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Floods in the WHO European Region: health effects and their prevention (WHO/EURO, May 20 2013)

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  • Floods in the WHO European Region: health effects and their prevention (WHO/EURO, May 20 2013)

    [Source: World Health Organization, Regional Office for Europe, full PDF document: (LINK). Extract, edited.]

    Floods in the WHO European Region: health effects and their prevention

    Edited by: Bettina Menne and Virginia Murray


    In 2009?2011, the WHO Regional Office for Europe and the United Kingdom Health Protection Agency undertook a project to investigate the adverse health effects of floods and to understand how best to protect the health of populations during floods in the European Region. The project had two main components. A questionnaire was sent to 50 of the 53 Member States of the WHO European Region (plus the United Nations Administered Province of Kosovo(1)) to collect information on recent experience of floods, their health effects and current preparedness and response mechanisms. Furthermore, a systematic review was undertaken of the epidemiological literature on the global impact of flooding on health. Analysis of the returned questionnaires and the peer-reviewed literature brought to light many issues pertinent to Europe. These findings will help WHO to prepare evidence-based guidance for the European Region on health concerns before, during and after flooding incidents and the measures for prevention, response and recovery.

    • Delivery of health care ? organization and administration
    • Disaster planning
    • Emergencies
    • Environment and public health
    • Natural disasters
    • Public health
    (1) In accordance with Security Council resolution 1244 (1999)

    ISBN 978 92 890 0011 6

    Address requests about publications of the WHO Regional Office for Europe to:

    Publications, WHO Regional Office for Europe, UN City, Marmorvej 51, DK-2100 Copenhagen ?, Denmark, Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the Regional Office web site ( ).


    Natural disasters commonly have deep, far-reaching consequences for the communities affected. In the European Region, floods are the most common disasters, causing extensive damage and disruption. The magnitude of the physical and human cost of such events can, however, be reduced if adequate emergency preparedness and planning are implemented, mitigation actions are undertaken and timely and coordinated responses are launched throughout and after the event.

    In particular, much can be done to prevent or minimize the health impacts and human suffering. Globally and at the European level, WHO has been heavily involved in addressing the health dimensions of emergency management. The Hyogo Framework for Action (2005?2015) adopted by the World Conference on Disaster Reduction highlights the need to integrate planning for disaster risk reduction into the health sector. World Health Assembly resolutions 58.1 and 59.22 (2005 and 2006, respectively) urged Member States to formulate national emergency preparedness plans giving due attention to public health, including health infrastructure, and reiterated the importance of building national capacity in emergency preparedness. The WHO Eleventh General Programme of Work (2006?2015) identifies strengthening of global security as a priority, supporting an integrated approach and societywide responses to emerging and new threats to health, including disasters and emergencies.

    At the European level, the Regional Framework for action on climate change sets as an objective improved provision of early warning systems, the preparation of action plans for extreme weather events, disaster preparedness and response and development of climate-resilient health care and other public service infrastructure.

    The purpose of this review is to assist Member States in better understanding the health risks of flooding and developing their own public health responses for flood prevention in the context of wider emergency planning. Its findings are based on a comprehensive review of the scientific literature, web-based governmental and nongovernmental reports and a survey conducted by the WHO Regional Office for Europe with the United Kingdom Health Protection Agency (HPA)1 between 2009 and 2011.

    Resilient, proactive health systems that anticipate needs and challenges are more likely to respond effectively during emergencies, save lives and alleviate human suffering. The WHO Regional Office for Europe will continue to support Member States in their efforts to minimize the health impacts of floods. We hope this publication will provide background for that collaborative work and promote progress in this area.

    Gu?na?l R. Rodier, Director, Division of Communicable Diseases, Health Security and Environment, WHO Regional Office for Europe

    David L. Heymann, Chairman, Advisory Board of Public Health, England

    (1) Since 1 April 2013, the HPA has been part of Public Health England.

