Public Health Needs Assessments of Tutuila Island, American Samoa, After the 2009 Tsunami

Abstract

Objective:
An 8.3 magnitude earthquake followed by tsunami waves devastated American Samoa on September 29, 2009, resulting in widespread loss of property and public services. An initial and a follow-up Community Needs Assessment for Public Health Emergency Response (CASPER) objectively quantified disaster-affected population needs.

Methods:
Using a 2-stage cluster sampling method of CASPER, a household questionnaire eliciting information about medical and basic needs, illnesses, and injuries was administered. To assess response efforts, percent changes in basic and medical needs, illnesses, and injuries between the initial and follow-up CASPER were calculated.

Results:
During the initial CASPER (N = 212 households), 47.6% and 51.6% of households reported needing a tarpaulin and having no electricity, respectively. The self-reported greatest needs were water (27.8%) and financial help with cleanup (25.5%). The follow-up CASPER (N = 207 households) identified increased vector problems compared to pre-tsunami, and food (26%) was identified as the self-reported greatest need. As compared to the initial CASPER, the follow-up CASPER observed decreases in electricity (-78.3%), drinking water (-44.4%), and clothing (-26.6%).

Conclusion:
This study highlights the use of CASPER during the response and recovery phases following a disaster. The initial CASPER identified basic needs immediately after the earthquake, whereas the follow-up CASPER assessed effectiveness of relief efforts and identified ongoing community needs.

Full text

FROM THE FIELD
Public Health Needs Assessments of Tutuila Island,
American Samoa, After the 2009 Tsunami
Ekta Choudhary, PhD, MPH; Tai-Ho Chen, MD; Colleen Martin, MPH; Sara Vagi, PhD, MPH;
Joseph Roth Jr, MPH; Mark Keim, MD; Rebecca Noe, RN, MPH; Seiuli Elisapeta Ponausuia, MBA;
Siitia Lemusu, MPH; Tesfaye Bayleyegn, MD; Amy Wolkin, MSPH
ABSTRACT
Objective: An 8.3 magnitude earthquake followed by tsunami waves devastated American Samoa on September
29, 2009, resulting in widespread loss of property and public services. An initial and a follow-up Community
Needs Assessment for Public Health Emergency Response (CASPER) objectively quantified disaster-affected
population needs.
Methods: Using a 2-stage cluster sampling method of CASPER, a household questionnaire eliciting information
about medical and basic needs, illnesses, and injuries was administered. To assess response efforts, percent
changes in basic and medical needs, illnesses, and injuries between the initial and follow-up CASPER were
calculated.
Results: During the initial CASPER (N=212 households), 47.6% and 51.6% of households reported needing a
tarpaulin and having no electricity, respectively. The self-reported greatest needs were water (27.8%) and
financial help with cleanup (25.5%). The follow-up CASPER (N=207 households) identified increased vector
problems compared to pre-tsunami, and food (26%) was identified as the self-reported greatest need. As com-
pared to the initial CASPER, the follow-up CASPER observed decreases in electricity (−78.3%), drinking wa-
ter (−44.4%), and clothing (−26.6%).
Conclusion: This study highlights the use of CASPER during the response and recovery phases following a di-
saster. The initial CASPER identified basic needs immediately after the earthquake, whereas the follow-up CASPER
assessed effectiveness of relief efforts and identified ongoing community needs.
(Disaster Med Public Health Preparedness. 2012;6:209-216)
Key Words: community assessment, disaster, tsunami response, public health assessment, rapid needs assessment
Natural disasters such as tsunamis can signifi-
cantly damage infrastructure and cause mor-
bidity and mortality, home damage, and popu-
lation displacement. Tsunamis, which can occur
following an earthquake, are a series of ocean waves gen-
erated by any disturbance that displaces a large water
mass.1Tsunami-related injuries may result from blunt
force trauma, and deaths may occur immediately as a
result of drowning or injuries sustained in the event af-
termath. Illness may occur as a result of water source
contamination or increased vector population, and men-
tal health problems may occur because of stress or trau-
matic experience related to the tsunami.2The 2004
Asian tsunami, a particularly devastating event, re-
sulted in more than 175 000 deaths, nearly 50 000 miss-
ing persons, and more than 1.7 million displaced per-
sons in the Indian Ocean region.3
On September 29, 2009, an earthquake measuring 8.3
on the Richter scale struck 190 km southwest of Ameri-
can Samoa,4an island territory with a population of 57 291
people.5The resulting tsunami caused 34 deaths and wide-
spread destruction of coastal homes, mainly in the capi-
tol city of Pago Pago and western coast of Tutuila Island
near the town of Leone.6The waves damaged public utili-
ties, resulting in immediate, widespread loss of water, elec-
tricity, and sanitation throughout Tutuila Island. In ad-
dition to injuries and deaths, many families were displaced
from their homes and potentially exposed to environ-
mental and other public health hazards.
