Superstorm Sandy Mortality Surveillance
in New York City
Elizabeth “Beth” Begier, MD, MPHAssistant Commissioner, Bureau of Vital StatisticsNYC Department of Health and Mental Hygiene
Overview
• Sandy Impact and Public Health Threats• NYC Death Registration System• Mortality Surveillance Activities/Findings• Challenges and Lessons Learned• Next Steps
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Hurricane Sandy
• October 29, 2012 post-tropical cyclone hit 100 miles south of NYC
• Record storm surge flooding (4 to 11 ft. predicted vs. 14 actual)
• Wind-downed trees and power lines caused fatal drowning and injuries (direct mortality)
NYC Sandy Impacts and Hazards• Widespread power and heat outages resulting cold
stress and lack of refrigeration (some prolonged building-related issues)
• High rise buildings lost elevators and running water– Mobility-impaired stranded
• Transit disruption– Total subway/transit shutdown followed by slow
phased resumption– Bridge and tunnel closures– Gasoline shortages
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5
NYC Sandy Impacts and Hazards• Evacuation of 4 hospitals (1,262 pts.) and 17 nursing
homes (2507 residents)• Disruption of ambulatory health care and pharmacy
access• Respiratory hazards and concerns– Indoor demolition and flooded building cleanup– Outdoor dust from debris movement– Emissions from temporary generators and boilers
• Mental health stress and loss of 300 psychiatric inpatient beds due to evacuations
• Injuries relating to rebuilding efforts
Routine Death Registration in NYC• NYC Health Code Death Reporting Requirements:– 24 or less hours for certification• Clinician's report of decedent's name, sex,
time/date/place of death, and free-text cause of death• Medical providers start “case” in EDRS
– 72 hours or less for FD completes and sends for registration • Decedent's address, DOB, and other demographics
completed by funeral director– After FD completes, “case” goes electronically to death
registration staff for review and registration• 94% of deaths reported fully electronically reported via EDRS
Death Registration during/after Sandy • 1 registration staff member stayed at Manhattan
office through storm (Steve S relieved him morning after)• Bureau of Vital Statistics’ Office building in lower
Manhattan closed for ~1 week due to power and heat outage that began overnight during storm
• Relocated Registration Unit morning after hurricane to alternate site in Brooklyn (Thanks Flor Betancourt!)
• EDRS up during/after storm; no prolonged outages• A few hospitals initially with internet connectivity
issues preventing use of EDRS
Tracking: Deaths directly related to Hurricane
• Most of such deaths initially registered by MEs with cause pending
• ME notified us via email of deaths believed to be Hurricane-related after preliminary investigation
• All CODs reviewed in real-time by registration unit for possible ME cases (per routine)
• Added pop-up to EDRS cause-of-death page to prompt ME referrals for any deaths related to storm
• Conducted free-text searches of DC text fields post-registration for injury deaths as double check
Tracking: Indirectly Related Deaths • Health Commissioner very concerned about
unrecognized morbidity and mortality increases associated with extensive environmental hazards and stresses in aftermath – Syndromic surveillance for morbidity– Initiated mortality surveillance
• Timeframes– Categorized 10 days following hurricane as
immediate aftermath (1/1–10)– Rest of time examined as rolling post-aftermath
Mortality Surveillance – ApproachAll-cause mortality counts by date to identify excess mortality of any cause: primary focus post-event– Used pre-registration certified deaths to enhance
timeliness of close to complete counts• Concerned about decreased registration
timeliness 2° to storm-related disruptions – Adjusted prior year comparison counts for
“reporting lag”, i.e., limited to deaths certified by same date in prior years• Had to add certification date to stats file (only
