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COVID-19 disrupted many aspects of domestic violence services including sheltering, in-person advocacy, and access to mental health, visitation, and legal services. Increased demand for services occurred concurrent with the highest levels of pandemic disruptions. Adaptations to many systems and services were made to address survivor’s changing needs. To understand how various aspects of service provision were disrupted during the pandemic, we surveyed a national census of U.S. based domestic violence direct service agencies. Email addresses were collected from online directories and each agency received a link to complete a survey using the online platform Qualtrics. The survey included five sections: services provided; work environment during COVID-19; disruptions caused by COVID-19; personal and organizational disaster preparedness; and demographics. Twenty-two percent of 1,341 agencies responded to the survey. At the start of the pandemic, the most disrupted services were legal and court, sheltering, and mental health/counselling services. Hazard pay, flexible scheduling, and additional information technology support were most frequently mentioned supports provided to mitigate disruptions and support providers and advocates. Disruptions and supports changed over the course of the pandemic. The COVID-19 pandemic disrupted the provision of services and advocacy to victims and survivors of domestic violence. Adaptations were made as new control measures were available (e.g. vaccines) and lessons learned were identified (e.g. successful implementation of virtual legal and court services). Maintaining supportive measures post-pandemic will require continued investment in this chronically underfunded, yet critical, sector and applying lessons learned from COVID-19 related disruptions and adaptations.

Abstract The Greater Fifth Ward (GFW) is a Northeast Houston, Texas, neighborhood with a legacy of industrial contamination and a confirmed cancer cluster. To understand self-rated health in the GFW, community-based participatory research (CBPR), was used to promote the inclusion of all partners. CBPR involves the community during each stage of the research process from design to research dissemination. A complete census was conducted, and 114 surveys were obtained in the environmental justice (EJ) community from July to November 2021. EJ communities shoulder an unfair burden of environmental exposures, pollution, and poor built environments. Mental and physical health were measured using the validated 12-item Short Form Health Survey (SF-12v2). We posited that the Black or African American (Black/AA) community would have lower mental composite scores (MCS) and physical composite scores (PCS) compared to the nation and their White counterparts. The MCS and PCS were calculated and compared against the national mean. Overall, participants had higher MCS and lower PCS than the national mean. Black/AA males and females had lower MCS compared to their White counterparts. White females had the lowest PCS among all respondents, significantly lower than the national average. MCS was lower among those who lived in the neighborhood longer. Burdens from pollution may impact residents’ health and perceived health. Targeted interventions or programs that improve mental or physical health would benefit this community and other inequitably burdened neighborhoods.

Abstract Communicable disease risk is high in refugee camps and reception centers. To better understand the risks for communicable disease diagnoses among refugees and asylum seekers, this study assesses individual- and camp-level risk factors among individuals utilizing Médecins du Monde clinics in four large refugee camps—Elliniko, Malakasa, Koutsochero, and Raidestos—on mainland Greece between July 2016 and May 2017. Descriptive statistics are reported for the demographic characteristics of the study population and for communicable disease burdens within the four camps—Elliniko, Malakasa, Raidestos, and Koutsochero. A hierarchical generalized linear model was used to assess risk factors for communicable disease diagnoses while accounting for individual-level clustering. This study shows marginal patterns in risk factors for communicable disease. Males had marginally higher risk of communicable disease diagnosis than females (OR = 1.12; 95% CI 0.97—1.29), and increased age was more protective against communicable disease for females (OR = 0.957; 95% CI 0.953—0.961) than for males (OR = 0.963; 95% CI 0.959—0.967). Communicable disease risk was significantly different between camps, with Elliniko (OR = 1.58; 95% CI 1.40–1.79) and Malakasa (OR = 1.43; 95% CI 1.25–1.63) having higher odds of communicable disease than Raidestos. The demographic and epidemiologic profiles of displaced populations differ across settings, and epidemiologic baselines for displaced populations are fundamental to evidence-informed provision of humanitarian aid. Further, while influences and risks for negative health outcomes in complex emergencies are broadly, the causal mechanisms that underpin these relationships are not as well understood. Both practitioners and researchers should engage with further research to elucidate the mechanisms through which these risks operate among displaced populations, including multilevel analyses.

