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Abstract
Objective On 6 February 2023, two massive earthquakes occurred in Kahramanmaras province in Türkiye. In addition to direct physical damage, earthquakes can also significantly affect individuals’ respiratory health in the postdisaster period. This study aimed to investigate respiratory diseases and related mortality following earthquakes.
Design This is a retrospective observational study. 1 month following the earthquake, all cases that came to the emergency department between 6 February 2023 and 6 March 2023 who required a pulmonologist consultation were included (n=278). All cases requiring a pulmonologist consultation who were admitted to the emergency department within the same date period 1 year ago (6 February 2022–6 March 2022) were included in the control group (n=255).
Setting Türkiye, Adana Province.
Outcome measures Respiratory diseases, mortality risks in 3 weeks and 3 months, and factors that may affect mortality were investigated in the population exposed to the earthquake.
Results Pneumonia had the highest rate among admissions in the postearthquake period (36.0%). The pneumonia rate and pneumonia-related deaths were significantly higher compared with those in the previous year (OR: 2.28, 95% CI: 1.05 to 4.94 and OR: 2.49, 95% CI: 1.15 to 5.39; 3-week and 3-month mortality, respectively). The disease that had the second highest admissions rate was chronic obstructive pulmonary disease exacerbation (25.9%). Earthquake exposure is associated with increased risk of 3-week (OR: 1.58, 95% CI: 1.03 to 2.43) and 3-month mortality (OR: 1.55, 95% CI: 1.03 to 2.36).
Conclusions The period after the earthquake is associated with an increase in the incidence of pneumonia and a poor prognosis for patients with pneumonia. Considering all cases, earthquake exposure has a negative impact on the prognosis of respiratory diseases.
- Mortality
- Pulmonary Disease
- EPIDEMIOLOGY
Data availability statement
Data are available on reasonable request. No data are available.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
The strength of the study was that all non-traumatic respiratory patients who presented to the study hospital within 3 months after the earthquake disaster were evaluated.
The limitations included only examining hospital applications, not reaching all patients in the environment, and the inability to evaluate which exposed agents had what level of effect in the postdisaster area.
Introduction
The 7.7 and 7.6 magnitude earthquakes that occurred in Kahramanmaras on 6 February 2023 went down in history as one of the biggest disasters in Türkiye.1 2 It was the strongest earthquake to shake Türkiye since 1939, and it was described as the disaster of the century.3 The impact of this seismic duo reverberated across an expansive area of approximately 350 000 km² (140 000 square miles), leaving a trail of widespread devastation. Epicentred in Kahramanmaras, the earthquake’s effects rippled across various provinces, including Hatay, Adiyaman, Gaziantep, Adana, Osmaniye, Kilis, Malatya and Sanliurfa. Approximately 15 million individuals within the region experienced repercussions. According to recent statistics, the occurrence resulted in an excess of 50 000 fatalities and 120 000 injuries.4 More than 2 500 000 buildings were affected in total, including 450 000 in Adana and 400 000 in Hatay.5 Following the earthquake, Hatay province emerged as one of the most severely affected regions. In the postdisaster environment, Adana City Hospital played an important role as a critical treatment centre, and given its geographical location, became the primary destination for a significant number of patients seeking medical care after the earthquake.
The environmental conditions precipitated by potentially hazardous substances and waste arising from earthquakes exert adverse effects on respiratory health.6 During and after the earthquake, acute, subacute and chronic airway pathologies develop due to environmental factors. Dust, smoke and other particulate matter emitted into the atmosphere can damage the respiratory tract and lead to respiratory infections or diseases.7 Collapsed structures, fires and other postdisaster effects can increase air pollutants, increasing the risk of respiratory disease and triggering already existing chronic respiratory diseases. Harmful chemicals released from damaged buildings after an earthquake can affect respiratory health and cause lung irritation.6–11 The purpose of this study is to determine the effects of earthquakes on the respiratory system and respiratory disease mortality.