The American Samoa Department of Health (ASDOH)
requested assistance from the US Public Health Ser-
vice (USPHS) and the Centers for Disease Control and
Prevention (CDC) to assess the public health needs and
health status of the affected population. In response, a
team from the USPHS and the CDC was deployed to
assist in conducting an initial (five days after tsunami)
and follow-up (three weeks after the tsunami) Com-
munity Assessment for Public Health Emergency Re-
sponse (CASPER).7CASPER is a type of needs assess-
ment that uses a two-stage cluster sampling method
originally developed by the World Health Organiza-
tion to assess immunization coverage.8This methodol-
ogy has been used previously to assess community needs
and health status following natural disasters9,10 and pro-
vides household-based estimates of specific needs, in-
juries, and illnesses after a disaster.11
Disaster Medicine and Public Health Preparedness 209
©2012 American Medical Association. All rights reserved.

The objectives of the initial CASPER were to rapidly identify
basic public health needs of affected communities, special needs,
and vulnerable populations, and environmental and other health
hazards that might result in further morbidity and mortality.
The follow-up CASPER objectives were to identify ongoing and
newly emerged community public health issues and to assess
the effectiveness of the public health response following the
initial CASPER. This report summarizes and compares the find-
ings of the initial and follow-up CASPERs conducted follow-
ing the American Samoa earthquake and tsunami.
METHODS
Sample Selection
Based on ASDOH’s visual surveys of Tutuila Island following
the earthquake and tsunami and geospatial data from the Na-
tional Oceanic and Atmospheric Administration (NOAA),12
our sampling frame for both CASPERs included all coastal cen-
sus blocks affected by 15 ft of surge water, up to one mile in-
land (Figure). A total of 244 census blocks with one or more
housing units was identified within our sampling frame. For both
CASPERs, a two-stage cluster sampling methodology (30 clus-
ters, 7 households) was used. We used ESRI ArcGIS software
to select the clusters, represented by a single census block, in
the first sampling stage. Using probability-proportionate-to-
size, based on the number of housing units in each census block,
we selected 30 census blocks (clusters) covering 16 villages from
western Fagalii to eastern Alao. For the second stage of sam-
pling, the team selected seven households within each se-
lected census block. Once in the field, the teams randomly chose
a starting point within the cluster and then systematically (ie,
every nth house) selected the 7 households to interview for a
goal of 210 household interviews.
Survey Instrument
ASDOH, USPHS, and CDC jointly developed a two-page ques-
tionnaire for each CASPER. The questionnaire covered the fol-
lowing: medical needs; availability of medical care, food, drink-
ing water, and clothing; and earthquake- and tsunami-related
injuries, illnesses, and preexisting chronic conditions. For the
follow-up CASPER, we adapted questions from the initial
CASPER questionnaire and added questions based on ASDOH
public health priorities for the recovery phase, including in-
creases in disease vector problems and vector control mea-
sures. The interviewers kept tracking sheets to track response
FIGURE
Map of Sampling Frame for Initial and Follow-up CASPERs Following the Earthquake-Tsunami in American Samoa, 2009.
American Samoa
NOTES:
LEGEND:
Census Blocks Within
1 Mile of Flood areas
Flood Areas
of Interest
Map Produced By:
GEOSPATIAL, RESEARCH, ANALYSIS,
AND SERVICES PROGRAM
DIV OF HEALTH STUDIES, ATSDR, CDC
Miles
52.50
Community Assessment for Public
Health Emergency Response (CASPER)
UNITED STATES
DEPARTMENT
OF HEALTH AND
HUMAN SERVICES
Public Health Needs Assessments After Tsunami
210 Disaster Medicine and Public Health Preparedness VOL. 6/NO. 3
©2012 American Medical Association. All rights reserved.

