‘emergency box’ containing vital patient and staff information should be retrieved. The dialysis facility disaster plan should be activated and the most senior staff member present be placed in charge. A situation assessment must be conducted early to assess patient and staff injuries, and dialysis unit damage. A command centre should be established allowing communication with other emergency personnel, assessment of infrastructure damage, determination of staff availability and assessment of patient’s needs. There must be continuous monitoring of news reports, weather and reports from gov878
ernment disaster agencies. A decision needs to be made as to whether haemodialysis can continue in the facility or evacuation to other predetermined dialysis sites needs to occur. If not functional, patients will need to be contacted and plans implemented for alternate dialysis sites. If the dialysis unit is functional, patients will need to know scheduling, staff will need to be rostered and supplies may need to be delivered. It is likely that patients will present anxious, with other medical problems, and without supplies of medication or adequate shelter.29 Assistance from social workers, dieticians and pharmacists will be essential. External assistance should be sought early. This may be from surrounding dialysis facilities or renal networks. For massive disasters the International Society of Nephrology Renal Disaster Relief Task Force is available to take a leading role. This entity was established following the 1988 Spitak earthquake in Armenia and has assisted at numerous disasters since.27
RECOVERY A disaster may lead to long-term effects for patients and staff. Following Hurricane Katrina, 23.8% of dialysis patients reported symptoms consistent with post-traumatic stress disorder (PTSD), whereas another 18.4% had partial PTSD.39 Furthermore, 45.5% of patients studied had symptoms of depression.40 Following the 2004 Asian tsunami, prolonged grief disorder affected 14.2% overall and 25.9% of bereaved survivors (not dialysis alone) in India.41 A cognitive behavioural intervention by social workers after Hurricane Katrina and Rita resulted in improved general health status, social functioning and reduction in depression scores.42 It is essential to debrief staff following any disaster. This will identify areas for improvement and refinement in the event of another disaster.18,20 Furthermore, many staff may experience loss in the form of possessions, relatives or friends, and may therefore be experiencing their own grief, depression or PTSD. Learning from a disaster to improve future preparedness is essential. The Japanese Association of Dialysis Physicians in collaboration with the Japan Association for Clinical Engineering Technologists operate an information sharing system that has been used in at least 11 disasters and facilitates investigation, research, education and crisis management.43
CONCLUSION Natural disasters are prevalent and unpredictable. The AsiaPacific is at higher risk than most regions and must plan for an increased impact of disasters in the future. Planning and preparation of dialysis facilities and patients is critical, including consideration of dialysis modality. The kidney community has demonstrated an ability to work together at times of disaster for the best possible outcomes for patients. © 2015 Asian Paciﬁc Society of Nephrology
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ACKNOWLEDGEMENTS A/Prof Gray, A/Prof Liew and Prof Nakayama have received speaker’s fees from Baxter Healthcare. Financial support – nil.
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