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Objective: This study aimed to investigate the relationship between the unique weather change and acute ischemic stroke (AIS) in the southern Zhejiang Province of China and to provide evidence for better predicting and preventing stroke., Methods: We retrospectively collected 14,996 ischemic stroke patients data and weather data from January 2019 to December 2021 in the southern Zhejiang Province of China. The correlation and risk between meteorological factors and the number of AIS daily cases were calculated. Wilcoxon rank sum test was used to calculate the difference in the number of cases between typhoon-affected and non-affected periods. A prediction model obeying Poisson regression was established, and the accuracy of the correlation factors in predicting the number of cases was verified., Results: In southern Zhejiang Province, the number of AIS was the highest in summer and the lowest in spring. Stroke onset is associated with temperature, water vapor pressure and typhoons (P < 0.05). The presence of typhoon (RR 0.882; 95% CI 0.834 to 0.933, P < 0.001) was a protective factor, while maximum temperature (RR 1.021; 95% CI 1.008 to 1.033, P = 0.043) and the water vapor pressure (RR 1.036; 95% CI 1.006 to 1.067, P = 0.036) were risk factors. The occurrence under the influence of typhoons was lower than that without the influence of typhoons (P < 0.05). The prediction model can predict the occurrence of stroke., Conclusion: An association was observed between the occurrence of AIS, temperature, water vapor pressure and typhoon in the southern Zhejiang Province of China. Typhoon occurrence was associated with fewer cases. The predictive model may help high-risk populations prevent diseases early and assist hospitals in allocating resources promptly., Competing Interests: Declarations. Ethics approval and consent to participate: The need for ethics approval and consent to participate were waived by the Ethics Committee in Clinical Research of the First Affiliated Hospital of Wenzhou Medical University due to the retrospective nature of this study. We only collected the number of cases with ischemic stroke. No other patient private information was collected and no follow-up of patients was required. Consent for publication: Not Applicable. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Natural disasters trigger complex chains of events within human societies 1 . Immediate deaths and damage are directly observed after a disaster and are widely studied, but delayed downstream outcomes, indirectly caused by the disaster, are difficult to trace back to the initial event 1,2 . Tropical cyclones (TCs)-that is, hurricanes and tropical storms-are widespread globally and have lasting economic impacts 3-5 , but their full health impact remains unknown. Here we conduct a large-scale evaluation of long-term effects of TCs on human mortality in the contiguous United States (CONUS) for all TCs between 1930 and 2015. We observe a robust increase in excess mortality that persists for 15 years after each geophysical event. We estimate that the average TC generates 7,000-11,000 excess deaths, exceeding the average of 24 immediate deaths reported in government statistics 6,7 . Tracking the effects of 501 historical storms, we compute that the TC climate of CONUS imposes an undocumented mortality burden that explains a substantial fraction of the higher mortality rates along the Atlantic coast and is equal to roughly 3.2-5.1% of all deaths. These findings suggest that the TC climate, previously thought to be unimportant for broader public health outcomes, is a meaningful underlying driver for the distribution of mortality risk in CONUS, especially among infants (less than 1 year of age), people 1-44 years of age, and the Black population. Understanding why TCs induce this excess mortality is likely to yield substantial health benefits., (© 2024. The Author(s).)

Importance: Evacuation has been found to be associated with adverse outcomes among nursing home residents during hurricanes, but the outcomes for assisted living (AL) residents remain unknown., Objective: To examine the association between evacuation and health care outcomes (ie, emergency department visits, hospitalizations, mortality, and nursing home visits) among Florida AL residents exposed to Hurricane Irma., Design, Setting, and Participants: Retrospective cohort study using 2017 Medicare claims data. Participants were a cohort of Florida AL residents who were aged 65 years or older, enrolled in Medicare fee-for-service, and resided in 9-digit zip codes corresponding to US assisted living communities with 25 or more beds on September 10, 2017, the day of Hurricane Irma's landfall. Propensity score matching was used to match evacuated residents to those that sheltered-in-place based on resident and AL characteristics. Data were analyzed from September 2022 to February 2024., Exposure: Whether the AL community evacuated or sheltered-in-place before Hurricane Irma made landfall., Main Outcomes and Measures: Thirty- and 90-day emergency department visits, hospitalizations, mortality, and nursing home admissions., Results: The study cohort included 25 130 Florida AL residents (mean [SD] age 81 [9] years); 3402 (13.5%) evacuated and 21 728 (86.5%) did not evacuate. The evacuated group had 2223 women (65.3%), and the group that sheltered-in-place had 14 556 women (67.0%). In the evacuated group, 42 residents (1.2%) were Black, 93 (2.7%) were Hispanic, and 3225 (94.8%) were White. In the group that sheltered in place, 490 residents (2.3%) were Black, 707 (3.3%) were Hispanic, and 20 212 (93.0%) were White. After 1:4 propensity score matching, when compared with sheltering-in-place, evacuation was associated with a 16% greater odds of emergency department visits (adjusted odds ratio [AOR], 1.16; 95% CI, 1.01-1.33; P = .04) and 51% greater odds of nursing home visits (AOR, 1.51; 95% CI, 1.14-2.00; P = .01) within 30 days of Hurricane Irma's landfall. Hospitalization and mortality did not vary significantly by evacuation status within 30 or 90 days after the landfall date., Conclusions and Relevance: In this cohort study of Florida AL residents, there was an increased risk of nursing home and emergency department visits within 30 days of Hurricane Irma's landfall among residents from communities that evacuated before the storm when compared with residents from communities that sheltered-in-place. The stress and disruption caused by evacuation may yield poorer immediate health outcomes after a major storm for AL residents. Therefore, the potential benefits and harms of evacuating vs sheltering-in-place must be carefully considered when developing emergency planning and response.