rates. We used confidential referral forms to report immediate
needs pertaining to safety threats, such as chemical spills or acute
medical needs (eg, need for urgent mental health counseling).
In addition, we disseminated health education materials per-
tinent to the disaster and a list of public health and relief agen-
cies to each household approached. The questionnaire was writ-
ten in English; survey teams, consisting of at least one member
who spoke Samoan, translated questions into Samoan when
needed.
Data Collection
Before conducting interviews, CDC personnel trained the in-
terview teams, which were composed of CDC and ASDOH staff.
The training included instructions on selecting the house-
holds in the second stage of sampling, administering the inter-
views, and completing the referral and tracking forms. CDC
also briefed the teams on Samoan culture, safety issues, field
communication, and the local incident command system (ICS)
structure. Teams conducted interviews from October 5-7, 2009,
for the initial CASPER and October 22-24, 2009, for the follow-
up. In each household, we interviewed one adult representa-
tive, aged at least 18 years or older.
Data Analysis
The data entry and analyses were performed using Epi Info 3.5.1.
The percentage and estimates (ie, projected number of house-
holds based on weighted analysis using census 2000 data) for
questionnaire items were calculated and reported. Contact rates
were calculated by dividing the number of completed inter-
views by the number of all housing units where contact was at-
tempted. Cooperation rates were calculated by dividing the num-
ber of completed interviews by the number of all housing units
where contact was made. To compare the findings of the ini-
tial and follow-up CASPERs, the differences in response per-
centages were calculated using percent change, with the ini-
tial CASPER as baseline.
RESULTS
Initial CASPER
The interview teams conducted 212 interviews, with a contact
rate of 77.9% and a cooperation rate of 98.1%. Thirty-two per-
cent of households had at least one child younger than age 2 years,
and 30% of households had at least one adult family member who
was 65 years of age or older. Approximately 9% of households
included at least one pregnant woman. Table 1 shows informa-
tion on residence, utilities, drinking water, and other needs. Dur-
ing the initial CASPER, 42% of households believed that their
house was not safe to live in, 47.6% reported needing a tarpau-
lin, and 51.6% reported a lack of electricity. Most households
reported using bottled drinking water from either a relief agency
(31.1%) or another source (60.8%), while a small percentage
(3.8%) reported drinking stream water. Approximately 37% of
households reported a need for clothing.
During the initial CASPER, the most frequent self-reported
symptoms or conditions were respiratory conditions (21.2%),
stress or sleep disturbance (11.8%), and stomach ache or diar-
rhea (9.0%). Lacerations (11.8%); bruises or contusions (6.1%);
impalement or puncture wounds (2.4%); and strains, sprains,
or dislocations (2.4%) were the most frequently reported inju-
ries (Table 2). Nineteen percent of households reported need-
ing medical care or supplies since the tsunami, 16.7% reported
having immediate medical needs, and 23.5% reported antici-
pating needs within 3 to 7 days (Table 2). Thirty-nine percent
of households reported barriers to obtaining medical care or sup-
TABLE 1
Characteristics of Households in Affected Areas Following the Earthquake-Tsunami, American Samoa, 2009
Initial Community Needs Assessment for Public
Health Emergency Response (CASPER) Follow-up CASPER
Characteristics
% of Households
(95% CI)
(N = 212)
ProjectedaNo.
of Households
(95% CI)
% of Households
(95% CI)
(N = 207)
ProjectedbNo.
of Households
(95% CI) % Changeb
Residence
Feels residence is not safe 41.9 (28.8-54.9) 1867 (1146-2588) 40.4 (29.2-51.6) 1788 (1191-2385) −3.6
Needs tarpaulin 47.6 (35.3-59.8) 1872 (1235-2509) 47.3 (34.6-60.0) 2160 (1426-2893) −0.6
Utilities
No electricity 51.6 (38.5-69.1) 2399 (1578-3220) 11.2 (2.6-19.8) 498 (145-851) −78.3c
Drinking Water Source
Drinking bottled water from agency 31.1 (18.9-43.3) 1400 (749-2050) 17.4 (8.2-26.5) 773 (300-1246) −17.4
Drinking bottled water from other
source
60.8 (50.0-71.7) 2748 (2192-3304) 44.4 (34.2-54.6) 2001 (1257-2746) −44.1
Drinking from stream 3.8 (0.0-9.7) 172 (0-441) 1.4 (0.0-2.9) 64 (0-138) −63.2
Other
Need clothing 38.3 (24.5-52.2) 1676 (1013-2339) 28.1 (17.98-38.30) 1203 (753-1654) −26.6
aBased on weighted analyses using information from 2000 census (4513 housing units with a total population of 25 700).