    Executive summary

    Floods are the most common natural disaster in the European Region, which has experienced in recent years some of the largest flooding events in its history. The effects of flooding on health are extensive and significant, ranging from mortality and injuries resulting from trauma and drowning to infectious diseases and mental health problems (acute and long-term). While some of these outcomes are relatively easy to track, ascertainment of the human impact of floods in Europe is still weak. The WHO Regional Office for Europe and the United Kingdom HPA collaborated to assess the health effects of floods as well as to identify measures to prevent or minimize their health effects. The result is this document, which is intended to provide decision-makers with evidence for action before, during and after flooding events.

    The information for this report was obtained through a comprehensive review of scientific evidence and ?grey? literature, governmental and nongovernmental reports and data. Valuable information on practices and experiences of flooding and related public health measures was ascertained from the responses to a questionnaire sent to WHO Member States in the European Region. The key messages of this publication are as follows.

    Extreme precipitation events and floods are frequent, and projected to increase, in the European Region.
    • Flooding occurred in 50 of the 53 countries in the WHO European Region during the past decade, with the most severe floods in Romania, the Russian Federation, Turkey and the United Kingdom.
    • It is projected that climate change will cause more rainfall. This may result in more frequent and more intense floods of various types such as local, sudden floods (flash floods); extensive, longer-lasting pluvial and fluvial floods; coastal floods and snowmelt floods.
    • Heavy precipitation is likely to become more frequent throughout Europe. Even in summer, when the frequency of wet days is projected to decrease, the intensity of extreme rain showers may still increase. In addition, the frequency of precipitation for several days is projected to increase. In consequence, if no measures are taken, river flooding is projected to affect 250 000?400 000 additional people per year in Europe by the 2080s, more than doubling the numbers from those in 1961?1990. The populations most severely affected will be those of central Europe and the British Isles (1). Rises in sea-level and storm surges, which cause coastal flooding, will affect several million more people, in particular in northern and western Europe, by 2080 (2).
    Floods have significant health impacts.
    • During the past 30 years, flooding killed more than 200 000 people and affected more than 2.8 billion others worldwide. During the past 10 years, in the European Region, 1000 persons are reported to have been killed by floods and more than 3.4 million affected (42). A review of European data for the years 2000?2011 shows that the number of deaths from flooding was highest in central Europe and the former Soviet Republics.
    • Two thirds of deaths associated with flooding are from drowning, and the other third are from physical trauma, heart attacks, electrocution, carbon monoxide (CO) poisoning and fire. Often, only immediate traumatic deaths from flooding are recorded.
    • Morbidity associated with floods is usually due to injuries, infections, chemical hazards and mental health effects (acute as well as delayed). The longer-term health effects associated with a flood are less easily identified. They include effects due to displacement, destruction of homes, delayed recovery and water shortages.
    • The most common health-relevant occurrences during floods reported by European Member States are shortages of safe water, injuries and disruption of access to health services. Outbreaks of infectious diseases are rare.
    • Known risk factors for flood-related mortality and morbidity are: fast-flowing water, hidden hazards, water of unknown depth, driving and walking through flood-water, flood-water contamination (by chemicals, sewage and residual mud), exposure to electrical hazards during recovery and cleaning, unsafe drinking-water and food shortages and contamination, incomplete routine hygiene, CO poisoning, and lack of access to health services.
    • Flooding of health facilities results in interruption of business, loss of infrastructure, such as water supply and electrical power, increased patient admissions and increased difficulty in providing routine medical and nursing care for patients with chronic diseases, such as diabetes, renal failure, cystic fibrosis, cancer and mental illness.
    • Population vulnerability to the health effects of flooding is due to a complex interaction of a variety of factors: severity and rapidity of the flooding, health status and necessity of regular treatment, access and availability of warning, rapidity of response measures and being located in high-risk areas and high-risk built environments.
    Adequate planning is vital in order to effectively minimize health effects from floods.
    • The most important measure to minimize health impacts from floods is implementation of a wide, multisectoral all-hazards approach to emergency preparedness, translated into a local plan that includes public health and primary care.
    • Adequate land use is important in reducing health effects from floods. For instance, the building of health care facilities in a flood-plain should be avoided.
    • Early warning systems are important components of flood emergency plans, allowing adequate time for preparation and response.
    • Provisions should be made to ensure water quality, sanitation and hygiene and food safety after the flood; health precautions during clean-up activities; protective measures against communicable diseases and chemical hazards; and measures to track and ensure mental health and well-being.
    • In addition to the core elements, emergency planning should be comprehensive, taking into account gender considerations, recommendations on evacuation and displacement and the health protection of vulnerable groups.
    • Surveillance for mortality and morbidity during and after the event is important, in order to obtain timely information for any interventions required.
    • Further work is needed to integrate health into emergency flood plans. Whereas health is often not considered explicitly in emergency plans, flood?health prevention requires an adequate coordination of health authorities with emergency response agencies.
    • Very often, only short-term health effects of floods are considered in emergency plans. However, several outcomes (including long term mental health problems) have longer latency periods and need to be monitored and acted upon in the longer term.
    A multisectoral approach is required to prevent flood health effects.