Abstract Background Despite the importance of baseline health data for evidence-informed decision-making, these data are rarely available for displaced populations. At the height of the European refugee crisis, most of those seeking asylum in Europe were from regions with high prevalences of communicable and non-communicable diseases. To create an epidemiologic profile for refugees in camps on mainland Greece, this study assessed the prevalence of 11 communicable and non-communicable diseases among refugees utilizing Médecins du Monde (MdM) in-camp clinics. Methods The proportional morbidity of selected diseases among individuals utilizing MdM services were determined from data collected at refugee camp clinics on mainland Greece from April 2016 - July 2017. Overall and age-specific proportional morbidities were reported. Differences in disease burden among refugees from the largest sending countries - Afghanistan and Syria - were compared using proportional morbidity ratios and 95% confidence intervals. Patterns in results were compared with disease burden estimates in sending countries and with findings from comparable settings. Results Respiratory tract infections (RTIs) were the most prevalent outcome. Among RTIs, upper RTIs were most common, with a proportional morbidity of nearly 40%; throughout the study period, over 46% of children under 18 years had at least one upper RTI consultation. Musculoskeletal conditions (3.64%), were the most prevalent non-communicable outcome, followed by hypertension (2.21%) and asthma (1.28%). Afghans were 31.68% more likely than Syrians to have a consultation for at least one condition (PR: 1.32; 95% CI: 1.25, 1.39). The proportional morbidity of RTIs was comparable to sending countries, but there was a comparatively lower burden of other conditions among refugees than literature estimates from sending countries. Conclusion Refugees utilizing MdM clinics in camps had higher burdens of communicable diseases - predominantly RTIs - relative to non-communicable diseases. Non-communicable disease burdens were comparatively lower than reported prevalences from in-country populations. These findings can be attributed to a range of considerations including differences in demographic profiles between sending countries and refugee populations and missed opportunities for utilizing clinical care. Further investment is needed to capture the health profiles of displaced populations to support evidence-informed decision-making processes in humanitarian emergency responses.

Abstract Background Prior to the availability of pharmaceutical control measures, non-pharmaceutical control measures, including travel restrictions, physical distancing, isolation and quarantine, closure of schools and workplaces, and the use of personal protective equipment were the only tools available to public health authorities to control the spread of COVID-19. The implementation of these non-pharmaceutical control measures had unintended impacts on the ability of state and territorial domestic violence coalitions to provide services to victims. Methods A semi-structured interview guide to assess how the COVID-19 pandemic impacted service provision and advocacy generally, and how COVID-19 control measures specifically, created barriers to services and advocacy, was developed, pilot tested, and revised based on feedback. Interviews with state and territorial domestic violence coalition executive directors were conducted between November 2021 and March 2022. Transcripts were inductively and deductively coded using both hand-coding and qualitative software. Results Forty-five percent (25 of 56) of state and territorial domestic violence coalition executive directors representing all 8 National Network to End Domestic Violence (NNEDV) regions were interviewed. Five themes related to the use of non-pharmaceutical pandemic control measures with impacts on the provision of services and advocacy were identified. Conclusions The use of non-pharmaceutical control measures early in the COVID-19 pandemic had negative impacts on the health and safety of some vulnerable groups, including domestic violence victims. Organizations that provide services and advocacy to victims faced many unique challenges in carrying out their missions while adhering to required public health control measures. Policy and preparedness plan changes are needed to prevent unintended consequences of control measure implementation among vulnerable groups as well as to identify lessons learned that should be applied in future disasters and emergencies.

Media reports and data from public health professional membership organizations have demonstrated high levels of harassment experienced by public health workers throughout the COVID-19 response. We documented personal and political threats to public health workers across the first 12 months of pandemic response through a longitudinal survey completed in Fall 2020 and Summer 2021. The web-based survey was distributed to respondents using the Qualtrics survey platform. Survey items measured domains including demographic information, public health roles and training, mental and physical health, and work-life balance. Respondents were also asked if they had received any personal or political threats, from whom these threats were received, and completed an open-ended question describing the nature of the threats. Among the 85 public health workers completing both surveys, threats from members of the public and from elected and appointed leaders were most prevalent at both timepoints; however, as the pandemic response progressed, the nature of threats to public health workers changed. While those remaining in the public health workforce may be more resilient to these threats, increased prevalence of personal and political threats has the potential to deter new graduates from entering the field, impacting the public health system's future response capacity.