bPercent change= (% of households in follow-up CASPER) – (% of households in initial CASPER)/(% of households in Initial CASPER).
cStatistically significant as 95% CI does not overlap; A positive (⫹) sign indicates an increase in the response percentage, whereas a negative (−) sign suggests a decrease in the
response percentage.
Public Health Needs Assessments After Tsunami
Disaster Medicine and Public Health Preparedness 211
©2012 American Medical Association. All rights reserved.

plies, including financial reasons (9%) and fear of traveling af-
ter the tsunami (2.8%).
Table 3 shows households’ greatest reported needs; respon-
dents often gave more than one response. During the initial
CASPER, the most frequently reported needs included elec-
tricity (34.0%), water (27.8%), and financial help (25.5%). In-
terview teams also made more than 25 medical referrals for per-
sons in need of immediate medical care or supplies and arranged
transportation for one critically ill patient to the emergency de-
partment.
Follow-up CASPER
Three weeks after the tsunami, the interview teams conducted
the follow-up CASPER, completing 207 interviews, with a con-
tact rate of 88% and a cooperation rate of 99%. During the fol-
low-up CASPER, 37% of households had at least one child
younger than age 2 years, and 35.1% of households had at least
one adult family member who was 65 years of age or older. Ap-
proximately 10% of the households included at least one preg-
nant woman. Forty percent of households felt their homes were
not safe to live in, 47.3% reported needing a tarpaulin, and 11.2%
reported a lack of electricity (Table 1). The majority (62.8%)
of households reported using bottled water as their sole po-
table water source, and approximately 28% of the households
reported a need for clothing.
During the follow-up CASPER, 13.5% of households reported
respiratory symptoms, and 16% reported fever (Table 2). At
least one household member sustained lacerations (3.4%), mo-
tor vehicle injuries (2.4%), and bruises or contusions (1.4%)
in the aftermath of the tsunami. Approximately 25% of house-
holds reported needing medical care or supplies since the tsu-
nami; 26% reported having immediate medical needs (Table 2).
Thirty-three percent of households reported having barriers to
obtaining medical care or supplies, including financial reasons
(15%) and lack of transportation (5.3%).
Table 3 shows households’ self-reported greatest needs three
weeks after the tsunami: food (26.1%), financial help with
cleanup (14%), water (13.5%), and medical care (3.9%). In-
terview teams also made 11 medical referrals for persons in need
of medical care or supplies and arranged transportation for one
critically ill patient to the emergency department.
TABLE 2
Illnesses, Injuries, and Medical Care Needs and Access by Household Following the Earthquake-Tsunami, American
Samoa, 2009
Initial Community Needs Assessment for Public
Health Emergency Response (CASPER) Follow-up CASPER
Illness/Conditions
% of Households
(95% CI)
ProjectedaNo.
of Households
(95% CI)
% of Households
(95% CI)
ProjectedcNo.