Tropical cyclones have far-reaching impacts on livelihoods and population health that often persist years after the event 1-4 . Characterizing the demographic and socioeconomic profile and the vulnerabilities of exposed populations is essential to assess health and other risks associated with future tropical cyclone events 5 . Estimates of exposure to tropical cyclones are often regional rather than global 6 and do not consider population vulnerabilities 7 . Here we combine spatially resolved annual demographic estimates with tropical cyclone wind fields estimates to construct a global profile of the populations exposed to tropical cyclones between 2002 and 2019. We find that approximately 560 million people are exposed yearly and that the number of people exposed has increased across all cyclone intensities over the study period. The age distribution of those exposed has shifted away from children (less than 5 years old) and towards older people (more than 60 years old) in recent years compared with the early 2000s. Populations exposed to tropical cyclones are more socioeconomically deprived than those unexposed within the same country, and this relationship is more pronounced for people exposed to higher-intensity storms. By characterizing the patterns and vulnerabilities of exposed populations, our results can help identify mitigation strategies and assess the global burden and future risks of tropical cyclones., (© 2023. The Author(s), under exclusive licence to Springer Nature Limited.)

Intense tropical cyclones (TCs), which often peak in autumn 1,2 , have destructive impacts on life and property 3-5 , making it crucial to determine whether any changes in intense TCs are likely to occur. Here, we identify a significant seasonal advance of intense TCs since the 1980s in most tropical oceans, with earlier-shifting rates of 3.7 and 3.2 days per decade for the Northern and Southern Hemispheres, respectively. This seasonal advance of intense TCs is closely related to the seasonal advance of rapid intensification events, favoured by the observed earlier onset of favourable oceanic conditions. Using simulations from multiple global climate models, large ensembles and individual forcing experiments, the earlier onset of favourable oceanic conditions is detectable and primarily driven by greenhouse gas forcing. The seasonal advance of intense TCs will increase the likelihood of intersecting with other extreme rainfall events, which usually peak in summer 6,7 , thereby leading to disproportionate impacts., (© 2023. The Author(s).)

Importance: Hurricanes and flooding can interrupt health care utilization. Understanding the magnitude and duration of interruptions, as well as how they vary according to hazard exposure, race, and income, are important for identifying populations in need of greater retention in care., Objective: To determine how the differential exposure to Hurricane Harvey in August 2017 is associated with changes in utilization of Veterans Health Administration health care., Design, Setting, and Participants: This is a retrospective cohort analysis of primary care practitioner (PCP) visits, emergency department visits, and inpatient admissions in the Veterans Health Administration among Texas veterans residing in counties impacted by Hurricane Harvey from 2016 to 2018. Data analysis was performed from September 2020 to May 2021., Exposures: Residential flooding after Hurricane Harvey., Main Outcomes and Measures: Interrupted time series analysis measured changes in health care utilization over time, stratified by residential flood exposure, race, and income., Results: Of the 99 858 patients in the cohort, 89 931 (90.06%) were male, and their median (range) age was 58 (21 to 102) years. Compared with veterans in nonflooded areas, veterans living in flooded areas were more likely to be Black (24 715 veterans [33.80%] vs 4237 veterans [15.85%]) and low-income (14 895 veterans [20.37%] vs 4853 veterans [18.15%]). Rates of PCP visits decreased by 49.78% (95% CI, -64.52% to -35.15%) for veterans in flooded areas and by 45.89% (95% CI, -61.93% to -29.91%) for veterans in nonflooded areas and did not rebound until more than 8 weeks after the hurricane. Rates of PCP visits in flooded areas remained lower than expected for 11 weeks among White veterans (-6.99%; 95% CI, -14.36% to 0.81%) and for 13 weeks among racial minority veterans (-7.22%; 95% CI, -14.11% to 0.30%). Low-income veterans, regardless of flood status, experienced greater suppression of PCP visits in the 8 weeks following the hurricane (-13.72%; 95% CI, -20.51% to -6.68%) compared with their wealthier counterparts (-9.63%; 95% CI, -16.74% to -2.26%)., Conclusions and Relevance: These findings suggest that flood disasters such as Hurricane Harvey may be associated with declines in health care utilization that differ according to flood status, race, and income strata. Patients most exposed to the disaster also had the greatest delay or nonreceipt of care.

The magnitude, timing, and etiology of morbidity associated with tropical cyclones remains incompletely quantified. We examined the relative change in cause-specific emergency department (ED) visits among residents of New York City during and after Hurricane Sandy, a tropical cyclone that affected the northeastern United States in October 2012. We used quasi-Poisson constrained distributed lag models to compare the number of ED visits on and after Hurricane Sandy with all other days, 2005-2014, adjusting for temporal trends. Among residents aged ≥65 years, Hurricane Sandy was associated with a higher rate of ED visits due to injuries and poisoning (relative risk (RR) = 1.19, 95% confidence interval (CI): 1.10, 1.28), respiratory disease (RR = 1.35, 95% CI: 1.21, 1.49), cardiovascular disease (RR = 1.10, 95% CI: 1.02, 1.19), renal disease (RR = 1.44, 95% CI: 1.22, 1.72), and skin and soft tissue infections (RR = 1.20, 95% CI: 1.03, 1.39) in the first week following the storm. Among adults aged 18-64 years, Hurricane Sandy was associated with a higher rate of ED visits for renal disease (RR = 2.15, 95% CI: 1.79, 2.59). Among those aged 0-17 years, the storm was associated with lower rates of ED visits for up to 3 weeks. These results suggest that tropical cyclones might result in increased health-care utilization due to a wide range of causes, particularly among older adults., (© The Author(s) 2021. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