had registration date)
Mortality Surveillance – Approach• Categorized deaths by age and cause with post-
registration data– Cause-of-death routinely ICD-10 coded locally by
NYC nosologists 1st business day post-registration• Seemed too complicated to change routine to
pre-registration on fly– Date of birth not on certification – provided by FD
Mortality Surveillance:Neighborhood Flood Levels
• Categorized deaths by decedent residence neighborhood flood levels with post-registration data– Quickly geocoded residence address to census tract
level, including quickly resolving manual rejects• Quickly recoded prior years to 2010 census for
accurate comparisons– Do not get decedent address until registration (from
funeral directors)– Excluded nursing home deaths to focus on deaths
occurring in community• Separate analysis done for evacuated nursing
homes
Mortality – Other investigations• Initial assessment of Hospital evacuations– Calculated mortality counts at receiving hospitals in
10 days following storm– Added expected death counts for evacuated hospitals
to receiving hospitals’ baselines based on count of evacuees received to improve comparability
– Did not have names or acuity of transferees (ICU, etc)• Initial look at nursing home evacuations– Identified decadents with evacuated nursing homes
as their residence address– Compared counts for 4 weeks post-sandy to 2 prior
years
RESULTS
Results: Timeliness
• Time to certification & registration increased during/after storm compared to current and prior year baselines
Timeliness by Date– Certification:Deaths Certified in <24 hours in Blue
10/15/2012
10/17/2012
10/19/2012
10/21/2012
10/23/2012
10/25/2012
10/27/2012
10/29/2012
10/31/2012
11/2/2012
11/4/2012
11/6/2012
11/8/2012
11/10/2012
11/12/2012
11/14/2012
11/16/2012
11/18/2012
11/20/2012
11/22/2012
11/24/2012
11/26/2012
11/28/2012
11/30/20120
10
20
30
40
50
60
70
80
90
100
> 5 days4-5 days3-4 days2-3 days1-2 days<1 days
Perc
ent o
f Reg
istra
tions
Timeliness by Date– Registration:Day 1 Blue, Day 2 Red, Day 3 Green
10/15/2012
10/17/2012
10/19/2012
10/21/2012
10/23/2012
10/25/2012
10/27/2012
10/29/2012
10/31/2012
11/2/2012
11/4/2012
11/6/2012
11/8/2012
11/10/2012
11/12/2012
11/14/2012
11/16/2012
11/18/2012
11/20/2012
11/22/2012
11/24/2012
11/26/2012
11/28/2012
11/30/2012
0
10
20
30
40
50
60
70
80
90
100
> 5 days4-5 days3-4 days2-3 days1-2 days<1 days
Perc
ent o
f Reg
istra
tions
Median Days to Registration from Death by Percent of Census Tract Flooded and Year: Oct 29–Nov 10
0% 0-10% 10-75% >75%0
0.5
1
1.5
2
2.5
3
3.5
4
201020112012
Mortality Surveillance - Findings
• Relied on ME email notification to BVS for timely notification of preliminary Sandy-related deaths – N=43; Major causes drowning (81%), blunt
trauma (16%)– >50% on Staten Island, nearly half aged 65+– No Sandy-related deaths found through free-text
search of post-registration data for injury terms that had not already sent by ME
Sample Early Table: Number of Certified Daily Deaths from All Causes, Nov 1–19, 2010-2012, NYC, Reported As of 21NOV2012
(Deaths Certified Through 11/20 of Each Year)
Date of Death 2010 2011 2012
Absolute difference between 2012 and
average of 2010-2011
Percent difference between 2012 and
average of 2010-201111012012 146 151 137 -11.5 -8%11022012 127 130 146 17.5 14%11032012 134 135 157 22.5 17%11042012 153 149 162 11 7%11052012 129 122 161 35.5 28%11062012 133 135 163 29 22%11072012 155 156 161 5.5 4%11082012 168 159 164 0.5 0%11092012 129 150 173 33.5 24%11102012 152 149 185 34.5 23%11112012 140 158 155 6 4%11122012 152 143 154 6.5 4%11132012 136 145 163 22.5 16%11142012 141 162 145 -6.5 -4%11152012 123 140 145 13.5 10%11162012 155 147 154 3 2%11172012 143 122 136 3.5 3%11182012 127 127 119 -8 -6%11192012 101 111 111 5 5%Mean 139.2 141.6 152.2 11.8 8%
Median 140.0 145.0 155.0 12.5 9%Total 2,644 2,691 2,891 223.5 8%
Please note additional deaths are expected to be registered ongoing on all these dates.