Objectives: Vaccine hesitancy, including vaccination delay and refusal, threatens gains made to improve global health. Recent outbreaks of measles attributed to lower vaccination rates and the COVID-19 pandemic have added urgency to the need for current and future healthcare providers to effectively identify and address barriers to vaccination. Study design: Cross-sectional interviews and online surveys. Methods: Healthcare providers in Cluj-Napoca, Romania were interviewed. Transcripts were translated for inductive coding. Medical students at the Iuliu Hațieganu University completed an online survey accessed via a university social media group. Descriptive statistics were calculated for each survey question. Results: Practicing clinicians lack confidence in their ability to communicate risks and benefits of vaccination, including the need to use social media for this purpose and seek greater support from the Ministry of Health and parents. Medical students have higher confidence in national and local health officials than practitioners. Conclusion: Neither practicing clinicians nor medical students feel adequately prepared to effectively address vaccine hesitancy. They need additional support from health authorities, particularly around communication and policy.

Background. Hurricane Harvey made landfall along the Texas Gulf Coast as a Category 4 hurricane on August 25, 2017, producing unprecedented precipitation that devastated coastal areas. Catastrophic flooding in the City of Houston inundated industrial and residential properties resulting in the displacement and transfer of soil, sediment, and debris and heightening existing environmental justice (EJ) concerns. Objectives. The primary aim of this study was to evaluate the presence, distribution, and potential human health implications of polycyclic aromatic hydrocarbons (PAHs) in a residential neighborhood of Houston, Texas following a major hurricane. Methods. Concentrations of PAHs in 40 soil samples collected from a residential neighborhood in Houston, Texas were measured. Spatial interpolation was applied to determine the distribution of PAHs. Potential human health risks were evaluated by calculating toxicity equivalency quotients (TEQs) and incremental excess lifetime cancer risk (IELCR). Results. Total priority PAH concentrations varied across samples (range: 9.7 × 101 ng/g-1.6 × 104 ng/g; mean: 3.0 × 103 ng/g ± 3.6 × 103 standard deviation). Spatial analysis indicated a variable distribution of PAH constituents and concentrations. The IELCR analysis indicated that nine of the 40 samples were above minimum standards. Conclusions. Findings from this study highlight the need for fine scale soil testing in residential areas as well as the importance of site-specific risk assessment. Competing Interests. The authors declare no competing financial interests.

Low-impact development (LID) is a planning and design strategy that addresses water quality and quantity while providing co-benefits in the urban and suburban landscape. The Long-Term Hydrologic Impact Assessment (L-THIA) model estimates runoff and pollutant loadings using simple inputs of land use, soil type, and climatic data for the watershed-scale analysis of average annual runoff based on curve number analysis. Using Scopus, Web of Science, and Google Scholar, we screened 303 articles that included the search term “L-THIA”, identifying 47 where L-THIA was used as the primary research method. After review, articles were categorized on the basis of the primary purpose of the use of L-THIA, including site screening, future scenarios and long-term impacts, site planning and design, economic impacts, model verification and calibration, and broader applications including policy development or flood mitigation. A growing body of research documents the use of L-THIA models across landscapes in applications such as the simulations of pollutant loadings for land use change scenarios and the evaluation of designs and cost-effectiveness. While the existing literature demonstrates that L-THIA models are a useful tool, future directions should include more innovative applications such as intentional community engagement and a focus on equity, climate change impacts, and the return on investment and performance of LID practices to address gaps in knowledge.

Abstract Background In the last decade there has been an increase in community-based organizations providing support and educational outreach to populations effected by hazards. Prior research has demonstrated various roles that community social capital can play in both the enhancement of disaster preparedness and the mitigation of physical and mental health impacts following a natural disaster. Methods To assess self-reported health of residents of South Houston, Texas impacted by Hurricane Harvey, attendees of a community event completed a survey that included the 12 item short form health survey version 2 (SF-12v2). Results Although survey participants were older and more likely to be African-American than the overall population of Houston, they had higher mental health composite scores that the national average, with increases in mental wellbeing associated with a longer length of residence in their neighborhood. Conclusions The City of Houston, with highly segregated, socially vulnerable populations at high risk from natural hazards, should consider ways to support community engagement around disaster preparedness, response, and recovery that may build community cohesion and improve post-disaster mental health.