Materials and methods
Study population and method
This is a retrospective observational study examining respiratory diseases in non-traumatic patients exposed to the Kahramanmaras earthquake compared with patients from the same time period 1 year earlier. The effects of the earthquake reached provinces in the surrounding area. Adana, located in the north of Hatay, is among the provinces affected by the earthquake and our hospital is located there. It is also critically located in the west of all the provinces affected by the earthquake (figure 1). All cases that were assigned to our hospital’s emergency department and required pulmonologist consultation within 1-month postearthquake (6 February 2023–6 March 2023) were included. All cases that required pulmonologist consultation in the emergency department on the same date 1 year before (6 February 2022–6 March 2022) were included as the control group. Trauma patients, injured patients and those requiring surgical intervention were not included. Data on patients for 3-week mortality and 3-month mortality were obtained through the national death notification system and hospital information management software. The Death Notification System is a web application that enables data exchange between the relevant units of the Ministry of Health, the General Directorate of Population and Citizenship Affairs, and the Turkish Statistical Institute, for the complete compilation of death statistics. Those who died within 3 weeks after admission to the emergency department were included in the 3-week mortality group, and those who died within 3 months were included in the 3-month mortality group. The 3-month mortality rates also included the 3-week mortality rates. Demographic data such as age and gender were obtained from patient records. Pulmonary embolism was defined in cases who presented to the emergency department with complaints and whose pulmonologist decided on coagulation therapy. Pleural effusion was defined as a newly occurring effusion in a patient with no history. Interstitial lung disease and lung cancer were defined as having requirements for admission for a disease-associated condition such as dehydration, respiratory failure, chest tightness or uncontrolled pain. Those with additional respiratory diseases other than the reason for admission to the emergency department were included in the additional respiratory disease group. Those with one or more additional internal comorbid diseases, such as diabetes mellitus and hypertension, were put in a different category. Patients admitted to the hospital with respiratory failure due to extrapulmonary diseases, such as neurological diseases, were defined as having non-lung respiratory failure. The definition of other respiratory diseases was made according to the diagnosis of the pulmonologist. The researchers ensured the confidentiality of patient data throughout the study and upheld the ethical principles of clinical research outlined in the Declaration of Helsinki.
Earthquake epicentres, affected areas and localisation of the study hospital.
Statistical analysis
All analyses were performed using the SPSS V.23 package program for Windows. Numerical variables were presented as means, and categorical variables were presented as proportions. The analysis of categorical data and percentages was calculated using the χ2 test. If columns have more than two rows, the Bonferroni method was used as a post hoc test to determine the difference in column ratios. The Bonferroni method is one of the corrections used to eliminate the multiple comparison problem. In the study, the Bonferroni corrections were made automatically by the package program, and asterisk symbols (*) were used to indicate which rates in the column were different. The binary logistic regression was used to compare the risk of pulmonary disease mortality between the exposed and non-exposed groups. Using conditional logistic regression analysis, each pulmonary disease type was compared with the identical disease from the previous year. Additional comorbid illness and additional pulmonary disease were statistically different between both groups, which were confounding factors of the analysis together with age and gender. The control of confounding factors that have an impact on mortality was recalculated using multivariable logistic regression and conditional multivariable logistic regression analysis. To evaluate the effect of the earthquake factors on mortality, adjusted ORs were calculated using basic confounding factors (sex, age) and diagnosed pulmonary disease. In the 95% CI, a p<0.05 was considered statistically significant. The Microsoft Excel program in the Microsoft V.365 app for Windows was used for graphical presentations and map drawing.
Results
The average age of the group exposed (n=278) to the earthquake was 65.9 years, and 42.1% were females. In the control group (n=255), the average age was 66.7 years, and 43.1% were females. There was no statistical difference between the two groups in terms of age and gender. There was a 17.3% additional pulmonary disease in the earthquake-exposed population, and it was statistically higher than that in the control group. The presence of additional comorbid diseases was higher in the control group. Referrals from another hospital and respiratory failure admission rates were similar in both groups. Chronic obstructive pulmonary disease (COPD) exacerbations (n=72, 25.9%) were significantly higher in the postearthquake period. Pneumonia was present in 36% (n=100) of patients and was significantly higher than in the previous year (n=62). The number of admissions with asthma attacks was lower in the earthquake-affected group. In the earthquake-exposed group, 74 patients (26.6%) were referrals from other hospitals that were affected or damaged. The 3-week and 3-month mortality rates were significantly higher in the earthquake-exposed group (p=0.03). Demographic data, pulmonary diseases, mortality rates and comparisons between both groups are shown in table 1.