In September 2017, Hurricane Maria made landfall across the Caribbean region as a category 4 storm. In the aftermath, many residents of Puerto Rico were without power or clean running water for nearly a year. Using both English and Spanish tweets from September 16 to October 15 2017, we investigate discussion of Maria both on and off the island, constructing a proxy for the temporal network of communication between victims of the hurricane and others. We use information theoretic tools to compare the lexical divergence of different subgroups within the network. Lastly, we quantify temporal changes in user prominence throughout the event. We find at the global level that Spanish tweets more often contained messages of hope and a focus on those helping. At the local level, we find that information propagating among Puerto Ricans most often originated from sources local to the island, such as journalists and politicians. Critically, content from these accounts overshadows content from celebrities, global news networks, and the like for the large majority of the time period studied. Our findings reveal insight into ways social media campaigns could be deployed to disseminate relief information during similar events in the future., Competing Interests: The authors have declared that no competing interests exist.

We study collective attention paid towards hurricanes through the lens of n-grams on Twitter, a social media platform with global reach. Using hurricane name mentions as a proxy for awareness, we find that the exogenous temporal dynamics are remarkably similar across storms, but that overall collective attention varies widely even among storms causing comparable deaths and damage. We construct 'hurricane attention maps' and observe that hurricanes causing deaths on (or economic damage to) the continental United States generate substantially more attention in English language tweets than those that do not. We find that a hurricane's Saffir-Simpson wind scale category assignment is strongly associated with the amount of attention it receives. Higher category storms receive higher proportional increases of attention per proportional increases in number of deaths or dollars of damage, than lower category storms. The most damaging and deadly storms of the 2010s, Hurricanes Harvey and Maria, generated the most attention and were remembered the longest, respectively. On average, a category 5 storm receives 4.6 times more attention than a category 1 storm causing the same number of deaths and economic damage., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: Author DRD’s commercial affiliation with paid employment. Additionally, we have received funding from a commerical source: Massachusetts Mutual Life Insurance Company and Google. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Natural disturbances are an important driver of population dynamics. Because it is difficult to observe wildlife during these events, our understanding of the strategies that species use to survive these disturbances is limited. On October 10, 2018, Hurricane Michael made landfall on Florida's northwest coast. Using satellite and acoustic telemetry, we documented movements of 6 individual turtles: one loggerhead sea turtle, one Kemp's ridley sea turtle, three green sea turtles and one diamondback terrapin, in a coastal bay located less than 30 km from hurricane landfall. Post-storm survival was confirmed for all but the Kemp's ridley; the final condition of that individual remains unknown. No obvious movements were observed for the remaining turtles however the loggerhead used a larger home range in the week after the storm. This study highlights the resiliency of turtles in response to extreme weather conditions. However, long-term impacts to these species from habitat changes post-hurricane are unknown.

Objectives. To examine how physical health symptoms developed and resolved in response to Hurricane Katrina. Methods. We used data from a 2003 to 2018 study of young, low-income mothers who were living in New Orleans, Louisiana, when Hurricane Katrina struck in 2005 (n = 276). We fit logistic regressions to model the odds of first reporting or "developing" headaches or migraines, back problems, and digestive problems, and of experiencing remission or "recovery" from previously reported symptoms, across surveys. Results. The prevalence of each symptom increased after Hurricane Katrina, but the odds of developing symptoms shortly before versus after the storm were comparable. The number of traumatic experiences endured during Hurricane Katrina increased the odds of developing back and digestive problems just after the hurricane. Headaches or migraines and back problems that developed shortly after Hurricane Katrina were more likely to resolve than those that developed just before the storm. Conclusions. While traumatic experiences endured in disasters such as Hurricane Katrina appear to prompt the development of new physical symptoms, disaster-induced symptoms may be less likely to persist or become chronic than those emerging for other reasons.

Food insecurity is of heightened concern during and after natural disasters; higher prevalence is typically reported in post-disaster settings. The current study examines food insecurity prevalence and specific risk/resource variables that may act as barriers or advantages in accessing food in such a setting. Using a modified quota sample ( n = 316), Hurricane Harvey survivors participated in face-to-face interviews and/or online surveys that assessed health, social and household factors, and sociodemographic characteristics. Using logistic regression analyses we find that social vulnerabilities, circumstantial risk, and social and psychological resources are important in determining the odds of food insecurity. Hispanic and/or Nonwhite survivors, renters, and those persons displaced during the natural disaster have higher food insecurity odds. Survivors with stronger social ties, higher levels of mastery, and a greater sense of connectedness to their community are found to have lower food insecurity odds. A more nuanced analysis of circumstantial risk finds that while the independent effects of displacement and home ownership are important, so too is the intersection of these two factors, with displaced-renters experiencing significantly higher odds than any other residence and displacement combinations, and particularly those who are homeowners not displaced during the disaster. Strategies for addressing differential risks, as well as practical approaches for implementation and education programming related to disaster recovery, are discussed.

Objectives. To review the trends in pregnancy outcomes after Hurricane Katrina and assess effects of the disaster on research and public health related to pregnant women. Methods. We reexamined the 2004-2006 vital statistics data from Alabama, Louisiana, and Mississippi, assessing what the risk of adverse pregnancy outcomes in the population would have been under varying risk scenarios. Results. We saw a reduction in number of births as well as in low birth weight and preterm birth. If the number of births had stayed constant and the relative higher risk in the "missing" births had been between 17% and 100%, the storm would have been associated with an increased risk instead of a decrease. Because the relative decline in births was larger in Black women, the higher risk in the "missing" births required to create a significant increase associated with the storm was generally not as great as for White women. Conclusions. Higher exposure to Katrina may have produced a reduction in births among high-risk women in the region rather than increasing adverse outcomes among those who did give birth.