Abstract Background To estimate changes in the cost and utilization of Medicare among beneficiaries over age 65 who have been impacted by a natural disaster, we merged publically available county-level Medicare claims for the years 2008–2012 with Federal Emergency Management Agency (FEMA) data related to disasters in each U.S. County from 2007 to 2012. Methods Fixed-effects generalized linear models were used to calculate change in per capita costs standardized by region and utilization per 1000 beneficiaries at the county level. Aggregate county demographic characteristics of Medicare participants were included as predictors of change in county-level utilization and cost. FEMA data was used to determine counties that experienced no, some, high, and extreme hazard exposure. FEMA data was merged with claims data to create a balanced panel dataset from 2008 to 2012. Results In general, both cost and utilization of Medicare services were higher in counties with more hazard exposure. However, utilization of home health services was lower in counties with more hazard exposure. Conclusions Additional research using individual-level data is needed to address limitations and determine the impacts of the substitution of services (e.g., inpatient rehabilitation for home health) that may be occurring in disaster affected areas during the post-disaster period.

Background: Elevated rates of mental morbidity have been reported among residents of areas exposed to hurricanes. This study aims to assess the self-rated mental health of Texas residents exposed to Hurricane Harvey and identify factors associated with variations in self-rated mental health. Methods: The 12-item Short Form Health Survey (SF-12) was administered to 1086 residents of the Texas Gulf Coast exposed to Hurricane Harvey. Responses were scored using the algorithm recommended by Quality Metric. A multiple linear regression model was fitted to identify the factors that predicted the respondents' mental component summary scores (MCS). Results: Texas Gulf Coast residents exposed to Harvey exhibited poorer self-rated mental health than the U.S national population (Mean MCS = 34.58 (SD = 8.89)). Respondents with graduate or professional degrees, older adults, and those with higher perception of surge risk had better reported mental health after Hurricane Harvey, while females and mobile home residents had poorer reported mental health. Conclusion: Residents of areas exposed to Hurricane Harvey reported poorer self-rated mental health compared to national standards. These findings support the enhanced provision of mental health services after a disaster, and suggest that they may be most effective when integrated with economic and educational programs and directed towards populations that are younger and less-educated in addition to women with children as well as those who live in mobile homes. Keywords: Mental health, Texas, Hurricane, Harvey, Disaster

Background: Socially vulnerable residents of US Gulf Coast counties have higher exposure to physical hazards and disaster-associated risks. Evacuation is one way to mitigate the consequences of disaster exposure among socially vulnerable populations. However, it is unknown whether existing evacuation shelter capacity and locations in designated hurricane evacuation zones of Texas are adequate to accommodate persons with housing and transportation needs. This study estimated the evacuation shelter deficit arising from demand from socially vulnerable residents of the Houston-Galveston area. Methods: Spatial statistical methods including Global Moran’s I and Getis-Ord (Gi*) were used to measure spatial autocorrelation and identify census tracts in the study area with high (hot spots) and low (cold spots) social vulnerability in both housing and transportation domains. The shelter deficit in each county within the study area was estimated as well as for the entire Houston-Galveston Metropolitan Statistical Area. Results: Designated evacuation zones in the Houston-Galveston area have an overall shelter deficit of 163 317 persons. Shelters in the area can only accommodate 36% of evacuees with significant housing and transportation needs, while 3 of 4 counties had county-specific evacuation shelter deficits. The highest deficits were in Harris County, where Houston is located, and the lowest were in Matagorda County, a rural county southwest of Harris County. Conclusion: Emergency managers and other authorities should consider data related to demand from socially vulnerable residents for public shelters during disasters and increase shelter capacity in certain locations to address evacuation shelter shortage for vulnerable persons in designated evacuation zones of Texas.