Comparison of the control group and the earthquake disaster group
The effect of earthquake-related conditions on mortality is presented in table 2. In the exposed group, 61.2% (n=170) of the patients were sheltering in tents or vehicles because they could not live at home. Sheltering outside was associated with 3-week and 3-month mortality (OR: 2.59, 95% CI: 1.32 to 5.01 and OR: 2.96, 95% CI: 1.52 to 5.77, respectively). In those coming from the Hatay province, the 3-month mortality was significantly higher compared with that in other provinces (OR: 1.88, 95% CI: 1.02 to 3.45).
Effect of the earthquake factors on mortality in the earthquake population (n=278)
In our study population, earthquake exposure increased the risk of 3-week (OR: 1.58, 95% CI: 1.03 to 2.43), and 3-month mortality from respiratory diseases (OR: 1.55, 95% CI: 1.03 to 2.36). There was no difference in mortality between the two groups among those presenting with asthma and COPD exacerbations. Among patients with pneumonia, it was observed that both the 3-week (OR: 2.28, 95% CI: 1.05 to 4.94) and 3-month mortality (OR: 2.49, 95% CI: 1.15 to 5.39) were high in those exposed to the earthquake (table 3).
Risk of pulmonary disease mortality in the affected earthquake disaster population
Considering that the presence of additional pulmonary disease and comorbid diseases may affect mortality, the adjusted OR was calculated to control the confounding factors (table 4). At the same time, although there is no statistical significance between the two groups, age and gender were included in the analysis. It was found that the adjusted mortality risk showed similar values to those in table 3 in all cases and in the pneumonia group. Figure 2 shows the distribution of diseases by weeks. It was observed that pneumonia, COPD and pulmonary embolism cases were more common in the other weeks compared with the first week.
Multivariable logistic regression for mortality of pulmonary diseases
The frequency of cases in the weeks following the earthquakes.
Discussion
In our study which evaluated admissions to our hospital’s emergency department due to respiratory disease in the first month after the earthquake, it was seen that COPD exacerbations and pneumonia were significantly higher than those in the previous year. In the study population, mortality was higher in those affected by the earthquake. Yamanda et al examined the relationship between earthquakes and respiratory health following the 2011 Great East Japan Earthquake. In the postearthquake period of 2011, 18.2% of patients had lung diseases. It is considerably higher than the figures of previous years (11.6% and 10.2%), and there has been a significant increase in the rate of lung diseases. The most common reason for admission for lung disease was pneumonia (n=190, 59.0%), followed by acute exacerbations of COPD (n=53, 16.5%). The results of the study were similar to our findings.12 The earthquake significantly affects public health due to deaths and injuries, and it also creates difficult conditions that will cause the emergence of infectious diseases in the postearthquake period. Earthquake-affected populations have reported an increase in gastrointestinal and vectorborne diseases, as well as skin and respiratory infections.13 Pneumonia has an important place among infectious diseases. The main reasons for the development of pneumonia are toxic gas and smoke inhalation; intense exposure to dust; collective housing and inadequate hygiene conditions and severe hypothermia. In another study, it was reported that 1 month after the Great East Japan Earthquake, pneumonia cases constituted 43% of hospital admissions due to infectious diseases,14 and the number of pneumonia cases increased 2.2 times compared with that in the previous year.15 After the 1995 Kobe earthquake, the number of respiratory diseases increased by approximately 4.5 times in a 1-month period. While the mortality rate from pneumonia was 14% a year ago, it was 25% after the earthquake.16 Therefore, it is necessary to pay attention to the infectious causes of chest diseases and develop preventive strategies. According to Tsuboi et al, the median time from disaster to mortality following the Great East Japan earthquake was 24 days. Approximately 80% of deaths due to disasters happen in 3 months or less. With 31.1% of deaths connected to disasters, respiratory diseases were the most frequent direct cause of death. Pneumonia was the cause of 86.0% of deaths related to respiratory diseases.17 In our study, the risk of mortality following pneumonia was significantly higher compared with the populations not exposed to earthquakes. We found that the mortality trend continued when we controlled for confounders. We think that the control of pneumonia is of vital importance among infection control strategies in the postearthquake period.
