台灣災害之健康危害分析及預防策略之應用

Abstract

災難指自然或人為力量的健康損害，需要外來支援才能恢復原先的狀態。除了衛生與醫療的衝擊外，對於生態也有鉅大的衝擊。從減災、準備、應變與復原等四方面，去進行災難的介入及改善，稱為災難管理。台灣處於地震及熱帶氣旋頻繁的地區，而文明的進步，使人為災難層出不窮。針對過去災難之健康衝擊缺乏完整的分析，本研究以減災應變準備為中心，探究災難健康衝擊之危害因子及緊急醫療資源特色並提出防範策略。 本研究包括：一、採用世界衛生組織的定義與架構，以過去的政府紀錄及報紙，進行回溯流病分析；二、以不同時期的災難事件進行質性分析其應變組織策略，並探索長期發展的趨勢；三、從歷史資料及衛生署的災難病患登錄系統，分析傷病種類、嚴重度及醫療資源耗用，推估實際醫療資源需求；四、以颱風歷史資料，以潛在製造傷害事件（Potential Injury Creating Event）分類法分為三級而與氣象特徵利用多變項邏輯回歸（polytomonous logistic regression），找出危害因子；五、探究災難緊急醫療的特徵，利用醫療救護體系的要素及相關社會指標，利用因數分析歸納出精簡的成分，並利用群聚分析，將其分為數個基本型態。 颱風死亡發生在20歲以上族群，可能與危險的暴露有關。輕重病患最大多數，透過緊急醫療體系就醫的只是一部份。住院的需求不高（16.6％），加護病房者需求少（1.8％）。院外死亡者，以溺水（45.5％）及土石流活埋（40.0％）最多，重點應為預防而非緊急救護。其他大量傷患事件，型態也以類似。相關氣象因子中，登陸與否、中心氣壓、中心風速及雨量對於健康衝擊有統計上相關。 經由災例分析，應變從地方主導，逐漸成為中央管理，民間義工逐漸變為政府資源為主力，但應變功能一直是獨立運作，體系間較缺法整合。醫療機構容易因災害而發生機構失效。因素分析可歸納出兩個主要特徵：資源充沛度及地理的遼闊。此因素上也與各地的創傷、心血管及腦血管疾病的死亡率。群聚分析可以歸納出三種基本型態，資源多地方小的都會型、醫療夠地方狹小的城市郊區型，及資源少但遼闊的荒野型，未來可針對這兩項因素務實規劃緊醫體系。 除了直接的傷害與死亡，醫療體系及社區結構的損害，也形成間接損害。。氣象預測、緊急醫療、大眾傳媒的進步，無法完全避免健康衝擊，須靠傷害預防配合現有資源的有效利用及社區的長期發展才能減少健康損害重。社區層次中，危害減災措施的執行、建立以改變人群行為的預警系統、及改善災難各後果應變單位及各區域的協調及效率；醫療體系中，改善體系的抗災準備使其能在災難中維持醫療運作，嫻熟各種新興危害的相關應變技能，經由體系的強化改善突發作業能力與能量；個人層次，基本防災的教育及相關技能訓練、加強危害的警覺，以上才能系統化地進行社區防災準備與減災措施，以最合乎經濟效益的方式，平衡社區發展與減少危害的衝擊。

Disaster, a sudden ecological disruption by natural or manmade force that requires external assistance, may results in huge impact to social welfare and health loss. Disaster could be managed through mitigation, preparedness, response and recovery. Taiwan is vulnerable to earthquakes, typhoons, and technical disasters though history data were inadequate. Focusing on the mitigation and preparedness, this study proposed strategies for alleviating the impact through describing the epidemiology of disaster health impact and emergency medical preparedness. Firstly, a framework definition of disaster by World Health Organization was applied in analyzing the history document. Then response mechanism and strategies of disasters in different stages were analyzed qualitatively. Thirdly, the casualty data in governmental reporting system was analyzed for injury pattern, triage categories, medical resources utilization. Fourthly, the typhoons were grouped into three levels according to the Potential Injury Creating Event Nomenclature based on health loss. Polytomonous logistic regression was used to identified the risk meteorological factors. Finally, the demographical data relating to disaster preparedness was collected. Variable reduction was performed by using factor analysis and cluster analysis was further used to define prototypes of medical preparedness. For typhoon casualty, minor injuries was the majority and only a small portion was sent by fire services ambulance. Admission was indicated in small part. Drowning (45.5％) and mudslide burial (40.0％) was the most common pre-hospital death, injury prevention would be the only strategies. Finding was similar in other hazards. The meteorological risk factors were: landing of typhoon, central pressure depression, wind velocity, and rainfalls. The disaster case studies demonstrated the response system from local to central and from volunteer to official. Functions responded independently with little tactical coordination, and hospitals were vulnerable to disasters. Results of factor analysis revealed two main factors: medical resources and area size. They were related to mortality of heart, stroke and injury. The districts could be grouped into three patterns: urban, luxurious medical resources with moderate area; city/suburb, adequate resources with small area; wildness, huge area with scarce resources. Besides direct injury and death, indirect health impact from disruption of health care system and community infrastructure was also important. Advanced warning technique, sophisticated medical care and increase coverage of mass media, can not alleviate the impact without injury prevention intervention, risk perception of the civilian, behavior modification and maximize the utilization of current resources. In community level, the implementation of disaster mitigation program including warning system towards behavior change and risk perception, efficient command structure should be emphasized. The health delivery system should focus on resilience of the facility, increasing surge capability and capability through system improvement. In civilian level, fundamental education/training to protect themselves during disasters, and support the mitigation program balancing the economic development and hazards management.