of Households
(95% CI)
%
Changeb,c
Respiratory (cough, flu) 21.2 (14.9-27.5) 967 (632-1302) 13.5 (7.2-19.7) 610 (295-925) −36.3
Stress/sleep disturbance 11.8 (7.2-16.3) 537 (114-303) 5.3 (2.3-8.3) 236 (67-405) −55.1
Stomachache/diarrhea 8.9 (4.8-13.1) 405 (198-613) 7.2 (2.1-12.3) 322 (37-608) −19.1
Skin condition/rash/burn 4.3 (1.6-6.9) 193 (66-320) 2.9 (0.0-5.9) 129 (0-261) −32.6
Inability to perform daily tasks 3.8 (1.7-5.8) 172 (65-278) 1.9 (0.2-3.6) 86 (3-169) −50.0
Dehydration/heat stress 3.3 (0.4-6.2) 150 (14-287) 3.9 (1.0-6.7) 172 (19-324) ⫹18.2
Injuries
Laceration, abrasion 11.8 (4.5-19.0) 537 (179-895) 3.4 (0.4-6.4) 150 (15-286) −71.2
Bruise/contusion 6.1 (2.4-9.8) 279 (96-463) 1.4 (0.0-3.2) 64 (0-138) −77.0
Impalement/puncture wound 2.4 (0.0-4.7) 107 (0-218) 0 (0) 0 (0) −100.0
Strain/sprain/dislocation 2.4 (0.4-4.3) 107 (17-198) 1.0 (0.0-2.4) 43 (0-104) −58.3
Motor vehicle-related or other blunt
trauma
1.9 (0.0-4.1) 86 (0-190) 2.4 (0.6-4.2) 107 (17-197) ⫹26.3
Insect bite 0.9 (0.0-2.2) 43 (0-104) 0.5 (0.0-1.4) 21 (0-66) −44.4
Electrical injury 0.5 (0.0-1.4) 21 (0-66) 0 (0) 0 (0) −100.0
Burn/sunburn 0.5 (0.0-1.4) 21 (0-66) 0.5 (0.0-1.4) 21 (0-66) 0
Brain injury/concussion 0.5 (0.0-1.4) 21 (0-66) 0 (0) 0 (0) −100.0
Medical Care
Needed medical care since tsunami 19.0 (13.6-24.4) 854 (575-1134) 24.6 (16.4-32.8) 1087 (660-1513) ⫹29.5
Need care immediately 16.6 (10.0-23.3) 696 (408-984) 26.2 (18.6-33.8) 1155 (746-1563) ⫹57.8
Cannot get medical care/supplies 31.2 (23.6-38.8) 1389 (1030-1748) 33.2 (22.7-43.6) 1473 (921-2024) ⫹6.4
Lack of transportation 6.6 (2.5-10.6) 301 (107-495) 5.3 (0.0-11.3) 236 (0-523) −19.7
No medical services available 1.4 (0.0-3.6) 64 (0-162) 0.5 (0.0-1.4) 21 (0-66) −64.3
Financial reasons 9.0 (5.0-12.9) 406 (219-592) 15.0 (7.8-22.1) 666 (271-1061) ⫹66.7
Afraid to travel 2.8 (0.2-5.4) 129 (13-245) 0.5 (0.0-1.5) 21 (0-66) −82.1
aBased on weighted analyses using information from 2000 census (4513 housing units with a total population of 25 700).
bPercent change= (% of households in follow-up CASPER) – (% of households in initial CASPER)/ (% of households in Initial CASPER).
cA positive (⫹) sign indicates an increase in the response percentage, whereas a negative (−) sign suggests a decrease in the response percentage.
Public Health Needs Assessments After Tsunami
212 Disaster Medicine and Public Health Preparedness VOL. 6/NO. 3
©2012 American Medical Association. All rights reserved.

The follow-up CASPER assessed current vector problems com-
pared to pre-tsunami and use of mosquito protection; these vec-
tor issues were not assessed during the first CASPER. As shown
in Table 4,households reported increases in vector problems
such as night time (which can result in malaria) (77%) and day
time (which can result in dengue fever) (68%) mosquito bites;
increases in mosquito breeding sites (50%); and increases in flies
(59%), rats (37%), and stray dogs (16%). The most com-
monly reported methods for preventing mosquito bites in-
cluded mosquito coils (64%), aerosol insecticides (43%), and
window screens (18%). Almost 7% of households reported not
using any type of mosquito prevention method (Table 4).
Evaluation of the Initial and Follow-up CASPERs
Compared to the initial CASPER, results from the follow-up
CASPER indicated that the number of households reporting a
lack of electricity had decreased by approximately 78.3%
(Table 1). Consumption of bottled water from relief agencies
and other sources decreased by 17.4% and 44.1%, respec-
tively, and the need for clothes decreased by 26.6%.
Table 2 compares illnesses and injuries between the initial and
follow-up CASPERs. The largest decreases in percent change
were reported for stress or sleep disturbance (55.1%) and re-
spiratory illness (36.6%). An increase of 18.2% was observed
in dehydration or heat stress illnesses. Decreases in all injuries
were reported, with the exception of an increase in motor ve-
hicle-related or blunt trauma (26.3%). However, none of these
percent changes were statistically significant.