Objectives: Although research shows that public health is substantially affected during and after disasters, few studies have examined the health effects of Hurricane Harvey, which made landfall on the Texas coast in August 2017. We assessed disparities in physical health, mental health, and health care access after Hurricane Harvey among residents of the Houston-The Woodlands-Sugar Land, Texas, metropolitan statistical area (ie, Houston MSA)., Methods: We used structured survey data collected through telephone and online surveys from a population-based random sample of Houston MSA residents (n = 403) collected from November 29, 2017, through January 6, 2018. We used descriptive statistics to describe the prevalence of physical health/mental health and health care access outcomes and multivariable generalized linear models to assess disparities (eg, based on race/ethnicity, socioeconomic status, disability) in health outcomes., Results: Physical health problems disproportionately affected persons who did not evacuate (odds ratio [OR] = 0.41; 95% confidence interval [CI], 0.19-0.87). Non-Hispanic black persons were more likely than non-Hispanic white persons to have posttraumatic stress (OR = 5.03; 95% CI, 1.90-13.10), as were persons in households that experienced job loss post-Harvey (vs did not experience job loss post-Harvey; OR = 2.89; 95% CI, 1.14-7.32) and older persons (OR = 1.04; 95% CI, 1.01-1.06). Health care access was constrained for persons whose households lost jobs post-Harvey (vs did not lose jobs post-Harvey; OR = 2.73; 95% CI, 1.29-5.78) and for persons with disabilities (vs without disabilities; OR = 3.19; 95% CI, 1.37-7.45)., Conclusions: Our findings underscore the need to plan for and ameliorate public health disparities resulting from climate change-related disasters, which are expected to occur with increased frequency and magnitude.

Extreme climate events such as droughts, cold snaps, and hurricanes can be powerful agents of natural selection, producing acute selective pressures very different from the everyday pressures acting on organisms. However, it remains unknown whether these infrequent but severe disruptions are quickly erased by quotidian selective forces, or whether they have the potential to durably shape biodiversity patterns across regions and clades. Here, we show that hurricanes have enduring evolutionary impacts on the morphology of anoles, a diverse Neotropical lizard clade. We first demonstrate a transgenerational effect of extreme selection on toepad area for two populations struck by hurricanes in 2017. Given this short-term effect of hurricanes, we then asked whether populations and species that more frequently experienced hurricanes have larger toepads. Using 70 y of historical hurricane data, we demonstrate that, indeed, toepad area positively correlates with hurricane activity for both 12 island populations of Anolis sagrei and 188 Anolis species throughout the Neotropics. Extreme climate events are intensifying due to climate change and may represent overlooked drivers of biogeographic and large-scale biodiversity patterns., Competing Interests: The authors declare no competing interest.

This study analyses the effects of exposure to tropical storms and hurricanes during pregnancy on children's anthropometric measures taken within the first five years of life. We merge destruction indexes calculated at the district level with 13 yearly rounds of household level surveys from Jamaica. The empirical strategy exploits variation arising from the storms' timing and intensity across different cohorts within the same district. The findings rule out medium-to-large overall adverse effects of tropical storms. However, when expectant mothers living in coastal-rural areas are affected by the cumulative destruction of two hurricanes, their children experience negative impacts on both weight-for-age and weight-for-height measures., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Introduction: Hurricanes have increased in severity over the past 35 years, and climate change has led to an increased frequency of catastrophic flooding. The impact of floods on emergency department (ED) operations and patient health has not been well studied. We sought to detail challenges and lessons learned from the severe weather event caused by Hurricane Harvey in Houston, Texas, in August 2017., Methods: This report combines narrative data from interviews with retrospective data on patient volumes, mode of arrival, and ED lengths of stay (LOS). We compared the five-week peri-storm period for the 2017 hurricane to similar periods in 2015 and 2016., Results: For five days, flooding limited access to the hospital, with a consequent negative impact on provider staffing availability, disposition and transfer processes, and resource consumption. Interruption of patient transfer capabilities threatened patient safety, but flexibility of operations prevented poor outcomes. The total ED patient census for the study period decreased in 2017 (7062 patients) compared to 2015 (7665 patients) and 2016 (7770) patients). Over the five-week study period, the arrival-by-ambulance rate was 12.45% in 2017 compared to 10.1% in 2016 (p < 0.0001) and 13.7% in 2015 (p < 0.0001). The median ED length of stay (LOS) in minutes for admitted patients was 976 minutes in 2015 (p < 0.0001) compared to 723 minutes in 2016 and 591 in 2017 (p < 0.0001). For discharged patients, median ED LOS was 336 minutes in 2016 compared to 356 in 2015 (p < 0.0001) and 261 in 2017 (p < 0.0001). Median boarding time for admitted ED patients was 284 minutes in 2016 compared to 470 in 2015 (p < 0.0001) and 234.5 in 2017 (p < 0.001). Water damage resulted in a loss of 133 of 179 inpatient beds (74%). Rapid and dynamic ED process changes were made to share ED beds with admitted patients and to maximize transfers post-flooding to decrease ED boarding times., Conclusion: A number of pre-storm preparations could have allowed for smoother and safer ride-out functioning for both hospital personnel and patients. These measures include surplus provisioning of staff and supplies to account for limited facility access. During a disaster, innovative flexibility of both ED and hospital operations may be critical when disposition and transfer capibilities or bedding capacity are compromised.

