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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. A Framework for Assessing Mortality and Morbidity After Large-Scale Disasters. Washington, DC: The National Academies Press. doi: 10.17226/25863.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. A Framework for Assessing Mortality and Morbidity After Large-Scale Disasters. Washington, DC: The National Academies Press. doi: 10.17226/25863.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. A Framework for Assessing Mortality and Morbidity After Large-Scale Disasters. Washington, DC: The National Academies Press. doi: 10.17226/25863.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. A Framework for Assessing Mortality and Morbidity After Large-Scale Disasters. Washington, DC: The National Academies Press. doi: 10.17226/25863.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. A Framework for Assessing Mortality and Morbidity After Large-Scale Disasters. Washington, DC: The National Academies Press. doi: 10.17226/25863.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. A Framework for Assessing Mortality and Morbidity After Large-Scale Disasters. Washington, DC: The National Academies Press. doi: 10.17226/25863.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. A Framework for Assessing Mortality and Morbidity After Large-Scale Disasters. Washington, DC: The National Academies Press. doi: 10.17226/25863.
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Page viii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. A Framework for Assessing Mortality and Morbidity After Large-Scale Disasters. Washington, DC: The National Academies Press. doi: 10.17226/25863.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. A Framework for Assessing Mortality and Morbidity After Large-Scale Disasters. Washington, DC: The National Academies Press. doi: 10.17226/25863.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2020. A Framework for Assessing Mortality and Morbidity After Large-Scale Disasters. Washington, DC: The National Academies Press. doi: 10.17226/25863.
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Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

A FRAMEWORK FOR ASSESSING MORTALITY AND MORBIDITY AFTER LARGE-SCALE DISASTERS Ellen J. MacKenzie, Scott H. Wollek, Olivia C. Yost, and Daniel L. Cork, Editors Committee on Best Practices for Assessing Mortality and Significant Morbidity Following Large-Scale Disasters Board on Health Sciences Policy Health and Medicine Division A Consensus Study Report of PREPUBLICATION COPY: UNCORRECTED PROOFS

THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001 This activity was supported by a contract between the National Academy of Sciences and the Federal Emergency Management Agency. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project. International Standard Book Number-13: 978-0-309-XXXXX-X International Standard Book Number-10: 0-309-XXXXX-X Digital Object Identifier: https://doi.org/10.17226/25863 Additional copies of this publication are available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. Copyright 2020 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2020. A framework for assessing mortality and morbidity after large-scale disasters. Washington, DC: The National Academies Press. https://doi.org/10.17226/25863. PREPUBLICATION COPY: UNCORRECTED PROOFS

The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president. The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. John L. Anderson is president. The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president. The three Academies work together as the National Academies of Sciences, Engineering, and Medicine to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine. Learn more about the National Academies of Sciences, Engineering, and Medicine at www.nationalacademies.org. PREPUBLICATION COPY: UNCORRECTED PROOFS

Consensus Study Reports published by the National Academies of Sciences, Engineering, and Medicine document the evidence-based consensus on the study’s statement of task by an authoring committee of experts. Reports typically include findings, conclusions, and recommendations based on information gathered by the committee and the committee’s deliberations. Each report has been subjected to a rigorous and independent peer-review process and it represents the position of the National Academies on the statement of task. Proceedings published by the National Academies of Sciences, Engineering, and Medicine chronicle the presentations and discussions at a workshop, symposium, or other event convened by the National Academies. The statements and opinions contained in proceedings are those of the participants and are not endorsed by other participants, the planning committee, or the National Academies. For information about other products and activities of the National Academies, please visit www.nationalacademies.org/about/whatwedo. PREPUBLICATION COPY: UNCORRECTED PROOFS

COMMITTEE ON BEST PRACTICES FOR ASSESSING MORTALITY AND SIGNIFICANT MORBIDITY FOLLOWING LARGE-SCALE DISASTERS ELLEN J. MACKENZIE (Chair), Bloomberg Distinguished Professor and Dean, Johns Hopkins Bloomberg School of Public Health SUE ANNE BELL, Assistant Professor, University of Michigan School of Nursing H. RUSSELL BERNARD, Research Professor and Director, Arizona State University ARAM DOBALIAN, Professor and Director, Division of Health Systems Management and Policy, The University of Memphis MARCELLA F. FIERRO, Chief Medical Examiner (retired), Commonwealth of Virginia; Consultant Forensic Pathologist, Fierro Forensics ELIZABETH FRANKENBERG, Director, Carolina Population Center, University of North Carolina JOHN L. HICK, Faculty Emergency Physician, Hennepin Healthcare; Professor of Emergency Medicine, University of Minnesota ALI S. KHAN, Dean, College of Public Health, University of Nebraska Medical Center MAUREEN LICHTVELD, Professor and Chair, Department of Environmental Health Sciences, Tulane University School of Public Health and Tropical Medicine CHARLES ROTHWELL, Director (retired), National Center for Health Statistics RICHARD SERINO, Distinguished Senior Fellow, Harvard T.H. Chan School of Public Health MICHAEL A. STOTO, Professor, Health Systems Administration and Population Health, Georgetown University W. CRAIG VANDERWAGEN, Founder and General Manager, East West Protection, LLC DANIEL WALL, Emergency Manager, City of Ventura MATTHEW WYNIA, Director, Center for Bioethics and Humanities, University of Colorado Study Staff SCOTT WOLLEK, Study Director (from August 2019) MICHELLE MANCHER, Study Director (until August 2019) DANIEL CORK, Senior Program Officer OLIVIA YOST, Program Officer MARIAM SHELTON, Research Associate (until December 2019) MICHAEL BERRIOS, Research Associate ANDREW POPE, Senior Director, Board on Health Sciences Policy Consultant ANNA NICHOLSON, Doxastic, Inc. PREPUBLICATION COPY: UNCORRECTED PROOFS v