Table 2 compares medical care needs captured in the initial
CASPER to those of the follow-up. Medical care needs in-
creased by 29.5%, while a need for immediate care increased
by 57.8%. The number of households reporting an inability to
obtain medical care and supplies increased by 6.4%; the ma-
jority (66.7%) resulted from lack of financial resources.
Table 3 compares households’ greatest needs between the ini-
tial and follow-up CASPERs. Household needs for electricity
and trash removal decreased by 92.9% and 90.4%, respec-
tively. Similarly, the needs for medications, physical help with
cleanup or repairs, and transportation decreased by 92.7%,
94.6%, and 85.9%, respectively.
DISCUSSION
To our knowledge, this study is the first to compare findings of
CASPERs conducted during the response and recovery phases
of an earthquake and tsunami disaster response. Our findings
show the extent of tsunami-related public health problems dur-
ing the response and recovery phase in American Samoa.
CASPER results were used to assess the effectiveness of ASDOH
relief efforts.
Early identification of affected communities’ disaster-
associated needs can guide resource management during the im-
mediate response, especially when limited information is avail-
able about characteristics of the affected population.13-15 During
the recovery phase, assessment of response efforts and identi-
fication of emerging needs are equally important.16 Follow-up
assessments are often recommended during the recovery phase
to monitor affected communities’ changing needs.11 Only lim-
ited information is available about characteristics of the af-
fected population.13-15 These assessments can elucidate the chang-
ing patterns of access to medical care, basic household needs,
and other health needs.
Electricity outage following a disaster is common.13 As dem-
onstrated by results from the initial CASPER, a significant num-
ber of households in American Samoa lost electricity because
of tsunami-related damage. Immediately following the tsu-
nami, many households in the affected area evacuated at least
one night, and a substantial number had residence-related safety
concerns. Many reported the need for additional sheltering ma-
TABLE 3
Self-Reported Greatest Needs by Household Following the Earthquake-Tsunami in American Samoa, 2009
Initial Community Needs Assessment for Public
Health Emergency Response (CASPER) Follow-up CASPER
Current Greatest Need
% of Households
(95% CI)
ProjectedaNo. of
Households
(95% CI)
% of Households
(95% CI)
ProjectedcNo. of
Households
(95% CI) % Changeb,c
Electricity 34.0 (54.8-77.3) 1531 (931-2131) 2.4 (0.5-4.3) 107 (17-197) −92.9
Water 27.8 (17.2-38.4) 1263 (761-1764) 13.5 (7.8-19.2) 601 (280-923) −51.4
Financial help with clean up/repairs 25.5 (14.3-36.6) 1144 (625-1663) 14.0 (4.4-23.6) 623 (166-1080) −45.1
Food 21.7 (12.3-31.0) 986 (511-1461) 26.1 (19.0-33.1) 1185 (82-1550) ⫹20.3
Medications 13.7 (6.1-21.0) 612 (251-973) 1.0 (0.0-2.4) 42 (0-104) −92.7
Trash removal 10.4 (3.3-17.4) 470 (128-812) 1.0 (0.0-2.4) 43 (0-104) −90.4
Physical help with clean up/repairs 9.4 (3.1-15.7) 430 (121-738) 0.5 (0.0-1.5) 21 (0-66) −94.7
Transportation 7.1 (2.6-11.5) 320 (97-542) 1.0 (0.0-2.4) 43 (0-104) −85.9
Medical care 6.6 (0.3-2.8) 298 (127-469) 3.9 (0.2-7.5) 172 (6-337) −40.9
aBased on weighted analyses using information from 2000 census (4513 housing units with a total population of 25 700).
bPercent change= (% of households in follow-up CASPER) – (% of households in initial CASPER)/ (% of households in Initial CASPER).
cStatistically significant as 95% CI does not overlap. A positive (⫹) sign indicates an increase in the response percentage, whereas a negative (−) sign suggests a decrease in the
response percentage.
Public Health Needs Assessments After Tsunami
Disaster Medicine and Public Health Preparedness 213
©2012 American Medical Association. All rights reserved.

terials, such as a tarpaulin. At the time of the initial CASPER,
four to five days post-tsunami, we estimated that 600 house-
holds in affected Tutuila areas were still displaced. Three weeks
after the tsunami, many households reported their houses were
still not safe to inhabit.