The potential effect of a typhoon track on the extent of damage makes the track a critical factor during the emergency response phase. Historical typhoon data may provide information for decision makers to anticipate the impact of an upcoming typhoon and develop prevention strategies to reduce the damage. In our preliminary work, we proposed a track similarity algorithm and implemented a real-time search engine for past typhoon events. However, the proposed algorithm was not discussed thoroughly in the preliminary work, and the great number of historical typhoon track records slowed down the similarity calculations. In addition, the tool did not feature the option of automatically importing upcoming typhoon track predictions. This research introduces the assumption of the recentness dominance principle (RDP), explores the details of the track similarity algorithm of the preliminary work, completes the discussion of parameter setting, and developed a method to improve the efficiency of the similarity calculation. In this research, we implemented the proposed advanced methodology by developing a new information display panel featuring the ability to auto-import forecast data. The results of this study provide decision makers and the public with a concise and handy search engine for searching similar historical typhoon records.

Importance: Temporary disruptions in health care access are common, but their associations with chronic disease control remain unknown., Objective: To evaluate whether long-term changes in chronic disease control were associated with a temporary 6-month decrease in access to health care services., Design, Setting, and Participants: This cohort study examined the long-term changes in chronic disease control associated with the 6-month closure of the Manhattan facility of the Veterans Affairs (VA) New York Harbor Healthcare System after superstorm Sandy, which caused a significant disruption in health care access for veterans in the region. Electronic health records from the VA Healthcare System between October 29, 2010, and October 29, 2014, were used to identify a total of 81 544 veterans who were and were not exposed to the 6-month closure of the VA Manhattan Medical Center after superstorm Sandy. Of those, 19 207 veterans were included in the exposed cohort and 62 337 were included in the nonexposed control cohort, which included veterans who were equally exposed to the storm but who retained regular access to health care from 3 VA medical centers (Brooklyn and the Bronx in New York and New Haven in Connecticut) during and after the storm. A difference-in-differences analysis was used to assess within-patient changes in chronic disease control over time between a cohort that was exposed to decreased health care access compared with a similar cohort that was not exposed to decreased access. All analyses adjusted for individual demographic and socioeconomic characteristics, between-zip code differences, and common time trends. Data analyses were conducted between February 1, 2016, and September 30, 2019., Exposure: The 6-month closure of the VA Manhattan Medical Center after superstorm Sandy on October 29, 2012., Main Outcomes and Measures: The outcomes measured were uncontrolled blood pressure (defined as mean blood pressure per patient per quarter >140/90 mm Hg), uncontrolled diabetes (defined as mean hemoglobin A1c per patient per quarter >8%), uncontrolled cholesterol (defined as mean low density lipoprotein per patient per quarter >140 mg/dL), and patient weight., Results: Among the 81 544 veterans included in the study, the mean (SD) age was 62.1 (17.6) years, and 93.6% were men, 62.7% were white, and 31.8% were black. At the 3-month midpoint of the 6-month facility closure of the VA Manhattan Medical Center, an absolute decrease of 24.8% (95% CI, -26.5% to -23.0%; P < .001) was observed in the percentage of veterans who had any VA primary care visit per quarter compared with a baseline of 47.8% before the closure (relative decrease, 51.9%; 95% CI, -55.4% to -48.1%; P < .001). One year after the facility reopened, no differential change was observed in the percentage of patients with a primary care visit between the exposed vs nonexposed cohorts (absolute decrease, -0.1%; 95% CI, -1.5% to 1.4%; P = .94); however, patients in the exposed cohort were 25.9% more likely to have uncontrolled blood pressure than patients in the nonexposed cohort (unadjusted increase, 5.5% in the exposed cohort vs 1.3% in the nonexposed cohort; adjusted absolute increase, 5.0%; 95% CI, 3.5%-6.0%; P < .001). Two years after superstorm Sandy, patients in the exposed cohort were 10.9% more likely to experience uncontrolled blood pressure than those in the nonexposed cohort (unadjusted increase, 5.2% in the exposed cohort vs 3.5% in the nonexposed cohort; adjusted absolute increase, 2.1%; 95% CI, 0.5%-3.6%; P < .001). Compared with the nonexposed cohort, the exposed cohort also experienced a decrease in filled medication prescriptions per patient per quarter of 6.9% during the facility closure (absolute decrease, -0.7 prescriptions filled per patient per quarter; 95% CI, -0.9 to -0.5; P < .001) and of 2.2% a year after the facility reopened (absolute decrease, -0.2 prescriptions filled per patient per quarter; 95% CI, -0.4 to -0.1; P = .04). No differential changes were observed in uncontrolled diabetes, uncontrolled cholesterol, or patient weight., Conclusions and Relevance: In this study, a temporary period of decreased access to health care services was associated with increased rates of uncontrolled hypertension, but not with increased rates of uncontrolled diabetes or hyperlipidemia, more than 1 year after the Manhattan VA facility reopened. Temporary gaps in access to health care may be associated with long-term increases in uncontrolled blood pressure among patients with hypertension.

The rate of change on coastlines is accelerating from climate change and coastal development. Coastal flooding is a particularly pressing and increasing problem, which affects hundreds of millions of people and damages trillions of US$ in property. Scientists, practitioners and managers must be able to quickly assess flood risk and identify appropriate adaptation and risk reduction measures often with limited data and tools, particularly in developing countries. To inform these decision-making processes, we identify how sensitive flood risk and adaptation analyses are to changes in the resolution of data and models. We further do these comparisons in the context of assess the benefits of an ecosystem-based approach for risk reduction. There is growing interest in these ecosystem-based approaches as cost effective measures for adaptation and risk reduction. We assess flood risks from tropical cyclones and the flood risk reduction benefits provided by mangroves in Pagbilao (the Philippines). Then, we also compare risks and risk reduction (benefits) using different quality data and models, to identify where to invest in in new modeling and data acquisition to improve decision-making. We find that coastal flood risk valuation improves by using high resolution topography and long time series of data on tropical cyclones, while flood reduction benefits of mangroves are better valued by using consistent databases and models along the whole process rather than investing in single measures., Competing Interests: The authors have declared that no competing interests exist.