Objective: Nearly 300 million people in India use some type of tobacco product, with about 60% of those using smokeless tobacco. Smokeless tobacco use has been associated with a number adverse health outcomes in India and across South Asia. Method: A cross-sectional study of outpatients at a dental hospital in Navi Mumbai, India was conducted between January and June 2015. Trained interviewers administered a 19-item questionnaire to all patients receiving regular dental care. In addition to demographic information, data about the use of smokeless tobacco was collected. Nicotine dependence was assessed using the six-item Fagerstrom Nicotine Dependence Scale, adapted for smokeless tobacco. Results: Approximately one third of 1,067 respondents (30.55%; N = 326) reported use of smokeless tobacco. Neither use of smokeless tobacco nor nicotine dependence was associated with any demographic variables. High nicotine dependence was associated with a younger age of initiation of smokeless tobacco use (RD = 0.14; 95% CI: 0.03, 0.25) and with frequency of use, with those who reported daily use having an excess risk of high nicotine dependence of 14% (95% CI: 2%, 27%). Conclusion: To reduce dependence on smokeless tobacco in India and subsequent adverse health outcomes, interventions should emphasize a combination of policy and public health interventions focused on increasing the age at which a person initially uses smokeless tobacco and decreasing the frequency of use.

Although rainfall patterns are complex and difficult to predict, climate models suggest precipitation in Texas will occur less frequently and with greater intensity in the future. In combination with rapid population growth and development, extreme rainfall events are likely to lead to flash floods and necessitate swift water rescues. Swift water rescues are used to retrieve person(s) from swift water flowing at a rate of 1 knot or greater. Data were obtained from the Texas Fire Marshal’s Office and analyzed to describe spatial and temporal characteristics of rescues. Between 2005 and 2014, 3256 swift water rescues were reported from 136 of 254 (54%) counties. Over half (54.6%, n = 1777) occurred in counties known as Flash Flood Alley, which includes Texas’ largest and fastest growing cities. Less than 1.0% (n = 18) were reported from 49 counties designated as completely rural, or with an urban population less than 2500. Increases in swift water rescues were seen between March and September and during major weather events such as tropical storms. Because county-level data was utilized and demographic data was missing in all but 2% (n = 47) of the incidents, our ability to identify populations at risk or target interventions in the future using this data is limited. Despite the frequency of flash flood events and swift water rescues in Texas, knowledge gaps persist that should be addressed through the conduct of interdisciplinary research by epidemiologists and climatologists and by disseminating evidence-based health education and safety programs, particularly in rapidly growing counties that make up Texas’ Flash Flood Alley.

The need for a well-prepared public health workforce to prepare for and respond to threats of terrorism, infectious diseases, and other public health emergencies is well documented, as is the reality that the public health workforce in the United States is under-trained and unprepared to handle public health emergencies. The impact of training on the public health workforce is often measured by the volume of training completed and post-course evaluation data. A survey of current, high-volume users (n = 759) of the University of North Carolina Center for Public Health Preparedness Training Web Site, defined as individuals who had completed 12 or more training modules was conducted in order to determine if measurable changes in preparedness and response knowledge and capacity were brought about by the trainings. Two-hundred and seventy respondents completed the survey (response rate = 36%), with 52% reporting employment in governmental public health. Individual changes reported as a result of training included increased personal satisfaction (71%), increased job satisfaction (38%), and recognition by supervisors for training completion (23%); Organizational changes included updates to training plans (19%), making trainings mandatory (19%), and revising standard operating procedures (13%). Results from this survey indicate that the knowledge learned from completing online trainings led to changes in individuals and, to a lesser extent, changes in organizations.

Rural counties face unique challenges with regard to disaster vulnerability and resilience. We compared the quality of hazard mitigation plans (HMPs) completed in accordance with provisions of the Disaster Mitigation Act of 2000 from 21 urban and 36 rural counties in three southeastern states. HMPs were content analyzed to calculate a score for six principles of plan quality. Generalized linear models were used to assess how the mean number of items within each of the six principles was related to urban status, adjusting for total county population and state-level differences. Adjusted mean ratios were higher in urban areas for goals, fact base, policies and participation. Rural areas performed better than urban counterparts in both implementation and monitoring and inter-organizational coordination. Our results suggest that there are important differences in hazard mitigation plan quality between urban and rural counties. Future research should explore characteristics of urban and rural counties that explain the observed differences, and whether such differences can help explain the inequalities in response and recovery to disasters between urban and rural counties.