Another common concern after any natural disaster is avail-
ability of potable drinking water, as most of the population uses
municipal water for daily needs.17 At the time of the follow-up
CASPER, nearly 60% of households were still using bottled wa-
ter. We also estimated that 60 households in the affected areas
on Tutuila Island were drinking water from streams, in spite of
endemic risks of water-associated infectious diseases, includ-
ing leptospirosis.18
The ASDOH indicated that the number one priority of relief
agencies was to provide basic needs (such as food, water, and
shelter) to affected households. During the initial CASPER,
households’ self-reported greatest needs included electricity, wa-
ter, and financial help with cleanup. ASDOH informed the
American Samoa Power Authority about the estimated num-
ber of households without public utilities, using data from the
initial CASPER. Providing information throughout the power
restoration prioritization process facilitated rapid restoration of
electric and water services. With the help of the American Red
Cross, ASDOH also provided meals to families in need. Even
though a significant decrease in need for electricity (−78.3%)
and water (−44.1%) was reported during the follow-up CASPER
three weeks after the tsunami, food and water remained the most
commonly reported greatest needs.
The follow-up CASPER identified access to medical care as an
ongoing public health need. Tutuila Island has only one hos-
pital, and after the tsunami its medical services were limited,
and its three well-baby clinics were understaffed. Limited medi-
cal capacity and persistent post-tsunami medical needs may have
hindered access to medical services. Compared with the ini-
tial CASPER, the follow-up CASPER found an increase in the
percent of households reporting problems related to access to
medical care, including the need for immediate medical care
and inability to get medical supplies. Previous studies suggest
that the majority of disaster-related illnesses and injuries oc-
cur during the post-impact (ie, cleanup) phase.10,19 However,
these findings show an overall decrease in illnesses and inju-
ries three weeks after the tsunami (ie, cleanup phase).
Limitations
These results are subject to several limitations. First, because
the survey was conducted only in accessible households,
these estimates may underestimate the actual impact of the
disaster. For example, houses completely destroyed or
vacated were not included in initial and follow-up
CASPERs. Second, because the estimated number of house-
holds was reported using census 2000 data, the weighted
analysis does not account for changes in the number of hous-
ing units from 2000 to 2009. Third, if participants believed
that their responses were linked to relief resources, this per-
ception could have introduced bias.
Strengths
Despite these limitations, CASPER provided a rapid and ef-
fective method to determine the immediate needs of commu-
nities in American Samoa following the tsunami. CASPER ob-
jectively quantified disaster-affected population needs that may
have been identified anecdotally but not enumerated. CASPER
has been used in many other disaster situations to provide popu-
lation-based estimates within a few days or hours after data col-
lection. Findings were provided to ASDOH officials within 72
hours of each CASPER; this information assisted in decisions
about deploying resources to tsunami-affected areas. While de-
termining the proportion of households with a particular need
is useful, the projection of an estimate of the number of house-
holds with a specific need is even more useful. This informa-
tion provided the ASDOH disaster response with quantities
TABLE 4
Percent of Households Reporting Increases in Vectors and Practices Associated With Protection From Mosquitoes Following
the Earthquake-Tsunami in the Follow-up CASPER, American Samoa, 2009
Vectors % of Households (95% CI) ProjectedaNo. of Households (95% CI)
Night time mosquito 77.3 (69.3-85.3) 3475 (2480-4470)
Day time mosquito 68.1 (58.1-77.9) 3070 (2142-3999)
Flies 58.5 (48.1-67.9) 2618 (834-3401)
Breeding sites for mosquitoes 49.8 (39.0-59.8) 2230 (1368-3093)
Rats 36.7 (20.0-52.7) 1642 (603-2680)
Dogs 16.4 (8.7-24.4) 748 (380-1116)
Practices
Mosquito coils 63.8 (54.6-72.9) 2861 (1959-3763)
Aerosol insecticides 42.5 (32.2-52.8) 1903 (1225-2582)
Window screen 29.5 (9.3-49.6) 1310 (214-2408)
Repellent 18.4 (3.2-33.4) 816 (0-1646)
Removing breeding sites 17.4 (7.3-27.4) 773 (292-1255)
Protective clothing 6.3 (0.9-11.6) 279 (0-566)
Abbreviation: CASPER, Community Needs Assessment for Public Health Emergency Response.
aBased on weighted analyses using information from 2000 census (4513 housing units with a total population of 25 700).