    A range of primary, secondary and tertiary prevention measures can be adopted to minimize the health impact of flooding events.
    • Primary prevention can be either structural (physically engineered interventions) or non structural (policy and organization). Examples of primary prevention include emergency plans and other methods to reduce the effects of floods, like land use management; tree planting; control of water sources and flow, including drainage systems; flood defences and barriers; design and architectural strategies; and flood insurance. These measures are normally planned far in advance.
    • Secondary prevention includes identification of vulnerable or high-risk populations before floods occur, early warning systems, evacuation plans including communication and information strategies, and planned refuge areas. Secondary prevention measures for flood risk management can be taken either just before or during a flood to mitigate the health effects of the flood. Multisectoral collaboration is required between health services, early warning systems, water supply companies and emergency services for evacuation. Secondary prevention measures for vulnerable populations should account for difficulties in communication and mobility and the needs of people with chronic diseases.
    • Tertiary measures include moving belongings to safe areas, ensuring the provision of clean drinking-water, surveillance and monitoring of health impacts, treating ill people to reduce the health impacts of flooding, and recovery and rehabilitation of flooded houses. Multisectoral collaboration among the military, fire department, police, water supply companies and health services is required. Robust surveillance is necessary during and after flood events to identify and control infectious disease outbreaks and non-infectious health hazards, tailor health service provision to the needs of the population, monitor vulnerable groups and provide information for research on possible associations between flooding and ill health.
    There are still many gaps in knowledge regarding floods and health.

    There are a number of gaps in knowledge about health impacts, response and recovery:
    • a definition of ?flood? for health purposes (The three approaches commonly used are water depth and spatial scale, population effects and temporal perspectives.
    Definitions would be particularly useful for assessing effects on health and on infrastructure and the financial toll and as a trigger for activation of emergency responses.);
    • impacts of flooding on health facilities and health care provision, including economic impacts;
    • delivery of health care and ensuring the continuity of care during a flood, especially for people with chronic diseases;
    • structural protection and flood-proofing of health care facilities;
    • risk mapping, including the identification and involvement of vulnerable groups and targeted interventions;
    • health information management during floods, including how to set up effective surveillance and monitoring systems;
    • health effects of population displacement by evacuation and relocation;
    • health protection for victims and vulnerable groups during the disaster recovery phase;
    • appropriateness of triggering indicators for activation of emergency plans;
    • locally relevant climate change adaptation planning to protect health from extreme weather events;
    • validity of alternative sources of information for flood events (e.g. media, nongovernmental organizations, differences in reporting);
    • culturally appropriate, age- and gender-sensitive mental health programmes for disaster victims;
    • vulnerability to flooding, increased resilience, vulnerability boundaries;
    • interactions between emergency response agencies and health care providers, response of hospitals to early warning systems;
    • timely, effective communication during electricity cuts and population movement;
    • better institutional and public responses to early warning systems; and
    • emergency and longer-term mental health care in response and recovery.