Changes in levels and patterns of physical activity might be a mechanism to assess and inform disaster recovery through the lens of wellbeing. However, few studies have examined disaster impacts on physical activity or the potential for physical activity to serve as an indicator of disaster recovery. In this exploratory study, we examined daily bicycle and pedestrian counts from four public bicycle/pedestrian trails in Houston, before and after Hurricane Harvey landfall, to assess if physical activity returned to pre-Harvey levels. An interrupted time series analysis was conducted to examine the immediate impact of Harvey landfall on physical activity; t -tests were performed to assess if trail usage returned to pre-Harvey levels. Hurricane Harvey was found to have a significant negative impact on daily pedestrian and bicycle counts for three of the four trails. Daily pedestrian and bicycle counts were found to return to pre-Harvey or higher levels at 6 weeks post-landfall at all locations studied. We discuss the potential for further research to examine the trends, feasibility, validity, and limitations of using bicycle and pedestrian use levels as a proxy for disaster recovery and wellbeing among affected populations.

The research on how health and health care disparities impact response to and recovery from a disaster, especially among diverse and underserved populations is in great need for a thorough evaluation. The time series analysis utilizing most complete national databases of medical records is an indispensable tool in assessing the destruction and health toll brought about by natural disasters. In this study, we demonstrated such an application by evaluating the impact of Hurricane Katrina in 2005 on cardiovascular disease (CVD), a primary cause of mortality among older adults that can be aggravated by natural disasters. We compared CVD hospitalizations before, during and after Katrina between white and black residents of three most populated parishes in Louisiana: Orleans and Jefferson, which were severely affected by the landfall and subsequent floods, and East Baton Rouge, which hosted many of the evacuees. We abstracted 383,552 CVD hospitalization records for Louisiana's patients aged 65+ in 2005⁻2006 from the database maintained by the Center of Medicare & Medicaid Services. Daily time series of CVD-related hospitalization rates at each study parish were compiled, and the changes were characterized using segmented regression. In Orleans Parish, directly affected by the hurricane, hospitalization rates peaked on the 6th day after landfall with an increase (mean ± SD) from 7.25 ± 2.4 to 18.5 ± 17.3 cases/day per 10,000 adults aged 65+ ( p < 0.001) and returned to pre-landfall level after ~2 months. Disparities in CVD rates between black and white older adults were exacerbated during and following landfall. In Orleans Parish, a week after landfall, the CVD rates increased to 26.3 ± 23.7 and 16.6 ± 11.7 cases/day per 10,000 people ( p < 0.001) for black and white patients, respectively. The abrupt increase in CVDs is likely due to psychosocial and post-traumatic stress caused by the disaster and inadequate response. Inequities in resource allocation and access have to be addressed in disaster preparation and mitigation.

This study investigates long-term changes in the variability of TC intensity of global tropical cyclones, a topic which has been relatively infrequently studied to date. Our study finds that the variability of global TC lifetime maximum intensity (LMI), as measured by the LMI standard deviation, increases during 1981-2016. The increasing trend in LMI variability is statistically significant for both the Northern and Southern Hemispheres, with three individual TC basins: the western North Pacific, the South Indian and the South Pacific also having statistically significant increases. This increasing trend primarily results from distinct changes in the relative percentages of TCs with different intensities. When comparing two periods: 1981-1998 and 1999-2016, the proportions of weak and strong TCs increase, whereas moderate TCs occur relatively less frequently. This bimodal pattern of observed LMI distribution change is further linked to opposite trends in the average intensities of TCs that undergo rapid intensification (RI) during their lifetime (RI TCs) and those that do not (non-RI TCs). The LMI distributions of RI and non-RI TCs migrate to higher and lower intensities, respectively. Our results demonstrate from an observational perspective that strong TCs have strengthened while weak TCs have weakened as the global climate has warmed since 1981.

Predicting North Atlantic hurricane activity months in advance is of great potential societal significance. The ocean temperature, both in terms of North Atlantic/tropical averages and upper ocean heat content, is demonstrated to be a significant predictor. To investigate the relationship between the thermal state of the Atlantic Ocean and the tropical cyclone (TC) activity in terms of accumulated cyclone energy (ACE), we use observed 1980-2015 TC records and a 1/4° resolution global ocean reanalysis. This paper highlights the nonlocal effect associated with eastern Atlantic Ocean temperature, via a reduction of wind shear, and provides additional predictive skill of TC activity, when considering subsurface temperature instead of sea surface temperature (SST) only. The most active TC seasons occur for lower than normal wind shear conditions over the main development region, which is also driven by reduced trade wind strength. A significant step toward operationally reliable TC activity predictions is gained after including upper ocean mean temperatures over the eastern Atlantic domain. Remote effects are found to provide potential skill of ACE up to 3 months in advance. These results indicate that consideration of the upper 40-m ocean average temperature improves upon a prediction of September Atlantic hurricane activity using only SST., Competing Interests: The authors declare no conflict of interest.