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214 Disaster Medicine and Public Health Preparedness VOL. 6/NO. 3
©2012 American Medical Association. All rights reserved.

needed in their recovery efforts (eg, estimated housing units in
need of tarpaulins or how much food/water to take to an af-
fected area). Because the findings determined the greatest needs
of the affected population, they were also used to help identify
and prioritize needs (such as water, food, and shelter) and to
target delivery to affected communities of resources such as medi-
cation, which was especially in need at that time because of the
H1N1 pandemic, an additional strain on the ASDOH. An-
other problem was the limited medical resources in American
Samoa. The territory has only one 128-bed hospital, which was
overburdened after the tsunami. ASDOH used the informa-
tion provided by CASPER to plan short- and long-term inter-
vention programs, including distribution of food and water in
affected areas. Confidential referrals made during the assess-
ment helped ASDOH address individuals’ most urgent issues
immediately by directing appropriate resources. ASDOH used
this opportunity to assess local capacity to conduct future
CASPERs and collaborated with CDC to implement disaster
epidemiology training for ASDOH staff to enhance disaster pre-
paredness and response capacities.
CONCLUSIONS
The results of the initial CASPER highlighted environmental
and other health hazards that could lead to further morbidity
and mortality. Immediately following the tsunami, many house-
holds in affected areas left their dwelling for at least one night,
and a substantial number were projected to have residence-
related safety concerns. Fears about the safety of municipal wa-
ter resulted in a boil-water advisory. Based on data from the ini-
tial CASPER, the following recommendations were made:
• Provide a continuing source of potable water, especially to
those dependent on relief agencies for water deliveries.
• Provide immediate, appropriate shelter for displaced persons.
• Providea short-term food distributionprogram for displaced popu-
lations depending on food banks or shelters for meals.
The follow-up CASPER identified ongoing public health needs
for food, water, and access to medical care. Survey results also
indicated that a small number of households reported family
members with injuries and acute illnesses. Based on the fol-
low-up CASPER findings, the CDC team made recommenda-
tions to disseminate community education materials regard-
ing safe drinking and bathing water sources, including promoting
American Samoa Power Authority’s (ASPA) water as a safe
drinking water source, and disseminating infectious disease bro-
chures (eg, dengue fever, H1N1, leptospirosis). CASPER pro-
vided information about the changing public health needs of
the affected community. These findings helped the ASDOH
and emergency managers to prioritize and direct resources to
address immediate and ongoing needs, as well as to assess re-
sponse efforts.
The most common natural hazards experienced by American
Samoa are cyclones or hurricanes and flooding caused by
hurricanes.20 American Samoa lies just to the northern end
of Tongan Trench, one of the most active seismic areas
worldwide; therefore, the area experiences frequent earth-
quakes that can result in tsunamis.20,21 While the public
health consequences of earthquakes in American Samoa
have ranged from destruction of infrastructure to mass casu-
alties and fatalities, no earthquake fatalities were noted in
this event, probably also due in part to a well-developed
emergency operations plan, which describes a public pre-
paredness plan during a natural disaster event. However,
before the 2009 tsunami, the last confirmed tsunami in
American Samoa occurred in 1837.21 Response efforts
during the 2009 earthquake and tsunami post-disaster opera-
tions, including findings from initial and follow-up
CASPERs, helped ASDOH to revise and improve their haz-
ard vulnerability assessment and emergency operations plan
for tsunamis.
Author Affiliations: Division of Environmental Hazards and Health Effects
(Drs Choudhary, Vagi, and Bayleyegen and Mss Martin, Noe, and Wolkin),
Office of the Director National Center for Environmental Health (Dr Keim),
and Office of Public Health Preparedness and Response (Dr Chen and Mr Roth),
Centers for Diseases Control and Prevention, Atlanta, Georgia; and Ameri-
can Samoa Department of Health, Pago Pago, American Samoa (Mss Ponau-
suia and Lemusu).
Correspondence: Ekta Choudhary, PhD, MPH, CDC/NCEH/HSB, 4770 Bu-
ford Hwy NE, MS F-57, Atlanta, GA 30341 (e-mail: Echoudhary@CDC.gov).
Received for publication November 21, 2011; accepted February 7, 2012.
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