Patients with chronic respiratory diseases such as COPD are affected in the postearthquake period.18 Patients with COPD often encounter challenges in obtaining access to essential medications, particularly during times of disaster when medication loss becomes a prevalent issue.19 It has been determined that dust arising from construction is an important component of particulate air pollution, loss of medication or inability to access treatment, and therefore, interruption of regular medication treatment; and these were determined as causes of acute exacerbation of COPD that developed after the Great Japan earthquake.20 Due to the aftershocks following the earthquake, people living in high-rise buildings could not stay in their homes for the first month, even though the houses were not damaged. These people found it safer to stay in tents or vehicles. However, this situation without the comfort of home may have affected the group with chronic diseases.19 A retrospective cohort study, conducted 6 months postdisaster involving 100 patients, sought to delineate the characteristics, clinical trajectory and outcomes of patients with COPD admitted to the hospital following emergency visits.21 Notably, within the initial days, individuals needing home oxygen therapy sought hospitalisation for continued oxygen support. In the subacute phase, spanning from the third to the fifth week postearthquake, there was a marked increase in hospitalisations attributed to COPD exacerbations compared with the pre-earthquake levels.21 Mori et al identified the significance of emergency preparedness planning and care priorities following the earthquake, highlighting medication accessibility, support for daily living activities, the provision of suitable nourishment, and the availability of requisite devices as crucial focal points for individuals with chronic health conditions.22
Patients coming from the Hatay province were 29.5% (n=82) of the patients exposed to the earthquake. Of the cases, 34 patients were referred from tent polyclinics established within the Hatay province, while an additional 48 patients were transferred from hospitals that had been evacuated, also situated within Hatay (data not shown in tables). Earthquakes can also affect pre-existing respiratory diseases by blocking or restricting access to healthcare.23 Many hospitals and health facilities in the earthquake area were partially or completely damaged and became unusable. Healthcare providers and rescue teams serving the area also had to work in an environment at risk for respiratory illnesses, infectious diseases, post-traumatic stress or fire burns.23 According to the results of our study, considering that the mortality rate is higher in those coming from the Hatay province, it cannot be denied that the health services provided at the primary impact points of the disaster area are of critical importance. The most unexpected finding of our study was the decrease in asthma attacks in the postearthquake period. We would expect the postearthquake period, which has intense interaction with the respiratory tract, to increase asthma attacks. There are results reporting a decrease in asthma attacks similar to the results of our study.16 24 On the contrary, increases in hospital admission and hospitalisation rates have been observed.12 25 26 The results are inconsistent, and we believe that postearthquake asthma attacks need to be investigated further.
One of the limitations of our study lies in its single-centre design, where only cases presenting to our hospital were assessed. Although this is a limitation, we believe that a multicentre study would not have changed the results due to our hospital’s critical location and status as the largest hospital in the earthquake-affected area. Our study examined only patients who were able to come to the hospital. Severe and symptomatic older patients are likely to come to the hospital. Real-world incidence and prevalence rates can be obtained when the entire population is examined. Our study was a hospital-based retrospective study. Although it seems technically impossible, there is a need for studies that measure environmental toxic agents emerging in the earthquake region and directly examine their effects on respiration. As a result, in order to protect respiratory disease patients from disaster-induced environmental damage and reduce their mortality, it is important to establish and provide support for medical care systems that provide special care and treatment after disasters. In the postearthquake period, pneumonia increases and is an important cause of mortality. By evaluating the factors affecting mortality, future mitigation strategies and preparedness measures can be developed.
Data availability statement
Data are available on reasonable request. No data are available.
Ethics statements
Patient consent for publication
Ethics approval
This study received ethics committee approval from Adana City Training and Research Hospital with reference number 128 and protocol number 2640 (8 June 2023).
Acknowledgments
This study was written in memory of the people who lost their lives in the Kahramanmaras earthquakes.
References
Footnotes
Contributors ÖG (corresponding author) is the guarantor. Study conception: ÖG and ÖED. Study design and protocol development: ÖED and AA. Statistical analysis: ÖG. Administrative support: ÖED, AA, SBS and AIA. Supervision: ÖG and ÖED. Batch testing of study products: ÖED, ÖG, AA, SBS and AIA. Drafting of manuscript: ÖED and ÖG. Critical review of manuscript and reviewed and approved the final version of the manuscript: ÖG, ÖED, AA, SBS and AIA.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
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Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.