Category 4 landfalling hurricane Harvey poured more than a metre of rainfall across the heavily populated Houston area, leading to unprecedented flooding and damage. Although studies have focused on the contribution of anthropogenic climate change to this extreme rainfall event 1-3 , limited attention has been paid to the potential effects of urbanization on the hydrometeorology associated with hurricane Harvey. Here we find that urbanization exacerbated not only the flood response but also the storm total rainfall. Using the Weather Research and Forecast model-a numerical model for simulating weather and climate at regional scales-and statistical models, we quantify the contribution of urbanization to rainfall and flooding. Overall, we find that the probability of such extreme flood events across the studied basins increased on average by about 21 times in the period 25-30 August 2017 because of urbanization. The effect of urbanization on storm-induced extreme precipitation and flooding should be more explicitly included in global climate models, and this study highlights its importance when assessing the future risk of such extreme events in highly urbanized coastal areas.

There is no consensus on whether climate change has yet affected the statistics of tropical cyclones, owing to their large natural variability and the limited period of consistent observations. In addition, projections of future tropical cyclone activity are uncertain, because they often rely on coarse-resolution climate models that parameterize convection and hence have difficulty in directly representing tropical cyclones. Here we used convection-permitting regional climate model simulations to investigate whether and how recent destructive tropical cyclones would change if these events had occurred in pre-industrial and in future climates. We found that, relative to pre-industrial conditions, climate change so far has enhanced the average and extreme rainfall of hurricanes Katrina, Irma and Maria, but did not change tropical cyclone wind-speed intensity. In addition, future anthropogenic warming would robustly increase the wind speed and rainfall of 11 of 13 intense tropical cyclones (of 15 events sampled globally). Additional regional climate model simulations suggest that convective parameterization introduces minimal uncertainty into the sign of projected changes in tropical cyclone intensity and rainfall, which allows us to have confidence in projections from global models with parameterized convection and resolution fine enough to include tropical cyclones.

Public health risks from urban floods are a global concern. A typhoon is a devastating natural hazard that is often accompanied by heavy rainfall and high storm surges and causes serious floods in coastal cities. Affected by the same meteorological systems, typhoons, rainfall, and storm surges are three variables with significant correlations. In the study, the joint risk of rainfall and storm surges during typhoons was investigated based on principal component analysis, copula-based probability analysis, urban flood inundation model, and flood risk model methods. First, a typhoon was characterized by principal component analysis, integrating the maximum sustained wind (MSW), center pressure, and distance between the typhoon center and the study area. Following this, the Gumbel copula was selected as the best-fit copula function for the joint probability distribution of typhoons, rainfall, and storm surges. Finally, the impact of typhoons on the joint risk of rainfall and storm surges was investigated. The results indicate the following: (1) Typhoons can be well quantified by the principal component analysis method. (2) Ignoring the dependence between these flood drivers can inappropriately underestimate the flood risk in coastal regions. (3) The co-occurrence probability of rainfall and storm surges increases by at least 200% during typhoons. Therefore, coastal urban flood management should pay more attention to the joint impact of rainfall and storm surges on flood risk when a typhoon has occurred. (4) The expected annual damage is 0.82 million dollars when there is no typhoon, and it rises to 3.27 million dollars when typhoons have occurred. This indicates that typhoons greatly increase the flood risk in coastal zones. The obtained results may provide a scientific basis for urban flood risk assessment and management in the study area.

Objectives: Extreme weather events require extensive tree removal and disposal, tasks associated with severe injury risks among workers and residents. To help understand the risks of such activities, we evaluated the impact of a large and destructive storm (Hurricane Sandy in 2012) on the incidence of tree-related injuries., Methods: We searched chief-complaint text fields for patients aged 18-65 from 2011-2014 emergency department visit records submitted by New Jersey hospitals through the state-based syndromic surveillance system. Tree-related keywords (eg, saw, branch, wood chip, woodchip, tree) identified possible injuries that we then reviewed to exclude unrelated cases and classify mechanisms of tree-related injury. We used Poisson regression analysis to evaluate changes in the rates of probable tree-related injuries, adjusting for total emergency department visits and seasonal variation., Results: We identified 698 probable tree-related injuries from 2011-2014 among patients aged 18-65, including 104 (14.9%) falls, 241 (34.5%) machine-related injuries, 311 (44.6%) struck-by injuries, and 42 (6.0%) other tree-related injuries. Tree-related injuries increased significantly in the quarter immediately after Hurricane Sandy (November 2012-January 2013) compared with the same quarter the year before (rate ratio [RR] = 1.67; 95% confidence interval [CI], 1.13-2.47) and the year after (RR = 2.47; 95% CI, 1.62-3.78) Hurricane Sandy, especially for struck-by injuries compared with the year before (RR = 2.74; 95% CI, 1.47-5.12) and the year after (RR = 4.17; 95% CI, 2.09-8.32) Hurricane Sandy. More than one-third of the injuries (33.4%) involved chainsaws., Conclusions: A major hurricane was associated with an increase in tree-related injuries in emergency departments, especially for mechanisms consistent with handling downed and damaged trees. Further research should confirm these findings and evaluate opportunities for preventing tree-related injuries.

Objective: This study examined changes in utilization of mental health services after Hurricane Katrina among children with preexisting conditions who were displaced from their homes in Louisiana disaster counties and resettled in Texas., Methods: A retrospective analysis was performed on Medicaid claims data for 101,950 children from 2004 to 2006. Pre-post changes in utilization of mental health services by the displaced children and three control groups were compared. The control groups were children from Louisiana disaster counties who were not displaced, Louisiana children from nondisaster counties, and Texas children enrolled in Medicaid., Results: The proportion of children who had a prescription fill for psychotropic medication and the average days' supply per child decreased in each group, but the decreases were significantly larger for the displaced group than for the control groups. The decreases in both measures were largest for stimulants and antidepressants, the two most common medication classes. By contrast, changes in the proportion of children with an encounter involving psychiatric services and the average number of psychiatric services encounters per child did not vary systematically across the displaced and control groups., Conclusions: The contrast between the results for medication utilization and encounters reveals a potential gap in post-Katrina provision of care. Although the findings for encounters indicate that, on average, displaced children did not experience a disruption in provider visits, the medication estimates suggest that they often did not obtain pharmaceutical treatment. Future disaster responses may be improved by addressing logistical impediments faced by disaster victims in filling their prescriptions for psychiatric medications.