Reviewers This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We thank the following individuals for their review of this report: JAMES FICKE, Johns Hopkins Hospital NICHOLAS P. JEWELL, London School of Hygiene & Tropical Medicine ROGER J. LEWIS, Harbor-UCLA Medical Center NICOLE LURIE, Harvard Medical School PABLO A. MARQUET, Pontificia Universidad Católica de Chile SAMANTHA MONTANO, Massachusetts Maritime Academy DAN MORGAN, National Transportation Safety Board JOSEPH O. PREWITT DIAZ, American Red Cross International Services WILLIAM ROUSE, Georgetown University KIMBERLY SHOAF, The University of Utah TENER VEENEMA, Johns Hopkins Bloomberg School of Public Health ROBERT WALLACE, The University of Iowa MARY C. WATERS, Harvard University VICTOR WEEDN, The George Washington University Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations of this report nor did they see the final draft before its release. The review of this report was overseen by ALFRED O. BERG, University of Washington School of Medicine, and CHARLES E. PHELPS, University of Rochester. They were responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies. PREPUBLICATION COPY: UNCORRECTED PROOFS vii

Contents PREFACE P-1 SUMMARY S-1 1 INTRODUCTION 1-1 Study Background and Scope, 1-1 Value and Meaningful Use of Mortality and Morbidity Data in Disaster Management, 1-8 Current Issues in Mortality and Morbidity Assessment, 1-9 Terminology Choices and Key Concepts, 1-15 Organization of This Report, 1-18 2 VALUE AND USE OF MORTALITY AND MORBIDITY DATA 2-1 Conceptualizing All-Cause Mortality and Morbidity, 2-1 Attributing Morbidity to a Disaster, 2-10 Overlooked Value of Morbidity Data, 2-12 Value and Use of Data across the Disaster Lifecycle, 2-13 Recommendations, 2-19 3 OPERATIONAL CONSIDERATIONS FOR INDIVIDUAL COUNTS OF MORTALITY AND MORBIDITY 3-1 The Investigation and Registration of Deaths in the United States, 3-3 Challenges with Uniform Attribution Across These Systems, 3-8 Opportunities to Facilitate the Capture and Registration of Individual Disaster Deaths, 3-18 Considerations Specific to the Collection of Morbidity Data, 3-24 Use of Individual-Level Mortality and Morbidity Data to Inform Disaster Management, 3-27 Recommendations, 3-28 4 ANALYTICAL CONSIDERATIONS FOR POPULATION ESTIMATES OF MORTALITY AND MORBIDITY 4-1 Survey Data Collection in the Wake of Disasters, 4-3 Estimation of Excess Mortality or Morbidity, 4-10 Specialized Methods for Measuring Hard-to-Count or Hidden Populations, 4-16 Common Issues Related to Estimation Techniques, 4-20 Conclusions and Recommendations, 4-23 5 MEETING THE MISSION 5-1 Moving Forward, 5-2 Conclusions and Recommendations, 5-6 PREPUBLICATION COPY: UNCORRECTED PROOFS ix

APPENDIXES A PRELIMINARY LITERATURE REVIEW STRATEGY A-1 B PUBLIC SESSION AGENDAS B-1 C ASSESSING MORBIDITY AND MORTALITY ASSOCIATED WITH THE COVID-19 PANDEMIC: A CASE STUDY ILLUSTRATING THE NEED FOR THE RECOMMNEDATIONS IN THIS REPORT C-1 D INTEGRATING COMMUNITY VULNERABILITIES INTO THE ASSESSMENT OF DISASTER-RELATED MORBIDITY AND MORTALITY: TWO ILLUSTRATIVE CASES D-1 E COMMITTEE AND STAFF BIOGRAPHICAL SKETCHES E-1 PREPUBLICATION COPY: UNCORRECTED PROOFS x

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In the wake of a large-scale disaster, from the initial devastation through the long tail of recovery, protecting the health and well-being of the affected individuals and communities is paramount. Accurate and timely information about mortality and significant morbidity related to the disaster are the cornerstone of the efforts of the disaster management enterprise to save lives and prevent further health impacts. Conversely, failure to accurately capture mortality and significant morbidity data undercuts the nation's capacity to protect its population. Information about disaster-related mortality and significant morbidity adds value at all phases of the disaster management cycle. As a disaster unfolds, the data are crucial in guiding response and recovery priorities, ensuring a common operating picture and real-time situational awareness across stakeholders, and protecting vulnerable populations and settings at heightened risk.

A Framework for Assessing Mortality and Morbidity After Large-Scale Disasters reviews and describes the current state of the field of disaster-related mortality and significant morbidity assessment. This report examines practices and methods for data collection, recording, sharing, and use across state, local, tribal, and territorial stakeholders; evaluates best practices; and identifies areas for future resource investment.

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