Sample Early Table: T Number of Certified Daily Deaths from All Causes, Nov 1–19, 2010-2012, NYC, Reported As of 21NOV2012
(Deaths Certified Through 11/20 of Each Year)
Date of Death 2010 2011 2012
Absolute difference between 2012 and
average of 2010-2011
Percent difference between 2012 and
average of 2010-201111012012 146 151 137 -11.5 -8%11022012 127 130 146 17.5 14%11032012 134 135 157 22.5 17%11042012 153 149 162 11 7%11052012 129 122 161 35.5 28%11062012 133 135 163 29 22%11072012 155 156 161 5.5 4%11082012 168 159 164 0.5 0%11092012 129 150 173 33.5 24%11102012 152 149 185 34.5 23%11112012 140 158 155 6 4%11122012 152 143 154 6.5 4%11132012 136 145 163 22.5 16%11142012 141 162 145 -6.5 -4%11152012 123 140 145 13.5 10%11162012 155 147 154 3 2%11172012 143 122 136 3.5 3%11182012 127 127 119 -8 -6%11192012 101 111 111 5 5%Mean 139.2 141.6 152.2 11.8 8%
Median 140.0 145.0 155.0 12.5 9%Total 2,644 2,691 2,891 223.5 8%
Please note additional deaths are expected to be registered ongoing on all these dates.
• 11/19/2012 on 11/21 report: • Deaths certified by 11/20: 111• Adjusted baseline 101 and 111 deaths indicated not beyond historical norms• That day would eventually get to 138 deaths
100
110
120
130
140
150
160
170
180
190
200
New York City All-Cause Daily Deaths Counts, October 20–December 31, 2012
Date of Death
Num
ber o
f Dea
ths
October November December
Hurricane Sandy10 day aftermathDeaths up 11%
Influenza Season Starts
Sample Table: Analysis by Flooding Level
N ROW% N ROW% N ROW% N ROW% N ROW% N COL%CLRD 35 73 0 . 6 13 7 15 0 . 48 4CVD 303 72 19 5 47 11 48 12 2 1 419 36P_I 58 80 2 3 10 14 3 4 0 . 73 6
OTHER 494 78 25 4 52 8 59 9 1 0 631 54All 890 76 46 4 115 10 117 10 3 0 1,171 100
CLRD 31 76 3 7 1 2 6 15 0 . 41 4CVD 321 78 12 3 39 10 39 10 0 . 411 36P_I 51 80 2 3 5 8 6 9 0 . 64 6
OTHER 473 75 32 5 63 10 59 9 2 0 629 55All 876 77 49 4 108 9 110 10 2 0 1,145 100
CLRD 31 74 2 5 4 10 4 10 1 2 42 3CVD 284 76 13 4 37 10 40 11 0 . 374 30P_I 69 84 1 1 7 9 5 6 0 . 82 6
OTHER 594 78 36 5 69 9 66 9 1 0 766 61All 978 77 52 4 117 9 115 9 2 0 1,264 100
CLRD 94% 133% 114% 62% -- 94%CVD 91% 84% 86% 92% 0% 90%P_I 127% 50% 93% 111% -- 120%
OTHER 123% 126% 120% 112% 67% 122%All 111% 109% 105% 101% 80% 109%
2010
2011
2012
YEAR/CAUSE Proportion of Census Tract in Inundation Zone All0% >0-10% >10-75% >75% Unknown
Percent Increase
Sample Table: Analysis by Flooding Level November 1–10, 2010-2012
N ROW% N ROW% N ROW% N ROW% N ROW% N COL%CLRD 35 73 0 . 6 13 7 15 0 . 48 4CVD 303 72 19 5 47 11 48 12 2 1 419 36P_I 58 80 2 3 10 14 3 4 0 . 73 6
OTHER 494 78 25 4 52 8 59 9 1 0 631 54All 890 76 46 4 115 10 117 10 3 0 1,171 100
CLRD 31 76 3 7 1 2 6 15 0 . 41 4CVD 321 78 12 3 39 10 39 10 0 . 411 36P_I 51 80 2 3 5 8 6 9 0 . 64 6
OTHER 473 75 32 5 63 10 59 9 2 0 629 55All 876 77 49 4 108 9 110 10 2 0 1,145 100
CLRD 31 74 2 5 4 10 4 10 1 2 42 3CVD 284 76 13 4 37 10 40 11 0 . 374 30P_I 69 84 1 1 7 9 5 6 0 . 82 6
OTHER 594 78 36 5 69 9 66 9 1 0 766 61All 978 77 52 4 117 9 115 9 2 0 1,264 100
CLRD 94% 133% 114% 62% -- 94%CVD 91% 84% 86% 92% 0% 90%P_I 127% 50% 93% 111% -- 120%
OTHER 123% 126% 120% 112% 67% 122%All 111% 109% 105% 101% 80% 109%
2010
2011
2012
YEAR/CAUSE Proportion of Census Tract in Inundation Zone All0% >0-10% >10-75% >75% Unknown
Percent Increase
• Overall results:• 0% flooded: 111% of baseline• >0-10%: 109% of baseline• >10-75%: 105% of baseline • >75%: 101% of baseline
Investigating Death Increase in Immediate post-Sandy Period
• Up 11% (156 deaths)• Not concentrated in flooded areas• Not concentrated in any specific age/cause group• Resolved after about 10 days as most of city
operations returned to normal outside of flooded areas
• No increase with past subway shutdowns seen• Later second rise in deaths found to related to
onset of influenza season
Investigating Death Increase in Immediate Post-Sandy Period: Healthcare Facility Evacuations
• Deaths among evacuated nursing home residents up only 5-6 over prior years (preliminary)