The unexpected nature of disasters leaves little time or resources for organized health surveillance of the affected population, and even less for those who are unaffected. An ideal epidemiologic study would monitor both groups equally well, but would typically be decided against as infeasible or costly. Exposure and health outcome data at the level of the individual can be difficult to obtain. Despite these challenges, the health effects of a disaster can be approximated. Approaches include 1) the use of publicly available exposure data in geographic detail, 2) health outcomes data-collected before, during, and after the event, and 3) statistical modeling designed to compare the observed frequency of health outcomes with the counterfactual frequency hidden by the disaster itself. We applied these strategies to Hurricane Sandy, which struck the northeastern United States in October 2012. Hospital admissions data from the state of New York with information on primary payer as well as patient demographic characteristics were analyzed. To illustrate the method, we present multivariate logistic regression results for the first 2 months after the hurricane. Inferential implications of admissions data on nearly the entire target population in the wake of a disaster are discussed., (© The Author(s) 2017. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: National health security requires that healthcare facilities be prepared to provide rapid, effective emergency and trauma care to all patients affected by a catastrophic event. We sought to quantify changes in healthcare utilization patterns for an at-risk Medicare population before, during, and after Superstorm Sandy's 2012 landfall in New Jersey (NJ)., Methods: This study is a retrospective cohort study of Medicare beneficiaries impacted by Superstorm Sandy. We compared hospital emergency department (ED) and healthcare facility inpatient utilization in the weeks before and after Superstorm Sandy landfall using a 20% random sample of Medicare fee-for-service beneficiaries continuously enrolled in 2011 and 2012 (N=224,116). Outcome measures were pre-storm discharges (or transfers), average length of stay, service intensity weight, and post-storm ED visits resulting in either discharge or hospital admission., Results: In the pre-storm week, hospital transfers from skilled nursing facilities (SNF) increased by 39% and inpatient discharges had a 0.3 day decreased mean length of stay compared to the prior year. In the post-storm week, ED visits increased by 14% statewide; of these additional "surge" patients, 20% were admitted to the hospital. The increase in ED demand was more than double the statewide average in the most highly impacted coastal regions (35% versus 14%)., Conclusion: Superstorm Sandy impacted both pre- and post-storm patient movement in New Jersey; post-landfall ED surge was associated with overall storm impact, which was greatest in coastal counties. A significant increase in the number and severity of pre-storm transfer patients, in particular from SNF, as well as in post-storm ED visits and inpatient admissions, draws attention to the importance of collaborative regional approaches to healthcare in large-scale events., Competing Interests: Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. The findings and conclusions in this report are those of the authors and do not necessarily represent the view of the U.S. Department of Health and Human Services or its components.

Due to their destructive and sporadic nature, it is often difficult to evaluate and predict the effects of typhoon on forest ecosystem patterns and processes. We used a 21-yr record of litterfall rates to explore the influence of typhoon frequency and intensity, along with other meteorological variables, on ecosystem dynamics in a subtropical rainforest. Over the past half century there has been an increasing frequency of strong typhoons (category 3; >49.6 m s -1 ; increase of 1.5 typhoons/decade) impacting the Fushan Experimental Forest, Taiwan. At Fushan strong typhoons drive total litterfall mass with an average of 1100 kg ha -1 litterfall typhoon -1 . While mean typhoon season litterfall has been observed to vary by an order of magnitude, mean litterfall rates associated with annual leaf senescence vary by <20%. In response to increasing typhoon frequency, total annual litter mass increased gradually over the 21-year record following three major typhoons in 1994. Monthly maximum wind speed was predictive of monthly litterfall, yet the influence of precipitation and temperature was only evident in non-typhoon affected months. The response of this subtropical forest to strong typhoons suggests that increasing typhoon frequency has already shifted ecosystem structure and function (declining carbon sequestration and forest stature).

Southeast China is frequently hit by tropical cyclones (TCs) with significant economic and health burdens each year. However, there is a lack of understanding of what infectious diseases could be affected by tropical cyclones. This study aimed to examine the impacts of tropical cyclones on notifiable infectious diseases in southeast China. Disease data between 2005 and 2011 from four coastal provinces in southeast China, including Guangdong, Hainan, Zhejiang, and Fujian province, were collected. Numbers of cases of 14 infectious diseases were compared between risk periods and reference periods for each tropical cyclone. Risk ratios (RR s ) were calculated to estimate the risks. TCs were more likely to increase the risk of bacillary dysentery, paratyphoid fever, dengue fever and acute hemorrhagic conjunctivitis ( ps < 0.05) than to decrease the risk, more likely to decrease the risk of measles, mumps, varicella and vivax malaria ( ps < 0.05) than to increase the risk. In conclusion, TCs have mixed effects on the risk of infectious diseases. TCs are more likely to increase the risk of intestinal and contact transmitted infectious diseases than to decrease the risk, and more likely to decrease the risk of respiratory infectious diseases than to increase the risk. Findings of this study would assist in developing public health strategies and interventions for the reduction of the adverse health impacts from tropical cyclones.