• Deaths at receiving hospitals up ~20-25 deaths after adjustment of baselines (preliminary)– No adjustment made for medical acuity of
transferees– Unable to examine by transferring hospital
• No deaths reported to ME as transfer-related (would be reportable in NYC)
Challenges I• Time-consuming ad hoc SQL queries required to extract
needed mortality data from EDRS to get certified data and additional data elements needed
• Needed to quickly resolve current year geocoding rejects and recode prior years to 2010 census
• SAS programs needed to be urgently developed for reports, delaying results despite timely data transfer from death reporters (ideally have canned reports/programs ready)
• De-duplicating pre-registration death certifications for analysis added extra step to analysis
• Difficult to account for evacuation impact
Lessons Learned• EDRS effectively adapted to provide disaster-related mortality
surveillance• Pre-registration records increase timeliness but require staff with
SQL programming skills• Local MMDS software and nosologists essential to timely cause of
death coding• Zip code proved too coarse a measure in urban area to accurately
categorize areas by flood levels – Few zip codes with majority flooded and many with just small area
affected• Need to restricting comparison data by certification/registration
date 2°reporting lag• Post-registration free-text in injury searches not helpful in our
setting
Next Steps I• Planned investigation for potential excess all-cause mortality
(some pending grant-related resources) – Time-series analysis of deaths counts to better account for
known environmental factors that influence daily death counts (EH)
– Use of hospital discharge data to characterize death increase – More detailed analysis of possible transfer related mortality
using linked hospital discharge data and mortality data (account for medical acuity)
– More detailed analysis of possible nursing home related death transfers with IJE data and possibly chart reviews given small counts
Next Steps II• Consider adding DOB and address to DC
certification screens to allow for age and neighborhood analyses on more timely certified only data
• Consider operationalizing reports for expected emergencies (applied for staff as part syndromic surveillance program request)
• Advocate to NCHS for access to updated MMDS software to allow this kind of work for emergency response
Food for Thought
• Most post-disaster mortality analyses not based on Vital Statistics– Recent MMWR used red cross data– Stand alone mortality reporting systems have
been used in US for other hurricanes• Issues are timeliness and lack of accurate capture of
disaster-related deaths in some areas (e.g., COD “fall” but does not mention Hurricane as cause)
CoAuthors
• Renata Howland, MPH (CSTE epi fellow)• Wenhui Li, PhD (in attendance at NAPHSIS)• Ann Madsen, PhD, MPH• Howard Wong, MSc• Tara Das, PhD (in attendance at NAPHSIS)• Thomas Matte, MD, MPH• Catherine Stayton, DrPH, MPH
All Cause Death Counts, Nov 1–10, 2010–2012
Date of Death 2010 2011 2012
Absolute difference
between 2012 and average of
2010-2011
Percent difference
between 2012 and average of
2010-201111/1/2012 150 153 134 -17.5 -12%11/2/2012 128 131 147 17.5 14%11/3/2012 135 140 157 19.5 14%11/4/2012 157 151 162 8 5%11/5/2012 130 125 161 33.5 26%11/6/2012 133 136 164 29.5 22%11/7/2012 156 159 161 3.5 2%11/8/2012 174 161 164 -3.5 -2%11/9/2012 130 153 172 30.5 22%
11/10/2012 153 150 186 34.5 23%Mean 144.6 145.9 160.8 15.6 11%
Median 142.5 150.5 161.5 15.0 10%Total 1,446 1,459 1,608 155.5 11%
Death Registration
Mortality Surveillance Findings
• Pre-registration certificates provided timely and relatively high quality data– Address most likely to be missing (80%), delaying
geographical analyses– Retrospective comparison between queried
records and registered records showed high agreement (94%) where fields were present